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Admission Date: [**2125-6-6**] Discharge Date: [**2125-6-12**] Date of Birth: [**2059-2-6**] Sex: F Service: NEUROLOGY Allergies: Sulfonamides / Bactrim Attending:[**First Name3 (LF) 7575**] Chief Complaint: fall with subsequent back and neck pain Major Surgical or Invasive Procedure: None History of Present Illness: 66 yo R-handed woman with a history of right-sided sciatica, b/l lumbosacral plexitis, seizure disorder, and qualitiative platelet disorder who presents to the emergency room s/p fall complaining of head and neck pain that radiates to between her shoulder blades. Upon waking up this morning, the patient reports that she felt light-headed as she walked down the [**Doctor Last Name **] near the top of the stair-case. This happened after standing up from bed. This has happened in the past. She subsequently fell in a supine position down the first several stairs, hitting her buttocks and upper back. She was able to cup the posterior aspect of her head with her hands but reports hitting the stairs hard enough to cause 15/10 occipital head pain as well as pain to both hands. She was able to stand-up and with her husband's support walk back up the stairs. She has also been on ultram for pain management. She has not taken any ultram since yesterday, though. There are no remarkable changes on her medications. She was not on any narcotics otherwise. She was in such distress that her husband suggested that she come to the ED via ambulance and she agreed. Prior to the fall she does not recall any prodromal symptoms, nor did she experience any bowel/bladder incontinence. She also denies LOC, weakness, numbness. She reports that her movement is limited by pain. She reports her pain has improved after receiving morphine in the ED and is now of 6/ 10 intensity as compared to 25/ 20 previously. She does have a history of myclonic seizures, but none in last 35 years. Reports occasional periods of getting lost while driving or confusion in the grocery line which she believes may be seizures. She also recalls episodes of shaking in her hands, buttocks, or legs that she feels are seizure activity. When she feels this shaking feeling coming on, she takes a lamictal tablet in order to prevent progression of seizure. She reports that these episodes have occurred more often recently so she increased her lamictal dose on her own (from 150 [**Hospital1 **] to 200/ 250). She also reports occasional difficulty spelling or writing on a line. Past Medical History: Past Medical History: 1. Right-sided sciatica, bilateral lumbosacral plexitis, fibromyalgia 2. Mitral valve prolapse 3. Seizure disorder. 4. Qualitative platelet disorder. By history, has had "spontaneous renal hemorrhage with ureteral clots requiring ureteral stenting, bleeding s/p hysterectomy, tonsillectomy, and once post-partum." 5. Diverticulitis. Surgical Hx: s/p left colectomy [**2124-4-16**], appendectomy, tonsillectomy, TAH salpingo-oophorectomy Social History: She is a former hospice nurse, now retired. She drinks an occasional glass of alcohol, but denies a history of tobacco or drug use. She lives in [**Location 620**]. Family History: Father died of subarachnoid hemorrhage, brother died at age 29 from an intracerebral aneurysm, and maternal grandmother had stroke Physical Exam: Vitals: T 98.9 F BP 117/57 P 87 RR 22 SaO2 97 [**Last Name (un) **] could not check orthosthatics as far as her pain prevents her from sitting up. HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, nontender, non-distended. No masses or megalies. Percussion within normal limits. +BS. Ext: no edema, no DVT data. Pulses ++ and symmetric. Neurologic examination: No photophobia. On a hard neck collar. Anal winck positive, tone mildly decreased. MS: General: alert, awake, normal affect Orientation: oriented to person, place, date, situation Attention: 20 to 1 backwards +. Follows simple/complex commands. Speech/Language: fluent w/o paraphasic errors; comprehension, repetition, naming: normal. Prosody: normal. Memory: Registers [**1-16**] and Recalls [**1-16**] when given choices at 5 min Praxis/ agnosia: Able to brush teeth. No field cuts. CN: I: not tested II,III: VFF to confrontation, PERRL 3mm to 2mm, fundus w/o papilledema. III,IV,VI: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: SCM/trapezeii [**3-20**] bilaterally XII: tongue protrudes midline. Rinne: R ear: AC>BC, LEFT ear AC> BC [**Doctor Last Name 15716**]: central. Motor: Normal bulk. Tone: normal. No tremor, no asterixis or myoclonus. No pronator drift: Both arms are antigravity, however there is give away weakness (symmetrical) Flexor Digiti Minimi preserved bilaterally Abductor Pollicis Brevis preserved. Extensor Digitorum brevis there is bl atrophy and weakness 4/5. Legs exam is limited by pain. Bragard and Lassage are: questionably positive on the RIGHT leg. She does exhibit more pain at mobilization of her RIGHT leg than the left. She does flex her hips bl, wiggles her toes and is antigravity with her LEFT ileospsoas. Would not attempt to elevate her RIGHT leg. Foot plantar flextion is [**3-20**], dorsiflex, inversion and eversion are [**2-18**]. Deep tendon Reflexes: 2+ in bl arms. Bicip:C5 Tric:C7 Brachial:C6 Patellar:L4 Achilles Toes: Right 2 2 2 3 2 mute Left 2 2 2 3 2 mute There is crossed adduction. Sensation: RIGHT hemibody:decreased vibration (from 5 seconds to 8 seconds in the toe). Position sense: normal. Decreased light touch and pinprickfrom T3 to T12 and also in anterior aspect of her LEFT leg from groin to ankle with her toes preserved. LEFT hemibody: intact to pinprick and vibration and position sense and noxious stimuli. Coordination: *Finger-nose-finger symmetrically and inconsistently dysmetric *Rapid Arm Movementswould not cooperate due to pain in her shoulder blades. *Fine finger tapping: normal. *Heal to shin: unable to examine. *Gait/Romberg: unable to perform it. Brief Hospital Course: 66 yr old female with rt sided sciatica, lumbosacral plexitis, seizure disorder, myoclonic twitching who presented to the ED [**2125-6-6**] s/p fall after feeling lightheaded and dizzy. Electrolytes and toxicology screening negative. MRI C-S spine showed C3-C4 -C6-7 canal stenosis. T/L spine were without traumatic injury. Placed in cervical collar. No cord lesion. Her MRA is negative. This is reassuring given her FH of two first degree relatives with CNS aneurysms. Initially, she remained in pain (partially controlled with morphine iv rescue doses and standing ultram. Finally a HYDROmorphone (Dilaudid) 0.25 mg IVPCA was started. While on the floor, found to be orthostatic and therefore her medications were adjusted. She was also given IV fluids. She is no longer on percocet or firocet. Nortryptaline was discontinued. Trazadone is now only prescribed at night. Ultram was lowered to 50 mg PO q6. Lyrica is at 100 mg PO qam and pm. Her urine was positive for UTI and she was treated with Ciprofloxacin for 3 days. Initially had urinary retention, but this resolved by the time of discharge. Her exam has been unchanged. She has no new focal findings. Given her cervical ligament lesion, she has remained on a rigid collar. Medications on Admission: Medications: 1. Lamictal 200 mg AM; 250mg PM 2. Nexium 20 mg [**Hospital1 **] 3. Lyrica 100 mg [**Hospital1 **], trazodone 50mg [**Hospital1 **], Tizanidine 4 mg TID prn spasm 4. Calcium supplement 5. Fioricet as needed for headache Discharge Medications: 1. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO q 6 hours PRN as needed for pain: please hold if lightheaded . Disp:*240 Tablet(s)* Refills:*0* 3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Pregabalin 25 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p fall Muscoskeletal neck pain s/p UTI Seizure disorder right sided sciatica myoclonus lumbosacral disc plexitis Discharge Condition: Stable. Neurologic exam shows slight myoclonus in arms. Improved myoclonus. Improved orthostatic hypotension. Discharge Instructions: You presented to the ED because of a fall after feeling lightheaded and dizzy. Electrolytes and toxicology screening negative. MRI C-S spine showed C3-C4 -C6-7 canal stenosis. T/L spine without traumatic injury. You were placed in cervical collar. While on the floor, you were found to be orthostatic and medications were adjusted. You should no longer take percocet or firocet. Nortryptaline was also discontinued. Trazadone is to be taken only at night. Ultram was lowered to 50 mg PO q6. Lyrica is at 100 mg PO qam and pm. You have a urinary tract infection and were treated with antibiotics. Initially you had urinary retention, but this has resolved. Please take all of your medications and go to follow up appointments. Followup Instructions: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5088**] [**2125-7-4**] at 2:30 pm Completed by:[**2125-7-10**]

Admission Date: [**2130-10-2**] Discharge Date: [**2130-10-4**] Date of Birth: [**2085-9-4**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5810**] Chief Complaint: Stridor Major Surgical or Invasive Procedure: mechanical ventilation Extubation History of Present Illness: Ms. [**Known lastname 87445**] is a 45F with schizoaffective disorder, polysubstance dependence, and SAH s/p coiling L MCA aneurysm [**2130-7-2**] and repeat coiling for recannalization on [**9-20**], [**2129**] who initially presented to OSH ED with sore throat x 1 week. Neck X-ray was performed and revealed possible thickened epiglottis but she left the ED AMA prior to finalized [**Location (un) 1131**]. She then returned to the OSH ED at approximately 10pm with new onset stridor and hoarseness. She was also noted to be altered with slurred speech and there was concern for intoxication. She was intubated with a 7-0 ETT for airway protection with emesis noted post-intubation. CT neck reportedly revealed thickened epiglottis and CT head was negative for acute process. She received Ceftriaxone, Decadron 10mg IV, and was transferred here by [**Location (un) 7622**]. She received pancuronium, 4mg IV versed, 4mg IV ativan at OSH. Labs there remarkable for ABG 7.40/53/75, WBC 4.6. In [**Hospital1 18**] ED, initial vs were: 98.6 77 101/76 16 96%. She was given propofol for sedation. CXR confirmed ETT placement. ENT was consulted and epiglottis was visualized and felt to be slightly inflamed. They recommended continuing dex 10mg IV q8 and antibiotics and plan for extubation when has cuff leak. Neurosurgery was also notified. VS prior to transfer: 98.6 113/74 72 16 100% on AC FiO2 100% Vt500 RR16 PEEP 5. On the floor, she is intubated and sedated. Past Medical History: - Asthma - h/o polysubstance abuse - ADHD - Depression/anxiety vs bipolar disorder - Schizoaffective disorder - s/p overdose [**2125**] c/b respiratory failure - SAH s/p coiling L MCA aneurysm [**7-/2130**] with recannalization on MRI and repeat coiling [**2130-9-20**] Social History: - originally from [**Male First Name (un) **]; has a son and a daughter but no contact info at time of admission - Tobacco: denied at osh - per her nephew, she was a heavy smoker in past - Alcohol: denied at osh after extubation here, denied any substance use, reported only taking prescribed medications Family History: unable to otbain at time of admission Physical Exam: Physical Exam on Arrival to ICU: VS: Tcurrent: 36.2 ??????C, HR: 79, BP 104/70, RR 18, O2Sat 98% on CMV/Assist. PEEP 5, FiO2 50%, RR 18, ABG: 7.51/41/205//9 General: Intubated, sedated HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, 2mm Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally with crackles R base, no wheezes or ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No lesions or rashes. Pertinent Results: [**2130-10-2**] 02:05AM BLOOD WBC-11.1* RBC-3.59* Hgb-11.4* Hct-34.4* MCV-96 MCH-31.9 MCHC-33.2 RDW-13.3 Plt Ct-279 [**2130-10-2**] 05:52AM BLOOD WBC-9.3 RBC-3.65* Hgb-11.8* Hct-35.4* MCV-97 MCH-32.3* MCHC-33.3 RDW-13.1 Plt Ct-281 [**2130-10-2**] 05:52AM BLOOD Neuts-91.1* Lymphs-7.1* Monos-1.0* Eos-0.3 Baso-0.5 [**2130-10-3**] 04:37AM BLOOD WBC-15.7*# RBC-3.67* Hgb-11.6* Hct-35.0* MCV-95 MCH-31.8 MCHC-33.3 RDW-12.8 Plt Ct-286 [**2130-10-2**] 02:05AM BLOOD PT-12.7 PTT-24.1 INR(PT)-1.1 [**2130-10-3**] 04:37AM BLOOD PT-12.6 PTT-123.1* INR(PT)-1.1 [**2130-10-2**] 02:05AM BLOOD Fibrino-335 [**2130-10-2**] 05:52AM BLOOD Glucose-167* UreaN-10 Creat-0.6 Na-141 K-4.1 Cl-101 HCO3-29 AnGap-15 [**2130-10-2**] 03:00AM BLOOD ALT-12 AST-18 LD(LDH)-157 AlkPhos-75 TotBili-0.2 [**2130-10-2**] 02:05AM BLOOD Lipase-22 [**2130-10-2**] 05:52AM BLOOD Calcium-9.5 Phos-2.7 Mg-2.1 Iron-66 [**2130-10-2**] 05:52AM BLOOD calTIBC-326 Ferritn-21 TRF-251 [**2130-10-2**] 03:00AM BLOOD VitB12-393 Folate-9.5 [**2130-10-2**] 07:36PM BLOOD Vanco-5.2* [**2130-10-2**] 02:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-POS Tricycl-NEG [**2130-10-2**] 03:14AM BLOOD Type-ART Temp-37.0 Rates-/16 Tidal V-500 FiO2-100 pO2-205* pCO2-41 pH-7.51* calTCO2-34* Base XS-9 AADO2-488 REQ O2-80 -ASSIST/CON Intubat-INTUBATED Comment-GREEN TOP [**2130-10-2**] 01:54PM BLOOD Type-ART Rates-/16 Tidal V-450 PEEP-5 FiO2-40 pO2-137* pCO2-48* pH-7.39 calTCO2-30 Base XS-3 Intubat-INTUBATED Vent-CONTROLLED [**2130-10-2**] 12:13PM BLOOD Lactate-4.4* [**2130-10-2**] 01:54PM BLOOD Lactate-2.2* HISTORY: Epiglottitis with intubation, to assess for acute abnormality. FINDINGS: In comparison with the study of [**10-2**], the endotracheal and nasogastric tubes have been removed. The atelectatic streak in the left mid zone has cleared. At the current time, there is no evidence of acute pneumonia or vascular congestion or pleural effusion. Brief Hospital Course: Assessment and Plan: 44 year old woman with schizoaffective disorder and SAH s/p coiling L MCA aneurysm transferred from OSH with with epiglottitis and resp distress now intubated. . #. Epiglottitis/Hypercarbic Respiratory Failure: Patient initially presented to OSH with sore throat and was found to have imaging (Neck X ray and CT per report) consistent with epiglottitis. ABG also consistent with hypercarbia and respiratory acidosis with concomitant metabolic alkalosis. She left OSH ED and subsequently presented with stridor and was intubated for airway protection. Epiglottitis can be caused by thermal or inhalational injury but is more commonly caused by infection. The most common bacterial causes include H flu, strep pneumo, beta hemolytic strep and staph aureus but viral causes are also possible. Patient was intially treated with decadron and empiric ceftriaxne. She was on insulin ss while on steroids. Rapid resp viral panel sent, antigen was negative, viral cultures pending at the time of discharge; blood cx sent and were no growth. Patient was evaluated by ENT with laryngoscopy while intubated and again after extubation. Initial impression was that epiglottis was mildly inflamed. After she was extubated, she had another endoscopic exam and was noted to have some vocal cord dysfunction, improved with relaxation techniques and no obvious epiglottitis. Patient was transferred to the floor on [**10-3**] and continued to do well. Still had a sore throat, but no wheezing or shortness of breath, no dysphagia. ENT also recommended increasing omprazole to 40 mg daily. Have scheduled outpt ENT follow-up . # PEA cardiac arrest- this occured while in ICU, patients pulse returned after 1 minute or so of chest compressions. Etiology was felt to be possibly secondary to biting the tube versus related to propofol. Patient had some pleuritic chest pain related to chest compressions later in hospital course, treated with ibuprofen, tylenol and one dose oxycodone. patient has oxycodone at home still for headaches and continue to take these as needed for chest pain as well. #. Anemia: HCT at current baseline 30-32 with high normal MCV. . #. h/o SAH and MCA aneurysm s/p coiling [**2130-7-2**] and repeat coiling [**2130-9-1**]: Neurosurgery aware. No current active issues - continue aspirin 325mg PO daily , has f/u scheduled with Neurosurgery. . #. Asthma: Continue albuterol prn (MDI while intubated) although no current wheezing on exam . #. Schizoaffective disorder: - continued home seroquel - restarted home benzos, trazodone and gabapentin . #. h/o Polysubstance abuse: had urine tox positive for benzos (gets these rx), amphetamines (on adderal) and barbiturates (on butalbital for migraines). Denied current substance use. #. ADHD: Held adderal in icu, restarted prior to discharge. Medications on Admission: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever. 2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 7. trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 9. amphetamine-dextroamphetamine 5 mg Tablet Sig: Four (4) Tablet PO bid (). 10. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). Discharge Medications: 1. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 2. quetiapine 50 mg Tablet Sig: Six (6) Tablet PO QHS (once a day (at bedtime)). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 4. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 8. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 9. amphetamine-dextroamphetamine 5 mg Capsule, Sust. Release 24 hr Sig: Four (4) Capsule, Sust. Release 24 hr PO bid (). 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every [**5-9**] hours. 11. trazodone 50 mg Tablet Sig: Three (3) Tablet PO ONCE (Once). 12. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: Vocal cord dysfunction Epiglottitis Cardiac arrest Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with wheezing and difficulty breathing and required intubation. You also had a cardiac arrest which lasted a short period with return of your heart beat with cpr/chest compressions. The likely cause of the wheezing was vocal cord dysfunction, although a viral illness and or gastric reflux may have been contributing. There was initially concern about epiglottitis (inflammation of the epiglottis), but this only mildly inflamed when they looked with a camera in your throat. You will need to take a higher dose of omeprazole (40mg) and will need to follow-up with ENT and pcp as scheduled. You should continue your other outpatient medications as you did previously Followup Instructions: Name: [**Last Name (LF) **], [**First Name3 (LF) **] V. MD Address: [**Location (un) 3881**],[**Apartment Address(1) 3882**], [**Location (un) **],[**Numeric Identifier 3883**] Phone: [**Telephone/Fax (1) 2349**] Appointment: Friday [**2130-10-6**] 1:30pm Name: [**Last Name (LF) 1447**],[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Location (un) **] FAMILY PRACTICE Address: [**Street Address(2) 75551**] [**Apartment Address(1) 87446**], [**Location (un) **],[**Numeric Identifier 75553**] Phone: [**Telephone/Fax (1) 44915**] Appointment: Wednesday [**2130-10-11**] 2:00pm

Admission Date: [**2174-6-7**] Discharge Date: [**2174-6-12**] Date of Birth: [**2093-6-13**] Sex: F Service: SURGERY Allergies: Ibuprofen / Penicillins / Nsaids Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 80F s/p mechanical fall from standing +LOC, tx from [**Hospital 73290**] hospital with liver laceration and R rib fx. Patient c/o R abdominal pain. Denies F/C/N/V. Denies dizziness, weakness or CP prior to or post fall. Past Medical History: HTN Gout Hypercholesterolemia Social History: lives alone Family History: non-contrib Physical Exam: (on admission) 56 158/56 18 95RA GEN: NAD CV: RRR S1/S2 LUNGS: CTA b/l ABD: Soft, ND, RUQ TTP, TTP costal margin EXT: Stable, no deformity, no edema NEURO: grossly intact Pertinent Results: [**2174-6-7**] 10:54PM POTASSIUM-6.5* [**2174-6-7**] 09:07PM GLUCOSE-143* UREA N-30* CREAT-1.0 SODIUM-136 POTASSIUM-6.2* CHLORIDE-106 TOTAL CO2-19* ANION GAP-17 [**2174-6-7**] 09:07PM CALCIUM-7.7* PHOSPHATE-4.1 MAGNESIUM-2.4 [**2174-6-7**] 09:07PM WBC-10.4 RBC-3.25* HGB-10.2* HCT-30.2* MCV-93 MCH-31.4 MCHC-33.8 RDW-14.9 [**2174-6-7**] 09:07PM NEUTS-90.5* BANDS-0 LYMPHS-7.3* MONOS-2.0 EOS-0.1 BASOS-0.2 [**2174-6-7**] 09:07PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL [**2174-6-7**] 09:07PM PLT SMR-NORMAL PLT COUNT-193 [**2174-6-7**] 09:07PM PT-12.6 PTT-24.5 INR(PT)-1.1 [**2174-6-7**] 09:05PM TYPE-ART PO2-126* PCO2-42 PH-7.31* TOTAL CO2-22 BASE XS--4 [**2174-6-7**] 09:05PM LACTATE-1.7 [**2174-6-7**] 09:05PM freeCa-1.06* [**2174-6-7**] 07:11PM GLUCOSE-144* LACTATE-1.6 NA+-142 K+-5.5* CL--110 TCO2-21 [**2174-6-7**] 06:57PM UREA N-30* CREAT-1.0 [**2174-6-7**] 06:57PM estGFR-Using this [**2174-6-7**] 06:57PM AMYLASE-96 [**2174-6-7**] 06:57PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2174-6-7**] 06:57PM URINE HOURS-RANDOM [**2174-6-7**] 06:57PM URINE HOURS-RANDOM [**2174-6-7**] 06:57PM URINE GR HOLD-HOLD [**2174-6-7**] 06:57PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2174-6-7**] 06:57PM WBC-12.8* RBC-3.10* HGB-9.8* HCT-29.5* MCV-95 MCH-31.7 MCHC-33.2 RDW-14.7 [**2174-6-7**] 06:57PM PLT COUNT-213 [**2174-6-7**] 06:57PM PT-12.5 PTT-22.2 INR(PT)-1.1 [**2174-6-7**] 06:57PM FIBRINOGE-401* [**2174-6-7**] 06:57PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.043* [**2174-6-7**] 06:57PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2174-6-7**] 06:57PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2174-6-10**] 06:40AM BLOOD Hct-30.6* [**2174-6-10**] 12:07AM BLOOD Hct-29.3* [**2174-6-9**] 05:54PM BLOOD Hct-33.6* [**2174-6-9**] 02:41PM BLOOD Hct-32.3* CT ABD [**6-7**] 1. Large 9.0-cm hepatic lesion is incompletely characterized, but CT appearance favors a large hemangioma. MR would be necessary for definitive characterization. 2. Stable right adrenal hemorrhage. Given stability, acute arterial extravasation is very unlikely. Possibilities include adrenal contusion secondary to trauma versus a primary spontaneous adrenal hemorrhage with subsequent fall. MRI would be helpful to identified an underlying cause of spontaneous hemorrhage if warranted clinically. CT ABD [**6-8**] 1. Large, approximately 9-cm liver laceration with small central areas of vascularity. However, this has slightly decreased in size since [**2174-6-7**]. Smaller linear parenchymal abnormalities in the posterior right lobe are unchanged and other parenchymal injury cannot be excluded. 2. Stable adrenal laceration. MRI ABD: 1. Large hepatic laceration with hematoma, as seen on recent CT scan, not significantly changed in size since the most recent CT scan. 2. Hemorrhage into a right upper pole renal cyst. 3. Right adrenal hemorrhage as seen on CT scan. 4. Bilateral pleural effusions and bibasilar atelectasis. Brief Hospital Course: Patient had unremarkable hospital course. Upon admission to the [**Hospital1 18**] emergency department, the lesion in the patient's lesion was deemed stable hemagioma vs. liver laceration. The patient was admitted to the TICU for monitoring and serial HCT. The patient hct was stable over 24hrs - repeat CT abdomen and MRI confirmed that the lesion was in fact a stable liver laceration. The patient was transfered to the regular general surgery [**Hospital1 **] were serial HCT continued to be monitored. The patient complained of R shoulder and wrist pain - plain films revealled no bony abnormality. Patient had a urinary analysis that was positive and started on a three day course of ciprofloxacin. Patient was evaluated by physical therapy and deemed stable for discharge. Discharged home HD 6. Medications on Admission: Atenolol Lisinopril Actonel Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Cipro 250 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 2 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Liver laceration Discharge Condition: Stable Discharge Instructions: Please call phyisician or return to ED if any of the following occur: 1. Fever >101.5 2. Increased pain not controlled with medication 3. Shortness of breath/chest pain 4. Change in mental status 5. Any other concerning symptoms Followup Instructions: Please follow-up with Trauma clinic in 2 weeks. Call [**Telephone/Fax (1) 2756**] for appointment. Completed by:[**2174-6-12**]

Admission Date: [**2135-2-14**] Discharge Date: [**2135-2-20**] Service: MEDICINE Allergies: Ativan / Compazine Attending:[**First Name3 (LF) 2751**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: EGD x3 with clipping History of Present Illness: 86 yo F h/o HTN, sCHF, bleeding gastric ulcer s/p partial gastrectomy [**2072**], sarcoidosis, afib not on coumadin, hematemesis with anastamotic ulcer on EGD in [**2128**] p/w nausea and vomiting last night. She was in her usual state of health during the day, went out for Chinese food for dinner around 5 pm. Initially felt well afterwards, around 10 pm felt nauseated and started vomiting. Was up all night with abdominal pain and nausea, vomited about five times last night. This morning around 6 am vomited bright red blood. Not sure how much it was, no coffee grounds. Also may have had a dark stool this AM but she is not sure. Denies any diarrhea currently, but had diarrhea last week. She does get nauseated about once a week, used to be followed in [**Hospital **] clinic for this and was thought to be related to GERD and possible ulcer disease, has been on a [**Hospital1 **] PPI and PRN promethazine at home, takes promethazine about weekly. Unable to take last night due to nausea. No h/o liver disease. No h/o liver disease. Denies chest pain, shortness of breath, lightheadedness, joint pain, rashes, sick contacts. . In the ED, initial VS were HR 82, BP 162/98, RR 14, sat 99% 3L NC. EKG showed sinus rhythm 82 bpm, prolonged PR interval, PVCs and new lateral ST depressions. Pt given IV NS, protonix 80 mg bolus and started on drip, zofran 4 mg, and morphine. Pt appeared dry on exam, rectal exam with no stool in the vault. NG lavage not done given presence of bright red blood in vomit. Hct 36 so no blood products were given, coags wnl. Access with PIV x 2. Received 2.5 L of IV NS. GI called from [**Location **], recommended EGD. Admitted to ICU for active vomiting of blood noted in ED. VS on transfer temperature 97.8. HR 86 RR 20 BP 152/81, afib, sat 100% 2L. . On arrival to ICU, pt feels nauseated and abdominal pain in lower part of abdomen which started last night as well, nonradiating, feels like cramping. No fever since episodes started but did have a fever to 101 about 2 weeks ago for which she was treated with amoxicillin. Has had 4 episodes total of blood in vomit, although unable to quantify amount of blood. . Review of systems: (+) Per HPI, also + for cough for the last few weeks, recently treated for presumed PNA with 10 day course of amoxicillin, suspected that cough may be related to pulmonary sarcoidosis per daughter (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. HTN 2. Hypercholesterolemia 3. systolic CHF, etiology unclear 4. Bleeding gastric ulcer s/p partial gastrectomy in [**2072**]. 5. Hematemesis 6-7 years ago. No source was found on EGD. 6. Lap cholecystetomy in [**2124**] complicated by liver laceration and PE 7. Post-op PE requiring brief intubation and s/p IVC filter and anticoagulation in [**2124**] 8. S/p appendectomy 9. Iron deficiency anemia 10. OA of left knee requiring knee replacement 11. S/p fall complicated by displacement of anterior arch of C1 one year ago; wore hard collar for one year and is now s/p surgical fixation in [**7-11**] at [**Hospital3 **] 12. L TKR due to non [**Hospital1 **] of femur fx [**3-12**] at OSH 13. h/o depression 14. atrial fibrillation 15. hematemesis bleeding ulcer noted at billroth II anasthamosis in [**2128**] (gastrin level wnl and H. pylori negative) 16. sarcoidosis dx [**2129**] with pulmonary symptoms and lymph node bx Social History: - Tobacco: denies, prior 10 pack year history per OMR - Alcohol: denies currently, h/o EtOH abuse quit 35 years ago, detox x 3 in the past - Illicits: pt denies, but per OMR h/o prescription drug abuse (opiates) Family History: Her father died of renal cancer; brother with lung cancer; no hx of CAD; no hx of colon cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.7 HR 86 BP 143/74 sat 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, tacky mucous membranes, no oropharyngeal lesions Neck: supple, JVP not elevated, no LAD Lungs: crackles at bases bilaterally, no wheezes, rhonchi CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic murmur best heard at apex Abdomen: soft, mild ttp throughout, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2135-2-14**] 07:05AM BLOOD WBC-15.5* RBC-4.02* Hgb-11.7* Hct-36.9 MCV-92 MCH-29.1 MCHC-31.6 RDW-14.9 Plt Ct-167 [**2135-2-14**] 12:55PM BLOOD WBC-10.6 RBC-2.90*# Hgb-8.7*# Hct-26.4*# MCV-91 MCH-29.9 MCHC-32.9 RDW-15.0 Plt Ct-148* [**2135-2-14**] 07:25PM BLOOD Hct-24.0* [**2135-2-15**] 02:53AM BLOOD WBC-14.9* RBC-3.22* Hgb-9.6* Hct-28.8* MCV-89 MCH-29.9 MCHC-33.5 RDW-14.8 Plt Ct-113* [**2135-2-15**] 09:22AM BLOOD Hct-26.0* [**2135-2-15**] 03:30PM BLOOD Hct-28.9* [**2135-2-16**] 04:24AM BLOOD WBC-8.6 RBC-2.66*# Hgb-8.1*# Hct-23.6*# MCV-89 MCH-30.3 MCHC-34.2 RDW-14.8 Plt Ct-84* [**2135-2-14**] 07:05AM BLOOD PT-10.9 PTT-29.9 INR(PT)-1.0 [**2135-2-16**] 04:59AM BLOOD PT-13.1* PTT-29.2 INR(PT)-1.2* [**2135-2-14**] 07:05AM BLOOD Fibrino-390 [**2135-2-14**] 07:05AM BLOOD Glucose-159* UreaN-17 Creat-0.7 Na-140 K-4.3 Cl-102 HCO3-25 AnGap-17 [**2135-2-15**] 02:53AM BLOOD Glucose-124* UreaN-25* Creat-0.6 Na-141 K-3.8 Cl-110* HCO3-22 AnGap-13 [**2135-2-16**] 04:24AM BLOOD Glucose-67* UreaN-21* Creat-0.5 Na-141 K-3.6 Cl-112* HCO3-21* AnGap-12 [**2135-2-14**] 07:05AM BLOOD ALT-20 AST-43* LD(LDH)-432* AlkPhos-120* TotBili-0.3 [**2135-2-15**] 02:53AM BLOOD ALT-14 AST-24 AlkPhos-77 [**2135-2-14**] 07:05AM BLOOD Lipase-19 [**2135-2-14**] 07:05AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.8 [**2135-2-15**] 02:53AM BLOOD Calcium-7.1* Phos-2.5* Mg-1.9 [**2135-2-16**] 04:24AM BLOOD Calcium-6.5* Phos-2.6* Mg-1.7 [**2135-2-16**] 03:10AM BLOOD Digoxin-0.5* [**2135-2-16**] 04:34AM BLOOD freeCa-1.00* [**2135-2-14**] 08:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2135-2-14**] 08:00AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR [**2135-2-14**] 08:00AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 MICRO: Urine ([**2-14**]): no growth EKG ([**2-14**]): Rate 82. Sinus rhythm. First degree A-V block. Leftward axis. Poor R wave progression. Lateral ST-T wave abnormalities. Compared to the previous tracing of [**2134-3-27**] first degree A-V block is now present. CXR ([**2-14**]): IMPRESSION: 1. No evidence of intra-abdominal free air. 2. Stable cardiomegaly. 3. No evidence of decompensated congestive heart failure or pneumonia. Hand ([**2-16**]) Xray: PND EGD [**2-14**]: Impression: Normal mucosa in the esophagus Blood in the stomach body Dieulafoy lesion in the Anastomotic site (endoclip) Both the limbs were identified and no source of bleeding was noticed in those. Otherwise normal EGD to third part of the duodenum Brief Hospital Course: BRIEF HOSPITAL COURSE: 86 yo F h/o HTN, sCHF, bleeding gastric ulcer s/p partial gastrectomy [**2072**], hematemesis in [**2128**] [**2-3**] anastamotic bleed, afib not on coumadin p/w nausea and vomiting, hematemesis . ACTIVE ISSUES: # Hematemesis/Acute blood loss Anemia: Patient was initially admitted to the ICU for frequent episodes of hematemesis with stable blood pressures and heart rate in the ED. Initially Hct was 36 in setting of dehydration and decreased to 26 after fluid repletion. GI was consulted and EGD was done on day of admission which showed likely Dieulafoy's lesion near anastatmotic site from prior gastric bypass surgery, and three clips were placed. Followup Hct was 24 after EGD, transfused 2 units of PRBC. She was scoped again the following day which again showed bleeding Dieulafoy lesion and 2 clips were placed and lesion injected. Followup Hct suggested continued bleeding so she was transfused 2 more units PRBC. Third EGD was done on [**2-16**] which showed no bleeding at anastamotic site and areas suggestive of ischemia around the anastamotic site. Patient was evaluated by the surgical team who recommended no acute intervention and transfusion goal of Hct >30 and platelets >70, IR was made aware of patient who recommended no acute intervention. Throughout course in MICU patient's blood pressure, urine output remained stable and patient was continued on protonix 40 mg IV BID. She received total of 6 units PRBC in MICU and antihypertensives were held. Her Hct remained stable and she was transitioned to orals. H. pylori was also sent and was negative. . # Afib: Pt history with atrial fibrillation, not on coumadin. At home she is on rate control with atenolol and on digoxin, however this was held in setting of acute bleed. She had one episode of afib w/ RVR to 140s [**2-15**] around the EGD procedure. The patient was given 2.5mg metoprolol IVx2 and 5mg IV x1. Pt was otherwise in sinus during MICU stay. Her digoxin was continued. Her beta blocker was started as Metoprolol on [**2-17**], and she remained stable. Aspirin is being held in light of GI bleeding. . #Hand pain/ swelling: Patient has chronic pain at baseline, on [**2-16**] noted to have swollen and tender MCP joints. Pt with history of sarcoidosis and inflammatory appearance of joints, started short course of prednisone 20 mg x 4 days and standing tylenol. Pseudogout was also a consideration. Hand xrays ordered and showed nothing acute. . # Nausea/vomiting/abd pain: Pt has had episodes in the past of nausea and vomiting usually post-prandial and is on PPI [**Hospital1 **] as symptoms thought to be [**2-3**] GERD or recurrence of ulcers in the past, viral gastroenteritis was also on differential. It is possible that symptoms were also related to lesion at anastamotic site. Zofran and IV morphine given with symptomatic improvement. This was transitioned to oral oxycodone, and then this was weaned because of fall risk. Abdominal exam remained benign. # leukocytosis: Initally WBC 15.5, improved without intervention. [**Month (only) 116**] have been in setting of stress vs gastroenteritis given sx of nausea, vomiting. No fevers during stay in MICU, but was recently treated for cough and fever with amoxicillin. # Cough: has been ongoing for about 2 weeks, no change with antibiotics and CXR with no acute process making PNA or CHF exac less likely. [**Month (only) 116**] be related to viral bronchitis vs re-occurance of sarcoidosis (had pulmonary sarcoid in the past, follows in pulmonology). Being worked up as outpatient # HTN: Held atenolol, lisinopril in setting of acute bleed. Restarted low dose BB first on [**2-17**]. ACE-I held and restarted at a lower dose (10mg daily, instead of 30mg daily). Should be revaluated by PCP. . # chronic pain: pt with chronic pain in setting of multiple knee and neck surgeries. She is on an oxycodone regimen per her PCP, [**Name10 (NameIs) **] IV morphine in ICU since pt had increased pain and was NPO. I did not give her more oxycodone since this increases risk of falls, and she at times felt light-headed after taking it when walking with walker (though proved to be stable on evaluation). she was instructed not to drive on this medication. # chronic systolic CHF: She appeared euvolemic on exam. Most recent EF is 50% from dobutamine stress test. Beta blocker and ACEI held in setting of bleed, but restarted gradually once her bleeding resolved. # depression: continued effexor # Communication: Patient, daughter/hcp [**Name (NI) **] cell:[**Telephone/Fax (1) 106059**] home: [**Telephone/Fax (1) 106060**] # Code status: DNR, ok to intubate Medications on Admission: alendronate 70 qweek atenolol 25mg qam 50 qpm dig 0.125 qd lidoderm patch for back or knee lisionpril 30mg qday omeprazole 20mg [**Hospital1 **] pravastatin 40mg qd ropinirole 1mg qhs effexor 150 mg qd vit d -allergies: ativan, compazine and advair Discharge Medications: 1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 4. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO DAILY (Daily). 5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed due to gastric ulcer Acute blood loss anemia Atrial fibrillation Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted after vomiting blood. You were found to have a GI bleed with anemia. In the ICU, you underwent EGD showing bleeding ulcers. These were successfully clipped. After 6 blood transfusions your bleeding stopped. It is very important that you take the twice daily Protonix to prevent bleeding. You were also found to have mild arthritis in your hand, most likely felt to be "Pseudogout." You completed a short course of Prednisone. Please see the medication sheet on discharge. Please note that your Lisinopril dose was decreased to 10mg daily. Please minimize the use of any opiate medications you receive from your physicians as this can cause an increased risk of falls. Oxycodone will only be prescribed by your PCP. Followup Instructions: PCP: [**Name10 (NameIs) 106056**],[**Name11 (NameIs) 1569**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 35502**] - within 1 week You should [**2135-2-22**] call to make an appointment for follow up.

Admission Date: [**2127-3-24**] Discharge Date: [**2127-4-1**] Date of Birth: [**2053-3-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Location (un) 1279**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization ECMO History of Present Illness: 74yo F referred to [**Hospital1 18**] for chest tightness and dyspnea for the past month. It occurs both at rest and with exertion, related to stress. She reports associated dizziness. She has episodes [**3-28**] times per week. They last for a few minutes and resolve when she lies down and relaxes. During cardiac catheterization, she clotted off her left circumflex artery and left anterior descending artery. Patient became hypotensive requiring atropine and dopamine. Code was called. Patient required 7 defibrillations.An IABP was placed. A temporary RV pacing wire was placed. The patient was intubated. Cardiopulmonary support (ECMO)was initiated via CPS perfusion catheters placed in the RFA and RFV (the IABP and RV pacing wire were removed). Access obtained in the LFA and LFV. Emergent bedside echo showed no evidence of tamponade.She was successfully resuscitated using CPS with emergent deployment of drug eluting stents in LAD and LCx(Kissing stenting of the LMCA into the LAD and LCX ).Patient had resumption of pulsatile central aortic pressure after stenting of the LAD and LCx. An IABP was placed.PA cath c/w ischemic MR. She has massive blood loss during the procedure and has recieved 5U PRBC and 1u platelet prior to transfer to CCU. Echo post cath showed small pericardial effusion, mild aymmetric LVH, nl LV size, mildly depressed LVEF Patient did well in cath lab and ECMO weaned off. Given the ACT of >900, it was determined to be safer to have the ECMO catheters removed in OR. Patient went to the OR and vascular surgery removed the ECMO catheters Past Medical History: Diabetes mellitus Hypertension C section hysterectomy mild LV systolic dysfunction at baseline Social History: Married, lives with her husband in [**Location (un) 686**]. No stairs. Daughter lives on the [**Location (un) **] of her house. Family History: noncontributory Physical Exam: T 93.6 P88-96 BP 114/70 IABP 1:1 vent: Fi)2 0.8 550 x 16, PEEP5 Gen-sedated HEENT-anicteric, mmm, JVD hard to visualizes CV-RRR, no r/m/g resp-CTAB(anterior exam) [**Last Name (un) 103**]-soft, NT/ND, mostly in bandage extremities-cold extremities, no pitting edema, pulses dopplerable bilaterally, left groin hematoma noted Pertinent Results: -echo [**2127-3-24**] 1. The left atrium is normal in size. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. LV appears underfilled. Overall left ventricular systolic function is mild to moderately depressed. Resting regional wall motion abnormalities include inferior and inferoseptal akinesis. 3. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed with apical akinesis. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 5.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6.There is a small pericardial effusion. There are no echocardiographic signs of tamponade. 7. There is an echogenic density in the right ventricle consistent with a catheter. PROCEDURE DATE: [**2127-3-24**] INDICATIONS FOR CATHETERIZATION: chest pain FINAL DIAGNOSIS: 1. Acute embolic occlusion of the LCx artery during cardiac catherization complicated by cardiac arrest requiring initiation of cardiopulmonary support. 2. Kissing stenting of the LMCA into the LAD and LCX. COMMENTS: 1. Initial resting hemodynamics revealed normal right and left sided filling pressures. 2. Left ventriculography revealed normal systolic function. 3. In preparation for selective coronary angiography, the JL4 was advanced into the ascending aorta. This was done without difficulty and the catheter was cleared and flushed per routine, with contrast clearing in the ascending aorta (well outside the sinuses of Valsalva). The first puff in the LMCA suggested occlusion of the LCx. The first cineangiogram showed mild LMCA plaquing with abrupt cutoff and total occlusion of the LCx. There was mild diffuse plaqing in the LAD. 4. The patient became progressively bradycardic and hypotensive (SBP < 40mmHg) and a code was called. Atropine, dopamine and epinephrine were given. Chest compressions were started. The patient developed recurrent VT and VF and the patient was defibrillated at 360J approximately 7 times. An IABP was placed. A temporary RV pacing wire was placed. The patient was intubated. 5. CT surgery was emergently consulted. Cardiopulmonary support (ECMO) was initiated via CPS perfusion catheters placed in the RFA and RFV (the IABP and RV pacing wire were removed). Access obtained in the LFA and LFV. Emergent bedside echo showed no evidence of tamponade. 6. Limited angiography of the RCA showed minimal CAD. 7. Successful kissing stenting of the LAD/LCX back to the ostium of the LMCA was performed with a 3.0 x 33 mm Cypher DES (LAD) and LCX 2.5 x 28 mm Cypher DES (LCX). 8. Patient had resumption of pulsatile central aortic pressure after stenting of the LAD and LCx. An IABP was placed. 9. HCt from ABG 20%. Transfusion with emergency release blood products was begun. 10. PA catheterization was performed via the LFV. It showed a marked increase in filling pressures (RA mean 23mmHg, PCWP mean 40 with tall v-waves and rounded dicrotic notch on PA pressure tracing. Findings consistent with iscehmic mitral regurgitation. 11. Repeat emergent echo showed a small pericardial space, posterobasal hypokinesis and a hyperdynamic anterior wall with moderate mitral regurgitation. 12. Hand injection of the LFA showed no obvious major extravasation. 13. Vascular surgery consulted (together with CT surgery) regarding weaning of CPS and removal of CPS catheter CT abdomen and pelvis [**2127-3-25**]: CT OF THE ABDOMEN WITHOUT CONTRAST: There are bilateral pleural effusions and bibasilar collapse/consolidation. An NG tube is noted coiled within the stomach. The inflated portion of the intraaortic balloon pump terminates just above the aortic bifurcation. Note is made of a non-calcified gallstone. There is biliary excretion of previously administered contrast. The liver is unremarkable on this noncontrast study. The adrenal glands, pancreas, kidneys, spleen, and intraabdominal loops of bowel are unchanged. There is high attenuation fluid in the anterior and posterior pararenal spaces consistent with hemorrhage. There is perihepatic ascites. No pathologically enlarged lymph nodes are identified. CT OF THE PELVIS WITHOUT IV CONTRAST: There is diffuse stranding in the subcutaneous tissues in the left groin with obliteration of the normal fat planes with asymmetry with expansion of the anterior thigh musculature consistent with a hematoma. There is low-density free pelvic fluid. A Foley catheter is noted in the bladder. There is sigmoid diverticulosis, without evidence of diverticulitis. Bone windows reveal no suspicious lytic or sclerotic foci. There are degenerative changes. IMPRESSION: 1) Left groin hematoma. 2) Retroperitoneal hemorrhage as described above. 3) Apparent low position of intraaortic balloon pump terminating with its inflated portion just above the aortic bifurcation. Echo [**2127-3-28**]: 1. The left atrium is mildly dilated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. No left ventricular aneurysm is seen. There is mild regional left ventricular systolic dysfunction. Overall left ventricular systolic function is modertately depressed. Resting regional wall motion abnormalities include basal and mid inferior hypokinesis with basal and mid inferolateral and lateral akinesis. 3. Right ventricular chamber size and free wall motion are normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 5.The mitral valve leaflets are structurally normal. Mioderate (2+) mitral regurgitation is seen. 6.There is mild pulmonary artery systolic hypertension. [**2127-3-24**] 07:42PM TYPE-ART TEMP-33.7 PO2-135* PCO2-35 PH-7.35 TOTAL CO2-20* BASE XS--5 INTUBATED-INTUBATED [**2127-3-24**] 07:42PM LACTATE-7.3* [**2127-3-24**] 07:42PM O2 SAT-98 [**2127-3-24**] 07:42PM freeCa-1.13 [**2127-3-24**] 07:28PM GLUCOSE-188* UREA N-17 CREAT-1.0 SODIUM-146* POTASSIUM-3.1* CHLORIDE-112* TOTAL CO2-20* ANION GAP-17 [**2127-3-24**] 07:28PM ALT(SGPT)-1093* AST(SGOT)-2155* LD(LDH)-[**2149**]* CK(CPK)-4492* ALK PHOS-54 TOT BILI-0.6 [**2127-3-24**] 07:28PM cTropnT-13.41* [**2127-3-24**] 07:28PM ALBUMIN-2.4* CALCIUM-8.0* PHOSPHATE-3.7 MAGNESIUM-1.1* [**2127-3-24**] 07:28PM WBC-16.2* RBC-5.00 HGB-15.4 HCT-43.1 MCV-86 MCH-30.8 MCHC-35.7* RDW-14.8 [**2127-3-24**] 07:28PM NEUTS-71* BANDS-16* LYMPHS-10* MONOS-1* EOS-1 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2127-3-24**] 07:28PM PLT SMR-LOW PLT COUNT-122* [**2127-3-24**] 07:28PM PT-18.3* PTT-72.1* INR(PT)-2.1 [**2127-3-24**] 07:28PM FIBRINOGE-201 [**2127-3-24**] 05:45PM WBC-14.7* RBC-4.48# HGB-13.8# HCT-39.4# MCV-88# MCH-30.8 MCHC-35.0# RDW-14.7 [**2127-3-24**] 05:45PM PLT COUNT-115* [**2127-3-24**] 05:45PM PT-17.0* PTT-66.1* INR(PT)-1.8 [**2127-3-24**] 05:45PM FIBRINOGE-178 [**2127-3-24**] 05:41PM TYPE-ART PO2-143* PCO2-39 PH-7.26* TOTAL CO2-18* BASE XS--8 INTUBATED-INTUBATED VENT-CONTROLLED [**2127-3-24**] 05:41PM GLUCOSE-317* NA+-139 K+-4.2 [**2127-3-24**] 05:41PM HGB-13.4 calcHCT-40 [**2127-3-24**] 05:41PM freeCa-1.16 [**2127-3-24**] 05:02PM TYPE-ART PO2-131* PCO2-47* PH-7.26* TOTAL CO2-22 BASE XS--5 INTUBATED-INTUBATED [**2127-3-24**] 05:02PM GLUCOSE-370* NA+-140 K+-3.5 [**2127-3-24**] 05:02PM HGB-10.3* calcHCT-31 [**2127-3-24**] 05:02PM freeCa-1.41* [**2127-3-24**] 04:31PM TYPE-ART PO2-427* PCO2-20* PH-7.43 TOTAL CO2-14* BASE XS--7 INTUBATED-INTUBATED [**2127-3-24**] 04:31PM GLUCOSE-428* NA+-137 K+-2.8* [**2127-3-24**] 04:31PM HGB-9.8* calcHCT-29 [**2127-3-24**] 04:31PM freeCa-0.84* [**2127-3-24**] 02:45PM GLUCOSE-569* UREA N-17 CREAT-1.1 SODIUM-136 POTASSIUM-2.7* CHLORIDE-99 TOTAL CO2-14* ANION GAP-26* [**2127-3-24**] 02:45PM ALT(SGPT)-1177* AST(SGOT)-874* CK(CPK)-460* ALK PHOS-54 AMYLASE-162* TOT BILI-0.3 [**2127-3-24**] 02:45PM CK-MB-28* MB INDX-6.1* cTropnT-0.66* [**2127-3-24**] 02:45PM ALBUMIN-2.1* [**2127-3-24**] 02:45PM WBC-11.9*# RBC-2.65*# HGB-7.8*# HCT-25.2*# MCV-95 MCH-29.5 MCHC-30.9* RDW-13.0 [**2127-3-24**] 02:45PM NEUTS-60 BANDS-12* LYMPHS-19 MONOS-4 EOS-1 BASOS-1 ATYPS-3* METAS-0 MYELOS-0 [**2127-3-24**] 02:45PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2127-3-24**] 02:45PM PLT SMR-NORMAL PLT COUNT-177 [**2127-3-24**] 02:45PM PT->100* PTT->150* INR(PT)->63 [**2127-3-24**] 02:25PM TYPE-ART RATES-16/ TIDAL VOL-500 PEEP-5 O2 FLOW-100 PO2-389* PCO2-27* PH-7.30* TOTAL CO2-14* BASE XS--11 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-VENTED [**2127-3-24**] 02:25PM GLUCOSE-565* LACTATE-13.2* K+-2.6* [**2127-3-24**] 02:25PM HGB-6.7* calcHCT-20 O2 SAT-97 [**2127-3-24**] 01:30PM RATES-16/ TIDAL VOL-500 PEEP-5 O2 FLOW-100 PO2-582* PCO2-29* PH-7.25* TOTAL CO2-13* BASE XS--12 -ASSIST/CON INTUBATED-INTUBATED [**2127-3-24**] 01:30PM GLUCOSE-496* LACTATE-13.1* NA+-132* K+-3.2* CL--105 [**2127-3-24**] 01:30PM HGB-7.5* calcHCT-23 O2 SAT-99 Brief Hospital Course: 74yo female with history of hypertension and nonobstructive coronary artery disease referred to [**Hospital1 18**] for cardiac catheterization because of increasing dyspnea. During procedure, she clotted off her LCx and LAD. She had 7 ventricular fibrillation arrest requiring ECMO being placed by surgery. She had emergent placement of kissing stents to LAD and LCx. Post procedure, she went to the OR to have ECMO catheters removed on the right groin, IABP and PA catheter placed on the left groin. She recieved a total of 6 units of blood during the procedure. On arrival to the CCU, she was on pressors and intubated. Over the course of the next few days, her hemodynamics were monitored by swan and improved. She was eventually extubated. IABP and pressors were removed on [**2127-3-26**] with good hemodynamics. However, she developed acute respiratory distress on the night of [**2127-3-26**] responsive to lasix, nitroglycerin drip and positive pressure ventilation with CPAP. Her blood pressure dropped drastically requiring a brief period of pressure support with levophed, which was quickly weaned off. It was thought that she could have had acute pulmonary edema. She continues to improve thereafter and was eventually transferred to regular floors for a few days. She is currently on aspirin, lipitor, plavix(minimal 3 months). SHe was also started on lisinopril and toprol. Echo was performed on [**2127-3-28**] with the concern of posterior wall aneurysm seen by ECG changes. That turned out to be negative. SHe was started on daily lasix for heart failure. SHe also had a short run of atrial fibrillation which spontanouesly converted on [**2127-3-29**]. Her blood pressure control is satisfactory with metoprolol, lisinopril and imdur. During this hospitalization, she also had retroperitoneal bleed. She was transfused to keep her hematocrit above 30. Her hematocrit remained stable thereafter. Vancomycin, levofloxacin and metronidazole was initially started for presumed aspiration penumonia given that she spiked temperature, had increased WBC and increasing sputum production. She continued the course of levofloxacin and metronidazole for 7 days. Vancomycin was discontinued since sputum culture did not grow any organism. SHe was also c.diff negative. Medications on Admission: Lisinopril 40mg daily Nifedical 60mg daily Metformin HCL 1000mg qam, 500mg qlunch, 1000mg qpm Lipitor 40mg daily Atenolol 25mg daily Protonix 40mg daily Aspirin 325mg daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 300 days. Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: acute coronary syndrome diabetes hypertension retroperitoneal bleed Discharge Condition: stable Discharge Instructions: PLease return to the hospital or call your doctor if you experience chest pain or shortness of breath or if there are any concerns at all Please take all prescribed medication Followup Instructions: please follow up with your cardiologist(Dr. [**Last Name (STitle) 1911**] within one month of your discharge Completed by:[**2127-4-1**]

Admission Date: [**2176-3-22**] Discharge Date: [**2176-5-19**] Date of Birth: [**2124-9-13**] Sex: M Service: Transplant Surgery CHIEF COMPLAINT: Fever and chills, sepsis, history of orthotopic liver transplant. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 19672**] is a 51-year-old male with a history of hepatitis C and alcohol abuse with cirrhosis, who underwent a liver transplant in [**2176-3-9**]. His transplant was complicated by a biliary leak and a septic knee with orthopedic washout. Mr. [**Known lastname 19672**] had been discharged just a few days prior to his presentation. He had been discharged to a rehabilitation facility after an extended stay after his liver transplant here. In his previous stay, he had been treated with multiple ERCPs as well as stents. He also had a drain placed and a washout of his knee as noted above. He now presents with two days after his discharge to rehabilitation with fevers and chills to 101.9. He denies any abdominal pain. No nausea or vomiting. No dysuria, no cough, and no diarrhea. He denies no changes in his baseline left knee pain. PAST MEDICAL HISTORY: 1. Hepatitis C and alcoholic cirrhosis, Childs Class C. 2. Status post orthotopic liver transplant in [**2176-3-9**]. 3. Status post septic left knee joint washout. 4. Portal gastropathy. 5. Grade II varices. 6. Ascites. 7. Multiple episodes of spontaneous bacterial peritonitis. 8. Multiple episodes of encephalopathy. 9. Type 1 diabetes. 10. Gastroparesis. 11. Chronic renal insufficiency. 12. Osteoporosis. 13. Diverticulitis. 14. Status post hemicolectomy secondary to diverticulitis. MEDICATIONS ON ADMISSION: 1. Neoral 150 mg po bid. 2. Insulin-sliding scale as well as 18 units of NPH am and 18 units NPH pm. 3. Lasix 40 mg po bid. 4. Prednisone 50 mg po q day. 5. CellCept 1,000 mg po bid. 6. Nystatin swish and swallow 5 mg po qid. 7. Vicodin prn. 8. Fluconazole 400 mg po q day. 9. Trazodone 7.5 mg po q hs. 10. Actigall 300 mg po tid. 11. Valcyte 450 mg po q day. 12. Protonix 40 mg po q day. 13. Bactrim one tablet one q day. ALLERGIES: Ceftriaxone and questionable Heparin. PHYSICAL EXAMINATION: In general, he is chronically ill appearing, however, in no apparent distress. His vital signs: Temperature is 99.7, rest of his vitals are stable. His heart is regular, rate, and rhythm. His lungs are clear to auscultation with decreased breath sounds at the bases. His abdomen is soft, nontender, and mildly distended. His extremities are warm. His left knee is mildly tender. The rectal is guaiac negative. [**Hospital 1749**] HOSPITAL COURSE: On [**3-22**], the patient was admitted to the hospital for his fevers and chills. He was placed on broad-spectrum antibiotics and pancultured. A CT scan was also performed as well as a HIDA scan and laboratories were checked. There was a worry of biliary sepsis given his history. The HIDA and CT scan, however, were negative, so the patient was scheduled for an ERCP and was afebrile on his first presentation. Of note, the Endocrine Service as well as Nutrition and Infectious Disease followed this patient while he was in the hospital. The patient was placed on broad-spectrum antibiotics including levofloxacin, linazolid, and meropenem. On [**3-25**], [**Numeric Identifier 105901**], the patient went for an ERCP and the ERCP, the stent in the common bile duct was removed, and dark bile and pus drained from the bile duct. He had a large anastomotic biliary leak. A plastic and Teflon stent were then placed across the biliary leak. Also of note, some of his cultures at this point, grew out Klebsiella, and his antibiotics were tailored to the bacteria. On [**2176-5-27**], the patient underwent a percutaneous transhepatic cholangiogram with a right percutaneous transhepatic biliary drain placement. This PTC demonstrated a biliary leak. After this percutaneous biliary drain was placed, the patient was scheduled for an EGD and stent removal which was scheduled and done. After his EGD and stent removal, the patient was started to spike temperatures to 101.3. This was most likely cholangitis and he was cultured. These cultures would grow out gram-positive cocci, and the patient was also put on neutropenic precautions due to his white [**Year (4 digits) **] cell count . These organisms would soon be noticed to be Vancomycin resistant Enterococcus, and the patient was again started on broad-spectrum antibiotics. The Infectious Disease team was following closely. On hospital day 14, the patient went for angiogram to assess his hepatic artery. This angiogram showed hepatic artery stenosis and in light of his laboratories, there was a concern that Mr. [**Known lastname 19672**] had ischemic cholangitis with irreparable bile duct injury. A repeat angio was then performed to possibly open up this artery and treat his hepatic artery thrombosis. On hospital day 19, the patient underwent an ultrasound-guided liver biopsy. This biopsy showed mild rejection and the next day, the patient underwent a hepatic arteriogram which appeared to have a patent hepatic artery. On hospital day 25, the patient went for a cholangiogram. The cholangiogram showed patent ducts. Postprocedure, the patient had some chills and spiked a temperature after the manipulation to his biliary tree. Cultures were again sent [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Name8 (MD) 1750**] MEDQUIST36 D: [**2176-5-23**] 02:50 T: [**2176-5-27**] 07:29 JOB#: [**Job Number 105902**]

Admission Date: [**2191-9-2**] Discharge Date: [**2191-9-6**] Date of Birth: [**2153-2-21**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1055**] Chief Complaint: fever chills Major Surgical or Invasive Procedure: Left IJ line placement History of Present Illness: 38 year old female with pMHx of anxiety comes into the ER with fever, chills, and malaise starting [**9-1**] AM. They had been in the Turks and Caicos from sunday until thursday ([**9-1**]). Reports that she had been feeling well until thursday morning when she initially developed onset of muscle aches. Shortly thereafter developed shaking chills (no rigors) and was too weak to stand from a seated position. Chose to return to the US immediately. Noted to have subj fever in airport, refused further medical evaluation in [**Doctor First Name 5256**]. Reports that on the plane she was having crampy abd pain. . Denies sob/cough/cp/palpitations/rashes. States that she was having stiffness of her elbows b/l on the plane, w/o associated erythema/swelling. +generalized neck stiffness, now dramatically improved, +mild ha, no visual changes. . In the carribean, did not drink directly from local water but did brush teeth with it, +ice cubes, +lettuce/fresh vegetables. + mosquito bites. On Tuesday ate raw conch. Husband describes onset of self limited diarrheal illness on thursday morning as well. Wed, niece developed aches and shakes, w/o documented fever or diarrhea/abdominal symptoms. . In ED initially noted to be afebrile, [**9-1**] 11p- 98.8, 102/59, 24, 100%ra. Initial lactate drawn at 12:45 am was 3.7. 1am noted to be febrile to 103.8, 89/41, 100. Sepsis protocol initiated. Developed profuse diarhea x2. Rec'd cipro/flagyl. Past Medical History: Anxiety Social History: Denies etoh/ivdu/tobacco Married, 22 month old child at home. Family History: mother with HTN Physical Exam: Vitals: t98.8, bp 86/41, p 97, r 18, 98% General: Well-appearing Caucasian female. AOX3. HEENT: PERRL, EOMI. No scleral icterus. Oropharynx clear. Neck is supple, good ROM. Negative Brudzinki's, negative Kernig's. Lungs: With decreased breath sounds on the right, dullness to percussion at right base. Otherwise clear to auscultation. CV: RRR S1 and S2 audible. No murmurs, rubs, or gallops. Abd: Soft, tenderness to soft palpation in the right upper, epigastric, and left upper quadrants. No rebound. No guarding. Negative [**Doctor Last Name 515**]. Positive bowel sounds. Peripheral ext: No cyanosis/clubbing/edema. 2+ peripheral DP pulses bilaterally. Pertinent Results: [**2191-9-2**] 12:40AM GLUCOSE-137* UREA N-16 CREAT-0.8 SODIUM-135 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-20* ANION GAP-20 [**2191-9-2**] 12:45AM LACTATE-3.7* [**2191-9-2**] 12:40AM CK(CPK)-70 . [**2191-9-2**] 05:54AM LIPASE-26 [**2191-9-2**] 05:54AM ALT(SGPT)-74* AST(SGOT)-90* ALK PHOS-50 AMYLASE-40 TOT BILI-0.9 . [**2191-9-2**] 12:40AM WBC-6.0 RBC-4.55 HGB-13.9 HCT-40.0 MCV-88 MCH-30.5 MCHC-34.7 RDW-12.8 [**2191-9-2**] 12:40AM NEUTS-81.5* BANDS-0 LYMPHS-13.4* MONOS-4.8 EOS-0.3 BASOS-0.1 . [**2191-9-2**] 12:40AM PT-13.7* PTT-29.1 INR(PT)-1.3 . [**2191-9-2**] 12:25AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2191-9-2**] 12:25AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2191-9-2**] 12:25AM URINE RBC-0-2 WBC-[**1-22**] BACTERIA-FEW YEAST-NONE EPI-[**4-29**] . [**2191-9-2**] 03:04PM CORTISOL-8.6 [**2191-9-2**] 03:42PM CORTISOL-25.6* [**2191-9-2**] 04:37PM CORTISOL-37.3* . CXR [**9-3**]: No significant change in the right lower lobe opacity - aspiration/pneumonia. . Abd CT [**9-2**]: Extensive pancolitis, without any definite small-bowel abnormality, free intraperitoneal air, or pneumatosis c/w an infectious etiology. . urine cx: neg stool cx: no campylobacter, yersinia, vibrio, E.Coli H, C.Diff. blood cx [**9-5**]: P urine cx [**9-5**]: P Brief Hospital Course: 38 y/o woman, previously healthy, presents with fever, chills, profuse watery diarrhea, sepsis. The etiology of the patient's sepsis was unclear, but was thought to be pulmonary (? of RLL infiltrate) vs GI. GI includes any cause of diarrheal illness resulting in mucosal breakdown vs primary sepsis. Differential included salmonella, e.coli, and vibrio. Yersinia and entamoeba were less likely. The patient was admitted to the ICU and covered with levofloxacin, metronidazole, and vancomycin (for empiric enterococcus coverage). Her [**Last Name (un) 104**] stim was normal. IVF were continued to maintain map>60; the patient required levophed for one day. She was kept NPO for pancolitis. . Upon transfer to the floor, the patient had negative stool cx for ova and parasites, c.diff, bacteria. UA was clear with negative urine culture. Lactate was normal. The patient continued to spike and new cultures were sent. The patient was transitioned to PO Antibiotics and PO fluids. She had a mild transaminitis and HAV, HBV, and HCV were pending. Her diet was advanced slowly, with aggressive electrolyte repletion due to diarrhea losses. On discharge she was tolerating a BRAT diet with formed bowel movements. She was advised to continue BRAT diet for next 3 days. . The patient was extremely anxious. She was continued on paxil and received lorazepam prn. She was very nervous about having peripheral access placed so her IJ was left in place until discharge. She was maintained on pneumoboots, PPI, tylenol, trazodone Qhs. Communication was with the patient and her husband. . On day of discharge she developed a mild inner thigh rash, possibly folliculitis. She was advised to show this to her PCP at their follow up appointment the next day. Ig titers were drawn and were pending at discharge; she is also to follow these up with her PCP. Medications on Admission: Paxil 20mg qday Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: diarrhea septic shock .... anxiety disorder Discharge Condition: stable - tolerating BRAT diet with formed BMs. Discharge Instructions: Please return if you experience worsening diarrhea, fever >101.5, inability to eat or drink, or any other worrisome symptoms. You are to continue a conservative BRAT diet (bananas, rice, apple sauce, and toast) for the next 3 days. Please show your inner thigh rash to Dr. [**Last Name (STitle) **]. Followup Instructions: You should follow-up with Dr. [**Last Name (STitle) **] within the next 1-2 weeks. Please let her know that we ordered IgA, IgG, and IgM levels that are still pending at discharge. You should also show her your innter thigh rash. You should also follow-up with [**Hospital **] clinic to discuss if you have any underlying digestive conditions. Please call [**Telephone/Fax (1) **] to arrange an appointment.

Admission Date: [**2180-8-24**] Discharge Date: [**2180-8-29**] Date of Birth: [**2112-12-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: PCI with 3 sequential stents widely patent, first two to LAD, third to amend LMCA dissection, all with good angiographic result. History of Present Illness: 67 year old blind, deaf man with ESRD, htn, CAD s/p NSTEMI, cardiomyopathy with EF 35%, initially admitted to [**Hospital3 **] hospital with burning chest pain radiating to shoulders. Ruled out for MI. Yesterday, patient returned to [**Location **] with burning chest pain radiating to his shoulder. No EKG changes, but known LBBB. Initial negative troponin negative, but afternoon trop elevated to 0.97. Overnight episodes of CP responded to 2 SL NTG +/- morphine. Continued to have episodes of CP responsive to NTG. Patient was transferred directly to [**Hospital1 18**] cath lab on [**8-24**]. . Coronary angiography on [**8-24**] revealed a right dominant system with diffuse coronary artery disease. The LMCA was without angiographically apparent stenosis. The LAD had 3 sequencial stents that were widely patent. There was a 50% stenosis at the D1 level proximal to the stents. There was diffuse disease between the 2nd and 3rd stents with approximately 60% stenosis, and there was a 90% focal lesion just distal to the 3rd stent that was new since the prior catheterization in [**2180-4-28**]. The D1 had 90% proximal disease that was not apparently changed since prior. The LCX had a widely patent stent and no significant disease. The RCA had chronic subtotal occlusion in the mid-portion, with collaterals from the LAD distally. He had a successful PCI of the distal LAD with a DES which was post-dilated to 2.5mm. At this point the patient could not tolerate further intervention due to marked agitation, so it was elected not to intervene on the D1 lesion. . After this intervention the patient was transferred to [**Hospital Ward Name 121**] 3 and continued to have chest pain on the floor. He continued to ask for nitroglycerin for chest pain overnight. EKGs were consistently unchanged. The pain was not relieved with a GI cocktail. Trop was 0.63, CK=53 on AM of [**8-25**] and previously was trop=0.97 at OSH on [**8-24**]. Due to his continued symptoms, he was taken to cath again on the afternoon of [**8-25**] after his regularly scheduled HD session. The D1 lesion was successfully angioplastied and a successful PCI of prox/mid LAD with DES was performed, but the procedure was complicated by LMCA artery dissection. On the last final angiography injection, the LMCA was dissected, at which point the patient arrested. CPR was immmediately initiated and atropine was given. The Prowater wire was still in place in the LAD and a 3.5x28mm Xience DES was able to be delivered to the LMCA/prox LAD. This stent was post-dilated to 4.0 NC balloon with sealing of the dissection and restoration of TIMI 3 flow into the LAD and LCx. The patient left the lab intubated and on 5mcg/kg/min of dopamine to maintain a SBP of 100-110mmHg. Reportedly, his home SBP runs in the 90s-100s. . Upon transfer to the CCU the patient was sedated, intubated, and on dopamine to maintain his pressures. He had a peripheral line and femoral sheath for access. Initial blood gas was pH 7.53, pCO2 36, pO2 237, HCO3 31, BaseXS 7. Past Medical History: As above, and: 1) Hypertension. 2) Speech and hearing deficit. 3) Peptic ulcer disease, dyspepsia 4) Gout 5) Osteoarthritis. 6) Chronic renal insufficiency, thought [**1-31**] nephrosclerosis 7) Retinitis pigmentosa 8) A fib on Amio 9) h/o NSTEMI Social History: He denies tobacco or alcohol use. He is currently unemployed on disability and lives with girlfriend. Family History: Mother died of MI after age 80. Father died at 20's of an unspecified brain "problem". Other family history is not known by patient. Physical Exam: VS: T=99.7 BP=126/68 HR=103 RR=18 O2 sat=100% intubated GENERAL: Caucasian male, sedated, intubated. HEENT: NCAT. Sclera anicteric. PERRL. NECK: Supple with no JVD CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTAB, no crackles, wheezes, or rhonchi. Right chest wall with temporary HD cath site clean, intact. ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation. No abdominial bruits. Has bowel sounds in all four quadrants. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No rashes PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Exam at discharge: T 98.1 BP 104/61 HR 85 RR 20 99% RA GENERAL: Caucasian male, sedated, intubated. HEENT: NCAT. Sclera anicteric. PERRL. NECK: Supple with no JVD CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: rare rales left base, otherwise CTAB ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation. No abdominial bruits. Has bowel sounds in all four quadrants. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No rashes PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: CXR [**2180-8-26**]: FINDINGS: In comparison with study of [**8-25**], the nasogastric tube has been pushed forward slightly so that the side hole appears to extend beyond the esophagogastric junction. Endotracheal tube has been removed. Progressive improvement in pulmonary vascular status. . TTE [**2180-8-26**]: The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) with global hypokinesis and akinesis of the infero-lateral and apical segments. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. with mild global free wall hypokinesis. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**12-31**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Coompared to the prior study dated [**2180-5-26**], no major change. . Cardiac cath [**2180-8-25**]: FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful PTCA of D1 branch. 3. Successful PCI of prox/mid LAD with DES. 4. LMCA dissection successfully treated with DES. . Cardiac cath [**2180-8-24**]: COMMENTS: 1. Coronary angiography in this right dominant system revealed diffuse coronary artery disease. The LMCA was without angiographically apparent stenosis. The LAD had 3 sequencial stents that were widely patent. There was a 50% stenosis at the D1 level proximal to the stents. There was diffuse disease between the 2nd and 3rd stents with approximately 60% stenosis, and there was a 90% focal lesion just distal to the 3rd stent that was new since the prior catheterization in [**2180-4-28**]. The D1 had 90% proximal disease that was not apparently changed since prior. The LCX had a widely patent stent and no significant disease. The RCA had chronic subtotal occlusion in the mid-portion, with collaterals from the LAD distally. 2. Resting hemodynamics demonstrated low to normal systemic blood pressures with SBP 101 mmHg and DBP 51 mmHg. 3. Successful PCI of the distal LAD with a 2.25x12mm Taxus DES, post-dilated to 2.5mm. 4. Successful closure of the right femoral arteriotomy site with a 8F Angioseal device. FINAL DIAGNOSIS: 1. Diffuse coronary artery disease with new distal LAD stenosis. 2. Successful PCI of the distal LAD with DES. Labs at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 7.8 3.45* 9.6* 30.6* 89 27.7 31.3 19.6* 171 Glucose UreaN Creat Na K Cl HCO3 AnGap 101 35* 6.1*# 143 4.0 99 32 16 Calcium Phos Mg 8.3* 3.7# 2.5 Brief Hospital Course: 67 y/o blind, deaf male w/ESRD, cardiomyopathy with EF 35%, transferred to [**Hospital1 18**] with NSTEMI, s/p cath here on [**8-24**] with stenting of distal LAD stenosis with continued chest pain, whose repeat cath on [**2180-8-25**] was complicated by LMCA dissection. . # CORONARIES: Cath [**2180-8-24**]: LAD w/ 3 sequential stents widely patient. 50% lesion at D1 proximal to stents. 60% diffuse disease between 2nd and 3rd stents; 90% focal lesion just distal to 3rd stent (new since [**5-6**]). D1 with prximal 90% disease (unchanged). New stent placed over distal LAD lesion. Procedure stopped prematurely secondary to agitation. Patient returned to the floor and continued with chest pain. Went back to the cath lab on [**2180-8-25**] where he received a DES to mid LAD. This second cath was complicated by LAD dissection, the patient became asystolic, coded for 20 minutes and received DES to LMCA. On return to the CCU, patient did well. He was continued on his aspirin, plavix, metoprolol, lipitor. Imdur was discontinued. Lisinopril was started, and he was sent home on this regimen on [**2180-8-29**]. He is to take aspirin and plavix for life given his stent to the LMCA. He was discharged on [**2180-8-29**] in improved and stable condition. . # PUMP: Has known cardiomyopathy with EF 35% on [**5-6**] Echo. No overt clinical signs of heart failure at this time. No peripheral edema, crackles, or JVD. . # RHYTHM: h/o paroxysmal atrial fibrillation, but was in NSR for most of admission. Patient was continued on amiodarone, started on metoprolol as bp could tolerate. . # Hypotension: initially on dopamine, but weaned off. Goal sbp maintained near 90s-100s. Patient continued on metoprolol, and eventually tolerated introduction of lisinopril, as indicated post-myocardial infarction. . # Anemia: Hct dropped from 30.9 pre-procedure to 24.8 post-procedure. Hct on discharge was 30.6, at baseline. . # ESRD w/ HD on MWF: Underwent normal session of HD Friday morning prior to cath. Patient continued on nephrocaps, renagel. Patient will continue regular Monday, Wednesday, Friday schedule for hemodialysis. . # Gout: allopurinol continued on discharge. . # Congenital deafness: Can read lips effectively at baseline. Involved ASL interpreters as needed following extubation. . # Peptic ulcer disease, dyspepsia: continued on famotidine. Pt remained a full code throughout hospitalization. Medications on Admission: Lopressor 100 PO BID ASA 325 mg PO daily Zocor 40 mg PO daily Colace 100 mg PO daily Esomeprazole 40 mg PO daily Sevelamer 1600 mg PO with meals MVI PO daily Allopurinol 100 mg PO daily Cholecalciferol 400 units PO daily Amiodarone 200 mg PO daily Isosorbide mononitrate 120 mg PO daily Metoprolol tartrate 100 mg PO BID Lorazepam 0.5 mg PO Q6 hrs PRN Oxazepam 10 PO QHS PRN Maalox 30 cc PO Q8 PRN Morphine Sulfate 2 mg IV Q4 hrs PRN Nitroglycerin 1 tab SL PRN Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*90 Tablet(s)* Refills:*2* 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*90 Tablet(s)* Refills:*2* 3. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). [**Month/Year (2) **]:*180 Tablet(s)* Refills:*2* 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*90 Tablet(s)* Refills:*2* 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*90 Tablet(s)* Refills:*2* 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*90 Tablet(s)* Refills:*2* 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*90 Tablet(s)* Refills:*2* 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*90 Tablet(s)* Refills:*2* 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). [**Month/Year (2) **]:*90 Cap(s)* Refills:*2* 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*90 Tablet(s)* Refills:*2* 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [**Month/Year (2) **]:*90 Tablet(s)* Refills:*2* 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-31**] Tablet, Sublinguals Sublingual PRN (as needed) as needed for angina: take one tablet every 5 minuties for chest pain, if pain continues after three doses, call your doctor. [**Last Name (Titles) **]:*30 Tablet, Sublingual(s)* Refills:*0* 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary Diagosis: NSTEMI, s/p stent x 2 to LAD, with subsequent LAD dissection, s/p stent to LMCA with good angiographic result Secondary Diagnoses: (prior to this hospitalization) 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: Dilated Cardiomyopathy (EF 35%); NSTEMI [**5-6**], LAD stent in [**2169**], cypher to OM3 with POBA to distal LCX in [**5-3**]; unsuccessful PTCA of RCA chronic total occlusion [**5-6**]; Paroxysmal atrial fibrillation 3. OTHER PAST MEDICAL HISTORY: ESRD w/ HD on MWF Gout Congenital deafness Retinitis pigmentosa Hypertension Speech deficit Peptic ulcer disease, dyspepsia Gout Osteoarthritis. Discharge Condition: stable and improved Discharge Instructions: You were admitted to the hospital for chest pain. After initially being evaluated at [**Hospital3 417**] Hospital, you were transferred to [**Hospital1 18**] for further care. Your chest pain was coming from your heart, and you required 3 stent placements during your hospital course. Your heart stopped for a short period of time, and you were resuscitated. You needed assistance breathing, and had a breathing tube for a short period of time. After the heart procedure, you were cared for in the ICU. You continued to improve, and had the breathing tube removed. Other medications used to support your heart were also no longer needed. You resumed your regularly scheduled hemodialysis, which you tolerated well. You were discharged on [**2180-8-29**] in good condition. The following changes were made to your medications: You will continue taking Aspirin 325 mg daily and Plavix 75 mg daily for the rest of your life unless you are told to stop by your Cardiologist You have been started on lisinopril 2.5 mg daily for your heart You will stop taking Imdur for your blood pressure. Please see below for follow up appointments. You will need to have repeat catheterizations in the next 12 months to ensure that the stents are working well. Please call your doctor or 911 if you develop chest pain/pressure, shortness of breath, fevers/chills, lightheadedness, or any other concerning medical symptoms. Followup Instructions: You have a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] at [**Telephone/Fax (1) 8725**]. They will contact you. Please discuss a repeat cardiac catheterization with him during this visit. . Please follow up with your primary care doctor within one week of discharge.

Admission Date: [**2144-5-5**] Discharge Date: [**2144-5-12**] Date of Birth: [**2070-6-18**] Sex: F Service: [**Hospital1 **] Inpatient Medicine CHIEF COMPLAINT: Hypotension HISTORY OF PRESENT ILLNESS: Ms [**Known lastname **] is a 73 year old woman with end stage renal disease secondary to diabetes, requiring hemodialysis Monday, Wednesday and Friday who recently had an admission to [**Hospital6 2018**] from [**2144-3-21**] to [**2144-4-20**] after experiencing a mechanical fall. At that time she was diagnosed with a left intertrochanteric femur fracture. She had a left open reduction and internal fixation with a screw placed on [**4-2**]. Her hospital course was complicated by a right femoral vein thrombosis with initiation of Coumadin, with a repeat ultrasound to be performed in six weeks. She also had rapid atrial fibrillation requiring intravenous Diltiazem, line infection and bacteremia with Methicillin- resistant Staphylococcus aureus; Vancomycin-resistant Enterococcus bacteremia; and UTI with Proteus bacteremia and sepsis. The patient was treated with multiple antibiotics and was transferred to rehabilitation at the end of [**2144-3-28**], to receive continued treatment for end stage renal disease, anticoagulation for DVT and atrial fibrillation, and for consideration of a percutaneous endoscopic gastrostomy tube due to decreased p.o. intake secondary to delirium. On [**5-5**], the patient returned to the [**Hospital6 649**] for decreased blood pressure into the 80s persistently, preventing hemodialysis. The patient's code status was recently changed from full to Do-Not-Resuscitate/Do-Not- Intubate by the family. The patient, prior to admission, had experienced increased white blood cell count, hypoxia and hypotension on [**4-29**], and was taken to [**Hospital 8**] Hospital where she was diagnosed with urosepsis versus aspiration pneumonia and stated on Gentamicin and Linezolid. She had an increased gentamicin level and the gentamicin and Linezolid were held as of [**5-4**], but her blood pressure continued to be low. Upon transfer to [**Hospital6 256**] her pressure was 57/45. She was given a 500 cc bolus and started on pressors and transferred to the Medicine Intensive Care Unit for further evaluation of her hemodynamic instability. PAST MEDICAL HISTORY: 1. End stage renal disease, secondary to diabetes, hemodialysis since [**2141**], now on a Monday, Wednesday and Friday schedule with an estimated dry weight of between 64.5 and 68 kg. 2. Diabetes mellitus Type 2, neuropathy and retinopathy and nephropathy. 3. Hypotension. 4. Peripheral vascular disease. 5. Gastroesophageal reflux disease. 6. Atrial fibrillation, failed Amiodarone in the past. 7. Congestive heart failure, apparently diastolic dysfunction with a normal ejection fraction. 8. Coronary artery disease. 9. Glaucoma. 10. Hypercholesterolemia. 11. Depression. 12. Vertebral compression fractures. 13. Ligation of left arteriovenous graft secondary to steal phenomenon, left ulnar nerve palsy. 14. Breast carcinoma, status post lumpectomy. 15. Osteoarthritis. 16. Klebsiella bacteremia [**2142-4-29**], Vancomycin-resistant Enterococcus, Methicillin-resistant Staphylococcus aureus bacteremia Proteus urosepsis. 17. Restrictive lung disease. 18. Deep vein thrombosis, right common femoral vein, anticoagulation until the end of [**2144-4-28**]. 19. Left foot drop. 20. Dementia. 21. Delirium uncertain etiology. 22. Mechanical falls with left intertrochanteric hip fracture. 23. History of aspiration pneumonias. PAST SURGICAL HISTORY: 1. Total abdominal hysterectomy. 2. Third toe amputation secondary to gangrene and focal chronic osteomyelitis. 3. Left parietal mastectomy, ductal carcinoma in situ in [**2139-7-29**]. 4. Retinal detachment, left eye, status post partial vitrectomy in [**2141-3-29**]. 5. Right brachiocephalic arteriovenous fistula and right internal jugular Quinton placement. 6. Left forearm arteriovenous graft, [**Doctor Last Name 4726**]-Tex [**2143-11-29**] with subsequent ligation secondary to steal phenomenon in [**2143-12-29**]. MEDICATIONS ON ADMISSION: 1. Lipitor 20 mg p.o. q.h.s.; 2. Tylenol prn; 3. Miconazole powder b.i.d.; 4. Linezolid; 5. Ranitidine 115 mg p.o. q.d.; 6. Metoprolol 50 mg p.o. t.i.d.; 7. Coumadin 2.0 mg p.o. q.h.s. to a target INR of 2.0 to 3.0; 8. Regular insulin sliding scale, NPH 6 units b.i.d.; 9. Epo 3000 units subcutaneous t.i.d. with dialysis; 10. Aspirin 325 mg p.o. q.d.; 11. Diltiazem 60 mg p.o. q.i.d.; 12. Gentamicin. ALLERGIES: 1. Sensitive to narcotics regarding blood pressure and mental status examination; 2. Penicillin; 3. Sulfa; 4. ? Verapamil. SOCIAL HISTORY: The patient lives in an [**Hospital3 **] facility, her doctor is Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**]. Her family spokesperson is her daughter [**Name (NI) **], at [**Telephone/Fax (1) 16861**]12, ? Her home #[**Telephone/Fax (1) 16784**], cellular telephone #[**Telephone/Fax (1) 16785**]. PHYSICAL EXAMINATION: On presentation the patient's vital signs after 500 cc bolus of normal saline and starting on Neo-Synephrine were 120/70, heartrate 120 and irregular, respiratory rate 16, and sating 96% on 2 liters. Physical examination was notable for the following findings, dry mucous membranes, irregularly irregular heart rhythm, no murmurs, rubs or gallops, coarse breathsounds bilaterally in the lungs with scattered rhonchi. She had 1 to 2+ pitting edema bilaterally and multipodus boots on. Her mental status was confused and unresponsive. LABORATORY DATA: The patient on admission had a white blood cell count of 10.7, 86% neutrophils, 0% bands. Her hematocrit was 29.5, platelets 339, her INR on admission was 8.3 with a PTT of 61.6 and PT 35.5. Her chem-7 was sodium 137, potassium 4.6, chloride 105, bicarbonate notable for 13. Her BUN was 37, creatinine 4.6. Her chest x-ray showed no infiltrate or overt failure on admission and electrocardiogram showed atrial fibrillation with a rate of 120, left axis deviation and 2 to [**Street Address(2) 2051**] depression in V2 through V4 unchanged from [**2144-4-4**]. Subsequently the patient had negative blood cultures times two. She had no urine cultures as she is anuric. Chest x-ray later on demonstrated worsening left retrocardiac opacity / consolidation / collapse, suspicious for possible infection. Her hematocrit remained stable between 27 and 30. Her INR had decreased to 1.0. Two days prior to admission, she was started on her Coumadin and her INR was 1.2 on the day of discharge. The patient, under fluoroscopic guidance, had jejunostomy tube placed which showed pigtail catheter to be in good condition. HOSPITAL COURSE: 1. Cardiovascular - As previously mentioned, the patient came in significantly hypotensive. The etiology was deemed likely secondary to hypovolemia from decreased p.o. intake with a questionable history of diarrhea. She was given 500 cc bolus and started on pressors. She had a good response to the pressors and a normal saline bolus. Her blood pressure came back up to systolic/100. During the remainder of her hospital stay her pressure generally remained over 100 systolic on the floor with occasional drops into the 90s. However, while at dialysis the patient's pressure tended to drop into the 80s. The etiology of her hypertension as previously mentioned was likely hypovolemia as all the cultures were negative and she did not appear to have impaired cardiac function. The hypotension was not rate-related either. She was quickly weaned off of her pressors in the Intensive Care Unit within two days and then transferred to the floor with further management. With regard to the patient's atrial fibrillation she remained atrially fibrillated throughout the remainder of her hospital stay with ventricular rate as high as 130 but generally in 80 to 100 range and for the 24 hours prior to discharge she remained in the 80s, on 60 mg of Diltiazem p.o. q.i.d. 2. Hematology - The patient came in with a highly elevated INR Of greater than 8. She has a history of a right lower extremity deep vein thrombosis from her prior admission. She needs to be anticoagulated for this deep vein thrombosis for six months, that would take her through the end of summer, however, since she has atrial fibrillation, she needs to be anticoagulated to a target INR of 2.0 to 3.0 for life. This anticoagulation for the deep vein thrombosis is not an issue at this point. Her Coumadin was held and restarted two days prior to discharge at 5 mg p.o. q.d. with INR to be checked on Thursday, [**5-14**]. The patient was covered with a heparin drip because of her history of deep vein thrombosis and she should continue on the heparin drip with a target PTT of 50 to 70 until she becomes therapeutic with an INR of 2 to 3. 3. Neurologic - The patient has a history of dementia with superimposed delirium of uncertain etiology. It is possible that her hypotension contributes to her delirium as well as possible underlying lung infection. From a dementia standpoint, at her best, the patient is able to answer simple questions in respond to her name, however, her mental status greatly fluctuates and often she is unresponsive except for the most simple commands and questions. This has been a significant decline in her cognitive function. According to her primary care physician and her daughter, six months ago the patient completely normal neurologically. The etiology of the neurological decline during this admission is uncertain. Of note - The patient is exquisitely sensitive to narcotics with regard to her mental status. 4. Renal - The patient has end stage renal disease secondary to diabetes and she is on dialysis three times a week schedule, now Monday, Wednesday and Friday. She may have had difficulty taking any fluid off and have just been ultra-filtering her because of her hypotension. 5. Gastrointestinal - The patient has poor p.o. intake, likely secondary to neurological status. She is on Nepro 1/2 strength at a goal of 6 cc/hr which she tolerated generally well through the hospital stay. She had a gastrojejunostomy placed the day prior to discharge and was tolerating her tube feeds. These should be advanced to a goal as mentioned of 60 cc/hr of Nepro 1/2 strength through the gastrojejunostomy tube. 6. Infectious disease - The patient has questionable left lower lobe infiltrate. She is being treated with Levofloxacin for presumed pneumonia and questions whether it is aspiration versus community acquired, although the patient has had an excellent response to the Levofloxacin and has been afebrile with decreased sputum production and no respiratory distress. It is deemed that she does not need further anaerobic coverage. She is taking 250 mg q. 48 hours of Levofloxacin and her last day will be [**2144-5-21**]. 7. Endocrinologic - The patient had diabetes mellitus and came in on a dose of insulin NPH 6 units b.i.d. with a regular insulin sliding scale q.i.d. Her NPH insulin is said to be titrated because of variations in her p.o. intake and that should continue to be the case. She is currently on 3 units q. AM and 1 unit q. PM of the regular insulin sliding scale q.i.d. The had some blood sugars in the 60s the day of discharge secondary to being NPO for the jejunostomy tube placement but these had resolved with resumption of her tube feeds. The patient was also treated with proton pump inhibitors for a known history of gastroesophageal reflux disease, 30 mg of Prevacid b.i.d. 8. Dermatologic - The patient has several healed ulcers in her lower extremities, there are no active infections there, however, there is a tinea infection in her buttock area and this should be treated with Miconazole cream b.i.d. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: Back to [**Hospital1 **]. DISCHARGE DIAGNOSIS: 1. Hypotension, likely secondary to hypovolemia 2. End stage renal disease on hemodialysis Monday, Wednesday and Friday with estimated dry weight of 64 to 68 kg 3. Diabetes mellitus Type 2 4. Tinea cruris 5. Left lower lobe pneumonia 6. Dementia 7. Delirium, uncertain etiology DISCHARGE MEDICATIONS: 1. Miconazole 2% cream to the buttocks rash b.i.d. 2. Tylenol 325 to 650 per jejunostomy tube prn, fever or pain 3. Colace 100 mg jejunostomy tube b.i.d. 4. Levofloxacin 250 mg jejunostomy tube q. 48 hours, ten days, the last dose [**2144-5-21**] 5. Prevacid 30 mg jejunostomy tube b.i.d. 6. Heparin, GTT, target PTT 50 to 70 until the INR is 2.0 to 3.0 7. Warfarin 5 mg p.o. q.d. adjust per INR 2.0 to 3.0 8. Diltiazem 60 mg p.o. q.i.d. 9. Insulin NPH 3 units q. AM, one unit q. PM to be adjusted as the tube feeds are titrated up to goal 10. Regular insulin sliding scale q.i.d. 11. Miconazole powder b.i.d. to buttocks FOLLOW UP PLANS: The patient is follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**] for an appointment two weeks from discharge from [**Hospital1 **]. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 10885**] Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2144-5-12**] 11:00 T: [**2144-5-12**] 11:38 JOB#: [**Job Number 16862**] cc:[**Hospital1 **]

Admission Date: [**2137-12-25**] Discharge Date: [**2138-1-1**] Date of Birth: [**2090-7-30**] Sex: F Service: MEDICINE Allergies: Morphine / Iodine; Iodine Containing Attending:[**First Name3 (LF) 898**] Chief Complaint: abdominal pain, nausea and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Patient is a 47-year-old female with h/o metastatic breast cancer to the liver and bone (currently on treatment with Navelbine), h/o pancreatitis secondary to hypertriglyceridemia who presents with nausea, vomiting and abdominal pain. States she woke up this AM with severe, diffuse abdominal pain radiating across the front of her abdomen. No radiation to her back. Pain was [**11-4**] and assoicated with frequent emesis. Patient immediately came to the ER. Denies fevers of chills. No diarrhea or constipation. Last BM was last night. Last treatment with navelbine was one week ago. Patient says she was febrile to 101.3 two days ago, was seen in ER for backpain but no new fractures were seen on MRI. Was sent home after bcx were drawn for close follow-up with heme/onc. Blood cultures show NGTD. . In ER patient was given IV dilaudid and phenergan without much improvement in nausea or pain. She was afebrile with nl HR. She was given 3 L NS. Amylase was 406, lipase 1191, WBC 30.5. Abdominal CT was done and showed acute pancreatitis with extensive inflammatory stranding surrounding the entire pancreas without focal fluid collections. Increased mets in liver were seen and stable lytic and sclerotic bone lesions were also noted. . Currently patient is in severe pain and having episodes of emesis. She feels dizzy with some numbness in nose and fingertips. Husband states that she has had some peripheral neuropathy for chemo, but she states this is a different feeling. Past Medical History: Past Medical History: Metastatic Breast ca- undergone chemo w/ adriamycin/cytoxan, then taxol. Also with 5FU/leukovorin and Zometa. Currently on therapy with Navelbine s/p radiation to the T4 region for mets this year s/p ccy h/o ovarian clot- requiring coumadin, was post Taxol therapy hypertrigylceridemia pancreatitis in [**2130**]. Had elevated triglycerides at that time and told it was genetic. Social History: Social History: Married with 3 children. Denies any T/A/D Used to drink occasiounally Family History: Family History: Aunt with breast cancer on father's side. Mother with bladder cancer. Uncle with unknown cancer. Physical Exam: Tc 100.0 BP 122/74 P 102 R 22 O2 sat 96% RA Gen: A& O x3 in severe pain and having episodes of emesis HEENT: MMM, anicteric sclera, patient is able to feel me touching her face, even though she feels it is numb Neck: supple Cardio: tachycardic with regular rhythm, nl S1 S2, no m/r/g Pulm: few crackles at bases and scattered expiratory wheezes but moving air well Abd: soft, distended, pain on light palpation diffusely, hypoactive; BS in all 4 quadrants; no bruising seen on abd or flank Ext: no edema; 2+ PT pulses, warm extremities Neuro: A& O x3 muscle strength grossly intact in all four extremities patient does not feel light touch in her fingertips bilaterally but is able to move her fingers. Extremities are warm. Pertinent Results: [**2137-12-25**] 12:54PM BLOOD WBC-30.5*# RBC-UNABLE TO Hgb-12.6 Hct-30.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO Plt Ct-206 [**2137-12-26**] 05:01AM BLOOD WBC-32.1* RBC-4.01* Hgb-12.7 Hct-34.3* MCV-85 MCH-31.5 MCHC-37.0* RDW-18.7* Plt Ct-172 [**2137-12-26**] 09:01AM BLOOD WBC-24.4* RBC-3.60* Hgb-11.3* Hct-30.9* MCV-86 MCH-31.3 MCHC-36.5* RDW-18.9* Plt Ct-139* [**2137-12-25**] 12:54PM BLOOD Neuts-53 Bands-31* Lymphs-4* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-5* NRBC-1* [**2137-12-26**] 05:01AM BLOOD Neuts-67 Bands-16* Lymphs-5* Monos-3 Eos-0 Baso-1 Atyps-0 Metas-5* Myelos-3* [**2137-12-25**] 12:54PM BLOOD PT-12.7 PTT-22.6 INR(PT)-1.1 [**2137-12-26**] 05:01AM BLOOD PT-13.7* PTT-23.5 INR(PT)-1.3 [**2137-12-25**] 12:54PM BLOOD Glucose-107* UreaN-9 Creat-0.7 Na-141 K-3.5 Cl-105 HCO3-22 AnGap-18 [**2137-12-26**] 05:01AM BLOOD Glucose-133* UreaN-7 Creat-0.6 Na-137 K-3.1* Cl-102 HCO3-20* AnGap-18 [**2137-12-26**] 09:01AM BLOOD Glucose-123* UreaN-8 Creat-0.6 Na-136 K-2.9* Cl-106 HCO3-21* AnGap-12 [**2137-12-25**] 12:54PM BLOOD ALT-38 AST-40 LD(LDH)-809* AlkPhos-124* Amylase-406* TotBili-0.6 [**2137-12-26**] 05:01AM BLOOD ALT-25 AST-31 Amylase-205* TotBili-1.0 [**2137-12-25**] 12:54PM BLOOD Lipase-1191* [**2137-12-26**] 05:01AM BLOOD Lipase-437* [**2137-12-26**] 09:01AM BLOOD Calcium-7.1* Phos-1.9* Mg-1.3* [**2137-12-26**] 05:01AM BLOOD Calcium-7.1* Phos-2.2* Mg-1.3* [**2137-12-25**] 12:54PM BLOOD Calcium-9.2 Cholest-375* [**2137-12-25**] 12:54PM BLOOD Triglyc-2736* HDL-39 CHOL/HD-9.6 LDLmeas-PND [**2137-12-26**] 10:32AM BLOOD Lactate-1.5 K-2.6* [**2137-12-25**] 02:12PM BLOOD Lactate-1.2 [**2137-12-26**] 10:32AM BLOOD freeCa-1.08* [**2138-1-1**] 03:11AM BLOOD WBC-11.8* RBC-2.84* Hgb-8.6* Hct-24.8* MCV-88 MCH-30.3 MCHC-34.6 RDW-18.2* Plt Ct-238 [**2138-1-1**] 03:11AM BLOOD Amylase-96 [**2138-1-1**] 03:11AM BLOOD Lipase-126* . CXR [**2137-12-25**]: No airspace consolidations or pleural effusions are identified. However, increased vascular markings and peripheral interstitial lines suggest tiny degree of fluid overload. Some of this appearance is enhanced by lower lung volumes. The right hemidiaphragm continues to be slightly elevated. The tip of a right central venous catheter overlies the right atrium. No pneumothorax. No pleural effusions. The cardiac and mediastinal contours are unchanged. . Abd CT [**2137-12-24**]: 1. Acute pancreatitis with extensive inflammatory stranding surrounding the entire pancreas without focal fluid collections, pseudocyst, splenic vein thrombosis or splenic artery aneurysm. 2. Slight interval increase in the size of the multiple liver metastatic lesions. 3. Stable mixed lytic and sclerotic bone lesions. . Abd CT [**12-30**]: IMPRESSION: 1. Interval development of left-sided pleural effusion with associated atelectasis and interval increase in degree of peripancreatic stranding and effusion with no evidence of pancreatic necrosis. No evidence of retroperitoneal hemorrhage. No pseudoaneurysm identified in the pancreatic bed. 2. Unchanged appearance of multiple hepatic lesions. 3. Interval apparent development of a right-sided 4.5 cm adnexal cyst. . Bcx [**12-25**], [**12-26**]: no growth Ucx [**12-28**]: no growth Stool c. diff [**12-28**], [**12-29**]: no growth Brief Hospital Course: 47-year-old female with h/o metastatic breast cancer to the liver and bone, currently on treatment with Navelbine and h/o pancreatitis secondary to hypertriglyceridemia who presented with nausea, vomiting and abdominal pain which appeared secondary to acute pancreatitis. . *Acute Pancreatitis: Patient presented with severe abdominal pain,nausea and vomiting. In the ER she was given IV dilaudid and phenergan without much improvement in nausea or pain. She was afebrile with a nl HR. Amylase was 406, lipase 1191 and WBC 30.5. Abdominal CT was done and showed acute pancreatitis with extensive inflammatory stranding surrounding the entire pancreas without focal fluid collections. Increased mets in the liver were seen and stable lytic and sclerotic bone lesions were also noted. Her pancreatitis was likely secondary to hypertriglyceridemia (Trig 2736), but could have been secondary to Navelbine treatment. Patient had an initial admission [**Last Name (un) 5063**] score of 2. She was given 3L of NS in the ER. After admission, she received aggressive IVF hydration, dilaudid PCA for pain control and anti-emetics. She was given 2 L NS at 200 cc/hr initially. When her hct was found to be higher, it suggested her fluid requirement was not being met so her fluids were increased to 500cc/hr. Her calcium dropped to 7.1 on [**2137-12-26**] and her K+ to 2.6. Her pain was not well controlled on the PCA and she had continued N/V. She was transferred to the MICU for monitoring. She was empirically started on flugyl and cipro for high fevers, but there was no CT evidence of necrotizing pacnreatitis. In the ICU she had close electrolyte monitoring and received IVFs. Her dilaudid PCA was changed to fentanyl. Her N/V and pain improved and WBC trended down. Repeat abd CT was done on [**12-30**] and showed interval developement of left sidedd pleural effusion and increase in degree of peripanreatic stranding and effusion with no evidence of necrosis. While the CT showed more stranding, the patient improved clinically. Her diet was advanced and she was started on Tricor for her hypertriglyceridemia. Her amylase, lipase, WBC and triglycerides trended down over her stay. She was discharged home in stable condition. . * Diarrhea: She developed diarrhea in the MICU which improved after arrival to the floor. 2 sets of c. diff toxin were negative. . *h/o metastatic breast CA: Patient had known metastatic breast cancer and was being treated with Navelbine as an outpatient. Her abdominal CT showed increased liver mets. Her cancer care was deferred to her outpatient doctors. . *H/o ovarian clot: Patient had a known ovarian clot for which she was on coumadin . Coumadin was initially held out of concern that she might require surgery. It was re-started upon discharge. Medications on Admission: Navelbine Ativan prn Coumadin 1mg QD Neurontin 300 HS Oxycontin 80mg [**Hospital1 **] Vocodin prn Recently on Neulasta for neutropenia, last dose 1 week ago Protonix qd Zofran prn . Discharge Medications: 1. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*40 Tablet(s)* Refills:*0* 2. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:*40 Tablet(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. OxyContin 40 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO twice a day for 1 months. Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0* 5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO QD (). Disp:*30 Tablet(s)* Refills:*1* 6. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for diarrhea for 1 weeks. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute pancreatitis Hypertriglicidemia Metastatic Breast Cancer Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital with Acute Pancreatitis. Please return to the hospital if you develop shortness of breath, chest pain or severe nausea/vomiting/diarrhea. If you are unable to eat or drink fluid due to nausea and vomiting please return to the hospital. Please call your doctor if you have any questions about your symptoms. You should advance your diet slowly. Concentrate on taking in fluids and then bland foods such as rice, bread, and fruits such as bananas. Please take medications as prescribed. Followup Instructions: Please call your PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 2936**] to make a follow-up appointment for next week.

Admission Date: [**2160-11-3**] Discharge Date: [**2160-11-11**] Date of Birth: [**2133-5-22**] Sex: F Service: MED Allergies: Cephalosporins / Penicillins / Compazine Attending:[**Known firstname 759**] Chief Complaint: Fever Major Surgical or Invasive Procedure: None. History of Present Illness: (ACOVE transfer note from [**Hospital Unit Name 153**]) The pt is a 27 y.o. female with interstitial lung disease status post open lung biopsy on [**2160-10-8**], on chronic TPN for GI dysmotility, suprapubic catheter for bladder atony who presented to the ED with a two-day history of fevers to 101 F. She also complained of chills, increased abdominal pain, nausea without vomiting, bladder spasm, and mild headache. In ER her T was 101.4, HR 112, BP 95/69, RR 24 and she was 95% on 2L. Labs were notable for a lactate of 2.4, alkpho of 161 aa WBC of 3.6 with N89. Patient was empirically started on Vanc, Flagyl, Levofloxacin, Linezolid for urosepsis vs. line sepsis. An abdominal CT demonstrated a non-loculated pelvic fluid collection for which surgery was following. One set of blood cultures grew coag negative staphylococcus, and antibiotics were transitioned to Vancomycin. The patient's blood pressure responded to fluids and antibiotics and her temperature normalized. Of note the patient came with a history of vasculitis documented by report from her PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16004**] on colectomy specimen many years ago. Dr. [**Last Name (STitle) 16004**] reports the initial pathology was done at [**Hospital6 4620**] and then reviewed a second time at [**Hospital 4415**]. Dr. [**Last Name (STitle) **] referred her for a lung biopsy because patient she had had a previous lung biopsy which was "concerning for a diffuse microthrombotic process without much in the way of inflammatory infiltrates" as well as four months of progressive pulmonary deterioration for which a course of IV salumedrol was tried. Biopsy performed [**10-8**] showed no vasculitis/no amyloid. On transfer to medical floor patient reported feeling weak, with no change in her baseline shortness of breath, no diarrhea, no fever or chills, no chest pain. She reported not ambulating at baseline secondary to contractures in her legs. She reported bloating in her stomach with some nausea but no emesis. She denied photobia, cough, chills, neck stiffness, jaundice. Past Medical History: 1. Neuropathic vasculitis. See note from Dr. [**Last Name (STitle) 6426**] of Rheumatology on [**2155-11-17**] in OMR for complete details. Diagnosed at the age of 13. The exact nature of the vasculitis has not been completely characterized. Has been on brief courses of steroids in the past. Status post multiple organ biopsies including muscle, skin, liver, and bowel demonstrating perivasculitis. 2. Gastrointestinal dysmotility syndrome diagnosed in [**2144**], status post subtotal colectomy in [**2147**] with result in short gut syndrome, on total parenteral nutrition via central line since [**2148**]. 3. Multiple central line infections including Staphylococcus epidermidis, [**Female First Name (un) 564**], and Klebsiella. 4. Right internal jugular central line thrombosis in [**5-/2159**], status post TPA therapy. 5. Interstitial pattern on chest x-ray, etiology unclear, status post VATS. Biopsy showed organizing and organized arterial thrombi with recanalization, patchy eosinophilic inflammatory infiltrate extending into the pulmonary arteries, patchy pulmonary scarring, and no evidence of vasculitis. No exact diagnosis could be made. Pulmonary function tests [**2159-5-14**] suggests a restrictive defect, no lung volume is recorded. 6. Status post cholecystectomy in [**2149**]. 7. Question of [**Doctor Last Name **] optic atrophy. 8. Anemia of chronic disease status post multiple blood transfusions. 9. Reflex sympathetic dystrophy with chronic pain. 10. Bladder atony status post suprapubic catheter placement in [**2150**]. 11. History of gastroesophageal reflux disease. 12. Status post dental extraction. 13. Status post left salpingo-oophorectomy. 14. History of Vancomycin-resistant Enterococcus in urine. 15. Status post G-J tube placement in the past. 16. Status post multiple vascular stents right IJ, left brachiocephalic, left iliac veins. 17. Eosinophilic pneumonia- the possibility of chemical irritant exposure through intravenous injection was raised on her last admission. Social History: Lives at home with mother and father, receives 24hour nursing 2x/week. Family History: Noncontributory. Physical Exam: T 97.2 BP 109/74 Hr 84 R 19 98% on intermittent 1L NC General: ill-appearing, pale young woman HEENT: PERRL 9 mm->8 mm EOMI, dry, evidence of scarring from central line placement CV: RRR, no evidence of JVD, evidence of port-a-cath Respiratory: poor inspirator effort, mild expiratory grunts, no flank pain ABD: w/evidence of G-J tube, no evidence of erythema/crusting around site suprapubic tube no evidence of erythema/crusting aroudn site, with BS, soft, miminimal tenderness to paplpation diffusely, no guarding, no rebound EXT: pulses intact in UE,LE, 1+edema LE, patient able to move all extremities CN: [**3-13**] intact, symmetric, AOX3, sleepy, conversent Pertinent Results: RUQ ([**11-3**]) IMPRESSION: The hepatic veins are patent. Portal vein pulsatility suggests right hepatic failure. [**2160-11-3**] chest CT 1. The liver is enlarged and heterogeneous. This could be due to edema. The hepatic veins are not opacified with intravenous contrast which could be due to technical reasons, however due to the congestive appearance of the parenchyma this is concerning for Budd- Chiari syndrome. Recommend ultrasound of the liver with doppler for better evaluate. 2. Diffuse edema of the soft tissues. 3. Small amount of free fluid in the abdomen. There is a partially loculated fluid collection in the left pelvis. However, the fact that the walls are not enhancing suggests this is probably not an abscess. [**2160-11-3**] 06:52PM LACTATE-1.8 [**2160-11-3**] 06:40PM GLUCOSE-77 UREA N-23* CREAT-0.7 SODIUM-141 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14 [**2160-11-3**] 06:40PM ALT(SGPT)-24 AST(SGOT)-34 ALK PHOS-141* AMYLASE-40 [**2160-11-3**] 06:40PM LIPASE-69* [**2160-11-3**] 06:40PM ALBUMIN-3.0* CALCIUM-7.5* [**2160-11-3**] 06:40PM CORTISOL-12.0 [**2160-11-3**] 06:40PM WBC-3.1* RBC-3.08* HGB-7.3* HCT-24.4* MCV-79* MCH-23.9* MCHC-30.1* RDW-18.1* [**2160-11-3**] 06:40PM NEUTS-85.2* BANDS-0 LYMPHS-10.4* MONOS-3.0 EOS-1.1 BASOS-0.3 [**2160-11-3**] 06:40PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ OVALOCYT-1+ SCHISTOCY-OCCASIONAL [**2160-11-3**] 06:40PM PLT SMR-VERY LOW PLT COUNT-59* [**2160-11-3**] 06:40PM PT-16.7* PTT-51.4* INR(PT)-1.8 [**2160-11-3**] 06:40PM FIBRINOGE-392 D-DIMER-790* echo: [**2160-2-4**] Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function appears depressed. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure cxray [**2160-11-3**] IMPRESSION: 1. Stable interstitial pattern of opacity, in keeping with known history of vasculitis. Other inflammatory processes and mild interstitial edema cannot be excluded. 2. Lucency of the distal clavicle with possible distal clavicular fracture. Dedicated radiograph of the clavicle are suggested if clinically warranted. [**2160-8-27**] PFTs SPIROMETRY 1:38P Pre drug Actual Pred %Pred FVC 0.93 4.32 22 FEV1 0.92 3.43 27 MMF 1.04 3.81 27 FEV1/FVC 99 79 125 Impression: Unacceptable test quality precludes interpretation of results. Biopsy: [**2160-10-8**] biopsy: Her final pathology is back and demonstrates extensive organized arterial thrombi with focally associated foreign material. There is no evidence of vasculitis. Microbiology is all negative. This is felt to be associated with her chronic TPN use. Brief Hospital Course: 27 year old with history of neuropathic vasculitis, interstial lung disease status post recent lung biopsy, subtotal colectomy on chronic TPN, and G-J tube who presented to [**Hospital Unit Name 153**] on [**11-3**] with fever and concern for line sepsis. 1. Fever - Pt was admitted to [**Hospital Unit Name 153**] on linezolid for coverage of suspected line infection given her past history of VRE. She was also started on levofloxacin and metronidazole for a possible intra-abdominal infection with fluid collection seen on CT A/P. One of two sets of blood cx drawn on admission grew coag-neg staph. Levofloxacin, metronidazole, and linezolid were discontinued, and vancomycin was started for treatment of likely Staph epidermidis line sepsis. (Micro grew coag negative staph) Interventional followed the patient and suggested to treat with antibiotics through the line, rather then discontinue the line because the patient has few access options. No pneumonia noted on cxray. Liver function tests were notable for an elevated alk phosphatase. She ultimately grew gram negative rods as well late in the afternoon of [**2160-11-10**] and was placed on Levofloxacin. Infectious disease was consulted to evaluate the patient on [**2160-11-11**]. 2. Anemia/Leukopenia - Patient with history of anemia 23-31. History of leukopenia (1.9-4.0) In house, hematocrit dropped to 21 level from initial 27, thought secondary to fluid/possible reaction to Linezolid. Patient hematocrit up to 22 on [**11-7**]. Patient was guiac negative on admission. 3. Partially loculated fluid collection in the left pelvis - Of note patient with fluid collection noted on CT. Surgery has been following patient and has no current intent to intervene. Infectious disease called to comment. Would have evaluated patient on [**2160-11-11**]. 4. On [**2160-11-11**] at approximately 12:30 am, the nurse found the patient unresponsive and stiff. A code was called and the patient was pronounced dead. It is unclear what the cause of death was as the patient did not appear septic and her vitals until that time were stable. By report, she had been seen by nursing less than an hour before she was found and had been "fine." It did not appear that the PCA had been activated prior to the patient's demise. The patient's father was [**Name (NI) 653**] as the mother was out of the state. Both parents, once informed, declined an autopsy. Medications on Admission: On transfer from [**Hospital Unit Name 153**]: 1. MED Heparin Flush Hickman (100 units/ml) 2 ml IV QD:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen QD and PRN. Inspect site every shift. [**11-3**] @ 2308 2. MED Ondansetron 2 mg IV Q6H:PRN [**11-3**] @ 2308 3. MED Diphenhydramine HCl 100 mg IV Q3HR PRN hold for excess sedation [**11-3**] @ 2308 4. MED Lorazepam 4 mg PO/IV Q4H:PRN hold for sedation [**11-4**] @ 0817 5. MED Hydromorphone 4 mg IVPCA Lockout Interval: 6 minutes Basal Rate: 4 mg(s)/hour 1-hr Max Limit: 28 mg(s) per home dose [**11-4**] @ 1331 6. MED Enoxaparin Sodium 40 mg SC Q24H [**11-4**] @ 1436 7. MED Estraderm *NF* 0.1 mg/24 hr Transdermal twice per week please place today [**2160-11-4**] and Friday [**2160-11-7**] and then all following Tuesdays and Fridays [**11-4**] @ 1758 8. MED Vancomycin HCl 1000 mg IV Q12H [**11-5**] @ 1147 9. MED Calcium Gluconate 2 gm / 100 ml IV ONCE Duration: 1 Doses [**11-6**] @ 1755 10. MED Insulin SC (per Insulin Flowsheet) Sliding Scale 10/07 @ [**2073**] 11. MED Potassium Chloride 40 mEq / 100 ml IV ONCE Duration: 1 Doses [**11-7**] @ 0903 12. IV IV access: Hickman [**11-3**] @ Discharge Medications: Dilaudid 4 mg/hr basal rate with 4 mg per push with 10-min lockout and max of 28 mg/hr enoxaparin 30 mg/0.3 ml daily furosemide 20 mg IV bid diphenhydramine 100 mg IV q3h prn metoclopramide 10 mg IV q12 ondansetron 10 mg IV five times daily prn lorazepam q3 prn pepcid 40 mg IV q12 Discharge Disposition: Home Discharge Diagnosis: Line sepsis Discharge Condition: Deceased.

