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Admission Date: [**2115-8-6**] Discharge Date: [**2115-8-10**] Date of Birth: [**2069-11-17**] Sex: M Service: VSU HISTORY OF PRESENT ILLNESS: This is a 45-year-old male with a left leg plantar ischemic ulcer admitted to the vascular surgery service for a left femoral artery to anterior tibial artery bypass. The patient was recently admitted on [**2115-7-28**]. During his admission he underwent a left lower extremity angiogram which demonstrated occlusive disease in the left superficial femoral artery, popliteal artery, and tibial artery. These were reconstituted in the distal anterior tibial artery and peroneal artery. It was felt that a bypass operation would alleviate his ischemic symptoms. PAST MEDICAL HISTORY: Significant for diabetes mellitus type 1 for which the patient self-administers an insulin pump. Past medical history is also significant for a kidney and pancreas transplant in the past. PAST SURGICAL HISTORY: 1. Simultaneous pancreas/kidney transplant in [**2112**]. 2. Cadaveric pancreas transplant in [**2114-11-2**]. 3. Phlegmon evacuation in [**2114-12-3**] including washout, debridement, and closure in [**2114-12-3**]. 4. Fistula tract embolization in [**2115-3-5**]. MEDICATIONS: 1. Prograf 5 mg b.i.d. 2. Prednisone 5 mg daily. 3. CellCept [**Pager number **] mg b.i.d. 4. Aspirin 325 mg daily. 5. Celexa 40 mg daily. 6. Midodrine 10 mg daily. 7. Florinef 0.4 mg daily. 8. Pravachol 80 mg daily. 9. Folic acid 1 tablet daily. PHYSICAL EXAMINATION: The patient is a middle-aged male in no acute distress. Appears his stated age. He is awake and oriented x 3. The patient is afebrile. His vital signs are stable. Chest is clear. Heart is regular. Abdomen is soft, nontender, and nondistended. There is an old healing surgical scar with 2 approximately 2- x 2-cm granulating areas. Pulses: The patient has 2+ femoral pulses bilaterally. No palpable popliteal pulse on the left, and barely audible dorsalis pedis and posterior tibial pulses on Doppler exam on the left side. LABORATORY DATA ON ADMISSION: Complete blood count: The patient's hematocrit is 40.4 preoperatively. Electrolytes: Sodium of 140, potassium of 4.6, chloride of 112, bicarbonate of 21, BUN of 26, creatinine of 0.9, glucose of 163. Calcium of 8.9, phosphorous of 2.8, magnesium of 1.8. DICTATION ENDED [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 30134**] MEDQUIST36 D: [**2115-8-9**] 16:07:48 T: [**2115-8-9**] 20:51:38 Job#: [**Job Number 33999**]

Admission Date: [**2185-10-31**] Discharge Date: [**2185-11-8**] Date of Birth: [**2125-11-6**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 59 year old female patient who was struck by a motor vehicle. She presented to the Emergency Department as a trauma patient. Trauma workup revealed the presence of intracranial bleeding which was followed by the neurosurgical service. In addition to this injury, she had an anterior plateau fracture in the lower extremity which was addressed by my service. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Bilateral total hips. MEDICATIONS ON ADMISSION: 1. Norvasc. 2. Lopressor. 3. Plavix. 4. Zocor. 5. ______. HOSPITAL COURSE: After appropriate clearing was provided by neurosurgical service, the patient was taken to the operating room mainly for management of her anterior plateau fracture. The patient was cleared for surgery and went to the operating room on [**2185-11-3**]. She underwent an uncomplicated open reduction, internal fixation of a Schatzker 6 left anterior plateau fracture. She remained nonweight-bearing on the operated extremity with a hinge brace. She was anticoagulated with Lovenox for deep venous thrombosis prophylaxis and she was managed with 24 hours preoperative antibiotics. She was followed by the physical therapy service and was discharged to rehabilitation on [**2185-11-8**]. The patient had an uneventful hospital course and was to be followed two week postoperative for wound checks. MEDICATIONS ON DISCHARGE: 1. Percocet one to two q4hours p.r.n. 2. Preoperative regimen. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16347**] Dictated By:[**Last Name (NamePattern1) 16348**] MEDQUIST36 D: [**2186-2-16**] 08:27:53 T: [**2186-2-18**] 09:47:35 Job#: [**Job Number 98782**]

Admission Date: [**2144-10-1**] Discharge Date: [**2144-11-26**] Date of Birth: [**2144-10-1**] Sex: F Service: Neonatology HISTORY: Baby Girl [**Known lastname **] is a 1,540-gram product of a 30-5/7- weeks gestation born to a 30-year-old G2, P1 woman whose pregnancy was uncomplicated until several days prior to delivery when she presented with vaginal bleeding and abdominal cramping. She was treated with betamethasone and then transferred to [**Hospital1 69**]. At [**Hospital1 18**], tocolysis with magnesium sulfate was undertaken. Rupture of membranes and progression of labor on [**2144-10-1**] led to vaginal delivery. No sepsis risk factors were noted. Prenatal screens were complete and unremarkable: O- positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune. At delivery, the infant emerged vigorous. The skin was noted to be without lesions. HEENT exam was within normal limits. Bilateral red reflex. Lungs were clear, and she was breathing comfortably. Heart exam was normal S1, S2. Abdomen was benign. Neuro: Nonfocal and age appropriate. Genitalia: Normal female. Hips: Stable to exam. Extremities showed full range of motion. Anus: Patent and spine intact. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Baby Girl [**Known lastname **] was alternating between nasal cannula and room air until hospital day #25. Since that time, she has breathing room air comfortably. At this point, on [**11-26**] day of discharge, she has also completed a 5-day spell count for desaturations and bradycardia noted with feeds. Cardiovascularly: This infant is known to have an intermittent murmur. She has normal cardiac exam at this time with normal blood pressures and normal heart rate. FEN/GI: Discharge weight 2970 grams. Birth weight was 1540 grams. This infant was initially NPO on IV fluids and slowly advanced on p.o. PG feeds of breast milk 26 with Beneprotein. On day of life #45, which was [**2144-11-15**], she did achieve all p.o. feeds with breast milk 26 with Beneprotein, and she was also breast-feeding on top of that. GI: Pertinent diagnoses for this infant include hyperbilirubinemia. She did reach a peak bilirubin of 6.8/0.3 on hospital day #3 for which she underwent phototherapy x3 days. Her rebound bilirubin was 3.4/0.2 and this is now a resolved issue. At one point blood specks were noted in the stool. Her abdominal exam was normal and has remained normal. The mild hematochezia resolved. Infectious disease: Baby Girl [**Known lastname **] did undergo a 48-hour sepsis rule out at the time of her birth. All cultures are negative to date. Hematology: The most recent hematocrit obtained on [**11-9**] revealed a hematocrit of 36.9, reticulocyte count of 3.5. This infant is being discharged on p.o. vitamin E and p.o. iron as well. She does have a resolved issue of anemia for which she did have a hematology consult during her 1st month of life. She was seen by Dr. [**Last Name (STitle) **] of [**Hospital3 1810**]. Dr. [**Last Name (STitle) **] feels that the anemia was multifactorial and due to her prematurity and physiologic anemia. Neuro: This infant did have normal head ultrasounds on [**9-29**] and [**10-29**]. The most recent normal head ultrasound was performed on [**2144-11-25**]. Sensory: Audiology: Hearing screening was performed with automated auditory brainstem responses. Baby Girl [**Known lastname **] passed her hearing screen on [**2144-11-26**]. Ophthalmology: Her most recent eye exam was performed on [**2144-11-15**] and revealed mature eyes bilaterally, and it is recommended that she follow up in 9 months. Psychosocial: The [**Hospital1 18**] social worker is involved with this family. The contact social worker can be reached at [**Telephone/Fax (1) 55529**]. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: Home with parents. NAME OF PEDIATRICIAN: Dr. [**Last Name (STitle) 56527**], telephone number [**Telephone/Fax (1) 68493**] of [**Hospital 17566**] Pediatrics. CARE RECOMMENDATIONS: Feeds at discharge: Infant is to continue on her breast milk 24 with Beneprotein and breast- feeding ad-lib. Medications: Iron 0.5 cc once daily by mouth and multivitamins 1 cc once daily by mouth. Car seat position screening was passed on [**2144-10-25**]. State newborn screening status was normal on both [**10-22**] and [**2144-11-5**]. Immunizations received: Baby Girl [**Known lastname **] received her 1st hepatitis B vaccine on [**2144-10-31**]. She also received Synagis on [**2144-10-25**]. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 3 criteria: 1) born at less than 32 weeks; 2) born between 32-35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school- age siblings; or 3) with chronic lung disease. 2. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the 1st 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW-UP APPOINTMENTS: Baby Girl [**Known lastname **] is to followup with her primary care pediatrician, Dr. [**Last Name (STitle) 56527**] of [**Hospital 17566**] Pediatrics on [**2144-11-27**]. Again, the telephone number is [**Telephone/Fax (1) 52275**]. She will also have VNA come into the home on [**2144-11-30**]. She is also scheduled for early intervention via the Criterion Early Intervention Program, telephone number [**Telephone/Fax (1) 43148**]. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Hyperbilirubinemia resolved. 3. Presumed sepsis resolved. 4. Anemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**] Dictated By:[**Last Name (NamePattern1) 62404**] MEDQUIST36 D: [**2144-11-26**] 12:01:11 T: [**2144-11-26**] 12:44:44 Job#: [**Job Number 68494**]

Admission Date: [**2157-2-14**] Discharge Date: [**2157-5-26**] Date of Birth: [**2084-7-29**] Sex: M Service: BLUE [**Doctor First Name 147**]. HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old male with a complicated past surgical history of appendectomy, multiple exploratory laparotomies for small bowel obstruction and lysis of adhesions and multiple ventral hernia repairs, the latest of which resulted in enterocutaneous fistula through a [**Doctor Last Name 4726**]-Tex/Marlex composite mesh. The patient was transferred from a hospital in [**Location (un) 7498**] complaining of enterocutaneous fistulae. PAST MEDICAL HISTORY: Significant for: 1. Coronary artery disease. 2. Atrial fibrillation. 3. Atrial flutter. 4. Severe chronic obstructive pulmonary disease. PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile at 97.9 degrees. The pulse was irregularly irregular at a rate of 71. Blood pressure 110/65. Respiratory rate of 18. Saturating at 95% on three liters nasal cannula. The patient was alert and oriented times three. Cardiovascular examination was significant for irregularly irregular rate. S1, S2. The lung examination revealed hoarse breath sounds with transmitted sounds and end expiratory wheezing. The abdominal examination had positive bowel sounds. A Vac dressing applied over two enterocutaneous fistulae in the lower quadrants and a third enterocutaneous fistula through the mesh in the right abdominal area. LABORATORY ON ADMISSION: White count 8.3, hemoglobin and hematocrit of 9.7/29.6, platelet count 429,000. Serum chemistries: Sodium 134, potassium 4.7, chloride 96, CO2 30, BUN 25, creatinine 0.5, glucose 88. Calcium 8.3, magnesium 1.9, phosphorus 4.7. AST and ALT 10 and 9 respectively. Alk phos was 211. Total bilirubin was 0.5. Amylase and lipase were 108 and 38. Albumin was 2.2. PT/PTT were 13.5 and 27.1 respectively with an INR of 1.2. HOSPITAL COURSE: A vacuum dressing was put over the abdominal wound site with enterocutaneous fistulae and dressing was changed regularly by the surgical team. The patient was made NPO and then initially started on TPN via PICC line that was placed [**2157-2-14**]. G-tube was changed [**2-15**] and patient was slowed started on J-tube feeding at one-half strength starting at 20 cc/hr and slowly increased to a goal rate of 100 cc. The patient was restarted at two-thirds strength at 20 cc and rate increased incrementally. Nutritional consult follow up was done to assess caloric count and to make sure that the patient was receiving adequate nutrition. The week before surgery the patient underwent abdominal chest wall preparation with Hibiclens everyday and was optimized for Operating Room on [**2157-4-26**]. On [**4-26**] the patient underwent two part surgery. The first part was exploratory laparotomy with removal of [**Doctor Last Name 4726**]-Tex and Marlex mesh, lysis of adhesions, enterectomy, enterostomy and feeding jejunostomy. During this surgery, 18 inches of small bowel starting three feet distally to the ligament of Treitz were removed because the segment _________ anastomosis of enterocutaneous fistulae. This first part of the surgery was done by Dr. [**Last Name (STitle) 957**] and the Blue Surgery team. The second part of the surgery was done by Dr. [**Last Name (STitle) **] and the Plastic Surgery team and the procedures included bilateral muscle flap component separation, abdominal wall reconstruction with left pedicle tensor fascia lata fascia and split thickness skin graft of approximately 440 cm squared. The patient underwent the two part surgery without any complication and postoperatively was transferred to the Trauma Surgical Intensive Care Unit intubated in stable condition. On postoperative day one, the patient was extubated without complications. The patient was restarted on tube feeds at one-half strength of 20 cc and it was advanced in rate. During his stay in the Surgical Intensive Care Unit the patient received appropriate antibiotics and was transferred to the floor on postoperative day six without any complications. While on the floor, the surgical wound had the vacuum dressing changed every other day by the Plastics Service. On postoperative day seven, the patient tolerated clear liquids and was advanced to a regular diet as tolerated with discontinuation of TPN and tube feed cycled only during the night. By discharge, the surgical wound has granulated beautifully but still requires vacuum dressing change every other day. The patient is eating regular diet with Boost t.i.d. in addition to two-thirds strength tube feed at 90 cc/hour overnight. I will now review the rest of the hospital course stay by system and highlight the most relevant events. 1. Cardiovascular system: The patient has a significant past medical history of coronary artery disease and atrial fibrillation and atrial flutter with occasional PVCs. The patient was put on telemetry and cardiologist consulted. On [**2-16**], transthoracic echocardiogram was done which revealed a normal wall thickness with a left ventricular cavity and left ventricular ejection fraction of greater than or equal to 40%. The right ventricle was noted to be dilated by the systolic right ventricular function was within normal limits. The patient was started on intravenous Lopressor for rate control and monitored on telemetry. Postoperatively, the patient had supraventricular tachycardia and Cardiology Service was consulted again and this was controlled with intravenous Lopressor, digoxin and amiodarone. The patient was diuresed with intravenous Lasix and did well. Towards the end of his hospital stay, the patient had an episode of bradycardia and this was resolved with discontinuation of amiodarone and decrease in the dose of Lopressor. 2. Respiratory system: The patient has a history of long-standing severe chronic obstructive pulmonary disease. The patient was continued on his preadmission medications which included fluticasone 110 mcg two puffs inhaler b.i.d., albuterol nebulizer one treatment q. 3h. p.r.n. and Atrovent nebulizer treatment one treatment q. 4h. p.r.n. as well as albuterol one to two puffs inhaler q. 6h. p.r.n. The patient was also continued on his p.o. prednisone 5 mg q. day. During his prolonged hospital stay, the patient has always had productive sputum and had transmitted sounds on lung examinations. The patient underwent chest PT. Chest x-ray on [**4-12**] showed questionable right lower lobe infiltrate, however, clinically patient did not develop any signs or symptoms of pneumonia. 3. Renal system: The patient's creatinine value was 0.5 on admission and throughout his prolonged hospital stay the creatinine values stayed within normal limits. 4. Genitourinary system: The patient had Foley catheter in postoperatively to prevent contamination of his skin graft donor site with urine. The Foley catheter was eventually discontinued with healing skin graft donor site and patient received terazosin q. hs. The tip of the glans of the penis had a small ulceration with Foley catheter use. With appropriate skin care provided, the ulceration has improved and Foley catheter was discontinued. 5. Hematology: On [**4-11**] to 27th, the patient received two units of packed red blood cells with a decrease in hematocrit. During his operation on [**4-26**] the patient also received three units of packed red blood cells and three units of fresh frozen plasma. Since his operation, his hematocrit has been stable at a level of 30.2 +/- 1. The patient is currently on iron sulfate 325 mg b.i.d. 6. Endocrine system: The patient was covered with regular insulin sliding scale but did not require much dosage. During his prolonged hospital stay, the patient received steroids, parenteral and p.o. forms, because of his history of severe chronic obstructive pulmonary disease and currently remains on prednisone 5 mg p.o. q. day. 7. Infectious Disease: On [**3-3**] patient's Kefzol was changed to penicillin for presumed local cellulitis around the abdominal wound site, however, patient remained afebrile. On [**3-21**] gentamicin was added to penicillin for persistent cellulitis around the surgical wound site. Postoperatively, patient was started on gentamicin and levofloxacin. Vancomycin was added to his gentamicin and levofloxacin when the tissue culture from [**4-26**] came back with Proteus, Pseudomonas and methicillin-resistant Staphylococcus aureus. Catheter tip culture from [**5-1**] also came back positive for MRSA and patient was continued on vancomycin, levofloxacin and gentamicin. On [**5-4**] the urine culture grew yeast, more than 100,000 colonies, and patient was started on fluconazole 400 mg. Subsequent urine culture was negative times two and fluconazole was discontinued. Levofloxacin, vancomycin, gentamicin and fluconazole are now currently discontinued. Patient is now only on Keflex 500 mg p.o. q.i.d. Erythema and induration around the G-tube site was noted and was treated with Neosporin topical antibiotic ointment and Betadine with dressing changes. During the early part of the patient's admission, the patient was also found to have an area that looked like a fungal infection over his gluteal regions and has been getting clotrimazole cream applied two times a day to the affected area. 8. Pain management: The patient was initially managed kept on morphine PCA and was switched over to p.o. morphine p.r.n. Neurontin p.o. was added because of patient's complaining of burning and cramping pain. Postoperatively, patient was initially sedated with propofol while in Surgical Intensive Care Unit. When he was awake, patient was using morphine sulfate PCA. On discharge to the floor patient received Roxicet 10 cc p.o. q. 4h. with morphine 2 mg IV q. 4h. p.r.n. for breakthrough pain. During Vac dressing changes, patient was premedicated with morphine 4 mg to 12 mg IV q.o.d. as needed in increments of 2 mg IV. 9. Neurology and Psychiatry: Patient remained alert and oriented times three without mental status changes. The patient is currently on Celexa and Paxil. Toward the end of his prolonged hospital stay, the patient complained of some moderate tremors of the upper and lower extremities and was evaluated by the Neurology consulting service. It was recommended that the patient discontinue Neurontin and mirtazapine and patient was started on quinine sulfate 300 mg p.o. t.i.d. for muscle relaxation. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: Discharged to [**Hospital 1514**] [**Hospital **] Hospital. DISCHARGE DIAGNOSES: 1. Enterocutaneous fistulae status post exploratory laparotomy, removal of [**Doctor Last Name 4726**]-Tex and Marlex mesh, lysis of adhesions, enterectomy, enterostomy and feeding jejunostomy, bilateral muscle flap component separation, abdominal wall reconstruction with left pedicle tensor fascia lata and split thickness skin graft. 2. Coronary artery disease. 3. Severe chronic obstructive pulmonary disease. 4. Atrial fibrillation. 5. Atrial flutter. DISCHARGE MEDICATIONS: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Last Name (NamePattern1) 10201**] MEDQUIST36 D: [**2157-5-25**] 23:09 T: [**2157-5-25**] 20:42 JOB#: [**Job Number 48834**]

Admission Date: [**2109-2-14**] Discharge Date: [**2109-2-20**] Service: CCU CHIEF COMPLAINT: Chest pain. HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old male with hypertension and hypothyroidism who presents with fatigue and dyspnea on exertion after taking down his with rest occurring the day prior to admission. The patient denied any nausea, vomiting, chest pain, or diaphoresis associated with these symptoms. There is no history of orthopnea, paroxysmal nocturnal dyspnea, or pedal edema. The patient states that he has never had chest pain before but has had what he calls an ache in his chest along with headache and abdominal cramps as part of his polymyalgia PAST MEDICAL HISTORY: 1. Polymyalgia rheumatica, on steroids for the last seven years. 2. Hypothyroidism. 3. Hypertension. 4. Macular degeneration. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Aspirin. 2. Vasotec 10 mg p.o. q.d. 3. Zantac 150 mg p.o. b.i.d. 4. Atenolol 25 mg p.o. q.d. 5. Levoxyl 50 micrograms p.o. q.d. 6. Prednisone 10 mg p.o. q.d. for the last seven years. SOCIAL HISTORY: Tobacco, quit 35 years ago, 40 pack year history. No alcohol use. FAMILY HISTORY: Daughter with lung CA. No history of CAD in any immediate family members. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.3, blood pressure 150/80, pulse 76, respiratory rate 24, 02 saturation 96% on room air. HEENT: The pupils were equal, round, and reactive to light and accommodation. The mucous membranes were moist. The oropharynx was clear. There was no jugular venous distention. Cardiovascular: Regular rate and rhythm, normal S1, S2. The lungs were clear to auscultation bilaterally. Neck: Supple. No JVD, no lymphadenopathy. No carotid bruits. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. Extremities: No cyanosis, clubbing, 2+ DP pulses. No femoral bruits. There was 1+ pitting edema to the knees bilaterally. There was diffuse bruising on the bilateral upper extremities. LABORATORY DATA ON ADMISSION: White blood count 13.8, hematocrit 40.0, platelets 280,000. Sodium 144, potassium 4.4, chloride 105, bicarbonate 25, BUN 31, creatinine 1.3. INR 1.0, PTT 21.4, PT 12.1, ESR 13. CK number one 645 with an MB of 109. Troponin greater than 50. Lipid panel: Cholesterol total of 207, LDL 116, triglycerides 111, HDL 69. Chest x-ray revealed no acute cardiopulmonary process. EKG revealed a normal sinus rhythm at 55, LAD, increased QT intervals, 0.[**Street Address(2) 1755**] depression in I and aVL, [**Street Address(2) 4793**] depression in V4 through V6 with T wave inversions in V2 and V3. IMPRESSION: The patient is a [**Age over 90 **]-year-old male with hypertension, history of tobacco use who presents with anterolateral non ST elevation myocardial infarction. HOSPITAL COURSE: 1. CARDIOVASCULAR: The patient was initially started on heparin and nitroglycerin drips, metoprolol 25 mg p.o. t.i.d., continued on ACE inhibitor, aspirin, statin, and was taken to the cardiac catheterization laboratory on [**2109-2-15**]. At catheterization, he was found to have severe three vessel disease which was discussed with the Cardiothoracic Surgery Team and as the patient was felt to be a poor surgical candidate given his chronic steroid use as well as his age, it was felt that medical maximization would be pursued as well as potentially intervening on the coronary lesions. During the interventional portion of the catheterization, the LAD was stented with 0% residual stenosis. There was a dissection in the process of catheterization and the left main dissected into the ascending aorta. This was corrected with a stent placed in the left main artery with 20% residual stenosis. Other findings on catheterization included an 80% left circumflex lesion at the origin and proximal disease. The right coronary was 79-90% lesion with collaterals from the LAD. During catheterization, the patient was becoming significantly more agitated and was given a heavy amount of sedation and intubated for airway protection. The patient underwent a transesophageal echocardiogram to determine the extent of the dissection of the aorta. TE revealed a dissection in the proximal ascending aorta which did not extend beyond the coronary cusp and the patient was admitted to the Cardiac Care Unit for further intensive monitoring. On transfer to the CCU, the patient was noted to be becoming more hypotensive and an arterial line was placed for closer monitoring of blood pressure and a central line was placed in the left subclavian vein after multiple attempts at central access in the right IJ and right subclavian veins. The patient was briefly started on dopamine for pressor support which was discontinued after only being on it for several minutes. The patient was noted to have a significant amount of hematemesis and the hypotension was attributed largely to blood loss as well as sedation effect. There was possibly also a contributing factor of chronic steroid use with relative adrenal insufficiency. From a coronary standpoint, there was no further evidence of ischemia or further hypotension the following morning and the patient was extubated without complications and started on a beta blocker as well as an ACE inhibitor. TEE had demonstrated significant LV dysfunction and the patient was noted to be wet on lung examination. He was started on increasing doses of ACE inhibitor and was diuresed with one dose of Lasix. From a rhythm standpoint, the patient was noted to have one episode of nonsustained ventricular tachycardia with four beats with no other significant ectopy and will be continued on a beta blocker as an outpatient with no further workup as far as an EP study given the patient's age and chronic steroid use. 2. GASTROINTESTINAL: The patient was noted to have hematemesis post TEE which was felt to be likely due to traumatic transesophageal echocardiogram. He was lavaged with an OG tube which showed clearing after only 200-300 cc of lavaged fluid. While on suction, the lavage fluid turned pink and then began to have blood in it again. He was lavaged with 50 cc and it again cleared. As a result, the patient was transfused 2 units of packed red blood cells and had a stable hematocrit after this point. The Gastroenterology Service was consulted and agreed that likely this was a bleed in the setting of the transesophageal echocardiogram. The OG tube was recommended to be discontinued and hematocrits were to be followed as well as hemodynamics. There was no further evidence of bleeding either by hematocrit or by hemodynamic monitoring and the patient continues to be stable at the time of discharge. 3. ENDOCRINE: The patient has a history of chronic steroid use and was given stress-dose steroids while in the Intensive Care Unit which were rapidly tapered from 100 mg t.i.d. of hydrocortisone to 50 mg of prednisone to 30 mg of prednisone and now back to his 10 mg outpatient dose of prednisone with no evidence from a pressure standpoint of adrenal insufficiency and no evidence of electrolyte abnormalities as the result of the steroids. 4. PLASTICS: While the patient was agitated, he was briefly restrained when trying to remove his endotracheal tube and in the process the skin on his hand peeled due to easy friability from chronic steroid use. Plastic Surgery was consulted and sutured the laceration on the right hand. They recommended continuing dressing changes q.d. which will be done by the visiting nurse. The patient is to follow-up in the Hand Clinic in two weeks for suture removal and wound check. The number for the [**Hospital 3595**] Clinic was given to the patient. This was discussed with his family who will set up an appointment in two weeks for the hand clinic. 5. PULMONARY: The patient was briefly intubated for airway protection due to agitation and sedation. He was extubated the following morning after checking his settings on pressure support and having adequate ventilation and oxygenation. The tube was removed. The patient was oxygenating well on his own postextubation. 6. INFECTIOUS DISEASE: The patient was noted to have a urinary tract infection likely due to Foley placement and was treated with a seven day course of levofloxacin which he is to continue as an outpatient for the next three days post discharge. DISCHARGE DIAGNOSIS: 1. Acute myocardial infarction. 2. Status post left main dissection. 3. Status post left main and left anterior descending artery stenting. 4. Status post upper gastrointestinal bleed. 5. Hypothyroidism. 6. Polymyalgia rheumatica. DISCHARGE CONDITION: Good. The patient was seen by Physical Therapy and was felt to be walking well on his own and will be continued to be followed as an outpatient with home PT as well as visiting nursing for dressing changes and medications. The patient is to follow-up with the Hand Clinic in two weeks as well as his primary care physician, [**Last Name (NamePattern4) **]. ....................< in the next week to two weeks. DISCHARGE MEDICATIONS: 1. Toprol XL 100 mg p.o. q.d. 2. Imdur 30 mg p.o. q.d. 3. Lisinopril 10 mg p.o. q.d. 4. Aspirin 325 mg p.o. q.d. 5. Prednisone 10 mg p.o. q.d. 6. Plavix 75 mg p.o. q.d. 7. Lipitor 20 mg p.o. q.d. 8. Synthroid 50 micrograms p.o. q.d. 9. Levofloxacin 250 mg p.o. q.d. for the next three days. 10. Zantac 150 mg p.o. b.i.d. 11. Quinine 260 mg p.o. q.d. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Name8 (MD) 4630**] MEDQUIST36 D: [**2109-2-20**] 02:17 T: [**2109-2-20**] 14:22 JOB#: [**Job Number 93705**]

Admission Date: [**2175-11-13**] Discharge Date: [**2175-11-17**] Date of Birth: [**2115-3-26**] Sex: M 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: Cardiac catheterization Cutting balloon angioplasty with drug eluting stent placement. History of Present Illness: Pt is a 60 year old male with hx of HTN, hypercholesterolemia and smoking history who presented to OSH with SSCP radiating to the left arm. He was found to have STE V1-V5. He was ASA, heparin, integrillin, plavix and morphine. Then, he was flown over here and underwent emergent cath. . Cath showed 100% mid LAD s/p DES and 70% ostial D1 treated with cutting balloon angioplasty (complicated by grade B dissection) RA 15 RV 49/16 PA: 53/29 PCWP: 29 CO: 4.5 CI: 1.9 Past Medical History: HTN Hypercholesterolemia BPH PTSD Social History: - 20-40 pack year hx - quit in [**2160**] - 1-2 drinks/night - no illicit drug use - separated from wife Family History: NC Physical Exam: T: 96.7 HR: 71 sinus rhythm BP: 133/80 PA: 36/20 RR: 16 O2 sat: 99% on 3L NC Gen: comfortable in supine pos HEENT: OP clear Neck: thick - difficult to assess JVP CV: RRR, distant heart sounds Lungs: crackles L anterolateral Abd: +BS Soft, NT obese Ext: wnl Neuro: AAO x3 . ECG (OSH) : NSR @ 74 bpm; nl axis/intervals, q wave in III, aVF, STE V1-V5, No reciprocal ST depressions. persistent STE v1-v5 here Pertinent Results: [**2175-11-13**]: Cath Results: - R dominant circulation - 100% occlusion of mid LAD w/ thrombus - 70% occlusion of D1 proximal to LAD occlusion - no collaterals visualized - underwent cutting balloon angioplasty -> grade B1 dissection -> monitored and did not find progressive dissection of the lumen - received drug eluting stent . [**2175-11-14**]: ECHO - EF 35% - The left atrium is mildly dilated - There is mild to moderate regional left ventricular systolic dysfunction with severe hypo/akinesis of the distal half of the anterior and anteroseptal walls. - The distal inferior wall is also severely hypokinetic. The apex is mildly dyskinetic, but not aneurysmal.. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. The aortic root is mildly dilated . [**2175-11-13**] 09:40PM BLOOD WBC-14.6* RBC-4.47* Hgb-14.5 Hct-38.6* MCV-86 MCH-32.5* MCHC-37.7* RDW-14.0 Plt Ct-135* [**2175-11-16**] 07:10AM BLOOD WBC-10.5 RBC-4.19* Hgb-13.7* Hct-36.9* MCV-88 MCH-32.7* MCHC-37.1* RDW-14.0 Plt Ct-128* [**2175-11-14**] 05:18AM BLOOD PT-12.8 PTT-20.5* INR(PT)-1.1 [**2175-11-15**] 04:33AM BLOOD PT-18.2* PTT-44.5* INR(PT)-2.3 [**2175-11-17**] 07:00AM BLOOD PT-15.0* PTT-99.4* INR(PT)-1.5 [**2175-11-13**] 09:40PM BLOOD Glucose-115* UreaN-25* Creat-1.1 Na-141 K-3.4 Cl-99 HCO3-26 AnGap-19 [**2175-11-16**] 07:10AM BLOOD Glucose-97 UreaN-23* Creat-1.3* Na-141 K-4.1 Cl-101 HCO3-27 AnGap-17 [**2175-11-13**] 09:40PM BLOOD CK(CPK)-5699* [**2175-11-14**] 05:18AM BLOOD CK(CPK)-3233* [**2175-11-15**] 04:33AM BLOOD CK(CPK)-695* [**2175-11-13**] 09:40PM BLOOD CK-MB->500 cTropnT-24.28* [**2175-11-14**] 05:18AM BLOOD CK-MB-304* MB Indx-9.4* cTropnT-12.93* [**2175-11-13**] 09:40PM BLOOD Mg-1.7 [**2175-11-16**] 07:10AM BLOOD Calcium-9.6 Phos-2.9 Mg-2.0 [**2175-11-14**] 05:18AM BLOOD Triglyc-274* HDL-57 CHOL/HD-3.4 LDLcalc-82 [**2175-11-14**] 05:35AM BLOOD Hgb-13.8* calcHCT-41 O2 Sat-69 Brief Hospital Course: A/P: 60 yo male with anterior wall MI s/p cutting balloon angioplasty with DES . ## Cardiac: Patient came in from OSH with STE in V1-V5; Q wave in III and AVF. His cath results revealed R dominant circulation with 100% occlusion of mid LAD w/ thrombus and 70% occlusion of D1 proximal to LAD occlusion. There were no collaterals visualized. He underwent cutting balloon angioplasty -> grade B1 dissection -> monitored and did not find progressive dissection of the lumen - received drug eluting stent. . - on ASA/Plavix/Statin, captopril 25 TID -> changed to lisinopril 10 on d/c - [**11-15**] started metoprolol 12.5 TID and titrated up on discharge per BP control SBP< 120. - CK trended down from 5700 on [**11-13**] to 650 on [**11-15**]. - Patient was chest pain free at time of discharge . AFter his procedure, his ECHO demostrated - EF 35% - L ventricular hypokinesis - CI: 1.93L/min/m2 and CO: 4.52 L/min during cath -> though his CI improved to 2.4 on floor - PCWP mean: 29, RA: 15mmHg, PA: 29/15 . - He remained mostly in sinus rhythm on floor. He had a few PVCs and a 4 beat run of NSVT. . - after the procedure, he was maintained on IV heparin while bridging to coumadin. He was on a PPI in house. Discharged on 5mg warfarin. INRs to be followed at the VA. . Other: - he was seen by PT before discharge and cleared to go. He was instructed to stay away from a heavy workload and to refrain from excessive stresses such as shoveling snow. - do not change statin to atorvastatin as this is not covered by the VA Medications on Admission: ASA 325 Dilt 360mg daily simvastatin 20mg daily omeprazole 20 mg daily HCTZ 25mg daily Nefazodone 100mg daily Sertraline 100mg daily Buspirone 10mg daily TRazodone 100mg daily Viagra APAP PRN Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*180 Tablet(s)* Refills:*2* 4. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*90 Tablet(s)* Refills:*2* 5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 6. Buspirone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-11**] Tablet, Sublinguals Sublingual PRN (as needed). Disp:*30 Tablet, Sublingual(s)* Refills:*2* 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*90 Tablet(s)* Refills:*2* 9. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 11. Nefazodone 100 mg Tablet Sig: One (1) Tablet PO once a day: Continue home dose and frequency. 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: Please resume home dose. 13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day as needed for water retention. Discharge Disposition: Home Discharge Diagnosis: Anterior wall myocardial infarction s/p cutting balloon angioplasty with drug eluting stent placement in the Left anterior descending artery Discharge Condition: AAOx3 Chest pain free Ambulating Discharge Instructions: During this admission, we found that you had a myocardial infarction (heart attack) that involved the front of your heart. This was due to "clogged arteries." The main clogged artery was opened and a stent was placed there. For this reason, Plavix(clopidogrel) has been added to your medication regimen. It is very important that you remain on this medication to prevent the stent from getting blocked. . Please adhere to the medication regimen that we have outlined for you. - please stop taking the diltiazem at this time. - please stop taking the viagra at this time . - we have started you on 5 new medications: - Plavix(clopidogrel) - to prevent your stent from clogging - Warfarin(coumadin) - a blood thinner - Toprol XL(metoprolol) - for blood pressure control - Lisinopril - for blood pressure control - Lovenox(enoxaparin) - for 7 days - a blood thinner . - Please only take the medications that we have listed on the next page. And stop the ones that we have told you to. . . You need to be followed by a cardiologist for this recent heart attack. This should ideally be done within the next [**2-10**] weeks. Please have your primary care provider refer you to a cardiologist at the [**Hospital1 1474**] VA or another location which is convenient to you. . ****You need to be seen on Monday at the VA to have your blood work checked. You need to have your INR checked. If this number is >2.0, then you can stop taking the Lovenox. Please call the VA on [**2175-11-17**] and explain to them that you have had a major heart attack and that you need to have your blood checked.**** Followup Instructions: You need to schedule an appointment with a cardiologist within the next 3-4 weeks. . You need to schedule an appointment with your primary care doctor. Completed by:[**2176-1-14**]

Admission Date: [**2132-10-23**] Discharge Date: [**2132-10-28**] Date of Birth: [**2062-12-26**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: ICH Major Surgical or Invasive Procedure: None History of Present Illness: 69 year-old man from [**Location (un) 3844**] with a history of atrial fibrillation on warfarin and hypertension presents as a transfer from [**Hospital3 **] for further management of a non-traumatic right basal ganglionic hemorrhage. The patient was in his usual state of health until this evening, when he was sitting at a dinner party and noted his left hand to be "falling asleep." All of the sudden, his left face felt "like novocaine" and his left foot was "useless." His left face was drooped and his speech was slurred, according to family who had observed the event. He seemed to be leaning to the left. 911 was called. The patient states that he had difficulty moving or feeling his left side by the time EMS arrived. He was brought to [**Hospital3 25150**]. On arrival to [**Hospital1 **], his blood pressure was noted to be 204/110. He was noted to be moderately dysarthric, with left facial weakness. He had a "moderate" left hemiparesis. Reflexes were apparently "normal" and no sensory deficit was described. He was noted to have abnormal finger to nose testing, though laterality was not specified. INR was 3.15. Head CT at 8:25 pm revealed a 10 x 13 mm right basal ganglionic hemorrhage without shift or hydrocephalus. He was given 10 mg IV x 1 and started on a nitroprusside drip, titrated to a systolic blood pressure of 160. The patient was transferred to [**Hospital1 18**] by med-flight for further evaluation. Here he was loaded with 1 g phenytoin and ordered for 2 units FFP. Neurology was consulted. A repeat head CT was performed here at 10:40 pm was stable by report. Review of Systems: Other than described above, the patient denies fevers, chills, headache, nausea, vomiting, chest pain, dyspnea, vision change, dysphagia, language difficulties or incomprehension, shaking/jerking, or incontinence. Past Medical History: -Atrial fibrillation, on warfarin for 20 years. No history of hemorrhage -Hypertension -Dyslipidemia -BPH -Melanoma of the right ear, s/p multiple excisions -Basal cell carcinoma -Bilateral cataracts s/p repair on the left in [**2130**] and the right in [**2131**] -s/p cholecystectomy -s/p hernia repair Social History: He is a retired proofreader, who lives in [**Location **], New [**Location (un) **] with his wife. Smoked 1 ppd for over 30 years, but quit 24 years ago. He drinks alcohol only socially, and had one drink this evening at the party. He denies a history of drug use. Family History: No history or stroke or ICH. Father and mother with heart disease. Nephew with diabetes. Physical Exam: Vitals: T 97.7 F BP 163/87 P 90 RR 18 SaO2 100 RA General: NAD, well-nourished HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx Neck: no nuchal rigidity, no bruits Lungs: clear to auscultation, but decreased throughout CV: irregularly irregular rhythm, no MMRG Abdomen: soft, non-tender, non-distended, bowel sounds present, cholecystectomy scar noted Ext: warm, no edema, pedal pulses appreciated Skin: no rashes Neurologic Examination: Mental Status: Awake and alert, attentive, fully oriented, able to relay history, cooperative with exam, normal affect Language: fluent, mildly dysarthric speech, no paraphasic errors, naming, comprehension, repetition intact; [**Location (un) 1131**] intact Calculation: can determine 7 quarters in $1.75 Fund of knowledge: normal Memory: registration: [**1-21**] items, recall [**12-23**] items at 3 minutes, [**1-21**] with clue No evidence of apraxia or neglect Cranial Nerves: Fundoscopy was limited, though no papilledema appreciated; no clear field cut could be demonstrated. Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Extraocular movements intact, no nystagmus. Facial sensation intact bilaterally. Facial movement normal and symmetric. Hearing intact to finger rub bilaterally. Palate elevates midline. Tongue protrudes midline, no fasciculations. Trapezii full strength bilaterally. Motor: Normal bulk and increased tone in the legs. He has a left hemiparesis in an UMN distribution with 4/5 strength in the deltoids, triceps, wrist and finger extensors in the arms, as well as the IP, hamstring, and tibialis anterior in the leg. The right side is full. Sensation: Reduced light touch, pin prick, and temperature (cold) to the left arm and leg. Vibration intact throughout, though he does demonstrate reduced proprioception in the second digit of the left hand. Reflexes: B T Br Pa Pl Right 2 2 2 3 1 Left 2 2 2 3 1 Toes were upgoing on the left and downgoing on the right. Coordination: + intention tremor bilaterally, there is left-sided ataxia on FNF and HKS, likely related to his weakness. Gait: Patient was unable even to sit up at to the side of the bed with assistance. Pertinent Results: [**2132-10-22**] 10:20PM BLOOD WBC-9.4 RBC-4.37* Hgb-13.2* Hct-37.8* MCV-87 MCH-30.2 MCHC-34.9 RDW-13.3 Plt Ct-389 [**2132-10-22**] 10:20PM BLOOD Neuts-65.0 Lymphs-25.1 Monos-6.1 Eos-2.9 Baso-0.9 [**2132-10-22**] 10:20PM BLOOD PT-26.1* PTT-35.8* INR(PT)-2.6* [**2132-10-22**] 10:20PM BLOOD Glucose-112* UreaN-21* Creat-1.1 Na-142 K-4.1 Cl-106 HCO3-27 AnGap-13 [**2132-10-23**] 04:40AM BLOOD ALT-20 AST-23 LD(LDH)-189 CK(CPK)-156 AlkPhos-79 TotBili-0.7 [**2132-10-22**] 10:20PM BLOOD CK(CPK)-125 [**2132-10-23**] 12:31PM BLOOD CK(CPK)-125 [**2132-10-22**] 10:20PM BLOOD CK-MB-4 cTropnT-<0.01 [**2132-10-23**] 04:40AM BLOOD CK-MB-4 cTropnT-<0.01 [**2132-10-23**] 12:31PM BLOOD CK-MB-4 cTropnT-0.02* [**2132-10-23**] 04:40AM BLOOD Albumin-4.7 Calcium-9.4 Phos-3.2 Mg-2.1 Cholest-204* [**2132-10-23**] 04:40AM BLOOD %HbA1c-5.8 [**2132-10-23**] 04:40AM BLOOD Triglyc-157* HDL-43 CHOL/HD-4.7 LDLcalc-130* [**2132-10-23**] 04:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2132-10-23**] 04:37AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 [**2132-10-23**] 04:37AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2132-10-23**] 04:37AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG NCHCT - 14 x 10-mm right putaminal, capsular, and thalamic hemorrhage. Sinus disease as described above. EKG - Atrial fibrillation. Non-specific inferolateral T wave flattening. Poor R wave progression. Cannot exclude prior anterior myocardial infarction. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 70 0 80 388/405 0 -15 -73 PCXR - No evidence of CHF or pneumonia. MRI/MRA brain - Small area of hemorrhage in the right thalamus. No definite underlying lesion identified. No evidence of acute infarct, midline shift or hydrocephalus. Absent flow signal in the distal left vertebral artery could be due to occlusion in the neck. Otherwise, normal MRA of the head. No abnormal vascular structures are seen to indicate arteriovenous malformation around the hemorrhage. Brief Hospital Course: Patient admited to NICU for blood pressure control. Most likely etiology of the right basal ganglia bleed was hypertension. Being on Coumadin may have worsened the bleed, but it does not appear to have been the primary etiology. He was subsequently transferred to the floor after repeat CT brain imaging showed stable bleed in the right basal ganglia. Patient had a mechanical fall hitting his head and sustaining a laceration which was closed by plastics on [**2132-10-24**]. Repeat NCHCT was unchanged. He had runs of atrial fibrillation with rapid ventricular response. Metoprolol was started with improvement in rate control and blood pressure values. Medications on Admission: -Warfarin 2.5 mg on 5 days of the week, 1.25 mg on Wednesday and Saturday -Verapamil SR 180 mg daily -Simvastatin 40 mg daily -Lisinopril 20 mg daily -Omeprazole 20 mg daily -Avodart 0.5 mg daily -Multivitamin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for fever or pain. 3. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale units Injection ASDIR (AS DIRECTED). 4. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 5. Simvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 17921**] Center - [**Location (un) 5450**], NH Discharge Diagnosis: primary diagnosis: right thalamic hemorrhage hypertension atrial fibrillation with rapid ventricular response supratherapeutic INR left eyebrow laceration secondary diagnosis: dyslipidemia benign prostatic hypertrophy melanoma of the right ear status post multiple excisions basal cell carcinoma bilateral cataracts status post repair left in [**2130**] and right in [**2131**] status post cholecystectomy status post hernia repair Discharge Condition: Left eyebrow laceration, left periorbital ecchymosis, left hemisensory loss Discharge Instructions: You have had a hemorrhagic stroke (right thalamus) likely due to hypertension. Your INR was supratherapeutic on presentation to the hospital. Due to the bleed, your warfarin was held and should be held until [**2132-11-6**] (at least 2 weeks from onset of bleed). You have been started on Metoprolol for improved rate control of your atrial fibrillation. You were also continued on Verapamil SR 180mg QD. Lisinopril 20mg (your home dose) was continued. You sustained a left eyebrow laceration and sutures were placed for closure. The sutures should be removed on [**2132-10-30**]. Dressings should be changed twice daily. Please take medications as prescribed. Please keep your follow-up appointments. If you have any worsening or worrying symptoms, please call your PCP or return to the emergency room. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 81364**], [**Name Initial (NameIs) **].D. Phone: [**Telephone/Fax (1) 63696**] Please follow-up with your PCP [**Name Initial (PRE) 176**] 2 weeks of discharge. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone: [**Telephone/Fax (1) 2574**] Please follow-up within 1-2 months of discharge. Completed by:[**2132-10-28**]

Admission Date: [**2149-2-20**] Discharge Date: [**2149-2-25**] Date of Birth: [**2093-8-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: DOE x 2 months Major Surgical or Invasive Procedure: [**2-20**] CABG x 3 (LIMA->LAD, SVG->OM, SVG->Diag), MVRepair (28mm band) History of Present Illness: 55 y/o with known CAD, cypher stent to LCx [**3-3**], now with recurrent angina. Past Medical History: CAD s/p LCx cypher stent h/o rheumatic fever HTN lipids Physical Exam: NAD HR 70, B/P 128/68 Admission exam unremarkable. Pertinent Results: [**2149-2-25**] 06:10AM BLOOD Hct-25.4* [**2149-2-24**] 06:05AM BLOOD WBC-5.6 RBC-3.48* Hgb-7.9* Hct-24.0* MCV-69* MCH-22.7* MCHC-32.9 RDW-18.3* Plt Ct-144* [**2149-2-24**] 06:05AM BLOOD Plt Ct-144* [**2149-2-23**] 05:16AM BLOOD PT-13.4* PTT-27.0 INR(PT)-1.2* [**2149-2-25**] 06:10AM BLOOD K-4.2 [**2149-2-24**] 06:05AM BLOOD Glucose-113* UreaN-13 Creat-0.8 Na-135 K-3.8 Cl-99 HCO3-30 AnGap-10 Brief Hospital Course: He was taken to the operating room on [**2149-2-20**] where he underwent a CABG x 3 and MVRepair. He was transferred to the SICU in critical but stable condition. He was extubated later that same day. He was found to be in SVT and started on an esmolol drip. His SVT resolved and he was weaned from his vasoactive drips. He was transferred to the floor on POD #3. He continued to do well post operatively and was ready for discharge home on POD #5. Medications on Admission: toprol, quinapril, HCTZ, lipitor, plavix, tricor, asa Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. 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* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. 10. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD s/p LCx cypher stent h/o rheumatic fever HTN lipids Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pound sin one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds in one day or five in one week. Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) 14522**] 2 weeks Completed by:[**2149-2-25**]

Admission Date: [**2116-4-29**] Discharge Date: [**2116-5-13**] Date of Birth: [**2052-9-4**] Sex: F Service: ENT HISTORY OF PRESENT ILLNESS: The patient was admitted with a history of laryngeal squamous cell carcinoma status post supraglottic laryngectomy in [**2107**]; no chemotherapy or radiation therapy at that time. The patient subsequently had a right neck mass which was a recurrence in [**2114**]. At that time, she had chemotherapy with Cisplatin and 5FU plus radiation therapy and had a tracheostomy done at that time in [**2114**]. The Tracheostomy was then closed later in [**2114**]. The patient presented recently to [**Hospital 26260**] Hospital on [**2116-4-25**], to the Emergency Department in respiratory distress and was intubated orally with laryngoscope and much difficulty. CT of the neck was consistent with recurrent disease. There was an attempt in the Operating Room on [**2116-4-28**], to extubate with fiberoptic evaluation, which revealed however, that she had edematous AE fold, 1-2 mm airway, poor vocal cord abduction, and the patient had stridors after extubation and was then reintubated at that time and transferred to the [**Hospital1 **] Hospital for further management. The patient presented on [**2116-4-29**], in the evening, to have her tracheostomy redone tomorrow. PAST MEDICAL HISTORY: As above, as well as alcohol abuse, intravenous drug abuse, hypothyroidism, depressions, sleep apnea, hepatitis C, herpes zoster. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Colace, Albuterol, Atrovent, Solu-Medrol 40 mg b.i.d., Prevacid 30 mg b.i.d., Synthroid 50 mcg q.d., Remeron 15 mg q.h. p.r.n., Ativan p.r.n., Vancomycin. SOCIAL HISTORY: The patient denied alcohol or intravenous drug abuse currently, as well as tobacco. PHYSICAL EXAMINATION: General: On presentation, the patient was awake, was communicative, but intubated. She was communicative via writing on a pad. Neck: Exam revealed old scars from post radiation therapy treatment changes. The larynx was fairly mobile. Lungs: She had decreased breath sounds of the left lung base. Extremities: There was trace edema bilaterally of the lower extremities. ASSESSMENT AND PLAN: This was a 52-year-old woman with recurrent laryngeal cancer with airway obstruction secondary to her second recurrence of the disease. She was admitted under Dr. [**First Name (STitle) **] to the Surgical Intensive Care Unit with a plan for tracheostomy. The patient was taken to the Operating Room on [**2116-4-30**]. HOSPITAL COURSE: She underwent tracheostomy and rigid laryngoscopy. Findings were that of a small anterior mass, anterior to the left vocal cord. Biopsy was sent to Pathology. She was then returned to the SICU. The patient had her vent-trach weaned and was then transferred to the floor on [**5-1**], which was postoperative day #1, at [**Hospital6 1760**] on postoperative day #3 from the previous operation. Postoperatively, the patient was kept on Vancomycin. She had a good cough. The tracheostomy and the airway were patent and well secured. Physical Therapy helped with ambulation. It was noted that she had right arm swelling, and she had had a PICC line in the right arm which was then removed, and subsequently the PICC line was placed in the left side. On [**2116-5-4**], the patient was found to have a deep venous thrombosis in the right upper extremity on ultrasound and was treated with Heparin. She was continued on Heparin, and when she was therapeutic, she was started on Coumadin with a goal INR around 2.0. She also had a Hematology/Oncology consult. A CT of the head and neck was done which did not reveal obvious recurrent disease. The patient also a had a right arm elevation ...................., in addition to her Heparin and Coumadin .................. The Foley was discontinued successfully. She continued to have a good airway and patent tracheostomy. Finally on the 17th, the INR was 2.2. Heparin was discontinued. The patient was kept on Coumadin ............... and Vancomycin. Plans were made for discharge home with services on [**5-13**]. The patient was seen by Respiratory during her hospital course. She was able to cough and clear her secretions. She is going home on Vancomycin. She is to get her INR checked via her primary care physician [**Name Initial (PRE) 20515**]. DISCHARGE MEDICATIONS: She will go home on all of her preoperative medications, as well as saline bolus. FOLLOW-UP: She is to have follow-up with Dr. [**First Name (STitle) **] in [**8-8**] days. [**Name6 (MD) **] [**Last Name (NamePattern4) 13798**], M.D. [**MD Number(1) 13799**] Dictated By:[**Last Name (NamePattern1) 8344**] MEDQUIST36 D: [**2116-5-13**] 09:21 T: [**2116-5-13**] 10:59 JOB#: [**Job Number 26261**]

Admission Date: [**2121-6-26**] Discharge Date: [**2121-7-4**] Date of Birth: [**2071-7-18**] Sex: M Service: Cardiothoracic HISTORY OF PRESENT ILLNESS: This is a 49-year-old gentleman who has a history of aortic stenosis with increased dyspnea on exertion over the past year with associated dizziness and lightheadedness. Cardiac catheter on [**2121-6-18**] showed left ventricular end-diastolic pressure of 20, an aortic valve area of 1.3, and a left ventricular ejection fraction of 72%. Catheterization also revealed no significant coronary artery disease. The patient was then scheduled for an elective aortic valve replacement with Dr. [**Last Name (STitle) 1537**] at a later date, however, on [**2121-6-25**], the patient noticed chest pain and shortness of breath and presented to the Emergency Department. He was found to be in rapid atrial fibrillation and at that time he was treated with diltiazem and discharged home. The patient was admitted on [**2121-6-26**] to the cardiac surgery service in preparation for aortic valve replacement. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Hypertension. MEDICATIONS: Pravachol 10 mg p.o. q.d. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: His physical examination upon admission was unremarkable with the exception of a grade 3/6 systolic ejection murmur. LABORATORY DATA: His EKG upon admission was sinus rhythm with no acute ischemic changes. His chest x-ray upon admission was also within normal limits. HOSPITAL COURSE: The patient was taken to the operating room on [**2121-6-27**] where he underwent an aortic valve replacement with a limited access incision by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. He had a 25-mm CarboMedics mechanical valve placed. Postoperatively he was transported from the operating room to the cardiac surgery recovery unit in good condition. He was weaned from the mechanical ventilator and extubated later on the day of surgery. On postoperative day one the patient was noted to have some atrial fibrillation which was treated with IV diltiazem through the course of the day. He had been out of bed and was beginning to ambulate. On postoperative day two the patient had since converted back to normal sinus rhythm on the diltiazem. This was transitioned to Lopressor and the diltiazem was ultimately discontinued. He was started on Coumadin on postoperative day two, and transferred out of the intensive care unit to the telemetry floor. The patient began to progress with cardiac rehabilitation, increasing ambulation and pulmonary toilet, and had tolerated that advancement in his activity level well. The patient had a subsequent episode of atrial fibrillation with a ventricular response in the 120s the following day on [**2121-7-1**], which was treated with IV Lopressor, and he has since converted back to normal sinus rhythm. He had been started on a heparin drip at that point due to his atrial fibrillation as well as having a mechanical aortic valve placed. He had been maintained on the telemetry floor over the next few days on an IV heparin drip, with a PTT in the 50-70 range while increasing his daily Coumadin dosing to get him to a therapeutic level for his mechanical aortic valve. He has remained in sinus rhythm with good hemodynamics, and he is now ambulating independently, has not had any other difficulties during his postoperative course, and is ready to be discharged today, [**2121-7-4**]. CONDITION ON DISCHARGE: Good; neurologically he is completely intact. His lungs are clear to auscultation bilaterally. His heart is regular rate and rhythm. His abdomen is benign and he has no peripheral edema. DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg p.o. q.d. This is to be continued until stopped by the patient's primary cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13175**] at his discretion. 2. Lasix 20 mg p.o. b.i.d. x 5 days. 3. Potassium chloride 20 mEq p.o. b.i.d. x 5 days. 4. Ibuprofen 400 mg p.o. q. 6 hours p.r.n. pain. 5. Percocet 5/325, 1-2 tablets p.o. q. 4-6 hours p.r.n. pain. 6. Coumadin 7.5 mg today, [**2121-7-4**], [**2121-7-5**], and [**2121-7-6**]. The patient is to then report to Dr.[**Name (NI) 51522**] office on Monday, [**2121-7-7**] to have an INR checked and to have his Coumadin dosed accordingly. His target INR is 2.5 to 3 and this has already been discussed with the office staff from Dr.[**Name (NI) 51523**] office. 7. Lopressor 75 mg p.o. b.i.d. 8. Protonix 40 mg p.o. q.d. DISCHARGE DIAGNOSES: 1. Aortic stenosis status post aortic valve replacement. 2. Postoperative atrial fibrillation. CONDITION ON DISCHARGE: Good. FOLLOW-UP PLANS: The patient is to follow up with his primary care doctor in [**11-28**] weeks, Dr. [**Last Name (STitle) 9969**]. The patient is also to follow up with his primary cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13175**], in [**12-30**] weeks, and the patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] in approximately one month for postoperative check. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2121-7-4**] 11:16 T: [**2121-7-4**] 11:33 JOB#: [**Job Number 51524**]