Admission Date: [**2150-3-7**] Discharge Date: [**2150-3-13**] Date of Birth: [**2100-1-23**] Sex: F Service: MEDICINE Allergies: Penicillins / Darvocet-N 100 / Aspirin / Amitriptyline / Wellbutrin Attending:[**First Name3 (LF) 2009**] Chief Complaint: Pancreatitis, AMS, respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 55 year-old female with a PMH of HTN, PVD, seizure disorder, chronic pain on oxycodone, methadone, OSA who presented to an OSH on [**2150-3-6**] after being found stuporous with white foam and white poweder around her mouth at home. Her son, whom she lives with, reviewed her [**Date Range 4085**] boxes and verified that no medications were missing or overconsumed. EMS brought her to the ED and en route she was given Narcan with some effect. On presentation, she was found to be hypoxic to 74% on RA with rhonchi and had a Glascow of 4. She was noted to have a depressed mental status with an absent gag and some secretions at the glottic opening. She was intubated for airway protection (7.34/60/322). A CXR was performed and was negative for pneumonia per report. Her labs were significant for a lipase of 3882 and WBC of 15 and serum and urine tox were significant for positive TCA, methadone, and THC, but negative for tylenol, phenobarbital, and alcohol. Creatinine and LFTs were normal with a mildly elevated Alk phos. An EKG was also NSR. The differential was thought to include seizure versus aspiration vs overdose. She was transferred to [**Hospital1 18**] for further mgmnt and her ventilator settings at the time were Vt 500, 90% PEEP 5 RR 18. There was difficulty noted in weaning the FiO2. She was intermittently sedated with ativan. . On arrival, her VS were T 102.6 P 110 100%ra BP 170/100. She was intubated but awake and alert, following simple commands. A RSBI was performed and was 150, with a RR of 25 and Vt of ~200. She was also witnessed to aspirate. . Review of systems is otherwise unremarkable per report. Past Medical History: - pulmonary htn - OSA - pt refuses CPAP. - COPD - PFTs in [**6-20**] showed FEV1/FEV 87% predicted - AS - s/p AVR with 21mm [**Company 1543**] Mosaic valve [**2149-4-1**] ([**Doctor Last Name **]) - hypertension - high cholesterol - Crohn's disease since age 19, no surgeries, treated with prednisone off and on - prednisone induced hyperglycemia - gastritis/GERD, h/o GI bleed - one seizures in the setting of emesis in [**12-20**], no AEDs - basal cell skin cancer on nose - inflammatory [**Last Name **] problem periodically - pyoderma gangrenosum-on L calf and R ankle, tx with Prednisone - osteopenia - all teeth extracted secondary to prednisone - right arm arterial bypass when she presented with right arm pain and pulselessness Social History: completed 12th grade, currently on disability but formerly worked in an airplane factory, divorced, lives with son, active [**Name2 (NI) 1818**] - 1-1.5 ppd x 32 years. No drinking or drug use (IVDA). Family History: mother deceased age 62 of stroke, HTN, high chol, father deceased age 56 of MI and also had low back pain, sisters x 4 one with diabetes and neuropathy, one brother deceased (in army), and another alive with HTN, high chol, and prostate cancer, one son healthy. Physical Exam: T 102.6 P 110 100%ra BP 170/100 PHYSICAL EXAM GENERAL: intubated, agitated, awake, alert, responds to commands HEENT: Normocephalic, atraumatic, ETT. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. [**2-20**] ejection murmur at RUSB. No JVD. LUNGS: coarse B b/l. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: Follows commands. Moves all extremities. CN 2-12 grossly intact. Pertinent Results: [**3-9**] echo: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). There is no left ventricular outflow obstruction at rest or with Valsalva. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. A bioprosthetic 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 fully excluded due to suboptimal image quality. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal regional and global systolic function. Bioprosthetic AVR with higher than expected gradients. Endocarditis cannot be excluded on the basis of this study. Moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2150-3-8**], inferior hypokinesis is not seen on the current study. The apex is well seen and contracts normally. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. . CXR [**3-9**]: Left moderately severe left lower lobe atelectasis has progressed, mild interstitial edema is new accompanied by increasing small bilateral pleural effusions and increase in top normal heart size as well as congestion of the hilar and mediastinal vessels. ET tube, right internal jugular line, nasogastric tube in standard placements. No pneumothorax. . MRI head [**3-9**]: 1. No acute infarction. 2. Contour irregularity of the left middle cerebral artery, and some of the branches of the right middle cerebral artery with minimal decrease in caliber of the left middle cerebral artery in the interval since the prior study, with mild narrowing. Vasculitis related changes or other etiology cannot be excluded. Interventional neuorradiology consult can be consdiered for further management decision. 3. No flow-limiting stenosis or occlusion or aneurysm more than 3 mm within the resolution of MR angiogram. . CXR [**3-10**]: Lateral aspect of the right chest is excluded from the examination. Mild pulmonary edema and small right pleural effusion increased. Heart size top normal. Mediastinal venous engorgement unchanged. Left lower lobe largely airless probably due to atelectasis. ET tube, nasogastric tube and right internal jugular line in standard placements. No pneumothorax. . CXR [**3-12**] 1. Improved CHF. 2. Multifocal patchy and linear opacities in mid and lower lungs, many of which may be due to atelectasis, but coexisting pneumonia should be considered considering clinical suspicion for infection. 3. Right middle lobe atelectasis, for which followup radiographs are suggested to document resolution. 4. Small bilateral pleural effusions. . EEG [**3-9**] This is an abnormal portable EEG recording due to the background activity which was at times slow and disorganized and at other times showed a burst suppression pattern. These abnormalities are suggestive of encephalopathy. The first one of moderate encephalopathy and the second one with a more severe encephalopathy. The fact that the patient's background was viable throughout the recording is suggestive of the possibility of a better prognosis of encephalopathy. Metabolic disturbances, medications, infection, and ischemia are among the most common causes of encephalopathy. There are no clear epileptiform features seen in this recording. Of note is the tachycardia. Brief Hospital Course: 55 year-old female with a PMH of HTN, PVD, seizure disorder, chronic pain on oxycodone, methadone, OSA who presented with after being found down with inability to be roused by her son. . #. Acutely altered mental status: intubated for airway protection from MS changes, cause was unclear, possibilities included toxic metabolic encephalopathy, delirium, [**Month/Year (2) 4085**] effect (hx of seroquel, cyclobenzaprine, methadone, trazadone), seizure, CVA, infection (pancreatitis, aspiration pna, meningitis). She was prescribed seroquel on [**3-6**], tox screen positive for TCA (Duloxetine, cyclobenz, and seroquel can cause false positives), opiate (methadone hx), THC, and phenobarbital (in Donnatal), but negative for alcohol. Also hypercapnia in setting of COPD and aggravating factor also possible. She had no nuchal rigidity, photophobia, or focal neural deficits. Her sedatives were initially held, she was pancultures and treated for an aspiration pna, and her metabolic work-up was negative. Upon extubation, she continued to show an atypical affect, but was alert and oriented x3, and tolerating the reinitiation of her SSRI and percocet for pain. . The etiology of the episode was unclear, but thought possibly due to polypharmacy after EEG was negative, and MRI was without acute changes. Seroquel was discontinued as possible cause for decompensation. Given the episodes, she was advised not to drive until cleared by the neurologists. . #. Acute Hypoxemic respiratory failure: thought liklely respiratory acidosis with metabolic compensation at baseline secondary to COPD. CXR showed right base atelectasis and scant infiltrates. She was on stress dose steroids for airway and relative hypotension, as she was on budesonide at baseline. As above, she was intubated for respiratory failure, then extubated two days prior to transfer to floor, and demonstrated good respiratory mechanics. She was transferred to the floor with stable oxygen saturations on low O2 requirement (3L NC). Upon transfer, she was transitioned back to her budesonide dosing. She ultimately stabilized from a respiratory perspective, although she had a cough, and finding on her CXR of possible infiltrate. She was discharged to complete a course of levofloxacin. . #. Pneumonia: She presented with leukocytosis. CXR ultimately showed likely infiltrate. She was pan cultured, as above, her only positive cultures were GPC in her sputum. She was initially on vanco, levo, flagyl, then transitioned to levofloxacin as monotherapy, with plan to complete 7d course on [**3-14**]. . # EKG changes/?Takasubo's cardiomyopathy: while intubated on hospital day 2, pt was noted to have t wave inversions in 7 of 12 leads, predominantly in lateral leads, cardiac enzymes/troponin was elevated at OSH, cks flat upon admit here. Cardiology was consulted, bedside echo performed, with mild hypokinesis, concern for takayasu's cardiomyopathy, started on beta blockade, and mild diuresis while on ventilator. A repeat echocardiogram was performed, which showed improved systolic dysfunction without apical ballooning, but her EKG continued to show t wave inversions at discharge. She has close follow up with Dr. [**Last Name (STitle) 171**] for further evaluation. On his review of her echocardiograms, there was no apical ballooning seen. . # Acute renal failure: She developed acute renal failure while in the ICU, likely due to diuresis. She was rehydrated, her lisinopril was held, and her renal function was still elevated at baseline. Her urine eos were negative. Her Cr was still elevated at 1.2 at discharge, and her lisinopril was held until she sees Dr. [**Last Name (STitle) **]. . #. pancreatitis: Pt had elevated lipase secondary to possibly gallstone pancreatitis (alk phos elevated at 190), alcohol (though tox neg), or other less common etiologies such as hypertriglycerides, pancreatic carcinoma, medications, viral infections, abdominal trauma. Enzymatic analysis of pancreatitis resolved, pt denies abd pain on exam, and her diet was advanced without issue. . #. Crohns Disease: pt followed by Dr. [**First Name (STitle) 572**]; diagnosis was mainly symptom based with little objective evidence, on chronic budesonide. EGD and colonoscopy normal in 1/[**2150**]. . # chronic pain: She has a history of chronic pain and has been on methadone. Given concern for polypharmacy, the methadone was discontinued on discharge, and she was discharged on dialudid. . #. HTN: Patient's lisinopril and atenolol were initially held due to infection. . #. Obstructive sleep apnea: notes indicate pt use BiPap at home, pt refused to wear bipap in the icu. . #. Depression/anxiety: her anxiolytics were initially held in icu as per work-up of mental status changes, then restarted at lower doses upon transfer to floor. She was discharged on her home doses, and Dr. [**Last Name (STitle) 18529**] will continue to work with her on other anxiety management. She may consider psychotherapy as an outpatient, at a facility close to her home. . #. COPD: On baseline home O2 of 3L and has a long smoking history. She did not require oxygen at discharge, with O2 sat of 95% with ambulation, and will only use O2 at night. She was also urged to stop smoking. . # Follow up: Given the unclear etiology of the episode, she will have close outpatient follow up with Dr. [**Last Name (STitle) **] ([**3-24**]), Dr. [**Last Name (STitle) 171**] (first week of [**Month (only) 958**]), Dr. [**Last Name (STitle) 18529**] (psychiatry - 2 weeks) and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18530**]/[**Doctor Last Name **] of neurology. Dr. [**Last Name (STitle) **], precepting Dr. [**First Name (STitle) **], is aware of all events and will continue to coordinate care for this complex patient. . EMERGENCY CONTACT: HCP is sister: [**Name (NI) **] [**Name (NI) 18531**] at [**Telephone/Fax (5) 18532**] and secondary HCP is son [**Name (NI) 6644**] [**Name (NI) 18533**] at same #. . Medications on Admission: Albuterol inhaler 1-2puffs QID prn Atenolol 25mg daily Atorvastatin 20mg daily Budesonide 6mg daily Cyclobenzaprine 10mg TID prn Duloxetine 50mg [**Hospital1 **] Folic acid 1mg daily Abandronate 150mg monthly Lisinopril 20mg daily Methadone 5mg Q4H, 10mg QHS Nicotine patch 21 Pantoprazole 40mg [**Hospital1 **] Donnatal (phenobarbital/belladonna) Pregabalin 225mg [**Hospital1 **] Sucralfate 1g [**Hospital1 **] Sulfasalazine 1g TID Tiotropium 18mcg daily Trazodone 100-200mg QHS prn ASA 81mg daily Calcium 500mg [**Hospital1 **] Vitamin B12 100mcg daily Ferrous sulfate 160mg daily MVI Seroquel 6.125-12.5mg [**Hospital1 **] prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Fifty (50) mg PO BID (2 times a day). 13. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 14. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for muscle spasm. 15. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 16. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 17. Lyrica 75 mg Capsule Sig: Three (3) Capsule PO twice a day. 18. Boniva 150 mg Tablet Sig: One (1) Tablet PO once a month. 19. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*45 Tablet(s)* Refills:*0* 20. Nocturnal O2, 3L 21. Levofloxacin 500 mg daily, for 3 more days Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Acute altered mental status Acute respiratory failure EKG changes Chronic pain syndrome Severe anxiety Oxygen dependent COPD Obstructive sleep apnea Acute renal failure Discharge Condition: stable, tolerating diet, on home oxygen supplementation. Discharge Instructions: You were admitted after your son found you and could not awaken you. You were having trouble breathing, and needed to be intubated. You got agitated and were in the ICU for several days. Your MRI did not show an acute stroke, and your EEG did not show an obvious seizure. It is possible that the seroquel caused this problem, or some combination of all of your medications. . You should continue to talk to your doctors about your [**Name5 (PTitle) 4085**] regimen, which is extremly complicated, and may be causing problems. DO NOT DRIVE UNTIL YOU SEE THE NEUROLOGISTS. Do not change any of your medications without talking to your doctors. . You need a repeat chest xray . Return to the ED if you have trouble breathing, get confused or agitated again, develop high fevers or chills, or chest pain. . Changes to your medications: Seroquel was discontinued. Levofloxacin was added (for possible pneumonia). Followup Instructions: Provider: [**Name10 (NameIs) **],TEACHING [**Hospital **] CLINIC-CC2 (SB) Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2150-3-17**] 11:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2150-3-24**] 6:20 Provider: [**First Name8 (NamePattern2) 18534**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2150-3-30**] 9:00 . Repeat chest xray in [**3-18**] weeks. Repeat basic metabolic panel with Dr. [**Last Name (STitle) **].

Admission Date: [**2130-1-9**] Discharge Date: [**2130-1-12**] Date of Birth: [**2047-4-6**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is an 82 year old woman with bovine aortic valve on coumadin, breast cancer s/p lumpectomy and radiation now with ? fall and SAH. She lives in [**Hospital3 **] in [**Location (un) 47**] and went on an outing to Target. Upon returning to the bus she has little recollection of subsequent events. She thinks she may have fallen. It was likely unwitnessed. Unclear if there was LOC. SHe was taken to [**Location (un) 47**] where head CT revealed L temporal and R frontal SAH. No mass effect. She was given vitamin K 5mg and started on FFP. Transferred to [**Hospital1 18**] for further care. At present pt reports severe occipital headache, there is blood from her left ear. She denies difficulty producing or comprehending speech, though makes clear occasional paraphasic errors. Denies tingling, numbness or weakness. Past Medical History: HTN Bovine aortic valve replacement- done at [**Hospital1 112**] Left breast cancer- s/p lumpectomy, radiation (last dose ~3 weeks ago), planning to start chemotherapy with [**Hospital1 **] form (yet to start taking). ? atrial fibrillation- daughter is unsure of this. Diabetes Mellitus- on glyburide Social History: lives in [**Hospital3 **] Family History: noncontributory Physical Exam: PHYSICAL EXAM: O: T: 96.36 BP: 136/60 HR:72 R:18 O2Sats:98% Gen: comfortable, NAD. HEENT: blood at left ear, anicteric conjunctiva, OP clear Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: 1+ pitting LE edema, Warm and well-perfused. Neuro: Mental status: Awake and alert, oriented to "hospital." makes occasional paraphasic errors. She is inattentive and perseverative. gets stuck on Wednesday while naming DOW backwards. Naming of most objects intact, able to name hammock, but then paraphasia for "watch" calling it a completely nonsensical term. [**Location (un) **] is intact. No dysarthria. No apraxia. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-24**] throughout, but for [**4-24**] IP's bilterally. No pronator drift Sensation: Intact to light touch, pinprick and vibration bilaterally. No extinction to DSS. Reflexes: B T Br Pa Ac Right 1 0 1 0 0 Left 1 0 1 0 0 Toes tonically upgoing Coordination: normal on finger-nose-finger. Pertinent Results: CT: SAH layering in L anterior temporal lobe, small SAH in central sulcus on R high convexity. No masses or mass effect. CTA [**2130-1-9**]: 1. Evolving and slightly increased subdural and subarachnoid hemorrhage with no hydrocephalus. 2. New 14 mm left frontal intraparenchymal hemorrhage. 3. Mild atherosclerotic disease with no aneurysm or vascular malformation. 4. Large mass arising from the posterior aspect of the left thyroid lobe, which may represent a goiter, though should be correlated with clinical findings and would be amenable to ultrasound-guided biopsy if indicated. Brief Hospital Course: Pt was admitted to the ICU for close monitoring, her exam remained stable (baseline dementia) and she was transferred to floor. CTA was negative for vascular lesion. Her diet and activity were advanced. She had some drainage from right ear, this was monitored with guaze in ear which was dry [**2130-1-11**]. She was seen by PT/OT and recommended for rehab. Medications on Admission: Coumadin per INR Chemotherapy [**Name (NI) **] (unclear what medication, has not yet started) Metoprolol 25mg [**Hospital1 **] Sotalol 80mg [**Hospital1 **] Lipitor 10mg daily Lasix 40mg daily Potassium chloride 10meq daily Actos PO 15mg daily Glyburide PO 5mg daily Metformin 50mg [**Hospital1 **] Effexor 150mg [**Hospital1 **] Ambien 5mg QHS PRN Alprazolam 1mg daily Discharge Medications: 1. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic TID (3 times a day). 5. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): take until [**2130-1-19**]. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: traumatic subarachnoid hemorrhage Discharge Condition: stable Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc for one month. ?????? You were on a Coumadin (Warfarin) prior to your injury, remain off of this until follow up. CALL IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ??????Please call ([**Telephone/Fax (1) 2726**] to schedule an appointment with Dr. [**Last Name (STitle) 548**] to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Please make an appt to follow up with your PCP for follow up of your thyroid nodule and follow up of right ear drainage. Completed by:[**2130-1-12**]

Admission Date: [**2119-1-24**] Discharge Date: [**2119-2-2**] Date of Birth: [**2061-3-1**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: seizure/unresponsiveness SAH / L PCOMM aneurysm Major Surgical or Invasive Procedure: [**2119-1-24**]: Cerebral angiogram with coiling of L PCOMM aneurysm History of Present Illness: This is a 57 year old woman with a history of HTN who presented after ? of seizure and unconsciousness. She was brought to OSH where a head CT showed diffuse SAH and she was treated with ativan for a seizure. Per family, patient was complaining of n/v and headache on [**1-1**] in which she just took tylenol and felt better. Over the past week patient reported slight persistent headache unrelieved by tylenol. In the ED, she reported severe headache and R sided weakness. She denies any dysarthria or change in vision. Past Medical History: HTN, anemia, hysterectomy Social History: Lives husband, denies tobacco, +ETOH Family History: NC Physical Exam: On Admission: Hunt and [**Doctor Last Name 9381**]: 3 [**Doctor Last Name **]: 2 GCS E: 3 V:5 Motor:6 O: T:96.5 BP:151/85 HR: 60 O2Sats: 100% 2L Gen: WD/WN, comfortable, NAD. HEENT: atraumatic, normocephalic Pupils: 3-2mm bilaterally EOMs: intact, no nystagmus Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-11**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: L nasolabial flattening. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-13**] throughout. No pronator drift Sensation: Intact to light touch On Discharge: AOx3, [**Last Name (LF) 2994**], [**First Name3 (LF) 2995**], nonfocal, No drift Pertinent Results: CTA head [**2119-1-24**]: Head CT: Bilateral subarachnoid hemorrhage is noted with a small amount of blood pooling in both lateral ventricles as well as the thrid ventricle but without intraprenchymal component. There is no evidence of edema, mass, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. No fracture is identified. The paranasal sinuses and mastoid air cells are clear. Head and neck CTA: A bilobed aneurysm of 6 mm of greatest dimension is observed at the origin of the left posterior communicating artery. No other aneurysms or vascular malformations are identified. Otherwise, the carotid and vertebral arteries and their major branches are patent with no evidence of stenosis. The A1 segment of the right anterior cerebral artery and the P1 segment of the right posterior cerebral artery are absent, but the vessels of the circle of [**Location (un) 431**] as well as the major arteries of the anterior and posterior circulation enhaced normally and grossly symmetrically. IMPRESSION: 1. Bilateral subarachnoid hemorrhage with intraventricular but not intraprenchymal extension. 2. A bilobed aneurysm is identified at the origin of the left posterior communicating artery. 3. Congenitally absent A1 segment of right ACA and P1 segment of right PCA. Cerebral Angiogram [**2119-1-24**]: [**Known firstname **] [**Known lastname 122**] underwent cerebral angiography and coil embolization of a left posterior communicating artery aneurysm 3mm in diameter that was uneventful. TCDs [**2119-1-30**]: Results show normal velocities of the bilateral proximal middle cerebral arteries, anterior cerebral anteries, bilateral P2 segments of the PCA, distal cervical internal carotid arteries, and vertebral arteries, as well as the basilar artery. The waveforms of all vessels were normal. The pulsatility indices of all vessels were within normal limits. No emboli were seen. Impression: Normal TCD evaluation. There was no evidence of vasospasm in any vessel. BILAT LOWER EXT VEINS [**2119-2-1**] No evidence of DVT in right or left lower extremity Brief Hospital Course: Ms. [**Name13 (STitle) **] was admitted to the Neurosurgery service under the care of Dr. [**First Name (STitle) **] after a CT showed a SAH and L PCOMM aneurysm. She was admitted to the Neuro ICU. She was started on Nimodipine. She was taken to the INR suite and a cerebral angiogam was performed with coiling of the L PCOMM anuerysm. Post-angio she remained stable but still lethargic. On [**1-25**], she was more awake and her exam remained nonfocal. Her TCDs were normal. On [**1-26**], patient was up to a chair, c/o headache but no worse, TCDs were normal. On [**1-27**], her exam remained stable, there was a slight left pronator drift that seemed to be intermitant, but otherwise nonfocal exam. Patient Hed TCDS performed daily during her stay in the ICU withough evidece of vasospasm. She was transferred to the floor on [**1-31**]. On [**2-1**], patient remained stable, LENIS were done for screening purposes and were negative. On [**2-2**], patient was discahrged home after voiding appropriately and ambulating independently. Medications on Admission: HCTZ Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-9**] Tablets PO Q6H (every 6 hours) as needed for headache. Disp:*60 Tablet(s)* Refills:*0* 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for break through pain . Disp:*40 Tablet(s)* Refills:*0* 6. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO every four (4) hours for 11 days. Disp:*132 Capsule(s)* Refills:*0* 7. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO every four (4) hours for 1 days. Disp:*14 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Subarachnoid hemorrhage L PCOMM aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with MRI/MRA brain ([**Doctor Last Name **] protocol). Please call [**Telephone/Fax (1) 4296**] to make this appointment. Completed by:[**2119-2-2**]

Admission Date: [**2128-5-4**] Discharge Date: [**2128-5-7**] Date of Birth: [**2071-10-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: evaluation by interventional pulomonology Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: This is a 56 yo female with history of hypercapnic respiratory failure, s/p tracheostomy ([**2127-12-16**]), COPD, HTN, depression/anxiety being transferred from [**Hospital3 **] for evaluation by IP for tracheal stent. Per [**Hospital1 **] report the patient was admitted back in [**12-14**] after having a tracheostomy placed that month. She has been unable to wean off her vent which is presumably why she is being evaluated by interventional pulmonology. . At this time she reports being comfortable other than anxiety. She denies any recent illnesses. Per [**Hospital1 **] staff she had a PNA treated 2 mo ago. . Past Medical History: COPD s/p tracheostomy [**12-14**] h/o hypercarbic respiratory failure anxiety/depression Anemia Stress Incontinence HTN h/o rectal sheath hematoma . Social History: Divorced. Living at [**Hospital1 **] since [**12-14**]. Smoked cigarettes for 20yrs and quit 4 yrs ago. No history of ETOH or illicit drug use. . Family History: No lung disease Physical Exam: GENERAL: anxious, cushingoid appearing female, NAD HEENT: NC/AT, OP clear, MMM CARDIAC: s1/s2 present, no murmurs LUNG: scattered expiratory wheezes ABDOMEN: +BS, soft, non-tender, non-distended EXT: [**2-7**]+ bilateral LE edema NEURO: AOx3, 5/5 strength in all 4 ext DERM: no skin lesions Pertinent Results: ADMISSION LABS: [**2128-5-4**] 11:27PM BLOOD WBC-12.2* RBC-3.19* Hgb-9.1* Hct-29.4* MCV-92 MCH-28.7 MCHC-31.2 RDW-14.0 Plt Ct-341 [**2128-5-4**] 11:27PM BLOOD PT-12.6 PTT-26.4 INR(PT)-1.1 [**2128-5-4**] 11:27PM BLOOD Glucose-175* UreaN-24* Creat-1.2* Na-140 K-3.2* Cl-86* HCO3-46* AnGap-11 [**2128-5-4**] 11:27PM BLOOD Theophy-5.6* DISCHARGE LABS: [**2128-5-7**] 04:01AM BLOOD WBC-8.7 RBC-2.82* Hgb-8.5* Hct-26.2* MCV-93 MCH-30.1 MCHC-32.4 RDW-14.2 Plt Ct-367 [**2128-5-7**] 04:01AM BLOOD Glucose-84 UreaN-23* Creat-0.9 Na-140 K-3.7 Cl-86* HCO3-48* AnGap-10 [**2128-5-6**] 01:51PM BLOOD Type-ART Rates-/14 Tidal V-400 FiO2-100 pO2-77* pCO2-93* pH-7.38 calTCO2-57* Base XS-24 AADO2-553 REQ O2-90 Brief Hospital Course: This is a 56 yo female with history of COPD, s/p tracheostomy, anxiety/depression with suspected tracheobronchomalacia being evaluated for tracheal stent. . ## Failure to Wean from Vent: Bronchoscopy by interventional pulmonology showed severe laryngeal stenosis and edema involving the supraglottic and subglottic region. There was only a mild degree of tracheobronchomalacia but no airway obstruction,significant amount of secretions or other endobronchial lesions. Interventional pulmonology did not feel there was significant airway pathology to explain the patient's failure to wean off the ventilator. They also felt that given the degree of laryngeal edema and stenosis it is unlikely she will ever decannulate. It is suggested she begin a PPI [**Hospital1 **] and head of the bed elevated. . ## COPD: Patient wheezy with reduced air movement on admission. She was started on a prednisone taper 40mg daily which we suggest continuing until [**2128-5-12**]. Continued on outpatient regimen of theophylline, fluticasone, ipratropium/albuterol, alb PRN. A theophylline level was checked and was 5.6. . ## HTN: BP remained stable. She was continued on amlodipine and metoprolol . ## Depression/Anxiety: Continued on paroxetine, abilify, ativan. Given significant anxiety would consider uptitrating paroxetine and having her see a psychopharmacologist for management of this condition. . ## Contraction Alkalosis: Patient will contraction alkalosis on admission. Furosemide reduced from 80mg [**Hospital1 **] to 80mg daily. Patient was a full code on this admission. Medications on Admission: Theophylline 200mg [**Hospital1 **] Ditropan XL 5mg daily Prevacid 30mg daily Paroxetine 40mg daily Amlodipine 10mg daily MVI Flovent 220 4 puffs [**Hospital1 **] Combivent 4 puffs Q4 Metoprolol tartate 50mg [**Hospital1 **] Calcium and Vit D Ativan 1mg qHS, 0.5mg [**Hospital1 **] Loratidine 10mg daily Abilify 4mg daily Ambien 10mg qHS Bactrim DS 1 tab [**Hospital1 **] Lasix 80mg [**Hospital1 **] KCl Discharge Medications: 1. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID (2 times a day). 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for Shortness of breath. 3. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). 11. Aripiprazole 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 13. Ditropan XL 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 14. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 5 days: last day [**2128-5-12**]. 17. Potassium Chloride Oral 18. Calcium 500 + D (D3) Oral 19. Flovent HFA 220 mcg/Actuation Aerosol Sig: Four (4) Inhalation twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: 1.Mild tracheobronchomalacia 2.Severe laryngeal stenosis and edema 3.Chronic Obstructive Pulmonary Disease 4.Hypertension 5.Anxiety Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were transferred to [**Hospital1 18**] for evaluation of your tracheobroncheomalacia. You underwent bronchochoscopy that showed mild tracheobronchomalacia so tracheal stent placement was not indicated. . We did determine that you had bronchospasm and were started on a 7 day prednisone taper. . We started the following new medications: --Prednisone 40mg daily taper ([**Date range (1) 86208**]) --Omeprazole 40mg twice a day Changes to your medications: --Furosemide reduced to 80mg daily Followup Instructions: You should follow up with your pulmonologists at rehab. We do suggest you make an appointment with a psychiatrist to discuss your current medications for anxiety as this is not well controlled. Completed by:[**2128-5-7**]

Admission Date: [**2183-9-8**] Discharge Date: [**2183-9-12**] Date of Birth: [**2108-1-7**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Lorazepam Attending:[**First Name3 (LF) 2704**] Chief Complaint: Transferred for carotid stenting Major Surgical or Invasive Procedure: Percutaneous placement of stent in left internal carotid History of Present Illness: 75M h/o PVD, small cell lung CA with left neck mass s/p radiation, and symptomatic bilateral carotid stenoses (90% left, totally occluded right) transferred from OSH for percutaneous carotid stenting. He has had several recent "drop attacks" considered to be TIAs. He has had several months of transient light-headedness associated with a feeling of his 'legs giving out' followed by syncope. These episodes have been becoming more frequent recently. Last week he underwent carotid U/S which revealed progression of left carotid disease to >70%. The patient was scheduled for an elective carotid endarterectomy today at [**Hospital6 33**] that was cancelled as he was deemed a poor surgical candidate due to multiple comorbidities. He was started on plavix, given IVFs and mucomyst for renal protection, and transferred to [**Hospital1 18**] for percutaneous carotid stenting. Past Medical History: h/o metastatic small cell lung CA s/p left neck lymph node dissection, chemotherapy (6 cycles VP-16 and platinol), and radiation (436 [**Doctor Last Name 352**], [**2171**]) h/o colon CA s/p right hemicolectomy and chemotherapy (5-FU and levamisole, [**2174**]) CRI (baseline Cre 2.0) Bilateral carotid stenoses (90% left, totally occluded right) h/o TIAs PVD s/p left fem-[**Doctor Last Name **] bypass and right-to-left fem/fem bypass Early dementia (short term memory loss) HTN PAF GERD s/p cataract surgery DJD h/o difficult intubation [**3-7**] radiation and neck resection Social History: Social history is significant for the absence of current tobacco use although he is a former smoker (quit 20 years prior). There is no history of alcohol abuse. Married, lives with his wife. [**Name (NI) **] is active at baseline. Family History: There is a family history of premature coronary artery disease in his father at age 50. There is also a history of diabetes in his father, mother, and sister. Physical Exam: VS - T 95.1 HR 60 BP left 203/64 right 121/91 RR 16 SpO2 96%/RA Gen: Weathered elderly male, 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. Poor dentition. No pain on palpation of oral mucosa or jaw and no palpable fluid collection. Neck: Supple with JVP of 8 cm. 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 unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Well-healed midline abdominal scar. Ext: No c/c/e. Warm. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: Strength 5/5 in upper a lower extremities, sensation intact to light touch throughout, no dysmetria, CN II-XII intact . Pulses: Right: Carotid absent Radial 1+ Popliteal absent DP dopp Left: Carotid 2+ Radial 2+ Popliteal absent DP dopp Pertinent Results: Admission labs: [**2183-9-8**] 05:30PM BLOOD WBC-8.0 RBC-4.08* Hgb-13.2* Hct-38.0* MCV-93 MCH-32.2* MCHC-34.7 RDW-14.2 Plt Ct-192 [**2183-9-8**] 05:30PM BLOOD PT-11.7 PTT-28.6 INR(PT)-1.0 [**2183-9-8**] 05:30PM BLOOD Glucose-89 UreaN-27* Creat-1.9* Na-140 K-4.1 Cl-107 HCO3-25 AnGap-12 [**2183-9-8**] 05:30PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.3 . Discharge labs: . EKG demonstrated NSR, Q-waves III/aVF, <1mm ST depression V5-6 with no significant change compared with prior dated [**2182-8-28**]. . 2D-ECHOCARDIOGRAM performed on [**5-/2180**] demonstrated: EF 60-65%, trace MR, 2+ TR . ETT performed on [**2182-8-24**] demonstrated: No chest pain or significant ECG changes. . Bilateral duplex carotid U/S ([**2183-9-5**]): Right total occlusion, Left >70% stenosis. . Brief Hospital Course: The patient is a 75 y/o man w/ bilateral critical carotid stenosis (Right completely occluded and left>70% occluded) who had a history oif multiple TIAs and drop attacks, who was transferred from an outside hospital for percutaneous carotid stenting. He was transfered for percutaneous intervention as he was a poor operative candidate secondary to multiple medical comorbidities. He was initially admitted to the floor prior to the procedure. Post-procedure, he was transfered to the CCU. He had a drug eluuting stent placed in his left ICA without complications. On his first night post procedure, he was put on a neo drip for SBP in the 90s. The neo was discontinued 24 hours later. He also received fluid boluses with good response. The patient had a bruit in his right groin area and an ultrasound was obtained, which showed no pseudoaneurysm or hematoma. This bruit might have been old and related to his extensive atherosclerotic disease. His hematocrit dropped during his hospitalization by about 8 points. Hemolysis laboratories were negative and he was guaiac negative. CT abdomen and pelvis was negative for bleed. He received one unit PRBCs and did well post transfusion. His hematocrit was stable prior to discharge. For two days after his stent, he was somewhat bradycardic and hypotensive. This might have been due to autonomic disregulation due to carotid barorreceptor manipulation. By the third day, his compensatory responses had normalized. Physical therapy evaluated him and he was discharged home with PT services and VNA services. His neurologic exam remained normal throughout hospitalization. His Aricept was discontinued as it is a drug known to cause bradycardia and orthostasis. It was recommended that he undergo posterior circulation evaluation as an outpatient. Medications on Admission: HOME MEDICATIONS: Amoxicillin 500mg [**Hospital1 **] Zocor 20mg daily Aricept 10mg qhs Toprol XL 50mg daily Aspirin 325mg daily . TRANSFER MEDICATIONS: Plavix 300mg once Mucomyst 600mg po once Aspirin 325mg daily Amoxicillin 500mg [**Hospital1 **] (2 more days for dental abscess) Toprol XL 50mg daily Aricept 10mg daily Zocor 20mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Start taking this medication [**2183-9-14**]. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Carotid stenosis (bilateral) S/p stenting left internal carotid Discharge Condition: Good. No pain. No weakness or dizziness. Ambulatory. Discharge Instructions: You were transferred to this hospital because the blood vessel that carries blood to your brain was critically narrow. The blood vessel was kept open by means of a stent. The procedure had no complications. Please note that you should not take the medicine called metoprolol (toprol XL) for 2 days. After that, you must begin taking it as before. You must also take the rest of your medications as prescribed from the moment of discharge. You are taking a new medication called plavix (clopidogrel) Please see your primary care doctor within 4 days of discharge. Also, call your doctor or return to the Emergency Department if you experience any more drop attacks, chest pain, shortness of breatth, bleeding, weakness, or any other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4022**] Follow-up appointment [**9-23**], 3PM [**Hospital Ward Name 23**]-7, [**Hospital1 18**] Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 18368**] Call to schedule appointment, [**2187-9-23**]:10 AM ([**Street Address(1) **], Waymouth)

Admission Date: [**2194-4-21**] Discharge Date: [**2194-5-9**] Date of Birth: [**2153-9-29**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: ICH Major Surgical or Invasive Procedure: Right hemicraniectomy with evacuation of clot L EVD placement PEG placement History of Present Illness: The pt is a 40 y/o man who presents as an OSH transfer after being found to have a large right sided IPH.He showed up at [**Hospital **] hospital around 10pm with complaints of headaceh and left sided weakness. He was found to have left hemiplegia and a Ct was done which showed a large IPH on the right side. He was also noted to be hypertensive to at least 225 over 133. he was elactively intubated with fentanyl, succs. For his hypertension he recieved labetolol. he also received lasix and 50grams of mannitol. On transfer he was on a nipride gtt and versed gtt intubated.No family at bedise at that time to get more information. Past Medical History: HTN, Psoriasis, CVA? Social History: Unknown Family History: Unknown Physical Exam: Physical Exam: Vitals: T: P: 70 R: 18 BP: 165/118 SaO2:100% General: Intubated. Not on sedation. Pulm: Some light crackles bilaterally CVL: RRR, with systolic flow murmum Ext: no edema. Neurologic: Intubated. Eyes closed not opening to voice or pain. Pupils pinpoitn at 2mm with very very minimal reaction. Dolls present. Positive corneals bilaterally. No gag noted, no cough noted. LUE flacid. LLE triple flexion. RUE Postures. RLE spontaneous flexion at the knee. upgoing toes bilaterally. Physical Exam upon discharge: eyes open to voice/minimal stimulation alert to self PERRL following simple commands with R UE and LE. moves both spontaneously. L UE hemiparesis, extends to noxious stimuli L LE withdraws Incision- well healing. no sign of infection Pertinent Results: Laboratory Data: 135 97 15 168 AGap=16 2.5 25 0.8 7.45 pCO245 pO2368 HCO332 11.9 14.8 228 PT: 14.3 PTT: 22.3 INR: 1.2 Fibrinogen: 414 UA negative Serum tox negative Radiologic Data: NCHCT [**2194-4-21**]: Intraparenchymal hemorrhage centered in the R basal ganglia measuring approx 7.3 x 4.1 cm, similar in size to the OSH study. Interval increase in the intra-ventricular extension of the bleed. Sub-falcine herniation, with stable to minimal increase in the leftward shift of midline structures. Mass-effect on the third ventricle with mild dilation of the lateral ventricles. CT brain [**4-22**] - 1. Stable large hematoma centered in the right basal ganglia, with stable intraventricular extension. Stable mass effect. Stable size of the ventricles. 2. S/p right parietal craniectomy with a small right extraaxial hematoma, as before. 3. Hypodensities in the left subinsular white matter could represent chronic small vessel infarcts, unusual for age. Please correlate with risk factors. If clinically indicated, they may be further assessed by contrast-enhanced MRI to exlude other etiologies, when the patient is stabilized. CT brain [**4-23**] - 1. Large right basal ganglionic hematoma with intraventricular extension and surrounding vasogenic edema, unchanged in size and appearance from most recent study, with stable size of ventricles. 2. Leftward shift of normally-midline structures appears slightly worse when compared to the most recent study, some of which may be due to differences in plane of scanning. 3. Status post right parietal craniectomy, with small right extra-axial hematoma is unchanged. [**4-24**] Renal U/S - Bilateral renal calcifications. Overall, the pattern is suggestive of medullary nephrocalcinosis. In the right lower pole, a partially calcified cyst or stones within a caliceal diverticulum are also seen. No solid mass is identified. Normal renal Doppler, with resistive indices ranging from 0.64-0.69 in the right and 0.69-0.77 on the left. [**4-26**] CT brain - 1. Right basal ganglia intraparenchymal hematoma, surrounding edema and mass with shift of midline structures similar to the prior study. 2. Left frontal approach EVD in stable position terminating in the left caudothalamic groove. 3. Mild interval decrease in the intraventricular hemorrhage.Ventricular size not significantly changed. [**2194-4-28**] CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: Included lung bases are clear and there is no pleural or pericardial effusion. No focal masses are noted within the adrenal glands which display symmetrical, slightly increased thickening bilaterally, which may reflect a component of hyperplasia with no additional masses noted along the sympathetic chain including in the expected location of the organ of Zuckerkandl. Limited evaluation of the liver, gallbladder, spleen, pancreas, stomach, and bowel appear unremarkable. A post-pyloric feeding tube is in place with its tip terminating at the third portion of the duodenum. Dense medullary calcification is present within the kidneys. In addition to some cysts within the medulla, the largest within the left lower pole measuring 14 x 14 mm. Normal excretion of contrast is noted within the collecting systems. No free air, free fluid, or pathologically enlarged lymph nodes are present. No significant atherosclerotic plaque is noted near the origins of the renal arteries to suggest any underlying stenosis. BONE WINDOWS: No aggressive osseous lesions are noted. IMPRESSION: 1. No focal adrenal masses or findings of adrenal/extra-adrenal paraganglioma. Mild symmetrical thickening to the adrenal glands may suggest a component of underlying hyperplasia. 2. Bilateral medullary nephrocalcinosis with imaging appearance most suggestive of medullary sponge kidney, with differential including renal tubular acidosis or hyperparathyroidism. [**2194-4-30**] BUE dopplers: IMPRESSION: No DVT in either upper extremity [**2194-4-30**] CTA Head:IMPRESSION: 1. Stable appearance of a right basal ganglia parenchymal hemorrhage with ventricular extension. Slight increase in anterior parenchymal edema is seen, with suggestion of increased transcranial herniation at the anterior aspect of the craniectomy site. 2. No vascular stenosis, aneurysm, dissection, or malformations seen. There is no active contrast extravasation (so-called "CTA spot sign"). [**5-1**] CT Head: IMPRESSION: No interval change of a right basal ganglia hematoma, with neighboring edema or evolving infarction, local mass effect, intraventricular extension, and mild transgaleal herniation through the craniectomy site. [**5-3**] CT Head: IMPRESSION: Status post removal of the ventricular drain without change in ventricular size or brain compared with the prior CT from [**2194-5-1**]. [**5-5**] LENIS: IMPRESSION: No evidence of deep vein thrombosis in either leg. [**2194-5-9**] 06:45a 138 103 57 104 AGap=14 4.3 25 1.0 Ca: 9.3 Mg: 2.7 P: 6.2 Brief Hospital Course: Pt was brought immediately to the OR for hemicraniectomy and evacuation of clot. Post-operatively his exam showed localizing on the right and left plegic. He had EVD placed at bedside with high ICP upon insertion. [**4-22**] Records were obtained from a previous admission [**1-6**] to [**Hospital **] hospital that indicated a previous hospitalization for hypertensive emergency resulting in a right [**Doctor First Name **] Ganglia hemorrhage. Exam is somewhat improved on this mornings exam with intermitant commands. EVD was raised to 15 after review of CT that shows the left lateral ventricl to be collapsed. A fever work up has been initiated for fevers and elevated WBC. [**4-23**] Oral antihypertensive meds were increased to wean off the IV nicardipine. Patient was febrile and was pancultured. Overnight, he remained febrile and on [**4-24**] CSF cultures were sent and were essentially negative for growth. Sputum Culture was positive for multiple organisms and as a result pt was started on vanc/cef. On [**4-25**] he was extubated without incident and respiratory status has remained unchanged during his ICU course. He continued to remain stable during is ICU course and received tPA through EVD daily. He became febrile on [**4-28**] and CSF was sent which showed some PMNs. Additionally, his EVD was increased to 20 cm H20 and his ICPs continued to remain stable. Overnight he remained afebrile. His serum NA was 150 and he was given free water with good effect. Later in the day, it was noted that the distal portion of the EVD tubing had air and his system was changed out. On [**4-29**], his EVD was raised again to 25cm. His serum NA was stable. He was afebrile overnight. Coreg was increased and he was given a dose of Lasix 20mg. He underwent his PEG placement on [**2194-4-29**]. His feeds were started on [**4-30**] and tolerating. On [**5-1**], he remained stable with his EVD clamped. A head CT was done whcih showed no evidence of ventricular enlargement after clamping of his EVD. He remained stable without ICP spikes and on 5.6 his EVD was removed and a stitch placed. He was transferred to the SDU for further montioring ojn the evening of [**5-2**]. he remained stable voernight and on [**5-3**] he had a temperature of 101 and urine was sent for testing. On [**5-4**] he was evalauted by renal medicine regarding his Sponge Kidney and recommendations for 24 urine metanephrines and increasing free water through his PEG were recieved. On [**5-5**] screening LENI's were negative and free water was again increased per renal. On [**5-6**] repeat 24hr urine revealed increased Na so his free water was increased. On [**5-7**] he was neurologically stable. Free water was decreased and increased per renal recs and serum Na's. On [**5-8**] the patient's hypernatremia continued to resolve. His IVF was discontinued and he was continued on 400ml of free water. Overnight his tube feed residuals were high so tube feeds were held. He was started on reglan to stimulate gastric motility. Feeds were restarted at 6 AM on [**5-9**]. He remained neurologically stable overnight and was cleared for discharge in the AM. Medications on Admission: unknown Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) Solution PO Q6H (every 6 hours) as needed for pain or fever >100.4. 4. insulin regular human 100 unit/mL Solution Sig: per SS Injection ASDIR (AS DIRECTED). 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 6. levetiracetam 100 mg/mL Solution Sig: Ten (10) ml PO BID (2 times a day). 7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for puritis. 9. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Reglan 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Left intraparenchymal hemorrhage Obstructive Hydrocephalus Intraventricular hemorrhage Intracranial hypertension Hypertension Fever Left hemipalegia Dysphagia Acute respiratory failure Hypernatremia Spongy renal disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury,do not resume these until cleared by your surgeon. ??????You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: *** Please follow up with Dr [**First Name (STitle) **] in 3 weeks with a non-contrast head CT. This can be scheduled by calling [**Telephone/Fax (1) 1669**]. *** Please call the [**Hospital 2793**] Clinic to make a follow up for your Completed by:[**2194-5-9**]

Admission Date: [**2168-5-30**] Discharge Date: [**2168-6-6**] Date of Birth: [**2122-2-2**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old man with known anomalous right superior pulmonary vein draining into the superior vena cava. Magnetic resonance imaging scan performed on [**2167-10-14**] showed an ejection fraction of 60 percent with hypokinesis of the right ventricle. His QP/QS was 1.7 consistent with a significant intracardiac shunt. A catheterization was performed on [**2168-5-18**] which showed normal coronary arteries and again an anomalous pulmonary vein. PHYSICAL EXAMINATION: His blood pressure was 120/80, heart rate was 70 and regular, and he had a 2/6 systolic murmur. Lungs were clear bilaterally. Abdomen was slightly obese, but soft and nontender. No masses palpable. Neurological exam was normal. He had palpable lower extremity pulses and no lower extremity edema. LABORATORY FINDINGS: Potassium was 4.1, sodium was 134, chloride 100, BUN 13, creatinine 1.0, calcium 8.9, white blood count 8900, and hematocrit was 43 percent. PAST MEDICAL HISTORY: Significant for diabetes mellitus and he is being treated with oral medication. After the different treatment options were explained to the patient and his wife, they elected to proceed with repair of the anomalous pulmonary vein. This was performed on [**2168-5-30**]. At that time, a baffle was created between the anomalous pulmonary vein and the foramen ovale. This was performed using glutaraldehyde-treated autologous pericardium. Postoperatively, he had some problems with pain control and had atrial fibrillation, but this was converted to sinus rhythm prior to discharge. At the time of discharge, he is ambulating without assistance. He is tolerating a regular diet. He is to see Dr. [**Last Name (STitle) **] in 2 weeks in followup and Dr. [**Last Name (STitle) **] also in 2 weeks. DISCHARGE DIAGNOSES: Anomalous right superior pulmonary vein. Congestive heart failure. Diabetes mellitus. Chronic cough. Status post repair of anomalous pulmonary vein. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern1) 5297**] MEDQUIST36 D: [**2168-6-29**] 10:15:04 T: [**2168-6-29**] 20:44:13 Job#: [**Job Number 47111**]

Admission Date: [**2116-8-25**] Discharge Date: [**2116-9-9**] Date of Birth: [**2033-2-2**] Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1835**] Chief Complaint: S/P Fall with facial fractures and right sided subdural hematoma Major Surgical or Invasive Procedure: PEG Placement [**9-4**] Upper Endscopy [**2116-9-6**] History of Present Illness: Ms. [**Known lastname 7931**] is an 83 year old woman with late stage Parkinson's disease who fell at home today sustaining facial fractures and R Subdural hematoma. Her husband reports he was at home with his wife today and found it odd she did not hang the phone back onto the receiever following a conversation with her daughter in the living room. While placing the phone on the receiver he heard a thud in the kitchen and found his wife on the floor. She was conscious, able to speak and follow commands. Copious hemorrhage from her face and nares. Was taken to [**Hospital3 **], found to have SDH and facial fractures. Transferred to [**Hospital1 18**] for further care. The patient is unable to provide a reliable history of events. She denies any headache. She denies any weakness numbness or tingling. She does not provide a reliable ROS. Per husband and daughter, no recent F/c or NS. no cough, no SOB, no CP. no diarrhea. no N/V. She does have intermittent dysphagia chronically. chronic urinary incontinence. no bowel incontinence. Past Medical History: Parkinson's disease- cared for by Dr. [**Last Name (STitle) **] at [**Hospital1 18**]. Urinary incontinence osteoporosis compression spine fractures eczema/psoriasis Social History: Former telephone operator who lives at home and uses a cane to walk. Husband does cooking and cleaning. Pt requires some assist with bathing and dressing. quit tobacco 30 years ago with 10 pack year history. no current ETOH use. Family History: Noncontributory Physical Exam: Vitals T 98.7, HR 78, BP 160/70, R 16, 100% 2LNC Gen- on ED gurney with hard collar, facial trauma, attends only briefly to examiner. HEENT: Right facial hematoma, anicteric sclera. Neck: in c collar, attempted to clear following review of CT scan and pt report mid-C-spine pain with head rotation. Hard collar was replaced. CV- RRR, no MRG Pulm- CTA B ABd- soft, NT, ND, BS+ Extrem- no CCE, warm, well perfused. Neurologic Exam: MS- she is unable to describe where she is. unable to choose from a list of places. Her speech is fluent, "I'm doing okay doctor, I'm fine." She does not answer questions appropriately. + Inattention. Follows few appendicular commands intermittently. CN- PERRL 3-->2mm bilat, R eye edematous and difficult to visualize. Gaze appears conjugate. lateral versions intact. would not cooperate with inferior or superior gaze. R facial edema/hematoma resulting in asymmetry. She is able to smile with reasonable symmetry. sensation is intact to LT. palate elevates symmetrically. Motor- no pronator drift. L > right cogwheel rigidity. + resting tremor. Holds arms and legs antigravity to command. Sensory- intact to light touch. difficult to reliably assess given inattention. Plantar response was extensor bilaterally Reflexes: 2+ symmetric at [**Hospital1 **], tri, brachirad, patellars 3+, abent ankle jerks. Gait: deferred on discharge: AOx2,PERRL, Spontaneous movement in all extremties, intermittant commands(pt [**Name (NI) **] Pertinent Results: Cardiology Report ECG Study Date of [**2116-8-25**] 4:59:18 PM Sinus rhythm. Baseline artifact. No previous tracing available for comparison. Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K. Intervals Axes Rate PR QRS QT/QTc P QRS T 80 178 90 366/401 63 -10 43 [**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2116-8-25**] 4:57 PM [**Last Name (LF) 4174**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2116-8-25**] 4:57 PM CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 65112**] Reason: eval for fx, bleed [**Hospital 93**] MEDICAL CONDITION: 83 year old woman with fall ?Lefort fracture, SDH vs. epidural REASON FOR THIS EXAMINATION: eval for fx, bleed CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: GWp TUE [**2116-8-25**] 8:19 PM R likely SDH No significant shift Complex facial fractures Final Report INDICATION: 82-year-old woman with fall, query subdural hematoma versus epidural. COMPARISON: [**2115-12-26**]. TECHNIQUE: Non-contrast head CT. FINDINGS: There is a 7-mm wide crescentic extra-axial hyperdense collection layering over the right cerebral convexity, compatible with an acute subdural hematoma. There is no significant shift of midline structures. There is no mass effect or edema. Ventricles, sulci, and cisterns are similar to prior. Basal cisterns are preserved. Periventricular white matter hypodensity is likely the sequela of chronic small vessel ischemic disease. There is a left frontal cephalohematoma with subcutaneous gas seen (series 2, image 18). There are comminuted fractures of the right lamina papyracea and floor of the right orbit, with extensive subcutaneous and retroorbital gas, proptosis, and periorbital hematoma. A depressed fracture fragement from the orbital floor fracture is seen within the right maxillary sinus, but without entrapment of the inferior rectus muscle. Comminuted fractures of both nasal bones, as well as the anterior, medial, posterior, and lateral walls of the right maxillary sinus are present. The frontal process of the right zygoma also demonstrates comminuted fractures.The left maxillary sinus also demonstrates comminuted fractures of the lateral and medial walls. Minimally displaced fractures of the medial and lateral plates of the pterygoid processes bilaterally are fractured. Both orbits remain intact. For further details, see the CT of the facial bones. High- attenuation fluid is seen in both maxillary and ethmoid sinuses consistent with hemorrhage. IMPRESSION: 1. Right subdural hematoma layering over the right cerebral convexity without midline shift. 2. Extensive complex facial fractures. Refer to the CT facial bones. 3. Right frontal subgaleal hematoma. [**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**] Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2116-8-25**] 7:03 PM [**Last Name (LF) 4174**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2116-8-25**] 7:03 PM CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 65113**] Reason: FALL, ? FX [**Hospital 93**] MEDICAL CONDITION: 83 year old woman with fall REASON FOR THIS EXAMINATION: eval for fracture CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: Fall. COMPARISON: None available. TECHNIQUE: MDCT axial images were obtained from the base of the skull through T1 without intravenous contrast. Multiplanar reformats were derived. FINDINGS: There is no acute fracture of the cervical spine. Exaggerated lordosis of the cervical spine is present, without subluxation. The atlantodental and craniocervical junctions are normal. The central canal is patent. There is prominence of the soft tissues in the nasopharynx posteriorly (series 200B, image 31). Otherwise, prevertebral tissues are unremarkable. The dens appears normal. Lateral masses of C1 well seated on C2. There is [**Hospital1 **]- apical scarring within the lungs. Calcification of the cervical carotid arteries bilaterally is present. Multiple facial fractures are redemonstrated, better characterized on concurrent facial bone CT. IMPRESSION: 1. No acute fracture or subluxation of the cervical spine. 2. Prominence of posterior nasopharyngeal tissues. Recommend direct visualization. 3. [**Hospital1 **]-apical scarring. The study and the report were reviewed by the staff radiologist. [**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**] Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2116-8-25**] 7:11 PM [**Last Name (LF) 4174**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2116-8-25**] 7:11 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # [**Clip Number (Radiology) 65114**] Reason: FALL, ? INJURIES. Field of view: 36 Contrast: OPTIRAY Amt: 130 [**Hospital 93**] MEDICAL CONDITION: 83 year old woman with fall REASON FOR THIS EXAMINATION: eval for chest trauma CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: GWp TUE [**2116-8-25**] 8:26 PM Mult T L spine compression deformities Distended bladder w/Foley balloon inflated in urethra / vagina Final Report INDICATION: Fall. COMPARISON: None available. TECHNIQUE: Multiple MDCT axial images were obtained from the base of the neck through the proximal thighs after the uneventful administration of 130 cc of Optiray intravenously. Enteric contrast was not administered. Multiplanar reformats were derived. CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The thyroid enhances homogenously. There is no axillary or mediastinal lymphadenopathy. The pulmonary artery is normal in caliber. The aorta is normal. The heart is normal in size. There is no pericardial effusion. There are coronary artery calcifications. There is a moderate-sized hiatal hernia. Central airways are patent to the level of subsegmental bronchi. There is no pulmonary mass, pleural effusion or pneumothorax. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder, and spleen appear normal. The pancreas is atrophic. The kidneys symmetrically take up and excrete contrast without hydronephrosis. A subcentimeter renal hypodensities are too small to characterize and likely represent benign cysts. The adrenals are unremarkable. Abdominal loops of bowel are unremarkable. There is no abdominal free air, free fluid, or pathologic lymphadenopathy. The abdominal aorta is normal in caliber and contour but demonstrates prolific atherosclerotic calcifications. CT OF THE PELVIS WITH CONTRAST: The bladder is distended. A Foley is malpositioned with the balloon abnormally inflated in the urethra. The uterus and adnexa are unremarkable. There is no pelvic free air or free fluid, or pathologic lymphadenopathy. MUSCULOSKELETAL: There is no suspicious osteolytic or osteoblastic lesion. There is vertebra plana at T9 and mild compression deformities at L1 and L4. There is mild anterolisthesis of L5 on S1. IMPRESSION: 1. Malpositioned Foley balloon catheter in the urethra. 2. Multiple thoracolumbar compression deformities. Grade 1 anterolisthesis of L5 on S1. These are age indeterminate. Correlate clinically. 3. Moderate sized hiatal hernia. 4. Coronary artery calcifications. 5. Bilateral renal hypodensities, possibly renal cysts. [**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**] Radiology Report CT CHEST W/CONTRAST Study Date of [**2116-8-25**] 7:11 PM [**Last Name (LF) 4174**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] EU [**2116-8-25**] 7:11 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # [**Clip Number (Radiology) 65114**] Reason: FALL, ? INJURIES. Field of view: 36 Contrast: OPTIRAY Amt: 130 [**Hospital 93**] MEDICAL CONDITION: 83 year old woman with fall REASON FOR THIS EXAMINATION: eval for chest trauma CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: GWp TUE [**2116-8-25**] 8:26 PM Mult T L spine compression deformities Distended bladder w/Foley balloon inflated in urethra / vagina Final Report INDICATION: Fall. COMPARISON: None available. TECHNIQUE: Multiple MDCT axial images were obtained from the base of the neck through the proximal thighs after the uneventful administration of 130 cc of Optiray intravenously. Enteric contrast was not administered. Multiplanar reformats were derived. CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The thyroid enhances homogenously. There is no axillary or mediastinal lymphadenopathy. The pulmonary artery is normal in caliber. The aorta is normal. The heart is normal in size. There is no pericardial effusion. There are coronary artery calcifications. There is a moderate-sized hiatal hernia. Central airways are patent to the level of subsegmental bronchi. There is no pulmonary mass, pleural effusion or pneumothorax. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder, and spleen appear normal. The pancreas is atrophic. The kidneys symmetrically take up and excrete contrast without hydronephrosis. A subcentimeter renal hypodensities are too small to characterize and likely represent benign cysts. The adrenals are unremarkable. Abdominal loops of bowel are unremarkable. There is no abdominal free air, free fluid, or pathologic lymphadenopathy. The abdominal aorta is normal in caliber and contour but demonstrates prolific atherosclerotic calcifications. CT OF THE PELVIS WITH CONTRAST: The bladder is distended. A Foley is malpositioned with the balloon abnormally inflated in the urethra. The uterus and adnexa are unremarkable. There is no pelvic free air or free fluid, or pathologic lymphadenopathy. MUSCULOSKELETAL: There is no suspicious osteolytic or osteoblastic lesion. There is vertebra plana at T9 and mild compression deformities at L1 and L4. There is mild anterolisthesis of L5 on S1. IMPRESSION: 1. Malpositioned Foley balloon catheter in the urethra. 2. Multiple thoracolumbar compression deformities. Grade 1 anterolisthesis of L5 on S1. These are age indeterminate. Correlate clinically. 3. Moderate sized hiatal hernia. 4. Coronary artery calcifications. 5. Bilateral renal hypodensities, possibly renal cysts. [**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2116-8-27**] 3:57 AM [**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG SICU-A [**2116-8-27**] 3:57 AM CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 65115**] Reason: please eval for interval change. pls do at 0500 on [**8-27**] [**Hospital 93**] MEDICAL CONDITION: 83 year old woman with 83 year old woman with sdh and facial fx REASON FOR THIS EXAMINATION: please eval for interval change. pls do at 0500 on [**8-27**] CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: 83-year-old woman with subdural hematoma and facial fractures. Please evaluate for interval change. COMPARISON: Multiple head CTs, most recent of [**8-26**], performed approximately 11 hours prior. TECHNIQUE: MDCT-acquired axial images were obtained of the head without contrast. FINDINGS: No interval change when compared to study performed 11 hours prior. Again seen are bilateral acute on chronic subdural hematomas, which remain stable. Acute subdural hematoma seen over the right temporoparietal lobe measures 6 mm and is unchanged. No areas of intracranial hemorrhage, large areas of edema are seen. There is no new mass effect. High-density material within the maxillary sinuses bilaterally, consistent with blood, are unchanged. IMPRESSION: No change in acute on chronic subdural hematomas. No new areas of intracranial hemorrhage. The study and the report were reviewed by the staff radiologist. [**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**] Radiology Report PORTABLE ABDOMEN Study Date of [**2116-8-27**] 12:59 PM [**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG SICU-A [**2116-8-27**] 12:59 PM PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVIC Clip # [**Clip Number (Radiology) 65116**] Reason: NG tube placement [**Hospital 93**] MEDICAL CONDITION: 83 year old woman with stroke. ng tube placement REASON FOR THIS EXAMINATION: NG tube placement Provisional Findings Impression: [**Last Name (un) **] [**Doctor First Name **] [**2116-8-27**] 2:41 PM In correct placement of NG tube. Final Report INDICATION: 83-year-old woman with stroke, status post NG tube placement. Evaluate for NG tube placement. COMPARISON: CT chest, abdomen and pelvis with contrast [**2116-8-25**]. TECHNIQUE: Portable abdominal radiograph. FINDINGS: NG tube is noted, with sideport above the level of the diaphragm likely within the lumen of the stomach in this patient with hiatal hernia noted on previous CT. Compression fracture noted at vertebral body T9. A mild compression deformity is also noted at L1-L4 as previously noted on CT dated [**2116-8-25**]. Costochondral calcifications are noted. Colon is noted to be filled with stool and gas. IMPRESSION: Side port of NG tube above the diaphragm, likely in the lumen of the stomach in patient with known hiatal hernia. [**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2116-8-30**] 11:23 AM [**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG FA11 [**2116-8-30**] 11:23 AM CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 65117**] Reason: 202 [**Hospital 93**] MEDICAL CONDITION: 83 year old woman with right sdh REASON FOR THIS EXAMINATION: less responsive? worseing bleed CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: JXRl SUN [**2116-8-30**] 1:27 PM Unchanged bilateral subdural collections, with high-density material, consistent with blood on the right. Small amount of intraventricular blood is less prominent than on the study from two days prior. No hydrocephalus. Final Report HISTORY: 83-year-old woman with right subdural hematoma and decreased responsiveness. COMPARISON: Non-contrast head CT [**2116-8-28**]. TECHNIQUE: Non-contrast head CT was obtained. FINDINGS: There is no significant change in the right subdural collection, with has a mixture of more acute hyperdense blood and chronic hypodense blood. The hypodense left subdural collection has slightly decreased in size. Hyperdense subdural blood along the posterior falx and along the tentorium is unchanged. A small amount of blood in the occipital [**Doctor Last Name 534**] of the left lateral ventricle is slightly decreased in density. There is no shift of normally midline structures. Moderate ventricular prominence is unchanged since [**2115-12-26**], likely related to cerebral atrophy High-density material within the maxillary sinuses bilaterally, consistent with blood is unchanged. Known maxillary sinus and nasal bone fractures are partially visualized. There is a nasogastric tube. IMPRESSION: The hypodense left subdural collection has slightly decreased in size. The mixed-density right subdural collection is unchanged. Posterior parafalcine subdural hematoma is unchanged. Expected evolution of intraventricular hemorrhage. [**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**] Radiology Report C-SPINE NON TRAUMA FLEX & EXT ONLY Study Date of [**2116-9-2**] 9:53 AM [**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG FA11 [**2116-9-2**] 9:53 AM C-SPINE NON TRAUMA FLEX & EXT Clip # [**Clip Number (Radiology) 65118**] Reason: 83 year old woman s/p fall with R SDH and facial bone fx, pl [**Hospital 93**] MEDICAL CONDITION: 83 year old woman s/p fall with R SDH and facial bone fx, please call [**Numeric Identifier 65119**], manual manipulation required for flexion and extension, team member will need to be present. REASON FOR THIS EXAMINATION: 83 year old woman s/p fall with R SDH and facial bone fx, please call [**Numeric Identifier 65119**], manual manipulation required for flexion and extension, team member will need to be present. Final Report HISTORY: 83-year-old female with fall, declining mental status. C-SPINE, TWO VIEWS WITH FLEXION AND EXTENSION. Cervical spine is visualized to the level of the C7-T1 disc. There is minimal cervical motion observed between the flexion and extension views. An NG tube is seen in the esophagus. The vertebral bodies are normal in height and alignment. There is diffuse demineralization. There is a mild anterior vertebral spurring at multiple levels. There are no fractures or dislocations. The prevertebral soft tissues appear normal. The visualized portions of the lungs appear normal. [**Known lastname **],[**Known firstname **] [**Medical Record Number 65111**] F 83 [**2033-2-2**] Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2116-9-3**] 9:24 AM [**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG FA11 [**2116-9-3**] 9:24 AM VIDEO OROPHARYNGEAL SWALLOW Clip # [**Clip Number (Radiology) 65120**] Reason: evaluate for aspiration [**Hospital 93**] MEDICAL CONDITION: 83 year old woman with SDH REASON FOR THIS EXAMINATION: evaluate for aspiration Final Report INDICATION: 83-year-old woman with subdural hematoma, evaluate for aspiration. TECHNIQUE: This study was performed in conjunction with speech and swallow pathologist. A limited oral and pharyngeal swallowing videofluoroscopy was performed. Nectar thick liquid, two tablespoon and pureed consistency barium, one tablespoon were administered. Following administration of nectar- thick liquid, there was significant prolongation of the oral transit time with immediate penetration and aspiration. Following this one tablespoon of pureed consistency barium was administered which also demonstrated immediate penetration and aspiration. The patient was unable to clear the pharyngeal residue. There was inability to consistently trigger a second swallow or cough. At this point the study was aborted. IMPRESSION: Penetration and aspiration with nectar-thick and pureed consistencies of barium. Please refer to the full speech and swallow pathologist's note for recommendations. Brief Hospital Course: Ms [**Known lastname 7931**] was admitted to the neurosurgery service for ICU close neurological monitoring due to her subdural and facial fractures. She had a trauma consult and was found to to have multiple facial fractures including pterygoid processes, floor of the right orbit, both maxillary sinuses, right lamina papyracea, right zygoma, bilateral nasal bones, and [**Last Name (un) 2043**] nasal septum. No muscular entrapment is seen within the right orbital floor fracture. She also had extensive right periorbital hematoma and subcutaneous gas, with extension of gas retroorbitally. The right globe is proptotic, but remains intact. She was noted to have a triponin leak of 0.05 for which a beta bloker was added. Plastic surgery recommended clindamycin for 5 days and a soft diet. Follow up head CTs were stable size of subdural hematoma. She was transferred to step down unit on [**8-26**]. Physical therapy and occupational therapy felt she was appropriate for acute rehab. Her mentation improved on a daily basis and she began to speak and follow simple commands. She had a video swallow on [**8-31**] which showed some aspiration. The patient had a flex/extension x-ray of the cervical spine on [**9-2**] which was negative for fracture or malalignment. Therefore her collar was removed. She had a repeat video swallow evaluation on [**9-2**] because she was able to have different positioning after the collar was removed. The evaluation showed continued aspiration. On [**9-4**] she had a PEG placed. Following the PEG placement she had approx 200-250cc of melanotic stool. Gasteroenterology was consulted to assess for etiology of bleeding and recommendations. She was then scoped by GI and duodenal ulcers x2 were noted and cauterized. She was maintained on a PPI, with stable Hct. On [**9-9**], she was discharged to an appropriate rehab facility, and given instructions for follow up in 6 weeks with a non-contrast Head CT. Medications on Admission: CARBIDOPA-LEVODOPA - 25 mg-100 mg Tablet - Two tablets at 10 am and 6 pm and 1 tablet at 2 pm and 10pm Tablet(s) by mouth As above CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime GABAPENTIN [NEURONTIN] - (Prescribed by Other Provider) - 300 mg Capsule - One Capsule(s) by mouth three times a day OXYBUTYNIN CHLORIDE - (Prescribed by Other Provider) - 5 mg Tablet - One Tablet(s) by mouth daily Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg IV Q12H 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO Q12H (every 12 hours). 4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): AT 8AM AND 8PM PLEASE GIVE TWO TABS / AT 12 NOON AND 4 PM GIVE 1 TAB ONLY. 5. HydrALAzine 10 mg IV Q6H:PRN SPB >160 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Right frontal Subdural Hematoma GI Bleed Acute blood loss anemia Extensive facial fractures including involvement of both pterygoid processes, floor of the right orbit, both maxillary sinuses, right lamina papyracea, right zygoma, bilateral nasal bones, and [**Last Name (un) 2043**] nasal septum. No muscular entrapment is seen within the right orbital floor fracture. Discharge Condition: Neurologically stable Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. *you have been prescribed Keppra for seizure prophylaxsis. This does not require blood work for monitoring. Please continue to take this until you are seen in follow up in 6 weeks. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow up with Dr [**Last Name (STitle) **] in 6 weeks with a head CT, call [**Telephone/Fax (1) 1669**] for an appointment. Please call Dr. [**First Name (STitle) 2795**] in the [**Hospital **] CLINIC in 4 weeks at [**Telephone/Fax (1) **] If you have dark tarry bowel movements or bright red blood in your bowel movements you should call the clinic immediately or go to the nearest emergency room. ** PLEASE NOTE: YOUR H.PYLORI TEST WAS NEGATIVE (SEROLOGY STUDY) Follow up as planned with Dr [**Last Name (STitle) **]. Your daughter is to email Dr [**Name (NI) 17281**] in two weeks time Completed by:[**2116-9-9**]

Admission Date: [**2109-10-14**] Discharge Date: [**2109-10-28**] Service: ACOVE HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old resident of [**Hospital **] Nursing Home who was transferred to [**Hospital1 1444**] for shortness of breath, tachypnea, fever, history of right middle lung nodule without workup in the past, with possible history of aspiration on the day of admission. He had a history of right lower lobe pneumonia in [**Month (only) **]. He was in the Emergency Department with a heart rate of 130, blood pressure 100/60, respiratory rate 30, given Clindamycin 600 mg and Levaquin 500 mg intravenously. Blood pressure decreased to 94 systolic with further respiratory distress. Therefore, the patient was intubated. Postintubation blood pressure was 60 systolic. The patient was given Dopamine drip and taken to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Dementia. 2. Gastroesophageal reflux disease. 3. Constipation. 4. Decreased hearing. 5. Right midlung nodule. PHYSICAL EXAMINATION: Blood pressure is 96/34, pulse 92, respiratory rate 12. In general, the patient was sedated. The pupils are equal, round, and reactive to light and accommodation. The lungs were clear to auscultation bilaterally. Heart - regular rate and rhythm, III/VI systolic ejection murmur that radiates to the carotids and across the precordium. The abdomen was soft, mildly distended with active bowel sounds. LABORATORY DATA: White blood count 31.6, hematocrit 32.8, platelets 683,000. Chemistries were notable for a blood urea nitrogen of 44, creatinine 2.3, lactic acid of 5.5. Arterial blood gases on admission were pH 7.42, 35 and 72. HOSPITAL COURSE: The patient was treated for aspiration pneumonia and respiratory failure in the Medical Intensive Care Unit. He was then transferred to the floor on the following medications: Vancomycin intravenously, Flagyl intravenously, Lopressor, Zestril, Xalatan, Heparin, Protonix, Iron Sulfate, Tylenol and Morphine. The patient had been transferred to the floor after discussion to make him DNR/DNI. On the medicine floor, discussion was had with the patient's family about making him comfort measures as it appeared he would not be able to tolerate p.o. feeding and the family was against gastrostomy tube placement. Therefore, the patient was made comfort measures on [**2109-10-26**], and given Morphine drip. The patient finally expired on [**2109-10-28**], at 1:30 a.m. at which time the attending, Dr. [**Last Name (STitle) 5762**], and the patient's wife were notified. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Name8 (MD) 6069**] MEDQUIST36 D: [**2109-12-31**] 17:51 T: [**2110-1-6**] 14:36 JOB#: [**Job Number 34596**]

Admission Date: [**2144-7-31**] Discharge Date: [**2144-9-17**] Date of Birth: [**2067-6-25**] Sex: F Service: VSURG Allergies: Iodine / Heparinoids Attending:[**First Name3 (LF) 6346**] Chief Complaint: Ischemic right lower extremity Major Surgical or Invasive Procedure: [**2144-7-31**] Thrombectomy of right iliofemoral artery. [**2144-8-4**] Superficial femoral artery thrombectomy. Intraoperative arteriography. Bilateral lower extremity arteriography, Rheolytic thrombectomy left common and external iliac artery,left external iliac stent placement. [**2144-8-14**] Left thoracoscopy [**2144-8-20**] Tracheostomy [**2144-9-3**] Gastroscopy. Attempted laparoscopy. Open gastrostomy tube placement. Lysis of adhesions. [**2144-9-9**] Left thoracoscopy with removal of pleural fibrin and evacuation of empyema cavity with placement of chest tubes. History of Present Illness: 76 yo female s/p emergency CABG x2 is referred from [**Hospital1 **] due to abdominal pain and mental status changes. Early on [**2144-7-31**] the patient was noted to develop right leg pain; worse with movement. She had previously not had a history of claudication. Past Medical History: 1. Hypertension. 2. Polymyalgia rheumatica on prednisone. 3. Cerebrovascular accident in [**2144**], [**2-26**]. Coronary artery disease status post coronary artery bypass grafting of two vessels on [**2144-7-16**] with limit to the RCA and her vein graft to be LAD. 5. Hyperlipidemia. Social History: Mrs. [**Known lastname 55840**] has a large and dedicated family. Family History: Noncontributory Physical Exam: Awake, alert. GCS 15 Pulm: frequent rhonchi; moderate work of breathing Chest: RRR, distant. 2 left chest tubes have been cut and left open to drain. Abd: Obese, well healing midline laparotomy incision. Gastrostomy tube f functioning well. Well healing bilateral groin incisions from thrombectomies. Ext: Warm, edematous. Pertinent Results: [**2144-9-17**] 03:56AM BLOOD WBC-12.7* RBC-3.46* Hgb-10.4* Hct-30.8* MCV-89 MCH-30.1 MCHC-33.9 RDW-15.1 Plt Ct-190 [**2144-9-16**] 03:25AM BLOOD WBC-10.3 RBC-3.54* Hgb-10.3* Hct-32.2* MCV-91 MCH-29.1 MCHC-32.0 RDW-15.0 Plt Ct-192 [**2144-9-15**] 03:59AM BLOOD WBC-11.9* RBC-3.60* Hgb-10.7* Hct-32.3* MCV-90 MCH-29.6 MCHC-33.1 RDW-14.6 Plt Ct-160 [**2144-8-28**] 06:34AM BLOOD Neuts-87.5* Bands-0 Lymphs-7.7* Monos-1.7* Eos-2.7 Baso-0.3 [**2144-9-17**] 03:56AM BLOOD Plt Ct-190 [**2144-9-17**] 03:56AM BLOOD PT-13.2 PTT-26.1 INR(PT)-1.1 [**2144-9-16**] 03:25AM BLOOD Plt Ct-192 [**2144-9-16**] 03:25AM BLOOD PT-13.1 PTT-26.1 INR(PT)-1.1 [**2144-9-15**] 03:59AM BLOOD Plt Ct-160 [**2144-9-15**] 03:59AM BLOOD PT-13.0 PTT-25.0 INR(PT)-1.1 [**2144-8-7**] 02:05AM BLOOD Plt Ct-66* [**2144-8-7**] 02:05AM BLOOD PT-17.9* PTT-61.2* INR(PT)-2.1 [**2144-8-4**] 03:35AM BLOOD Plt Ct-49* [**2144-8-4**] 03:35AM BLOOD PT-15.9* PTT-59.2* INR(PT)-1.7 [**2144-9-17**] 03:56AM BLOOD Glucose-115* UreaN-26* Creat-0.8 Na-139 K-4.9 Cl-101 HCO3-29 AnGap-14 [**2144-9-16**] 02:59PM BLOOD K-4.4 [**2144-9-16**] 03:25AM BLOOD Glucose-108* UreaN-24* Creat-0.8 Na-138 K-3.2* Cl-97 HCO3-31* AnGap-13 [**2144-9-15**] 03:59AM BLOOD Glucose-92 UreaN-22* Creat-0.8 Na-138 K-4.1 Cl-98 HCO3-32* AnGap-12 [**2144-9-14**] 02:30PM BLOOD Glucose-118* K-3.8 [**2144-9-14**] 03:27AM BLOOD Glucose-94 UreaN-20 Creat-0.7 Na-137 K-4.2 Cl-96 HCO3-32* AnGap-13 [**2144-9-8**] 04:07AM BLOOD CK-MB-2 cTropnT-0.04* [**2144-9-7**] 10:24PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2144-9-7**] 02:30PM BLOOD CK-MB-NotDone cTropnT-0.03* [**2144-9-17**] 03:56AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0 [**2144-9-16**] 03:25AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.1 [**2144-9-15**] 03:59AM BLOOD Calcium-7.9* Phos-4.5 Mg-1.9 [**2144-8-4**] 12:10AM BLOOD Vanco-18.9* [**2144-9-14**] 10:13AM BLOOD Type-ART pO2-89 pCO2-42 pH-7.46* calHCO3-31* Base XS-5 [**2144-9-10**] 05:13PM BLOOD Type-ART Temp-37.2 Tidal V-400 PEEP-5 pO2-PND pCO2-PND pH-PND calHCO3-PND Base XS-PND Intubat-INTUBATED [**2144-9-10**] 11:47AM BLOOD Type-ART Rates-/28 Tidal V-500 PEEP-5 O2-40 pO2-83* pCO2-33* pH-7.48* calHCO3-25 Base XS-1 [**2144-9-10**] 02:14AM BLOOD Type-ART Temp-37.1 Rates-14/6 Tidal V-55 PEEP-5 O2-50 pO2-124* pCO2-35 pH-7.48* calHCO3-27 Base XS-3 -ASSIST/CON Intubat-INTUBATED Time Taken Not Noted Log-In Date/Time: [**2144-9-9**] 4:06 pm SWAB Site: PLEURAL L. PLEURAL EFFUSION. GRAM STAIN (Final [**2144-9-9**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2144-9-11**]): A swab is not the optimal specimen collection to evaluate body fluids. ESCHERICHIA COLI. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 174-8037M ([**2144-9-8**]). ACID FAST SMEAR (Final [**2144-9-10**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. POTASSIUM HYDROXIDE PREPARATION (Final [**2144-9-10**]): Test cancelled by laboratory. PATIENT CREDITED. Inappropriate specimen for Fungal Smear (KOH). ANAEROBIC CULTURE (Final [**2144-9-10**]): SPECIMEN NOT TRANSPORTED ANAEROBICALLY. TEST CANCELLED, PATIENT CREDITED. [**2144-9-9**] 2:00 pm TISSUE PLEURAL FIBRIN. GRAM STAIN (Final [**2144-9-9**]): THIS IS A CORRECTED REPORT ([**2144-9-10**]). 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). PREVIOUSLY REPORTED AS. NO MICROORGANISMS SEEN. TISSUE (Final [**2144-9-12**]): ESCHERICHIA COLI. MODERATE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 174-8037M ([**2144-9-8**]). ANAEROBIC CULTURE (Final [**2144-9-11**]): DUE TO LABORATORY ERROR, UNABLE TO PROCESS. ANAEROBES ARE SCREENED FOR IN THE TISSUE CULTURE. TEST CANCELLED, PATIENT CREDITED. ACID FAST CULTURE (Pending): ACID FAST SMEAR (Final [**2144-9-10**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2144-9-10**]): NO FUNGAL ELEMENTS SEEN. [**2144-9-4**] 4:45 pm SPUTUM **FINAL REPORT [**2144-9-7**]** GRAM STAIN (Final [**2144-9-4**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2144-9-7**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. OROPHARYNGEAL FLORA ABSENT. ESCHERICHIA COLI. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. YEAST. SPARSE GROWTH. STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 55841**] ([**2144-8-28**]). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2144-9-3**] 4:16 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2144-9-5**]** GRAM STAIN (Final [**2144-9-3**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2144-9-5**]): RARE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 55841**] [**2144-8-28**]. YEAST. SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 55841**] [**2144-8-28**]. [**2144-8-28**] 12:38 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2144-9-2**]** GRAM STAIN (Final [**2144-8-28**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2144-9-2**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. HEAVY GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**7-/2446**]) immediately if sensitivity to clindamycin is required on this patient's isolate. ESCHERICHIA COLI. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S <=1 S LEVOFLOXACIN---------- =>8 R =>8 R MEROPENEM------------- <=0.25 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ <=1 S [**2144-8-18**] 6:34 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. **FINAL REPORT [**2144-8-24**]** GRAM STAIN (Final [**2144-8-19**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2144-8-22**]): OROPHARYNGEAL FLORA ABSENT. ESCHERICHIA COLI. MODERATE GROWTH. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**7-/2446**]) immediately if sensitivity to clindamycin is required on this patient's isolate. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | STAPH AUREUS COAG + | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=1 S <=0.5 S LEVOFLOXACIN---------- =>8 R =>8 R MEROPENEM-------------<=0.25 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ <=1 S [**2144-8-2**] 10:00A TEST RESULT HEPARIN DEPENDENT ANTIBODIES POSITIVE COMMENT: POSITIVE FOR HEPARIN PF4 ANTIBODY [**Doctor First Name **] REPORTED TO [**Name8 (MD) **], RN [**2144-8-3**] 2 PM. Complete report on file in the laboratory. Brief Hospital Course: A brief summary of the patient's course is summarized below by problem: 1. Heparin induced thrombocytopenia Invasive procedures relating to the problem: [**2144-7-31**] Thrombectomy of right iliofemoral artery. [**2144-8-4**] Superficial femoral artery thrombectomy. Intraoperative arteriography. Bilateral lower extremity arteriography, Rheolytic thrombectomy left common and external iliac artery,left external iliac stent placement. Heparin induced thrombocytopenia was recognized as the etiology of the patient's presenting problem of bilateral lower extremity ischemia. She underwent the above listed interventions and was anticoagulated with Lepirudin, Plavix, and Aspirin. This was continued until a recalcitrant bleeding duodenal ulcer developed after which she was maintained on aspirin only for the majority of her remaining hospital stay. After the initial treatment of the HIT, there were no recurrent clinical sequels of her HIT. 2. Duodenal ulcer, bleeding s/p endoscopic treatment with cautery and epinephrine injection x 3 After anticoagulation for the patient's HIT and bilateral lower extremity arterial thromboses, she developed significant UGI bleeding. It was ultimately controlled with a combination of multiple upper endoscopies, and cessation of her lepirudin and plavix. Endoscopic evaluation revealed a duodenal ulcer and a gastric ulcer as the source of her bleeding. The duodenal ulcer was the primary contributor. Prior to discharge, she was restarted on Coumadin 5 mg nightly and has tolerated resumption of the coumadin without evidence of recurrence of her bleeding. 3. Supraventricular tachycardia Throughout her hospital stay, the patient has had SVT on occasion but this has improved significantly with beta blockade, amiodarone, and diuresis. She is being discharged with amiodarone but it may be possible to discontinue this after further resolution of her current illness. 4. Subacute subdural hematoma The patient developed a diminished level of consciousness and increased agitation several weeks into her admission. This was evaluated with a CT scan of the head. Bilateral subacute subdural hematomas were demonstrated. A neurosurgical consult was obtained. No neurosurgical intervention was recommended. With time her sensorium has improved dramatically. This is considered an inactive issue. 6. Acute blood loss anemia requiring transfusion The patient's blood loss was secondary to her upper GI bleeding. She is currently hemostatic. 7. Left pleural effusion requiring thoracentesis, ultimately requiring video assisted thoracoscopy with partial decortication and chest tube placement: [**2144-8-14**] Left thoracoscopy [**2144-9-9**] Left thoracoscopy with removal of pleural fibrin and evacuation of empyema cavity with placement of chest tubes The patient had developed a chronic left thoracic pleural effusion following her CABG. Ultimately this became an infected collection and was found, following VATS, to contain E. Coli. Chest tubes were left in place following the VATS procedure. These have had diminishing output since the day of the procedure. The thoracic surgery team has taken the tubes off of waterseal as the collections do not communicate significantly with the patient's airway. These will be removed, an inch per week, until the chest tubes are completely removed. Summation: The patient has undergone a series of insults following her emergency CABG on [**2144-7-16**] beginning with bilateral lower extremity ischemia due to heparin induced thrombocytopenia, bleeding duodenal ulcer and bilateral subdural hematomas probably secondary to anticoagulation, and multiple foci of infection with the Left empyema representing the largest one. Taken together these injuries have required a prolonged course accelerated to some extent by tracheostomy and gastrostomy. Ms. [**Known lastname 55840**] has made major progress from a serious illness and is being transferred to [**Hospital3 7**] in fair, stable, but improving condition. Medications on Admission: 1. Lasix 20 mg b.i.d. 2. Aspirin 325 mg daily. 3. Captopril 25 mg t.i.d. 4. Prednisone 20 mg daily. 5. Lopressor 25 mg daily. 6. KCL 40 mg daily. 7. Protonix daily 40 mg. Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal QD (once a day) as needed. 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once a day). 8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): D/C after [**2144-9-23**]. Tablet(s) 9. Metoclopramide HCl 5 mg/5 mL Solution Sig: One (1) PO QID (4 times a day). 10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): discontinue after [**2144-9-19**]. 11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 12. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 14. Ondansetron HCl 2 mg/mL Solution Sig: One (1) Intravenous Q6H (every 6 hours) as needed for nausea. 15. Furosemide 10 mg/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a day: titrate as needed based on diuretic usage; potassium levels. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1. Duodenal ulcer, bleeding status post endoscopic treatment with cautery and epinephrine injection x 3 2. Heparin induced thrombocytopenia, (HIT type 2), white clot syndrome 3. supraventricular tachycardia 4. acute bilateral lower extremity ischemia s/p bilateral groin cutdown and thrombectomy 5. subacute subdural hematoma 6. acute blood loss anemia requiring transfusion 7. Left pleural effusion requiring thoracentesis, ultimately requiring video assisted thoracoscopy with partial decortication and chest tube placement 8. Left chest empyema Discharge Condition: Fair Discharge Instructions: 1. Routine Trach care 2. Anticoagulate with coumadin to goal INR 2.0-3.0 3. Activity as tolerated 4. Routine Gastrostomy care 5. Tube feeds at goal rate 6. [**Month (only) 116**] remove abdominal staples after [**2144-10-13**] Followup Instructions: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2819**], M.D, General Surgery ([**Telephone/Fax (1) 6347**] [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**], M.D., Thoracic Surgery 2A ([**Telephone/Fax (1) 1504**] [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D., Hematology ([**Telephone/Fax (1) 15328**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D., Vascular Surgery ([**Telephone/Fax (1) 9393**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], MD, Cardiothoracic Surgery ([**Telephone/Fax (1) 1504**]

Admission Date: [**2129-9-14**] Discharge Date: [**2129-10-6**] Date of Birth: [**2072-9-6**] Sex: M Service: MEDICINE Allergies: sertraline Attending:[**First Name3 (LF) 603**] Chief Complaint: Agitation, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: The patient was unable to participate in interview with me. This note is based heavily on the information gathered by the ED physicians and the Neurologist who consulted in the ED. Mr. [**Known lastname 62523**] is a 56-year-old man with a history of alcohol abuse with recent admission for presumed Wernicke encephalopathy, alcohol withdrawal who presented from his skilled nursing/rehab center for agitation after being discharged from [**Hospital1 18**] two days ago. At the rehab facility, the patient spent the last 24 hours in severe agitation that required 4-point restraints and multiple chemical restraints in order for him to calm down. According to the Neurologist in the ED, he was disoriented, tachycardic, agitated, and diaphoretic in the setting of presumed 3 days abstinence from benzos. Mr. [**Known lastname 62523**] had some restriction in eye movements but no gaze deviation and no lateralizing signs at this point. Neurology believes withdrawal is the most likely etiology. If fevers develop, he may require a lumbar puncture. such as infection Metabolic derangements, drug overdose, hepatic failure, and gastrointestinal bleeding can also mimic or coexist with withdrawal. In the absence of complications, symptoms can persist for up to seven days. Additionally as he does not seem to have full abduction of his eyes, Neurology recommends continuing on IV thiamine for presumed Wernicke's. Given that the mammillary bodies are enriched with dopamine receptors, would avoid Haldol as this may exacerbate his Wernicke Korsakoff's pathology. Past Medical History: -HTN -ETOH abuse -HCV -h/o Agoraphobia previously treated w/ sertraline, but stopped for concern of serotonin syndrome - Methadone maintenance for opioid detox Social History: Former waste management truck worker and cement mixer for 22 years. Last HIV test negative 2.5 years ago. Last drink was 3pm on [**2129-8-23**]. Denies ever smoking. Lives with his brother, [**Name (NI) **]. Family History: DM2 in both parents, PTSD in his father. Brother is also on methadone maintenance program. Physical Exam: Admission physical exam: Vitals: T: 97.7, BP:128/81, P: 57, R: 19, O2: 97% RA General: Diaphoretic, mumbling to self, arouses only to noxious stimuli, can state name but not following other directions HEENT: Sclera anicteric, MMM, oropharynx clear and without erythema and exudate, PERRL, small pupils but responsive to light Neck: supple CV: S1, S2, no murmurs auscultated Lungs: Clear to auscultation bilaterally Abdomen: soft, non-tender, non-distended, bowel sounds present, bruising from heparin injections GU: condom catheter in place Ext: warm, well perfused, 2+ pulses, scarring on left knee Neuro: Patient cannot follow instructions for neurological exam, moving all four limbs spontaneously Discharge: VS: 97.6, 110/75, 83, 16, 100%RA General: alert, NAD, oriented to self, [**Hospital1 18**], year and month and date HEENT: Sclera anicteric, MMM, PERRLA, supple, no LAD CV: RRR, normal S1, S2, no m/r/g Lungs: CTAB, no rales wheezes or rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, bruising from heparin injections Ext: warm, well perfused, 2+ pulses, no edema Back: mild tenderness of R flank Neuro: CN II-XII intact,rigid with some mild cogwheeling and occasional myoclonic spasms of his bil LE. Pertinent Results: Labs: [**2129-9-14**] 05:14PM WBC-7.4 RBC-3.68* HGB-12.5* HCT-36.2* MCV-98 MCH-34.0* MCHC-34.6 RDW-14.2 [**2129-9-14**] 05:14PM NEUTS-68.5 LYMPHS-20.5 MONOS-6.0 EOS-4.3* BASOS-0.6 [**2129-9-14**] 05:14PM ASA-NEG ETHANOL-NEG ACETMNPHN-5* bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2129-9-14**] 05:14PM TSH-0.59 [**2129-9-14**] 05:14PM TSH-0.59 [**2129-9-14**] 05:14PM ALBUMIN-3.8 [**2129-9-14**] 05:14PM ALT(SGPT)-45* AST(SGOT)-31 ALK PHOS-51 TOT BILI-0.3 [**2129-9-14**] 05:14PM GLUCOSE-111* UREA N-16 CREAT-1.0 SODIUM-131* POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-23 ANION GAP-15 [**2129-9-14**] 05:19PM LACTATE-1.5 [**2129-9-15**] 05:14AM BLOOD Ammonia-35 [**2129-9-14**] head CT: IMPRESSION: No acute intracranial process. [**2129-9-14**] CXR: FINDINGS: A single portable supine chest radiograph was obtained. Exam is limited by patient rotation. Lung volumes are low. Pulmonary vessels are engorged. There is no effusion or pneumothorax. Cardiac and mediastinal contours are normal. IMPRESSION: Low lung volumes and engorged pulmonary vessels [**2129-9-15**] EKG: Sinus bradycardia. Non-specific slight ST segment elevation in the precordial leads and lateral leads. Possible early repolarization. Compared to the previous tracing of [**2129-9-7**] bradycardia is new, ST segment elevation is slightly more pronounced and could be rate related. Brief Hospital Course: The patient is a 57-year-old man with a history of alcohol dependence who was recently discharged after detoxifying at [**Hospital1 1535**] but also suffering from Wernicke-Korsakoff's syndrome, who presented from his nursing facility with altered mental status. #. Delirium/altered mental status: Patient had been agitated at nursing facility. TSH, B12, folate, and lactate all within normal limits. Ammonia also normal. Patient was been afebrile, WBC was normal, CXR and UA negative. CT head was negative. Neurology and Psychiatry consulted. Psychiatry discovered that patient was receiving oxazepam at facility. Combined with the significant (12mg IV) lorazepam he received in Emergency Department and 5mg IV more on initial evening in ICU, benzodiazepine intoxication felt to be responsible for much of altered mental status. Benzos stopped and replaced with Zyprexa to a maximum dose of 35mg daily with monitoring of QTc (407 on last day of ICU stay). Patient continued on folate, multivitamin, vitamin D and thiamine. Patient restarted on home olanzapine 5 mg QAM and 15 mg QPM per psychiatry recs. EKG was periodically monitored for prolongation of the QTc. He continued to be agitated particularly at night and was started on trazadone 100 mg QHS and mirtazepine 30 mg PO QHS. He improved on this regimen. After originally planning to send the patient to a dementia unit, eventually his brother made the decision to take him home with 24 hour supervision at his home. Vitamin supplementation was discontinued on discharge as patient is no longer drinking alcohol. He will follow up frequently with his PCP and will also follow up with cognitive neurology. #. Hyponatremia: Patient presented with hyponatremia. He may have been volume down at his nursing facility, esecially if he has been agitated and unable to take PO. During his last hospitalization, his sodium was well within normal limits. Sodium corrected to low normal with maintenance fluids. # Back pain- Patient has migratory low back pain without any neurological deficits or signs of infection. This is a chronic issue for Mr. [**Known lastname 62523**]. He was treated with ibuprofen, tylenol and lidocaine patch, which helped. Chronic Issues: #. Hypertension: Continued home propranolol and lisinopril. #. Essential tremor: Continued home proprnaolol. #. Presumed CAD: Continued home aspirin. #. Presumed BPH: Continued home tamsulosin. #. Presumed GERD: Continued home omeprazole. Transitional Issues: - Olanzapine: maximum dose 30 mg daily in a 24 hour span - Monitor QTc regularly (goal QTc < 500 ms)Qtc on [**2129-10-4**] 400 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY Start: In am 2. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **] 3. FoLIC Acid 1 mg PO DAILY Start: In am 4. Lisinopril 10 mg PO DAILY Hold for SBP < 100. 5. Multivitamins 1 TAB PO DAILY Start: In am 6. Omeprazole 20 mg PO DAILY Start: In am 7. Propranolol 20 mg PO BID Start: In am Hold for HR < 60, SBP < 100. 8. Tamsulosin 0.4 mg PO HS 9. Thiamine 100 mg PO DAILY Start: In am 10. Vitamin D 400 UNIT PO DAILY Start: In am 11. Mirtazapine 15 mg PO HS 12. OLANZapine 5 mg PO QAM 13. OLANZapine 15 mg PO QPM 14. OLANZapine 5 mg PO BID:PRN agitation/psychosis Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 2. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **] RX *fluticasone 50 mcg 2 sprays intranasal twice a day Disp #*1 Unit Refills:*0 3. Lisinopril 10 mg PO DAILY Hold for SBP < 100. RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Multivitamins 1 TAB PO DAILY RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. OLANZapine 15 mg PO QPM RX *olanzapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*1 6. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Propranolol 20 mg PO BID Hold for HR < 60, SBP < 100. RX *propranolol 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Tamsulosin 0.4 mg PO HS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 9. Mirtazapine 30 mg PO HS RX *mirtazapine 30 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*1 10. OLANZapine 5 mg PO QAM RX *olanzapine 5 mg 1 tablet(s) by mouth in the morning Disp #*30 Tablet Refills:*1 11. traZODONE 100 mg PO HS RX *trazodone 100 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*1 12. Acetaminophen 325-650 mg PO Q6H:PRN pain RX *acetaminophen 325 mg [**11-22**] tablet(s) by mouth every six (6) hours Disp #*120 Tablet Refills:*0 13. Ibuprofen 600 mg PO Q8H:PRN back pain RX *ibuprofen [Advil] 200 mg 3 tablet(s) by mouth every eight (8) hours Disp #*120 Tablet Refills:*0 14. Outpatient Occupational Therapy Patient needs outpatient OT, would recommend Cognitive Neurology Department at Spauling. Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Primary: Korsakoff's psychosis, back pain, agitation Secondary: Hypertension, BPH, GERD Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [**Known lastname 62523**], You were admitted to the hospital with confusion and agitation from your rehabilitation hospital. You were seen by neurology and psychiatry and your medications were changed. There was no infection or new [**Last Name **] problem found. This may have been due to a kind of medication called benzodiazepine. Your agitation and confusion improved over the course of your hospitalization. You also worked with physical therapy and occupational therapy. You were treated with tylenol and ibuprofen for your back pain. We really encourage you to abstain from alcohol. Any further drinking will cause your mental status to deteriorate. Medication changes: Please take trazadone 100 mg at night Please take mirtazepine 30 mg at night Please take acetominophen 325-650mg every 6 hours as needed for back pain (do not exceed 4 grams per day) Please take Ibuprofen 600mg every 8 hours as needed for back pain, must take with food to avoid stomach damage Please stop taking Thiamine. Please stop taking Vitamin D. Please stop taking Folic acid. Followup Instructions: Department: BIDHC [**Location (un) **] When: MONDAY [**2129-10-10**] at 10:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], MD [**0-0-**] Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) 861**] Campus: OFF CAMPUS Best Parking: On Street Parking Department: BIDHC [**Location (un) **] When: WEDNESDAY [**2129-11-2**] at 2:45 PM With: [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **], MD [**0-0-**] Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) 861**] Campus: OFF CAMPUS Best Parking: On Street Parking Department: COGNITIVE NEUROLOGY UNIT When: FRIDAY [**2129-11-18**] at 2:00 PM With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) 15661**] [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: BIDHC [**Location (un) **] When: FRIDAY [**2130-1-6**] at 1 PM With: [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **], MD [**0-0-**] Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) 861**] Campus: OFF CAMPUS Best Parking: On Street Parking

Admission Date: [**2111-1-12**] Discharge Date: [**2111-1-19**] Date of Birth: [**2111-1-12**] Sex: F Service: DISCHARGE DIAGNOSIS: Premature female infant twin number two 34 weeks gestation. HISTORY OF PRESENT ILLNESS: Baby girl [**Name2 (NI) **] [**Known lastname 3095**] is a former 34 week gestational age twin number two born to a 28 year-old prima gravida. Prenatal screens were noncontributory except for group B strep status unknown. Pregnancy was uncomplicated until two weeks prior to admission when mother had elevated maternal blood pressure and was admitted to bed rest at [**Hospital1 **]. Her pregnancy induced hypertension evaluation just revealed proteinuria, but no other signs of symptoms. Mother received betamethasone on [**1-10**] and [**1-11**]. Because of sporadic decelerations mother was induced. The infant was born by vaginal delivery with Apgars of 7 and 8. On admission the baby weighed 1890 [**Name2 (NI) **]. Head circumference 31.5 cm and length 44.5 cm. All appropriate for gestational age. PROBLEMS DURING HOSPITAL STAY: 1. Respiratory, infant remained in room air throughout her hospital course. There were no episodes of apnea or bradycardia. 2. Cardiovascular, there were no cardiovascular issues. 3. Infectious disease, infant had an initial blood culture and CBC. White count 7.7, 39 polys, 1 band, 48 lymphocytes, 326 platelets, hematocrit 42.8. Blood culture remained negative at 48 hours. No antibiotics were initiated. 4. Hematologic, mother O positive, baby's initial hematocrit 42.8. The infant had a peak bilirubin of 6.9. No treatment was initiated. The infant is on Fer-In-[**Male First Name (un) **]. 5. Feeding and nutrition, at the time of discharge the infant weighed 1895 [**Male First Name (un) **]. She was feeding well. She is to be discharged home on Neosure 24 calories per ounce. 6. Hearing screening performed on [**1-17**] and was normal. 7. Immunizations, hepatitis B immunization deferred until infant reaches 2 kilograms. DISCHARGE MEDICATIONS: 1. Fer-In-[**Male First Name (un) **] 0.2 cc po q day. 2. Neosure 24 calories per ounce. The patient is to be discharged home with family to have a visiting nurse come to home the day after discharge. The family is to make a follow up at [**Hospital1 **] Copy Center. As of yet have not picked their pediatrician. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 38370**] Dictated By:[**Last Name (NamePattern1) 38304**] MEDQUIST36 D: [**2111-1-19**] 08:56 T: [**2111-1-19**] 09:59 JOB#: [**Job Number **]