Admission Date: [**2171-1-24**] Discharge Date: [**2171-1-26**] Date of Birth: [**2103-9-18**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 3556**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy with polypectomy site clipping [**2171-1-25**] History of Present Illness: 67 y/o M CAD who presents with bright red blood per rectum. Patient had a colonoscopy [**2171-1-17**] and underwent a cecum polypectomy (final pathology adenoma). He restarted his Aspirin/Plavix on [**1-19**] and had one episode of bloody stool on the morning of admission ([**1-24**])with several clots. and consequently presented to the ED. Past Medical History: - CAD. Last catheterization was [**5-/2170**], which showed one-vessel disease of the main coronary artery of 30 to 50%. There was diffuse narrowing. He also had two patent stents in his LAD. His circumflex showed 70% stenosis which underwent pressure wire, but no new stent was placed. Cath [**2169-11-15**] mid-LAD had a 80% lesion at the D2 which was small and had an ostial 70% lesion. The Lcx had a 60-70% ostial lesion. Two DES placed in the mid-LAD. - Prostate cancer status post brachytherapy, followed by Dr. [**Last Name (STitle) **] in radiation oncology. Last visit was in [**10-8**], at which time PSA was normal. - External hemorrhoids - Erectile dysfunction - Hypertension - Low back pain for status post lumbar surgery at [**Location (un) **] [**Location (un) 1459**] approximately 12 years ago. Social History: He lives in [**Hospital1 392**], [**State 350**]. He is married and his wife works as a clerk. He retired from his job as an airline mechanic in [**2160**]. He has history of 60 pack years tobacco use - he quit 30 years ago smoked two packs a day. Denies any illicit substances. He has no drug use. Family History: His father had cirrhosis at age 47. His mother had a stroke in her 90s. He has three brothers. Two brothers with carotid stenosis and CAD. One brother is healthy. He has three healthy children and numerous grandchildren who are also healthy. No history of GI cancer. Physical Exam: on admission to the ICU: GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - pale conjunctiva, NC/AT, PERRLA, EOMI, sclerae anicteric, dryMM NECK - no thyromegaly, no JVD, no carotid bruits LUNGS - CTA b/l HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-3**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric Pertinent Results: [**2171-1-24**] 04:25PM Hct-37.2* [**2171-1-24**] 09:58PM Hct-33.6* [**2171-1-25**] 04:23AM Hct-35.7* [**2171-1-25**] 07:44AM Hct-34.4* [**2171-1-25**] 01:29PM Hct-34.1* [**2171-1-25**] 09:14PM Hct-33.7* [**2171-1-26**] 05:30AM Hct-34.0* . [**2171-1-24**] 04:25PM WBC-6.8 Plt Ct-167 [**2171-1-25**] 04:23AM BLOOD WBC-9.4 Plt Ct-127* [**2171-1-25**] 01:29PM WBC-6.3 Plt Ct-122* [**2171-1-25**] 09:14PM WBC-6.4 Plt Ct-115* [**2171-1-26**] 05:30AM WBC-5.8 Plt Ct-111* . [**2171-1-26**] 05:30AM Glucose-95 UreaN-10 Creat-0.9 Na-143 K-3.8 Cl-113* HCO3-25 AnGap-9 [**2171-1-25**] 04:23AM ALT-16 AST-25 LD(LDH)-297* AlkPhos-43 TotBili-2.5* DirBili-0.2 IndBili-2.3 [**2171-1-25**] 04:23AM Hapto-94 Brief Hospital Course: #Acute blood loss anemia from lower GI bleed: Patient's presenting vitals were T 97.1, BP 114/77, HR 58, RR 20, Sa 99%. Patient's HCT was found to be 37 from baseline 41. Patient was initially admitted to the general medicine floor with plan to prep overnight for colonoscopy in the morning. Aspirin and plavix were stopped and his anti-hypertensives were held. . After starting prep he had a large bright red bloody bowel movement and became hypotensive with a blood pressure of 80/palpable. His repeat hematocrit was 33 (from 37) Patient was started on 1 L with mild improvement in BP (SBP 104). Given the concern for inability to control the site of bleeding, he was transferred to the MICU to complete the prep and have a colonoscopy. . In the ICU, the patient received a total of 3 units of PRBCs. His HCT did not increase appropriately but did increase to 35.7. He had a colonoscopy the next morning by GI who found ulceration with 2 visible vessels at prior polypectomy site. 2 clips were placed for hemostasis, they also saw small rectal ulcers; grade 2 internal hemorrhoids. . His HCTs were checked q4 hours for 24 hours and remained stable 33-35. He tolerated clears and then on the morning of diacharge ate a full breakfast. He had no more bowel movements, no abdominal pain and he remained normotensive without any more fluids or blood products. His atenolol and aspirin were restarted on the day of discharge. He was instructed to restart his lisinopril on the day after discharge (Sunday) and come to the clinic for a CBC on Monday. After the results of his CBC, if HCT is stable, he was instructed to restart his plavix after discussion with his PCP and his cardiologist. His cardiologist wand PCP were not [**Name9 (PRE) 12304**] during his admission but an email was sent to let them know the patient was off his plavix (had DES in [**2168**]). . # Indirect Hyperbilirubinemia: Patient with T. Bili of 2.5 and I. Bili of 2.3, LDH was increased and platelets were decreased so there was concern for hemolysis or DIC but it was then realized that these were checked on a hemolyzed sample of blood which would falsely elevate these tests. Haptoglobin was normal and reticulocyte count was 1.8. . # Thrombocytopenia: Platelets trended down from 167 to 111. It was felt most likely dilutional from IVF and packed RBCs. The patient did not receive any heparin products. He will have an outpatient CBC on Monday [**1-28**]. . # h/o CAD s/p DES: No chest pain during admission. EKG was unchanged. As above, Aspirin and plavix were held, aspirin restarted. Patient was continued on his simvastatin. . # HTN: Patient's anti-hypertensives were held during admission given hypotension and GI bleed. . Medications on Admission: - ATENOLOL - 25 mg by mouth daily - CLOPIDOGREL [PLAVIX] - 75 mg Tablet by mouth once a day do NOT stop this medication without to speaking to your cardiologist - LISINOPRIL - 10 mg by mouth once a day - NITROGLYCERIN - 0.4 mg prn as needed for chest pain - SIMVASTATIN - 40 mg Tablet by mouth once a day - ASPIRIN - 81 mg by mouth daily - OMEGA-3 FATTY ACIDS-VITAMIN E 1,000 mg Capsule - 2 Capsule(s) by mouth once a day ** Currently on hold due to hypotension: HYDROCHLOROTHIAZIDE - 25 mg by mouth daily ** Currently on hold ISOSORBIDE MONONITRATE - 30 mg Sustained Release 24 hr by mouth daily Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omega-3 Fatty Acids-Vitamin E 1,000 mg Capsule Sig: Two (2) Capsule PO once a day. 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day: Please restart this medication today upon arriving home. 6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet Sublingual once a day as needed for chest pain. Discharge Disposition: Home Discharge Diagnosis: Primary: Gastrointestinal bleeding after polypectomy Discharge Condition: Mental status intact, ambulating freely without difficulty. Discharge Instructions: You were admitted with bleeding from your rectum and blood in your stool This was due to bleeding from your recent polyp removal in your colon. You were transfused 3 units of blood cells. The GI specialists put clips on your prior polyps sites and there was no further evidence of bleeding. You need to get a repeat blood test done on Monday, [**1-28**] to check your blood levels. This can be done at your primary care office. You should not take your Clopidogrel (Plavix) until instructed to do so. Please continue your prior outpatient medications. Please keep all your outpatient appointments. Followup Instructions: You should call and schedule a follow-up appointment for the next 1-2 weeks post-discharge with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Her office can be contact[**Name (NI) **] at [**Telephone/Fax (1) 250**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

Admission Date: [**2126-10-3**] Discharge Date: [**2126-10-10**] Date of Birth: [**2054-8-10**] Sex: F Service: NEUROSURGERY Allergies: Morphine / Codeine Attending:[**First Name3 (LF) 3227**] Chief Complaint: Headache and Nausea Major Surgical or Invasive Procedure: None History of Present Illness: 72F with MS [**First Name (Titles) **] [**Last Name (Titles) **] for h/o DVT and PE has had progressive headche today with associated nausea and vomiting. Presented to OSH with CT showing left cerebellar hemorrhage. Pt received Vit K for INR 5.5 and was transferred to [**Hospital1 18**] ED. Past Medical History: MS,HTN, incontinence,inc chol,neuropathy,non-healing L ankle wound, fx R ankle Social History: Hx:lives with husband, [**Name (NI) 269**], nonsmoker, no EToH Family History: Noncontributory Physical Exam: O: T: 97.5 BP: 186/50 HR:83 R18 O2Sats92 Gen: WD/WN, comfortable, NAD, drowsy but easily arousable HEENT: Pupils:L 5, R 4.5 both briskly reactive EOMs full Neck: Supple. Extrem: Warm and well-perfused. birthmark left arm Neuro: Mental status: Awake though slightly drowsy, trying to be cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils round and reactive to light, 5mm on left and 4.5 on right. 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. antigravity all 4 extremities, cast on right LE Sensation: Intact to light touch bilaterally. Coordination:unable to assess ** Upon Discharge ** AOx3, PERRL, EOM intact, face symm, tongue midline. MAE [**3-26**] except RLE in cast- + antigravity Pertinent Results: [**2126-10-4**] 02:11AM BLOOD WBC-10.2 RBC-3.22* Hgb-9.9* Hct-30.1* MCV-94 MCH-30.9 MCHC-32.9 RDW-14.8 Plt Ct-324 [**2126-10-4**] 02:11AM BLOOD Plt Ct-324 [**2126-10-2**] 11:00PM BLOOD Neuts-90.1* Lymphs-7.6* Monos-1.7* Eos-0.5 Baso-0.1 [**2126-10-4**] 02:11AM BLOOD Glucose-84 UreaN-44* Creat-2.0* Na-144 K-4.9 Cl-113* HCO3-23 AnGap-13 [**2126-10-4**] 02:11AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1 [**2126-10-3**] 02:27AM BLOOD Triglyc-78 HDL-46 CHOL/HD-3.6 LDLcalc-104 HEAD CT [**2126-10-2**]: IMPRESSION: Interval mild enlargement of the left superior cerebellar hyperdense area with mildly increased mass effect. Clinical correlation is recommended. While this is most likely to represent hemorrhage, DDX includes dense neoplasms like meningioma; underlying vascular or neoplastic causes cannot be excluded. HEAD CT [**2126-10-3**]: IMPRESSION: Little change since the prior study of the left cerebellar hemorrhage with mass effect on 4th ventricle and cerebral aqueduct. Stable 2- mm rightward shift of midline structures. Underlying vascular or neoplastic lesions, if any, can be better assessed by MR/CTA after resolution or as indicated clinically. EKG [**2126-10-6**] Normal sinus rhythm, rate 59. Non-specific anterolateral repolarization changes. Possible inferior myocardial infarction of indeterminate age. Compared to the previous tracing of [**2126-10-2**] no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 59 146 92 422/420 41 -4 75 NECK/Soft tissue Ultrasound [**2126-10-6**]: No abnormal fluid collection or mass in the right neck. Carotid US [**2126-10-7**]: Less than 40% stenosis of the bilateral extracranial internal carotid arteries. Brief Hospital Course: Ms [**Known lastname 4223**] was admitted to the NeuroICU after a CT showed cerebellar hemorrhage. Her neurological status was monitored very closely and remained unchanged throughout her hospital course. Her INR was reversed to a goal of less than 1.5 A CTA was desired for rule out vascular cause of bleed. Due to her renal insufficiency a MRA was recommended. Given her exterme claustrophobia, an open MRI was scheduled after discharge. On [**10-6**] it was noted that there was some swelling to her right neck- a soft tissue ultrasound was done which was negative. She subsequenty had one 15 minute episode of Left chest discomfort. Cardiac work up was unimpressive and cardiology consult felt that there were no acute cardiac episodes. She was evaluated by PT and ultimately discharged home. Medications on Admission: [**Month/Year (2) **] 6.5', lipitor 20',altase5',metoprolol 25',valium 2qhs,neurontin 400'',ramipril 5', lasix 80', aspirin 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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Ramipril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Care Tenders Discharge Diagnosis: Cerebellar Hemorrhage Carotid stenosis UTI 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. ?????? 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 Appointment Instructions ??????We are making your appointments for MRI, CT and Dr [**Location (un) 84339**] will be sending you a letter with the exact appointment times. The follow up appointment is in the next 4 weeks. ??????You will need a MRA +gad in open MRI prior to your appointment. This can be scheduled when you call to make your office visit appointment or you may have the scan done at an outside facility. You must bring a CD with the images to your appointment. During your hospital stay you had an ultrasound of the neck. This showed carotid stenosis. You should follow up with you PCP [**Name Initial (PRE) 176**] 2 weeks to discuss this diagnosis. Completed by:[**2126-10-10**]

Admission Date: [**2153-11-6**] Discharge Date: [**2153-11-13**] Date of Birth: [**2100-1-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: [**2153-11-6**] - CABGx3 [**Last Name (NamePattern4) 15255**] of Present Illness: Splendid 53 year old gentleman with shortness of breath and chest pressure with activity. A cardiac catheterization was performed which revealed three vessel disease. Due to the severity of his disease, he was referred for elective coronary artery bypass grafting with Dr. [**Last Name (Prefixes) **]. Past Medical History: Hypercholesterolemia HTN Anxiety Postoperative Corneal Abrasion Torn Bicep s/p Repair Asthma GERD Separated Right Shoulder Current Smoker S/P (R) Bicep Repair S/P (R) Peri-renal abscess Social History: Currently not working. Smokes around [**12-10**] pack per day. "Few" drinks/beers daily. Lives with wife in [**Name (NI) 5176**], MA Family History: Mother with CABG in her 60's Father with prostate cancer Physical Exam: GEN: WDWN in NAD SKIN: Warm, no edema HEENT: NCAT, PERRL, OP benign. Few remaining teeth in fair repair. NECK: Supple, no JVD LUNGS: Clear HEART: RRR, nl s1-s2 ABD: Soft, nontender, benign EXT: Well perfused, no edema, no varicosities noted NEURO: Nonfocal Pertinent Results: [**2153-11-8**] 06:35AM BLOOD WBC-7.9# RBC-3.34* Hgb-10.9* Hct-30.3* MCV-91 MCH-32.8* MCHC-36.0* RDW-12.5 Plt Ct-208 [**2153-11-8**] 06:35AM BLOOD Plt Ct-208 [**2153-11-8**] 06:35AM BLOOD Glucose-152* UreaN-13 Creat-0.9 Na-135 K-4.1 Cl-99 HCO3-26 AnGap-14 [**2153-11-8**] CXR Comparison made to prior study of one day earlier. The cardiomediastinal silhouette is unchanged. There has been interval removal of the left basilar chest tube. Minimal linear atelectasis is present in the left mid lung zone. There is no pneumothorax. There is mild subcutaneous emphysema in the left chest. Minimal linear atelectasis is present in the right lung. [**2153-11-6**] EKG Sinus rhythm. Consider inferior myocardial infarction, of indeterminate age. Diffuse ST-T wave abnormalities, cannot exclude ischemia/injury. Clinical correlation is suggested. Since the previous tracing of [**2153-10-30**] further ST-T wave changes are present. Brief Hospital Course: Mr. [**Known lastname 5261**] was admitted to the [**Hospital1 18**] on [**2153-11-6**] for elective surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to three vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname 5261**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta blockade and aspirin were resumed. He was then transferred to the cardiac surgical step down unit for further recovery. He was gently diuresed towards his preoperative weight. He complained of left eye pain for which the ophthalmology service was consulted. A corneal abrasion was found on exam and polymyxin eye ointment was prescribed four times daily. An eye patch was worn and his eye pain and irritation slowly improved. Mr. [**Known lastname 5261**] [**Last Name (Titles) 77102**] and pacing wires were removed per protocol. stopped [**2153-11-8**]\ [**Last Name (STitle) 58527**]nued to make steady progress and was discharged home on postoperative day seven. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Toprol XL 50mg daily Aspirin 325mg daily Nitrostat as needed Lipitor 20mg daily Advair as needed Nexium 40mg daily Xanax 0.5mg as needed Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1 weeks. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD Hypercholesterolemia HTN Corneal abrasion GERD S/P Right Bicep Repair S/P Drainage of perirenal abcess Current smoker Asthma Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain greater then 2 pounds in 24 hours or 5 pounds in one week. 4) Take lasix as directed with potassium and stop ________. 5) No lifting more then 10 pounds for 10 weeks. 6) No creams, lotions or powders to wounds until they have healed. Steristrips will fall off on there own. If have not fallen off in 2 weeks from discharge, please remove. 7) Call with any questions or concerns. [**Last Name (NamePattern4) 2138**]p Instructions: Follow-up with Dr. [**Last Name (Prefixes) **] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. ([**Telephone/Fax (1) 104910**] Follow-up with cardiologist Dr. [**Last Name (STitle) **] in [**12-10**] weeks. Call all providers for appointments.

Admission Date: [**2157-5-29**] Discharge Date: [**2157-6-16**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: SSCP x 3 days Major Surgical or Invasive Procedure: Catheterization cabg x3 on [**2157-6-3**] (LIMA to LAD, SVG to OM, SVG to RCA) History of Present Illness: Pt is as [**Age over 90 **] y/o male who was seen in the ER for non-radiating SSCP of three days duration and now admitted to the floor for Acute Coronary Syndrome. Pt explains CP as a "tooth ache", that will last 10-20 minutes at most. He denies CP currently, SOB, diaphoresis, dizziness, nausea or vomitting during his prior CP. Pt explains that he had a dry non-productive cough without fever and chills. He states that his son had pneumonia last week. No previous cardiac hx. Past Medical History: HTN Left shoulder hemiarthroplasty Legally blind CRI (baseline 2.1) Social History: lives at home with children, denies smoking/alcohol/drugs Family History: non-contrib Physical Exam: PEx: Vitals: 97.2 143/67 59 18 95% on 2L Gen: AAOx3, NAD, [**Last Name (un) 1425**] HEENT: normocephalic, PERRLA, MMM, no LAD, no JVD PULM: CTA b/l CV: RRR, nl S1 S2, no m/r/g Abd: soft, NT/ND, obese, no r/g LE: + palpable pedal pulses, minimal non-pitting edema b/l 73" 275# Pertinent Results: [**2157-6-16**] 10:40AM BLOOD WBC-5.2 RBC-3.76* Hgb-10.8* Hct-32.6* MCV-87 MCH-28.6 MCHC-33.0 RDW-15.2 Plt Ct-281 [**2157-6-12**] 05:10AM BLOOD PT-13.9* PTT-26.7 INR(PT)-1.2* [**2157-6-16**] 10:40AM BLOOD Glucose-125* UreaN-38* Creat-2.7* Na-143 K-3.9 Cl-110* HCO3-23 AnGap-14 RADIOLOGY Final Report CHEST (PA & LAT) [**2157-6-14**] 10:46 AM CHEST (PA & LAT) Reason: eval effusions [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old man with HTN, and ACS s/p CABGx3 REASON FOR THIS EXAMINATION: eval effusions PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: [**Age over 90 **]-year-old man with hypertension, ACS, S/P CABG. Please follow up pleural effusions. Comparison is made with prior study dated [**2157-6-10**]. FINDINGS: Allowing the difference of technique and positioning of the patient, moderate bilateral pleural effusions are again seen, likely the right decreased and increase in the left side. There is no evidence of CHF. There are bibasilar atelectasis. Patient is S/P median sternotomy and CABG. Stable cardiomegaly. Widened superior mediastinum and deviation of the trachea to the right, unchanged from prior studies. IMPRESSION: Bilateral pleural effusions, likely increase in the left and decrease in the right side. Bibasilar atelectasis. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 3901**] [**Name (STitle) 3902**] DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Approved: WED [**2157-6-15**] 4:36 PM Cardiology Report ECHO Study Date of [**2157-6-3**] PATIENT/TEST INFORMATION: Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Valvular heart disease. Status: Inpatient Date/Time: [**2157-6-3**] at 09:59 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW04-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.6 cm Left Ventricle - Fractional Shortening: *0.23 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: 2.1 cm (nl <= 3.6 cm) Aorta - Ascending: 3.3 cm (nl <= 3.4 cm) Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 0.86 Mitral Valve - E Wave Deceleration Time: 299 msec INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No spontaneous echo contrast or thrombus in the body of the RA or RAA. No ASD by 2D or color Doppler. The IVC is normal in diameter with appropriate phasic respirator variation. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of mitral valve chordae. Mild to moderate ([**11-22**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Conclusions: PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-22**]+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: Preserved biventricular systolic function. Mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. No other change. Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD on [**2157-6-3**] 12:43. [**Location (un) **] PHYSICIAN: ([**Numeric Identifier 22048**]) Brief Hospital Course: Pt received ASA, Lopressor and Heparin in the ED. Labs of note were troponin at .11, and a chest x-ray that stated possible pneumonia in his left lower lobe. Pt underwent catheterization on [**5-30**] which revealed severe 3 vessel disease, and did not receive stenting. It was then determined that his best next option would be CABG, CT surgery was consulted. Pt was monitored on the floor, received SL nitro for CP and repeat EKGs. Of concern was his renal function, however his creatinine remained stable around 2.0 pre- and post- catheterization. He had an echo, carotid US, UA and LFTs completed before his CABG procedure on [**6-3**] with results above. Underwent cabg x3 with Dr. [**Last Name (STitle) **] on [**6-3**] and transferred to the CSRu in stable condition on neosynephrine and propofol drips. Epinephrine and insulin drips added overnight, slightly acidotic and transfused on POD #1 as vent wean started. Platelet count decreased to 88K and HIT panel sent. Extubated on POD #2 and Swan removed. Went into AFib on POD #3 and amiodarone started as well as beta blockade and gentle diuresis. Pacing wires removed without incident on POD #4.HIT negative on [**6-7**] and converted to SR on amiodarone.Foley removed on POD #5 and transferred to the floor to begin increasing his activity level. Lethargy improved and alert and oriented on POD #6. Had some confusion overnight and treated with haldol. He eventually improved and had a creat of 3.0. Renal was consulted and felt that he was pre renal, and he was encouraged to increase PO intake. His creat decreased to 2.7 and he was discharged to home on POD#13 in stable condition. Medications on Admission: ASA 325mg daily lipitor 10 mg daily plavix 75 mg daily (LD [**5-31**]) Protonix 40 mg daily lopressor 25 mg [**Hospital1 **] SL NTG ? Multivitamin mucomyst bicarbonate heparin drip colace 100 mg daily 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. 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* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 month supply* Refills:*2* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Amiodarone 200 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: s/p cabg x3 HTN CRI renal calculi legally blind left shoulder surgery Discharge Condition: stable Discharge Instructions: may shower over incisions and pat dry may not drive for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness, or drainage no lotions, creams or powders on any incision Followup Instructions: follow up with Dr. [**Last Name (STitle) **] in [**11-22**] weeks follow up with Dr. [**Last Name (STitle) 171**] in [**12-24**] weeks follow up with Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Completed by:[**2157-6-16**]

Admission Date: [**2158-7-14**] Discharge Date: [**2158-7-20**] Date of Birth: [**2120-3-22**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 38-year-old white male has a history of chest discomfort. He had a history of mitral valve prolapse and mitral regurgitation. He is status post cardiac catheterization in [**2154**], which was negative and in [**2158-4-25**], he had an episode of severe substernal chest pain associated with diaphoresis, shortness of breath, nausea, and vomiting. He ruled out for a MI and had exercise tolerance test, which was negative for reversible defects, but had a possible small LAD infarct. An echocardiogram at that time revealed worsening MR and he again had chest pain in [**Month (only) **] and was admitted to [**Hospital1 69**] for rule out MI and had a positive tox screen for cocaine, but ruled out for MI. An echocardiogram on [**5-23**] revealed a left to right shunt across the intraatrial septum, a secundum ASD and EF of 75 percent, mitral valve leaflets were myxomatous and elongated. He had moderate-to-severe mitral valve prolapse with partial mitral leaflet flail and 4 plus MR. His stress test at that time revealed no significant ST changes and he underwent cardiac catheterization in [**2158-5-25**], which revealed an EF of 71 percent, 4 plus MR, and normal coronaries. He was admitted for elective mitral valve repair, and on [**7-14**], he underwent mitral valve repair with a quadrangular resection of the posterior leaflet and an anuloplasty with a 30 mm [**Doctor Last Name 405**] band. He had some bleeding in the OR. His chest was opened right after it was closed. They had not left the OR yet, and he had platelet transfusion and his bleeding subsided. He was transferred to the CSRU in stable condition. He remained intubated overnight. He was on Precedex overnight. He was extubated on postoperative day number one. Postoperative day two, his chest tubes were D/C'd, and he was transferred to the floor in stable condition. He continued to progress and had pacing wires D/C'd on postoperative day number three. DICTATION ENDED HERE. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) 18588**] MEDQUIST36 D: [**2158-7-20**] 16:05:35 T: [**2158-7-20**] 16:32:03 Job#: [**Job Number 36691**]

Admission Date: [**2201-8-14**] Discharge Date: [**2201-8-20**] Date of Birth: [**2168-1-8**] Sex: M Service: MEDICINE Allergies: Clindamycin Attending:[**First Name3 (LF) 613**] Chief Complaint: Constiption; AFl with RVR Major Surgical or Invasive Procedure: None History of Present Illness: 33M with PMH of seronegative spondyloarthropathy s/p multiple joint replacements, diastolic heart failure, and ileostomy complicated by necrotizing fasciitis who present with constipation. The patient states that it has been several weeks since he last moved his bowel. He is tolerating po, passing gas and is having mildly increased output from his ostomy. Patient denies nausea, vomit, diarrhea, chest pain, palpitations, SOB, worsening of his leg edema. He was wanting to be manually desimpacted and requested to be transfered to the [**Hospital1 18**] to be done under sedation. Patient was tolerating PO, but states that has lower intake within the last 24 hours. Notes from his nursing home states that he has been refusing colace, MOM and mag citrate. He is noted to have bowel sounds and stool in his ostomy bag. . In the ER he was found to have Temp 98 F PO, HR 160, BP 114/67, RR 20, SpO2 97%. EKG showed F waves with 2:1 ventricular conduction. Patient was given 60mg of diltiazem and then was started on a dilt drip. However, BP dropped, so dilt was stopped. Cardiology was consulted. Patient received adenosine and the diagnosis of atrial flutter was confirmed. Cardiology suggested digoxin load. Pt states that he has been told that he has this condition for at least the last year and that he had been on lopressor previously. He denies any chest pain, shortness of breath or palpitations. . Patient has had chronic whole-body pain and received 9mg of IV dilaudid, benadryl, 30 mg PO morphine, 5mg oxycodione, 2mg IV ativan and was started on Vancomycin/Levo/Flagyl, zofran, hydrocortisone. Past Medical History: Past medical history: Seronegative arthritis, possibly ankylosing spondylitis, of hips, knees, wrist, on steroids/immunosuppressants since [**2190**] (methotrexate, sulfasalazine, Enbrel, Humira, Remicade, prednisone) L prosthetic knee infection with C. albicans and CoNS - now with spacer Citrobacter fasciitis of abdominal and chest wall - required skin grafting Multiple abdominal abscess - citrobacter, VRE Right lower extremity DVT requiring IVC filter anemia of chronic disease MRSA infection PUD anabolic steroid abuse (16 months in early 20s) -Recent MRI knee suggestive of osteomyelitis PSH: [**2200-8-28**] radical debridement of soft tissues of R chest wall, abdominal wall, flank, groin; step incisions in abdominal wall fascia & musculature with drainage of peritoneal abscess [**2200-8-29**] repeat debridement of necrotic soft tissues of R chest, abdominal wall, b/l groins, additional step incisions in abdominal wall fascia & musculature with drainage of peritoneal abscess -[**2200-9-4**] tracheostomy with 8-0 cuffec Portex tube, irrigation & debridement of wounds with further drainage of periappendiceal abscess, placement of 26Fr mushroom-tipped catheter into appendiceal stump within cecum -[**2200-9-17**] IVC filter placement -[**2200-9-26**] vac dressing change under general anesthesia -[**2200-9-30**] vac dressing change under general anesthesia -[**2200-10-2**] preparation of wound bed with debridement & excision of scar, meshed skin graft (16/1000" meshed at 1.5, total surface area 40x55 cm) -[**2200-10-7**] removal of bolster, skin graft, replacement of wound dressing with DuoDerm gel & Xeroform gauze ... -L TKR [**3-1**] c/b wound dehiscence & septic arthritis in [**3-2**] -R THR [**10-30**] -L THR [**1-26**] -R TKR [**4-28**] -L tibial osteotomy -L4-L5 laminectomy [**2193**] (s/p MVA with traumatic disc herniation) . Current hardware: spacer left knee, prosthesis right knee, bilateral hips Social History: Has been living in nursning home for the last ~5 months due to multiple joint problems due to his arthritis. He used to live with his mother and used to have 2 dogs, which passed away recently. He denies any travel. Has h/o smoking 10 pack-year (difficult to assess) and currently smokes ~1 pack/month. Patient denies ingestion of alcohol or any illegal substance. He is currently unemployed.Most recently at Rehab--came from rehab via St V's. Family History: Mother with CAD and DM; grandmother (mother's side) with severe CAD. Dad healthy. [**Name2 (NI) **] one with severe arthritis as he is. No family history for cancer. Physical Exam: Temp 97.7 HR 108 BP 107/67 RR 18 SpO2 99% . General: NAD, A&Ox3, lyiing in bed, morbidly obese HEENT: PEERLA, mucous membranes well hydrated, no jaundice, normal eye moevment Neck: No JVD visible, no bruits or murmurs, pulses ok. Heart: RRR, no m/r/g/ Lungs: CTAB Abdomen: distended, non-tender, increased bowel sounds, midline scare, right-side skin grafting, sun burning in the upper neck. Normal intercostal reflexes. Extremities: R leg with 4+ edema, palpable [**Last Name (un) **] pulses, warm, scar in anterior region of the knee, old graft sites with crusts. Left leg warm with 1+ edema, good pulses. Both legs with [**2-28**] strenght and normal ROTs. Neuro: non-focal, craneal nerves WNL ([**1-6**]). Pertinent Results: On admission: [**2201-8-14**] 12:15PM WBC-15.8* RBC-4.77 HGB-9.7* HCT-34.2* MCV-72* MCH-20.4* MCHC-28.4* RDW-16.9* [**2201-8-14**] 12:15PM NEUTS-90.3* LYMPHS-6.0* MONOS-3.2 EOS-0.3 BASOS-0.2 [**2201-8-14**] 12:15PM GLUCOSE-106* UREA N-13 CREAT-0.6 SODIUM-136 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-28 ANION GAP-15 [**2201-8-14**] 12:15PM ALT(SGPT)-20 AST(SGOT)-10 ALK PHOS-296* [**2201-8-14**] 12:15PM FIBRINOGE-1000*# D-DIMER-2516* [**2201-8-14**] 02:02PM LACTATE-0.8 [**8-18**] Transesophageal Echo No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No thrombus is seen in the right atrial appendage No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Aortic arch not well seen secondary to patient discomfort. Dr. [**Last Name (STitle) **] was notified in person of the results on the morning of the study. IMPRESSION: No intracardiac thrombus or spontaneous echo contrast. Preserved biventricular function. [**8-19**] Transthoracic Echo The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**8-18**] WBC 9.4 Hgb 7.9 HCT 28.1 Plt 569 INR 2.1 Creatinine 0.6 [**8-14**] Blood culture: Negative Brief Hospital Course: Patient is a 33M with a complicated PMH notable for seronegative spondyloarthropathy s/p multiple joint replacements, found to be in atrial flutter with HR in 100-120s. . #. Rhythm: Atrial flutter with rate in 100-110s on admission. Rate as high as 150s in ICU. Started on Metoprolol and Digoxin in ICU. Rate was better controlled on floor with rates in 100-120s. Successfully cardioverted. Back in NSR with rate in 70s to 100. Digoxin was discontinued. Patient was discharged on Metoprolol 25mg po qhs, to control heart rate. Coumadin was restarted at usual home dose of 3mg. Patient was closely monitored on telemetry. Had no significant events on telemetry after cardioversion. . #. Constipation: secondary to high dose opioids and non compliance with bowel regimen. Abdominal X-ray shows colon full of stool. Patient was always passing gas, tolerating po, no peritoneal signs on exam during hospitalization. Continues to have good ostomy output. Patient is refusing oral bowel regimen, bowel regimen via ostomy, and enemas. He is insisting on manual disimpaction under sedation. . Surgery was consulted, who initially didn't believe that this was a surgical issue requiring anesthesia. Anesthesia did not want him disimpacted after Cardioversion, as anesthesia would only last 1-2 minutes after Cardioversion. They did not see any medical indication for prolonged anesthesia in this setting. On day of discharge, patient was taken to OR for disimpaction under sedation. Please see operative report for details of procedure. It was emphasized to the patient that it is important for him to continue daily oral bowel regimen and as needed suppositories. He may have some streak rectal bleeding from below after the procedure which is normal. . # Coagulopathy - Patient on chronic coumadin for prior DVT 8 months ago with supratherapeutic INR. INR was held until 2.1, and then restarted on home regimen. -Please continue Coumadin, with goal INR between 2 and 3. . . # Pain control: Patient has high level of chronic pain at baseline. -Continued on home regimen of MS Contin, Morphine, Clonazepam, Benadryl, Oxycodone, Seroquel -Pain service was been consulted. They did not recommend further narcotics as he is already on very high doses, and they are contributing to his constipation. They have recommended standing Tylenol 1000mg q6h, Lidoderm patch, and Neurontin. Patient continues to ask for IV dilaudid for full body pain. He has not received any while on the Cardiology service, as it is not medically indicated at this time. -Pain service has also recommended outpatient Psychiatry consultation -It was recommended that the patient try to taper down on his narcotics which will help with his chronic constipation. . #. CAD: Patient has no known history of CAD. Patient was continued on Aspirin, and monitored on telemetry. . #. Pump: Echo in [**2200-11-25**] was normal. EF > 55% with No LA enlargement. No evidence of fluid overload . # Seronegative Arthritis - Continuee prednisone and bactrim prophylaxis, per outpatient regimen. Medications on Admission: PredniSONE 20 mg PO DAILY Omeprazole 20 mg PO QD Quetiapine Fumarate 400 mg PO HS Sulfameth/Trimethoprim DS 1 TAB PO QODHS Aspirin 81 mg PO DAILY Docusate Sodium 200 mg PO BID Ferrous Sulfate 325 mg PO DAILY Vitamin D 800 UNIT PO DAILY Metoclopramide 10 mg PO Q8H:PRN nausea Acetaminophen 700 mg PO Q6H:PRN OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain Morphine SR (MS Contin) 120 mg PO Q8H Morphine IR 30mg Q6hrs Benadryl 25 mg Q4 HRS Warfarin 3.5 mg QD changed to 3.5mg T TH S S, 3mg MWF on [**2201-8-13**] Discharge Medications: 1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Quetiapine 100 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q4H (every 4 hours) as needed for pain. 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAYS (MO,WE,FR). 11. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for anxiety. 12. Morphine 30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 14. Terbinafine 125 mg Granules in Packet Sig: Two (2) packets PO daily (). 15. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) ML PO Q6H (every 6 hours). 16. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet Sig: One (1) packet PO DAILY (Daily). 18. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 19. Clotrimazole 1 % Cream Sig: [**11-26**] Appls Topical [**Hospital1 **] (2 times a day). 20. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for pain. 21. Morphine 120 mg Cap, Multiphasic Release 24 hr Sig: One (1) Cap, Multiphasic Release 24 hr PO TID (3 times a day). 22. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical DAILY (Daily). 23. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 24. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO Tuesday, Thursday, Saturday. 25. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 26. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime). 27. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day. 28. Lactulose 10 gram/15 mL Solution Sig: 30-60ml PO twice a day: Titrate up to achieve bowel movements. 29. Fleets enema Sig: One (1) enema once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] Care and Rehab-Sandalwood-[**Location (un) **] Discharge Diagnosis: Primary diagnosis 1. Atrial flutter 2. fecal impaction Secondary diagnosis Seronegative Arthritis s/p multiple joint replacements history of DVT requiring anticoagulation Discharge Condition: Stable. Normal sinus rhythm. Disimpacted. Discharge Instructions: You were admitted with atrial flutter. Your heart rate was controlled with medications. You had an echo done to look at your heart, and a Cardioversion done to shock your heart back into normal rhythm. You had no complications. You were also disimpacted under anesthesia, per your request. It is normal for some bleeding from below after the procedure. 10 centimeters of impacted stool was removed from below. It is very important that you take your oral bowel medications. Please continue all of your medications as you were taking them before. We have added 25mg Metoprolol for you to take every night to control your heart rate. Please continue with your home medications, including Coumadin. If you have palpitations, chest pain, or shortness of breath, please go to the Emergency room or contact your primary doctor. Please stop smoking. Information was given to you on admission regarding smoking cessation. Followup Instructions: Please follow up with your doctors at rehab. Please follow up with psychiatry for an evaluation. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Admission Date: [**2141-7-23**] Discharge Date: [**2141-8-2**] Date of Birth: [**2060-10-13**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: nausea, vomiting, unsteadiness Major Surgical or Invasive Procedure: none History of Present Illness: 80 RHM chinese speaking only, with PMH significant for HTN, a. fib (on Coumadin), presented to ED for evaluation of nausea and vomiting. History provided by son in law, who speaks English. Per him and patient, he went out at around 11 am today to have breakfast and tea with the family. After having the refreshments , he was returning from subway to home. he felt a little lightheaded while travelling back but was able to walk and come back home. After coming home, around 3 pm, as he tried standing up, he felt sudden onset dizziness. He means lightheadness by :"dizzy". He could not stand and was going towards right when tried to stand and felt like a drunk man. He felt "imbalance". Shortly, he had an episode of vomiting and 3 more after that in next hour. He started having dull bifrontal diffuse headache with no radiation. It was [**5-29**], non throbbing, no photophobia but nausea. Due to this , the family called 911 who brought him to [**Hospital1 18**] ED. Per ED team, his blood pressure was 177 systolic when he presented. ED team got CT head which revealed 3.2 cm right cerebellar bleed, hence neurology and neurosurg were consulted. ROS Neuro- No visual symptoms, diplopia, No sensory symptoms, no weakness, no bladder/ bowel issues. Gen- Negative than mentioned Past Medical History: HTN dyslipidemia a. fib (on Coumadin) Social History: No smoking No alcohol retired restaurant worker Family History: Neg for stroke, DM Physical Exam: General: Awake, NAD HEENT: NC/AT, , MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: rapid, regular 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: done with help of son in law as chinese interpreter Mental Status: Awake and alert, cooperative with exam, normal affect Oriented to person, place, month Language: Fluent with good comprehension and repetition. There is no dysarthria, no paraphasic errors and naming is intact Fund of knowledge normal No apraxia, No neglect Cranial Nerves: pupils [**3-21**] equally round and reactive to light bilaterally.Visual fields are full to confrontation Extraocular movements intact. He has nystagmus on right as well as upgaze. Facial sensation intact to pain and touch . facial movement are normal and face is symmetric. Hearing intact to finger rub bilaterally. Tongue midline, no fasciculations. Sternocleidomastoid and trapezius normal bilaterally. Motor: Normal bulk and tone bilaterally. D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE Right 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 No pronator drift Sensation was intact to light touch, pin prick, temperature (cold), vibration, and proprioception all over. Reflexes: B T Br Pa A Right 2 2 2 1 - Left 2 2 2 1 - Toes were upgoing bilaterally. Coordination - Has dysmetria on FNF on right side, RAMS clumpsy on right side, has difficulty with alternate hand tapping on right, knee shin test clumsy on right side, repetitive foot tapping was clumspy and incoordiated on the right side. Gait / Rhomberg - deferred. Pertinent Results: [**2141-7-23**] 06:45PM WBC-16.2* RBC-4.67 HGB-13.6* HCT-39.5* MCV-85 MCH-29.1 MCHC-34.3 RDW-13.9 [**2141-7-23**] 06:45PM NEUTS-87.8* LYMPHS-8.6* MONOS-2.8 EOS-0.6 BASOS-0.2 [**2141-7-23**] 06:45PM PLT COUNT-267 [**2141-7-23**] 06:45PM GLUCOSE-190* UREA N-23* CREAT-1.2 SODIUM-142 POTASSIUM-2.6* CHLORIDE-101 TOTAL CO2-28 ANION GAP-16 [**2141-7-23**] 06:45PM ALT(SGPT)-11 AST(SGOT)-28 ALK PHOS-75 AMYLASE-55 TOT BILI-0.4 [**2141-7-23**] 08:18PM LACTATE-2.5* [**2141-7-23**] 06:45PM MAGNESIUM-1.8 [**2141-7-23**] 06:45PM cTropnT-<0.01 [**2141-7-23**] 09:59PM PT-29.5* PTT-27.3 INR(PT)-2.9* [**2141-7-23**] 06:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2141-7-23**] 06:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 Imaging: EKG: sinus rhythm CXR: Low lung volumes which may accentuate the hila, but small right hilar opacity cannot be excluded, which may reflect developing pneumonia. CT head: 3.2 cm right intraparenchymal cerebellar hemorrhage. no herniation. MRI head: Right cerebellar hemorrhage unchanged compared to recent CTs. Little to no mass effect. Multiple additional foci of prior parenchymal hemorrhage noted in the basal ganglia, thalamus, pons, subcortical white matter and left cerebellum. Overall, this pattern is most compatible with amyloid angiopathy. ECHO: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**1-21**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 1) Neuro: Patient presented with symptoms of nausea, vomiting, unsteadiness. CT scan of the head was performed, which showed a 3.2 cm right cerebellar hemorrhage. Neurology and Neurosurgery were subsequently consulted and the patient was admitted to the ICU for close monitoring. No neurosurgical intervention was required. Antiseizure prophylaxis was not indicated given the region of the hemorrhage. The patient was managed medically. A repeat CT scan was performed the morning after admission, which showed a stable hemorrhage. An MRI was subsequently performed to evaluate for possible etiologies of the bleed and this showed multiple additional foci of prior parenchymal hemorrhage in the basal ganglia, thalamus, pons, subcortical white matter and left cerebellum. These multiple microhemorrhages noted is most consistent with a diagnosis of amyloid angiopathy. The hemorrhage secondary to the amyloid angiopathy was then likely exacerbated by the patient being coagulopathic secondary to the Coumadin the patient was on for a. fib (initial INR was 2.9). The INR was corrected with FFP and Vitamin K. INR should be less than 1.6 to avoid extension of hemorrhage. The patient continued to note vertiginous symptoms and was started on Meclizine for symptomatic relief. The patient was started on baby aspirin (to avoid further bleeding risks) for anti-platelet activity. A lipid panel was performed as part of the stroke work-up and this noted dyslipidemia, so the patient was started on Simvastatin. Patient's condition gradually improved and he was stable for transfer to floor. While on floor, patient eventually passed speech and swallow and was started on regular diet. Patient was seen by PT/OT who determined that patient would benefit from rehab placement. 2. Cardiology: Patient initially hypertensive, with goal <160 given hemorrhage. Patient received prn doses IV Hydralazine to help control blood pressure. For continued elevated BP, patient was on Metoprolol 50 mg [**Hospital1 **] and Lisinopril 5 mg daily. The patient continued to require IV doses Hydralazine despite the standing anti-HTN meds; however, one night after receiving a dose of IV Hydrlazine for a BP of 170s systolic, the patient developed an episode of epigastric pain and chest pain without radiation that was associated with lightheadedness. Patient became hypotensive at this time with SBP into 80s. An EKG was performed which showed ST changes concerning for ischemia. A cardiology consult was obtained and the patient was transfered back to the ICU for closer monitoring. The ST depression on EKG were transient and have since resolved. Cariology noted this was most likely demand-perfusion ischemia. An outpatient stress test is reccomended to further work-up this event. In a separate event, patient developed a. fib episode with RVR; heart rate into 160s. The patient received IV Metoprolol and PO Metroprolol was increased to 50 mg tid. Patient has remained rate controlled on this higher dose. Will avoid anticoagulation with Coumadin for the a. fib at this time given the hemorrhage. 3. Renal: After the hypotensive episode, patient had Creatinine level rise to 1.4 from 1.2. Determined to be pre-renal and was likely secondary to hypotension. The [**Last Name (un) **] imrpoved with IVF; it is currently 1.1. Another possibility for the elevated creatinine is the addition of Lisinopril for blood pressure control. The Lisinopril has been stopped. Will need to monitor BUN and creatinine as an outpatient. 4. Heme: Hematocrit trended down after hypotensive episode with concurrent drop in Hemoglobin from 13.5 to 11.5. Iron panel was ordered, there was no evidence of acute blood loss or iron deficiency anemia. 5. HTN: Patient initially required IV Hydralazine prn for BP control. Metoprolol now at 50 tid for rate as well as blood pressure control. Patient initially started on lisinopril for BP control but given elevated Creatinine, this was swtiched to Amlodipine 5 mg daily, with possible need to increase to 10 mg daily in future if BP remains elevated. Medications on Admission: Terazosin 10 mg po qhs Metoprolol (dose unknown) Discharge Medications: 1. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for vertigo. 2. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain fever. Tablet(s) 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for c. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: R cerebellar hemorrhage secondary to amyloid angiopathy atrial fibrillation Acute kidney injury Demand Ischemia HTN Hyperlipidemia 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: You came to the hospital with sudden onset nausea, vomiting, and unsteadiness. A CT scan of your brain showed that there was a bleed in a part of your brain called the cerebellum, resulting in the above symptoms. This bleed was due to something called amyloid angiopathy. The bleed was likely made worse because of Coumadin, the medication you were on for your heart arrythmia, atrial fibrillation. Because of the bleeding, your Coumadin was stopped. You were started on a baby ASA for the stroke. You were also started on a medication called Simvastatin for a high cholesterol. While you were in the hospital, you had an episode of low blood pressure, which caused some EKG changes that have since returned to normal. The cardiologists would like you to get a stress test as an outpatient to be followed by your PCP. [**Name10 (NameIs) **] also had an episode of a fast heart rate, so your Metoprolol was increased to 50 mg three times a day. Also, on Friday [**2141-8-4**], would like you to have your kindey function checked with labwork (BUN, Creatinine) as the time you were hypotensive seemed to affect your kidneys, though function has improved with the IV fluids you received. Followup Instructions: Please follow with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-1**] 1:30 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-8-31**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2141-8-31**] 2:00 ([**Hospital **] Medical Building [**Hospital Unit Name 12193**]) Completed by:[**2141-8-2**]

Admission Date: [**2141-6-26**] Discharge Date: [**2141-6-30**] Date of Birth: [**2068-12-15**] Sex: F Service: Cardiothoracic Surgery CHIEF COMPLAINT: Heart palpitations and fatigue times two years with mild shortness of breath. HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: The patient is a 72-year-old female with a history of heart murmurs since childhood with increasing frequency and intensity of heart palpitations, fatigue and shortness of breath. Over the last several years the patient sought medical attention, at which time she had an echocardiogram revealing a "leaky valve." The patient was then referred to Dr. [**Last Name (Prefixes) **] for a mitral valve replacement. The patient's echocardiogram which was done on [**2140-5-20**] showed: (1) Left atrium mildly dilated. (2) Thickened mitral valve, moderate-to-severe. (3) Mitral valve prolapse of the posterior leaflet. (4) Torn mitral chordae. (5) Moderate-to-severe mitral regurgitation. PAST MEDICAL HISTORY: 1. Esophagitis/gastroesophageal reflux disease. 2. Hypercholesterolemia. 3. Mild arthritis. 4. No hypertension. PAST SURGICAL HISTORY: (Past surgical history includes) 1. Appendectomy at the age of 10. 2. Status post cataract surgery of left eye in [**2137**]. 3. Status post breast reduction in [**2125**]. 4. Status post lip tumor removal. 5. Status post face lift six to seven years ago. MEDICATIONS ON ADMISSION: (Preoperative medications include) 1. Prilosec 20 mg p.o. q.d. 2. Celexa 30 mg p.o. q.d. 3. Gentle eyedrops OU b.i.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Initial physical examination included a heart rate of 64, blood pressure of 138/87, an initial weight of 140 pounds. In general, in no acute distress. Skin was well hydrated, no rashes. HEENT revealed pupils were equal, round, and reactive to light and accommodation. Extraocular muscles were intact. No dentures. No abnormal buckle mucosa. Neck was supple, mild jugular venous distention. Chest was clear to auscultation bilaterally. No wheezes or rhonchi. Cardiovascular revealed a regular rate and rhythm, positive S1 and S2, plus [**2-24**] murmur heard best at point of maximal impulse. Abdomen was soft, nontender, and nondistended. Positive well-healed right lower quadrant scar. Extremities were warm, minimal edema, varicosities, mild spider veins bilaterally, nontender. Neurologically, cranial nerves II through XII were grossly intact. Normal motor and sensory function. Pulses were 2+ femoral, dorsalis pedis, posterior tibialis, and radially bilaterally. Negative carotid bruits right or left. RADIOLOGY/IMAGING: Electrocardiogram showed normal sinus rhythm at 62 beats per minute. HOSPITAL COURSE: The patient was admitted on [**2141-6-26**], and taken to the operating room with the initial diagnosis of mitral regurgitation. The procedure was a mitral valve replacement (#33-CE-[**Location (un) **]). The patient tolerated the procedure well and was transported to the Postanesthesia Care Unit in stable condition. On postoperative day one the patient did well in the Cardiothoracic Intensive Care Unit and was transported to the floor. On postoperative day two, the patient's chest tube was put on water seal and discontinued later that day. The patient also increased ambulation and had her Foley discontinued. On postoperative day three, the patient continued to do well with a PT level of 4. On postoperative day four, during the final physical therapy session, the patient ambulated well with an oxygen saturation in the 90s, but desaturated to the middle 80s several times at rest. The patient was reassessed, and in her latest x-ray which was taken on [**6-30**] was reviewed. The x-ray showed no changes from the previous x-ray with no infiltrates suggesting pneumonia. It was decided that the patient could be discharged to home with [**Hospital6 407**] and home oxygen until followup. On postoperative day five, the patient continued to ambulate well and was reassessed with a PT level of 5. After weighing the options between rehabilitation and discharge home, the surgical team, care coordinator, and patient thought she was well enough to go home. PHYSICAL EXAMINATION ON DISCHARGE: Temperature 97.7, pulse 76, blood pressure 98/50, respiratory rate 20, oxygen saturation was 90% on room air. Cardiovascular revealed a regular rate and rhythm. Respiratory was clear to auscultation bilaterally. Abdomen was soft, nontender, and nondistended. The incision was clean, dry and intact. PT level was 5. COMPLICATIONS: None. MEDICATIONS ON DISCHARGE: 1. Lopressor 12.5 mg p.o. b.i.d. 2. Colace 100 mg p.o. b.i.d. times seven days with Percocet. 3. Percocet one to two tablets p.o. q.4-6h. p.r.n. 4. Captopril 6.25 mg p.o. t.i.d. 5. Lasix 20 mg p.o. b.i.d. times seven days. 6. Home oxygen with [**Hospital6 407**], titrate for SaO2 greater than 93%. CONDITION AT DISCHARGE: Good/stable. DISCHARGE STATUS: To home with [**Hospital6 407**] and home oxygen. DI[**Last Name (STitle) 408**]E FOLLOWUP: Follow up with Dr. [**Last Name (Prefixes) **] in three to four weeks. DISCHARGE DIAGNOSES: 1. Status post mitral valve replacement. 2. Gastroesophageal reflux disease. 3. Hypercholesterolemia. 4. Mild arthritis. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 33068**] MEDQUIST36 D: [**2141-6-30**] 21:42 T: [**2141-7-1**] 06:16 JOB#: [**Job Number 20434**]

Admission Date: [**2166-4-11**] Discharge Date: [**2166-4-17**] Date of Birth: [**2113-11-25**] Sex: M Service: CME HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old male admitted to an outside hospital on [**4-7**] for a four-day history of dyspnea. The patient was found to be in pulmonary edema, and further review of systems indicated that the patient had nausea and vomiting four days prior to the outside hospital admission. The patient also had the sensation of abdominal discomfort at that time. Although no labs were available from the outside hospital, the patient reportedly had a flat CK but positive troponin, suggesting nausea, vomiting, and abdominal pain were symptoms of acute myocardial infarction. At that time, the patient was treated with intravenous Lasix, heparin drip, Aspirin, ACE inhibitor, Metoprolol, Plavix, and Zocor. His dyspnea improved, but a TTE at the outside hospital showed an ejection fraction of 50 percent with severe inferior-posterior lateral akinesis/hypokinesis. Earlier this morning, the patient had epigastric discomfort, similar to that which he experienced recently and was transferred to [**Hospital6 256**] for cardiac catheterization. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypercholesterolemia. 3. Hypertension. 4. Bipolar disorder. 5. Recent dental infection. MEDICATIONS ON TRANSFER: Lopressor 12.5 b.i.d., Lisinopril 2.5 q.d., Plavix 75 q.d., Zocor 80 q.d., Lasix 40 p.o. q.d., Aspirin 325 q.d., Protonix 40 q.d., Depakote 2500 q.a.m., Lamotrigine 1000 mg p.o. b.i.d., Gabapentin 300 h.s., Augment 500 t.i.d., Duragesic 15 mg transdermal q.72 hours, regular Insulin sliding scale. SOCIAL HISTORY: He smokes [**11-28**] 1/2 packs per day. He quit alcohol four years ago. He has a remote cocaine history. His father passed at age 65 secondary to myocardial infarction and cerebrovascular accident. His mother is alive at 85. The patient was brought to the Cardiac Catheterization Laboratory. Cath showed a mildly diseased left main, mild diffuse disease in the left anterior descending coronary artery, and a totally occluded proximal left circumflex with right-to-left and left-to-left collaterals to the first obtuse marginal. The patient subsequently had a left circumflex stent placed. He was also noted to have normal cardiac input and cardiac index. PHYSICAL EXAMINATION: Vital signs: Temperature 100, blood pressure 137/80, heart rate 97, respirations 14. General: He was a disheveled-appearing male in no acute distress. He had poor dentition with no purulence drainage in his mouth. HEENT: His JVP was 9 cm. Lungs: He had crackles one-half of the way up bilaterally. Heart: Regular rate and rhythm. No murmurs, rubs, or gallops. Extremities: He had 2+ pulses throughout and had no peripheral edema. Electrocardiogram at the catheterization laboratory showed normal sinus at 95, right atrial abnormality, normal axis, T- wave inversions in I, II and AVF, V4-V6, as well as 1-2 mm ST segment depressions in V2-V4. An echocardiogram on [**2166-4-8**], showed an ejection fraction of 30 percent with severe hypokinesis and akinesis of the inferior wall, severe hypokinesis of the posterolateral wall, [**11-29**]+ mitral regurgitation, 2+ tricuspid regurgitation, and mild pulmonary hypertension. HOSPITAL COURSE: 1. Coronary artery disease: The patient was continued on Aspirin, Plavix, and Integrelin for 18 hours. He was also continued on Lipitor 80 mg p.o. q.d. His cardiac medications were subsequently titrated. Eventually his medications were titrated up, and he was switched to Lisinopril 5 mg p.o. q.d., Lopressor 37 mg p.o. b.i.d., and was given Lasix p.r.n. for edema. During the rest of his hospitalization, his coronary artery disease issues remained stable. 2. Infectious disease: The patient spiked a fever on [**2166-4-14**] to over 102 degrees. As noted, the patient had a history of a recent dental infection and had been started on Augmentin 500 mg t.i.d. by the outside hospital. Blood and urine cultures were subsequently sent and were unrevealing. The Cardiac Care Unit Team empirically added Clindamycin for better anaerobic coverage. The Coronary Care Unit Team requested an inpatient dental consult. The Dental consult felt that he did not have a dental abscess, and Panorex films that obtained were unrevealing. An Oromaxofacial Surgery consult was also obtained, and they felt that while the patient had chronic dental issues, they did not believe that his teeth were the cause of fevers (and they represented chronic infection). Subsequent work-up of the fevers included placement of a PPD which was negative. The patient also reported a mild cough and a [**12-31**] week history of chronic night sweats. A chest x- ray was obtained which showed a very large left-sided pleural effusion. This was eventually tapped and was exudative in nature. The patient three induced sputums which did not grow any acid-fast bacilli. Furthermore, as mentioned previously, he had several series of blood and urine cultures which were all pending to date. Studies from the pleural fluid showed no organismss. There were no AFB on direct smear from the fluid, and fluid cultures were also negative. The patient subsequently returned for an addition thoracentesis, as a CAT scan of the chest (after the initial thoracentesis) showed that the remaining fluid had become loculated. An addition 900 cc of fluid was drained. A chest CT was obtained to evaluate for possible malignancy or granulomatous disease suggestive of tuberculosis. CT of the chest showed a small right-sided pleural effusion, a tiny patchy opacity within the right lower lobe, and a loculated left-sided pleural effusion which was lying the major fissure. There were also patchy ground glass opacities in the left lung. There was a tiny nodule in the left lower lobe. There were also noted to be mild cardiomegaly. There was also a small pericardial effusion, as well as nonpathologically enlarged mediastinal and axillary nodes. There was no significant axillary mediastinal hilar adenopathy. To complete his Infectious Disease work-up, a sinus CT was also obtained, as the patient had also been complaining of some sinus pain. This showed minimal mucosal thickening in the right maxillary sinus. The remainder of this study was unremarkable. 3. Endocrine: The patient was continued on sliding scale Insulin, as well as his outpatient dose of Glyburide. 4. Psychiatric: He was continued on all of his outpatient psychiatric medications. Also Celexa was added 20 mg p.o. q.d. Because the patient's acute coronary issues had been intervened upon, the patient was transferred to the Medicine Team for resolution of the patient's infectious disease issues, as well as the issues regarding his pleural effusion. This dictation covers the [**Hospital 228**] hospital course from [**2166-4-11**], through [**2166-4-17**]. The remainder of the [**Hospital 228**] hospital course will be dictated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name 1299**], INT Dictated By:[**Doctor Last Name 10457**] MEDQUIST36 D: [**2166-4-19**] 19:02:03 T: [**2166-4-21**] 10:23:14 Job#: [**Job Number 55754**]

Admission Date: [**2184-1-21**] Discharge Date: [**2184-1-25**] Service: MEDICINE Allergies: Codeine / Penicillins / Aspirin / Fentanyl Attending:[**First Name3 (LF) 3552**] Chief Complaint: Elective bronchoscopy Major Surgical or Invasive Procedure: Bronchoscopy x2 with biopsy of LUL mass Intubation Arterial Line Central Venous Line History of Present Illness: 80 year old woman with past medical history significant for broncheoalveolar carcinoma who was undergoing an elective bronchoscopy for biopsy of a LUL mass on [**2183-1-20**]. Approximately ~45 minutes into procedure, the patient became hypertensive , rigid and unresponsive, with oxygen saturations falling into the 50s. These symptoms resolved immediately once the bronchoscope was removed and she was bagged. She was given hydralazine IV with improvement in her SBP from 2227 to 125. She was subsequently intubated for airway protection. The patient had received 3.5mg versed and 100mg fentanyl over 45 minutes. Noted by IP staff to be very difficult to ventillate when bagmask initiated. She was transferred to the MICU with what was thought to be a dystonic reaction to fentanyl. She was noted to have a right sided neck mass after CVL placement (during which the subclavian artery was hit) and underwent an U/S which did not show a hematoma. She was also noted to have very labile BPs with systolics going into the 80s after propofol. An arterial line was placed. She was briefly placed on neo with resultant SBPs in the 220s and then controlled on a labetolol gtt; once BPs were well controlled she was transitioned to po meds (norvasc, isordil). She was extubated without incident on [**2184-1-22**]. She was also noted to have a UTI (GNR) and was started on ciprofloxacin. Past Medical History: 1. Chronic obstructive pulmonary disease. 2. Bronchoalveolar carcinoma; status post right and left upper lobectomies. 3. Hypothyroidism. 4. History of strokes and transient ischemic attacks. 5. Parkinson disease. 6. Claudication. 7. Cervical myelopathy; status post anterior disc excisions and fusions at C3-C4, C4-C5, and C5-C6. 8. Hypertension. 9. Osteoarthritis. 10. Status post right total hip replacement in [**2171**]. 11. History of drop attacks; previously on Dilantin but this was stopped and she has had no further symptoms. 12. Obstructive sleep apnea; on continuous positive airway pressure at home. 13. Restless leg syndrome. Social History: The patient lives in [**Hospital3 **] in Springhouse. She is widowed. She has no children. She smoked three quarters of a pack per day for 45 years; she quit in [**2169**]. She drank wine, one to three glasses per day, for 30 years until several months ago. No history of illicit drug use. She is a retired lawyer. Family History: Father died of gastric cancer in his 70s. Mother died of a myocardial infarction in her 60s. Physical Exam: Tm 99.2 BP 133-193/51-83 HR 69-80 RR 15 O2Sat 96%RA Gen: reclining in bed, NAD. Very gravelly voice. HEENT: PERRL, EOMI, OP clear, MMM Neck: non tender right sided neck bulge, +subclavian line. CV: regular, S1S2 2/6 SEM at RUSB Lungs: coarse breath sounds bilaterally Abd: soft, NTND, +BS Ext: w/wp, no edema Neuro: alert and oriented x3. Pertinent Results: Chemistries [**2184-1-21**] 03:55PM GLUCOSE-104 UREA N-28* CREAT-1.8* SODIUM-144 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-27 ANION GAP-14 [**2184-1-21**] 03:55PM CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-1.8 CBC [**2184-1-21**] 03:55PM WBC-7.6 RBC-3.80* HGB-11.9* HCT-33.8* MCV-89 MCH-31.3 MCHC-35.2* RDW-13.6 [**2184-1-21**] 03:55PM PLT COUNT-350 Coags [**2184-1-21**] 03:55PM PT-12.2 PTT-25.3 INR(PT)-0.9 [**2184-1-22**] 03:50AM BLOOD CK(CPK)-43 [**2184-1-23**] 04:28AM BLOOD CK(CPK)-130 [**2184-1-22**] 03:50AM BLOOD CK-MB-2 cTropnT-<0.01 [**2184-1-23**] 04:28AM BLOOD CK-MB-3 cTropnT-<0.01 [**2184-1-22**] 10:40 am URINE CULTURE > 100,000 Klebsiella, I to nitrofurantoin, S to all else. Bronch [**1-21**] COMPLICATIONS: Muscle rigidity secondary to Fentanyl resulting in hypoxemia, airway obstruction and respiratory failure. Bronch [**1-22**] DESCRIPTION OF PROCEDURE: The bronchoscope was inserted via the endotracheal tube which terminated 2 cm proximal to the carina. The right-sided airways were within normal limits, as was the trachea and left mainstem bronchus, except the presence of severe tracheobronchomalacia. The left lower lobe was patent, however, the left upper lobe lingular bronchus was completely obstructed. Endobronchial biopsies of the soft tissue mass were obtained and sent to pathology. COMPLICATIONS: None. Tissue Biopsies of LUL pending on discharge Brief Hospital Course: 80 year old woman with complicated PMH including broncheoalveolar carcinoma for which she was undergoing an elective bronchoscopy when she had an episode of rigidity, hypertension and desaturation attributed to a dystonic reaction to fentanyl and was subsequently intubated and in the MICU. s/p extubation she was transferred to the floor for observation prior to discharge back to [**Hospital3 **]. Dystonic Reaction The patient's rigidity, desaturation and hypertension were thought to be due to a dystonic reaction to fentanyl. She was intubated for airway protection and extubated without diffuculty. She subsequently maintained her oxygen saturations on room air. Fentanly was added to the patient's allergies. Broncheoalveolar Cancer The patient successfully underwent bronchoscopy the day after her dystonic reaction and biopsy specimens were obtained of her LUL mass. These were pending on discharge. Right neck mass After right sided central line placement, complicated by puncture of the subclavian artery, the patient was noted to have a right sided neck mass. This mass was non tender and stable in size, however, a neck U/S was done to rule out hematoma/aneurism and was negative. This should be followed as an outpatient. Labile BP The patient has a history of hypertension and was on isordil and norvasc as an outpatient. During her dystonic reaction her systolic pressure went as high as 225, she was given 10mg IV diltiazem with good effect and systolic pressure returning down to 125. Subsequently her ICU course was complicated by lability in blood pressures, with systolics falling to the 80s with administration of propofol. For this the patient was briefly on a neo gtt and pressures again went >200 for which she was on a labetolol gtt. Prior to leaving the MICU her pressures were stabilized on her home medications and remained well controlled through the remainder of her stay. UTI In the MICU, the patient was noted to have a urinary tract infection growing gram negative rods. She was started on a 7 day course of ciprofloxacin for a complicated UTI, which grew out klebsiella that was pan sensitive (I to nitrofurantoin). Elevated Cr Peaked at 2.2 and trended down; likely UTI and prerenal. OSA The patient will resume her CPAP at night on discharge (she declined it here). ?Dementia Continued Aricept. Hypothyroidism. Continued levoxyl. Claudication. Continue pletal. GERD Continue prevacid. Access Radial line dc'd [**2184-1-23**]. Right subclavian central line dc'd on [**2184-1-24**]. Communication With patient and nephew, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 102585**]. Discharged back to [**Hospital3 **] with her 24 hour caregiver. Medications on Admission: Methylphenidate 10mg [**Hospital1 **] Aricept 10mg qhs MVT Norvasc 10mg daily Zocor 40mg daily Lexapro 20mg daily Pletal 100mg [**Hospital1 **] levoxyl 50mg daily prevacid 30mg daily loratidine 10mg daily isordil 10mg tid Discharge Medications: 1. Donepezil Hydrochloride 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Methylphenidate HCl 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Pletal 100 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: 1. Respiratory failure requiring intubation [**1-21**] reaction to Fentanyl 2. Labile Hypertension 3. Catheter associated UTI 4. Tracheobronchomalacia 5. COPD Discharge Condition: stable Discharge Instructions: 1. Please f/u with your PCP (Dr. [**Last Name (STitle) 713**] or Dr. [**Last Name (STitle) **] in the next week. Call to schedule an appointment 2. Please note that you are allergic to a medicine called FENTANYL. Please list it as an allergy on all medical papers. 3. You have been diagnosed with a bladder infection. Please take the antibiotic Cipro for next 5 days. 4. Take all other medications as previously prescribed. 5. Call Dr. [**Name (NI) **] should you develop worsening shortness of breath, chest pain, blood sputum. 6. Call your PCP if you develop painful swallowing or swelling of the mouth or worsened swelling of the right side of the face. Followup Instructions: Call Dr.[**Name (NI) 1602**] office at ([**Telephone/Fax (1) 6846**] to schedule a follow up appointment in 1 week. Keep the following appointment: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Where: [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[**2184-5-26**] 2:30 [**Name6 (MD) 1592**] [**Name8 (MD) 1593**] MD, [**MD Number(3) 3555**]

Admission Date: [**2102-3-21**] Discharge Date: [**2102-3-28**] Date of Birth: [**2036-3-2**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine Attending:[**Doctor First Name 3290**] Chief Complaint: Pancreatitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: Medicine Admission Note CC: Abdominal pain HPI: Ms. [**Known lastname **] is a 66 yo woman with history of hypertension, possible CKD, prior CCY ([**2089**]), here from [**Hospital1 5979**] with pancreatits, after she presented there with abdominal pain. She in fact developed abdominal pain 10 days ago, on good [**Hospital1 2974**], and presented to LGH. She was discharged from the ED. She was called back for possible pulmonary edema, and to rule out MI, which was negative. After discharge, she continued to have abdominal pain, with nausea and anorexia. The pain has been constant, throughout her entire abdomen, and radiating to her back. The pain was not relieved by tylenol. She has had shortness of breath with the pain. She had dark urine, but no changes in her stool. She has not had fevers, but has had chills. Prior to the onset of pain, she had been taking protein shakes, substituting for one meal a day, for weight loss. She lost 7 lbs. She has intermittent headaches. She denies any other urinary symptoms, rashes, diarrhea, masses or lesions. ROS otherwise reviewed in 13 systems and negative. Past Medical History: PMH Hypertension, poorly controlled ?Hyperlipidemia ?CKD Prior CCY, [**2089**] Prior hysterectomy, for benign mass Prior abnormal pap smears Social History: SH: Originally from [**Male First Name (un) 1056**]. Works as secretary. No alcohol or tobacco. Married, 2 children, grown, one grandchild. Family History: FH: Mother died in early 80s, "old age", father still alive, age [**Age over 90 **], just diagnosed with cancer. Physical Exam: Physical exam Vital signs: Tmax 98.0 BP 148/78 HR 60 16 91% RA O2 sat General: in NAD, obese HEENT: Faint scleral icterus, OP moist, no LAD, JVP difficult to see. Lungs: decreased at bases, no rales, no wheezes with forced expiration. CV: RRR without murmurs Abdomen: soft, tender in epigastrium, and throughout upper abdomen, no rebound or guarding. Nondistended, bowel sounds present. Ext: no edema Neuro: alert/oriented X3, face symmetric, answers all questions appropriately, full strength in upper and lower extremities. Sensation normal. Pertinent Results: Relevant data: Labs [**3-21**] 139 105 11 119 AGap=15 ------------- 3.7 23 1.0 Trop-T: <0.01 Ca: 8.7 Mg: 1.9 P: 3.1 ALT: 803 AP: 329 Tbili: 4.1 Alb: 3.8 AST: 628 Lip: 8590 wbc 6.4 hgb 12.0 hct 38.1 plts 259 N:81.1 L:15.5 M:2.8 E:0.4 Bas:0.2 PT: 11.6 PTT: 27.8 INR: 1.1 UA with trace ketones, trace protein, 1 wbc, 1 rbc urine culture pending RUQUS [**Hospital1 18**] [**3-21**]: IMPRESSION: 1. Status post cholecystectomy with common bile duct dilatation to 13 mm, but no intrahepatic biliary duct dilatation. No stones are seem in the visualized portions of the common bile duct, though the distal duct is not well evaluated. MRCP is a more sensitive exam for the detection of choledocholithiasis and can be performed for further evaluation. 2. Echogenic liver consistent with fatty infiltration of the liver. More severe hepatic disease including significant hepatic fibrosis/cirrhosis cannot be excluded on the basis of this study EKG [**3-21**] SB nl axis, intervals, no ischemic changes. Labs at LGH [**3-21**]: Cr 1.04 Alk phos 372 Bili 5.4 AST 732 alt 911 Lipase 6741 CT from LGH, dissection protocol: No dissection, found to have acute pancreatitis, without pseudocyst or abscess. Small 5 mm increased density in the region of the pancreatic head/distal CBD could be an obstructing stone/choledocholithiasis. ERCP REPORT: A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A single stone was extracted successfully using a balloon. Two more balloon sweeps were performed that did not reveal additional stones or sludge. Impression: The ampulla appeared bulging concerning for an impacted stone Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique A moderate diffuse dilation was seen at the biliary tree with the CBD measuring 13 mm. The cholangiogram did not definitively show a filling defect in the distal CBD. However given the clinical picture suggestive of gallstone pancreatitis and the finding of bulging ampulla concerning for an impacted stone, a decision was made to perform a sphincterotomy. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A single stone was extracted successfully using a balloon. Two more balloon sweeps were performed that did not reveal additional stones or sludge. Otherwise normal ercp to second part of the duodenum [**2102-3-26**] 06:10AM BLOOD ALT-132* AST-25 LD(LDH)-223 AlkPhos-159* TotBili-0.7 Brief Hospital Course: ICU Course: 66F with PMHx of hypertension, s/p CCY [**2089**], who was transferred to [**Hospital1 18**] from LGH for acute gallstone pancreatitis s/p ERCP w/sphincterotomy [**3-22**], hospital course complicated by new onset atrial fibrillation with rapid ventricular response. # Afib w/RVR: After the ERCP, the patient developed new-onset afib w/RVR. Etiology unclear, possibly related to hypersympathetic tone in the context of acute pancreatitis. TSH was normal. Cardiac enzymes were negative. Did not anticoagulate her given CHADS2 score of 1 and bleeding risk from sphincterotomy [**3-22**] during ERCP. A TTE was performed which showed normal global and regional biventricular systolic function, However there was mild left atrial dilatation which may have been a cause or effect of the atrial fibrillation. The patient spontanously converted back to sinus rhythm. Given her CHADS 2 score, use of both aspirin and plavix can be considered. She was started on aspirin alone, and advised to discuss with her PCP any additional use of plavix. # Hypoxemia: Most likely secondary to flash pulmonary edema in the context of fluid resuscitation and new atrial fibrillation. Resolved. # Pancreatitis: Patient is s/p ERCP with sphincterotomy and stone extraction. LFTs are trending down and she reports improvement in her abdominal pain. Will continue symptom management. LFTs improved over course of hospitalization. # Leukocytosis: Patient presented with normal WBC 6.4 on admission, which rose to 16.8. Likely due to inflammation from acute pancreatitis. S/p ERCP w/sphincterotomy; no evidence of cholangitis on ERCP, but given low-grade fevers (99.5) and increasing leukocytosis, started empiric cipro. No evidence of pneumonia on CXR. She will complete one week of ciprofloxacin at home. # Hypertension: She was discharged on amlodipine and metoprolol. She will f/u with her PCP for continued blood pressure management. # ? NASH/hepatic fibrosis on ultrasound. PCP should discuss dietary measures, consider liver biopsy to further assess. Medications on Admission: Home medications: Per [**Company 25282**] - she does not know her medications Metoprolol tartare 25 mg po bid lisinopril 10 mg po bid HCTZ 12.5 mg po daily (last refilled in [**Month (only) 958**]) amlodipine 5 mg po daily (last refilled in [**Month (only) 958**]) Discharge Medications: 1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:*5 Tablet(s)* Refills:*0* 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. Disp:*10 Tablet(s)* Refills:*0* 5. Aspirin [**Hospital1 1926**] 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Home Discharge Diagnosis: gallstone pancreatitis atrial fibrillation pumonary edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with abdominal pain and found to have pancreatitis caused by gallstones. An ERCP was performed to remove the stone. Your course was complicated by Atrial Fibrillation (irregular heart rhythm) with rapid heart rate and fluid in the lung requiring ICU stay. Your heart rate was controlled and you were moved back to the medical floor. You were able to start eating on [**2102-3-26**]. You will need to follow up with your PCP to discuss treatment for Atrial Fibrillation with at least daily aspirin, but this may also include an additonal medication, Clopidogrel. You need to complete one week of antibiotic treatment with ciprofloxacin and this will end on [**3-30**]. In regards to your blood pressure, please take metoprolol 25 mg by mouth twice a day, and restart the amlodipine at 5 mg daily. Hold the hydrochlorothiazide and lisinopril until you see Dr [**Last Name (STitle) 63252**] on [**Last Name (STitle) 2974**]. Please start taking a baby aspirin every day starting on [**3-30**]. You may take dulcolax (bisacodyl) to help you move your bowels. Followup Instructions: PCP [**Name Initial (PRE) **]: [**Last Name (LF) 2974**], [**3-31**] at 4:15pm With: [**Name6 (MD) **] [**Name8 (MD) **],MD Location: [**Hospital 46644**] MEDICAL ASSOCIATES Address: [**Location (un) 46645**], [**Hospital1 **],[**Numeric Identifier 46646**] Phone: [**Telephone/Fax (1) 34574**]

Admission Date: [**2186-1-25**] Discharge Date: [**2186-1-28**] Date of Birth: [**2138-12-11**] Sex: F Service: PLASTIC Allergies: Aspirin Attending:[**First Name3 (LF) 16920**] Chief Complaint: acquired deformity, right breast Major Surgical or Invasive Procedure: right [**Last Name (un) **] breast flap on [**2186-1-25**] History of Present Illness: This 47-year-old female was seen in the Multidisciplinary Breast Unit with a new diagnosis of carcinoma of the right breast diagnosed by core needle biopsy [**2185-11-14**]. This was ductal carcinoma in situ. She is here for mastectomy and breast reconstruction. Past Medical History: The patient sustained a right hemiparesis from a subarachnoid brain hemorrhage in [**2185-10-20**]. She has recovered almost completely from the right hemiparesis. Other significant past medical history includes hypertension and vertigo. Social History: n/c Family History: She has a sister who was diagnosed with breast cancer at age 36. Physical Exam: GENERAL: She is a very pleasant 47-year-old woman who looks her stated age, pleasant, and appropriate affect. VITAL SIGNS: Height five feet eight inches. Weight 190 pounds. Blood pressure 150/90. Pulse is 66. HEENT: Within normal limits. NECK: Supple. There is no thyroid enlargement or nodules. There is no cervical or supraclavicular adenopathy. BREASTS: Symmetric. There is no nipple retraction nor skin dimpling. She has an area suggestive of some fullness in the lower outer quadrant of the right breast. There is no axillary adenopathy. CHEST: Clear to percussion and auscultation. CARDIAC: Regular rate and rhythm. BACK: Nontender without bony tenderness. There are no abnormal pigmented lesions and she has a normal gait. Pertinent Results: [**2186-1-25**] 10:23PM BLOOD Calcium-8.0* Phos-5.2* Mg-1.3* [**2186-1-25**] 10:23PM BLOOD Glucose-136* UreaN-10 Creat-0.7 Na-138 K-4.6 Cl-106 [**2186-1-25**] 10:23PM BLOOD Plt Ct-318 [**2186-1-25**] 10:23PM BLOOD WBC-15.3*# RBC-3.87* Hgb-10.7* Hct-33.5* MCV-87 MCH-27.7 MCHC-32.0 RDW-15.2 Plt Ct-318 [**2186-1-26**] 02:54AM BLOOD Calcium-7.7* Phos-4.1 Mg-2.5 [**2186-1-26**] 02:54AM BLOOD Glucose-126* UreaN-11 Creat-0.6 Na-139 K-4.4 Cl-107 HCO3-24 AnGap-12 [**2186-1-26**] 02:54AM BLOOD Plt Ct-287 [**2186-1-26**] 02:45PM BLOOD Plt Ct-224 [**2186-1-26**] 02:54AM BLOOD WBC-14.2* RBC-3.38* Hgb-9.5* Hct-29.1* MCV-86 MCH-28.0 MCHC-32.5 RDW-15.5 Plt Ct-287 [**2186-1-26**] 02:45PM BLOOD WBC-9.2 RBC-2.86* Hgb-8.0* Hct-24.6* MCV-86 MCH-28.1 MCHC-32.6 RDW-15.4 Plt Ct-224 [**2186-1-27**] 01:33AM BLOOD Calcium-7.7* Phos-2.0*# Mg-1.7 [**2186-1-27**] 01:33AM BLOOD Glucose-96 UreaN-8 Creat-0.5 Na-139 K-3.7 Cl-108 HCO3-27 AnGap-8 [**2186-1-27**] 01:33AM BLOOD Plt Ct-213 [**2186-1-27**] 01:33AM BLOOD WBC-9.6 RBC-3.13* Hgb-8.9* Hct-26.9* MCV-86 MCH-28.6 MCHC-33.3 RDW-15.6* Plt Ct-213 Brief Hospital Course: The patient was taken to the operating room where she underwent a mastectomy and [**Last Name (un) **] flap of the right breast. She tolerated the procedure well and was transferred to the ICU. She had good dopplerable pulses throughout her ICU stay. She tolerated a regular diet on POD 1. She voided appropriately and her foley was removed on POD 2. She was transferred to the floor on POD 2 and continued to have good dopplerable pulses on the floor. She was discharged in good condition on POD 3. Medications on Admission: Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 4. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p right [**Last Name (un) **] breast flap on [**2186-1-25**] Discharge Condition: good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Be sure to record your drain output every day. Followup Instructions: Call to schedule a follow-up appointment next week with Dr. [**First Name (STitle) 3228**]. His phone number is ([**Telephone/Fax (1) 23640**].

Admission Date: [**2132-8-6**] Discharge Date: [**2132-8-21**] Date of Birth: [**2062-5-28**] Sex: M Service: CHIEF COMPLAINT: Difficulty swallowing x2 days HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old man with a history of diabetes, hypertension and alcohol abuse, as well as a recent embolic stroke diagnosed on [**2132-7-19**]. He presented with his initial stroke to [**Hospital3 **] Hospital. He apparently had multiple small embolic strokes that left him with a left sided residual hemiparesis. At that time, he had a CT scan, MRI, cardiac echocardiogram and Holter monitor. His head CT was significant for an area of low attenuation at the left head caudate and another area adjacent to the occipital lobe with no mass effect. His MRI on [**7-20**] showed a wedge shaped infarct in the medial cortex of the left occipital lobe and multiple smaller areas extending from this area anterior into the left occipital lobe and posterior temporal lobe, also significant for lesions in the left cerebellar hemisphere, several small punctate lesions in the brain stem and the right median lower pons and centrally in the upper pons. and there was a questionable lesion in the right cerebellar hemisphere, as well as a possible region in the right thalamus. His MRA on [**7-20**] showed stenosis of the right vertebral artery and abrupt termination of the distal left vertebral artery. His basilar artery was patent without any significant stenosis and he had an abnormal appearance of both posterior cerebral arteries. He had a Holter monitor which showed no evidence of any abnormal activity. His echocardiogram on [**7-21**] was a transesophageal echocardiogram which showed his left atrium was normal size, normal right ventricular and left ventricular function with mild atheroma of the left descending aorta and no evidence of a patent foramen ovale and his tricuspid aortic valve showed mild thickening. He was eventually discharged from [**Hospital3 **] Hospital and sent to [**Hospital3 **] Manor for acute rehabilitation from his multiple infarcts. According to his primary care physician, [**Name10 (NameIs) **] was doing well in his rehabilitation until Monday, [**2132-8-4**]. At that time, he was noted to have significant left residual weakness in both arms and legs, but he seemed motivated to participate in rehabilitation and was able to feed himself, as well as participate in group activities. According to his primary care physician, [**Name10 (NameIs) **] was an acute change in his behavior on the Monday prior to admission. He appeared to be less interested in group activities and to have a lot more difficulty with feeding himself. He was observed to take food into his mouth, but then did not seem to know what to do with it. He had pushed it around, but he would not swallow it appropriately. He was also observed not to have any choking with these events. He denied having any swallowing problems himself when the patient is asked directly. REVIEW OF SYSTEMS: On admission, he denies chest pain, shortness of breath, palpitations, abdominal pain, nausea, dysuria and diarrhea. PAST MEDICAL HISTORY: 1. Diabetes mellitus type II 2. Stroke on [**2132-7-19**] 3. Hypertension 4. Coronary artery disease, status post myocardial infarction at uncertain time in past. 5. Possible history of alcohol abuse ADMISSION MEDICATIONS: 1. Plavix 75 mg po q day 2. Aspirin 325 mg po q day 3. Colace 100 mg po bid 4. Senokot 2 tablets po q hs 5. Zestril 10 mg po q day 6. Cardizem 90 mg po 4x a day ALLERGIES: He has no known drug allergies. SOCIAL HISTORY: The patient reports a history of heavy alcohol use in the past. When asked, the patient says he used to drink about half a bottle of whiskey a day. History of tobacco use in the past of a half pack per day, however he has not smoked since his initial stroke on [**2132-7-19**]. He lives in [**Location 3615**] and has four children in [**State 350**]. FAMILY HISTORY: The patient was unable to answer at that time. EXAMINATION ON ADMISSION: GENERAL: The patient was sleepy, but easily arousable. VITAL SIGNS: His blood pressure was 173/106. Pulse was 87, respirations 18. HEAD, EARS, EYES, NOSE AND THROAT: He was normocephalic, atraumatic. Oropharynx was clear. Dry mucous membranes. He had no carotid bruits. Audible breath sounds, but he would not cooperate with holding his breath. LUNGS: Clear to auscultation bilaterally. CARDIAC: Regular rate and rhythm, S1, S2 normal, no murmurs, rubs or gallops appreciated. ABDOMEN: Soft, obese, nontender with normoactive bowel sounds. EXTREMITIES: He had no edema. ADMISSION NEUROLOGIC EXAM: Mental status: He was oriented to person and [**Location (un) 86**], but could not come up with the word hospital. He said it was [**2093**] and that it was Spring. Asked how he knew it was Spring and he said because the snow melts in the Spring. He agreed that he was in the hospital when asked and when asked if he was in school, he said no. The patient was moderately attentive, able to name the days of the weeks forwards and backwards, but unable to get past [**Month (only) 1096**] on months of the year backwards. He recalled zero objects at two minutes. He was able to repeat three objects, however and was able to repeat sentences with mild dysarthria. His naming was intact to ring, watch, eyeglasses and pen. He had poor knowledge for current events. He said that the current president is [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 780**] and when asked if [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 780**] was still alive, he said probably not. The patient had no spontaneous verbal output for responding to questions, without any paresthesias or perseveration. His sentence length was varied and up to at least five or six words. When asked if I was wearing a hat, he appropriately responded no. He was able to demonstrate brushing his teeth. When asked to pretend to drink a cup of coffee, he refused. His writing was very poor. When asked to write today is a sunny day, he started writing in the middle of the paper and then quickly ran out of paper on the side of the page and tried to write on the examiner's hand. When given a piece of paper with two numbers written on it, he was only to name the number on the right hand side and ignored the other number. When asked to draw a clock, he drew a tiny circle on the right hand side of the page and when asked to draw the numbers on the face, he drew the 1 and 2 inside the circle and then proceeded to draw the other numbers off the right hand side of the paper. Cranial nerves: His visual acuity was normal, but difficult to test. He was able to name objects shown to him appropriately, however when shown a visual acuity card, he was only able to name the first number and then just appeared to name numbers randomly. His pupils react normally to light. His visual fields appeared possibly reduced over the left hemifield, though again the patient would not cooperate His optic fundi were normal in appearance. His eye movements were normal and full. Sensation on his face was decreased to light touch and pinprick over V1 through V3 on the left base. He has a left facial droop. His hearing is intact to bilaterally. He had a palate that elevated in the midline with a good gag reflex. His sternocleidomastoid muscles were 5/5 strength bilaterally. His tongue was midline. Motor system: The patient had decreased tone in the left upper extremity and left lower extremity. No adventitious movements. His drain on the left in his deltoid was one. Biceps strength was [**4-1**], triceps strength was [**2-2**]. Wrist flexors and wrist extensors only had 3/5 strength. His finger flexors and finger extensors had minimal movement. Iliopsoas on the left was 4/5 strength. His hamstrings were [**3-4**]. Tibialis anterior was only [**2-2**] and his toe extensors and toe flexors only had about 2/5 strength. His right upper extremity and lower extremity had full strength throughout. Sensory exam was difficult due to poor cooperation, however the patient had sensation intact to light touch and position sense in all four extremities. Decreased vibration sense bilaterally in the lower extremities and pinprick decreased over the left base and left leg, but not decreased in the left arm. His reflexes were 2+ and symmetric throughout, except for plantar responses upgoing in the left and downgoing in the right. On coordination testing, the patient was unable to cooperate on left upper extremity because of weakness, however on his right finger nose finger test he significantly overshot to the right on every motion. His gait was not assessed on admission. ADMISSION LABS AND STUDIES: White count 7.9, hematocrit 39.3, platelets 149. Sodium 135, potassium 3.5, BUN 10, creatinine 0.8, glucose 204. His urine output was unremarkable and he had a chest x-ray that showed no evidence of any infiltrates or effusions. The patient had an MRI on the night of admission which showed bilateral occipital infarcts on FLAIR imaging. Diffusion weighted imaging was unobtained due to problems with the scanner. Also, note was made of a lesion in the right dome. His MRA was significant for a hypoplastic left vertebral artery that possibly ended in pica. His right vertebral artery was noted to be significantly stenotic, although the basilar artery was unremarkable. The patient was admitted to the neurological service. HISTORY OF HOSPITAL COURSE: The morning after admission, it was decided to start him on a heparin drip due to the stenosis in his right vertebral artery as well as the thought that he may be continuing to throw emboli into his posterior circulation. He had a angiogram on the [**8-7**] which again was significant for right vertebral artery stenosis. He remained stable over the weekend on heparin except for the fact that he was unable to be propped up in bed at all because his mental status significantly decreased any time you sat him up. Due to the nature of his significant inability to tolerate any position other than lying flat, decision was made to try and place a stent in his right vertebral artery. On [**8-11**], he had a repeat angiogram in the interventional radiology suite and two stents were placed in his right vertebral artery. There were no complications of the procedure and the patient did well. The patient was briefly transferred out to the floor team on [**2132-8-14**], but then was noted to have a fever to about 102?????? and it was noted that in the area of his right wrist where he had had his arterial line, he now had evidence of an infection and right hand cellulitis. He had blood cultures, urine cultures, a chest x-ray and an abdominal film done. The chest x-ray and his abdominal film were both unremarkable. His blood cultures ended up growing 4/4 bottles of coagulase positive Staphylococcus aureus bacteria which were sensitive to oxacillin. The patient was started on oxacillin for this infection as well as for his cellulitis. He was also found to have an enterococcal urinary tract infection which was treated with levofloxacin. Surgery was also consulted regarding his right wrist infection, however they recommended antibiotics only with no debridement. After several days, his fever cleared and his mental status improved significantly. Overall, throughout his hospital course, he has had minimal improvement in his right upper extremity and left lower extremity weakness with progressive increase in tone and hyperreflexia throughout his hospital course. He did improve significantly after his right vertebral stent in the sense that he is now able to tolerate multiple postural positions without any worsening of his mental status. The patient had a swallowing study which he successfully passed and he will be started on a pureed and honey thickened diet and advanced if he tolerates it. He is going to continue on oxacillin, as well as continue Diltiazem for his blood pressure control. DISCHARGE DIAGNOSES: 1. Status post multiple embolic strokes in the past month 2. Hypertension 3. Diabetes 4. Coronary artery disease 5. History of prior heavy alcohol use DISCHARGE CONDITION: Stable DISCHARGE STATUS: Discharge to rehabilitation facility. DISCHARGE MEDICATIONS: 1. Plavix 75 mg po q day 2. Zantac 150 mg po bid 3. Oxacillin 2 gm intravenous q6h 4. Diltiazem 90 mg po qid 5. Multivitamin 1 tablet po q day 6. Aspirin 325 mg po q day 7. NPH insulin 5 units subcutaneous breakfast and dinner time DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-190 Dictated By:[**Last Name (NamePattern1) 1203**] MEDQUIST36 D: [**2132-8-20**] 08:22 T: [**2132-8-20**] 08:31 JOB#: [**Job Number 42864**]

Admission Date: [**2188-6-11**] Discharge Date: [**2188-6-30**] Date of Birth: [**2124-3-3**] Sex: F Service: SURGERY Allergies: aspirin / Erythromycin Base / Ether / Penicillins / Sulfa(Sulfonamide Antibiotics) / Tetracycline Attending:[**First Name3 (LF) 598**] Chief Complaint: Perineal erythema and pain. Major Surgical or Invasive Procedure: Incision and debridements of Fournier's gangrene X 5 ([**2188-6-11**], [**2188-6-12**], [**2188-6-13**], [**2188-6-13**], [**2188-6-15**]) Wound vac change X 4 ([**2188-6-17**], [**2188-6-19**]) Abdominal and perineal wound washout, V.A.C. change, partial wound closure ([**2188-6-21**], [**2188-6-24**], [**2188-6-27**]). PICC line insertion: [**2188-6-23**] History of Present Illness: 64F presents to the [**Hospital1 18**] ER as a transfer from an OSH with increasing erythema and pain in her perineum. She stated she first noticed some mild pain and swelling in the perineal region 2 days prior. She stated over the past 2 days the erythema has been spreading and increasingly more painful. A CT performed at the OSH demonstrated subcutaneous edema and air concerning for Fournier's gangrene and the patient was immediately transferred to [**Hospital1 18**] for further care. She was also given Vancomycin, cefepime and clindamycin en route. Past Medical History: Past Medical History: COPD, OA, Meniere's, Anxiety, AVNRT s/p ablation Past Surgical History: cholecystectomy, appendectomy, tonsillectomy, breast biopsy, knee surgery Social History: [**1-27**] ppd smoker, occasional alcohol, denies illicit drugs. Family History: Non-contributory. Physical Exam: On admission: Vitals: T 100.0 P 116 BP 94/58 RR 20 O2 99% 2L GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses, well healed midline scar DRE: decreased tone, no gross or occult blood Skin: Erythema and edema extending for the right perineum through the labia and mons pubis, area is very tender to mild palpation Ext: No LE edema, LE warm and well perfused On discharge: Vitals: T 98, HR 98, BP 128/60, RR 18, Sat 92% room air. Gen: AAO x 3, NAD. Card: S1, S2, RRR. No m/r/g. Pulm: Clear bilaterally (from anterior). Abd: Soft, obese, non-tender. Active BS throughout. GU: Foley catheter with clear yellow urine. Skin and wounds: Four large surgical wounds closed with stures. CDI. 1) Right lateral superior (just lateral to umbilicus) 2) Right lateral inferior (in close proximity to incision #1) 3) Right groin incision 4) Left groin incision Extrem: Warm, dry, well-perfused. Patient with erythema and pruritis of upper extremities. Pertinent Results: [**2188-6-11**] 03:30AM WBC-21.0* RBC-3.79* HGB-12.1 HCT-35.6* MCV-94 MCH-31.9 MCHC-33.9 RDW-13.4 [**2188-6-11**] 03:30AM NEUTS-91.1* LYMPHS-6.6* MONOS-2.0 EOS-0.2 BASOS-0.1 [**2188-6-11**] 03:30AM PLT COUNT-240 [**2188-6-11**] 03:30AM CALCIUM-8.3* PHOSPHATE-2.7 MAGNESIUM-1.7 [**2188-6-11**] 03:30AM GLUCOSE-103* UREA N-16 CREAT-0.9 SODIUM-135 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-22 ANION GAP-18 [**2188-6-11**] 03:42AM LACTATE-2.9* [**2188-6-12**] 07:05AM BLOOD WBC-17.2* RBC-3.43* Hgb-10.7* Hct-32.6* MCV-95 MCH-31.1 MCHC-32.7 RDW-13.5 Plt Ct-240 [**2188-6-12**] 07:05AM BLOOD Plt Ct-240 [**2188-6-11**] 03:30AM BLOOD Glucose-103* UreaN-16 Creat-0.9 Na-135 K-3.8 Cl-99 HCO3-22 AnGap-18 [**2188-6-12**] 07:05AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9 Brief Hospital Course: Ms. [**Known lastname 43313**] was admitted to the TSICU after her operation. She was initially kept NPO and on IVFs. Her wound was closely monitored. She did not complain of pain and felt better throughout the day. She was given a regular diet. She was able to get out of bed to chair. She was ready for transfer out of ICU on HD 1. However, once on the floor, her cellulitis continued to spread. She was taken to the OR urgently that night and had further debridement. She was taken to the SICU after the OR, intubated and sedated. Her cellulitis continued to spread and she was again taken to the OR for further debridement and packed with saline gauze. On HD 5, she was taken back to the OR. There appeared to be no further evidence of infection and her fascia and soft tissues appeared okay, a wound VAC x2 was placed over her abdomen & perineal incisions. She was stable in the ICU. Her vent settings were weaned until she was successfully extubated on [**2188-6-16**]. She was intermittently agitated and haldol and ativan were given prn. She went to the OR again on [**6-17**] for VAC change. She was started on tylenol and dilaudid prn for pain control. Speech and swallow evaluated her and she was given thin liquids, which she tolerated. On [**6-18**] clindamycin was dc'd. Overnight, she had high stool output, with diarrhea multiple times during the day, and she was taken to the OR for VAC change. A rectal tube was placed the next day and a cdiff sent, which was negative. Vancomycin was also discontinued and a planned 3 week course of meropenem was recommended by ID. She passed speech and swallow eval and was continued on a regular diet, which she tolerated. She was transferred to the floor on [**6-19**]. On the floor she remained alert and oriented. She continued on meropenem. A PICC line was placed under fluoroscopy on [**6-23**]. Her leukocytosis resolved and vac changes continued q3 days and as needed in the operating room. Through each procedure, the majority of her wounds have been surgically closed. Her diarrhea slowed and her rectal tube was discontinued. Her foley catheter was kept in place to avoid wound contamination. She has been urinating without issue. She was encouraged to mobilize out of bed as tolerated. On the day of discharge, Mrs.[**Known lastname 112272**] right lateral (most superior) wound was closed at the bedside. She is hemodynamically stable and afebrile. She remains with a foley catheter, which may be discontinued once assessed at the rehab facility. She has been informed of her transfer to a rehabilitation facility. I have also instructed her on the importance of keeping her wounds (perineal, groin area) clean and use of miconazole powder to prevent fungal infections. Medications on Admission: Calcium, vit b12 100 mcg, omeprazole 20'', prednisone 10', effexor 225', vicodin prn, atrovent 17mcg 2 puffs '''', ativan 2''' prn, meclizine 25 q4h prn, compazine 5 q4h prn, ultram 50 q6h prn, hydrochlorathiazide 12.5' Discharge Medications: 1. Sarna Lotion 1 Appl TP QID:PRN itching 2. Miconazole Powder 2% 1 Appl TP [**Hospital1 **] apply to groin, clean area daily before re-application 3. Meropenem 1000 mg IV Q8H 4. Omeprazole 20 mg PO DAILY 5. PredniSONE 10 mg PO DAILY 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Venlafaxine XR 225 mg PO DAILY 8. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain 9. Albuterol Inhaler [**11-26**] PUFF IH Q4H:PRN wheeze 10. Ipratropium Bromide MDI 2 PUFF IH QID 11. Lorazepam 2 mg PO Q4H:PRN anxiety 12. Meclizine 25 mg PO Q6H:PRN dizziness 13. Prochlorperazine 5 mg PO Q4H:PRN nausea Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**] Discharge Diagnosis: Fournier's Gangrene Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with an infection of your fascia in your perineal area called Fournier's Gangrene. This infection required multiple debridements in the operating room and a wound vac dressings. You were treated with IV antibiotics along with surgical debridment and your infection stopped. After your surgeries, you now have multiple surgical incisions that are closed with sutures. It will be very important that you keep those areas clean and dry. Wash with soap and water in your perineal area daily, if not twice a day, and place Miconazole (anti-fungal) powder to those areas after cleaning. You are being discharged to a rehabilitation facility who will coordinate and administer your medications. Follow up appointments have been made for you to see your PCP and [**Name Initial (PRE) **] surgeon from [**Hospital1 18**] (see below). Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD When: THURSDAY [**2188-7-17**] at 2:30 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 112273**], MD Specialty: Primary Care Address: [**Last Name (un) 59485**], [**Location **],[**Numeric Identifier 21478**] Phone: [**Telephone/Fax (1) 9674**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2188-6-30**]

Admission Date: [**2155-8-16**] Discharge Date: [**2155-8-22**] Date of Birth: [**2079-10-10**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old woman with a past medical history notable for peptic ulcer disease with a history of "bleeding ulcer," coronary artery disease, diabetes mellitus type 2 and multiple sclerosis, who presented to the [**Hospital1 69**] emergency department early on the morning of admission complaining of epigastric pain. The patient stated that, approximately two weeks prior to presentation, she began experiencing diarrhea alternating with constipation. Then, approximately two days prior to admission, the patient began having only constipation. When the patient did have bowel movements, they were black and tarry. This was an unprecedented occurrence for her. The patient denied having any recent hematochezia, hemoptysis or hematemesis. At approximately 2 AM on the morning of admission, the patient was awakened by epigastric pain which was [**6-10**] in severity and constant in duration. The patient could not describe the quality of pain. She felt that it was well localized to her epigastrium, although she admitted that she also experienced interscapular pain with this episode of epigastric pain. She was not surprised by this, as she reported that she had interscapular pain "whenever I get stomachaches--since I was a kid." The patient was brought by EMS to the [**Hospital1 69**] emergency department, where her pain abated completely shortly after receiving Maalox at approximately 9:30 AM. REVIEW OF SYSTEMS: Of note, the patient admitted that for approximately five years her stool had been of smaller caliber. She denied any other change in her bowel or bladder patterns. She specifically denied fevers, chills, nausea, vomiting, diarrhea or headache. She denied sore throat, cough, recent change in weight and night sweats. In terms of the patient's cardiovascular status, she specifically denied having had any pain radiating to her left jaw (her anginal equivalent) since her coronary artery bypass grafting in [**2141**]. She denied chest pain, dyspnea, palpitations, diaphoresis, lower extremity edema, paroxysmal nocturnal dyspnea and orthopnea. (Although she used two pillows for sleeping, she said that she did not become dyspneic without them.) The patient denied any recent illnesses, including changes in her multiple sclerosis. Similarly, she denied recent changes in her appetite, diet and medication regimen. Her fingerstick blood sugars had been consistently running under 120. PAST MEDICAL HISTORY: 1. Coronary artery disease: The patient had no history of known myocardial infarction. She did have angina (left jaw pain), which led to cardiac catheterization, which subsequently led to coronary artery bypass grafting in [**2151**]. The patient had not had any angina since her coronary artery bypass grafting. 2. Congestive heart failure: The patient had an ejection fraction of 20-25% by echocardiogram in [**2155-10-2**] with left ventricular hypokinesis, moderate mitral regurgitation and mild pulmonary hypertension. 3. Peptic ulcer disease: The patient had a history of a "bleeding ulcer" in [**2146**] with hematochezia. Per the patient, this was an upper gastrointestinal bleed. No intervention was required at that time. No pertinent records were currently available for this history of bleeding ulcer. The patient was on ranitidine. 4. Diabetes mellitus type 2: This was diagnosed approximately one year prior to admission, per the patient. This was well controlled on Glyburide with fingersticks consistently under 120. 5. Hypertension: Per the patient, her blood pressure typically ran in the 120s-130s/80s. 6. Hypercholesterolemia. 7. Multiple sclerosis: This was diagnosed when the patient was approximately 35 years old. Per the patient, this had not affected her vision but rather her lower extremities and balance, such that she had difficulty walking well. 8. Spinal stenosis. 9. Mild dementia. 10. Urinary incontinence, likely functional, as the patient had trouble getting to the bathroom in time. 11. History of right shoulder pain, status post a fall. 12. Chronic lower back pain, which continued status post laminectomy in [**2148**]. 13. Status post appendectomy in [**2120**]. 14. Status post surgery to correct trigeminal neuralgia in [**2118**]. MEDICATIONS ON ADMISSION: 1. Amantadine 100 mg p.o. b.i.d. 2. K-Dur p.o. q.d. 3. Lopressor 50 mg p.o. b.i.d. 4. Lipitor 20 mg p.o. q.d. 5. Lorazepam 2 mg p.o. h.s. 6. Vioxx p.o. q.d. 7. Glyburide 1.25 mg p.o. q.d. 8. NitroQuick p.r.n. 9. Ranitidine 150 mg p.o. b.i.d. 10. Folic acid 400 mg p.o. q.d. 11. Aspirin 325 mg p.o. q.d. 12. Moexipril 15 mg p.o. q.d. 13. Lasix 20 mg p.o. q.d. 14. Zoloft p.o. q.d. 15. Tylenol #3 p.r.n. 15. Ditropan p.r.n. SOCIAL HISTORY: The patient lived alone at home in [**Location (un) **], [**State 350**]. She had two boarders who lived upstairs in her home. She would like to move to an [**Hospital3 12272**] facility soon. The patient denied a tobacco history. She admitted rare alcohol use, but not abuse. The patient denied any other drug use. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a temperature of 97.2??????F, a heart rate of 86, a blood pressure of 171/86 in the left arm and 181/80 in the right arm, respirations of 14 per minute and an oxygen saturation of 97% on room air. In general, the patient was a pleasant 75-year-old woman, awake and in bed, in no acute distress. On head, eyes, ears, nose and throat examination, the pupils were equal, round and reactive to light and accommodation bilaterally. The extraocular movements were intact bilaterally. The nasal and oral mucosa were clear. The mucous membranes were moist. The neck was supple without thyromegaly, jugular venous distention, lymphadenopathy or bruits. The heart had a II/VI systolic ejection murmur heard maximally at the apex with a sinus S1 and S2 and no rubs or gallops. The chest had mildly decreased breath sounds with occasional rhonchi at the bases bilaterally. Otherwise, the chest was clear to auscultation bilaterally with a well healed sternotomy scar. The abdomen was soft, but mildly tender to palpation, especially in the left lower quadrant. The abdomen was nondistended with positive normal active bowel sounds. There was a well healed midline scar, apparently due to exploratory laparotomy, which eventually led to appendectomy. The gastrointestinal evaluation revealed dark stool that was guaiac positive. The patient was nasogastrically lavaged in the emergency department with 250 cc of fluid, revealing no blood and no bile. In the extremities, the venous graft harvest site was well healed at the right lower extremity with no clubbing, cyanosis or edema. Pedal pulses were 2+ bilaterally. On neurological examination, the patient was alert and oriented times three. Speech was normal and appropriate. Cranial nerves II through XII were intact bilaterally with the possible exception of the tongue deviating slightly to the right. Strength was [**4-5**] in the upper extremities and lower extremities proximally and distally bilaterally. Sensation was intact to light touch bilaterally at the distal lower and upper extremities as well as the three divisions of cranial nerve V. Rapid alternating movements were intact bilaterally. Reflexes were 0 at the lower extremities bilaterally and 2+ symmetrically at the upper extremities. The right toe was downgoing and the left toe was equivocal. LABORATORY DATA ON PRESENTATION: Note that the patient was guaiac positive, but nasogastric lavage negative (as noted above.) The CBC revealed a white blood cell count of 10,300, hematocrit of 30.0 (which upon repeat was 31) and platelet count of 289,000. Chem 7 revealed a sodium of 138, potassium of 6.0 (which upon repeat was 4.0), chloride of 108, bicarbonate of 19, BUN of 49, creatinine of 1.3 and glucose of 121. Coagulation studies revealed a prothrombin time of 12.4, partial thromboplastin time of 25.6 and INR of 1.0. Liver function tests and pancreatic function tests revealed an ALT of 33, AST of 52, total bilirubin of 0.2, amylase of 41 and lipase of 21. Cardiac enzymes were cycled times three: CK #1 was 287 with an MB of 6, CK #2 was 177 with an MB of 4 and a troponin of less than 3 and CK #3 was likewise negative. RADIOLOGY DATA ON PRESENTATION: The chest x-ray showed cardiomegaly with no increase in pulmonary vasculature and no infiltrates or effusions. There was degenerative joint disease of the spine. There was no air under the diaphragm. ELECTROCARDIOGRAM: The electrocardiogram showed an old left bundle branch block and sinus rhythm with no acute changes. HOSPITAL COURSE: What follows is an outline of the [**Hospital 228**] hospital course by problem list. 1. GASTROINTESTINAL BLEED: The patient was admitted initially to the medicine service and the gastrointestinal service was consulted. On [**2155-8-17**], the patient underwent an esophagogastroduodenoscopy, which revealed grade 1 esophagitis at the gastroesophageal junction as well as a large, cratered, 3 cm ulcer with adherent clot in the proximal bulb of the duodenum. A visible vessel suggested recent bleeding. BICAP electrocautery was applied successfully for hemostasis. Otherwise, the esophagogastroduodenoscopy was normal to the third part of the duodenum. The patient was continued on Protonix 40 mg p.o. b.i.d. Her aspirin and Vioxx had been held since admission. Helicobacter pylori was sent, which eventually came back as positive. Late in the evening of [**2155-8-17**], the patient began to experience hematemesis. Nasogastric lavage could not successfully clear the patient and thus she was transferred to the medical intensive care unit. The patient was transfused two units of packed red blood cells and subsequently underwent embolization by the interventional radiology team. Following embolization, the patient experienced a second mild hematocrit drop and was transfused an additional two units. Thereafter, her hematocrit remained stable. In terms of the patient's Helicobacter pylori, she was started on a Prevpac, which she is to continue for two weeks. Following conclusion of the Prevpac, the patient should be maintained on Protonix or some other gastrointestinal prophylaxis and she should not be given non-steroidal anti-inflammatory drugs or aspirin, as she has a risk of re-bleeding. Other gastrointestinal issues for the patient include the fact that she has a history of decreased stool caliber for approximately the past five years. Thus, she will need a follow up colonoscopy as an outpatient to evaluate for possible malignancy. 2. CARDIOVASCULAR: a) In terms of the patient's coronary artery disease, she was ruled out for myocardial infarction. Her aspirin was discontinued upon admission because of the risk of gastrointestinal bleed. She was continued on Lipitor, Lopressor and a cardiac diet. b) In terms of the patient's blood pressure, pump status and history of congestive heart failure, she was continued on Lopressor and Lasix. 3. DIABETES MELLITUS TYPE 2: The patient was maintained on her outpatient regimen of Glyburide and maintained good fingerstick blood sugars. 4. MULTIPLE SCLEROSIS: The patient was continued on her amantadine without any exacerbations of her multiple sclerosis. 5. FLUID, ELECTROLYTES AND NUTRITION: Following embolization, the patient's diet was advanced successfully and she tolerated it without nausea, vomiting or diarrhea. Her electrolytes remained stable. 6. PROPHYLAXIS: The patient was maintained for a time on Protonix drip, followed thereafter by her Prevpac which, after outpatient discharge, is to be followed by other gastrointestinal prophylaxis per her primary care physician. CONDITION ON DISCHARGE: The patient remained stable and afebrile. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed: duodenal ulcer. 2. History of coronary artery disease. 3. Congestive heart failure. 4. Diabetes mellitus type 2. 5. Hypertension. 6. Multiple sclerosis. DISCHARGE MEDICATIONS: The patient was discharged on her above noted outpatient medication regimen with the notable exceptions of aspirin and non-steroidal anti-inflammatory drugs, which were discontinued due to the risk of re-bleed. Furthermore, the patient was discharged on Prevpac q.d., of which she is to finish a two week course. Following conclusion of her Prevpac, the patient should be placed on gastrointestinal prophylaxis such as Protonix or an H2 blocker. FOLLOW UP: The patient should follow up with her primary care physician within the following week. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (NamePattern1) 1550**] MEDQUIST36 D: [**2155-8-22**] 11:00 T: [**2155-8-22**] 11:52 JOB#: [**Job Number 27714**]