Admission Date: [**2100-7-16**] Discharge Date: [**2100-7-24**] Date of Birth: [**2024-1-26**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2100-7-20**] Aortic Valve Replacement with 23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue valve History of Present Illness: 76 year old man with history of coronary artery disease, diabetes, hypercholesterolemia, and aortic stenosis who was admitted to [**Hospital6 3105**] with two days of intermittent dyspnea, and malaise. A subsequent cardiac catheterization revealed patent left anterior descending artery and severe aortic stenosis. He was then referred to [**Hospital1 18**] for AVR Past Medical History: Coronary artery disease(s/p stent x3)last stent spring [**2099**], diabetes mellitus, dyslipidemia, aortic stenosis Past Surgical History: none Past Cardiac Procedures: PTCA-stent LAD spring [**2099**] Social History: Race: Caucasian Last Dental Exam: none recently Lives with: alone in [**Male First Name (un) 1056**]-staying w/ daughter(recently widowed) Contact: [**Name (NI) 111955**] [**Last Name (NamePattern1) 13621**]-daughter Phone # [**Telephone/Fax (1) 111956**] [**Name2 (NI) **]ation: Cigarettes: Smoked no [x] Other Tobacco use: Pipe [] Cigars [] Smokeless [] ETOH: denies Illicit drug use: denies Family History: Family History: Sister in 50's with heart disease-unspecified Father died in 90's Mother died in 60's of "smoking" Physical Exam: Admission: Pulse: 75 B/P 145/66 Resp: 18 O2 sat:97%RA Height: 63in Weight: 175 lbs General: NAD Skin: Warm [x] Dry [x] intact [x] 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 3/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit: none Pertinent Results: [**2100-7-24**] 06:45AM BLOOD WBC-7.7 RBC-3.62* Hgb-10.1* Hct-29.9* MCV-83 MCH-28.0 MCHC-33.8 RDW-13.2 Plt Ct-184# [**2100-7-23**] 04:57AM BLOOD WBC-7.7 RBC-3.76* Hgb-10.6* Hct-31.9* MCV-85 MCH-28.2 MCHC-33.2 RDW-13.4 Plt Ct-118* [**2100-7-22**] 04:58AM BLOOD WBC-6.5 RBC-3.80* Hgb-10.4* Hct-32.2* MCV-85 MCH-27.5 MCHC-32.4 RDW-13.3 Plt Ct-100* [**2100-7-24**] 06:45AM BLOOD UreaN-30* Creat-1.1 Na-129* K-4.7 Cl-94* [**2100-7-23**] 04:57AM BLOOD Glucose-129* UreaN-24* Creat-1.0 Na-131* K-4.8 Cl-97 HCO3-30 AnGap-9 [**2100-7-22**] 04:58AM BLOOD Glucose-185* UreaN-19 Creat-1.0 Na-130* K-5.2* Cl-97 HCO3-29 AnGap-9 [**2100-7-21**] 11:01PM BLOOD Na-130* K-5.1 Cl-98 [**2100-7-20**] 06:30PM BLOOD Na-137 K-4.3 Cl-108 TTE [**2100-7-20**] LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Low normal LVEF. RIGHT VENTRICLE: Borderline normal RV systolic function. AORTA: Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). with borderline normal free wall function. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is AV-Paced, on no inotropes. Unchanged biventricular systolic fx. There is a bio-prosthetic valve in the aortic position with no leak and no AI. Residual mean gradient = 11 mmHg. Aorta intact. Trace MR. Brief Hospital Course: The patient was admitted to the hospital, completed a unremarkable pre-operative workup and was brought to the operating room on [**2100-7-20**] where the patient underwent an Aortic valve replacement (23 St. [**Male First Name (un) 923**] tissue). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vanco was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. He did have less than 24 hours of rapid atrial fibrillation but converted to sinus rhythm with Amiodarone and increased Lopressor. He was in sinus rhythm at the time of discharge. The patient failed to void when his Foley was removed and was found to have 800cc in his bladder via bladder scan and the Foley was re-inserted. A repeat voiding trial was done and the patient was able to void successfully. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions via the Spanish interpreter. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. GlipiZIDE 10 mg PO BID 3. Enalapril Maleate 20 mg PO BID 4. Doxazosin 2 mg PO HS 5. Clopidogrel 75 mg PO DAILY 6. Simvastatin 20 mg PO DAILY 7. Amlodipine 10 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. GlipiZIDE 10 mg PO BID 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Simvastatin 20 mg PO DAILY 6. Acetaminophen 650 mg PO Q4H:PRN pain/fever 7. Amiodarone 400 mg PO TID RX *amiodarone 400 mg 1 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*0 8. Aspirin EC 81 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Metoprolol Tartrate 50 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 11. Milk of Magnesia 30 ml PO HS:PRN constipation 12. Oxycodone-Acetaminophen (5mg-325mg) [**1-11**] TAB PO Q4H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg [**1-11**] tablet(s) by mouth four times a day Disp #*30 Tablet Refills:*0 13. Bisacodyl 10 mg PR DAILY:PRN constipation 14. Potassium Chloride 20 mEq PO Q12H Hold for K+ > 4.5 RX *potassium chloride 20 mEq 1 tablet by mouth once a day Disp #*7 Tablet Refills:*0 15. Ranitidine 150 mg PO DAILY RX *Acid Reducer (ranitidine) 150 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 16. Doxazosin 2 mg PO HS 17. Furosemide 20 mg PO DAILY Duration: 7 Days RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: aortic stenosis s/p AVR(StJude tissue)[**7-20**] PMH: coronary artery disease(s/p stent x3)last stent spring [**2099**], diabetes mellitus, dyslipidemia, PSH: none Past Cardiac Procedures: PTCA-stent LAD spring [**2099**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema: Trace lower extremity edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] on in the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **] [**2100-8-25**] at 1:15p Cardiologist: [**Doctor Last Name 29070**] (office will call patient with appt) Wound check on [**2100-8-3**] at 10:00a [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **] Please obtain a primary care physician as soon as possible and see your primary Care Doctor in [**4-15**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2100-7-24**]

Admission Date: [**2144-10-16**] Discharge Date: [**2144-11-18**] Date of Birth: [**2144-10-16**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 9434**] is a 29-2/7 weeks gestational age male twin born at 1305 gm to a 28-year- old G1P0 mother with the following prenatal labs. Blood type O negative, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, GC/C negative. This twin diamniotic-dichorionic pregnancy was spontaneously conceived. No complications other than the mother developed cervical shortening and was treated with betamethasone on [**2144-10-2**]. She was transferred to [**Hospital6 2561**] on the day prior to delivery with preterm labor and further cervical changes. She was subsequently transferred to [**Hospital6 1760**] for further care. Spontaneous rupture of membranes occurred three hours prior to delivery. Delivery was by cesarean section secondary to fetal breech position. The baby emerged with reduced tone and minimal respiratory effort. The patient was treated with stimulation and facial CPAP with prompt resolution of irregular respirations. Apgars were seven and eight at one and five minutes. The patient was transferred to the Neonatal Intensive Care Unit for further management. PHYSICAL EXAMINATION: On presentation, vital signs showed a temperature of 97.3, heart rate 164, respiratory rate 50, O2 saturation 95 percent on room air, blood pressure 34/16 with a mean of 29, weight is 1305 gm, length is 42 cm, head circumference 27.5 cm. General: Preterm male in radiant warmer, no apparent distress. HEENT: AFOS, OP clear, palate intact, red reflex intact bilaterally. Neck: Supple, no crepitus. Respiratory: Clear to auscultation bilaterally, good air entry, mild intermittent retractions. Cardiac: Regular rate and rhythm, S1-S2 normal, no murmur. Abdomen: Soft, nondistended, no bowel sounds, no hepatosplenomegaly, anus patent. Genitourinary: Normal male genitalia, descended bilaterally. Extremities: Well perfused bilaterally, femoral pulses two plus bilaterally. No cyanosis or edema. Spine: Intact, no dimpling, no Ortolani or Barlow sign is present. Neurological: Spontaneous MAE, appropriate tone on exam. Motor - normal suck, palmar and plantar grasp intact. HOSPITAL COURSE: Respiratory: Upon arrival to the Neonatal Intensive Care Unit, the patient exhibited irregular respirations as well as poor spontaneous respiratory effort and was intubated. By day of life number three, the patient was extubated to CPAP plus five and remained on CPAP until hospital day number six, [**2144-10-22**]. On the next day, hospital day number seven, the patient was transitioned to room air and remained so until hospital day fourteen at which time, he was placed on nasal cannula 21 percent on varying flows of O2 from 100-200 cc. The patient was placed on nasal cannula O2 at this time for increased apnea of prematurity. The patient was weaned off nasal cannula by [**2144-11-10**] and has remained so until the date of interim discharge summary. The patient exhibited apnea of prematurity by day of life number three at which point he was loaded with caffeine citrate. Caffeine citrate was continued until [**2144-11-11**] at which point it was discontinued. Cardiovascular: This patient remained cardiovascularly stable throughout his hospital course. Secondary to a murmur heard on day of life number two, the patient received a cardiac echocardiogram which revealed a small ventricular septal defect, as well as a small patent ductus arteriosus. In addition, a small patent foramen ovale was detected with bidirectional flow present. Fluids, electrolytes and nutrition: The patient was NPO on day of life number one at 80 cc/kg/day of parenteral nutrition. The patient was started on enteral feeds on day of life number four and was quickly increased to full feeds of 150 cc/kg/day by day of life number ten. Currently at the time of this interim summary, the patient is on breast milk 32 kilocalories per ounce and 150 cc/kg/day PO/PG. Hematology: The patient's initial CBC was benign with a white blood cell count of 5.5, hematocrit of 50.1, platelets 231, differential white count of 27 polycytes, 58 lymphocytes. The patient was placed on ampicillin and gentamycin secondary to maternal sepsis risk factors and continued on antibiotics until 48 hours at which point they were discontinued secondary to negative blood cultures. The patient had no other infectious disease issues during his hospitalization. The patient's bilirubin on day of life number two was 8.6 mg/dl at which point phototherapy was initiated until day of life number six. The patient's bilirubin dropped to 4.3 mg/dl at which point phototherapy was discontinued. Neurologic: The patient remained neurologically stable throughout his hospital course. CARE/RECOMMENDATIONS: At the time of interim summary, breast milk 30 kilocalories per ounce at 150 cc/kg/day. Medications include ferrous sulfate and vitamin E. State newborn screening sent. No immunizations administered. DISCHARGE DIAGNOSES: Prematurity at 29-2/7 weeks gestational age. Respiratory distress, resolved. Hyperbilirubinemia, resolved. Immature feeding. Small ventricular septal defect, small patent ductus arteriosus. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**] Dictated By:[**Last Name (NamePattern1) 56932**] MEDQUIST36 D: [**2144-11-18**] 14:27:27 T: [**2144-11-18**] 15:09:53 Job#: [**Job Number 59620**]

Admission Date: [**2199-4-19**] Discharge Date: [**2199-4-25**] Date of Birth: [**2135-4-2**] Sex: M Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 2145**] Chief Complaint: unresponsive, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 64 M w/ hx catastrophic central cord syndrome s/p fall ([**11/2198**]) w/ resultant C5 quadriplegia (was trached and had peg as well, now removed) who has urostomy tube in place, hospital course also complicated by segmental PE and VAP, discharged from rehab 3 days ago and brought to ED because of unresponsive episode and hypotension. Per wife, pt has had increased sleepiness and fatigue since discharge from rehab 3 days prior to admission. Today, pt had episode of unresponsiveness while getting into shower. Episode lasted ~10 sec, at which time his eyes were open, but pt wasn't following commands. EMS arrived and found pt minimally responisve, hypotensive to 60s, but protecting airway. He opened his eyes to command, and he was answering basic questions. No F/C (but thermal regulation is poor), N/V, abd pain, chest pain, SOB or signs of autonomic ysregulation. Regular daily BMs with enema. No diplopia, other episodes of LOC, change in strength or weakness. Per report, pt had foul-smelling drainage from urostomy tube. Urostomy initially placed in [**1-/2199**], most recently changed [**4-16**] by nurse prior to discharge from [**Hospital3 **]. . In the ED, VS were: 97.2 68 120/77 16 100% 2 L NC. Given unclear allergy to vanc/zosyn, pt given clinda/cefepime. Had a R-groin triple lumen, clean line. Received total 5L NS, and initially started on levophed. Levophed has slowly been titrated down w/ volume from IVF, currently at 0.15 mcg/kg. Labs remarkable for WBC 18.5 (PMN predominant), +UA, lactate 3.0 --> 1.8. Per ED, at time of transfer, pt mentating better than when he came in but not back to baseline. Of note, urostomy was initially clogged; irrigated it and got back 500cc purulent urine. Intial U/A, urine and BCx pending. . On the floor, pt without complaints aside from dry cough that began in ED, arms feeling uncomfortable (in flexion), and uncomfortable, cold legs. Re: ADLs, pt needs help to feed self; able to use some OT tools to help, but still difficult. [**Hospital3 **] cough. Due to enter [**Hospital1 **] outpt program in ~5wks, and frustrated that this might set him back. Has not been told how long will need Coumadin, but still taking. Diet without restrictions. . . Review of systems: (+) Per HPI (-) Denies recent weight loss or gain, headache, sinus tenderness, rhinorrhea or congestion, shortness of breath, wheezing, palpitations, or weakness. Denies rashes or skin changes. Past Medical History: -Admitted to hospital in [**11/2198**] s/p fall, found to have central cord syndrome with quadriplegia with hospital course c/b PE and respiratory failure requiring intubation c/b ventilator acquired pneumonia --> MRI [**11/2198**] of cervical spine was consistent with multiple cervical spine fractures and stir changes within the cord from C2-C6 but showed no canal compromise and no role for emergent surgical intervention. -Quadriplegia, motor level C5 -left hand fracture -Segmental Pulmonary Embolism, first discovered on [**12-2**], started on anticoagulation with LE Doppler on [**2198-12-9**] showing superficial thrombus in R peroneal vein; hematology finally recommended against formal anticoagulation since PE was subsegmental. HOWEVER, then on [**12-11**], pt had episode of desaturation and chest CT on [**12-12**] revealed new segmental PE in right lung --> anticoagulation -s/p IVC filter Social History: - Recently discharged home from [**Hospital3 **] ([**4-16**]); lives with wife, has [**Name (NI) 269**] services; has son in [**Name (NI) **] studying linguistics and anthromology - Biology professor [**First Name (Titles) **] [**Last Name (Titles) **] - Tobacco: none - Alcohol: none since [**2198-11-16**] - Illicits: none Family History: Non-contributory Physical Exam: ADMISSION EXAM: Vitals: T: afebrile BP: 141/72 P: 88 R: 10 @100%(2L) General: Alert, oriented, no acute distress, laying still in bed with blankets up to chin HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Old trache scar near jugular arch, supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly with some basilar crackles on lateral exam. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present GU: Suprapubic catheter with some visible purulence; no erythema, blood. Ext: R femoral line in place (c/d/i). UE warm, well perfused, 2+ pulses; LE cool to touch, but pulses intact. No clubbing, cyanosis. Trace LE edema. Neuro: AOx3. MS [**First Name (Titles) 151**] [**Last Name (Titles) **] voice, but normal prosody, recall. CN 2-12 intact. Strength in C5 dermatome 4+/5 ([**2-20**] below biceps). Initially, UE in flexion and LLE externally rotated, but after arm exercises done with this physician, [**Name10 (NameIs) 460**] to extend L arm to ~160 degrees and R arm to 170 degrees. Sensory level with some sense of pressure to legs bilaterally. Coordination unassessed. Babinski + bilaterally, but no notable clonus or hyperreflexia in LE. In UE, has spasticity that can be overcome with exercises. DISCHARGE EXAM: T: afebrile BP: 128/78 P: 86 R: 18 @100%RA General: Alert, oriented, no acute distress, laying still in bed HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Old trache scar near jugular arch, supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly with some basilar crackles on lateral exam. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present GU: Suprapubic catheter in place; no erythema, blood. Ext: UE warm, well perfused, 2+ pulses; LE 1+edema, but pulses intact. No clubbing, cyanosis. Neuro: AOx3. MS [**First Name (Titles) 151**] [**Last Name (Titles) **] voice, but normal prosody, recall. CN 2-12 intact. Pertinent Results: ADMISSION LABS: [**2199-4-19**] 10:35AM BLOOD WBC-18.5*# RBC-4.34*# Hgb-12.7*# Hct-38.6*# MCV-89 MCH-29.1 MCHC-32.8 RDW-15.1 Plt Ct-395# [**2199-4-19**] 10:35AM BLOOD Neuts-90.6* Lymphs-4.6* Monos-4.2 Eos-0.3 Baso-0.3 [**2199-4-19**] 10:35AM BLOOD PT-31.6* PTT-44.5* INR(PT)-3.1* [**2199-4-19**] 10:35AM BLOOD Glucose-158* UreaN-41* Creat-1.4* Na-138 K-5.7* Cl-105 HCO3-22 AnGap-17 [**2199-4-20**] 03:27AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.3 [**2199-4-19**] 10:46AM BLOOD Glucose-154* Lactate-3.0* K-5.6* [**2199-4-19**] 10:46AM BLOOD Hgb-12.8* calcHCT-38 [**2199-4-19**] 11:05AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.013 [**2199-4-19**] 11:05AM URINE Blood-NEG Nitrite-POS Protein->600 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-LG [**2199-4-19**] 11:05AM URINE RBC-2 WBC-0 Bacteri-FEW Yeast-NONE Epi-0 [**2199-4-19**] 11:05AM URINE Mucous-RARE . DISCHARGE LABS: [**2199-4-25**] 05:59AM BLOOD WBC-7.0 RBC-3.48* Hgb-10.2* Hct-30.4* MCV-87 MCH-29.3 MCHC-33.5 RDW-15.1 Plt Ct-312 [**2199-4-25**] 05:59AM BLOOD PT-14.5* PTT-28.4 INR(PT)-1.3* [**2199-4-25**] 05:59AM BLOOD Glucose-89 UreaN-17 Creat-0.4* Na-139 K-4.6 Cl-103 HCO3-27 AnGap-14 [**2199-4-25**] 05:59AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.2 . IMAGING [**2199-4-19**] CXR: Mild left base atelectasis, mild component of aspiration not excluded. . [**2199-4-22**] ECHO: normal left ventricular cavity size with regional systolic dysfunction c/w CAD (PDA distribution). Pulmonary artery systolic hypertension. Right ventricular cavity enlargement with borderline normal free wall motion. . MICROBIOLOGY: -[**2199-4-19**] 11:05 PM urine culture: PROTEUS MIRABILIS. >100,000 ORGANISMS/ML. c+. 10,000-100,000 ORGANISMS/ML. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephem carbapenems, and beta-lactamase inhibitor combinations. -[**2199-4-19**] 2:30 pm urine culture:MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. -[**2199-4-22**] 5:43 pm urine culture: NO GROWTH. -[**2199-4-23**] 8:53 pm urine culture: NO GROWTH. Brief Hospital Course: 64 M s/p fall in [**11/2198**] now with C5 quadriplegia (s/p trach, peg, and urostomy tube), who was brought into the ED following unresponsive episode with hypotension, and found to have grossly purulent urine, leukocytosis with neutrophil predominance, and positive UA with clinical picture concerning for sepsis. . # Urosepsis: Patient was empirically started on clindamycin and cefepime in the ED, and was hypotensive requiring fluid reuscitation and a brief span of Levophed. In the MICU antibiotics were switched to meropenem and linezolid (questionable hx of vancomyin/zosyn reaction, thrombocytopenia, when the two antibiotics were used together). Urine culture returned positive for Proteus sensitive to meropenem so the linezolid was stopped. Final sensitivity showed pt's Proteus was sensitive to Ceftriaxone as well, so his antibiotic was changed from Meropenem to Ceftriaxone. Urology was consulted and recommended continuing the antibiotic for several days prior to changing the urostomy tube. He remained afebrile and was clinically stable for transfer to the floor. While on the medicine floor, pt spiked a fever and blood cultures and urine cultures were obtained. One set of the urine cultures returned positive for staph aureus coag positive. Pt was started on Vancomycin while the rest of the urine cultures were pending. When the other urine cultures returned negative, pt was taken off the vancomycin since the staph aureus coag positive was likely due to skin contamination. Pt was d/c'd home after he was afebrile for >24 hrs with continuation of Meropenem for additional eight days to complete a 14 day course at home. In addition, pt was seen by the urology consult team, and his supra-pubic catheter was changed. Urology discussed with pt and his wife the importance of flushing the catheter when needed, changing the catheter every 4 weeks, and try to avoid up sizing the catheter if possible. If there is a leakage, this can be a sign of infection and pt should contact his primary care physician as soon as possible. . # EKG Changes: The patient was noted to have asymptomatic t wave inversions in V4-V6 with troponin elevated to 0.11, and then 0.08. He was given ASA and was seen by the Atrius cardiologist. This was felt to be secondary to the underlying sepsis, rather than ACS. A repeat EKG in the AM had normalized. While on the medicine floor, pt was asymptomatic and did not have any chest pain. A follow up ECHO was done, and it was positive for regional systolic dysfunction c/w CAD (PDA distribution). His troponin was 0.05 and CKMB was 3 at that time. The Atrius cardiologist was reconsulted. EKG was repeated. Similar T waves changes were appreciated. The decision was made to start medical management only as pt was asymptomatic and the troponin leak was not significant at this time and trending down. Please see Dr.[**Last Name (STitle) **]. [**Doctor Last Name **] (Atrius cardiologist) note for details. pt was started on Aspirin, Metoprolol, Lisinopril, and Simvastatin. Pt tolerated the medications well. He was instructed to follow up with Dr.[**First Name (STitle) 2920**] as outpatient in 1 month and for repeat EKG. . # Quadriplegia s/p fall in [**11/2198**]: continued baclofen, neurotin, IS, and bowel regimen. Gabapentin was stopped at pt's request because he felt it was not effective at all. . # S/p Segmental Pulmonary Embolism in [**11/2198**] s/p IVC filter: INR was supratherapeutic at 4.3, so warfarin was initally held. When INR was below 2, Coumadin was restarted. At the time of discharge, pt's INR was only 1.3, so he was instructed to continue Lovenox treatment until his INR is between [**3-21**]. . #Anemia: on admission pt's HCT was 38 and then trended down to 28. Pt's stool was guiac negative and physical exam was negative for acute bleeding. Given pt's stable vital sign, the HCT drop was thought to be due to dilutional effect from the large amount of IVF for his hypotension. . #Insomnia: pt reported he was able to sleep without any problems. His Trazodone was stopped at his request. . Transitional issues: # Access: PICC for IV antibiotic(placed [**4-21**]) # Communication: patient, wife [**Doctor Last Name 2048**], [**Telephone/Fax (3) 74208**], cell) # Code: Full # Disposition: discharged home with services on [**2199-4-25**]. Medications on Admission: -Tylenol 650mg PRN fever -Fosamax 70mg [**Doctor First Name **] at 6AM -Baclofen 20mg q6hrs -Oscal 500 + D2 [**Hospital1 **] -Colace 100mg [**Hospital1 **] -Lasix 20mg daily -Neurontin 100mg TID -Lidocaine patches 2 PRN -Maalox/mylanta 30mg q6h -Magic bullet 10mg daily -Milk of magnesia 30ml [**Hospital1 **] -MVI daily -Nystatin powder [**Hospital1 **] -Omeprazole 20mg daily -oxycodone 5mg q4hr PRN -Senna 2tab daily -Coumadin 6mg daily -Oxycontin 10mg TID -Trazodone 50mg daily -Tramadol 50mg q6hr PRN Discharge Medications: 1. acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 2. alendronate 70 mg Tablet [**Hospital1 **]: One (1) Tablet PO QSUN (every Sunday). 3. baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QID (4 times a day). 4. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal DAILY (Daily). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 11. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO BID (2 times a day). 12. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 13. oxycodone 10 mg Tablet Extended Release 12 hr [**Hospital1 **]: One (1) Tablet Extended Release 12 hr PO Q8H (every 8 hours). 14. tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 15. warfarin 6 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 16. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a day): please do not take if blood pressure <100 or heart rate < 60. Disp:*30 Tablet(s)* Refills:*0* 17. simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 18. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 19. lisinopril 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 20. Lovenox 120 mg/0.8 mL Syringe [**Hospital1 **]: One (1) Subcutaneous once a day: please administer 110 mg. . Disp:*4 syringes* Refills:*1* 21. Outpatient Lab Work please obtain INR level on [**4-27**] and on [**4-29**], and fax all results to anticoagulation lab ( Phone [**Telephone/Fax (1) 74209**], Fax [**Telephone/Fax (1) 31021**]) and primary care physician (Phone: [**Telephone/Fax (1) 11962**], Fax: [**Telephone/Fax (1) 6808**]). 22. saline syringes Please order [**Last Name (un) 74210**] with saline (60 CC) for pt to flash catheter as needed. Disp #30. 23. ceftriaxone 1 gram Recon Soln [**Last Name (un) **]: One (1) Intravenous once a day for 8 days. Disp:*8 bags* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (un) 269**] Care Discharge Diagnosis: urosepsis troponin leak Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: quadriplegic Discharge Instructions: Dear Mr.[**Known lastname 55450**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for low blood pressure and hypotension, and were found to have a urinary tract infection and abnormal EKG changes. . # Sepsis: The source of infection was likely proteus from urine. You were treated with IV antibiotics and will need to continue these at home until [**2199-5-3**] for a 2 week course. . Your suprapubic catheter was replaced by the urology consult team on [**2199-4-22**]. They also discussed with you the importance of irrigation as needed to maintain urine flow. They also recommended that you change your catheter every 4 weeks and avoid up sizing the tube if possible. Leakage from the tube can be a sign of infection and you should contact your physician as soon as possible if there is leakage. . #hx of segmental pulmonary embolism w/IVC filter ([**11-25**]): on admission your INR was elevated. We held your coumadin and trended your labs. You INR was then found to be sub-therapeautic, and we restarted your Coumadin. While your Coumadin was being titrated, we started you on Lovenox (this should be continued until your INR is [**3-21**]).INR labs will be obtained by the [**Month/Day (3) 269**] and they will send result to the anticoagulation nurses and your primary care physician. . # Elevated cardiac enzymes and T wave inversions: you did not have any chest pain or shortness of breath. You were seen by the Atrius cardiologists and had an ultrasound of your heart (ECHO). The result of the ECHO was abnormal. The cardiologist recommended medical management with beta blocker, aspirin, ACE inhibitor, and simvastatin and follow up as outpatient in 1 month and repeat EKG. . # Quadriplegia s/p fall in [**11/2198**]: you were continued on Baclofen. Gabapentin was stopped at your request because it was not effective. . #Increase bowel movements: you were tested for c. diff and the result was negative. Your bowel movement returned to baseline at the time of discharge. . #anemia: your hematocrit dropped from 38 on admission to 28. Labs were followed and it was stable. Your stool was guiac negative. You received IVF for hypotension, this can lead to the dilution effect. . Transition issues: -PICC line was placed on [**4-21**] for IV antibiotic. In summary, the following changes were made: -Stopped Gabapentin -Stopped Trazodone -Started IV Ceftriaxone -Started Lovenox -Started metoprolol -Started baby aspirin -[**Name2 (NI) **] Lisinopril -Started simvastatin Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] L. Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 11962**] Appointment: Friday [**5-10**] at 5:10PM Name: [**Last Name (LF) 2920**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] Appointment: Tuesday [**5-28**] at 11:10AM Department: SPINE CENTER When: TUESDAY [**2199-6-11**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD [**Telephone/Fax (1) 3736**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2199-4-29**]

Admission Date: [**2113-5-8**] Discharge Date: [**2113-5-31**] Service: CARDIOTHORACIC CHIEF COMPLAINT: Fatigue HISTORY OF PRESENT ILLNESS: A 77-year-old woman with known AS recently admitted for congestive heart failure underwent a balloon valvuloplasty on [**2113-4-4**]. Post valvuloplasty, aortic valve area is 1.1 with a gradient of 10, discharged to home on [**2113-4-7**]. Cardiac catheterization data - aortic valve area 0.6, gradient 43 with three vessel disease. Echocardiogram from [**3-1**] - ejection fraction of 45% to 50%, 2+ mitral regurgitation, 2+ tricuspid regurgitation and moderate to severe AS. PAST MEDICAL HISTORY: 1. Neurogenic bladder 2. Diverticulosis 3. Hypertension 4. Restrictive lung disease on home O2 5. Tonsillectomy and appendectomy both in the [**2051**] 6. Multiple cervical and lumbar spine procedures 7. Kidney repair in the [**2071**] 8. Gastroesophageal reflux disease 9. Complete heart block, status post pacemaker [**2112-3-3**] 10. Bilateral mastectomies in the [**2081**] 11. Hysterectomy in [**2084**] 12. Left pneumonectomy due to lung cancer 13. Multiple hand surgeries for arthritis. 14. Left humeral fracture in [**2112-10-3**] 15. Positive PPD MEDICATIONS PRIOR TO ADMISSION: 1. Atenolol 12.5 mg po qd 2. Cozaar 25 mg qd 3. Ditropan 2.5 mg [**Hospital1 **] 4. Prevacid 30 mg qd 5. [**Doctor First Name **] 60 mg [**Hospital1 **] 6. Aspirin 81 mg qd 7. Atrovent metered dose inhalers 8. Amoxicillin for urinary tract infection which was completed on [**5-4**]. ALLERGIES: MORPHINE FROM WHICH SHE DEVELOPS RASH. CIPRO AND LEVAQUIN FROM WHICH SHE DEVELOPS FLU-LIKE SYMPTOMS, INCLUDING NAUSEA AND DIARRHEA. FENTANYL FROM WHICH SHE DEVELOPS AGITATION. PHYSICAL EXAMINATION PRIOR TO ADMISSION: VITAL SIGNS: Heart rate 80 and regular, respiratory rate 24, blood pressure 159/62. Height is 48 inches. Weight is 88 pounds. GENERAL: Frail appearing woman in no acute distress. SKIN: Intact. HEAD, EARS, EYES, NOSE AND THROAT: Unremarkable. NECK: Limited range of motion. CHEST: Clear to auscultation in the right lung field. HEART: Regular rate and rhythm, grade [**4-8**] ejection murmur. ABDOMEN: Softly distended, nontender, positive bowel sounds. EXTREMITIES: Warm with no peripheral edema, limited mobility of the left arm secondary to a humeral fracture. No varicosities. NEUROLOGIC: Grossly intact. LABS: All labs are pending. Electrocardiogram is a V-paced rhythm. Chest x-ray is also pending. HOSPITAL COURSE: The patient is to be admitted as a postoperative admission for coronary artery bypass graft AVR on [**2113-5-8**]. As stated previously, the patient was postoperative admit. On [**5-8**], she was admitted to the Operating Room at which time she underwent coronary artery bypass graft x2 with a saphenous vein graft to the LAD and saphenous vein graft to distal RCA, as well as an aortic valve replacement with a #19 pericardial valve. Please see the Operating Room report for full details. The patient was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit with an open chest. At that time, she had epinephrine at 0.5 mcg per kg per minute, Levophed at 0.1 mcg per kg per minute, propofol, ............ and ............. The patient also had an anterior aortic balloon pump in place at 1 to 1. Upon arrival in the CSRU, the patient was noted to have bright red blood per nasogastric tube. The gastrointestinal service was consulted and an esophagogastroduodenoscopy was done. Unfortunately, the patient was unstable during the esophagogastroduodenoscopy and the procedure had to be aborted before completion. No source of gastrointestinal bleeding was noted in the stomach. Blood was pooled in the cardia. There was no blood in the antrum or the duodenum. During her cardiac procedure and subsequent upper gastrointestinal bleed, the patient received a total of 13 units of packed red blood cells, 12 units of platelets and 10 units of fresh frozen plasma on the day of her surgery. Over the next several days, the patient remained in the Cardiothoracic Intensive Care Unit sedated and paralyzed. Hemodynamically, she continued to slowly improve and was weaned from some of her cardioactive drugs. On postoperative day 3, she returned to the Operating Room. At that time, her balloon pump remained in place,however she was able to have her chest closed. She returned from the Operating Room to the Cardiothoracic Intensive Care Unit again with propofol, Neo-Synephrine and intra-aortic balloon pump at 1 to 1. This patient was hemodynamically stable upon arrival to Cardiothoracic Intensive Care Unit for the course of the evening and night. Following closure, the patient was weaned from all cardioactive drugs. On the morning of postoperative day 4 and 1, she was weaned from the intra-aortic balloon pump which was ultimately discontinued without any hemodynamic compromise. Following the removal of the intra-aortic balloon pump, all sedation was discontinued. The patient was weaned from full support mechanical ventilation to pressure support ventilation. Neurologically, the patient was slow to awaken for her sedation. She as initially unresponsive and over the next several days, regained the ability to follow commands. Two days following chest closure, the patient's chest tubes were removed. On postoperative day 3 and 6, the patient's Swan-Ganz catheter was removed. On postoperative 7 and 4, the patient was transferred from the Cardiothoracic Intensive Care Unit to the Surgical Intensive Care Unit for continuing postoperative care in an Intensive Care Unit environment. Over the next several days, the patient was slowly weaned from pressure support ventilation and ultimately on [**5-19**], she was successfully extubated. Following extubation, the patient remained in the Intensive Care Unit where we closely monitored her respiratory status. Several days following extubation a swallow study was performed which the patient felt initial plans were made to have a PEG placed, however, decision was made not to place PEG. Her nasogastric feeding tube was changed to a Dobbhoff tube. The patient remained in the Intensive Care Unit throughout the rest of her hospital course due to weakness and her high risk of aspiration. On [**5-30**], it was decided that [**Last Name (un) 12315**] as stable and ready for transfer to rehabilitation center of continuing postoperative care and cardiac rehabilitation. At the time of transfer, the patient's physical exam is as follows: VITAL SIGNS: Temperature 96.1??????, heart rate 90 AV placed, blood pressure 155/75, respiratory rate 24, Os2 %100 on 2 liters nasal oxygen. Weight preoperatively is 89.5 pounds, at discharge it s 116 pounds. LAB DATA ON [**5-30**]: White count 8.6, hematocrit 34, platelets 168, od 147, potassium 3.9, chloride 102, CO2 28, BUN 33, creatinine 0.4, glucose 137. Chloride 111, CO2 28, BUN 33, creatinine 0.4. PHYSICAL EXAM: GENERAL: Alert and responsive, follows some commands. RESPIRATORY: Breath sounds clear to auscultation on the right, no breath sounds on the left. COR: Regular rate and rhythm, S1, S2. STERNUM: Stable, incision with Steri-Strips open to air, clean and dry. ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. EXTREMITIES: Warm and well perfused with 2+ edema and Dopplerable pulses bilaterally. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg [**Hospital1 **] 2. Heparin 5000 units subcutaneous [**Hospital1 **] 3. ............ 4 mg q hs 4. Colace 100 mg [**Hospital1 **] 5. Enteric coated aspirin 325 qd 6. Lansoprazole 30 mg qd 7. Regular insulin sliding scale 8. Dulcolax suppository 1 pr qd prn DISCHARGE DIAGNOSES: 1. AS status post AVL with #19 pericardial valve 2. Coronary artery disease, status post coronary artery bypass graft x2 with a saphenous vein graft to the LAD and the saphenous vein graft to the distal RCA. 3. Hypertension 4. Diverticulosis 5. Restrictive lung disease 6. Kidney repair 7. Neurogenic bladder 8. Complete heart block status post permanent pacemaker 9. Gastroesophageal reflux disease 10. Bilateral mastectomies 11. Status post left pneumonectomy 12. Status post hysterectomy 13. Status post appendectomy ALLERGIES: CIPRO AND LEVOFLOXACIN FROM WHICH SHE GETS FLU-LIKE SYMPTOMS. MORPHINE FROM WHICH SHE GETS A RASH AND FENTANYL FROM WHICH SHE DEVELOPS AGITATION. ALSO LISTED IN ACE inhibitor FOR WHICH NO REACTION IS LISTED. FOLLOW UP: The patient is to have follow up with Dr. [**Last Name (STitle) 1537**] in one month and follow up with her primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13844**], in three to four weeks following discharge from rehabilitation. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2113-5-30**] 14:23 T: [**2113-5-30**] 14:31 JOB#: [**Job Number 13845**]

Admission Date: [**2163-1-17**] Discharge Date: [**2163-1-19**] Date of Birth: [**2098-2-26**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old male with known ST elevation, MI, status post elective cath complicated by hypotension and bradycardia who was transferred to CCU for observation. The patient initially presented to [**Hospital3 417**] Medical Center on [**2163-1-14**] with chest pain radiating to the jaw. He was found to have increased troponin of 1.76, was given Nitroglycerin and remained pain free over the next three days at the outside hospital on Aspirin, Plavix and Nitroglycerin prn. He was then transferred to [**Hospital1 69**] for elective catheterization on [**2163-1-17**]. The catheterization showed double occlusion of PDA, no intervention was done. The patient was transferred to post-op area where he became hypotensive after continuous pressure to his groin was applied in order to stop the bleeding from the femoral artery. The patient was noticed to have groin hematoma and angiocele was attempted. He was also given 40 mg of Protamine in order to stop the bleeding. At this time he became hypotensive. This was thought to be secondary to vagal reflux. He was given IV fluids and Dopamine after which he developed upper body pruritic rash. Because of the concern for anaphylaxis secondary to dye Protamine, the patient was given 120 mg of Solu-Medrol and Benadryl as well as Promethazine and Pepcid. CT of the head and abdomen were obtained in order to rule out retroperitoneal or head bleeding. Both were negative. Vascular surgery was consulted and the patient was transferred to the CCU. PAST MEDICAL HISTORY: Significant for lung cancer. The patient had left lung cancer in [**2147**] and right lung cancer in [**2155**], both resected. He also had a brain metastasis thought to be due to left lung cancer in [**2149**], prostatic cancer diagnosed in [**2160**]. Also has a history of hypertension, peripheral vascular disease and hypercholesterolemia. ALLERGIES: No known drug allergies. MEDICATIONS: On admission, Aspirin 325 mg, Lipitor 10 mg, Lisinopril 20 mg, Serax [**11-14**] q 8 hours prn, Percocet 1-2 tabs q 4-6 hours, Dilantin extended release 400 mg q a.m., 300 mg q p.m., Compazine prn, Simethicone prn, Lopressor 12.5 mg [**Hospital1 **]. SOCIAL HISTORY: The patient has a history of 30 pack year smoking, quit in [**2162-2-26**], alcohol occasional use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Heart rate 64, blood pressure 141/65, temperature 97.2, respirations 18, O2 saturation 98% on three liters. General, no acute distress, somnolent, oriented times two, oropharynx dry, mucosal membranes dry, sclera anicteric. JVP at 6-7 cm of water. Regular rhythm and rate, S1 and S2, no murmurs, rubs or gallops. Pulmonary exam clear to auscultation anteriorly. Abdomen soft, nontender, non distended. Extremities, moderate sized hematoma of the left groin, dopplerable PT bilaterally and dorsal pedal pulse on the right, foot only. Echocardiogram showed ejection fraction more than 55% and basal inferior hypokinesis. White cell count 10.2, hematocrit 39.5, platelet count 247,000, sodium 137, potassium 3.9, chloride 106, CO2 19, BUN 15, creatinine 0.6, glucose 166. ABG 7.26, 48, 113. EKG showed ST elevations in V1 to V3, improved with Nitroglycerin. Catheterization showed occluded left posterior descending artery and non obstructive LAD with non dominant RCA. HOSPITAL COURSE: The patient was admitted to the CCU for observation and treatment of possible anaphylactic reaction. Solu-Medrol and Nitro were continued over the next 24 hours. The patient's mental status cleared the next morning. His hematoma continued to ooze slowly and the patient was transferred to the regular floor for observation of his hematoma overnight. Duplex ultrasound of left femoral artery was done and showed no evidence of pseudoaneurysm or an AV fistula. Over the 24 hours prior to discharge his hematoma remained stable with no symptoms or signs of bleeding. The patient remained symptom free during his hospital stay. He was discharged to home on [**2163-1-19**] in good condition on cardiac diet, on the following medications. DISCHARGE MEDICATIONS: Imdur 20 mg once a day, Dilantin 300 mg q p.m., 400 mg q a.m., Lopressor 12.5 mg [**Hospital1 **], Lisinopril 20 mg q d, Lipitor 10 mg q d, Aspirin 325 mg q d and Nitroglycerin sublingual tablets prn. The patient is to follow-up with his cardiologist, Dr. [**Last Name (STitle) 7047**] within 7 days after discharge. DISCHARGE DIAGNOSIS: 1. Myocardial infarction and profound vagal reaction. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**MD Number(1) 25755**] Dictated By:[**Doctor Last Name 47224**] MEDQUIST36 D: [**2163-1-19**] 10:52 T: [**2163-1-19**] 12:18 JOB#: [**Job Number 35439**]

Admission Date: [**2114-3-6**] Discharge Date: [**2114-3-15**] Date of Birth: [**2064-12-28**] Sex: M Service: NEUROLOGY Allergies: Cipro Attending:[**First Name3 (LF) 848**] Chief Complaint: seizures Major Surgical or Invasive Procedure: nasal intubation [**2114-3-5**] History of Present Illness: (history obtained from OSH and our medical records) The pt is a 49 year-old man with PMH of seizure disorder who presents as a transfer from [**Location (un) **] [**Location (un) 1459**] ED after having [**1-5**] seizures. Per OSH records, patient presented after with report of a 20 minute GTC seizure after which he was minimally responsive, followed by a 2nd GTC for which he received ativan. Unfortunately no further details available. In the OSH ED there was a report of 1 episode of shaking thought to be seizure activity. They reported vitals wnl, no acute findings on NCHCT, and a INR 7. He received a total 9mg ativan, fosphenytoin 1g, and vitamin K 10 prior to transfer. Past Medical History: seizure disorder - GTC followed here by Dr. [**First Name (STitle) 437**], most recently discharged from [**Hospital1 **] on [**2-1**] on Lamictal 100 [**Hospital1 **] and Dilantin Extended 300mg po daily. paranoid schizophrenia, epilepsy with short-term memory loss/developmental delay, history of DVT and PE in [**2096**], HTN, HLD, retroperitoneal bleed in [**2111-3-4**], diverticulitis, BPH, bilateral jaw fracture [**2114-1-3**] treated here Social History: Lives in [**Location **] alone in an apartment, sister checks in on him frequently. Denies tobacco, alcohol or ellicit drug use. Family History: No FHx of DVT, PE. Mom had Breast CA, father lung CA. Physical Exam: ADMISSION EXAM: Physical Exam: (prior to intubation, while receiving midaz/propofol/ketamine/fentanyl in prep for intubation) Vitals: T: P: 106 R: 17 BP: 119/62 SaO2: 100% on face mask General: eyes closed, moaning HEENT: NC/AT, jaw wired shut Neck: Supple. 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: Eyes closed spontaneously. Moaning. Nonverbal, not following commands. -Cranial Nerves: PERRL 3 to 2mm and brisk. No blink to threat bilaterally, Corneal on right, no corneal on left. EOMI on OCR, no nystagmus. No facial droop -Motor/Sensory: Moving left arm and leg more spontaneously than right side. Localizes pain in all extremities equally. Grimaces/localizes to pain throughout -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 mute bilaterally. ---- Pertinent Results: [**2114-3-6**] 12:40AM WBC-11.6* RBC-3.63* HGB-11.4* HCT-37.0* MCV-102* MCH-31.4 MCHC-30.7* RDW-14.2 [**2114-3-6**] 12:40AM PLT COUNT-252 [**2114-3-6**] 12:40AM PT-121.8* PTT-45.9* INR(PT)-12.6* [**2114-3-6**] 12:40AM ALBUMIN-2.8* CALCIUM-7.7* PHOSPHATE-2.9 MAGNESIUM-1.5* [**2114-3-6**] 12:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2114-3-6**] 12:40AM ALT(SGPT)-13 AST(SGOT)-31 ALK PHOS-121 TOT BILI-0.3 [**2114-3-6**] 12:50AM GLUCOSE-59* LACTATE-0.7 NA+-139 K+-1.5* CL--130* TCO2-12* [**2114-3-6**] 12:50AM PO2-73* PCO2-21* PH-7.27* TOTAL CO2-10* BASE XS--14 COMMENTS-GREEN TOP [**2114-3-6**] 01:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2114-3-6**] 01:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2114-3-6**] 01:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2114-3-6**] 01:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2114-3-6**] 01:20AM PHENYTOIN-14.8 [**2114-3-6**] 04:57AM PT-26.8* PTT-35.3 INR(PT)-2.6* [**2114-3-6**] 02:21PM PT-15.9* INR(PT)-1.5* [**2114-3-6**] CXR FINDINGS: The endotracheal tube ends about 6 cm above the carina. The cardiomediastinal silhouette and hila are normal. There is no pleural effusion and no pneumothorax. IMPRESSION: ETT ends 6 cm above the carina, could be advanced by about 2cm for optimal position. Brief Hospital Course: 49yoM h/o developmental delay, epilepsy, HTN, DVT/PE p/w recurrent generalized convulsions without return to baseline. [] Epilepsy/Seizures - He reportedly had at least two 20 minute long seizures and an additional episode at the [**Hospital1 **] ED. He was given at least 9mg of lorazepam, 1000 mg of fosphenytoin, and then a propofol infusion for a few hours before this was held on the morning of admission. 24h EEG was initiated which did not reveal any signs of clinical seizures. He was continued on Fosphenytoin 100 q8h with a corrected level of 22 in the absence of PO access to deliver his prior lamotrigine (his jaw was wired shut due to his prior maxillary repair surgery, and one nares was occupied by the nasotracheal tube). His sister reported that a [**Name (NI) 269**] was visiting him and was helping him take his medications by mouth daily; she thought the PHT second taper may have already ended prior to this admission, but she did not know his current home LTG dose. After discussing his case with OMFS, a nasogastric tube was placed and he was restarted on his home dose of LTG (100 [**Hospital1 **]). Two doses of PHT were held to help him wake up. He woke up and was extubated and transferred to the Epilepsy floor. He had no further seizures since the transfer. [] DVT/PE/Supratherapeutic INR - His INR upon arrival was 12. He was given prothrombin complex concentrate which brought the INR to 2.6. Warfarin was delivered through the NGT. When the INR dropped below 2, he was started on a heparin GTT to bridge him to a therapeutic INR. He was then transitionned to Sub cutaneous lovenox as a bridge until his INR became therapeutic. His coumadin dose was increased to 7.5mg, then decreased to 5mg. He reached therapeutic INR On [**2114-3-14**] and therefore the lovenox was discontinued. [] Swallowing Status - He was eating a liquid diet and taking pills at home after his last admission. A bedside dysphagia screen was performed by the [**Hospital Ward Name 121**] 11 nurses which he passed. [ ] Orthostatic hypotension: He was found to be orthostatic when PT started to walk with him on [**2114-3-13**]. He was given fluid boluses, placed on maintenance fluids and encouraged to drink plenty of fluids. He improved over the subsequent days. Given the history of seizures and him being on coumadin, his sister as well as the neurology team are concerned about him living at home by himself. We will plan for discharge to a skilled nursing facility for a short stay (less than 30 days). Medications on Admission: Suspected Medication List 1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID 4. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) cup PO Q6H (every 6 hours) as needed for pain. 5. oxycodone 5 mg/5 mL Solution Sig: [**4-12**] mL PO Q4H (every 4 hours) as needed for pain. Disp:*200 mL* Refills:*0* 6. doxazosin 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). Disp:*900 ML(s)* Refills:*2* 11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Please take 5 mg [**2-1**]. Goal INR [**1-5**]. Disp:*30 Tablet(s)* Refills:*0* 12. lamotrigine 100 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day). 13. Ensure Liquid Sig: One (1) can PO three times a day. 14. Dilantin Extended 100 mg Capsule Sig: Three (3) Capsule PO once a day. Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. risperidone 1 mg/mL Solution Sig: One (1) mg PO BID (2 times a day). 7. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. phenytoin 125 mg/5 mL Suspension Sig: Two Hundred (200) mg PO BID (2 times a day). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain or T > 99. Discharge Disposition: Extended Care Facility: Academy Manor of [**Location (un) 7658**] - [**Location (un) 7658**] Discharge Diagnosis: Increased seizure frequency. Discharge Condition: condition: stable. Mental status: Alert and oriented Ambulatory: indepedent, but need to make sure he is not orthostatic therefore will require supervision to walk. Discharge Instructions: Mr. [**Known lastname 84881**], You were admitted to us because of prolonged generalized seizures. You required assistance with your breathing, and a tube was placed through your nose to help you with the breathing. When you improved, you did not require the tube anymore. We believe you had your seizures because some changes were made to your medications, and we restarted you on your regular home medications in the hospital. You had no further seizures since you were admitted to us. Your INR has also been lower than the goal of [**1-5**]. we started you on lovenox until your INR reached 2 then we stopped it Followup Instructions: Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**] Date/Time:[**2114-4-13**] 9:00

Admission Date: [**2154-6-19**] Discharge Date: [**2154-6-25**] Date of Birth: [**2090-5-14**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Abnormal EKG, no symptoms Major Surgical or Invasive Procedure: Coronary artery bypass grafts x 4(Left Internal Mammary Artery > left anterior descending, saphenous vein graft > obtuse marginal, saphenous vein graft > diagonal, saphenous vein graft > Posterior descending artery) [**2154-6-21**] History of Present Illness: 64 year old white male underwent a strees test, which was positive due to an abnormal EKG on routine examination. He underwent cardiac catherization at outside hospital which revealed coronary artery disease. He was referred for surgical intervention. Past Medical History: Diabetes mellitus ( diet-controlled) hypertension hyperlipidemia s/p Melanoma resection Social History: Works as a custodian. 52 pack year smoker, quit 20 years ago. Drinks 8 shots/weekend Lives with his wife Family History: non contributory Physical Exam: Pulse:55 Resp: 18 O2 sat: 100 RA B/P Right: 116/76 Left: Height: 6 feet Weight: 91.2 kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: bilat [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: no Left: no Pertinent Results: Conclusions PRE-BYPASS: 1. The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The diameters of aorta at the sinus, ascending and arch levels are normal. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. 7. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is in sinus rhythm. Mid-esophageal views are very sub-optimal. 1. Biventricular function is intact. 2. Arch and descending aorta are intact. Dr. [**Last Name (STitle) **] was notified in person of the results. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2154-6-21**] 14:26 Portable chest radiograph of [**2154-6-23**] with comparison to [**2154-6-21**] and indication of chest tube removal. FINDINGS: Various indwelling devices have been removed, with no evidence of pneumothorax. Cardiomediastinal contours are unchanged in appearance in the postoperative period. Patchy areas of atelectasis are present in both retrocardiac regions, and a small left pleural effusion is also demonstrated. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: MON [**2154-6-24**] 10:15 AM Imaging Lab Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2154-6-23**] 06:55AM 10.9 3.17* 10.1* 28.7* 91 31.9 35.2* 13.2 190 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2154-6-23**] 06:55AM 190 BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2154-6-21**] 01:57PM 317 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2154-6-23**] 06:55AM 127* 19 0.9 134 4.7 96 28 15 ESTIMATED GFR (MDRD CALCULATION) estGFR [**2154-6-19**] 11:45PM Using this1 Using this patient's age, gender, and serum creatinine value of 1.0, Estimated GFR = 75 if non African-American (mL/min/1.73 m2) Estimated GFR = >75 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 60-69 is 85 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2154-6-19**] 11:45PM 21 24 187 51 0.4 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2154-6-23**] 06:55AM 2.0 DIABETES MONITORING %HbA1c [**2154-6-19**] 11:45PM 6.2*1 [**Doctor First Name **] RECOMMENDATIONS:; <7% GOAL OF THERAPY; >8% WARRANTS THERAPEUTIC ACTION ?????? [**2148**] CareGroup IS. All rights reserved. Brief Hospital Course: He was transferred for surgical evaluation and underwent preoperative work up. On [**2154-6-21**] he went to the operating Room and underwent coronary artery bypass graft surgery. See operative note for details. He received vancomycin for perioperative antibiotics. He was transferred to the intensive care unit for hemodynamic management. He was weaned from sedation, awoke neurologically intact, and was extubated without complications. He was transferred to the floor on post operative day one. Chest tubes and pacing wires removed per protocol. Physical therapy worked with him on strength and mobility. He continued to progress and was ready for discharge home with services on post operative day four.Pt. is to make all followup appts as per discharge instructions. Medications on Admission: Crestor 5mg/D Lisinopril 20mg/Hctz 25mg/D Amlodipine 2.5 mg/D Atenolol 25 mg/D ASA 162mg/D MVI Discharge Medications: 1. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts hypertension Diabetes mellitus type 2 ( diet-controlled) hypercholesterolemia h/o melanoma Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in [**1-4**] weeks ([**Telephone/Fax (1) 68885**]) Dr. [**Last Name (STitle) 5017**] in 2 weeks Wound check [**Hospital Ward Name **] 6 - please schedule with RN [**Telephone/Fax (1) 3071**] Completed by:[**2154-6-25**]

Admission Date: [**2146-9-19**] Discharge Date: [**2146-9-22**] Date of Birth: [**2096-10-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4654**] Chief Complaint: lethargy, respiratory depression Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 49 y/o F with PMHx of paraplegia s/p MVA ([**2142**]), recurrent UTIs, recent admission for PNA who was started on methadone for chronic pain in [**8-9**], presented with lethargy and difficulty breathing. Patient is accompanied by her husband and her friend, [**Name (NI) **], who helps care for her. They report patient was found very somnolent and was difficult to arouse, and reportedly presents this way when she has a urinary track infection. Family noted drowsiness starting the day prior to admission, and poor po intake. On the am of admission, caretakers noted desaturation to 89-90% on 2L o2 NC., which prompted them to bring her into the ED. ROS: Pt reports a low grade cough that has persisted from last admission for PNA, that has been improving, some urinary frequency (requiring additional catheterizations in addition to Q4H) from 3 days PTA. Denies any shortness of breath, nausea, vomiting, diarrhea, fevers or chills. Last bowel movement on Friday night. Regarding medications, patient is given her medications by either her husband or friend. She has not run out of any of her medications and does not recall taking any additional doses of anything. In the ED, VS were 98 60 110/69 16 100% on nonrebreather. UA was mildly positive with 6-10WBC, few bacteria, neg leuk est, neg nitrates. Pt was given empiric 1g Vanco X1, Zosyn 4.5 g X1, and Levo 750 mg X1 for ?LLL opacity on CXR. Official read of CXR showed bibasilar ateletasis, no definitive evidence of PNA. Primary care giver reported increased narcotic regimen including Methadone. Pt was given Narcan 0.1mg and had significant improvement in mental status, awake and responding appropriately. Pt required two addl doses of Narcan 0.1mg in ED with rapid recovery of respiratory rate and transferred to the ICU for closer monitoring. On transfer, VS were 95.9 66 110/76, 16 95% on 2L NC. Of note, last admission to [**Hospital1 18**] was [**2146-8-29**], where pt was diagnosed with RUL-RML PNA and UTI and completed a 5 day course of levofloxacin and bactrim respectively, and was started on methadone in addition to longstanding gabapentin, oxycodone, oxybutinin, and baclofen. Past Medical History: 1. Recurrent UTIs (q 2-3 months): last episode of ESBL Klebsiella [**3-5**] to atonic bladder, intermittent catheterization done by PCA or husband. Finished course of Bactrim on [**8-27**]. 2. T1-T2 paraplegia following MVC [**1-5**] s/p trach, s/p ORIF of R proximal humerus, s/p titanium steel plates in arms 3. HCV with apparent clearing of viremia as of [**5-10**] 4. Pneumonia (including MRSA in [**10-7**], last episode [**8-29**], finished 5 day course of levofloxacin 5. Anxiety 6. DVT in [**2142**] -IVC filter placed in [**2142**] 7. Pulmonary nodules 8. Hypothyroidism 9. Chronic pain 10. Peri-menopausal; LMP [**9-8**] Social History: Lives at home with her husband. PCA is best friend, [**Name (NI) **]. Occasional EtOH, 35 pack-year tobacco on a nicotine patch; last cigarette 3 weeks ago; no drugs. Family History: mother- lung CA Physical Exam: Vitals: T: 95.9 BP: 119/76 HR: 66 RR: 12 O2Sat: 97% 2L NC GEN: Well-appearing, somnolent but arousable HEENT: EOMI, PERRL with 3mm pupils bilaterally, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: healed tracheotomy scar. No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: (+) Crackles at the LLB ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. Spelled world backwards correctly, deferred on serial 7s. [**2-3**] items on 3 item recall. [**Doctor First Name **] intact. no Asterixis. 5/5 strength in UEs bilaterally. Babinski could not be elicited b/l. 1+ brachioradialis DTR b/l. sensation to touch intact up to level of nipples. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2146-9-19**]: WBC 6.1 Hgb 11.4 Hct 34.5 Plt 208 N:69.0 L:24.6 M:4.0 E:1.9 Bas:0.6 . PT: 14.5 PTT: 31.2 INR: 1.3 . 136 97 8 BS 93 AGap=12 ------------ 5.9 33 0.3 Grossly hemolyzed . ECG: NSR CXR [**2146-9-19**]: No definite evidence of pneumonia. Plate-like atelectasis at both lung bases. . UA:SpecGr 1.004 pH 7.0 Leuk-Sm RBC 0 WBC [**7-12**] Bact-Few Yeast-None Epi 0-2 . Urine Cultures Sent Brief Hospital Course: Assessment: This is a 49 yo F/ T1-2 paraplegia, with chronic pain, neurogenic bladder w/ hx of recurrent UTI, hx of DVT/PE s/p IVC filter placement not being anticoagulated now p/w altered mental status/lethargy and difficulty breathing in setting of change in narcotic regimen 4 weeks ago. . # Mental status change with respiratory depression: [**3-5**] toxic metabolic encephalopathy [**3-5**] narcotics and benzo polypharmacy, infection (sources include urinary given hx of UTIs and self- catherization, PNA given cough and recent PNA), and CXR shows persistent LLL opacity, and undertreated hypothyroidism. - f/u blood cx - f/u Urine Culture - hold benzos - empiric zosyn given prior last klebsiella UTI sensitivities, until speciated - titrate up levoxyl # Paraplegia s/p MVA: complicated by atonic bladder requiring self-catherization, DVT/PE s/p IVC filter, chronic pain syndrome, post SCI anxiety/depression - pain service consulted for simplification of regimen - oxybutinin for urinary retention - straight cath TID - hold benzos # Pain control -pain service recommended 1. Restart Baclofen home dose 10mg po bid and 5mg po mid day. 2. Lidocaine patch to affected area 3. Continue Neurontin 800mg QID 4. Hold Lyrica as it has similar action as neurontin. 5. Hold methadone and continue Oxycodone 5-10mg po Q4H PRN. Will see how much she needs over the next 24h. 6. Continue NSAIDS and can give Toradol IV PRN if no contraindication. 7. [**Month (only) 116**] restart all other home meds which are non-narcotic. # obstructive lung disease: Last CT chest showed ground glass opacities [**3-5**] PNA, emphysematous changes c/w COPD, and may have component of restrictive lung dz [**3-5**] chest wall weakness related to paraplegia. No hx of pfts, yet on home inhaler and intermittant 2L home O2 since [**8-9**]. - continue Ipratropium-Albuterol - incentive spirometry - NC - neb prn - f/u with pulmonary as outpt for pfts - check ABG if in respiratory distress . # HCV: chronic with undetectable viral load as of [**10-9**], with baseline LFts ALT 15 ALT 17 Alk phos 66 tBil 0.2. LFts wnl. stable. . # Anemia: normocytic anemia with baseline Hct 30-36; [**3-5**] ACD. - f/u CBC qam . # gastritis: hx of antral erosions, on Omeprazole at home, no GIB in past - continue PPI - on Sucralfate 1 g PO QID . # insomnia: hold ambien . # smoking cessation: nicotine patch. -consider wellbutrin given hx of depression. . # Hypothyroid: continue Levothyroxine 50mcg daily, untreated. - titrate up levoxyl . # Comm: [**First Name4 (NamePattern1) **] [**Name (NI) **], Husband, c [**Telephone/Fax (1) 104915**] / h [**Telephone/Fax (1) 104916**] Medications on Admission: Sucralfate 1 gram QID Ipratropium-Albuterol q6hr prn Lidocaine patch Oxycodone 5 mg Tablet [**2-2**] q4hrs prn (approx [**6-7**]/day) Gabapentin 400 mg QID Loratadine 10mg daily Levothyroxine 50 mcg Baclofen 10 mg Tablet [**Hospital1 **] Baclofen 5mg daily Oxybutynin Chloride 5 mg Tablet TID Trazodone 200mg qhs Clonazepam 1 mg QID prn (often takes 3 tabs before bed) Methadone 10 mg Tablet TID Nicotine 21 mg/24 hr Omeprazole 20 mg [**Hospital1 **] Discharge Medications: Baclofen 10mg po bid and 5mg po mid day. Lidocaine patch to affected area Neurontin 800mg QID Oxycodone 5-10mg po Q4H PRN Sucralfate 1 gram QID Ipratropium-Albuterol q6hr prn Loratadine 10mg daily Levothyroxine 50 mcg Trazodone 200mg qhs Clonazepam 1 mg QID prn (often takes 3 tabs before bed) Nicotine 21 mg/24 hr Omeprazole 20 mg [**Hospital1 **] Discharge Disposition: Home with Service Discharge Diagnosis: Primary diagnosis: Altered mental status secondary to sedating medications Secondary diagnosis #. Recurrent UTIs (q 2-3 months): last episode of ESBL #. Klebsiella [**3-5**] to atonic bladder #. T1-T2 paraplegia following MVC [**1-5**] s/p trach, s/p ORIF of R proximal humerus, s/p titanium steel plates in arms #. HCV with apparent clearing of viremia as of [**5-10**] #. Pneumonia (including MRSA in [**10-7**], last episode [**8-29**]) #. Anxiety #. DVT in [**2142**] -IVC filter placed in [**2142**] #. Pulmonary nodules #. Hypothyroidism #. Chronic pain Discharge Condition: stable Discharge Instructions: You were admitted with changed mental status and decreased breathing due to oversedation from your pain medications. Please confirm appropriate doses of your pain medications with your primary doctor and your pain doctor. Please do not administer pain medications when respiratory rate is less than 10 breaths/minute. Please do not drive or operate machinery after having taken narcotic pain medications. Please follow up with your primary care doctor to follow up on blood culture and urine culture results to ensure that you do not have an infection. Followup Instructions: Please follow up with your primary care provider as soon as possible regarding correct dosage of your pain medications, and to follow up on your blood and urine cultures. [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**] Completed by:[**2146-9-21**]

Admission Date: [**2172-2-21**] Discharge Date: [**2172-2-29**] Date of Birth: [**2107-8-9**] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3645**] Chief Complaint: back pain and right lower extremity weakness Major Surgical or Invasive Procedure: 1. mass excision, T8-L1 posterior decompression and instrumented fusion History of Present Illness: 64yo male who is transfered to [**Hospital1 18**] from [**Hospital3 1280**] due to a spinal mass. He has had approx 6 weeks of back pain after falling on the ice, then about 1 month ago noticed RLE weakness. This has gotten much worse over the last 2 weeks, and particularly in the last 2 days. Two days ago the pt fell because his leg was too weak and today he was unable to walk [**12-25**] weakness . Past Medical History: PMH: HTN, HDL PSH: bilateral hernia repair, R meniscus repair Social History: Activity Level: baseline independent ambulation Mobility Devices: none Occupation: works in Public Relations Tobacco: none EtOH: occasional Physical Exam: Vitals: 99.2 88 146/76 18 100% General: well appearing, comfortable, conversant, but anxious Mental Status: AOx3 Cranial nerves II-XII grossly intact. Vascular (R/L): -Radial 2+/2+ -Popliteal 2+/2+ -DP 2+/2+ -PT 2+/2+ Sensory (R/L): intact for upper and lower extremities bilaterally BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; RLE- 2/5 strength at hip flexion/extension, [**1-25**] knee flexion/extension; [**1-25**] ankle dorsiflexion and plantar flexion, [**1-25**] [**Last Name (un) 938**]/FHL LLE - 4/5 strength at hip flexion/extension,[**2-25**] knee flexion/extension; [**3-26**] ankle dorsiflexion and plantar flexion, [**3-26**] [**Last Name (un) 938**]/FHL Reflexes: symmetric for Biceps, BR, Triceps, Patellar, Achilles Straight Leg Raise Test: positive [**Doctor Last Name 937**]: negative Babinski: downgoing toes bilaterally Clonus: none Perianal sensation: normal Rectal tone: intact Estimated Level of Cooperation: complete Estimated Reliability of Exam: reliable Pertinent Results: [**2172-2-20**] 11:55PM PT-12.9 PTT-21.8* INR(PT)-1.1 [**2172-2-20**] 11:55PM PLT COUNT-258 [**2172-2-20**] 11:55PM NEUTS-95.3* LYMPHS-3.3* MONOS-0.7* EOS-0.7 BASOS-0.1 [**2172-2-20**] 11:55PM WBC-6.9 RBC-4.76 HGB-15.8 HCT-43.5 MCV-91 MCH-33.1* MCHC-36.3* RDW-12.4 [**2172-2-20**] 11:55PM GLUCOSE-126* UREA N-19 CREAT-0.8 SODIUM-142 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17 Pathology report: DIAGNOSIS: T10 mass for frozen section, excision (A-C): Metastatic carcinoma (see note). T10 mass, excision (D): Metastatic carcinoma (see note). Note: The tumor consists of well-formed thyroid follicles lined by oxyphilic cells with prominent nucleoli. Immunohistochemical stains show that tumor cells stain positive for cytokeratin cocktail (AE1/3 and CAM 5.2) and TTF-1. A stain for thyroglobulin shows high background staining and is non-contributory. The histomorphologic and immunophenotypic findings are consistent with metastatic follicular carcinoma, oxyphilic (Hurthle cell) type. Clinical: Thoracic stenosis. Gross: The specimen is received fresh labeled with the patient's name, "[**Known lastname 7168**], [**Known firstname **]" and the medical record number in two parts. Part 1 is submitted for intraoperative consultation and is additionally labeled "mass." It consists of a piece of red hemorrhagic and cauterized soft tissue with associated tendon and bone that measures 8 x 6 x 1 cm. A portion was taken for intraoperative exam and the frozen section diagnosis by Dr. [**Last Name (STitle) **]. [**Doctor Last Name 7017**] is "metastatic carcinoma, final diagnosis pending permanent section." The specimen is represented as follows: A = frozen section remnant, B = sections with bone and C = additional representative sections. Part 2 is additionally labeled "T10 mass." It consists of a piece of tan red soft tissue with associated tendon and bone that measure 4 x 3 x 2.5 cm. The specimen is serially sectioned to reveal hemorrhagic cut surfaces without any mass lesions and represented in cassette D. Brief Hospital Course: The patient was admitted to the [**Hospital1 18**] Spine Surgery Service and taken to the Operating Room for the above procedure without complication and was taken to the SICU intubated for intraoperative hypotension. For details please refer to the dictated operative note and detailed sicu note for his course there. TEDs / pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postoperatively per standard protocol. The patient's pain was controlled with IV pain medications followed by oral analgesics once tolerating POs. The patient's diet was advanced as tolerated. The foley was removed on POD#2. Physical therapy was consulted for mobilization. He continued to improve on a daily basis and was limited by proprioceptive deficits in his feet. He regained much of his lower extremity strength and was 4/5 strength. His intraoperative pathology report was consistent with metastatic carcinoma, likely thyroid. Oncology and endocrinology and surgical oncology was consulted. His CT scan of chest did show a nodule in his thyroid. Plan was for surgical resection in follow-up. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. The patient was discharged to rehab with instructions to follow up in clinic as directed with ortho spine, surgical oncology, endocrinology and medical oncology. Medications on Admission: Amlodipine 10mg/Benapril 20mg Qday, Simvastatin 10mg Qday, Naproxen prn pain Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: 1. Large epidural mass at T10-T11. 2. Thoracic stenosis, severe, with spinal cord injury. Mass on thoracic spine compressing spinal cord with pathology consistent with metastatic carcinoma, likely thyroid Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You have undergone the following operation: 1. Thoraco-lumbar spine posterior decompression with fusion Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: * 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. * Limit any kind of lifting. - Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. - Brace: You may have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: * Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. * At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. * We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Focus on proprioceptive and gait training, heel-cord stretching Treatments Frequency: Staples to be removed approximately [**2172-3-6**], ok to be d/c'ed at rehab facility Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2172-3-6**] 2:30 [**Hospital Ward Name 23**] Building [**Location (un) **] side A Provider: [**First Name4 (NamePattern1) 2053**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2172-3-6**] 2:30 [**Hospital Ward Name 23**] Building [**Location (un) **] side A Please also followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]. Please call for an appointment. Follow-up with surgical oncology Follow-up with endocrinology Completed by:[**2172-2-29**]

Admission Date: [**2138-12-19**] Discharge Date: [**2139-1-20**] Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1556**] Chief Complaint: Nausea, vomiting, Abdominal pain, distention. Major Surgical or Invasive Procedure: 1. Subtotal colectomy, end ileostomy, Hartmann's pouch, G-tube 2. Completion sigmoid colectomy, repair of colovesicular fistula, small bowel repair History of Present Illness: Ms [**Known lastname 71508**] is an 84 year old female with complaints of abdominal pain, diarrhea, nausea and vomiting x 1 week, who presented to an outside hospital. She was transferred to [**Hospital1 18**] on [**2139-12-19**] for bowel obstruction, ischemia and worsening abdominal distention and pain. Past Medical History: CAD s/p MI, HTN, DMII Social History: Lives independently, but in the same building with daughter. [**Name (NI) **] 3 children, 2 daughters and 1 son. Daughter [**Name2 (NI) **] is Durable Power of Attorney. The other daughter was recently in a car accident and underwent surgery at [**Hospital1 2025**]. Family History: NC Physical Exam: At time of discharge: Afebrile, VSS A&O X 3, NAD RRR CTAB, mildly decreased breath sounds b/l Abd soft, NT/ND, + bs, no masses, ostomy in RLQ pink, with stool G-tube in place LE trace edema Pertinent Results: [**2138-12-19**] 12:20PM BLOOD WBC-10.2 RBC-5.32 Hgb-14.9 Hct-43.4 MCV-82 MCH-28.0 MCHC-34.4 RDW-16.0* Plt Ct-204 [**2138-12-19**] 12:20PM BLOOD PT-12.9 PTT-32.5 INR(PT)-1.1 [**2138-12-19**] 12:20PM BLOOD Glucose-345* UreaN-34* Creat-1.0 Na-137 K-4.3 Cl-99 HCO3-24 AnGap-18 [**2138-12-19**] 12:20PM BLOOD ALT-17 AST-27 AlkPhos-119* Amylase-27 TotBili-0.9 [**2138-12-19**] 12:20PM BLOOD Lipase-11 [**2138-12-19**] 12:20PM BLOOD CK-MB-7 cTropnT-<0.01 [**2139-1-4**] 02:59AM BLOOD cTropnT-0.21* [**2139-1-4**] 11:29AM BLOOD CK-MB-35* MB Indx-25.5* cTropnT-0.45* [**2139-1-4**] 07:52PM BLOOD CK-MB-NotDone cTropnT-0.55* [**2139-1-5**] 05:25PM BLOOD cTropnT-0.42* [**2139-1-6**] 02:00AM BLOOD cTropnT-0.45* [**2139-1-14**] 07:13AM BLOOD CK-MB-3 cTropnT-0.19* [**2139-1-14**] 01:33PM BLOOD CK-MB-NotDone cTropnT-0.17* [**2139-1-16**] 09:58AM BLOOD CK-MB-NotDone cTropnT-0.06* . [**1-2**] wound swab: VRE . CT Abd [**12-19**]: 1. Markedly dilated colon throughout ascending, transverse, and descending colon with air-fluid levels, overall unchanged since prior study performed on the same day with pneumatosis in the ascending colon. Sigmoid diverticulosis with focal narrowing of the sigmoid colon just distal to the dilatation with wall thickening, due to diverticulitis. This area can be a leading point of obstruction. An underlying mass lesion or cancer cannot be excluded in this area, and further clinical investigation is recommended. 2. Limited evaluation for known sigmoid-vesicle fistula. 3. Small amount of ascites, somewhat increased anterior to the liver. 4. Bilateral renal cysts. 5. Heavy calcification of the aorta and SMA and its branches. Due to atherosclerosis, assessment of the intraluminal process of these branches is limited. . CTA/CT abd [**1-2**]: 1. No evidence of pulmonary embolism. Small bilateral pleural effusions with compressive atelectasis. 2. Left lower quadrant thick-walled peripherally enhancing fluid collection, which appears to communicate with the sutured end of the proximal sigmoid colon via a small collection of extraluminal gas. In the correct clincial setting, this could be consistent with an abscess. 3. Moderate intraabdominal ascites. 4. Status post ileostomy without evidence of small-bowel obstruction. 5. Distended gallbladder. 6. Diverticulosis within the right remnant sigmoid colon. . [**1-16**] VCUG - no leak Brief Hospital Course: Ms [**Known lastname 71508**] was admitted on [**2139-12-19**] from an outside hospital to the ICU. Neuro: Developed confusion during her first 5 days in the ICU. Post-operatively mental status improved. Intermitent delirium throughout admission. Required restraints to prevent DC of pertinent therapies while in the ICU. Currently AAOx3. . Cardiovascular: Complained of chest pain during first few days of admission, a cardiology consult was obtained. She recieved serial enzymes and EKGs. Troponins remained mildly elevated as high as 0.6 throughout her admission, and most recent result now 0.1. She was treated in IUC for unstable angina with nitroglycerin. It was recommended to maximize her medical treatment with Beta blockers, aspirin, a statin and an ACE Inhibitor. Required diuresis of >9L while in the ICU, after 2nd surgery. Continues to have trace lower extremity edema, and recieves lasix po. . Respiratory: She was intubated briefly post-op subtotal colectomy and again for several days after second surgery. Recieved nebulizer treatments post-op in the ICU, after successfully extubated. . Gastrointestinal: Her initial CT scan showed dilated [**Last Name (un) 2432**] colon, wall thickening and pneumatosis see pertinent results. She was initially treated nonoperatively with IV fluids, antibiotics, serial exams and NGT decompression. On HD#5 flexible sigmoidoscopy was performed for colonic decompression. On HD#6, colonscopy was performed for decompression, and revealed pseudomembrane and friable colonic tissue. Her abdomen remained tender and distended despite attempted decompression. She was taken to the OR for Subtotal Colectomy, G tube and ileostomy due to unresponsiveness to non-operative treatment. Ileostomy remains pink and intact, draining green-brown soft stool. Her post-operative course continued uneventfully in the ICU, and she was transferred to the floor POD#6. She developed additional abdominal tenderness and distention. Her HCT dropped and she recieved 1 unit PRBCs. Geriatric consult was obtained to assist with management. On POD#8 a CT scan was obtained which revealed an abcess with a colovesicular fistula. She was taken to the OR for exploration and drainage. She recieved further resection of remaining colon, repair of a leak from [**Doctor Last Name 3379**] pouch and repair of colovesicular fistula. After her 2nd surgery she returned to the ICU and improved steadily. Abdomen remained soft and nontender. She remained on IV antibiotics x 14 days and required pressors for the first few days post-op. Her incision has remained clean, dry, intact, with staples removed on POD#27/18. . Genitourinary: She had a foley catheter from the time of admission. POD#23/14 she recieved a cystoscopy which revealed no leak. Her foley was subsequently dc'd. . Musculoskeletal: Has suffered significant deconditioning since admission, but has consisitently recieved PT. See PT note for further assessment and discussion. Nutrition: She was held NPO at admission, and initiated on TPN by HD#3. Post-operatively she began on TFs, and the TPN was weaned down. By POD#[**3-26**] she was having high residuals on TFs, so TPN was reinitiated. Tf's were dc'ed prior to second surgery. POD# 15/6, she resumed TF's and TPN was tapered again. TF goals were achieved and TPN dc'ed. A diet by mouth was initiated. At time of discharge she is tolerating a regular diet with TF's at goal. Patient is an insulin dependent diabetic. She was followed by [**Hospital **] Clinic for treatment of persistent hyperglycemia. . Pain: Her pain was controlled with IV pain medicines while in ICU. She has been adequately controlled with Tylenol, Motrin & Oxycodone by mouth, per recommendations by Geriatrics. . POD#22/15 Ms [**Known lastname 71508**] was transferred to [**Hospital Ward Name 121**] 9 where she continued to progress well with PT, increasing PO intake, tolerating TFs, and weaning from nasal cannula oxygen. She has remained stable with no acute events. She is discharged to rehab on POD# 27/18. Medications on Admission: Norvasc Atenolol Isosorbide Lasix Insulin Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-23**] Drops Ophthalmic PRN (as needed). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 14. Glargine Sig: Twenty Two (22) units at bedtime. 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 16. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 17. Ibuprofen 100 mg/5 mL Suspension Sig: Twenty (20) mL PO Q8H (every 8 hours) as needed. 18. Debrox 6.5 % Drops Sig: Five (5) Drop Otic [**Hospital1 **] (2 times a day) for 5 days: both ears. 19. Trazodone 50 mg Tablet Sig: 1/2-1 Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Hospital **] hospital Discharge Diagnosis: [**Last Name (un) **] Colon Diverticulitis S/P Subtotal Colectomy, Ileostomy, Gastrostomy tube S/P Exploratory laparotomy, resection of small intestine with primary anastomosis, Sigmoid colectomy, repair of colovesicular fistula Unstable Angina Discharge Condition: stable Discharge Instructions: Please call the surgeon or return to the Emergency Department if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [**10-5**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2139-2-6**] 1:15 Completed by:[**2139-1-20**]

Admission Date: [**2156-11-9**] Discharge Date: [**2156-11-15**] Service: TRA HISTORY OF PRESENT ILLNESS: This is an 82 year old female found down earlier this evening in her nursing home by her caregiver, noted to be confused with a laceration to her left head and she was taken to an Emergency Room at [**Hospital **] Hospital and found to have a right subdural hematoma and a small right subarachnoid hemorrhage. She became increasingly confused and then she was transferred for further management to [**Hospital6 256**]. She was intubated for transport. PAST MEDICAL HISTORY: Past medical history is significant for depression, osteoarthritis, constipation, urinary incontinence and unknown cardiac disease. She has had a hysterectomy and an incarcerated hernia in the past. PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.0, pulse 101, blood pressure 129/64, respiratory rate 14, oxygen saturation 100 percent, intubated in no apparent distress, responding minimally to voice and responding minimally to pain, noted to have posterior occipital head laceration that is stapled. Pupils equally round and reactive to light. Tympanic membranes are clear. Carotids 2 plus bruits bilaterally. She was noted to have decreased breathsounds bilaterally, good excursion, but no obvious chest wall deformity. Heart was in regular rhythm, sinus tachycardia. Abdomen was soft, nondistended with no rebound or guarding and had normal bowel sounds and she had no midline spine tenderness at this point, no obvious stepoff and was guaiac negative. Over her left thigh her leg had some mild swelling without ecchymosis. Toes were upgoing bilaterally and moves well. She moves all of her extremities to pain. Her distal pulses were 2 plus and her sensation was intact throughout. HOSPITAL COURSE: The patient was admitted to [**Hospital3 **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for further management and to be admitted to the Trauma Intensive Care Unit. Computerized axial tomography scan of her head repeated at [**Hospital3 **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] showed right subdural hematoma and emerged with small right subarachnoid hemorrhage. Chest x- ray was largely unremarkable. Left hip revealed an intertrochanteric femoral fracture and computerized axial tomography scan of the cervical spine and the neck revealed no fracture. The patient was kept NPO at this time and a nasogastric tube was placed. The patient received thoracic, lumbar and sacral films of her spine which revealed old compression fractures and likely scoliosis. She was started on intravenous fluids at this time. The patient was also seen by Orthopedics and shortly thereafter taken to the Operating Room where her left femur was fixed. The patient was also seen by Neurosurgery who suggested that no procedures would be needed and the goal was keep her blood pressure less than 150 and to keep her INR less than 1.3. These recommendations were all followed by the Trauma Service at this time. The patient was also seen by Cardiology for a rising troponin to 0.28 and the history of her being found on the floor with a broken hip. She was cleared at this time for hip surgery with beta blocker and tight blood pressure control. It was determined that she was not a candidate at this time for any interventional procedure by the Cardiology Team. She received a repeat computerized axial tomography scan of the head on [**2156-11-10**], hospital day Number 2, before she was to go to the Operating Room for Orthopedics. This was noted to be stable and did not reveal any new or increased bleeding. Aspirin was started for her likely myocardial infarction as she was not a candidate for catheterization. Goals were to see a hematocrit greater than 30. The patient also received a statin. She was started on Lipitor at this time. Computerized axial tomography scan of the abdomen was also unremarkable, performed at this time. The computerized axial tomography scan of the chest revealed no fractures. The patient was seen by Neurosurgery who at this time signed off on the patient, and said the patient could follow up in clinic in six weeks with repeat computerized axial tomography scan. She will receive physical therapy and occupational therapy. The patient also had an echocardiogram during her stay that revealed an ejection fraction of greater than 55 percent with some thickened aortic valve and mild mitral regurgitation and moderate pulmonary artery hypertension. A Dobhoff tube was also placed during this time for tube feedings and another computerized axial tomography scan was performed that was stable, and on hospital day Number 4 the patient was able to be extubated in the Intensive Care Unit. He tolerated this procedure well and continued to respirate well without difficulty. On hospital day Number 5, [**2156-11-13**], the patient was moved to all oral medications and proceeded to have good pain control. She continued to be followed by Orthopedics and was continued on Telemetry throughout this time. The patient was also seen by the Swallow Service to evaluate her bedside swallow and see if she was safe to move to oral foods and liquids. The patient passed the test and was then advanced to regular diet. Tube feeds were stopped. On the day of discharge the patient was noted to be stable. Electrolytes were repleted appropriately. The patient was screened for rehabilitation and the case was discussed with her health care proxy, [**Name (NI) **] [**Name (NI) 1356**]. All aspects of his care were discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1356**]. The patient was noted to be Do-Not-Resuscitate, Do-Not-Intubate at this time and she was made so appropriately in the ordering system. Anticoagulation was discussed with Neurosurgery as Orthopedics wanted the patient to be receiving Lovenox at this time. The patient had been on heparin subcutaneously, 5000 units t.i.d. A head computerized tomography scan was performed and it was revealed to be stable, and the patient was able to be discharged to rehabilitation on Lovenox to start the day after discharge. There were no other needs at this time for the patient and she was able to be discharged for rehabilitation services and she was to follow up with Neurosurgery in six weeks for repeat head computerized axial tomography scan and Orthopedics in two weeks for follow up evaluation. DISCHARGE DIAGNOSIS: Right subdural hematoma. Bilateral subarachnoid hemorrhage. Left femur fracture. Depression. Osteoarthritis. Urinary incontinence. Constipation. Status post incisional hernia repair. Status post hysterectomy in the remote past. DISCHARGE MEDICATIONS: 1. Atorvastatin 40 mg once daily. 2. Aspirin 81 mg once daily. 3. Metoprolol 75 mg b.i.d. 4. Percocet 5/325 5 to 10 ml p.o. q. 4-6 hours as needed. 5. Furosemide 20 mg p.o. once daily. 6. Paroxetine 20 mg q. AM. 7. Paroxetine 10 mg every bedtime. 8. Lisinopril 10 mg once daily. 9. Pioglitazone 30 mg once daily. 10. Oxybutynin chloride 5 mg b.i.d. DISCHARGE DISPOSITION: The patient will be discharged to a rehabilitation facility. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**] Dictated By:[**Last Name (NamePattern1) 15912**] MEDQUIST36 D: [**2156-11-15**] 13:45:00 T: [**2156-11-15**] 15:47:09 Job#: [**Job Number 60015**]

Admission Date: [**2138-1-23**] Discharge Date: [**2138-2-23**] Date of Birth: [**2138-1-23**] Sex: F Service: NB REASON FOR ADMISSION: 1. Prematurity (33-5/7-weeks gestation). 2. Mild respiratory distress syndrome. PRENATAL HISTORY: Baby [**Known lastname 3501**] was born to a 32-year-old G2, P0 mother with the following prenatal screens: Hepatitis B surface antigen negative, RPR NR, blood group A-positive, antibody negative, rubella immune. EDC [**2138-3-8**]. The prenatal course was significant for: 1. Fetal survey with bilateral clubbed feet. Fetal echocardiogram at [**Hospital3 1810**] with trace TR at 24 weeks, repeat echocardiogram at 32 weeks normal,no amniocentesis done. 2. Mother presented at [**2138-1-20**] with hypertension. Evaluation showed atypical PIH with cholestasis and thrombocytopenia, thought possibly due to gestational etiology. Platelets 90-100K, LFTs elevated (AST 94, ALT 126). CMV IgG/M negative, toxo IgG/M negative. 3. Daily nonstress test since admission with normal BPP. Normal intrauterine growth. Of note, NST on [**1-22**] with fetal tachycardia to 190s, which eventually decreased to 170s. 4. Received betamethasone 2nd dose on [**2138-1-23**]. She proceeded for cesarean section due to concerns for maternal cholestatic liver disease. PAST OBSTETRIC HISTORY: SAB in [**2136-12-22**]. DELIVERY: Baby was delivered by cesarean section and born on [**2138-1-23**] at 11:40 p.m. She emerged active, but then was noted to have apnea with central cyanosis and pale legs. She received PPV with good response. Apgars were 5 and 8 at 1 and 5 minutes respectively. She was noted to have mild cyanosis and required oxygen during transport to NICU. POSTNATAL: Upon arrival, infant noted to have room air oxygen saturations at less than 75%, oxygen saturations increased to 90% when received blow-by oxygen. PHYSICAL EXAMINATION ON ADMISSION: Weight 2115 grams (50th percentile); length 43.5 cm (25-50th percentile); HR=170s, RR=28, Baby receiving blow-by oxygen with oxygen saturations over 90%, MBP=52. Pale infant in moderate respiratory distress, air flow to right naris is audible. HEENT: Anterior fontanel at level, slightly small palpebral fissure, normal ears, palate intact. Cardiovascular: Normal S1, S2, no murmur. Chest: Moderate aeration bilateral, pectus noted with mild-to-moderate intercostal and subcostal retractions,Nasal flaring, no grunting. Abdomen: Soft, nontender, nondistended. Extremities: Well perfused. Hips: Stable. Bilateral club feet. Neuro: Tone & reflexes normal. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: A. Respiratory: The initial respiratory course was consistent with mild RDS/retained lung fluid. She needed CPAP for the 1st day of life and was quickly weaned to nasal cannula oxygen and subsequently weaned to room air by day of life 9. At the time of discharge, she is comfortably breathing in room air with no respiratory distress. B. Cardiovascular: Normal. She was noted to have a soft systolic murmur that was heard intermittently. Of note, the fetal echocardiogram was normal. C. Fluid, electrolytes, and nutrition: She was initially started on intravenous fluids D10W. Feeds were introduced and gradually advanced so that she was on full feeds by day of life 4. The volume and calorie of the feed was subsequently increased to a maximum of 24 calories per ounce feed at 150 mls/kg/day. She has been on full p.o. feeds for at least 72 hours prior to discharge and is gaining weight. Weight at discharge: 3045 grams. D. GI: No complications. She had physiological jaundice exaggerated by prematurity with maximum bilirubin of 10.4. E. Hematology: She did not need any blood transfusions during hospital stay. F. Infectious disease: Baby [**Known lastname 3501**] had no episodes of culture proven sepsis. She received IV antibiotics for the 1st 48 hours of life for sepsis rule out. G. Neurology: She exhibited normal neurology with no concerns. H. Orthopedic: She was noted to have prenatally diagnosed congenital talipes. She underwent weekly cast change for her talipes. She will be followed up by the Ortho team as outpatient. I. Sensory/audiology: Hearing screening was performed with automated auditory brainstem responses. Results: Passed. Ophthalmology: Not examined. J. Psychosocial: No concerns. CONDITION AT DISCHARGE: Baby [**Known lastname 3501**] appeared well. She is active, alert, and demonstrating good p.o. feedings skills. DISCHARGE DISPOSITION: Home. Name of the primary care pediatrician is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66204**], the Practice Group, [**Location (un) 8641**] Pediatric Associates, [**Street Address(2) 66205**], [**Location (un) 8641**], [**Numeric Identifier 66206**]. Phone number1-[**Telephone/Fax (1) 66207**]. FEEDS AT DISCHARGE: Ad-lib breast milk/E20 with a minimum of 130 cc per kilogram per day. MEDICATIONS: None. CAR SEAT POSITION SCREENING: Passed. STATE NEWBORN SCREEN STATUS: Normal. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2138-1-30**]. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following criteria: i) Born at less than 32 weeks, ii) born between 32-35 weeks with 2 of the following: Daycare during RSV season, smoker in the household, neuromuscular disease, airway abnormalities, with school-age siblings, or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age (and for the 1st 24 months of the child's life), immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW-UP APPOINTMENTS SCHEDULED/RECOMMENDED: 1.Primary care Pediatrician 2-3 days post discharge 2. Dr. [**Last Name (STitle) 10675**] (orthopedics)-1 week post discharge. clinic tel no. [**Telephone/Fax (1) 38453**] DISCHARGE DIAGNOSES: 1. Prematurity. 2. Mild Respiratory distress syndrome. Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**] Dictated By:[**Name8 (MD) 66208**] MEDQUIST36 D: [**2138-2-24**] 08:41:08 T: [**2138-2-24**] 09:26:58 Job#: [**Job Number 66209**]

Admission Date: [**2176-2-2**] Discharge Date: [**2176-2-13**] Date of Birth: [**2121-7-29**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: CABGx4 (LIMA->LAD, SVG->OM, Ramus, RCA) [**2176-2-8**] Cardiac Catheterization [**2176-2-5**] History of Present Illness: HPI: 54 year old man with a past medical history of gastroesophageal reflux disease, Barrett's esophagus, hyperlipidemia, smoking up to 2 months ago and a positive family history who has experienced several months of increasing exertional dyspnea and intermittent substernal chest pain on exertion associated diaphoresis. This has increased to the point that he now has chest pain, dyspnea and diaphoresis with minimal exertion, but not at rest. His ECG is notable for flipped T waves in lead 3 and F which are old compared to [**2175-7-31**] as well as flipped Q waves in leads III and F which are new. There is also a J point elevation in V2 and V3 with a PR interval of .186. He is admitted for mecical management and a cardiac catheterization. Past Medical History: gastroesophageal reflux disease Barrett's esophagus Prostatits Hypercholesterolemia Obstructive sleep apnea - On CPAP with setting of 9 and 2.5LPM Hyperlipidemia Hypertension Social History: Smoked until 2 months ago; prior, smoke 1.5 packs daily for 9 years. No alcohol use. Has used methamphetamine recreationally and was in rehab in [**Month (only) 547**] for this. He restarted using again in [**Month (only) 359**] but quit in [**Month (only) 1096**]. Is sexually active with a single male partner for 10 years. Family History: Father with superior mesenteric artery occlusion. Mother with coronary artery disease and CABG X 2. Grandfather with diabetes. Physical Exam: PE: 98.1 55 137/66 17 98% room air saturations Obese friendly man lying in bed in No apparent distress, speaking easily in full sentances Pupils equal round and reactive to light, occular motor intact, oromucosa moist and clear Clear lungs RRR, normal S1/S2 Soft, nontender, Nondistended, no organomegaly, normoactivebowel sounds Warm, dry. pulses 2+ throughout. no clubbing/edema/cyanosis Alert and oriented X 3, moving all 4 extremities - ECG:Sinus @50 with Q3, flipped T3 old since [**7-8**] and 1mm ST elevation in V2, V3 new Pertinent Results: [**2176-2-2**] 12:20PM PT-12.8 PTT-25.9 INR(PT)-1.0 [**2176-2-2**] 12:20PM PLT COUNT-217 [**2176-2-2**] 12:20PM WBC-5.8 RBC-4.73 HGB-14.9 HCT-39.5* MCV-84 MCH-31.5 MCHC-37.7* RDW-13.5 [**2176-2-2**] 12:20PM cTropnT-<0.01 [**2176-2-2**] 12:20PM CK(CPK)-118 [**2176-2-2**] 12:20PM GLUCOSE-122* UREA N-20 CREAT-0.9 SODIUM-138 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13 [**2176-2-12**] 06:15AM BLOOD WBC-5.7 RBC-2.45* Hgb-7.6* Hct-21.2* MCV-87 MCH-30.9 MCHC-35.6* RDW-14.6 Plt Ct-164 [**2176-2-12**] 06:15AM BLOOD Glucose-121* UreaN-14 Creat-0.9 Na-136 K-3.4 Cl-99 HCO3-29 AnGap-11 [**2176-2-5**] 09:00AM BLOOD ALT-29 AST-18 AlkPhos-63 TotBili-1.2 [**2176-2-2**] EKG Sinus bradycardia. Probable inferior myocardial infarction of indeterminate age. Rate 50's. [**2176-2-8**] EKG Sinus rhythm. Possible inferior myocardial infarction - age undetermined. Compared to the previous tracing bradycardia is absent. [**2176-2-2**] CXR No acute cardiopulmonary process. [**2176-2-12**] CXR Status post CABG with median sternotomy. Improving atelectasis with persistent effusion. [**2176-2-5**] Cardiac Catheterization 1. Left main and Right coronary artery disease. 2. Mild LV diastolic dysfunction. [**2176-2-5**] ECHO Overall preserved global biventricular systolic function. No definite valvular disease identified. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) 23773**]r on [**2176-2-2**] for further management of his chest pain. He ruled out for a myocardial infarction by enzymes. The cardiology service was consulted and recommended a cardiac catheterization. Overnight. he had some vague chest discomfort without EKG changes and heparin was started. On [**2176-2-5**], a cardiac catheterization was performed which revealed an 80% stenosed left main coronary artery, an 80% stenosed left anterior descending artery, an 80% stenosed first diagonal artery, an occluded right coronary artery and an ejection fraction of 60%. Due to the severity of his disease, the cardiac surgical service was consulted. Mr. [**Known lastname **] was worked-up in the usual preoperative manner and found to be a suitable candidate for surgery. Ativan was used as need for anxiety. On [**2176-2-8**], Mr. [**Known lastname **] was taken to the operating room where he underwent coronary artery bypass grafting to four vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated. He was then transferred to the cardiac surgical step down unit for continued recovery. Mr. [**Last Name (Titles) **] was gently diuresed towards his preoperative weight. Beta blockade and aspirin were resumed. His chest tubes and epicardial pacing wires were reomved per protocol. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Mr. [**Last Name (Titles) **] continued to make steady progress and was discharge dto his home on postoperative day five. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Flonase as needed Atenolol 25mg QD Prilosec 20 mg daily Discharge Medications: 1. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. 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* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*20 Tablet(s)* Refills:*0* 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 14. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four times a day for 5 days. Disp:*20 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: CAD Discharge Condition: good Discharge Instructions: no lifting > 10 # or driving for 1 month may shower, no bathing or swimming for 1 month no creams or lotions to incisions Call us immediately if sternal drainage increases, or sternal incision is red. Followup Instructions: with Dr. [**Last Name (STitle) 8499**] in [**2-8**] weeks with Dr. [**Last Name (STitle) **] in 4 weeks Completed by:[**2176-3-5**]

Admission Date: [**2110-7-11**] Discharge Date: [**2110-7-17**] Service: MEDICINE Allergies: Plaquenil / Glyburide Attending:[**First Name3 (LF) 2880**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2110-7-11**] Cardiac catheterization [**2110-7-12**] Pericardiocentesis with drain placement and L+R heart cath History of Present Illness: [**Age over 90 **] yo F with h/o HTN, rheumatoid arthritis and gallstones (but no cholecystitis) presents with 1 day history of chest pain. Was in her USOH when yesterday afternoon ([**7-10**]) she began having a "choking sensation"-like pain in her chest. This progressed to include sharp pains up and down her left arm. Later in the afternoon, she began to have a "burning" sensation from her epigastrium up into her mouth/jaw. Pain was worse with lying down, associated with some dizziness and diaphoresis, but no shortness of breath, nausea, or palpitations. Also noticed yesterday that her urine was darker than normal, but stool was still normal color. Pain continued to get worse until she told her sister at 2 AM "I feel like I'm having a heart attack", so her sister rushed her to the [**Name (NI) **]. She had never had a pain like this before, no history of reflux disease. At baseline walks around her house and occasionally outside with a cane, but only goes short distances because of gait instability. In the ED, initial vitals: 97.6, 88, 118/58, 18, 100%. ECG notable for SR @ 89 with ?ST-elevations and hyperacute T waves in anterolateral leads with Q waves that are new compared to last prior ECG in [**2107**]. Troponin was 0.04, MB (added on later) was 5, hct was decreased to 29 from previous baseline 35. Guaiac negative. LFTs revealed bili 4.4 (4.1 indirect), so RUQ obtained and showed gallstones with no sign of obstruction. CXR showed no acute abnormalities. Bedside US showed small pericardial effusion but no evidence of aortic dissection (no comment on WMAs). She was given aspirin 325, 1 SL NTG, after which BP dropped to 60s but improved with 200cc bolus. Chest pain resolved but then came back, responded well to morphine. Started briefly on heparin gtt but then stopped prior to admission to the floor. On arrival to the floor, the patient was feeling comfortable with no chest pain since receiving morphine in the ED. She relayed the above story with no difficulty and with excellent memory and attention to detail. Shortly after her arrival, she began to have chest pain again, same in quality as her previous chest pain. Also complained of feeling very very weak. REVIEW OF SYSTEMS: On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for: + chest pain, syncope and presyncope (most recently last week) - dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations Past Medical History: - Hypertension - Rhematoid arthritis - Gallstones - s/p hysterectomy - s/p appendectomy Social History: Lives with her sister (also in her 90s) in [**Location (un) 1468**], MA. Formerly worked in a school nursery, post office, and Navy ship yards. She is still completely independent at home with all ADLs, cooks her own food and cleans the home herself. # Tobacco: never # Alcohol: none # Illicit: none Family History: Brother died of an MI in his 70s. Brother died of unknown causes in his 60s. Sister died of AD at 91. Sister died at age 7 durng tonsillectomy from ether use. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 98.3, BP 109/60, HR 91, RR 20, SpO2 95% RA GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Slightly icteric sclera. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Edentulous NECK: Supple with JVP of [**11-6**] cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Systolic II/VI murmur heard at LLSB, provoked/worsened with valsalva. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. NEURO: CN II-XII tested and intact, strength 5/5 throughout, sensation grossly normal. Gait not tested. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: LABS: On admission: [**2110-7-11**] 04:45AM BLOOD WBC-8.5# RBC-2.79*# Hgb-9.0*# Hct-29.3* MCV-105*# MCH-32.4* MCHC-30.9* RDW-13.2 Plt Ct-515* [**2110-7-11**] 04:45AM BLOOD Neuts-78.5* Lymphs-16.6* Monos-3.5 Eos-0.7 Baso-0.7 [**2110-7-11**] 01:55PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL Spheroc-OCCASIONAL [**2110-7-11**] 04:45AM BLOOD PT-12.1 PTT-25.7 INR(PT)-1.1 [**2110-7-11**] 04:45AM BLOOD Ret Aut-3.6* [**2110-7-11**] 04:45AM BLOOD Glucose-125* UreaN-27* Creat-0.8 Na-129* K-4.7 Cl-93* HCO3-26 AnGap-15 [**2110-7-11**] 04:45AM BLOOD ALT-13 AST-36 LD(LDH)-356* CK(CPK)-124 AlkPhos-69 TotBili-4.4* DirBili-0.3 IndBili-4.1 [**2110-7-11**] 04:45AM BLOOD Lipase-30 [**2110-7-11**] 04:45AM BLOOD CK-MB-5 cTropnT-0.04* [**2110-7-11**] 04:45AM BLOOD Albumin-4.1 [**2110-7-11**] 11:53PM BLOOD Calcium-8.5 Phos-2.9 Mg-1.8 [**2110-7-11**] 04:45AM BLOOD Hapto-<5* [**2110-7-11**] 07:10AM BLOOD Lactate-1.3 On discharge: [**2110-7-17**] 06:15AM BLOOD WBC-8.8 RBC-3.49* Hgb-11.2* Hct-34.0* MCV-97 MCH-32.0 MCHC-32.8 RDW-16.6* Plt Ct-361 [**2110-7-17**] 06:15AM BLOOD PT-11.9 INR(PT)-1.1 [**2110-7-17**] 06:15AM BLOOD Glucose-87 UreaN-31* Creat-1.0 Na-131* K-4.4 Cl-99 HCO3-28 AnGap-8 [**2110-7-17**] 06:15AM BLOOD ALT-241* AST-113* AlkPhos-60 TotBili-0.5 [**2110-7-17**] 06:15AM BLOOD Calcium-7.7* Phos-2.0* Mg-2.0 MICRO: [**2110-7-11**] Blood culture negative [**2110-7-11**] Urine culture negative [**2110-7-12**] Pericardial fluid: GRAM STAIN (Final [**2110-7-12**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2110-7-15**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST CULTURE (Preliminary): ACID FAST SMEAR (Final [**2110-7-14**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2110-7-12**] Urine culture negative [**2110-7-12**] Blood culture negative [**2110-7-13**] Blood culture negative STUDIES/IMAGING: [**2110-7-11**] Cardiac cath: COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrated single vessel coronary artery disease. The LMCA had distal tapering into a 90% lesion at the origin of the LAD. The LAD was otherwise free of angiographically significant coronary artery disease. The LCX was free of angiographically apparant coronary artery disease. The RCA had an ostial 30% lesion and a 60% distal lesion. 2. Limited resting hemodynamics revealed normal systemic arterial blood pressure with a central aortic blood pressure of 109/49 mmHg. 3. Successful PTCA and stenting of distal LMCA into LAD origin with 3.0x18mm Integrity bare metal stent with proximal stent segment postdilated to 4.0mm. LCx jailed, however only minimal pinching of origin with TIMI 3 flow. 4. Successful closure of right femoral arteritomy with 6F angioseal. FINAL DIAGNOSIS: 1. Single vessel coronary artery disease of the LAD. 2. Normal systemic arterial blood pressure. 3. Successful distal LMCA-LAD PCI with BMS 4. Successful RFA angioseal. [**2110-7-11**] TTE: There is mild (non-obstructive) focal hypertrophy of the basal septum. There is severe regional left ventricular systolic dysfunction with anterior, septal and apical akinesis. The remaining segments contract normally (LVEF = 25-30%). The right ventricular cavity is unusually small. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a moderate sized pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. IMPRESSION: Moderate pericardial effusion with evidence of early tamponade physiology [**2110-7-12**] TTE: There is a small to moderate sized pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. Compared with the findings of the prior study (images reviewed) of [**2110-7-11**] pericardial effusion is slightly larger. [**2110-7-12**] Cardiac cath: COMMENTS: 1. Selective coronary angiography of the left coronary artery demonstrated a patent distal LMCA/proximal LAD stent. There was no contrast extravasation. 2. Right heart catheterization initially revealed low-normal right sided and minimally elevated left sided filling pressures. The mean RA was low-normal at 5 mmHg, and the RVEDP was low-normal at 6 mmHg. The pulmonary arterial pressure was normal at 30/12 mmHg with a mean PA pressure of 18 mmHg. The mean wedge was minimally elevated at 12 mmHg with prominant x and y descents. 3. The cardiac output and index were normal at 5.5 L/min and 3.5 L/min/m2. 4. Systemic vascular resistance was normal at 814 dyne-sec/cm5, and pulmonary vascular resistance was normal at 86 dyne-sec/cm5. 5. There was a 9% step up in oxygen saturation between the RA and PA, but a significant amount of time had ellapsed between these two measurements, and in the interim the patient's respiratory status was not stable. 6. Additional resting hemodynamics revealed a low-normal systemic arterial bloood pressure with a central aortic blood pressure of 96/40 mmHg. FINAL DIAGNOSIS: 1. Patent LMCA/LAD stent with no signs of coronary artery perforation or contrast extravasation. 2. Low pressure cardiac tamponade. [**2110-7-12**] TTE: This study is a series of images during pericardiocentesis. Initial images demonstrate a large pericardial effusion, significantly expanded since the prior series of images two hours earlier. The effusion appears echodense, most consistent with blood. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. After completion of pericardiocentesis there is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. The effusion appears loculated. There are no longer echocardiographic signs of tamponade. Compared with the findings of the prior study, pericardial effusion has expanded. The final images confirm a successful pericardiocentesis with echocardiographic evidence of tamponade resolution. [**2110-7-12**] TTE: The left atrium is normal in size. There is mild (non-obstructive) focal hypertrophy of the basal septum. There is severe regional left ventricular systolic dysfunction with anterior, septal and apical akinesis. 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 moderately thickened. The study is inadequate to exclude significant aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a very small echodense pericardial effusion anterior to the right ventricle. There are no echocardiographic signs of tamponade. IMPRESSION: Very small echodense pericardial effusion. Severe regional left ventricular systolic dysfunction. Compared with the prior study (images reviewed) of [**2110-7-12**], no major change. Brief Hospital Course: Ms. [**Name14 (STitle) 109444**] is a [**Age over 90 **] year old female with history of hypertension (HTN), rheumatoid arthritis and gallstones (but no cholecystitis) who presented with 1 day history of chest pain and anemia, thought to be hemolytic. She was found to have a large STEMI with placement of bare metal stent. Course complicated by large pericardial effusion and subsequent cardiac tamponade requiring pericardiocentesis and transfer to the CCU, as well as hypotension requiring pressors and acute kidney injury. ACTIVE ISSUES BY PROBLEM: # ST elevation myocardial infarction: Shortly after her arrival to the floor, she began to have chest pain again. ECG showed evolving/worsening ST-elevations in the anteroseptal leads. Next cardiac enzymes rose, overall trend: trop 0.04-> 0.35-> 1.36 -> 2.13 and MB 5-> 41-> 103. Bedside echo showed anterior wall hypokinesis with depressed EF of 25% (from 75%) prompting transfer to the cath lab. Patient had a right femoral artery approach with mostly single vessel LAD disease with a 90% proximal ostial LAD lesion, s/p BMS placement. During the cath, she suffered a brief period of hypotension with systolics in the high 60's mmHg associated with balloon inflation, otherwise systolics maintained in the mid 100's mm Hg range. She was started on full dose aspirin 325mg, atorvastatin 80, and plavix 75mg initially. After developing pericardial effusion (see below), her aspirin dose was decreased to 162mg to avoid bleeding complications, and her statin was stopped due to transaminitis. Unable to tolerate beta blocker or ACEI given hypotension. She will need to continue aspirin and plavix at rehab, with possible re-initiation of statin when LFTs normalize and beta blocker/ACEU when BPs will tolerate. Will follow up with Dr.[**Name8 (MD) 5103**] NP in clinic on [**2110-8-19**], and she should have a repeat echo in 1 month to determine if there has been any recovery in cardiac function with improvement of EF. # Cardiac tamponade: On the floor post-cath, started to have episodes of hypotension, with blood pressures dropped from 121/58 to 58/38, after using bedpan for a bowel movement. Patient's mental status also became more lethargic. Bolused with 500 cc's NS x 2 with BP up to the 80's. Physical exam concerning revealed elevated JVP and crackles on exam. She was urgently transferred to the CCU (see CCU course above), where she was started on dopamine. STAT bedside echo revealed large pericardial effusion causing early tamponade. She was sent urgently back to the cath lab, where 600 cc of frank blood was drained from the pericardium, complicated by a small puncture of the right ventricle. She briefly lost her pulse during the procedure, but she had ROSC with 1 amp epinephrine (no CPR). She had signficant bleeding so she was given a total of 4units PRBC. She had some reaccumulation of pericardial fluid, so drain was placed. The drain output was low over the next day, so this was pulled the following day with no evidence of fluid reaccumulation. Cause of her tamponade is not entirely clear-- no dye extravasation seen from coronary arteries on repeat cath during pericardiocentesis, however she may have had a small puncture that then clotted off. # Acute kidney injury: She was noted to be oliguric on [**7-13**] and her urine sediment showed muddy brown casts consistent with ATN from the setting of hypotension. Baseline creatinine 0.6-0.8, rose to maximum of 1.7. She was given 60mg iV lasix and diuresed well and has return to normal urine output. Creatinine downtrended to 1.0 on discharge. She should have her BUN/Cr checked at next PCP visit to ensure full return to baseline. # Anemia: no recent baseline, but hct was in 36-39 range in 11/[**2109**]. Has noted darkened urine in the past day and has evidence of hemolysis on labs-- indirect bilirubinemia, elevated LDH, low haptoglobin, high retic. No history of bleeding (no blood in stool), guaiac negative in the ED. No new meds that may have provoked G6PD deficiency related hemolysis, no exposures suggestive of infectious cause. No known liver disease, no hypersplenism on exam, no known hemoglobinopathy. Received 4 units packed RBCs due to bleeding post-pericardiocentesis (see above) with improvement of hct to 30-36 range. Her hematocrit then remained stable with no signs of hemolysis. Hct 34 on discharge. Should have hct rechecked at next visit with PCP to ensure it has remained stable. # Ischemic cardiomyopathy: EF now 25% following anterior STEMI. Appeared well-compensated without signs of congestive heart failure during admission. On aspirin 162mg, however not on b-blocker or ACEI due to low BPs and no statin due to transaminitis. Should have a repeat echo as an outpatient in 1 month to see if she has any improvement in systolic function. # Transaminitis: AST 100s, ALT 200s, tBili initially high from hemolysis but trended down to normal, alk phos normal. Etiology likely due to ischemic injury to the liver during hypotensive episodes plus some degree of passive congestive from heart failure. Atorvastatin was stopped, but could consider restarting in the future once LFTs have normalized. # Hyponatremia: Chronic ongoing hyponatremia, stable this admission. # Hyperbilirubinemia: Seems more likely related to hemolysis (see above) than from hepatobiliary dysfunction. RUQ US normal other than cholelithiases (non-obstructing), LFTs normal. # Hypertension: Was taking diltiazem and lisinopril at home. Due to hypotension, home medications were held. Could consider starting beta clocker and ACEI one hypotension has resolved # Rheumatoid arthritis: given tylenol PRN TRANSITION OF CARE ISSUES: - STEMI: s/p BMS to LAD ostium, now on aspirin 162mg and plavix 75mg. Will follow up with Dr. [**Last Name (STitle) 171**] and his NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2110-8-19**] for follow up. She should have a repeat echo at that time to see if EF has improved. Should start metoprolol and ACEI/[**Last Name (un) **] once blood pressure allows and restart statin once LFTs have normalized - [**Last Name (un) **]: should have BUN/Cr checked at next PCP visit to ensure renal function has remained normal - Transaminitis: should recheck LFTs at next PCP [**Name Initial (PRE) **]. If normalized, consider restarting low dose atorvastatin. - Anemia: due to hemolysis (cause unknown) and acute blood loss, should have hct checked at next PCP follow up - FULL CODE (was DNR/DNI while in the CCU, however now wants "to live a little longer") Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Diltiazem Extended-Release 240 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Ibuprofen 200 mg PO Q8H:PRN pain Discharge Medications: 1. Aspirin 162 mg PO DAILY RX *aspirin 81 mg once a day Disp #*60 Tablet Refills:*2 2. Clopidogrel 75 mg PO DAILY for the recommended duration RX *clopidogrel 75 mg once a day Disp #*30 Tablet Refills:*2 Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Elmhurst - [**Location (un) **] Discharge Diagnosis: PRIMARY DIAGNOSES: ST-elevation myocardial infarction Acute kidney injury Cardiac tamponade Acute systolic heart failure Cardiogenic shock Hemolytica and acute blood loss anemia SECONDARY DIAGNOSES: Rheumatoid arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 90256**], It was a pleasure taking care of you at [**Hospital1 **]. You were admitted to the hospital due to chest pain, and we found that you had a large heart attack. You were taken for a procedure called cardiac catheterization, where a large blockage in your coronary artery was found and opened with a stent. After the procedure you developed fluid around your heart that needed to be drained, and you were sent to the intensive care unit for close monitoring. Slowly but surely, you got better, but we feel you should go to rehab to help get your strength back before you go home. Changes to your medications: START aspirin 162mg daily START plavix 75 mg daily STOP diltiazem temporarily, until your blood pressure and kidney function improves STOP lisinopril, temporarily, until your blood pressure and kidney function improves Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2110-8-19**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2110-8-4**] at 8:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**State **]When: FRIDAY [**2110-12-5**] at 8:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]

Admission Date: [**2169-2-10**] Discharge Date: [**2169-2-20**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: History obtained from medical records. This is a [**Age over 90 **] year-old female with a history of dementia and HTN who presents with fever, tachycardia, and hypoxia from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Pt treated for bronchitis with levaquin 250 mg X 7 days starting on [**1-29**]. This am, not responding to stimuli and noted to be in respiratory distress. VS 100.1 (po) although ED reported up to 101F, HR 84, BP 131/57, RR 28, O2 sat 90% RA. Per PCP [**Name9 (PRE) 7421**], there was some concern for an aspiration event. Given tylenol 650 mg PR and albuterol nebulizer prior to being sent to ED. In the ED, T 99.8, BP 121/55, HR 95, RR 24, O2 sat 95% 6L NC --> 98% on 100% NRB --> 97% on 3L NC. Labs notable for WBC 30.1 without associated left shift or bands, Na 169, BUN 116, Cr 2.6, AG 18, and lactate 2.0. UA few bacteria, 0-2 WBC, mod LE. CXR with ? bilateral upper lobe opacities, final read pending. Pt DNR/DNI per NH records. Given Vancomycin 1 gm X 1, zoysn 4.5 gm IV X 1, 1L IVFs, and admitted to [**Hospital Unit Name 153**] for further mgmt. ROS: Unable to assess. Past Medical History: 1. Hypertension. 2. Grave's disease. 3. Dementia. 4. Depression. 5. Spinal stenosis. 6. Degenerative joint disease. 7. Status post multiple falls with a gait disturbance. Social History: Resides at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Niece is HCP Family History: Unknown/Noncontributory Physical Exam: Vitals: Afebrile 132/55 p72 r20 100% 2L GEN: elderly female, non-toxic. HEENT: MM dry. COR: RRR, no M/G/R, normal S1 S2 PULM: Coarse wheeze throughout. ABD: Soft, NT/ND. EXT: No C/C/E, no palpable cords NEURO: +dementia, non-focal. PICC in place Pertinent Results: Admission Labs: [**2169-2-10**] 10:56AM WBC-30.1*# RBC-4.07* HGB-11.2* HCT-34.9* MCV-86 MCH-27.5 MCHC-32.1 RDW-13.8 [**2169-2-10**] 10:56AM NEUTS-64.3 LYMPHS-33.9 MONOS-1.5* EOS-0.2 BASOS-0.2 [**2169-2-10**] 10:56AM PT-14.5* PTT-21.1* INR(PT)-1.3* [**2169-2-10**] 10:56AM PLT COUNT-406 [**2169-2-10**] 10:56AM ASA-NEG ETHANOL-NEG ACETMNPHN-9.6 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2169-2-10**] 10:56AM TSH-0.88 [**2169-2-10**] 10:56AM CALCIUM-9.4 PHOSPHATE-4.5 MAGNESIUM-2.9* [**2169-2-10**] 10:56AM ALT(SGPT)-12 AST(SGOT)-12 CK(CPK)-32 ALK PHOS-136* TOT BILI-0.2 [**2169-2-10**] 10:56AM GLUCOSE-262* UREA N-116* CREAT-2.6*# SODIUM-169* POTASSIUM-4.0 CHLORIDE-130* TOTAL CO2-21* ANION GAP-22* [**2169-2-10**] 11:12AM LACTATE-2.0 [**2169-2-10**] 11:40AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014 [**2169-2-10**] 11:40AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD [**2169-2-10**] 11:40AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2169-2-10**] 11:40AM URINE EOS-NEGATIVE [**2169-2-10**] 02:17PM TYPE-ART TEMP-36.2 PO2-116* PCO2-34* PH-7.41 TOTAL CO2-22 BASE XS--1 INTUBATED-NOT INTUBA . . CXR [**2169-2-14**]: FINDINGS: Persistent cardiomegaly and pulmonary vascular engorgement. Diffuse hazy opacities are again demonstrated in the right lung without substantial change. As noted previously, this could be due to resolving asymmetrical pulmonary edema or infection. New area of opacity has developed in the left retrocardiac region, and may reflect atelectasis, aspiration, or early focus of pneumonia. . [**2169-2-20**] 05:01AM BLOOD WBC-17.9* RBC-3.12* Hgb-8.8* Hct-26.8* MCV-86 MCH-28.1 MCHC-32.6 RDW-15.6* Plt Ct-365 [**2169-2-14**] 04:24AM BLOOD PT-13.8* PTT-31.9 INR(PT)-1.2* [**2169-2-20**] 05:01AM BLOOD Glucose-132* UreaN-16 Creat-1.3* Na-146* K-4.5 Cl-112* HCO3-24 AnGap-15 [**2169-2-20**] 05:01AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.5* (Note: Mg repleted after this result) [**2169-2-15**] 04:00AM BLOOD calTIBC-130* VitB12-[**2137**]* Folate-11.8 Ferritn-256* TRF-100* [**2169-2-10**] 10:56AM BLOOD TSH-0.88 . Micro: MRSA SCREEN (Final [**2169-2-15**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. . C-diff negative x 3 . URINE CULTURE (Final [**2169-2-13**]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PROTEUS MIRABILIS | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- 4 S CEFTAZIDIME----------- =>2 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R . Brief Hospital Course: Sepsis from left lower lobe pneumonia: treated with multiple antibiotics initially, but ultimately to complete a course of ceftriaxone and vancomycin. Leukocytosis initially improved, but recently has been trending up. Note patient has a history of CLL with persistent hx of leukocytosis, making WBC questionable as a marker for infection. Blood cultures negative, rapid resp viral screen negative, urine legionella antigen is negative. She received vancomycin and ceftriaxone for a total ten day course. Patient had a speech and swallow evaluation performed initially, which she failed, and was reattempted several days later, and again failed. After discussion with the family, decision was made not to place a PEG tube and she was permitted to eat for comfort. . Altered mental status: combination of sepsis and hypernatremia on baseline dementia. LFTs and TSH wnl, tox screens negative. Sedating medications held at admission Mental status improved quickly with correction of her multiple medical issues. - patient on D5W for mild hypernatremia and sl increased Cr. . Acute renal failure: peak at 2.9 at admission. Most likely pre-renal etiology given concurrent hypernatremia, story and exam. Urine eosinophils negative, renal ultrasound without obstruction. Lasix held at admission, and then restarted. Her creatinine improved with rehydration, now slightly increased to 1.3 from 1.1. Getting addt'l D5W today. . Hypernatremia: due to poor po intake and ongoing lasix prior to admission. Patient clinically dry on exam at admission. Treated with D5W with improvement in values, and sodium normalized at time of discharge. Getting addt'l D5W today. . Melena: She was also noted to have several episodes of melena. She received 1u pRBC, and remained hemodynamically stable. . Code: DNR/DNI, copy of form in chart. Confirmed with family that despite failing speech and swalloe evaluation, patient should be allowed to continue to eat for comfort. . Comm: next of [**Doctor First Name **] listed in chart [**Name (NI) **] [**Last Name (NamePattern1) 18942**], [**Telephone/Fax (1) 18943**] (h), [**Telephone/Fax (1) 18944**] (c). Access: PICC line. Will maintain on discharge for continued IV hydration as outpt for several days. DISPO: Discharge to day to [**Hospital1 1501**] Medications on Admission: Trazodone 25 mg daily Trazodone 25 mg qid prn for agitation Trazodone 75 mg qhs Dulcolax 10 mg qod Citalopram 20 mg daily Lasix 10 mg daily MVI daily Milk of magnesia 30 ml qod Nitrobid 2% ointment [**2-17**] inch prn for SBP > 170, DBP > 90 Flovent INH 2 puffs [**Hospital1 **] Maalox prn Anusol-HC 2.5% cream [**Hospital1 **] prn Guiafenesin 20 ml q6h prn Tylenol 650 PR q4h prn s/p Levofloxain 250 mg daily X 7 days Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection TID (3 times a day). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Recommend hold until resumed by MD. 8. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection daily and prn. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: 1. Aspiration pneumonia 2. Altered mental status 3. Hypernatremia 4. Acute renal failure 5. Urinary tract infection 6. Acute blood loss anemia 7. Dementia Discharge Condition: Stable Discharge Instructions: You were admitted with an aspiration pneumonia and urinary tract infection, with associated dehydration. You were treated with antibiotics. Followup Instructions: Please follow up with your primary care doctor [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Recommend feed patient at times when most awake (which may fluctuate according to parkinson medications) (per Speech and Swallow recommendations).