Admission Date: [**2105-6-12**] Discharge Date: [**2105-6-19**] Date of Birth: [**2018-1-15**] Sex: F Service: NEUROLOGY Allergies: Novocain Attending:[**First Name3 (LF) 618**] Chief Complaint: left sided weakness Major Surgical or Invasive Procedure: IV tPA before arrival at this hospital History of Present Illness: 87 yo RHF with past medical history of AFib off coumadin for past week for colonoscopy, HTN,HL,AR, CHF p/w acute onset left sided weakness at 3:15 p.m. She was in USOH till 3:00 p.m. today and was seen by her son at 3:15 p.m. while eating to have acute onset weakness on the left side, noticed due to her food dribbling down on the left side of her face. EMS was called and she was taken to [**Hospital1 **] [**Location (un) 620**] at 3:26 p.m. and was found to have dense left hemiplegia, hemineglect and left visual field cut. Head CT showed a dense RMCA M1 thrombus extending up to M2. She received IV tPA starting at 4:29 p.m. and received the full dose. She then started complaining of mild right sided headcahe ([**12-2**]) which persisted. She was then transferred to [**Hospital1 18**] for evaluation for possible neurointerventional procedure. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: -AFib previously on coumadin, but held for colonoscopy on [**6-10**] (for 1 week now) -HTN -HL -moderate aortic regurgitation -PDA -CHF EF 55-60% -h/o syncope -hypothyroidism -polymylagia rheumatica Social History: lives independently and is fully functional at baseline. Retired secretary, drives a car. Has very involved children. Denies tobacco, occasional alcohol. Family History: Father died at age 75 of CAD, mother died at 95 of CHF, brothers with [**Name2 (NI) 499**] cancer, daughter with lymphoma. Physical Exam: Vitals: T: AF P:86 (afib) R: 16 BP: 146/102 SaO2: 99%RA General: Eyes closed, arouses to voice, cooperative, NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: irregularly irregular. Abdomen: soft, NT/ND Extremities: WWP Skin: Bruises/ecchymoses noted in bilateral arms, with large skin tear on left elbow. Neurologic: (If applicable) NIH Stroke Scale score was: 14 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 2 3. Visual fields: 2 4. Facial palsy: 1 5a. Motor arm, left: 3 5b. Motor arm, right: 0 6a. Motor leg, left: 2 6b. Motor leg, right: 1 7. Limb Ataxia: 0 8. Sensory: 1 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 2 -Mental Status: Alert, oriented to name, month, and [**Hospital1 **] [**Location (un) 620**]. Drowsy, and dozes off when not being questioned. Speech is fluent in conversation. There were no paraphasias. Only able to report "chair" and read the word "room" on stroke card, which are the farmost right items, demonstrating dense neglect vs hemianopia. Speech was not dysarthric. Able to follow both midline and appendicular one-step commands. Dense visual, sensory, and auditory neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. Does not BTT in left visual field in either eye. Funduscopic exam deferred. III, IV, VI: Forced gaze deviation to R that does not cross midline. No nystagmus noted. V: Facial sensation intact to light touch. VII: Left facial paresis w NLF and inability to close L eye. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, decreased tone on left. Moves LLE in plane of bed but is unable to lift antigravity. Withdrawal response to pain in LUE. Right sided extremities are antigravity. -Sensory: Senses light touch reliably on right; sometimes when left side is touched, she states she feels it on the right, othertimes she does not feel it at all. Again sensory neglect is profound. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response was upgoing on the left. -Coordination: No gross dysmetria when reaching out w right hand. -Gait: deferred. ********** Laboratory Data: Pertinent Results: [**2105-6-13**] 02:58AM BLOOD WBC-8.1 RBC-4.12* Hgb-12.6 Hct-38.5 MCV-93 MCH-30.6 MCHC-32.7 RDW-15.4 Plt Ct-157 [**2105-6-13**] 02:58AM BLOOD PT-11.2 PTT-25.2 INR(PT)-1.0 [**2105-6-13**] 02:58AM BLOOD PT-11.2 PTT-25.2 INR(PT)-1.0 [**2105-6-13**] 02:58AM BLOOD Glucose-119* UreaN-15 Creat-0.7 Na-133 K-3.8 Cl-99 HCO3-26 AnGap-12 [**2105-6-13**] 02:58AM BLOOD CK-MB-1 cTropnT-<0.01 [**2105-6-13**] 02:58AM BLOOD Triglyc-99 HDL-57 CHOL/HD-2.5 LDLcalc-66 [**2105-6-13**] 02:58AM BLOOD %HbA1c-5.6 eAG-114 [**2105-6-15**] 06:20AM BLOOD Digoxin-0.4* CT/CTA/CTP No acute intracranial hemorrhage. 2. CT perfusion study suggests acute infarctions in the superior right middle cerebral artery territory and in the right posterior cerebral artery territory. These are not yet detectible on the conventional CT images, with only a small focus of mild cytotoxic edema noted in the right anterior insula. 3. Large thrombus extending from the distal right common carotid artery into the proximal right internal carotid artery with 99% stenosis. This thrombus also extends into and completely occludes the proximal right external carotid artery, which demonstrates distal reconstitution, most likely via retrograde filling through its branches. 4. Occlusion of the superior division of the right middle cerebral artery. 5. Bilateral fetal configuration of posterior cerebral arteries. The posterior communicating arteries appear patent bilaterally. 6. Enlarged and multinodular thyroid. This may be further evaluated by [**Name (NI) 13416**], if not previously performed elsewhere. MRI/MRA head and NEck 1. Large acute infarctions involving the right frontal lobe, insula, and temporal lobe in the middle cerebral artery territory and the right occipital lobe in the posterior cerebral artery territory. 2. Focal hemorrhagic transformation in the posterior right temporal lobe. 3. Motion-limited MRAs of the head and neck demonstrate no appreciable change from the preceding CTAs of the head and neck. There is a large thrombus extending from the distal right common carotid into the proximal right internal carotid and external carotid arteries, with 99% stenosis of the right internal carotid artery, better demonstrated on the CTA, and complete occlusion of the proximal external carotid artery (with reconstitution via retrograde filling). Persistent occlusion of the superior division of the right middle cerebral artery. Bilateral fetal posterior cerebral arteries with bilateral patent posterior communicating arteries. Echocardiogram: Patent ductus arteriosus. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderate to severe tricuspid regurgitation. Pulmonary artery hypertension. Mild aortic valve stenosis. Mild aortic regurgitation. Dilated ascending aorta. CTA neck [**6-18**]:Interval decrease in size of the thrombus in the right common carotid artery extending into both the internal and external branches. A small amount of thrombus is still present. 2. The previously seen occlusion of the superior division of the right MCA is not completely included in the field of view of today's study given that the study is a neck CTA. If there is any clinical concern for continued occlusion, recommend a dedicated CTA of the head for further evaluation. 3. Worsening pulmonary edema with bilateral pleural effusions. Brief Hospital Course: The patient is an 87 y/o with past medical history of AFib off coumadin for pastweek for colonoscopy, HTN,HL,AR, CHF p/w acute onset left sided weakness and found to have left hempiplegia and profound neglect consistent with R MCA syndrome. Neuro: At [**Hospital1 **] [**Location (un) 620**] a dense MCA sign was seen on imaging, and the pt received IV TPA at 90 min after onset of symptoms. NIHSS was slightly improved here to 14 from 17 at [**Location (un) 620**]. The patient had a CTA head and neck here which revealed recanalization of the R MCA with cutoff seen at R M2 superior division and evidence of thrombus at the R CCA occluding 99%, extending to R ECA and R ICA with recanalization distally. Endovascular intervention was discussed with the neurointerventional attending as well as stroke attending, Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] and the decision was made that the risk of attempting recanalization of the R CCA thrombus could potentially outweigh the benefit given the risk of distal embolization with manipulation, and relatively intact blood supply currently to circle of [**Location (un) 431**]. The patient had a MRI head which showed large acute infarctions involving the right frontal lobe, insula, and temporal lobe in the middle cerebral artery territory and the right occipital lobe in the posterior cerebral artery territory as well asa focal hemorrhagic conversion. The patient was briefly placed on a heparin drip despite this due to concern for the right carotid occlusion. This was later discontinued when the patient had a headache due to concern for bleed. CT head was obtained 24hours after tPA and showed no progression of hemorrhagic conversion noted on MRI the previous day. The patient remained in the ICU overnight and then was transferred to the floor the following day. She was started on aspirin and then restarted on Coumadin. The patient regained some left sided strength and her left sided neglect improved slightly. While on the floor she began to open her eyes spontaneously and answered questions appropriately. A repeat CTA of the neck showed decreased thrombus of the right common carotid. Cardiac: The patient was monitored on telemetry and remained in atrial fibrillation. Her cardiac enzymes were negative. She was continued on metoprolol at lower doses initially and home antihypertensives were held to allow for autoregulation. Her heart rate trended up and her metoprolol was increased to her home dose. As above, she was started on aspirin bridge to coumadin. Echocardiogram revealed a PFO. Endocrine: Her fingersticks were checked and she was placed on sliding scale insulin. Glycohemoglobin was normal and LDL cholesterol was <100. FEN: The patient was not able to swallow safely so a NG tube was placed and tube feeds begun on [**6-13**]. On [**6-17**] the patient was cleared to start ground solids and nectar thickened liquids. Her tube feeds were held during the day and the plan is to continue nightly tube feed until she is able to take in an adequate number of calories. Infection: The patient was noted to be delerious on [**6-15**] and UA came back positive. She was started on Ceftriaxone for UTI, urine culture pending at this time. Once antibiotics were started her delerium cleared. 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes 5. Intensive statin therapy administered? (for LDL > 100) () Yes - (x) No (if LDL >100, Reason Not Given: ) 6. Smoking cessation counseling given? () Yes - () No (Reason (x) non-smoker - () unable to participate) 7. Stroke education given? (x) Yes - () No 8. Assessment for rehabilitation? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No (if LDL >100, Reason Not Given: ) 10. Discharged on antithrombotic therapy? x() Yes (Type: (x) Antiplatelet - (x) Anticoagulation) - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - () N/A Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Simvastatin 40 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Warfarin MD to order daily dose PO DAILY16 2.5-5mg as directed 4. Digoxin 0.125 mg PO DAILY 5. Levothyroxine Sodium 75 mcg PO DAILY 6. Metoprolol Tartrate 100 mg PO BID 7. PredniSONE 1 mg PO DAILY 7 tabs daily 8. Docusate Sodium 100 mg PO BID 9. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **] Discharge Medications: 1. Digoxin 0.125 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Levothyroxine Sodium 75 mcg PO DAILY 4. PredniSONE 1 mg PO DAILY 7 tabs daily 5. Metoprolol Tartrate 100 mg PO BID 6. Simvastatin 40 mg PO DAILY 7. Aspirin 325 mg PO DAILY stop when INR [**12-26**] 8. Nystatin Cream 1 Appl TP [**Hospital1 **] 9. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **] 10. Nitrofurantoin (Macrodantin) 50 mg PO Q6H Please continue through [**6-22**] 11. Warfarin 3 mg PO DAILY16 Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Right frontal, temporal and occipital lobe stroke Patent foramen ovale Discharge Condition: oriented to date, does not believe we are at [**Hospital1 18**], thinks she's in hospital in [**Country 6607**]. opening eyes. Answers questions appropriately. Naming intact. left facial droop, L hemineglect, L hemiparesis (antigravity). Increased tone in left arm. localizes to pain on the left arm, withdraws to pain in left leg. Toes up on left and down on Right. Bibasilar crackles in lungs, improved. Discharge Instructions: Dear Ms [**Known lastname **], You were admitted for a stroke. This was thought to be secondary to your atrial fibrillation. You were restarted on coumadin for stroke protection. Your stroke risk factors were checked. You should continue to not smoke. Your LDL cholesterol was 66. You were continued on a statin. You had a cardiac echocardiogram which demonstrated no cardioembolic source, but did show a patent foremen ovale. You were checked for blood glucose control with a HgB A1c. The level was 5.6 which is normal. You need to continue your blood pressure control. You should continue to eat a low fat healthy diet, and follow up with your primary care physician and stroke Neurology as detailed below. It was a pleasure taking care of you. Followup Instructions: PLease follow up Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern1) 57824**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 17200**] Date/Time:[**2105-6-30**] 11:00 Provider: (neurology) [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2105-8-18**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2762**], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2106-4-14**] 1:30 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Admission Date: [**2175-9-11**] Discharge Date: [**2175-9-14**] Date of Birth: [**2113-6-17**] Sex: F Service: MEDICINE Allergies: Adalat Cc Attending:[**First Name3 (LF) 2817**] Chief Complaint: dizziness, vomiting, hypertension Major Surgical or Invasive Procedure: none History of Present Illness: 62yo F w/ a PMH of afib, CAD, and CHF (diastolic dysfunction) now admitted with nausea and dizziness in the setting of afib w/ RVR. Pt states that she first had symptoms of dizziness [**1-21**] weeks ago in the setting of what she thought was a cold. She took Sudafed for several days and the symptoms seemed to improve. Her cold then seemed to settle into her chest, with a sore throat predominating. She had 24hrs of diarrhea but then felt well up until last night. During dinner last night, she began to feel dizzy again. She describes her dizziness as a sensation of a "heaviness" in her head. She denies any spinning sensation, of either herself or the room. She denies any vision changes. She states that she came home from dinner and went to bed, but then got up in the middle of the night and had difficulty walking to the bathroom and had to hold on to the walls as she walked. She then decided to come to the ER for further evaluation. . The dizziness is associated with a mild headache and nausea. She's had emesis or more specifically, dry heaves x2. She denies any presyncope, LH, falls or LOC. She denies any URI sx, including cough, rhinorrhea or sinus tenderness. She denies any SOB, CP or palpitations. She has had minimal PO's since the start of these sx, but previously denied any weight loss, night sweats, diarrhea. No urinary sx. No leg swelling, numbness, tingling or weakness in her arms or legs. . In the ER, VS were T 97.5, BP 236/106, HR 120-130s, RR 16, sats of 99% on RA. Past Medical History: Afib - On [**Month/Day (3) 197**]/Coreg - S/P cardioversion [**6-24**] CAD - cath in [**2169**]: The LMCA was angiographically normal. The LAD had a 40-50% stenosis in the mid portion. The D2 branch had an ostial/proximal 70% stenosis. The LCX had proximal mild luminal irregularities. The RCA had a 30% mid stenosis. The R-PDA had a 70-80% proximal stenosis involving its takeoff. Papillary thyroid cancer - Diagnosed in the summer of [**2173**], s/p total thyroidectomy and radiation, on synthroid Obesity - S/P gastric bypass in [**12-22**] HTN CHF - Diastolic Dysfunction, EF of 55%, LVH DM type II Hypercholesterolemia TTP OA Social History: Patient has a remote history of tobacco use for approximately 5 years, up to 1 ppd. She reports being a social alcohol drinker and denies any illicit drug use. Family History: M died of lung cancer at age 56; F died of pna at 72, but also had stomach cancer. Brother is 58 and healthy, other than HTN. Physical Exam: VS: T - 97.6, BP - 140/57, HR - 77, RR - 16, O2 - 97% on RA Gen: Fatigued, intermittently dry heaving, but awake, alert and oriented x 3 in NAD HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous with mildy dry mucous membranes CV: S1, S2 nl, no m/r/g appreciated Lungs: CTAB Abd: Soft, obese, NT, ND, +BS Ext: No c/c/e Neuro: CN II - XII intact; sensation intact; strength 5/5 in UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**], reflexes 2+ in biceps, triceps, brachioradialis bilaterally; downgoing toes bilaterally; finger-to-nose intact, no dysdiadokokinesia; gait not assessed, [**Last Name (un) **]-Hallpike deferred given patient's nausea Pertinent Results: WBC-10.7 RBC-4.97 HGB-12.7 HCT-39.9 MCV-80 MCH-25.6 MCHC-31.9 RDW-17.7 TSH 0.053, T4 10.2 CALCIUM-8.7 PHOSPHATE-2.8 MAGNESIUM-2.2 GLUCOSE-193* UREA N-21* CREAT-0.7 SODIUM-139 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-31 ANION GAP-11 URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG CK-MB-3 cTropnT-<0.01 CK(CPK)-54 . Studies: CT Head with contrast: There is no hemorrhage, mass effect, shift of normally midline structures or hydrocephalus. Tiny hypodensity is seen in the right centrum semiovale, unchanged from the prior study, consistent with microangiopathic change. No air- fluid levels are seen in the paranasal sinuses. The mastoid air cells are clear. The soft tissues appear unremarkable. . EKG: Baseline artifact. Regular supraventricular rhythm. There is a late transition which is probably normal. Compared to the prior tracing regular supraventricular tachycardia is now present. . MRI/A Brain: Multiple T2 and FLAIR hyperintense signals seen in the periventricular and subcortical white matter, consistent with chronic microangiopathic changes. No evidence of acute hemorrhage or stroke. Brief Hospital Course: A/P: 62 y.o. female with PMHx of A fib, s/p cardioversion, HTN, CHF who presents with complaints of N/V and dizziness in the setting of a. fib with RVR and hypertensive urgency. . # Nausea/Dizziness: Initial differential included vertigo, acute MI, posterior CVA, labrynthitis with recent URI. ACS ruled out by CEs x 2, 12 hours apart and has no ischemic changes on EKG, making MI less likely. Posterior CVA assessed by MRI/MRA without evidence of thrombosis or new CVA. Patient was followed by neurology during stay and gave input concerning symptom management. On the third day of admission, symptoms had completely resolved, which is consistent with vertigo associated with labrynthitis following her recent URI. Upon discharge denies any further symptoms of nausea, vomiting or vertigo. . # HTN: Poorly controlled upon arrival to the ED at 236/106. OMR notes demonstrate BP range of 120s-150s, though given 3 antihypertensive agents, suspected that patient likely has chronically elevated blood pressure. Cause of acute elevation was unclear, but likely related to poorly tolerating po medications. Patient does report compliance with her medications prior to hospitalization. Acute cardiac event was ruled out as detailed above. Initially on ICU admit BP was being controlled on Labetalol gtt. She denied HA and UA shows no evidence of end-organ damage. Labetalol gtt was discontinued and she was briefly hypotensive to low 100s. She continued to have labile BP, with averages to 170s but had much improvement with addition of home lasix dosing. Electrophysiology was consulted concerning her afib despite prior cardioconversion and suggested adding verapamil 80mg [**Hospital1 **]. This medication was only given once while inpatient as she persistently had heart rates in the mid-60s. She was not discharged on this medication, but sent home on her prior antihypertensive medications with a VNA to visit and perform BP checks. . # Atrial Fibrillation: S/P cardioversion in [**Month (only) 205**] on admit found to be in atrial fibrillation again. Patient denied chest pain or palpitations on presentation which might suggest asymptomatic a. fib, thus making it difficult to tell if she has been in sinus since her conversion. Underlying etiologies include hyperthyroidism or infection. TSH suppressed, not hyperthyroid on labs. Patient is afebrile now with no signs of infection, but had a recent URI. Again, MI has been ruled out as above. HR labile the evening of admit with swings from HR 120s to 65s indicative of possible Afib vs autonomic dysfuntion. EP consulted and thought she likely had atrial tachycardia and recommended verapamil, maximum dosing of carvediol/lisinopril and lasix. Verapamil held as above. Discharged with instruction to decrease [**Month (only) 197**] dosing for next three days, given elevated INR of 3.6. Should follow-up with [**Hospital 197**] Clinic next week for INR check and dose adjustment. . # CAD: History of two vessel CAD with no intervention. Admitted on ASA, BB and statin at outpatient dosing. No evidence of MI on admit. Continue all outpatient meds. . # CHF: Preserved EF with LVH and elevated left-sided filling pressures on echo in [**2173**] with overall greater evidence of diastolic dysfunction, compared to previous echo in [**2169**]. Patient is followed by Dr. [**First Name (STitle) 437**] as an outpatient and took Lasix PRN. On admit was hypovolemic given recent nausea and vomiting. Given IVF and tolerated po on discharge, sent home on outpatient medications. . # S/P Thyroidectomy: On suppressive therapy with Synthroid, recently decreased. TSH is very suppresed at 0.053 despite recent decrease in Synthroid from 225 mcg to 200 mcg. Patient is followed by Dr. [**Last Name (STitle) **] in endocrine and per a conversation with her yesterday, patient could benefit from decrease in Synthroid to 175 mcg. On discharge was instructed to continue Synthroid at 175 mcg and follow-up with her endocrinologist as outpatient. . # DM: Patient has a history of DM2, reportedly controlled with diet and improved since gastric bypass. Most recent HbA1C is 6.5 in 4/[**2174**]. Patient is not on standing diabetic medications as an outpatient. Was monitored with QID fingersticks and did require a low dose ISS while inpatient. Instructed to follow-up with PCP on this issue and continue to monitor her fingersticks as an outpatient. . # TTP: Stable. Platelets are normal though slightly lower than baseline approximately one year ago. Currently no signs of bleeding. Patient also has no fever and hematocrit and creatinine are normal. No active issues during hospital stay. Medications on Admission: Aspirin 81mg PO QD Coreg 50mg PO BID [**Year (4 digits) 197**] 5mg PO QHS Cyanocobalamin 1000mcg PO QD Co Q-10 100mg PO BID Diovan 40mg PO QD Lasix 40mg PO QD Ibuprofen 800mg PO TID Levoxyl 200mcg PO QD Lisinopril 40mg PO QD MVI 1tab PO QD Simvastatin 80mg PO QD Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Primary: Hypertension, vertigo Secondary: DM, coronary artery disease, congestive heart failure, history of papillary thyroid cancer, atrial fibrillation. Discharge Condition: Hemodynamically stable, tolerating oral intake and afebrile. Discharge Instructions: You have been admitted for hypertensive urgency, nausea and dizziness. You were treated symptomatically with medicine for nausea and your blood pressure. You were additionally evaluated with CT Scan and MRI of your head, which did not reveal new abnormalities concerning of recent stroke or bleeding. Once your symptoms had resolved, you were discharged home with continued services to help you during your recovery period. While in the hospital, your medications were continued. The only medication change we advise on discharge is that you hold your [**First Name3 (LF) 197**] dose tonight, and then take only 3mg daily for the following two days. After that you should resume your regular dosing and follow-up with your [**Hospital 197**] Clinic in the next [**6-27**] days for monitoring of your INR. Additionally, you have required insulin while inpatient to control your blood sugar. You should continue checking your blood sugar four times daily and follow-up with your PCP in the next 1-2 weeks to discuss your diabetic management. Please return to the ED or contact Dr. [**Last Name (STitle) **] should your symptoms return or should you become nauseated and unable to tolerate oral intake. Followup Instructions: Provider: [**Name10 (NameIs) **] CLINIC [**Telephone/Fax (1) 10413**] Call to schedule appointment Please call your Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] to schedule and appointment in the next 1-2 weeks to discuss your hypertension and diabetes management further.

Admission Date: [**2168-6-16**] Discharge Date: [**2168-6-21**] Date of Birth: [**2098-6-17**] Sex: F Service: MEDICINE Allergies: Ceclor / Vasotec / Talwin / Elavil / Iodine; Iodine Containing / Vioxx / Bactrim Ds / Colchicine Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: s/p septal ablation Major Surgical or Invasive Procedure: ETOH septal ablation Cardiac cath History of Present Illness: 69 yo lady with h/o CAD (one vessel dz), diastolic CHF, longstanding HTN, obesity, PBC, DJD admitted s/p etoh septal ablation of LVOT obstruction. Patient was first diagnosed with LVOT obstruction in [**2-25**] when she was admitted for chest pressure and shortness of breath. Patient notes longstanding chest pressure symptoms that have been present for more than 10 years. She says that she has diffuse chest pressure over her mid sternum, poorly localized, not associated with any other symptoms such as sob, diaphoresis, radiation. Her first cardiac cath in [**2156**] revealed clean coronaries. In terms of her sob, she reports symptoms starting in [**2-25**] where she could only walk 20 yards before having to stop to cath her breath. Also sob with walking [**12-25**] stairs. She reports sleeping in a recliner with her feet elevated, "can't breath" if lying flat. She states that she was diagnosed with HTN at 15 and has been "well controlled" however does not check her BP at home. She was admitted [**2090-3-17**] with chest pressure, sob, LE edema. It was felt that her SOB was likely due to diastolic dysfuntion with CHF exacerbation due to Prednisone, dietary indescretion, and poorly controlled HTN. She was diuresed with Lasix and sent home with outpatient follow up of her LVOT obstruction. Most recently, she was referred for a diagnostic catheterization at [**Hospital6 **] on [**2168-5-30**]. During the procedure it was noted that her LAD had a 50% lesion and confirmed the left ventricular outflow obstruction (50mmHg). She is now admitted for elective septal ablation and LAD stenting. . Upon arrival to the floor, patient talkative and feeling well, no sob or chest pain. Lying flat, having some back pain, groin site minimally painful. ROS negative for F/C/S, no N/V/D, no other recent illnesses. Past Medical History: # Primary biliary cirrhosis [**2158-11-8**] by liver biopsy, recent biopsy [**1-25**] w/ minimal findings # Lactose intolerance. # Celiac sprue:has not followed a gluten-free diet. Her last upper endoscopy was done in [**2158**] with findings consistent with celiac sprue. # neuropathy from ?celiac # gout # Hypertension. # Obesity. # osteoporosis- not on treatment # Obstructive sleep apnea, moderate-to-severe on study [**2159-3-2**]. # Musculoskeletal problem, cervical spondylotic myopathy, C5,C6, C7 discectomies, anterior C6 carpectomy, anterior cervical fusion with iliac crest bone graft, knee osteoarthritis, lower spine degenerative spondylosis, left knee torn meniscus, left hip trochanteric bursitis, recent knee replacement. She also had recent surgery on her back to repair prior surgery. # monoclonal gammopathy of uncertain significance in 09/00 # spine surgery(anterior spinal fixation) in [**Month (only) **] followed by a postoperative wound infection Social History: She is divorced with one adult son. [**Name (NI) 3003**] to retiring she worked as a bookkeeper for an insurance agency. Quit smoking approximately 15 years ago. Prior to quitting she smoked 1.5ppd for approximately 40 years. Rare etoh. Family History: Non-contributory Physical Exam: VS: 166/74 48 15 95% RA Ht: 5'2" Wt: 210lbs BMI 38.4 Gen: Obese, NAD, very pleasant HEENT: OP clear, moist, EOM, anicteric, no pallor Neck: obese, ?JVD to mid jaw at 30 deg, normal carotids Chest: clear anteriorly, trace crackles at bases CVS: nl S1 S2, harsh ESM at LSB, radiates throughout Abd: obese, soft, NT x 4, NABS Ext: groin site intact, non tender, no hematoma, distal pulses 2+ b/l Neuro: grossly intact Pertinent Results: [**2168-6-16**] 10:17PM CK(CPK)-709* [**2168-6-16**] 10:17PM CK-MB-94* MB INDX-13.3* [**2168-6-16**] 03:58PM CK(CPK)-444* [**2168-6-16**] 03:58PM CK-MB-55* MB INDX-12.4* [**2168-6-16**] 09:23AM GLUCOSE-102 UREA N-43* CREAT-1.4* SODIUM-141 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15 [**2168-6-16**] 09:23AM CK(CPK)-61 [**2168-6-16**] 09:23AM cTropnT-<0.01 [**2168-6-16**] 09:23AM WBC-17.5* RBC-4.63 HGB-11.8* HCT-34.4* MCV-74* MCH-25.5* MCHC-34.3 RDW-17.7* [**2168-6-16**] 09:23AM NEUTS-77.0* LYMPHS-17.0* MONOS-4.8 EOS-0.6 BASOS-0.7 [**2168-6-16**] 09:23AM ANISOCYT-1+ POIKILOCY-1+ MICROCYT-3+ [**2168-6-16**] 09:23AM PLT COUNT-456* [**2168-6-16**] 09:23AM PT-11.4 PTT-21.0* INR(PT)-1.0 [**2168-6-15**] 04:05PM GLUCOSE-123* [**2168-6-15**] 04:05PM UREA N-42* CREAT-1.4* SODIUM-141 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-23 ANION GAP-19 [**2168-6-15**] 04:05PM WBC-19.2*# RBC-4.58 HGB-11.5* HCT-35.2* MCV-77* MCH-25.0* MCHC-32.6 RDW-17.8* [**2168-6-15**] 04:05PM PLT COUNT-557* [**2168-6-15**] 04:05PM PT-11.7 PTT-23.2 INR(PT)-1.0 . ECHO ([**2168-6-16**])Pre-Ablation:There is symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. There is a severe resting left ventricular outflow tract/midcavity obstruction (125 mmHg). Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. . ECHO ([**2168-6-16**])Post-Ablation:Post ethanol injection into the third septal perforator (2 injections) and the second septal perforator (1 injection), the resting intracavity pressure gradient is 24 mmHg. Compared to the previous study prior to ethanol injection, the intracavbity gradient is greatly reduced. . Cardiac Cath ([**2168-6-16**]):One vessel coronary artery disease. Elevated left-sided filling pressures at rest. Dynamic left ventricular outflow tract gradient of 20-30 mmHg at rest and > 90 mmHg with valsalva manuever, post-PVC, and dobutamine infusion. Successful alcohol septal ablation with decrease in the left ventricular outflow gradient to < 25mmHg with dobutamine infusion. . Cardiac Cath [**2168-6-20**]: 1. One vessel coronary artery disease. 2. Mildly elevated left and right sided filling pressures. 3. Resting LVOT gradient present on day#4 post alcohol septal ablation. 4. Successful stenting of the mid LAD. Brief Hospital Course: The patient is a 69yo F with CAD (70% mid LAD), HTN, CHF, MMP underwent cardiac catheterization on [**6-16**] for septal ablation to relieve left ventricular outflow tract obstruction. The LVOT gradient was 80-90 mmHg on dobutamine infusion prior to ablation and 25 mmHg post ablation, both measured during the procedure (see results section). A 70% concentric hazy lesion of the LAD was also noted during this procedure (and was known prior to admission). On [**6-20**] she underwent a second cardiac catheterization for elective stenting of the LAD lesion with a drug eluting Cypher stent. Her creatinine was slightly above baseline on admission and she received renal protection prior catheterization with mucomyst and iv fluids with bicarb. During her hospitalization, she had native sinus bradycardia and was discharged on half her previous dose of her outpatient atenolol. Her verapamil was discontinued because of it's nodal blocking properties, and for blood pressure control, she was switched to amlodipine 10 mg daily. . Medications on Admission: Verapamil 180mg daily every morning Atenolol 100mg daily every morning Lasix 40mg daily every morning Allopurinol 300mg daily every morning Fexofenadine 180mg daily every morning Lyrica 100mg three times a day Ursodiol 900mg every morning and 600mg every evening Aspirin 325mg daily every morning 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:*3* 2. Ursodiol 300 mg Capsule Sig: Three (3) Capsule PO QAM (once a day (in the morning)). 3. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). 5. Lyrica 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*3* 8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*6* Discharge Disposition: Home Discharge Diagnosis: 1. s/p Septal Ablation 2. Hypertension 3. Coronary Artery Disease Discharge Condition: Good Discharge Instructions: Please take your medications as directed. Please note that you are no longer taking Lasix or Verapamil. Your Atenolol dose have been decreased to 50 mg daily and you are now taking a new medication called Amlodipine 10 mg (two tablets) daily. It is of utmost importance that you take your Aspirin and Plavix every single day until directed by your Cardiologist. * Call your primary care physician to schedule [**Name Initial (PRE) **] follow-up appointment within the next 2 weeks. Please note that your white blood cell count was slightly elevated during your hospitalization and your primary care doctor should check this in the future to make sure that it is now back down to normal. * Please call your doctor or come to the nearest emergency room if you experience any chest pain, shortness of breath or any other complaints. Followup Instructions: 1. Primary Care Doctor in [**11-23**] weeks following discharge Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2936**] Appointment should be in [**5-30**] days 2. Dr. [**Last Name (STitle) 9751**] within one month following discharge You also have the following appointments scheduled: Provider: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2168-9-21**] 1:00 Completed by:[**2168-12-5**]

Admission Date: [**2176-11-16**] Discharge Date: [**2176-12-4**] Date of Birth: [**2111-1-21**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: IVC filter, tracheostomy and percutaneous gastrostomy tube placement History of Present Illness: Ms. [**Known lastname 75891**] is a 65 F who was transferred [**Hospital 75892**] Hospital with gallstone pancreatitis. The patient reports that the pain began at 11am with nausea and small bouts of comitting. The patient denies alcohol use. She reports that at the time of admission, her abdominal pain has improved Past Medical History: HTN, DM, DVT [**2173**], hyperlipidemia, anxiety, PSHx: D&C Social History: The patient denies alcohol use. She is married by separated from her husband who is an alcoholic and banned from her housing complex. She also denies tobacco, drug use. She lives independently. Family History: noncontributory Physical Exam: On admission: 97.1 80-120 ST 140/60 16 97% AAOx3 tachycardic, regular rhythm CTA b/l + BC, spigastric tenderness, - [**Doctor Last Name 515**] sign mild abdominal dilation DRE: Guiac neg, NL tome no c/c/e Pertinent Results: [**2176-11-16**] 09:37PM BLOOD WBC-26.7* RBC-5.11 Hgb-14.0 Hct-43.8 MCV-86 MCH-27.4 MCHC-32.0 RDW-13.7 Plt Ct-297 [**2176-12-4**] 03:12AM BLOOD WBC-11.2* RBC-3.43* Hgb-9.3* Hct-30.1* MCV-88 MCH-27.1 MCHC-30.9* RDW-16.7* Plt Ct-981* [**2176-11-16**] 09:37PM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1 [**2176-12-4**] 03:12AM BLOOD PT-13.3 PTT-29.5 INR(PT)-1.1 [**2176-12-4**] 03:12AM BLOOD Plt Ct-981* [**2176-11-16**] 09:37PM BLOOD Plt Smr-NORMAL Plt Ct-297 [**2176-12-4**] 03:12AM BLOOD Glucose-219* UreaN-16 Creat-0.6 Na-145 K-4.5 Cl-108 HCO3-33* AnGap-9 [**2176-11-16**] 09:37PM BLOOD Glucose-323* UreaN-19 Creat-1.0 Na-144 K-2.9* Cl-105 HCO3-26 AnGap-16 [**2176-12-2**] 01:45AM BLOOD ALT-23 AST-34 AlkPhos-295* Amylase-52 TotBili-0.4 [**2176-12-3**] 02:44AM BLOOD AlkPhos-229* [**2176-11-16**] 09:37PM BLOOD ALT-124* AST-102* LD(LDH)-236 AlkPhos-197* Amylase-1494* TotBili-2.0* DirBili-1.6* IndBili-0.4 [**2176-12-2**] 01:45AM BLOOD Lipase-32 [**2176-11-16**] 09:37PM BLOOD Lipase-2211* [**2176-12-4**] 03:12AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.5 [**2176-11-16**] 09:37PM BLOOD Albumin-3.7 Calcium-9.0 Phos-2.9 Mg-1.5* [**2176-11-20**] 12:33AM BLOOD calTIBC-202* Ferritn-155* TRF-155* [**2176-11-23**] 11:26AM BLOOD Lactate-0.8 K-4.7 [**2176-11-29**] 03:31AM BLOOD freeCa-1.13 [**11-16**]: RIGHT UPPER QUADRANT ULTRASOUND: Exam is somewhat limited due to patient body habitus. The liver is unremarkable with no focal lesions. The gallbladder has multiple gallstones, with a large gallstone measuring up to 1.4 cm. There is no wall thickening or pericholecystic fluid to suggest cholecystitis. No son[**Name (NI) 493**] [**Name (NI) **] sign was present. The common bile duct is markedly dilated measuring 1.5 cm, and there is central intrahepatic biliary ductal dilatation, raising the possibility of a distal CBD obstruction. The distal CBD and pancreas are not able to be visualized due to overlying bowel gas. The portal vein is patent with anterograde flow. There is no ascites [**11-17**]: ERCP: Ten fluoroscopic spot images obtained during ERCP procedure without radiologist present. Cholangiogram demonstrates dilated intra- and extra- hepatic bile ducts. There is suggestion of irregularity of the intrahepatic ducts which may be projectional. No filling defect is identified within the opacified biliary tree. The cystic duct is normally opacified. IMPRESSION: Intra- and extra-hepatic biliary dilatation. No filling defect is identified within the biliary tree. [**11-18**]: Ampullary mucosal biopsy: Ampullary mucosa with focal acute inflammation and fibrinopurulent exudates consistent with ulceration. [**11-26**]: U/S FINDINGS: The study is limited due to patient's body habitus. The liver texture is within normal limits allowing for technique. The gallbladder demonstrates multiple gallstones. There is no gallbladder wall edema or pericholecystic fluid. There is no intra- or extra- hepatic biliary ductal dilatation, and the common duct measures 7 mm. Main portal vein is patent with antegrade flow. [**12-2**]:CT- 1. Extensive severe pancreatitis with diffuse enlargement of the pancreas and fat stranding and ongoing formation of peripancreatic fluid collection/pseudocyst with attenuated SMV. Diffuse peritoneal fat stranding suggestive of panperitonitis with bowel dilatation. 2. Cholelithiasis. 3. Small ascites, slightly decreased in the lower pelvis. 4. Diffuse anasarca. 5. Diverticulosis. 6. Post G-tube placement. 7. New pneumomediastinum within the pericardial fat along the pericardium, of unknown etiology. Clinical correlation with recent procedure and interventions is recommended. Brief Hospital Course: On transfer to [**Hospital1 18**], Ms. [**Known lastname 75891**] was admitted to the trauma service and transferred to the SICU for further evaluation. She was made NPO, with IVF and a FOley was placed; the patient refused an NGT at the time. The patient's pain was to be controlled, and the patient was consented for an ERCP. THe patient received subcutaneous heparin for DVT prophylaxis, her hematocrit was watched on a dialy basis, ad the patient was put on an insulin sliding scale. The patient was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 3 at admission. A RUQ ultrasound was performed revealing cholelithiasis without cholecystitis, and CBD dilation as well. On [**11-17**], the patient underwent an ERCP with sphincterotomy; the report read "Intra- and extra-hepatic biliary dilatation. No filling defect is identified within the biliary." Her post procedure course was complicated by increased secretions, and hypoxia to 78%; the patient was made aware of the risk of aspiration pneumonia and respiratory distress, but she refused both an NGT and intubation at the time. The patient was made comfortable with anti-anxiety and pain medications, and her vital signs were closely monitored. The patient required fluid bolusing for volume depletion. A geriatric consult was called for further treatment and evaluation while the patient was in the ICU as the patient became delirious and had been quite agitated despite lorazepam and Haldol. Geriatrics recommended low dose dilaudid for pain control PRN, altering the dose of Haldol, removing all unneccessary tubes, lines and drains, and getting the patinet on a better sleep cycle. On [**11-18**], the patient became tachypneic to a respiratory rate in the 30s, oxygen saturation of 82% on RA, and was put on a face tent as she was not tolerating other oxygen supplementation. The patient's vital signs were unstable, and the patient was combative and aggressive. Her mental status began deteriorating, and the patient required intubation for airway protection, and adequate sedation for safety during hospital treatment. The patient was started on Unasyn for pneumonia (aspiration). On [**11-19**], the patient was intermittently tachycardic with decreased urine output; she was bolused for presumed volume depletion; her urine output improved and her renal function remained within normal limits. The patient also had an OGT and subsequently a DObhoff tube placed for tube feeds. The patient's respiratory status was frequently monitored and changed according to evaluations. Her sedation and ventilation were attempted to be weaned. Her hospital course was complicated by post-procedure fevers; blood cultures were sent when the patient spiked, and chest x-rays, urine analysis/cultures were also taken. The patiemt was noted to have a R base consolidation, and went for bronchoalveolar lavage on [**11-23**]. The patient was put on vancomycin and later levo as well as zosyn for empiric VAP treatment; these antibiotics were stopped when appropriate, i.e, when cultures returned with sensitivities, and/or fevers and leukocytosis decreased. The patient was diuresed when appropriate as she was fluid overloaded with pleural effusions during her hospital stay. A right sided pleural effusion was worsening, and the patient underwent a pleural tap and pigtail placement to expand the lung and rule out empyema as the patient continued to be febrile with some vital sign lability. The patient had stable post procedure anemia until [**11-26**], at which time, the patient had to be transfused 2units of prbcs. As the pt continued to be vent dependednt, the patient underwent a trach, IVC filter, and PEG on [**11-27**]; for details please see operative note. Om [**11-30**], the patient's trach was inadvertently dislodged, and an emergent trach had to be placed; placement was confirmed by bronch. The patient was discharged to rehab on [**12-4**] in stable condition; she was hemodynmically stable, afebrile, tolerating tube feeds, off antibiotics, with normalizing wbc and LFTs. Medications on Admission: GLipizide, Lipitor, Metformin, Lisinopril, Prilosec Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 4. Bisacodyl 10 mg Suppository Sig: Ten (10) mg Rectal DAILY (Daily): Suppository(s). 5. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q6H (every 6 hours) as needed for fever. 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Insulin Regular Human Injection 16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q6H (every 6 hours) as needed for n/v. 17. Magnesium Sulfate 4 % Solution Sig: Sliding SCale Injection PRN (as needed). 18. Calcium Gluconate 100 mg/mL (10%) Solution Sig: Sliding Scale Intravenous ASDIR (AS DIRECTED). 19. Potassium Chloride Intravenous 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 21. Potassium Phosphate Dibasic 3 mMole/mL Parenteral Solution Sig: Sliding Scale Intravenous ASDIR (AS DIRECTED). 22. Lorazepam 2 mg/mL Syringe Sig: 0.5-1.0 mg Injection Q4H (every 4 hours) as needed for agitation. 23. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 24. Roxicet 5-325 mg/5 mL Solution Sig: [**5-30**] ml PO every [**4-26**] hours. 25. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Gallstone pancreatitis Discharge Condition: stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in [**1-23**] weeks; make an appointment at [**Telephone/Fax (1) 6429**]

Admission Date: [**2199-10-20**] Discharge Date: [**2199-10-23**] Date of Birth: [**2135-3-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: cough Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: Mr. [**Known lastname **] is 64-year-old man with liver cirrhosis [**1-19**] NASH, DM, HTN, CHF EF 40%, CAD, Sizure disorder who p/w cough. Per report from his nursing home, he has had cough, low grade fever x 3 days. Today, he had an episode of likely aspiration while using mouth wash, had a coughing fit and during this episode desat'ed to 80's. His family reports that he has been on small amounts of oxygen at the nursing home, which he has been on chronically since [**Hospital 671**] Rehab for unclear reasons. They state that he has had a ratteling cough for several days but has not appeared unwell. They also note that he has normally waxing and [**Doctor Last Name 688**] mental status, that he is not "chatty" normally and that his mental status appears to be at baseline. Per the patient, he feels relatively well and denies SOB. He was BIBA from his NH, enroute EMS had a difficult time obtaining a good pleth/sats and reported variable O2 sats in high 80's. . In the ED: The patient was thought to be ill appearing and "dry". His vital signs were temp 100.0, HR 107, BP 120/80's, RR 22-26, Sa 96% 2LNC. EKG unchanged, trop 0.06.CXR was noted to have hazy RLL and LLL. He received Vanc and CTX. Past Medical History: 1. Seizure disorder with history of status epilepticus with recent admission for recurrent seizures & 2 prior admission in [**2197**] & [**2199-1-18**] for status requiring intubation. He has been on multiple antiepileptic drugs 2. NASH, cirrhosis, hepatocellular carcinoma, recently removed from [**Year (4 digits) **] list [**1-19**] chronic illness 3. Diabetes. 4. Hypothyroidism. 5. Hypertension. 6. CHF with ejection fraction of 40% on an echo in [**2198-7-18**]. 7. Coronary artery disease status post cardiac catheterization in [**2187**] w/o stenting. 8. History of upper GI bleed status post tips in [**2197**]. 9. Stage IV sacral decubitus ulcer. Social History: Prior to his illness, he was living with wife; remote tobacco, no EtOH or drug use. He now resides at [**Hospital 1820**] Nursing Home. Family History: Non-contributory. Physical Exam: General: Awake, alert, NAD. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally 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 and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: sacral ulcer, heel ulcers Neurologic: -mental status: waxing and [**Doctor Last Name 688**] between, persistently alert but oriented to person only at times and occasionally a&ox3. -contractures in hands and arms. Pertinent Results: Labwork on admission: [**2199-10-20**] 09:45AM BLOOD WBC-5.2 RBC-3.63* Hgb-12.5* Hct-37.6* MCV-104*# MCH-34.4* MCHC-33.2 RDW-15.1 Plt Ct-65* [**2199-10-20**] 09:45AM BLOOD Neuts-81.1* Lymphs-12.2* Monos-5.2 Eos-1.4 Baso-0.2 [**2199-10-20**] 09:45AM BLOOD Glucose-178* UreaN-50* Creat-1.1 Na-150* K-4.1 Cl-110* HCO3-34* AnGap-10 [**2199-10-20**] 09:45AM BLOOD ALT-27 AST-23 CK(CPK)-53 AlkPhos-124* TotBili-0.3 [**2199-10-20**] 10:35AM BLOOD Ammonia-73* [**2199-10-20**] 09:45AM BLOOD TSH-0.77 [**2199-10-20**] 09:45AM BLOOD Free T4-1.9* . Labwork on discharge: [**2199-10-23**] 07:45AM BLOOD WBC-2.2* RBC-2.95* Hgb-9.9* Hct-30.7* MCV-104* MCH-33.7* MCHC-32.4 RDW-14.6 Plt Ct-59* [**2199-10-23**] 07:45AM BLOOD Glucose-72 UreaN-22* Creat-0.8 Na-146* K-3.9 Cl-109* HCO3-34* AnGap-7* . CHEST (PORTABLE AP) Study Date of [**2199-10-20**] Formal report pending, but right upper and lower lobe consolidations present. . CHEST PORT. LINE PLACEMENT Study Date of [**2199-10-23**] Preliminary Report !! PFI !! Tip of PICC catheter 8 cm from SVC will need to be withdrawn. Brief Hospital Course: 64 year-old man with cirrhosis, type 2 diabetes, coronary artery disease, hypertension, congestive heart failure with EF 40%, and seizure disorder presenting with cough, fevers, and consolidations on chest x-ray consistent with pneumonia. . 1. Pneumonia: Chest x-ray from admission showed right middle and lower lobe consolidations. His oxygen saturations remained above 92% on room air. He was monitored in the intensive care unit overnight and transferred to a general medical floor the morning after admission. He was started on vancomycin and ampicillin-sulbactam to complete a two-week course for hospital-acquired versus aspiration pneumonia. A PICC line was placed [**2199-10-23**] for intravenous access to complete the course of antibiotics, ending [**2199-11-4**]. . 2. Hypernatremia: Asymptomatic and due to free water depletion. His free water flushes were increased to 400 cc q4h with improvement in sodium. His sodium should be monitored intermittently and his free water flushes should be adjusted accordingly for hypernatremia. . 3. Question urinary tract infection from nursing home: The patient was on nitrofurantoin on admission, and it is unclear whether this was for treatment or prophylaxis of urinary tract infection. This was discontinued when the above antibiotics were started for pneumonia. He can restart nitrofurantoin if this was being given for prophylaxis when the course of vancomycin and unasyn is complete. . 4. Mental status: It was believed that the patient was delirious on admission, however, after discussion with the patient's wife and the nursing home his mental status was thought to be at baseline. He was treated for pneumonia as above. He was frequently redirected. . 5. History of nonacloholic steatohepatitis/cirrhosis: The patient is status post TIPS. He is not [**Month/Day/Year **] candidate currently due to his multiple comorbiditis. His MELD score was 5 on admission. He was continued on rifamixin and lactulose. . 6. Chronic systolic congestive heart failure: EF is 40%. His metoprolol was continued during admission. The patient was hypovolemic on admission and lasix was held. Lasix was restarted prior to discharge. . 7. Seizure disorder: No active issues. The patient was continued on keppra, topomax and zonisamide. There was initial confusion regarding his dose of keppra, and the patient was initially given 2250 mg on admission, however, this was subsequently changed to his home dose of 500 mg twice daily. . 8. Type 2 diabetes: No active issues. The patient was continued on glargine 100 units twice daily as per his outpatient regimen. He received humalog sliding scale insulin as needed. . 9. Coronary artery disease: No active issues. The patient was continued on metoprolol. He is not on aspirin or statin at baseline, likely due to his liver disease, and this can be readdressed as an outpatient. 10. Hypothyroidism: The patient was continued on his outpatietn dose of levothyroxine 400 mcg daily. During admission, his T4 was elevated to 1.9 with normal TSH. His laboratories should be checked after resolution of this acute illness and his dose of levothyroxine adjusted accordingly. . 11. Sacral decubitus ulcer: The patient was followed by the [**Month/Day/Year **] care nurse. . 12. Pancytopenia: His blood counts were at baseline during admission. His pancytopenia is believed secondary to liver disease. This should be monitored intermittently. Medications on Admission: Topiramate 100 mg PO BID Metoprolol 25 mg PO BID Levetiracetam PO BID Zonisamide 500 mg DAILY Levothyroxine PO DAILY Fluocinolone 0.025 % Cream Lactulose 10 gram/15 mL Syrup Rifaximin PO TID Lorazepam 0.5 mg PO DAILY Furosemide 40 mg PO DAILY Heparin (Porcine) 5,000 unit/mL Multivitamin PO DAILY Folic Acid 1 mg PO DAILY Lansoprazole 30 mg Thiamine HCl 100 mg PO DAILY Polyvinyl Alcohol 1.4 % Drops Discharge Medications: 1. Topiramate 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day). 2. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO BID (2 times a day). 3. Levetiracetam 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day). 4. Zonisamide 100 mg Capsule [**Month/Day/Year **]: Five (5) Capsule PO DAILY (Daily). 5. Levothyroxine 100 mcg Tablet [**Month/Day/Year **]: Four (4) Tablet PO DAILY (Daily). 6. Lactulose 10 gram/15 mL Syrup [**Month/Day/Year **]: Thirty (30) ML PO TID (3 times a day). 7. Rifaximin 200 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times a day). 8. Lorazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day. 9. Furosemide 40 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day. 10. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1) Injection TID (3 times a day). 11. Multivitamin Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 12. Folic Acid 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 13. Omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. Thiamine HCl 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Day/Year **]: [**12-19**] Drops Ophthalmic Q6H (every 6 hours). 16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 17. Insulin Glargine 300 unit/3 mL Insulin Pen [**Month/Day (2) **]: One Hundred (100) units Subcutaneous twice a day: plus novolin sliding scale. 18. Tramadol 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO three times a day: hold for oversedation and confusion. 19. Scopolamine Base 1.5 mg Patch 72 hr [**Month/Day (2) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 20. Ascorbic Acid 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day). 21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Day (2) **]: One (1) Inhalation Q4H (every 4 hours). 22. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation Q4H (every 4 hours). 23. Nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Five (5) ML PO TID (3 times a day). 24. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day (2) **]: One (1) ML Intravenous PRN (as needed) as needed for line flush. 25. Ampicillin-Sulbactam 3 gram Recon Soln [**Month/Day (2) **]: One (1) Recon Soln Injection Q6H (every 6 hours): continue until [**2199-11-4**]. 26. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1) Intravenous Q 12H (Every 12 Hours): continue until [**2199-11-4**]. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) 731**] Discharge Diagnosis: Primary diagnoses: Pneumonia (hospital acquired versus. aspiration) Hypernatremia Delirium Secondary diagnoses: 1. Seizure disorder with history of status epilepticus with recent admission for recurrent seizures & two prior admission in [**2197**] & [**2199-1-18**] for status requiring intubation. He has been on multiple antiepileptic drugs 2. Nonalcholic steatohepatitis, cirrhosis, hepatocellular carcinoma, recently removed from [**Year (4 digits) **] list due chronic illness 3. Diabetes - insulin dependent 4. Hypothyroidism 5. Hypertension 6. Congestive heart failure with ejection fraction of 40% on an echo in [**2198-7-18**] 7. Coronary artery disease status post cardiac catheterization in [**2187**] w/o stenting 8. History of upper GI bleed status post tips in [**2197**] 9. Stage IV sacral decubitus ulcer Discharge Condition: Afebrile, vital signs stable Discharge Instructions: Dear Mr. [**Known lastname **], You were transferred to the hospital with fevers and a cough. You were found to have a pneumonia and PICC line was placed in your arm so that you can complete a two week course of antibiotics (12 more days). You were also noted to have high levels of sodium in your blood, and this is probably because you were not getting enough water in your diet. You are being given more water with your tube feeds. We did not change any of your medications (except adding those two antibiotics for two weeks). Your thyroid levels were high, and they should be re-checked and the dose of your thyroid medicine may need to be adjusted. If you develop increased difficulty breathing or any other symptoms which seriously concerns you, please return to the hospital. Followup Instructions: Previously scheduled appointments: Provider: [**Name10 (NameIs) 2841**] LABORATORY Phone:[**Telephone/Fax (1) 2846**] Date/Time:[**2199-11-5**] 10:00 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 19105**] Date/Time:[**2199-11-5**] 1:00 Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-11-27**] 10:20 . You should try to see your Primary care Provider [**Name Initial (PRE) 176**] 2 weeks. PCP: [**Name10 (NameIs) **],[**Known firstname **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 70526**] Completed by:[**2199-10-29**]

Admission Date: [**2164-5-30**] [**Month/Day/Year **] Date: [**2164-6-1**] Date of Birth: [**2121-8-14**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: Hallucinations, agitation Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 78755**] is a 42yoM with a history of diabetes mellitus and longstanding alcoholism s/p numerous hospitalizations for detoxification who was brought to the emergency room after being found running through the streets naked and trying to choke himself. He was barking like a dog during his ambulance ride, and continued to seemingly respond to internal stimuli thereafter. . On arrival to the ED, his initial vital signs were T100 P120 BP160/112 RR18 99% ra. Collateral information was gathered by the psychiatry team, who evaluated him for a possible primary psychiatric disorder, and spoke at length to both the patient and the patient's mother. [**Name (NI) **] apparently drank "a lot of vodka and windex" yesterday morning and subsequently blacked out. He has detoxed many times and was prescrived antabuse, which he has not recently taken. He endorses actively experiencing visual and auditory hallucinations, including "voices" and "shadows" but is again not able to elaborate with further details about these symptoms. He has experienced both alcoholic hallucinosis and delirium tremens, however fails to specify when those symptoms occurred. . His mother, with whom he lives, notes a 20 year alcohol dependence and despite many detoxification hospitalizations, found a half-gallon of vodka in is closet recently. He had been sober for 6 months and had been acting normally through yesterday, but made paranoid statements about his neighbors this morning. . Per the psychiatrist note, a psych review of systems, he denies symptoms consistent with depression including anhedonia, hopelessness, guilt, fatigue, difficulty concentrating, changes in appetite, and sleep disturbances. He denies symptoms consistent with anxiety including panic attacks or agoraphobia. He denies symptoms consistent with mania including elevated mood, racing thoughts, decreased need for sleep, or thoughtlessness. . His ED management involved a liter of NS with IV thiamine. A head CT did not reveal any structural disease and a chest XR did not show any acute cardiopulmonary abnormality. He received an 2mg IM lorazepam dose and 10mg IV diazepam. Serum tox was negative but Cr elevated to 1.8 from unknown baseline. Toxicology consulted re: windex ingestion and was told it is relatively benign and that fluids would help. . On arrival to the [**Hospital Unit Name 153**], his VS were: T98.7 HR80 BP128/78 RR19 Sat 98RA. He is fully AAOx3. He had been sober for six months but started drinking again when the Bruins won the championship, at which point he has been drinking [**3-13**] pints of vodka daily with about 6 beers daily for chasing. He drank an unknown amount of windex two days ago, which also was around the same time of his last alcoholic drink. He drank the windex to experiment with harming himself but denies frank SI. With regard to the events leading up to his hospitalization, he ran naked down the street on a dare. He does not recall having been brought in by ambulance or barking like a dog. He does not recall audio/visual hallucinations. He hopes to get sober again but cannot elaborate a specific plan. He does confirm that he had a bad alcohol withdrawal about 5 months ago complicated by hallucinations, though no DTs. Past Medical History: - alcohol abuse/dependence s/p previous withdrawal hallucinosis/DT's Social History: Patient lives with his mother and brother in [**Name (NI) 2312**]. Unemployed. Family History: maternal grandmother with alcohol dependence Physical Exam: Admission: Vitals: T98.7 HR80 BP128/78 RR19 Sat 98RA. General: fatigued appearing in NAD, answering all questions appropriately, very mildly tremulous HEENT: Sclera anicteric, dry MM Neck: tenderness upon palpation of submandibular neck. No LAD. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, positive bowel sounds, liver span to 7cm by percussion, no splenomegaly, diffuse mild soreness GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema [**Name (NI) **]: T 98.9, BP 143/93, HR 87, RR 22, 98% on RA General: Awake in bed, comfortable, NAD. Denies active hallucinations. Pertinent Results: [**2164-5-30**] 05:30PM WBC-11.8* RBC-5.46 HGB-15.3 HCT-45.0 MCV-82 MCH-28.1 MCHC-34.1 RDW-18.3* [**2164-5-30**] 05:30PM NEUTS-79* BANDS-1 LYMPHS-15* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2164-5-30**] 05:30PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2164-5-30**] 05:30PM PLT COUNT-162 [**2164-5-30**] 05:30PM ALT(SGPT)-84* AST(SGOT)-81* LD(LDH)-325* CK(CPK)-243 ALK PHOS-82 AMYLASE-194* TOT BILI-0.8 [**2164-5-30**] 05:30PM LIPASE-23 [**2164-5-30**] 05:30PM ALBUMIN-5.0 [**2164-5-30**] 05:30PM OSMOLAL-279 [**2164-5-30**] 05:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2164-5-30**] 11:30PM URINE HOURS-RANDOM UREA N-445 CREAT-234 SODIUM-20 POTASSIUM-35 CHLORIDE-11 [**2164-5-30**] 11:30PM URINE HOURS-RANDOM [**2164-5-30**] 11:30PM URINE GR HOLD-HOLD [**2164-5-30**] 11:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2164-5-30**] 11:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2164-5-30**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2164-5-30**] 11:30PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [**2164-5-30**] 11:30PM URINE HYALINE-51* [**2164-5-30**] 11:30PM URINE MUCOUS-FEW [**2164-5-30**] 05:30PM GLUCOSE-137* UREA N-16 CREAT-1.8* SODIUM-134 POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-19* ANION GAP-23* Brief Hospital Course: Mr. [**Known lastname 78755**] is a 42yoM with alcohol dependence presenting with hallucinations and agitation. The patient presented with bizarre behavior as per HPI and was noted to have elevated creatinine to 1.8, transaminitis, and anion gap acidosis; he was felt to be at high risk for withdrawal and was therefore admitted to the ICU for close monitoring. During his brief hospitalization, he remained alert and oriented and did not exhibit evidence of alcohol withdrawal; labs trended toward normal. # HALLUCINATIONS, AGITATION: The patient provides a variable drinking history over the past few days though a relapse appears likely given his mother's finding of vodka in his closet, and his history of multiple withdrawal syndromes. While he did show autonomic hyperactivity, agitation, and hallucinosis, his current generally preserved orientation is inconsistent with delirium tremens, as is the brief time course since his last drink (<48hr). That he improved so quickly with a very small benzo load is highly unusual for withdrawal. He was monitored on a CIWA scale though did not receive any further benzodiazepine after arrival to the ICU. He also received folate and thiamine given his history of alcoholism. He was seen by the psychiatry service who recommended dual-diagnosis inpatient treatment. He was also seen by social work. During the day, he was oriented x 3 and did not exhibit evidence of withdrawal. He did not offer direct answers in response to questions about the events leading up to this admission (would not state exactly what substances he used or describe why he was behaving so oddly). He did state that the Windex ingestion was in part in response to a desire to harm himself. He reports that he has had visual hallucinations for some time, and has been disturbed by these though he knows that they are not real. His overall presentation raises concern for a possible primary psychiatric diagnosis. PCP and ketamine levels were sent as these substances could produce a similar picture, though he denied use of either substance. These labs were pending at the time of [**Known lastname **]. # AMMONIA INGESTION: He ingested an unknown amount of ammonia. Household cleaners typically do not have the concentration to cause severe alkali burns. He has the typical sore throat and irritation caused by such ingestions, and his elevated amylase may be reflecting some of this inflammation. He received a dose of PPI while inpatient. The hospital toxicologist was consulted and recommended supportive care and IV fluids. # ELEVATED CREATININE: Cr up to 1.8 from unclear baseline. His relatively low BUN may reflect poor nutritional status at baseline, but may also indicate chronic renal disease. His creatinine improved to 1.3 following IVF. He should have repeat electrolytes checked on follow up with PCP. # ANION GAP METABOLIC ACIDOSIS: On arrival, the patient had an anion gap of 20. His lactate was normal at the time that it was checked several hours after arrival. His blood alcohol was negative and there was no evidence of DKA, uremia, salicylates. Anion gap closed with repeat electrolytes. # ELEVATED TRANSAMINASES: This may be secondary to chronic alcoholism though he does not display the characteristic AST:ALT ratio of 2:1. His actual ingestion history is unclear as above, and it is possible that he used substances which he does not report that may have caused this finding. His LFTs trended down on repeat labs in the AM though had not yet fully normalized at the time of [**Known lastname **] (ALT 73, AST 61). # POSSIBLE OSA: Patient was noted to snore loudly with periods of apnea. He may benefit from sleep study as an outpatient. TRANSITION OF CARE: - PCP and ketamine levels pending [**2164-5-31**] - Patient will require PCP follow up after [**Month/Day/Year **] from dual-diagnosis facility with re-check of liver and kidney function Medications on Admission: Antabuse [**Month/Day/Year **] Medications: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. [**Month/Day/Year **] Disposition: Extended Care [**Month/Day/Year **] Diagnosis: Visual hallucinations Transaminitis Anion gap acidosis [**Month/Day/Year **] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [**Month/Day/Year **] Instructions: Mr. [**Known lastname 78755**], It was a pleasure to care for you during this hospital stay. You were admitted to [**Hospital1 69**] after you exhibited strange behavior and reported visual hallucinations and ingestion of alcohol and Windex. You were admitted to the ICU for close monitoring, and you remained medically stable throughout your stay. You were seen by social work and psychiatry, who have recommended transfer to a dual-diagnosis facility to further [**Hospital1 4656**] your substance abuse problems and the possibility of a psychiatric illness as the cause of your hallucinations. We have made the following changes to your medication regimen: - BEGIN TAKING folate 1 mg PO daily - BEGIN TAKING thiamine 100 mg PO daily - BEGIN TAKING multivitamin 100 mg PO daily Please follow up with your primary care doctor as recommended below. Followup Instructions: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 11144**] Please schedule a follow up appointment with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from the dual-diagnosis facility. Please ask your doctor [**First Name (Titles) **] [**Last Name (Titles) 4656**] your liver and kidney function with blood tests to make sure that the abnormalities noted during this stay have resovled. Completed by:[**2164-6-1**]

Admission Date: [**2134-1-31**] Discharge Date: [**2134-2-16**] Date of Birth: [**2084-2-25**] Sex: F Service: CARDIOTHORACIC Allergies: Cafergot / Prochlorperazine / Penicillins / Chlorpromazine Hcl / Prozac Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2134-2-1**] Mitral valve replacement with a 25 mm Biocor tissue valve. Tricuspid valve replacement with a 27 mm Biocor apical tissue valve. [**2134-2-4**] PICC placement History of Present Illness: 49 year old female with history of paroxysmal atrial fibrillation, rheumatic heart disease, Hepatitis C, liver fibrosis found to have moderate MS and mild tomoderate MR [**First Name (Titles) **] [**Last Name (Titles) 113**]. She reports symptoms of shortness of breath and chest pain which have gotten progressively worse. She states that she is unable to climb a flight of stairs without stopping 3 times to rest. Past Medical History: Rheumatic heart disease with 2-3+ MR, minimal MS (valve area 1.3 cm2), [**1-22**]+ tricuspid regurgitation and mild pulmonary hypertension RVE/[**Last Name (un) **] with IVC dilation by [**Last Name (un) 113**] Global RV dysfunction AI Prior IVDA-currently methadone clinic, stopped drugs 1.5 yrs ago ETOH abuse-stopped about 1.5 yrs ago Atypical chest pain PAF-on Coumadin last dose [**2134-1-24**] Chronic anemia Hepatitis C c/b liver fibrosis->followed by Dr. [**Last Name (STitle) 86971**] False Positive Syphilis Test Fibromyalgia Migraines IBS GERD Prior suicide attempt PTSD Pleural effusion s/p evacuation Bipolar Disorder Arthritis Acid reflux Breast Lumpectomy Endometriosis s/p laparoscopy Syncope/fall -approx [**2130**] Hypoglycemia Cholecystectomy Hysterectomy Tonsillectomy Endometriosis s/p laparoscopy s/p tubal ligation s/p lumpectomy from breast Social History: Lives with:husband- [**Name (NI) **] Occupation: unemployed Tobacco:1.5ppd x 30 years ETOH:none in 1.5 yrs Rec drugs: none in 1.5 yrs. H/o IVDA and cocaine use in past Family History: father died of an MI mother died of heart problems Brother died in his 50s from heart problems Physical Exam: Pulse:76 Resp:18 O2 sat:99% RA pO2 76 on 2L NC B/P Right: 113/89 Left: Height:5'1" Weight: 67.3 kg General: NAD, alert and cooperative 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 [**1-24**] HSM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + sl. hepatomegaly Extremities: Warm [x], well-perfused [x] Edema Varicosities: None 2+ pitting edema on bilat. LE Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**2134-2-16**] 05:10AM BLOOD WBC-6.5 RBC-3.15* Hgb-9.4* Hct-27.8* MCV-89 MCH-29.8 MCHC-33.6 RDW-17.4* Plt Ct-215 [**2134-1-31**] 09:00PM BLOOD WBC-5.4 RBC-4.35 Hgb-13.1 Hct-36.6 MCV-84# MCH-30.1 MCHC-35.8* RDW-15.8* Plt Ct-151 [**2134-2-1**] 12:32PM BLOOD Neuts-89.2* Lymphs-9.1* Monos-1.1* Eos-0.5 Baso-0.1 [**2134-2-16**] 05:10AM BLOOD Plt Ct-215 [**2134-2-16**] 05:10AM BLOOD PT-18.1* PTT-28.7 INR(PT)-1.6* [**2134-1-31**] 09:00PM BLOOD PT-13.3 PTT-34.7 INR(PT)-1.1 [**2134-1-31**] 09:00PM BLOOD Plt Ct-151 [**2134-2-16**] 05:10AM BLOOD Glucose-108* UreaN-42* Creat-0.8 Na-133 K-3.6 Cl-96 HCO3-28 AnGap-13 [**2134-2-15**] 05:40PM BLOOD Glucose-119* UreaN-50* Creat-1.0 Na-133 K-4.6 Cl-95* HCO3-28 AnGap-15 [**2134-2-1**] 02:05PM BLOOD UreaN-8 Creat-0.6 Na-136 K-4.2 Cl-104 HCO3-27 AnGap-9 [**2134-1-31**] 09:00PM BLOOD Glucose-92 UreaN-9 Creat-0.7 Na-135 K-4.5 Cl-99 HCO3-29 AnGap-12 [**2134-2-9**] 03:04AM BLOOD ALT-17 AST-37 LD(LDH)-525* AlkPhos-67 TotBili-1.4 [**2134-1-31**] 09:00PM BLOOD ALT-41* AST-49* LD(LDH)-224 AlkPhos-87 Amylase-66 TotBili-0.6 [**2134-2-3**] 03:29AM BLOOD Lipase-11 [**2134-2-16**] 05:10AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.4 [**2134-1-31**] 09:00PM BLOOD %HbA1c-5.9 eAG-123 [**2134-2-5**] 05:14AM BLOOD Osmolal-276 [**2134-2-5**] 09:23AM BLOOD TSH-1.7 [**2134-2-5**] 09:23AM BLOOD T4-9.0 T3-78* [**2134-2-5**] 09:23AM BLOOD Cortsol-36.1* CHEST TWO VIEWS, [**2134-2-14**] FINDINGS: Two views of the chest compared to prior study from [**2134-2-11**]. There is multifocal interstitial and airspace opacification, not appreciably changed from the prior study, could represent a combination of congestive failure or even ARDS. Heart is enlarged. Mediastinum is within normal limits. IMPRESSION: Left PICC unchanged in superior vena cava. Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.5 cm Left Ventricle - Fractional Shortening: 0.38 >= 0.29 Left Ventricle - Ejection Fraction: 70% >= 55% Left Ventricle - Lateral Peak E': *0.04 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.03 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *40 < 15 Aorta - Sinus Level: 2.4 cm <= 3.6 cm Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - Peak Velocity: 1.4 m/sec Mitral Valve - Mean Gradient: 6 mm Hg Mitral Valve - E Wave: 1.4 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 2.00 Mitral Valve - E Wave deceleration time: *400 ms 140-250 ms TR Gradient (+ RA = PASP): 7 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Mild LA enlargement. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV free wall thickness. Dilated RV cavity. RV function depressed. AORTA: Normal aortic diameter at the sinus level. MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR well seated, with normal leaflet/disc motion and transvalvular gradients. TRICUSID VALVE: Bioprosthetic tricuspid valve (TVR). TVR well seated, with normal leaflet motion and transvalvular gradients. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or electrodes. Conclusions The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with depressed free wall contractility. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. A bioprosthetic tricuspid valve is present. The tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2133-8-3**], the mitral and tricuspid valves have been replaced. The right ventricle is somewhat hypocontractile. Brief Hospital Course: Admitted [**2134-1-31**] for bridge from coumadin with heparin drip. Completed preoperative workup and [**2134-2-1**] was brought to the operating room and underwent mitral valve and tricuspid valve replacements, see operative report for further details. She was transferred to the intensive care unit for postoperative management. In the first few hours she had significant ventricular ectopy that was treated with amiodarone boluses and drip with improvement however underlying rhythm was complete heart block and continued to be paced with epicardial wires. She remained intubated overnight for hemodynamics and was extubated the morning of postoperative day one. She was started on lasix for diuresis due to pulmonary edema and continued amiodarone. Electrophysiology was consulted for rhythm management and she was placed on lidocaine drip with improvement but continued runs on ventricular tachycardia that worsened with activity. Pain medications were adjusted, she was weaned off lidocaine and started on betablockers for rhythm management. She continues with ventricular ectopy but no ventricular tachycardia. She was restarted on coumadin for history of pulmonary embolism and atrial fibrillation. She was continued to be diuresed for pulmonary edema, however was noted to have hyponatremia with sodium to 122 with no clear cause that was treated with hypertonic saline and saline tabs and sodium improved however pulmonary edema worsened. Her oxygen requirements increased and she continued to require aggressive diuresis and non invasive ventilation for few days. She continued to improve and respiratory status improved. She was transferred to the floor for the remainder of her care. Physical therapy worked with her on strength and mobility. She continues on intravenous lasix for diuresis via PICC line that she is being discharged to rehab with, and plan for PICC removal when no longer requires IV lasix. She was discharged to acute rehab on post operative day 15 to [**Hospital3 **] in [**Hospital1 **] new [**Location (un) **]. Medications on Admission: DIGOXIN - 250 mcg Tablet - 1 Tablet(s) by mouth daily in the PM FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth daily in the PM HYDROXYZINE HCL 25 mg Tablet by mouth twice a day METHADONE - 40 mg Tablet Soluble - 1 Tablet(s) by mouth daily plus 5mg tablet = 45mg daily dose METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth daily in the PM POTASSIUM CHLORIDE [KLOR-CON 10] - 10 mEq Tablet Sustained Release - 1 Tablet(s) by mouth daily SERTRALINE - 100 mg Tablet in the PM TRAZODONE - 100 mg Tablet - [**12-24**] Tablet(s) by mouth daily at hs WARFARIN [COUMADIN] - 7.5 mg Tablet - 1 Tablet(s) by mouth daily on Fridays only, 5mg all other days last dose [**2134-1-24**] ZOLPIDEM [AMBIEN] 10 mg Tablet - 1 Tablet(s) by mouth at bedtime Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day. 5. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO DAILY (Daily): total dose 45 mg . 9. methadone 5 mg Tablet Sig: One (1) Tablet PO once a day: total dose 45 mg daily . 10. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. guaifenesin 600 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO bid () for 2 days. 14. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. PICC line Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. [**Month (only) 116**] remove PICC line when no longer on intravenous lasix 16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO twice a day for 3 days: then decrease to 40 meq daily with IV lasix . 17. furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection DAILY (Daily) for 3 days: then decrease to 40 mg IV daily . 18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation every four (4) hours as needed for shortness of breath or wheezing. 19. methadone clinic Methadone clnic in [**Hospital1 487**], [**Street Address(2) 86972**]. Phone # [**Telephone/Fax (1) 86973**]. Open from 6am to 1015am daily Has received 45 mg daily while in the hospital [**Date range (1) 86974**] 20. coumadin and INR [**2-16**] coumadin 7.5 mg inr 1.6 [**2-15**] coumadin 4 mg inr 1.8 [**2-14**] coumadin 5 mg inr 1.9 [**2-13**] coumadin 2.5mg inr 2.2 [**2-12**] coumadin 4 mg inr 2.6 [**2-11**] coumadin 2.5mg inr 2.7 [**2-10**] coumadin 2.5mg inr 3.1 [**2-9**] coumadn 3mg inr 2.2 [**2-8**] coumadin 5 mg inr 1.9 [**2-7**] coumadin 5 mg inr 1.5 [**2-6**] coumadin 5 mg inr 1.4 nutriton had been poored and now improved with shakes (ensure) which contain vitamin K home doses prior to admission 5-7.5 mg daily 21. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation and pulmonary embolism Goal INR [**12-24**] First draw wendesday [**2-17**] Physician at rehab to monitor INR and dose coumadin based on results - please check monday and wednesday and friday for 3 weeks to maintain close monitoring due to liver disease and then twice a week Please arrange for coumadin management with PCP prior to discharge from rehab 22. Outpatient Lab Work Chem 10 twice a week while on IV lasix 23. warfarin 5 mg Tablet Sig: Goal INR 2.0-3.0 Tablets PO once a day: dose based on INR by rehab physician [**Name Initial (PRE) **] [**Name10 (NameIs) **] draw [**2-17**] for further dosing . Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Mitral regurgitation s/p MNR Tricuspid regurgitation s/p TVR Ventricular trachycardia Respiratory failure Rheumatic heart disease Hypertension Right ventricular failure Prior IVDA-currently on methadone ETOH abuse-stopped about 1.5 yrs ago Atypical chest pain paroxysmal atrial fibrillation Chronic anemia Hepatitis C Liver fibrosis Fibromyalgia Migraines Irritable bowel syndrome Gastric esophageal reflux disease Post traumatic stress disorder Pleural effusion Bipolar Disorder Arthritis Breast Lumpectomy Endometriosis s/p laparoscopy Syncope/fall -approx [**2130**] Hypoglycemia Cholecystectomy Hysterectomy Tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with 1 assist Incisional pain managed with tylenol prn Continues on methadone 45 mg as prior to admission Incisions: Sternal - healing well, no erythema or drainage Edema +1 bilateral LE Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2134-2-25**] 1:00 Cardiologist: Dr [**Last Name (STitle) 4783**] - cardiac surgery office to contact you with appointment Liver: Dr [**Last Name (STitle) 497**] [**Telephone/Fax (1) 2422**] [**2134-4-2**] 11:00 Please call to schedule appointments with your Primary [**First Name (STitle) 86975**] in [**2-23**] weeks [**Telephone/Fax (1) 77368**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation and pulmonary embolism Goal INR [**12-24**] First draw wendesday [**2-17**] Physician at rehab to monitor INR and dose coumadin based on results - please check monday and wednesday and friday for 3 weeks to maintain close monitoring due to liver disease and then twice a week Please arrange for coumadin management with PCP prior to discharge from rehab Completed by:[**2134-2-16**]

Admission Date: [**2169-6-26**] Discharge Date: [**2169-6-30**] Date of Birth: [**2143-4-5**] Sex: F Service: MEDICINE Allergies: Penicillins / morphine / Codeine Attending:[**First Name3 (LF) 2195**] Chief Complaint: Abdominal pain, hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 9625**] is a 26F with a history of type I diabetes complicated by chronic gastroparesis and prior DKA (last episode [**5-/2169**]) who presents with a ~4 day history of uncontrolled sugars, abdominal pain, and malaise. She states that her symptoms began on Thursday, when she noticed that her fingerstick values were getting very high. Since that time, she reports that her lowest FS were in the 300s, and many were > 400 (in the early part of the month, she estimates that average readings were in the 160s). She takes 36 units Lantus QHS and [**10-26**] untis of Novolog per day with her sliding scale. States that she has been compliant with fingersticks and insulin administration. Took 16 units of insulin (Novolog) prior to coming to ED at 11:00 AM today. . She has chronic gastroparesis and is never fully pain-free, but notes that her abdominal pain is worse than baseline and different from her standard pain. She feels bloated. This pain does not feel like her prior episodes of kidney stones. In the ED, she reported vomiting 5-10 times daily, but on the floor reports that N/V have not been severe and that she feels that she has been keeping down fluids adequately. She has poor appetite and did not eat solid food today but was able to keep down food yesterday. However, she has had "no energy" and was in bed most of the day yesterday, which she states is very unusual for her. Denies diarrhea but does suffer from chronic problems with constipation. She does report that she has had on-and-off chills and drenching nightsweats two of the last four nights to the point that her boyfriend has had to wake her because the sheets were wet. She does not own a thermometer so did not take her temperature. She has not had SOB or URI symptoms, and though she does report some dysuria she states that this is usual for her and unchanged from her baseline. She reports several prior UTI which have caused "kidney infections" and states that she has been hospitalized for treatment multiple times. She does not currently have flank pain but does report that she had some mild right flank pain on Saturday. Also reports feeling "out of it" like she's drunk, though has not had any alcohol. . In the ED, initial vs were: T 98.1, HR 102, BP 125/82, RR 16, O2 sat 100%. Patient was given IV cipro x 400 mg for possible UTI, at least one liter IVF, started on an insulin gtt, dilaudid 1 mg IV, and IV Zofran. . On the floor, she reports abdominal pain is [**8-16**] severity. Also states that she is hungry and would like to eat, feels that she could tolerate food at this time. . Review of sytems: (+) Per HPI. Also reports recent episode of leg swelling in feet and ankles one week ago, now largely resolved. (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No recent change in bowel or bladder habits. Denied arthralgias or myalgias. Past Medical History: - Type I diabetes complicated by gastroparesis and prior DKA, diagnosed age 2 - GERD - Anxiety - Cholecystectomy Social History: Lived in [**Location **] with her aunt and uncle until recently, when she moved in with her boyfriend in [**Name (NI) 86**]. She does not work (disabled). She denies cigarette use but occasionally smokes marijuana (none in past few weeks). Does not drink alcohol. No other recreational drug use. Family History: Paternal grandfather had [**Name2 (NI) 499**] cancer. Maternal grandmother had breast cancer. Per notes, her mother is deceased from heroin overdose and her father was murdered by her step mother. She has one brother and one sister who are alive and healthy. Physical Exam: Physical on Arrival to [**Hospital Unit Name 153**] Vitals: T:97.6 BP:104/73 P:98 R: 14 O2: 97% on RA General: Alert, oriented, appears comfortable in bed from doorway though reports [**8-16**] pain HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, MMM Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Back: No vertebral body, SI or CVA tenderness Abdomen: Soft, diffusely tender to palpation but worse in RLQ, non-distended, bowel sounds present, + rebound tenderness but no guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on Admission: [**2169-6-26**] 12:10PM lucose-671* UreaN-14 Creat-0.7 Na-129* K-5.3* Cl-90* HCO3-24 AnGap-20 WBC-5.8 RBC-4.61 Hgb-12.6 Hct-39.0 MCV-85 Plt Ct-324 Neuts-65.9 Lymphs-29.1 Monos-2.5 Eos-1.7 Baso-0.8 ALT-19 AST-23 LD(LDH)-140 AlkPhos-177* Amylase-44 TotBili-0.2 Lipase-22 Calcium-9.1 Phos-4.1 Mg-1.7 Acetone-NEG Osmolal-285 HCG-<5 URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.016 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD URINE RBC-1 WBC-9* Bacteri-NONE Yeast-NONE Epi-<1 Microbiology: [**2169-6-26**] - URINE CULTURE: E. coli sensitive to Cipro Brief Hospital Course: 26 F with type I diabetes presenting with anion gap acidosis and + ketones in urine. # DKA. Patient's 2nd DKA in 1 month. Last HgbA1C 8.4. Trigger thought likely to be her underlying UTI given her symptoms, + UA, and + UCx growing E. coli. Prior notes also suggested possible problem with compliance with her insulin and her uncle has raised concern that she may on occasion have intentionally elevated her blood glucose in order to be treated in the hospital with narcotic pain medication. Per her last D/C summary, she was scheduled to see a new PCP, [**Name10 (NameIs) **] missed the appointment and has yet to reschedule. Patient was transitioned to D5 and subcutaneous glargine soon after arriving the ICU. Her BS improved significantly with taking in po. Her anion gap closed. [**Last Name (un) **] followed her throughout her hospitalization, and she was discharged on an adjusted sliding scale and Lantus 23u in the evening. # ABDOMINAL PAIN: Initially thought to have rebound tenderness and RLQ pain, concerning for appendicitis and other intra-abdominal pathology (no ovarian cyst, but has prominent right ovary). Her presentation is nearly identical to that at her prior admission in [**Month (only) 116**], at which time she underwent CT abdomen/pelvis which was unrevealing. Given her young age and desire to minimize radiation exposure, patient had serial abdominal exam. She did not have persistent nausea or vomiting and she reported being able to pass gas and tolerate food intake. She was given IV dilaudid, which was transitioned to her home regimen of PO Oxycodone. She was given a prescription for several days worth of Oxycodone and instructed to follow-up with her new PCP. # URINARY TRACT INFECTION: U/A is mildly positive with 9 WBC, + LE, and also + UCx. Patient states that she has chronic dysuria, frequent UTI's, and that she has had multiple prior hospitalization for pyelonephritis and two prior episodes of kidney stones. She was started on ciprofloxacin and discharged to complete a total of 7 days. # ANXIETY: Per patient, prescriptions had previously been given by her PCP prior to moving to [**Location (un) 86**]. Per last discharge summary, attempts were made to contact a pharmacy and her prior PCP, [**Name10 (NameIs) **] no record of prescriptions could be obtained. She was continued on her home medications and no prescriptions were given at discharge. Contact: HCP is uncle [**Name (NI) **] [**Name (NI) 9625**] [**Telephone/Fax (1) 88920**]. Boyfriend with whom she lives is second emergency contact at [**Telephone/Fax (1) 88922**]. Medications on Admission: - Zoloft 100 mg PO daily (this is dose per recent D/C summary; patient reported 400 mg daily) - Buspar 20 mg PO BID - Clonazepam 2 mg PO TID - Hydroxyzine 50 mg QID - Trazadone 50 mg [**1-8**] tab qHS for insomnia - Omeprazole 40 mg PO BID (this is dose per patient report; D/C summary had 20 mg PO daily) - Novolog insulin sliding scale - Lantus 36 units SC QHS - oxycodone 5 mg 1-2 tabs po q4h prn for pain Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with diabetic ketoacidosis and a urinary tract infection. You were treated with antibiotics and an insulin infusion. You tolerated a regular diet prior to discharge. Your blood sugars will continue to be adjusted by your [**Last Name (un) **] doctors. Please call them with any questions or concerns regarding your blood sugars or your insulin dosage. You will need to complete a course of Ciprofloxacin as an outpatient; a prescription for this medicaiton is provided. Followup Instructions: Please follow-up with Dr.[**Last Name (STitle) 32886**] on [**7-4**] at 2pm at the [**Last Name (un) **] Diabetes Center. You are also scheduled for the following appointment with your new PCP, [**Last Name (NamePattern4) **].[**First Name (STitle) **]: Department: [**Hospital3 249**] When: WEDNESDAY [**2169-7-5**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 815**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2137-2-27**] Discharge Date: [**2137-3-19**] Date of Birth: [**2058-10-27**] Sex: M Service: MEDICINE Allergies: Hydromorphone / Morphine / Amoxicillin Attending:[**First Name3 (LF) 1145**] Chief Complaint: SOB Major Surgical or Invasive Procedure: HD catheter placement History of Present Illness: Patient is a 78 year old male with past medical history of CAD NSTEMI, s/p CABG (LIMA to the LAD, SVG to OM1 and OM2) and St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] ([**12-12**]) with course complivated by wound dehisence, chronic systolic dysfunction EF 30%, ESRD on HD, afib on coumadin, stroke, chronic anemia, recent lower GI bleed with bleeding rectal ulcers and CMV colitis, and chronic left-sided pleural effusion transferred from [**Hospital 100**] Rehab for increasing SOB and lethargy after receiving 1 unit PRBCs earlier today for Hct 21; he recieved HD yesterday. HD was stopped prematurely yesterday due to hypotension to 60/40. His discharge weight on [**2-15**] was 60 kg; he was 73 kg pre-dialysis on [**2-21**]. Of note, patient was discharged on [**2-15**] from the [**Hospital1 **] service after a similar presentation, with status improving after emergent dialysis removing 10 liters and thoracentesis. Course complicated during this admission by presumed c. diff colitis due to profuse diarrhea, treated with 14 days flagyl. . On arrival to the ED, initial vitals were T 97.2 HR 120 (afib) BP 123/110 RR 20 100% 4L NC in acute respiratory distress. Labs significant for H/H 7.1 AND 21.0, BNP [**Numeric Identifier 89668**] INR 2.3. He was placed on BiPAP with resolution of respiratory distress. Prior to transfer, patient was started on levophed for SBPs in 80s. . On review of systems, he has a history of stroke, PE, bleeding with surgery, deep venous thrombosis. He denies myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for chest pain, severe SOB, DOE, ankle edema, PND, Orthopnea, absence of chest pain, palpitations. . In the ED initial VS were noted to be T97.2, HR 120, BP 123/110, RR 20, Sat 100% on 4L. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: In [**2135-9-3**], per the patient's wife report, the patient had a stent placed to the LAD and two other vessels and did well on plavix, aspirin and coreg with an EF of 45%. On [**2136-12-7**] after episode of CP, the patient was admitted to OSH with non- Q wave MI and underwent cardiac catheterization which revealed 70% LAD instent stenosis, 70-80% instent stenosis at the RCA and the LCx had 90% stenosis and an aortic valve area of 0.9cm. He underwent a CABG LIMA to LAD saphenous graft sequential to an OM1 and OM2 and [**Hospital3 **] [**Hospital3 1291**]. Post -operatively course complicated by severe hyptnesion requiring high dose pressor support with vasopressin, epinephrine and levophed. A balloon pump was placed for several days. He required multiple blood products. His post-op EF was noted to be 30% per [**Hospital 100**] Rehab records. he was transferred to [**Hospital 100**] rehab from OSH for an NSTEMI, [**Hospital 1291**] and CABG complicated by multiple issues described below. -CABG: LIMA to LAD saphenous graft sequential to an OM1 and OM2 and [**Hospital3 **] [**Hospital3 1291**] [**12-12**] -PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD in [**2136**], prior stent to RCA and LAD -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Chronic systolic dysfunction (EF 30%) ESRD on HD Chronic left-sided pleural effusion Prior GI bleed - ?rectal ulcer Hyperlipidemia IDDM chronic atrial fibrillation on coumadin Stoke with no residual neurologic deficits Hypothyroid AS s/p [**Year (4 digits) 1291**] [**Hospital3 **] Hyperparathyroidism Right AV fistula Rectal Ulcers: CMV positive Blood cultures during his prior hospitalization grew gram negative rods speciated to Aeromonas hydrophilia for which he was treated with 6 weeks of ciprofloxacin last day of therapy [**2137-2-5**]. During this time he developed lower GI bleed, colonscopy revealed rectal uclers which were cauterizated and biospy was CMV positive. Patient s/p 2 wks IV ganciclovir. Coumadin for afib held and was restarted the nigth prior to admission to [**Hospital1 18**]. More recently on [**2-5**] at [**Hospital 100**] Rehab, due to persistent diarrhea, the patient was empirically started on Flagyl for cdiff colitis Social History: -Tobacco history: none -ETOH: none -Illicit drugs: none Married, former salesman, several children. His wife and children are very involved in his care. Family History: non contributatory Physical Exam: VS: BP= 69/37 HR=120s-130s RR= 24 O2 sat= 99% BiPAP 10/5 40% FiO2 GENERAL: Mild respiratory distress. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at mandible. CARDIAC: Irreg irreg nl S1 mechanical S2 . LUNGS: CTAB, diffuse crackles. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Warm wel perfused Pertinent Results: ADMISSION LABS: [**2137-2-27**] 07:45PM BLOOD WBC-15.9* RBC-2.35*# Hgb-7.1*# Hct-21.0*# MCV-90 MCH-30.7 MCHC-34.3 RDW-16.9* Plt Ct-297 [**2137-2-27**] 07:45PM BLOOD PT-23.7* PTT-30.8 INR(PT)-2.3* [**2137-2-27**] 07:45PM BLOOD Glucose-139* UreaN-33* Creat-2.0*# Na-138 K-3.8 Cl-96 HCO3-34* AnGap-12 [**2137-2-27**] 07:45PM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 89668**]* [**2137-2-28**] 05:10AM BLOOD Calcium-10.3 Phos-4.7* Mg-2.1 [**2137-2-27**] 10:26PM BLOOD Type-ART pO2-330* pCO2-51* pH-7.45 calTCO2-37* Base XS-10 Intubat-NOT INTUBA . CHEST XRAY [**2137-2-28**] IMPRESSION: Findings compatible with pulmonary edema. . . TTE [**2137-2-28**] The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 25 %) with regional variation (lateral wall relatively preserved). The right ventricular free wall thickness is normal. Right ventricular chamber size is normal. with depressed free wall contractility. There are focal calcifications in the aortic arch. A bileaflet aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of 10 Janaury [**2137**], the tricuspid regurgitation appears reduced, but the technically suboptimal nature of both studies precludes definitive comparison. . CARDIAC CATHETERIZATION [**2137-2-28**] 1. Resting hemodynamics revealed elevated left-sided filling pressure with a mean PCWP of 20 mmHg. There was moderate pulmonary hypertension with a PA pressure of 60/28 mmHg. Cardiac output was mildly depressed at 4.76 L/min with an index of 2.61 L/min/m2. 2. The RVH sheath was coverted to a CVVH catheter following right heart cathterization. . FINAL DIAGNOSIS: 1. Elevated left sided filling pressure 2. Moderate-severe pulmonary hypertension. 3. CVVH catheter placed. . . CT ABD/PELVIS: [**2137-3-2**] 1. No CT evidence of colitis. 2. Stable appearance of bilateral pleural effusions and compressive atelectasis. 3. Stable small pericardial effusion. . . TTE [**2137-3-4**] The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is moderate global left ventricular hypokinesis (LVEF = 30 %). Right ventricular chamber size and free wall motion are normal. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2137-2-28**], the findings are similar (estimated PASP may be slightly lower). . CHEST XRAY IMPRESSION: AP chest compared to [**2-27**] through 30: . Progressive consolidation at the left lung base is most likely atelectasis, worsened since [**3-3**], but pneumonia, particularly due to aspiration could have the same appearance. Previous pulmonary vascular congestion continues to improve. Moderate cardiomegaly is longstanding. Small left pleural effusion is stable. Stomach is distended with air and fluid, gastrostomy tube in place. No pneumothorax . MICRO DATA . [**2137-2-28**] 12:27 am STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT [**2137-3-2**]** FECAL CULTURE (Final [**2137-3-2**]): NO SALMONELLA OR SHIGELLA FOUND. NO ENTERIC GRAM NEGATIVE RODS FOUND. CAMPYLOBACTER CULTURE (Final [**2137-3-2**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-2-28**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . [**2137-2-28**] 2:52 pm Immunology (CMV) Source: Line-A Line. **FINAL REPORT [**2137-3-5**]** CMV Viral Load (Final [**2137-3-5**]): CMV DNA not detected. . [**2137-3-4**] 7:36 am BLOOD CULTURE Source: Line-femoral dialysis line. **FINAL REPORT [**2137-3-7**]** Blood Culture, Routine (Final [**2137-3-7**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. SENSITIVITIES PERFORMED ON REQUEST.. Isolated from only one set in the previous five days. Aerobic Bottle Gram Stain (Final [**2137-3-5**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 89669**] #[**Numeric Identifier 25630**] [**2137-3-5**] 1350. Anaerobic Bottle Gram Stain (Final [**2137-3-5**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. . **FINAL REPORT [**2137-3-12**]** Blood Culture, Routine (Final [**2137-3-12**]): ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S [**Year/Month/Day **]------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R Anaerobic Bottle Gram Stain (Final [**2137-3-7**]): REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 25629**] ON [**2137-3-7**] AT 0030. GRAM POSITIVE COCCI IN PAIRS AND CHAINS. . Labs at discharge [**3-18**]: HGB:9.3* HCT:28.7* PTT: 97 INR 1.4 WBC: 10.3 PLT: 246 Na: 123 K: 4.1 CL: 94 BUN: 20 Creat: 3.3 Gluc: 123 CA:10.3 Phos: 5.6* Mag: 2.2 . Brief Hospital Course: HOSPITAL COURSE 78 year old male with past medical history of CAD, NSTEMI, s/p CABG (LIMA to the LAD, SVG to OM1 and OM2) and St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] ([**12-12**]) with course complivated by wound dehisence, chronic systolic dysfunction EF 30%, ESRD on HD, afib on coumadin, anemia, recent lower GI bleed with bleeding rectal ulcers and CMV colitis with worsening SOB, acute decompensated heart failure. . # GOALS OF CARE: Goals of care continuously discussed with family members and the [**Name (NI) 89670**] consult team who had care for the patient through two hospitalizations. After significant discussion regarding sepsis, failure of dialysis without pressor support, multiple wound infections and multiple co-morbities, the patients was made comfort measures only on HD 9. Heparin gtt was continued to prevent stroke per families wishes and dopamin was slowly weaned off. CVVH, antibiotic therapy and all other medications and lab draws were discontinued. On HD 13, the patient was noted to be more alert with improved quality of life. Goals of care was readdressed with the family and hemodialysis was re-initiated. Antibiotic therapy ([**Name (NI) **]) was restarted to cover staph and enterococcus (VRE) positive blood cultures. As Mr. [**Known lastname 89671**] [**Last Name (Titles) **] picture continued to stabilize and he tolerated HD, there needs to be continuing discussions regarding quality of life and goals of treatment. Still holding all cardiac meds to allow BP for HD. .... # CHF: Patient initially floridly volume overloaded in acute decompensated heart failure. Patient 13 kg over discharge weight several days prior to admission at dialysis, likely 15-20 Liters overloaded. Hyponatremia and extremely high BNP also consistent with florid hypervolemia. Patient did not get full HD session prior to admission due to hypotension. Acute decompensation also likely triggered by unit of blood given earlier today at rehab facility. Swan could not be floated but had RHC during HD cath placement which showed wedge of 20. CKMB stabilized at 6. Echo on [**2-28**] showed mild symmetric left ventricular hypertrophy. The left ventricular cavity size was normal. Overall left ventricular systolic function is severely depressed (LVEF= 25 %) with regional variation (lateral wall relatively preserved). CVVH initiated for volume management and NC for respiratory support. Dopamine gtt required to maintain diuresis with CVVH. Ultimately, unable to wean dopamine gtt with CVVH. Goals of care were discussed as above. Pt's fluid status now being managed through HD and ACEi, Beta blocker being held to allow for blood presure room during HD. . #. ESRD: Status post HD catheter placement on [**2-28**] after large graft hematoma. CVVH via right groin line. Right upper arm fistula repaired and now working normally. Tolerating HD treatments as above and plan Mon/Wed/Fri schedule. Dr. [**Name (NI) 118**], pt's nephrologist who has followed pt very closely here, will continue to consult for HD issues after transfer. . #. ANEMIA: Patient with Hct 21 on admission, has a history of transfusion-dependent anemia with GI sources, including rectal ulcers. Transfused 3 units of PRBCs during admission. Initially concerning for CMV colitis versus rectal ulcers. C diff sent off as patient was being treated at rehab facility with PO vanco and flagyl. Flexiseal placed. CMV VL negative and cdiff PCR negative. Hct now 28. Has rec'd 2U PRBC during last HD treatments and continued epogen injections during HD. . # GPC BACTEREMIA: GPC??????s in pairs & clusters grew from blood cx from femoral line and art line on HD 6 which ultimately speciated to staph aureus. Likely responsible for his leukocytosis and worsening [**Name (NI) **] picture. He was continued on Vancomycin. HD line was not removed, but changed over wire HD 7 after extensive discussion with Renal consult and family regarding access. Dopamine was continued. After patient was made CMO, vancomycin resistent enterococcus was positive in a second set of blood cultures from HD 8. At this time the patient was CMO and off antibiotic therapy. On HD 13, [**Name (NI) **] PO was started to treat staph aureas and VRE after rediscussion of goals of care. His last day will be [**2137-3-20**]. . # HYPERCALCEMIA: Unclear etiology. Developed in the setting of discontinuation of CVVH (in absence of citrate). Hypercalcemia also possibly secondary to ischemia, in setting of hypotension and elevated lactate. Lastly, patient likely has underlying tertiary hyperparathyroidism from ESRD, known to have chronic hypercalcemia in prior records. Likely acute on chronic physiology. Ca has been stable at 10. . #. HYPOTENSION: Likely secondary decompensated heart failure, septic physiology, and overdiuresis at times w/ CVVH. He was continued on continuous dopamine for pressor support until goals of care were discussed and dopamine was discontinued. Now BP is rising off of cardiac meds. . #. GRAFT HEMATOMA: Large hematoma of RUE near graft site. Tender to touch with small area of induration. Transplant surgery had no plans to evacuate hematoma or fix graft while patient unstable and bacteremic. Heparin gtt was continued for anticoagulation. Now fixed and functioning well. . #. DIARRHEA: Flexiseal placed at rehab facility. Prior history of CMV colitis. Per [**Hospital 100**] Rehab med list, was on PO Vanco. He was started on oral vancomycin, metronidazole and gancyclovir. C diff negative toxin two times, and PCR negative. No evidence of colitis on CT scan. CMV VL negative. Gangcyclovir discontinued on HD 6. Oral vancomycin and IV metronidazole were discontinued on HD 7 after culture date negative. Has resolved but perineal area still red and inflamed. . #. ANTICOAGULATION: Despite persistent anemia and GIB risk with rectal ulcers, he was continued on heparin gtt given multiple indications, including atrial fibrillation, mechanical valve and presumed clot burden noted on previous hospitalizations. Coumadin was restarted on [**3-18**] at 2mg daily and INR should be checked on [**3-20**]. . # AF: Patient presented in AFib with RVR. Has history of chronic AFib, rate controlled with carvedilol, anticoagulated on coumadin. He was started on amiodarone 400mg three times daily but this medicine was held when pt made comfort care. Pt currently in AF wtih rates 70's-80's. Coumadin restarted on [**3-18**] at 2mg daily and currently on heparin drip as a bridge. Needs INR on [**2137-3-20**] with goal 2.0-3.0. . #. CAD: Status post CABG [**12-12**]. Holding aspirin due to GIB. No evidence of acute MI on ECG. Lateral ST changes on admission likely secondary to demand ischemia from tachycardia. Enzymes elevated likely due to renal failure. . # IDDM: Humalog SS, fingersticks QID. Will need to restart lantus when tube feedings are started. Holding Lantus now in setting of poor PO's. . #. Hypothyroid: On levothyroxine 75 mcg. . #. Depression: Zoloft should be restarted after [**Year (2 digits) **] is finished on [**3-20**]. Pt is alert, talkative, aware of his situation but wants to continue aggressive care for his family. He currently has minimal SOB that is managed well with low dose Morphine IV and no further CP. His goals of care may change if his SOB and chest pain return and cannot be managed. Medications on Admission: Acetaminophen 650 mg QID PRN pain ASA 81 mg daily Ergocalciferol (vitamin D2) 50,000 unit qWednesday Lantus 17units qPM Lactobacillus acidoph-pectin Levothyroxine 75 mcg daily Metronidazole 500 mg TID (completed [**2-26**]) Omeprazole 40 mg daily Sertraline 50 mg daily Warfarin 1 mg daily Carvedilol 3.125 mg [**Hospital1 **] B complex-vitamin C-folic acid 1 mg daily Cinacalcet 30 mg daily PO Vanco Megestrol Discharge Medications: 1. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) ml PO Q6H (every 6 hours) as needed for fever, pain. 2. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 3. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Mid-line, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 4. zinc oxide-cod liver oil 40 % Ointment Sig: One (1) application Topical [**Hospital1 **] (2 times a day) as needed for bottom irritation. 5. [**Hospital1 11958**] 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Last dose after dialysis on [**2137-3-20**]. 6. morphine 2 mg/mL Syringe Sig: 0.5-1 ml Injection five times a day as needed for pain or shortness of breath. 7. lorazepam 2 mg/mL Syringe Sig: 0.5-1 ml Injection Q4H (every 4 hours) as needed for anxiety. 8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO TID (3 times a day) as needed for confusion or agitation. 9. insulin lispro 100 unit/mL Solution Sig: 0-14 units Subcutaneous four times a day: before meals and qhs. 10. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please start on [**2137-3-21**] when [**Date Range **] is finished. 12. heparin (porcine)-0.45% NaCl 25,000 unit/250 mL Parenteral Solution Sig: as per weight based heparin protocol units Intravenous continuous: D/C when INR > 2.0. 13. warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: Check INR on Thursday [**2137-3-21**] and adjust dose accordingly. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Acute on Chronic Systolic Congestive Heart Failure Sepsis End Stage Renal disease Atrial Fibrillation Anemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You had trouble breathing and was found to be in an acute exacerbation of your congestive heart failure. It was difficult to do dialysis because your blood pressure was very low and you needed medicines to help keep your blood pressure up. At one point, you and your family decided that you wanted to be made comfortable. After we stopped all of your medicines, you improved and was not short of breath or having chest pain. We have resumed dialysis and restarted some of your medicines. . We made the following changes to your medicines: 1. Stop taking Omeprazole, Megatrol, vancomycin, carvedilol, lactobacillus, aspirin, ergocalciferol, and nephrocaps. 2. Start taking Tylenol as needed for pain and fever 3. Start Heparin drip to prevent blood clots. We have started coumadin pills to replace the heparin when the coumadin level is therapeutic 4. Start Zinc ointment to use on your perineal area 5. Start [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic to treat the bacteria in your blood. Your last day is [**3-20**]. 6. Start Morphine as needed for pain 7. Start Lorazepam as needed for anxiety 8. Start olanzipine as needed to agitation 9. Use Humalog as per sliding scale to treat your high blood sugars. 10. You will need to restart lantus if tube feedings are started. . Daily weights. Call provider if weight goes up more than 3 lbs in 1 day. Followup Instructions: Dr. [**Last Name (STitle) 118**] from Nephrology will follow patient in the MACU in a consultative fashion. . Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 62**] on [**Hospital Ward Name 23**] 7 at [**Hospital1 18**]. He will be available to see patient on an emergent basis but does not feel that routine f/u is needed at this time.

Admission Date: [**2156-6-1**] Discharge Date: [**2156-6-4**] Date of Birth: [**2093-5-29**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Tape Attending:[**First Name3 (LF) 2969**] Chief Complaint: Right lower lobe nodule Major Surgical or Invasive Procedure: [**2156-6-1**] Flexible bronchoscopy, Video assisted thoracoscopic thoracoscopy. Right lower lobe superior segment and inferior right middle lobe wedge resections. History of Present Illness: Mr. [**Known lastname 55562**] is a 63-year-old man who, 4 years ago, was found to have a 2 cm right upper lobe nodule for which he underwent a right upper lobectomy. The nodule at that time was found to be carcinoid tumor. He developed a new right lower lobe nodule which was suspicious for cancer and he is being admitted for excision of this nodule. Past Medical History: Right lower lobe superior segment nodule RUL typical carcinoid Asthma/COPD Parkinson's Coronary artery disease Sick sinus syndrome w/pacemaker Anxiety/Depression Osteoarthritis PSH: RULobectomy [**2151**], Partial Nephrectomy [**2151**], Cholecystectomy [**2151**] Social History: Married lives with wife. Quit smoking [**2117**] Family History: non-contributory Physical Exam: VS: General: 63 year-old male no apparent distress HEENT: normocephalic Neck: supple no lymphadenopathy Card: RRR Lungs: scattered crackles on right, left clear GI: bowel sounds positive, abdomen soft non-tender/non-distended Extr: warm no edema Incision: Right VATs site clean/dry/intact no erythema Neuro: flat affect, mobility difficult to mobilize Pertinent Results: [**2156-6-2**] WBC-12.4*# RBC-4.14* Hgb-12.7* Hct-36.7 Plt Ct-205 Brief Hospital Course: Mr. [**Known lastname 55562**] was admitted on [**2157-6-1**] and underwent Flexible bronchoscopy, Video assisted thoracoscopic thoracoscopy, Right lower lobe superior segment and inferior right middle lobe wedge resections. He was monitored in the PACU prior to transfer to the floor with a right chest-tube, foley and an epidural in place managed by the acute pain service. On POD #1 the epidural removed and he was converted to PO pain medication with good control. The chest-tube was removed and a chest x-ray revealed a collapsed right lower lobe and his oxygenation requirements increased. He was later transferred to the TSICU and was bronched for a mucus plug. A repeat film revealed a re-expanded right lower lobe. He was restarted on his parkinsion's medication. The foley was removed but was re-inserted for urinary retention. Physical therapy was consulted to assist with mobilization. On POD #2 he transferred back to the floor. He continued to progress, was ambulating with assistance, tolerating a regular diet, urinating without difficulty, he is discharged home with PT services Medications on Admission: Carbidopa-Levodopa 25-100 mg qid, entacapone 200 mg qid, amantadine 100 mg daily, tamsulosin 0.4 mg daily, clonazepam 0.5-1mg qhs prn anxiety. Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Entacapone 200 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. Amantadine 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety/insomnia. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Take while taking oxycodone. Disp:*60 Capsule(s)* Refills:*0* 9. Medications Take Tylenol 1000mg every 6 hours for pain. You can alternate with ibuprofen 400mg every 6 hours for pain. These do not interact, so you can take them together. Discharge Disposition: Home With Service Facility: [**Hospital3 3765**] Hospice Program Discharge Diagnosis: Right lower lobe superior segment nodule RUL typical carcinoid Parkinson's Coronary artery disease Sick sinus syndrome w/pacemaker, Anxiety/Depression Osteoarthritis Discharge Condition: stable Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience: -Fever > 101 or chills -Increased shortness of breath, or cough -Chest pain -Incision develops drainage or increased redness Chest-tube remove dressing Friday and cover site with a bandaid Should site begin to drain cover with a clean dressing and change as needed to keep site dry. You may shower on Friday: No Swimming or tub bathing for 4 weeks No driving while taking narcotics Walk frequently throughout day Followup Instructions: Follow-up with Dr.[**Doctor Last Name 4738**] [**Telephone/Fax (1) 170**] NPs [**Female First Name (un) **] or [**First Name4 (NamePattern1) 1439**] [**6-15**] at 1:00pm in the [**Hospital Ward Name 121**] Building, [**Hospital1 **] I Chest Disease Center. Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiolgoy Department for a Chest X-Ray 45 minutes before your appointment. Completed by:[**2156-6-4**]

Admission Date: [**2104-6-3**] Discharge Date: [**2104-6-19**] Date of Birth: [**2043-10-7**] Sex: M Service: SURGERY Allergies: Enalapril Attending:[**First Name3 (LF) 668**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**6-10**]: ex lap, colon & SBR, abd left open [**6-11**]: ex lap, hematoma evacuation, [**6-12**]: ex lap, end jejunostomy History of Present Illness: 60M with PMHx of COPD, HTN, ESRD s/o CRT, DM2 presented overnight to ED with acute onset SOB. States he noted progressively worsening dyspnea over past two days. Reports subjective fevers 99-100 at home with chills. No recent increase in sputum production. Past Medical History: -Coag negative staph right hip joint infection, s/p removal, spacer placement 9/08and prolonged abx course. -Chronic pain on narcotics -COPD, not on home 02, last spirometry from [**2092**] with mild to moderate obstructive defect. -HTN -End stage renal disease secondary to malignant hypertension -s/p CRT [**2097**] -baseline creat [**3-4**] -Diverticulitis s/p right colectomy. -Prostate cancer status post radiation therapy in [**3-5**] -Diabetes, not on medication -Perirectal abscess [**1-31**] -bilateral avascular necrosis -s/p fall with femoral neck fracture Social History: Lives alone at home, now retired, formerly worked as a security guard. Tobacco x 30-40 yrs, [**2-1**] pk/day, [**Doctor First Name 1638**] EtOH or illicit drugs, per OMR has h/o alcoholism and marijuana use. Family History: malignant hyperthermia - mother, siblings Physical Exam: On admission Vitals: T:96.8 BP: 190/90 P:61 R:13 SaO2: 96%3L NC General: Awake, alert, appears comfortable. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM slightly dry. Muddy sclera. Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary: Limited air movement, quiet deep pitched wheezes anteriorly and posteriorly, with prolonged expiratory phase. No crackles, no rhonchi. Cardiac: Unable to appreciate through breath sounds. Abdomen: Minimally distended, hypoactive bowel sounds present. Diffusely minimally tender to palpation. No rebound or guarding. No tympany Extremities: No edema. Has non-functional right UE fistula. Skin: Multiple keloids Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. Pertinent Results: [**2104-6-19**] 04:05AM BLOOD WBC-2.3*# RBC-2.34* Hgb-7.1* Hct-22.6* MCV-97 MCH-30.2 MCHC-31.2 RDW-16.5* Plt Ct-35* [**2104-6-19**] 04:05AM BLOOD PT-24.1* PTT-96.9* INR(PT)-2.3* [**2104-6-19**] 04:05AM BLOOD Glucose-138* UreaN-54* Creat-2.0* Na-134 K-5.5* Cl-102 HCO3-18* AnGap-20 [**2104-6-19**] 04:05AM BLOOD ALT-91* AST-123* AlkPhos-67 TotBili-8.3* DirBili-6.6* IndBili-1.7 [**2104-6-19**] 06:13AM BLOOD Type-ART Temp-35.6 pO2-62* pCO2-78* pH-6.97* calTCO2-19* Base XS--16 [**2104-6-19**] 04:19AM BLOOD Type-ART pO2-148* pCO2-76* pH-7.00* calTCO2-20* Base XS--14 [**2104-6-19**] 06:13AM BLOOD Glucose-88 Lactate-8.6* Brief Hospital Course: In ED, initial VS 96.8 193/113 78 24 100% NRB. He desatted to 91% on RA. He had a CXR which did not show any infiltrate or effusion. His labs were notable for acute renal failure and hypernatremia, BNP lower than last value from [**6-4**]. His shortness of breath worsened acutely and he was tried on BiPap which he did not tolerate. He was admitted to the [**Hospital Unit Name 153**] for further monitoring in setting of elevated BP and transient need for BiPap. He detereorated further and was intubated. Abdominal exam became more distended and a tranplant Surgery consult was requested . Initially, he was persistently hypertensive and was treated with nitro and nicardipine drips. On HD #2, renal U/S showed no abnormalities. On HD #3, he was intubated for progressive pulmonary decompensation. On HD #4, renal biopsy concerning for rejection with superimposed ATN. Progressive acidosis at this time. On HD #7, acute hypotensive episode, SBP 70, minimally responsive to fluid resuscitation and vasopressors, guiac positive stool, KUB showing bowel dilatation. CT abdomen showed bowel pneumatosis. On HD #8, approximately 6 hours after initial surgical consultation, the patient was taken to the OR. At this point, he was on three vasopressors, LFT markedly elevated, coagulopathic, and anemic. Also of note, he demonstrated a methemoglobinemia as high as 13% (nl 0-2%) on the day of his decompensation. There was frankly necrotic and perforated bowel, encompassing the majority of his small bowel and transverse/proximal left colon, as well patchy necrosis of his liver. These portions of dead bowel were resected and the patient was left in discontinuity, abdomen open, and returned to the [**Hospital Unit Name 153**] and then later transferred to the SICU. Massive resuscitation continued, with copious blood product transfusions, CVVH initiated. On POD #1, he was taken back to the OR and there was a large amount of hematoma evacuated without obvious source of bleeding, omentectomy was performed, bowel looked viable, abdomen left open. On POD #2, he went into rapid afib with associated hypotension, treated with electrical cardioversion and rate control. Later that day, he was taken back to the OR and an end jejunostomy was performed after failed attempts at re-establishing continuity secondary to tissue friability. On POD #[**4-4**], vasopressors on and off, continued CVVH, developed neutropenia (WBC 0.3) treated with Neupogen, gradual increase in ventilator requirements (increased FiO2 and PEEP). On POD #7, he was taken back to the OR for abdominal wash-out, vicryl mesh closure of abdomen, and VAC dressing placement. Bowel looked viable at this time. On POD #8, the patient went back into rapid afib with hypotension, treated with electrical cardioversion, but progressed to refractory shock requiring three vasopressors. On POD #9, precipitous decompensation ensued, family was consulted, CMO status and expiration shortly thereafter. Medications on Admission: HOME MEDICATIONS (per OMR as pt did not know on admit, now intubated:) Albuterol inhaler 1-2 puffs Q4 hours Atorvastatin 20mg daily duloxetine 30mg daily ezetimibe 10mg daily Fosomax 70mg daily Furosemide 40mg daily Gabapentin 900mg TID Hydromorphone 4mg up to 5x per day prn Methadone 7.5mg PO TID Metaclopromide 10mg TID (per transplant) Metoprolol 50mg [**Hospital1 **] Mycophenolate mofetil 500mg [**Hospital1 **] Omeprazole 20mg [**Hospital1 **] Oxycodone SR 30mg [**Hospital1 **] Prednisone 5mg daily Salmeterol 50mcg 2 puffs [**Hospital1 **] Tacrolimus 4mg [**Hospital1 **] Valsartan 160mg [**Hospital1 **] Varenicline 0.5mg [**Hospital1 **] Ferrous sulfate 325mg daily Discharge Medications: Calcium Gluconate/ 500 mL D5W Albuterol Inhaler Artificial Tears Calcium Chloride Chlorhexidine Gluconate 0.12% Oral Rinse Citrate Dextrose 3% (ACD-A) CRRT Ciprofloxacin Famotidine Fentanyl Citrate Filgrastim Fluticasone Propionate 110mcg Hydrocortisone Na Succ. Insulin Ipratropium Bromide MDI Magnesium Sulfate MetRONIDAZOLE (FLagyl) Meropenem Midazolam gtt Phenylephrine Potassium Chloride Prismasate (B22 K4)* Tacrolimus Vancomycin Vasopressin Discharge Disposition: Expired Discharge Diagnosis: COPD, Sepsis, Mesenteric ischemia, Afib, Death Discharge Condition: Deceased Completed by:[**2104-6-20**]