Admission Date: [**2150-11-23**] Discharge Date: [**2150-11-29**] Date of Birth: [**2150-11-23**] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 4048**]-[**Known lastname **], #1 is an infant born at 34 2/7 weeks to a 23 year old gravida 3, para 0 mother, prenatal screens blood type B positive, antibody negative, Group Beta Streptococcus status unknown. Hepatitis B surface antigen negative, RPR nonreactive, Rubella immune. Dates by 13 week ultrasound, antepartum remarkable for spontaneous di-di twins, also remarkable for admission on [**10-5**] to [**10-7**] for shortened cervix. At that time she was treated with betamethasone and discharge to home on Terbutaline. She was readmitted on [**10-26**] through [**11-5**] for decreased fetal movement of this twin with noted spontaneous decelerations to the 90s. She was admitted again on the day of delivery for uterine contractions and cervical dilatation. Growth restriction (6th percentile) of this twin now appreciated. Twin B is in the 19th percentile. Mom underwent a cesarean section for breech position of Twin B. This twin emerged with good tone and cry. Apgar scores were 8 at one minute and 8 at five minutes. He received bulb suctioning and Blow-by oxygen in the Delivery Room and was admitted to the Newborn Intensive Care Unit for monitoring of prematurity. PHYSICAL EXAMINATION: Vital signs on admission revealed temperature 95.2 rectally. Heartrate is 140. Blood pressure is 65/41 with a mean arterial pressure of 53. Respiratory rate is 62 and dextrose stick of 49. Weight 1470 gm, (7th percentile), length 40 cm (10th percentile) and head circumference 30.5 cm (25th percentile). Examination was remarkable for a pink preterm infant in no distress. Normal facies. Soft anterior fontanelle, intact palate, no grunting, flaring or retracting. Clear breathsounds bilaterally. Grade I to II/VI systolic murmur at the left lower sternal border. Femoral pulses flat, soft, nontender abdomen without hepatosplenomegaly. Normal phallus, testes and scrotum, stable hips. Normal perfusion, normal tone and activity for gestational age. SUMMARY OF HOSPITAL COURSE: Respiratory - This infant has been in room air for his entire hospital course. He has not required any respiratory support. He has not had any episodes of apnea of prematurity and has not required methylxanthines. Cardiovascular - His blood pressure has been stable throughout his hospital course. He has not required any fluid boluses or pressors for blood pressure support. His latest exam reveals no murmur. Fluids, electrolytes and nutrition - Intravenous fluids of D10/W were initiated upon admission to the Newborn Intensive Care Unit at 80 cc/kg/day. Enteral feeds were initiated on day of life #2 of PE 20 at 20 cc/kg. He advanced without difficulty to 120 cc/kg. The plan is to continue advancement at 15 cc/kg [**Hospital1 **] to a goal TF of 150 cc/k/day. Electrolytes have been within normal limits throughout his hospitalization. Last electrolytes on [**11-27**] were sodium 143, potassium 6.3, (hemolyzed), chloride 110 and total carbon dioxide of 21. His weight at the time of transfer is 1465. Gastrointestinal - Peak bilirubin on day of life #4 was a total bilirubin of 5.3 with a direct bilirubin of .4. No phototherapy has been initiated at this time. Hematology - No transfusions have been given throughout his hospital stay. Hematocrit on admission was 52. Infectious disease - A complete blood count with differential and blood cultures were drawn upon admission to the Newborn Intensive Care Unit. White blood cell count was 7,000, hematocrit 52, platelet count 252,000 with 27% polys and 0% bands. Blood culture was negative. He received a 48 hour course of Ampicillin and gentamicin. Neurology - A head ultrasound was not indicated for this 34 [**12-24**] weeker. Sensory - Hearing screen has not yet been performed. Ophthalmology exam not indicated. PSYCHOSOCIAL: A [**Hospital6 256**] social worker has been involved with the family, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. She can be reached at [**Telephone/Fax (1) **]. Parents are involved. Father is currently in [**State 760**]. Both are pleases with transfer closer to Mother's current residence. See last SW note [**2150-11-27**]. CONDITION ON TRANSFER: Infant stable in room air, stable temperature in isolette and tolerating enteral feedings. MEDICATIONS ON TRANSFER: None. DISCHARGE INSTRUCTIONS: State newborn screen was sent at 72 hours of age and no abnormal results have been reported. No immunizations have been given to date. 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; 2. Born between 32 and 35 weeks with plans for daycare during respiratory syncytial virus season, with a smoker in the household or with preschool siblings; or 3. With chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age, before this age the family and other caregivers should be considered for immunization against influenza to protect the infant. Name of primary pediatrician is to be determined. DISCHARGE DIAGNOSIS: 1. Prematurity at 34 2/7 weeks gestation 2. Marginal for small-for-gestational age 3. Rule out sepsis [**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**] Dictated By:[**Name8 (MD) 37391**] MEDQUIST36 D: [**2150-11-28**] 06:09 T: [**2150-11-28**] 08:09 JOB#: [**Job Number 37392**]

Admission Date: [**2191-7-22**] Discharge Date: [**2191-7-29**] Date of Birth: [**2191-7-22**] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 48062**] is the 1675 gm product of a 30 [**2-22**] week gestation, born to a 32 year old gravida 1, para 0 now 1 mother. Prenatal screens - A positive, antibody negative, hepatitis B surface antigen negative, Rubella immune, RPR nonreactive, Group B Streptotoccus unknown. Antepartum course complicated by prolonged premature rupture of membranes since [**2191-7-12**]. Betamethasone complete on [**2191-7-13**]. Maternal white blood cell count increasing on day of delivery, prompting decision to deliver infant. Baby delivered by cesarean section secondary to breech presentation. Apgars were 8 at one minute and 8 at five minutes. Infant was transferred to Neonatal Intensive Care Unit for management of prematurity. PHYSICAL EXAMINATION: On admission, birthweight 1675 gm (75th percentile), length 40 cm (50th percentile), head circumference 29.5 cm (50th percentile). On examination, pink, active nondysmorphic infant. Head, misshapen related to positioning. Sutures mobile. Palate intact. Nares patent. No murmur, normal S1 and S2. Lungs with coarse breathsounds bilaterally. Moderate distress. Abdomen, benign. Genitalia normal male with both testes and canals. Anus patent. Hips stable. Neurological, nonfocal and age appropriate. HOSPITAL COURSE: Respiratory - Infant was orally intubated on arrival to the Neonatal Intensive Care Unit for respiratory distress. Initial ventilator settings of IMV rate of 26, positive inspiratory pressure 22, positive end-expiratory pressure 6. The infant received two doses of Surfactant. Infant weaned on the ventilator settings and was extubated on day of life 2 to CPAP of 5 and was transitioned to nasal cannula by day of life #3 and has been in room air since day of life #4. Infant was started on caffeine, day of life #2 and continues on caffeine at this time. The infant has had approximately 1 to 2 bradycardiac spells of prematurity a day. Cardiovascular - Infant has remained hemodynamically stable this hospitalization. Heartrate 120 to 140. On day of life #7 the infant was noted to have a new onset murmur at that time four extremity blood pressures were obtained which were all within normal limits with no discrepancy between the upper no acute distress lower extremities. A chest x-ray was obtained also at that time which showed no cardiomegaly and no increased vascular markings. Mean blood pressures have been 49 to 59. Fluids, electrolytes and nutrition - The infant was initially NPO and receiving 80 cc/kg/day on D10/W, on day of life #3 enteral feedings were started and he advanced to full volume enteral feedings at 150 cc/kg/day by day of life #6. The infant is currently receiving 150 cc/kg/day and advanced to breast milk 22 calories on day of life #7, infant tolerated feeding advancement without difficulty, most recent electrolytes on day of life #6 showed a sodium of 143, chloride 109, potassium 5.4, and pCO2 21. The most recent weight is 1565 gm. Gastrointestinal - The infant was placed on single phototherapy on day of life #2 for maximum bilirubin levels, total 8.3, 0.3. Single phototherapy discontinued on day of life #5 and the most recent bilirubin level on day of life #6 showed a total bilirubin of 6.1, 0.3. Hematology - The patient did not receive any blood transfusions this hospitalization. Most recent hematocrit on day of delivery was 46%. Infectious disease - Due to elevated maternal white blood cell count and prolonged premature rupture of membranes, the infant received 7 days of Ampicillin and Gentamicin which were discontinued on [**7-28**]. The complete blood count on admission showed a white blood cell count of 8.2, hematocrit 46%, platelets 323,000, 28 neutrophils, 14 bands, 14 enucleated red blood cells. Lumbar puncture on day of life #5 showed white blood cell count of 2, red blood cell count of 0, protein 122, glucose 55, and all cultures remained negative to date. Neurological - A head ultrasound on day of life #6 showed no interventricular hemorrhage. Sensory - Hearing screening was recommended prior to discharge. Psychosocial - Parents involved with infant. Contact social worker can be reached at [**Telephone/Fax (1) 8717**]. CONDITION ON DISCHARGE: 31 [**2-22**] week gestation male now seven days old, currently in room air. DISCHARGE DISPOSITION: To [**Hospital3 **], Level 2 Nursery. Name of primary pediatrician, parents undecided at this time. CARE RECOMMENDATIONS: Feedings at discharge - Feedings at discharge 150 cc/kg/day of breastmilk, 22 cal/oz, p.g. Medications - Caffeine citrate q. day. State newborn screen - Sent on day of life #3 which showed a slightly elevated 17 OHP, repeat newborn screen was sent on [**2191-7-29**] Immunizations - The infant has not received any immunizations this hospitalization. DISCHARGE DIAGNOSIS: 1. Prematurity 30 [**2-22**] week male 2. Status post respiratory distress 3. Status post presumed sepsis 4. Status post direct hyperbilirubinemia 5. Apnea of prematurity [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**] Dictated By:[**Last Name (NamePattern1) 47014**] MEDQUIST36 D: [**2191-7-29**] 13:32 T: [**2191-7-29**] 15:11 JOB#: [**Job Number 48063**]

Admission Date: [**2162-1-2**] Discharge Date: [**2162-1-12**] Date of Birth: [**2084-5-20**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Levofloxacin / Iodine; Iodine Containing / Atorvastatin Attending:[**First Name3 (LF) 7881**] Chief Complaint: Right sided chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with drug eluting stent placement. History of Present Illness: The patient is a 77 year old female with a history of CAD s/p CABG, insulin dependent diabetes, hypertension, hyperlipidemia and achalasia who presents with an episode of right sided chest pain. The patient reports that over the past week she has been experiencing upper respiratory type symptoms including rhinorrhea, sore throat and mild cough. Her daughter had similar symptoms. She was prescribed azithromycin for a five day course over the phone but did not see a doctor or have a chest xray. She is currently on her last day of antibiotics and says that these original symptoms have resolved. She now presents with an episode of right sided chest pain. She describes the pain as sharp and well localized beneath her right breast. It is worsened with deep inspiration. It was not improved by SL nitroglycerine. It does not feel like her typical anginal pain which occurs consistently with exertion and which she describes a pressure across her chest associated with shortness of breath. She says that this new pain is very similar to that which she had on the left side two months ago when she was diagnosed with a left sided pneumonia at [**Hospital1 1774**]. The patient recently presented to her outpatient cardiologist Dr. [**Last Name (STitle) **] with worsening anginal symptoms. She says that she experienced angina prior to her CABG seven years ago. She did not experience any symptoms until approximatley two months ago when she started experiencing her anginal symptoms with increasing frequency and severity. She now experiences chest pain and dyspnea with minimal exertion. She was scheduled for elective cardiac catheterization to occur [**2162-1-6**]. . In the emergency room her vitals were T: 97.8, HR 54, BP: 124/44, RR: 18, O2: 93% on RA. She received aspirin 81 mg, sublingual nitroglycerin, a second 325 mg aspirin, n-acetylcystein 600 mg PO x 1 and was started on a heparin and nitroglycerin drips. She has a CXR which appears to have evidence of congestion but no clear infiltrates. She had an EKG which showed normal sinus rhythm, normal axis and a LBBB. Per the patient's daughter the left bundle branch block is old although this is not documented in our system. She had cardiac enzymes which were positive at Troponin 0.72. She was found to have a creatinine of 1.9 which is up from her last recorded value in [**Month (only) 116**] of this year of 1.2. She had an elevated D-dimer at 4040. She did not receive a PE-CT scan given her elevated creatinine. . On review of systems she currently denies lightheadedness, dizziness, fevers, chills, shortness of breath, nausea, vomiting, diarrhea, constipation, abdominal pain, dysuria, hematuria, decreased urine output, leg pain or swelling. She does have chronic back and joint pain. She has neuropathy in her arms which is chronic. She has right sided chest pain as described above. She does not have any left sided chest pressure at current. Past Medical History: CAD s/p five vessel CABG in [**2155**] (Left internal mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to obtuse marginal II, to ramus, saphenous vein graft to posterior descending artery. Type II Diabetes - insulin dependent complicated by neuropathy, mild retinopathy, and nephropathy. Hypertension Hyperlipidemia - poorly treated as patient is intolerant of most lipid lowering agents GERD Achalasia s/p balloon dilation complicated by esophageal perforation and s/p repair Hypothyroidism Arthritis Depression Social History: Quit smoking 45 years ago. No current tobacco or ethanol use. No illict drug use. Retired banker. Livers with her son and her grandaughter. Family History: She has five children, one passed away of heart disease at the age of 38, another son has known coronary artery disease and is doing well. Two of her five siblings have heart disease. Her father died of heart disease. Physical Exam: Vitals: T: 98.3 BP: 120/80 HR: 60 RR: 20 O2: 99% on 2L FS: 134 General: alert, oriented, no distress HEENT: sclera anicteric, MMM Neck: JVP not elevated CV: RRR, S1 + S2, harsh SEM at RUSB, no chest wall tenderness Resp: crackles 1/3 up lung fields bilaterally, no wheezes or ronchi GI: soft, non-tender, non-distended, +BS Ext: WWP, 2+ pulses, trace edema in feet, no calf tenderness Pertinent Results: Admission Laboratories: Hematology: WBC-12.4*# RBC-3.35* Hgb-10.2* Hct-30.2* MCV-90 MCH-30.3 MCHC-33.7 RDW-13.2 Plt Ct-298 Neuts-78.8* Lymphs-15.3* Monos-4.6 Eos-1.1 Baso-0.2 PT-13.1 PTT-23.7 INR(PT)-1.1 . Chemistries: Glucose-257* UreaN-51* Creat-1.9* Na-134 K-4.9 Cl-95* HCO3-29 AnGap-15 . Cardiac Enzymes: [**2162-1-2**] 12:45PM BLOOD CK-MB-5 BLOOD CK(CPK)-159* cTropnT-0.72* [**2162-1-3**] 12:05AM BLOOD CK(CPK)-138 CK-MB-4 cTropnT-0.71* [**2162-1-3**] 06:28AM BLOOD CK(CPK)-492* CK-MB-12* MB Indx-2.4 cTropnT-0.63* [**2162-1-4**] 05:40AM BLOOD CK(CPK)-1187* CK-MB-15* MB Indx-1.3 cTropnT-0.40* [**2162-1-4**] 11:16PM BLOOD CK(CPK)-681* CK-MB-7 cTropnT-0.44* [**2162-1-5**] 06:15AM BLOOD CK(CPK)-509* CK-MB-7 cTropnT-0.47* . Other: D-Dimer-4040* calTIBC-217* VitB12-882 Folate-GREATER TH Ferritn-319* TRF-167* Ret Aut-1.5 . EKG: Normal sinus rhythm, rate of 53, normal axis, LBBB. . Imaging: CXR PA and Lateral [**2162-1-2**]: Cardiac silhouette is enlarged. Median sternotomy wires are seen. There is again seen areas of focal consolidation within the right upper lobe, right perihilar region, and left lower lobe. These findings are more apparent than the prior study and suspicious for infectious/inflammatory etiology. . Renal Ultrasound: The right kidney measures 12.9 cm. The left kidney measures 11.6 cm. There is no evidence of hydronephrosis, stones or masses. Note is made of a questionable duplex left kidney as noted by a possible column of cortex extending across the mid-to-upper pole. The urinary bladder is not visualized and likely empty. . BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler son[**Name (NI) 1417**] of the right and left common femoral, superficial, and popliteal veins were performed. Normal compressibility, augmentation, flow and waveforms were demonstrated. There is no evidence of intraluminal thrombus. . CTA OF THE CHEST: There is no evidence of pulmonary embolism or aortic dissection. The bronchi are patent to the subsegmental level, though there is significant tracheomalacia. In the tracheo-esophageal space, there is soft tissue thickening, likely lymphadenopathy. There are multiple areas of consolidation throughout all lobes of the lungs, predominantly in the superior portion of the left lower lobe and apical portion of the right upper lobe. Smaller foci of consolidation are seen within the right middle lobe and lingula. There is a moderate-sized right pleural effusion, layering dependently, measuring simple fluid density. There is also a smaller left- sided pleural effusion layering dependently and extending into the major fissure, also measuring simple fluid density. A punctate calcification is noted at the left lung base, likely a granuloma. A prominent prevascular lymph node is noted anterior to the aortic arch measuring 9 mm in short axis. There are other small mediastinal lymph nodes including a 7-mm left prevascular lymph node, 6-mm precarinal lymph node, and a prominent subcarinal lymph node which is not easily distinguished from the esophagus. Probable hiatal hernia, incompletely visualized, is noted. There are dense calcifications within the native coronary arteries, particularly the LAD and its branches. Aortic valve calcifications are noted. There is no pericardial effusion. The heart is moderately enlarged. Median sternotomy wires and CABG clips are noted. This examination is not tailored for subdiaphragmatic assessment. Limited views of the upper abdomen are unremarkable. There are no bone findings of malignancy. Multilevel degenerative changes are noted throughout the thoracic spine. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Multifocal pneumonia, predominantly in the right upper and left lower lobes. 3. Moderate right and small left pleural effusions, likely reactive to the pneumonic process. 4. Significant tracheomalacia with probable lymphadenopathy posterior to the trachea. . Echocardiogram: The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (area 1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets and supporting structures are mildly thickened. At least 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 moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2160-12-24**], regional and global left ventricular systolic function appears preserved on the current study. The severity of aortic stenosis is increased and moderate pulmonary artery systolic hypertension is now present. Is there a history to suggest a primary pulmonary process (e.g., pulmonary embolism, bronchospasm, COPD exacerbation, etc.?). . Cardiac Cathterization: 1. Coronary angiography in this right-dominant system revealed native three-vessel disease. --the LMCA had diffuse disease, with greatest stenosis being 90%. --the LAD was occluded after a large Diag; the Diag itself had a 70% stenosis. --the LCx had an 80% proximal stenosis. OM1 was occluded, OM2 was patent filling OM1 via jump segment of graft. --the RCA was occluded proximally. 2. Arterial conduit angiography revealed the LIMA to be widely patent. The SVG graft to the LCX territory was occluded; this graft appeared to be an SVG-to-OM1-OM2 jump graft (rather than to Ramus as reported previously). The SVG-to-Diag was occluded. The SVG-to-LPDA was occluded. 3. Resting hemodynamics revealed elevated right-sided filling pressures, with RVEDP 29 mmHg. The PCWP was elevated at 33 mmHg. PA pressures were elevated, with PASP 68 mmHg. 4. Successful ptca and stenting of the LCx with a 3.0x28mm cypher stent post dilated to 3.25mm. Successful ptca and stenting of the LM overlapping the Lcx stent with a 3.0x18mm cypher which was postdilated to 3.25mm. Final angiography revealed 0% residual stenosis, no angiographically apparent dissection and TIMI3 flow (see ptca comments). FINAL DIAGNOSIS: 1. Native three-vessel coronary artery disease. 2. Occluded vein grafts, patent LIMA-LAD 5. Continue aspirin/plavix, statin 6. Plan diuresis, weaning ventilatory support 7. Serial ECGs and biomarkers 8. CXR to check ETT placement and r/o PTX as well as assess for infiltrate given extubation episode with emesis. 9. BP control 10. Renal u/s with doppler Brief Hospital Course: Assessment/Plan: 77 year old female with a history of CAD s/p CABG, hypertension, hyperlipidemia, diabetes and achalasia who originally admitted with NSTEMI and pneumonia who developed acute respiratory distress likely secondary to flash pulmonary edema requiring emergent intubation. She was taken to emergent cardiac catheterization where she underwent DES to the left main and LCx. She was extubated [**2162-1-7**] and is now transferred out to the floor. . Coronary Artery Disease: On presentation the patient endorsed crescendo anginal type symptoms. On admission she was found to have elevated troponins consistent with an NSTEMI. She was continued on plavix and started on a heparin drip. Given that she presented in acute renal failure with evidence of a new pneumonia urgent catheterization was deferred at that time. In the afternoon of [**2162-1-4**] the patient suffered an episode of flash pulmonary edema requiring emergent intubation. There was initial concern that she was experience an acute coronary syndrome at that time. The patient has a baseline EKG with LBBB. She underwent emergent catheterization which revealed occluded vein grafts with the exception of the LIMA-LAD. She had two cypher stents placed to the left main and the left circumflex. She was transferred to the CCU for a brief period of time for aggressive diuresis and was transferred back to the general cardiology service. Her cardiac enzymes did not increase following this acute event. Following her catheterization she did not experience any further episodes of chest pain. She ambulated with physical therapy. She was continued on her outpatient cardiac regimen including aspirin and plavix. Given that the patient showed signs of congestive failure her atenolol was switched to carvedilol. She tolerated only 12.5 mg [**Hospital1 **] secondary to bradycardia. She was also discharged on her home dose of Tricor as she has been intolerant in the past to even low doses of statins. She will follow up with her cardiologist Dr. [**Last Name (STitle) 8906**]. . Acute on Chronic Diastolic CHF: The patient underwent repeat echocardiogram on [**2162-1-4**] which showed mildly dilated [**Last Name (LF) **], [**First Name3 (LF) **] >55%, mild symmetric LVH, moderately thickened AV, moderate AS ([**Location (un) 109**] 1.2cm), 1+ AR, 1+ MR, mod PA systolic HTN and preserved global LV systolic function. In the afternoon of [**2162-1-4**] the patient had an episode of acute respiratory distress requiring intubation. It was thought that this was most likely secondary to flash pulmonary edema in the setting of a receiving a high osmotic fluid load during CTA. She was aggressively diuresed while in the CCU with IV lasix. On transfer to the floor she appeared euvolemic. She was discharged on lasix 20 mg daily. She was continued on her home dose of lisinopril 30 mg daily. She was switched from atenolol to carvedilol for her heart failure. She will follow up with Dr. [**Last Name (STitle) 8906**] for her heart failure and her primary care physician for [**Name Initial (PRE) **] repeat creatinine and potassium check. . Rate/Rhythm: During this hospitalization the patient's heart rate was noted on telemetry to be primarily in the 50s to 60s. With increased doses of beta blocker she had more profound episodes of bradycardia in the 30s. She also was noted to have short episodes of NSVT on telemetry. These were reduced in frequency with the addition of carvedilol. . Pneumonia: On admission the patient was noted to have a multifocal pneumonia on CXR. Initially there was concern for pulmonary embolism given that she presented with pleuritic chest pain with an elevated D-dimer. She had bilateral lower extremity ultrasounds which were negative and a CTA showed clear evidence of diffuse infiltrates. She completed a ten day course of ceftriaxone with improvement in her pain as well as her respiratory status. On discharge she was oxygenating well on room air. . Hypertension: The patient was noted to have fluctuating blood pressures during this admission. Given that her renal function was tenuous her lisinopril was held on two different occasions with significant increase in her blood pressure. As noted above her atenolol was changed to carvedilol. She was discharged on amlodipine, hydrochlorothiazide, carvedilol and lisinopril will good control of her blood pressure. . Acute Renal Failure: On admission the patient's creatinine was 1.9 from a baseline of 1.0. Her FeNa was 0.6% consistent with a prerenal etiology. She had bilateral renal ultrasounds which were negative for hydronephrosis. Her renal function quickly improved with gentle fluid hydration. On discharge her renal function was at her baseline. . Respiratory Failure: As above the patient required emergent intubation for respiratory distress likely secondary to flash pulmonary edema. She was aggressively diuresed and was intubated successfully on [**2162-1-7**]. On discharge she was satting well on room air and was ambulating without shortness of breath. . Anemia: On admission the patient was noted to have an hematocrit of 30.2. Her last recorded value was 38. Iron function studies were consistent with anemia of inflammation. B12 and folate were normal. Her hematocrit was stable throughout this admission. She did not require transfusion. She should follow up with her primary care physician for this issue. . Urinary Tract Infection: On [**2162-1-9**] the patient was noted to have a positive UA and a WBC count of 14. She was afebrile but given that she had an indwelling foley catheter at that time there was concern that she had developed a UTI. She was discharged with plans to complete a 7 day course of ciprofloxacin. . Diabetes: Stable during this admission. She was maintained on NPH and an insulin sliding scale during this admission. She was discharged on her outpatient regimen. . Hypothyroidism: Stable. She was continued on her home dose of synthroid 200 mcg daily. Thyroid function tests were notable for a TSH of 0.26 with a T4 of 1.4. Given that these were performed during an acute illness they should be repeated as an outpatient. . Arthritis/Neuropathy: Stable. She was continued on neurontin at decreased doses given her presentation with acute renal failure. She was discharged on her outpatient regimen of neurontin 900 mg TID with standing tylenol. . Depression: Stable. She was continued on her outpatient regimen of zoloft and ativan. . Asthma: Stable. She was continued on her outpatient ipratropium with albuterol as needed for increased wheezing. . GERD: Stable. She was continued on protonix and ranitidine. . Prophylaxis: She received both IV heparin and subcutaneous heparin during this admission for DVT prophylaxis. . Code: Full Code Medications on Admission: Insulin - NPH 48 in AM, 18 at bedtime Insulin - Regular 8 units in AM ICAPS - eye vitamins daily Lutein - eye vitamins [**Hospital1 **] Lucentis - eye injections q month Liquigel 2 drops each eye as needed for dryness Erythromycin eye ointment to right eye QHS Lisinopril 30 mg daily Hydrochlorothiazide 25 mg daily Synthroid 200 mcg daily Gabapentin 900 mg TID Tylenol 1000 mg TID Tylenol #3 PRN Atenolol 25 mg PO QAM Ativan 0.25 mg QAM, 0.5 mg at 4 PM Zoloft 25 mg daily Ranitidine 200 mg [**Hospital1 **] Aciphex 2 tabs QHS Tricor 48 mg daily Folic Acid 400 mcg daily Calcium 2 tabs daily Aspirin 81 mg daily Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day. 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 9. Lorazepam 0.5 mg Tablet Sig: one half Tablet PO QAM (once a day (in the morning)). 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*5* 12. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 13. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice Discharge Diagnosis: Non ST-segement elevation myocardial infarction Acute pulmonary edema Multilobar pneumonia-community acquired Urinary tract infection-hospital acquired Diabetes mellitus Hypertension Peripheral neuropathy Spinal stenosis Coronary artery disease Hyperlipidemia Gastroesophageal reflux disease Esophageal achalasia Hypothyroidism Depression Discharge Condition: stable, on room air. Discharge Instructions: You were admitted with right sided chest pain. You were found to have multiple areas of pneumonia and were treated with 10 days of antibiotics for community-acquired pneumonia. We were concerned about a pulmonary embolism, and you underwent Lower extremity ultrasound and CT scan which were negative for blood clots. Your course was complicated by a heart attack and acute pulmonary edema requiring emergent intubation and cardiac cathterization. You had 2 drug-eluting stents placed. You were successfully extubated and improved. You also developed a urinary tract infection, which was treated with antibiotics. The following changes were made to your home medication regimen: 1. Stop Atenolol 2. Start Carvedilol (Coreg) 12.5 mg by mouth twice daily 3. Increase aspirin dose to 325 mg daily 4. Start plavix 75 mg daily 5. Neurontin: please up-titrate your dose as tolerated. You are currently receiving 300 mg three times daily. Increase to 600 mg three times daily as tolerated for 5 days. Then increase to 900 mg three times daily, if tolerating 600 mg dose. 6. Ciprofloxacin: 1 tab by mouth twice daily for five days, then stop. 7. Please stop hydrochlorothiazide 8. Start Lasix 20 mg by mouth daily . Please call your doctor or 911 if you develop chest pain, shortness of breath, new neurologic symptoms, or any other concerning symptoms. Followup Instructions: 1. Please see your PCP [**Name Initial (PRE) 176**] 1-2 weeks of hospital discharge. Dr. [**Last Name (STitle) 3707**] [**Telephone/Fax (1) 2205**], please call for appointment. At this appointment, you will need to have your labs checked to evaluate your kidney function and potassium. 2. Please see your primary cardiologist, Dr. [**Last Name (STitle) **], ([**Telephone/Fax (1) 31834**] within 2 weeks of hospital discharge.

Admission Date: [**2179-7-24**] Discharge Date: [**2179-8-3**] Date of Birth: [**2130-3-23**] Sex: M Service: MICU CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: He is a 49-year-old male with a history of cirrhosis from ethanol abuse and chronic hepatitis C, portal hypertension with history of variceal bleeds and multiple admissions for ascites, who was actually recently admitted from [**6-20**] to the 13th for clinical trial, where he received an infusion of methylene blue, and was seen in Liver Clinic on [**7-20**], where large volume paracentesis of 5 liters was performed which revealed no SBP. The patient now presents with increasing abdominal girth, abdominal pain, and nausea and vomiting x1 day. He said he felt better for about two days following the large volume paracentesis, but his ascites returned. He denied any blood or coffee grounds in his vomitus. He had normal color bowel movements. No bright red blood per rectum or melena. No pale stools. He is taking his lactulose with 2-3 bowel movements per day. No confusion, sleeping at night okay. He denies any fever or chills. The patient states he has gained approximately 12 pounds in the past three days. He says he has been compliant with all of his medications. He says he is also compliant with a low salt diet. The patient did note some shortness of breath and difficulty taking large breaths. He states that his fingersticks have been well controlled. PAST MEDICAL HISTORY: 1. Hepatitis C. 2. Ethanol abuse. 3. Cirrhosis. 4. Portal hypertension. 5. History of variceal bleeding which had been banded in the past. 6. History of ascites. 7. History of hemorrhoids and a small rectal AVM. 8. Anemia. 9. Diabetes mellitus. ALLERGIES: He had no known reported drug allergies. MEDICATIONS ON ADMISSION: 1. Aldactone 100 mg p.o. q.d. 2. Lasix 80 mg p.o. q.d. 3. Lantus 40 units q.p.m. 4. Regular insulin-sliding scale. 5. Iron sulfate 325 mg p.o. t.i.d. 6. Lactulose 30 cc p.o. q.6h. 7. Percocet 30 mg p.o. q.d. 8. Zoloft 50 mg p.o. q.d. 9. Remeron 30 mg p.o. q.d. 10. Anusol suppository prn. 11. Prevacid 30 mg p.o. q.d. SOCIAL HISTORY: He has not consumed alcohol for the past 1.5 years. He denies any tobacco or IV drug use. He is single with seven children and lives alone in an apartment. PHYSICAL EXAMINATION: Pertinent findings: He was afebrile. His blood pressure was 108/68 with a pulse of 95. He was sating at 100% on room air. He was a middle-age man appearing somewhat uncomfortable, but in no acute distress, no jaundice. Pertinent findings on exam: His sclerae were icteric. He had dry mucous membranes. His neck was supple with no JVD or adenopathy. Heart was regular, rate, and rhythm with no murmurs. His lungs are clear. His abdominal exam: His belly was distended and tense with positive bowel sounds. He had mild epigastric tenderness with no guarding or rebound. He did have some mild right lower quadrant tenderness as well. There was caput medusa, but no spider angiomata. He had 2+ lower extremity pitting edema without clubbing. He did also have some palmar erythema. Neurological examination: He had mild tremor, but no flapping. He was alert and oriented times three. PERTINENT LABORATORY DATA: His Chem-7 was essentially unremarkable. His ALT was 28, AST 42, alkaline phosphatase 119, amylase 115, and T bilirubin 1.7. His albumin was 3.0. He had a white count of 12.8, hematocrit 31.2, platelets of 128. He had an INR of 1.6. An aFP was 8.1. ASSESSMENT: Patient was a 49-year-old male with history of cirrhosis from ethanol abuse and chronic HCV, portal hypertension with a history of esophageal varices, hemorrhoids and recurrent ascites, who recently had a large volume paracentesis performed three days prior to admission, who now presents with increasing abdominal girth, belly pain, and weight gain from ascites. On [**7-24**], the patient had another large volume paracentesis with 5 liters of fluid removed. He was also considered for possible TIPS placement as well. Before the TIPS procedure, he had an abdominal ultrasound to assess portal patency. The findings on the ultrasound essentially showed that there were no focal liver lesions, and the liver had a cirrhotic appearance. The left middle and right portal vein and the extrahepatic portal vein had normal flow. The hepatic veins also had normal flow. There was a large amount of abdominal ascites noted. On the [**7-28**], the patient did have a TIPS procedure, and was transferred to the MICU for closer observation. His preoperative hematocrit before the procedure was 25.4, but his hematocrit status post procedure was 21. Patient was felt to be at high risk for bleeding given his coagulopathy. His INR on the day of the procedure is 1.8. Of note, the patient's hematocrit on admission was 31.2. The patient did receive 2 units of packed red cells after the procedure. At the time of his admission to the MICU, he had no complaints. He denied chest pain, shortness of breath, abdominal pain, nausea, or vomiting. Patient had a repeat abdominal ultrasound on [**7-29**], which showed patency of the TIPS. On [**7-30**], patient was complaining of right back pain as well as epigastric and right upper quadrant pain. A CT scan obtained showed a 6 mm pseudoaneurysm in the posterior right hepatic artery near the porta hepatis, but there was no contrast extravasation. Again, there was no focal mass noted. Again the TIPS was in stable position, however, there was again noted large amount of ascites throughout the abdomen and pelvis. Up to this point, the patient continued to receive units of packed red blood cells as well as FFP as needed for his anemia and coagulopathy. Also on [**7-30**], the patient spiked a fever to 101.4, and blood cultures were sent. His white count rose to 15.1. He was started on levofloxacin to cover for possible SBP. Patient also started to become slightly hypotensive, although the patient did have a baseline low blood pressure. A paracentesis was also attempted, however, after several attempts with a 14 gauge thoracentesis kit, 1 cc of brown feculent material was aspirated. There was concern for possible bowel perforation. A KUB and chest x-ray were ordered to assess for free air. No free air was seen on either of these examinations. On the day of [**7-31**], the patient had progressive dyspnea with a chest x-ray showing increasing bilateral infiltrates. He was placed on supplemental oxygen and IV Lasix was given. His heart rate was in the 120s with a blood pressure in the 100s. He was also noted to have bilateral crackles 1.5 to [**3-16**] of the way up, and at this time given the patient's fever, hypotension, and respiratory status, he was electively intubated. Patient on the 20th, had blood cultures which returned showing gram-positive cocci and the patient was felt to be septic with gram-positive cocci in his blood, and the origin of the gram-positive cocci was felt likely to be due to the initial paracentesis on admission. His new onset of respiratory failure was thought to be either due to massive fluid overload from worsening cirrhosis, possibly high output failure from his TIPS procedure or possible sepsis/ARDS with his recent blood infection. Patient became hypotensive ranging from the 60s-100s/40s-780s. He eventually required Neo-Synephrine for blood pressure support. Patient also had a Swan-Ganz catheter placed for better hemodynamic monitoring, and the patient on [**8-1**], again became increasingly hypotensive and required three pressors for blood pressure support. It was thought that his deteriorating status was likely from MRSA bacteremia from a line infection and in-fact not from his abdomen. Additional abdominal CT did not show any bowel perforation or leak. The Swan-Ganz catheter revealed a distributive sepsis with decreased SVR and increasing cardiac output. He also noted to have increasing lactate from both sepsis and severe liver dysfunction. Patient had been during this time started on Vancomycin, Zosyn, and Flagyl for MRSA bacteremia as well as broad-spectrum antibiotic coverage. Patient was also noted on the 21st to have a profound acidosis with a pH of 7.09 and on [**8-3**], the patient was made comfort measures only. He was extubated shortly before 3 o'clock in the morning and at 3:06 a.m., the covering intern, Dr. [**Last Name (STitle) **] was called to examine the patient for asystole. His pupils were noted to be fixed and dilated. He had no pulse and no breath sounds, and no heart sounds are auscultated after 60 seconds. He was pronounced dead at 3:06 a.m. on the morning of [**2179-8-3**]. An autopsy was granted by his health care proxy. DISCHARGE STATUS: Expired. DISCHARGE DIAGNOSES: 1. Methicillin-resistant Staphylococcus aureus bacteremia and sepsis. 2. Hepatitis C. 3. Cirrhosis. 4. Portal hypertension. 5. Acute respiratory distress syndrome. The autopsy report designated the following: Pertinent findings: The patient, in general, was noted to be anisaric, jaundiced, and had scleral icterus. The heart weighed 440 grams and had cardiomegaly. There was opaque fibrous plaques on the anterior and posterior epicardium as well as 20 mL of straw colored pericardial fluid. The area that was noted to have mild-to-moderate atherosclerosis. The lungs: There was 100 mL of straw colored pleural effusion bilaterally. There are pleural adhesions to the thoracic wall and diaphragm. The digestive system: There are 3 liters of peritoneal fluid. In the esophagus, there were esophageal varices, but no recent hemorrhage. In the large bowel, there was no evidence of perforation. The liver showed cirrhosis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D. [**MD Number(2) 8038**] Dictated By:[**Name8 (MD) 8288**] MEDQUIST36 D: [**2179-10-26**] 17:44 T: [**2179-10-27**] 04:38 JOB#: [**Job Number 30543**]

Admission Date: [**2159-10-16**] Discharge Date: [**2159-10-23**] Date of Birth: [**2100-4-12**] Sex: M Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) / Tetanus / Tuberculin,Purif.Prot.Deriv. / metoprolol Attending:[**First Name3 (LF) 13256**] Chief Complaint: bloody emesis and BRBPR Major Surgical or Invasive Procedure: EGD on [**2159-10-16**] and [**2159-10-20**] History of Present Illness: Pt is a 59yo M with bright red bloody emesis and BRBPR. The pt is s/p variceal banding on [**10-5**] with 5 bands for an acute variceal bleed with BRBPR and epigastric pain. At that time the pt was noted to have a hematocrit of 31.1, and he was observed at [**Hospital3 **] until [**10-15**]. Subsequently the pt did well and was advanced to PO solids, and he was planned to be discharged today, but then had "black" diarrhea all day and was vomiting "dark brown" material x1 around lunch, as well as diaphoresis and right anterior abdominal wall tenderness, without radiation. The pt was re-evaluated by the MDs there and they determined that the pt would be a poor candidate for a repeat EGD, and the pt was transferred here to [**Hospital1 18**] for evaluation and presumptively for a TIPS procedure. At [**Hospital1 **] today the pt's hematocrit continued to fall and he was transfused 4 units of pRBC, and then transfered here. . On arrival to the MICU the pt was complaining of abdominal pain, had an SBP of the 90's, HR 120's. Story c/w outside records. Past Medical History: - EtOH abuse - EtOH cirrhosis - Variceal bleeds - Erosive esophagitis and gastic varicies - CVA and left hemiplegia - IDDM - Schizophrenia - Anemia - Hypothyroidism - Obesity - HTN - HL - Migranes - COPD Social History: Patient lives in a nursing home. He denies recent alcohol use and says it was "in the past", he denies smoking or other drugs. He is originally from [**Country 7192**] and has children in [**Country **]. He has a sister in [**Location (un) 538**]. He does not have a HCP. Family History: Non-contributory. Physical Exam: Physical Exam on Admission: T: 98.9 BP:92/45 P:116 R:16 O2: 99 General: Alert, oriented to person, place, time, event, talking in fluent sentences. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, tender to palpation over right anterior abdominal wall, no body wall ecchymoses, no tenderness to percussion, no rebound, no guarding, no organomegaly appreciated though physical exam is severely limited. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Dried blood between legs. Physical Exam on Discharge: O: 99.3, 97.6, 144/67, 87, 20, 99%RA HEENT: MMM, dentures in place Neck- unable to assess JVP due to habitus Cardiac: RRR, 2/6 systolic murmur in LUSB, no gallops or rubs appreciated Lungs: Clear to auscultation bilaterally. Abdomen: Obese, soft, nontender, unable to palpate liver or spleen tip. No capute medusae. No appreciable shifting dullness. Extremities: 2+ edema bilaterally 2+ pulses. Skin- no palmar erythema. Multiple actinic keratoses on the back. Pertinent Results: Labs upon admission: . [**2159-10-16**] 01:50AM BLOOD WBC-11.0 RBC-3.92* Hgb-12.0* Hct-33.7* MCV-86 MCH-30.6 MCHC-35.6* RDW-14.9 Plt Ct-241 [**2159-10-16**] 01:50AM BLOOD Neuts-86.8* Lymphs-9.7* Monos-2.7 Eos-0.5 Baso-0.3 [**2159-10-16**] 01:50AM BLOOD PT-15.8* PTT-26.2 INR(PT)-1.4* [**2159-10-16**] 01:50AM BLOOD Glucose-237* UreaN-12 Creat-1.0 Na-140 K-4.4 Cl-106 HCO3-28 AnGap-10 [**2159-10-16**] 01:50AM BLOOD ALT-95* AST-140* LD(LDH)-377* AlkPhos-77 TotBili-0.8 [**2159-10-16**] 01:50AM BLOOD Lipase-44 [**2159-10-16**] 01:50AM BLOOD Albumin-2.9* Calcium-7.7* Phos-3.3 Mg-1.8 [**2159-10-16**] 11:11PM BLOOD freeCa-1.03* . Labs upon discharge: . [**2159-10-23**] 05:45AM BLOOD WBC-1.4* RBC-2.85* Hgb-8.8* Hct-26.6* MCV-93 MCH-30.7 MCHC-33.1 RDW-15.8* Plt Ct-226 [**2159-10-23**] 05:45AM BLOOD PT-15.4* PTT-29.4 INR(PT)-1.3* [**2159-10-23**] 05:45AM BLOOD Glucose-162* UreaN-5* Creat-0.7 Na-139 K-3.6 Cl-104 HCO3-24 AnGap-15 [**2159-10-23**] 05:45AM BLOOD ALT-116* AST-24 AlkPhos-81 TotBili-0.6 [**2159-10-23**] 05:45AM BLOOD Calcium-7.7* Phos-2.5* Mg-2.0 . Imaging: Echo [**2159-10-17**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. 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 root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2159-10-17**]: Abd US: IMPRESSION: 1. Limited study. Findings consistent with hepatic cirrhosis with patent hepatic vasculature. 2. Small amount of ascites. 3. Splenomegaly. 4. No evidence of gallstones or cholecystitis. . [**2159-10-19**]: CXR: FINDINGS: There are mild bilateral lower lobe opacities likely atelectasis. Minimal pulmonary vascular congestion is seen. Widening of the mediastinum is attributed to the tortuous course of thoracic aorta. The heart size is normal. Pleural effusion if any is minimal on the right side. No opacities concerning for pneumonia. . Blood cultures: [**10-16**], [**10-17**], [**10-19**]: NGTD Urine culture: [**2159-10-16**]: negative . EGD [**2159-10-16**]: . Esophagus: Protruding Lesions 5 cords of grade III-IV varices were seen in the lower third of the esophagus. The varices were not bleeding. Excavated Lesions Two ulcers ranging in size from 5 mm to 5 mm were found in the lower third of the esophagus. One had stigmata of recent bleeding. Both ulcers seemed to be post-banding ulcers. . Stomach: Mucosa: Normal mucosa was noted. Duodenum: Mucosa: Normal mucosa was noted. Impression: Varices at the lower third of the esophagus Ulcers in the lower third of the esophagus Normal mucosa in the stomach Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Recommendations: Continue PPI and Octreotide infusion. Add Carafate as well. If he should bleed again, he will need TIPS procedure. Further management per Liver team. Additional notes: The attending was present for the entire procedure. The patient's home medication list is appended to this report. FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology . EGD [**2159-10-20**]: . Esophagus: Protruding Lesions 2 cords of grade II varices were seen starting at 36 cm from the incisors in the lower third of the esophagus. 2 bands were successfully placed. 1 band was placed below the ulcer. Excavated Lesions A single oozing 6 mm ulcer was found in the on the previously banded esophageal varix. Stomach: Contents: Red blood was seen in the whole stomach. Other No gastric varices were seen. Duodenum: Normal duodenum. Other findings: Bile in duodenum. Impression: Varices at the lower third of the esophagus (ligation) Ulcer in the on the previously banded esophageal varix Blood in the whole stomach No gastric varices were seen. Bile in duodenum. Otherwise normal EGD to second part of the duodenum Recommendations: serial hct, transfuse if hct<24 or active bleeding Cont' Octreotide gtt, PPI gtt, ceftriaxone 1 g daily, lactulose, carafate 1 g QID No NG tube placement Additional notes: The procedure was performed by the attending physician and fellow FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology . Brief Hospital Course: 59 yo male with history of alcoholic cirrhosis and variceal bleeding s/p recent banding on [**10-5**], presented with recurrent variceal bleeding. . #. Variceal bleeding: He was initially admitted to the MICU on [**2159-10-16**] with hypotension and tachycardia believed to be secondary to a variceal bleed. He was intubated initially for airway protection prior to EGD. Endoscopy showed 5 cords of grade III-IV nonbleeding varices in the lower third of the esophagus, and two post-banding ulcers, with one having stigmata of recent bleeding, no interventions were performed at that time. He received 2 units of pRBC. He was transferred to the floor on [**2159-10-17**]. He was doing well with no additional melena or hematochezia until [**10-20**] when he developed hematochezia and had a 7 point HCT drop. He was transferred to the MICU where he underwent repeat EGD which showed 2 cords of grade 2 varices in the lower [**1-22**] of the esophages and an oozing ulcer on the previously banded esophageal varix. He received an additional 2units PRBC. He was monitored on the floor after his octreotide and PPI drips were stopped and he had no further episodes. He was not started on a beta-blocker due to concern for worsening of his reactive airway disease and a history of possible beta-blocker allergy. His protonix drip was changed to protonix 40mg PO BID. He will follow up with the hepatology departement in the next 1-2 weeks for likely re-scope. If he rebleeds, then consideration for a TIPS may be warranted. . #Hepatitis- patient developed shock liver in the setting of his GI bleed with his LFTs increasing into the AST and ALT of 700s and were downtrending and resolving at the time of discharge. . #. Abdominal Pain: Pt's abdominal pain is atypical for a variceal bleed, which generally are painless. The pt presented intially to the OSH on [**10-5**] with abdominal pain as well. On the CT performed then the pt was seen to have a duodenitis. The clinical relevance of this is not certain. US was performed, which did not show signficant ascites. . # Fever: unclear etiology. SBP was considered, though he did not have any obvious ascites to tap. Regardless, he was treated empirically with a course of Ceftriaxone 2g daily with transition to cipro 500mg [**Hospital1 **] on discharge. He should complete a total of 10 days of antibiotics to be completed [**2159-10-26**]. He remained afebrile on discharge with negative cultures to date. . # [**Name (NI) **] Pt noted to develop leukopenia with a total WBC=1.4 on discharge. The origin of this was unclear. It was thought that this could have been in the setting of his ceftriaxone course and thus this was changed to cipro as above. However, he was continuing to nadir on discharge. It is also possible that his risperidone could have been contributing. We recommend a follow up CBC within a week after discharge. His outpatient providers to should address whether to continue his risperidone. . # SOB- patient had several episodes of shortness of breath while in house. It was likely multifactorial from his known reactive airway disease, significant anemia in the setting of UGIB, volume overload, and possible transient hepatopulmonary syndrome in the setting of his shock liver. He was continued on nebs, and his diuresis was adjusted to lasix 40mg daily and spironolactone 50mg daily. On discharge his SOB had markedly improved. . #. IDDM: Pt was maintained on a regimen of lantus 20U QHS and Humalog SS. Note that his lantus regimen was much less aggressive in-house than at home. This is likely due to eating a different diet in-house. Thus, we increased his lantus to 36U QHS on discharge to account for this, but this is still less than his home dose. Note that re-uptitration of his insulin may be warranted if glucose control is not adequate. . #. Volume overload: Pt noted to become more volume overloaded while in house. It appears he is on lasix 40mg daily at home, but this was held in the setting of his bleeding. We restarted this along with spironolactone 50mg daily on discharge. . #. Schizophrenia: Not an active issue. Continued home risperidone, though this may be further addressed by outpatient providers given the possibility of this medication contributing to his leukopenia . #. Hypothyroidism: Not an active issue. Continued home levothyroxine. . #. HL: Not an active issue. Initially held simvastatin [**2-21**] [**Last Name (LF) 105984**], [**First Name3 (LF) **] be restarted in the future after resolution of LFTs . # Follow-up/Transitional -CBC should be followed up within the next week to ensure resolution of leukopenia -[**Month (only) 116**] consider changing risperidone in setting of leukopenia -Final blood cultures still pending on discharge -Whether to restart statin should be addressed as outpatient Medications on Admission: Advair 250/50 1 puff [**Hospital1 **] Cepacol 1 tab q4hrs prn cough Docusate 100mg tab - 2 tabs qhs Ferrous sulf 325 1 tab [**Hospital1 **] Folic acid 1mg qday Furosemide 40 mg po qday vicodin 1 tab [**Hospital1 **] Latanoprost 0.005% 1 drop L eye qhs levothyroxine 225mcg qday Lisinopril 5mg po qhs KCl ER 10meq cap qday prilosec otc 20mg po qday risperidone 1.5mg po qhs Simvastatin 10 mg po qhs albuterol 0.083# i unit q4h ibuprofen 600mg po qhs prn for pain lactulose 30ml TID prn for constipation proair hfa 2 puffs q4hrs prn SOB/wheeze humalog 20 U qam, 20 U qlunch 40U qdinner Lantus 74U qam lantus 36U qpm bisacodyl prn fleet enema prn milk of mag prn Discharge Medications: 1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): in left eye. 2. risperidone 3 mg Tablet Sig: One "half" tablet Tablet PO at bedtime: 1.5mg . 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. levothyroxine 25 mcg Capsule Sig: One (1) Capsule PO once a day: Take in addition to 200mcg dose. Total dose of 225mcg. 7. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): please only give so patient has 3 bowel movements per day. 9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. 14. Cepacol Sore Throat 15-3.6 mg Lozenge Sig: One (1) Mucous membrane every four (4) hours as needed for sore throat. 15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 16. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Inhalation 18. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 19. Lantus 100 unit/mL Solution Sig: Thirty Six (36) Units Subcutaneous qPM. 20. Humalog 100 unit/mL Solution Sig: see below Subcutaneous see below: 20 Units given with breakfast 20 Units given with lunch 40 units given with dinner. 21. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day: total dose of 225mcg. 22. Outpatient Lab Work Please draw CBC and Complete Metabolic panel during the week of [**2159-10-29**]. Discharge Disposition: Extended Care Facility: [**Hospital 10246**] Extended Care Center - [**Location (un) 2268**] Discharge Diagnosis: Primary: Variceal bleed, Alcoholic cirrhosis, shock liver, shortness of breath Secondary: Diabetes Mellitus Type II, 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 while you were here at [**Hospital1 18**]. You were admitted to our hospital from another hospital for concern that you were having bleeding in your stomach and esophagus. You had had two bleeds at that hospital. When you arrived here you were in the intensive care unit (where we looked inside your esophagus and stomach) to see if there was bleeding and did not see any, so there was nothing done at that time. You were then on the regular hospital [**Hospital1 **] floor. We kept you on some medicines to prevent you from bleeding and watched you over the next few days. You developed some bright red blood in your stools and you were transfered to the intensive care unit to be monitored and had another endoscopy(look inside the esophagus and stomach) and they saw an ulcer that was bleeding ontop of one of the varices (blood vessels that had previously bled). They put a couple of bands on this to stop the bleeding and gave you a blood transfusion and you were feeling better and had no more bleeding. You will need to stay on the pantoprazole twice a day for now, as well as need to have another endoscopy to have the varices taken care of. You also had a fever when you arrived to our hospital, and we are not exactly sure where the infection is coming from. Because you can get infections with having these type of bleeds we put you on IV antibiotics at first and then switched this to a pill antibiotic called bactrim which you will need to finish the course of when you leave. Your white blood cell count (indicating body's response to infection) got very low while you were on the IV antibiotic and we think this caused it to drop too much. We stopped that medicine, but this will need to be followed-up by your primary care doctor to make sure it gets back up into the normal range. For your diabetes- your blood sugars were well controlled on a much lower dose of insulin (20U at bedtime) than you receive at home. So we will ask you to stop your morning dose of Lantus when you return home. You should have your blood sugars closely monitored while you are at home, and adjustments can be made further. You developed some worsening swelling of your legs during your stay, most likely due to all of the blood transfusion that we were giving you. We are adding another medication call spironolactone to your medication list to help you get more fluid off of you. It will also be important that you stick to a low sodium diet. Transitional Issues: Pending labs: None Medications started: 1. Ciprofloxacin 500mg tab by mouth twice a day (to finish course on [**2159-10-26**]) 2. Spironolactone 50mg tab by mouth once a day 3. Pantoprazole 40 mg by mouth twice a day 4. Sulcrafate (for the stomach) Medications changed: 1. Lantus- please stop MORNING dose of lantus, and continue to check blood sugars before each meal Medications stopped: 1. Omeprazole (taking another form of it) 2. Simvastatin (because liver function not back to normal) 3. Ibuprofen- this is an NSAID and these should not be taken given history of bleeding ulcer on the esophageal varix Follow-up- 1.You will need to have your varices (blood vessels that are exposed) in your esophagus, banded again and you will need to schedule this appointment (see below) 2.Your blood sugars should be monitored closely and medication changes should be made based on these numbers when you are eating your home diet 3.Your primary care doctor will need to recheck your liver function tests and determine if you should be restarted on your simvastatin if they feel it will be beneficial. Followup Instructions: Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Liver Clinic follow up- Unfortunately we were unable to schedule this appointment for you prior to discharge. You will need to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the Liver Clinic at [**Hospital1 18**] within 10-14 days, to have another endoscopy with (banding and obliteration of your varices). To make this appointment please call [**Telephone/Fax (1) 105985**]

Admission Date: [**2135-7-16**] Discharge Date: [**2135-7-19**] Date of Birth: [**2051-12-15**] Sex: M Service: SURGERY Allergies: morphine Attending:[**First Name3 (LF) 3200**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: [**2135-7-19**] Colonoscopy History of Present Illness: 83M s/p right hemicolectomy for colon cancer on [**2135-6-22**] by Dr. [**Last Name (STitle) 43078**] at [**Hospital3 90829**] transferred from [**Hospital1 **] for lower GI bleed. He presented to [**Hospital3 **] on [**2135-7-14**] after having a bloody bowel movement at home. Colonoscopy was performed, but they were unable to identify a source of bleeding due to the amount of blood in his colon. He was hypotensive during the procedure, but responded to volume resuscitation. He is on coumadin for afib, and his INR was 3.5 upon admission. He was given 4 units FFP and may have received vitamin K, though cannot be confirmed. He was transfused a total of 6u PRBC's but continued to have BRBPR, and was transferred. At the time of admission to the SICU, he states he feels well. His last bloody bm was prior to transfer from [**Hospital3 **]. Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] for transfer, as IR and angio are not available at [**Hospital3 **]. Past Medical History: Past Medical History: right colon cancer, a-fib, hypertension, hyperlipidemia Past Surgical History: tonsillectomy, knee arthroscopy, R hemicolectomy Social History: Lives with wife. Social EtOH. No tobacco. Family History: Non-contributory Physical Exam: Vitals: 99.3, 86, 131/76, 17, 96RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: tachycardic but regular, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, red blood mixed with stool in rectal vault Ext: No LE edema, LE warm and well perfused Pertinent Results: Hct: 29.4->27.0-24.4-(2u PRBC)-26.0-26.6-27.0-28.1-26.1-26.4 INR: 3.5 at OSH, given ffp and vitamin K -> 1.2 here Bleeding study [**7-17**]: Normal study, specifically with no evidence of gastrointestinal, or other source of bleeding. [**2135-7-19**] Colonoscopy : Diverticulosis of the descending colon and sigmoid colon Previous colorectal anastomosis of the proximal transverse colon Normal mucosa in the colon Otherwise normal colonoscopy to cecum [**2135-7-19**] HCT 29.3 Brief Hospital Course: Mr. [**Known lastname 3646**] was transferred to the TICU on [**2135-7-16**] for management of his lower GI bleed. He was hemodynamically stable upon transfer and remained so throughout his ICU stay. He had 3 small bloody bowel movements the evening of [**7-16**] and the early morning of [**7-17**], as well as a Hct drop from 29.4 to 24.4. He received 2u PRBC's and his Hct improved to 28.1. He had a bleeding scan on [**2135-7-17**], which was negative, and he had a normal bm the morning of [**7-18**]. Neuro: He received intermittent narcotics for pain control. His mental status remained intact throughout his stay. CV: He was reportedly hypotensive during his colonoscopy at the OSH, but remained hemodynamically stable here. He was in NSR and his Coumadin was not resumed. Dr. [**Last Name (STitle) 10543**] was notified and he will follow up with him in a few weeks. Resp: No issues. FEN/GI: He was initially NPO with IV fluids while watching for active bleeding. His electrolytes were monitored and repleted when necessary. Once his bleeding stopped, he was allowed a clear liquid diet. GI was consulted and recommended a colonoscopy which was done on [**2135-7-19**]. There was no active bleeding noted, simply diverticulosis of the descending and sigmoid colon. A regular diet was resumed and he tolerated it well. GU: His urine output was monitored and remained adequate throughout his stay. Heme: He was transferred with a Hct of 29.4, which was after receiving 6u PRBC at the OSH over 48 hours. He received an additional 2u at [**Hospital1 18**] for Hct 24.4, after which it stabilized at 28. On the day of discharge his hematocrit was 29.3. ID: No issues. After an uneventful stay he was discharged to home on [**2135-7-19**] and will follow up with Dr. [**Last Name (STitle) 43078**] his surgeon at [**Hospital1 **]. Medications on Admission: Coreg 3.125mg po bid, zocor 10mg po daily, warfarin 2.5mg po alternating w/5mg po daily, amiodarone 200mg po MWF, percocet prn Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 2. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital with a lower GI bleed and required 2 units of blood in addition to the blood that you received at [**Hospital3 **]. Your hematocrit has been stable along with your vital signs. The tagged red cell scan did not show any abnormalities and the Gi service then did a colonoscopy which showed diverticulosis of the lower colon. There was no active bleeding. * You should continue to eat a regular diet and stay well hydrated. * Do NOT resume your Coumadin. You can discuss that with Dr. [**Last Name (STitle) 10543**] at your next appointment. * If you develop any more rectal bleeding, lightheadedness, dizziness or any other symptoms that concern you please call your doctor or return to the Emergency Room. * If you have any questions about this hospitalization please call the Acute Care Clinic at [**Telephone/Fax (1) 600**]. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 43078**] at [**Hospital3 **] for post operative evaluation. Call Dr. [**Last Name (STitle) 10543**] at [**Telephone/Fax (1) 4475**] for a follow up appointment in [**1-13**] weeks. Completed by:[**2135-7-19**]

Admission Date: [**2142-3-23**] Discharge Date: [**2142-4-23**] Date of Birth: [**2080-6-29**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Hydrochlorothiazide Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Acute myelogenous leukemia Major Surgical or Invasive Procedure: Central venous line placement PICC line placement History of Present Illness: 61 y/o F hypertension, hyperlipidemia, and anxiety, presents after referral from [**Hospital1 1474**] for induction chemotherapy for acute myelogenous leukemia. Pt initially presented to her PCP for evaluation of persistent fatigue and decreased appetite x 1-2months, and was found to have anemia and abnormal differential on CBC. In note from referring oncologist's initial visit with pt, automated differential from PCP [**Name Initial (PRE) 654**] 45.8% monocytes. Pt underwent a techinically difficult bone marrow biopsy, and pathology showed hypercellular bone marrow with left-shifted granulopoiesis and increased blasts, consistent with AML. Flow cytometry interpretation showed approximately 39% blasts identified, and there were increased monocytic/myelomonocytic cells, suggestive of an M4/M5 subtype of AML. Morphologic and cytogenetic/FISH analysis was pending at time of report. See below for available details. . Of note, over the past several months, pt reports having 2 episodes of the flu, an episode of pneumonia (diagnosed by CXR, treated with Z-pak with resolution), and UTI (treated with Cipro with resolution.) . On review of systems, pt reports low-grade fevers and chills following her bone marrow biopsy last week, but none since. She has pain over the biopsy site on her right hip. Otherwise, denies any chest, abdominal, joint, muscle, or other pain. She denies nausea/vomiting. She has occasional diarrhea/constipation that she associates with her hx of dysfunctional bowel syndrome. She denies shortness of breath, palpitations, orthopnea, PND. She reports occasional migraines with visual auras, none at present. She reports blurry vision recently, that she has seen an optomeetrist for and was told that she did not need correction. She denies hemoptysis, melena, or hematochezia. She endorses fatigue and decreased appetite as mentioned above. Otherwise, remaining ROS is negative. Past Medical History: Hypertension Hyperlipidemia Anxiety Dysfunctional bowel syndrome s/p hysterectomy, cyst removal s/p appendectomy s/p cholecystectomy Bladder suspension surgery with ?R upper thigh nerve impingement:pt says R leg sometimes flops to side Hx breast augmentation (silicone) R face/blepharospasm (extends from R front scalp-> R neck): used to have botox injections, but stopped to try and see if it resolves on its own, last dose ~2months ago Social History: Pt is a homemaker. She lives with her husband in [**Name (NI) 21627**]. She spends most days each week baby-sitting her 3 grandchildren. She has 2 children- son age 40, daughter age 37. She denies history of smoking, and drinks alcohol occasionally. Family History: Maternal aunt had lymphoma. Another maternal aunt had cervical cancer. Children and sister are healthy. Physical Exam: VS-T 98.6 BP 140/90 RR 24 HR 70 O2sat 97%RA Gen: awake, alert, NAD, anxious, obese HEENT: PERRL, EOMI, sclera non-icteric, ?canker sore in R upper mouth, otherwise mucous membranes moist without obvious ulcers NECK: supple, no palpable LAD CV: regular rate and rhythm, no murmurs/rubs/gallops, S1 S2 present LUNGS: clear to auscultation bilaterally, no wheezes/rales/rhonchi ABD: soft, non-tender, non-distended, bowel sounds present, no HSM EXT: no cyanosis/clubbing/edema, 2+ DP pulses bilaterally NEURO: CN2-12 intact grossly, strength 5/5 diffusely in extremities x 4, sensation intact grossly, coordination intact GENITAL: lichen sclerosis inside labia majora, no other visible ulcers; ecchymosis with induration over right hip, TTP (site of BM bx); resolving faint ecchymosis over left hip (site of prior pain med injection) Pertinent Results: Labs on Admission: 138 103 15 96 4.3 24 0.9 . Ca: 9.2 Mg: 2.2 P: 4.3 . WBC 6.3, Hb 10.6, Crit 30.1, MCV 104, Plt-pending Diff: 8%N, 1%Band, 30%L, 41%M, 5%E, 0%B, 3%atypical, 12%"other"-pending (ANC 567) INR 1.2, PT 14.2, PTT 32 . ALT 16 AST 33 AP 46 LDH 354* Amylase 63 TBili 0.7 Alb 4.5 Uric acid 6.4* TSH- pending Iron- pending . Labs from outside clinic: WBC 7100, Hb 11.5, Crit 35.7, Plt 70K, normocytic Diff 10%N, 48%M, 5%atypical L, 32%M, 5%E, ANC 710 Smear reveals "question of blast", plts of "adequate size" . Flow Cytometry Report ([**2142-3-21**], paraphrased) Interpretation: Aspirate smears [**Last Name (un) **] increased cellularity without particles. Megakaryocytes are identified. Lymphocytes comprise approximately 8% of gated cells, include 2% B-cells, 6% T-cells, and <1%NK cells. There are approximately 30%myeloid cells and 22% monocytes. CD38-bright cells (including plasma cells) are not increased. B-lymphocytes show a kappa:lambda raatio of 1:1. There is no evidence of a monotypic B-cell population. T-lymphocytes show no aberrant antigen expression, and the CD4:CD8 ratio is inverted, at 0.8:1. Flow abnormalities that support a dysplastic myeloid population include decreased orthogonal light scatter, decreased CD45 expression, CD11b/CD16 pattern abnormalties, CD13/CD16 pattern abnormalities, and few myelomonocytic cells, CD34-positive blasts are increased,comprising 39% of nucleated cells, and they exhibit the expected immunophenotype for myeloblasts (CD34+, CD13+, CD33+, CD117+, HLA-DR+, and negative for most other markers.) Findings are suggestive of AML, non-M3 type. Presence of increased monocytic and myelomonocytic cells raises the question of an M4/M5 subtype. Flow Cytometry Differential - CD117+ HLA-DR+ 34 - CD34+ CD13+ 38 - CD34+ CD33+ 39 - CD34+ HLA-DR+ 35 - Lymphocytes 8 --B cells 2 ---Kappa <1 ---Lambda <1 ---Kappa:Lambda ratio 1.0 --T cells 6 ---CD4 3 --- CD3 3 ---CD4: CD8 ratio 0.8 ---CD3+ CD58+ 1 ---NK cells <1 --Monocytes 22 --Granulocytes 30 --CD34+ blasts 39 --Plasma cells <1 --Viability 97 . Imaging on Admission: None TTE/TEE: EF > 55%. 2+ MR. [**Name13 (STitle) **] evidence of endocarditis. Chest CT: [**2142-4-19**] 1. Worsening of micro-nodules throughout the lungs in a tree-in-[**Male First Name (un) 239**] distribution, suggestive of worsening viral disease. 2. Slightly decreased size of small bilateral pleural effusions. 3. Unchanged stranding surrounding the sigmoid colon, consistent with subacute diverticulitis. No abscess. 4. Resolution of previously seen mass-like lesion within the cecum which likely represented mixing of fluid and contrast. No definite mass identified. Brief Hospital Course: 61 y/o F with hypertension, hyperlipidemia, anxiety, presenting with new diagnosis of acute myelogenous leukemia, admitted for 7+3 induction chemotherapy. Hospital course complicated by fever, neutropenia, and sepsis secondary to fever and neutropenia (likely etiologies VRE bacteremia, diverticulitis/typhlitis) and pulmonary nodules noted on Chest CT. # AML: Pt is newly diagnosed with AML, possibly M4/M5 subtype given monocytic predominance on flow cytometry and BM biopsy. Patient underwent 7 + 3 induction chemotherapy (7 days ara-c, 3 days idarubicin) and tolerated it well. However, blasts were still present in her bone marrow biopsy and CBC differential after completion of chemotherapy, indicating residual disease. She had a repeat bone marrow biopsy the day before discharge, the results of which were pending on the day of discharge. She was scheduled to follow-up with her outpatient oncologist on [**4-30**], and have another round of chemotherapy on [**4-20**] pending the results of the bone marrow biopsy. #VRE Bacteremia: Hospital course complicated by Vancomycin resistant enterococcal bacteremia (4/4 bottles). Patient briefly required ICU admission. Followed by ID during admission. Central line was removed. Patient was treated with daptomycin, meropenem, and voriconazole/micafungin during her neutropenic phase. Surveillance blood cx's were negative for four days, after which a PICC was placed. TTE showed mildly worsened mitral regurgitation, but TEE showed no evidence of endocarditis, mitral valve or otherwise. Patient was hemodynamically stabilized and was treated with a 14 day course of daptomycin and meropenem starting from [**2142-4-16**] (the day she was no longer neutropenic.) # Diverticulitis/Typhlitis: Treated with 14 day course of meropenem after patient was no longer neutropenic. #Pulmonary Nodules: Pt noted to be short of breath and hypoxic with a new oxygen requirement, improved with diuresis with IV lasix. Patient briefly required ICU admission for her hypoxia. Chest CT showed pulmonary nodules concerning for fungal vs. viral infection. Treated initially with albuterol/ipratroprium nebulizers and voriconazole, which was later d/c-ed due to LFT abnormalities and changed to micafungin. Nodules were slightly worsened on repeat Chest CT, but patient clincally improved. Pulmonary followed patient in-house. Decision was made not to bronchoscopy/BAL as she clinically improved. Anti-fungal were eventually d/c-ed. Patient should have repeat Chest CT I- high resolution 1 week after discharge to assess for stability/interval change of pulmonary nodules. # Hypertension: Poorly controlled on patient's home regimen of metoprolol 25 mg PO BID, with SBPs into the 170s-190s. Once patient was hemodynamically stable, increased metoprolol to 50 mg PO TID and added amlodipine 5 mg daily, bridged with PRN doses of IV hydralazine. Patient's blood pressure was 148-150s systolic on discharge with the initiation of calcium channel blocker and increase in beta-blocker. # Anxiety: Pt has baseline anxiety, which has been augmented by this new diagnosis. Pt may experience decreased PO intake with nausea during chemo course, so would like to wean her off Lexapro for now and address anxiety with PO/IV meds. Tapered celexa to 20 mg by mouth daily, and controlled anxiety with Ativan IV/PO as needed. Discharged patient on tapered celexa dose with PRN oral ativan, as she may likely need chemotherapy to treat her residual disease and may have difficulty with oral medications (requiring IV meds for anxiety). # Silicone breast implant: Noted to have silicone breast implant leakage, stable on mammogram/ultrasound and Chest CT. Patient may follow up with the outpatient breast surgeons once chemotherapy is completed. Medications on Admission: Crestor 10mg PO daily Metoprolol 25mg PO bid Celexa 40mg PO daily Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. Disp:*42 Tablet(s)* Refills:*0* 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 4. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 6 days: 600 mg SOLUTION start date: [**2142-4-24**] end date: [**2142-4-29**]. Disp:*6 Recon Soln(s)* Refills:*0* 5. Ertapenem 1 gram Recon Soln Sig: One (1) gram recon solution Intravenous once a day for 6 days: start date: [**2142-4-24**] end date: [**2142-4-29**]. . Disp:*6 grams* Refills:*0* 6. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) mL Injection once a day for 7 days: SASH and PRN. Disp:*14 syringes* Refills:*0* 8. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous once a day for 7 days: SASH and PRN. Disp:*14 syringes* Refills:*0* 9. Daptomycin 500 mg Recon Soln Sig: Six Hundred (600) mg Intravenous once a day for 6 days: start date: [**2142-4-24**] end date: [**2142-4-29**]. Disp:*6 units* Refills:*0* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: 1' Diagnosis Acute Myelogenous Leukemia Vancomycin Resistant Enteroccocal Bacteremia 2' Diagnosis Pulmonary Nodules of Undetermined Significance Hypertension Anxiety Discharge Condition: afebrile, hemodynamically stable Discharge Instructions: You were admitted for chemotherapy for your acute myelogenous leukemia. Your hospital course was complicated by a blood stream infection, which required a brief stay in the intensive care unit. You recovered from this infection, and will be treated with antibiotics. Please take your medications as directed. We have made the following changes: - Given the liver function test abnormalities, your crestor was held. This can be restarted as an outpatient by your primary care physician. [**Name Initial (NameIs) **] We had added amlodipine 5 mg by mouth daily - We have increased your metoprolol to 50 mg by mouth three times a day. - We decreased your celexa to 20 mg by mouth daily, with ativan as needed for your anxiety. This was done as you will likely need more chemotherapy, and as you may have nausea associated with it, we wanted to decrease the number of medications you would need to take orally. We have given you a limited supply of ativan until you are seen in a hospital setting later this week. - Please restart your crestor at the discretion of your outpatient oncologist. - You need to take antibiotics for 6 more days (daptomycin and ertapenem). You will need to have some lab tests checked when you see your oncologist next week. Please return to the hospital if you have fever > 100.4, chills, nausea, a worsening rash, abdominal pain, diarrhea, cough with sputum production, or any other symptoms not listed here concerning enough to you to warrant physician [**Name Initial (PRE) 2742**]. Followup Instructions: with your oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2142-4-30**] 2:00 Please have your CK levels checked when you see your oncologist next. You will also need a Chest CT next week, which has been ordered by your discharging physician and will be followed up by Dr. [**First Name (STitle) **]. It is scheduled for [**Last Name (LF) 766**], [**2142-4-30**] at 9:15 AM in the [**Hospital Unit Name 1825**]. There is no need at this time to follow up with pulmonary unless you deveolop further symptoms. Other appointments: Provider: [**Name Initial (NameIs) 455**] 2-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2142-4-25**] 9:00 Provider: [**Name Initial (NameIs) 455**] 1-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2142-4-26**] 9:00 Completed by:[**2142-5-3**]

Admission Date: [**2169-3-29**] Discharge Date: [**2169-4-4**] Date of Birth: [**2092-11-3**] Sex: M Service: MEDICINE Allergies: Neosporin / Latex Attending:[**First Name3 (LF) 689**] Chief Complaint: Fever at home and pus draining from sternal wound Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 76 year old man with history of CAD, 4-vessel cabg [**2166**] c/b sternal osteo, sternotomy, flap, multiple wound infections, DM2, COPD, small cell lung carcinoma of RUL followed by Rad Onc for cyper knife treatment currently, who presented 2 days ago with pus draining from sternal wound, fever and change in mental status for two days. He was admitted 2 weeks earlier for UTI/? LLL PNA/? wound infection and was discharged with PO levo (7 day course finished two days earlier) and VNA [**Hospital1 **] dressing changes. Then nurse and wife noted increasing confusion, unsteady gait, fever to 99.4 and pus draining from sternal wound. Past Medical History: RUL nodule- biopsied on [**2169-3-6**]: poorly differentiated carcinoma, likely small cell ca; currently followed by Radiation Oncology with ongoing preparation for Cyber Knife Therapy. CAD - IMI in [**2165**], s/p CABGx4 in [**2166**], which was complicated by mediastinitis and sternal osteomyelitis and MRSA wound infection. He had a pec flap repair on [**5-16**]. incisional hernia -- s/p repair and recurrence COPD/emphysema on home night time O2 T2DM - controlled by meds and diet HTN hypercholesterolemia GERD anemia - monthly procrit hyperlipidemia prior right frontal lobe and left caudate infarct Social History: Married for 52 years; taken care by wife at home. Former smoking of cigar x 20yrs, and 10ppy hx of cigarettes; quit 30 years ago. No EtOH. Family History: FH: no h/x of cancer or CAD . Physical Exam: PE: T 97; HR 90, BP 150/90; 93%RA; FS 124 Gen: comfortable in bed, NAD; HEENT: ROMI PERRL Face symmetric; no JVD Chest: R sternal wound with dressing stained with serosanginous fluid; some erythema surrounding the wound; breath sounds distant; Cor: RRR, no murmurs Abd: +BS, NT, obese; reducible umbilical hernia ext: No edema or rash, 2+ DP pulses; extremities are warm. neuro: AOx3, baseline mental status . Pertinent Results: [**2169-3-29**] 01:05PM WBC-6.7# RBC-3.84* HGB-10.4* HCT-30.6* MCV-80* MCH-27.0 MCHC-33.9 RDW-16.5* [**2169-3-29**] 01:05PM NEUTS-80* BANDS-0 LYMPHS-10* MONOS-10 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2169-3-29**] 01:05PM PLT COUNT-266 [**2169-3-29**] 01:05PM GLUCOSE-123* UREA N-22* CREAT-1.0 SODIUM-137 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14 [**2169-3-29**] 01:11PM LACTATE-1.3 [**2169-3-29**] 03:05PM TYPE-ART PO2-105 PCO2-46* PH-7.36 TOTAL CO2-27 BASE XS-0 [**2169-3-29**] 03:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2169-3-29**] 03:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2169-3-29**] 03:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-RARE EPI-0-2 [**2169-3-29**] 03:45PM URINE HYALINE-0-2 [**2169-3-29**] 08:30PM PT-12.9 PTT-25.8 INR(PT)-1.1 [**2169-3-29**] 08:30PM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-1.8 [**2169-3-29**] 08:30PM CK-MB-NotDone cTropnT-0.07* [**2169-3-29**] 08:30PM LIPASE-15 [**2169-3-29**] 08:30PM ALT(SGPT)-23 AST(SGOT)-16 LD(LDH)-165 CK(CPK)-37* ALK PHOS-72 TOT BILI-0.4 [**2169-3-29**] 08:30PM GLUCOSE-208* UREA N-25* CREAT-1.0 SODIUM-139 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 [**2169-3-30**] 02:33AM BLOOD WBC-6.4 RBC-3.79* Hgb-9.9* Hct-30.5* MCV-81* MCH-26.0* MCHC-32.3 RDW-16.3* Plt Ct-265 [**2169-4-1**] 05:00AM BLOOD WBC-5.0 RBC-3.72* Hgb-10.1* Hct-29.9* MCV-80* MCH-27.3 MCHC-33.9 RDW-16.4* Plt Ct-307 [**2169-4-1**] 05:00AM BLOOD Plt Ct-307 [**2169-3-31**] 02:25AM BLOOD PT-12.3 PTT-26.6 INR(PT)-1.1 [**2169-3-31**] 02:25AM BLOOD Glucose-132* UreaN-36* Creat-1.0 Na-139 K-3.9 Cl-108 HCO3-25 AnGap-10 [**2169-4-1**] 05:00AM BLOOD Glucose-109* UreaN-23* Creat-0.8 Na-143 K-3.9 Cl-107 HCO3-26 AnGap-14 [**2169-3-29**] 08:30PM BLOOD ALT-23 AST-16 LD(LDH)-165 CK(CPK)-37* AlkPhos-72 TotBili-0.4 [**2169-3-30**] 02:33AM BLOOD CK(CPK)-37* [**2169-3-30**] 09:00AM BLOOD CK(CPK)-33* [**2169-3-29**] 08:30PM BLOOD CK-MB-NotDone cTropnT-0.07* [**2169-3-30**] 02:33AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2169-3-30**] 09:00AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2169-3-30**] 02:33AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.9 [**2169-3-31**] 02:25AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.1 [**2169-4-1**] 05:00AM BLOOD WBC-5.0 RBC-3.72* Hgb-10.1* Hct-29.9* MCV-80* MCH-27.3 MCHC-33.9 RDW-16.4* Plt Ct-307 [**2169-4-3**] 03:41PM BLOOD Hct-28.4* Brief Hospital Course: A/P: 76 year old man with history of CAD (4V CABG [**2166**]), sternotomy/MRSA infection, flap, T2DM, COPD, recently diagnosed smal cell lung CA in RUL, presented with 2 day history of pus draining from bronchoscopy/mediastinoscopy wound, fever to 99.4, and change in mental status. . 1. fever: This presentation is similar to his prior presentation two weeks earlier. Fever's source this time is presumed to be an infected wound, given the pus drainage. Wound and blood cultures were taken immediately in the ED, and he was started on IV vanco, given his MRSA history. Shortly after, a purulent material was expressed from his sternal wound during exploration; one minute after this, the patient was noted by his wife to "turn red all over", becoming tachypneic and tachycardic to the 130's, and with notable and new, diffuse wheezing. An ECG was obtained which showed an SVT at 143, with lateral ST depressions. Patient had received IV vanco previously without incident. He was admitted to MICU for close monitoring. MICU staff felt it was unlikely to be Redman syndrome, and more likely a transient episode of bacteremia caused by wound exploration or an anxiety attack. IV vancomycin was continued, without further incident. [**Hospital1 **] wet to dry dressing changes continued, and thoracic surgery followed the patient; they felt the wound to be not infected. On HD#[**3-17**], his erythema surrounding the wound improved. His wound culture returned sparse MSSA, and he was switched from IV vanco to IV oxacillin. Patient never developed a fever in the hospital. Blood cultures were negative at the time of discharge. A PICC line was placed in RUE. He will continue to receive 9 more days of IV oxacillin for a total of 2-week IV antibiotics course. . 2. CAD: Patient's lateral ST depressions on EKG that occurred during the episode after IV vanco infusion resolved with the resolution of tachycardia. He was ruled out for MI, with CKs of 37, 37, 33, and TnT of 0.07, 0.05 and 0.03. Patient was continued on Lipitor, Zetia, Toprol, losartan, and SL NG prn; he was started on 81mg of aspirin. He remained on telemetry for his two day stay in the MICU; upon transfer to the medicine floor, he remained off of telemetry. On HD#3, he had an echo, which showed LV EF 30% and LV infereolateral akinesis (see echo [**2169-3-31**]). . 3. Sternal Wound: No more pus was expressed from the wound while in the hospital. [**Hospital1 **] wet to dry dressing changes continued. Thoracic surgery team examined the wound daily and felt the wound to be not contaminated. Erythema surrounding the wound resolved. He was maintained on IV vanco for 3 days, and then switched to IV oxacillin after wound culture grew sparse MSSA. He will continue on IV oxacillin for 9 more days for a total of 2-week IV antiobiotics course. . 4. HTN: home medications were continued. . 5. DM: His home meds of metformin was continued. He was also covered with regular insulin sliding scale. He was on a heart healthy diet. His blood sugar was relatively well controlled during this admission, with finger sticks ranging from 100 to low 200s. . 6. small cell cancer in R lung: This is a new diagnosis for the patient from the FNA cytology done on [**2169-3-23**]. Patient and family was made known of this diagnosis during this admission. Further therapy will be coordinated asn an outpatient between Dr. [**Last Name (STitle) 952**] of thoracics, Dr. [**Last Name (STitle) **] of radiation oncology, and Dr. [**Last Name (STitle) 3274**] of oncology. Dr. [**Last Name (STitle) 3274**] was emailed about this patient. . Medications on Admission: prevacid 30mg qd toprol XL 50mg qd furosemide 20mg qd metformin 500mg tid potassium 20meq prn vitamin C 500mg [**Hospital1 **] colace 100mg [**Hospital1 **] ferrous sulfate 300mg [**Hospital1 **] zetia 10mg qd lipitor 10mg qd MVI qd atrovent 2 puff QID prn: wheezing spiriva 18mcg qd advair 1 pufff 250/50 qd cozaar 50mg qd Discharge Medications: oxacillin 2mg IV Q6hr aspirin 81mg qd prevacid 30mg qd toprol XL 50mg qd furosemide 20mg qd metformin 500mg tid potassium 20meq prn vitamin C 500mg [**Hospital1 **] colace 100mg [**Hospital1 **] ferrous sulfate 300mg [**Hospital1 **] zetia 10mg qd lipitor 10mg qd MVI qd atrovent 2 puff QID prn: wheezing spiriva 18mcg qd advair 1 pufff 250/50 qd cozaar 50mg qd Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: fever and wound infection Discharge Condition: Stable to be discharged to home with VNA services for wound care. Discharge Instructions: Please contact Dr. [**Last Name (STitle) 8430**], your PCP, [**Name10 (NameIs) **] you should develop fever above 100.4 or have pus draining out of your wound. Followup Instructions: Please see Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] (thoracic surgery) in two weeks. An appointment has been made for you on [**4-13**] at 4pm in [**Hospital1 18**] [**Hospital Ward Name 23**] [**Location (un) **]. Please call his office at [**Telephone/Fax (1) 170**] if you have any questions. You should see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3274**], [**First Name3 (LF) **] oncologist and lung cancer specialist. Both Dr. [**Last Name (STitle) 3274**] and his office staff were notified, and they will contact you to arrange an appointment. If you do not hear from Dr.[**Name (NI) 3279**] office in the next few days, you can call [**Telephone/Fax (1) 15512**]. You may have your initial appointment at [**Hospital1 18**] in [**Location (un) 86**], and then follow up in [**Location (un) 620**]. Please call Dr.[**Name (NI) 97057**] office [**Telephone/Fax (1) 8431**] to schedule a follow-up appointment in [**2-13**] weeks.