Admission Date: [**2164-2-18**] Discharge Date: [**2164-2-22**] Date of Birth: [**2090-1-23**] Sex: F Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 689**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 25383**] is a 74 year-old woman, patient of Dr. [**Last Name (STitle) **], with history of treated MAC, obstructive lung disease (FEV1/FVC 56 in [**10-18**]), and s/p recent right TKR on [**2164-1-24**] who presents with cough, fevers, and dyspnea and is admitted to the MICU for respiratory distress. She was feeling well until three days ago when her symptoms began. She noted cough productive of yellow sputum, worsening dyspnea, and fevers with tmax 101.5. No sick contacts. She did receive seasonal flu vaccine but not H1N1. She has also lost 10 lbs over the last 6 weeks because of lack of appetite. In the ED, vital signs were initially: 97.4 155 115/57 24 90%ra. She was noted to be speaking in short sentences with pursed lip breathing. Exam was significant for wheezes and rales. CXR was negative for acute process. She was given 2L NS and ceftriaxone/azithro and admitted to the MICU. Past Medical History: - Mycobacterium avium intracellularae - treated for MAC from [**2-/2157**] to [**7-/2158**] - bronchiectasis - Right total knee replacement [**2164-1-24**], on coumadin - cholecystitis s/p cholecystectomy - endometrial carcinoma s/p hysterectomy in [**10/2152**] - Obstructive lung disease (FEV1/FVC 56 IN [**10-18**]), NOT on home 02 - Anxiety Social History: Retired, lives alone. Friend [**Name (NI) 1312**] has been staying with her since her surgery. Her HCP is her sister. Smoked 1 pack/week x 20 years. Has not smoked for 25 years. She drinks 6-8 drinks per week. Last drink 3 days ago. No history of withdrawl. Family History: colon cancer Physical Exam: Admission Vitals - T:97.8 BP:117/82 HR:95 RR:22 02 sat:98% 3L GENERAL: Thin, frail appearing elderly woman sitting in chair. HEENT: Normocephalic, temporal wasting. MM dry. Multiple telangiectasias. CARDIAC: Tachycardic, regular LUNGS: Decreased air movement. Fine crackles and distant wheeze. can only speak [**3-14**] words at a time, is easily winded. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. s/p recent TKR, incision well healed. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. PSYCH: Listens and responds to questions appropriately, pleasant . Discharge Vitals: T:96.5 BP:136/65 HR:64 RR:20 02 sat:95%RA Pertinent Results: [**2164-2-18**] 01:18PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016 [**2164-2-18**] 01:18PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2164-2-18**] 01:18PM URINE RBC-89* WBC-2 BACTERIA-NONE YEAST-NONE EPI-1 [**2164-2-18**] 01:18PM URINE MUCOUS-RARE [**2164-2-18**] 06:29AM TYPE-ART TEMP-38.1 O2 FLOW-4 PO2-98 PCO2-50* PH-7.32* TOTAL CO2-27 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2164-2-18**] 04:01AM LACTATE-1.0 [**2164-2-18**] 02:19AM GLUCOSE-121* UREA N-15 CREAT-1.0 SODIUM-136 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13 [**2164-2-18**] 02:19AM estGFR-Using this [**2164-2-18**] 02:19AM CK(CPK)-41 [**2164-2-18**] 02:19AM CK-MB-NotDone cTropnT-0.01 [**2164-2-18**] 02:19AM TSH-1.4 [**2164-2-18**] 02:19AM WBC-9.2 RBC-4.35# HGB-12.9# HCT-40.4# MCV-93 MCH-29.5 MCHC-31.8 RDW-15.3 [**2164-2-18**] 02:19AM NEUTS-79.0* LYMPHS-15.0* MONOS-3.3 EOS-2.3 BASOS-0.4 [**2164-2-18**] 02:19AM PLT COUNT-515* [**2164-2-18**] 02:19AM PT-51.9* PTT-47.4* INR(PT)-5.7* . [**2164-2-18**] URINE Legionella Urinary Antigen -FINAL INPATIENT [**2164-2-18**] URINE URINE CULTURE-FINAL INPATIENT [**2164-2-18**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL {RESPIRATORY SYNCYTIAL VIRUS (RSV)}; Respiratory Viral Antigen Screen-FINAL INPATIENT [**2164-2-18**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [**2164-2-18**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2164-2-18**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2164-2-18**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT . BASIC COAGULATION (PT, PTT, PLT, INR) [**2164-2-22**] 06:50AM 17.4* 29.8 1.6* [**2164-2-21**] 04:55AM 18.8* 31.4 1.7* [**2164-2-20**] 08:50AM 23.0* 32.8 2.2* [**2164-2-19**] 03:51AM 51.0* 44.6* 5.6*1 [**2164-2-18**] 02:19AM 51.9* 47.4* 5.7*2 . [**2-18**] CXR No focal consolidations. Hyperinflation suggestive of possible emphysema or COPD. Brief Hospital Course: Ms [**Known lastname 25383**] was initially admitted to the MICU given concern for her tachypnea and tachycardia. She was treated for pneumonia with levofloxacin and for COPD with steroids and nebulizers. Her oxygen saturations remained in the high 90s with 3L supplemental oxygen. Her chest-xray did not show consolidation. She tested negative for legionella urinary antigen and was negative for flu. She was transferred to a regular medical floor on the second day of her hospitalization. Her warfarin for her knee replacement was held when her INR became supratherapeutic >5 in the setting of antibiotic use. On the floor, the following issues were managed: # Respiratory distress. Patient was treated for CAP/HAP with levoquin and discharged to complete a 7 day course. CXR on admission showed hyperinflation without focal findings and repeat showed now interval change. No sputum culture to guide therapy. She was also treated for COPD flare/bronchitis with burst of prednisone 60mg daily and with aggressive nebulizer treatment. Over the course her stay, her resp status dramatically improved. She was discharged with a slow 10 day taper. She was weaned off oxygen with some residual cough. Lung exam improved with some residual crackles and wheezing at bases. Had been ruled out for flu. PE also possible but less likely given therapeutic on coumadin on admission. Viral culture showed RSV and after discussion with ID the treatment is just supportive care. . #.Anemia. Hct stable. Iron studies c/w mixed iron deficiency and likely chronic disease. Recent baseline hct low 30s, however was 40 on admission likely hemoconcentrated in setting of illness. No obvious bleeding. Hct remained stable. Her iron was increased to [**Hospital1 **]. . # Coagulopathy: Pt on warfarin at home for planned 4 week post-op course since [**1-26**]. Elevated INR in setting of abx use on admission but then became subtherapeutic after holding doses. It was restarted but she was not yet therapeutic upon discharge. No evidence of bleeding. . # Anxiety: stable, cont home PRN ativan . # HTN: reasonably controlled, cont home lisinopril . # TKR: Followed by Dr. [**Last Name (STitle) **]. Has outpatient appt with him on Friday. Cont warfarin management as above, patient to go home with PT, pain control with oxycodone. Given subQhep while subtherapeutic on coumadin and TEDS. . # General Care: FEN: noIVFs / replete lytes prn / regular diet, PPX: home PPI, subQ hep, bowel regimen, ACCESS: PIV, CODE: FULL, confirmed with pt, CONTACT: [**Name (NI) **] and sister is HCP [**Name (NI) 2147**] [**Name (NI) 5263**] [**Telephone/Fax (1) 25384**], DISPO: home with services Medications on Admission: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q4h PRN as needed for pain. 3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 4 weeks: goal INR 2.0-2.5 adjust dose accordingly. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 10. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheeze. 12. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP<110. 16. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 17. Desonide 0.05 % Cream Sig: One (1) Appl Topical DAILY (Daily). 18. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl Topical DAILY (Daily). 19. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Discharge Medications: 1. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 2. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day for 14 days. Disp:*42 Tablet(s)* Refills:*0* 3. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. 12. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation twice a day. 13. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day for 10 days: Take 5 tab for 2 days([**Date range (1) 25385**]), take 4 tab for 2 days ([**Date range (1) 25386**]), take 3 tab for 2([**2073-2-25**]), take 2 tab for 2 days([**Date range (1) 25387**]), take 1 tab for 2 days([**Date range (1) 25388**]). Disp:*30 Tablet(s)* Refills:*0* 14. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*15 Tablet(s)* Refills:*0* 15. Outpatient Lab Work Please have INR drawn twice a week starting on Thursday [**2164-2-23**] and have results called in to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1228**] who should call you with instructions on how to change the coumadin dosing. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Community Acquired Pneumonia COPD flare Iron deficient anemia Supratherapeutic INR . Secondary: bronchiectasis anxiety 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 because of difficulty breathing which required you to be admitted to the intensive care unit overnight. We believe this was secondary to a pneumonia and possible exacerbation of your chronic lung disease. You were given antibiotics for the infection and steroids to help with the inflammation. You slowly improved and we were able to get you off oxygen. . Medication changes: 1)We started you on an antibiotic called levaquin which you should take for 2 more days. 2)You iron was increased to twice a day. 3)We started you on prednisone with decreasing doses over the next 10 days. 4)We started compazine if you have any nausea. . You should have your INR drawn and Thursday by the visiting nurses. . Please keep all your follow up appontments. . If you develop any of the warning signs below or any other concerning symptoms, please do not hesitate to call or your PCP or go to your local emergency room. Followup Instructions: You have an appointment with Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] on Wednesday, [**2-29**] at 10:40am. [**Telephone/Fax (1) 24396**]. Please have him follow up your anemia. Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2164-2-24**] 10:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-3-2**] 11:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2164-4-19**] 11:10 Completed by:[**2164-2-22**]

Admission Date: [**2146-3-22**] Discharge Date: [**2146-3-24**] Date of Birth: [**2106-12-1**] Sex: M Service: MEDICINE Allergies: Penicillins / Keflex / Ciprofloxacin / Sulfa (Sulfonamides) / Clarithromycin / Demerol / Red Dye / Haldol Attending:[**First Name3 (LF) 2745**] Chief Complaint: fevers, abdominal pain, diarrhea, cough Major Surgical or Invasive Procedure: None History of Present Illness: This is a 39 year-old male with a history of cerebral palsy, chronic aspiration, GERD, ? ulcerative colitis who presents with low grade temps at home, cough, abdominal pain. He is accompanied by his mother. [**Name (NI) **] had a colonoscopy on [**3-17**] to evaluate for IBD, with fairly normal appearing bowel but biopsies are pending. Afterwards, he was constipated, but then started have very loose stools yesterday and today. He has had low grade temps, about 100 at home. Also, his mother states his cough seems to be worse lately. He has also been complaining of abdominal pain as well. He gets his nutrition via his G-tube at home. Also of note, he recently completed a course of azithromycin for a skin boil. . In the ED, inital vitals were 101.2, 140, 113/79, 28, 92%RA. He was given a total of 3L IVFs in the ED with improvement of his tachycardia. He was also given morphine and zofran in the ED. Subsequently, his SBP dropped to the 80s and high 70s, and was not improving with IVFs. He was started on peripheral dopamine. There were lengthy discussions with the family regarding a central line, but they did not want one at this time. His CXR was concerning for a LLL consolidation. He underwent CT abdomen/pelvis which did not show any specific findings, but did show some inflammation of the rectum and ? prostatitis. Rectal exam did not show e/o tenderness of his prostate. He was given vancomycin, flagyl, and gentamicin in the ED. He has multiple abx allergies. He was then transferred to the ICU for further monitoring. . ROS: the patient has limited communication at baseline. Denies pain at this time. Past Medical History: -Cerebral Palsy -Chronic Aspiration -Gastroesophageal reflux disease -? Ulcerative Colitis- currently undergoing workup -Seizure disorder Social History: Lives at home with his parents who provide his care. He is wheelchair bouns and non verbal at baseline. He receives nutrition through a G-tube, though he can take certain liquid medications by mouth. He has a personal care assistant at home who also helps with his care. No tobacco, ETOH or illicit drug use. Family History: Paternal grandfather with multiple [**Month/Year (2) 499**] polyps. Paternal great grandfather with [**Name2 (NI) 499**] cancer. Paternal grandmother died of [**Name2 (NI) 499**] cancer in her 30's. Maternal grandmother with [**Name2 (NI) 499**] cancer. Brother with polyps of unknown type. Father "a few adenomas". Physical Exam: Vitals: T: BP: HR: RR: O2Sat: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: 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: Lungs CTAB, no W/R/R 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. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: Imaging: CXR: IMPRESSION: Hazy subtle opacity within the left lung base, which could represent early pneumonia. . [**3-21**] CT ABD/PELVIS: CT PELVIS WITH IV CONTRAST: There is apparent mild rectal thickening, which may relate to recent instrumentation or be inflammatory in nature. A slightly edematous appearance of the prostate and seminal vesicles is again seen, but of unclear etiology. There is no pelvic or inguinal lymphadenopathy. Bilateral fat and fluid-containing inguinal hernias are identified. Osseous structures demonstrate a right convex curvature of the lumbosacral spine. There are bilateral pars defects of the L5 vertebral body, without evidence of antero- or retrolisthesis. There are apparent undescended or high-riding testicles, for which non-urgent scrotal ultrasound should be consisdered. IMPRESSION: 1. No evidence of perforation or abscess. 2. Mild rectal thickening may be inflammatory or post-procedural in nature. 3. Consider non-urgent scrotal ultrasound. . Brief Hospital Course: This is a 39 year-old male with a history of cerebral palsy, chronic aspiration, GERD who presents with fevers, cough, abdominal pain, and diarrhea with persistent hypotension. . Plan: # Hypotension - on initial admit, febrile, tachycardic, and had leukocytosis. Potential likely sources included LLL pneumonia with infiltrate on CXR, c.diff given diarrhea and recent abx exposure. Other possible causes are prostate though no specific findings on exam. urine clear. no clear reason to suspect meningitis (no neck stiffness than baseline per mother). GI was consulted. Family deferred CVL; team discussed risks of dopamine peripherally. Dopamine was initially given for ~10 hours to maintian MAPs>60. Pt was initially treated for possible aspiration pna and cdiff with vanco, gentamicin, and flagyl. On hospital day #2, gentamicin and vancomycin were discontinued and flaygl was continued as the infiltrates on cxr were not felt to be the active site of infection. Patient did not have evidence of c.diff and was discontinued. The patient clinically improved and was discharged home on loperamide. . # Hypotension: as above, thought likely component of dehydration, medication effect from meds given in the ED and infection. Pt was treated with IVF and initially with dopamine. Hemodynamics were stabilized. . # Abd pain/gerd: CT scan ruled out acute pathology, suggested duodenitis. CXR suggested possible chronic aspiration. Pt remained on his at-home PPI and H2 blocker. He was restarted on his TFs via G-tube on hospital day #2. . # Seizure d/o: continued home phenobarb and diazepam . Medications on Admission: 1. Mesalamine DR 1200 mg PO BID 2. Citalopram Hydrobromide 40 mg PO DAILY 3. PHENObarbital 32.4 mg tabs 3 tabs PO HS 4. Diazepam 6 mg PO HS 5. Pantoprazole 40 mg PO Q12H 6. Famotidine 20 mg PO HS 7. Nasonex 1 SPRY NU DAILY Discharge Medications: 1. Diazepam 2 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO HS (at bedtime). 2. Phenobarbital 30 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO HS (at bedtime). 3. Famotidine 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 4. Citalopram 20 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One (1) Tablet, Delayed Release (E.C.) PO every twenty-four(24) hours. 6. Loperamide 2 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:*30 Capsule(s)* Refills:*1* 7. Fluticasone 50 mcg/Actuation Spray, Suspension [**Month/Year (2) **]: One (1) Spray Nasal DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Diarrhea Fevers Hypotension Cerebral Palsy GERD Siezure disorder Discharge Condition: Vital Signs Stable Discharge Instructions: Return the ED for high fevers, significantly worsening diarrhea, profuse vomiting. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2146-4-15**] 8:20 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2146-4-27**] 1:10 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2146-4-27**] 1:30

Admission Date: [**2106-8-30**] Discharge Date: [**2106-9-2**] Date of Birth: [**2067-4-16**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Headache Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 39 year old right handed woman with a history of hypertension, DM2, and oral contraceptive use who presents with an 8 day history of bilateral frontal throbbing headaches associated with blurry peripheral vision which changed to left occipital throbbing headaches on the day prior to admission, an episode of loss of power and balance in her right arm and leg 5 days prior to admission, 2 episodes of vertigo and projectile vomiting, and leaning to the left when walking, who was found to have occlusion of her left vertebral artery with embolic left PICA and PCA infarcts. The patient reports that her symptoms started 8 days ago on Sunday ([**8-22**]). She reports that she very rarely gets headaches, but on Sunday woke up from her afternoon nap with a bilateral frontal, throbbing, [**2107-3-10**] headache. She said this was associated with blurry vision out of the peripheral vision of her bilateral eyes. She noticed this when watching TV and when [**Location (un) 1131**] her book. She did not close each eye individually to test her vision. There was no sensation of movement in her periphery, and no fortification spectra. She took Advil for this headache, which improved after 2-3 hours. She slept well overnight, and then on Monday ([**8-23**]) woke up again with a [**2107-6-13**] frontal throbbing headache, this time was associated with photophobia, phonophobia, and nausea but no vomiting. The headache did not get worse when she layed flat. Because of this, she went to her PCP where she described the headache as the worse headache of her life, and was referred to the [**Hospital1 18**] ED where head CT was normal. She was given Compazine and Ibuprofen with improvement in her headache. Her headache ended up lasting 6-7 hours. On Tuesday ([**8-24**]) she was able to go to work in the lab, and did not have a headache. On Wednesday ([**8-25**]) she had a central frontal headache, which improved with Advil. That day, she had an episode in which she was holding the door with her left hand and then lost power and lost balance in her right leg. She could not bear weight on the right leg, and this lasted 5 minutes. During the episode for 1 minute she also felt as though she had lost power and balance in her right arm. Her sensation on the right side was normal during this episode, and she had no facial weakness, dyarthria, or aphasia. She called her PCP, [**Name10 (NameIs) 1023**] reassured her given the normal head CT in the ED. On Thursday ([**8-26**]), she did not have a headache but was evaluated by ophthomology where her vision was 20/20 bilaterally. On Friday ([**8-27**]), she had a left frontal headache despite taking Motrin. She continued to have blurry vision with each frontal headache (and even reported that if she had a headache on one side, she would have the blurry vision on the opposite side). She again saw her PCP who recommended Claritin D for a possible sinus infection, and ordered the patient an MRI head. At 10:00 pm that night, the patient had [**2107-6-14**] pain in her left frontal region despite the Motrin. She took Claritin and went to bed. She woke up from sleep on Saturday morning ([**8-28**]) at 2:00 am and felt the room spinning around her. She even remembers feeling a spinning sensation in her dream before waking up. She began to have projectile vomiting which she said she could not control. The dizziness lasted for 15-30 minutes, and she had no associated diplopia, dysarthria, or dysphagia. She had a slight headache at that time. She did not get up to walk during this event, and ended up going back to bed. However, she woke up again at 5:00 am with the room spinning around her and projectile vomiting. She could not get up, so again was taken to the [**Hospital1 18**] ED. Per the ED report she had a "negative [**Last Name (un) **]-Hallpike, and was thought to have a sinus infection as the cause of her symptoms". No further imaging was obtained. She was given Valium 5 mg prn and discharged home. The dizziness lasted a total of [**4-11**] hours and improved with Valium. Yesterday ([**8-29**]), at 6:00-7:00 pm she developed a mild, throbbing, left occipital headache, and she noticed when she walked she was drifting to the left side. She called her PCP about these symptoms on [**8-30**], and she changed her MRI head with and without contrast to be done today. This showed an acute/subacute embolic infarct in the left PICA territory and small left PCA territory with long segment occlusion of the left vertebral artery. The patient was referred to the [**Hospital1 18**] ED. On ROS, she currently reports a [**2107-4-11**] left occipital headache. She denies any numbness. She denies neck pain. She denies bowel/bladder incontinence. She denies diplopia, dysarthria, dysphagia, or aphasia. She denies fevers/chills, coughs/colds, diarrhea, or pain/burning on urination. She has not had any recent travel outside of the country, and the last trip was to Montreal x1 day in [**11-14**]. She does not have a history of miscarriages or blood clots. She has never had symptoms like this before. Past Medical History: Hypertension x7 years Diabetes type 2 diagnosed in [**3-/2106**] PCOS diagnosed in [**2101**] Social History: She lives at home with her husband and 7 year old daughter. She works as an instructor in Dr.[**Name (NI) 80545**] laboratory in sleep and circadian rhythm. She denies working with any viruses and denies any chemical exposure. She denies cigarette, EtOH, or illicit drug use ever. Family History: There is no family history of blood clots or miscarriages. There is no family history of stroke. Her father had hypertension and died of an MI at age 60. There is a strong maternal family history of type 2 diabetes. Physical Exam: VS: temp 98.2, HR 109, bp 136/100, RR 21, SaO2 99% on RA Genl: Awake, alert, NAD HEENT: Sclerae anicteric, no conjunctival injection, oropharynx clear CV: Tachycardic, Nl S1, S2, no murmurs, rubs, or gallops Chest: CTA bilaterally anteriorly and laterally, no wheezes, rhonchi, rales Abd: +BS, soft, NTND abdomen Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**] backwards. Speech is fluent with normal repetition; naming intact. No dysarthria. Registers [**3-9**], recalls [**2-9**] in 5 minutes even with prompting. No right-left confusion. No evidence of apraxia or neglect. Cranial Nerves: Fundoscopic examination reveals sharp disc margins bilaterally. Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields are full to confrontation. Extraocular movements intact bilaterally without nystagmus. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Normal tone bilaterally. No observed myoclonus, asterixis, or tremor. No pronator drift. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE R 5 5 5 5 5 5 4+ 5 5 5 5 5 L 5 5 5 5 5 5 4+ 5 5 5 5 5 Sensation: Intact to position sense throughout. She has decreased sensation to cold temperature and pinprick in her entire right leg which she says is 80% of the left side. No extinction to DSS. Reflexes: 2+ and symmetric in biceps, brachioradialis, triceps, and knees. 1+ and symmetric in ankles. Toe downgoing on the left, upgoing on the right. Coordination: Finger-nose-finger, finger-to-nose, and [**Doctor First Name **] normal. Fine finger movements slightly slowed on the left, but not clumsy bilaterally. Gait: Wide based, unsteady and tends to lean to the left. Unable to tandem and leans to the left. Romberg positive and leans to the left and forward. Pertinent Results: Admission Labs: [**2106-8-30**] 11:25AM RET AUT-1.5 PLT COUNT-443* WBC-11.8* RBC-5.88* HGB-11.2* HCT-35.0* MCV-60* MCH-19.0* MCHC-31.9 RDW-16.0* NEUTS-64.0 LYMPHS-31.8 MONOS-2.5 EOS-1.0 BASOS-0.7 FERRITIN-78 IRON-37 PT-11.5 PTT-22.2 INR(PT)-1.0 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG GLUCOSE-102 UREA N-11 CREAT-0.5 SODIUM-135 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-21* ANION GAP-19 MR HEAD W & W/O CONTRAST Study Date of [**2106-8-30**] 12:53 PM IMPRESSION: 1. Acute/subacute embolic infarct in the left PICA territory and small left PCA territory. 2. Long segment occlusion of the left vertebral artery. CTA NECK W&W/OC & RECONS Study Date of [**2106-8-30**] 9:03 PM IMPRESSION: 1. Occlusion of the left vertebral artery from the distal V2 segment through the distal V4 segment. While there are no specific signs to help differentiate between thrombosis and dissection, the distribution of the occlusion is suggestive of dissection. 2. Left posterior inferior cerebellar artery origin is not opacified. Vessels along the inferior left cerebellar hemisphere appear to represent branches of the large left anterior inferior cerebellar artery and veins. 3. Infarctions in the left posterior inferior cerebellar artery distribution, shown to be acute on the preceding MRI. The small left occipital lobe acute infarction seen on the preceding MRI is poorly visualized on this study. 4. Aberrant right subclavian artery. Common origin of the right and left common carotid arteries. 5. Enlarged left thyroid lobe and bilateral thyroid nodules. Recommend thyroid ultrasound if not done previously. Discharge labs: [**2106-9-2**] 04:40AM BLOOD WBC-11.5* RBC-5.33 Hgb-9.7* Hct-32.7* MCV-61* MCH-18.2* MCHC-29.6* RDW-15.5 Plt Ct-438 [**2106-9-1**] 04:45AM BLOOD Neuts-40.9* Lymphs-51.8* Monos-3.5 Eos-3.0 Baso-0.8 [**2106-9-2**] 04:40AM BLOOD Plt Ct-438 [**2106-9-2**] 04:40AM BLOOD PT-15.1* PTT-26.5 INR(PT)-1.3* [**2106-8-31**] 05:01AM BLOOD ESR-21* [**2106-8-30**] 11:25AM BLOOD Ret Aut-1.5 [**2106-9-2**] 04:40AM BLOOD Glucose-129* UreaN-10 Creat-0.6 Na-137 K-4.7 Cl-102 HCO3-20* AnGap-20 [**2106-8-31**] 05:01AM BLOOD ALT-7 AST-15 LD(LDH)-176 CK(CPK)-24* AlkPhos-63 TotBili-0.2 [**2106-9-2**] 04:40AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.1 [**2106-9-1**] 04:45AM BLOOD calTIBC-378 VitB12-151* TRF-291 [**2106-8-31**] 05:01AM BLOOD %HbA1c-6.8* [**2106-8-31**] 05:01AM BLOOD Triglyc-881* HDL-55 CHOL/HD-3.9 [**2106-9-1**] 04:45AM BLOOD TSH-2.8 Brief Hospital Course: Ms. [**Known firstname 80546**] is a 39 yo woman with a history of hypertension, diabetes (type II) and PCOS who presented with 8 days of headache with progression to vertigo and left neck/occipital pain. # PICA/PCA infarcts/Vertebral Dissections: The patient was referred to the ED by her PCP following MRI identification of a cerebellar infarct. An occipital infarct was also identified. CTA of the head was notable for an apparent intracranial left vertebral artery dissection. She was started on a heparin gtt, and then switched to a Lovenox bridge to Coumadin. An echocardiogram was performed and showed no abnormalities. She is currently on Lovenox while bridging to a goal INR of 2.0-2.5. She was found to have significantly elevated triglycerides, and was also on oral contraceptives, both of which could make her hypercoagulable. In addition, a hypercoagulable panel was sent, the results of which are still pending. Her exam on discharge is notable only for slight slowing of rapid alternating movements with the left hand, and very mild gait instability, most notable when turning. # Hypertriglyceridemia. The patient was noted to have a triglyceride of 880. She was started on gemfibrozil and simvastatin. She is not aware of any family history of lipid elevations, however this raises suspicion for Type IV hyperlipidemia. It is also possible that her high triglycerides increased the viscosity of her blood, contributing to her current stroke. # Diabetes: HgA1c on admission was 6.8. Metformin was held in the setting of IV contrast. Blood sugars were controlled with insulin. She is to resume her metformin on discharge, however given her significant hyperlipidemia, she may benefit from switching back to insulin in the future. # Tachycardia: Throughout her admission the patient had constant asymptomatic sinus tachycardia. Her heart rate did increase to the 140s with activity, but even at rest, while sleeping she remained in the 100-110s. The tachycardia was not fluid responsive, and not related to pain. She remained afebrile during the entire admission. She had a TSH checked, which was normal at 2.8. While she was anemic, her Hct ranged from 30-32, which is around her baseline. While pulmonary embolism should be considered, given the possibility that she may be hypercoagulable, her SaO2 remained 97-100% on room air, and she was not tachypnic. She had both an EKG and TTE which showed no signs of right heart strain. Given that constellation of findings, there was a much lower suspicion for PE. She had already had significant contrast exposure from her earlier imaging, and she was already being anticoagulated, so the decision was made not to get a PE CT, as it would not change management and there was low suspicion that this was causing her tachycardia. Given her known thrombus elsewhere, a D-dimer would not have been useful. There is evidence that medullary involvement in PICA strokes can result in tachycardia, and it is suspected that this was the underlying cause. She was started on a low dose beta-blocker for rate control, and this should continue to be followed. # PCOS: The patient was taking oral contraceptives for treatment of her PCOS. Given her stroke, this medication was discontinued. Reinitiation of this medication verus alternative treatment should be discussed with her endocrinologist. # Hypertension: Micardis was held on admission to allow for autoregulation in the setting of stroke, but was restarted on discharge, in addition to a low dose of metoprolol. # Anemia: The patient was noted to have a significantly microcytic anemia. On further questioning she noted that she actually had been diagnosed with thalassemia trait in the past. It also appears as though she has a component of iron deficiency, and should continue on iron supplementation. # Thyroid: Incidentally the patient was noted to have an enlarged left thyroid lobe and bilateral nodules on MRI. TSH was normal at 2.8. It is recommended that she have a thyroid ultrasound as an outpatient. Medications on Admission: Metformin 500 mg daily Micardis 80 mg-12.5 mg daily Ocella (Drospirenone-Ethinyl Estradiol) 0.03 mg-3 mg daily x7 years Tylenol prn Discharge Medications: 1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 2. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) 60mg syringe Subcutaneous Q12H (every 12 hours): Continue taking until instructed by Dr. [**First Name (STitle) **] to stop. Disp:*12 60mg syringe* Refills:*1* 5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. Disp:*10 Tablet(s)* Refills:*0* 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 8. Micardis HCT 80-12.5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Only take if instructed to do so by Dr. [**First Name (STitle) **]. Disp:*30 Tablet(s)* Refills:*2* 10. Outpatient Lab Work Please check INR on [**2106-9-4**] and every other day after that. Please FAX results to Dr. [**First Name (STitle) 9466**] [**Name (STitle) **] at [**Telephone/Fax (1) 4004**]. Discharge Disposition: Home Discharge Diagnosis: Cerebellar infarction Vertebral artery dissection Hypertriglyceridemia Anemia - thalassemia trait Discharge Condition: Improved. Very mild dysmetria and impaired rapid alternating movements on the left. Very mild gait instability. Discharge Instructions: You were seen for headache, nausea and vomiting. You were found to have a cerebellar stroke. This is likely due to a vertebral dissection. You were started on Coumadin, but will need to take Lovenox until your Coumadin levels become therapeutic. You should have your INR checked every other day, and have the results sent to Dr. [**First Name (STitle) **]. You were also found to have an elevated heart rate, and were started on a new medication called Metoprolol. If you developing worsening headache, nausea or dizziness, or any other new neurological symptoms, please return to the ED for further evaluation. Followup Instructions: You have the following follow-up appointments: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9501**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2106-9-6**] 9:40 Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2106-10-19**] 2:00 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

Admission Date: [**2177-1-30**] Discharge Date: [**2177-2-7**] Date of Birth: [**2158-2-7**] Sex: M Service: OTOLARYNGOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7729**] Chief Complaint: Left neck mass Major Surgical or Invasive Procedure: [**2177-1-30**]: Incision and drainage of left deep neck abscess with sacrifice of internal jugular vein. History of Present Illness: The patient is an 18 M who presents with worsening L neck fullness, pain and dysphagia two weeks after L wisdom teeth extraction. The patient reports that he noticed neck fullness 8 days ago and presented to his dentist; at that time, swelling was felt to be postoperative in nature. Because of persistent symptoms, he saw his PCP four days ago who started him on amoxicillin and Tylenol/codeine; he had some difficulty with nausea with these medications. Tm 101 over the past several days. He noticed difficulty with normal eating starting five days ago, with sensation that liquid gets stuck in his throat and regurgitates upward to nose for the past 2 days. He noticed change in his voice since yesterday. No odynophagia. He is able to tolerate his oral secretions. No difficulty breathing, no stridor. No trismus, no otalgia. No chest pain. No sick contacts. Past Medical History: None Social History: Works as a fire fighter. Denies tobacco, EtOH. Family History: No history of immunodeficiency or bleeding disorder. Physical Exam: On admission [**2177-1-30**]: VS: 99.0 103 153/95 16 99% RA Gen: NAD, pleasant, voice slightly muffled, no stridor, no increased work of breathing Ear: AD: auricle, canal and TM normal [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]: Septum midline, no purulent drainage, turbinates normal. OC/OP: Moist mucus membranes. Good dentition. L molar area without fluctuance. Masseter space without fullness or fluctuance. No trismus, symmetrical palatal elevation, no erythema. FOM, BOT and oral cavity mucosa, and palatal area soft and nontender without abnormal lesions. Neck: Fullness in the left lateral neck with tenderness to palpation extending from anterior to SCM to posteriorly. Displacement of laryngeal apparatus anteriorly and to the right. CNII-XII intact FOE: Verbal consent obtained. Nasal cavity sprayed with Afrin. Scope passed through nasal cavity. No purulent drainage, eustachian tubes patent, nasopharynx normal. L lateral and L posterior pharyngeal walls with significant bulge into the airway, touching epiglottis, obscuring visualization of the L piriform. Glottic apparatus deviated anteriorly and toward the right. Minimal supraglottic edema. No significant pooling of secretions. TVF fully mobile and symmetric. Airway compromised given displacement from pharyngeal abscess. Pertinent Results: On admission: [**2177-1-30**] 02:40PM WBC-18.3* RBC-4.40* HGB-13.4* HCT-39.4* MCV-90 MCH-30.5 MCHC-34.0 RDW-12.5 [**2177-1-30**] 02:40PM NEUTS-79.6* LYMPHS-12.4* MONOS-6.6 EOS-0.5 BASOS-0.9 CT Neck on admission: 1. Large left retropharyngeal and parapharyngeal abscess,extending to the carotid space measuring 7.0 x 4.2 x 3.2 cm. Stranding in the base of the neck, but no definite extension into the mediastinum. 2. Significant mass effect on the oropharyngeal airway, 3. Compression of the left internal jugular vein, without complete occlusion. 4. No osteomyelitis. Brief Hospital Course: The patient is a 18 year old male who presented to the [**Hospital1 18**] ED with enlarging left neck mass with CT demonstrating a large parapharyngeal and retropharyngeal abscess surrounding the great vessels. He was taken urgently to the OR for drainage. He underwent fiberoptic intubation and incision and drainage of the abscess. Intra-op findings notable for a well loculated abscess in the parapharyngeal and retropharyngeal space as well as lateral to the SCM. The left internal jugular vein was ligated as it was involved in the abscess pocket. A large amount of purulent material was drained and three penroses placed in the potential spaces. The patient tolerated the procedure without immediate complications. For details, please see separately dictated operative note by Dr. [**Last Name (STitle) 1837**]. Postoperatively, the patient was kept intubated and taken to the ICU for closer observation. The remainder of his hospital course is reviewed here by systems: Wound: The patient had a horizontal incision left neck incision with three penroses in place. The wound continued to be open and drain during this period. On POD #4, the patient underwent repeat CT imaging of the neck in the setting of a slight rise in his WBC to 12 and chest pain, which was negative for any residual abscess or for evidence of mediastinitis. His symptoms thereafter resolved. The penroses were slowly inched out daily and removed on POD #7. Following removal of the penroses, the wound cavity was irrigated and then packed with 1-inch iodaform strip gauze (10 cm) with plan for continued dressing changes daily as an outpatient with assistance of VNA, as the cavity slowly seals in. Neuro: The patient's cranial nerves were fully intact following the procedure. His voice was strong and a post-op FOE demonstrated bilateral, symmetric vocal cord mobility. He was noted to have a left-sided Horner's syndrome, without significant functional compromise. The patient's pain was initially controlled with IV antibiotics. He was kept sedated while on the ventilator. Post-extubation, the patient was transitioned to PO pain medications with good effect. By time of discharge, the patient was requiring minimal narcotic pain medications. He was given 0.5mg ativan as needed for anxiety with good effect. Resp: The patient remained intubated in the ICU until POD#2. He was extubated on this date without difficulty and subsequently transferred to the floor. He was weaned off of oxygen by POD #4. CT on [**2-3**], showed scattered opacities which were consistent with aspiration or pneumonia. He received aggressive chest PT, ambulation and incentive spirometry throughout his hospital course and was satting >95% by time of discharge. CV: The patient remained hemodynamically stable throughout his hospitalization. He complained of transient left chest pain on [**2-3**] with EKG showing ? of T-wave inversions in lateral leads. His cardiac enzymes were cycled and negative x 3. His symptoms resolved. CT performed on this date showed no evidence of mediastinitis. ID: The infectious disease department was consulted and they recommended Unasyn, Clindamycin and vancomycin as emperic coverage initially, which was subsequently simplified to Unasyn/Vancomycin. The patient had repeat imaging on [**2177-2-3**] which demonstrated a well drained abscess pocket without evidence of mediastinal involvement or residual abscess. The patient remained afebrile and his WBC trended down for the remainder of the hospitalization. Per ID, the patient is being dicharged on Ertapenem and Vancomycin to complete a 14 day IV course, and thereafter transition to moxifloxacin for additional 14 days or as instructed further by ID. GI: The patient was NPO until extubation. Thereafter, his diet was advanced to regular, which he tolerated without coughing or difficulty. GU: The patient had a foley in place which was discontinued following extubation. He voided without issue. Endo: No issues. Heme: The patient remained hemodynamically stable throughout his hospitalizaiton. He received SQH throughout his hospital course and was ambulating the halls frequently. The remainder of the hospital course was uneventful; the patient remained afebrile and hemodynamically stable. His pain was well controlled on oral pain medications. By the day of discharge, on [**2177-2-7**], he was tolerating a regular diet, able to void without difficulty and ambulate without assistance. He and his family expressed the readiness and desire to go home and was discharged to home with VNA services for dressing changes and IV antibiotics, on POD # 8, [**2177-2-7**], with instructions to follow up with Dr. [**Last Name (STitle) 1837**] and Dr. [**Last Name (STitle) 6137**] (Infectious disease) as an outpatient. Additional discharge instructions as listed below. Medications on Admission: Amoxicillin Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 3. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous Q24H (every 24 hours) as needed for infection, deep neck for 6 days: to start [**2177-2-8**] at home. First dose given in hospital on [**2177-2-7**]. To complete on [**2177-2-13**]. Disp:*6 gram* Refills:*0* 4. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**5-14**] hours for 35 doses: take with stool softener to avoid constipation, do not drink or drive while taking narcotic pain medication. try to wean off pain medication by follow-up. Disp:*35 Tablet(s)* Refills:*0* 5. vancomycin in 0.9% sodium Cl 1.5 gram/250 mL Solution Sig: One (1) vial Intravenous every twelve (12) hours for 7 days: to continue at home [**2177-2-7**] and to end on [**2177-2-13**]. Disp:*14 vials* Refills:*0* 6. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO every twenty-four(24) hours for 14 days: To start [**2177-2-14**] and resume for 14 days until further instructed by infectious disease. Disp:*14 Tablet(s)* Refills:*0* 7. Outpatient Lab Work CBC, Bun, Crea, LFTs, CRP, ESR, Vanco trough FREQUENCY: on [**2177-2-12**]. Please fax results to: [**Hospital1 18**] Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] 8. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for anxiety for 30 doses: try to wean off in two weeks. follow-up with PCP regarding refills. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 3765**] Home Care Discharge Diagnosis: Left deep space neck infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: - continue antibiotics as perscribed, You should take Ertapenem and Vancomycin IV until/through [**2177-2-13**]. Then on [**2177-2-14**], start moxifloxacin PO for 14 days or unless otherwise instructed by ID. - have your labs checked on [**2177-2-12**] and results sent to ID department for follow-up. These are routine labs for monitoring: CBC, Bun, Crea, LFTs, CRP, ESR, Vanco trough - All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] - All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**], or to on call infectious disease MD in when clinic is closed - Your neck wound should be packed with 10 cm of 1-inch iodaform packing gently. Gradually, the amount of packing should be decreased to allow the cavity to heal in from the inside out. This should be changed daily. Apply a dry gauze dressing on the outside and you can change the outer dressing as needed. - Seek immediate medical attention for fever >101.5, chills, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. OK to shower. No strenuous exercise or heavy lifting until follow up appointment, at least. Do not drive or drink alcohol while taking narcotic pain medications. Narcotic pain medications may cause constipation, if this occurs take an over the counter stool softener. Resume all home medications. Followup Instructions: - Follow up with infectious disease, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**] on [**2177-2-17**] at 11:30am. The [**Hospital **] clinic lis located in the LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT, ID WEST (SB). Call ([**Telephone/Fax (1) 88244**] if you have any questions regarding your appointment. - Call Dr.[**Name (NI) 20390**] office at ([**Telephone/Fax (1) 21740**] to make follow up appointment to be seen within 1-2 weeks. His office is located on [**Doctor First Name **], [**Location (un) **] ENT SUITE 6E. - Follow-up with your PCP [**Last Name (NamePattern4) **] [**2-10**] weeks regarding this hospitalization Completed by:[**2177-2-9**]

Admission Date: [**2124-3-22**] Discharge Date: [**2124-3-30**] Date of Birth: [**2059-4-10**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old lady with dementia, seen in the catheterization holding area for two vessel disease. She is status post ventricular fibrillation arrest on [**2123-10-6**], cardioverted to atrial fibrillation by medics. She is status post silent myocardial infarction x 2, status post stent and arterectomy to the mid-left anterior descending on [**2123-10-13**], diabetes mellitus, hypertension, high cholesterol. She presented to an outside hospital with profuse diaphoresis. It was seen that she had a large are of anteroseptal ischemia. She has an ejection fraction of 45%. The patient is unable to give a history due to her dementia. History obtained from the chart. HOME MEDICATIONS: Insulin, Lopressor, Zestril, Synthroid, Lipitor, iron, Colace, multivitamin, aspirin. ALLERGIES: Sulfa, Biaxin. PAST MEDICAL HISTORY: Myocardial infarction x 2, arterectomy to mid-left anterior descending and stent. SOCIAL HISTORY: The patient is a nonsmoker. PHYSICAL EXAMINATION: In general, the patient is somnolent. She doesn't know why she is in the hospital. Blood pressure 138/48, heart rate 58. Extremities: All pulses are felt. Heart: Regular rate and rhythm. PLAN: The patient was admitted to [**Hospital1 190**] for coronary artery bypass graft. HOSPITAL COURSE: The patient was admitted on [**2124-3-22**]. On [**2124-3-23**], the patient was taken to the operating room, where a coronary artery bypass graft was performed, with left internal mammary artery to the diagonal, and saphenous vein graft to the obtuse marginal. The patient was thereafter sent to the Intensive Care Unit for postoperative care. Postoperative care appeared to be somewhat unremarkable. She was seen by Physical Therapy. While in the Intensive Care Unit, the patient experienced quite brittle blood sugar control, and the [**Last Name (un) **] was consulted for assistance in controlling her insulin. The patient was transferred to the floor on [**2124-3-28**] in good condition. Her pacing wires and sutures were removed on [**2124-3-29**]. It is now [**2124-3-30**], and the patient is being discharged in good condition. She is to follow up with her cardiologist in two to three weeks, with her primary care physician in one to two weeks, and with Dr. [**Last Name (STitle) 1537**] in four weeks. She is being discharged with Lopressor 12.5 mg by mouth twice a day, sliding scale and fixed doses of insulin, atorvastatin 10 mg by mouth once daily, multivitamin one capsule by mouth once daily, Benecol 50 mg by mouth four times a day, Haloperidol 1 mg by mouth once daily, Protonix 40 mg by mouth once daily, Risperidone .5 mg by mouth once daily, fluticasone 110 mcg two puffs inhaled twice a day, levothyroxine 75 mcg by mouth once daily, citalopram 20 mg by mouth once daily, levofloxacin 500 mg by mouth once daily for three days, amiodarone 400 mg by mouth once daily, Colace 100 mg by mouth twice a day, ibuprofen 400 mg by mouth every six hours as needed, Tylenol 650 mg by mouth every four hours as needed, enteric-coated aspirin 325 mg by mouth once daily, potassium chloride 20 mEq by mouth every 12 hours, and lasix 20 mg by mouth once daily. She may shower. She may observe ad lib activity, although she should be closely monitored when standing or walking. She has had a fall in the hospital when standing. Diet: Diabetic, heart healthy. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 1332**] MEDQUIST36 D: [**2124-3-30**] 08:57 T: [**2124-3-30**] 09:02 JOB#: [**Job Number 20762**]

Admission Date: [**2186-7-16**] Discharge Date: [**2186-7-21**] Date of Birth: [**2135-4-22**] Sex: M Service: MEDICINE Allergies: Cocaine Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Thoracic back pain and leg weakness Major Surgical or Invasive Procedure: T4 laminectomy History of Present Illness: 51 yo man w/ PMH of esophageal CA s/p chemo and radiation w/ known progressive disease presented to OSH [**7-16**] for evaluation of new onset LE paralysis. He had upper back pain for 2 days prior to admission. On the day of presentation he woke up and noted LLE weakness. Over the course of the day he developed RLE weakness and came to the ED for further evaluation. His ROS is significant for reporting no bowel movements or urination for 1-2 days. . Team was concerned for spinal cord compression, but could not get MRI as pt has surgical clips after traumatic head injury. CT myelogram showed occlusion of spinal canal at T4, so taken emergently to OR. Found epidural abscess, which was washed out. . On POD#2, pt became acute dyspneic and hypoxic to 77% after nasotracheal suctioning. ABG 7.40/40/43 on 100% FM. On arrival to MICU, Sats ranged from 85-95% on NRB + 6L NC; briefly placed on BiPAP, but oxygenation actually decreased with this. After repositioning and chest PT, Sats stabilized between 90-96% on 6L NC. Past Medical History: -Esophageal CA s/p chemo and radiation- Oncologist is Dr. [**First Name (STitle) **] [**Name (STitle) 103290**] stenting after radiation induced esophageal stenosis -Suicide attempt ([**2171**]) w/ a circular saw, surgically repaired injury w/ L eye ptosis and brain clips, treated at [**Hospital1 2025**] -GERD -HTN -Former EtOH -MI's x 2 ([**2174**], [**2175**]?) Social History: Homeless; lived in shelter before diagnosis of cancer, but has been living with his mother since being treated for cancer. -tobacco: 1ppd (80 PYH) -"off and on" EtOH use, occasional marijuana, history of cocaine use Family History: noncontributory Physical Exam: T: 96.4 BP: 112/74 HR: 101 R 22 O2Sats 86-96% on 6L + NRB; pulsus 8 mm Hg Gen: able to speak [**12-20**] words between breaths, wearing NRB and 10L NC Neck: Supple. Lungs: bronchial breath sounds, Left lower and mid fields; rhonchorous R field. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect.Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension. No dysarthria or paraphasic errors. Cranial Nerves: II: Pupils round and reactive to light w/ mild anisocoria (R>L) III, IV, VI: Extraocular movements intact bilaterally with few beats of nystagmus, ptosis of L eye 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: No pronator drift. Normal bulk and tone bilaterally in UE. LE decreased muscle bulk. No adventitious movements, no tremor, no asterixis. D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE Right 5 - - - - - - - > 0 - - - - - - - - - > Left 5 - - - - - - - > 0 - - - - - - - - - > REFLEXES: Toes: mute bilaterally B T Br Pa Pl Right 2+ 2+ 2+ 0 0 Left 2+ 2+ 2+ 0 0 SENSORY SYSTEM: -light touch: symmetric and intact in UE; sensation in legs intact to deep pressure only -pinprick: absent until T3-T4 bilaterally (L side is slightly higher than R), pt able to feel touch very faintly at T12 posteriorly COORDINATION: nl [**Doctor First Name **] in UE GAIT: unable to access Pertinent Results: [**2186-7-16**] 08:04AM WBC-10.1 RBC-4.12* HGB-13.4* HCT-40.1 MCV-97 MCH-32.7* MCHC-33.5 RDW-14.9 [**2186-7-16**] 08:04AM NEUTS-70.9* BANDS-0 LYMPHS-5.1* MONOS-23.9* EOS-0.1 BASOS-0.1 [**2186-7-16**] 08:04AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2186-7-16**] 08:04AM PLT SMR-NORMAL PLT COUNT-235 [**2186-7-16**] 08:04AM GLUCOSE-142* UREA N-17 CREAT-0.9 SODIUM-136 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13 [**2186-7-16**] 08:04AM ALT(SGPT)-6 AST(SGOT)-13 LD(LDH)-163 ALK PHOS-75 AMYLASE-24 TOT BILI-0.6 [**2186-7-16**] 10:40AM CEREBROSPINAL FLUID (CSF) WBC-92 RBC-31* POLYS-42 LYMPHS-4 MONOS-54 [**2186-7-16**] 10:40AM CEREBROSPINAL FLUID (CSF) PROTEIN-670* GLUCOSE-59 LD(LDH)-52 CT Myelogram (pre-op): Contrast flowed readily from the injected level (L3/4) through the lumbar spine and extending cephalad to the thoracic spine. There is complete block of contrast material at the thoracic [**3-23**] vertebral body level. The post- myelogram CT of the thoracic and cervical spine reconfirmed that there is complete block of contrast within the subarachnoid space at the T4/5 level. Bedside Echocardiogram: There is a moderate sized pericardial effusion most prominent anterior to the right atrium with brief right atrial diastolic collapse. A promient echogenic area is seen overlying the right ventricular free wall which likely represents epicardial fat (cannot exclude thrombus or tumor if this is clinically suggested). There is but no right ventricular diastolic collapse with relatively minimal fluid anterior to the right ventricle. There is mild eccentuation of transmitral Doppler E wave suggesting increased pericardial pressure. Serial evaluation is suggested. CXRs have shown intermittent, recurrent opacification alternately of the left and right lungs. Chest CT on [**7-18**] showed debris in the distal L mainstem bronchus consistent with aspirated material. CTA was negative for PE. Brief Hospital Course: 51 yo man with esophageal cancer s/p chemo and XRT presenting with abrupt onset lower extremity flacid paralysis found to have T4 epidural abscess, s/p operative debridement, now with acute onset respiratory distress . # Respiratory distress: acute dyspnea with severe hypoxemia and tachycardia on HD#3, now maintaining adequate saturation on high flow nebulizer mask. Ruled out DVT and PE with lower extremity dopplers and CTA. The combination of locally advanced esophageal cancer and weakened chest muscles leading to poor cough predispose to recurrent, significant aspiration. This was discussed at length with the patient, and he wishes to continue chest PT and other non-invasive measures to augment his cough and support his breathing. If non-invasive measures cease to be effective, he has stated clearly that he would want to be made comfortable. He has continued to affirm that he should not be intubated. - aggressive chest PT & nebs since cough is very weak due to T4 spinal lesion. - supplemental O2 as needed to keep SpO2>90%, currently requiring Hi Flow venti mask; titrate up to non rebreather if needed - DNR/DNI; if noninvasive means to support oxygenation are ineffective, pt would want to transition to hospice . # Pericardial effusion: given cardiomediastinal enlargement on CXR, stat echo was obtained, which showed moderate pericardial effusion with invagination of RA, equivocal respiratory variation of RV movement, but no collapse of RV. Given low/normal pulsus and no signs of tamponade by echo, this effusion is likely not the cause of his respiratory decompensation. . # T4 epidural abscess: s/p open debridement on [**7-16**], wound cultures growing Strep milleri, but wound GM stain also showed a GM Neg coccobacillus, suspect mouth flora. Ceftriaxone 2gm Q24H for once-daily dosing regimen to cover Strep milleri, and metronidazole 500mg tid for anaerobes. Will plan to continue course for 6 weeks given serious CNS infection. After 6 week course is complete, recommend suppressive therapy with amoxicillin 500mg daily indefinitely, as the locally advanced esophageal cancer will remain a risk for thoracic spine infection. - TLSO brace while out of bed, multipodis boots to prevent heel breakdown - Neurology consult indicated that patient will most likely not recover meaningful motor function of his legs, ie, ambulation is unlikely. Any recovery of motor function will be limited and gradual. . # Esophageal CA: s/p chemo and xrt, with stenting for stenosis. Pain control. Patient's goals for treatment have been to be able to eat; oncologist Dr [**First Name (STitle) **] has indicated that further chemo or xrt will likely not help in this regard but continue to follow. Pain control. . # GERD: continue protonix . # Nutrition: pt cannot tolerate solid foods. Ensure supplements, soft foods only. . # Tobacco Dependance: nicotine patch . # Prophylaxis: -heparing subcutaneous, pneumoboots, and protonix . # Code Status: DNR/DNI, discussed with patient and family including HCP (mother) Medications on Admission: -Percocet -Prilosec -Unknown BP med -Stool softener Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 3. Thiamine HCl 100 mg/mL Solution Sig: One (1) Injection DAILY (Daily). 4. Folic Acid 5 mg/mL Solution Sig: One (1) Injection DAILY (Daily). 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for COPD. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for COPD. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 weeks. 12. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 14. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. 15. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for shortness of breath or wheezing. 16. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 17. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 18. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two (2) grams Intravenous Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: esophageal cancer T4 epidural abscess, polymicrobial, with spinal cord compression and paraplegia Discharge Condition: fair, although with tenuous respiratory status. Discharge Instructions: You had surgical decompression of a T4 epidural abscess and will need 6 weeks of antibiotics to treat this. You may or may not regain much motor function in your legs because of the spinal cord compression injury. For your respiratory status, the combination of esophageal cancer and weakness have predisposed you to aspirating and prevent you from coughing effectively. Continue with aggressive chest physical therapy and MIE as long as patient feels subjective benefit. Supplemental O2. Followup Instructions: Dr [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 92277**], Friday [**7-28**], 2:00pm. (Oncology) [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Admission Date: [**2105-5-22**] Discharge Date: [**2105-5-25**] Date of Birth: [**2044-9-11**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1515**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac catheterization with placement of bare mental stents x 4 History of Present Illness: 60 yo male with history of gout, HLD, HTN, anemia of chronic inflammation presents with substernal chest pain. . Patient notes that over the last several days he has had intermittent chest discomfort when at work. He notes that the pain would go away if he stopped relaxed and took a deep breath. The day of presentation the patient developed substernal chest pain without radiation which was associated with palpitations, diaphoresis, shortness of breath. His brother gave him 4 baby aspirins which he chewed and called 911. In the ambulance the patient recieved nitroglycerin without improvement in his [**9-7**] chest pain. . In the ED, initial vitals 80 160/80 16 98% 2L. EKG concerning for inferior [**Month/Year (2) **] with A. Fib with [**Month/Year (2) 5509**]. Code [**Month/Year (2) **] called. Patient started on heparin gtt, morphine 4 mg IV, Diltiazem 50mg IV x one, Plavix 300mg. . In the Cath lab, catheterization revealed a 90% mid RCA lesions. Other vessels without significant disease. Case complicated by RCA dissection, at one point vessel was lost, entire vessel ballooned with four bare metal stents. Patient transiently on dopamine for borderline hypotension. Patient in A. Fib with [**Month/Year (2) 5509**] and given Lopressor 17.5 mg IV total IV. One unit of blood given for HCT of 24.9 . Bivalrudin given during case given history of iron deficiency anemai. Angioseal placed. . In the CCU, patient remains in Afib with [**Month/Year (2) 5509**] with stable blood pressure. He reports no chest pain. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. SHe denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension, Hyperlipidemia 2. CARDIAC HISTORY: None 3. OTHER PAST MEDICAL HISTORY: - Gout - Anemia: Admission in [**3-/2105**] with HCT of 15 without clear etiology 7 units of pRBCs transfused. Hemolysis labs negative. Stool Guaiac negative. Bone marrow biopsy with Heme/Onc negative. Last colonoscopy 10 years ago. Social History: He is unmarried and has no children. He lives with his brother in [**Name (NI) 64936**]. He is currently unemployed, but works odd jobs when he can, usually construction. He has a 42 pack year history. He drinks 4-6 beers a week. He denies use of illicits. Family History: Hypertension - mother (died at 92) Father - unknown medical history, died of unknown causes Physical Exam: On Admission: VS: Afebrile BP=114/86 HR=150 RR=15 O2 sat= 100% 2L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Poor dentition. NECK: Supple with JVP at base of neck. CARDIAC: Irregular, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Unable to examine posterior lung field as patient post cath. Anterior lung field with coarse breath sounds. 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. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Radial 2+ DP 2+ PT 2+ Left: Radial 2+ DP 2+ PT 2+ On Discharge: Temp Max:101.9 Temp current: 99.1 HR:67-83 RR:18 BP:139-183/87-98 O2 Sat: 100% RA Gen: NAD, sitting comfortably in chair CV: RRR, systolic murmur RUSB RESP: CTAB, no rales or wheezes, unlabored ABD: S/NT/ND, +BS EXTR: no peripheral edema, R knee edematous, blottable, no erythema or warmth NEURO: A/O, no focal deficits Pertinent Results: CBC WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2105-5-25**] 06:50 9.4 4.15* 11.7* 35.5* 86 28.2 33.0 17.1* 242 [**2105-5-24**] 23:00 30.9* [**2105-5-24**] 15:00 32.5* [**2105-5-24**] 06:30 10.0 3.77* 10.8 32.3* 86 28.7 33.4 17.3* 223 [**2105-5-23**] 21:20 30.1* [**2105-5-23**] 13:15 29.1* [**2105-5-23**] 04:55 8.5 3.01* 8.6* 25.7* 86 28.7 33.5 17.3* 232 [**2105-5-22**] 21:45 9.8 2.87* 7.9* 24.9*1 87 27.6 31.8 18.0* 273 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2105-5-25**] 06:50 109*1 16 0.9 139 4.7 102 26 16 [**2105-5-24**] 06:30 961 15 0.9 138 4.7 105 24 14 [**2105-5-23**] 04:55 108*1 23* 0.8 141 4.7 111* 19* 16 [**2105-5-22**] 21:45 111*1 27* 0.9 142 3.4 106 18* 21* CPK ISOENZYMES CK-MB cTropnT [**2105-5-23**] 13:15 27* [**2105-5-23**] 04:55 38* [**2105-5-22**] 21:45 0.02* HEMATOLOGIC Hapto [**2105-5-23**] 04:55 253* Studies/Procedures - ECG: Afib with [**Year (4 digits) 5509**] approx 160, Normal Axis. ST elevation in III with depresssions V3-V6. Right sided leads with 1mm ST elevation V4-V6. . - CARDIAC CATH: Per Report. 90% occlusion of MID RCA. Case complicated by dissection with near loss of vessel. Vessel balloned and 4 BMS placed with resolution of flow. Final report pending at time of discharge. . - TTE: The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior hypokinesis to akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. with borderline normal free wall function. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2105-4-13**], regional LV systolic dysfunction is new. The aortic valve area is similar despite lower gradients due to decreased stroke volume. Brief Hospital Course: 60 yo male with HLD, HTN, Gout, Anemia who presents with CP found to have inferior [**Year (4 digits) **] s/p cardiac catheterization complicated by RCA dissection necessitating placement of BMS x 4. ACTIVE ISSUES: #[**Name (NI) **] - Pt presented with CP and was found to have inferior [**Name (NI) **] on EKG. In the Cath lab, catheterization revealed a 90% mid RCA lesions. Other vessels without significant disease. Case complicated by RCA dissection, entire vessel ballooned with four bare metal stents. Patient transiently on dopamine for borderline hypotension. One unit of blood given for HCT of 24.9. Bivalrudin given during case given history of iron deficiency anemia. Pt started on clopidogrel 75 mg PO daily, simvastatin 40mg, metoprolol XL 150 po daily, and losartan 50 mg PO daily. ECHO revealed mild regional left ventricular systolic dysfunction with inferior hypokinesis to akinesis. He was initially started on aspirin 325mg, however this was decreased to 81mg po daily given concern for possible GI bleed. This should be re-evaluated as an out-patient with PCP and GI. Patient will follow up with cardiology on [**6-2**]. . #Afib with [**Name (NI) 5509**] - Pt was in Afib with [**Name (NI) 5509**] in Cath lab and CCU so given Lopressor 17.5 mg IV total during cardiac catheterization. In the CCU, started on esmolol gtt. Blood pressures remained stable. Pt returned to sinus rhythm, esmolol gtt d/c'ed [**5-23**], remained in sinus for remainder of hospitalization. . #Normocytic Anemia - Hct at 24.9 following catheterization, down from baseline in low 30s. Pt responded well to 3 units PRBC. Ongoing outpt work up of anemia without clear etiology. Hemolysis labs negative. GI was consulted given hct drop in setting of dark stools while on plavix and aspirin. Given recent [**Month/Year (2) **], stablization of hct, and normalization of stools, EGD was deferred at this time. Pt needs to follow-up with GI in 6 weeks for EGD and colonoscopy for continued work-up of anemia. He was started on pantoprazole 40mg PO BID. He should continue Plavix 75mg po daily, however aspirin was decreased from 325mg to 81mg pending further work-up because of increased risk of bleeding. CHRONIC ISSUES: #Gout - Pt complained of gouty R knee pain, so started on colchicine in addition to his home allopurinol. He was not started on prednisone given the risk of GI bleeding. His pain was well managed with oxydocone 5mg po prn. . #HTN - Increased blood pressure managment with Metoprolol XL 150 po daily, losartan 50mg PO. His blood pressure improved to 130's/80s so will need close monitoring and medication adjustment by PCP. . #HL - increased simvastatin to 40mg po daily in setting of recent [**Month/Year (2) **]. TRANSITIONAL ISSUES: Full Code. Blood cultures and urine cultures were sent given low grade fever and are still pending at time of discharge. Pt is being discharged home with many new medications and medication changes. These changes were discussed with the patient in detail. He has several follow-up appointments in the next few weeks including PCP ([**5-29**]), Cardiology ([**6-2**]), Endocrine and HEM/ONC([**6-3**]). He will need a referral from his PCP to see GI for EGD and colonoscopy. Medications on Admission: --Metoprolol 50mg [**Hospital1 **] --Simvastatin 20mg Daily --Cyclobenzaprine 10mg TID --Tramadol 50 [**11-29**] Q6hrs PRN Pain --Prednisone 10mg PRN gout flair --ASA 325mg Daily --Allopurinol 200mg Daily --Losartan 25mg Daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. 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* 6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for knee pain for 2 days: Do not take this medication and drive or consume alcohol. Disp:*4 Tablet(s)* Refills:*0* 8. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2* 9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 10. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. 11. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three times a day. 12. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Inferior [**Month/Day (3) **] Atrial Fibrillation with [**Month/Day (3) 5509**] Hypertension Gout Anemia requiring blood transfusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for chest pain. You were found to be in atrial fibrillation and were diagnosed with a heart attack. We treated your heart attack by placing 4 stents in the arteries to keep the blood flowing. Your heart rate returned to [**Location 213**] during your hospitalization. Take all your home medications as directed EXCEPT for the following medication changes or additions that were made during your hospital stay: 1. Increase the dose of Losartan to 50 mg by mouth daily. 2. Increase simvastatin to 40mg by mouth daily. 3. Start taking Clopidogrel 75mg by mouth daily. Do not stop taking this medication unless instructed by your cardiologist. 4. Stop taking Aspirin 325 mg and instead take Aspirin 81mg until GI follow-up. You must take this medication daily unless instructed otherwise by your cardiologist. 5. Change metoprolol to metoprolol XL 150mg by mouth daily. 6. Start taking Pantoprazole 40mg by mouth twice a day until GI follow-up. 7. Start taking colchicine 0.6 mg by mouth twice a day until gout flare resolves. 8. Stop prednisone until GI follow-up because of increased risk of bleeding. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2105-6-2**] at 10:30 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DIV OF GI AND ENDOCRINE When: WEDNESDAY [**2105-6-3**] at 1:40 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2105-6-3**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name3 (LF) **] Location: [**Apartment Address(1) 89324**], [**Location (un) **],[**Numeric Identifier 14512**] Phone: [**Telephone/Fax (1) 31235**] Appt: Friday, [**5-29**] at 1pm NOTE: It is recommended that you have an EGD and Colonoscopy within the next 6 weeks. Please work with Dr [**Last Name (STitle) **] for help coordinating these procedures. Completed by:[**2105-5-26**]