Admission Date: [**2156-12-22**] Discharge Date: [**2156-12-29**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2610**] Chief Complaint: Transfer for STEs Major Surgical or Invasive Procedure: None History of Present Illness: This patient is a [**Age over 90 **] year old female who is transferred from [**Hospital **] hospital with concern for STEMI. . She had an unwitnessed fall and was found at the bottom of the stairs. She last spoke with her son yesterday at noon and this morning her visiting nurse came and found her down. She was confused after the fall and has been unable to provide a clear story around the time of the fall. She was admitted to [**Hospital 4199**] hospital where there was concern for a C4 fracture as well as STEMI with elevated troponins. . In the ED she was CP free, EKG showed STEs in V3 and V4, and was started on Heparin gtt. A CT Torso did not show any acute injuries. CT Cspine did not show a definite fracture and her c-spine was cleared by ortho. Cardiology was consulted in the ED who recommended admission to CCU and discontinuing Heparin gtt as suspicion for STEMI was low. . In the CCU she is A&Ox0 with likely baseline dementia. On discussion with her son, she does not have documented dementia but has not left her house in over a year because she gets lost and confused, has people come to her house to cut her hair and her nails, but is apparently up and about without issues while within her home. She is unable to provide any history but does deny CP, neck/jaw pain, epigastric pain, n/v, and SOB. . The pt is unable to provide any ROS. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: Unknown, son denies - CABG: Son denies - PERCUTANEOUS CORONARY INTERVENTIONS: Son denies - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: COPD (per CT read) Macular Degeneration Rectal prolapse Hemmorhoids Pagets disease Colon cancer s/p sigmoid resection 30 years ago Social History: - Tobacco history: never smoked per son - ETOH: none - Illicit drugs: none Lives in [**Location 88484**] alone, has VNA daily. Again, she has not left her home in over a year and has people who come by to help her obtain food, cut her hair and nails, and help with tasks around the home. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: NAD, in C-collar. Oriented x0. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 2 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 SEM at RUSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM: Pertinent Results: Admission Labs: [**2156-12-22**] 02:45PM WBC-8.3 RBC-3.57* HGB-11.1* HCT-32.2* MCV-90 MCH-29.6 MCHC-32.9 RDW-12.4 [**2156-12-22**] 02:45PM NEUTS-86.6* LYMPHS-9.7* MONOS-3.1 EOS-0.3 BASOS-0.2 [**2156-12-22**] 02:45PM PLT COUNT-168 [**2156-12-22**] 02:45PM GLUCOSE-136* UREA N-26* CREAT-1.1 SODIUM-139 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13 [**2156-12-22**] 02:45PM ALT(SGPT)-24 AST(SGOT)-82* CK(CPK)-1863* ALK PHOS-592* TOT BILI-0.6 [**2156-12-22**] 02:45PM LIPASE-51 [**2156-12-22**] 05:45PM URINE BLOOD-MOD NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG [**2156-12-22**] 05:45PM URINE RBC-3* WBC-20* BACTERIA-MANY YEAST-NONE EPI-<1 . Pertinent labs: [**2156-12-22**] 02:45PM BLOOD CK-MB-69* MB Indx-3.7 cTropnT-0.38* [**2156-12-22**] 10:42PM BLOOD CK-MB-57* MB Indx-3.1 cTropnT-0.36* [**2156-12-23**] 05:16AM BLOOD CK-MB-39* MB Indx-2.3 cTropnT-0.34* [**2156-12-22**] 02:45PM BLOOD ALT-24 AST-82* CK(CPK)-1863* AlkPhos-592* [**2156-12-22**] 10:42PM BLOOD CK(CPK)-1842* [**2156-12-23**] 05:16AM BLOOD ALT-29 AST-95* CK(CPK)-1687* . Micro/Path: . Urine Culture [**12-22**]: Pan-sensitive E. coli Urine Culture [**12-23**]: < 10,000 organisms Blood Cultures x 2 [**12-22**]: NGTD Blood Cultures x 2 [**12-24**]: NGTD . Imaging/Studies: CT Torso [**12-22**]: IMPRESSION: 1. Small ground-glass opacity in the right upper lobe which is nonspecific but may represent contusion in setting of trauma vs infection. If clinically relevant given patient age, recommend follow-up to resolution to exclude underlying lesion. 2. Markedly distended bladder. Consider Foley catheter placement if not already completed. 3. Hypodense lesion within the upper pole of the right kidney, likely a cyst. 4. Paget's disease of the pelvis and the right femur. 5. Atherosclerotic disease of the aorta. . CXR Portable [**12-22**]: FINDINGS AND IMPRESSION: No focal opacity to suggest pneumonia is seen. There may be mild edema. No pleural effusion or pneumothorax is identified. There is moderate cardiomegaly. Calcifications of the aortic arch are present. No displaced fracture is identified. . CXR Portable [**12-24**]: IMPRESSION: 1. Improved aeration, particularly in the right upper lobe. 2. No evidence of pneumonia. 3. Radiographic evidence of COPD. 4. Stable cardiomegaly. . ECHO [**12-24**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with distal septal and apical hypokinesis. The remaining segments contract normally (LVEF = 45-50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Symmetric left ventricular hypertrophy with mild systolic dysfunction, c/w CAD. Moderate aortic regurgitation. Mild mitral regurgitation. Mild pulmonary hypertension. . Discharge: CK: 279 creatinine 1.1 INR 1.0 Hgb and hematocrit: 10.8/33 RPR neg Brief Hospital Course: [**Age over 90 **]F with hx of HTN, HLD, COPD (diagnosed by our CT scan), and likely severe baseline dementia transferred from OSH for concern of ACS after being found down. . # Hyperactive Delerium and Severe Dementia: During this admission, Ms. [**Known lastname 60680**] had waxing and [**Doctor Last Name 688**] mental status with agitation. She was oftentimes found speaking to herself for hours on end with poor sleep and agitation. Per report of the family, she was also noted to have poor baseline functioning without having left her house for years and not being able to perform ADL's c/w severe dementia. It was felt that she was likely delirious from a new environment, UTI which was effectively treated, tethers, lack of sleep, and her baseline poor vision (due to macular degeneration). She did not respond well to redirection or small doses PO zydis but responded somewhat to small doses of subQ haldol in the CCU, but responded slightly to 0.25 risperidone [**Hospital1 **]. She had negative CT head, non-focal neuro exam. She was followed by [**Female First Name (un) **] psych while in-house. She was determined to be medically unsafe to live at home by herself and was screened for placement in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-psych facility. . # E. Coli UTI: She had a positive UA on admission and was started on IV ceftriaxone in the ED. Urine cultures grew pan-sensitive e. coli which cleared on repeat culture and blood cultures were NGTD. She was not febrile or HD unstable at any point and finished a 3 day course of IV ceftriaxone. . # Syncope Workup: Pt was found at the base of stairs although imaging including CT torso did not demonstrate any fractures making it unlikely that she fell down the stairs. She had STE's in the anteroseptal leads on his EKG in the ED which were stable from EKG's in [**2154**]. She also had LVH on EKG so her ST changes were thought to likely represent repolarization abnormality. She had elevated troponins but negative CKMB's which raised the possibility that we were catching the tail end of a myocardial event although this was unclear. She had no events on tele, and a fairly unremarkable echo with LVEF of 45-50%. It was felt that her fall was more likely mechanical related to her near complete blindness, UTI, and mild dehydration from her home lasix. She was screened for placement in a long-term care facility. . # Rhabdomyolysis/Acute Kidney Injury: Pt was admitted with CK elevation to 1863 and Cr of 1.1 (baseline unclear but we expect something in the 0.7-0.8 range given her old age and size) after being down for possibly 18 hours. She was given gentle IV fluids and lasix was held and she had good urine output. Repeat CK was 279 and at time of discharge Cr had decreased to baseline. . CODE STATUS: DNR/DNI . CONTACT/ HCP: [**Name (NI) **], [**First Name3 (LF) **] [**Telephone/Fax (1) 91246**] TRANSITIONAL ISSUES: #She was deemed unsafe to continue living at home with occasional VNA visits and was screened for placement in a long-term care facility with [**Female First Name (un) **] psych capabilities. . # Pt will need frequent EKGs to monitor for QTc prolongation while she is on risperidone . # pt's lasix was d/ced during hospitalization. She will need daily weights monitored and if she puts on more than three pounds in one day or signs of fluid overload, should restart lasix Medications on Admission: Meloxicam 7.5 mg daily Furosemide 60mg daily MVI Metoprolol succinate 25mg daily Aspirin 81mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed for constipation. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO qHS: PRN as needed for delerium. 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**] Discharge Diagnosis: Urinary tract infection acute kidney injury rhabdomyolysis altered mental status Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mrs. [**Known lastname 60680**], It was a pleasure taking care of you. You were admitted to the hospital for a UTI and altered mental status. You were transferred to [**Hospital1 18**] because the outside hospital was concerned that you were having a heart attack. In the cardiac intensive care unit, it was determined that you were actually not having a heart attack. You were found to have an acute kidney injury and a condition called rhabdomyolysis. We treated you with IV fluids and your kidney injury and rhabdomyolysis improved. Your urinary tract infection was treated with IV antibiotics. You remained confused and not completely oriented despite treating your infection and are being discharged to a facility to continue to work on your mental status. . We have made the following changes to your home medications: 1. Stop Lasix 2. Stop meloxicam 3. start risperidone 0.25 tablet one tablet twice daily 4. start risperidone 0.25 tablet qHS PRN for delerium Please follow-up with your PCP after discharge from your rehab. Followup Instructions: extended care facility

Admission Date: [**2177-2-1**] Discharge Date: [**2177-2-25**] Date of Birth: [**2119-4-5**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: intra cranial bleed Major Surgical or Invasive Procedure: Right occipital craniotomy for cerebellar bleed evacuation. History of Present Illness: Pt is a 57y/o M who was in his USOH until this morning when he was noted to have a HA and then collapsed. He was responsive at the scene (GCS 15) and taken by EMS to OSH where his mental status deteriorated and he was intubated. CT revealed a 4.3 cm hemorrhage in the R cerebellum. He was then transferred to [**Hospital1 18**] for further management. Past Medical History: HTN, nasal polyps. Social History: Occasional cigars, no cigarette smoking hx; occasional etoh on weekends, no other drugs, no supplements. Lives with wife, works in research and development for electronics company. Family History: unknown Physical Exam: PE:HR 62, BP 193/106, RR 14 on CMV, SaO2 100% on FiO2 100% Gen: Intubated in NAD HEENT: no signs of trauma, no racoon eyes, no battle sign, anicteric sclera CV: rrr Pulm: LCTA b/l Abd: soft NT ND BS present Neuro: Moves only lower extremities. Withdrawls lower extremities to pain but does not follow commands. Pupils fixed and constricted ~2mm. No dolls eye reflex, corneal reflex present only on the left side. Pertinent Results: [**2177-2-1**] 03:15PM PT-12.2 PTT-20.8* INR(PT)-1.0 [**2177-2-1**] 03:15PM PLT COUNT-275 [**2177-2-1**] 03:15PM NEUTS-90.5* BANDS-0 LYMPHS-6.3* MONOS-2.9 EOS-0.1 BASOS-0.1 [**2177-2-1**] 03:15PM WBC-18.1* RBC-4.79 HGB-15.0 HCT-41.7 MCV-87 MCH-31.2 MCHC-35.9* RDW-12.9 [**2177-2-1**] 03:15PM GLUCOSE-206* UREA N-21* CREAT-1.0 SODIUM-145 POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-21* [**2177-2-1**] 03:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG Brief Hospital Course: [**Known firstname **] [**Known lastname 64942**] is a 57 year-old male with right cerebellar bleed initially he was lucid at the scene then quickly detorioted requiring intubation where he admitted to neuro ICU unit, started on dexamethasone and dilantin. He was taken to OR on [**2177-2-1**] for occipital craniotomy for right cerebellar hematoma evacuation with a ventriculostomy placement without intraoperative complications. Patient transferred back to ICU for hemodynamic and neurologic monitoring. Immediate post-op neuro exam: pupils were reactive bilaterally, no eye opening, extensor posturing on bilateral upper extremities, with a flexion on bilateral lower extremities. Post operative MRI requested on postop day two to evaluate for infarction, given that his neurologic exam was not improving. MRI of the brain showed no infarct besides some compression of the brainstem at the level of the pons, therefore neurology consulted regarding "locked in syndrome". Neurology team felt that patient demonstrated some elements of locked in syndrome with preserved vertical eye movements and blinking, and comprehension without motor activity. If the compression of the brain stem is related to cerebral edema there is a chance for him to regain his fucntions as edema resolves. Neurology recommended a repeat MRI to evaluate cerebral edema on [**2-5**] without significant change in the appearance of edema, no mannitol was given. Over subsequent hospital stay, his neuroloigcal status slowly but gradually improved. [**2177-2-6**] IVC filter palced for DVT prophylaxis since he cannot be anticoagulated and possible prolonged hospitalization/rehabilitation without any complication. On [**2177-2-8**] patient started spiking fever up to 103 which continued until [**2177-2-18**] without a clear source all of his cultures were negative, HBV/HCV neg, ([**2-8**])CSF negative, except sputum culture grew E COLI. Empiric triple antibiotic coverage initiated, and infectious disease consulted. Patient had bouts of diarrhea requiring rectal bag, cdiff was negative several assays. ID recommeneded continue metronidazole total of 14 days despite negtive c-diff on stool. His external ventricular drain removed on [**2177-2-10**]. Serial Head CT' obtained to evaluate interval change in brain. On [**2-11**] head CT showed Status post removal of the right-sided ventricular catheter without evidence for hydrocephalus seen. Resolving right-sided cerebellar and intraventricular hemorrhage. Persistent low density in the right cerebellar hemisphere, which could either represent a small evolving infarct or residual edema.Suboccipital craniectomy staples removed on [**2177-2-11**]. [**2177-2-12**] patient had bedside trache placement Size#8 without any complications, gradually weaned FiO2 as tolarated. PEG palced on [**2177-2-19**] with out a complication, able to tranfer stepdown floor on [**2-20**].on [**2-21**] LENI Right upper and BLE lower neg for DVT, changed to floor status on [**2-22**]. Upon discharge, patient had almost full strength and use of his left side, right side had decreased strength (about 1-2/4), nystagmus had disappeared, had good eye movement, was OOB to chair for a good portion of the day, communicated via mouth wording followed commands, was on 35% trahc collar mask and was at full strength tube feeds. PT & OT re-evaluated patient just before discharge for rehab recommendations. Patient evaluated by speech pathologist regarding [**Last Name (un) 64943**] muir valve, which was failed this may be due to the trach being too large to get adequate airflow to the vocal cords, &/OR upper airway edema, &/OR impaired vocal cord mobility or closure. His trache needs to down sized at rehab in order to use [**Last Name (un) 64943**] muir valve, if problem is continued should followed with ENT. Patient will f/u with stroke team as an outpt, and f/u w/[**Doctor Last Name **] 3 months in office. Medications on Admission: Toprol, HCTZ, Lisinopril Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection twice a day. 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every 8 hours) as needed. 8. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days: needs through wed [**2-26**]. 12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Intraparenchymal cerebellar hemorrhage with incipient herniation. Discharge Condition: good Discharge Instructions: please seek medical attention if you experience fever > 101.5, severe nausea/vomitting/pain/dizziness; new or increased numbness/tingling/paralysis please take new medications as directed please keep foloow-up appointment please work with physical therapy to improvement range of motion, strength, speech Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 3months with Ct call [**Telephone/Fax (1) 1669**] for appt. Follow up with stroke neurology call [**Telephone/Fax (1) 7207**] for appt. Completed by:[**2177-2-25**]

Admission Date: [**2173-12-5**] Discharge Date: [**2173-12-10**] Date of Birth: [**2107-9-11**] Sex: F Service: MEDICINE Allergies: Gantrisin / Lactose Attending:[**First Name3 (LF) 348**] Chief Complaint: diarrhea and hypotension Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Mrs. [**Known lastname **] is a 66yo female with type I DM, ESRD on HD, recently discharged after prolonged hospitalization w/ citrobacter UTI complicated by seizures. Pt complete total 7days tx for UTI w/ tobramycin--abx selection based on citrobacter sensitivities plus pt's susceptibility to sz's. Pt then dc'd on [**2173-11-26**] to [**Hospital **] rehab. She was noted to have persistent diarrhea there and was started on empiric PO vanc on [**12-3**]. Stool C. Diff test negative x1. Pt noted as being more fatigued, lethargic, with continued diarrhea. Then, developed hypotension (BP 90/50), at which time she was brought for eval at [**Hospital1 18**]. . In ED, BP initially 78/48, and persistently SBP 80s/50s per ED signout, however ED nursing records show only one pressure 97/58. L femoral triple lumen was placed as pt had no access other than tessio dialysis cath. Pt admitted to MICU for hypotension. In the MICU, she was aggressively hydrated & SBP improved to 90s-120s. Her hypotension was thought to be due to dehydration in setting of diarrhea. She did not require pressors. Pt was tx'd w/ flagyl for empiric coverage of cdiff (toxin negative x2; B-toxin also sent). She was noted to have positive UA (>50 WBCs, 21-50 RBCs, many bacteria, and moderate yeast, w/ 0-2 epi's). Urine cx grew only mixed bacterial flora c/w contamination. Pt was not started on abx for UA--team reportedly discussed contacting ID regarding need for tx & choice of tx given pt's prior cx data & risk for sz. (Unclear if this was done). Additionally, pt was ruled out for an MI. Given improvement in BP, her beta-blocker was restarted at 1/2 dose. ACE still being held. She underwent HD on [**2173-12-6**], 1.5L removed, which she reportedly tolerated well. Her [**Date Range 15338**] were noted to be elevated >400 x2. She was transiently on insulin gtt, then started on lantus 10u. She was noted to have sacral decub, which did not appear infected. She was started on cipro eye drops for eye crusting over L eye (which is blind). . ROS: Pt c/o intermittent rectal pain [**2-19**] diarrhea. Otherwise, feeling well. Still some loose stool (w/ rectal tube). Denies, fever, dysuria, cough, nausea, vomiting. + crustiness in eyes Past Medical History: 1. DM type 1 x 35 years. Previous admissions for DKA and hypoglycemic episodes. Her DM is complicated by peripheral neuropathy, proliferative retinopathy (left eye blindness), and nephropathy. Followed at [**Last Name (un) **]. 2. Chronic renal failure: Appears [**2-19**] to DM and Cr has been 5 over past few months. On hemodialysis. 3. CAD - NSTEMI [**10-23**] in the setting of hospitalization for DKA, Nuclear stress test [**8-23**]: P-MIBI, without fixed or reversible defects, normal wall motion. EF 72%. 4. Hypertension 5. History of osteomyelitis, status post left transmetatarsal amputation. 6. History of herpes zoster of left chest in [**2163**]. 7. Bezoar, disclosed on UGI series [**7-/2166**]. 8. Achalasia 9. Carpal Tunnel Syndrome Social History: She lives at home with her son, who is mentally retarded. Past history of EtOH use. Ex-smoker, quit in [**2154**]. Previously smoked for 8yrs. No history of illicit drug use. Family History: Mother - DM Sister - breast ca, DM Brother - HTN [**Name (NI) 2957**] - SLE, d. renal failure Physical Exam: Vitals: T:97.9 BP:97/47 (90-120/40-50s) P: 100s R: 20 SaO2:100% on RA General: thin, cachetic woman, pleasant, resting comfortably in bed, A&Ox3, answering all questions appropriately HEENT: Bilateral eyes with crusty white exudate, scleral and conjunctival injection. L eye blind, lid closed. OP clear. MMM Neck: supple, no JVD flat Pulmonary: Lungs CTA bilaterally Cardiac: sl tachy, Regular rhyth,, nl. S1S2, holosystolic murmur heard best at LUSB Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: no edema, L foot with all toes amputated. 2+ DPs bilaterally Skin: Back with large, diffuse stage 1 decub; R tunneled HD cath C/D/I Neuro: decreased bulk throughout, appears deconditioned, but no focal weakness. Pertinent Results: [**2173-12-4**] 10:25PM GLUCOSE-92 LACTATE-1.4 NA+-138 K+-5.7* CL--106 TCO2-23 [**2173-12-4**] 10:25PM HGB-11.8* calcHCT-35 [**2173-12-4**] 10:00PM GLUCOSE-102 UREA N-29* CREAT-4.5*# SODIUM-138 POTASSIUM-5.9* CHLORIDE-107 TOTAL CO2-22 ANION GAP-15 [**2173-12-4**] 10:00PM CK(CPK)-26 [**2173-12-4**] 10:00PM CK-MB-NotDone cTropnT-0.07* [**2173-12-4**] 10:00PM WBC-7.5 RBC-4.19* HGB-11.4* HCT-36.9 MCV-88 MCH-27.2 MCHC-30.9* RDW-16.5* [**2173-12-4**] 10:00PM NEUTS-74.0* LYMPHS-19.0 MONOS-6.7 EOS-0.2 BASOS-0.2 [**2173-12-4**] 10:00PM PLT COUNT-197 [**2173-12-4**] 10:00PM PT-13.4 PTT-39.4* INR(PT)-1.2* [**2173-12-10**] 11:00AM BLOOD WBC-12.7*# RBC-4.14* Hgb-11.2* Hct-36.6 MCV-88 MCH-27.0 MCHC-30.6* RDW-16.5* Plt Ct-284# [**2173-12-10**] 11:00AM BLOOD PT-17.6* PTT-58.2* INR(PT)-1.6* [**2173-12-10**] 11:00AM BLOOD Glucose-88 UreaN-16 Creat-3.8*# Na-136 K-5.0 Cl-103 HCO3-24 AnGap-14 [**2173-12-10**] 11:00AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.7* [**2173-12-4**] CXR - : No consolidation. [**2173-12-8**] Right Foot XR - 1. No third toe abnormality is seen that suggests osteomyelitis. 2. The displaced proximal metatarsal fracture seen on [**2170-8-13**], have healed with persistent dorsal displacement of metatarsal shafts relative to the hindfoot. [**2173-12-8**] CT Head - No evidence of intracranial hemorrhage. Brief Hospital Course: 65yo with ESRD on HD, type I diabetes, recent citrobacter UTI c/b seizures was admitted with diarrhea and resultant hypotension. . 1. Hypotension. Patient was admitted from her rehab facility with lethargy and hypotension. She was found to have initial SBPs in the 70s and required aggressive fluid resuscitation in the ICU. After fluid resuscitation, she was transferred from the ICU to the floor, where her hypotension improved with maintenance fluids, improvement in diarrhea, and decreased fluid removal during dialysis. She was slowly restarted on a 1/2 dose of her home metoprolol. Her lisinopril is still being held and will need to be restarted as her blood pressure tolerates. . 2. Diarrhea: Diff dx includes C. diff or antibiotic associated diarrhea. C. Diff negative X 3 and Toxin B is still pending. Patient was treated with oral metronidazole for presumptive C. diff and is to complete a 14 day course ([**Date range (1) 98145**]). Additional stool studies such as vibrio, ova and parasites, campylobacter, and yersinia, and were sent and were unremarkable. Patient's Cdiff toxin B will need to be followed. . 3. UTI: Patient was recently admitted with citrobacter UTI and received a 7 day course of tobramycin. UA on admission was notable for likely fecal contamination. Urine culture was negative x 2. . 4. H/O status epilepticus: Patient had episode of generalized tonic clonic seizures during the previous admission and were thought to be secondary to her citrobacter UTI. No prophylactic anti-epileptic medications were given. . 5. ESRD on HD Patient was continued on her TThSat schedule and received nephrocaps and calcium carbonate. . 6. CAD: Patient has a history of a NSTEMI during a previous admission. She remained chest pain free and was maintained on her statin, aspirin, and beta blocker. Her ACEI and beta blocker were held due to her relative hypotension. [**Name2 (NI) **] beta blocker was started at 1/2 dose. Her ACEI has been held and will need to be restarted over the next week as her blood pressure tolerates. . 7. Sacral Decub: Patient had evidence of sacral breakdown due to her copious amounts of stool. Wound care was consulted and made several recommendations, which were listed on the Page 1 summary. . 8. Type 1 Diabetes Mellitus: Patient was receiving 10 units lantus. Briefly increased to 14 units lantus, with resulting hypoglycemia to 39. She was then maintained on a humalog sliding scale and lantus 10 units without difficulty. Her insulin sliding scale is attached. . 9. Conjunctivitis: continue cipro eye drops, moisten to allow eye opening. . Code Status: FULL CODE Contact: son [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 98146**] ([**Telephone/Fax (1) 98147**] Medications on Admission: Atorvastatin 80 qd Lisinopril 20 qd ASA 81mg hep SC tid folic acid 1mg qdaily tylenol 650 PRN Metoprolol 75 tid acidophilus CaCo3 1250 [**Hospital1 **] cholestyramine ciprofloxacin eye drops EPO with dialysis colace 10U lantus lactase with meals MVI neutra phos [**Hospital1 **] omeprazole senna vancomycin 125 po qid lactulose PRN . Medications on Transfer: Heparin 5000 UNIT SC TID Acetaminophen 325-650 mg PO Q6H:PRN Insulin SC (per Insulin Flowsheet) Aspirin 81 mg PO DAILY MetRONIDAZOLE (FLagyl) 500 mg PO TID Day 1 = [**12-5**]. Atorvastatin 80 mg PO DAILY Metoprolol 37.5 mg PO TID Calcium Carbonate 1250 mg PO BID Nephrocaps 1 CAP PO DAILY Ciprofloxacin 0.3% Ophth Soln 1-2 DROP BOTH EYES Q4H Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 7. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days. 11. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q4H (every 4 hours) for 4 days. 12. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection qHD: Please continue epo with hemodialysis. . 13. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a day). 14. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 15. Humalog 100 unit/mL Solution Sig: according to scale Subcutaneous four times a day: Please administer according to attached sliding scale. . Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Antibiotic associated diarrhea 2. Hypotension 3. ESRD . SECONDARY DIAGNOSIS: 1. Type 1 Diabetes Mellitus c/b retinopathy, neuropathy, nephropathy 2. ESRD secondary to DM - on HD 3. CAD - NSTEMI [**10-23**] in the setting of hospitalization for DKA, Nuclear stress test [**8-23**]: P-MIBI, without fixed or reversible defects, normal wall motion. EF 72%. 4. Hypertension 5. History of osteomyelitis, status post left transmetatarsal amputation. 6. History of herpes zoster of left chest in [**2163**]. 7. Bezoar, disclosed on UGI series [**7-/2166**]. 8. Achalasia 9. Carpal Tunnel Syndrome Discharge Condition: Stable. Patient is tolerating oral intake, answering questions appropriately, and has returned to her condition at admission. Discharge Instructions: You were admitted to the hospital due to low blood pressures and diarrhea. Your blood pressure improved with intravenous fluids and with improvement in your diarrhea. We think your diarrhea was due to your antibiotics and you are to complete a 2 week course of the antibiotic flagyl. . While you were here, we held your hypertension medications (lisinopril, metoprolol) because your blood pressure had been low. We restarted your metoprolol but are still holding your lisinopril. As your blood pressure improves over the next several days, you can restart your lisinopril and increase your metoprolol as needed. . Please continue to take the rest of your medications as prescribed. We have made the following changes to your medications: - lisinopril - we are holding this medication. Please restart over the next several days as blood pressure tolerates. - metoprolol - we restarted this medication at 1/2 dose. Please titrate up as tolerated. - colace, senna, and lactulose - holding in the setting of diarrhea . If you have any light-headedness, shortness of breath, fevers, chills, night sweats, chest pain, abdominal pain, please seek immediate medical attention. Followup Instructions: - We have scheduled a follow-up appointment for you with your primary care [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. on [**2173-12-21**] 11:00. - We have also scheduled a follow-up appointment for you with [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Last Name (NamePattern1) 280**] on [**2174-1-6**] 2:00. - We have scheduled a follow-up appointment with RADIOLOGY on [**2174-3-2**] 2:45. Please call their office at [**Telephone/Fax (1) 327**] to reschedule. - We have scheduled an appointment for you with a podiatrist [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM on [**2173-12-28**] 11:00. If you need to reschedule, please call their office at [**Telephone/Fax (1) 543**].

Unit No: [**Numeric Identifier 102524**] Admission Date: [**2104-5-12**] Discharge Date: [**2104-5-18**] Date of Birth: [**2046-1-27**] Sex: M Service: [**Last Name (un) 7081**] HISTORY OF PRESENT ILLNESS: This 58 year old patient of Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] was referred in for outpatient cardiac catheterization due to a recently abnormal exercise tolerance test. He had been followed for many years for episodes of chest discomfort and he was told that this was not cardiac in origin but most likely related to stress. Stress testing in the past had always been negative for perfusion defects and symptoms but notable for EKG changes. His chest discomfort had occurred several times a week and came and went periodically so he had another stress test done on [**3-31**] which showed EKG changes with ST depressions in V4 through V6 that did resolve. There were no perfusion defects. Ejection fraction was 64 percent. He was referred in for cardiac catheterization which was performed on the following day, [**2104-5-13**]. PAST MEDICAL HISTORY: Hypertension. Non insulin dependent diabetes mellitus. Hypercholesterolemia. BPH. History of renal cell CA status post nephrectomy on the left. Grade 1 anterolisthesis of L5-S1 in his lower back. PAST SURGICAL HISTORY: Left nephrectomy approximately 6-7 years prior to this admission and a small benign tumor removed from his testicle. MEDICATIONS: Medications at the time of consult with Cardiac Surgery were as follows: 1. Aspirin 325 mg po qd. 2. Lisinopril 10 mg po bid. 3. Lipitor 20 mg po bid. 4. Naprosyn 500 mg po prn. 5. Metformin 850 mg po bid. 6. Flomax 0.4 mg prn. 7. Viagra prn. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He had a 10 pack year history of cigarette smoking. He quit approximately 25 years ago. He had rare use of alcohol and lives with his wife. PHYSICAL EXAMINATION: On examination, his review of systems in addition to his medical history listed above was positive for nocturia. His vital signs were stable. His pupils were equally round and reactive to light and accommodation. Extraocular muscles were intact. His oropharynx was benign. His neck was supple with no lymphadenopathy noted. His carotids were 2+ bilaterally without any bruits. His lungs were clear to auscultation bilaterally. His heart was regular rate with no murmurs, rubs or gallops. His extremities were negative for cyanosis, clubbing or edema. Pulses were 2+ bilaterally. His cardiac catheterization showed the following: Left main 60 percent distal lesion, LAD ostial 50-60 percent proximal stenosis, a large OM with proximal 70 percent stenosis and a clean right coronary artery. He was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] for coronary bypass surgery. On the following day, on [**5-14**], he underwent coronary artery bypass grafting times three by Dr. [**Last Name (STitle) 70**] with a LIMA to the LAD and advanced sequentially from the ramus/diagonal to the OM. He was transferred to the Cardiothoracic ICU in stable condition on a propofol drip. On postoperative day 1, he had been extubated overnight. His nitroglycerin drip from overnight had been weaned off. He started his aspirin and remained on an insulin drip. He was receiving Dilaudid for pain and continuing his perioperative vancomycin. Postoperatively, his blood pressure was 139/68. He was in sinus rhythm with a pulse of 88. PA pressures were 30/14 with a CVP of 7. His cardiac index was 2.29 with an output of 4.96 and SVR of 1290. His blood gas was reasonable. He was sating 99 percent on 1 liter nasal prongs. He was alert and oriented. His lungs were clear bilaterally. His heart was regular rate and rhythm with S1 and S2 sounds. The sternum was stable. His abdomen was soft, nontender, nondistended with positive bowel sounds. His extremities were warm and well perfused without any edema. His PA line in his right IJ was discontinued. He started Lopressor beta blockade with 25 mg [**Hospital1 **] and resumed his Lipitor and metformin. His insulin drip was switched over to regular insulin sliding scale. On postoperative day 2, his beta blockade was increased. He increased his activity. He was on no cardiovascular drips. He continued with beta blockade at Lopressor 50 mg [**Hospital1 **] now and continued with aspirin on no drips. He was switched over to his oral agents, metformin and finished his vancomycin. His labs were as follows: white count 7.6, hematocrit 25.1, platelet count 171,000, sodium 136, K 4.4, chloride 105, bicarb 26, BUN 12, creatinine 1.0 with a blood sugar of 165. He was following all commands. His exam was benign. His sternum was stable and incisions looked good. His IJ Cordis, which had been switched over from the prior day from the Swan line, was discontinued. His chest tubes were pulled and he was transferred to FA2. On FA2, he was seen and evaluated by Physical Therapy to continue with his ambulation. On postoperative day 3, his temperature was 98.6. He was in sinus rhythm in the 70's with a blood pressure of 100/60, sating 92 percent on room air. His lungs were clear on the left but slight crackles on the right. He was alert and oriented. Heart was regular rate and rhythm. His abdominal exam was benign. His chest was stable. Incision was clean, dry and intact. He was doing very well. His metoprolol was at 50 mg [**Hospital1 **] and he continued working with Physical Therapy and getting out of bed. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3208**] consult was obtained on [**5-17**] for his six month history of type [**Known lastname **] diabetes. His sugar the prior day rose to about 221 and we thought that starting him back on his metformin without any side effects, but the patient did complain of a little bit of numbness on his feet so [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3208**] consult was called for evaluation and management of his diabetes. They recommended starting him on glipizide and doing additional lab work. On postoperative day 4, the day of discharge, the patient had a T-max of 98.6 with a temperature of 98.2. His heart rate was 75 in sinus rhythm with a blood pressure of 108/62, sating 96 percent on room air. His exam was benign with the exception of some slight crackles bilaterally in his lungs but he was doing very well. The [**Last Name (un) 3208**] consult recommendations were followed. The glipizide was added. Follow-up lab work was ordered with a plan to discharge him if he continued to do well. DISCHARGE DIAGNOSES: In fact, he was discharged on [**5-18**] with the following discharge diagnoses: Status post coronary artery bypass grafting times three. Coronary artery disease. Hypertension. Hypercholesterolemia. Non insulin dependent diabetes mellitus. BPH. Renal cell cancer status post left nephrectomy. Grade I anterolisthesis of L5-S1. DISCHARGE MEDICATIONS: 1. Metoprolol 50 mg po bid. 2. Colace 100 mg po bid. 3. Ranitidine 150 mg po bid. 4. Aspirin 325 mg enteric coated, delayed release, po qd. 5. Percocet 5/325 one to two tablets po prn q4h for pain. 6. Lipitor 20 mg po qd. 7. Metformin 850 mg po bid. 8. Tamsulosin hydrochloride 0.4 mg, sustained release, one capsule po qhs. 9. Glipizide 5 mg po qd. DISCHARGE INSTRUCTIONS: The patient was discharged with instructions to follow up with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] in two to three weeks postop, to follow up with his primary care physician in approximately two to three weeks postop and to see Dr. [**Last Name (STitle) 70**] in the office for his postop surgical visit at approximately six weeks. Again, he was discharged in stable condition to home on [**2104-5-18**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2104-6-17**] 09:25:46 T: [**2104-6-17**] 10:11:22 Job#: [**Job Number 102525**]

Admission Date: [**2173-10-4**] Discharge Date: [**2173-10-6**] Date of Birth: [**2104-4-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: observation following bronchoscopy Major Surgical or Invasive Procedure: fiberoptic bronchoscopy History of Present Illness: Ms. [**Known lastname **] is a 69 year old Cambodian woman with a history of cardioresp arrest secondary neck mass (thyroid ca) - resected, c/b tracheal stenosis - tracheostomy which stenosed - was changed to a T tube 3 weeks ago - presented today from rehab hospital for f/u bronch. The patient's history dates back to [**2173-3-10**] when she was found unresponsive at home. She recovered and was found to have papillary thyroid cancer, and in [**Month (only) 958**] her cancer had an extensive resection involving a sternotomy. Subsequently, her course was complicated by subglotic edema, requiring a trach, and multiple vent-acquired PNA's. Most recently, for progessive tracheal stenosis, she was changed to a t-tube about three weeks ago. Of note, she has also had several episodes of respiratory arrest thought due to mucus plugging and respiratory compromise at [**Hospital1 18**] and rehab. Today, she presented to IP for a followup bronchoscopy. Following sedation after initiation of the bronch, the patient desaturated and developed resp. arrest. After some manual ventilation she was resuscitated but she has had frequent ectopy (PVC's) on the cardiac monitor (this was also noted following her cardiac arrest in [**Month (only) 205**]). The IP team requested that she be admitted to the MICU for observation given the respiratory arrest and the frequent ectopy. Past Medical History: 1. Mult episodes of cardiac and respiratory arrest prompting inpatient hospitalizations here [**4-12**] and [**9-12**]; most recently s/p VAP with respiratory difficulties and Cardiac arrest [**9-2**] at OSH 2. thyroid cancer dx in [**3-/2173**]- Papillary cancer with positive nodes status post sternotomy and partial right and total left 3. thyroidectomy on [**2173-4-12**]. 3. IDDM 4. HTN 5. Hiatal hernia 6. B12 defic 7. B cell lymphoma-s/p chemo 8. h/o acinetobacter and enterobacter pneumonias at [**Hospital1 18**] [**4-12**] 9. a flutter 10. tracheomalacia, subglottic stenosis, and infra and superior glottic swelling seen on bronch [**8-/2173**] Social History: The pt has six children living in the area, 2 children living in [**Country **]. She is from [**Country **] and speaks Cantonese. She understands some English. Apparently she was independent with mobility and basic ADL prior to her last hospitalization. Her functional capacity recently has been the need for maximal assistance to total dependency in most areas Family History: Noncontributory Physical Exam: VS: T 98.6 HR 67 BP 100/57 RR 13 Sat 100% 4L trach collar GEN: Pleasant woman in bed in no apparent distress. HEENT: MMM, sclerae anicteric, NC/AT. NECK: T-tube in trach, JVP no elevated COR: Normal s1/s2, RRR, no m/r/g appreciated PULM: Scattered rhonchi ABD: Soft, NT, ND +BS. +Gtube EXT: No edema, FROM NEURO: Awake, alert. Pertinent Results: [**2173-10-4**] 12:49PM GLUCOSE-128* UREA N-14 CREAT-0.8 SODIUM-133 POTASSIUM-6.6* CHLORIDE-101 TOTAL CO2-23 ANION GAP-16 [**2173-10-4**] 12:49PM TSH-13* [**2173-10-4**] 12:49PM FREE T4-1.4 [**2173-10-4**] 12:49PM WBC-4.3 RBC-3.95* HGB-12.2# HCT-35.2*# MCV-89 MCH-30.8 MCHC-34.6 RDW-15.3 [**2173-10-4**] 12:28PM TYPE-ART PO2-44* PCO2-47* PH-7.34* TOTAL CO2-26 BASE XS-0 [**2173-10-4**] 12:28PM K+-5.2 Brief Hospital Course: 69 year old woman with history of papillary thyroid ca s/p resection, complicated by tracheal stenosis. Here today for elective bronch complicated by respiratory arrest. 1) For her respiratory failure, the patient s/p respiratory arrest after bronch, s/p t-tube for tracheomalacia. The most likely etiology was a combination of over-sedation and mucus plugging. On arrival to the MICU the patient was satting very well on trach collar and was comfortable. 2) For her frequent ectopy, s/p respiratory arrest during the bronch. It is unclear how much ectopy she had prior to the bronch, but according to old [**Hospital1 18**] records, she had this during her previous hospitalizations. She responds very well to her beta-blockade. Her LDL was 73 and HDL was 66 so a statin was not started. 3) For f/en, the pt has a history of aspiration, with a g-tube in place. She did past a speech & swalllow eval during her previous admit. Her most recent diet here was diabetic/Consistent carbohydrate, consistency: Ground; w/ Nectar prethickened liquids with aspiration precautions and this was continued. 4) Endocrine: h/o DM, h/o thyroid resection, cont RISS and thyroid hormone replacement 5) Code is full 6) Communication is with her daughter, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 65849**], pt also understands some english 7) Access: PIVS 8) Disposition: to [**Hospital **] Rehab. Medications on Admission: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: Seven (7) ml PO BID (2 times a day). 3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: 2.5 Tablet, Chewables PO BID (2 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): last dose [**2173-9-27**]. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 13. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day) as needed for secretions. 14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ml Miscell. [**Hospital1 **] (2 times a day). 16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): last dose [**2173-9-27**]. 17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days: last dose [**2173-9-28**]. 18. regular insulin per sliding scale finger sticks. 19. T-Tube cap cap T-Tube during day and uncap at noc and provide humidified oxygen 20. NPH insulin 20 units NPH Sq qam and 17 units NPH Sq qpm 21. Decadron 0.5 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days: then decrease to 0.5mg x 7days then d/c Discharge Medications: 1. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Calcium Carbonate 1,250 mg (500 mg) Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Respiratory failure s/p bronchoscopy Discharge Condition: Stable Discharge Instructions: Please seek medical attention for fevers > 101.4, or for anything else concerning. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12647**] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2173-10-15**] 2:30 (Endocrinology)

Admission Date: [**2154-8-25**] Discharge Date: [**2154-8-28**] Date of Birth: [**2086-10-11**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old woman who was found unconscious by a neighbor on [**2154-8-23**]. [**Name2 (NI) 430**] CT showed at an outside hospital revealed an intracranial hemorrhage, right frontal parietal with mild shift of the falx and moderate edema with no evidence of herniation. The patient was admitted to the outside hospital, started on labetalol and loaded with Dilantin. She did have a decrease in mental status one to two days after being there and was transferred to [**Hospital6 649**] for further management. PAST MEDICAL HISTORY: 1. Hypertension 2. Diabetes PAST SURGICAL HISTORY: Unknown EXAM: Heart rate was 117, temperature 97.7??????, blood pressure 148/59, respiratory rate was 24, saturations 97%. She was on Nipride drip on admission. Pupils were equal, round and reactive to light but sluggish bilaterally. She did not follow commands. She was arousable to sternal rub, but drowsy. Heart was regular rate and rhythm. Chest was clear to auscultation. Abdomen soft, nontender, nondistended. She also had incontinence and was unable to move the left side when found. On arrival to [**Hospital3 **], she was arousable to sternal rub only. She was spontaneously moving the right side and right upper extremity and bilateral lower extremities with no movement in the left upper extremity. She was admitted to the Surgical Intensive Care Unit for close monitoring. On the morning of [**8-26**], the patient was less awake. Pupils were trace reactive. She continued to localize on the right side, withdrew the left side to pain. She had a repeat head CT which was unchanged on [**8-26**]. The patient's family decided not to undergo any surgical treatment or blood transfusions since the patient was a Jehovah's Witness. The patient was transferred to the neurology service. Dr. [**Last Name (STitle) 6910**] met with the family on [**2154-8-27**] and it was decided that the patient would be comfort measures only. The patient passed away on [**2154-8-28**]. [**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2154-9-30**] 11:37 T: [**2154-9-30**] 11:51 JOB#: [**Job Number 44724**]

Admission Date: [**2148-7-17**] Discharge Date: [**2148-8-8**] Date of Birth: [**2082-9-12**] Sex: F Service: MEDICINE Allergies: Antihistamines Attending:[**First Name3 (LF) 16983**] Chief Complaint: recurrent pneumonia Major Surgical or Invasive Procedure: PICC, left arm History of Present Illness: Briefly, this is a 65 year-old F with COPD who has been admitted to an OSH 3 times in the past 2 months for a RLL pneumonia/ consolidation. She initially presented 2 months ago with RLL PNA, and returned one month ago with RLL and lingular PNA. She underwent bronchoscopy on [**7-2**] at which time BAL cultures were negative and cytology from the washings was negative. A CT of the chest was reportedly without malignancy. She most recently returned to [**Hospital3 **] Hospital 8 days after discharge ([**7-12**]) with increasing cough, sputum production, and left sided rib pain which started two days prior to presentation. A CT again showed mass-like consolidation in the lingula with interval increase in size since the previous film, RLL atelectasis and dense consolidation which is unchanged, stable mediastinal adenopathy, and an acute left 7th rib fracture. A PPD placed at [**Hospital3 **] was negative according to their records. She was started on zosyn on [**7-12**]; after sputum cx grew out MRSA she was started on vancomycin on [**7-15**]. She was transferred to [**Hospital1 18**] on [**7-18**] for further work-up and management of her recurrent pneumonias. She had a repeat bronchoscopy on [**7-22**], cytology from which revealed BAC. While her current exacerbation was considered to be due to infection, the pt was felt to have poor underlying lung function from involvement of her tumor and therefore was started on tarceva. . In the MICU the patient had waxing and [**Doctor Last Name 688**] respiratory status and required a NRB. SHe was never intubated. Currently she is on 70% face mask. She continued to be treated for hospital acquired pna with vanc/levo/flagyl. While the bronchoal lavage cx was negative but a sputum cx grew MRSA. The pt was also found to have new ARF with a creatinine of 1.5, which was thought to be prerenal and resolved with IVF. Her chest pain was felt to be due to a rib fracture and was treated with dilaudid. . The pt is now transfered for further management of her BAC. She is currently on 6L NC with intermittent episodes of SOB and a dry cough and denies CP, nausea, vomiting Past Medical History: Hypertension MRSA pneumonia in [**2138**] GERD Dyslipidemia Depression Anxiety Social History: Patient lives a alone in [**Hospital3 **]. She had previous worked in retail. She quit smoking in [**Month (only) 547**] and now uses nicorette gum. She had smoked approximately 0.5 packs a day for 45 years. She drink alcohol only socially. She reports no use of recreational drugs. Family History: Mother (former smoker) is [**Age over 90 **] years old and carries a diagnosis of "asthma". Mother had breast cancer. Father had liver disease. Not family history of lung disease. Physical Exam: Vitals: t 96.6 bp 122/62 P 93 RR 20 97 70% mask Gen: mildly tachypneic when moving around, NAD HEENT: MMM, op clear, perrl Neck: no LAD, no thyromegaly, no JVD Pulm: decreased breath sounds at the bases Heart: RRR, no m/r/g Abdomen: soft, NT/ND Extr: no cyanosis , no edma, no clubing Neuro: AxO3, cranial nerves grossly intact Pertinent Results: [**2148-8-8**] 12:00AM BLOOD WBC-13.8* RBC-2.97* Hgb-9.7* Hct-28.8* MCV-97 MCH-32.8* MCHC-33.8 RDW-12.7 Plt Ct-422 [**2148-8-8**] 12:00AM BLOOD Plt Ct-422 [**2148-8-8**] 12:00AM BLOOD Glucose-126* UreaN-19 Creat-1.2* Na-138 K-4.2 Cl-97 HCO3-27 AnGap-18 [**2148-8-8**] 12:00AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.2 [**2148-8-4**] 01:30AM BLOOD Hapto-312* [**2148-8-2**] 12:00AM BLOOD calTIBC-203* Ferritn-408* TRF-156* [**2148-8-1**] 12:27AM BLOOD VitB12-590 Folate-10.5 [**2148-8-6**] 07:10PM BLOOD Vanco-5.2* [**2148-7-23**] 12:19AM BLOOD Type-ART pO2-84* pCO2-44 pH-7.35 calTCO2-25 Base XS--1 [**Date range (1) 56011**] C. Diff Assay: Negative x3 . GRAM STAIN (Final [**2148-8-6**]): [**11-28**] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | Bronchial lavage:[**7-23**] Suspicious for non-small cell carcinoma. Scattered single cells and loose clusters of cells with high nuclear cytoplasmic and nuclear membrane irregularity, nucleoli and chromatin clearing. These findings are suspiciuos for non-small cell carcinoma, possibly bronchioloalveolar type . Chest CT w/ contrast [**8-6**]: IMPRESSION: 1. Improving right lower lobe consolidation and lymphadenopathy. 2. Improving left basilar atelectasis. 3. Stable suspicious mass in the lingula. A nearby area of well-marginated ground-glass opacity may be inflammatory or also raises suspicion for malignancy. The opacities are unchanged. 4. New mixed patchy ground glass and consolidative opacity in the superior segment of the left lower lobe, which could be infectious, inflammatory or due to aspiration. 5. No evidence of bony metastases, but several rib fractures, which are unchanged in retrospect. 6. Pneumobilia, which could be seen in prior sphincterotomy. 7. Suspicious renal lesion not imaged. . Brain MRI:IMPRESSION: Mild-to-moderate brain atrophy. No evidence of acute infarct or abnormal enhancement. No evidence of mass effect or hydrocephalus. . Bone Scan: IMPRESSION: 1. Two adjacent areas of focal increased tracer uptake in the left lateral 7th and 8th ribs consistent with fractures. 2. Nonspecific increased tracer uptake within the right 6th posterior and 7th lateral ribs. Given the findings in the contralateral ribs, this tracer uptake may also be due to a trauma; however, correlation with cross-sectional imaging (CT scan) could be used for further evaluation if clinically indicated. . CT Abdomen/pelvis: [**7-26**] IMPRESSION: 1. Complete consolidation of the right lower lobe, which may be filled with fluid (perhaps related to recent lavage), hemorrhage, or tumor. This appearance is rather extensive for BAC, however, it is possible. No focal masses are identified within the consolidated lobe. 2. Spiculated mass within the lingula with associated left hilar lymphadenopathy is highly concerning for malignancy. 3. Vague airspace opacities at the left posterior lung base and medial aspect of the right middle lobe may represent infection or less likely tumor. 4. 1.3 cm soft tissue lesion within the right kidney which may represent a hemorrhagic cyst, or renal cell carcinoma. Recommend further evaluation with MRI. 5. Three hypoattenuating lesions within the liver are likely cysts, however, attention should be paid to these on future exams to ensure stability. 6. Diverticulosis without diverticulitis. 7. Moderate centrilobular emphysema. . TBBX: Atypical mucinous glands, highly suspicious for bronchiolo-alveolar carcinoma, mucinous type. Brief Hospital Course: 63F with recurrent pneumonias, htn was transfered on [**7-17**] from an OSH after 3 hospitalizations for RLL pneumonia in the last 2 months. The next hospitalization found RLL and Lingular PNA. A BAL on [**7-2**] was negative for bacteria or atypical/malignant cytology. On the most recent admission, Ms. [**Known lastname 56012**] was found to have sputum positive for MRSA. The patient was at home for 8 days with 2.5 L continous oxygen requirement with dyspnea on excertion. On [**7-12**] the patient returned to the hospital with excruciating laft sided rib pain that developed over 3 days that was though to be secondary to severe coughing. Admission CT was postive for RLL a persistent RLL consildation, left lingular process, and 7th rib fracture. Ms. [**Known lastname 56012**] was treated with Zosyn starting [**7-12**] and vancomycin on [**7-15**] following a sputum positive for MRSA on [**7-15**]. was found to have have a positive MRSA result cultured from sputum. She underwent bronch at OSH which revealed no evidence of tumor. She was transferred to [**Hospital1 18**] for further management. At [**Hospital1 18**], she underwent work-up for the hypoxia which involved pulmonary consult which recommended repeat bronch. The patient underwent bronch with biopsies on [**7-22**]. Bronch was remarkable for abundant secretions. . Negative PPD at OSH . Studies from OSH: [**7-12**] CXR PA/lat [**Last Name (un) **] improvemtn of RLL consolidation, resolving [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 56013**] in LLL . Left rib films [**7-12**] on fracture . CTA chest [**7-12**] no PE, unchaged RLL atelectasis with dense consliation interal increase in mass like lingular consliation stable , medistial adeopathy, acute left 7th [**Last Name (un) **] fracture. . A/P: 63F with recurrent pneumonias, htn p/w hypoxia s/p bronch . # Acute hypoxia; Patient experienced multiple episodes of acute hypoxia most concerning for mucous plugging given the abundant secretions on bronch. No evidence of CHF. Patient never intubated throughout ICU stay, was able to be maintained on NRB and then titrated as secretions improved to Face Mask and 6L NC. Two febrile episodes with rising white count and worsening respiratory status treated empirically for post-obstructive PNA with course of vanco and zosyn. Patient to complete a ten day course of IV Vancomycin and Zosyn (total of 7 days post-dsicharge). . # Bronchoalveolar Carcinoma, mucinous type: Persistent RLL cosolidation and cough over months despite treatment, BAL demonstrated bronchorrhea from bronchoavelolar cancer, mucinous type on pathology. CT chest also demonstrated spiculated mass in the lingula. Patient started on 60mg prednisone and Tarceva daily with improvement in brochorrhea. Nebs given standing. Patient to continue with Tarceva until she is evaluated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20889**] ([**Telephone/Fax (1) 56014**]) as outpatient for further management of BAC. She also will continue with a Prednisone taper over 30 days for bronchorrhea. Chest CT prior to discharge showed resolving areas of consolidation suggesting improved control of mucinous secretions. . # Pain: Left Rib Fracture c/o pathologic fx -Contolled on MsContin and prn oxycodone . # ARF: Cr 1.5 on admission, was 0.9 on [**7-18**]. Prerenal state. Stabilized with IVF at 1.0-1.2. . # Anxiety Depression: - Continued buspar, celexa, seroquel, trazadone - prn ativan for an acute anxiety attack . # HTN: -continued norvasc, diovan Medications on Admission: Medications at home: Buspirone 10 Qid Diovan 160 mg qd FemHRT 1/.005 qd [**Doctor First Name **] D 1 tab Protonix 60 mg qd Celexa 60 mg qd Seroqul 200 mg qhs potassium chloride 10 to 20 meq qd trazonde 50 to 100 mg PO qhs prn Albuterol prn . Medications on transfer: PredniSONE 60 mg PO DAILY Erlotinib (Tarceva) *NF* 150 mg PO DAILY Start Morphine SR (MS Contin) 60 mg PO Q12H Clonazepam 0.25 mg PO BID Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Acetaminophen 650 mg PO Q6H:PRN Lidocaine 5% Patch 2 PTCH TD QD Guaifenesin [**6-13**] ml PO Q4H Vancomycin 1000 mg IV Q 12H HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6 minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s) MetRONIDAZOLE (FLagyl) 500 mg PO TID Levofloxacin 250 mg PO Q24H [**7-23**] @ 0937 View Fexofenadine 60 mg PO DAILY [**7-23**] @ 0409 View Lorazepam 0.5 mg PO/IV Q4-6H:PRN anxiety Aspirin 81 mg PO DAILY Senna 1 TAB PO BID:PRN Quetiapine Fumarate 200 mg PO QHS Docusate Sodium 100 mg PO BID Heparin 5000 UNIT SC TID traZODONE HCl 50 mg PO HS:PRN [**7-23**] @ 0409 View Amlodipine 10 mg PO DAILY Citalopram Hydrobromide 60 mg PO DAILY Pantoprazole 40 mg PO Q12H Femhrt [**2-9**] *NF* 5-1 mcg-mg Oral QD BusPIRone 10 mg PO QID Discharge Medications: 1. Buspirone 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for anxiety. 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. 14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours). 17. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 18. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 19. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q4H (every 4 hours) as needed. 20. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours). 21. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 22. Sodium Chloride 0.9% Flush 10 ml IV DAILY:PRN For PASV Picc flush before and after each use Inspect site daily 23. Heparin Flush (10 units/ml) 2 ml IV PRN 24. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 7 days. 25. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q 12H (Every 12 Hours) for 7 days. 26. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 30 days: Please take 6 pills x5 days, 5 pills x5 days, 4 pills x5 days, 3 pills x5 days, 2 pills x5 days, 1 pills x5 days. Tablet(s) 27. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day for 30 days: Please take 6 pills x 5 days then taper to 5 pills x5days, 4 pills x5 days, 3 pills x5 days, 2 pills x5days, 1 pill x5 days. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Senior Healthcare - [**Location (un) 23638**] Discharge Diagnosis: Bronchoalveloar Carcinoma Post-Obstructive Pneumonia in MRSA carrier Chemotherapy-induced diarrhea Acute Renal Failure Normocytic Anemia of Chronic Disease Vitamin K deficiency Coagulopathy Stress Urinary Incontinence Anxiety Depression Benign Hypertension Vaginal Candidiasis Discharge Condition: Stable, requiring 6L of NC to maintain oxygen saturation. Discharge Instructions: You have been treated for Bronchoalveolar carcinoma and associated bronchorrhea and post-obstructive pneumonia. Please complete a 7 day course of IV Vancomycin and Zosyn for empiric treatment of MRSA post-obstructive pneumonia. Please continue a one month taper of your prednisone. You are to follow-up once discharged from the rehab facility with an oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20889**] [**Telephone/Fax (1) 56014**] in [**Location (un) 15566**], MA. In the interim, please continue with Tarceva for the next month until otherwise instructed by Dr [**Last Name (STitle) 20889**]. Followup Instructions: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20889**] [**Telephone/Fax (1) 56014**] in [**Location (un) 15566**], MA for further management of your lung cancer. Rahbilitation facility is to call to schedule an appointment prior to discharge home. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16984**] MD, [**MD Number(3) 16985**]

Admission Date: [**2101-3-30**] Discharge Date: [**2101-4-7**] Date of Birth: [**2024-6-29**] Sex: F Service: CARDIOTHORACIC Allergies: Percocet / Tramadol Attending:[**First Name3 (LF) 1505**] Chief Complaint: critical aortic stenosis Major Surgical or Invasive Procedure: [**2101-4-1**] Aortic valve replacement (#19 mm Magna tissue pericardial valve) History of Present Illness: This 76 year old white female has known aortic stenosis, followed by serial echos. The valve area has tightened over the previous year from 0.9cm2 to 0.7cm2 now. She has recently developed dizziness and light-headedness. Cardiac cath the day of transfer from [**Hospital **] Hospital reveals normal coronary arteries. She is transferred for aortic valve replacement. Past Medical History: hypertension hyperlipidemia aortic stenosis depression Social History: Lives with: husband [**Name (NI) **] (87yo- uses walker), has 2 sons living nearby Occupation: retired- worked at [**Hospital1 **] library Tobacco: never ETOH: rare Family History: mother- had an "enlarged heart" and died at 76yo following complications from AAA repair father- died at 80 of cancer Physical Exam: Admission; Pulse: 70SR Resp: 16 O2 sat: 95%RA B/P Right: Left: 138/80 Height: Weight: 185lb General: NAD 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 3/6 SEM- loudest at LSB Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] small/superficial varicosities 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: Left: no carotid bruits appreciated Pertinent Results: [**2101-4-4**] 03:35AM BLOOD WBC-10.9 RBC-2.93* Hgb-8.7* Hct-25.7* MCV-88 MCH-29.6 MCHC-33.7 RDW-14.1 Plt Ct-177 [**2101-4-4**] 03:35AM BLOOD PT-12.7 PTT-24.1 INR(PT)-1.1 [**2101-4-4**] 03:35AM BLOOD Glucose-119* UreaN-23* Creat-0.8 Na-136 K-3.7 Cl-100 HCO3-27 AnGap-13 intra-op echo [**2101-4-1**] Pre-bypass: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. There is a 4 cm x 4cm echodense object seen in the transgastric views that is near the descending thoracic aorta. The surgeons were made aware of this finding. Post-bypass: The patient is receiving no inotropic support post-CPB. There is a well-seated bioprosthesis in the aortic position with good leaflet excursion. There is no transvalvular or paravalvular regurgitation. The mean transvalvular gradient is 10 mm Hg at a cardiac output of 5.9 L/min. Biventricular systolic function is preserved and all other findings are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings were communicated to the surgeon intraoperatively. [**2101-4-5**] 04:32AM BLOOD WBC-7.9 RBC-3.06* Hgb-9.0* Hct-26.5* MCV-87 MCH-29.4 MCHC-34.0 RDW-14.0 Plt Ct-220 [**2101-4-4**] 03:35AM BLOOD WBC-10.9 RBC-2.93* Hgb-8.7* Hct-25.7* MCV-88 MCH-29.6 MCHC-33.7 RDW-14.1 Plt Ct-177 [**2101-4-5**] 04:32AM BLOOD Glucose-114* UreaN-20 Creat-0.6 Na-135 K-4.3 Cl-99 HCO3-29 AnGap-11 [**2101-4-4**] 03:35AM BLOOD Glucose-119* UreaN-23* Creat-0.8 Na-136 K-3.7 Cl-100 HCO3-27 AnGap-13 Brief Hospital Course: Following transfer, the usual workup was completed and she was prepared for surgery. On [**4-1**] she was taken to the Operating Room where aortic valve replacement was accomplished. See operative note for details. She weaned from bypass on Neo Synephrine and Propofol. She remained stable, pressors were weaned and discontinued. She was extubated and remained stable. On POD 2she experienced an hour or so of expressive aphasia which completely resolved. Neurology saw her and a Head CT and EEG were unremarkable; all narcotics were discontinued. She continued to progress and transferred to the floor on POD# 3 for further monitoring. Beta blockers were begun and she was diuresed towards her preoperative weight. Wires and CTs were removed per protocols, without complications, and Physical Therapy evaluated her for strength and mobility. A stay at a rehab facility for a brief time was felt approprite before return home to independent living. At the time of transfer to rehab her wound was clean and healing well, she was tolerating a diet and pain was well controlled with oral medications. POD#6 she was cleared by Dr.[**Last Name (STitle) **] for discharge to [**Hospital **] Nursing and Rehab Center in [**Location (un) **] for rehabilitation. Follow-up appointments were advised. Medications on Admission: metoprolol 25 daily, sertraline 50 daily, lipitor 20 daily, actonel 35, ecotrin 81 daily, diovan 40 daily, abilify 5mg alternating with 2.5mg QOD, zolpidem 5 hs prn, MVI, viactiv 500 [**Hospital1 **], B-100 complex, CoQ10 and fish oil Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain for 4 weeks. 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 14. Aripiprazole 5 mg Tablet Sig: 0.5 Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: critical aortic stenosis s/p aortic valve replacement hypertension hyperlipidemia depression Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage 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**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Surgeon: Dr. [**Last Name (STitle) **] on [**2101-5-5**] at 1:45pm ([**Telephone/Fax (1) 170**]) Please call to schedule appointments Primary Care: Dr. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 40075**] ([**Telephone/Fax (1) 40076**]) in [**12-4**] weeks Cardiologist: Dr. [**Last Name (STitle) 8579**] in [**12-4**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2101-4-7**]

Admission Date: [**2192-12-27**] Discharge Date: [**2193-1-6**] Date of Birth: [**2192-12-27**] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: [**Known lastname 8254**] [**Known lastname 59598**] is a former 3.510 kilogram product of a 36 and [**3-18**] gestation pregnancy born to a 34-year-old gravida 5, para 2 (now 3) woman. PRENATAL SCREENS: Blood type O positive, antibody screen negative, Rubella immune, rapid plasma reagin nonreactive, hepatitis B surface antigen negative, group B strep status negative. PAST OBSTETRICAL HISTORY: Notable for two previous infants delivered at 35 weeks with Surfactant requirement due to respiratory distress. Estimated date of confinement was [**2192-1-21**]. The pregnancy was complicated by preterm labor treated with bed rest and terbutaline from 25 through 33 weeks gestation. There was spontaneous progression of labor leading to a spontaneous vaginal delivery under epidural anesthesia. There was no antepartum maternal fever or other clinical evidence of sepsis. No intrapartum antibacterial prophylaxis was given. Rupture of membranes occurred five hours prior to delivery with clear fluid. The infant required tactile stimulation and bulb suctioning. Apgar scores were 7 at 1 minute and 8 at 5 minutes. She was transferred to the Neonatal Intensive Care Unit for management of her respiratory distress. PHYSICAL EXAMINATION ON PRESENTATION: On admission to the Neonatal Intensive Care Unit weight was 3.51 kilograms (greater than the 90th percentile), head circumference was 34.5 cm (90th percentile), and length was 49.5 cm (90th percentile). In general, a nondysmorphic infant in moderate respiratory distress. Head, eyes, ears, nose, and throat examination revealed palate was intact and normocephalic. Neck and mouth were normal. Chest revealed moderate intercostal retractions with spontaneous breath spare excursion. Breath sounds were fair bilaterally. No crackles. Cardiovascular examination revealed well perfused. A regular rate and rhythm. Femoral pulses were normal. There was a 1/6 systolic ejection murmur at the left lower sternal border without radiation. The abdomen was soft and nondistended. There were no organomegaly. There were no masses. Bowel sounds were active. The anus was patent. Genitourinary examination revealed normal female genitalia. Neurological examination revealed responsive to stimulation. Tone was slightly decreased in a symmetrical distribution. Moved all extremities. Back was intact. The skin was normal. Musculoskeletal examination revealed normal spine, hips, and clavicles. There was bruising of the right foot. SUMMARY OF HOSPITAL COURSE BY SYSTEM INCLUDING PERTINENT LABORATORY DATA: 1. RESPIRATORY: [**Known lastname 8254**] was initially placed on continuous positive airway pressure without improvement in her respiratory distress. She was subsequently intubated and received two doses of Surfactant. She was extubated to continuous positive airway pressure on day of life one. She was changed to nasal cannula oxygen on day of life three and weaned to room air on day of life four. At the time of discharge, she was breathing comfortably on room air with respiratory rates in the 40s to 50s. 2. CARDIOVASCULAR: The murmur noted on admission resolved within the first 48 hours of life. At the time of discharge, her heart rates were 130 to 160 beats per minute with a recent blood pressure of 68/39 with a mean of 54 mmHg. 3. FLUIDS, ELECTROLYTES AND NUTRITION: Feedings were initiated on day of life two and gradually advanced to full volume. At the time of discharge, she was breast feeding or feeding expressed mother's milk; minimum of 140 cc/kilogram per day. Weight at the time of discharge was 3.185 kilograms. Serum electrolytes were checked in the first three days of life and were within normal limits. 4. INFECTIOUS DISEASE: Due to the unknown etiology of her respiratory distress, [**Known lastname 8254**] was evaluated for sepsis. Her complete blood count was normal. A blood culture was obtained prior to starting intravenous ampicillin and gentamicin. Blood culture was no growth at 48 hours, and the antibiotics were discontinued. 5. HEMATOLOGICAL: Hematocrit at birth was 49.7 percent. [**Known lastname 8254**] is blood type O positive and Coombs negative. She did not receive any transfusions of blood products. 6. GASTROINTESTINAL: [**Known lastname 8254**] required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of life four - with a total of 15.8/0.4 mg/dL direct. She received phototherapy for approximately 72 hours. Her phototherapy was discontinued on [**2193-1-2**] with a rebound bilirubin on [**2193-1-3**] of 10.2/0.3. She still had clinical jaundice, and a repeat bilirubin was drawn on [**2193-1-5**] with a total of 12/0.3 mmHg direct. Bilirubin on the day of discharge was a total of 11.3/0.3 mmHg direct. 7. NEUROLOGICAL: [**Known lastname 8254**] has maintained a normal neurological examination during admission, and there were no neurological concerns at the time of discharge. 8. SENSORY/AUDIOLOGY: Hearing screening was performed with automated auditory brain stem responses. [**Known lastname 8254**] passed in both ears. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43143**] - [**Hospital 47**] Pediatrics; PC [**Hospital1 50919**], [**Location (un) 47**], [**Numeric Identifier 59599**] (telephone number [**Telephone/Fax (1) 43144**]; fax number [**Telephone/Fax (1) 46702**]). CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feedings: Ad lib breast feeding or oral feeding expressed mother's milk ad lib. 2. Medications: Tri-Vi-[**Male First Name (un) **] 1 mL by mouth once daily. 3. Car seat position screening was performed - [**Known lastname 8254**] was observed in her car seat for 90 minutes without any episodes of bradycardia or oxygen desaturations. 4. State newborn screening was sent on [**12-31**] and [**2193-1-6**] with no notification of abnormal results to date. Pediatrician will need to follow-up final results. 5. Hepatitis B vaccine was administered on [**2193-1-4**]. IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial virus prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria: (1) born at less than 32 weeks gestation; (2) born between 32 and 35 weeks gestation with two of the following: Daycare during respiratory syncytial virus season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or (3) with chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach six months of age. Before this age (and for the first 24 months of the child's life) immunization against influenza is recommended for household contacts and out of home caregivers. DISCHARGE DIAGNOSES: 1. Prematurity at 36 and [**3-18**] gestation. 2. Respiratory distress syndrome secondary to Surfactant deficiency. 3. Suspicion for sepsis ruled out. 4. Unconjugated hyperbilirubinemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**] Dictated By:[**Last Name (Titles) **] MEDQUIST36 D: [**2193-1-6**] 05:46:17 T: [**2193-1-6**] 10:00:13 Job#: [**Job Number 59600**]

Admission Date: [**2197-11-12**] Discharge Date: [**2197-11-23**] Date of Birth: [**2197-11-12**] Sex: F Service: NEONATOLOGY HISTORY OF THE PRESENT ILLNESS: The patient is a 2,630 gram female infant born at 36 weeks gestation to a 28-year-old G2, P2 mother with prenatal screens blood type O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune. The patient was born via repeat cesarean section, uncomplicated pregnancy. No sepsis risk factors. The NICU Team was called to the Delivery Room at approximately ten minutes of life for respiratory distress with grunting, flaring, and retracting. Apgar scores were seven, eight, and eight. The patient continued to require blow-by 02. The patient was brought to the NICU after visiting with parents. PHYSICAL EXAMINATION ON ADMISSION: The patient was pink, active, nondysmorphic, on blow-by 02, mild respiratory distress, with tachypnea, grunting, flaring, and retracting. HEENT: Within normal limits. Heart: Regular rate and rhythm. Normal S1, S2, no murmurs. Lungs: With coarse breath sounds bilaterally. Abdomen: Benign. Neurologic: Nonfocal, age appropriate. Spine intact. Hips normal. HOSPITAL COURSE: 1. RESPIRATORY: The patient was initially on CPAP with FI02 in the 20s. The patient was weaned off CPAP on day of life number one and on nasal cannula 02 until [**2197-11-18**], subsequently in room air, breathing comfortably. Occasional desaturations with feeds and drifting 02 sats which was resolving. The patient was with no episodes of desaturations in the two days prior to discharge. 2. CARDIOVASCULAR: The patient was cardiovascularly stable with normal blood pressures throughout admission. The patient has a murmur at the left lower sternal border radiating to the back consistent with PPS. 3. FLUIDS, ELECTROLYTES, AND NUTRITION: Initially n.p.o. and on IV fluids. The patient was started on feeds on day of life number one. The patient required a combination of oral and gavage feeds. The patient began taking full p.o. feeds on [**2197-11-19**] and PG tube discontinued. At the time of discharge, the patient was taking full p.o. feeds of breast milk 20 and E20 ad lib. The patient consistently gained in the five days prior to discharge. The weight at discharge was 2,485 grams. 4. GI: The bilirubin levels were monitored. The bilirubin peaked at 11.0/0.3 on day of life number four. The patient did not require phototherapy during this hospitalization. 5. HEMATOLOGY: The patient is with a hematocrit of 44.4 on [**2197-11-14**]. The patient required no blood products during this hospitalization. 6. INFECTIOUS DISEASE: CBC and blood cultures sent on admission. Initial CBC clotted. CBC repeated on [**2197-11-14**] and revealed a white count of 14.5 with 60 polys and no bands, platelet count of 377,000. Blood culture with no growth at 48 hours and antibiotics were discontinued. 7. SENSORY/AUDIOLOGY: Hearing screening was performed with automated auditory brain stem responses. The baby passed bilaterally. 8. IMMUNIZATIONS: The patient received hepatitis B vaccine on [**2197-11-16**]. 9. CAR SEAT TEST: The patient passed car seat test prior to discharge. 10. PSYCHOSOCIAL: [**Hospital1 18**] social work involved with the family. Contact social worker can be reached at [**Telephone/Fax (1) 8717**]. DISCHARGE DISPOSITION: Discharged to home with parents. PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] at [**Hospital3 2358**], [**Location (un) 8985**]. Phone number [**Telephone/Fax (1) 50542**]83. CARE AND RECOMMENDATIONS: 1. Feeds at discharge: The patient is on p.o. ad lib feeds of breast milk and E20. 2. Medications: None. 3. Car seat test: Passed car seat test prior to discharge. 4. Newborn screen: Sent and pending at the time of discharge. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2197-11-16**]. FOLLOW-UP APPOINTMENTS: The patient is scheduled to follow-up with Dr. [**Last Name (STitle) **] on [**2197-11-24**] at 1:00 p.m. DISCHARGE DIAGNOSIS: 1. Prematurity at 36 weeks gestational age. 2. Status post rule out sepsis, on antibiotics. 3. Respiratory distress syndrome, resolved. 4. Requiring gavage feeds, resolved. [**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**] Dictated By:[**Last Name (NamePattern1) 50027**] MEDQUIST36 D: [**2197-11-23**] 11:29 T: [**2197-11-23**] 11:57 JOB#: [**Job Number 50543**]

Admission Date: [**2106-9-22**] Discharge Date: [**2106-9-29**] Date of Birth: [**2059-9-20**] Sex: M Service: MEDICINE Allergies: Epoetin Alfa Attending:[**First Name3 (LF) 905**] Chief Complaint: Fever and chills Major Surgical or Invasive Procedure: 1. Revision left total knee replacement (polyethylene exchange). 2. Extensive irrigation, debridement and extensive synovectomy left septic knee. 3. Temporary hemodialysis line placement and removal 4. Tunneled hemodialysis catheter placement History of Present Illness: 47 year old male with ESRD, DM and HTN with chief complaint of not feeling well for one week. Pt. has had chills, fever, feeling hot, diarrhea, n/v on [**9-19**]). Feeling worse over this past weekend. Pt. has a R IJ tunneled HD catheter and a L AVF that is not mature. Still had chills todat at HD. In addition, the catheter was not functioning at dialysis this am. Blood cultures done at HD on [**2106-9-14**]. These came back positive for gram positive cocci in pairs in both the aerobic and anaerobic bottles, were confirmed enterococcus faecalis. Pt was initially treated with cefazolin at HD until the sensitivities. He was changed to vancomycin and received 1 gm vanc on Sat [**9-18**] and 500 mg vanc today. Yesterday noted onset of left knee swelling and pain. Had temp of 101.8 at HD today. He did not complete scheduled hemodialysis today (only 2 hrs total). Last complete HD was Saturday. Past Medical History: 1. Diabetes mellitus type I, on insulin, complications include in neuropathy, a left toe amputation, and retinopathy. 2. Chronic renal insufficiency, started on HD [**2106-7-30**]. 3. Peripheral vascular disease. 4. History of syncopal episodes. 5. Status post left toe amputation. 6. Autonomic neuropathy. 7. Degenerative joint disease. 8. Anemia of chronic inflammation. 9. History of orthostatic hypotension. 10. Hypertension. 11. Chronic diarrhea thought to be secondary to diabetic enteropathy. 12. HCV. 13. History of left knee replacement secondary to trauma, [**2105**] at [**Hospital1 112**]. Social History: There is a prior history of IV drug abuse nine years ago. No alcohol. Quit tobacco two years ago. Lives in a house with wife and owns a shoe store. Has several grown children, all in good health. Family History: Mother died of heart attack in early 50's. h/o DM, sister has DM. Physical Exam: Vitals: Tc 98.6 BP 105/59 HR 79 RR 20 O2 sat 96%RA Gen: NAD, alter, oriented HEENT: PERRL, nl conjunctiva, clear mucous membranes Neck: no LAD Lungs: bibasliar crackles Cor: RR, nls1 and s2, 2-3/6 systolic ejection murmur Abd: +BS, NT, ND Ext: Left knee swollen, warm to touch, pain with movement, no petechia, splinter hemorrhages, or oslers node on fingers Neuro: wnl Pertinent Results: [**2106-9-21**] 01:45PM BLOOD WBC-20.0*# RBC-2.97* Hgb-8.1* Hct-25.4* MCV-86 MCH-27.3 MCHC-31.8 RDW-14.1 Plt Ct-352 [**2106-9-23**] 10:40AM BLOOD WBC-13.6* RBC-2.67* Hgb-7.3* Hct-22.7* MCV-85 MCH-27.3 MCHC-32.1 RDW-14.6 Plt Ct-404 [**2106-9-24**] 05:15AM BLOOD WBC-14.6* RBC-2.97* Hgb-8.3* Hct-24.8* MCV-84 MCH-27.8 MCHC-33.3 RDW-14.4 Plt Ct-388 [**2106-9-21**] 01:45PM BLOOD Glucose-251* UreaN-33* Creat-5.9* Na-134 K-4.1 Cl-96 HCO3-26 AnGap-16 [**2106-9-23**] 10:40AM BLOOD Glucose-56* UreaN-46* Creat-7.3* Na-138 K-3.5 Cl-100 HCO3-26 AnGap-16 [**2106-9-24**] 05:15AM BLOOD Glucose-130* UreaN-51* Creat-7.5* Na-135 K-3.9 Cl-98 HCO3-25 AnGap-16 [**2106-9-21**] 01:45PM BLOOD Vanco-11.5* [**2106-9-22**] 05:45PM BLOOD Vanco-34.4 [**2106-9-23**] 10:40AM BLOOD Vanco-22.1* CATHETER TIP-IV RT. IJ GRAM NEGATIVE ROD Brief Hospital Course: 1. Bacteremia: The patient was admitted with fevers, chills, and blood cultures growing enterococcus, with his HD catheter being the culprit source. The line was discontinued and the line tip and swab from the line swab grew enteroBACTER, pan-sensitive. The patient was continued on vancomycin, with levels followed for target trough of 15-20, for enterococcus as well as levofloxacin for enterobacter, in addition to gentamicin. TTE showed 1+ MR, no other valvular abnormalities. He is discharged with five weeks of Vancomycin to complete a six-week course. He is also being discharged on Levofloxacin and Gentamicin. . 2. Knee pain/swelling- The patient was diagnosed with a septic prosthetic knee, with joint fluid that grew enterococcus. Orthopedic surgery was consulted and performed a knee wash out in the OR on [**2106-9-22**] with polyethylene exchange. X-ray on admission showed femoral periosteal thickening which raised the question of chronic osteomyelitis; this is of uncertain activity without prior films. No findings to suggest acute osteomyelitis, but pt may need knee replacement or further debridement. HV in place until [**9-25**]. The plan is for the patient to eventually have the hardware replaced in his knee, once his infectious disease issues resolve. . 3. HCV- The patient was previously scheduled for a liver biopsy but this was cancelled until bacteremia resolved. . 4. ESRD: Renal followed the patient throughout his admission. His creatinine steadily increased throughout the start of his hospitalization. Renal attempted to use his new fistula on [**9-23**] (placed [**8-11**]), but did the fistula did not function properly. A tunnelled HD line was placed by IR on [**2107-9-28**] and the patient reinitiated dialysis. . 5. Anemia: The patient was noted to have a hematocrit that trended down to 23.2, down from a baseline around 26. Per the recommendation of Renal, the patient was given 1U PRBC with lasix (pt does have some urine output). . 6. DM- The patient was continued on a regular insulin sliding scale Medications on Admission: Vancomycin insulin sliding scale Discharge Medications: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) as needed. 5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO QOD for 1 weeks. [**Date Range **]:*4 Tablet(s)* Refills:*0* 6. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous QOD for 5 weeks: Will be dosed by level at Hemodialysis. Please give this prescription to the hemodialysis nurse. [**Last Name (Titles) **]:*15 -* Refills:*0* 7. Gentamicin 10 mg/mL Solution Sig: 0.7 mg/kg Intravenous QOD for 2 weeks: Please check trough before hemodialysis. If less than 1, give 0.7mg/kg dose. Please hand this prescription to hemodialysis nurse. [**Last Name (Titles) **]:*6 -* Refills:*0* 8. Insulin NPH 12U, Regular 10U in AM 9. OxyContin 80 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO twice a day. 10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: 1. Enterobacter associated line infection 2. Enterococcus bacteremia 3. Enterococcus septic prosthetic knee Secondary diagnoses: 1. Diabetes Mellitus 2. End stage renal disease on HD 3. Hypertension Discharge Condition: Good Discharge Instructions: You are discharged to home and should continue all medications as prescribed. Please contact your primary care physician or present to the ER if you experience fevers, chills, night sweats, increased knee swelling or tenderness or other concerns. You have many important follow-up appointments- please attend every one. Followup Instructions: [**First Name8 (NamePattern2) 1955**] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 4337**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2106-10-5**] 2:00 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2106-10-8**] 10:10 Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Where: BA [**Hospital Unit Name **] ([**Hospital Ward Name **] COMPLEX) PODIATRY Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2106-10-11**] 11:00 You have a follow-up appointment with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**] on [**2106-10-13**] at 10:00. [**Telephone/Fax (1) 1792**] Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2106-10-13**] 1:40 You have a follow-up appointment with Orthopedic surgeon Dr. [**First Name (STitle) **] on [**2106-11-3**] at 10:30am. [**Telephone/Fax (1) 1113**] Hemodialysis three times/week: Vancomycin trough drawn and dosed at HD for five weeks Gentamicin trough checked before each HD session. If less than 1, please give 0.7mg/kg dose for two weeks [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

Admission Date: [**2146-3-30**] Discharge Date: [**2146-4-4**] Date of Birth: [**2146-3-25**] Sex: M Service: NB HISTORY: Baby boy [**Known lastname 11679**] was a 3.080 kg product of a 35 and 4/7 weeks delivery born to a 31-year-old G2, P0, now 1 mother with insulin dependent diabetes mellitus, chronic hypertension, and hypothyroidism. She has been on an insulin pump, labetalol and levothyroxine during this pregnancy. Prenatal screens - blood type A positive, direct Coombs negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, GBS unknown. Pregnancy was benign other than for increased intensity of monitoring for the maternal medical condition. She had a cesarean section for spontaneous decelerations. No maternal fever or other critical evidence of chorioamnionitis. The infant was vigorous at birth with Apgars of 8 at 1 minute, and 8 at 5 minutes and required oxygen initially but was weaned in the first few hours of life and was transferred to [**Hospital3 1810**] NICU due to bed availability for monitoring of respiratory status and glucose. He remained in room air with well maintained glucose on ad lib demand feeding. He was transferred back to the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] regular nursery on [**2145-3-28**], for routine neonatal care. In the newborn nursery he was noted to be jaundiced with a bilirubin of 15.8/0.3 on [**3-29**]. Phototherapy was started at that time and subsequent reduction to 15.2/0.4. The screening car seat test resulted in desaturations. At 0500 he was noted to have circumoral cyanosis with an oral feed which resolved with free flow oxygen. He was transferred to the NICU for further observation. HISTORY OF HOSPITAL COURSE IN THE NEWBORN INTENSIVE CARE UNIT: RESPIRATORY: He has been stable in room air throughout hospital course. In the initial 24 hours in the newborn intensive care unit, he was noted to have 2 episodes of desaturations to 79 and 80 with oral feedings. This has resolved. The last documented episode was on [**4-1**]. CARDIOVASCULAR: No issues. FLUIDS, ELECTROLYTES AND NUTRITION: Discharge weight is 3225 grams. The infant has been ad lib feeding Enfamil 20 calorie or breast milk, taking in adequate amounts. GASTROINTESTINAL: His most recent bilirubin was on [**2146-3-31**], and was 9.9/0.3. SENSORY: Hearing screen was performed with automated auditory brain stem responses and the infant passed. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **]. CARE RECOMMENDATIONS: Continue ad lib breast feeding on Enfamil 20 calories. MEDICATIONS: Not applicable. CAR SEAT POSITION SCREENING: The car seat position screening test was performed and the infant passed 90 minute screening. THE STATE NEWBORN SCREEN: The state newborn screens have been sent per protocol. IMMUNIZATIONS RECEIVED: The infant received Hepatitis B vaccine on [**2146-3-30**]. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria. 1. Born at less than 32 weeks. 2. Born between 32 and 35 weeks with two of the following: 2. daycare during the RSV season. 3. a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings. 4. with chronic lung disease. 1. 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. DISCHARGE DIAGNOSES: 1. Premature infant born at 35 and 4/7 weeks. 2. Respiratory immaturity. 3. Hyperbilirubinemia. [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2146-4-3**] 22:04:22 T: [**2146-4-3**] 23:52:33 Job#: [**Job Number 66426**]

Admission Date: [**2154-7-28**] Discharge Date: [**2154-8-1**] Date of Birth: [**2090-5-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: EGD History of Present Illness: 64 yo F with h/o DM1 now admitted with hypertensive crisis. Pt states she has had bouts of chest pain with her hiatal hernia in the past that have lasted for several days. States 4 days PTA at [**Hospital1 18**] she awoke with chest pain and nausea and vomiting that was typical of her nml hiatal hernia pain only was more severe in nature. Also had some chills but no fevers, no SOB, cough. Went to a hospital in NH and states she was diagnosed with pna and started on an antibiotic. States she was told that her chest pain was [**1-3**] the hiatal hernia. She continued to have vomiting and states she was only able to tolerate sips of clears. She did tolerate jello before being discharged 1 day PTA. States she was given all of her regular BP meds at the OSH but was told that her sBP was persistently in the 190's. States she went home and continued to have nausea, vomiting, and was unable to tolerate any po's so came to [**Hospital1 18**] the following day. On day of admission she states she was able to take the Diovan 160mg but no other BP meds. On admission in the ED, BP 211/90, HR 82. Initial ECG showed 1mm ST depressions V5-6. <1mm STE in V1-2. She was started on heparin gtt, nitro gtt, 5mg IV metoprolol x 3 and morphine 10mg IV. CTA negative for dissection and PE. Nitro gtt was titrated up to 300mcg and a CCU bed was requested because the pt was still experiencing some chest discomfort. ROS: Denies PND, SOB. Has some DOE with walking but attributes this to deconditioning given that she is unable to exercise b/c of her sciatica. With regards to BP states that Diovan was recently decreased from 320 to 160mg daily due to hyperkalemia. States had a black stool this a.m. that was formed and soft. Had a cscope 1 month ago which showed only grade 1 internal hemorrhoids. Past Medical History: 1. Sciatica with h/o laminectomy. 2. DM1 for 36 years, on insulin pump 3. Hypercholesterolemia 4. h/o CP in [**2137**], cardiac cath clean - sx's felt to be ?spasms. 5. HTN 6. Hiatal hernia 7. s/p hysterectomy Social History: Married, lives with husband, has 4 children, smokes 10 cig/day, occassional EtOH, no illicit drug use. Family History: Mother MI [**97**]'s Father MI [**07**]'s Physical Exam: PE: VS: 99.0, 69, 142/65, 11, 100% on 2L NC. Gen: alert, oriented, cooperative female in NAD HEENT: MM dry, OP clear, PERRL Neck: no lymphadenopathy, no thyromegally, no JVD Lungs: clear to ausculatation bilaterally CV: RRR, nl S1S2, II/VI systolic murmer at LLSB Abd: soft, non-tender, non-distended, positive BS, insulin pump in place with no erythema or tenderness surrounding insertion site. Ext: no edema Neuro: strength 5/5 UE and LE, no slurred speech, CN II-XII intact. Pertinent Results: [**2154-7-28**] 11:48PM GLUCOSE-100 UREA N-16 CREAT-1.0 SODIUM-137 POTASSIUM-3.0* [**2154-7-28**] 11:48PM PHOSPHATE-1.7* MAGNESIUM-1.5* [**2154-7-28**] 11:48PM PT-14.8* PTT-68.5* INR(PT)-1.3* [**2154-7-28**] 05:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2154-7-28**] 05:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2154-7-28**] 05:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2154-7-28**] 04:15PM GLUCOSE-122* UREA N-15 CREAT-1.0 SODIUM-137 POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-28 ANION GAP-15 [**2154-7-28**] 04:15PM ALT(SGPT)-32 AST(SGOT)-40 LD(LDH)-301* CK(CPK)-270* ALK PHOS-86 AMYLASE-88 TOT BILI-0.7 [**2154-7-28**] 04:15PM LIPASE-63* [**2154-7-28**] 04:15PM CK-MB-3 cTropnT-<0.01 [**2154-7-28**] 04:15PM PHOSPHATE-1.8* MAGNESIUM-1.6 [**2154-7-28**] 04:15PM WBC-8.2 RBC-3.34* HGB-10.9* HCT-30.5* MCV-91 MCH-32.6* MCHC-35.8* RDW-13.8 [**2154-7-28**] 04:15PM NEUTS-73.6* LYMPHS-17.9* MONOS-7.8 EOS-0.5 BASOS-0.2 [**2154-7-28**] 04:15PM PLT COUNT-184 [**2154-7-28**] 04:15PM PT-12.5 PTT-27.1 INR(PT)-1.1 CTA [**2154-7-28**]: 1) No PE or aortic dissection. 2) Small bilateral pleural effusions, without CT evidence of congestive heart failure. 3) Left renal calculus with small amount of nonspecific fluid and stranding lateral to the left kidney. CTU could be performed if concerned about obstructing ureteral stone. 4) Cholelithiasis. 5) Small hiatal hernia. . CXR [**2154-7-28**]: no acute cardiopulmonary abnmlity. . Echo [**2154-2-19**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] in size. No ASD. Mild symmetric LVH. LV size is normal. LVEF>55%. No masses or thrombi are seen in the LV. No VSD. RV chamber size and free wall motion are normal. Aortic valve leaflets mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Stress [**6-/2148**]: Exercised for 6 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol. The test was stopped at the patient's request due to neck discomfort, lower back discomfort and fatigue. This represents a limited physical working capacity. She reported a progressive discomfort in the back of her neck beginning at 3.75 minutes of exercise, progressing to [**7-11**] at 4 minutes of exercise, subsiding to [**5-11**] at peak exercise and resolving completely with rest by 5 minutes of recovery. No ST segment changes were noted during exercise or recovery periods. The rhythm was sinus with no ectopy. Blood pressure response to exercise was appropriate, heart rate response was blunted. IMPRESSION: Possible atypical anginal type symptoms with no ischemic EKG changes at the achieved workload. Nuclear report sent separately. . pMIBI [**6-/2148**]: Resting perfusion images were obtained with thallium. Tracer was injected 15 minutes prior to obtaining the resting images. Exercise images were obtained with MIBI. Stress images show no perfusion defects. Resting perfusion images show no abnormality. LVEF calculated from gated wall motion images obtained after exercise shows a LVEF that is visually estimated at 50%. The wall motion is normal. IMPRESSION: No perfusion defects at the level of exercise achieved. . EGD ([**2154-7-31**]): Grade 2 esphagitis in distal [**12-4**] of esophagus. Mild antral gastritis. Brief Hospital Course: 64 yo F with h/o DM1 admitted with hypertensive urgency and chest pain. . # Hypertensive crisis: Ms [**Known lastname 5936**] was admitted with SBP >200 despite having taken her regular BP meds at home; she reports her SBP was similarly elevated throughout her recent admission to OSH. She has not been able to take her medication regularly recently however due to persistant nausea and vomiting. Her HTN is likely secondary to a) lack of BP meds, b) pain and n/v causing increased sympathetic stimulation. She was initially started on a nitro gtt in the ED; upon admission to the CCU she was transitioned to PO labetolol overnight. She was restarted on her outpatient medications with the addition of carvedilol, which was titrated to 25 [**Hospital1 **]. The patient continued to have elevated BP, so Amlodipine was added. The patient will follow up with her PCP [**Last Name (NamePattern4) **] 1 week; as she recovers from this acute illness her PCP may be able to wean her BP regimen. She may need an outpatient renal artery MRA to evaluate for secondary hypertension. . # Chest pain: Ms [**Known lastname 5936**] reports that this episode of chest pain is similar to pain she has had with her hiatal hernia/gastritis in the past. Cardiac ischemia was thought to be very unlikely given ECG relatively unchanged and 2 sets of negative cardiac enzymes. Her pain was treated with standing reglan, PPI, [**Last Name (LF) 16606**], [**First Name3 (LF) **] dPRN morphine. She was continued on her [**First Name3 (LF) **], statin. We recommend an outpatient follow up stress test. . # N/V: The patient reports that her symptoms were consistent with her hiatal hernia/gastroparesis/gastritis in the past. She may have had a viral syndrome (had chills previously), though she did not have diarrhea. Obstruction was thought to be very unlikely as the patient had regular BM's with active bowel sounds. GI was consulted, and an EGD was performed, which showed mild antral gastritis and Grade 2 distal esophagitis. She was treated with anzemet prn and ativan PRN as well as reglan, [**First Name3 (LF) 16606**], and PPI [**Hospital1 **]. She was also given IVF hydration. She will follow up with GI as an outpatient. . # h/o black stools with anemia: had cscope 1 month ago which was negative, and EGD this admission did not show active bleed. She likely has. Now likely has anemia of inflammation; anemia labs were sent (including B12, folate and iron studies) and were pending at discharge. She did not require transfusion. She will follow up with her PCP. . # FEN: her electrolytes were followed and repleted as needed. She tolerated PO diet. . # Endocrine: She was continued on her insulin pump for her type 1 DM; however on [**7-31**] she ran out of insulin cartridges (though she did not tell her doctors) and she developed DKA. She was treated with IVF, IV insulin and started on NPH/ISS with rapid correction of the DKA. [**Last Name (un) **] was consulted; she was discharged on her insulin pump. She will follow up with [**Last Name (un) **]. She was continued on levothyroxine for her hypothyroidism. . # h/o pna diagnosed at OSH: The patient had no signos or symptoms of pneumonia throughout her admission, therefore no antibiotices were given. . # h/o depression: continue citalopram. No active issues. . # h/o sciatica: cont [**Last Name (un) 16604**] and neurontin. Medications on Admission: Diovan 160mg daily Lisinopril 40 daily HCTZ 25 daily [**Last Name (un) **] 325 Citalopram 20mg po daily Levoxyl 75mcg daily Lorazepam 0.5mg po prn Neurontin 800 qam, 800mg qpm, and 1600 qhs [**Last Name (un) **] 30mg qam, 10 qpm Ranitidine 300mg daily Reglan 10mg before meals and at bedtime Rocaltrol 0.25mcg qam Zocor 40mg po qhs Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 400 mg Capsule Sig: Four (4) Capsule PO HS (at bedtime). 6. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3) Tablet Sustained Release 12HR PO QAM (once a day (in the morning)). 7. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO QPM (once a day (in the evening)). 8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO bid (). Disp:*60 Tablet(s)* Refills:*2* 13. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 15. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 18. Insulin Continue your insulin pump regimen as prescribed by your doctors at [**Name5 (PTitle) **]. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency. Esophagitis (grade 2). Antral gastritis Discharge Condition: Good- blood pressure controlled, tolerating PO diet. Pain resolved. Discharge Instructions: During this admission you have been treated for hypertension, esophagitis and gastritis. Please continue to take all medications as prescribed. Please follow up with your PCP and the [**Hospital **] clinic as listed below. Please discuss the following at your follow up visit with Dr [**Last Name (STitle) **]: 1. Blood pressure medication regimen 2. Workup for secondary causes of hypertension (specifically, MRA of renal arteries) 3. Blood sugar control 4. Status of your abdominal pain/nausea 5. Anemia If you develop [**Last Name (STitle) 9140**] headache, dizziness or lightheadedness, chest pain, increased nausea/vomiting, difficulty controling your blood sugars or any other symptom that is concerning to you, please seek immediate medical care. You have been started on the following new medications: Carvedilol, amlodipine, [**Last Name (STitle) 16606**], pantoprazole Followup Instructions: DR [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2154-8-7**] 3:50 Phone: [**Telephone/Fax (1) 250**] DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (GI) Date/Time: [**2154-8-19**] 12:30 Phone: [**Telephone/Fax (1) 682**]

Admission Date: [**2174-6-8**] Discharge Date: [**2174-6-11**] Service: [**Location (un) **] General Medicine Firm HISTORY OF PRESENT ILLNESS: 85-year-old woman with history of metastatic pancreatic biliary cancer who presents from home with 3-4 days of malaise with weakness. Her last bowel movement was three days prior to admission. She has decreased urine output the prior two days, no chest pain although she does have some shortness of breath and abdominal pain over the past few days. She feels weak and has diffuse aches and pains. She has a history of GI bleed in the setting of anticoagulation for pulmonary embolism. In [**2174-2-18**] she underwent embolization of a duodenal artery by interventional radiology at that time. She has a large pancreatic mass requiring gastrojejunostomy done by Dr. [**Last Name (STitle) **] because of stricture/obstruction. She has not noticed any melena or bright red blood per rectum. In the Emergency Room she was with blood pressure 80/60, hematocrit 12.5, received one liter of normal saline, one unit of packed red blood cells. EGD showed bleeding of a pancreatic mass in the stomach. Patient and family wanted to proceed with IR intervention. PAST MEDICAL HISTORY: Metastatic pancreatic cancer, biliary cancer with mets to the liver diagnosed in [**2-19**] during GJ tube placement with liver biopsy. Pulmonary embolism status post IVC filter placement in [**2173-12-18**]. GI bleed in the setting of anticoagulation for pulmonary embolism. Hypertension. Diabetes mellitus type 2, coronary artery disease status post MI, status post cholecystectomy, chronic obstructive pulmonary disease. ALLERGIES: No known drug allergies. MEDICATIONS: Calcium carbonate 1 gm tid, Captopril 150 mg po tid, Reglan 10 mg po tid, Metoprolol 50 mg po bid, Zantac 150 mg po bid, Ativan .25 mg po q 8 hours prn, Darvocet two tablets po prn, OxyContin 20 mg po bid prn, Ambien 5 mg po q h.s. prn, Glucotrol 5 mg po bid. SOCIAL HISTORY: No tobacco or alcohol use, she immigrated 9 years ago. FAMILY HISTORY: Father had esophageal cancer, mother had a stroke, brother has lung cancer. PHYSICAL EXAMINATION: On admission is notable for temperature 97.7, pulse 79, blood pressure 94/63, respirations 15. 100% sat on room air. In general, alert and oriented times three, no acute distress, Russian speaking. HEENT: Pupils are equal, round, and reactive to light, extraocular movements intact, oropharynx clear, right IJ line in place, no lymphadenopathy. Heart tachycardic, no murmurs, rubs or gallops. Chest is clear to auscultation bilaterally, no wheezes or rales. Abdomen soft, nontender, active bowel sounds, positive ascites. Extremities, no edema, dorsalis pedis pulses +2 bilaterally. Neuro, cranial nerves II through XII intact. LABORATORY DATA: White blood count 13.2, hematocrit 12.5, platelet count 219,000, INR 1.3, BUN 56, creatinine 1.0. LFTs within normal limits. CK and troponin within normal limits. Albumin 2.9. EKG was normal sinus rhythm at 86 with normal axis, normal intervals, a Q in lead 3 which is old with flipped T in 1 and 2 and 3 which is new. HOSPITAL COURSE: The patient was admitted and taken to the Intensive Care Unit. For left GI bleed she received multiple units of packed red blood cells and then a stable hematocrit after transfusions in the mid 30's. EGD was done which showed a bleeding pancreatic mass and therefore patient went to angiography, had embolization of her gastroduodenal branch with good results. She has been hemodynamically stable since the procedure and was called out of the Intensive Care Unit on [**2174-6-9**]. The procedure was complicated with right groin hematoma which has since improved. A radiation oncology consult was obtained to evaluate for palliative radiation to the site of her mass. They felt it would not be of benefit. After discussion with the family and with the patient, we decided on no further treatment at this time for the malignancy but to try to optimize her status by transferring her to [**Hospital **] [**Hospital **] Rehab. Her PO intake has been gradually increased with the normal 50 cc IV fluids. Also of note, her CKs were normal and her blood pressure was initially low and then as it increased the Metoprolol and then the Captopril were able to be added back on. She had occasional runs of supraventricular tachycardia which all stopped spontaneously. Her hematocrit after 6 units of packed red blood cells is in the mid 30's. DISCHARGE MEDICATIONS: Calcium carbonate one po tid, Captopril 25 mg po tid, Metoprolol 50 mg po bid, Reglan 10 mg po tid, Protonix 40 mg po bid, Ativan .25 mg po q 8 hours prn, Darvocet two tabs prn, OxyContin 20 mg po bid prn, Ambien 5 mg po q h.s. prn, Glucotrol 5 mg po bid, Colace 100 mg po bid. Diet is cardiac and diabetic. She will have physical therapy at [**Hospital1 **]. FINAL DIAGNOSIS: 1. Metastatic pancreatic cancer/biliary cancer. 2. Pulmonary embolism. 3. Upper GI bleed, now status post embolization. Patient is stable for transfer. Upon transfer her oncologist will have further discussions with the family about code status and possible hospice placement. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Name8 (MD) 6069**] MEDQUIST36 D: [**2174-6-10**] 16:15 T: [**2174-6-10**] 17:54 JOB#: [**Job Number 6070**]

Admission Date: [**2117-10-1**] Discharge Date: [**2117-10-6**] Service: NEUROLOGY Allergies: Lipitor Attending:[**First Name3 (LF) 5868**] Chief Complaint: Code Stroke Major Surgical or Invasive Procedure: IV tPA History of Present Illness: Patient is a [**Age over 90 **] year old Russian speaking unknown handedness woman with past medical history of TIA [**7-3**] with slurring of speech, atrial fibrillation not on anticoagulation, hypertension, severe AS, glaucoma and cataracts with legal blindness who presented to [**Hospital1 18**] ED on [**2117-10-1**] at 11:55 am as a "Code Stroke". Per information from her family and her home health aide, patient was well this morning. Her daughter, who lives next door, was visiting. Patient ate normally and spent all morning playing with her great grandson [**Name (NI) 12130**]. [**Name2 (NI) **] daughter left around 10:15 am. Around 11 or 11:15am, her home health aide [**Doctor First Name 38329**] arrived. Family and I spoke to [**Doctor First Name 38329**] via telephone. Per [**Doctor First Name 38329**], patient was able to open door to let [**Doctor First Name 38329**] in and was walking around the house normally (in her usual fashion, which is holding onto the walls because she is legally blind and refuses to use a walker). [**Doctor First Name 38329**] and patient had conversation. Patient complained about the weather, but did not endorse any neurologic complaints. Per [**Doctor First Name 38329**], patient's speech was normal. Then, around 11:30 am, they went into bathroom to get patient ready for bath. While in bathroom, patient started to have slurring of speech, was diaphoretic, and had left facial droop and difficulty using her left side. [**Doctor First Name 38329**] called the patient's son [**Name (NI) 2491**] who then called EMS. She arrived at [**Hospital1 18**] ED at 11:55am. Code Stroke called at 11:57am. Neurology Resident on scene at 12:08pm; stroke fellow had arrived several minutes earlier. NIH stroke scale was performed and graded as follows: 1a LOC: Alert=0 1b LOC questions: Said name=1 1c Commands: Able to follow commands=0 2 Gaze: Fixed to right. Could not overcome with OCR=2 3 Vision: Blind per family. No consistent blink to threat=3 4. Facial: Left UMN palsy=2 [**6-4**]. Motor: Holds right arm and leg off bed with no drift. Left arm and leg are plegic with no withdrawal to pain=3+0+3+0 7. Limb ataxia: Proportional to weakness=0 8. Sensory: Severe sensory loss on left arm/leg/face=2 9. Language: Limited by language barrier, but some perseveration, stuttering=1 10. Dysarthria: Speech slurred by family=1. 11. Neglect: Left hemineglect profound=2 Scored at 21. Noncontrast head CT showed no evidence of hemorrhage. Discussed with Stroke Fellow, Attg Dr. [**Last Name (STitle) **], and patient's family members. Risks/benefits of thrombolysis reviewed. Contraindications reviewed with family and patient had no absolute contraindications by history. Decision made to proceed with thrombolysis with bolus 4.9 mg and infusion of 44.2mg. Bolus started at 1:30pm. While bolus was being infused, patient noted to move left arm and to have resolution of her right eye deviation. Post tPA bolus, BP elevated to 190s systolic, so at 1:50pm, 5 mg IV Labetalol given per stroke fellow. 10 mg IV Labetalol given at 2:15pm after BP goals changed to systolic of 140-160 after recanulization. Per family, no recent fevers, chills, chest pain, palpitations, nausea, vomiting, abdominal pain. Past Medical History: 1. TIA [**7-3**] with slurred speech 2. Atrial fibrillation not on coumadin 3. Hypertension 4. Severe Aortic Stenosis 5. Dyspnea 6. Leg swelling 7. Hearing loss 8. Glaucoma 9. Cataracts , legally blind Social History: Social Hx: Lives alone. Moved here from [**Country 532**] 24 years ago. Employed as a food engineer. No alcohol, tobacco, drug use. Daughter lives next door. Proxies are her children [**Female First Name (un) **] and [**Doctor First Name 2491**]. Family History: Non-contributory Physical Exam: Tc: BP: 194/122 HR: 125 RR: 18 O2Sat.: 100%/NRB Finger stick 122 Gen: WD/WN elderly female, resisting examiners, agitated. HEENT: NC/AT. Anicteric. Corneas clouded bilaterally. Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No carotid bruits. Lungs: CTA bilaterally. No R/R/W. Cardiac: Tachycardic, irregularly irregular. S1/S2. Grade [**3-7**] murmur at upper right sternal border, radiating to carotids. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. No C/C/E. Neuro pre tPA: Mental status: Awake and alert, nods to family if asked if she is in the hospital. Able to state name, but occasionally stuttering her speech and having word finding problems. [**Name (NI) **] to follow commands to raise arm and leg, grip hand. Cranial Nerves: I: Not tested II: Pupils irregular, post surgical. No blinks at all to left threat. Inconsistent blink to threat on right. III, IV, VI: Eyes fixed to right, could not overcome with oculocephalic manuever. V, VII: Left upper motor neuron pattern facial droop. Has brisk bilateral corneal reflexes. VIII: Hearing grossly intact. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Did not assess. XII: Tongue midline without fasciculations. Motor: Diffusely diminished bulk. Left upper extremity flaccid. Tone in left lower extremity reduced as well. Holds right arm and leg off bed against gravity for several seconds without drift. Unable to hold left arm or leg off bed; they immediately fall back. No withdrawal in left arm or leg to nailbed or more proximal pressure. Sensation: Intact to light touch in right arm and leg. Reflexes: B T Br Pa Ac Right 1 1 1 0 0 Left 2 1 1 0 0 Exam limited by patient cooperation. Right arm depressed compared with left. Toes mute. Coordination: Normal FNF on right. Unable to assess on left secondary to weakness. Gait: Did not assess. . At the time of discharge, the patient had recovered her speech and was alert and oriented x 3. She was moving all 4 extremities without difficulty. Pertinent Results: [**2117-10-1**] 10:17PM CK(CPK)-71 [**2117-10-1**] 10:17PM CK-MB-NotDone cTropnT-<0.01 [**2117-10-1**] 03:15PM URINE HOURS-RANDOM [**2117-10-1**] 03:15PM URINE GR HOLD-HOLD [**2117-10-1**] 03:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2117-10-1**] 03:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2117-10-1**] 03:15PM URINE RBC-<1 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2117-10-1**] 03:15PM URINE HYALINE-<1 [**2117-10-1**] 12:46PM GLUCOSE-113* UREA N-17 CREAT-1.0 SODIUM-140 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-16 [**2117-10-1**] 12:46PM CK(CPK)-144* [**2117-10-1**] 12:46PM CK-MB-1 cTropnT-<0.01 [**2117-10-1**] 12:46PM WBC-9.8 RBC-4.23 HGB-11.8* HCT-36.0 MCV-85 MCH-27.8 MCHC-32.6 RDW-16.3* [**2117-10-1**] 12:46PM PLT COUNT-248 [**2117-10-1**] 12:46PM PT-13.7* PTT-23.8 INR(PT)-1.3 . [**2117-10-1**] CT head - 1. No acute intracranial hemorrhage. 2. Likely subacute-to-chronic infarcts in the left parietal and right frontoparietal distributions. It is difficult to exclude early acute stroke given these findings, and if clinical suspicion remains high, MRI is recommended. . ECG - Atrial flutter with 2:1 response. Left anterior fascicular block Probable left ventricular hypertrophy with ST-T wave abnormalities The ST-T wave changes are nonspecific - clinical correlation is suggested . CXR - Evidence of failure. No evidence for pneumonia. . [**2117-10-2**] CT head - 1. Stable appearance of right middle cerebral artery area infarction. No evidence of interval intracranial hemorrhage. 2. Stable appearance of left posterior parietal infarction. . Carotid US - report pending at time of d/c Brief Hospital Course: The patient was transferred to the ICU on cardiac telemetry after administration of tPA. She ruled out for an acute myocardial infarction with three sets of negative cardiac enzymes. She had almost a total recovery from her symptoms after 1 day in the ICU. Her blood pressure was maintained in the 140-160 systolic range. After two days she was started on a heparin drip. She was eventually transferred to the floor after four days. Lisinopril was added for blood pressure control. The patient was started on warfarin with a goal INR of 2.0-3.0. She had several episodes of mild shortness of breath. This responded very well to light diuresis and atrovent nebulizers. The patient had carotid US that were found to be negative for significant disease. The etiology of her stroke was felt to be most consistent with a cardioembolic source secondary to atrial fibrillation. She was discharged to rehab with a follow up appointment to be seen in the stroke clinic within six weeks. Medications on Admission: 1. Alphagan 2. ECASA 325 mg po qd 3. Atenolol 50 mg po qd 4. Lasic 20 mg po qd 5. Levobunolol HCL 0.5% gtt 6. Lipitor 10 mg po qd 7. Xalatan 0.005% Discharge Medications: 1. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: Seven Hundred (700) units Intravenous per hour for until coumadin therapeutic w/ INR of 2.0-3.0 days: goal PTT between 45-60. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Levobunolol 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Right MCA embolic stroke Hypertension Aortic Stenosis CHF Discharge Condition: stable Discharge Instructions: Please call your primary care physcian or come to the emergency room if you experience slurred speeh, facial droop, impaired vision, difficulty swallowing, numbness, tingling, worsened weakness above baseline, shortness of breath, chest pain. Followup Instructions: Please make an appointment to be seen in stroke clinic with Dr. [**First Name8 (NamePattern2) 26055**] [**Name (STitle) **] ([**Telephone/Fax (1) 22692**] in 6 weeks. You will need to call to give your demographic information prior to making an appointment.

Admission Date: [**2191-5-21**] Discharge Date: [**2191-5-29**] Date of Birth: [**2154-7-26**] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: This is a 36-year-old male with a nonsignificant history was admitted 3 days ago from an outside hospital. According to his wife, the patient was in normal state of excellent health until a week-and-a-half ago, before his admission, when he noted the onset of left flank pain a few days after his return from a golf trip to [**State 108**]. The patient notes that the day before his admission, he had developed gross blood in his urine. However, despite this symptom, his wife reports that he went to work the morning of his admission, returned around noon, seemingly to be in normal health. He was found by a neighbor around 8 p.m., on the day of admission incoherent and crawled up in a fetal position in his front lawn, he was very agitated, but highly confused leading the neighbor to contact the EMS and police. Police noted that he was agitated, combative, and confused resulting in his transport to [**Hospital 1474**] Hospital. While at this outside hospital, he was initially alert and oriented times 3, but due to his combative behavior, he was given 60 mg of IV Ativan. By report, he was found to have a fever of 103 degrees, a negative head CT and EKG showing [**Street Address(2) 4793**] elevation from leads V1 through V4, and troponin level of 13. The urine toxic screen positive for benzodiazepines and cocaine. He was given IV Rocephin, aspirin, nitroglycerin, and an amp of D50, was intubated. He was transported by Med flight to [**Hospital1 18**] for emergent cardiac catheterization. At presentation to [**Hospital1 18**] ER, he was found to have a blood pressure of 205/101, a heart rate of 123, saturations at 99 percent on FiO2 of 0.6. His labs were significant for a white blood cell count of 13.6, platelets of 114, creatinine 2.7, serum glucose of 31, and ABG of 7.21 per pH, PCO2 41, PO2 134. He received bedside echocardiogram, which revealed normal LV function and no valvular disease with a question of apical hypokinesis. He was sent emergently to the cardiac catheterization lab, which did not reveal any evidence of coronary artery disease. His wedge was 22 mmHg, the cardiac output of 8 liters a minute and cardiac index of 4.2; however, his CK level increased from 450 at the outside hospital to 3835 on admission to [**Hospital1 18**] leading to suspicion of rhabdomyolysis. Following catheterization, the patient was admitted to the MICU. PAST MEDICAL HISTORY: Genital herpes. Muscle spasms on muscle relaxants at home. OUTSIDE MEDICATIONS: 1. Muscle relaxant that the patient cannot remember the name of. 2. Xanax p.r.n. HOSPITAL MEDICATIONS: 1. Protonix 40 mg p.o. q.d. 2. Flagyl 500 mg p.o. b.i.d. 3. Levofloxacin 250 mg p.o. q. 48h. 4. Sevelamer 800 mg p.o. t.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is married. He lives with his wife and a 1-year-old child. Child was left locked inside when Mr. [**Known lastname 12967**] was found outside forcing police to break down the door. VSS is involved in this case. The patient works as an occupational therapist. His wife denies the patient had any previous tobacco history or history of alcohol use or recreational drug use. However, the patient admits to having used cocaine for a total of 6 times as well as a red pill and [**First Name8 (NamePattern2) **] [**Location (un) 2452**] pill, which he is unable to mention the names of. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Temperature maximum 99.6 degrees, blood pressure 99-145 systolic over 60-74 diastolic. Heart rate 75 to 97, respiratory rate 13 to 28. Oxygen saturation 91 to 95 percent on room air. The patient was overall 15 liters positive upon transfer to the medicine service. Generally: Well-appearing, no apparent distress. HEENT: Normocephalic, atraumatic. Head, no pharyngeal erythema or exudate. Sclera anicteric. Neck: No JVD or lymphadenopathy. Cardiac: Normal. Pulmonary: Normal. Abdomen: Normal. Skin: No clubbing, cyanosis or edema. Neurologically: Alert and oriented, mildly delayed recall process. Cranial nerves intact. Visual fields full to confrontation. No pronator drift. Negative Romberg's. Rapid alternating movements intact. Touch and proprioception intact. Motor strength 5/5 in all extremities. LABORATORY DATA: From admission, white blood cell count 17.1, hematocrit 32.1, platelets 68. PTT 41.8, INR 3.7, fibrinogen 106, haptoglobin less than 20. Chemistry profile notable for a BUN of 15, creatinine is 7.9, glucose 104, calcium 7.4, phosphorous 7.2, magnesium 1.8. LFTs notable for an ALT of 2508, AST of 1871, LDH 1802, CK 6751, alkaline phosphatase of 81, T-bili 1.2. MICU course was complicated by persistent hypoglycemia requiring 4 amp's of D50. He developed hypotension requiring a Levophed infusion. His hematologic parameters continued to degrade with his hematocrit dropping to 33.6 from 44, and his platelets dropping to a low of 36,000 requiring a platelet transfusion. His thrombocytopenia was complicated by the development of coagulopathy with his INR increasing to a high of 3.5. His fibrinogen dropping to 63 and D-dimer level greater than 10,000, that was considered that this could be TTP/HUS, given the initial fever, mental status change, acute renal failure, and thrombocytopenia. However, the absence of a microangiopathic process on blood smear argued for the diagnosis of DIC instead. Chest radiograph showed evidence of patchy opacities in the right upper lobe and left lower lobe consistent with aspiration pneumonia. Infectious Disease was consulted while in the ICU. He was placed on Flagyl, vancomycin, and levofloxacin for presumed aspiration pneumonia and Acyclovir for HSV meningitis given his acute mental status changes. Additionally, renal consult and GI consults were obtained while the patient was in the ICU and as he had put out guaiac positive diarrhea and had rapidly progressed to acute renal failure. HOSPITAL COURSE WHILE ON FLOOR: Cardiac. The patient ruled in for myocardial infarction by cardiac enzymes and by his EKG changes consistent with that. However, his catheterization was unrevealing in terms of evidence for cardiac ischemia. The likely explanation was that this was mostly likely a cocaine induced vasospasm causing myocyte ischemia and death. His LV function was preserved according to the echocardiogram. Rhabdomyolysis. Given the patient's enormous increase in his CK, the patient had evidence of heme-positive urine. Again, this was mostly likely attributed to cocaine induced rhabdomyolysis. Other possible etiologies could have been virally induced or possibly related to the patient's status of being found down. The patient's CK slowly began to trend down with aggressive IV fluid hydration. Acute renal failure. The patient had nonoliguric acute renal failure. There was evidence of bloody-brown casts seen in his urine, which is characteristic of ATN. The patient maintained adequate urinary output without requiring dialysis. Liver dysfunction. The patient had evidence of hepatic involvement to his multisystem organ failure. This is mostly likely attributed to shock liver given his known development of DIC and profound hypertension during his first hospital day. Coagulopathy. It is most likely attributed to DIC. Hematology was consulted to assist in the management. There is no evidence of schistocytes on peripheral smears. Mental status changes. Although, the patient's mental status changes seemed highly likely to be solely to his cocaine use. It was also attributed to delirium and the onset of fever and possible sepsis. This improved after antibiotic treatment and IV fluid hydration. Uremia may have also contributed to his mental status decline. Hypoglycemia. The patient's initial metabolic derangements were noted in the ICU, the thought was that the patient may have had an adulterated form of cocaine with quinine, which is apparently common and can cause protracted hypoglycemia. Infectious disease. The patient was febrile without any obvious source of infection, felt that this may be attributed to the patient's atelectasis versus cytokine response to muscle or liver necrosis. The patient although was maintained on antibiotics for aspiration pneumonia. DISCHARGE DIAGNOSES: Acute myocardial infarction with cardiac catheterization showing no occluded coronary arteries. Acute nonoliguric renal failure. Disseminated intravascular coagulopathy. Rhabdomyolysis. Hepatitis consistent with shock liver contributing diagnosis include cocaine abuse. CONDITION ON DISCHARGE: The patient is stable without oxygen requirement, tolerating POs, mentating clearly. DISCHARGE STATUS: The patient would be discharged to home. MAJOR SURGICAL OR INVASIVE PROCEDURES PERFORMED: The patient had cardiac catheterization. He was intubated and he had a central line placement. FOLLOW UP: The patient will follow-up with his PCP [**Name Initial (PRE) 176**] 1 week. The patient will also follow-up with gastroenterology for an elective colonoscopy given his history of bloody diarrhea as an inpatient. Additionally, the patient will follow-up with intensive outpatient treatment program for substance abuse. The patient will have a follow-up renal ultrasound and follow-up with Dr. [**Last Name (STitle) 4883**] nephrology to monitor his renal function. DISCHARGE MEDICATIONS: 1. Amlodipine 5 mg p.o. q.d. 2. Protonix 40 mg p.o. q.d. 3. Ciprofloxacin 500 mg p.o. q.d. for 2 weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 27875**] Dictated By:[**Last Name (NamePattern1) 12866**] MEDQUIST36 D: [**2191-8-3**] 14:52:19 T: [**2191-8-4**] 10:17:06 Job#: [**Job Number **]

Admission Date: [**2102-11-23**] Discharge Date: [**2102-12-1**] Date of Birth: [**2040-2-29**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 62-year-old woman who presented as an outpatient with left flank pain and a 20-pound weight loss over a 5-month period. A CT scan at that time revealed a left renal mass with apparent tumor thrombus in the left renal vein. A subsequent magnetic resonance imaging scan confirmed this finding and also noted that this mass extended into the vena cava. A CT of the head and lungs, as well as a bone scan, did not demonstrate any obvious metastatic disease; however, there were several lung nodules which were not definitely excluded as representative of metastatic disease. After discussions with medical oncology and urology attending Dr. [**Last Name (STitle) **], it was determined that the patient would undergo a left radical nephrectomy with excision of the tumor thrombus in the vena cava as well as a perirenal lymph node dissection. HOSPITAL COURSE: The patient was admitted to the hospital on [**2102-11-23**] and underwent an uncomplicated preoperative embolization of the left renal artery in the Interventional Radiology suite. On [**11-24**], the patient went to the operating room and an uncomplicated left radical nephrectomy with a left renal vein tumor thrombectomy as well as a left periaortic lymph node dissection. The patient tolerated the procedure well and was transported to the Postanesthesia Care Unit intubated, in stable condition. The patient's postoperative course was relatively uneventful with the exception of a transient elevation of her bilirubin thought to be secondary to a transfusion reaction from the 8 units of packed red blood cells that she received during the operative procedure. The Pain Service was consulted to manage postoperative pain. Her medical oncologist, Dr. [**Last Name (STitle) 1729**], was contact[**Name (NI) **] and a fellow from medical oncology met with the patient to set up follow-up appointments as an outpatient. By postoperative day four her bowel function had returned, her diet was advanced, and she was tolerating a regular diet by the day of discharge. Her pain was well controlled, and she was ambulating independently. Her bilirubin continued to normalize, reaching a level of 2.7 from a high of 7.5 on the day of discharge. Her alkaline phosphatase, however, was slightly increased; again, thought to be secondary to transfusion reaction. Amylase and lipase remained normal. The patient's urine output throughout her postoperative course was excellent. The Pain Service came up with a regimen of a Fentanyl patch with the addition or oral Dilaudid for breakthrough pain as her outpatient regimen. The patient was discharged on [**12-1**], postoperative seven, afebrile with stable vital signs. The patient's pathology report subsequently revealed renal cell carcinoma (a clear-cell type, grade III) demonstrating invasion through the capsule into the perinephric fat with venous invasion; 0/2 perihilar nodes were positive for malignancy; [**3-14**] periaortic nodes were positive for malignancy. MEDICATIONS ON DISCHARGE: 1. Fentanyl patch 25-mcg q.72h. 2. Dilaudid 2 mg to 4 mg p.o. q.6h. p.r.n. for breakthrough pain. 3. Colace 100 mg p.o. b.i.d. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE DIAGNOSES: Renal cell carcinoma of the left kidney with tumor thrombus into the vena cava, status post left radical nephrectomy and left renal vein thrombectomy. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**] Dictated By:[**Last Name (NamePattern1) 3801**] MEDQUIST36 D: [**2102-12-7**] 19:14 T: [**2102-12-7**] 18:50 JOB#: [**Job Number 37003**]

Admission Date: [**2193-10-14**] Discharge Date: [**2193-10-17**] Date of Birth: [**2109-8-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 84 year old male with PMH significant for systolic heart failure EF 30%, HTN, hyperlipidemia, DM, CAD s/p CABG who presented with dyspnea on exertion of 3 days in duration. Patient presented to his pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and was referred to ED following a CXR which demonstrated bilateral pleural effusion. Patient reports he has not been taking his Lasix (60 mg [**Hospital1 **]) for the past "few" days. He reports associated cough, exertional dyspnea, fatigue and increasing lower extremity edema. Denies dyspnea at rest, PND or worsened orthopnea (sleeps with head of bed elevated at baseline). Denies chest pain or palpatations. Patient denies fevers, chills. Per his PCP, [**Name10 (NameIs) **] is ongoing concern about medication compliance at home with cardiac meds. . Presenting vitals to ED HR 53, BP 131/49, RR 26, O2 sat 81% 6L. Patient was placed on NRB, then Bipap, then transferred to ICU on 100% ventimask. In ED patient was given Lasix 40 mg IV, Nitropaste 1 inch, Levaquin and ASA. Due to respiratory compromise he was transferred to the ICU for futher care. . On review of systems, he denies any prior history of 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. He denies syncope or presyncope. The rest of the review of systems was negative in detail. Past Medical History: CAD s/p CABG x4v '[**74**] CHF EF 30-40% PVD DM c/b neuropathy HbgA1c 6.0% 4/09 CVA Gastritis Carotid stenosis HTN Hyperlipidemia BPH Depression Chronic constipation T12 compression fracture Cataract s/p surgery Glaucoma Social History: He grew up in [**State 5887**], has been living in [**Location (un) 86**] since [**2130**]. He is a veteran of World War II. He worked as a coal miner and then as a manual laborer. He has been retired for years. He is widowed and now living with his son and girlfriend (both are HCP). Distant history of smoking 40 years x 2 pack/yr, quit over 20 years ago. No alcohol use. No drug use. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: on admission: VS: T=98.7 BP=135/52 HR=56 RR=20 O2 sat=100% venti-mask GENERAL: Breathing on ventimask. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Unable to appreciate JVP. CARDIAC: Distant heart sounds. Irregular rate, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Decreased breath sounds left base, crackles right base. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Chest x-ray [**2193-10-14**] 1. Increased size of small-to-moderate right and tiny left pleural effusion with associated central vascular congestion compatible with CHF. 2. Increased left retrocardiac opacity which likely represents atelectasis, although pneumonia would be difficult to exclude. Pertinent Results: [**2193-10-14**] 04:20PM BLOOD WBC-7.2 RBC-4.11* Hgb-11.7* Hct-35.9* MCV-87 MCH-28.5 MCHC-32.6 RDW-17.0* Plt Ct-219 [**2193-10-17**] 06:50AM BLOOD WBC-6.5 RBC-3.74* Hgb-11.0* Hct-32.4* MCV-87 MCH-29.3 MCHC-33.8 RDW-16.7* Plt Ct-216 [**2193-10-14**] 04:20PM BLOOD PT-39.8* PTT-38.0* INR(PT)-4.2* [**2193-10-17**] 01:13PM BLOOD PT-22.2* PTT-33.4 INR(PT)-2.1* [**2193-10-14**] 04:20PM BLOOD Glucose-170* UreaN-27* Creat-1.3* Na-140 K-3.6 Cl-103 HCO3-26 AnGap-15 [**2193-10-17**] 06:50AM BLOOD Glucose-103 UreaN-28* Creat-1.3* Na-140 K-3.8 Cl-102 HCO3-31 AnGap-11 [**2193-10-14**] 04:20PM BLOOD CK-MB-5 proBNP-2458* [**2193-10-14**] 04:20PM BLOOD cTropnT-0.02* [**2193-10-15**] 12:03AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2193-10-15**] 06:02AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2193-10-15**] 06:02AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.2 [**2193-10-17**] 06:50AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.1 Brief Hospital Course: In summary, Mr. [**Known lastname **] is a 82M with CAD s/p CABG, systolic CHF who presented with dyspnea on exertion for 3 days duration in the setting of medication non-compliance. He was admitted to the cardiac intensive care unit and showed significant improvement with diuresis. . # Respiratory Distress: Patient's symptoms of dyspnea on exertion, increased lower extremity edema and non compliance with lasix suppported acute systolic CHF episode. CXR also supported this with b/l pleural effusions and associated central vascular congestion. Patient transferred from ED on venti mask. There was less concern for pneumonia as no symptoms, fever or elevated white count. Trigger of acute CHF was most likely med non-compliance; there were no EKG changes to suggest ACS, cardiac enzymes were never significantly elevated, and the patient denied increase of salt in diet. Patient was on 60 mg po BID lasix at home however was not taking it because of his frustration with needing to urinate frequently while on the medication. Pt did well with diuresis and fluid restriction and was transfered to the floor after a couple days in the ICU. He was discharged with an indwelling foley cath to help with his urine output and medication non-compliance with a follow-up appointment scheduled with urology. . # RHYTHM: Rate controlled atrial fibrillation. He was supratherapeutic on his INR on admission therefore warfarin was initially held. His outpatient Metoprolol was continued at 25mg qd. He was discharged with instructions to follow up in [**Hospital 2786**] clinic for titration of his warfarin dosing, and to resume coumadin dose at 7mg on [**10-18**] and [**10-19**] and [**10-20**] prior to [**Hospital 2786**] clinic visit. . # Coronaries: 3vd s/p CABG. His aspirin, statin and beta blocker were continued as an inpatient. His lisinopril was held given his acute renal failure. . # Acute renal failure: Hyaline casts on admission Ua were concerning for poor perfusion. Creatinine elevated mildly from baseline of 1.1, peaked at 1.5, then was downtrending prior to admission with a discharge creatinine of 1.3. Meds were renally dosed, electrolytes repleted and Lisinopril held. Would recommend outpatient follow-up to ensure complete resolution of his renal failure. . # HTN: his amlodipine was continued for hx of hypertension, lisinopril held as noted previously. . # DM: treated with NPH and insulin sliding scale while inpatient . # Depression: his celexa and risperidone were continued in the inpatient setting. . # Glaucoma: Brimonidine/Dorzolamide/Timolol were continued in the inpatient setting. The patient was full code, this was confirmed with [**Name (NI) **] [**Name (NI) **], [**First Name3 (LF) **]/HCP [**Telephone/Fax (1) 106933**]. Medications on Admission: MEDICATIONS: confirmed with son AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily BRIMONIDINE - 0.15 % Drops - 1 gtt(s) OD [**Hospital1 **] CITALOPRAM 40 mg Tablet - 1and [**1-18**] Tablet(s) by mouth once a day DORZOLAMIDE-TIMOLOL 0.5 %-2 % Drops - 1 gtt OD twice a day FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - 40 mg Tablet - 1.5 Tablet(s) by mouth twice a day LISINOPRIL 40 mg Tablet - 1 Tablet(s) by mouth daily METOPROLOL SUCCINATE - 25 mg Tablet once a day PILOCARPINE HCL [PILOPINE HS] 4 % Gel - apply OD at bedtime RISPERIDONE 1 mg Tablet - 1.5 Tablet(s) by mouth at bedtime SIMVASTATIN - 20 mg Tablet 1 Tablet(s) by mouth once a day for WARFARIN - 10 mg MWF, every other day 7 mg tablet ASPIRIN - (OTC) - 81 mg Tablet once a day INSULIN NPH HUMAN RECOMB [HUMULIN N] - (Dose adjustment - no new Rx) - 100 unit/mL Suspension - 14 units twice a day Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic QHS (once a day (at bedtime)). 5. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day. 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Risperidone 1 mg Tablet Sig: 1.5 Tablets PO at bedtime. 10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fourteen (14) units Subcutaneous twice a day. 13. Outpatient Lab Work Please check INR and Chem-7 on Monday [**10-21**] and call results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1144**]. Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: Acute on Chronic systolic congestive Heart Failure Acute Renal Failure Diabetes Mellitus Type 2 Coronary Artery Disease Hypertension Hyperlipidemia Discharge Condition: stable BP= 124/53 HR= 56 weight= 190 pounds Discharge Instructions: You had an episode of congestive heart failure from stopping Lasix at home. We have restarted your Lasix and kept a Foley catheter in. You will see Dr. [**Last Name (STitle) 770**] next week for evaluation. In the meantime, empty the foley bag whenever it gets full. The visiting nurse will help you with this at home as well. Weigh yourself every morning, call Dr.[**Doctor Last Name 3733**] if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet Fluid Restriction: 1500cc or about 8 cups. . Medication changes: 1. do not take Coumadin today. Resume coumadin on [**10-18**] and [**10-19**] and [**10-20**] and take 7 mg. Please check INR on [**10-21**] and the [**Hospital3 271**] will tell you how much to take. 2. Take your lasix twice daily at 60 mg Followup Instructions: Urology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2193-10-24**] 11:45. Please call the office for directions. Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] A. Phone: [**Telephone/Fax (1) 1144**] Date/Time: [**10-24**] at 11:00am. Cardiology: Dr. [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/time: Tuesday [**10-29**] at 2:20pm.

Admission Date: [**2147-4-17**] Discharge Date: [**2147-4-24**] Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 4232**] Chief Complaint: mental status change Major Surgical or Invasive Procedure: central venous catheter placement History of Present Illness: This is a [**Age over 90 **] year-old man with coronary artery disease, diabetes mellitus, chronic renal insufficiency and dementia presenting from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] rehab with altered mental status. As per report there, patient noted to be shivering and moaning earlier tonight. (Baseline as per report is alert, verbal but confused and completely dependent for ADL's.) Vital signs largely unremarkable at that time. CBC/chem-10 sent and patient noted to be hyperglycemic to 800's, hypernatremic to 149, potassium of 7. 2, creatinine 3.6 and crit of 30 (unknown baselines). He was given levoquin and transferred to [**Hospital1 18**] for further management. . In the ER, patient afebrile, tachycardic to 102, tachypneic to 20's, bp's 130's to 140's, patient moaning, responsive to pain, moving all four extremities. Above lab abnormalities confirmed, lactate of 3.3, cxr revealed RML pneumonia, dirty U/A with apparent UTI, treated with 10 units insulin followed by drip, bicarbonate, calcium gluconate, 2 liters NS, vancomycin, levoquin and flagyl. Urine output not recorded but by report, good. Past Medical History: 1. Coronary Artery Disease 2. Diabetes Mellitus 3. Chronic Renal insufficiency 4. Dementia 5. UTI's 6. Suprapubic prostatectomy/catheter 7. S/p right nephrectomy? 8. hypertension Social History: lives at [**Hospital3 **]. former cook at [**Last Name (un) 16356**] [**Location (un) 16357**] in [**Location (un) 7349**], travelled extensively with the merchant marines, ? tobacco history. Family History: unavailable Physical Exam: On Admission- VS: Temp: 98.4/98.2 BP:122/58 HR:105 RR:24 95%rm airO2sat . general: responds to pain, moves all four extremities, intermittenly responds to name, cachectic HEENT: EOMI, anicteric, no sinus tenderness, MMdry, op without lesions, no jvd lungs: crackles at right base, left lung field clear heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: nd, +b/s, multiple scars, suprapubic catheter in place without surrounding erythema, soft, nt extremities: no edema skin/nails: no rashes/no jaundice/ neuro: unable to follow commands, intermittently responds to voice, moves all four extremities . Pertinent Results: [**2147-4-17**] 01:05AM BLOOD WBC-20.6*# RBC-3.26* Hgb-10.3* Hct-31.5* MCV-97# MCH-31.6 MCHC-32.7 RDW-15.4 Plt Ct-473* [**2147-4-23**] 07:05AM BLOOD WBC-15.3* RBC-3.69* Hgb-11.2* Hct-34.4* MCV-93 MCH-30.3 MCHC-32.5 RDW-15.3 Plt Ct-510* [**2147-4-23**] 07:05AM BLOOD Glucose-32* UreaN-41* Creat-2.5* Na-144 K-4.7 Cl-113* HCO3-17* AnGap-19 [**2147-4-18**] 03:52AM BLOOD ALT-19 AST-25 AlkPhos-93 Amylase-296* TotBili-0.4 [**2147-4-19**] 06:50AM BLOOD Lipase-57 [**2147-4-23**] 07:05AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.3 [**2147-4-19**] 06:50AM BLOOD calTIBC-183* Ferritn-421* TRF-141* [**2147-4-18**] 03:52AM BLOOD %HbA1c-7.5* . RENAL U.S. [**2147-4-20**] 4:08 PM RENAL ULTRASOUND: Study is limited due to patient cooperativity. No gross abnormality seen in the right renal bed. The left kidney measures 9.7 cm. There is no hydronephrosis. There is a small cyst in the mid-to-lower pole measuring up to 14 mm. There is no overt solid mass. Probable extrarenal pelvis. No hydronephrosis. . CHEST PORTABLE [**2147-4-17**] 2:02 AM FINDINGS: Placement of right internal jugular venous catheter is identified in the expected region of the mid SVC. No pleural effusion or pneumothorax identified. Again noted is airspace opacity within the right lower lobe. IMPRESSION: 1. Normal placement of right internal jugular venous catheter without pneumothorax identified. 2. Right lower lobe pneumonia as described previously. . Brief Hospital Course: This is a [**Age over 90 **] year-old man with history of dementia, cad, diabetes mellitus, chronic renal insufficiency who presented with mental status change, work up remarkable for HONK, hypernatremia, pneumonia, UTI. 1)Mental Status change: Multifactorial in secondary to hyperglycemia, hypernatremia, pneumonia, metabolic derangements. The patient's mental status returned to baseline once metabolic derangements and infections were treated. 2)Endocrine: The patient has an unclear history of DM, but not presently on medications. Hyperosmolar state (HONK) likely precipitated by pneumonia/UTI. He was given aggressive fluids with NS initially, then changed to D5W since hypernatremia was not improving. Briefly required an Insulin drip, added D5 when sugar <200, converted to long-acting insulin on [**4-17**]. He was tapered to standing NPH insulin, then later became hypoglycemic with treatment of his infection. He was discharged on Humalog sliding scale. Treatment with an oral antidiabetic [**Doctor Last Name 360**] should be considered as an outpatient as Pt's Hgb A1C was 7.5 on admission. 4)Acute on Chronic Renal Failure: Pt is s/p L nephrectomy. Likely secondary to ATN in setting of hypotension, hypovolemia. Pt's baseline Creatinine is 1.9 according to PCP. [**Name10 (NameIs) **] improved from 3.8 to 3.0 with IV fluids, but was in plateau phase for several days. Renal service was consulted, renal ultrasound did not reveal hydroureter. Gentle intravenous fluids continued to improved pt's Cr clearance leading up until discharge. His medications were renally dosed. 5) Heme: Anemia consistent with AKD in combination with chronic kidney disease. Guaiac negative. Renal recommended starting EPO q M,W,F. Hematocrit was stable on serial checks. 6) Infectious Disease: a) Pneumonia: required ICU admission --vancomycin, ceftriaxone, levoquin initially - was changed to vanc/zosyn on [**4-17**] for a health care associated pneumonia. He should complete a full 14 day course of Vancomycin as his sputum grew MRSA. b) UTI--grew cipro and bactrim resistant E. Coli- 14 day course of ceftriaxone for complicated UTI c) [**Name (NI) 1069**] Pt developed copius diarrhea on HD #4, was started on empiric Flagyl PO, C. diff x 2 negative. His stools normalized following initiation of treatment. He should complete a 14 day course following the last day of Vancomycin and Ceftriaxone. 7) Suprapubic Catheter: Pt was noted to have copious urine drainage from around his suprapubic catheter, without evidence for skin infection. Urology was consulted and recommended Tolteridine 1mg [**Hospital1 **] for potential bladder spasm. He has a 24 Fr foley. There is no further role for intervention except for continued monitoring to assure his catheter flushed, dressed properly for good position within the bladder. 8) Speech and Swallowing evaluation: Recommended PO diet of soft solids with thin liquids, pills crushed as allowable. Aspiration precautions with 1:1 assist at meals. Code Status: DNR/DNI per discussion with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] [**Telephone/Fax (1) 16358**] or [**Telephone/Fax (1) 16359**](lives in [**State 2690**]) and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] [**Telephone/Fax (1) 16360**](lives in [**Location 86**]) Pt's grandchildren and HCP. At this time, Ms. [**Name13 (STitle) 284**] expressed that they would not be opposed to dialysis should Mr. [**Known lastname 16361**] eventually require it. Medications on Admission: (As [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] notes): 1. omeprazole 20mg daily 2. felodipine 10mg daily 3. MVI 4. MOM 5. bisacodyl 6. tylenol prn 7. levoquin started [**4-16**] Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: [**11-15**] PO BID (2 times a day). 2. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 5. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 6. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Day 1 is [**4-19**]. continue for two weeks once vancomycin and ceftriaxone is given. 8. Acetaminophen 650 mg Suppository Sig: [**11-15**] Suppositorys Rectal Q6H (every 6 hours) as needed. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Humalog 100 unit/mL Solution Sig: per sliding scale protocol Subcutaneous four times a day. 11. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 4 days. 12. Tolterodine 2 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 4 days. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: hyperosmolar nonketotic hyperglycemia delirium hospital acquired pneumonia urinary tract infection clostridium dificile colitis hyponatremia anemia acute renal failure Secondary 1. Coronary Artery Disease 2. Diabetes Mellitus 3. Chronic Renal insufficiency 4. Dementia 5. chronic UTI's 6. Suprapubic prostatectomy/catheter 7. S/p right nephrectomy? 8. hypertension Discharge Condition: Stable Discharge Instructions: Take all medications as prescribed. Do not stop or change any medications without first speaking to your physician. Follow up as outlined below. Please contact your primary care physician if you experience any pain, shortness of breath, fever, chills, or any other concerning symptoms. Followup Instructions: You have an appointment with [**Doctor First Name 2951**] Sedo, the Nurse Practitioner who works with your primary care doctor Dr. [**Last Name (STitle) **] at 1:30 PM on [**5-1**]. Call [**Telephone/Fax (1) 608**] if you have any questions about thsi appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**] Completed by:[**2147-4-24**]

Admission Date: [**2199-4-29**] Discharge Date: [**2199-5-23**] Service: SURGERY Allergies: Labetalol Attending:[**First Name3 (LF) 2777**] Chief Complaint: right leg pain Major Surgical or Invasive Procedure: angiogram via left brachial artery acess [**2199-5-2**] right aorto angioplasty with right ABF limb thrombectomy with dacron patch [**2199-5-2**] right groin washout and vac dressing placement [**5-7**] removal of left brachial artery sheath, left brachial artery throm-embolectomy [**5-7**] CVL change History of Present Illness: Patient with known PVD s/pABF and [**First Name9 (NamePattern2) **] [**Doctor First Name **] presents with acute right leg ischemia and pain. Past Medical History: Hypertension, polycythemia [**Doctor First Name **], peripheral [**Doctor First Name 1106**] disease Acute and chronic large bowel obstruction requiring segmental colectomy s/p Aortobifemoral bypass [**5-/2189**] pancreatic lymph node enlargement history of pulmonary nodules history of arrythmia history of coronary artery disease s/p Mi history of CHF, systolic, compensated history of coronary artery disease s/p Mi history of DM1 history of hypertension history of bindness-legally histroy of degenerative joint disease s/p left TKR history of appendectomooy history of total abdominal hystrectomy Social History: Quit smoking [**2176**] Occasional wine drinker lives alone Family History: n/c Physical Exam: Vital signs: 99.6-100-22 O2 sat 100% room air b/p 120/65 Gen: no acute distress HEENT: unremarkable Heart: RRR no mumurs,gallop or rub Abd: soft nontender nodistanded, normal bowel sounds EXT: pulses: palpable left fem, dopperable pedal pulses dopperable rt. fem,dopperable DP, absent Pt Neuro: Ox3 nonfocal Pertinent Results: [**2199-4-29**] 05:00PM GLUCOSE-132* UREA N-14 CREAT-0.8 SODIUM-135 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-24 ANION GAP-20 [**2199-4-29**] 05:00PM estGFR-Using this [**2199-4-29**] 05:00PM ALT(SGPT)-26 AST(SGOT)-77* LD(LDH)-541* CK(CPK)-356* ALK PHOS-208* TOT BILI-0.7 [**2199-4-29**] 05:00PM TOT PROT-6.5 CALCIUM-9.1 PHOSPHATE-3.1 MAGNESIUM-2.2 [**2199-4-29**] 05:00PM TSH-3.3 [**2199-4-29**] 05:00PM PEP-NO SPECIFI [**2199-4-29**] 05:00PM WBC-11.1* RBC-2.82* HGB-10.4* HCT-31.0* MCV-110* MCH-37.0* MCHC-33.7 RDW-16.4* [**2199-4-29**] 05:00PM NEUTS-86.7* BANDS-0 LYMPHS-9.2* MONOS-2.7 EOS-0.8 BASOS-0.6 [**2199-4-29**] 05:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-1+ FRAGMENT-OCCASIONAL [**2199-4-29**] 05:00PM PLT SMR-NORMAL PLT COUNT-304 [**2199-4-29**] 05:00PM PT-12.7 PTT-24.5 INR(PT)-1.1 Brief Hospital Course: [**4-29**] Admitted from ER to medical service. IV heparin began [**4-30**] Neuro oconsulted reguarding spinal canal stenosi found on MRI.[**Month/Year (2) **] consulted for ischemic limb. [**5-1**] u/s of ABF graft: occluded [**5-2**] angiogram via left brachial artery approach. aortic angioplasty with right ABF limb thrombectomy and dacron patch angioplasty. Pulmonary consulted for pulmonary nodules recommend ct fine needle bx when [**Month/Year (2) 1106**] issues resolved. tranfered to CSRU. [**2199-5-3**] POD#1 renal consuted for acute renal failure-fluid resustated.renal U/s negative for obstruction.General surgery consulted for ileus and known pancreatic node. Recommend ERCP for pancreatic duct diltiation.Transfused for low Hct. extubated. [**Date range (3) 97932**] POD #[**12-22**] Swan converted to CVL. Patient transfered to VICU.Diet advanced as tolerated 6/18-19/07 POD# [**2-21**] returned to surgery for right groin washout. antibiotics began. brachial artery sheath pulled. left brachial artery with thrombosis s/p thrombo-embolectomy. Evaluated by wound care for gluteal skin pressure changes. CVL changed. 6/20-22/07 POD# 6-7-8 Vac dressing placed. Evaluaated by PT will require rehab prior to d/c home. Social service for support. 6/23-24/07 POD# [**7-29**] Vac dressing changed. MRCP and Abd CT done for abnormal lft's.Fluid collection around graft site ? infected. Thoracic reconsulted for staging of lung cancer and then detrmin if graft removal vs conserative treatment. MRCP bilaiary duct diltation with stenosis, pancreatic duct stenosis. GI consulted for ERCP. [**2199-5-16**] Venacaval node bx. ortho consulted for left ankle pain. Xray effusion. no joint spiration continued conserative treatment and antibiotics per orthopedics. ID consulted for recommendations for long term antibiotic treatment for infected rt. ABF limb graft. [**2199-5-17**] Psychiatric consulted secondary to extended illness. patient not sucidal. antidepressives recommended but patient has declined recommendation. Social service continues to follow for support. [**2199-5-20**] rt. groin hearld bleed with hypotension. controlled. transfused . CT scan reviewed patient with rt. femoral ABF graft anastmosis aneurysm. Dr. [**Last Name (STitle) **] discussed the prognosis with patient. DNR/DNI changed to comoft measures only. family notified. [**2199-5-21**] Family meeting held. Palliative care consulted.Patient placed on CMO [**2199-5-22**] groin rebleed [**2199-5-23**] groin rebleed, expired @ 1515 . Family present at time of death. Discharge Disposition: Expired Discharge Diagnosis: ischemic rt. leg,arterial embolus history of PCD s/p ABF [**2188**] histroy of [**First Name9 (NamePattern2) 97933**] [**Doctor First Name **] history of pulmonary nodules history of pancreatic lymph nodes history of coronary artery disease,s/p MI histroy of Dm2 histroy of arrythmia history of hypertension history of chronic large bowel obstruction s/p segmental colon resection history of degenerative joint disease s/p left TKR history of appendectomy and total abdominal hystrectomy history of smoking, former, d/c [**2176**] postop blood loss anemia, transfused postop acute renal failure, fluid resustated, resolved Discharge Condition: expired [**2199-5-23**] @1515 Completed by:[**2199-5-23**]

Admission Date: [**2185-9-20**] Discharge Date: [**2185-9-27**] Date of Birth: [**2128-6-5**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Shellfish Attending:[**First Name3 (LF) 618**] Chief Complaint: R eyelid drooping, slurred speech, Code Stroke Major Surgical or Invasive Procedure: Intraarterial TPA thrombolysis Right vertebral artery stent placement History of Present Illness: Pt. is a 57 year old with a history of Asthma, HTN, Hyperlipidemia, tobacco abuse, who presents with eyelid drooping and slurred speech. Code Stroke called at 3:33, Neurology at the bedside by 3:38. Pt. reports that she was at work this afternoon at 1:55 when she suddenly noticed that her right eyelid was drooping, and she had trouble keeping her eye open. Over the next 5-10 minutes her symptoms progressed, and she also noticed that her left eye was drooping and that the left side of her face was numb, like she'd just gotten a novacaine shot there. She noticed that her speech was slurred. She felt very dizzy, like the room was spinning. She had double vision, which she thinks was vertical. She told her co-workers and they called EMS, and she was transported here. Since she arrived here she feels that her speech has gotten more slurred, and that she has developed trouble swallowing, and feels like she is gagging on her secretions. She is not able to open either eye enough to see. She still feels dizzy. On ROS she denies any recent fever, chills, or URI symptoms. She has had some dysuria in the past few days. She does not remember any trauma to her head and neck. She just got home from a vacation on Saturday, and was lugging her baggage around the airport, and had a 3 hour flight. She denies any weakness or numbness in her arms or legs. Past Medical History: kidney stone with pyelonephritis in [**2170**] osteopenia GERD Asthma Hyperlipidemia Hypertension Migraines- last one over a year ago Seen by Neurology here in [**2170**] for an episode of sudden onset shooting pain L eye, followed by burning with looking up and to the left, diagnosed with trochleitis B12 deficiency Social History: + tobacco 1 PPD, [**1-25**] glasses of wine/week, financial consultant at AG [**Doctor Last Name **], no children Family History: Mother -> died of Lung CA at 65 Father -> died of PE at 55 Brother -> HTN Physical Exam: T- 95 BP- 153/73 HR- 93 RR- 20 O2Sat- 96% on RA Gen: Lying in bed, NAD, eyes closed HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema NIH SS: 5 1a. Level of Consciousness: 0 1b. LOC questions: 0 1c. LOC commands: 0 2. Best gaze: 1 3. Visual: 0 4. Facial palsy: 1 5a. Motor arm, left: 1 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb ataxia: 1 8. Sensory: 0 9. Best language: 0 10. Dysarthria: 1 11. Extinction and inattention: 0 Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive. Speech is fluent with normal comprehension and repetition; naming intact. Mild dysarthria, scanning speech with [**Location (un) 1131**], easily understanding. [**Location (un) **] intact. No right left confusion. Cranial Nerves: Pupils pinpoint and reactive bilaterally. Visual fields are full to confrontation. R eye abduction incomplete (just barely past midline). Unable to adduct R eye at all. Able to abduct L eye fully, adduction incomplete. Impaired upgaze on R > L. Sensation decreased to light touch V2- V3 on L. Bilateral ptosis, R > L (cannot open R eye at all, just opens L eye 5 mm). Mild NLF flattening on L. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor. + pronator drift on left [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 4+ 4+ 5- 5 5- 4+ 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, vibration and proprioception throughout. No extinction to DSS Reflexes: +2 and symmetric throughout. Toes upgoing bilaterally Coordination: dysmetria with finger-nose-finger and heel to shin on left Gait: Not assessed Pertinent Results: Admission Labs: 141 104 19 -------------< 139 3.7 24 0.9 WBC 9.4 Hgb 14.9 Plt 394 Hct 42.2 MCV 87 N:59.4 L:33.5 M:4.9 E:1.7 Bas:0.6 PT: 11.0 PTT: 22.3 INR: 0.9 Imaging CTA Head and Neck with perfusion: On the unenhanced scan, there is no evidence for acute ischemia or hemorrhage. On the CTP, there is no evidence for global perfusion defect in the MCA territory. Preliminary evaluation of the CTA images demonstrate what appears to be occlusion of the distal basilar artery extending to the proximal right PCA artery. This area also appears to be hyperdense on unenhanced CT. No definite acute infarction in the brainstem or cerebellum is seen, although MRI evaluation would be recommended for further evaluation. There is a 4.5-mm right lung apical nodule for which recommend correlation with dedicated chest CT. The right distal vertebral artery appears to taper to a thread and there is also a filling defect in the V4 segment, suggesting of acute nonocclusive thrombus. In light of this finding, the filling defect in the distal basilar artery could represent an acute clot from the right distal vertebral artery dissection rather than basilar artery thrombosis in the setting of atherosclerotic basilar artery disease. IMPRESSION: Preliminary images highly concerning for distal basilar artery thrombosis. No definite acute infarction is seen in the cerebellum or brainstem, but would recommend correlation with MRI. Repeat Head CT at 5:47: HEAD CT WITHOUT CONTRAST: There is no acute intracranial hemorrhage, mass effect, shift of normally midline structures or hydrocephalus. There is a hyperdense appearance of the distal basilar artery which correspond to the area of thrombosis seen on prior CTA. The surrounding osseous and soft tissue structures are unremarkable. IMPRESSION: No acute intracranial hemorrhage. Hyperdense appearance to the distal basilar artery consistent with recently diagnosed thrombosis. TTE [**2185-9-20**] Conclusions: The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is 5-10 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2183-8-1**], no change. No source of embolism identified. MR HEAD W & W/O CONTRAST [**2185-9-21**] 8:23 PM MRI BRAIN: Areas of slow diffusion are seen in the pons right greater than left, left superior cerebellum, and right cerebellum. Also seen are infarcts in the left occipital lobe. These correspond to areas of low diffusion coefficient on ADC map, and probably represent acute infarction secondary to the previous basilar thrombus. These findings are corroborated on the FLAIR and T2 images. No other areas of cerebral infarction are seen. Ventricles and sulci retain their normal caliber and configuration. There is fluid in the sphenoid sinuses. MR ANGIOGRAPHY HEAD: The basilar artery and posterior circulation appear now patent. The internal carotid arteries, Circle of [**Location (un) 431**] and major branches also appear patent. Posterior cerebral arteries appear to be fed by the posterior circulation; no definite posterior communicating arteries are seen. MR ANGIOGRAPHY NECK: The right vertebral artery has loss of signal at its origin, which may be due to the recently placed stent. However, due to artifact from the stent, we cannot assess the possibility of a stenosis. Otherwise, the right vertebral artery, left vertebral artery, right and left common and internal carotid arteries are patent. IMPRESSION: Reconstitution of flow in the basilar artery and branches, with bilateral posterior circulation infarctions, including the right cerebellum, left cerebellum, and pons. CTA HEAD W&W/O C & RECONS [**2185-9-23**] 2:35 PM HEAD CT: There is a large infarct involving the right cerebellar hemisphere and a small infarct involving the superior portion of the left cerebellar hemisphere as well as small infarcts involving the pons and midbrain. There are no intracranial hemorrhages. The ventricles and extra-axial CSF spaces are unchanged. Air-fluid levels are seen within the sphenoid air cells bilaterally. No suspicious bony abnormalities are noted. CTA HEAD AND NECK: A stent is seen at the origin of the right vertebral artery. The intraluminal content is difficult to visualize due to the streak artifacts from the stent but there appears to be contrast within the lumen. The vertebral artery distal to the stent is widely patent. The right vertebral artery is dominant. Incidental note is made of a prominent right posterior meningeal artery arising from the V3 segment of the right vertebral artery. The basilar artery is patent. There is minimal atherosclerotic disease involving the origin of the left vertebral artery, which comes off directly from the aortic arch. Minimal atherosclerotic disease at the origin of the left subclavian artery is also noted. Minimal calcified atherosclerotic plaques are seen involving the bulbs of the internal carotid arteries bilaterally. The maximal diameter of the left internal carotid artery at its bulb is 7 mm. The distal cervical left internal carotid artery has a diameter of 4.6 mm. The right internal carotid artery bulb has a diameter of 5.6 mm and the distal cervical right internal carotid artery has a diameter of 5.8 mm. Again seen is a 3 x 3 mm outpouching of the right supraclinoid internal carotid artery which likely represents a posterior communicating artery infundibulum. No new occlusions or stenoses are seen. There are several small nodular densities of the visualized lung apices bilaterally some of which are peripheral. A dedicated chest CT as previously recommended is again recommended. Degenerative changes of the cervical spine are again seen with multilevel foraminal stenosis. IMPRESSION: 1. Stent at the origin of the right vertebral artery which makes the evaluation of the intraluminal contents difficult due to streak artifacts but there is some contrast within the lumen and the vertebral artery distal to the stent is widely patent. 2. The basilar artery and its major branches are completely patent. 3. A chest CT to further evaluate multiple small nodular densities is again recommended. Brief Hospital Course: Ms. [**Known lastname **] is a 57 year old with a history of Asthma, HTN, Hyperlipidemia, tobacco use, who presented with acute onset of bilateral ptosis, diplopia, dsyarthria, dysphagia, and vertigo. On initial exam she had evidence of a 3rd and 6th nerve palsy on the R, and 3rd nerve palsy on the left, bilateral ptosis, dysarthric speech, left nasolabial flattening, and L UMN pattern weakness in the arm. These signs and symptoms were consistent with brainstem localization for possible infarction. On CTA she had evidence of a large basilar artery thrombus. Since she was in the window for IVtPA and had no contraindications to tPA, this was administered at 16:40 on [**9-20**]. One hour later her course in the ED was complicated by acute decompensation, with decreased level of arousal and vomiting. She was acutely intubated and sedated, and Head CT was repeated, which showed no evidence of hemorrhage. The most likely cause of this deterioration was propagation of the thrombus. She was rushed to the interventional radiology suite where she underwent intra-arterial TPA thrombolysis. Angiogram showed a severe narrowing of the proximal vertebral artery on the left (atherosclerosis versus dissection). The mid to distal portion of the basilar artery was closed and there was thrombus that extended into both PCAs. A total dose of 11mg of tPA was infused in the basilar artery and both PCAs. Limited revascularization was achieved, but the basilar artery successfully opened up. There was still some clot in the proximal right PCA and SCA. A stent was placed in the right proximal vertebral artery with return of good flow to the basilar artery, and proximal portions of the SCAs and the proximal PCAs She has a history of several recent plane flights as well as multiple vascular risk factors. She has a history of pulmonary embolism in the distant past. She was admitted to the neuro ICU following her several procedures and monitored. She was successfully extubated without complication and trasferred to the neurology floor. She was The cause of her infarct is unknown at present, given her vascular risk factors (long time smoker, HTN, hyperlipidemia) could consider atherosclerotic plaque in the basilar with thrombosis. Could also consider a cardioembolic source (though no known A fib) Echocardiogram did not reveal PFO, ASD, or sources for cardioemboli. She was started on aspirin 81mg daily 24 hours following TPA administration. Her discharge examination was notable for right eye ptosis and slight bilateral deficit of eye abduction. A hypercoagulable work up will proceed with Dr. [**Last Name (STitle) **] in follow up clinic at Vascular Neurology Center at [**Hospital1 18**]. She was discharged to home with physical therapy services. Chest CT is recommended at follow up for evaluation of multiple small nodular densities seen incidentally on CTA of the neck. Medications on Admission: Diovan 120 mg QD HCTZ 12.5 mg QD Advair 250/50 twice daily Albuterol PRN Lipitor 10 mg QD Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*3* 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. Capsule(s) 5. Diovan Oral 6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Basilar artery thrombosis Discharge Condition: right ptosis. slight right lateral eye abduction deficit. Discharge Instructions: You were admitted for a stroke. You underwent extensive intervention to break up the clot and prevent further neurologic deficits. Quit smoking. Please continue to take all medication as prescribed. Call your doctor or 911 if you experience any difficulty with speech, walking, new weakness, numbness, tingling, weakness, double vision, blurred vision or any other concerning symptoms. Followup Instructions: [**11-16**] at 1:30pm with Dr. [**Last Name (STitle) **]. He will order some blood work to be drawn for potential clotting disorder. Please call prior to your appointment to update your insurance information. You will also have home physical therapy services. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Admission Date: [**2149-10-8**] Discharge Date: [**2149-10-15**] Date of Birth: [**2098-5-29**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Prosthetic aortic valve fungal endocarditis Major Surgical or Invasive Procedure: [**2149-10-8**] - Redo Sternotomy, Replace Ascending Aorta and hemiarch, Reimplant anomalous right coronary artery, Aortic annulus repair with pericardial patch. History of Present Illness: Mr. [**Known lastname **] is a 51-year-old gentleman who underwent aortic valve replacement with replacement of his ascending aorta in [**2148-11-23**]. He did quite well until [**2149-7-25**] when he started to develop myalgias and fevers. A workup revealed fungal endocarditis of this prosthetic aortic valve. Since that time, he has been on intravenous antimicrobial therapy, and he presents today for reoperative intervention. His most recent echocardiogram was from today, which showed a moderate-sized vegetation on his aortic valve that was trace AI, trivial MR, and trivial TR. His ejection fraction was 55%. MRI of his head showed no significant change of the laminar necrosis and subacute infarct, and his abdominal CT scan showed a wedge- shaped splenic infarction in the superior spleen. Past Medical History: Past medical history is significant for bicuspid aortic valve and ascending aorta for which he underwent aortic valve replacement with replacement of his ascending aorta on [**2148-11-23**]. His past medical history is also significant for hyperlipidemia, varicose veins, and bilateral hernia repair as a child. He has had embolic cerebral infracts and a splenic infarct related to his fungal endocarditis. Social History: Patient is a cullinary arts professor [**First Name (Titles) **] [**Last Name (Titles) **] [**Location (un) **] of [**Location (un) 3844**], and lives at home with his wife. [**Name (NI) **] denies tobacco and IVDU. Denies EtOH use since [**Month (only) 116**]. Per prior notes, patient has ingested unpasteurized milk, and has had contact with horses. Family History: Significant for one aunt and one uncle with CVAs, and an aunt with SLE. Physical Exam: Physical examination in my office today was pulse of 82, respirations of 12, and a blood pressure of 90/48. In general, he was a well-developed and well-nourished male in no acute distress. He did appear mildly pale in color. His skin was warm and dry. There was no cyanosis or clubbing. Venous stasis changes were noted in both lower extremities. His oropharynx was benign. His teeth were in good repair. His sclerae were anicteric. His neck was supple with full range of motion. There was no JVD. Both lungs were clear to auscultation bilaterally. Pertinent Results: [**2149-10-7**] TEE The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). A bioprosthetic aortic valve prosthesis is present. There is a moderate-sized vegetation on the aortic side of the right cusp of the prosthetic aortic valve measuring 0.9 x 0.7cm. Trace aortic regurgitation is seen. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. IMPRESSION: Moderate-sized vegetation on the right cusp of the prosthetic aortic valve. Normal left ventricular function. Trace aortic regurgitation. Compared with the prior study (images reviewed) of [**2149-9-4**], the vegetation on the right cusp fo the aortic valve appears larger. The 1cm mass on the ascending aortic graft lumen is not well-visualized on the current study. [**2149-10-8**] TEE PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. 3. The descending thoracic aorta is mildly dilated. 4. A bioprosthetic aortic valve prosthesis is present. There is a moderate-sized vegetation on the aortic valve. Vegetation is attached to the right and left coronary cusps. 5. An abscess pocket was noted near the sino-tubular junction between the right and left coronary cusp just proximal to the ascending aortic graft. Color flow was noted into this pocket from the aortic root. Pocket measures 1 x 1.6 cm. 4. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. 5. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. 6. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified of results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including Phenylephrine and briefly on epinephrine. Pt is in a sinus rhythm. 1. A well-seated bioprosthetic valve is seen in the Aortic position with normal leaflet motion and gradients (Peak gradient = 20 mmHg). A mild central eccentric AI jet is seen directed towards the Interventricular septum. 2. An ascending aortic graft is seen. 3. Biventricular function is preserved. 4. Other findings are unchanged. [**2149-10-15**] 06:13AM BLOOD WBC-8.3 RBC-4.24* Hgb-11.6* Hct-34.8* MCV-82 MCH-27.3 MCHC-33.2 RDW-16.4* Plt Ct-437 [**2149-10-8**] 02:48PM BLOOD WBC-13.7*# RBC-2.70*# Hgb-7.1*# Hct-21.9*# MCV-81* MCH-26.3* MCHC-32.4 RDW-16.2* Plt Ct-164# [**2149-10-14**] 06:55AM BLOOD PT-14.5* INR(PT)-1.3* [**2149-10-15**] 06:13AM BLOOD UreaN-15 Creat-0.8 K-4.3 [**2149-10-13**] 05:30AM BLOOD Glucose-93 UreaN-16 Creat-0.8 Na-136 K-3.7 Cl-104 HCO3-26 AnGap-10 [**2149-10-9**] 02:22AM BLOOD Glucose-80 UreaN-10 Creat-0.7 Na-136 K-4.1 Cl-108 HCO3-25 AnGap-7* [**2149-10-11**] 02:42PM BLOOD ALT-26 AST-39 LD(LDH)-307* AlkPhos-108 Amylase-94 TotBili-0.4 [**2149-10-15**] 06:13AM BLOOD ALT-30 AST-36 LD(LDH)-256* AlkPhos-156* Amylase-106* TotBili-0.2 [**2149-10-11**] 02:42PM BLOOD Lipase-51 [**2149-10-15**] 06:13AM BLOOD Albumin-3.4 Mg-1.9 [**2149-10-9**] 11:09AM BLOOD Albumin-2.9* Calcium-8.1* Mg-2.1 [**2149-10-9**] 05:12PM BLOOD Phenyto-15.7 [**2149-10-15**] 06:13AM BLOOD Phenyto-7.1* Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2149-10-8**] for surgical management of his fungal endocarditis. He was taken directly to the operating room where he underwent a redo sternotomy with replacement of his ascending aorta and hemiarch, replacement of his aortic valve with a pericardial valve, remimplantation of his anomalous right coronary artery and repair of his aortic annulus with a pericardial patch. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. His antifungals (voriconazole + Caspofungin) and antibiotic (Ceftriaxone) were continued. On postoperative night, Mr. [**Last Name (Titles) **] awoke and was found to have left sided upper extremity weakness,left sided visual neglect, right upper extremity myoclonus, and was not able to consistently follow commands. He remained intubated over night.Dr.[**Last Name (STitle) 914**] was notified. POD#1 Mr.[**Known lastname **] [**Last Name (Titles) 66413**] appeared to be improving and he was extubated. Neurology was reconsulted and during the consultation, Mr [**Known lastname **] appeared to have tonic clonic seizure activity; with new right sided weakness. He was reintubated to protect his airway and a head CT scan was done. EEG performed showed encephalopathy, no seizure activity. Phenytoin was started. Also that morning his heart rhythm went into rapid atrial fibrillation and he was treated with IV lopressor and loaded with Amiodarone and placed on a drip. POD#2 Brain MRI showed acute right frontal/parietal cortical infarct, in addition to the previously noted old infarct. No anticoagulation for AFib per Dr.[**Last Name (STitle) 914**]. Neurology and Infectious Disease followed Mr.[**Known lastname **] throughout his postoperative course. POD#2 he was extubated and continued to show neurologic improvement with deficit resolution. He continued to progress and on POD#4 was transferred to step down unit for further monitoring and recovery.His rhythm converted back to sinus with a 1'AVB, LBBB, unchanged from postoperative EKG. Amio and beta-blocker adjusted as HR and BP tolerated. [**10-8**] Tissue/Fungal Cxs growing Scopulariopsis Brevicaulis (same as preop CXs), and ID sent Cx to [**State **] for drug sensitivities. ABX continued per ID recommendations with Voriconazole and Caspofungin. Discussed with Infectious disease Dr.[**Last Name (STitle) 438**] regarding Mr.[**Known lastname **] follow-up and ABX course. He had a PICC inserted for IV Caspofungin for a minimum 6 week course or per ID changes when sensitivities come in. Voriconazole was changed to po dosing for discharge. Mr.[**Known lastname **] is to follow-up with Dr.[**Last Name (STitle) 438**] 3-4 weeks following discharge and surveillance labs:LFTs, CBC, ESR,CRP,and BUN/Creatnine are to be monitored weekly.As per neurolgy recommendations,Mr.[**Known lastname **] is to follow-up with Dr.[**Last Name (STitle) 78537**] in 2 months as an outpt. and to continue Dilantin until otherwise advised.POD# 6 Mr.[**Known lastname **] was started on Keflex x 5 days for a left forearm phlebitis. Mr.[**Known lastname **] continued to progress in his recovery and on POD# 7 he was discharged to home with VNA/IV ABX. All follow-up visits were advised. Medications on Admission: Voriconazole 300 mg IV twice daily Caspofungin 50 mg IV once daily Ceftriaxone 2 g daily Multivitamin. Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Continue as long as you take narcotics for pain. Disp:*60 Capsule(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0* 6. Voriconazole 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO QID (4 times a day): Please take for total of 5 days ([**10-14**] was day 1). Disp:*20 Capsule(s)* Refills:*0* 10. Caspofungin 70 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). Disp:*30 Recon Soln(s)* Refills:*2* 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: community health and hospice Discharge Diagnosis: Fungal Endocarditis h/o bicuspid AV s/p AVR(tissue)/Ascending Aorta Replacement Hyperlipidemia Varicose veins Past phlebitis Bilateral hernia repair Embolic fungal CVA Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 6 months or unless otherwise cleared by Neurology 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr.[**Last Name (STitle) 28768**] in 2 weeks Please follow-up with Dr. [**Last Name (STitle) 111575**] in [**1-27**] weeks. [**Telephone/Fax (1) 111588**] Please follow-up with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**]: Infectious Disease Clinic ([**Telephone/Fax (1) 6732**] in [**2-25**] weeks Please follow-up with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 78537**], Neurology:([**Telephone/Fax (1) 8951**] in 2months Completed by:[**2149-10-15**]

Admission Date: [**2192-8-8**] Discharge Date: [**2192-8-16**] Date of Birth: [**2138-4-20**] Sex: M Service: Medicine HOSPITAL COURSE: (continued) the patient underwent cardiac catheterization given the ambiguous cardiac enzymes results as well as one episode of chest pain. The patient was found to have proximal right coronary artery stenosis of 70%, mid-right coronary artery stenosis of 99%, left main 40% stenosis, proximal left anterior descending artery 100% stenosis, mid-left anterior descending artery 80% stenosis, and saphenous vein graft to obtuse marginal graft 80% distal stenosis. This particular region was where a new coronary artery stent was placed. Subsequent to the cardiac catheterization, the patient was put on an Integrilin drip to help maintain patency of the stent overnight. The patient was also started on 75 mg daily of Plavix as well as continued on his daily aspirin. Also during the patient's hospitalization, the patient noted one episode which he described as shortness of breath. A portable chest x-ray was ordered and the initial report of the chest film indicated a possible left lobe pneumonia, however, careful review of this x-ray with the previous one, confirmed by radiology, revealed that the number of sternal wires shown on the portable x-ray differed from the number of sternal wires shown on previous as well as subsequent x-rays, suggesting that perhaps the portable film was of another film. For confirmation, a nonportable PA and lateral film of Mr. [**Known lastname 2520**] was performed, which revealed clear lung fields. Therefore, the patient was discharged without the diagnosis of pneumonia and required antibiotic therapy. DISCHARGE MEDICATIONS: Celexa. Aspirin 325 mg p.o.q.d. Plavix 75 mg p.o.q.d. times one month. Metoprolol 75 mg p.o.q.d. Norvasc 10 mg p.o.q.d. Imdur 60 mg p.o.q.d. Tricor 54 mg p.o.q.d. Procrit 5,000 units t.i.w. Actos 45 mg p.o.q.d. NPH insulin 18 units q.a.m., 8 units q. afternoon. Regular insulin 4 units q.a.m. and 4 units q. afternoon. Lasix 40 mg p.o.b.i.d. Of note, upon discharge, the patient noted that he had an appointment to be evaluated for placement of potential arteriovenous fistula for hemodialysis. Therefore, the patient was instructed to hold his aspirin dose but continue the Plavix until his appointment which was scheduled for Tuesday, [**2192-8-21**]. Of note, during the patient's hospitalization, he also underwent venous Doppler mapping of his antecubital fossas, both left and right, to identify possible sites for an arteriovenous fistula placement. DISCHARGE DIAGNOSIS: Congestive heart failure exacerbation. CONDITION AT DISCHARGE: Stable. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**], M.D. [**MD Number(1) 7715**] Dictated By:[**Last Name (NamePattern1) 8442**] MEDQUIST36 D: [**2192-8-19**] 23:06 T: [**2192-8-27**] 08:50 JOB#: [**Job Number 8445**]

Admission Date: [**2171-8-12**] Discharge Date: [**2171-8-16**] Date of Birth: [**2131-12-6**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Increasing dyspnea on exertion Major Surgical or Invasive Procedure: [**2171-8-12**] MV repair (30 mm [**Company 1543**] CG Future ring) History of Present Illness: This is a 39 year old man who has been followed here for 10+ years for mitral valve prolapse and moderate-to-severe mitral regurgitation. He has undergone routine echocardiograms and presents now with probable valve related symptoms (dyspnea on exertion) and worsening of MR [**First Name (Titles) **] [**Last Name (Titles) **]. After appropriate evaluation, he was cleared to proceed with cardiac surgical intervention. Past Medical History: Mitral valve prolapse, Mitral Regurgitation Seizure disorder Osteoporosis Social History: Last Dental Exam: [**2171-7-3**] Lives with: Mother - currently staying with sister and will continue to stay with sister post op until return to [**Name (NI) 108**] Occupation: unemployed Tobacco: none ETOH: none Family History: Non-contributory Physical Exam: Pulse: 98 Resp: 16 O2 sat: 98% B/P Right: 133/85 Left: 136/80 71" 65.7 kg General: no acute distress Skin: Dry [x] intact [x] small scab on forehead and right side of necking healing no erythema HEENT: NCAT [x] PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] no lymphadenopathy Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [**2-23**] holo-diastolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema none 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: no bruit Left: murmur Pertinent Results: [**2171-8-12**] Intraop [**Month/Day/Year **] PREBYPASS The left atrium is elongated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed however given degree of MR LV intrinsic function may be worse. (LVEF= 50%). Right ventricular chamber size is normal with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is partial posterior mitral leaflet flail likely at the junction of P1 and P2. Torn mitral chordae are present. Moderate to Severe (3+) mitral regurgitation is seen. There is no pericardial effusion. POSTBYPASS LV systolic function now appears normal. RV systolic function remains normal. There is a ring prosthesis in the mitral position. No MR [**First Name (Titles) **] [**Last Name (Titles) 48613**]. There is no mitral stenosis. However [**Male First Name (un) **] of the MV leaflets is present. The [**Male First Name (un) **] is mild however changes (worsens or improves SBP <90 vs SBP >130 respectively) depending on loading conditions. MR appears when [**Male First Name (un) **] becomes significant. The remaining study is otherwise unchanged from prebypass. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2171-8-12**] where the patient underwent mitral valve repair with resection of the middle scallop of the posterior leaflet and a mitral valve annuloplasty with a 30-mm Future CG annuloplasty ring. 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 on no inotropic or vasopressor support. Beta blocker was initiated. No diuresis was initiated due to [**Male First Name (un) **] seen on intraop echocardiogram. Echo was repeated to further evaluate this on the day of discharge and the report was pending. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with VNA services and appropriate follow up instructions. Medications on Admission: ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 (One) Tablet(s) by mouth weekly. - No Substitution DIGOXIN - (Prescribed by Other Provider) - Dosage uncertain LAMOTRIGINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC CALCIUM CARBONATE-VITAMIN D3 [CALTRATE-600 PLUS VITAMIN D3] - (OTC) - 600 mg-400 unit Tablet - 1 (One) Tablet(s) by mouth twice a day FOLIC ACID - 0.8MG Tablet - TAKE ONE TABLET PER DAY MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth once a day Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 6. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Mitral regurgitation s/p MV repair Seizure disorder Osteoporosis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema : Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2171-8-16**]

Admission Date: [**2167-8-28**] Discharge Date: [**2167-9-4**] Service: MEDICINE Allergies: Aricept / Zinc Attending:[**First Name3 (LF) 30**] Chief Complaint: head trauma Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 89 yo female with dementia transferred from [**Location (un) 620**] after being found to have subdural hematoma with midline shift. Per nursing home documentation it is believed the patient was assaulted by another NH resident. She was brought to [**Hospital1 18**] [**Location (un) 620**] where she was intubated for airway protection and transferred for neurosurgery evaluation. Notably, pt had DNR in place. Per the [**Hospital1 18**] [**Location (un) 620**] ED note the patient had no focal neurologic findings prior to intubation. Neurosurgery recommended surgical intervention, however, the family believes this is not compatible with her goals of care. They are asking that the patient be extubated and made comfort measures only. In the ED her vitals were 97.6 131/64 63 100 vented. She received a dilantin load and was sedated with fentanyl and versed. Past Medical History: Dementia HTN Diverticulitis Hypercholesterolemia Social History: Resident of Emeritus at [**Last Name (NamePattern1) 87359**]in [**Location (un) 1411**] ([**Telephone/Fax (1) 87360**]. Family History: NC Physical Exam: PHYSICAL EXAM ON ADMISSION VS: Temp: BP:111/60 HR:63 RR:11 O2sat: 100 GEN: intubated, sedated HEENT: 1mm pupils, mildly reactive (1-2mm), C-collar in place RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: 1+ LE edema SKIN: Right periorbital echymosses and swelling NEURO: Pupils reactive, + weak gag Physical Exam on Discharge VS: Tm 99.5, Tc 98.4, HR 92 (78-92), BP 147/86 (130-172/76-90), RR22, O2Sat 90% on 3L Gen: non-intubated, awake, alert, not oriented, on NC HEENT: PERRLA, mucous membrane moist Neck: supple CV: RRR, difficult to appreciate any m/r/g masked by patient's mumbling Resp: CTAB in anterior lung field with good air movements Abd: soft, NT, ND, BS present Ext: warm, dry, 2+ DP pulses bilaterally Neuro: PERRLA, moving all limbs, does not follow commands Pertinent Results: Labs: [**2167-8-28**] - CBC with diff: WBC-13.4* RBC-3.62* Hgb-10.4* Hct-31.7* MCV-88 MCH-28.8 MCHC-32.8 RDW-14.3 Plt Ct-227 Neuts-71.2* Lymphs-21.5 Monos-4.0 Eos-2.8 Baso-0.5 - Chem 10: Glucose-121* UreaN-13 Creat-0.7 Na-143 K-3.2* Cl-109* HCO3-24 Calcium-8.2* Phos-1.6* Mg-1.9 - ABG: Type-ART Rates-14/18 Tidal V-500 PEEP-5 FiO2-40 pO2-147* pCO2-35 pH-7.47* calTCO2-26 Base XS-2 Intubat-INTUBATED [**2167-9-3**] - CBC with diff: WBC-15.5* RBC-3.95* Hgb-11.2* Hct-34.2* MCV-87 MCH-28.3 MCHC-32.6 RDW-14.8 Plt Ct-453* Neuts-87* Bands-0 Lymphs-8.0* Monos-4 Eos-0 Baso-1 - CHEM 10: Glucose-160* UreaN-17 Creat-1.4* Na-138 K-3.9 Cl-104 HCO3-19* Calcium-8.4 Phos-3.7 Mg-1.9 - Phenyto-17.6 Images: [**8-28**] CXR portable 1: The endotracheal tube is with tip terminating just at the orifice of the right mainstem bronchus. The lungs are clear. There are no pleural effusions or pneumothorax. Cardiomediastinal contours demonstrate tortuosity of the thoracic aorta and mild cardiomegaly. Pulmonary vascularity is normal. There are extensive degenerative changes involving the thoracolumbar spine. IMPRESSION: Endotracheal tube with tip just at the orifice of the right mainstem bronchus and can be withdrawn by 4 cm for more optimal positioning. [**8-28**] CXR portable 2: In comparison with the earlier study of this date, the endotracheal tube has been pulled back so that the tip lies approximately 2.7 cm above the carina. However, the tube is directly positioned at the right wall of the trachea. Remainder of the heart and lungs is essentially unchanged. There has also been placement of a nasogastric tube. The side hole appears to be just distal to the esophagogastric junction. [**8-28**] CT C-spine IMPRESSION: No acute fracture or malalignment. Multilevel degenerative disease as noted above. [**8-28**] CT HEAD 1. No interval change in the appearance of the left subdural hematoma with stable 6-mm rightward midline shift. 2. Stable appearance of the bilateral nondisplaced nasal bone fractures. [**9-3**] CXR portable: The cardiomediastinal and hilar contours are stable. There is prominence of right hilum. There has been interval development of retrocardiac opacity. No effusions or pneumothorax. IMPRESSION: Interval development of retrocardiac opacity. This may represent atelectasis, although infection cannot be excluded. Brief Hospital Course: 89 yo female with dementia transferred from OSH for traumatic SDH on [**2167-8-28**] and discharged on [**2167-9-4**]. # SDH: Ocurred in setting of trauma at her nursing home. Neurosurgery initially recommended surgical intervention given SDH>1cm. Pt's daughter (HCP) declined surgery given her mother has not wanted aggressive medical interventions. Pt had a repeat head CT 12 hrs after the first head CT which did not show interval change. She was given dilantin load and kept on dilantin TID for seizure ppx with the goal of BP maintained < 140. Following extubation, pt alert and interactive. Mental status remains altered from baseline which certainly could be related to SDH but is likely also a manifestation of delirium. Patient will complete a 7 day course of dilantin to end at the end of [**2167-9-4**]. SDH can be monitored clinically. Comfort care is the goal per family. # Intubation: Pt intubated at [**Hospital1 **] [**Location (un) 620**] for airway protection. She was extubated on [**2167-8-29**] without complications. Pt has been firmly DNR/DNI and per HCP would not want re-intubation. # Aspiration pneumonitis/pneumonia. While in the MICU, patient was suspected to have aspiration pneumonia and was treated with Unasyn [**2167-8-30**]- [**2167-9-2**]. She was placed on a dysphagia diet. However, she had episodes of loose bowel movement, nausea and vomiting with repeat CXR showing retrocardiac opacification, suggesting aspiration pneumonia vs. pneumonitis. Discussion of restarting antibiotics was made with patient's HCP, and she felt strongly that her mother would prefer not to have escalation of care at this point. No antibiotics was started. Patient's respiratory symptoms and lowered O2 saturation was treated with O2 supplement and morphine as needed. She tolerated well. This can be monitored clinically. Discussion was made with family regarding her diet, and daughter agrees to trials of oral food at this time, knowing that she has increased risk of aspiration. However, if patient continues to exhibit signs of aspiration, will hold off on po food and readdress this with her family about diet. # Metabolic acidosis, noted on [**2167-9-3**] after the event mentioned above. No additional monitoring was done after discussion with family regarding goal of care. # Acute renal failure, noted on [**2167-9-3**] after the event mentioned above, likely result of nausea, vomiting, and loose bowel movement. She was given continuous IV fluid. No additional monitoring was done after discussion with family regarding goal of care. # Hypertension. This is patient's baseline. However, she was given lisinopril and amlodipine for blood pressure control when she was able to tolerate oral medications. Her medications were switched to IV metoprolol on [**2167-9-3**] given symptoms of nausea and vomiting. She may resume the oral medications as she transition to hospice. # Dementia: Held Namenda and celexa given altered mental status while she was in the hospital. Patient may continue to take her regular home medications. # Goals of care: HCP, [**Name (NI) **] [**Name (NI) 9063**] feels strongly that her mother should not have aggressive medical interventions and is transitioning her mother to a long term facility with hospice. Would highly recommend on-going discussion with family about not rehospitalize should Ms. [**Known lastname 22958**] condition deteriorates or to re-aspirate. Medications on Admission: ASA 81mg daily Namenda 10mg [**Hospital1 **] Simvastatin 80mg qHS Lisinopril 40mg [**Hospital1 **] Razadyne 4mg [**Hospital1 **] Robitussin AC QID:PRN Celexa 10mg daily Amlodipine 5mg daily Discharge Medications: 1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. Disp:*30 Tablet(s)* Refills:*2* 3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for agitation. Disp:*30 Tablet(s)* Refills:*0* 5. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 6. Razadyne 4 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 8. Lorazepam 2 mg/mL Concentrate Sig: One (1) mL PO every six (6) hours as needed for anxiety or agitation. Disp:*30 ml* Refills:*0* 9. Atropine 1 % Drops Sig: Two (2) drops Ophthalmic every four (4) hours as needed for secretions: drop under the tongue. Disp:*5 mL* Refills:*0* 10. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Phenytoin 100 mg/4 mL Suspension Sig: One Hundred (100) mg PO twice a day for 1 days: You will complete the course of seizure prophylaxis through [**2167-9-4**]. Disp:*200 mg* Refills:*0* 12. Morphine sulfate 20 mg/ml 5 mg (0.25 ml) by mouth or under the tongue every 4 hours as needed for severe pain, mild pain that is persistent or increasing and not responding to acetaminophen, or for breathlessness. Discharge Disposition: Extended Care Facility: [**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**] Discharge Diagnosis: Traumatic subdural hematoma End-stage dementia Aspiration pneumonitis/pneumonia Acute renal failure Metabolic acidosis Hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to [**Hospital1 69**] for bleeding into the brain (subdural hemorrhage). You were evaluated by neurosurgery who recommended nonoperative management with medicines instead of surgery and follow up CT head in 4 weeks. While in the hospital, there was a concern of pneumonia acquired from aspiration. You were treated with a a course of antibiotic for this possible infection. Later, you had episode of nausea and vomiting with lab results showing inflammatory response. A repeat chest X ray shows that there could be inflammation in the lung from the vomit or a pneumonia, but after a lengthy discussion with your daughter, it was decided not to restart another course of antibiotics because of the transition into comfort care. Your diet was discussed with your daughter, and it was thought that you can try to have food, but if you again show signs of aspiration, this will need to be address again with your daughter. Please note the following changes in your medications: - Please START Dilantin 100 mg, suspension, by mouth, twice a day through [**2167-9-4**], which would be the completion of a 7 day course seizure prophylaxis. - Please START acetaminophen 500 mg tab, 1-2 tabs, by mouth, every 6 hours as needed for pain. - Please START quetiapine (Seroquel) 12.5 mg, 0.5 tab of 25 mg tab, by mouth, at bed time as needed for agitation. - Please INCREASE amlodipine to 10 mg, 2 tabs of the 5 mg tabs, by mouth, once a day. - Please STOP Aspirin 81 mg, 1 tab, by mouth, once a day, because of the bleeding in your head. - Please DECREASE lisinopril to 40 mg, 1 tab, by mouth, once a day. - Please START morphine 0.25 mL (5 mg), by mouth or under the tongue every 4 hours as needed for severe pain or breathlessness. - Please START lorazepam 1 mg, by mouth, every 6 hours as needed for anxiety or agitation - Please START atropine 1% drops, 2 drops, under the tongue, ever 4 hours as needed for secretions. You can ask the hospice staff to assit you with symptom management. Followup Instructions: Because of your goal to hospice care, no follow-up appointment is made. However, if you feel strongly about following up with neurosurgery, you may arrange a follow up with neurosurgery ([**Telephone/Fax (1) 88**] in 4 weeks and requset that a CT of the head be scheduled. Completed by:[**2167-9-4**]

Admission Date: [**2118-1-5**] Discharge Date: [**2118-1-14**] Date of Birth: [**2058-5-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: fever/hypotension Major Surgical or Invasive Procedure: Dialysis catheter removal- left groin Dialysis catheter placement- left groin temporary [**2118-1-11**] and permanent [**2118-1-12**] History of Present Illness: 59M h/o of ESRD due to hypertensive nephropathy with R femoral tunneled HD line due to multiple AV graft infections (MSSA in [**10-29**] and [**6-30**], VRE (gallinarum) in [**2105**], CAD s/p MI, CHF, seizure disorder and CVA, sent from dialysis with fever to 101.8. Blood cultures were sent from HD and he was given vancomycin 1 gram x1. Able to complete HD. Had not had fevers prior to HD today. Denies changes in his chronic cough or yellow sputum production. No abdominal pain, diahrea, soar throat, nausea, vomiting, or neck stiffness. Also endorses being constipated x 2 weeks. + Chronic back pain, currently [**7-2**]. No CP/palpitations. Got H1N1 vaccine 2 days ago; seasonal flu vaccine 2 weeks ago. In the ED, initial vs were: T102.8 119 97/52 22 92% on RA. Patient was given tylenol and levofloxacin 750 mg IV. CXR with RLL opacity, though does not appear to be significantly changed from prior. R EJ placed. BPs as low as 81/40, then up to 104/57 and 100/54 prior to transfer to MICU. Received total of 2L IVFs with 3rd liter hanging. Past Medical History: - MSSA HD line infection with septic lung emboli [**9-1**] with left pleural effusion - h/o Hepatitis B, treated - Non-ischemic cardiomyopathy, last EF 40-45% - MI [**2086**] per pt - CVA [**2086**] per pt (?residual LE weakness) - ESRD on hemodialysis [**1-25**] HTN. Currently dialyzed through R femoral line. EDW 80 kg as of [**2118-1-3**]. - Multiple thrombectomies in LUE and R thigh AV fistula - Graft excision for infected thigh graft [**2117-5-26**] - Seizure disorder since mid [**2097**] after starting dialysis - Hungry bone syndrome status post parathyroidectomy - Pituitary mass - Anemia of chronic disease - s/p PEG tube placement [**2117-10-29**] Social History: Patient has a Ph.D. in history. He was an organist and choir director at a local church. No recent ETOH, tobacco, or illicit drugs. Family History: Father - DM Mother - Deceased age 41 of renal failure One son - healthy Physical Exam: Vitals: BP 100/54 General: Alert, oriented, no acute distress, midly diahrphoretic HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [**2118-1-5**] 12:15PM BLOOD WBC-12.2* RBC-3.29* Hgb-7.9* Hct-27.5* MCV-84 MCH-24.0* MCHC-28.6* RDW-19.0* Plt Ct-327 [**2118-1-6**] 04:07AM BLOOD PT-14.2* PTT-30.6 INR(PT)-1.2* [**2118-1-5**] 12:15PM BLOOD Glucose-88 UreaN-20 Creat-3.5*# Na-143 K-3.8 Cl-104 HCO3-32 AnGap-11 [**2118-1-7**] 11:53AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.1 . Discharge Labs: [**2118-1-14**] WBC RBC Hgb Hct MCV Plt Ct 6.0 3.52* 8.4* 29.5* 649* Glucose UreaN Creat Na K Cl HCO3 AnGap 81 23* 6.6*# 141 3.9 98 34* 13 . [**2118-1-5**] 8:30 am BLOOD CULTURE **FINAL REPORT [**2118-1-8**]** Blood Culture, Routine (Final [**2118-1-8**]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S [**2118-1-5**]- [**3-27**] sets of positive blood cultures [**2118-1-6**] - [**2118-1-12**] blood cultures: NGTD [**2118-1-5**] 10:11 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2118-1-7**]** MRSA SCREEN (Final [**2118-1-7**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [**2118-1-6**] 4:03 pm CATHETER TIP-IV Source: Left femoral HD line. **FINAL REPORT [**2118-1-8**]** WOUND CULTURE (Final [**2118-1-8**]): No significant growth. [**2118-1-5**] CXR: IMPRESSION: 1. Right lower lobe opacity, similar to the prior examinations; however, new pneumonia or underlying pulmonary lesion cannot be excluded. Recommend follow-up to resolution after appropriate treatment. Small right pleural effusion. 2. Slightly more cranial position of a femoral catheter with its tip in the right atrium. [**2118-1-6**] ECHO: The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the inferior septum, inferior and inferolateral segments. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Compared with the prior study (images reviewed) of [**2117-9-6**], pulmonary artery pressures can be estimated on the current study and are mildly elevated. The wall motion abnormalities and other findings are similar. [**2118-1-6**] FEMORAL ULTRASOUND: IMPRESSION: 1. No pseudoaneurysm, or fluid collections. There is an enlarged lymph node within the right groin. 2. Clotted AV graft within the right leg, present on prior CT examination. [**2118-1-6**] IMPRESSION: Successful removal of a tunneled right common femoral hemodialysis catheter. The tip was sent for culture. [**2118-1-11**] PFI: Successful placement of non-tunneled left femoral hemodialysis catheter, with tip in the IVC, 24 cm in length, ready to use. After resolution of hyperkalemia, the patient should return to interventional radiology for conversion to a tunneled line. Brief Hospital Course: 59M with ESRD on HD with tunnelled femoral line, recent prolonged hospital admission with MSSA bacteremia and lung abscesses, presents w/ fever and hypotension later found to be [**1-25**] MSSA. . # Hypotension: Patient initially admitted to MICU with significant hypotension, but resolved upon arrival after receiving IVF boluses. The most likely etiology of his hypotension was bacteremia. He grew [**3-27**] sets of positive blood cultures of MSSA on arrival. His hypotension resolved quickly. He maintained his blood pressures throughout his hospitalization. He never required pressors during his MICU course. . # Bacteremia: Patient was initially febrile and hypotensive. He was found to have 4 sets of MSSA positive blood cultures. The most likely source was his HD line. He was treated with vancomycin initially, then transitioned to cefazolin once sensitivities were back. His femoral dialysis catheter was removed, and after a line holiday of 5 days, the patient had a permanent tunnelled left groin dialysis catheter placed without any difficulty. His CXR also was initially concerning for possibly a PNA, but the findings were stable since his last hospitalization. The patient will continue on cefazolin at HD until [**2-6**]. ID would like weekly CBC w/ differential and LFTs faxed to [**Hospital **] clinic nurses at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatient antibiotics should be directed to the when clinic is closed. . # ERSD on HD: Renal was following and received dialysis during this hospitalization as needed. The patient will continue on his MWF HD as an outpatient. Will continue calcium carbonate, lanthanum, sevelamir and renal diet. # Seizure disorder: Will continue home oxcarbazepine and kepra. . # Chronic systolic CHF: As it was unclear why the patient was not on an ace inhibitor prior to admission, he was started on lisinopril 10mg daily. A statin was also started while he was hospitalized, and his digoxin and aspirin were continued. The patient has cardiology follow up arranged. Medications on Admission: - Renagel 1600 mg TID - PhosLo 2668 mg TID with meals - OXcarbazepine 300 mg TID plus additional pill post HD. - Keppra 500 mg TID plus additional pill post HD - Gabapentin - ASA 81 mg daily - Digoxin 125 mcg QOD - Allopurinol 100 mg daily - Dilaudid 2-4 mg PO Q4H prn pain - Epogen [**Numeric Identifier **] units TIW with HD - Folate 1 mg daily - ?HSQ - Sarna lotion Discharge Medications: 1. Oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 3. Cefazolin 10 gram Recon Soln Sig: Two (2) grams Injection QHD (each hemodialysis). 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHD (each hemodialysis). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inhalation Inhalation Q2H as needed for wheeze. 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 12. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 16. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO DAILY (Daily). 17. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1) injection Injection three times a day: subcutaneously. 18. Dilaudid-5 1 mg/mL Liquid Sig: 1-4 mg PO every four (4) hours as needed for pain: hold for sedation or rr<12. 19. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application Topical as directed: 0.5-0.5% Lotion APPLY LIBERALLY TO SKIN ON HANDS, FEET . 20. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 1643**] Center Discharge Diagnosis: Primary Diagnosis: 1. MSSA bactermia 2. CKD stage V on HD . Secondary Diagnosis: - Non-ischemic cardiomyopathy, EF 35-40% per echo in [**12/2117**] - MI [**2086**] per pt - CVA [**2086**] per pt - Seizure disorder - Hungry bone syndrome status post parathyroidectomy - Anemia of chronic disease Discharge Condition: Alert, not currently ambulatory Discharge Instructions: You were admitted to the hospital for fevers. You were found to have a bacteria growing in your blood, called MSSA. This was most likely from your right femoral HD line. Your right femoral HD line was removed and we temporarily stopped your hemodialysis. You were treated with antibiotics. You will continue to get antibiotics at HD. You had another HD line placed in your left groin, and your resumed hemodialysis. You tolerated your procedures well. . We have made the following changes to your medications: 1. Started Cephazolin 2mg IV at hemodialysis until [**2-6**]. Infectious disease doctors [**First Name (Titles) **] [**Last Name (Titles) 20407**] this date and will continue to follow you. 2. Started Chlestyramine 4grams by mouth every day 3. Started Atorvostatin 10mg by mouth each day 4. Discotninue PhosLo 5. Started Lanthanum 500mg by mouth twice a day 6. Started calcium carbonate 500mg by mouth three times a day with meals 7. Started lisinopril 10mg daily Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Appointment #1 MD: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] Specialty: Cardiology Date/ Time: [**2118-2-3**] 2:15pm Location: [**Location 20408**], [**Location (un) 86**] MA Phone number: [**Telephone/Fax (1) 5068**] Special instructions for patient: . Appointment #2: Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Date/Time:[**2118-1-27**] 1:30 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2118-1-14**]

Admission Date: [**2122-4-1**] Discharge Date: [**2122-4-3**] Date of Birth: [**2052-11-21**] Sex: F Service: MEDICINE Allergies: MRI contrast Attending:[**Doctor First Name 6807**] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: Cardiac catheterization with balloon angioplasty to total occlusion of OM 1 coronary artery-this failed to open the vessel History of Present Illness: 69 y/oF with type 2 DM, [**Hospital **] transferred to the CCU following NSTEMI c/b dissection of OM2 during attempted angioplasty. Patient was in her normal state of health until this am when she developed acute onset chest pressure that awoke her from sleep at 6am. Describes retrosternal chest pressure accompanied by tachycardia and headache. No associated dyspnea, diaphoresis, N/V or any other associated symptoms. Per patient recording, systolic blood pressure was in 200s. When symptoms did not after approx 1-2 hrs, patient called PCP who told her to come to the ED. In the ED, initial vitals were T97 P79 BP186/113 RR16 SaO100%. Patient given ASA 325mg and SLN x 3 which brought pain from [**8-26**] to [**3-26**] but also caused hypotension to SBP of 74. EKG showed old LBBB with no other evident ST changes, CXR wnl. Initial labs remarkable for Cr of 1.3, trop 0.04. Due to uniterpretable EKG in the setting of elevated cardiac enzymes, patient taking emergently to cardiac catheterization. Prior to cath, started on heparin gtt and plavix loaded. Catheterization showed diffuse atherosclerosis with likely acute occlusion of left circumflex OM2, and significant stenoses in distal LAD and Diag 1. Angioplasty of OM2 branch was complicated by dissection (no evidence of perforation) and attemts to stent thrombosed area were aborted. Following catheterization, patient had residual [**2-26**] chest discomfort with unchanged EKG. She was admitted to the CCU for further observation. On review of systems, she complains of intermittent uncontrolled blood pressure for the for the past 2 yrs with BP as high as 200s. These episodes are accompanied by flushing, headaches and tachycardia. Thorough evaluation revealed renal artery stenosis with normal urinary metanephrines and aldosterone. She is currently followed by a nephrologist with no planned intervention. Of note, despite hyperlipidemia, patient is not maintained on a statin. She previously tolerated atorvostatin but when she was changed to simvastatin for insurance purposes, she developed dark urine. As this was a listed side effect on the back of the bottle, patient decided to see d/c meds. Otherwise, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. OTHER PAST MEDICAL HISTORY: - renal artery stenosis - psoriasis Social History: originally from Romainia, lives with husband and has 2 grown children. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Mother and brother died of colorectal cancer in their 50s. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission PE: T: 98.4, P: 65, BP: 148/81, RR: 13, 99% on 2L NC GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, MMM. NECK: Supple with JVP at approx 7cm CARDIAC: RRR S1 S2 no m/r/g LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits. Bulky suprapubic mass EXTREMITIES: No c/c/[**Initials (NamePattern5) **] [**Last Name (NamePattern5) **] with dressing c/d/i. No femoral bruit or hematoma SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Discharge PE: Temp Max: 99.5 Temp current: 99.5 HR: 76-81 RR: 20 BP: 117-132/70-81 O2 Sat: 96% RA Gen: alert, Oriented, NAD, sleeping initially HEENT: supple, JVD at 10 cm CV: RRR, no M/R/G RESP: CTAB post ABD: soft, NT EXTR: no edema. Has old healed lesions on bilat knees [**2-18**] fall NEURO: Extremeties: right Groin with no hematoma, ecchymosis Pulses: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Skin: intact Pertinent Results: Hematology: [**2122-4-3**] 06:55AM BLOOD WBC-6.8 RBC-4.02* Hgb-12.0 Hct-33.9* MCV-84 MCH-30.0 MCHC-35.6* RDW-14.3 Plt Ct-152 [**2122-4-2**] 04:15PM BLOOD Hct-36.0 [**2122-4-2**] 06:05AM BLOOD WBC-7.5 RBC-4.25 Hgb-12.7 Hct-35.2* MCV-83 MCH-30.0 MCHC-36.1* RDW-14.1 Plt Ct-177 [**2122-4-1**] 09:05AM BLOOD WBC-7.7 RBC-4.96 Hgb-14.7 Hct-41.1 MCV-83 MCH-29.6 MCHC-35.7* RDW-14.3 Plt Ct-166 [**2122-4-1**] 09:05AM BLOOD Neuts-81.3* Lymphs-14.4* Monos-2.7 Eos-1.3 Baso-0.3 [**2122-4-2**] 06:05AM BLOOD PT-12.7 PTT-22.9 INR(PT)-1.1 [**2122-4-1**] 09:05AM BLOOD PT-12.2 PTT-22.2 INR(PT)-1.0 Chemistries: [**2122-4-3**] 06:55AM BLOOD Glucose-154* UreaN-25* Creat-1.3* Na-139 K-3.8 Cl-104 HCO3-24 AnGap-15 [**2122-4-2**] 06:05AM BLOOD Glucose-181* UreaN-25* Creat-1.3* Na-138 K-3.7 Cl-104 HCO3-21* AnGap-17 [**2122-4-1**] 09:05AM BLOOD Glucose-196* UreaN-27* Creat-1.3* Na-136 K-3.3 Cl-98 HCO3-24 AnGap-17 Cardiac Biomarkers: [**2122-4-3**] 06:55AM BLOOD CK(CPK)-469* [**2122-4-2**] 06:05AM BLOOD CK(CPK)-1052* [**2122-4-1**] 10:01PM BLOOD CK(CPK)-1025* [**2122-4-3**] 06:55AM BLOOD CK-MB-17* MB Indx-3.6 cTropnT-2.95* [**2122-4-2**] 06:05AM BLOOD CK-MB-109* MB Indx-10.4* cTropnT-2.80* [**2122-4-1**] 10:01PM BLOOD CK-MB-129* MB Indx-12.6* cTropnT-1.77* [**2122-4-1**] 09:05AM BLOOD cTropnT-0.04* LFTS: [**2122-4-1**] 09:05AM BLOOD ALT-13 AST-24 LD(LDH)-191 CK(CPK)-166 AlkPhos-56 Other: [**2122-4-2**] 06:05AM BLOOD %HbA1c-6.5* eAG-140* [**2122-4-2**] 06:05AM BLOOD Triglyc-226* HDL-33 CHOL/HD-7.3 LDLcalc-162* ECG [**2122-4-1**]: Sinus rhythm. Borderline P-R interval prolongation. Left bundle-branch block. CXR [**2122-4-1**]: FINDINGS: Single frontal view of the chest was obtained. Right infrahilar/perihilar opacity most likely relates to slight prominence of the vasculature, although an underlying minimal consolidation cannot be entirely excluded. Lingular atelectasis/scarring is noted. The remainder of the left lung is clear. No pleural effusion or pneumothorax is seen. Cardiac and mediastinal silhouettes are unremarkable. Cardiac Cath [**2122-4-1**]: 1. Selective coronary angiography in this right dominant system demonstrates two vessel coronary artery disease. The left main contains an ostial 30% lesion. There is a twin LAD system wtih a 90% lesion in the mid-portion of hte vessl. The first diagonal goes to the apex and has an 80% lesion. The circumflex artery is free of angiographically apparent flow limiting disease but a small OM2 branch is totally occluded. 2. Limited resting hemodynamics demonstarte moderate systemic hypertension. 3. Partially successful PTCA only of the proximal OM2 total occlusion. (see PTCA comments) 4. R 6Fr femoral artery Angioseal closure device deployed without complications. (see PTCA comments) FINAL DIAGNOSIS: 1. Severe three vessel artery disease: see comments 2. Moderate systemic hypertension 3. Partially successful PTCA only of the proximal OM2 total occlusion. (see PTCA comments) 4. ASA indefinitely; plavix (clopidogrel) 600 mg bolus given in cath lab and 75 mg daily with plan for LAD and DIAG revascularization to be pursued by Dr. [**First Name (STitle) **] [**Name (STitle) 33746**], interventional cardiology attending. 5. Plan for CCU observation/medical management at this time ECHO [**2122-4-2**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with mild basal inferolateral hypokinesis. The remaining segments contract normally (LVEF = 55%). The right ventricular cavity is mildly dilated with mild global 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. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Minimal regional left ventricular systolic dysfunction, c/w CAD. No clinically-significant valvular disease seen. Brief Hospital Course: Patient is a 69 y/oF with type 2 DM, [**Hospital **] transferred to the CCU following NSTEMI c/b carotid dissection of OM2 during attempted angioplasty. # CORONARIES: Patient presented with chest pressure. EKG showed NSEMI. She was sent to the cath lab and then admitted to the CCU s/p NSTEMI c/b OM2 dissection during attempted angioplasty. Cardiac catheterization revealed diffuse 3-vessel disease with significant stenoses in the distal LAD and diag. Patient had peristent low-grade chest discomfort after cath but no signs of significant complication from dissection including perforation. On discharge, she was chest pain free. She was treated with aspirin, plavix, metoprolol, and was started on atorvastatin. She was not given heparin in the setting of her dissection. Her CK peaked at 1052 on the am of [**2122-4-2**]. Patient plans to undergo elective PCI for treatment of her LAD lesion although at the time of discharge, she was still considering the possibility of CABG. # PUMP: Patient remained euvolemic with no signs of congestive heart failure. Her echo showed mild basal inferolateral hypokinesis with EF >55%. # Renal Artery Stenosis: appears to be etiology of episodic uncontrolled blood pressure with no planned intervention per outpatient nephrologist. Was previously tolerated high-dose ACEI although Cr elevated to 1.3 from unknown baseline (1.1 in [**3-/2121**]) upon admission. Her creatinine remained stable and she was restarted on her home dose of lisinopril 40 mg po daily. . # Hypertension: Patient presented to the ED with hypertensive emergency with BP 200/120, MI and headache. Her chest pressure improved with improvement in her BP. She was continued on metoprolol, hydrochlorothiazide and lisinopril. # Type 2 DM: Patient's A1C was 6.5, close to baseline. She was only using metformin intermittently. She will discuss restarting this medication with her PCP. [**Name10 (NameIs) **] was continued on a diabetic diet and humalog sliding scale while admitted. #Anemia: Patient was admitted with normal HCT at 41.1 which then trended as follows: 41.1->35.2-> 36-> 33.9. There were also decreases in her other cell counts (platelets, WBC). She should have a repeat CBC done as an outpatient. CODE: Full (confirmed with patient) Medications on Admission: - HCTZ 50mg daily - metformin 500 [**Hospital1 **] (only taking when BG high) - lisinopril 40mg daily - lopressor 50mg [**Hospital1 **] Discharge Medications: 1. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes for total of 2 doses as needed for chest pain: Call Dr. [**Last Name (STitle) 19**] immediately if you have any chest pain. Disp:*25 tablets* Refills:*0* 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. isosorbide mononitrate 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Non ST elevation myocardial infarction Renal artery stenosis Hypertension Diabetes Mellitus type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a heart attack and needed a cardiac catheterization to assess your heart arteries for blockages. One artery was thought to have caused the heart attack and was opened with a balloon. There was a small tear called a dissection that has not caused any complications. No stents were placed. You had some chest pain after the procedure and a medicine called isosorbide mononitrate was started to prevent more chest pain. This will cause a headache but you should speak to Dr. [**Last Name (STitle) 19**] if the headache is not relieved by tylenol. The plan is for you to return for another procedure to fix additional blockages in your coronary arteries. . We made the following changes to your medicines: 1. Start Isosorbide mononitrate to prevent chest pain. 2. Start nitroglycerin under your tongue if you have chest pain similar to the pain during your heart attack. You can take up to 2 tablets 5 minutes apart but please call Dr. [**Last Name (STitle) 19**] right away if you have any chest pain and take nitroglycerin. Call 911 if you take two nitroglycerin tablets and you still have chest pain. 3. Start taking Atorvastatin 80 mg to lower your cholesterol 4. Start taking Plavix to prevent blood clot formation in your coronary arteries 5. Continue to take Lisinopril, aspirin, hydrochlorothiazide and metoprolol as before. Followup Instructions: Name: CAMAC-[**Last Name (LF) **],[**First Name3 (LF) **] Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2261**] Appointment: Friday [**2122-4-10**] 12:10pm Name: Come, [**Name8 (MD) **] MD Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] Appointment: office will call you with an appt

Admission Date: [**2134-3-21**] Discharge Date: [**2134-3-26**] Date of Birth: [**2109-8-19**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [**2134-3-21**] Closure of scalp laceration Washout & closure of left arm laceration History of Present Illness: 24 year old female who was an unrestrained driver in a motor vehicle crash. The vehicle reportedly rotated 360 and was hit twice. The patient was partially ejected from the vehicle and sustained a open skull fracture as well as evulsed left arm. She was intubated at the scene with a BP 80/50 and brought to [**Hospital6 23267**] where she received blood and normal saline. She was then transferred to [**Hospital1 18**] ED. Upon initial presentation she was moving all extremities. Past Medical History: None Family History: Noncontributory Physical Exam: Upon admission: Vital Signs:T: 96.8 BP: 121/83 HR:105 R:20 O2Sats:100 Gen: intubated non-responsive HEENT: Pupils: left 2.5 mm fixed, right pupil 2.5 minimally responsive EOMs fixed Extrem: left arm evulsion fracture, finger with poor circulation pale blue color Neuro: Mental status: intubated , non responsive Orientation: non responsive Recall/Language:none Cranial Nerves: I: Not tested II: Pupils equal left 2.5 mm fixed, right pupil 2.5 minimally responsive III, IV, VI:Extraocular movements- eyes fixed V, VII,VIII,IX,X,[**Doctor First Name 81**],XII,Motor/Sensation/coordination:unable to test pt with [**Location (un) 2611**] scale 3 Corneal:absent Gag: present Toes downgoing bilaterally Pertinent Results: [**2134-3-21**] 09:19PM TYPE-[**Last Name (un) **] PO2-73* PCO2-42 PH-7.25* TOTAL CO2-19* BASE XS--8 COMMENTS-QUESTION S [**2134-3-21**] 09:19PM GLUCOSE-179* LACTATE-4.7* NA+-137 K+-3.1* CL--107 [**2134-3-21**] 09:19PM HGB-11.9* calcHCT-36 [**2134-3-21**] 07:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2134-3-21**] 07:40PM WBC-11.0 RBC-3.78* HGB-11.7* HCT-33.3* MCV-88 MCH-30.9 MCHC-35.0 RDW-13.3 [**2134-3-21**] 07:40PM PLT COUNT-230 [**2134-3-21**] 07:40PM PT-14.3* PTT-30.2 INR(PT)-1.2* [**2134-3-21**] 07:40PM FIBRINOGE-114* CT Head [**2134-3-22**] IMPRESSION: There is a left frontal epidural hematoma and a small associated subdural/epidural hematoma as described above. Final Attending Comment: There is a fracture of the left frontal bone and on image 36, a tiny bony fragment appears to have been displaced into the brain. Repeat head CT [**2134-3-23**] IMPRESSION: Unchanged left frontal hematoma with overlying frontoparietal skull fracture and scalp hematoma. Unchanged smaller more inferior extra-axial left frontal hematoma. CT cervical spine [**2134-3-23**] IMPRESSION: 1. No fracture or subluxation. 2. Extensive soft tissue stranding/hemorrhage in the left supraclavicular region which may relate to recent attempt at central venous access (no clavicular fracture is seen); correlate clinically. Brief Hospital Course: She was admitted to the Trauma service and taken to the operating room emergently for incision debridement repair of biceps and soft tissue defect left upper arm irrigation and debridement closure of open skull fracture with 12 cm scalp laceration. Postoperatively she was taken to the Trauma ICU where she remained sedated and intubated for several days. She was eventually extubated without any difficulty. Neurosurgery was consulted for the epidural/subdural frontal hemorrhage. She was placed on Dilantin which will continue for a 7 day course as prophylaxis for seizures. Repeat head CT scans remained stable. Neurologically she is alert and oriented x2 for the most part; some difficulty intermittently with remembering where she is. She has been able to follow commands and answer simple questions appropriately. She was eventually transferred to the regular nursing unit. She was evaluated by Plastics for her left metacarpal fracture; this was managed nonoperative with a ulnar splint and she will follow up in [**Hospital 3595**] clinic in about a week after discharge. Orthopedics was consulted for her left clavicle fracture, this was also managed nonoperative with a sling. She is to remain non weight bearing on her left arm and will follow up in 2 weeks in orthopedics clinic. On HD #5 she was noted to complain of blurred vision with intermittent diplopia; an Ophthalmology consult was placed and it was felt that she had a traumatic 6th nerve palsy and no operative intervention was warranted. Physical and Occupational therapy were consulted and have recommended acute rehab after her hospital stay. The screening process was initiated and discharge plans were underway. Social work was consulted for coping and emotional support. Medications on Admission: OCP's Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 5 days. 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 7. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain. 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: s/p Motor vehicle crash Scalp laceration Epidural Hematoma Skull Fracture Left clavicle fracture Left metacarpal fracture Left arm laceration Traumatic 6th nerve palsy Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: Continue Dilantin until [**2134-3-30**] Followup Instructions: Follow up with Dr. [**First Name (STitle) **], Neurosurgery in [**9-29**] days. Call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that a repeat non contrast head CT is needed for this appointment. Follow up in Plastics/Hand clinic next Tuesday [**3-30**], call [**Telephone/Fax (1) 3009**] for an appointment. Follow up next Tuesday [**3-30**] with Dr. [**Last Name (STitle) **], Trauma Surgery for removal of your scalp and left arm staples. Call [**Telephone/Fax (1) 6429**] for an appoitnment. Follow up in 2 weeks with Dr. [**Last Name (STitle) 1005**], Orthopedics for your clavicle fracture, call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in [**Hospital **] clinic in 2 weeks, call [**Telephone/Fax (1) 253**] for an appointnment. Completed by:[**2134-6-9**]

Admission Date: [**2165-9-13**] Discharge Date: [**2165-9-21**] Date of Birth: [**2097-9-1**] Sex: F Service: MEDICINE Allergies: Adhesive Tape / Hayfever Attending:[**Doctor First Name 1402**] Chief Complaint: melanoma resection Major Surgical or Invasive Procedure: PROCEDURE #1: 1. Radical resection of malignant melanoma involving the left temporalis muscle and adjacent soft tissue. 2. Left parotidectomy with facial nerve monitoring and dissection. 3. Left modified radical neck dissection. 4. Zygomatic osteotomy. PROCEDURE #2: 1. Left radial forearm free flap to left temporal defect. 2. Open reduction internal fixation of zygomatic arch defect. 3. Autologous fat grafting to the pedicle. 4. Split-thickness skin graft of the left upper arm and a 7 x 7 cm 14/1000 of an inch skin graft on the left thigh. History of Present Illness: Pt is a 68 yo F with h/o DMII, HTN, paroxysmal Afib and now s/p left temporal melanoma resection, parotidectomy, left neck dissection and flap reconstruction on [**2165-9-13**]. Since then, pt was intermittently in Afib RVR (HR iun 130-140s) and had received IV boluses of metoprolol. She was also restarted her Sotalol 120 [**Hospital1 **]. She has also had brief episodes of asymptomatic sinus bradycardia (slowest rate in 30s, no hemodynamic instability). Pt is being transferred to our service today for management of Afib RVR and possible cardioversion tomorrow. . Upon arrival the floor, pt appears well, denies any pain. Denies any palpitations. No nausea/vomiting or abdominal pain. Admits to constipation (no BM since admission). Denies any CP, DOE. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools. Admits to joint pains (from arthritis) and occasional bloody stools (hemorrhoids). She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Admits to occasional bilat leg swelling. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Hypertension 2. CARDIAC HISTORY: Atrial fibrillation (dx in [**2161**] on Sotalol and Coumadin at home) -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: arthritis (s/p R total hip replacement in [**2161**]) DMII (on no meds, recent HbA1C 7.1) HTN infectious hepatitis ([**2115**]) Social History: -Tobacco history: quit in [**2127**], 1PPD x 20yrs previously -ETOH: occ -Illicit drugs: denies Family History: Mother died of PE at 52yrs of age. Physical Exam: VS: T= 96.9 BP= 127/78 HR= 99 RR= 18 O2 sat= 96% on 3L GENERAL: AOriented x3. Mood, affect appropriate. HEENT: L temporal flap in place, appears well, JP drain in place draining serosangious fluid NECK: Supple with no JVD CARDIAC: irregularly irregular rhythm, normal rate, normal S1, S2. No m/r/g. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. pneumoboots in place. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: WBC Hb Hct Plts [**2165-9-20**] 07:10AM 15.2 9.9 29.5 372 [**2165-9-18**] 01:42AM 9.8 9.2 27.7 290 [**2165-9-17**] 01:48AM 12.0 8.6 25.7 240 [**2165-9-16**] 01:14AM 13.1 9.4 26.9 222 [**2165-9-15**] 01:04AM 9.7 9.2 27.0 190 [**2165-9-14**] 04:20AM 7.7 8.5 25.4 179 [**2165-9-13**] 11:23PM 6.4 8.8 26.3 202 PT PTT INR [**2165-9-20**] 07:10AM 15.5 85.9 1.4 [**2165-9-19**] 07:00AM 14.0 1.2 [**2165-9-18**] 01:42AM 14.0 25.4 1.2 [**2165-9-17**] 01:48AM 14.0 1.2 [**2165-9-13**] 11:23PM 15.1 34.0 1.3 Gluc BUN Cr Na K Cl HCO3 [**2165-9-20**] 07:10AM 139 19 0.9 139 4.0 106 26 [**2165-9-18**] 01:42AM 116 13 0.7 142 3.8 112 23 [**2165-9-17**] 07:42PM [**Telephone/Fax (2) 84744**] 3.6 109 25 [**2165-9-17**] 01:48AM 132 13 0.8 142 3.7 108 27 [**2165-9-16**] 12:11PM 162 9 0.8 141 3.8 108 27 [**2165-9-16**] 01:14AM 155 7 0.8 140 3.8 110 25 [**2165-9-15**] 01:04AM 167 8 0.8 142 3.4 111 26 [**2165-9-14**] 04:20AM 163 14 0.8 142 3.7 112 25 [**2165-9-13**] 11:23PM 133 16 0.8 141 4.2 113 22 [**2165-9-20**] 07:10AM Ca 8.3 Ph 3.4 Mg 1.9 CXR [**2165-9-17**]: IMPRESSION: Improved aeration of bilateral lower lungs with improved atelectasis and vascular congestion. Brief Hospital Course: 68 yo F with h/o DMII, HTN, paroxysmal Afib on Sotalol and Coumadin at home here for left temporal melanoma resection, parotidectomy, left neck dissection and flap reconstruction on [**2165-9-13**] and then in Afib RVR peri-op. . # Afib RVR: Pt was in Afib RVR, HR in 130-140s, subsequently rate controlled with IV Metoprolol doses PRN then, switched to 50mg PO BID. Also, anticoagulation with heparin gtt was started, but given the recent surgery was very cautious (no bolus, PTT goal of 50-70 and q3h checks). Pt was started back on Coumadin which was held for the surgery. Daily INRs were checked and Coumadin dose was adjusted accordingly. Although TEE/cardioversion was initially considered, this pt's current Afib is likely [**12-31**] to stress from recent surgery and period off her home Sotalol. Given recent surgery of neck and temporal area, head cannot be extended and a TEE may be putting the pt at risk in regards to the surgery. Thus, rate-control with Sotalol (120mg [**Hospital1 **]) and Metoprolol (50mg [**Hospital1 **]) and bridging to Coumadin for anticoagulation was pursued. Once pt is therapeutic on INR for 3-4 weeks, can consider cardioversion (with no need for TEE) at that time if pt is still in Afib. Meanwhile, pt spontaneously converted to NSR, thus Heparin gtt was discontinued. Coumadin was continud however and pt was discharged on home dose, to be followed up with INR check soon. . # S/P melanoma excision: Left temporal melanoma resection, parotidectomy, left neck dissection and flap reconstruction were performed by Plastics on [**2165-9-13**]. pt tolerated surgery well. Flap checks were performed every 4 hours. Pt is to be in soft diet for 2 weeks. Left forearm had xeroform/kerlex dressing changed daily. Left thig area has Xeroform that is left to open air, does not need changing. No head extension or full turning to the left. JP drain remained for a few days, was taken out eventually. Ancef was given as long as JP drain was in. . # DMII: Pt is diet controlled at home, no meds. Pt was maintained on insulin sliding scale. Fingersticks were checked 4x/day. . # HTN: Was well-controlled, not on home HCTZ currently. Can be restarted as outpatient. . # Arthritis: Was stable, with pain well-controlled on Percocet. Pt did well with physical therpy, needs more conditioning at a rehab facility. . # Anemia: Hct was 39 pre-op on [**9-6**], has been in 25-28 range since [**9-13**]. Pt is asymptomatic, hemodynamically stable. Required no tranfusions. . # Pt was on a diabetic diet. For DVT ppx, pt was initially on Heparin gtt, bridging to Coumadin, however once Heparin gtt stopped and Coumadin was still not therapeutic, started SC Heparin. Pain management was with Percocet and bowel regimen was with Docusate, Senna, Bisacodyl. Pt was full code. Medications on Admission: CELEBREX HYDROCHLOROTHIAZIDE LORAZEPAM [ATIVAN] SOTALOL - 120mg [**Hospital1 **] WARFARIN - 2.5mg daily CALCIUM - Dosage uncertain MULTIVITAMIN - Discharge Medications: 1. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day) as needed for afib. 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain for 2 weeks: hold for sedation. Disp:*30 Tablet(s)* Refills:*0* 3. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care Center - [**Hospital1 1559**] Discharge Diagnosis: 1) Left skull base defect and temple defect, status post resection of melanotic lesion. 2) Atrial Fibrillation with rapid rate Discharge Condition: stable Discharge Instructions: You were admitted to the hospital for melanoma removal and reconstruction. After your surgery you had a rapid irregular heart rhythm called atrial fibrillation. You were given medication to improve you heart and it returned to a normal rhythm. Please make the following changes to your medications: 1. Continue Sotalol 120 mg twice a day 2. Start Famotidine 20 mg twice a day 3. Start Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets every 6 hours as needed for pain for 2 weeks 4. Start Docusate Sodium 100 mg twice a day 5. Start Toprol XL 100 mg once a day 6. Continue Coumadin 2.5 mg once a day 7. Stop HCTZ until you follow-up with your PCP 8. Stop Celebrex until you follow-up with your PCP Please seek immediate medical attention if you have chest pain, increased shortness of breath, dizziness, fainting spells, increased leg swelling, confusion or any other concerning symptoms. Followup Instructions: Follow-up with ENT: Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**] Date/Time:[**2165-9-24**] 2:20 PM Follow-up with Cardiology: Provider: [**Name10 (NameIs) **] BROWNING, MD Phone: ([**Telephone/Fax (1) 84745**] Date/Time: [**2165-9-26**] 11:00 AM Follow-up with Plastics: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] Phone: [**Telephone/Fax (1) 6742**] Date/Time: [**2165-9-27**] 10:00 AM Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 50416**] within 1-2 weeks of discharge. Please call [**Telephone/Fax (1) 84746**] for appointment time. Completed by:[**2165-9-21**]

Admission Date: [**2157-3-16**] Discharge Date: [**2157-3-25**] Date of Birth: [**2088-8-7**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This 68 year old white male has a history of diabetes, hyperlipidemia and hypertension. He was recently diagnosed with three vessel coronary artery disease in [**State 108**] and was admitted with unstable angina. The night prior to admission here he had mid sternal chest pain with radiation and diaphoresis in ten minutes. He took Nitroglycerin without effect and was awoken with pain later on in the evening. On his way to the Emergency Room he had nitroglycerin spray and was pain-free on arrival to the Emergency Room. He was recommended to have a coronary artery bypass graft in [**State 108**] and wanted to come back to [**Location (un) 86**] for his surgery. PAST MEDICAL HISTORY: Significant for a history of Type 2 diabetes, history of peripheral neuropathy, history of retinopathy, history of coronary artery disease with a positive stress test and unstable angina in [**2157-2-13**]. He ruled out for an myocardial infarction and a cardiac catheterization revealed three vessel coronary artery disease with an ejection fraction of 70%. He was status post cerebrovascular accident in [**State 108**] as well with mild residua of the left hemiparesis, small lacunar hemorrhages. He has a history of hypercholesterolemia and neurogenic bladder. MEDICATIONS ON ADMISSION: Glyburide 5 mg p.o. q. day, Lopressor 75 mg p.o. b.i.d., Lipitor 10 mg p.o. q. day, Aggrenox 25/200 b.i.d., Metformin 1 gm b.i.d., Zoloft 100 mg p.o. q. day and Nitropatch. ALLERGIES: He is allergic to Bromocriptine. SOCIAL HISTORY: He does not smoke cigarettes, does not drink alcohol and lives alone. FAMILY HISTORY: Unremarkable. PHYSICAL EXAMINATION: He is a well developed, well nourished elderly white male in no apparent distress. Vital signs, stable, afebrile. Head, eyes, ears, nose and throat examination, normocephalic, atraumatic. Extraocular movements intact. Oropharynx benign. Neck was supple with full range of motion, no lymphadenopathy or thyromegaly. Carotids were 2+ and equal bilaterally without bruits. Lungs were clear to auscultation and percussion. Cardiovascular, regular rate and rhythm, normal S1 and S2, no rubs, murmurs or gallops. Abdomen was obese, soft, nontender with positive bowel sounds, no masses or hepatosplenomegaly. Extremities, without cyanosis, clubbing or edema. Femoral pulses were 1+ and equal bilaterally. Dorsalis pedis was 1+ on the right and trace on the left. Neurological examination was nonfocal. HOSPITAL COURSE: He was admitted and seen by Neurology. He had a head computerized tomography scan which revealed right small frontal subcortical hypodensity. Dr. [**Last Name (STitle) 70**] was consulted and the patient was uncertain as to whether he would like surgery. He eventually consented and on [**2157-3-18**] he underwent a coronary artery bypass graft times three with left internal mammary artery to the left anterior descending, reverse saphenous vein graft to the posterior descending artery and obtuse marginal. Cross clamp time was 60 minutes, total bypass time was 75 minutes. He was transferred to the Cardiac Surgery Recovery Unit in stable condition on Neo-Synephrine and Propofol. He was extubated and had a stable postoperative night. His chest tube was discontinued on postoperative day #2. He did notice some slurred speech and was seen by Neurology and they recommended decreasing his pain medications. He also complained of dysphagia. He did have an magnetic resonance imaging scan on postoperative day #3 which was unremarkable. He was transferred to the floor on postoperative day #3. He had a small episode of rapid atrial fibrillation. On postoperative day #4 he was treated with Lopressor and Amiodarone and converted to sinus rhythm. He continued to slowly improve but required aggressive physical therapy and on postoperative day #7 he was discharged to rehabilitation in stable condition. MEDICATIONS ON DISCHARGE: Lasix 20 mg p.o. b.i.d. for seven days. Potassium 20 mEq p.o. q. day for seven days. Zoloft 100 mg p.o. q. day. Glucophage 1000 mg p.o. b.i.d. Glyburide 10 mg p.o. b.i.d. Colace 100 mg p.o. b.i.d. Amiodarone 400 mg p.o. b.i.d. times one week and then decrease to 400 mg p.o. q.d. and then decrease to 200 mg, for one week and then decrease to 200 mg p.o. q. day. Dilaudid 2 mg p.o. q. 4-6 hours prn pain. Lipitor 10 mg p.o. q. day Aggrenox 1 p.o. b.i.d. Lopressor 50 mg p.o. b.i.d. LABORATORY DATA ON DISCHARGE: Hematocrit 34, white count 9,800, platelets 352, sodium 136, potassium 4.1, chloride 100, carbon dioxide 27, BUN 24, creatinine 1.0, glucose 139. FOLLOW UP: He will be followed by Dr. [**Last Name (STitle) **] in one to two weeks and Dr. [**Last Name (STitle) 70**] in six weeks. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Type 2 diabetes. 3. Cerebrovascular accident. 4. Atrial fibrillation. 5. Hypertension. 6. Hypercholesterolemia. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-358 Dictated By:[**Last Name (NamePattern1) 6516**] MEDQUIST36 D: [**2157-3-25**] 13:19 T: [**2157-3-25**] 16:03 JOB#: [**Job Number 98513**]

Admission Date: [**2121-9-27**] Discharge Date: [**2121-10-4**] Date of Birth: [**2037-2-3**] Sex: M Service: MEDICINE Allergies: Oxycodone Attending:[**First Name3 (LF) 11839**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: arterial embolization History of Present Illness: Mr. [**Known lastname 33372**] is an 84M with SCLC diagnosed 8 months ago undergoing 3rd cycle of chemotherapy who presents with hemoptysis. He began to have blood streaked sputum 1 month ago which has been progressing in volume over the past week. On the day of admission he began to cough up frank blood, approximately 1 tablespoon per cough for a total of one cup of frank blood with clots. He had a gurgling sensation in his chest and found it difficult to breath and called 911. . In ED, initial VS:98.9 60 118/68 18 96% RA. He continued to have frank blood with an intermittent cough but only pea sized amounts. CTA was negative for PE but revealed mass abutting pulm artery. Labs were significant for HCT stable at baseline 28-29. He was seen by IP and underwent flexible bronchoscopy which revealed large endobronchial vascular oozing mass almost obstructing RUL bronchus. IR was called and patient underwent right bronchial artery embolization. During procedure, he developed oxygen requirement and was satting mid 90s on NRB. He was transferred back to the ED, stabilized, and transferred to [**Hospital Unit Name 153**]. VS prior to transfer: 97.8 76 123/71 25 94% on NRB, not in any acute distress . On the floor, he reports improved SOB and no further hemoptysis. He reports stable cough for months and denies any CP, palpitations, fever, chills, LH or dizziness, HA. States he stopped ASA one month ago and is not on plavix, coumadin or any other blood thinning medications. Past Medical History: 1. SCLC diagnosed 8 months ago, undergoing 3rd cycle of chemo, has not receievd XRT. Receives care at Cancer Center in [**Location (un) 47**] 2. Coronary artery disease, status post coronary artery bypass grafting in [**2112-5-13**]. 3. Peptic ulcer disease. 4. Status post AAA repair in [**2112-1-14**] with intraoperative myocardial infarction. 5. Hypercholesterolemia. 6. Tuberculosis as a child. 7. Diverticulosis. 8. Left retinal artery thrombosis with reduced vision on that side. 9. Eczema. 10. Chronic renal insufficiency with a baseline creatinine of 1.3 to 1.6. 11. history of asbestos exposure. 12. Zoster 13. Anemia 14. HTN Social History: Tobacco: 80 pack year ex smoker Lives with wife of 14 years. Electrician on sick leave He quit smoking more than 20 years ago,but prior to that was smoking 3-4 packs per day. He started smoking in [**2054**]. He also quit EtOH over 10 years ago. Family History: NC Physical Exam: General: Alert, oriented, slightly agitated, pulling at sheets in bed HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP 8-9cm, no LAD Lungs: Anteriorly coarse breath sounds throughout R>L with bibasilar rales CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis. Trace edema Pertinent Results: [**2121-9-27**] 10:31PM GLUCOSE-98 UREA N-18 CREAT-1.4* SODIUM-139 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15 [**2121-9-27**] 10:31PM CALCIUM-7.8* PHOSPHATE-2.3* MAGNESIUM-2.0 [**2121-9-27**] 10:31PM WBC-19.6*# RBC-3.49* HGB-10.3* HCT-31.1* MCV-89 MCH-29.4 MCHC-33.0 RDW-14.9 [**2121-9-27**] 10:31PM NEUTS-95* BANDS-0 LYMPHS-5* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2121-9-27**] 10:31PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL SCHISTOCY-OCCASIONAL BITE-OCCASIONAL [**2121-9-27**] 10:31PM PLT SMR-LOW PLT COUNT-84* [**2121-9-27**] 10:31PM PT-14.4* PTT-31.0 INR(PT)-1.2* [**2121-9-27**] 10:43AM PT-13.4 PTT-28.6 INR(PT)-1.1 [**2121-9-27**] 08:10AM GLUCOSE-84 UREA N-24* CREAT-1.6* SODIUM-142 POTASSIUM-4.5 CHLORIDE-110* TOTAL CO2-27 ANION GAP-10 [**2121-9-27**] 08:10AM estGFR-Using this [**2121-9-27**] 08:10AM CALCIUM-7.9* PHOSPHATE-1.8*# MAGNESIUM-2.3 [**2121-9-27**] 08:10AM WBC-9.3# RBC-3.29* HGB-9.5* HCT-29.1* MCV-89 MCH-29.0 MCHC-32.7 RDW-15.5 [**2121-9-27**] 08:10AM NEUTS-79.9* LYMPHS-17.9* MONOS-1.5* EOS-0.4 BASOS-0.3 [**2121-9-27**] 08:10AM PLT COUNT-84*# GRAM STAIN (Final [**2121-10-1**]): <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. Blood cultures: negative Brief Hospital Course: This 84 year old gentleman with SCLC receiving chemo was admitted with hemoptysis and RUL endobronchial mass and developed increasing hypoxia after undergoing IR guided bronchial artery embolization. . # Hemoptysis: Presented with hemoptysis and bronchoscopy consistent with RUL vascular mass and underwent right bronchial artery embolization. Pt was monitored closely and no recurrent episodes of [**Female First Name (un) **] hemoptysis. H?H was followed an dreained stable. Plts were also followed with th eintent to keep level close to 50k. On the day of discharge plt count was 47 an dpt did get 1 units of plts.Pt scheduled to return to [**Hospital Ward Name 1826**] 7 for a cbc to follow plt count. # SCLC:Pt was started on radiation treatment during the hospitalization. He completed 1500cgy out of 3000, and scheduled to return on Monday to radiation oncology fo rcompletion of treatment. pt to return to primary outside oncologist fo rfurther treatment of SCLC. # Hypoxemic respiratory distress: Pt still requiring O2 on transfer to floor. CXR c/w edema. Pt received lasix po x3 doses in total with good response. breathing improved an dpt weaned off oxygen. # Acute on chronic renal insufficiency: Pt has rising Cr 1.7 from baseline of 1.3-1.4, possibly due to large dye load received during bronchial artery embolization. FeNa 3%. Patient had good urine output and crea remained at 1.8. Creatinine shoul dbe followe dwith priary oncologist.. # Low grade fever: Pt had low grade fevers on th efloor. Blood and sputu culture sobtained and without growth. CXR also did not show a clear infiltrate. Fevers resolved and on d/c pt afebrile. # Leuopenia: Secondary to recent treatment with [**Doctor Last Name **]-etoposide. Pt was scheduled to get neulasta at primary oncologist but was admitted fo rhemoptysis. First dose of neupogen was given to pt on th eday of discharge . Pt scheduled to return to 7 [**Hospital Ward Name 1826**] to receive 3 additional daily doses. #. CAD s/p CABG: Pt restarted on a beta-blocker and rosuvastatin. Code status: DNR/DNI Medications on Admission: Atenolol 25 mg daily Niacin 500 mg Nitroglycerin prn Aspirin 81 mg daily Crestor 40 mg daily Amlodipine 5 mg po daily Discharge Medications: 1. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-14**] Inhalation every six (6) hours as needed for cough. Disp:*1 1* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Hemoptysis Pulmonary edema Small cell lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [**Known lastname 33372**], You were admitted with hemoptysis ( bleeding from your lungs). A chest CT showed that you have a mass abutting a pulmonary artery. You underwent an arterial embolization that was successful and you also started radiation treatment for your lung mass.You will need to continue follow up with your oncologist as scheduled as well as completion of teh radiation treatment at [**Hospital1 **]. Change in medication: Aspirin held because of bleeding- you should not continue aspirin for now. Niacin held-you will need to discuss the continuation of niacin in the future with your primary physician. Followup Instructions: 1. F/U with Radiation Oncology on Monday at 2pm at [**Location (un) 3387**] [**Hospital Ward Name 332**]-[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**], [**Numeric Identifier 718**]. Phone: [**Telephone/Fax (1) 9710**]. 2.Appointment on Monday at 1:30pm Oncology outpt infusion center [**Hospital Ward Name 1826**] 7 at [**Hospital1 18**], [**Location (un) **], tel [**Numeric Identifier 33374**] for neupogen shot and CBC. 2. Cont F/U with Primary oncologist at [**Location (un) 47**] cancer center.If you do not have an appointment, call to schedule an appointment.