Admission Date: [**2129-3-15**] Discharge Date: [**2129-3-24**] Date of Birth: [**2068-1-9**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [**2129-3-15**] Aortic Valve Replacement(21mm On-X mechanical valve) and Replacement of Ascending Aorta(26mm Gelweave Graft) History of Present Illness: Mrs. [**Known lastname 12143**] is a 61 year old female with hypertension. During evaluation for lymphadenopathy, she underwent CT scan which revealed dilated ascending aorta. Further workup included an echocardiogram which showed a bicuspid aortic valve with 1-2+ aortic insufficiency. Ascending aorta measured 4.7cm, aortic root measured 3.9 cm. The LVEF was 60-70%. Subsequent cardiac catheterization was notable for normal coronary arteries and normal left ventricular function. Given the above findings, she was admitted for surgical intervention. Of note, she recently underwent hematology evaluation for low white blood cell count. Etiology is unclear at this time but there was no contraindication to surgery. Past Medical History: Biscupid Aortic Valve; Aortic Insufficiency; Ascending Aortic Aneurysm; Hypertension; Epilepsy; History of Rheumatic Fever; Thyroid Nodules; Reactive Axillary Lymph Nodes; Pulmonary Nodules Social History: Quit tobacco over 30 years ago. Denies excessive ETOH. Works as a teacher. She is married. Family History: Denies premature CAD. Physical Exam: Vitals: BP 132/64, HR 70, RR 14 General: well developed female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, soft diastolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: Echo [**3-15**]: PRE-BYPASS: Overall left ventricular systolic function is normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve is bicuspid. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The sinotubular junction of the ascending aorta is preserved. The ascending aorta is moderately dilated. The mitral valve appears structurally normal with trivial mitral regurgitation. No atrial septal defect is seen by 2D or color Doppler. There are simple atheroma in the aortic arch and n the descending thoracic aorta. There is no pericardial effusion. POST-BYPASS: Preserved [**Hospital1 **]-ventricular systolic function. A well seated mechanical prosthetic valve is seen in the aortic position. Trivial aortic regurgitation. No perivalvular leak. Mean trans aortic valvular gradient is 8 mm Hg. A tubegraft is seen in the ascending aorta position with a diameter of 2.6 cm. Thoracic aortic contour is preserved. Trace TR and MR. CXR [**3-23**]: Interval decrease in pulmonary edema and vascular congestion, as well as cardiac size. Interval improvement in bibasilar atelectasis as well. Stable bibasilar pleural effusions. No major residual pneumothorax and stable appearance of the lung apices as compared to two days ago. [**2129-3-15**] 10:46AM BLOOD WBC-4.6 RBC-2.20*# Hgb-7.4*# Hct-20.4*# MCV-92 MCH-33.6* MCHC-36.4* RDW-13.6 Plt Ct-139*# [**2129-3-22**] 02:16AM BLOOD WBC-7.0 RBC-2.65* Hgb-9.0* Hct-26.0* MCV-98 MCH-33.8* MCHC-34.5 RDW-14.0 Plt Ct-447* [**2129-3-15**] 10:46AM BLOOD PT-16.1* PTT-75.8* INR(PT)-1.4* [**2129-3-23**] 07:25AM BLOOD PT-18.6* PTT-68.5* INR(PT)-1.8* [**2129-3-23**] 09:15PM BLOOD PT-22.0* PTT-150* INR(PT)-2.2* [**2129-3-24**] 12:48AM BLOOD PT-22.0* PTT-132.0* INR(PT)-2.2* [**2129-3-15**] 12:09PM BLOOD UreaN-13 Creat-0.5 Cl-109* HCO3-23 [**2129-3-22**] 02:16AM BLOOD Glucose-93 UreaN-11 Creat-0.6 Na-133 K-4.2 Cl-99 HCO3-26 AnGap-12 Brief Hospital Course: Mrs. [**Known lastname 12143**] was admitted and underwent aortic valve replacement with replacement of her ascending aorta. For surgical details, please see separate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She maintained stable hemodynamics and weaned from intravenous therapy without difficulty. Her CSRU course was uneventful and she transferred to the SDU on postoperative day one. On postoperative day two, chest tubes and epicardial wires were removed without complication. Warfarin anticoagulation was initiated. Prothrombin times were monitored daily and Warfarin was dosed for a goal INR between 2.0 - 3.0. Over several days, she continued to make clinical improvements with diuresis. On post-op day five she was treated for some atrial fibrillation and converted back to sinus rhythm. Heparin was restarted until INR was increased while receiving Coumadin. Over next couple of days her INR trended upward over 2. She appeared to be doing well and worked with physical therapy for strength and mobility. On post-operative day nine she was discharged home with VNA services and the appropriate follow-up appointments. Dr.[**Last Name (STitle) 2472**] will be following her INR and adjusting her Coumadin as needed. Medications on Admission: Tegretol XL 800 qam, 400 qlunch, 800 qhs Lisinopril 10 qd Labetolol 100 [**Hospital1 **] Evista 60 qd Caltrate-D 1200 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Carbamazepine 200 mg Tablet Sustained Release 12 hr Sig: Ten (10) Tablet Sustained Release 12 hr PO once a day: 4 tabs [**Hospital1 **] (morning & night)and 2 tabs once daily (midday)as before your surgery. Disp:*300 Tablet Sustained Release 12 hr(s)* Refills:*0* 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:*0* 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. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days: then daily until D/C'd by . Disp:*45 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:*135 Tablet(s)* Refills:*0* 8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Outpatient [**Name (NI) **] Work PT/INR PT/INR as needed goal 2.5-3.5 for Aortic Valve (On-x) first check [**2129-3-25**] with results to Dr [**Last Name (STitle) 2472**] office # [**Telephone/Fax (1) 133**] Fax: [**Telephone/Fax (1) 445**] 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Dose to be titrated per Dr.[**Name (NI) 5049**] instruction. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Biscupid Aortic Valve, Aortic Insufficiency, Ascending Aortic Aneurysm s/p Aortic Valve Replacement and Replacement of Ascending Aorta PMH: Hypertension, Epilepsy, History of Rheumatic Fever, Thyroid Nodules, Reactive Axillary Lymph Nodes, Pulmonary Nodules Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower, 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 Followup Instructions: Dr. [**Last Name (STitle) 1290**] in [**3-3**] weeks, call for appt [**Telephone/Fax (1) 170**] Dr. [**First Name (STitle) **] in [**1-1**] weeks, call for appt Dr. [**Last Name (STitle) 2472**] in [**1-1**] weeks, call for appt [**Telephone/Fax (1) 133**] PT/INR goal 2.5-3.5 for Aortic Valve (On-x) first check [**2129-3-25**] with results to Dr [**Last Name (STitle) 2472**] office # [**Telephone/Fax (1) 133**] Fax: [**Telephone/Fax (1) 445**] Completed by:[**2129-4-4**]

Admission Date: [**2163-4-15**] Discharge Date: [**2163-4-29**] Date of Birth: [**2087-2-26**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old female with a history of aortic stenosis, coronary artery disease, congestive heart failure, diabetes, hypertension. She was seen in the Emergency Room on [**4-11**] with bronchitis and treated with Azithromycin. She saw her primary care physician [**Last Name (NamePattern4) **] [**4-13**] who treated her with meter dose inhalers and cough syrup for shortness of breath and wheezing. The patient is now here with a two to three day history of chest tightness, increased shortness of breath, wheezing, cough, no history of GI bleeding and no fevers or chills. The patient is otherwise in her usual state of health until one week ago. PAST MEDICAL HISTORY: 1. Congestive heart failure. 2. Coronary artery disease. 3. Diabetes type 2. 4. Remote history of stroke. 5. Hypertension. 6. Gangrenous left first toe. 7. Left SFA. HOME MEDICATIONS: 1. Lopressor 25 b.i.d. 2. Lipitor 10 mg q.p.m. 3. Lasix 40 mg q.a.m. 4. Relafen 750 mg b.i.d. 5. Ecotrin 325 mg po q.d. 6. K-Dur 20 milliequivalents q.a.m. 7. Colace 100 mg b.i.d. 8. NPH 22 units q.a.m., 15 units q 8 p.m. SOCIAL HISTORY: No history of tobacco or alcohol. PHYSICAL EXAMINATION: Pulse 85. Blood pressure 95/69. Respiratory rate 24. 96% oxygen saturation on 4 liters. General, the patient is an elderly female in no acute distress. Neck JVP 10 cm. HEENT mucous membranes are moist. Extraocular movements intact. Left eye lateral abduction. Cardiac sounds obscured by increased rhonchi. Pulmonary diffuse rhonchi and wheezing. Abdomen positive bowel sounds, soft. Extremities bilateral lower extremity 1+ pitting edema, 1+ bilateral dorsalis pedis pulses. LABORATORY: The patient was hyponatremic with a sodium of 127 and acute elevation of her creatinine to 1.2 from .7. Chest x-ray showed bibasilar opacities bilaterally. Pulmonary edema infiltrate, versus atelectasis. Electrocardiogram showed ST elevation in V1 through V3. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2163-4-15**] and initially treated medically by the Medicine Service. She was started on Levaquin for pneumonia. She was started on aspirin, heparin drip, beta blocker for her myocardial infarction. The patient also received Lasix for her acute congestive heart failure exacerbation. Cardiology was involved in the patient's care. An echocardiogram was performed, which showed an ejection fraction of less then 20%. Cardiac catheterization was also performed showing mitral regurgitation, left ventricular ejection fraction of 25%, global hypokinesis, 1+ mitral regurgitation, right dominant coronary angiography LMCA calcified plaque 40% proximally, left anterior descending coronary artery diffuse 70% long proximal calcified, Dig okay, left circumflex moderate distal right coronary artery 70%, osteal 95% mid lesion. The patient was taken to the Operating Room on [**2163-4-21**] where a coronary artery bypass graft times four and aortic valve replacement was performed. The patient was left with a chest tube and pacing wires in place. She required immediately postoperatively epinephrine and Propofol drips. The first postoperative day she was noted overnight to have ventricular ectopy for which she received Amiodarone. The patient received Vancomycin times four perioperatively for prophylaxis. She was started on beta blockers and Lasix at the appropriate time. At the appropriate time the patient's pacing wires and chest tubes were removed. She was stopped from her various drips when appropriate. The patient was also shown to have a wide complex tachycardia at times per cardiologist Dr. [**Last Name (STitle) **]. The patient was sent out of the Intensive Care Unit when appropriate on Lasix, Captopril and Lopressor as well as Amiodarone. Due to the patient's age and stability it was determined by her cardiologist that Coumadin probably would not be an appropriate course of therapy due to significant risks. Once the patient was on the floor when of her major issues was blood pressure control for which her blood pressure medications were progressively increased. Physical therapy saw the patient on repeated occasions and believed the patient would do well at a rehab facility. It is now [**2163-4-29**] and the patient is in stable condition. It is likely that she will be discharged today or tomorrow for rehab. The patient may shower, but should not take baths. The patient is to avoid strenuous activity. The patient should not drive while on pain medication. She is to follow up with Dr. [**Last Name (STitle) 1537**] in four weeks. She is to follow up with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 11139**] in one to two weeks and Dr. [**Last Name (STitle) **] in two to three weeks. She will be discharged on Lopressor 50 mg po b.i.d., Captopril 37.5 mg po t.i.d., Reglan 10 mg q 6, Timolol .5% one drop OD b.i.d., _____________ 2%, Timolol .5% one drop OS b.i.d., insulin sliding scale, Atorvastatin 10 mg po q.d., Amiodarone 400 mg po q.d., Benadryl 25 to 50 mg po q.h.s. prn, Milk of Magnesia 30 mg po q.h.s. prn, Percocet one to two tabs q 4 prn, Ibuprofen 400 mg po q 6 prn, Tylenol 650 mg po q 4 prn, enteric coated aspirin 325 mg po q.d., Ranitidine 150 mg po b.i.d., Colace 100 mg po b.i.d., potassium 20 milliequivalents po q 12 and Lasix 20 mg intravenous q 12. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern4) 5919**] MEDQUIST36 D: [**2163-4-29**] 10:11 T: [**2163-4-29**] 10:31 JOB#: [**Job Number 107516**]

Admission Date: [**2148-6-25**] Discharge Date: [**2148-6-29**] Date of Birth: [**2088-11-25**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation for hypoxia History of Present Illness: 59F with recent left foot surgery and osteomyelitis, s/p ant-inf MI s/p stent to pLAD, hx EtOH abuse with CHF and EF 20-25% (? mixed myopathy) admitted to [**Hospital Unit Name 153**] [**6-25**] with acute pulmonary edema. She denied dietary indiscretion and did not have any chest pain PTA. Intubated and diuresed, then extubated. Initially required nitro gtt for HTN, then 1 day of dopamine for hypoTN (weaned [**6-26**]). Patient had 1 run of irregular short-lived (3 to 9 beats) WCT which resolved without treatment and was called out from [**Hospital Unit Name 153**] to [**Hospital1 1516**] service for ?ICD placement. Per EP consult note on [**6-26**], no emergent reason for ICD placement. . Prior to call out patient noted to have 6 point HCT drop (28-> 21)and drop in WBC (9 -> 2) of unclear etiology. Guiac negative. Got two units PRBC and transferred to floor. Past Medical History: s/p ant-inf MI with stent to pLAD ([**2142**]) CHF with EF 20-25% s/p Left foot HAV repair & 2nd digit PIPJ arthroplasty HTN Hypercholesterolemia Hx. of substance Abuse Hx. of EtOH Abuse Depression Anxiety Social History: (+) EtOH (+) Recreational Drug usage including Marijuana, but denies IVDU Family History: Father died of heart disease Physical Exam: Vitals: T: 98.9 P:76 BP:109/71 R: 18 General: Awake, alert, NAD. HEENT: NC/AT, EOMI without nystagmus, no scleral icterus noted Neck: supple, no JVD or carotid bruits appreciated Pulmonary: faint crackles BL Cardiac: RRR, nl. S1S2. II/VI SEM. No S3, no S4. Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Neurologic: alert, oriented, CN grossly intact, movess all extremities, no abnormal movements noted. Psych: Full affect, somewhat dramatic Pertinent Results: [**2148-6-24**] 10:47PM WBC-9.3# RBC-2.54* HGB-8.7* HCT-24.2* MCV-95 MCH-34.3* MCHC-36.0* RDW-14.7 [**2148-6-24**] 10:47PM MACROCYT-1+ [**2148-6-26**] 03:50AM BLOOD calTIBC-229* VitB12-811 Folate-16.3 Hapto-130 Ferritn-1177* TRF-176* [**2148-6-24**] 10:47PM NEUTS-41.8* LYMPHS-50.6* MONOS-5.3 EOS-2.0 BASOS-0.3 [**2148-6-24**] 10:47PM PLT COUNT-474*# . [**2148-6-24**] 10:47PM PT-13.4* PTT-26.4 INR(PT)-1.2* . [**2148-6-24**] 10:47PM GLUCOSE-302* UREA N-26* CREAT-1.4* SODIUM-125* POTASSIUM-4.3 CHLORIDE-89* TOTAL CO2-18* ANION GAP-22* . [**2148-6-24**] 11:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG . [**2148-6-25**] 03:06AM D-DIMER-2368* . [**2148-6-25**] 03:06AM CORTISOL-21.6* [**2148-6-25**] 03:06AM TSH-3.9 . [**2148-6-24**] 10:47PM BLOOD CK(CPK)-160* [**2148-6-24**] 10:45PM BLOOD cTropnT-<0.01 [**2148-6-25**] 03:06AM BLOOD ALT-11 AST-55* LD(LDH)-511* CK(CPK)-253* AlkPhos-97 Amylase-117* TotBili-0.6 [**2148-6-24**] 10:47PM BLOOD CK-MB-4 [**2148-6-25**] 02:59PM BLOOD CK(CPK)-208* [**2148-6-25**] 03:06AM BLOOD CK-MB-6 cTropnT-0.05* proBNP-7406* [**2148-6-25**] 02:59PM BLOOD CK-MB-7 cTropnT-0.02* . [**2148-6-29**] 05:30AM BLOOD WBC-4.8 RBC-3.47* Hgb-11.2* Hct-32.2* MCV-93 MCH-32.4* MCHC-34.9 RDW-16.6* Plt Ct-405 [**2148-6-29**] 05:30AM BLOOD Plt Ct-405 [**2148-6-29**] 05:30AM BLOOD PT-13.8* PTT-40.8* INR(PT)-1.2* [**2148-6-29**] 05:30AM BLOOD Glucose-96 UreaN-19 Creat-1.2* Na-133 K-4.7 Cl-99 HCO3-26 AnGap-13 [**2148-6-29**] 05:30AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7 . Tox Screen on admission: [**2148-6-24**] 10:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . AP ERECT PORTABLE RADIOGRAPH OF THE CHEST (on admission): A PICC is seen with the tip in the superior vena cava. Interval development of interstitial pulmonary edema. There is discoid atelectasis at the right lung base. No pleural effusions are apparent. The heart size is within normal limits. IMPRESSION: Interval development of pulmonary edema. Discoid atelectasis at the right lung base. . CHEST CT to R/O PE: IMPRESSION: 1. Bilateral patchy opacities represent asymmetric pulmonary edema versus multifocal pneumonia. Clinical correlation recommended. No evidence for PE. 2. Bibasilar atelectasis and very small bilateral pleural effusions. . EKG on admission: Sinus rhythm, Probable old anteroseptal infarct. Since previous tracing, no significant change Brief Hospital Course: 59F with osteomyelitis, s/p ant-inf MI s/p stent to pLAD, CHF with EF 20-25%, was admitted intially to the [**Hospital Unit Name 153**] with CHF exacerbation and then called out from [**Hospital Unit Name 153**] [**6-25**] to [**Hospital1 **] service for further work-up and treatment. . # CHF exacerbation: Patient was hypoxic on admission with pulmonary edema on CXR, so was intubated and diuresed in ICU; given her known EF = 20-25%, CHF was the most likely cause of her dyspnea. No apparent cause for the acute exacerbation could be identified; patient denies any dietary indiscretion, cardiac enzymes were negative and EKG was unchanged from prior. PE was also considered as a cause of her dyspnea, and given an elevated D dimer, CTA of the chest was performed which did not identify any PE. After 24 hours of ventilatory support and aggressive diuresis, she was able to be extubated and transferred to the [**Hospital Ward Name 121**] 3 telemetry [**Hospital1 **]. . At the time of transfer to the [**Hospital1 **], patient appeared clinically normovolemic. She was gently diuresed to slightly below her home dry weight of 95lbs. She was started on metoprolol and lisinopril was added once her creatinine had stabilized. . # Hct drop: From 28-21 with no evidence of active bleeding - guiac negative. Patient received 2 units of PRBC in [**Hospital Unit Name 153**] prior to transfer with appropriate response, Hct stable thereafter. Heme consult reviewed peripheral smear with no concerning findings. Does not appear to be a consumptive process--no signs of hemolysis on lab work. Iron studies c/w anemia of inflammation. Acute change in Hct during acute pulmonary edema appears to have resulted from fluid volume shifts. . # WBC drop: 9.1 to 2.3 on [**6-26**], gradually increased to 4.8 on [**6-29**] without intervention. Unclear etiology; lymphocyte predominant with a monocytosis suggestive of toxin-mediated bone marrow suppression. Heme consult suspects drug reaction, possibly levafloxacin, which was given in [**Hospital Unit Name 153**] and has been reported to cause agranulocytosis. HIV infection can also cause leukopenia, although patient denies high-risk behaviors such as unprotected sex with anyone other than husband or IVDA, she consented to be tested for HIV and test results pending. . # Short runs of WCT, asymptomatic: EP consulted and felt that emergent ICD placement was not indicated given current comorbidities. Had a negative V-Stim at [**Hospital1 112**] [**2145-12-17**] with Dr. [**Last Name (STitle) **] (EF 20-25% at that time). Pt. wants to avoid ICD if possible. Continued beta blocker therapy should decrease the incidence of the NSVT/WCT. . # Anxiety/depression: Patient says she has had a psychiatrist for many years and used to take valium with good effect. Her new doctor, Dr [**First Name4 (NamePattern1) 47716**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 108658**], stopped benzos b/c she had a history of abusing the valium and started prozac plus neurontin. [**6-27**] patient expressed SI and was seen by in-house psychiatry consult, who felt patient was not at risk to self and did not need 1:1 sitter but recommended treating her significant anxiety with resperidone and uptitrating neurontin. However, patient had symptomatic hypotension after first dose risperidone 1mg, but patient said she slept well and felt much better the morning after the risperidone, so restarted risperidone at 0.25mg hs prn. Continued home dose of fluoxetine 60 mg po and gabapentin 300mg tid as recommended per psych. Patient will see Dr [**Last Name (STitle) **] to adjust outpatient anti-anxiety and anti-depressant regimen next week. . # Substance abuse: Pt admits to smoking marijuana daily and has history of abusing diazepam. Social work consulted to discuss coping mechanisms with patient. They recommended, as did psychiatry consult, that patient go to day treatment center such as [**Doctor First Name 1191**] Day Center for ongoing substance, which psychiatry recommended is best arranged through her outpatient psychiatrist for continuity. . # Osteomyelitis - Receiving cefazolin via home pump. Per podiatry notes, still needs 3 more weeks, so D/C'd with prescription to continue through [**7-19**] to completely treat osteomyelitis of L great toe. Pt has home IV nursing who maintains PICC line and helps her with Abx infusions; will contact the agency before discharge to reinitiate their services. . # Hyponatremia - serum osms low, so hypoosmolar, hypervolemic hyponatremia upon presentation to ER, likely CHF as etiology. Resolved steadily with diuresis and sodium normal at 133 on the morning of discharge. Medications on Admission: Cefazolin 1gm IV Q8H for infection Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Gabapentin 300mg tid (patient has not been taking) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for heart disease. 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime: for cholesterol. [**Month (only) **]:*30 Tablet(s)* Refills:*2* 3. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily): for depression. [**Month (only) **]:*90 Capsule(s)* Refills:*2* 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): for anxiety. [**Month (only) **]:*90 Capsule(s)* Refills:*2* 5. Risperidone 0.5 mg Tablet Sig: one-half Tablet PO at bedtime as needed for insomnia for 4 days. [**Month (only) **]:*2 Tablet(s)* Refills:*0* 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): for blood pressure and heart failure. [**Month (only) **]:*15 Tablet(s)* Refills:*2* 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily): for blood pressure and heart failure. [**Month (only) **]:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for heart failure. [**Month (only) **]:*30 Tablet(s)* Refills:*2* 9. Cefazolin 1 g Piggyback Sig: One (1) Piggyback Intravenous Q8H (every 8 hours) for 3 weeks: for osteomyelitis, to be administered by IV nurse. [**Last Name (Titles) **]:*3 weeks' supply* Refills:*0* 10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed for 3 weeks: instill in PICC line. [**Last Name (Titles) **]:*qs for one month* Refills:*0* 11. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) mL Injection once a day for 3 weeks: to flush PICC line. [**Last Name (Titles) **]:*qs one month* Refills:*0* Discharge Disposition: Home With Service Facility: Crititcal Care Services Discharge Diagnosis: Primary: excerbation of congestive heart failure . Secondary: osteomyelitis of left great toe, hypertension, substance abuse, depression, hyperlipidemia Discharge Condition: At the time of discharge, patient is afebrile, tolerating po diet and meds, and ambulatory. Additionally, she does not have any suicidal or homicidal ideation. Discharge Instructions: Weigh yourself daily and call your cardiologist if you gain more than 2 pounds in one day. . Follow a low-sodium diet to prevent heart failure exacerbations. . Continue taking all medicines as prescribed. . Call 911 if you have chest pain or shortness of breath. Call your doctor if you have chills, fevers, nausea, vomiting, or diarrhea. Followup Instructions: On Monday, call Dr. [**Last Name (STitle) 4628**] [**Name (STitle) **] ([**Telephone/Fax (1) 108658**]), your psychiatrist, for first available appointment. . When you get home, call Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 32963**] ([**Telephone/Fax (1) 34119**]), your cardiologist, for an appointment in [**1-12**] weeks. . Provider: [**First Name8 (NamePattern2) 7618**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2148-7-9**] 9:30

Admission Date: [**2177-2-25**] Discharge Date: [**2177-2-28**] Date of Birth: [**2117-9-30**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 59-year-old gentleman who has a history of multiple myocardial infarctions in the past including an inferior myocardial infarction in [**2171**] and a non-Q-wave myocardial infarction in [**2176-11-19**] who is admitted from [**Hospital6 33**] with an unstable anginal syndrome, a positive troponin, and negative creatine kinases. The patient had been having several days of worsening exertional chest pain associated with some shortness of breath, diaphoresis; his typical anginal symptoms which led him to present to the outside hospital, at which time his studies became concerning for an acute coronary syndrome. He was started on Lopressor, Plavix, aspirin, Integrilin, and nitroglycerin and transferred to [**Hospital1 190**] for further care. The patient's most recent cardiac catheterization prior to this admission revealed the following: an ejection fraction of 38%, a normal left main, a 60% tubular middle left anterior descending artery with a totally occluded first diagonal, faint left-to-left collaterals, a distal left anterior descending artery of 90%, a small ramus with a proximal 70%, circumflex system with a 90% first obtuse marginal inferior lesion, and a 70% superior pole lesion, a diffusely diseased third obtuse marginal. The right coronary artery had mild diffuse disease with a moderate in-stent restenosis on previously placed posterior descending artery stent; unchanged from [**2175-8-20**] catheterization, and a posterior left ventricle that was totally occluded and filled by right-to-right collaterals. Left ventricular end-diastolic pressure was 20 mm; and at that time the patient had stent to the first obtuse marginal with additional percutaneous transluminal coronary angioplasty of the upper pole of the first obtuse marginal. The proximal to middle left anterior descending artery lesion underwent successful percutaneous transluminal coronary angioplasty and stenting, and the distal left anterior descending artery was treated with a stent also. The first diagonal which had an in-stent restenosis could not be treated at that time. The patient was directly admitted to the catheterization laboratory at [**Hospital6 33**], at which time he underwent a limited study notable for in-stent restenosis of the proximal left anterior descending artery stent placed in [**2175-8-20**] and a 90% distal left anterior descending artery occlusion, and a distal left anterior descending artery that was subtotally occluded immediately proximal to a prior distal left anterior descending artery stent. The proximal left anterior descending artery 80% in-stent restenosis underwent successful brachy therapy, and a stent was placed in the distal left anterior descending artery proximal to a prior stent to treat a restenosis. The procedure was complicated by hypotension in to the 70s with bradycardia into the 40s, in a sinus rhythm. An echocardiogram done on the catheterization table revealed no evidence of tamponade. It was felt that the patient was having an severe vagal reaction. He was started on dopamine which was eventually increased to 10 mcg/kg per minute, and the Coronary Care Unit team was then asked to evaluate and observe the patient overnight while peripheral anatropes were weaned. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post inferior myocardial infarction in [**2171**], status post non-Q-wave myocardial infarction in [**2176-11-19**]. Most recent intervention in [**2176-11-19**]. 2. Hypercholesterolemia. 3. Hypertension. 4. Cluster headaches. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d., Cardizem 240 mg p.o. q.d., Lipitor 10 mg p.o. q.d., Paxil 10 mg p.o. q.d., multivitamin. ALLERGIES: BETA BLOCKER apparently causing bronchospasm. FAMILY HISTORY: Family history notable for coronary artery disease and diabetes in multiple family members. SOCIAL HISTORY: The patient is a divorced high school teacher with six children. He does not smoke. There is no illicit drug use such as cocaine. PHYSICAL EXAMINATION ON PRESENTATION: Admission physical examination with vital signs revealing afebrile, blood pressure of 100/60, pulse of 80s on 10 mcg/kg per minute of dopamine, respiratory rate of 12, oxygen saturation of 98% on room air. In general, alert and oriented times three. Cranial nerves II through XII were intact. Head, eyes, ears, nose, and throat revealed pupils were equal, round, and reactive to light. Extraocular movements were intact. Sclerae were anicteric. The oropharynx was clear. Neck was supple, no lymphadenopathy, no jugular venous distention. Chest was clear to auscultation bilaterally. Cardiovascular revealed a regular rhythm with a normal rate. No murmurs, rubs or gallops. Abdomen was soft, nontender, and nondistended, normal active bowel sounds. Extremities revealed soaked dressing, no femoral bruits. No firmness or ecchymosis consistent with a hematoma, preserved distal pulses. PERTINENT LABORATORY DATA ON PRESENTATION: Admission laboratories from the outside hospital revealed troponin of 0.29, creatine kinases were flat. First creatine kinase at [**Hospital1 69**] was 94. RADIOLOGY/IMAGING: CT of the abdomen, pelvis, and leg revealed a 1.5-cm X 1.5-cm hematoma with surrounding fat stranding. No evidence of an acute hemorrhage or continued extravasation of fluid. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit for management of hypotension, for which the short differential included active blood loss which was effectively ruled out by the CT study and a vagal response necessitating inotropic support. Over the course of the first evening in the Coronary Care Unit the patient became progressively anxious and reported difficulty urinating, and eventually was given 1 mg of Ativan. After the dose of Ativan, the patient's dopamine requirement decreased from 9 mcg/kg per minute to 2 mcg/kg per minute over the course of an hour and a half. The following morning, dopamine was discontinued. The patient had excellent blood pressures, and the groin appeared stable. The patient's hematocrit was also stable, and subsequent creatine kinases remained flat. Electrocardiogram showed no evolving changes. The patient did suffer nonsustained ventricular tachycardia while in house. DISCHARGE DIAGNOSES: 1. Three vessel coronary artery disease; status post left anterior descending artery intervention times two on current admission. 2. Hypertension. 3. Exuberant vagal response. 4. Nonsustained ventricular tachycardia in the setting of unstable angina. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. q.d. 2. Cardizem 240 mg p.o. q.d. 3. Lipitor 10 mg p.o. q.d. 4. Paxil 10 mg p.o. q.d. 5. Multivitamin. 6. Plavix 75 mg p.o. q.d. (indefinitely). 7. Folate 1 mg p.o. q.d. DISCHARGE FOLLOWUP: The patient was to follow up for an electrophysiology study as an outpatient on [**2177-3-6**]. Otherwise, the patient was to follow up with his cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], for further followup. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-463 Dictated By:[**Name8 (MD) 2653**] MEDQUIST36 D: [**2177-3-3**] 13:48 T: [**2177-3-4**] 12:27 JOB#: [**Job Number 99685**]

Admission Date: [**2135-5-18**] Discharge Date: [**2135-6-17**] Date of Birth: [**2062-1-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: Fall with facial abrasions and neck pain Major Surgical or Invasive Procedure: Halo placement [**2135-5-26**], with revision [**2135-6-9**] GJ tube placement [**2135-5-26**], with revision [**2135-6-4**] Tracheostomy [**2135-5-26**] EGD x2 [**2135-5-28**], [**2135-6-3**] Cystoscopy [**2135-6-10**] History of Present Illness: Patient was trasfer from an OSH, he presented s/p fall at home with facial abrasions and neck pain after an unknown period of LOC. Patient was drinking heavily prior to fall. Past Medical History: Type 2 DM Rheumatic Heart Disease Aortic Mechanical Valve AI, MR, Afib Prostate CA Iron deficency Anemia LV failure s/p pacer/defibrillator Emphysema Depression Gout Social History: EtOH+ Denies Cocaine, Heroine Family History: denies Physical Exam: On admission: VS: 97, 116, 140/77, 15 93% Gen: Alert+O x3, NAD HEENT: antreior face abrasions Cardiac: irregularly irregular Chest: CTAB Abd: Soft, NT/ND +BS Ext: no c/c/e, no deformity Neuro: 5/5 strength UE/LE, sensation intact Pertinent Results: [**2135-6-17**] 05:38AM BLOOD WBC-8.3 RBC-3.06* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.2 MCHC-33.6 RDW-14.9 Plt Ct-237 [**2135-6-16**] 05:15AM BLOOD WBC-8.1 RBC-3.18* Hgb-9.7* Hct-28.8* MCV-91 MCH-30.4 MCHC-33.6 RDW-14.9 Plt Ct-223 [**2135-5-24**] 02:54PM BLOOD WBC-9.4 RBC-2.77* Hgb-9.2* Hct-26.3* MCV-95 MCH-33.3* MCHC-35.1* RDW-13.1 Plt Ct-181 [**2135-5-18**] 07:38PM BLOOD WBC-7.9 RBC-3.83* Hgb-12.6* Hct-35.9* MCV-94 MCH-32.8* MCHC-35.0 RDW-13.7 Plt Ct-198 [**2135-6-17**] 05:38AM BLOOD PT-12.7 PTT-49.2* INR(PT)-1.1 [**2135-6-16**] 07:00PM BLOOD PT-12.9 PTT-50.1* INR(PT)-1.1 [**2135-6-16**] 04:15PM BLOOD PT-13.0 PTT-54.6* INR(PT)-1.1 [**2135-5-18**] 07:38PM BLOOD PT-17.1* PTT-29.1 INR(PT)-1.9 [**2135-5-19**] 01:09AM BLOOD PT-17.7* PTT-52.0* INR(PT)-2.1 [**2135-5-19**] 08:26AM BLOOD PT-18.3* PTT-150* INR(PT)-2.2 [**2135-6-17**] 05:38AM BLOOD Glucose-182* UreaN-27* Creat-1.1 Na-135 K-3.8 Cl-98 HCO3-26 AnGap-15 [**2135-6-16**] 05:15AM BLOOD Glucose-137* UreaN-28* Creat-1.2 Na-136 K-4.2 Cl-99 HCO3-26 AnGap-15 [**2135-5-19**] 01:09AM BLOOD Glucose-167* UreaN-8 Creat-0.6 Na-130* K-3.5 Cl-97 HCO3-21* AnGap-16 [**2135-5-18**] 07:38PM BLOOD Glucose-186* UreaN-10 Creat-0.7 Na-135 K-4.4 Cl-100 HCO3-20* AnGap-19 [**2135-5-29**] 03:11AM BLOOD ALT-24 AST-26 LD(LDH)-294* AlkPhos-67 Amylase-30 TotBili-4.3* [**2135-5-28**] 01:00PM BLOOD ALT-21 AST-29 AlkPhos-60 Amylase-23 TotBili-4.1* [**2135-5-18**] 07:38PM BLOOD CK(CPK)-97 Amylase-40 [**2135-5-29**] 03:11AM BLOOD Lipase-40 [**2135-5-19**] 03:59PM BLOOD Lipase-23 [**2135-5-31**] 12:20PM BLOOD CK-MB-NotDone cTropnT-0.01 [**2135-5-18**] 07:38PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2135-6-17**] 05:38AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.9 [**2135-6-16**] 05:15AM BLOOD Calcium-9.2 Phos-5.2* Mg-2.0 [**2135-5-19**] 01:09AM BLOOD Calcium-6.1* Phos-2.5* Mg-2.2 [**2135-5-18**] 07:38PM BLOOD Calcium-9.8 Phos-2.6* Mg-2.5 [**2135-5-19**] 03:59PM BLOOD TSH-0.29 [**2135-6-12**] 08:30AM BLOOD PSA-0.2 [**2135-5-19**] 01:19PM BLOOD Type-ART pO2-338* pCO2-39 pH-7.35 calHCO3-22 Base XS--3 Psych Consult ([**6-13**]): ASSESSMENT: 73 y/o man presented s/p C2 traumatic neck fracture following fall 6 weeks ago. He is s/p Halo, trach, and PEG placement ([**5-26**]) with readjustment during this admission. In the past weeks, his mental status diminished to the point where he could not make medical decisions, so his proxy (son) served as a surrogate decision-maker. At this time, he is able to weigh benefits of risks of treatment, and in general is very accepting to continued medical treatment. He has capacity to medical decisions regarding his care. His current CODE status is DNR/DNI PLAN: reverse DNR/DNI status to FULL CODE approach pt re: medical decisions during this hospitalization make clear to son that his role as proxy is to represent patient's wishes if pt. were able to convey them Cytology on Cystoscopy ([**6-10**]): ATYPICAL. Atypical urothelial cells, present singly and in clusters. Squamous cells, anucleate squames, histiocytes, neutrophils and red blood cells. EGD: [**2135-6-3**]: Diffuse erosive esophagitis with active oozing of blood noted throughout the entire esophagus ECHO (TTE) [**5-30**]: Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 4. The aortic root is moderately dilated. The ascending aorta is moderately dilated. 5. A bileaflet aortic valve prosthesis is present. The aortic prosthesis leaflets appear to move normally. The transaortic gradient is normal for this prosthesis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. EGD ([**5-28**]) A single non-bleeding erosion was noted in the antrum, near the gastrostomy site. RUQ U/S ([**5-28**]) IMPRESSION: Normal right upper quadrant ultrasound without evidence for intrahepatic or extrahepatic biliary ductal dilatation or cholecystitis CT of Cspine [**2135-5-19**] IMPRESSION: 1) Fracture of C2, with posteriorly displaced odontoid fracture fragments causing spinal canal narrowing and cord compression at C1/2. 2) Anterior subluxation of C3 on C4, a finding that, in the setting of trauma, could indicate disruption of the joint capsule at the facet joints, and may be indicative of ligamentous instability. 3) No other fractures identified within the cervical spine. Brief Hospital Course: Pt is a 72 yo man with a significant PMH of Afib, LVF with pacer/defibrillator, Aortic Mechanical valve requiring anticoagulation, Rheumatic Heart Disease, MR, AI, DM, Emphysema, Gout, and Depression who presented to an OS s/p fall where he was found to have an unstable dens fracture. The patient was taken to the OR where a Halo was placed, tracheostomy was performed and open GJ tube was placed. The patient, did well post procedure but developed coffee ground emesis as anticoagulation was restarted, an EGD was performed finding a single non-bleeding 2cm, clean based ulcer in the gastroesophageal junction, a RUQ US was also performed which was normal, the patients Hcts remained stable. Subsequently, the patient developed leakage of gastric contents around the GJ tube and increased G tube output around the GJ site. The patient also developed some hematuria and Heme positive gastric secretions at this time. The Patients Hematocrits continued to drop so much so that Transfusions were required. At this point the decision was made to perform a follow up EGD which showed diffuse erosive esophagitis with active oozing of blood noted throughout the entire esophagus. This occurred despite antiulcer regimens, Heparin was stopped and the patient was brought back to the OR for repositioning of the GJ tube. After this procedure, gastric secretions around the GJ Tube decreased significantly, and the Pts Hct stabilized, the patient was restarted on Heparin, but hematuria persisted, Urology consult was obtained who did cystoscopy and found only an irritated portion of the bladder that was most likely from foley trauma. Bladder irrigation was performed and the patient's urine cleared, anticoagulation was restarted, and the patient's hematocrits remained stable. The patient did have continued episodes of hematuria, but hematocrits remained stable and events always subsided and were often after foley manipulation. In addition, during the course of his stay, the patient had episodes of Confusion and agitation which mostly occurred in the ICU and step down units. Once moved to the floor, the patient cleared considerably and Psych consult deemed the patient to have decision making capacity. Through out the patients stay, his Afib was rate controlled. Medications on Admission: Allopurinol Lasix Coumadin Lexapro Glyburide HCTZ Topral Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: [**12-5**] PO BID (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed for aggitation. 8. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 17. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 20. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 21. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): 1200 units/hr. 22. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): SSI:0-50 mg/dL [**12-5**] amp D50 51-120 mg/dL 0 Units 121-140 mg/dL 3 Units 141-160 mg/dL 7 Units 161-180 mg/dL 11 Units 181-200 mg/dL 15 Units 201-220 mg/dL 19 Units 221-240 mg/dL 23 Units > 240 mg/dL Notify M.D. . Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: C2 odontoid fracture, status post halo fixation and revision GE junctional nonbleeding ulcer Diffuse erosive esophagitis Hematuria Discharge Condition: Stable Discharge Instructions: Return to the Emergency room if you develop high fevers, abdominal Pain, weakness, sensory changes, or other concerns. Take medications as prescribed, follow up as indicated below. Halo must be on for 6-8 weeks, be sure to follow up with Orthopaedic spine regarding removal. Followup Instructions: Follow up with: Ortho Spine: Dr. [**Last Name (STitle) 363**], follow up lateral C-spine x-ray in 10 days, call ([**Telephone/Fax (1) 11061**] for appointment and eval of x-ray. Urology: Call ([**Telephone/Fax (1) 5278**] for appointment Gastroenterology: Dr. [**First Name (STitle) 2643**], follow up in 2 wks, call ([**Telephone/Fax (1) 26817**] for appointment Your Primary Care Doctor, Dr. [**Last Name (STitle) 12982**] ([**Telephone/Fax (1) 30118**], as needed Your Primary Cardiologist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 22764**], as needed

Admission Date: [**2154-12-16**] Discharge Date: [**2155-1-2**] Date of Birth: [**2071-12-4**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Morphine Attending:[**First Name3 (LF) 922**] Chief Complaint: SOB Major Surgical or Invasive Procedure: [**2154-12-24**] 1.Coronary artery bypass grafting x3 with left internal mammary artery, left anterior descending coronary; reverse saphenous vein single graft from aorta to first obtuse marginal coronary artery; reverse saphenous vein single graft from aorta to the distal right coronary artery. 2. Bilateral pulmonary vein isolation using the [**Company 1543**] BP2 irrigated bipolar RF system with resection of left atrial appendage. 3. Endoscopic left greater saphenous vein harvesting. 4. Epiaortic duplex scanning. History of Present Illness: 83yo man admitted to [**Hospital6 10443**] 6 days prior to transfer with dyspnea on exertion. He had history of COPD and was presumed to be having COPD exacerbation. CT revealed effusion and the patient had thoracentesis. He also had stress test that showed normal perfusion w/o defects. Following the stress test he develped chest pain and had ST depression in V2-6. During this episode the patient was noted to be in atrial fibrillation. He had cardiac catheterization today that revealed 3VD with preserved EF. Referred for surgery. Past Medical History: CAD COPD HTN Atrial fibrillation Past Surgical History: Laparoscopic Cholecystectomy Social History: Lives with: widowed-lives alone Occupation:currently works as driver Tobacco: Quit 35 yrs ago/105pack year hx ETOH:none Family History: non-contrib. Physical Exam: Pulse: 85 Resp: 22 O2 sat: 96%-2LNP B/P Right: 110/60 Left: Height: 66 in Weight: 160lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] no JVD Chest: Lungs diminished w/o rales or wheezing Heart: RRR [x] Irregular [] Murmur-no Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema: [**12-29**]+ bilat Varicosities: None [x] Neuro: Grossly intact, non focal exam Pulses: Femoral Right: cath site Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit none Right: Left: Pertinent Results: Conclusions PRE BYPASS The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is being a paced. There is normal biventricular systolic function. The left atrial appendage has been resected. There is mild to moderate tricuspid regurgitation. Other valvular function is unchanged from the pre-bypass study. The thoracic aorta is intact s/p decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2154-12-24**] 13:35 Brief Hospital Course: Mr. [**Known lastname 30620**] was admitted on [**12-16**] from an outside hospital and his pre-op work-up was done. Over the next several days he was diuresed and had thoracentesis by Dr. [**Last Name (STitle) **] for a pleural effusion. He also had a plavix washout. Antibiotics also were started as well as BP med titration. He underwent coronary artery bypass, MAZE, and left atrial appendage ligation with Dr. [**Last Name (STitle) 914**] on [**12-24**] and was transferred to the CVICU in stable condition on phenylephrine and propofol drips. He extubated later that day and remained in the CVICU over the next few days for aggressive pulmonary conditioning. His atrial fibrillation returned and he was treated with amiodarone. A renal consult was requested for acute renal failure with highest creat 3.8. He also had an ileus but was ultimately transferred to the floor on POD #6 to begin increasing his activity level. His beta blockade was titrated. Coumadin was not started for atrial fibrillation per Dr. [**Last Name (STitle) 914**] [**Name (STitle) 88067**] to fall risk. By post-operative day nince he was ready for discharge to rehab per Dr. [**Last Name (STitle) 914**]. All follow-up appointments were advised. Medications on Admission: Medications at home: Prilosec 20 [**Hospital1 **] ASA 81 QD Combivent 2 puffs QID Ativan 0.5 HS-prn Symbicort 160/45 1 puff [**Hospital1 **] Losartan 50 QD Colace 100 [**Hospital1 **] Meds on Transfer: Tylenol 650 Q4-prn Lactinex 2 abs TID Maalox 30cc Q$-prn Combivent 2 puffs QID ASA 81 QD Symbicort 160/4.5 1 puff [**Hospital1 **] Plavix 75 QD Colace 100 [**Hospital1 **] Pepcid 20 QD Lasix 40 QD Levaquin 250 QD Ativan 0.5 QHS-prn Cozaar 50 [**Hospital1 **] MOM-prn Metoprolol 25 [**Hospital1 **] NTG 0.4 sl-prn MSO4 2 IV-PRN Senna 1 tab [**Hospital1 **] Ocean spray nasal spray QID-prn Calan SR 180 QD Plavix - last dose:[**12-16**] Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units SQ Injection TID (3 times a day): until ambulating regularly. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 1 weeks: [**Date range (1) 33500**] (400 mg daily), then 200 mg daily starting [**1-8**]. 10. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): 75mg [**Hospital1 **]. Disp:*90 Tablet(s)* Refills:*2* 11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. Disp:*30 Tablet(s)* Refills:*0* 12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:*30 ML(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 12564**] hospital Discharge Diagnosis: Severe 3-vessel coronary diseases s/p Coronary artery bypass grafting x3(left internal mammary artery, left anterior descending coronary; reverse saphenous vein single graft from aorta to first obtuse marginal coronary artery; reverse saphenous vein single graft from aorta to the distal right coronary artery). 2. History of atrial fibrillation. 3. Severe chronic obstructive pulmonary disease. 4. acute renal failure 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 Leg Right/Left - healing well, no erythema or drainage. Edema ............ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr.[**Last Name (STitle) 914**] on [**2155-1-21**] at 1:30pm # [**Telephone/Fax (1) 170**] Cardiologist:Dr.[**Last Name (STitle) **] on [**2155-1-30**] at 2:15pm Please call to schedule appointments with your: Primary Care Dr.[**Last Name (STitle) 5239**] in [**12-29**] 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:[**2155-1-2**]

Admission Date: [**2162-5-16**] Discharge Date: [**2162-5-28**] Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) / Codeine / Amiodarone Attending:[**First Name3 (LF) 1283**] Chief Complaint: DOE Major Surgical or Invasive Procedure: MV Repair ([**5-17**]) History of Present Illness: 86 y/o female w/increasing DOE for 4 months, increased fatigue, Echo: severe MR. Past Medical History: 1) Atrial fibrillation X 15 years 2) s/p pacemaker placement 3) s/p appendectomy 4) s/p TAH 5) s/p tonsillectomy 6) s/p adenoidectomy Social History: The patient has 10 pk-yr smoking history, quit 15 years ago. [**12-6**] alcoholic beverages per week. No other drug use. Lives in North [**Doctor First Name **]; currently visiting her daughter. Family History: Sister has a pacemaker. Brother had a CVA. Father died of an MI at 72 years. Physical Exam: Unremarkable pre-op Pertinent Results: [**2162-5-27**] 07:05AM BLOOD Hct-33.8* [**2162-5-26**] 05:50AM BLOOD PT-17.8* INR(PT)-2.1 [**2162-5-25**] 06:35AM BLOOD Glucose-100 UreaN-25* Creat-0.9 Na-141 K-4.3 Cl-108 HCO3-26 AnGap-11 Brief Hospital Course: to OR [**2162-5-17**] for MV repair (26mm [**Doctor Last Name **] band) Weaned from vent and extubated day of surgery. Weaned off phenylephrine by POD # 1, transferred to telemetry floor on POD # 1. Had low urine output after transfer, with rising creatinine. Trasferred back to CSRU on morning of POD # 2, PA catheter placed, found to be hypovolemic, treated with volume. Also had PPM rate increased to 80/minute to maximize cardiac output. Creatinine peaked at 1.9, but quickly reverted back down to normal (0.9-1.0 for past 4 days) after fluid resuscitation. Anticoagulation resumed for atrial fibrillation, presently V-paced at 70/minute (rate decreased to 70 on [**5-26**]). She was not restarted on Altace due to elevatd creatinine (now normalizeed), she was started on Norvasc. This should be re-evaluated by Dr. [**First Name (STitle) 805**] or Dr. [**Last Name (STitle) 32548**] upon discharge from rehab. She has remained hemodynamically stable, with normalized creatinine, and good urine output. She remains weak, and requires assistance to ambulate. She is ready for discharge to rehab today. Medications on Admission: Coumadin 7.5 mg QD Lasix 40 mg QD Altace 5 mg QD Toprol XL 50mg QD Calcium Glocosamine Magnesium Selenium Folic Acid Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 10. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: then recheck INR, and dose for target INR 2.0-2.5. Disp:*30 Tablet(s)* Refills:*0* 11. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: MR AFib s/p PPM (SSS) Discharge Condition: good Discharge Instructions: no lifting > 10# or driving for 1 month no creams lotions, or powders to incisions may shower, no bathing or swimming for 1 month [**Last Name (NamePattern4) 2138**]p Instructions: with Dr. [**Last Name (Prefixes) **] in 4 weeks with Dr. [**First Name (STitle) 805**] in [**1-7**] weeks, or upon discharge from rehab with Dr. [**Last Name (STitle) 32548**] in [**1-7**] weeks or upon discharge from rehab Completed by:[**2162-5-27**]