Admission Date: [**2114-1-20**] Discharge Date: [**2114-2-1**] Date of Birth: [**2036-5-13**] Sex: M Service: MEDICINE Allergies: Amiodarone / Quinidine Attending:[**First Name3 (LF) 7333**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Pacemaker placement History of Present Illness: Mr. [**Name13 (STitle) 14077**] is a 77-year-old man with CAD s/p CABG (LIMA-LAD, RIMA-RCA, SVG-OM in [**2089**]) and PCI (DES to SVG-OM in [**2106**]), multiple atrial arrhythmias and tachybrady syndrome s/p multiple ablations and pacemaker placement in [**2106**], chronic systolic heart failure, stage IV CRF, recently admitted in [**12/2113**] for CHF exaceration who presents for CHF management prior to BiV pacemaker upgrade on [**2114-1-22**]. . Per Dr.[**Name (NI) 1565**] [**2114-1-17**] note Mr. [**Name13 (STitle) 14077**] has had increasing cardiac dysfunction primarily due to cardiac dyssynchrony secondary to chronic ventricular pacing. His ejection fraction has over the past four years progressively gone from normal to about 40% with measurements of synchrony being distinctly abnormal. He has hypokinesis of his septum, which is primarily related to his pacemaker. He has increasing fluid retention and inability to get the fluid to his kidneys and perfuse them well. An attempt to decrease the fluid accumulation and increasing Lasix has caused the deterioration of his kidney function, such that his BUN is 101 and creatinine 3.2 with concurrent hypokalemia and hypochloremia despite the concomitant use of Aldactone. Decision made to place BiV pacemarker in attempt to improve cardiac function and secondarily increase his renal perfusion. . On direct presentation from home patient reports ~5lb weight gain with abd distension since [**1-17**] appt. No changes made to medications, no dietary or medications non-complinance. Denies any worsening peripheral edema; stable 2 pillow orthopnea, no PND, no palpitations. . Patient admitted on [**1-20**]; BiV unable to be placed on [**1-22**] due to technically difficult therefore epicardial leads placed on [**1-23**]. Intra-op recevied received total of 15cc contrast. Patient underwent procedure successfully. Placed on coumadin and hep gtt. Patient received a dose of vanco during procedure; keflex continued x2days post. Post-operative course complicated by acute renal failure, nephrology consulted deterioration in function secondary to poor forward flow. . Of note on night prior to transfer patient s/p mechanical fall while walking - denies any preceding dizziness, chest pain, palpitations. . Current cardiac review of systems: denies dizziness, chest pressure, shortness of breath, stable abdominal distention. Denies diaphoresis, n/v. . On review of systems, reports pain at operative when coughing,he reports prior history of stroke, GI bleed in the setting of ASA, plavix; denies 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. . Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: CAD Sick sinus syndrome Chronic and diastolic CHF EF 40-45% Paroxysmal afib s/p multiple DCCV, aflutter ablations, and PVI in [**5-/2106**] -CABG: LIMA-LAD, RIMA-RCA, SVG-OM in [**2089**] -PERCUTANEOUS CORONARY INTERVENTIONS: DES to prox SVG-OM in [**9-/2107**] -PACING/ICD: [**Company 1543**] pacer in [**8-/2107**] for SSS PM settings: DDDR mode with a lower rate of 60, an upper track rate of 100, and an upper sensor rate of 110 beats per minute. The mode switch function is ON for atrial rates greater than 145 beats per minute. Of note, the PVARP time is set at 400 milliseconds. 3. OTHER PAST MEDICAL HISTORY: Stage III-IV chronic renal failure (baseline Cr 2.7-3.0) H/o CVA with bilateral lacunar infarcts in [**2100**] with residual left paresthesias and gait dysfunction OSA on CPAP H/o GI bleed on Plavix (now off ASA and Plavix) H/o scarlet [**Year (4 digits) **] Inflammatory bowel disease? Gout Obesity Fatty liver Left ear deafness Social History: Lives in [**State 792**]with his wife. Formerly worked at a dialysis medical device company. - Alcohol: Drinks wine weekly - Tobacco: 80 pack-year history but quit 12 years ago - Drugs: None Family History: Multiple family members with diabetes. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: VS: T 97.7 100/61 58 94%RA wt: 109.4 kg - 107.6 (on admission) Todays I/O: 530ccin/1235cc UOP GENERAL: WDWN in NAD. Speaking in full sentences without problems. Oriented x3. [**Name2 (NI) **], affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Central line in place. NECK: Supple, unable to assess JVP due to CVL placement CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4, minimal pretibial edema, + abd distension. CHEST: well-healed midline incision scar PPM site: -- bandage on the left anterior chest chest: minimal tenderness, dressing in place: c/d/i -- bandage on the posterior flank, dressing in place: c/d/i LUNGS: Resp were unlabored, no accessory muscle use. Decreased bs at b/l bases with overlying crackles, no wheezes or rhonchi. ABDOMEN: Distended, nontender. No HSM or tenderness. EXTREMITIES: Cool, 1+ pitting edema, skin changes consistent with chronic venous insufficiency. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ . On Discharge: VS: T 97.7 100/61 58 94%RA wt: 104 kg - 107.6 (on admission) GENERAL: WDWN in NAD. Speaking in full sentences without problems. Oriented x3. [**Name2 (NI) **], affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Central line in place. NECK: Supple, unable to assess JVP due to CVL placement CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4, 1+ symmetric LE edema, + abd distension. CHEST: well-healed midline incision scar PPM site: -- bandage on the left anterior chest chest: minimal tenderness, dressing in place: c/d/i -- bandage on the posterior flank, dressing in place: c/d/i -- wound on left knee: dressing in place - c/d/i LUNGS: Resp were unlabored, no accessory muscle use. Decreased bs at b/l bases scant overlying crackles, no wheezes or rhonchi. ABDOMEN: Distended, nontender. No HSM or tenderness. EXTREMITIES: WWP, 1+ pitting edema, skin changes consistent with chronic venous insufficiency. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: On Admission: [**2114-1-20**] 09:33PM WBC-9.2 RBC-3.53* HGB-11.8* HCT-33.3* MCV-94 MCH-33.6* MCHC-35.6* RDW-17.0* [**2114-1-20**] 09:33PM PLT COUNT-172 [**2114-1-20**] 09:33PM GLUCOSE-170* UREA N-104* CREAT-3.4* SODIUM-135 POTASSIUM-3.4 CHLORIDE-94* TOTAL CO2-25 ANION GAP-19 [**2114-1-20**] 09:33PM CALCIUM-9.4 PHOSPHATE-4.0 [**2114-1-20**] 09:33PM PT-19.3* PTT-30.3 INR(PT)-1.8* . On Discharge:[**2114-2-1**] 06:05 WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 7.4 3.26* 11.1* 31.3* 96 33.9* 35.3* 16.6* 241 . UreaN Creat Na K Cl HCO3 AnGap 138 3.9* 130* 3.8 88* 28 18 . INR: 2.2 . Studies TTE: [**1-23**] 1. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. 2. No spontaneous echo contrast is seen in the body of the right atrium. A small mobile echodense mass associated with a pacing wire is seen in the right atrium near the interatrial septum. 3. No atrial septal defect is seen by 2D or color Doppler. 4. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with dyskinesis of the apical anteroseptal and inferoseptal walls, and severe hypokinesis of the mid septum. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). 5. Right ventricular chamber size is normal with borderline normal free wall function and focal hypokinesis of the apical free wall. 6. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 7. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 8. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-10**]+) mitral regurgitation is seen. 9. The tricuspid valve leaflets are mildly thickened. 10. There is a very small pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results at the time of the study. . CXR [**1-25**] Right jugular line ends in the region of the superior cavoatrial junction, as before. As far as one can tell from a frontal view alone, the right atrial lead ends low in the right atrium and right ventricular lead along the floor of the right ventricle. Two epicardial leads projecting over the left heart border are unchanged since [**1-23**]. That procedure was presumably responsible for new small left pleural effusion. Pulmonary edema has resolved since [**1-24**], and lung volumes have improved. Mild cardiomegaly is unchanged, and there is no pneumothorax. . TTE: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis (LVEF = 45 %). Dyssnchrony is not visually apparent. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with mild global hypokinesis. Moderate pulmonary artery systolic hypertension. Increased PCWP. Compared with the prior study (images reviewed) of [**2114-1-22**], left ventricular systolic dysfunction appears more diffuse/global and the estimated pulmonary artery systolic pressure is highe Brief Hospital Course: [**Last Name (un) 14077**] is a 77-year-old man with CAD s/p CABG (LIMA-LAD, RIMA-RCA, SVG-OM in [**2089**]) and PCI (DES to SVG-OM in [**2106**]), multiple atrial arrhythmias and tachybrady syndrome s/p multiple ablations and pacemaker placement in [**2106**], CKD, and chronic systolic heart failure s/p epicardial lead placement via left mini-thoracotomy w/St.[**Male First Name (un) 923**] pacer [**2114-1-23**] with hospital course complicated by acute on chronic renal failure. . # Chronic systolic CHF: EF ~50 via [**12-19**] TTE. Patient is s/p epicardial lead placement on [**1-23**]. Hypothesized that patients worsening CHF symptoms secondary to ventricular dyssynchrony and placement of placemarker will improve forward flow and improve symptoms. Post-procedure patient with persistent volume overload. Patient intermittently diuresised with IV Lasix with good response. Patient transitioned to PO Lasix on [**1-30**] with continued diuresis (~1L/day). Patient discharged on Lasix 60mg PO BID, spironlactone 25mg QD and Metalozone 2.5mg PO every tuesday and friday. Patient continued on metoprolol XL. Repeat TTE demonstrated stable EF ~45% with ventricular synchrony. Surgical site clean, intact with no sign of infection at time of discharge - patient completed 7 day course of Keflex. 1. Monitor weights daily, adjust diuretics as needed for volume optimization. 2. Monitor surgical site, wound care as needed . # Acute on chronic kidney failure, stage 4. Baseline creatinine: 2.7-3.0. On admission patient's creatinine 3.4. After diuresis creatinine improved to 3.0. After procedure, creatinine peak to 4.0 on [**1-25**]. Etiology of [**Last Name (un) **]: poor perfusion secondary to poor forward flow vs contrast-induced nephropathy (however patient received minimal dye load) vs AIN in setting of ppx Abx. Urine and differential without eosinophilia. Renal consulted - hypothesized that elevation secondary to poor forward flow and recommended to continued diuretic use. Patient maintained good UOP throughout stay. Creatinine at time of discharge: 3.9. OUTPATIENT ISSUES: 1. Monitor creatinine regularly and I/O. . # CORONARIES: Patient with history of CAD. Last cardiac catheterization [**2106**] with stenting of SVG to OM. Due to h/o GI bleed not currently on ASA, Plavix. Patient cites 2-3x weekly exertional angina as well as infrequent episodes of angina at rest. Patient with 1/11 Stress echo: Rest and stress perfusion images reveal decreased tracer uptake in the anterior apical region on both stress and rest images with associated apical wall motion abnormality. Patient monitored on telemetry without event and continued on beta-blocker. OUTPATIENT ISSUE: 1. Monitor exertional symtoms and ascert need to repeat stress. . # RHYTHM. Patient with history multiple atrial arrhythmias: atrial fib/flutter, tachybrady syndrome s/p multiple ablations and PPM in [**2106**]. - Rate control. Patient was monitored on telemetry and remained in normal sinus for majority of stay with occassional reversion into atrial fibrillation. Rates consistently 50-70s. - Anticoagulation. CHADS 6. Patient maintained on lovenox daily when INR subtherapeutic. Continued on coumadin. INR at time of discharge: OUTPATIENT ISSUES: 1. Monitor on telemetry for arrhytmias. . # H/o CVA with bilateral lacunar infarcts in [**2100**] with residual left paresthesias and gait dysfunction. Neuro exam monitored. Patient ambulated without problems with the assistance of a walker. . # IDDM. Continue home regimen of lantus, humalog with meals and ISS . # OSA. Home CPAP continued. Medications on Admission: Metoprolol succinate 50 mg PO daily Spironolactone 25 mg PO daily Rosuvastatin 20 mg PO daily Furosemide 60 mg [**Hospital1 **] Metolazone 2.5 mg on Tuesdays Nitroglycerin 0.4 mg SL PRN chest pain Warfarin 2.5mg daily Insulin Glargine 25 units QAM and 50 units QHS Novalog 15 u with breakfast, 20-25 u with dinner, and 20-25 u at bedtime. He skips lunch. ? Calcitriol 0.5 mcg PO daily Allopurinol 300 mg PO daily Colchicine 0.6 mg PO daily prn Omeprazole 40 mg PO daily Multivitamin 1 tab PO daily Calcium Carbonate-Vitamin D3 Vitamin D2 Iron 325 mg PO daily Ascorbic acid Glucosamine Magnesium Zinc sulfate Fish Oil Discharge Medications: 1. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO Every Tuesday and Friday. 2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 3. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 9. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 14. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). 16. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 17. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 18. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 19. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for [**Hospital1 **], pain. 20. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 21. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed. 22. calcium carbonate-vitamin D3 Oral 23. ascorbic acid Oral 24. Fish Oil Oral 25. Glucosamine Oral 26. ergocalciferol (vitamin D2) Oral 27. insulin glargine 100 unit/mL Solution Sig: 25units in the AM, 50units in the PM as directed Subcutaneous as directed. 28. Humalog 100 unit/mL Solution Sig: as directed units Subcutaneous four times a day: 20units with breakfast, 25units at lunch, dinner and bedtime. 29. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Chronic Congestive Heart Failure . Secondary: Hypertension Hyperlipidemia Diabetes Discharge Condition: Mental status: clear and coherent Ambulates without asssitance Weight at time of discharge: Discharge Instructions: Dear Mr [**Last Name (Titles) 14077**], it was a pleasure taking care of you . You were admitted to [**Hospital1 18**] for optimization of volume status prior to Biventricular pacemarker placement. Unfortunately the initial attempt to place the pacemarker was unsuccessful and the decision was made to place your pacemarker surgically. You did well after the surgery. . At time of discharge it was determined that you would benefit greatly to participating in a cardiac rehab program to optimize your cardiac function after hospitalization. . CHANGES TO YOUR MEDICATIONS Stay taking metalozone every tuesday and FRIDAY. . No other changes were made to your medication. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2114-2-13**] at 3:00 PM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2114-3-12**] at 11:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2114-3-12**] at 2:00 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2114-4-6**] at 3:20 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2114-2-7**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Completed by:[**2114-2-1**]

Admission Date: [**2108-1-2**] Discharge Date: [**2108-1-4**] Date of Birth: [**2057-5-29**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: L supraclinoid artery aneurysm Major Surgical or Invasive Procedure: Angiogram for stent assisted coiling of supraclinoid artery aneurysm History of Present Illness: Elective admit for aneurysm coiling. Past Medical History: COPD, chronic pain, depression, anxiety, and C-section. Social History: She is divorced with two children. She smokes a pack per day for 30 years. She takes alcohol socially. Physical Exam: Post-angio: Nonfocal exam, MAE [**5-3**], ambulating independently. Pertinent Results: CT Head post-angio coiling: No intra- or extracranial hemorrhage. Brief Hospital Course: 50F s/p angiogram and coiling, post-angio she was placed on a Heparin drip and was discontinued [**2107-1-3**]. She did well post-angio, exam remained nonfocal and she was discharged home on [**2107-1-4**]. Medications on Admission: -fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). -lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. -amphetamine-dextroamphetamine 20 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO QAM (once a day (in the morning)). -quetiapine 300 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime). -tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 9. amphetamine-dextroamphetamine 20 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO QAM (once a day (in the morning)). 10. quetiapine 300 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime). 11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: L supraclinoid artery aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Take Plavix (Clopidogrel) 75mg once daily for two months. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] in 4 weeks, you will not need imaging at this appointment. You will need to follow-up in 3 months with a MRI/MRA Brain. Please call [**Telephone/Fax (1) 4296**] to schedule your appointments. Completed by:[**2108-1-4**]

Admission Date: [**2163-9-20**] Discharge Date: [**2163-9-30**] Date of Birth: [**2079-1-17**] Sex: M Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Streptomycin / Citric Acid / Atenolol / Torsemide / Heparin Agents Attending:[**First Name3 (LF) 2297**] Chief Complaint: Bacteremia Major Surgical or Invasive Procedure: Transesophagealechocardiogram History of Present Illness: 84 year old male with h/o CAD s/p stenting, systolic CHF (EF40-45%), atrial fibrillation, h/o cardiac arrest with heart block s/p AICD/pacemaker, trach/PEG, recent MRSA bacteremia, and recent MICU admission for hematuria and GI bleed who presents with fevers and baceteria. He was recently admitted [**Date range (1) 105469**] for pneumonia and MRSA bacteremia and sepsis. Discharged on IV vancomycin which he has been on since. He was then readmitted [**9-10**] to [**9-12**] for hematuria and blood from his colostomy bag felt to be secondary to recent aspirin initiation. He was discharged to [**Hospital 15159**] [**Hospital 100**] Rehab. He has had persistent fevers with Tm 101.5 and positive MRSA blood cultures at rehab. [**Hospital 4273**] cough, cold symptoms, nausea, or vomiting. Has had diarrhea over the last several days. [**Hospital 4273**] CP or SOB. His family reports that he was doing poorly a few days ago but has turned around in the past few days. [**Hospital 4273**] increasing secretions and he is vent-dependent. In the ED, initial vitals were 98.8 70 120/52 96%. He is being admitted to the MICU for an endocarditis workup given history of positive blood cultures. Currently, he reports feeling tired but otherwise okay. Complains of pain in his back and his legs. Review of systems: (+) Per HPI (-) [**Hospital 4273**] chills, night sweats, recent weight loss or gain. [**Hospital 4273**] headache, sinus tenderness, rhinorrhea or congestion. [**Hospital 4273**] cough, shortness of breath, or wheezing. [**Hospital 4273**] chest pain, chest pressure, palpitations, or weakness. [**Hospital 4273**] nausea, vomiting, constipation, abdominal pain, or changes in bowel habits. [**Hospital 4273**] dysuria, frequency, or urgency. [**Hospital 4273**] arthralgias or myalgias. [**Hospital 4273**] rashes or skin changes. Past Medical History: Rectal cancer s/p excision and XRT ([**2157**]) CAD s/p stents (?[**2159**]) CVA in [**2150**] with residual right hand dysthesia Complete heart block s/p pacemaker H/o cardiac arrest (now with AICD) GI bleed secondary to angiectasias in the duodenum ([**1-/2162**]) s/p cauterization via EGD Atrial fibrillation, not on [**Year (4 digits) **] Systolic CHF (EF 40-45%) S/p Fall with multiple rib fractures ([**2163-6-23**]) MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from trach Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **] Social History: Resident of [**Hospital 100**] Rehab; previously had lived in [**Location 745**] with his wife, now w some depression about moving out of their 42 year home. Has two children. Retired computer science professor. - Tobacco: 5 cigars daily for 30 years, quit [**2150**] s/p CVA - Alcohol: Previously [**1-16**] glasses/week, generally per wife "affects him quite a bit," changing his mood and making him sick - Illicits: [**Month/Day (2) 4273**] Family History: Father died in 80s from MI. Mother died in 80s from PE. No family history of colon, breast, uterine, or ovarian cancer. No family history of seizures. Physical Exam: On Admission: Vitals: 97.7 70 108/49 18 100% AC 500x12, PEEP 5, FiO2 35% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, trach in place with clear/white secretions Neck: supple, no LAD Lungs: Coarse rales at bases, no wheezes CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic murmur at apex Abdomen: soft, non-tender, distended, ostomy in place, bowel sounds present, no rebound tenderness or guarding GU: Foley in place Skin: 3cm sacral decub without surrounding erythema. PICC in place on right arm, only mild redness at insertion. Ext: Warm, well perfused with 2+ pitting edema, ulcerations on bilateral shins On discharge: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, trach in place Neck: Supple, no LAD Lungs: Coarse rales at bases, no wheezes CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic murmur at apex Abdomen: Soft, non-tender, distended, ostomy in place, bowel sounds present, no rebound tenderness or guarding GU: Foley in place Skin: 3cm sacral decub without surrounding erythema. PICC in place on left. Ext: Significant ulcerations on bilateral shins, some pain and swelling of both knees that is stable Pertinent Results: Admission Labs: [**2163-9-20**] 04:15PM WBC-8.9 RBC-2.79* HGB-8.0* HCT-24.2* MCV-87 MCH-28.8 MCHC-33.3 RDW-15.8* [**2163-9-20**] 04:15PM NEUTS-80.3* LYMPHS-9.0* MONOS-9.9 EOS-0.5 BASOS-0.2 [**2163-9-20**] 04:15PM PLT COUNT-168 [**2163-9-20**] 04:15PM PT-15.8* PTT-30.4 INR(PT)-1.4* [**2163-9-20**] 04:15PM LIPASE-69* [**2163-9-20**] 04:15PM ALT(SGPT)-26 AST(SGOT)-96* ALK PHOS-266* TOT BILI-1.1 [**2163-9-20**] 04:15PM GLUCOSE-127* UREA N-70* CREAT-1.7* SODIUM-134 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-27 ANION GAP-12 [**2163-9-20**] 05:00PM COMMENTS-GREEN TOP [**2163-9-20**] [**2163-9-20**] 4:15 pm BLOOD CULTURE Blood Culture, Routine (Final [**2163-9-23**]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S [**2163-9-20**] 4:15 pm URINE Site: CATHETER URINE CULTURE (Final [**2163-9-23**]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 16 I CEFTAZIDIME----------- 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM------------- =>16 R PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ <=1 S [**2163-9-21**] 4:00 pm SWAB Source: decubitus ulcer. GRAM STAIN (Final [**2163-9-21**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [**2163-9-24**]): PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML PSEUDOMONAS AERUGINOSA | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S CEFEPIME-------------- 32 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I LINEZOLID------------- 1 S MEROPENEM------------- 8 I PENICILLIN G---------- 8 S PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ <=1 S VANCOMYCIN------------ =>32 R [**2163-9-22**] 2:51 pm URINE Source: Catheter. URINE CULTURE (Final [**2163-9-25**]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML PSEUDOMONAS AERUGINOSA | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- 16 I 2 S CEFTAZIDIME----------- 16 I =>64 R CEFTRIAXONE----------- 16 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 8 I <=1 S MEROPENEM------------- 8 I <=0.25 S NITROFURANTOIN-------- =>512 R PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ <=1 S =>16 R TRIMETHOPRIM/SULFA---- <=1 S [**2163-9-21**] 3:54 am BLOOD CULTURE Source: Line-midline. Blood Culture, Routine (Final [**2163-9-27**]): NO GROWTH. [**2163-9-22**] 3:00 am BLOOD CULTURE FROM MIDLINE. Blood Culture, Routine (Final [**2163-9-28**]): NO GROWTH. [**2163-9-23**] 3:51 am BLOOD CULTURE: Pending [**2163-9-24**] 3:51 am BLOOD CULTURE: Pending Studies: CXR [**2163-9-20**]: No significant change from [**2163-9-9**] radiograph, with cardiomegaly, pulmonary vascular congestion and bilateral pleural effusions again noted. Left lower lobe opacity is compatible with atelectasis and/or pneumonia. TTE [**2163-9-21**]: The left atrium is moderately dilated. The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. The right ventricular cavity is moderately dilated There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. An eccentric, posteriorly directed jet of Moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study dated [**2163-9-8**] (images reviewed), the degree of pulmonary pressures is much lower (likely underestimated as the IVC was not well visualized). No vegetations or abscesses visualized. TEE [**2163-9-22**]: No vegetations seen on the cardiac leaflets. No mass or vegetation seen on the cardiac wires. Simple atheroma aortic arch. At least moderate in severity eccentric mitral regurgitation. Moderate tricuspid regurgitation. Mild to moderate pulmonary artery systolic hypertension. BLE Ultrasound [**2163-9-24**]: Limited study demonstrates no evidence of right or left lower extremity DVT. CXR [**2163-9-25**]: As compared to the previous radiograph, the position of the tracheostomy tube and of the pacemaker wires is unchanged. Unchanged moderate cardiomegaly with bilateral areas of atelectasis and substantial enlargement of the vascular structures at the lung hilus. Unchanged moderate pulmonary edema. No newly appeared focal parenchymal opacities. WBC scan [**2163-9-26**]: 1. Splenomegaly. 2. No focal source of infection localized. Bilateral UE ultrasound [**2163-9-28**]: No evidence of upper extremity deep venous thrombosis. Labs prior to discharge: [**2163-9-29**] 02:57AM BLOOD WBC-7.1 RBC-2.89* Hgb-8.1* Hct-24.9* MCV-86 MCH-28.0 MCHC-32.5 RDW-15.8* Plt Ct-154 [**2163-9-29**] 02:57AM BLOOD Neuts-75.9* Lymphs-11.7* Monos-10.6 Eos-1.2 Baso-0.5 [**2163-9-29**] 02:57AM BLOOD Glucose-154* UreaN-49* Creat-1.4* Na-135 K-3.5 Cl-96 HCO3-29 AnGap-14 [**2163-9-29**] 02:57AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1 [**2163-9-29**] 11:06AM BLOOD Tobra-1.9* [**2163-9-28**] 09:00PM BLOOD Tobra-2.5* [**2163-9-28**] 04:03AM BLOOD Vanco-21.5* [**2163-9-27**] 07:50PM BLOOD Vanco-21.7* [**2163-9-28**] 02:07PM BLOOD Type-[**Last Name (un) **] Temp-37.4 Rates-/35 Tidal V-309 PEEP-5 FiO2-50 pO2-48* pCO2-42 pH-7.48* calTCO2-32* Base XS-6 Intubat-INTUBATED Vent-SPONTANEOU Brief Hospital Course: Primary Reason for Hospitalization: Mr. [**Known lastname 108855**] is a 84 year old male with h/o CAD s/p stenting, systolic CHF (EF40-45%), atrial fibrillation, h/o cardiac arrest with heart block s/p AICD/pacemaker, trach/PEG, and recent ICU admission with GI bleed, hematuria, and MRSA bacteremia, who presented from rehab with fevers and persistent MRSA bacteremia while on vancomycin. #. MRSA Bacteremia: The source of the patient's persistent bacteremia was not found. He grew MRSA from multiple blood cultures at rehab and also on initial presentation despite appropriate vancomycin troughs. Multiple sources of persistent seeding were considered. He had a TTE and TEE which were both negative for vegetations and did not show any involvement of his pacer leads. A tagged WBC scan was performed to look for occult focus of infection which was negative. An upper extremity ultrasound was also performed to look for possible infected clot but was negative. His PICC line which had been recently replaced at [**Hospital **] rehab was removed. A new one was not placed until he had negative blood cultures. He was continued on vancomycin and dosing was changed to 1g q48h. Further blood cultures were negative. Ultimately it was felt he likely has an endovascular source but it was not found during this hospitalization. He should be continued on IV vancomycin for 6 weeks from the date of his last positive blood culture, with last day [**2163-11-2**]. #. Pseudomonas and Klebsiella UTI: Given that he has an indwelling foley it was suspected that this might be colonization however his cultures were positive even after changing his foley. He was found to have pseudomonas in his urine as well as wound culture. It was multidrug resistant pseudomonas and he was treated with tobramycin for a seven day course. He needs one more dose of tobramycin 320mg IV x 1 when trough < 1. He also grew multidrug resistant klebsiella in his urine and was started on a 7 day course of cefepime with last day [**10-2**]. #. Fevers: He had fevers on admission felt to be related to his MRSA bacteremia. Other cultures returned positive as above. He also had a knee arthrocentesis which was not consistent with septic arthritis. His PICC was changed after a 24 hour line holiday. He was ruled out for C diff. #. Acute renal failure: BUN/creatinine elevated to 70/1.7 on admission felt to be related to ongoing infection and poor forward floor from chronic systolic CHF. His creatinine slowly improved with diuresis. #. Chronic respiratory failure: He was continued on mechanical ventilation during this admission and was unable to be weaned to trach mask for any length of time. This was felt to be related to chronic respiratory fatigue in addition to substantial pulmonary edema. Diuresis was difficult due to his large obligate fluid intake, but was eventually acheived with lasix 80mg IV q6h plus metolazone 2.5mg po bid. His metolazone may need to be decreased over the next several days if he is overdiuresed as he was on average 1L negative on this regimen for the few days prior to discharge. On the day of discharge, he was on pressure support [**12-19**], PEEP 5, FiO2 50% with TV in the 300's. #. Anemia: His hematocrit remained stable in the low 20's during this admission. #. Chronic Diastolic CHF: Has EF 55%. He was continued on his home carvedilol. His lisinopril has been on hold indefinitely and was not restarted due to renal failure. He was diuresed with IV lasix and metolazone as above and will need his creatinine and electrolytes monitored closely with ongoing diuresis. #. Sacral decubitus ulcer: Stage IV. He was started on a fentanyl patch and continued on prn oxycodone for pain control. #. Atrial fibrillation: His heart rate and blood pressure remained stable during this admission. He is off anticoagulation due to h/o GI bleeding and hemothorax. He was continued on carvedilol. #. Wound care: He was evaluated by the wound care team who recommended the following: 1. Follow pressure ulcer guidelines. First Step for fluid management. Turn q 2 hours. 2. Cleanse wounds with commercial wound cleanser. Pat dry. 3. Apply Aquacel ag to sacrum wound, cover with 4x4's and soft sorb dressing, secure with Medipore tape. Change daily. 4. BLE ulcerations - cover with Adaptic dressing, place 4x4 and wrap with Kerlix. Secure with paper tape. 5. No tape on skin. 6. Mid upper back ulcer - Apply Mepilex 4x4 and change q3 days. 7. Mid lower back ulcer - apply DuoDerm wound gel to bed to assist with autolytic debridement of yellow slough. Cover with Mepilex 4x4 dressing, and change q 3 days. 8. Apply Critic Aid clear skin barrier ointment to scrotal tissue to protect from fluid exposure daily. Elevate scrotum to assess with edema. 9. Waffles bilateral feet. 10. Apply aloe vesta ointment to dry intact skin daily. 11. Support nutrition and hydration. TRANSITIONAL ISSUES: - Monitor I/O's closely and check electrolytes closely given large doses of lasix and metolazone. [**Month (only) 116**] need to back off on metalazone if signs of overdiuresis. However, would continue to aim for -500cc daily I/O balance. - Needs tobramycin trough drawn [**2163-10-1**] AM. Give tobramycin 320mg IV x 1 when trough is <1.0. - Continue vancomycin until [**2163-11-2**] for MRSA bacteremia. Should have trough measured intermittently to assess for appropriate dosing. - Needs 2 more days of cefepime treatment - Continue ventilator weaning and trach collar trials if possible. Diuresis should help with this. - Please draw weekly labs: CBC/diff, chem-7, LFTs and fax to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatient antibiotics should be directed to the when clinic is closed Medications on Admission: Acetaminophen 650mg po q4h prn pain Lidocaine patch 5% TD daily Trazodone 25mg po qhs prn insomnia Citalopram 20mg po daily Docusate 50mg po bid Ferrous sulfate 300mg po daily Folic acid 1mg po daily Multivitamin 1 tab po daily Omeprazole 20mg po daily Albuterol sulfate 90mcg q4h prn SOB/wheeze Simethicone 80mg po tid Miconazole nitrate 2% application qhs Oxycodone 5-10mg po q4h prn pain Lasix 40mg po daily Vancomycin 500mg IV q12h Psyllium one packet po tid Sucralfate 1gram po qid Carvedilol 6.25mg po bid Discharge Medications: 1. acetaminophen 650 mg/20.3 mL Solution [**Telephone/Fax (1) **]: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for pain, fever. 2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Age over 90 **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 3. trazodone 50 mg Tablet [**Age over 90 **]: 0.5-1 Tablet PO at bedtime as needed for insomnia. 4. citalopram 20 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 50 mg/5 mL Liquid [**Age over 90 **]: One Hundred (100) mg PO twice a day: Hold for loose stools. 6. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Age over 90 **]: Three Hundred (300) mg PO once a day. 7. folic acid 1 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Age over 90 **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Age over 90 **]: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for sob, wheeze. 11. simethicone 80 mg Tablet, Chewable [**Age over 90 **]: One (1) Tablet, Chewable PO TID (3 times a day). 12. miconazole nitrate 2 % Powder [**Age over 90 **]: One (1) Appl Topical HS (at bedtime) as needed for rash. 13. oxycodone 5 mg Tablet [**Age over 90 **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. fentanyl 12 mcg/hr Patch 72 hr [**Age over 90 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 15. psyllium Packet [**Age over 90 **]: One (1) Packet PO TID (3 times a day). 16. sucralfate 1 gram Tablet [**Age over 90 **]: One (1) Tablet PO QID (4 times a day). 17. carvedilol 6.25 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a day): Hold for SBP<100, HR<55. 18. cefepime 1 gram Recon Soln [**Age over 90 **]: One (1) gram Injection Q24H (every 24 hours) for 2 days: Last day [**2163-10-2**]. 19. vancomycin in D5W 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1) gram Intravenous q48h: Until [**2163-11-2**]. 20. furosemide 10 mg/mL Solution [**Year (4 digits) **]: Eighty (80) mg Injection Q6H (every 6 hours). 21. metolazone 2.5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a day): 30 minutes prior to Lasix dose. 22. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 23. tobramycin sulfate 40 mg/mL Solution [**Year (4 digits) **]: Three Hundred Twenty (320) mg Injection ONCE (Once) for 1 doses: Give one dose of 320mg when trough level < 1.0. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: MRSA bacteremia Klebsiella and pseudomonas UTI Chronic diastolic congestive heart failure Respiratory failure Secondary Diagnosis: Coronary Artery Disease Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital due to persistent fevers and a bacterial infection in your blood. You underwent multiple studies to evaluate the source of your infection. It does not appear that your heart valves or your pacemaker are infected. You were treated with antibiotics for your bloodstream infection, as well as urinary and wound infections. We also tried to give you diuretics to help your breathing. Changes to your medications: Increased docusate to 100mg po bid Increased albuterol to 4-6 puffs q4h prn SOB/wheeze Start fentanyl patch 12mcg/hr TD q72h Start cefepime 1g IV q24h for 2 more days, last day [**2163-10-2**] Change vancomycin to 1g q48h, last day [**2163-11-2**] Change furosemide to 80mg IV q6h Add metolazone to 2.5mg po bid, 30 mins prior to lasix dose Add tobramycin, needs one more dose of 320mg when trough <1.0 You should be weighed every day and the providers at rehab should be notified if your weight goes up by more than 3 pounds. Followup Instructions: You have the following appointments scheduled: Department: INFECTIOUS DISEASE When: [**Month/Day/Year **] [**2163-10-14**] at 10:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: MONDAY [**2163-10-31**] at 9:30 AM With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: GASTROENTEROLOGY When: MONDAY [**2163-10-31**] at 1:15 PM With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

Admission Date: [**2148-5-30**] Discharge Date: [**2148-6-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: Fever, hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 86 yo female s/p CABG [**4-13**] recently admitted from [**Date range (1) 27052**] to [**Hospital1 2025**] for c diff colilits sent in from rehab with fever to 101 and lethargy. Her CABG hospitalization was complicated by Psedumonas UTI and she was admitted to [**Hospital1 2025**] with fever and diarrhea and found to be C Diff positive. Pt. was very drowsy and tired due to the time of day and also was a poor historian. Per report, the patient had been lethargic and febrile at the RN home with continued diarrhea prompting her admission. On meeting the patient, she denied any CP or SOb at this time, but was cold. Denied cough or dysuria. Noted her hemorrhoids are acting up. . In the ED: - Febrile to 101.3 with QBC count of 25.7 (it was 21.8 on [**5-29**]) - She received: Vanco/ceftriaxone/Flagyl - 1L NS as her BP was initially in the 80s -> but quickly rose to the 110s. Past Medical History: CAD: - s/p MI [**3-/2147**] - 3V CABG ([**4-13**]) - [**Hospital6 **] - EF of 68% 5/07 C Diff Colitis - on flagyl 500mg TID PVD PMR - on prednisone therapy AFib HTN Hyperlipidemia Hx of bradycardia with syncope - on amiodarone Diverticulosis with IBS MR AI Social History: Lives at [**Hospital **] Rehab. Family History: NC Physical Exam: T: 95.4 oral BP:152/54 P:80 RR:22 O2 sats:98% on 2L Gen: Chronically ill appearing; shivering; tired HEENT: OP dry. Neck supple CV: +s1+s2 RRR No murmurs. CABG scar is healed well without signs of infection. Resp: Slight wheeze. Good air movement without crackles Abd: distended. Non tender. No rebound. No guarding. Ext: trace ankle edema. Extremities cool, but perfused. Neuro: CN: [**2-19**] grossly intact Strength: 4+/5 dorsi and plantar flexion. Sensation intact in LEs. Pertinent Results: [**2148-5-29**] 10:40PM PLT SMR-NORMAL PLT COUNT-317# [**2148-5-29**] 10:40PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2148-5-29**] 10:40PM NEUTS-68 BANDS-2 LYMPHS-7* MONOS-23* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2148-5-29**] 10:40PM WBC-25.7*# RBC-3.30* HGB-11.6* HCT-33.5* MCV-102* MCH-35.1* MCHC-34.5 RDW-18.4* [**2148-5-29**] 10:40PM estGFR-Using this [**2148-5-29**] 10:40PM GLUCOSE-140* UREA N-11 CREAT-0.6 SODIUM-128* POTASSIUM-3.8 CHLORIDE-92* TOTAL CO2-26 ANION GAP-14 [**2148-5-29**] 10:50PM LACTATE-1.9 [**2148-5-29**] 11:08PM URINE RBC-0-2 WBC-0 BACTERIA-MANY YEAST-NONE EPI-0 [**2148-5-29**] 11:08PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2148-5-30**] 06:30AM PLT SMR-NORMAL PLT COUNT-274 [**2148-5-30**] 06:30AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2148-5-30**] 06:30AM NEUTS-63 BANDS-4 LYMPHS-9* MONOS-17* EOS-0 BASOS-0 ATYPS-7* METAS-0 MYELOS-0 [**2148-5-30**] 06:30AM WBC-30.3* RBC-3.22* HGB-11.4* HCT-33.8* MCV-105* MCH-35.3* MCHC-33.6 RDW-18.6* [**2148-5-30**] 06:30AM ALT(SGPT)-7 AST(SGOT)-14 LD(LDH)-244 ALK PHOS-90 TOT BILI-0.4 [**2148-5-30**] 11:59AM LACTATE-1.8 [**2148-5-30**] 11:59AM TYPE-[**Last Name (un) **] PO2-221* PCO2-41 PH-7.42 TOTAL CO2-28 BASE XS-2 COMMENTS-GREEN TOP [**2148-5-30**] 12:50PM WBC-19.4* RBC-2.83* HGB-10.0* HCT-29.5* MCV-104* MCH-35.5* MCHC-34.0 RDW-18.5* [**2148-5-30**] 12:50PM ALBUMIN-2.7* CALCIUM-7.8* PHOSPHATE-3.3 MAGNESIUM-1.5* [**2148-5-30**] 12:50PM CK-MB-NotDone cTropnT-0.02* [**2148-5-30**] 12:50PM LIPASE-13 [**2148-5-30**] 12:50PM ALT(SGPT)-6 AST(SGOT)-12 LD(LDH)-181 CK(CPK)-27 ALK PHOS-71 AMYLASE-29 TOT BILI-0.4 [**2148-5-30**] 12:50PM GLUCOSE-91 UREA N-9 CREAT-0.7 SODIUM-134 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-28 ANION GAP-10 [**2148-5-30**] 01:11PM O2 SAT-75 [**2148-5-30**] 01:11PM LACTATE-2.2* [**2148-5-30**] 01:11PM PO2-41* PCO2-43 PH-7.42 TOTAL CO2-29 BASE XS-2 [**2148-5-30**] 07:14PM CK-MB-NotDone cTropnT-<0.01 [**2148-5-30**] 07:14PM CK(CPK)-38 [**2148-5-30**] 07:29PM GLUCOSE-101 LACTATE-1.1 K+-3.4* [**2148-5-30**] 07:29PM TYPE-[**Last Name (un) **] PH-7.36 . EKG: AFib with LAD normal int. V4-V6 TWI . CXR: [**2148-5-30**]: AP PORTABLE UPRIGHT VIEW OF THE CHEST: There are bilateral pleural effusions, left greater than right. There is a left lower lobe opacity. The pulmonary vasculature does not appear engorged. There is [**Hospital1 **]-apical scarring. The patient is status post CABG. There is calcification of the mitral annulus. IMPRESSION: Bilateral pleural effusions, left greater than right with left lower lobe associated opacity. The opacification of the left lower lung field may be secondary to the pleural effusion and/or an underlying lung process suggests pneumonia. . Imaging: 524/07; Portable Abdomen: UPRIGHT AND SUPINE VIEWS OF THE ABDOMEN: Patient is status post CABG. Chest is better evaluated on the dedicated chest film. Multiple loops of air and stool-filled colon are seen. Overlapping loops of small and large bowel containing air are present in the mid abdomen. Oral contrast is seen within the small bowel. There is a chronic left superior pubic ramus fracture. There are extensive vascular calcifications. There is a scoliotic curvature of the thoracolumbar spine convex right with extensive degenerative changes. IMPRESSION: Nonspecific bowel gas pattern. Please refer to the CT scan reported separately for further detail. . [**2148-5-30**]: CT Chest abd pelvis: CT OF THE ABDOMEN WITH IV CONTRAST: There are bilateral layering pleural effusions. There is associated compressive atelectasis. There are extensive coronary artery calcifications affecting all three vessels. There is mitral annular calcification. There is a small perihepatic fluid. There is a focal 10 mm area of hypo-enhancement in the right lobe of the liver (series 2, image 20), too small to characterize. There is periportal edema, a nonspecific finding. The gallbladder is nearly completely decompressed. Pancreas and spleen are unremarkable. There appears to be thickening of the left adrenal gland. Right adrenal gland is unremarkable. The left native kidney is atrophic. There is a 1.5 cm cyst at the interpolar region of the right kidney. There is no right-sided hydronephrosis. Loops of small and large bowel are of normal caliber. There is thickening of the cecum. The ascending and transverse colons appear normal. Descending colon is difficult to assess due to the presence of adjacent ascites in the left pericolic gutter. There is also thickening of the sigmoid colon and rectum, with adjacent fatty stranding. There is no intra-abdominal free air, pneumatosis, or portal venous gas. There are extensive calcifications of the aorta and iliac arteries. There are calcifications at the origins of the celiac and superior mesenteric arteries. CT OF THE PELVIS WITH IV CONTRAST: Foley catheter is within a decompressed bladder. Rectum and sigmoid colon demonstrate wall thickening with adjacent inflammatory changes. . BONE WINDOWS: There is a healed left inferior and left superior pubic ramus fractures. There are extensive degenerative changes of the spine. IMPRESSION: 1. Thickening of the cecum, rectum, and sigmoid colon consistent with colitis. 2. Bilateral pleural effusions. 3. Extensive atherosclerotic disease. 4. Small ascites and body wall edema consistent with anasarca . [**2148-5-30**]- TTE Conclusions: The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is small. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. The aortic root is moderately dilated athe sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. Mild to moderate ([**1-9**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad. . CHEST (PORTABLE AP) [**2148-6-2**] 1:35 AM A single AP view of the chest is obtained on [**2148-6-2**] at 01:43 hours and is compared with the prior morning's radiograph. There appears to have being an increase in the bilateral pleural effusions which is more marked on the left side. Cardiomegaly with congestive heart failure persists. Patient is status post median sternotomy. Marked thoracolumbar scoliosis is visualized. 1. Persistent congestive failure. 2. Increase in bilateral pleural effusions, left greater than right. . CHEST (PORTABLE AP) [**2148-6-4**] 7:29 AM Comparison with multiple previous examinations, the most recent of which is [**2148-6-2**]. Indistinct pulmonary vascular markings and fullness of the hila indicate pulmonary edema, slightly worse than the last examination. Bilateral pleural effusions are again identified, left greater than the right; the left is large and slightly larger than the last exam; the right pleural effusion is probably similar in size. Associated atelectasis is present; underlying pneumonic consolidation could also be present. Scarring in both lung apices is again noted. Changes of CABG and osseous structures are unchanged. IMPRESSION: 1. Increase in cardiac failure. 2. Bilateral pleural effusions, left greater than right, left slightly larger in the interim. Brief Hospital Course: 86 yo female w CAD s/p recent CABG, afib, PMR h/o and pseudomonas UTI, being treated for C Diff colitis admitted for fever and lethargy with transfer to the MICU for brief episode of hypotension. . # Dyspnea/respiratory failure- Hypoxia after volume resuscitation for C-diff, hypotension and question of sepsis. Concern for impending ARDS. Running diagnosis flash pulmonary edema in the setting of fluids. CHF on CXR persistent. Opacity was also seen on CXR which may indicate a pna. CTA negative for PE. Oxygen requirement at 4 L NC with 95-100% throughout stay. Pt was diuresed for a goal 1L neg daily. 40-80IV lasix given. Crackles on examination and bilateral pleural effusions L>R. Pt discharged with standing lasix. Potassium standing given hypokalemia in MICU on lasix. Pna treated initially with ceftriaxone and vanc, but changed to with linezolid and repleted as needed given diuretic. No utility in tapping effusions as likely result of VHF, patient clinically improving. Continuing abx course Zosyn, linezolid, 40 mg IV lasix to be adjusted as needed. . # Fever/WBC- 101.3 on admission. Pt with multiple possible sources of infection: C. diff colitis, UTI, PNA. f/u Blood, sputum cultures.Continued PO vanco for C.diff (stopped flagyl). Stopped vanc and ctx and started linezolid and zosyn [**6-1**] for pna linezolid for vre urine. No fever or leukocytosis at time of discharge. Linezolid 600 mg PO Q 12 for total of 14 days. Day 6. Zosyn 4.5 mg IV Q8 for a total of 14 days. Day 6 [**6-6**]. Oral vancomycin for C-diff to continue one week post stopping antibiotics to continue if continued symptoms. . #CHF-Appeared to be diastolic failure- Diuresis with 80 IV lasix during admission with goal negative 1 liter. Afterload reduction with ACE. Imdur also started. Atrial fibrillation worsening heart failure. ECHO with EF 70%, LVH with septal wall 1.5cm and small chamber diameter. 40 mg IV lasix daily to be decreased at rehab. . #Hypotension- Transient, likely result of hypovolemia and responded quickly to fluids. Considered cardiogenic shock, adrenal insufficiency PE. Sepsis. Lactate level at 2.2. Anterior TWI on EKG and tachycardia, atrial fibrillation, concerning for PE, but CTA negative for PE. Treated infection, limited fluids after initial bolus. Resolved within one day with subsequent hypertension. BB, and ACE held day 1. Then resumed metoprolol and captopril. . #Atrial fibrillation with RVR- HR to 140's. Likely in the setting of holding BB given hypotension. Increased metoprolol dose and considering Diltiazem for better rate control but patients HR to 40-50, bradycardia concerning. Cardiology consulted, recommended continued BB to increase to Metoprolol 100mg/100mg/75mg from previous 100 mg QAM, and 75 mg [**Hospital1 **]. Reported to hold on Diltiazem. Discussed anticoagulation. Pt is a fall risk in discussion and at this time will not start coumadin given risk for bleed. Discussed with husband risk for stroke when not anticoagulated. . # CAD s/p CABG- No current CP or cardiac symptoms at this time. However, EKG with new TWIs in V1-3. Neg for PE, Ruled out by enzymes. Continued ASA, Statin, increased BB, increased ACEI . # Anemia- No known bleeding currently. LDH, bili normal,coags relatively normal to rule against hemolysis/DIC. Possibly multifactorial (inflammation/dilution given IVF). Stable and cw iron def. Continued ferrous sulfate. . # PMR- Stable, continued prednisone during admission . # Code- FULL, discussed with family Medications on Admission: flagyl 500mg PO Q6 x 14 days (day #1 = [**5-29**]) Questram 4gm in 8oz fluids QD Lactinex 2tab PO TID x 14 days Ensure plus [**Hospital1 **] lisinopril 20mg daily lasix 10mg PO daily KCL 10meQ daily amlodipine 5mg daily (Stopped on [**5-25**]) ASA 325 daily metoprolol XL 150mg [**Hospital1 **] Prednisone 2mg/1mg QOD simvastatin 80mg QHS tylenol PRN albuterol PRN bisacodyl PRN ipratropium PRN ativan 0.5mg PO BID PRN MOM PRN Discharge Medications: 1. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO DAILY (Daily). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Prednisone 1 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days. 13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO once daily in the evening: hold for SBP<100. HR<55 . . 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID : hold for SBP<100. HR<55 . 16. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 17. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 20. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO ONCE (Once): 20 mg daily . 21. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 22. Piperacillin-Tazobactam Na 4.5 gm IV Q8H D#1 [**6-1**] 23. Furosemide 10 mg/mL Solution Sig: 40 mg Injection once a day: to be titrated as needed. . 24. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 15 days: to continue until one week post discontinuation of abx, continue if persistent symptoms. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Pulmonary edema A fibb with RVR Hypotension Pneumonia UTI . Secondary: Anemia PMR Discharge Condition: Stable Discharge Instructions: You were admitted with weakness, fatigue and developed shortness of breath and hypotension. You were treated with fluids and your hypotension improved. You were also treated with abx for the infection in your urine, gut and lungs. -Metoprolol changed to 100 mg twice a day and 75 mg at night. -Furosemide 40 mg IV daily, to be titrated as needed. -No anticoagulation at this time as fall risk. -Currently stable on 4 L NC -Please return to the hospital if patient is experiencing worsening shortness of breath, fever, severe diarrhea, chest pain, or other symptoms concerning to you. Followup Instructions: To [**Hospital6 459**] for the Aged MACU. Please contact PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27053**] [**Telephone/Fax (1) 27054**] for follow up

Admission Date: [**2113-4-10**] Discharge Date: [**2113-4-19**] Date of Birth: [**2058-1-11**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 55 year old male with a past medical history notable for Crohn's Disease status post multiple bowel resections on home TPN and Hepatitis C, who presented with fever and rigors for one day. The patient recently returned home from a two week cruise to [**Country 7936**] in the Caribbean two days prior to presentation. He was in his usual state of health until the morning of admission. The [**Hospital6 407**] nurse changed needle and Porta-Cath in the a.m. around 10 a.m. At 10:45 the patient was at work and felt feverish with rigors lasting about 45 seconds. The episode subsided spontaneously. At 2 p.m. the patient had a fever which was a non-documented temperature followed by rigors lasting another 45 seconds. The patient called his [**Hospital6 407**] nurse and his primary physician and the patient was instructed to come to the Emergency Department. He took Tylenol at home without relief. The patient describes chronic headache, backache and generalized body aches since Interferon therapy. He had dysuria on the day of admission without increased frequency, color change or other symptoms. He has no cough, no mental status change. He has no chest pain, shortness of breath, abdominal pain. No nausea although some nausea in the Emergency Department. No recent stool changes beyond normal Crohn's. No insect bite, rash or other illness. Chest and back have a light pink confluent rash. Last TPN was approximately two weeks prior to admission. The patient describes a six pound weight loss since that time. He has positive lightheadedness. PAST MEDICAL HISTORY: 1. Hepatitis C, being treated with Interferon and Ribavirin started in [**2112-11-17**]. 2. Crohn's Disease. 3. Status post multiple bowel resections. 4. Nephrolithiasis. 5. Short bowel syndrome, on TPN with Porta-Cath. 6. Asthma. 7. Status post appendectomy. 8. Eczema. 9. History of one of six bottles of Stenotrophomonas maltophilia. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Interferon 4 mg q. Wednesday. 2. Ribavirin 600 mg p.o. q. day. 3. Multivitamin. 4. Thiamine. SOCIAL HISTORY: Married and works on computers. No tobacco, alcohol or drugs. No pets. FAMILY HISTORY: Father died of a myocardial infarction in his 40s and had diabetes mellitus. No family history of inflammatory bowel disorder. PHYSICAL EXAMINATION: On admission, vital signs are heart rate of 107, blood pressure 104/58; breathing at 16; temperature 100 F., orally. O2 saturation 98% on room air; weight 115 pounds. In general, he is an ill appearing, cachectic male with resting hand tremor in bed. He is in no apparent distress. HEENT: Normocephalic, atraumatic. Pupils equally round and reactive to light. Sclerae anicteric. Mucous membranes slightly dry; no lesions and no lymphadenopathy. Jugular venous distention flat. He is tachycardic but regular rhythm. S1 and S2; no S3 or S4. Chest showed a tunnel Port-A-Cath with needle access dressed over the right anterior chest superiorly. The chest is diffusely erythematous. There is a macular rash, symmetric and warm. Back: Red macular rash noted. Lungs with a few crackles at the left base. No dullness to percussion. Otherwise, symmetric breath sounds, clear to auscultation bilaterally. Abdomen: There is a well healed midline abdominal scar. He has voluntary guarding. Decreased breath sounds. Extremities are warm with good color, intact distal pulses and capillary refill. Neurologically, he is alert and oriented times three. LABORATORY: White blood cell count 6.9, hematocrit 31.7, platelets 112. Sodium 138, potassium 3.0, chloride 102, bicarbonate 26, BUN 21, creatinine 0.6, glucose 96. ALT 21, AST 24, amylase 62, lipase 43, alkaline phosphatase 81, albumin 3.6. Urinalysis less than 1.005 specific gravity, pH is 5. No red blood cells, two white blood cells, occasional bacteria, one epithelial cell. Blood cultures are pending. EKG is normal sinus at 98. There is slight LAD. Chest x-ray shows no pneumonia, effusion or pneumothroax. Catheter tip is in the distal superior vena cava. HOSPITAL COURSE: 1. Cardiovascular: The patient was initially hypotensive in the Emergency Department. He was given three and a half liters of normal saline but he was still hypotensive. He received pressors at that time. The patient has Gentamicin and Vancomycin as treatment for presumed septic shock. After volume repletion, the patient's blood pressure returned to acceptable levels. The blood cultures drawn demonstrated Stenotrophomonas and Gram positive cocci. Gentamicin was discontinued as the Stenotrophomonas is the only Gram negative and it was sensitive to Bactrim. The source of this infection was presumed to be the patient's Port-A-Cath. The patient's Port-A-Cath was discontinued on [**2113-4-12**]. He has remained afebrile on a combination of Bactrim and Vancomycin after the discontinuation of the Port-A-Cath. The patient was re-started on TPN on this admission because of his short-gut syndrome secondary to multiple bowel resections from his Crohn's Disease. He tolerated the therapy well and will continue TPN at home. The patient was also started on Ribavirin, however, given his nausea and vomiting, this was discontinued. The patient received Oxy-Codon and morphine for pain initially. This was later changed to a Fentanyl patch and p.r.n. Percocet. The patient had good relief with this regimen. The patient had a new subclavian line placed in the left subclavian in the Intensive Care Unit. He did not develop a pneumothorax after this procedure. The line was discontinued after a PICC line was placed in on [**2113-4-17**]. The patient is being discharged home on [**2113-4-19**]. DISCHARGE MEDICATIONS: 1. Vancomycin 1 gram intravenous q. 12 hours for two weeks. 2. Protonix 40 mg p.o. q. day. 3. Lactulose 30 cc p.o. q. six hours. 4. Fentanyl patch 25 micrograms q. 72 hours. 5. Ribavirin 400 mg p.o. q. a.m.; 200 mg p.o. q. p.m.; hold for nausea or vomiting. 6. Ativan 1 mg p.o. q. eight hours standing for nausea and vomiting. 7. Bactrim one double strength tablet p.o. q. six hours for two weeks. DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with Dr. [**First Name (STitle) 452**]. 2. He will also see Dr. [**Last Name (STitle) **] for placement of a Port-A-Cath. 3. The patient is discharged on TPN as well. 4. He is to receive a 1.2 liter solution continuously over eight hours at night. This solution will contain 230 grams of dextrose, 60 grams of amino acids, 40 grams of lipids, 100 NACl, 20 NAPO4, 20 KCl, 15 MGSO4, 12 calcium gluconate, 8 of insulin. Also, include trace elements and multivitamin. DISCHARGE DIAGNOSES: 1. Sepsis from Port-A-Cath. 2. Hepatitis C, being treated with Interferon and Ribavirin started in [**2112-11-17**]. 3. Crohn's Disease. 4. Status post multiple bowel resections. 5. Nephrolithiasis. 6. Short bowel syndrome, on TPN with Porta-Cath. 7. Asthma. 8. Status post appendectomy. 9. Eczema. 10. History of one of six bottles of Stenotrophomonas maltophilia. CONDITION AT DISCHARGE: The patient is being discharged in stable condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7937**], M.D. [**MD Number(1) 7938**] Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2113-4-19**] 13:44 T: [**2113-4-19**] 14:19 JOB#: [**Job Number 7939**]

Admission Date: [**2136-1-12**] Discharge Date: [**2136-1-17**] Date of Birth: [**2069-11-27**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male who presented for an AVR on [**1-13**]. He was a repeat repair. He is status post MVR, AVR tissue repair in [**2131**] with a bioprosthetic valve. REVIEW OF SYSTEMS: Showed orthopnea, dyspnea which had been increasing. Catheterization earlier this month showed 4+ aortic regurgitation, ejection fraction preserved. ALLERGIES: Tetracycline. No allergy to shellfish, no allergy to dye. MEDICATIONS AT HOME: Lasix 80 mg by mouth once daily, K-Dur 20 mEq once daily, Xanax .5 mg by mouth three times a day as needed, Cardia XT 180 once daily which was held by Dr. [**Last Name (STitle) **]. PAST MEDICAL AND SURGICAL HISTORY: Significant for the AVR repair, MVR repair in [**2131**], hypertension, no diabetes, no hypercholesterolemia, no stroke, no cerebrovascular accident, no myocardial infarction. SOCIAL HISTORY: He denied smoking. He denied ethanol abuse. PHYSICAL EXAMINATION: Vitals on admission were a temperature of 98.4, pulse 73, blood pressure 124/62, respiratory rate 16, oxygen saturation 98% on room air. Physical examination was significant for bilateral lower extremity 2+ edema. There was a loud diastolic murmur. HO[**Last Name (STitle) **] COURSE: The patient was made nothing by mouth, consented, and taken to the operating room on [**2136-1-13**]. He had a CBC of 8.3/41.0/163. Chemistry 13.7/28.3/100.3 for the coags. Chemistry 143/4.7/106/27/30/1.4. The patient was taken for an AVR re-do with a CE-21 with Dr. [**Last Name (Prefixes) **]. He tolerated the procedure well. Postoperatively, he was transferred to the Unit, where he was on amiodarone and Nipride drips, which were slowly discontinued. He was on Cipro postoperatively, as well as Captopril and amiodarone since he had ventricular bigeminy. On [**2136-1-16**], the patient was transferred back to the floor. His chest tubes and wires had been discontinued as of postoperative day three. The patient was doing well, tolerating a diet, was Level IV, and was discharged on [**2136-1-17**] to home after completing a Level V. DISCHARGE MEDICATIONS: Captopril 12.5 mg by mouth three times a day, ciprofloxacin 500 mg by mouth twice a day, amiodarone 400 mg by mouth once daily, lasix 80 mg by mouth twice a day, potassium chloride 20 mEq by mouth twice a day, percocet for pain one to two tablets every four to six hours as needed, aspirin 325 mg by mouth once daily, Zantac 150 mg twice a day, Colace 100 mg by mouth twice a day. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2136-1-16**] 22:59 T: [**2136-1-17**] 00:17 JOB#: [**Job Number **]

Admission Date: [**2173-4-22**] Discharge Date: [**2173-5-10**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 87 year old man with a history of end stage renal disease from systemic lupus erythematosus (SLE) who was found to spike a temperature of 104 degrees at the end of his hemodialysis session on [**2173-4-23**]. He had been started on Vancomycin the day prior, that for a positive wound culture from a right Hickman's which was taken on [**4-15**], and was positive on [**4-18**] and grew Coagulase positive Staphylococcus which was sensitive to Oxacillin. He also did get a dose of Vancomycin of 500 mg at hemodialysis. The port site did appear erythematous and given his temperature of 104 degrees he was taken to the Emergency Room for further evaluation. En route to the Emergency Room the blood pressure was 110/58 with a heartrate of 106, and respirations were 20, however, in the Emergency Room his systolic blood pressure decreased to the low 80s; however, he was asymptomatic, maintaining well and had good urine output. He was given 1 liter of normal saline as well as started on a Dopamine drip. Systolic blood pressures remained in the 80s on this and he was therefore admitted to the Medicine Intensive Care Unit. The line was pulled by Interventional Radiology Service in the Emergency Room. The patient's white blood cell count was increased to 17 down to 7 from prior laboratory data, and he was also started on Levofloxacin and Flagyl in the Emergency Room. PAST MEDICAL HISTORY: 1. End stage renal disease secondary to systemic lupus erythematosus on hemodialysis since [**2167**]; 2. Dementia; 3. Hypertension; 4. Anemia; 5. Depression; 6. Hyperthyroidism; 7. Coronary artery disease, status post myocardial infarction in [**2168**] and catheterization in [**2168**] showed three vessel disease with percutaneous transluminal coronary angioplasty stent to the left anterior descending. 7. Status post cerebrovascular accident. 8. Status post deep vein thrombosis. 9. Ejection fraction of 30% on echocardiogram in [**2168**]. 10. Osteoarthritis. ALLERGIES: The patient is allergic to non-steroidal anti-inflammatory drugs, Aspirin, magnesium, laxatives and Plaquenil. MEDICATIONS ON ADMISSION: 1. Levoxyl 150 mcg q.d.; 2. Nephrocaps one tablet p.o. q.d.; 3. TUMS 650 mg t.i.d.; 4. Coumadin 5 mg q.d.; 5. Aricept 10 mg p.o. q.h.s.; 6. Atenolol 25 mg p.o. q.h.s.; 7. Tylenol prn; 8. Calcitonin spray one q.d. alternating nostrils; 9. Colace; 10. Effexor 75 mg q.h.s.; 11. Lisinopril 5 mg q.d.; 12. Sorbitol 70% 30 mg q.i.d. prn; 13. Ensure supplements. SOCIAL HISTORY: The patient has baseline dementia with intermittent hallucinations, however, is otherwise functional and those are at baseline. He has a very involved son, [**Name (NI) **] [**Name (NI) 23847**], home #[**Telephone/Fax (1) 23848**], work #[**Telephone/Fax (1) 23849**]. PHYSICAL EXAMINATION: The patient's temperature initially was 101.7, decreased to 99.2, heartrate 58, blood pressure 83/28, respiratory rate 14, oxygenation at 100%. In general he was a cachectic appearing elderly man in no acute distress. He was mentating, alert and oriented to time and place. His pupils equal, round and reactive. Extraocular movements intact. His oropharynx showed mild erythema and was dry. His neck was supple with no lymphadenopathy and no bruits and flat jugulovenous pressure. His lungs were clear to auscultation bilaterally. His heart was regular rate and rhythm with normal S1 and S2. Chest, chest wall had a dressing at the site of the removal of the old catheter. His abdomen was soft, nontender, nondistended with active bowel sounds. His extremities were cool with no cyanosis, clubbing or edema and distal pulses bilaterally and neurological examination was nonfocal. LABORATORY DATA: The patient's initial white blood cell count was 17 with a hematocrit of 34.1 and platelets 109. Differential showed 59% polys, 15% bands, 33% lymphocytes, 2% monocytes, and 1 metamyelocyte when the initial white blood cell count of 7 and changed to a differential of 93 polys, 0% bands when the white blood cell count was 17. Chem-7 showed a sodium 135, potassium 4, chloride 198, bicarbonate 24, BUN 17, creatinine 1.6, glucose 112, INR was 2.1. Chest x-ray showed no evidence of congestive heart failure or pneumonia. Heart size was upper limits of normal. Electrocardiogram showed normal sinus rhythm with Q waves in III and T wave inversion in V2, V3, V4 which were old as well as a biphasic T wave inversion in V5 and V6 all of which were old. The patient's blood cultures drawn at hemodialysis as well as after hemodialysis by Oncology on [**4-15**] from the Hickman Porta-cath site had grown Coagulase positive Staphylococcus which was sensitive to Oxacillin, Levofloxacin and Gentamicin and Erythromycin and Clindamycin. HOSPITAL COURSE: The patient was initially admitted to Medical Intensive Care Unit for monitoring of blood pressure as well as therapy for his infections. Blood cultures drawn on [**2173-4-22**] grew Escherichia coli which was sensitive to Ampicillin, Cefuroxime, ................., Gentamicin and Bactrim. The patient had initially been started on Vancomycin, however, once the cultures grew positive for Escherichia coli, this was switched to Ampicillin with a plan for a two week course. The patient did otherwise well on the Medical Intensive Care Unit and he had a temporary hemodialysis line placed with plans to arrange for a new line, originally planned for [**2173-4-26**]. The patient improved and was called off of the floor on [**2173-4-25**]. However, on [**2173-4-26**], the patient was sitting up in bed to have breakfast and slid out of bed with a result of hitting his head as well as his hip. A head computerized tomography scan done at the time was negative for any intracranial hemorrhage. The patient had a bruise over his right eye but no evidence of fracture. A right hip film showed a probable right neck femoral fracture which was recommended to be followed up by an magnetic resonance imaging scan. The hip magnetic resonance imaging scan showed a right subcapital femoral neck fracture with varus angulation as well as adjacent edema and a subacute L4 compression fracture. The patient was called out to the Medicine Floor with plans to schedule him for orthopedic surgery. He was also scheduled for a new line placement on [**2173-4-26**]. However, at about one hour before going to the Operating Room he had a temperature of 101 degrees. Given this, the procedure was cancelled and rescheduled for a later date. The patient otherwise was doing well. His hematocrit remained stable. He had no mental status changes and his distal leg showed no evidence of vascular compromise. The patient Coumadin had been held during the initial Medicine Intensive Care Unit admission in anticipation for the Operating Room as the INR was 1.0 on the day of transfer to the Medical Floor. The following is the hospital course on the Medical Floor by issues: 1. Infectious disease - The patient was continued on Ampicillin for Escherichia coli bacteremia, multiple cultures were drawn following the initial positive blood cultures. The catheter tip culture remained negative, all follow up blood cultures remained negative as well as several urine cultures done on the floor. After discussion with the Renal Service as well as Orthopedic Service, it was decided the patient should be continued for at least a total of two week course of Ampicillin and following the initially positive blood cultures, he was continued on intravenous Ampicillin throughout the hospitalization and this will be discontinued on the date of discharge as follow up cultures following the Orthopedic Surgery have remained negative throughout hospitalization. Likewise a right femoral head culture taken at the time of surgery showed polymorphonuclear leukocytes, however, no micro-organisms and no thick cultures or tissue as well as anaerobic cultures showed no growth. 2. Renal - The patient had been undergoing hemodialysis through a temporary femoral line. As this was in the right groin, goal was to replace this prior to orthopedic surgery. Given that the patient remained afebrile after the initial spike on [**2173-4-26**] and that all cultures remained negative, he was taken to the Operating Room for a Perma-cath placement on the left side on [**2173-4-30**]. However, when the patient returned to the floor it was noted that the Perma-cath had likely been lost or not been placed in the Operating Room. The Renal Service was felt unable to use the hemodialysis line for concerns of infection and it was revised on [**2173-5-2**]. This Perma-cath line was then successfully used for hemodialysis throughout the rest of the hospitalization and the temporary line was removed. 3. Orthopedics - The patient did go to the Operating Room for a right hemiarthroplasty on [**2173-5-4**]. He tolerated the procedure well and had no postoperative complications. At the date of discharge, he was able to ambulate slowly with physical therapy and per Orthopedics was able to do full weightbearing as tolerated. Physical therapy should be continued at rehabilitation. The staples will come out two weeks following discharge when he follows up with Dr. [**First Name (STitle) 1022**] as an outpatient. 4. Hematology - For postop the patient's Coumadin had been held on admission. Discussion was held between the Orthopedic Service and the Renal Service as well as the medical team for anticoagulation prophylaxis following both the hip fracture as well as following the hip surgery. Pneuma boots were placed on the patient. Lovenox was considered to be not of use in the setting of hemodialysis. The patient was started on intravenous heparin and maintained until the surgery. He did have repeated hematocrit drop in this setting with no source of bleeding ever identified and guaiac negative stools throughout. He received 2 units of blood at hemodialysis. His hematocrit dropped to 24.8 on [**2173-5-7**]. He received another unit of blood with increase to 27.8 and 30.9 on the day of discharge. After further discussion the heparin was held on [**2173-5-7**] in the setting of the more dramatic drop, and the hematocrit remained stable for 48 hours thereafter. His Coumadin had been restarted at a lower dose, 3 mg q.h.s. At the time of discharge his INR goal will be 1.5 to 2.0, it is 1.5 on the day of discharge, this should be adjusted as the patient tolerates. 5. Cardiovascular - The patient had baseline history of hypertension, and he is on Lisinopril as well as Atenolol. The Atenolol was initially held and then slowly restarted as Lopressor 12.5 mg b.i.d. This should be titrated up as tolerated with the goal to be returned to the 25 mg q.d. if the patient needs it. The patient's Lisinopril was also held, given the patient's eosinophilia and hypotension. It should be restarted as the patient's blood pressure tolerates. 6. Psychiatric - The patient had a baseline dementia but was oriented and interactive throughout the hospitalization. He did have intermittent hallucinations and was initially placed on sitter, however, he did not require a sitter and the sitter was discontinued. He remained oriented to time and place as well as recent history throughout, except that he occasionally stated that he was in a different place, however, he corrected himself to the correct location. He appeared to have a slightly more severe episode of this on [**2173-5-8**], so urine culture and chest x-ray were checked and urine culture was negative and chest x-ray was unchanged. The patient was otherwise tardy at baseline. The patient overall improved throughout the hospitalization and will be discharged to rehabilitation on [**2173-5-10**]. DISCHARGE STATUS: Do-Not-Resuscitate, Do-Not-Intubate. CONDITION ON DISCHARGE: Good. DISCHARGE MEDICATIONS: 1. Nephrocaps one capsule p.o. q.d. 2. Levoxyl 150 mcg p.o. q.d. 3. Calcium carbonate 500 mg p.o. b.i.d. 4. Coumadin 3 mg q.h.s., to be adjusted for INR 1.5 to 2 mg 5. Donepizil 10 mg p.o. q.h.s. 6. Lopressor 12.5 mg p.o. b.i.d. 7. Venlafaxine standard release 75 mg one capsule p.o. q.h.s. 8. Tylenol prn 9. Colace 100 mg p.o. b.i.d. 10. Dulcolax p.r. q.h.s. prn 11. Calcitonin spray, one nasal spray q.d. alternating nostrils DISCHARGE DIAGNOSIS: 1. Hemodialysis line sepsis with Escherichia coli 2. Placement of new hemodialysis line 3. Right hip fracture, status post hemiarthroplasty 4. See past medical history [**Name6 (MD) **] [**Name8 (MD) 16134**], M.D. [**MD Number(1) 16135**] Dictated By:[**Last Name (NamePattern1) 423**] MEDQUIST36 D: [**2173-5-9**] 15:32 T: [**2173-5-9**] 16:35 JOB#: [**Job Number 23850**]

Admission Date: [**2198-9-23**] Discharge Date: [**2198-9-24**] Date of Birth: [**2128-12-3**] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 3556**] Chief Complaint: abdominal pain, diarrhea, hypotension Major Surgical or Invasive Procedure: Arterial line placement History of Present Illness: 69F with DM, CAD, PVD, HTN, multiple MIs (most recently [**8-/2198**]), and AF recently hospitalized for treatment of bilateral heel ulcers, now transferred to [**Hospital1 18**] for abdominal pain, guaaic positive stool and hypotension SBP 80s. Per notes, pt was in USOH at [**Hospital 5503**] Rehab when noted to have decreased UOP last 3 days (<120ml last 24 hours). She had episode of CP 4-5 days ago for which CXR was obtained which revealed mild pulmonary edema. This was being treated with lasix IV with uptrending Cr 2.3->2.7. NGT also placed for TFs approx 4 days ago for decreased PO intake (albumin 1.7) and she was subsequently noted to have N/V/D x 3 days. She was also transfused 2 units [**9-21**] for HCT 25 and started on fluconazole for funguria. Today, she was noted to have guaiac positive stool so was sent to OSH for possible GIB. Of note, she has been on Primaxin and Xyvox for MRSA and VRE in bilateral heel ulcers and was noted to have downtrending PLT ?->70K->40K. . At [**Hospital3 **], she was guaiac positive with troponin 0.4 and a positive UA. CT abdomen revealed a distended gallbladder with layering gallstones but no other signs of cholecystitis. SBP 80s so LIJ was placed and she was started on dopamine and transferred to [**Hospital1 18**] for management of possible sepsis. She was given 2L NS, CTX 1G, Flagyl 500MG, Zosyn 3.375GIV, VANCO 1G. . In the ED, initial vs were: 96.7 100 81/56 20 99%2LNC. She was started on levophed with improvement in SBP to 100s and improved mentation to AAOx3. BP 86/47 2 hours after arrival on 0.3mcg/kg/min levophed so neo was added at 2200. She received Vancomycin 1g, Zofran and 3L NS. Surgery was consulted for abdominal pain and recommended serial exams and cx. Labs remarkable for pancytopenia with PLT 30K, WBC 12K, lactate 4.7, Cr 2.6, Na 129, HCT 30, Trop 0.39, INR 1.7 and positive UA. VS prior to transfer:95 99/69 13 94% 2L NC . On the floor, she feels "unwell" but unable to be more specific. Reports left sided abd pain, difficulty breathing and endorses recent nausea and dry heaves as well as diarrhea but unable to state how long. Denies cough, increased LE pain, fever, or chills. Past Medical History: Afib not on coumadin for unclear reasons [**Name (NI) 2091**] Stage 3 PVD HTN Morbid obesity IDDM CAD s/p CABG [**2189**], cath [**5-/2198**] and NSTEMI [**8-/2198**] Chronic VRE and MRSA heel ulcers tx with primaxin and zyvox VRE UTI Peripheral neuropathy Hyperlipidemia . Past Surgical History: hysterectomy, iridectomy bilaterally, laminectomy, CABG [**2198**], RCA stent ? [**2198**] Social History: Lives in MA with her husband prior to stays at rehab. Has one daughter (a nurse) who is her proxy. Denies E/T/D. Family History: unable to obtain Physical Exam: Vitals: T:96.5 BP:80s/60s P:90s R:26 O2:94% 4L General: Awake, somnolent but arousable, oriented to self, city, state, month, year, not date or hospital HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 10cm, LIJ, PICC R arm, no LAD Lungs: Anterior wheezes with bibasilar crackles CV: Irreg irreg. Distant. Normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, hypoactive BS, Mildly TTP RUQ, LLQ, LUQ. No rebound tenderness or guarding, No CVAT, no organomegaly GU: no foley Ext: Cool, dopplerable pulses, +anasarca, R and L heel ulcer with necrotic debris and exposed bone. No purulent exudate, mild erythema. Pertinent Results: [**2198-9-23**] Initial Labs Glucose-154* UreaN-60* Creat-2.6* Na-129* K-4.3 Cl-95* HCO3-19* AnGap-19 PT-18.7* PTT-36.9* INR(PT)-1.7* WBC-12.7* RBC-3.44* Hgb-9.9* Hct-30.2* MCV-88 MCH-28.8 MCHC-32.8 RDW-17.9* Neuts-79* Bands-1 Lymphs-13* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Plt Ct-59* Ret Aut-1.1* Lactate-4.7* Cortsol-50.3* Albumin-2.4* Calcium-7.2* Phos-4.8* Mg-2.2 Iron-147 proBNP-[**Numeric Identifier 86991**]* cTropnT-0.39* ALT-4 AST-14 LD(LDH)-222 AlkPhos-227* TotBili-0.4 DirBili-0.2 IndBili-0.2 [**2198-9-24**] 4am Labs Lactate-10.4* ART Temp-35.8 O2 Flow-4 pO2-135* pCO2-27* pH-7.19* calTCO2-11* Glucose-89 UreaN-61* Creat-2.7* Na-130* K-4.6 Cl-98 HCO3-10* AnGap-27* WBC-12.2* RBC-3.53* Hgb-10.2* Hct-31.7* MCV-90 MCH-28.8 MCHC-32.1 RDW-17.7* Plt Ct-42* Imaging CXR:PICC, left IJ catheters in appropriate position. NGT tip not clearly seen. Bibasilar effusions and atelectasis. Limited study. RUQ U/S:IMPRESSION: 1. Limited examination. Cholelithiasis, but no evidence for cholecystitis. ECG:Atrial fibrillation. Intraventricular conduction delay. No previous tracing available for comparison. Micro data: Urine cx: URINE CULTURE (Preliminary): YEAST. >100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML.. Blood cx NGTD .......... OSH Imaging [**9-19**] OSh CXR: No intestinal obstruction. Some gaseous distension of stomach. Mild CHF with vascular congestion. CT abd/pelvis: moderate bilateral effusions, distension of GB, layering stones, no wall thickening, no free air or fluid, diffuse SC edema in chest wall and abdominal wall CXR: loculated R pleural effusion/pleural thickening at R base KUB: No intestinal obtruction. Brief Hospital Course: 69F with CAD s/p CABG [**2189**] and MI x [**5-6**] and [**2198-8-5**], HTN, PVD, bilateral heel ulcers on impinem and linezolid, and [**Hospital **] transferred from OSH with vasopressor dependent shock, likely multifactorial. #. Shock/Hypotension: Differential diagnosis included septic, hypovolemic, cardiogenic shock. Cool extremities and recent CP with pulm edema on CXR and CVP 20-24 most consistent with cardiogenic shock. Patient also developed worsening hypoxia and increased O2 requirement which was exacerbated with laying flat. It is possible she had recent MI when c/o CP several days prior or worsening CHF related to transfusions received several days prior. Dobutamine was attempted for inotropy but hypotension worsened on max levophed and uptitrated neo. She was also treated with Dapto/PO Vanco/Zosyn/Fluconazole for possible infectious sources such as skin/osteo given heel ulcers which probe to bone, C difficile/colitis with recent diarrhea, UTI with positive UA, and line infection with PICC in place. Lack of leukocytosis and fever argued against infectious cause. Guaiac positive stool in the setting of thrombocytopenia make slow GIB a possible source of hypotension as well although HCT remained stable. UOP remained low and pt maxed out on 4 pressors as above with progressive hypotension MAPs in 40s-50s in addition to altered mental status and hypoxia requiring nonrebreather. Her daughter and HCP was called to discuss prognosis and pt was made DNR/DNI with focus on comfort care and she expired several hours later. #. Hypoxia: Likely secondary to pulmonary edema and cardiogenic shock. Started on bipap with no improvement. . #. Thrombocytopenia: Likely related to myelosuppressive effects of linezolid and imipenem +/- sepsis +/- GIB/consumptive process. . #. Anemia/Guaiac positive stool: Likely secondary to GIB +/- myelosuppression as above. HCT stable. #. Abdominal pain: Most likely secondary to ischemia in setting of poor florward flow but covered for infectoius sources with zosyn as well. CT A/P without contrast did not demonstrate acute pathology. . #. Hyponatremia: Likely related to volume overload and anasarca as appears total body hypervolemic. . #. [**Last Name (un) **] on [**Last Name (un) 2091**]: Unclear baseline. Likely prerenal secondary to CHF and decreased forward flow vs ATN from sepsis. Urine Na<10. . #. Heel ulcers: On chronic abx and probe to bone so likely has undergoing osteo. Covered with abx as above. # Code: Full then changed to DNR/DNI Medications on Admission: Carvedilol 3.125mg [**Hospital1 **] Crestor 40mg daily Colace 100mg [**Hospital1 **] Fluconazole 100mg PO daily x 1 more day (total 5 days) Isosorbide mononitrate Cr 30mg daily Levemir 100U/mL 10 U q bedtime Lisinopril 2.5mg daily Meclizine 12.5mg TID Novolog 10U q lunchtime and 8U qAM Reglan 10mg PO QID Rocephin 1gm IV x 10 days (started empirically [**9-21**]) Ranexa 500mg PO BID started [**9-21**] Primaxin 500-500mg IV TID (imipenem-cilastin) Zyvox 600mg [**Hospital1 **] Nystatin powder Triple pink cream Furosemide 20mg IV x 1 [**9-22**], 40mg IV daily SL nitro prn [**9-21**], vicodin prn Zofran prn Solumedrol 20mg IV x 1 [**9-22**] Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cardiogenic Shock Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

Admission Date: [**2174-11-3**] Discharge Date: [**2174-11-8**] Date of Birth: [**2109-3-19**] Sex: M Service: CARDIOTHORACIC Allergies: bee stings Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: [**2174-11-4**] 1. Coronary artery bypass grafting x2 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the ramus intermedius coronary artery. 2. Endoscopic left greater saphenous vein harvesting. History of Present Illness: Mr. [**Known lastname 61502**] is a 65 year old man who complains of increasing chest pain and dyspnea on exertion over the past 10-14 days. Cardiac Catheterization: Date: [**2174-11-3**] Place: [**Hospital 5279**] Hospital Severe LM ramus and PDA lesions. Normal EF Past Medical History: Diabetes with polyneuropathy Hypertension Hyperlipidemia Obesity Diverticulitis of the large intestine Chronic renal insufficiency Sleep apnea, CPAP of 10 Hyperthyroidism GERD Tubular edenoma w polypectomy, conoloscopy due [**2176**] HOH Social History: Race:Caucasian Last Dental Exam: 6 weeks ago, no infections at that time Lives with:girlfriend (pt is divorced) Occupation:barber Tobacco:20 pack year history, quit 1 wk ago ETOH:[**12-22**] drinks per week Family History: brother w CAD s/p stenting in 40s, died of bladder CA in 60s Physical Exam: On Admission Pulse: 56 Resp:23 O2 sat: 93 B/P 133/81 Height: 5'8" Weight:220 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: Admission Labs: [**2174-11-3**] 11:51PM GLUCOSE-134* UREA N-23* CREAT-1.0 SODIUM-133 POTASSIUM-8.6* CHLORIDE-100 TOTAL CO2-25 ANION GAP-17 [**2174-11-3**] 11:51PM CK-MB-2 cTropnT-<0.01 [**2174-11-3**] 11:51PM WBC-7.8 RBC-5.28 HGB-15.0 HCT-43.2 MCV-82 MCH-28.4 MCHC-34.7 RDW-14.3 [**2174-11-3**] 11:51PM PLT COUNT-177 [**2174-11-3**] 11:51PM PT-12.8 PTT-25.3 INR(PT)-1.1 [**2174-11-3**] 04:19PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2174-11-3**] 04:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2174-11-3**] 04:05PM GLUCOSE-112* UREA N-22* CREAT-0.8 SODIUM-138 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 [**2174-11-3**] 04:05PM ALT(SGPT)-47* AST(SGOT)-32 LD(LDH)-132 CK(CPK)-57 ALK PHOS-55 AMYLASE-54 TOT BILI-0.8 [**2174-11-3**] 04:05PM LIPASE-26 [**2174-11-3**] 04:05PM CK-MB-3 cTropnT-<0.01 [**2174-11-3**] 04:05PM TSH-3.4 [**2174-11-3**] 04:05PM T4-7.5 T3-117 [**2174-11-3**] 04:05PM BLOOD %HbA1c-7.4* eAG-166* Discharge LAbs: [**2174-11-8**] 04:45AM BLOOD WBC-7.6 RBC-2.93* Hgb-8.4* Hct-24.4* MCV-83 MCH-28.7 MCHC-34.4 RDW-14.7 Plt Ct-229# [**2174-11-8**] 04:45AM BLOOD Plt Ct-229# [**2174-11-4**] 07:50PM BLOOD PT-13.1 PTT-26.0 INR(PT)-1.1 [**2174-11-8**] 04:45AM BLOOD Glucose-134* UreaN-24* Creat-0.9 Na-135 K-4.3 Cl-99 HCO3-30 AnGap-10 Radiology Report CHEST (PA & LAT) Study Date of [**2174-11-6**] 1:46 PM [**Hospital 93**] MEDICAL CONDITION: 65 year old man with s/p POD 2 CABG CT removal Final Report Two views. Comparison with [**2174-11-4**]. The patient is status post CABG as before. An endotracheal tube, nasogastric tube, chest tube, mediastinal drain, and Swan-Ganz catheter have been withdrawn. Lung volumes are low. There is bibasilar streaky density consistent with subsegmental atelectasis or consolidation in the retrocardiac area as before. There is interval blunting of the left costophrenic sulcus. Mediastinal structures are unchanged. IMPRESSION: Interval increase in left pleural fluid. There is no other significant change since removal of line and tubes. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 40% >= 55% Aorta - Ascending: *3.8 cm <= 3.4 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apex, apical and mid portions of the anteroseptal walls. Overall left ventricular systolic function is mildly depressed (LVEF= 40%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2174-11-4**] at 1530 Post bypass Patient is in sinus rhythm. Biventricular systolic function is unchanged. Mild mitral regurgitation persists. Aorta is intact post decannulation. Brief Hospital Course: Mr. [**Known lastname 61502**] was transferred on [**2174-11-3**] from [**Hospital 9464**] Hospital for management of his coronary artery disease. He was continued on IV heparin. Preoperative work-up was completed. He was brought to the operating room on [**2174-11-4**] for coronary artery bypass graft surgery. See operative report for further details. He received cefazolin for perioperative antibiotics and was transferred to the intensive care unit for postoperative management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. On post operative day one he was started on beta blockers and diuretics. He continued to do well and was transferred to the floor hemodynamically stable. The remainder of his hospital coursewas uneventful. Exam below summaries hospital events: Respiratory: aggressive pulmonary toilet, nebs, incentive spirometer he titrated off oxygen with saturations of XXXX on room air. Chest-tubes: Mediastinal and left pleural chest tubes were removed on POD2. Cardiac: beta-blockers were titrated as tolerated hemodynamically. He remained hemodynamically stable in sinus rhythm. ASA and statin were continued. GI: H2 Blocker and bowel regime throughout hospital stay. Nutrition: cardiac healthy, diabetic diet was tolerated Renal: renal function within normal limits with good urine output. His electrolytes were replete as needed. He was diuresed to pre operative weight Endocrine: maintained on insulin drip in CVICU and transition to insulin sliding scale with blood sugars < 150. He was started on his home dose Metformin. Gabapentin was restarted on postoperative day 1 Neuro/Pain: No neurological events. Antidepressant was restarted. Well controlled with percocet. Disposition: He was seen by physical therapy and deemed safe for home. He was discharged home with visiting nurses on [**2174-11-8**]. Medications on Admission: Lopressor 25mg [**Hospital1 **] Nitrostat 0.4 SL PRN ASA 81mg daily Norvasc 2.5mg daily Vitamin C 500mg daily Lisinopril 10mg daily Pravachol 40mg HS Gabapentin 600mg [**Hospital1 **] Cymbalta 60mg QAM Fish Oil 1200mg [**Hospital1 **] Glucosamine Chondroitin 500mg [**Hospital1 **] Omeprazole 20mg daily Metformin 500mg daily Cialia 20mg PRN Discharge Medications: 1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO QAM (once a day (in the morning)). 2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 8. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 11. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Home Health & Hospice Care Discharge Diagnosis: Coronary Artery Disease s/p cabg Diabetes with polyneuropathy Hypertension Hyperlipidemia Obesity Diverticulitis of the large intestine Chronic renal insufficiency Sleep apnea, CPAP of 10 Hyperthyroidism GERD Tubular edenoma w polypectomy, conoloscopy due [**2176**] HOH Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Right leg - healing well, no erythema or drainage. Trace Edema Discharge Instructions: -Shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage -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 cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 914**], Tuesday, [**2174-11-22**], 2pm Cardiologist: none Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 76709**] [**Telephone/Fax (1) 76133**] in [**1-20**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2174-12-1**]

Admission Date: [**2121-10-23**] Discharge Date: [**2121-11-5**] Date of Birth: [**2056-5-19**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old white male with a history of type 2 diabetes and extensive peripheral vascular disease who was initially admitted to the Podiatry Service with a left forefoot cellulitis with associated fevers and chills. There was no trauma or foreign body associated with the cellulitis. Therefore, it was opened and drained. The patient was started on intravenous antibiotics. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypertension. 3. Peripheral vascular disease. 4. Hypercholesterolemia. 5. Gastroesophageal reflux disease. PAST SURGICAL HISTORY: 1. Multiple foot surgeries. 2. Right lower extremity bypass. 3. Femoral-popliteal bypass. 4. Aortobifemoral bypass. 5. Graft in the renal artery. 6. Endarterectomy. 7. Umbilical hernia repair. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Glucovance 5/500 mg p.o. b.i.d., hydrochlorothiazide 25 mg p.o. q.d., metoprolol 100 mg p.o. b.i.d., Norvasc 2.5 mg p.o. b.i.d., Zestril 40 mg p.o. q.d., Lipitor 40 mg p.o. q.d., Prilosec 20 mg p.o. q.d. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed the patient was alert and oriented times three. Head, eyes, ears, nose, and throat examination revealed were pupils were equal, round, and reactive to light. Extraocular movements were intact. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sound and second heart sound. No murmurs, gallops or rubs. Lungs were clear to auscultation bilaterally. No wheezes, rhonchi, or rales. The abdomen was soft, nontender, and nondistended. No guarding. Extremities revealed left foot with erythema and edema, an open wound from incision 1 cm long. Dorsalis pedis and posterior tibialis pulses were nonpalpable bilaterally. Left foot was very warm. Good movement, and biphasic on Doppler. ASSESSMENT: This is a 44-year-old male with a past medical history of type 2 diabetes, initially admitted for a left lower extremity cellulitis with hospital course complicated by a non-ST-elevation myocardial infarction, complicated catheterization, and workup of left upper lobe mass found on a pre-catheterization chest x-ray. HOSPITAL COURSE BY SYSTEM: 1. CARDIOVASCULAR SYSTEM: The patient was originally admitted on [**2121-10-23**] for left lower extremity cellulitis to the Podiatry Service. On [**2121-10-25**] the patient developed shortness of breath and bilateral shoulder pain and ruled in for a non-Q-wave myocardial infarction. At that time, the patient was transferred to the C-MED Service. The patient had 1-mm ST elevations in leads I and aVL with 2-mm ST depressions in leads III, aVF, and V3 through V6. The patient did not immediately undergo catheterization given that he was still febrile from his left lower extremity cellulitis, and it was unclear whether or not he would be okay to have stents placed given his history of osteomyelitis. In addition, in the interval between developing the non-Q-wave myocardial infarction, the patient also had some hemoptysis which was followed up with a CT of the chest which showed a left upper lobe mass. Once the patient was afebrile, the patient underwent catheterization. The procedure was complicated by a small dissection. The patient had six stents placed in the right coronary artery. Given these complications, the patient was transferred to the Coronary Care Unit for overnight observation. The patient was then transferred back to the C-MED Service. It should also be noted that the patient also had a echocardiogram after his myocardial infarction which was significant for a moderately dilated left atrium, mild symmetric left ventricular hypertrophy, with a normal left ventricular cavity size, overall left ventricular systolic function preservation; although, mild basal inferior hypokinesis could not be excluded. The right ventricular chamber size and free wall motion were normal. Simple atheroma on the aortic roots were seen. The ascending aorta was mildly dilated. The aortic valve leaflets were thickened. No aortic regurgitation was seen. The mitral valve leaflets were mildly thickened with mild mitral regurgitation. Left ventricular inflow pattern suggested impaired. Ejection fraction of greater than 55% was determined. The patient remained stable on the C-MED Service and was eventually transferred to the General Medicine Service. 2. PULMONARY SYSTEM: The patient apparently had a left upper lobe mass which was seen on chest x-ray one month prior to his presentation with left lower extremity cellulitis at that time. No further workup was done. While in house the patient developed hemoptysis, and a left lower lobe mass was also seen on a follow-up chest x-ray. A CT of the chest was done on [**10-27**] which showed a left upper lobe mass that was speculated which was 3.6-cm X 5.3-cm in size. The patient was seen by the Pulmonary Service in house, and he was preliminarily diagnosed with a likely stage III-B bronchogenic lung cancer. In order to make the full diagnosis, the patient would need a tissue biopsy; however, given his recent myocardial infarction, mediastinoscopy by Cardiothoracic Surgery was deferred until the patient recovered from his acute cardiovascular events. 3. INFECTIOUS DISEASE: The patient was treated for a left lower extremity cellulitis with intravenous antibiotics while he was in house. The patient was treated with ciprofloxacin, Flagyl, and oxacillin for cultures which grew out Staphylococcus coagulase-positive bacteria. The patient had a bone scan to both rule out metastases from his lung mass and also to determine if there was any osteomyelitis. As per Podiatry, no osteomyelitis was suggested, and the patient was continued on oxacillin while in the hospital and changed over to oral dicloxacillin when he was discharged from the hospital. 4. FLUIDS/ELECTROLYTES/NUTRITION: The patient seemed to have some hyponatremia while in the hospital. The patient was fluid restricted. It was unclear whether or not the patient had syndrome of inappropriate secretion of antidiuretic hormone. A hyponatremia workup was initiated while in house, and the patient was to follow up with his primary care physician regarding the results of these tests. DISCHARGE DIAGNOSES: (The patient's discharge diagnoses included) 1. Left lower extremity cellulitis. 2. Non-Q-wave myocardial infarction. 3. Status post catheterization complicated by a small dissection and six stent placement. 4. A left upper lobe mass. 5. Hyponatremia. 6. Anemia. CONDITION AT DISCHARGE: The patient condition on discharge was fair. DISCHARGE STATUS: The patient was discharged to home with [**Hospital6 407**] services. MEDICATIONS ON DISCHARGE: (The patient's discharge medications included) 1. Hydrochlorothiazide 25 mg p.o. q.d. 2. Amlodipine 2.5 mg p.o. b.i.d. 3. Atorvastatin 40 mg p.o. q.d. 4. Pantoprazole 40 mg p.o. q.d. 5. Multivitamin p.o. q.d. 6. Enteric-coated aspirin 325 mg p.o. q.d. 7. Sublingual nitroglycerin 0.4 mg sublingually as needed (for chest pain). 8. Clopidogrel 75 mg p.o. q.d. (for 30 days; with a start date being [**2121-10-31**]). 9. Enoxaparin Sodium 100 mg subcutaneous q.12h. (the patient was to continue taking this from the time of discharge on [**2121-11-5**] until two weeks after that date). 10. Lisinopril 40 mg p.o. q.d. 11. Metoprolol 100 mg p.o. b.i.d. 12. NPH insulin. 13. Dicloxacillin 250 mg p.o. q.d. for seven days (the patient was to take this until [**2121-11-12**]). 14. Glucovance 5/500 mg p.o. q.d. DISCHARGE INSTRUCTIONS/FOLLOWUP: (The patient had multiple follow-up appointments to be made) 1. The patient was to follow up with Cardiology (Dr. [**Last Name (STitle) 73**] in two weeks after his Lovenox course was completed (telephone number [**Telephone/Fax (1) 3312**]). 2. The patient was to follow up with Podiatry Service (Dr. [**Last Name (STitle) **]. The patient needed to follow up with Podiatry when his antibiotic course was complete (telephone number [**Telephone/Fax (1) 543**]). 3. The patient needed dressing changes every day by his visiting nurse. 4. The patient was to follow up with Cardiothoracic Surgery (Dr. [**Last Name (STitle) 175**] in one to two weeks after discharge to reassess whether or not it was time for a mediastinoscopy (telephone number [**Telephone/Fax (1) 170**]). 5. The patient was to follow up with the [**Hospital **] Clinic given his NPH insulin doses after being in the hospital and having increased insulin requirements in the setting of stress (telephone number [**Telephone/Fax (1) 2378**]). 6. The patient was also instructed to follow up with his primary care physician regarding the results of his hyponatremia workup. [**Name6 (MD) **] [**Name8 (MD) **], M.D. Dictated By:[**Name8 (MD) 6369**] MEDQUIST36 D: [**2121-11-11**] 19:07 T: [**2121-11-11**] 20:50 JOB#: [**Job Number 26072**]

Admission Date: [**2172-3-13**] Discharge Date: [**2172-3-25**] Date of Birth: [**2096-11-30**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Right sided weakness and facial droop Major Surgical or Invasive Procedure: Tracheostomy and PEG placement History of Present Illness: HPI: Mr [**Known lastname 36821**] is a 75 yo M who lives in a senior center who was found in his room this evening with 'paresis' of his right arm and leg, right facial droop and garbled speech. All the history is per records and report from ED team. He was last seen well at 4.30 pm in usual state of health. However at around 6 pm, he was found in his room and was not moving his right side. he was talking ' garbled speech and was not anwering appropriately. He was taken to OSH where BP was 210/110, was given 20 labetalol IV. stroke scale was done which was 20, CT head showed left BG bleed. BG was 175, other lab work was grossly unremarkable. EKG showed occasional PVCs. he was transfered to [**Hospital1 18**]. Upon arrival, BP still high 180-190 sytolic, he was somnolent, noted to have left sided gaze preference, right hemiplegia and was intubated and sedated. he was started on nitro drip, neuro surgery was called who suggested neuromed admit. when I saw him, he was intubated and sedated. He was on CMV mode of vent at PEEP of 5, f 16 TV around 480. he was loaded with keppra before I saw him. Additional history: Spoke with Mr. [**Known lastname 86868**] PCP today, Dr. [**Last Name (STitle) 74756**] at [**Hospital1 35174**], to obtain additional information about the patient's past medical history. Per report, in [**2167-10-6**] Mr. [**Known lastname 36821**] fell approximately 40 feet off the mast of his sailboat. He suffered a pelvic fracture, multiple vertebral and transverse process fractures and a basilar skull fracture. He also reportedly had bilateral frontal contusions. He was hospitalized at [**Hospital1 2025**] for ~1 month, after which Dr. [**Last Name (STitle) 74756**] took over his care. In [**2170-5-6**] he suffered a hemorrhagic stroke. CT scan at that time showed intraventricular hemorrhage, without obvious intraparenchymal source. He also had evidence of both left thalamic and right internal capsule lacunar infarct. He recovered from that, however eventually began having difficulty caring for himself at home and was transferred to an [**Hospital3 12272**] facility. In [**1-/2171**] he again fell, and this time was taken to [**Hospital3 1443**] Hospital, where he was found to have a humeral neck fracture. He did have a head CT at that time, which showed no new insults. He was last seen by his PCP [**Last Name (NamePattern4) **] [**4-/2171**], at which time he was noted to be conversant, but impulsive, with mild dementia. He was not noted to have any focal motor deficits. According to the facility he is currently living at, he has been progressively more unsteady over the past year, often falling backwards. His PCP also notes that he has always been poorly compliant with his medications, so his blood pressure has been poorly controlled. Medications on admission (verified with his nursing home): -Aspirin 81mg -Flomax 0.4mg -Lisinopril 20mg -Metformin 850mg [**Hospital1 **] -Simvastatin 10mg -B12 injections monthly Past Medical History: HTN, Diabetes, hyperlipidemia Hx of fall w/traumatic SAH and frontal contusions Hx of prior IPH Social History: Lives at [**Location 70637**] Place Family History: Unknown Physical Exam: O: T:98.6 BP:188/99 HR:70 R:16 O2Sats:98% 100% CMV mode Gen: Intubated, not responding to verbal commands, withdraws to pain and winces to sternal rub. Does not open eyes spontaneously or to voice. HEENT:slow EOMs: unable to assess Neck: No LND Lungs: upper airway sounds b/l, otherwise clear Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused, 1+ edema b/l Neuro: Mental status: Intubated, sedated. does not follow any commnads, does not open eyes to verbal or painful stimuli. Cranial Nerves: Pupils: 2-1.5 B/L and equal,looks post surgical on left. has right facial droop. Motor: Withdraws to pain on RUE and RLE, less than left side, and arm appears weaker than leg. Makes purposeful movement with LUE and moves LLE spontaneously. Sensation: winces to pain and withdrws. Reflexes: B T Br Pa Ac Right 1 1 1 2 - Left 2 2 2 2 - R toe upgoing, L toe downgoing Coordination/ gait/ Rhomberg - deferred Pertinent Results: Admission Labs: 141 | 106 | 18 ---------------< 188 4.1 | 23 | 1.2 11.5 8.8 >--------< 202 33.3 A1C: 6.2% Chol: 112 Tri: 871 HDL: 33 LDL: <50 Imaging: NCHCT([**3-12**]): NON-CONTRAST HEAD CT: There is intraparenchymal hemorrhage, centered in the left basal ganglia, measuring 2.2 x 4.5 cm in the axial plane. Measured in a similar fashion on prior study, this hematoma measured 1.9 x 3.8 cm, consistent with slight interval enlargement. There is minimal surrounding parenchymal edema. There is mass effect upon the left lateral ventricle, with compression of the body and the anterior [**Doctor Last Name 534**], but there is no significant shift of midline structures. The basal and perimesencephalic cisterns are preserved, without evidence for herniation. There is no evidence for intraventricular extension, as suggested in the requisition. There is no subarachnoid hemorrhage identified. There is underlying atrophy, with prominence of the sulci and ventricles. There is extensive periventricular white matter hypodensity, compatible with the sequelae of chronic small vessel infarction. There are no abnormal extra-axial fluid collections. There are extensive calcifications involving the anterior and posterior circulation. The visualized bones demonstrate no fracture, and the paranasal sinuses are normally pneumatized and clear. However, there are extensive secretions identified in the posterior nasopharynx. The extracranial soft tissues, including the globes and orbits, are unremarkable. IMPRESSION: Intraparenchymal hemorrhage, centered in the left basal ganglia, minimally enlarged compared to a study performed approximately three hours earlier. There is minimal surrounding parenchymal edema, and mass effect upon the adjacent lateral ventricle, without significant midline shift or evidence of herniation. There is no intraventricular extension. There is underlying global atrophy and chronic small vessel infarction. Extensive secretions in posterior nasopharynx noted. There are extensive vascular calcifications of the anterior and posterior circulations. NCHCT ([**3-13**]) FINDINGS: Again visualized is a 4.5 x 2.2 cm measuring left basal ganglia hematoma with surrounding edema, unchanged from prior exam. Unchanged effacement of the left lateral ventricle. No intraventricular hemorrhage and no new sites of intracranial hemorrhage. The basal cisterns are normal without evidence of herniation. No shift of normally midline structures. No evidence of acute infarctions. Unchanged chronic lacunar infarcts in the left thalamus and right basal ganglia. Unchanged confluent hypodensities in the centrum semiovale, periventricular and bifrontal deep and subcortical white matter consistent with sequelae of chronic small vessel disease. The paranasal sinuses and mastoid air cells are clear. The previously described secretions in the nasopharynx have resolved. Extensive vascular calcifications of the anterior and posterior circulation. IMPRESSION: Unchanged left basal ganglia hemorrhage with surrounding edema and effacement of the left lateral ventricle. No evidence of midline shift or new sites of hemorrhage. CXR ([**3-23**]): IMPRESSION: AP chest compared to [**3-12**] through 18. Right upper lobe consolidation which developed on [**3-21**] has progressed. Severe right lower lobe consolidation that developed two days earlier is stable. Left lower lobe consolidation is worsening. Whether the lower lobe abnormalities are pneumonia or atelectasis is radiographically indeterminate. Moderate right pleural effusion and pulmonary vascular congestion are increasing suggesting an element of cardiac decompensation. Heart size is top normal and modest distention of mediastinal veins could be a function of supine positioning. Tracheostomy tube in standard placement. Right subclavian line ends in the region of the superior cavoatrial junction. No pneumothorax. CXR ([**3-25**]): Micro: [**3-16**]: URINE CULTURE (Final [**2172-3-17**]): NO GROWTH. [**3-18**]: URINE CULTURE (Final [**2172-3-19**]): NO GROWTH. Sputum: [**3-16**]: GRAM STAIN (Final [**2172-3-16**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2172-3-18**]): MODERATE GROWTH Commensal Respiratory Flora. [**3-20**]: GRAM STAIN (Final [**2172-3-20**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2172-3-22**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. [**3-16**]: Blood Culture, Routine (Final [**2172-3-22**]): NO GROWTH. [**3-18**]: Blood Culture, Routine (Final [**2172-3-24**]): NO GROWTH. Discharge Labs: 141 | 104 | 38 ---------------< 145 4.1 | 28 | 1.3 Ca: 8.3 Mg: 2.1 PO4: 3.0 10.8 16.1 >------< 333 31.8 Vancomycin trough: 35.1 Brief Hospital Course: Mr. [**Known firstname 449**] [**Known lastname 36821**] is a 75 year old man with a history of HTN, HLD, DM and prior IPH presenting with right sided weakness and garbled speech. He had a non-contrast head CT which showed a 2.2x4.5 cm left basal ganglia hemorrhage. Hospital Course: #Neuro: The patient was intubated for airway protection and admitted to the NeuroICU. He had initially received a Keppra load, however as the hemorrhage was not cortical, this was not continued. Given his history of poorly controlled hypertension, recorded blood pressures as high as 220/120, and the location of the hemorrhage, it was thought most likely that this represented a hypertensive hemorrhage. He had repeat head CTs on [**3-13**] and [**3-16**], which showed stable hemorrhage. SQ heparin was restarted on [**3-17**] and can be continued for DVT prophylaxis. Exam on discharge was notable for flaccid paralysis on the right, but he will localize to painful stimuli on the right with his left hand. Left arm strength was full. Lower extremities were anti-gravity on the left, and withdrawal from pain on the right, with upgoing toes bilaterally. #CV: On admission Mr. [**Known lastname 36821**] was found to have significantly elevated blood pressure. He was initially brought under control with a nitroprusside drip, however given the potential for nitroprusside to increase intracranial pressure, this was discontinued. He was intermittently placed on a labetalol drip, however due to bradycardia this periodically had to be stopped, and he was eventually brought under control with hydralazine instead. His home doses of metoprolol and lisinopril were increased, initially with good control. However, given slightly worsening renal failure, he was transitioned from lisinopril to amlodipine and also started on PO hydralazine. Goal SBP remains less than 160, and he can be treated with additional IV hydralazine as needed, however blood pressures have been well controlled today (104/49-155/67) without need for IV medication. He had three sets of negative cardiac enzymes on admission. A lipid panel showed significant elevation in triglycerides, but with normal cholesterol, so his simvastatin was increased and he was also started on fish oil. #Resp: In the Emergency Department the patient developed respiratory distress, and had to be intubated for airway protection. He was initially extubated on [**3-14**], but then had to be reintubated due to respiratory fatigue. He was again extubated on [**3-18**]. On [**3-20**] he was noted to have continued respiratory failure, with significant difficulty clearing his secretions, and on [**3-21**] the decision was made to place a trach and PEG. He continues to require frequent suctioning for secretions, with signs of right sided aspiration pneumonia, however his most recent chest x-ray is showing signs of improvement. #ID: On [**3-16**] he developed a fever of 101. He had urine, sputum and blood cultures drawn, which were negative. CXR showed a small degree of atelectasis, but no pneumonia. Repeat cultures were drawn on [**3-18**] for temperature of 100.7. On [**3-20**] CXR showed significant aspiration pneumonia for which he was started on vanc/cipro/cefepime to continue through [**3-29**]. Sputum cultures from bronchial aspirates showed primarily normal flora. On [**3-25**] he had a vancomycin trough of 35, so his vancomycin is currently on hold. He should have repeat daily troughs drawn, with a goal trough of 15-20, and vancomycin should be restarted once his levels are back in therapeutic range. His WBC was slightly increased at 16.1 on [**3-25**], however he remains afebrile and cultures have so far been negative. He has not had loose stools, and did not have any bowel movements to test for c diff today, however this should be kept in mind, particularly if he develops any loose stools in the next few days. #Renal: He was noted to become progressively pre-renal throughout his ICU stay, with an increase in BUN from 20->40. This was thought to possibly be due to the lisinopril with an element of renal artery stenosis, as well as some degree of overdiuresis. The lisinopril was stopped, and diuresis was minimized, with slight improvement. BUN and Cr should continue to be monitored to assure that this continues to improve. Code status: Full - confirmed with HCP [**Name (NI) **] [**Name (NI) 7049**] [**Telephone/Fax (1) 86869**] Prior to this hospitalization had been living at Maplewood Place in [**Location (un) 3786**] - Phone [**Telephone/Fax (1) 86870**] Medications on Admission: -Aspirin 81mg -Flomax 0.4mg -Lisinopril 20mg -Metformin 850mg [**Hospital1 **] -Simvastatin 10mg -B12 injections monthly Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain fever. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID (2 times a day) as needed for constipation. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 8. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) dose Inhalation Q6H (every 6 hours) as needed for wheezing. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Hold if SBP<100, HR<60. 12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): Hold if SBP<100. 13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Hold if SBP<100, HR<60. 14. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. HydrALAzine 10 mg IV Q4H:PRN SBP>160 16. Cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q12H (every 12 hours) for 5 days. 17. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four Hundred (400) mg Intravenous Q12H (every 12 hours) for 5 days. 18. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous Qam. 19. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous at bedtime. 20. Insulin Regular Human 100 unit/mL Solution Sig: Sliding scale Injection AC and HS: 71-100mg/dl 0 Units 101-120mg/dl 0 Units 121-140mg/dl 2 Units 141-160mg/dl 4 Units 161-180mg/dl 6 Units 181-200mg/dl 8 Units 201-220mg/dl 10Units 221-240mg/dl 12Units 241-260mg/dl 14Units 261-280mg/dl 16Units 281-300mg/dl 18Units 301-320mg/dl 20Units. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary: Intraparenchymal hemorrhage Secondary: Hypertension Hyperlipidemia Diabetes Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Intermittently will follow commands. Full strength on left arm, minimal movement on right, but will localize with left arm to painful stimuli on the right arm. Withdrawal in bilateral lower extremities, left leg anti-gravity. Bilateral upgoing toes. Discharge Instructions: You were admitted for right sided weakness. You were found to have a large basal ganglia hemorrhage, which was thought to be secondary to hypertension. Your blood pressure medications were increased. You were also found to have an aspiration pneumonia for which you were started on antibiotics, to be continued through [**3-29**]. Medication changes: -Metoprolol 100mg [**Hospital1 **] -Hydralazine 25mg Q6hr -Amlodipine 10mg Qday -Simvastatin increased to 20mg/day -Started on fish oil for hypertriglyceridemia -Stopped lisinopril due to worsening renal function If you notice any of the concerning symptoms listed below, please call your doctor or return to the nearest emergency department for further evaluation. Followup Instructions: Neurology: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2172-5-12**] 3:30 Please call [**Telephone/Fax (1) 10676**] to update your information prior to your appointment Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74756**] at [**Telephone/Fax (1) 81655**] for a follow-up appointment upon leaving rehab. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

Admission Date: [**2123-11-10**] Discharge Date: [**2123-11-15**] Date of Birth: [**2051-10-23**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: back pain Major Surgical or Invasive Procedure: none History of Present Illness: 72M with type B dissection Past Medical History: BPH Social History: pos smoker pos alcohol Family History: non-contributary Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: [**2123-11-14**] WBC-9.1 RBC-3.97* Hgb-12.3* Hct-34.5* MCV-87 MCH-31.0 MCHC-35.6* RDW-13.8 Plt Ct-201 [**2123-11-14**] PT-13.3 PTT-22.6 INR(PT)-1.2 [**2123-11-14**] Plt Ct-201 [**2123-11-14**] Glucose-109* UreaN-12 Creat-0.7 Na-139 K-3.8 Cl-104 HCO3-23 AnGap-16 [**2123-11-14**] Calcium-8.9 Phos-4.0 Mg-2.1 Cholest-172 [**2123-11-12**] freeCa-1.16 [**2123-11-13**] 10:20 CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS [**Hospital 93**] MEDICAL CONDITION: 72 year old man follow up aortic diseection TECHNIQUE: MDCT acquired contiguous axial images were obtained from the thoracic inlet to the pubic symphysis. Multiplanar reconstructions were performed. CONTRAST: 150 cc of IV Optiray contrast was administered due to rapid rate of bolus injection. Non-contrast enhanced images were also obtained. CTA OF THE AORTA: There is a dissection extending from the mid portion of the aortic arch inferiorly to below the renal arteries. No intramural hematomas identified. The celiac artery, SMA, left renal artery, and [**Female First Name (un) 899**] all originate from the true lumen. The [**Female First Name (un) 899**] originates below the dissection. The right renal artery originates from the true lumen; however, the dissection appears to involve the very proximal portion of the origin of the right renal artery. No filling defects or pulmonary emboli are identified within the pulmonary arteries. There is a focal aneurysmal dilatation of the right common iliac artery, measuring 16 mm in maximum diameter. There is extensive calcification of the aorta. CT OF THE CHEST WITH IV CONTRAST: Soft tissue window images demonstrate several small mediastinal lymph nodes, none of which are pathologically enlarged by CT criteria. No hilar or axial lymphadenopathy seen. Bilateral pleural effusions are noted, greater on the right than the left, which demonstrate attenuation values consistent with simple fluid. Minimal atelectasis is noted at the lung bases. Lung window images demonstrate no pulmonary nodules or parenchymal masses. The heart and pericardium are normal in appearance. CT OF THE ABDOMEN WITH IV CONTRAST: A focal hypodensity is noted within the dome of the liver, which is too small to characterize. No other abnormalities are identified within in the liver. The spleen, gallbladder, and pancreas are within normal limits. The adrenal glands are normal. There is asymmetric parenchymal enhancement of the right kidney compared to the left, which may be related to involvement of the origin of the right renal artery with the dissection. No focal infarcts are identified. There is no hydronephrosis or perinephric fluid. The bowel is normal, without evidence of bowel wall thickening or dilatation. No free fluid or free air is noted. No pathologically enlarged retroperitoneal or mesenteric lymphadenopathy is seen. There is prominent submucosal fat within the gastric mucosa. CT OF THE PELVIS WITH IV CONTRAST: There is extensive diverticulosis of the sigmoid colon. No free fluid is noted. The bladder and rectum are normal in appearance. BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. Degenerative changes are seen within the mid thoracic spine, at the L5/S1 level. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating the anatomy and pathology. IMPRESSION: 1. There is an aortic dissection extending from the mid portion of the arch of the aorta distal to the origin of the left subclavian artery, and extending along the aorta to and below the renal arteries. The main branch vessels, including the SMA, celiac artery, and left renal artery arise off the true lumen. The dissection appears to involve the origin of the right renal artery. Additionally, there is increased cortical parenchymal enhancement of the right kidney in comparison to the left. No definite areas of infarct identified. No intramural hematoma is seen. 2. Focal hypodensity in the dome of the liver, which is too small to characterize. 3. Diverticulosis of the sigmoid colon, without any evidence of diverticulitis. 4. Focal aneurysmal dilatation of the right common iliac artery, measuring 16 mm. 5. Bilateral pleural effusions, greater on the left than the right. Results were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33863**] at 2:00 AM on [**2123-11-14**]. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Pt admitted recieves CTA Pt blood pressure control Pt to follow - up in one month with new CTA On Dc pt is taking PO / ambulatin / pos BM / urinating Medications on Admission: Doxazosin 4 mg Discharge Medications: 1. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 2. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: type B dissection Discharge Condition: stable Discharge Instructions: Watch for back pain / abdominal pain Keep all your follow - up appointments Follow - up with your PCP Blood pressure control Followup Instructions: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 20587**], call immediatly and schedule an appointment Follow-up with Dr [**Last Name (STitle) **] in one month. You will be scheduled for a CTA through the office. Please mention this when you schedule an appointment. He can be reached at [**Telephone/Fax (1) 3121**] Completed by:[**2123-11-15**]

Admission Date: [**2172-8-28**] Discharge Date: [**2172-8-31**] Date of Birth: [**2112-12-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 18141**] Chief Complaint: melena Major Surgical or Invasive Procedure: Esophagoduodenoscopy with cauterization and injection duodenal ulcer. History of Present Illness: The patient is a 59 yo woman s/p gastric bypass c/b bowel obstruction and ventral hernia repairs who presents with black tarry stools for one day. The patient was in her usual state of health until the afternoon of [**8-27**], when she started to have crampy abdominal pain and the urge to defecate while driving home from work. She subsequently had 4-5 episodes of large volume, dark brown, tarry, malodorous stool over several hours. These bowel movements also contained small streaks of maroon colored blood. She had some transient lightheadedness after her first bowel movement, but no LOC, palpiations, or CP. She also denies any nausea, vomiting, or retching. She had no changes in her stool color, consistency, or caliper prior to the onset of melena, and s/p gastric bypass had no symptoms dumping syndrome. She has had no known sick contacts, or recent weight loss, fevers or chills. She has a recent history of starting an NSAID, Voltaren, for OA pain several months ago. She has had EGD in the distant past, but has not ever had a colonoscopy. . ED Course: On arrival to the E.D., the patient had no abominal pain, and was no longer having large-volume stools. She did have several additional small volume black stools over the day on [**8-28**]. She was tachycardic to the 110s, SBP to 140s, which improved with IVF. Her Hct was found to be 31, down from a baseline of 39 by patient report. She was found to have brown stool, guaiac positive. She had a negative NG lavage. She was started on an IV PPI and transferred to the floor. Past Medical History: PMH/PSH: -S/p L salpingoophorectomy [**2158**] -S/p cholecystectomy, hernia repair [**2163**] -S/p gastric bypass [**2166**] c/b bowel obstruction, ventral hernia requiring mesh repair, and wound infection requiring 3 reoperations in post-operative period. GERD s/p bypass. -OA in feet and knees Social History: SH: Smokes occasionally, several cigarettes/week, cut down from approx ?????? ppd for 40 years. Very occasional EtOH. No illicit drugs. Lives at home by herself, with sister nearby. [**Name2 (NI) 1403**] for [**Location (un) 86**] Home Infusion Company. Family History: FH: Breast CA in mother and aunts. Stomach CA in maternal GM. Brother s/p colectomy for ? diverticulitis. Distant relatives with DM2. [**Name2 (NI) **] known FH of colon CA. Physical Exam: PE: Vitals: T 99.3, HR 98, BP 96/50, repeat 120/80, RR 20, 98% RA Gen: pleasant woman in NAD HEENT: MMM, no blood in oropharynx, sclera anicteric Neck: Supple, no LAD Chest: CTAB Cor: regular rate, normal S1, S2, no m/r/g Abd: obese with many well-healed scars, soft, NTND, +BS in all quadrants, no HSM, no palpable masses, Rectal: guaiac positive dark brown stool, no palpable masses. Extr: WWP, 2+ DPs, no c/c/e Neuro: A+O, appropriately interactive Pertinent Results: [**2172-8-28**] 03:00PM BLOOD WBC-12.3* RBC-3.63* Hgb-10.4* Hct-31.0* MCV-85 MCH-28.6 MCHC-33.5 RDW-14.8 Plt Ct-267 [**2172-8-28**] 09:21PM BLOOD Hct-25.0* [**2172-8-29**] 04:13AM BLOOD WBC-9.4 RBC-3.32* Hgb-9.9* Hct-28.9* MCV-87 MCH-29.6 MCHC-34.1 RDW-15.1 Plt Ct-196 [**2172-8-29**] 09:30AM BLOOD Hct-30.3* [**2172-8-29**] 03:00PM BLOOD Hct-28.7* . [**2172-8-28**] 03:00PM BLOOD PT-11.6 PTT-23.6 INR(PT)-1.0 . [**2172-8-28**] 03:00PM BLOOD Glucose-102 UreaN-19 Creat-0.7 Na-142 K-4.3 Cl-106 HCO3-25 AnGap-15 [**2172-8-29**] 04:13AM BLOOD Glucose-85 UreaN-16 Creat-0.6 Na-143 K-3.4 Cl-109* HCO3-28 AnGap-9 . [**2172-8-28**] 03:00PM BLOOD ALT-22 AST-27 CK(CPK)-68 AlkPhos-49 TotBili-0.5 Brief Hospital Course: GI: On transfer to the floor, the patient had initially had a SBP of 100 down from 140 in the ED, but repeat was 120/80, and she remained hemodynamically stable. However, Hct trended down from 31 to 25, and she was transferred to the ICU for closer monitoring and EGD. She recieved 2 units PRBCs, with Hct bump to 28.9. EGD was remarkable for a single cratered 15mm ulcer with oozing from the edges just distal to the gastrojejunal anastomosis, which was injected with epinephrine and cauterized successfully for hemostasis. Post-procedure, she was hemodynamically stable, her Hct was 30.3, and she was transferred back to the floor. Once back on the floor, she did very well, and remained hemodynamically stable. She had no abdominal pain, nausesa or vomiting. Her Hct at discharge was stable at 32.2, and her diet was advanced to regular. She had not yet had a bowel movement post-procedure, but was passing gas. She was discharged on hige dose PPI to follow-up with her PCP [**Name Initial (PRE) 176**] 2 weeks and GI for repeat EGD and biopsy in 1 month. Medications on Admission: Protonix [**Hospital1 **] Wellbutrin [**Hospital1 **] Volataren 100mg [**Name (NI) 244**] (unclear on doses) Discharge Medications: 1. Wellbutrin Oral 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Jejunal Ulcer Discharge Condition: The patient is hemodynamically stable with stable hematocrit. She is tolerating a regular diet. Discharge Instructions: You came to the hospital because of blood in your stools. Your stomach was examined with a camera, and you were found to have an ulcer in the beginning of your small intestine that was bleeding. The bleeding was stopped. . Please call your doctor or come to the emergency room if you have continued blood in your stools, vomiting, blood in your vomit, abdominal pain, fever>101, chills, dizziness, fainting, chest pain, shortness of breath, or any other concerns. Followup Instructions: Please schedule follow-up with [**Hospital1 18**] gastroenterology for repeat EGD in 1 month with Dr. [**Last Name (STitle) **]. The number to call is [**Telephone/Fax (1) 2799**]. Please also follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **] in 2 weeks. The number to call is [**Telephone/Fax (1) 18145**]. Completed by:[**2172-8-31**]

Admission Date: [**2180-4-18**] Discharge Date: [**2180-4-24**] Date of Birth: [**2108-12-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Syncopal episode, chest discomfort Major Surgical or Invasive Procedure: Cardiac catheterization with DES to LAD History of Present Illness: 71 yo male with RA, obesity, who p/w STEMI. Pt originally presented to [**Hospital3 3583**] earlier this afternoon following CP/syncopal episode. He had been performing activity in the yard for several hours, laying cinder bricks with his cousin, when he felt tired and SOB, fatigued. Occurred around noon. Also noted some mild mid-sternal CP - dull, tight pain. Did not radiate. Associated with mild SOB and mild nausea and lightheadedness. He rested and drank some iced tea and felt slightly better. He then returned to working with continued fatigue, exercised for ~[**11-22**] hour when his fatigue became severe and pain worsened. He continued to feel SOB and lightheaded, dizzy, nauseous. Went inside again. Found found by his cousin collapsed in chair - apparently he had syncopized for several seconds to minutes (pt does not recall). He was cold and clammy, and difficuly to arouse. Cousin called EMS, at scene he was tachy in low 100's, BP 90/P. Took to [**Hospital3 3583**] (~2pm). At [**Hospital1 46**], EKG showed RBBB with STE in V1 and V2. Initial enzymes with CK 101, trop 0.5. He was given SL ntg w/o improvement. Had head CT which was negative. Sx continued, and at ~9pm transferred to [**Hospital1 18**]. . In [**Hospital1 18**], EKG's now showed resolving ST elevations in V1, V2 with q in V1, with RBBB, LAFB. Started on plavix 600, heparin gttp, integrilin gttp, lopressor 25 x1, and mag 2gm x1. Enzymes returned with CK 1095, MB 156, MBI 14.2, trop 3.60. Cardiology consulted; given 11+ hours of CP, and pain-free, decision made to medically manage voernigh. Transferred to CCU for further management. . Pt confirms he is pain-free. His CP resolved sometime after arrival to [**Hospital1 18**]. He denies any previous occurences of CP or exertional dyspnea. He is not regularly active, but ambulates around his mobile home complex regularly and does occasional manual labor jobs without difficulty. Reports a stress test 2 years ago which was normal, otherwise no cardiac workup. Denies edema, orthopnea, PND, palpitations, or h/o angina/DOE. Past Medical History: RA - now on plaquenil/diclofenac; previously on mtx obesity Social History: Lives alone in Wereham. Son nearby; daughter and [**Name2 (NI) 7337**] in [**State 15946**]. H/o tobacco - quit 20 years ago, previous ~30 pack year hx. No EtOH or IVDA. Family History: No known family history of coronary artery disease. Physical Exam: VS- T=98.5 P=66 BP=115/17 R=16 O2sat= 97% Gen- sleepy but alert, conversant, in NAD HEENT- EOMI, o/p clear with dry MM Neck- soft and supple, thick neck with no visible JVD CV- RR, no m/r/g Pulm- CTA=bil Abd- S/NT/ND Ext- W&D, no edema, 1+ DP pulses Neuro- A&Ox3, non-focal Pertinent Results: Admission laboratories: [**2180-4-18**] 09:15PM BLOOD WBC-13.8* RBC-5.67 Hgb-18.0 Hct-50.1 MCV-88 MCH-31.7 MCHC-35.8* RDW-14.6 Plt Ct-231 [**2180-4-18**] 09:15PM BLOOD Neuts-86.6* Lymphs-10.2* Monos-3.0 Eos-0.1 Baso-0.2 [**2180-4-18**] 09:15PM BLOOD PT-14.2* PTT-23.7 INR(PT)-1.3* [**2180-4-18**] 09:15PM BLOOD Glucose-145* UreaN-22* Creat-1.2 Na-140 K-4.7 Cl-105 HCO3-24 AnGap-16 [**2180-4-18**] 09:15PM BLOOD Calcium-8.6 Phos-2.3* Mg-2.1 [**2180-4-20**] 06:04AM BLOOD %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE [**2180-4-19**] 04:02AM BLOOD Triglyc-78 HDL-69 CHOL/HD-2.9 LDLcalc-117 Cardiac enzyme trend: [**2180-4-18**] 09:15PM BLOOD CK(CPK)-1095* [**2180-4-18**] 09:15PM BLOOD CK-MB-156* MB Indx-14.2* [**2180-4-18**] 09:15PM BLOOD cTropnT-3.60* [**2180-4-19**] 04:02AM BLOOD CK(CPK)-1685* [**2180-4-19**] 04:02AM BLOOD CK-MB-182* MB Indx-10.8* cTropnT-4.73* [**2180-4-19**] 03:32PM BLOOD CK(CPK)-1357* [**2180-4-19**] 03:32PM BLOOD CK-MB-85* MB Indx-6.3* cTropnT-4.31* [**2180-4-19**] 10:03PM BLOOD CK(CPK)-1046* [**2180-4-19**] 10:03PM BLOOD CK-MB-39* MB Indx-3.7 cTropnT-4.14* [**2180-4-24**] 06:20AM BLOOD CK(CPK)-65 [**2180-4-24**] 06:20AM BLOOD CK-MB-2 cTropnT-2.06* Discharge laboratories: [**2180-4-24**] 06:20AM BLOOD WBC-9.0 RBC-4.94 Hgb-15.0 Hct-43.4 MCV-88 MCH-30.4 MCHC-34.6 RDW-14.6 Plt Ct-265 [**2180-4-24**] 06:20AM BLOOD Glucose-96 UreaN-18 Creat-1.0 Na-138 K-4.1 Cl-100 HCO3-26 AnGap-16 [**2180-4-24**] 06:20AM BLOOD PT-19.8* PTT-74.4* INR(PT)-1.9* EKG - RBBB, LAFB, .5 mm STE in V1, V2 . Chest x-ray - No signs of failure . head CT - no ICH; generalized atrophy; ?old lacunar stroke on right . Cath: ([**2180-4-19**]); pLAD- 90% thrombotic lesion s/p DES; RCA-PDA- 90% lesion; PCWP 22 . Cath of [**2180-4-21**]: stent to RCA lesion TTE: ([**2180-4-19**]) EF 35% The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed with akinesis of the mid to distal antero-septum and apex. The anterior wall is not well seen but appears hypokinetic. No masses or thrombi are seen in the left ventricle. 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. Trivial mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: This is a 71 year old gentleman with obesity, previous smoking, and rheumatoid arthritis who presented to an outside hospital after syncopal episode. He was found to have ST elevations on EKG but unfortunately, the diagnosis of STEMI MI was delayed due to misinterpretation of EKG. Trop I at OSH was 0.4 (nl range is 0-0.5). He was transferred here for non-emergent catheterization. On transfer here pt denied chest pain and was given aspirin; however, here the EKG was determined to be, in fact, consistent with ST elevated MI in anteroseptal region. Here, also, enzymes found highly elevated CK 1095, MB 156, MBI 14.2, trop 3.60. Repeat EKG here revealed resolving ST elevations. Given that he was 11+ hours out from event, and pain-free, acute intervention was deferred. The patient underwent catheterization on [**4-19**] with overlapping Cypher drug-eluting stents placed to a proximal LAD lesion (90%) and remained chest pain free thereafter; a 90% stenosis in the PDA which originated from the RCA was also noted but did not underog intervention. His cardiac enzymes are now trended downward thereafter. Of note, a pre-catheterization echo was obtained and revealed an EF of 35% and anteroseptal and apical hypokinesis. Given elevated pulmonary artery pressures and the depressed EF, the patient was diuresed with lasix. Given the hypokinesis at the apex, it was necessary to start the patient on anticoagulation and heparin was maintained. Before bridging to heparin, the patient underwent catheterization again and a [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] was placed in RCA/PDA lesion. The patient remained chest pain free and hemodynamically stable thereafter. He was discharged on hospital day 7 with plans to follow up with his new cardiologist Dr. [**Last Name (STitle) 7047**] as well as with Dr. [**Last Name (STitle) **] of [**Hospital1 18**] Cardiology. In summary, this is a 71 year old gentleman admitted with anterior STEMI associated with probable syncopal event who underwent successful stenting of lesions in the proximal LAD and in the RCA-PDA seen on catheterization. Also noted to have depressed systolic function with an EF of 35% on echo associated with anteroseptal and apical hypokinesis, the latter of which necessitated maintenance of anticoagulative therapy. Issues and plan from this hospitalization: 1) Cardiovascular- will follow up with Dr. [**Last Name (STitle) 7047**], cardiologist a) Perfusion, STEMI s/p catheterizatation with 2 overlapping DES to proximal LAD, and re-catheterization with stenosis in RCA. - ASA, plavix, high dose lipitor - metoprolol and captopril for blood pressure control. . b). Pump EF of 35%, anteroseptal, and apical hypokinesis. CXR not cw failure at this point, but O2 sat not optimal (O2 sat 95 on 2L, 90-91 on RA) - diuresed for goal of -1L over few days - apical hypokinesis; risk of thrombus will require at least 6 months of coumadin - captopril, metoprolol - follow up echo in [**12-24**] months **n.b. the patients' INR was 1.9 on discharge. He was given lovenox once on discharge as a bridge in anticipation of his INR becoming therapeutic on coumadin the next day. . c) Rhythm - in NSR with RBBB. Pt was at high risk for reperfusion arrhythmias and conduction disease/CHB with progression of MI. Given his low EF he may become at risk for arrhythmias should his EF further deteriorate - will follow up with Dr. [**Last Name (STitle) **] in 2 months to assess need for intracardiac defibrillator -continue metoprolol . 4. RA - on plaquenil/diclofenac as outpt. Held diclofenac given multiple agents that could be irritating to stomach. Continued plaquenil. -will follow up with rheumatologist, Dr. [**Last Name (STitle) 67929**], regarding when/ how to restart suitable RA drugs. . 5. Hyperglycemia - no h/o DM but elevated FSG here. Screen for DM. - hgb A1C borderline high - follow glucoses QID, covered with SSI. Had no insulin requirement by admission. - counseling for heart healthy diet. . 6. FEN - cardiac diet. Replete lytes prn. . 7. Prophylaxis included: protonix while NPO, colace to prevent straining, and heparin/coumadin secondarily for DVT prophylaxis . 8. Code status remains full, confirmed with pt at admission. Medications on Admission: diclofenac 75 mg [**Hospital1 **] plaquenil 75 mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*2* 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*180 Tablet(s)* Refills:*2* 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: take 1 for chest pain, if no relief in 5 min. take another, if no relief in 5 min. take another, seek medical attention. Disp:*90 Tablet, Sublingual(s)* Refills:*2* 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ST elevation myocardial infarction. Discharge Condition: Good. Free of chest pain. Able to breath normally on room air with adequate oxygen saturation. Discharge Instructions: Please follow up with all of your doctors. Your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 67929**] has been contact[**Name (NI) **] regarding this admission and is awaiting your phone call to confirm an appointment for Wed [**2180-4-26**]. Please call at [**Telephone/Fax (1) 67930**]. In addition, you should follow up with your new cardiologist Dr. [**Last Name (STitle) 7047**]. He can be contact[**Name (NI) **] at [**Telephone/Fax (1) 3183**]. Please continue to take all medications as prescribed. It is especially important you continue you take aspirin and plavix every day, your life may depend on it. Please note, you have been started on several new medications, primarily for your heart. Under no circumstance should you ever stop your aspirin or plavix without consulting your cardiologist first. 1. Aspirin 325mg once daily 2. Clopidogrel (Plavix) 75mg once daily 3. Metoprol XL 75mg once daily 4. Lisinopril 20mg once daily 5. Atorvastatin 80mg once daily 6. Warfarin (Coumadin) 7.5mg once daily at night. Please restrict yourself to a heart friendly, low cholesterole low salt diet. You should reduce your salt intake to 2grams per day. If you develop any chest pain, palpitations, shortness of breath, back pain, abdominal pain, nausea, vomiting, diarrhea, fevers, or chills please call your primary care doctor or come directly to the ED. Lastly, please refrain from taking the diclofenac for your rheumatoid arthritis. You may continue to take plaquenil. Ask Dr. [**Last Name (STitle) 67929**] or your rheumatologist whether you should take diclofenac anymore. Followup Instructions: Please follow up with your physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 67929**] in two days time. He was contact[**Name (NI) **] regarding this hospitalization and is awaiting a phone call to schedule a follow up visit. We have tentatively agreed on Wed [**2180-4-26**] for follow up, please call his office at [**Telephone/Fax (1) 67930**] to confirm. At the time, you should have a blood test for INR performed to adjust your coumadin dose as necessary. Your goal INR is between 2 and 3. Please arrange for a follow up visit with Dr. [**Last Name (STitle) 7047**], who will be your cardiologist. He office is located at [**Street Address(2) **]. in [**Hospital1 1474**] [**Numeric Identifier 8728**]. His office can be contact[**Name (NI) **] at [**Telephone/Fax (1) 3183**]. You should have a repeat cardiac echocardiogram performed in two months time to assess need for an implantable defibrillator/pacer. Please discuss the possibility of cardiac rehabilitation with your outpatient cardiologist. Please also follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in cardiology at [**Hospital1 18**] on Wednesday [**6-21**] at 12:40 p.m. Call ([**Telephone/Fax (1) 5862**] if you need to cancel or reschedule.

Admission Date: [**2116-12-4**] Discharge Date: [**2117-1-14**] Date of Birth: [**2058-5-20**] Sex: F Service: VASCULAR CHIEF COMPLAINT: Left thigh swelling. HISTORY OF PRESENT ILLNESS: This is a 58-year-old black female, with a past medical history significant for severe peripheral vascular disease, who has had multiple MIs and CVAs. The patient has end-stage renal disease on hemodialysis. She has previously had a left fem-[**Doctor Last Name **] bypass with [**Doctor Last Name 4726**]-Tex in [**2108**], which occluded and was later revised to a composite graft, one-third [**Doctor Last Name 4726**]-Tex and two-thirds greater saphenous vein fem-[**Doctor Last Name **] on the left. She also underwent a left axillofem-fem bypass and thrombectomy later. In [**2116-1-5**], she was noted to have a left lower quadrant mass. A CT scan at that time defined a 4x5 cm collection around the graft. This was treated conservatively. Subsequently, in [**Month (only) 359**] of this year she became febrile with abdominal pain and presented to an outside hospital. A CT demonstrated increasing perigraft fluid, but was noncontrast study. Blood cultures were positive for GPCs. She was given a dose of vanco and gent, and this was given at her last hemodialysis. Her hemodialysis schedule is Tuesday, Thursday and Saturday. The patient is now admitted for further evaluation and treatment. PAST MEDICAL HISTORY: 1. History of coronary artery disease, status post MI. 2. History of CVA. 3. History of peripheral vascular disease. 4. Type 2 diabetes, noninsulin dependent. 5. Hyperlipidemia. PAST SURGICAL HISTORY: 1. Axillofemoral-fem bypass. 2. Left fem-[**Doctor Last Name **] with revision x 2. 3. Left AV graft fistula. 4. Right carotid endarterectomy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Glyburide 5 mg [**Hospital1 **]. 2. Isosorbide dinitrate 20 mg tid. 3. Lisinopril 10 mg qd. 4. Lasix 80 mg qd. 5. Lipitor 10 mg hs. 6. Prevacid 30 mg qd. 7. Labetalol 100 mg tid. SOCIAL HISTORY: The patient is a smoker currently. Quantitation of smoking unknown. She does have a history of alcohol and drug abuse, but has abstained from alcohol or drug use. PHYSICAL EXAM: 99.6, 84, 20, 100% on room air. GENERAL APPEARANCE: This is a well-appearing female, oriented x 3, diminished recall. HEENT EXAM: Unremarkable. There is a Hickman catheter and a right IJ. PULSE EXAM: Shows palpable carotids bilaterally with a right carotid bruit. Brachial and radial pulses are palpable at 4+. On the right 3+ femoral, 2+ popliteal, dopplerable DP, and 3+ PT. On the left, the femoral is 2+, popliteal 2+, DP dopplerable, PT 3+ palpable. CHEST EXAM: Shows left an axillary incision well-healed. A catheter for hemodialysis in the right subclavian area. Her chest is clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmur, gallop or rub. ABDOMINAL EXAM: Soft, nontender. There is in the left lower quadrant a multilobular mass which extends to the left groin. It is nonpulsatile. HOSPITAL COURSE: The patient was admitted to the vascular service. Infectious disease was consulted. This is a patient with known MRSA. Recommendations were blood cultures, wound cultures. Gent and vanco should be continued. Gent should be dosed when level less than 2.0 and this should be a singular dose and then discontinued. The vancomycin should be dosed when random level less than 15. They felt that the Flagyl could be discontinued. The patient underwent on [**2116-12-15**] I&D of the left thigh abscess with drainage. I&D was done after undergoing an ultrasound localized needle aspiration of the left groin site. The Gram stain of the fluid demonstrated gram-positive cocci in pairs and clusters. This was identified as staph coag positive, heavy growth. Anaerobes and fungal cultures were negative. The patient was MRSA from the flank abscess fluid cultures. The patient was continued on vancomycin and dosed at a random level. The renal service followed the patient and managed her hemodialysis needs. The patient continued to be followed by infectious disease, and a diagnosis of MRSA bacteremia and perigraft infection was determined by cultures. The patient required multiple blood cultures for recurrent high fevers. She was placed empirically on Flagyl for anaerobic coverage. Stool cultures were sent, and the patient was positive for C. diff. She was empirically begun on Flagyl. After a 2-week course of Flagyl, the patient's most recent stool culture from [**1-10**] was negative for C. diff. On [**2116-12-21**], the patient underwent a redo right axillobifemoral bypass with removal of the infected left bypass graft, and a right #15 Quinton catheter was changed over a wire. There was noted to be purulent collection of fluid on the distal aspect of the left axillofemoral bypass. There was extensive fibrinous changes on the prior sartorius muscle area. The patient did require 4 units of packed red blood cells and 2 units of FFP intraoperatively. PTFE was used for the right axillobifemoral bypass. The patient tolerated the procedure well and was transferred to the PACU in stable condition. She was placed on an Insulin drip for glycemic control. The patient was reintubated on postoperative day #1. Blood gases were 7.31, 31, 184, 16-9 on an FIO2 of 40%. She was transferred to the SICU for continued monitoring and care. She had been placed on Levofloxacin and dopamine for vasopressor support, inotropic support, and this was slowly begun to be weaned on postoperative day #2. Her postoperative hematocrit after 5 units of packed red blood cells was 34, white 18.0, BUN 29, creatinine 4.4, K 4.5. Her CK was 57, MB 4, troponin 1.10. The patient did have a metabolic acidosis on postoperative day #1, and she was treated with bicarbonate IV infusion. The patient was followed by the cardiology service. They did not feel that the troponin levels were true myocardial infarction. With the broadening of her antibiotics and drainage of the wound, there was improvement in her white count. She received a unit of packed cells x 2. Her post-transfusion crit was 32.9. Blood cultures, as of date, from [**12-9**] through [**12-16**] were no growth. The [**12-8**] cultures grew staph coag positive. The [**12-19**] C. diff was negative. The catheter tip on [**12-12**] was staph epi. The wound culture continued to grow MRSA. The patient remained intubated with JPs in place. She required an additional 2 units of packed red blood cells. Post-transfusion crit was 32.9. Nutritional services was requested to see the patient. They felt that she had caloric nutritional needs of 1,588-1,900 cal, 25-30 cal/kg. Protein needs were 1.3-1.5 gm/kg. A multivitamin and mineral supplement was reinstituted. On postoperative day #3, the patient required a unit of packed red blood cells for a hematocrit of 28.6. She was continued on Levophed and dopamine for inotropic and vasopressor support. Her IV fluids were discontinued. The patient was begun on tube feeds, and she remained in the SICU. She was placed on CPAP with pressure support of 5 which she tolerated well. Her post-transfusion crit was 28.5. The white count continued to show improvement at 17.6. The cultures were no growth. Urine was no growth. She remained in SICU. The JPs were removed on a graduating basis. Line cath was changed on [**12-12**]. This tip grew staph epi, oxacillin resistant. The patient was weaned off her Levophed by postoperative day #4. She continued on CPAP with an FIO2 of 40%, blood gas 7.44, 34, 179, 24 and 0, 98% O2 sat. On [**2116-12-25**], the right internal jugular Quinton line was changed over a guide wire without difficulty. Post-transfusion crit was 30.9. A white count showed some increase to 20.1. The patient continued to run low-grade temperatures. The patient was transfused on postoperative day #6 for a hematocrit of 27.9. Post-transfusion crit was 29.9. White count remained persistently elevated at 20.6. The patient was extubated on postoperative day #7. Tube feeds were held, and TPN was instituted secondary to an acute episode of respiratory decompensation. Stool for C. diff was sent and this was positive. The patient was placed on Flagyl on [**2116-12-28**]. A Swan-Ganz catheter was placed on postoperative day #7 without difficulty. Chest x-ray was unremarkable. A new arterial line was also placed at the same time without any difficulty. The patient underwent LENIs of the pelvic veins which were negative; this was on postoperative day #8. White count remained stable at 20.2, hematocrit 28.4. The patient's dopamine was finally weaned off by postoperative day #9. Her post-transfusion crit was 32.9. Epogen was instituted. The patient did require Haldol dosing for an episode of confusion with improvement with the Haldol. The patient was transferred from the SICU to the VICU on [**2116-12-31**]. Calcium acetate 667 mg tablets tid were instituted. Repeat blood cultures were sent. The patient's central line was discontinued on postoperative day #12, and a PICC line was placed. Her white count showed improvement from 28.3 to 22.7. She was continued on her vancomycin and Flagyl. Because of the patient's persistent white count elevation, the patient was pancultured, and urinalysis was requested which was positive for bacteria, and RBC greater than 50, and WBC. The right thigh incision was I&D on postoperative day #3, and cultures were sent. Normal saline wet-to-dry dressings were begun. There was an improvement in her confusion. Her white count remained elevated at 24.7, but the patient was afebrile. She was continued on TPN. The patient remained in the VICU. The patient underwent a swallow evaluation on [**2117-1-4**]. It noted that the patient presented with functional speech, language and swallowing despite confusion and disorientation. She just has some oral candidiasis. There were no overt signs or symptoms of aspiration. They recommended that we could continue a regular diet with liquids, regular and soft solids, and treatment of the oral thrush. TPN was weaned on [**2117-1-4**]. Vancomycin was discontinued on [**2117-1-5**]. The patient was begun on Linezolid 75 mg q 12 h for VRE. The [**Last Name (un) **] service was consulted on [**1-5**] for management of her diabetes. Adjustments in her Insulin regime were made secondary to persistent hyperglycemia. Last JP was discontinued on [**2117-1-6**]. Blood cultures 11/28 grew VRE. Urine culture grew VRE. C. diff was positive. With Insulin adjusting, there was significant improvement in her glucose control. With the start of Linezolid there was improvement in the patient's total white count, and blood cultures were no growth. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2117-1-13**] 12:59 T: [**2117-1-13**] 14:08 JOB#: [**Job Number 98315**]

Admission Date: [**2140-3-15**] Discharge Date: [**2140-3-18**] Date of Birth: [**2082-7-23**] Sex: M Service: CCU CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: This is a 57 year old male with hypercholesterolemia and known coronary artery disease status post coronary artery bypass graft in [**2130**] with quiescent disease since then, not requiring sublingual Nitroglycerin; chest pain either. He presented with one day of chest pain that began this morning while putting up wallpaper. The patient noted ten out of ten chest pain, substernal chest pain with no radiation with associated diaphoresis but no shortness of breath, lightheadedness, nausea or vomiting. The patient took three sublingual Nitroglycerin that had already expired without effect, called Emergency Medical Services where he received Nitroglycerin spray times two without effect as well. At the outside hospital, he was noted to have ST elevations in leads II, III and F plus reciprocal ST depressions in leads V1 through V2. The patient received ReoPro and Retavase at full dose as well as Nitroglycerin and aspirin at the outside hospital. There was no change in his chest pain, therefore, the patient was transferred to [**Hospital1 346**]. In the Catheterization Laboratory here, he was noted to have a pulmonary arterial pressure of 38/21 with a pulmonary arterial mean of 26. A PCWP of 19. All grafts were found to be open. The right coronary artery was noted to have a 30% proximal stenosis and a mid-99% stenosis which was stented. After catheterization, the patient was made chest pain free. Note: The patient may have become transiently hypotensive at the outside hospital after Nitroglycerin. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Coronary artery disease status post myocardial infarction in [**2128**] and [**2130**]; coronary artery bypass graft in [**2130**] where he underwent three grafts including a left internal mammary artery to the left anterior descending, saphenous vein graft to obtuse marginal 1 and saphenous vein graft to D1. MEDICATIONS: 1. Accupril 10 q. day. 2. Aspirin 325 mg q. day. 3. Lipitor 10 q. day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Distant tobacco history. Currently no alcohol. He denies drug use. He is married with four children and he lives in [**Hospital1 **]. PHYSICAL EXAMINATION: Temperature 97.7 F.; blood pressure 113/75; heart rate of 76; O2 saturation of 100%. In general, alert and oriented times three in no acute distress. HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular motions are intact. Oropharynx is clear. Pulmonary clear to auscultation bilaterally, anteriorly. No wheezes. Cardiovascular: Regular rate and rhythm; no murmurs, rubs or gallops. Abdomen nontender, nondistended, normoactive bowel sounds. No hepatosplenomegaly. Extremities with no cyanosis, clubbing or edema. LABORATORY: White blood cell count of 9.4, hematocrit 35.2, platelets 174. INR of 1.4. Sodium of 141, potassium of 4.4, chloride 111, bicarbonate of 24, BUN of 11, creatinine of 0.7, glucose of 107. CK 1345. Arterial blood gases 7.31, 46, 120. EKG post catheterization revealed elevations in T and F, poor R wave progression, and T wave inversions in V5 through V6, II, III and F. ASSESSMENT: This is a 57 year old male with coronary artery disease, now with new right coronary artery disease, plus/minus inferior myocardial infarction. HOSPITAL COURSE: 1. CARDIAC: Status post right coronary artery intervention. The patient is now made chest pain free and was hemodynamically stable. He was continued on aspirin and Plavix and ReoPro for twelve hours. A beta blocker was started at low dose and his ACE inhibitor was continued. Fasting lipids were checked and were found to be a total cholesterol of 114, HDL of 41, LDL of 58 and triglycerides of 73. He was continued on his Lipitor. He was continued on Telemetry and his CKs were cycled and were found to be trending down. Nitroglycerin and morphine was avoided given possible right ventricular involvement. He underwent an echocardiogram the next morning which revealed an ejection fraction of 35 to 40%, a normal left atrium and left ventricle and right ventricle. Moderate left ventricular systolic dysfunction, mild mitral regurgitation; akinesis in the basal inferior, mid to distal anterior and apical areas. He also underwent an electrophysiology consultation in order to do a single average EKG to assess his sudden risk for death and this was positive; therefore, as an outpatient he will complete this work-up by undergoing a T wave alternans test as well as a Holter Monitor. The patient was transferred to the Floor on [**3-17**] and was doing well. His beta blocker was titrated up, his ACE inhibitor was continued, and he was doing well and was stable for admission on [**3-18**]. DISCHARGE STATUS: The patient was discharged to home. DISCHARGE INSTRUCTIONS: 1. He will be following up with Dr. [**Last Name (STitle) **]. 2. He will be returning for a T wave alternans test and a likely electrophysiology study. CONDITION ON DISCHARGE: Good. DISCHARGE MEDICATIONS: 1. Toprol XL 25 q. day. 2. Lipitor 10 q. day. 3. Quinapril 10 q. day. 4. Plavix 75 q. day for a total of nine months. 5. Aspirin 325 q. day. 6. Multivitamin. DISCHARGE DIAGNOSES: 1. Inferior myocardial infarction status post stent to the right coronary artery. 2. Positive single average Electrophysiology test. 3. Hypercholesterolemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 210**] MEDQUIST36 D: [**2140-6-17**] 16:01 T: [**2140-6-17**] 17:23 JOB#: [**Job Number 5814**]

Admission Date: [**2142-9-2**] Discharge Date: [**2142-9-5**] Date of Birth: [**2120-9-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: overdose Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: Ms. [**Known lastname 66715**] is a 21-year-old woman with a history of subclinical hypothyroidism, recent molar pregnancy resulting in miscarriage, adjustment disorder following miscarriage who was brought to ED by husband following tricyclic anti-depressant overdose. Per husband, patient has been very depressed since miscarriage, especially so for past week. 2 days PTA, patient expressed desire to cut wrists with steak knife. On day of admission, patient did not express any frank suicidal gestures to husband but was acting strange. Around noon, husband noticed that patient was drinking glass of water in bedroom and later found empty pill bottle of Nortriptyline which was dispensed with quantity of 30, he did not know how many pills were actually in bottle. He thought medication was muscle relaxant. Patient slept for a few hours after ingestion, then awoke to go to family event. On way to event in car, patient felt nauseous and expressed desire to return home. Patient also having menses, so husband assumed nausea/feeling unwell was related to this. On arriving home, husband noted patient to be very lethargic and did not appear well, so he brought her to the ED around 6 or 7 PM. . In the ED, initial VS were T 97.5; HR 125; BP 106/66; RR 16; 97% RA. Patient was intubated for airway protection. EKG showed QRS of .120 seconds, she was given 1 amp bicarbonate with decrease in QRS to 0.118 seconds. She received another amp of bicarb and then started on a bicarbonate drip. She also received activated charcoal given overdose. Posoin control was contact[**Name (NI) **] - typical half-life of nortriptyline is 18-35 hours. They advised continuing bicarbonate with goal pH of 7.45 - 7.55. Past Medical History: # iron deficiency anemia # gastritis # subclinical hypothyroidism # h/o Molar Pregnancy - complicated by miscarriage - s/p D+C [**2142-8-1**] for incomplete abortion - Karyotype: 49,XXX,+5,+7 # adjustment disorder following miscarriage # scoliosis Social History: Married, lives with husband. Social alcohol, no drugs or tobacco use. Studying to be pharmacy tech Family History: noncontributory Physical Exam: Afebrile BP: 135/90 HR: 80 RR: O2 100% AC TV 500 RR 18 PEEP 5 GEN: Sedated, intubated, comfortable HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD, No JVD. No thyromegaly. CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: Intubated. CTAB, good BS BL, No W/R/C ABD: NABS. Soft, NT, ND. No HSM EXT: WWP, NO CCE. 2+ DP pulses BL SKIN: No rashes/lesions, ecchymoses. NEURO: Intubated, sedated. PRRL. Pertinent Results: [**2142-9-2**] 08:15PM WBC-11.5* RBC-5.03 HGB-15.2 HCT-44.1 MCV-88 MCH-30.2 MCHC-34.4 RDW-12.9 [**2142-9-2**] 08:15PM NEUTS-71.1* LYMPHS-23.7 MONOS-2.9 EOS-0.9 BASOS-1.3 [**2142-9-2**] 08:15PM PLT COUNT-349 [**2142-9-2**] 08:15PM SERUM: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-POS [**2142-9-2**] 08:36PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2142-9-2**] 08:15PM GLUCOSE-104 UREA N-16 CREAT-1.0 SODIUM-142 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-23 ANION GAP-17 [**2142-9-2**] 09:42PM TYPE-ART RATES-/18 TIDAL VOL-500 O2-100 PO2-490* PCO2-31* PH-7.50* TOTAL CO2-25 BASE XS-2 AADO2-195 REQ O2-41 -ASSIST/CON INTUBATED-INTUBATED CXR: An endotracheal tube is seen with tip terminating at the thoracic inlet. A nasogastric tube is appropriately positioned. The cardiomediastinal silhouette is within normal limits. The pulmonary vasculature is unremarkable. There is no pneumothorax, pleural effusion, or focal consolidation. The osseous structures are unremarkable. Brief Hospital Course: 21F recent miscarriage, subclinical hypothyroidism p/w TCA overdose . # TCA overdose s/p intubation - On admission patient met some electrocardiographic crtieria for severe TCA poisoning, namely QRS > 100 msec (no prior for comparison), and rightward deflection of terminal end of QRS complex. Patient received sodium bicarbonate given QRS 0.12 seconds and activated charcoal, continued on bicarbonate drip with initial goal pH 7.45-7.55. Patient intubated in ED for airway protection. No underlying lung disease, CXR clear. She was quickly extubated without difficulty the morning after admission. For the remainder of the hospitalization, ECGs and ABGs were followed to have a goal QRS duration of <100 and pH 7.45-7.5. Sodium bicarbonate was given as needed to reach these goals. The QRS duration was <100 at discharge. . # Suicide Attempt: Likely secondary to adjustment disorder in the setting of recent molar pregnancy as well as marital problems. [**Name (NI) **] was seen by psychiatry on several occasions and the patient was felt not to be at acute risk to herself and felt stable to be discharged to an intensive outpatient regimen. She was kept on 1:1 sitter while inpatient. She expressed no suicidal ideations at time of discharge and was hopeful for the future. # Subclinical Hypothyroidism - Continue outpatient Levoxyl 25mcg # F/E/N - Initially put on D5 NS with 3 amps NaHCO3 for maintenance fluids - Replete lytes PRN Medications on Admission: levoxyl 25 mcg daily nortriptyline 10 mg qhs Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. [**Female First Name (un) **] 28 3-0.03 mg Tablet Sig: One (1) Tablet PO daily (). Discharge Disposition: Home Discharge Diagnosis: TCA overdose Adjustment disorder Depression hypothyroidism Discharge Condition: no suicidal ideation, medically stable Discharge Instructions: You were admitted after overdosing on your nortriptyline. As you know, this can have serious effects on your health. Please refrain from such activity again. If you feel that you might hurt yourself again, please seek help through your psychiatrist or by calling 911. You also have some lightheadedness when you stand as a result of prolonged effect of the nortriptyline. If this does not go away in the next few days, please follow-up with your physician. Please take all medications as prescibed only. Please keep all follow up appointments. Followup Instructions: Our psychiatry team will be in touch with you tomorrow regarding a treatment program. It is vital to your health that you keep this follow-up. Provider: [**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern4) 10591**], MD Phone:[**Telephone/Fax (1) 10590**] Date/Time:[**2142-11-20**] 10:15 PCP: [**Name10 (NameIs) 357**] follow up with Dr. [**Last Name (STitle) **] [**9-10**] at 4:15PM [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Admission Date: [**2169-3-27**] Discharge Date: [**2169-4-7**] Service: Vascular Surgery Service HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old gentleman who is a former surgeon who was admitted at midnight with right foot numbness and decrease in movements and decrease in temperature of the right foot. However, the patient denies pain on initial presentation and the patient has experienced recent fall with no trauma to the right lower extremity. He denies claudication or resting pain. The patient is ambulatory upon arrival to the Emergency Room. PAST MEDICAL HISTORY: Significant for hypertension, coronary artery disease, status post myocardial infarction times two and transient ischemic attacks. PAST SURGICAL HISTORY: Status post left carotid endarterectomy and status post appendectomy, status post open cholecystectomy, status post transurethral resection of prostate and status post hip replacement. MEDICATIONS ON ADMISSION: Detrol 4 mg p.o. q.d.; Nifedipine 30 mg p.o. q.d., Aspirin 325 mg p.o. q.d., Zantac 150 mg p.o. b.i.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On presentation the has palpable femoral pulse bilaterally, palpable popliteal triphasic bilaterally. No dopplerable dorsalis pedis or posterior tibial on the right side. He has monophasic dorsalis pedis and monophasic posterior tibial on the left side. HOSPITAL COURSE: At this time the patient was diagnosed with having peripheral vascular disease despite his long history of claudication. The patient was put on heparin for anticoagulation and the patient was admitted to the Vascular Surgery Service. Emergent arteriogram showed acute thrombosis of the right atrial artery. The patient was begun on total parenteral alimentation treatment and Cardiology was called to assess the patient's risk for bypass surgery. Cardiology cleared the patient for bypass surgery. The patient had preoperative laboratory work done which showed an ejection fraction of 30%. The patient was taken to the Operating Room on [**3-28**] and underwent a right femoral tibial bypass graft with greater saphenous vein in situ graft with valve lysis by Dr. [**Last Name (STitle) 1476**]. On postoperative day #1 the patient was noted to have loss of pulse signal and graft pulse was no longer palpable. The patient was also noted to have oozing from the incision site. The patient's pulse was noted to be decreased on postoperative day #1 and the patient's condition was guarded at that time. On postoperative day #1 the patient had a brief episode of bradycardia and a pacing Swan was placed and from electrocardiogram the patient appeared to have a right bundle branch block that was newly developed. Cardiology was on board and Lopressor beta blockade was discontinued. At the time due to the critical nature of the patient's condition the patient was transferred to the Intensive Care Unit and the patient's renal function appeared to be worsening and Nephrology was consulted. With their recommendation the ACE inhibitor was discontinued and non-steroidal anti-inflammatory drugs were discontinued. The patient was begun to be given transfusion. The patient appeared to have an acute myocardial infarction postoperatively and renal failure secondary to lack of volume resuscitation. The patient was transferred onto the Intensive Care Unit in guarded condition. On postoperative day #2, on repeat enzymes, the patient's peak CK appeared to be around 700 and it was clear that the patient had perioperative myocardial infarction and the patient was kept in the Intensive Care Unit to stabilize his cardiac and renal status. On postoperative day #3 the patient's graft appeared to be viable. The patient has a warm foot and palpable dorsalis pedis on the right foot. The incision appeared to be still slightly oozy and the patient had Ace bandage wrap around the right leg. On postoperative day #6 the patient was noted to have a lower gastrointestinal bleed and bled in stool and Gastroenterology was consulted. It was on their recommendation heparin was discontinued and the patient's bleeding appeared to stop and Gastroenterology recommended outpatient colonoscopy in the future. On postoperative day #8 the patient's condition appeared to be improving and the patient's renal function appeared to be improving and the patient appeared to be recovering from the acute tubular necrosis and renal failure. From the cardiology point of view, the patient's condition is stabilizing and the patient was transferred onto the Vascular Intensive Care Unit on [**4-6**], which was postoperative day #9. Under Cardiology's recommendation the ACE inhibitor was increased. Chest x-ray was taken to assess his cardiac status. The patient was put on sips for p.o. intakes and the patient appeared to be improving. On postoperative day #10 after discussion with the family the patient was made Do-Not-Resuscitate following the family and patient's wishes. On postoperative day #10 at approximately 6 PM the patient went into respiratory distress with audible wheezes bilaterally and a copious amount of secretion and respiratory treatment with Albuterol inhaler given and suctioning was carried out. At that time it was clear that the patient does not want to be nasotracheal suctioned and appears to be better coherent. The patient at that time was sating at 96% on 5 liters and it appeared that the patient went into bronchospasm and retained secretions with impaired secretion clearance, although after numerous Albuterol treatment the patient was not able to clear his secretion and the patient was made Do-Not-Intubate. The patient expired at 9:30 on [**2169-4-7**]. The patient is deceased on [**2169-4-7**] with final cause, the patient is a [**Age over 90 **] year old gentleman status post right femoral-tibial bypass graft. His course was complicated by myocardial infarction and renal failure. His condition appeared to be improving, however, on [**2169-4-7**], the patient had absolute bradycardia and became acutely apneic and the patient developed bronchospasm and retained secretion which was not able to be cleared by suctioning and the patient was made Do-Not-Intubate and no intubation was carried out. The patient deceased from respiratory distress. The patient underwent autopsy, results pending. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**] Dictated By:[**Name8 (MD) 186**] MEDQUIST36 D: [**2169-4-13**] 16:59 T: [**2169-4-13**] 18:01 JOB#: [**Job Number 40690**]

Admission Date: [**2146-9-13**] Discharge Date: [**2146-9-23**] Date of Birth: [**2102-8-5**] Sex: F Service: MEDICINE Allergies: Depakote / Aricept Attending:[**First Name3 (LF) 905**] Chief Complaint: Asthma Exaccerbation Major Surgical or Invasive Procedure: None Performed History of Present Illness: The patient is a 44F with history of bipolar disorder and lifelong asthma who now presents with a new asthma exaccerbation. The patient reports feeling ill over the weekend, with signs of an upper respiratory infection, including rhinitis, puffy eyes, and dry cough. She noticed that she was feeling increasingly dyspnic over this time, particularly when walking or during coughing/sneezing. She is not having difficulty breathing at rest. She has been having increased coughing with concurrent chest wall pain, the cough is not productive of any sputum. She does report fever, with home Tmax at 101.0 on Sunday, [**9-11**], she believes. She denies chills, night sweats, myalgias. She further denies chest pain (except during forceful coughing), palpitations, leg swelling, PND, nausea, vomiting, diarrhea, or constipation. She does not report sick contacts or recent travel. These symptoms have been bothersome to the point that the patient was unable to pursue her regular activities, and she has been unable to sleep at night secondary to coughing. On the day prior to admission, the patient consulted with her pulmonologist's office (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) and was advised to increase her daily fluticasone; the office also phoned in a prescription for azithromycin x5days. He advised her to come to the ED, but the patient defered, out of fear of bad experiences in the hospital. On the morning of admission, the patient continued to be symptomatic with shortness of breath, wheezing, and increased dry cough, and she presented to the ED via a friend's car. . The patient does have an extensive history of asthma dating to birth. She reports that "everything" triggers her asthma, including seasonal change, activity, dust, pollen, mold, and more. She has been hospitalized 4-5x for asthma, mostly between [**2136**]-[**2137**]; she has required steroids in the past but has never been intubated. Of note, the patient does report experiencing an episode of steroid-induced psychosis when given high dose IV steroids in [**2140**], prior to the diagnosis and management of her underlying bipolar disorder. She is currently followed by pulmonologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and her home medication regimen includes cromolyn, fluticasone, salmeterol, montelukast, and cetirizine. . In the ED, the patient received Combivent nebulizers x3 along with a single 500mg dose of azithromycin. She was afebrile and O2sat was 94% on room air on arrival. She did not require oxygen at the time. When the medicine team first met the patient in the ED, she reported feeling generally comfortable, but still dyspnic and "wheezy" on exertion/coughing. Past Medical History: 1. Asthma (as above, last PFTs in [**8-1**] with nl FVC (4.38) and FEV1 (2.89); FEV1/FVC mildly reduced at 66, flow volume loop with mild expiratory coving) 2. Atopic dermatitis 3. Bipolar Disorder (rapid cycler) 4. Knee surgery? Social History: The patient lives in [**Location 27256**]. No history of tobacco, EtOH, or other drugs. Family History: There is no family history of asthma, atopy, or other pulmonary disease. Physical Exam: VITALS: T-98.6, BP-119/59, P-84, RR-18, O2sat-99%onRA GEN: well appearing woman, NAD, able to complete full sentances, intermittent coughing spells HEENT: PERRL, MMM, oropharynx with whitish material on hard palpate, no erythema, no sinus tenderness NECK: no LAD, no thyromegaly, could not appreciate JVD CHEST: diffuse expiratory wheezes throughout, increased anteriorly; inspiratory crackles can be heard at the right base, no accessory muscles of respiration being used COR: heart sounds overwhelmed by wheezes, no M/R/G appreciated ABD: soft, NABS, NTND EXT: no pedal edema, no cyanosis, no clubbing Pertinent Results: Admission Labs: [**2146-9-13**] 02:35PM WBC-12.5* RBC-4.17* HGB-13.6 HCT-39.2 MCV-94 MCH-32.5* MCHC-34.6 RDW-12.8 [**2146-9-13**] 02:35PM PLT COUNT-289 [**2146-9-13**] 02:35PM NEUTS-73.2* LYMPHS-19.5 MONOS-4.0 EOS-3.1 BASOS-0.3 [**2146-9-13**] 02:35PM GLUCOSE-98 UREA N-7 CREAT-0.8 SODIUM-140 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13 CXR: unchanged 4mm calcified granuloma in RUL, peribronchial thickening in both lower lobes, no evidence of pneumonia Brief Hospital Course: 1. Asthma-The patient was initially started on aggressive albuterol and ipratropium nebulizer therapies alone, and a decision was made to withold oral steroids given clinical stability and history of steroid-induced psychosis. However, throughout the next day, the patient did not show signs of improvement, with very wheezy, rhochorous lungs and some slight decrease in O2sat to the low 90s, though she continued to look well clinically and was able to speak full sentances without shortness of breath. By the morning of hospital day three, the patient continued to still sound very wheezy and was requiring 1-2L oxygen to maintain oxygen saturation above the very low 90s, and a decision was made in conjunction with the patient's outpatient pulmonologist, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], to begin oral prednisone at 40mg daily. Pt showed minimal improvement after start of steroids. Her dose was increased to 60mg the following day. Her hypoxia worsened overnight and she was changed to to IV solumedrol. A CXR from that time showed a new LLL infiltrate that was read as atelectasis vs pneumonia vs pulmonary infarct. The patient was started on levofloxacin. She required admission to the ICU for closer monitoring due to progressive hypoxia despite steroids and nebulizers. She had a CTA that demonstrated ground glass opacities and tree and [**Male First Name (un) 239**] morphology suggestive of viral or an atypical bacterial pneumonia. She was continued on levofloxacin. She was treated with around the clock nebulizers and IV steroids and her peak flows imrpoved from 100s to 300. Additionally, she was given pneumovax and influenza vaccines. Given her history of mania on steroids, her steroids were changed to prednisone in preparation for a taper. She was transferred to the floor where she was weaned off of oxygen and did well with ambulation. She was discharged with a plan for steroid taper and close follow-up by Dr. [**Last Name (STitle) **] 2. Respiratory Infection-The patient presented with some evidence of underlying respiratory infection, including a pre-admission prodrome of URI symtoms such as rhinitis, puffy eyes, and cough that preceded the development of wheezing and dyspnea. There was a history of fever to 101 at home as well, though the patient was afebrile on admission. She has had a mildly elevated white count in the 12-13 range; no clinical evidence of pneumonia on chest radiograph. The patient had been started on azithromycin x5 days as an outpatient and, given this constellation of findings, a decision was made to continue the full course of treatment as bacterial etiologies of infection were included in the differential. With wrosening hypoxia a CXR was done that showed a possible new infiltrate. A CT chest revealed bilateral opactities and tree/[**First Name5 (NamePattern1) 239**] [**Last Name (NamePattern1) 106320**] suggestive of viral or atypical bacterial pneumonia. A 14 day course of levofloxacin was prescrbed and patient clinically improved to complete regimen as an outpatient 3. Bipolar disorder-The patient presented with a history of steroid-induced psychosis which followed the administration of high dose intravenous methylprednisolone during an admission for asthma/mold exposure in [**2140**]. Therefore, the decision to start even low dose oral predisone was made carefully in this patient and in consultation with her outpatient psychopharmacoloist. The patient did report some increased activiation/decreased sleep even after a single dose of prednisone. The patient was continued on her outpatient psychiatric regimen including nightly lithium 1200mg, lorazepam 2.5mg, quetiapine 150mg, and gabapentin 900mg. Her seroguel and lorazepam doses were increased per recommendation of patient's outpatient psychiatrist (Dr. [**Last Name (STitle) 106321**]. Pt did well obtaining sleep/rest with this regimen. She remained in near daily contact with her psychiatrist by phone throughout her hospital stay. She will have close follow-up with him while on a steroid taper 4. PPx-Bowel regimen. SC heparin. OOBTC. Insulin and protonix while on steroids. Pneumovax and influnza vaccination. . 5. Peripheral IV . 6. FEN: regular diet . 7. FULL CODE . Medications on Admission: 1. Atrovent 2puffs [**Hospital1 **] 2. Intal (cromolyn) 2puffs [**Hospital1 **] 3. Zyrtec 10mg PO daily 4. Serovent 1puff [**Hospital1 **] 5. Flovent 6puffs [**Hospital1 **] (increased from 4puffs [**Hospital1 **] on [**9-12**]) 6. Singulair 10mg PO daily 7. Neurontin 900mg PO QHS 8. Seroquel 125mg PO QHS 9. Lithium 1200mg PO QHS 10. Lorazepam 2.5mg PO QHS 11. Azithromycin 500mg x5d (started [**9-12**]) Discharge Medications: 1. Cromolyn Sodium 800 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 3. Lithium Carbonate 300 mg Capsule Sig: Four (4) Capsule PO HS (at bedtime). 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lorazepam 1 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime). 6. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 8. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO daily (). 9. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day) as needed for cough. 10. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day) for 7 days. Disp:*28 Troche(s)* Refills:*0* 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:*8 Tablet(s)* Refills:*0* 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours. Disp:*40 neb* Refills:*0* 16. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation every 4-6 hours. 17. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 18. Prednisone 10 mg Tablet Sig: taper Tablet PO once a day for 8 days: Take 4 tablets each day for 2 days ([**9-24**] and [**9-25**]), then take 2 tablets each day for 3 days, then take 1 tablet each day for 3 days. Disp:*17 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: asthma flare pneumonia bipolar disorder Discharge Condition: afebrile, improving peak flows, adequate sats on room air with ambulation Discharge Instructions: Please take all medications as prescribed. Please continue to keep in daily contact with your psychiatrist. Please speak with Dr. [**Last Name (STitle) 106321**] about lowering your bipolar medication dosage as your prednisone dose is tapered. Please make sure that you speak with Dr. [**Last Name (STitle) **] on Monday [**9-26**]. be sure to monitor your peak flows. Please discuss with him when it is best to change back to your regular inhalers. Please contact your pulmonologist with questions or concerns about your breathing. Please return to the emergency department immediately if you have worsening shortness of breath, worsening peak flows, fevers, chest pain, fatigue or any other worrisome symptoms. Followup Instructions: Please contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**] for an appointment within the next week. Please contact Dr. [**Last Name (STitle) 106321**] for a follow-up appointment next week. Please be sure to speak with Dr. [**Last Name (STitle) **], your pulmonologist on Monday [**9-26**] Please keep the following appointments: Provider: [**First Name8 (NamePattern2) 22181**] [**Last Name (NamePattern1) 22182**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2146-9-26**] 3:00 Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2147-2-6**] 10:55 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5265**], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2147-2-6**] 11:15 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2146-10-17**]

Admission Date: [**2193-1-18**] Discharge Date: [**2193-1-28**] Date of Birth: [**2151-6-16**] Sex: M Service: MEDICINE Allergies: clindamycin / Penicillins / Levaquin / cefazolin / Bactrim / Sulfamethoxazole / Vancomycin Attending:[**First Name3 (LF) 1257**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Amputation/disarticulation of 4th finger on left hand at PIP joint. History of Present Illness: 41 y/o with DM, h/o frostbite with chronic finger wound transfered from [**Hospital3 **] on [**1-18**]. He originally presented to his PCP 6 days PTA with worsening pain, swelling, and ? pus production in the left ring finger. Per the pt he chronically has an open wound at this site. He was seen by his PCP and treated with Bactrim near the onset of his symptoms, however did not have significant improvement with this therapy. Upon arrival at the OSH he recieved 1 gm IV vanco prior to transfer to [**Hospital1 18**]. He denies F/C/S, rash, abd pain prior to admission. . On the evening of arrival to [**Hospital1 18**] he underwent I+D with production of frank pus and he was started on IV vancomycin. Unfortunately cultures from this I+D appear to be lost. A finger X-ray was concerning for osteo in the left 4th digit. ID was consulted to help with abx management. Late on [**1-18**] he was sent to the OR for a washout. The procedure was un-complicated and a swab was sent for culture. A bone bx was not done at that time. Per the Hand surgery team the wound has been appearing well without drainage since the time of surgery. . Following the OR ([**1-18**], 2100) PACU notes mention the onset of diffuse erythema across the face and chest. This was feared to be a rxn to vancomycin and his coverage was switched to vancomycin. ID agreed with switching to Linezolid. . He became persistently febrile starting [**1-19**] at 9am with Tm of 103.2. Pt has also been progressively tachycardic to 130s, which appears as sinus tachycardia on telemetry. He transiently had a BP of 80/50 which resolved within 15 minutes. He was given a total of 4250cc of IVF [**3-19**] with 1375 of UO. On the evening of transfer surgery placed a right IJ at the bedside without complications. 3 passes of the right subclavian were first attempted without success. Past Medical History: Diet controlled diabetes mellitus Hyperlipidemia Polio Frostbite leading to amputation of digits Social History: 1ppd x 28 years. Quit smoking several months ago. No alcohol or drug use. Lives at home with cat and cockatoo. Family History: Noncontributory Physical Exam: Admission physical exam: GEN: pleasant, tired but comfortable, NAD HEENT: PERRL, EOMI, anicteric, dry MM but no OP or nasal lesions.,no jvd, RESP: CTA b/l with good air movement throughout CV: tachy, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly + right CVA tenderness EXT: BL nonpitting edema. multiple finger amputations and BL great toe amputations. left ring finger with 2 palmar and 2 side incisions with wicks. No erythema extending directly from wound. SKIN: no jaundice/no splinters. diffuse erythematous and warm macular rash, blanching, prominant over upper chest, UE. Over BL temporal area, upper chest, and flanks NEURO: AAOx3. Cn II-XII intact. grossly moving all ext (poor cooperation with exam). No sensory deficits to light touch appreciated. Pertinent Results: Admission labs: [**2193-1-18**] 02:10AM WBC-10.5 RBC-4.98 HGB-14.3 HCT-41.0 MCV-82 MCH-28.7 MCHC-34.9 RDW-13.5 [**2193-1-18**] 02:10AM GLUCOSE-111* UREA N-14 CREAT-1.1 SODIUM-137 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14 [**2193-1-18**] 02:10AM PT-14.3* PTT-32.4 INR(PT)-1.2* [**2193-1-18**] 02:10AM NEUTS-79.5* LYMPHS-13.7* MONOS-4.1 EOS-2.4 BASOS-0.3 . MRI hand [**1-21**] IMPRESSION: 1. Findings concerning for osteomyelitis at the distal tip of the fourth/ring finger amputation stump. Fluid communicates from skin to amputation stump. Diffuse soft tissue swelling of the ring finger. Remainder of osseous signal is normal. Base of middle phalanx demonstrates normal signal. PIP joint is normal. 2. Abnormal fluid tracking about the extensor tendons and the flexor tendons, contiguous with dorsal fluid in subcutaneous tissues. Could represent tenosynovitis or other fluid. 3. Thenar muscle edema. Lumbrical muscle edema. . [**1-21**] Echo The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . [**1-20**] Abdomen/pelvis CT 1. No acute intra-abdominal process; specifically no fluid collections, hydronephrosis, or perinephric stranding; gas-distended colon, but no obstruction or pneumatosis. 2. Prominent inguinal lymph nodes of uncertain clinical significance. 3. Well-corticated bony irregularities of the bilateral iliac bones may represent post traumatic change, enthesopathy, osteochondromas, or heterotopic bone. . Brief Hospital Course: OSTEOMYELITIS OF THE 4TH DIGIT ON LEFT HAND: This was confirmed with MRI. The patient had pus draining from an open wound on this finger. He was brought to the OR on [**2193-1-18**] for a washout and following this became septic. His septic picture was confounded by severe drug reactions to antibiotics (Bactrim and Vancomycin). He was brought to the ICU and was fluid resuscitated. He subsequently went to the OR again on [**1-22**] for a rising white count at which time he underwent a finger amputation. He was treated with an additional days of linezolid following the amputation (until [**2193-2-5**]. He remained in the hospital for several days beyoned his due discharge day to get approval for Zyvox from mass health. Dermatology was consulted after patient developed diffuse erythematous rash with pustules on face and upper body. Dermatology felt the patient likely had AGEP (acute generalized exantematous pustolosis) secondary to Bactrim that had been prescribed while outpatient. Biopsy samples taken that were consistent with AGEP. Per Dermatology recommendations, patient started on triamcinolone cream, which provided some improvement. Patient should only use steroidal topical for 14 days. We also believe that he devloped reaction similar to red man syndrome from Vancomycin. In regards to his diabetes, normally it is diet controlled. During hospitalization, it was controlled with insulin sliding scale. He was discharged home with VNA and PT. He could not remember his home medications, he was asked to resume them and follow up with PCP, [**Last Name (NamePattern4) **] ([**2193-2-5**]), and hand surgery (was asked to call the number for suture removal). He will continue Zyvox until he sees ID on that day. Total discharge time > 30 minutes Medications on Admission: ? simvastatin daily ? metoprolol daily Discharge Medications: 1. linezolid 600 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 11 days: last day [**2193-2-5**]. Disp:*22 Tablet(s)* Refills:*0* 2. metoprolol tartrate Oral 3. simvastatin Oral 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 5. Benadryl 25 mg Capsule Sig: One (1) Capsule PO four times a day as needed for itching. 6. triamcinolone acetonide 0.025 % Cream Sig: One (1) Appl Topical QD () for 7 days: do not use on face or genitals. Disp:*60 gram tube* Refills:*1* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Finger osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with a severe infection of your finger which required amputation of your finger and will require you to stay on antibiotics for several days since your amputation (last day [**2193-2-5**]). You also had a severe rash, likely from Bactrim (an antibiotic) please avoid this medication in the future. Please take your medications as prescribed and make your follow up appointments. Resume old medications as you were unable to provide us with dose. Followup Instructions: Department: INFECTIOUS DISEASE When: TUESDAY [**2193-2-5**] at 3:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Please call the hand clinic at [**Telephone/Fax (1) 1228**] for a follow up appointment within 10 days of your discharge ([**2193-2-5**] is a good day for a follow up) from the hospital. (you saw Dr. [**Last Name (STitle) **] in the hospital, she performed your surgery) You need to change dressing twice a day but clean your hand dry and clean at all times. You can shower and use water and soap.

Admission Date: [**2180-1-11**] Discharge Date: [**2180-1-12**] Date of Birth: [**2130-3-25**] Sex: M Service: SURGERY Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 6088**] Chief Complaint: Asymptomatic right internal carotid artery stenosis. Major Surgical or Invasive Procedure: Right Carotid Endarterectomy on [**2180-1-11**] History of Present Illness: 49yM presented in [**Month (only) **] with bilateral IPH s/p hypertension. During his hopsitalization angiogram demonstrated occluded [**Country **], and severe stenosis [**Doctor First Name 3098**] fitting criteria for repair of asymptomatic stenosis based on degree of stenosis. Past Medical History: HTN GERD [**2179-9-30**]: bilateral intraparenchymal hemorhhages in the bilateral temporal lobes, bilateral temporal and occipital lobe subarachnoid hemorrhages and a subdural hematoma [**2179-9-30**]: subacute anterior wall ST-elevation myocardial infarction ? ETOH history Social History: Has smoked since teenage years, approx 1 ppd. Drinks several shots of Vodka, Scotch, or pints of beer, family classified him as a "moderate drinker" Lives with his son, widowed, has a girlfriend called [**Name (NI) 1356**]. No IVDA Worked as a manager for [**Company **] PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] TEL: [**Telephone/Fax (1) 17753**] Brother and HCP is [**Name (NI) 11229**] [**Name (NI) **] [**Telephone/Fax (1) 66016**] Family History: Mother died of colorectal ca Father had HTN and CAD Pertinent Results: [**2180-1-12**] 03:27AM BLOOD WBC-8.5 RBC-3.23* Hgb-10.2* Hct-29.8* MCV-92 MCH-31.6 MCHC-34.2 RDW-13.2 Plt Ct-230 [**2180-1-11**] 07:52PM BLOOD WBC-8.8 RBC-3.22* Hgb-10.5* Hct-30.0* MCV-93 MCH-32.5* MCHC-35.0 RDW-13.1 Plt Ct-241 [**2180-1-11**] 11:21AM BLOOD Hct-32.8* [**2180-1-12**] 03:27AM BLOOD Plt Ct-230 [**2180-1-12**] 03:27AM BLOOD PT-13.6* PTT-31.7 INR(PT)-1.2* [**2180-1-11**] 07:52PM BLOOD Plt Ct-241 [**2180-1-12**] 03:27AM BLOOD Glucose-127* UreaN-9 Creat-0.6 Na-139 K-4.0 Cl-105 HCO3-26 AnGap-12 [**2180-1-11**] 07:52PM BLOOD Glucose-146* UreaN-10 Creat-0.7 Na-140 K-3.8 Cl-106 HCO3-22 AnGap-16 [**2180-1-12**] 03:27AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.1 [**2180-1-11**] 07:52PM BLOOD Calcium-8.3* Phos-3.1 Mg-1.7 [**2180-1-11**] 11:21AM BLOOD Mg-1.7 [**2180-1-12**] 06:08PM BLOOD Type-ART pO2-18* pCO2-71* pH-7.19* calTCO2-28 Base XS--4 Intubat-NOT INTUBA Brief Hospital Course: Pt returned on [**2180-1-11**] for repair of this asymptomatic stenosis of his right internal carotid artery. Right CEA was performed on [**2180-1-11**]. Pt recovered well from the procedure, was hemodynamically stable other than brief low BP immediately post op. Pt reported significant headache immediately post operatively and so he was admitted to the ICU and received a post op head CT w/o contrast. No acute intracranial hemorrhage or other acute intracranial abnormality was noted. Further evolution of prior parenchymal hemorrhage in the bilateral posterior temporal- parietal cortices. Pt stayed in the ICU overnight on [**1-11**] for close monitoring. On [**1-12**] he was transferred to the floor around 1600. Pt has been stable, making good urine, BP at goal of 120. Pt did continue to have a headache but indicated that it was slightly less severe in the am of [**1-12**]. Upon arriving on the floor, around 4:00 pt asked his nurse [**First Name (Titles) **] [**Last Name (Titles) 66019**]l for his head ache. Pt was sitting on the edge of his bed when the nurse left, talking, vitals signs stable (99 72 121/76 20 99% RA). When she returned pt was found lying supine in his bed, both legs flexed and externally rotated. pt skin was warm, but pt was non responsive, a second nurse believes that pupils were not equal. Nurses immediately began CPR and called a CODE. CODE TEAM arrived, pt was shown to be in Vfib. CPR was continued. ACLS resuscitation was attempted. During the code pt head became very blue, while his body appeared perfused with femoral pulses noted bilaterally. Breath sounds were heard bilaterally. After 30 minutes of ACLS resuscitation/ chest darts were placed for possible tension peumothorax/pericardial-centesis was attempted in case of tamponade to no avail. At 1717 CPR was stopped and Pt was pronounced. Medications on Admission: LEVETIRACETAM - 250 mg Tablet - 1 (One) Tablet(s) by mouth twice a day LISINOPRIL - 2.5 mg Tablet - 1 (One) Tablet(s) by mouth once a day METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice daily SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth daily ASPIRIN - 81 mg Tablet - 1 (One) Tablet(s) by mouth once a day Discharge Disposition: Expired Discharge Diagnosis: carotid vascular disease, PEA arrest Discharge Condition: Time of Death 17:[**1-16**]

Admission Date: [**2151-9-29**] Discharge Date: [**2151-10-5**] Date of Birth: [**2096-11-3**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Increased weakness Major Surgical or Invasive Procedure: EGD pill endoscopy History of Present Illness: 54 yo male with hx of CAD, CHF EF 30-35%, ETOH and cocaine who presented to ED with complaint of feeling unwell for few days. Pt presented to PCP [**Last Name (NamePattern4) **] [**9-29**] complaing of 3 days of fatigue and generalized weakness after his last crack cocaine use. He denied CP but had worsening SOB and DOE. Pt reports PND, orthopnea, and LE edema at baseline. He denied N/V/F but has had intermittent shaking chills. He also reported a headache with blurred vision which has since resolved without any neurological deficits. He reported nonbloody, nonmelenic diarrhea on 2 days prior to admission which resolved on own although he reports decreased appetite since this episode. He reports a normal diet including vegetables and red meat. Patient was hospitalized in [**6-18**] with similar presentation and had neg GI workup including EGD, SM bowel folllow through, and colonoscopy. Blood was drawn at the PCP office which showed patient had a Hct of 13 and he was sent to the ED. In [**Name (NI) **] pt was hypertensive to 190's and vitals otherwise stable. Gastric lavage was negative, guaiac positive and he was transfused 1 unit of blood. Patient was transfered to the ICU where he got an additional 3 units of blood for a total of 4 units. Iron studies were sent in the unit which showed that the patient had iron of 7 and ferritin of 3.9; he was given IV iron in the unit for concern that he was not absorbing iron. GI was consulted and he had an EGD which showed no bleed. Patient found to have H. pylori and treatment with amoxicillin/clarithromycin/protonix started. After 4 untis of blood patients Hct bumped from 13.5 to 23.5. Patient with no episodes of shortness of breath or desating while being trensfused blood. Past Medical History: 1. Alcohol and cocaine abuse. H/o DT's. 2. Diabetes. Insulin dependent 3. Chronic pancreatitis. 4. Affective illness. 5. Status post multiple psychiatric hospitalizations including some for suicidal ideation. 6. Hypertension. 7. Hypercholesterolemia. 8. GERD. 9. Gout. 10. s/p MI's. Cath in '[**48**] showed clean coronaries. Stress test in '[**50**] showed no ischemia. Social History: Positive tobacco use of a pack a day for 40years, positive alcohol use since age 15 with multipleadmissions for detox. He reports using cocaine since [**2136**]. Denies any other drugs and denies IV drugs. Patient denies any symptoms of withdrawal or seizures Family History: His father with alcoholism and an uncle who committed suicide by hanging, and a cousin with [**Name2 (NI) 14165**] cell anemia. Physical Exam: UPON CALL OUT TO FLOOR FROM [**Hospital Unit Name 107482**] T 97.3 BP 168/88 (150's-160's) P 86 (80'S) R 100%ra RR 18 I/O = 2685/1250 GEN: comfortable, AA gentleman, in no distress, on the phone, smiling HEENT: pale conjunctivae, MMM, no oral lesions/bleeding, poor dentition NECK supple, JVP flat, no JVD Chest: BCTA no crackles CV: RRR no m/r/g ABD: soft, mildy obese, non tender, no HSM, no masses, non tender, no rashes, no caput medusae RECTUM: GUAIAC positive this am in [**Hospital Unit Name 153**], rectal exam w/o lesions, masses, excoriations, abrasions. No BRBPR. NEURO: alert and oriented x 3, anxious, followed all commands, finger-to-nose intact, alternating movements intact. [**5-19**] strength everwhere in BLE, BUE. No asterixis. Pertinent Results: [**2151-9-29**] 10:38PM HCT-16.7* [**2151-9-29**] 04:08PM URINE HOURS-RANDOM [**2151-9-29**] 04:08PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [**2151-9-29**] 03:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2151-9-29**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2151-9-29**] 03:00PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2151-9-29**] 01:15PM GLUCOSE-356* UREA N-21* CREAT-1.4* SODIUM-138 POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-24 ANION GAP-13 [**2151-9-29**] 01:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2151-9-29**] 01:15PM WBC-6.0 RBC-2.11*# HGB-3.7*# HCT-13.9*# MCV-66* MCH-17.5*# MCHC-26.6*# RDW-14.7 [**2151-9-29**] 01:15PM NEUTS-73.6* LYMPHS-19.7 MONOS-5.1 EOS-1.2 BASOS-0.4 [**2151-9-29**] 01:15PM HYPOCHROM-3+ POIKILOCY-1+ MICROCYT-3+ [**2151-9-29**] 01:15PM PLT COUNT-325 [**2151-9-29**] 01:15PM PT-12.4 PTT-22.9 INR(PT)-1.0 [**2151-9-29**] 11:00AM GLUCOSE-382* [**2151-9-29**] 11:00AM UREA N-20 CREAT-1.3* SODIUM-137 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [**2151-9-29**] 11:00AM ALT(SGPT)-8 AST(SGOT)-10 [**2151-9-29**] 11:00AM IRON-7* [**2151-9-29**] 11:00AM calTIBC-424 FERRITIN-3.9* TRF-326 [**2151-9-29**] 11:00AM %HbA1c-8.6* [**2151-9-29**] 11:00AM WBC-6.9 RBC-2.18*# HGB-3.9*# HCT-15.3*# MCV-70* MCH-17.7*# MCHC-25.2*# RDW-15.4 [**2151-9-29**] 11:00AM PLT SMR-NORMAL PLT COUNT-355 [**2151-9-30**] 05:18AM BLOOD WBC-7.3 RBC-2.79*# Hgb-6.6*# Hct-20.7* MCV-74*# MCH-23.6*# MCHC-31.7# RDW-19.2* Plt Ct-253 [**2151-9-30**] 08:45AM BLOOD Hct-23.5* [**2151-9-30**] 02:58PM BLOOD Hct-24.9* [**2151-9-30**] 05:18AM BLOOD Plt Ct-253 [**2151-9-30**] 05:18AM BLOOD Glucose-177* UreaN-15 Creat-1.1 Na-141 K-4.0 Cl-109* HCO3-24 AnGap-12 [**2151-9-30**] 05:18AM BLOOD ALT-9 AST-9 LD(LDH)-PND CK(CPK)-46 AlkPhos-59 TotBili-0.7 [**2151-9-30**] 05:18AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.7 Brief Hospital Course: 54 y/o male with h/o chronic iron deficiency anemia, CAD, CHF, DMII, HTN who was recently admitted to MICU for severe anemia and guaiac positive stools. 1) GI Bleed - Patient with guaiac positive stool with negative upper endoscopy this am. Recent GI workup in [**Month (only) **] with negative colonoscopy and SBFT. Pill endoscopy performed [**2151-10-4**] with results pending. Pt instructed to follow up with GI (Dr. [**Last Name (STitle) 7307**] in approximately 1-2 weeks. (call to make appointment [**Telephone/Fax (1) 107483**]) 2) Iron deficiency anemia - Goal Hct of 30. Pt transfused total of 4 units PRBCs and given B12, folate, iron supplements. 3) Etoh use - Addictions consult obtained, patient successfully withdrawn from EtOH. Will be transferred to detox facility. 4) H. pylori - Will continue treatment with antibiotics for full 14 day course. Will continue PPI. 5) DM type II - stable without issues. 6) Cardiac - Initially held anti-hypertensives but restarted without issues. 7) Depression - Will continue celexa and remeron Medications on Admission: Insulin (NPH) 40/40 Celexa 20 Thiamine Lisinopril 40 Folate Remeron 15 Lipitor 10 Protonix 40 HCTZ 25 Discharge Disposition: Extended Care Facility: [**Hospital **] HOSPITAL Discharge Diagnosis: GI bleed Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please follow up with Dr. [**Last Name (STitle) 7307**] to talk about the results of your study ([**Telephone/Fax (1) 107483**]) in the next 1-2 weeks. Please follow up with Dr. [**First Name (STitle) 216**] as well in the next 1-2 weeks. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 7307**] to talk about the results of your study ([**Telephone/Fax (1) 107483**]) in the next 1-2 weeks. Please follow up with Dr. [**First Name (STitle) 216**] as well in the next 1-2 weeks.

Admission Date: [**2151-10-11**] Discharge Date: [**2151-10-15**] Date of Birth: [**2075-9-22**] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 1711**] Chief Complaint: pre-syncope, chest pain Major Surgical or Invasive Procedure: s/p dual chamber pacemaker placement History of Present Illness: 76 yo female with ESRD, DM2, HTN, hyperlipidemia, diastolic dysfunction, sarcoidosis presented to ED after waking up this am with sharp, pleuritic chest pain and dizziness. CP improved with sl ntg x2 but dizziness persisted. In ED, found to be hypotensive to sbp 70s initially. However, 1 hour later pt brady'ed to 30s with associated hypotension to 70's responsive to 0.5mg atropine followed by dopamine drip to 10 mcg. EP consulted with plan for possible pacer placement. . Pt was chest pain free in sinus brady with sbp to 200's on dopamine. Dopamine drip weaned down, pt coded and given atropine and dopamine. Seen by EP who felt it was sinus arrest. . ROS: She complained of abdominal pain with associated nausea but this is baseline for her. Otherwise no CP, SOB, f,c,v. . Past Medical History: ESRD on HD (MWF) IgA nephropathy DM2, diet controlled HTN hyperlipidemia HTN Persantine MIBI [**1-6**] with EF 59%, no defects Echo [**11-4**] with mild PAH, trivial MR/TR Sarcoidosis Diastolic dysfunction Gastritis Hiatal hernia Schatchi ring Anemia Glaucoma Diverticulosis Appendectomy Social History: Lives with husband and daughter denies tobacco and ETOH does IADL Family History: non-contributory Physical Exam: VS: t98.2, p56, 180/90, rr13, 100% 2Lnc Gen: pleasane, A&Ox3 HEENT: MM dry, poor dentition, JVD to tragus CVS: brady, regular, [**1-8**] sys murmur Lungs: diffuse scattered crackles with poor inspiratory effort Abd: sfot, ND, thin, NT Ext: no edema, 1+ DP bilaterally, shiny skin L UE fistula, R femoral line Neuro: face symmetric, moves all extremities Pertinent Results: [**2151-10-11**] 04:15AM WBC-4.5 RBC-3.51* HGB-10.4* HCT-32.8* MCV-93 MCH-29.7 MCHC-31.8 RDW-14.7 [**2151-10-11**] 04:15AM PLT COUNT-324 [**2151-10-11**] 04:15AM NEUTS-60.0 LYMPHS-28.1 MONOS-6.4 EOS-4.5* BASOS-1.1 [**2151-10-11**] 04:15AM PT-14.7* PTT-90.4* INR(PT)-1.4 . [**2151-10-11**] 04:15AM GLUCOSE-144* UREA N-41* CREAT-6.1*# SODIUM-135 POTASSIUM-4.8 CHLORIDE-91* TOTAL CO2-32* ANION GAP-17 [**2151-10-11**] 04:15AM CALCIUM-9.9 PHOSPHATE-3.7# MAGNESIUM-2.1 . [**2151-10-11**] 04:15AM CK(CPK)-23* [**2151-10-11**] 04:15AM CK-MB-NOT DONE cTropnT-0.14* [**2151-10-11**] 09:30AM CK(CPK)-25* [**2151-10-11**] 09:30AM cTropnT-0.13* [**2151-10-11**] 04:00PM CK(CPK)-46 [**2151-10-11**] 04:00PM CK-MB-NotDone cTropnT-0.17* . [**2151-10-11**] 09:30AM ALT(SGPT)-43* AST(SGOT)-65* ALK PHOS-299* TOT BILI-0.3 . [**2151-10-11**]: EKG Probable junctional escape rhythm, rate 34. Since the previous tracing of [**2151-9-11**] no P waves are seen. The rhythm appears to be a junctional escape rhythm. The Q-T interval is significantly prolonged. Non-specific ST-T wave abnormalities are noted. . [**2151-10-11**]: CXR Comparison made to prior study of [**2151-9-11**]. The heart is enlarged. There are prominent vascular markings. Linear atelectasis is present in the left retrocardiac region. . IMPRESSION: Findings consistent with mild congestive heart failure. . [**2151-10-11**]: TTE Conclusions: 1. The left atrium is mildly dilated. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 5. There is mild pulmonary artery systolic hypertension. 6. There is a trivial/physiologic pericardial effusion. 7. Compared with the findings of the prior study of [**2149-11-21**], there has been no significant change. . [**2151-10-12**]: CXR PA & LATERAL VIEWS OF THE CHEST: There has been interval placement of a dual- chamber pacemaker seen overlying the right upper chest with leads in satisfactory position. The heart is enlarged. There is slight upper zone vascular redistribution. No focal infiltrates identified. There is mild blunting of the posterior costophrenic angles consistent with small pleural effusions. . IMPRESSION: Interval placement of dual-lead pacemaker with leads in satisfactory position. Slight upper zone redistribution and small bilateral pleural effusions consistent with mild heart failure. . . Brief Hospital Course: 1. Rhythm: Pt admitted with symptomatic junctional bradycardia. Pt evaluated by EP who felt this was an indication for pacer placement. Pt had an urgent dual chamber pacemaker placed on HD1. Procedure was complicated by a small groin hematoma, which remained stable. Pacer site looked fine without signs of infection. Pt was given vanco for a couple of days after the procedure. . 2. CAD: Pt has history of multiple admissions for rule out MI without any history of MI. No prior cath. Had a MIBI in [**1-6**] which was unremarkable. Pt was continued on home aspirin. Given her multiple cardiac risk factors, she was started on bb, [**Last Name (un) **] (does not tolerate ACE), and statin. Would consider repeat ETT vs. cath. as an outpatient. Pt remained chest pain free and hemodynamically stable throughout hospitalization. . 3. Pump: Clinically, pt appeared euvolemic. Pt had mild CHF on CXR. Pt was continued on usual hemodialysis schedule which helped to remove volume. . 4. [**Name (NI) 5964**] Pt was seen by renal and continued on her usual hemodialysis schedule. Pt was continued on calcium carbonate. She was given epo during dialysis. Electrolytes remained within normal limits. . 5. Mental status/Home safety: Pt was A&O x 3 during the day. Pt would sundown in the evening, requiring a sitter. It was noted by daughter (who flew in from out of state) that here mother seemed more confused than baseline. We did not notice any acute change in her mental status during this hospitalization. Pt was evaluated by PT and OT who felt that pt was safe to return home with home PT. Pt lives with her husband and her daughter. 6. Gastritis: Pt was continue protonix. . 7. DM2: Diet controlled in house. Pt was put on SSI while in-house. . 8. Coagulopathy: Initially elevated PTT and INR. Most likely lab error, as repeat labs were normal. . 9.FEN: Pt was put on diabetic diet. Electrolytes were repleted as necessary to K 4.0 and Mg 2.0 . 10.FULL CODE Medications on Admission: calcium carbonate 1.25g tid colace [**Hospital1 **] norvasc qd folic acid qd protonix qd timolol eye drops cosopt eye drops asa 325 qd Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Junctional bradycardia s/p pacemaker placement ESRD Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: DEVICE CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2151-10-19**] 11:30 Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**] PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2151-10-21**] 9:45