Admission Date: [**2161-12-12**] Discharge Date: [**2162-1-5**] Service: ONCOLOGY CHIEF COMPLAINT: Worsening dyspnea. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old woman with metastatic breast cancer, diagnosed in [**2161-11-13**], presenting to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2161-12-12**] for shortness of breath times several weeks, worsening over the last few days. She does have two pillow orthopnea but negative paroxysmal nocturnal dyspnea, no chest pain or palpitations. She has noted increasing lower extremity edema over the last week. She has cough which is productive of white sputum but no night sweats or weight loss. She denies fever, chills, nausea or vomiting. She has been using inhalers but does not feel that they have been effective with regard to her dyspnea. She is not on any oxygen at home. The patient's previous workup for shortness of breath has included a CT angiogram on [**2161-12-2**] which was negative for pulmonary embolism but notable for bilateral ground-glass opacities. A transthoracic echocardiogram showed a left ventricular ejection fraction of greater than 70% with mild aortic and mitral regurgitation. She has moderate pericardial effusion as noted by the transthoracic echocardiogram. PAST MEDICAL HISTORY: 1. Pernicious anemia. 2. Chronic obstructive pulmonary disease. 3. Depression. 4. Bilateral total knee replacements. 5. Pelvic mass found in the left adnexal region measuring 6 x 4 cm, which is likely metastatic versus primary ovarian in origin. 6. Infiltrating ductal carcinoma, ER positive, HR2/neu negative with omental metastases, retroperitoneal lymph nodes. MRI of the head revealed no metastatic disease, however, bone scan indicated thoracic metastases. SOCIAL HISTORY: The patient lives alone on the third story of an apartment building and is independent. Her daughter and son-in-law live nearby and are very supportive. FAMILY HISTORY: Family history is significant for coronary artery disease in the patient's father, however, no family history of cancer. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: Zoloft 100 mg p.o.q.d., Lasix 40 mg p.o.b.i.d., Combivent one to two puffs q.i.d., AeroBid four puffs b.i.d., vitamin B12 q. month, Femara 2.5 mg p.o.q.d. PHYSICAL EXAMINATION: On physical examination on admission, the patient had a temperature of 97, blood pressure 162/82, heart rate 88, respiratory rate 28, and oxygen saturation 98% on three liters nasal cannula. General: Patient in no acute distress, resting comfortably in bed, appears younger than her stated age. Head, eyes, ears, nose and throat: Oropharynx clear, moist mucous membranes, jugular venous pulsation not elevated, neck supple, anicteric sclerae, extraocular movements intact, no lymphadenopathy present in the cervical region. Chest: Bilateral basilar crackles without wheezing, left axillary lymphadenopathy. Cardiovascular: Regular rate, normal S1 and S2, no S3 or S4, II/VI murmur at left sternal border. Abdomen: Soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly. Extremities: 2+ bilateral pitting edema, no cyanosis or clubbing, 2+ dorsalis pedis pulses bilaterally, skin warm and dry. Neurologic examination: Alert and oriented times three, cranial nerves II through XII intact, [**5-17**] motor strength in bilateral upper and lower extremities. LABORATORY DATA: Admission white blood cell count 6.1, hematocrit 32.2, platelet count 263,000, sodium 137, potassium 4.1, chloride 106, bicarbonate 18, BUN 34, creatinine 1.3, glucose 109. STUDIES DURING HOSPITALIZATION: 1. Chest x-ray, [**2161-12-12**] revealed bilateral interstitial infiltrates, bilateral pleural effusions, mild congestive heart failure. 2. Transthoracic echocardiogram, [**2161-12-16**] showed mild left ventricular hypertrophy, hyperdynamic left ventricular function with a moderate pericardial effusion, no change from echocardiogram on [**2161-12-8**]. 3. Transthoracic echocardiogram, [**2162-1-4**] showed left ventricular ejection fraction greater than 55% with loculated moderate sized 1.5 cm pericardial effusion with fibrin deposits on the surface of the heart; no echocardiographic signs of tamponade; compared with prior echocardiogram, the pericardial effusion appears loculated at this point. 4. Electrocardiogram on admission showed normal sinus rhythm, Q waves in III and AVF which were old and T wave abnormalities in V2 through V6 which were nonspecific. HOSPITAL COURSE: The patient is a [**Age over 90 **] year old female with chronic obstructive pulmonary disease, breast cancer and anemia, who presents with acute worsening of chronic shortness of breath. 1. Cardiovascular: The patient was initially thought to be in congestive heart failure and was aggressive diuresed until her creatinine bumped. She was ruled out for a myocardial infarction by negative cardiac enzymes on numerous occasions during her hospitalization. Serial echocardiograms were performed times four, which showed moderate sized pericardial effusion without signs of tamponade but evidence of diastolic dysfunction. As the patient's dyspnea did not improve, there was concern that the effusion was compromising cardiac output and her ability to mobilize fluid. Therefore, a pericardial window was placed on [**2162-1-1**] with greater than 200 cc of bloody fluid out, and the drain was left in until [**2162-1-5**]. There was no improvement in the patient's dyspnea after the window was placed and the pericardial drainage tube was pulled. As the pericardial fluid was bloody, there was concern for a malignant effusion, however, cytology revealed no malignant cells. It was significant for reactive mesothelial cells, red blood cells, lymphocytes and neutrophils. The patient also had occasional episodes of ectopy, both atrial fibrillation and supraventricular tachycardia, which was thought to be related to the pericardial window and drain, with resulting irritation. She was started on metoprolol 25 mg twice a day for both rhythm abnormalities and for improvement of congestive heart failure. 2. Pulmonary: The patient's main complaint on admission was acute worsening of chronic dyspnea over the last month. Upon medical record review, it appears that the patient has had complaints of dyspnea since [**2161-7-13**] and, during her previous admission at the beginning of [**Month (only) **], she was noted to have oxygen saturation of 91% in room air. The cardiologic etiologies of the dyspnea was extensively investigated but, as she had no improvement with diuresis, pericardial window and multiple rule outs for myocardial infarction, it was felt that there was a pulmonary etiology as the most likely explanation for her dyspnea. Given the patient's history of chronic metastatic breast cancer, lymphatic spread of the cancer was thought to be the source of her dyspnea. A thoracentesis was performed on [**2161-12-30**] and 600 cc of yellow straw colored fluid was removed. The fluid was later found to be positive for malignant cells, consistent with adenocarcinoma. The patient was ruled for pulmonary embolism just prior to admission. Although she was not on oxygen at home, she had a consistent three to four liter nasal cannula oxygen requirement throughout the hospitalization. The patient was transferred to the Medical Intensive Care Unit following pericardial window placement and consideration for Swan-Ganz catheter was undertaken, however, the patient and family opted to pursue a less aggressive treatment course. The Swan-Ganz was not placed and her volume status, instead, was estimated per clinical examination and radiograph evidence that was available. 3. Renal: On admission, the patient's creatinine was 1.3 and bumped to as high as 2.1 with diuresis. With fluid hydration after the pericardial window was placed, the creatinine trended down and is currently at 1.6 at the time of discharge. 4. Infectious disease: The patient was treated with a ten day course of antibiotics for presumed pneumonia, which did not improve her pulmonary status. 5. Hematology: The patient has a baseline pernicious anemia and received B12 injection on admission. She is to continue these injections monthly. 6. Gastrointestinal: The patient is chronically constipated but had worsening of her constipation throughout her hospitalization. Her abdomen became progressively more distended and tender during the end of her hospital course while she was in the MICU. Liver function tests were performed and found to be normal on several occasions. An abdominal x-ray showed a distended large bowel, however, she was eventually able to move her bowels two to three days prior to discharge. Her abdominal exam did not significantly improve after the bowel movements and, given her elevated lactate, there was concern for bowel wall ischemia, ileus or obstruction from her previous known large pelvic mass. The option of a CT abdomen was discussed with the patient and family, who both agreed not to perform the study given the risks of worsening renal function from contrast load and their wish not to pursue surgical intervention. The etiology of her abdominal pain was most likely functional constipation and she was continued on an aggressive bowel regimen with per rectum medication and enemas as needed. 7. Fluids, electrolytes and nutrition: Throughout her hospitalization, the patient had a minimal appetite secondary to cancer anorexia and had a few episodes of nausea and emesis. Her emesis was thought secondary to functional constipation. She was able to tolerate fluids and pureed food on occasion and was able to take most of her oral medications. During a family meeting, a nasogastric tube was discussed with the possibility of starting tube feeds. The family, however, did not think this was consistent with the patient's wishes and, therefore, no nasogastric tube was placed. Likewise, the option of a percutaneous endoscopic gastrostomy tube was also felt by the family not to be consistent with the patient's wishes. 8. Oncology: On admission, the patient had a known diagnosis of metastatic breast cancer, which was recently diagnosed in [**2161-11-13**]. Her outpatient oncologist, Dr. [**First Name (STitle) **], did not feel chemotherapy was indicated at the time of diagnosis. She was instead started on Femara given that the tumor was estrogen receptor positive. 9. Code status: A family meeting was held on [**2162-1-4**] and, after a long discussion of the progression of the patient's disease and lack of response to medical management, it was decided by both the patient and her family that she would be "Do Not Resuscitate", "Do Not Intubate" and not to pursue aggressive medical treatment at this point. Her medications were simplified and she was prepared for transition to a skilled nursing facility with the possibility of hospice care in the near future. At this time, she was not "Comfort Measures Only", however, future medical decision making would be contingent upon optimizing the quality of life. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Metastatic breast cancer, bone, retroperitoneal lymph nodes and omentum. 2. Pelvic mass thought secondary to breast cancer metastases or primary ovarian tumor. 3. Diastolic congestive heart failure. 4. Chronic obstructive pulmonary disease. 5. Acute renal failure/chronic renal insufficiency. 6. Constipation. 7. Status post pericardial window, [**2162-1-1**]. 8. Status post thoracentesis, [**2161-12-30**]. 9. Chronic dyspnea, thought secondary to lymphangitic spread of carcinoma. 10. Paroxysmal atrial fibrillation. 11. Pernicious anemia. DISCHARGE MEDICATIONS: Metoprolol 25 mg p.o.b.i.d. Pepcid 20 mg p.o.b.i.d. Reglan 10 mg p.o.q.i.d. Dulcolax p.r.p.r.n. Senna two tablets p.o.q.d. Colace 100 mg p.o.b.i.d. Lactulose 30 cc p.o. or 300 cc p.r.t.i.d.p.r.n. Combivent q.6h. Flovent 110 mcg two puffs b.i.d. Zoloft 100 mg p.o.q.d. Femara 2.5 mg p.o.q.d. Roxanol p.r.n. Supplemental oxygen, three to four liters. Tylenol p.r.n. DISCHARGE INSTRUCTIONS: The patient is to be discharged to [**Location (un) **] Skilled Nursing facility with the possibility of transition to hospice. Her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], [**First Name3 (LF) **] continue to follow the patient after discharge. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 16520**] Dictated By:[**Last Name (NamePattern1) 18697**] MEDQUIST36 D: [**2162-1-9**] 22:07 T: [**2162-1-14**] 17:24 JOB#: [**Job Number **]

Admission Date: [**2162-5-14**] Discharge Date: [**2162-5-21**] Date of Birth: [**2162-5-14**] Sex: M Service: NOTE: This is an interim summary covering the date of birth ([**2162-5-14**]) through [**2162-5-21**]. ADMISSION DIAGNOSES: 1. Premature male infant at 34-3/7 weeks gestation. 2. Hyperbilirubinemia. 3. Desaturations; some with apnea of prematurity and some without. HISTORY OF PRESENT ILLNESS: The infant is a former 2.24-kg male infant born to a 24-year-old O positive hepatitis B surface antigen female. Past obstetrical/gynecologic history was notable for a double uterus and cervix. The pregnancy was uncomplicated until premature rupture of membranes, and the infant was noted to be in the breech presentation, so a cesarean section was performed three hours status post rupture. The infant was born with Apgar scores were 8 at one minute and 8 at five minutes and was transferred to the Newborn Intensive Care Unit for further evaluation and management of prematurity. On admission, the baby weighed 2.24 kilograms, length 144 cm, head circumference was 30.5 cm; all appropriate for gestational age. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination was essentially within normal limits. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. RESPIRATORY ISSUES: The infant remained on room air throughout his hospital course; however, he did have multiple desaturations, some accompanied with apnea and bradycardia and others not. On [**5-21**], he had 2 full 24-hour periods of having no episodes. 2. CARDIOVASCULAR SYSTEM: There were no cardiovascular issues. 3. INFECTIOUS DISEASE ISSUES: The infant had a benign complete blood count, and no antibiotics were initiated. Because of the mother's hepatitis B surface antigen positive status, the infant received hepatitis B immune globulin and hepatitis B immune vaccine on [**5-14**]. 4. FEEDING AND NUTRITION ISSUES: On day of life seven, the infant weighed 2.140 kilograms and was being fed Enfamil 20 calories per ounce at 150 cc/kg. He required more than half of this by gavage feeding. 5. HEMATOLOGIC ISSUES: The infant had a bilirubin of 11.6 which peaked at 13.8, for which he underwent several days of phototherapy.Phototherapy d'c d on [**5-21**] with rebound bili pending on [**5-22**]. 6. HEARING SCREEN: Hearing screen was performed on [**5-16**] and was normal. 7. DISPOSITION ISSUES: Upon discharge from the Neonatal Intensive Care Unit when he is feeding well and has had five days free of any major desaturations or apnea or bradycardia, he will be seen at [**Hospital1 **] Center by Dr. [**First Name (STitle) **]. Parents decline VNA service. DR.[**Last Name (STitle) **],[**First Name3 (LF) 47613**] 50-393 Dictated By:[**Last Name (NamePattern1) 38304**] MEDQUIST36 D: [**2162-5-20**] 08:42 T: [**2162-5-20**] 08:51 JOB#: [**Job Number 47614**]

Admission Date: [**2141-10-16**] Discharge Date: [**2141-10-19**] Date of Birth: [**2099-1-29**] Sex: M Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 348**] Chief Complaint: I feel terrible Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 42 year old man with a PMH of alcohol abuse, seizures secondary to alcohol withdrawal and pericarditis who was in his usual state of health until 9 days ago when he had his last drink. He was admitted to [**Hospital1 **] for detox and had been doing well until a week ago when he developed the onset of subjective fevers and chills with HA and anorexia. He also had nonradiating right sided chest pain which worsened with deep inspiration. He became so weak that he could not get out of bed. On ROS, Mr. [**Known lastname **] [**Last Name (Titles) **] N/V/constipation/sick contacts. In the ED, he was found to have a blood pressure of 78/62 and tachycardia to 120 for which he was given 4L NS. He responded by increasing his BP to 94/63 with a HR of 89. He also got 500 mg of azithromycin and 1 gm ceftriaxone in addition to multivitamin and thiamine and folate. Past Medical History: EtOH with 3-4 detoxs including seizures pericarditis 5 years ago dislocated shoulder Social History: Lives with wife and 16 year old daughter. [**Last Name (Titles) 4273**] tobacco or illicits. Admits to drinking 12-16 beers per day or a quart of vodka. Family History: noncontributory Physical Exam: vitals: 97.1 HR 89 BP 94/63 RR 16 and 100% on NC Gen: looks uncomfortable, curled in fetal position, having a hard time participating in physical exam HEENT: MM, 2 front teeth from mandible absent (secondary to seizure trauma 1 month ago) Neck: supple Cor: tachy but regular Pulm: crackles and dullness to percussion on right Back: TTP at costovertebral angle on right Abd: soft without guarding +BS but TTP on RUQ Ext: WWP 2+ DP/PT, radial pulses bilaterally Neuro: CN II-XII grossly intact but patient unable/unwilling to open eyes simultaneously Pertinent Results: [**2141-10-15**] 11:52PM D-DIMER-5142* [**2141-10-16**] 01:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-8* PH-9.0* LEUK-NEG [**2141-10-15**] 10:51PM LACTATE-1.1 [**2141-10-15**] 10:40PM GLUCOSE-117* UREA N-9 CREAT-0.6 SODIUM-136 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-26 ANION GAP-16 [**2141-10-15**] 10:40PM ALT(SGPT)-13 AST(SGOT)-42* CK(CPK)-1144* ALK PHOS-131* AMYLASE-87 TOT BILI-1.2 [**2141-10-15**] 10:40PM LIPASE-20 [**2141-10-15**] 10:40PM CK-MB-3 cTropnT-<0.01 [**2141-10-15**] 10:40PM WBC-11.8* RBC-3.87* HGB-12.3* HCT-35.2* MCV-91 MCH-31.9 MCHC-35.1* RDW-13.4 [**2141-10-15**] 10:40PM NEUTS-79.8* LYMPHS-15.8* MONOS-3.1 EOS-1.1 BASOS-0.2 09/1/1/05 10:40PM PLT COUNT-254/ blood and urinary cultures were negative for growth EKG: [**10-15**]: Sinus tachycardia at 120 with normal axis and nonpathologic Qs in V3-V6. Poor R wave progression in leads VI-V3. Prolonged Q-T interval. Diphasic T waves in leads V4-V6 and low amplitude T waves in leads II, III and aVF which are non-specifically abnormal. Tall R waves fulfilling voltage criteria for left ventricular hypertrophy in lead V5. CXR [**2141-10-15**]: The heart is of normal size. The mediastinal and hilar contours are within normal limits. There are no pleural effusions seen. There is a nodular density seen in the lateral view anteriorly. The other pulmonary opacity seen in the right middle lobe in the CT in the same day cannot be identified in the radiograph. The aorta is tortuous. There is no evidence of pneumothorax. IMPRESSION: Nodular density seen in the lateral view anteriorly. Another density seen in the CT in the same day cannot be identified in the radiograph. Please review report of the CT performed in the same day for differential diagnosis. CTA [**2141-10-16**]: There are 2 large nodules in the right middle lobe. They are low attenuation and do not enhance. Considering the patients symptoms and the hypothesis that the patient is immunocompetent, this most likely represents bacterial pneumonia. However, follow up until resolution is necessary to exclude malignancy. small right pleural effusion. CXR: [**2141-10-18**] Pulmonary edema is resolved. Persistent consolidation at the base of the right lung is probably pneumonia. Hyperinflation suggests COPD. Heart size is normal. There is no pneumothorax or appreciable pleural effusion. Brief Hospital Course: A: 42 year old man with high Ddimer and PNA in addition to high CK and hypotension. P: PNA - ceftriaxone and azithro. He was also started on flagyl for question of aspiration. The flagyl was stopped on [**10-17**]. The patient initailly went to the [**Hospital Unit Name 153**] for concern of his hemodynamic status where overnight his hypotension improved after 5L NS. He was transfered to the floor on [**10-17**]. On the floor he was afebrile continued to improve and was discharged on [**2141-10-19**] with antibiotics. The patinet also received pneumovax prior to discharge # EtOH: patient most likely out of window for withdrawal, but was placed on a CIWA was used for which he required no meds. He was given thiamine, folate. An addiction consult was requested and it was recommended that he continue to attend AA meetings. Medications on Admission: NONE Discharge Medications: 1. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 10 days. Disp:*10 Capsule(s)* Refills:*0* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 5. Augmentin XR 1,000-62.5 mg Tablet Sustained Release 12HR Sig: Two (2) Tablet Sustained Release 12HR PO twice a day for 10 days. Disp:*40 Tablet Sustained Release 12HR(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Community acquired pneumonia Alcohol abuse Discharge Condition: Stable. Afebrile with improved chest pain on antibiotics. . Discharge Instructions: You were admitted with a community acquired pneumonia. Please continue to take your antibiotics for ten more days even if you start to feel better. You should call your physician or come to an emergency room if you develop fevers > 101, trouble breathing, cough with green or yellow sputum or chest pain. Please also call if you have diarrhea as the antibiotics can cause infectious diarrhea which will need to be treated by your physician. You will need to follow up with a primary care physician and have [**Name Initial (PRE) **] chest CT scan done in six to eight weeks to assess resolution of the pneumonia. Followup Instructions: Please schedule an appointment with your primary care physician for repeat chest CT to evaluate for pneumonia resolution in six to eight weeks. Completed by:[**2141-10-26**]

Admission Date: [**2119-3-31**] Discharge Date: [**2119-4-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: [**4-12**] Right-sided crani for evac of subdural hematoma History of Present Illness: 81 year-old male with history of CHF, atrial fibrillation, ascending aortic aneurysm and mitral regurgitation who is admitted with dyspnea and failure to thrive. . The patient's daughter reports that the patient has been sick for "a while", particularly since he was admitted in [**2119-2-22**]. Since his discharge, he was improving and doing better at home until three days ago when he started declining rather rapidly. She reports that he has had shortness of breath, slurred speech and difficulty walking over the last three days. He has also been confused and falling asleep in his chair and falling out of the chair and from his bed. He has been refusing help, but unable to get up. She also reports that her father has had decreased grip strength and things have been falling out of his hands. As a result of his confusion, he has been eating less, though he has been very thirsty and is drinking a lot of fluids. There have been no fevers, chills, night sweats, cough, emesis, diarrhea. She also reports "difficulty with motor planning", as if he had trouble "putting one foot in front of the other". Interestingly, his mental status has been waxing and [**Doctor Last Name 688**]. Although he has been confused, he was able to have a completely coherent conversation with his sister yesterday. [**Name2 (NI) **] was recently on Coumadin but this was held secondary to fall risk. . In the ED, he was given 100mg of IV Lasix and ASA 325mg x 1. . Today, the patient states that his main concern is his shortness of breath. He has been feeling dyspneic over the last several days. Has a mild cough, non-productive. No chest pain or palpitations. Denies edema. Reports orthopnea but no PND. Past Medical History: 1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely overestimation with degree of MR 2. 3+ mitral regurgitation 3. Atrial fibrillation 4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable (pt. currently not interested in surgery) 5. DM2 6. Gout 7. Inflammatory Colitis (?)on chronic sulfasalazine. No prior surgeries or recent flares. 8. Hypertension 9. GERD 10. h/o Asbestosis 11. Recent B12 and Fe def. anemia Social History: Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a salesman. h/o asbestosis exposure when in the service (?shipyards). Family History: no Alzhemer's or Parkinson's Physical Exam: Vitals: T 98.7 BP 116/69 (104-136/49-69) HR 91 (87-101) RR 25 (25-38) 100% 4L General: restless in bed, no spontaneous eye opening, answers questions, follows some commands (aside from eye opening) HEENT: pupils small but reactive, dry mucous membranes Neck: no evidence of JVD Lung: rales at bilateral bases Cor: irregularly irregular, 3/6 systolic murmur loudest at apex Abd: NABS, soft, non-distended, reports some tenderness in RUQ Ext: warm, no edema, pneumoboots in place Neuro: oriented x 2 (hospital, name), follows some commands, somewhat restless Pertinent Results: Head CT ([**4-1**]): Moderate right subdural hemorrhage with associated subfalcine herniation. . CTA ([**4-1**]): New CHF with enlarging moderate/large bilateral pleural effusions with concomitant atelectasis. No evidence for pulmonary embolus . Head CT ([**4-2**]): No significant change from prior study with right-sided pleural hematoma and subfalcine herniation again seen. . EKG ([**4-2**]): very wavy baseline, largely uninterpretable secondary to motion, afib with HR 100s, no ST changes (but diff to interpret) . Renal US ([**4-2**]): No evidence of hydronephrosis or stones. . Echo ([**4-3**]): LVEF>55%. Significant aortic regurgitation is present, but cannot be quantified. The mitral valve leaflets are mildly thickened. At least, moderate (2+) mitral regurgitation is seen. . Head CT ([**4-3**]): Stable appearance of the right-sided subdural hematoma and stable to mildly improved subfalcine herniation . Abd US ([**4-4**]): No focal or textural hepatic abnormality is identified. Patent portal vein with hepatopetal flow. Mild splenomegaly. Small amount of ascites. . Head CT ([**4-4**]): Stable appearance of a large right subdural hematoma . CXR ([**4-5**]): Cardiomegaly, bilateral effusions, and borderline vascular congestion with little interval change . Head CT [**4-14**] evacuation of hematoma stable. . Head CT [**4-17**] hematoma stable. Brief Hospital Course: 1. altered mental status - He was admitted with subacute course of non-specific mental status changes and was found to have a chronic appearing with superimposed acute features subdural hemorrhage. He was followed by neurosurgery, who deferred evacuation on account of the stability of the SDH as well as his concomitant medical issues (liver failure, renal failure, UTI, CHF). . His mental status was poor with marked delirium, but remained stable. Serial head CTs demonstrated stable subdural hemorrhage. Pt was taken to the operating room on [**4-12**] for a right crani for evacuation of Subdural hematoma. [**Name (NI) **] pt was extubated and reintubated within 1 hr. Pt had aggressive pulm toilet and self extubated overnoc on [**5-2**]. Drain removed [**4-13**]. Pt currently doing well extubated. Staples to be dc'd [**4-21**]. . Patient transferred to Neurosurgery service on [**2119-4-12**] for subdural hematoma evacuation after become medically stable. His INR has been stable under 1.3. His mental status improved over the course of time, as his electrolytes, and coags improved. His initial INR went up as high as 1.8 which stayed around the same level until given factor VIIa on [**4-5**] then stayed around 1.2-1.3 range per recommendation of Hematology service. His creatinine improved greatly, his creatinine jumped up to 2.5, but now dropped down to 1.5 renal service has been following along. He is cleared by medicine team to be operated on his subdural hematoma. He had a left lower lobe pneumonia which is treated with Levo. He had a hypernatremia Na up to 157 on [**4-11**], eventually corrected with fluid. . He underwent right craniotomy on [**2119-4-12**] for evacuation of subdural hematoma and placement of subdural JP drain placement under general anesthesia without complications, he was able to extubated in [**Hospital **] transferred to PACU, however 2 hour later he required re-intubation secondary to hypoventilation. He is neurologically moving all extremities, opens his eyes to voice intermittently, squeezes to command. He placed on a beta-blocker [**Hospital **] for heart rate control, [**Hospital **] ECG remained unchanged, underlying rhythm being atrial fibrillation. His postoperative head CT([**4-12**]) is revealed residual small amount of hemorrhage mixed with fluid, pneumocephalus and postoperative changes. No further shift of normally midline structures. Repeat head CT on [**4-13**] remained stable, therefore his right subdural JP removed, patient tolerated procedure well. . Patient will need drain stitch and staples removed on [**4-21**]. If cant be done at nursing home will need to see Dr. [**Last Name (STitle) 739**]. Switched from dilantin to keppra. . 2. congestive heart failure - He was worked up for dyspnea and hypoxemia. Final etiology was clearly congestive heart failure. He had a repeat Echo which demonstrated preserved EF and some MR. [**Name13 (STitle) **] was maintained on a regimen of hydral/nitro, beta blocker, and cautious diuresis. He was maintained on oxygen by nasal canula. Patient sent out on lasix. . 3. Liver failure/coagulopathy - He had a self limited course of liver failure with associated coagulopathy. This was felt to be secondary to dilantin toxicity. Dilantin was stopped and his liver enzymes ultimately trended down toward normal. Alternative explanation could have been acute hepatic congestion from heart failure. . Re: coagulopathy, he was treated with vitamin K, FFP, and also proplex in acute setting. Thereafter, his INR trended down and he was given po vitamin K. Heme/onc involved in his care; agreed with hepatic synthetic dysfunction as etiology of coagulopathy. . 4. Acute on chronic renal failure - Likely pre-renal exacerbation of chronic kidney disease. Resolving toward baseline. . 5. Atrial fibrillation Continued rate control with bblocker. Held warfarin on account of coagulopathy and SDH. . 6. DM Held oral hypoglycemics; kept RISS. Patient has been having low blood sugars so sliding scale reduced. Patient will need frequent blood sugar. Medications on Admission: levothyroxine 25mcg daily allopurinol 150mg qOD Toprol XL 25mg daily tylenol 325mg q4-6h prn lasix 40mg daily ferrous gluconate 300mg [**Hospital1 **] combivent inh [**Hospital1 **] celexa 10mg daily glipizide 2.5mg daily lipitor ? dose Discharge Medications: 1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-26**] Puffs Inhalation Q6H (every 6 hours) as needed. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED): see insulin sliding scale. 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): hold for SBP < 100. 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary diagnoses: 1. Subdural hematoma s/p evacuation 2. Congestive heart failure 3. Pneumonia 4. Urinary Tract infection . Secondary diagnoses: 1. Mitral regurgitation 2. Atrial fibrillation 3. Diabetes Mellitus Discharge Condition: Stable Discharge Instructions: You are discharged to a Rehabilitation facility where you should continue all medications as prescribed. Please alert the physicians at the facility or contact your physician if you experience headache, visual changes, shortness of breath, chest pain, palpitations, or other concerns. You should be weighed every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: You will need a follow-up appointment with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3649**] in [**1-27**] weeks. Please call [**Telephone/Fax (1) 3070**] to make that appointment. You will need an appointment with Dr. [**Last Name (STitle) 739**] 4 weeks after your surgery with a head CT. Please call ([**Telephone/Fax (1) 11314**] to make that appointment. Right craniotmy drain stitch to be dc'd [**4-21**]; Craniotomy staples to be dc'd [**4-21**]. If pt in house this will be done by neurosurgery team; if in rehab they can be dc'd there, otherwise pt to return to Dr.[**Name (NI) 4674**] office to be dc'd. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

Admission Date: [**2190-6-30**] Discharge Date: [**2190-7-3**] Date of Birth: [**2109-12-3**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2698**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2190-6-30**] cardiac catheterization with bare metal stent placement to SVG-LAD/D1 graft History of Present Illness: 80 year old male with history of CAD s/p CABG (SVG->LAD-D1, SVG->OM RPLB), a-fib on coumadin, CVA presenting with new onset chest pain. Pain had been occuring since yesterday morning. Improved slightly with one SL NTG but was worse this am. He reports that the pain started when he was having a bowel movement, no associated SOB, N/V, or diaphoresis. This pain did not feel like when he had his prior stents or CABG--at those times he did not have chest pain at all. In the ED, initial vitals were Temp: 98.6 HR: 90 BP: 144/82 Resp: 18 O(2)Sat: 98 Normal. Labs and imaging significant for EKG with ST depressions in lateral leads. Cardiology was consulted and they recommended a heparin gtt and nitro gtt for ongoing chest pain. However, after about 1 hour, he was still having chest pain and a posterior lead ECG with 1 mm STE in V5, and 1/2 mm STE V4. Thus, he was taken to the cath lab. In the cath lab, he had deployment of a BMS to the SVG-LAD near the 1st diag. Also administered metoprolol 12.5 mg, aspirin 325 mg, and lisinopril 5 mg. On arrival to the floor, patient is chest pain free. No compliants. REVIEW OF SYSTEMS On review of systems, he denies any prior deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: + Hypertension 2. CARDIAC HISTORY: -CABG: [**2158**] -PERCUTANEOUS CORONARY INTERVENTIONS: [**2177**], [**2181**] 3. OTHER PAST MEDICAL HISTORY: - embolic stroke in [**2177**] after PCI c/b hemorrhagic conversion after receiving TPA - psoriasis - hypothyroid - afib Social History: Retired, lives with his wife. [**Name (NI) **] is a doctor [**First Name (Titles) **] [**Last Name (Titles) 2025**]. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. His son does have CAD and is s/p MI with stent placement in his 50s. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T=afebrile, BP 154/85, HR 45, RR 10, O2 sat 97% 2LNC GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 5 cm. CARDIAC: IRRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. Right groin with dressing c/d/i, no ecchymoses. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ radial 2+ Left: DP 2+ radial 2+ . DISCHARGE PHYSICAL EXAM: VS: Tm 98.0 Tc 97.3 BP 114-129/63-76 HR 51-97 RR 18 GENERAL: WDWN M in NAD. Mood, affect appropriate. HEENT: MMM, OP clear NECK: Supple without appreciable JVD sitting up at 60 degrees. CARDIAC: Irregularly irregular rhythm, normal S1, S2. No m/r/g LUNGS:Nonlabored, CTAB. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Holds left arm in contracture. Left leg in brace with decreased strength SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: ADMISSION LABS: [**2190-6-30**] 08:20AM BLOOD WBC-4.9 RBC-4.46* Hgb-13.5* Hct-42.2 MCV-95 MCH-30.4 MCHC-32.1 RDW-15.0 Plt Ct-191 [**2190-6-30**] 08:20AM BLOOD Neuts-56.9 Lymphs-30.9 Monos-3.7 Eos-7.7* Baso-0.9 [**2190-6-30**] 08:20AM BLOOD PT-19.5* PTT-37.8* INR(PT)-1.8* [**2190-6-30**] 08:20AM BLOOD Glucose-104* UreaN-9 Creat-0.9 Na-142 K-4.6 Cl-108 HCO3-25 AnGap-14 [**2190-6-30**] 08:20AM BLOOD CK(CPK)-76 [**2190-6-30**] 08:20AM BLOOD CK-MB-4 [**2190-6-30**] 08:20AM BLOOD cTropnT-0.03* [**2190-6-30**] 08:20AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.1 . CXR [**2190-6-30**]: AP AND LATERAL VIEWS OF THE CHEST: Patchy left mid lung lower opacities are best seen on the frontal view. Heart size is top normal, slightly enlarged from [**2182**]. There is no pleural effusion or pneumothorax. Sternotomy wires and CABG clips are again noted. Small bowel appears minimally distended. Hypodensities overlying the area of the gallbladder may represent cholelithiasis. IMPRESSION: 1. Patchy mid left lung lower opacities could be pneumonia in the correct clinical setting, otherwise, may represent atelectasis. 2. Cholelithiasis. 3. Slight small bowel distension. . CATH [**2190-6-30**]: PRELIMINARY REPORT - diffuse instent restenosis < 50% to LCX - LAD: proximally occluded - Lcx: no significant disease - RCA: known occluded - SVG-ramus-OM: normal, provides collaterals to LAD - SVGY to LAD and D1: proximally thrombotic occlusion, stent placed . TTE [**2190-7-1**]: LEFT ATRIUM: Dilated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV systolic dysfunction. Doppler parameters are indeterminate for LV diastolic function. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. Normal aortic arch diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild to moderate ([**2-1**]+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate [[**2-1**]+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: Conclusions The left atrium is dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal anterior wall, anteroseptum and of the apex. The distal inferior wall is probably mildly hypokinetic also. Right ventricular chamber size and free wall motion are normal. The ascending aorta 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. There is no mitral valve prolapse. Mild to moderate ([**2-1**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Regional left ventricular systolic dysfunction consistent with CAD (distal LAD distribution). Mild aortic regurgitation. Mild to moderate MITRAL REGURGITATION. Brief Hospital Course: PRINCIPLEREASON FOR ADMISSION Mr. [**Known lastname **] is an 80 year old male with history of coronary artery disease (CAD) status post CABG and PCI who presented with chest pain x 24 hours with EKG showing ST depressions in V3-V4 and posterior EKG with [**Street Address(2) 4793**] elevations. He underwent stenting with bare metal stent (BMS) to SVG/LAD-D1 with resolution of his chest pain. . # non-ST elevation Myocardial infarction: His posterior leads showed ST elevations and he was taken to the cath lab with successful deployment of bare metal stent (BMS) to SVG/LAD-D1 via access in his right groin. He was monitored in CCU overnight and has been chest pain free since intervention. He had a transthoracic echo post-MI which showed apical hypokinesis in the LAD territory but preserve ejection fraction at 45-50% and no diastolic dysfunction. He was started on plavix 75 mg daily and his atorvastatin was increased from 20 mg daily to 80 mg daily. Lastly, his atenolol was converted to metoprolol in house and the dose was decreased to metoprolol succinate 12.5 mg daily due to pauses on higher doses. His discharge regimen was: ASA 325 mg daily, Plavix 75 daily, Metoprolol succinate 12.5 mg daily, Atorvastatin 80 mg daily, lisinopril 5 mg daily. # Atrial fibrillation (afib): Patient has afib and is on warfarin and atenolol at baseline. On admission he was subtherapeutic at 1.8 so he was bridged with heparin drip while his warfarin was restarted at home dosing 1 mg daily. On discharge, his INR was 2.5. He will have INR draw qweekly and followed by PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**]. For rate control, his atenolol was changed to metoprolol. He was having several second pauses so the dose was down titrated to metoprolol succinate 12.5 mg daily. Metoprolol was held day prior to discharge due to pauses and transient hypotension, which was fluid responsive, but was restarted when he was noted to increase his HR asymptomatically to 140's with exertion. # Hypertension: The patient's BP was stable during his admission although slightly elevated at 150s early in his stay. He did develop transient asymptomatic hypotension day prior to admission which was fluid responsive. His goal BP is <140/80. He was continued on lisinopril 5 mg daily. Metoprolol was dosed as above. By discharge his blood pressures were well controlled. CHRONIC ISSUES: # History of embolic stroke with hemorrhagic conversion: His afib was managed as above to prevent further strokes. He was also continued on keppra 500 mg daily for seizure prophylaxis. He was seen by physical therapy for his left hemiparesis and contractures and they felt that he was well compensated to go home. # Hypothyroid: continued home levothyroxine 75 mcg daily. # Psoriasis: continued clobetasol and desonide creams. . TRANSITIONAL ISSUES: - Please monitor his INR weekly and adjust the dose of warfarin as needed - Please continue to monitor systolic blood pressures Medications on Admission: warfarin 1 mg daily lisinopril 2.5 mg qam ASA 81 mg qam atorvastatin 20 mg qpm keppra 500 mg qpm atenolol 25 mg qpm levothyroxine 75 mcg qam clobetasol oint [**Hospital1 **] dovonex desonide cream [**Hospital1 **] Discharge Medications: 1. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 2. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 tablets* Refills:*0* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. aspirin 81 mg Tablet, Effervescent Sig: One (1) Tablet, Effervescent PO once a day. 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 (one half) Tablet Extended Release 24 hr PO once a day. Disp:*15 Tablet Extended Release 24 hr(s)* Refills:*2* 10. Dovonex Topical 11. desonide Topical Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: PRIMARY DIAGNOSIS non-ST elevation myocardial infarction hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you while you were here at [**Hospital1 18**]. You were admitted to the hospital because you had chest pain. Your EKG showed some changes in the electrical pattern of your heart, which indicated an impaired blood flow. Thus, you underwent a procedure called cardiac catheterization to place a stent in your heart and open up the blood flow. Your stent was placed in the bypass graft leading to your LAD artery. After the procedure you did well and your chest pain resolved. The following changes were made to your medications: Medications started: 1. Plavix (blood thinner since you have the stent in your artery) 2. Metoprolol succinate (Toprol XL) [**2-1**] a 25mg tablet daily (total 12.5mg) Medications changed: 1. Atorvastatin- increased from 20mg a day to 80mg a day Medications stopped: 1. Atenolol (blood pressure medicine similar to metoprolol) **Continue taking your baby aspirin (81mg) by mouth once a day** Follow-up needed for: 1. INR - Make sure to have your INR checked the morning of your doctors [**Name5 (PTitle) 648**] with Dr [**Last Name (STitle) 3357**] next week. It is also very important that you keep the follow-up appointments listed below. You should bring your medications to each [**Last Name (STitle) 648**] so your doctors [**Name5 (PTitle) **] update their records and adjust the doses as needed. It was a pleasure taking care of you in the hospital! Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] L. Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**] Phone: [**Telephone/Fax (1) 4606**] [**Telephone/Fax (1) **]: Friday [**2190-7-9**] 11:45am

Admission Date: [**2183-3-6**] Discharge Date: [**2183-3-21**] Date of Birth: [**2120-12-29**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 425**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation and extubation Hemodialysis catheter line placed cardiac catheterization with two bare metal stents to the left circumflex artery and the left [**Doctor Last Name **] artery. History of Present Illness: Please see nightfloat admission note for full details of admission history. In brief, this is a 62yoM with CAD s/p CABG [**11/2182**], dCHF, ESRD (on HD [**12/2182**] - [**2-6**]), history of DVT & PE on Coumadin who presented [**3-6**] with AMS and acute on chronic kidney injury. . Of note, the patient was recently admitted [**Date range (1) 91915**] for melena from duodenal ulcer from migration of a metal biliary tract stent that was exchanged for a new stent. His course was complicated by septic pancreatic stent, micro bowel perforation, citrobacter bacteremia, as well as hypoxia from volume overload. He was ultimately discharged to rehab. Two weeks ago, the patient developed abdominal pain for two weeks and began having nausea/vomiting on Monday. He was to have the biliary stent changed [**2183-3-3**] but missed his appointment due to excessive vomiting. . On [**3-5**], the patient went to the bathroom and had an unwitnessed fall for unclear reasons. The patient reports he slipped and fell. Since the fall, the patient had altered mental status and presented to an OSH with a negative CT head and neck. He was given vancomycin and zosyn at transferred to the [**Hospital1 18**] ED, where he was 99% NC. Repeat CT head and neck was negative, and abdominal CT showed no migration of the biliary stent. CXR showed pulmonary edema but not significantly different from prior, and trop 0.19, previously 0.26. K was 5.9 without EKG changes. Cr was 3.9 from 2.5. He remained afebrile. On transfer to the medicine floor, the patient had HR 101 with 92%3L. He was delirious and oriented x1 with myoclonic jerks but was redirectable. . The morning of transfer to the MICU, the patient became tachycardic and became hypoxic. He was transferred to the MICU for further management. . On arrival to the MICU, the patient was breathing comfortably on 4L NC and denied shortness of breath, chest pain, nausea, or other symptoms. However, he was delirious and oriented x1. Past Medical History: DMII complicated by neuropathy, nephropathy CKD on HD briefly [**12/2182**] CAD s/p CAB on [**11/2182**] at [**Hospital1 2177**] - 1 vessel -- Diffuse multi-vessel disease. LIMA-LAD [**11/2182**] but other vessels were not amenable to intervention ?COPD on 2L NC Hypothyroidism DVT in [**5-/2182**] has been on Coumadin PE ? Seizure Renal mass Right adrenal mass Cholecystectomy Left femur fracture Left humeral fracture [**2-27**] fall Depression Chronic pancreatitis s/p biliary tract metal stenting Pancrectomy in [**2176**] for necrosis PVD with angioplasty PVD s/p femoral popliteal artery PTA Pericarditis C. diff colitis [**12/2182**] on po Vanco s/p rotator cuff repair in [**2169**] s/p carotid endarterectomy Laminectomy c-spine Cholecystectomy Tonsillectomy Social History: Currently living in rehab. He has two daughters who are involved in his care - [**Female First Name (un) **] and [**Doctor First Name 3095**]. - Tobacco: quit 11 months prior - Alcohol: denies - Illicits: denies Family History: Unable to answer due to altered mental status Physical Exam: PHYSICAL EXAM: T 97.8 HR 111 BP 145/94 RR 18 SaO2 100% on 100% NRB GENERAL - Alert and interactive but oriented x1 HEENT - Dry mucous membranes, sclera anicteric NECK - Supple LUNGS - Coarse inspiratory crackes at bases b/l, no wheezes or rhonchi HEART - Tachycardic but normal rhythm, nl S1/S2, no m/g/r ABDOMEN - Soft, non-tender, non-distended, +BS EXTREMITIES - No pedal edema NEURO - Oriented to self, able to follow commands, moving all extremities. Pertinent Results: Admission Labs: [**2183-3-5**] 10:50PM BLOOD WBC-11.0 RBC-3.29* Hgb-9.8* Hct-30.0* MCV-91 MCH-29.7 MCHC-32.7 RDW-14.9 Plt Ct-173 [**2183-3-5**] 10:50PM BLOOD Neuts-79.2* Lymphs-10.8* Monos-3.0 Eos-6.7* Baso-0.4 [**2183-3-5**] 10:50PM BLOOD Plt Ct-173 [**2183-3-5**] 11:12PM BLOOD PT-32.3* PTT-48.2* INR(PT)-3.1* [**2183-3-7**] 09:30PM BLOOD FDP-10-40* [**2183-3-5**] 10:50PM BLOOD Glucose-119* UreaN-75* Creat-3.9*# Na-137 K-5.9* Cl-102 HCO3-22 AnGap-19 [**2183-3-5**] 10:50PM BLOOD ALT-12 AST-22 CK(CPK)-63 AlkPhos-126 TotBili-0.5 [**2183-3-5**] 10:50PM BLOOD cTropnT-0.19* [**2183-3-6**] 07:31AM BLOOD CK-MB-6 cTropnT-0.17* proBNP->[**Numeric Identifier **] [**2183-3-6**] 07:31AM BLOOD Calcium-8.7 Phos-5.5* Mg-1.3* [**2183-3-7**] 09:30PM BLOOD Hapto-260* [**2183-3-5**] 10:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2183-3-5**] 10:50PM BLOOD HoldBLu-HOLD [**2183-3-6**] 07:22AM BLOOD Type-ART pO2-98 pCO2-37 pH-7.31* calTCO2-20* Base XS--6 [**2183-3-5**] 11:05PM BLOOD Lactate-1.0 MICRO: [**2183-3-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-NEGATIVE [**2183-3-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL POSITIVE [**2183-3-15**] BLOOD CULTURE Blood Culture, Routine-NEGATIVE [**2183-3-15**] BLOOD CULTURE Blood Culture, Routine-NEGATIVE [**2183-3-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-NEG [**2183-3-12**] BLOOD CULTURE Blood Culture, Routine-NEGATIVE [**2183-3-12**] BLOOD CULTURE Blood Culture, Routine-NEGATIVE [**2183-3-12**] URINE URINE CULTURE-NEGATIVE [**2183-3-6**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-NEGATIVE [**2183-3-6**] URINE URINE CULTURE-NEGATIVE [**2183-3-6**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} INPATIENT [**2183-3-5**] BLOOD CULTURE Blood Culture, Routine-NEGATIVE Imaging: Echo: The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with inferior/inferolateral akinesis and lateral hypokinesis. The remaining segments contract normally (LVEF = 35-40%). 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 valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate to severe (3+) mitral regurgitation is seen, stemming from a posterior mitral leaflet being tethered to the akinetic inferolateral LV wall. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD. Moderate to severe ischemic mitral regurgitation. At least moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2183-2-12**], left ventircular cavity has further dilated, LV function has deteriorated and amount of mitral regurgitation has increased. The regional distribution of wall motion abnormalities is quite similar. Findings discussed with Dr. [**Last Name (STitle) **] at 1600 hours on the day of the study. [**2183-3-6**] Radiology CT ABD & PELVIS W/O CON [**Last Name (LF) 10902**],[**First Name3 (LF) **] Approved 1. Unchanged location of biliary stent. 2. Right lower lung consolidation may represent aspiration, pneumonia, or worsening atelectasis. 3. Within the limits of a non-contrast study, no acute intra-abdominal process. Bilateral adrenal and left renal nodules as described above. Consider non-emergent followup. [**2183-3-10**] Cardiovascular C.CATH [**2183-3-10**] [**Last Name (LF) **],[**First Name3 (LF) **] M. Preliminary 1. Limited selective coronary angiography of this right dominant system revealed three vessel coronary artery disease. The LMCA had a 50% ostial lesion and calcified distal 50% lesion. The LAD was heavily calcified and diffusely diseased with 80% ostial lesion; there was competative flow in the distal LAD indicating patent LIMA. The single diagonal arises from the proximal vessel and has 80% ostial lesion. The Lcx was severely and diffusely diseased; it had a retroflexed takeoff with 80% long segment from the ostium onward followed by ectatic segment, then another 60% lesion; the LCx supplies three OM's, the first is very proximal originating from the diseased segment and is substantive bifurcating with two branches supplying lateral wall. Collaterals to rca seen on prior cath are no longer as apparent. The RCA was not engaged and known to be chronically occluded from OSH films. 2. Limited resting hemodynamics showed severe systemic hypertension with central pressure of 184/91/131 mmHg on nitroglycerin IV gtt. 3. Successful PTCA and stenting of proximal LM into LCx with 2.5x26mm Integrity bare metal stent, postdilated with 3.5mm Nc Balloon. STent placement complicated by spiral dissection in distal Lcx. Final angiography showed dissection and TIMI 2 flow. 4. Successful PTCA and stenting of LMCA with 4.0x15mm INtegrity bare metal stent. 5. Unsuccessful attempt to stent distal spiral dissection as unable to deliver stents into LCx. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe systemic hypertension. 3. Successful PCI of proximal LCx with BMS, complicated by edge spiral dissection. 4. Successful PCI of LMCA with BMS. 5. Unsuccessful attempt to stent dissection. 6. Continue heparin and Reopro. 7. Continue aspirin and plavix. [**2183-3-10**] Cardiovascular ECHO [**2183-3-10**] [**Last Name (LF) **],[**First Name3 (LF) **] Finalized The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) with global hypokinesis and akinesis of the infero-lateral segments. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but cannot be quantified. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2183-3-10**], LVEF has decreased. [**2183-3-16**] Radiology SHOULDER 1 VIEW LEFT PO [**Last Name (LF) **],[**First Name3 (LF) **] M. \ HISTORY: Old left fracture with persistent pain. FINDINGS: In comparison with study of [**2-3**], there is progressive healing of the left proximal humeral fracture. Evidence of prior rotator cuff repair with mild widening of the AC joint. [**2183-3-6**] Radiology CT HEAD W/O CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] Approved IMPRESSION: No intracranial hemorrhage or fracture. [**2183-3-6**] Radiology CT C-SPINE W/O CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] Approved IMPRESSION: No fracture or malalignment with normal prevertebral soft tissue thickness. Brief Hospital Course: 62yoM with CAD s/p CABG [**11/2182**], dCHF, ESRD (on HD [**12/2182**] - [**2-6**]), history of DVT & PE on Coumadin admitted s/p fall with worsening respiratory distress in the setting of ARF and new ischemic MR, who is now s/p stenting to LAD and LCx c/b spiral dissection of LDx and recurrent MI, and who now has worsening renal failure requiring initiation of HD. . # ISCHEMIC MR/CAD: patient became acutely tachycardic and hypoxic on the floor, with flash pulmonary edema. He was monitored in the MICU after this event. The patient's wife reports she was in the room at the time of the event and the patient was resting in bed without any triggers for his tachycardia or dyspnea. He was given diuretics and improved. Another episode occured several hours later. He had an echocardiogram that showed ischemic MR affecting the posterior mitral leaflet and worsening LV function. Cardiology was consulted and requested transfer to the CCU for further intervention. Patient was electively intubated in preparation for possible cardiac cath. Prior CABG records from [**Hospital1 2177**] revealed that pt has completely occluded RCA and significant disease of collaterals perfusing the posterior wall. It was decided to perform cardiac cath to determine whether pt having intermittent occlusion of coronary artery (e.g. RCA) causing posterior leaflet dysfunction and posterior wall dysfunction. Prior to cath, MR [**First Name (Titles) **] [**Last Name (Titles) 91916**] managed with afterload reduction and goal CVP~8. On [**3-10**] pt had viability study and then underwent cardiac cath, with stents placed to LMCA and LCx. Procedure c/b spiral dissection inside the LCx stent. Several balloon angioplasties were performed at dissection site without success, but as interim angiography showed reasonable flow in dissected LCx attempts were aborted and it was decided not to repeat cath as risks outweigh benefits. MB peaked to 49 and troponin to 0.77 after the dissection. After this, pt went into acute pulmonary edema several more times (see below), in the setting of becoming progressively more oliguric and volume overloaded. Repeat TTE showed [**Month/Year (2) 28495**] EF to 20% and basilar hypokinesis. Pulmonary edema improved greatly once pt started CVVH with significant fluid ultrafiltration. Mitral valve replacement was considered, but per patient and family preference this was ultimately not pursued. Given EF 20% and basilar hypokinesis, patient was anticoagulated with heparin gtt (goal PTT 60-80) to decrease risk of apical thrombus. He also received Plavix 75mg PO daily, ASA 81mg PO daily, atorvastatin 80mg PO daily and metoprolol 12.5mg PO BID. Hydralazine and isosorbide mononitrate were also started for afterload reduction (pt was also intermittently on nitro gtt and esmolol gtt for refractory HTN before starting CVVH). Lisinopril was initiated on [**3-18**] after CVVH was initiated. . #.ACUTE ON CHRONIC RENAL FAILURE: patient has h/o stage IV CKD and required HD during prior hospitalization, at the end of which Cr was 2.9. On admission Cr had risen to 3.9, and pt was acutely hyperkalemic with anion gap acidosis. Etiology of worsening renal failure most likely poor forward flow [**2-27**] new severe ischemic MR [**First Name (Titles) 39849**] [**Last Name (Titles) 28495**] cardiac output. Patient also had peripheral eosinophilia on admission, making AIN or cholesterol embolus as possible etiology. Renal U/S showed good flow to both kidneys with no e/o thrombolembolic events. Patient was making urine up to the point of cardiac catheterization. Despite pre- and post-hydration with HCO3, and Lasix during cath, his creatinine rose significantly in the 48 hours following cath and he became severely oliguric. He had several episodes of flash pulmonary edema at this time with suboptimal response to Lasix, morphine, nitrates and afterload reduction. Due to these changes he required initiation of CVVH on [**3-12**], with large ultrafiltrate removal daily and temporary line was placed by Interventional Radiology. His volume status subsequently improved greatly, with improved BPs and resolution of pulmonary edema on CXR. As patient had now progressed to stage V CKD, decision was made to initiate hemodialysis. Tunnelled line was placed on [**2183-3-18**]. . # Leukocytosis likely secondary to c diff colitis: - initial DDx included infectious versus reactive versus allergic given eosinophilia. No new medications, but initially considered allergic interstitial nephritis in context ARF, eosinophilia and urinary eosinophils. Initially, Mr. [**Known lastname 28221**] was treated for VAP starting [**3-15**] with Vanc/Zosyn/levaquin. C diff stool assay was positive, and PO vancomycin was started. After Mr. [**Known lastname 91917**] cardiogenic pulmonary edema resolved, there were no further pulmonary infiltrates and VAP therapy was stopped. Furthermore, Mr. [**Initials (NamePattern4) 91917**] [**Last Name (NamePattern4) 91918**] and decrease in WBC coincided with PO vanc therapy for c diff. Oral vancomycin was started on [**3-16**] and will be continued until [**3-31**] for a planned 14 day course. # AMS: The patient had been delirious with leukocytosis and was worked up for potential infectious cause of AMS. CT head following his fall showed no ICH. There were reportedly no new medication changes. BUN 70s near baseline and not high enough to cause uremia typically. Renal also felt the patient was not likely to have uremic encephalitis. Neurology was curbsided overnight and recommended r/o infection, seizure (given history), toxic metabolic syndrome. Given the patient's recent abdominal pain, n/v, initial consideration was given to a gastrointestinal cause but GI felt this to be unlikely. After discontinuation of benzodiazepines and initiation of HD, Mr. [**Known lastname 91917**] mental status began to clear tremendously. He was Alert and oriented x 3 upon discharge. # Pain control: During this admission, Mr. [**Known lastname 28221**] complained of worsening of his baseline back/abdominal and flank pain. Due to exquisite pain, a left shoulder X ray was obtained on [**3-16**] which demonstrated a healing proximal humerus fracture. Pain control improved with starting long acting oxycodone. According to his outpatient pain specialist he took a total of 240 of oxycodone at home (including long and short acting medications) in addition to 30mg morphine (long acting mscontin) at night. Given his new onset renal failure, we decided to go slow on the morphine, but at patient's insistence we started PRN IV morphine for breakthrough pain. . # Biliary stent: Mr. [**Known lastname 28221**] is status post stenting of the biliary duct. CT Abdomen this admission demonstrated stability of the placement. He should follow up with ERCP for follow up for this stent as an outpatient. . # Depression: Continued home duloxetine at 40mg initially. Due to concerns for worsening mood, a psych consult was obtained. They recommended 60mg daily, avoidance of benzodiazepines given profound altered mental status in the peri-extubation setting, use of trazodone for sleep (with caution for orthostatic hypotension), and recommended referral for an outpatient therapist. . # History of DVT/PE: Mr. [**Known lastname 28221**] suffered a provoked perioperative DVT/PE 6 months prior to admission, and was on warfarin for this indication. He was continued on anticoagulation for low-EF and concern for apical hypokinesis and LV thrombus. . Transitional Issues: - needs TSH/LFTs rechecked 6 weeks after discharge as adjustments have been made to levoxyl while inpatient and his statin was increased. - Mr. [**Known lastname 28221**] will need to follow up in psych as an outpatient following discharge from rehab for evaluation and management of his chronic depression and anxiety. - Mr. [**Known lastname 28221**] will need to follow up with ERCP at [**Hospital1 18**] for follow up of stent placement and possible removal upon discharge from rehab - See other f/u appts Medications on Admission: Furosemide 120 mg [**Hospital1 **] - Furosemide 160 mg daily prn shortness of breath or wheezing - Diltiazem 30 mg tid - Duloxetine 40 mg daily - Labetalol 200 mg [**Hospital1 **] - Levothyroxine 25 mcg daily - Simvastatin 40 mg qhs - Aspirin 81 mg daily - Insulin Lispro sliding scale tid FBS: 100-150=2U 151-200=4U 201-250=6U 251-300=8U 301-350=10U - NPH 12 units SC bid - Warfarin 3 mg daily - Lidocaine 5% patch daily - Ativan 1 mg po q6h prn anxiety - Morphine 30 mg ER q12h - Hydromorphine 8 mg q4h prn pain - Niacin 500 mg [**Hospital1 **] - Zofran 8 mg q8h prn nausea - Pantoprazole 40 mg [**Hospital1 **] - Sevelamer 800 mg tid - B complex-vitamin C-folic acid 1 mg daily - Camphor-menthol 0.5-0.5 % Lotion qid prn itching - Trazodone 50 mg qhs prn - Acetaminophen 325-650 mg po q6h prn - Polyvinyl alcohol-povidone 1.4-0.6 % [**1-27**] Eye Drops PRN dry eyes - Prochlorperazine 10 mg q6h 30 minutes prior to meals - Miconazole 2 % [**Hospital1 **] prn - Epoetin alfa 10,000 unit/mL injection qweek - Cholecalciferol (vitamin D3) 800 units daily - Calcium carbonate 500 mg tid - Sodium polystyrene sulfonate 15 g/60 mL Suspension: 30 g PO bid prn K > 5.5 Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day): with meals. 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): continue for at least one month. 9. heparin (porcine) 1,000 unit/mL Solution Sig: 4,000-11,000 units Injection PRN (as needed) as needed for line flush. 10. sodium citrate 4 % (3 mL) Syringe Sig: 1.2-1.4 ml Miscellaneous ASDIR (AS DIRECTED): Dialysis catheter. 11. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days: last day [**2183-3-30**]. 13. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 15. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-27**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 17. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Check INR on [**3-22**] and titrate warfarin to INR 2.0-3.0. 18. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 19. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day: before breakfast. 20. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for back pain. 21. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Three (3) Tablet Extended Release 12 hr PO Q12H (every 12 hours): pts dose at home was 240 mg daily (oxycodone PO). 22. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 23. heparin (porcine) in NS 2,500 unit/500 mL (5 unit/mL) Parenteral Solution Sig: 0-[**2171**] units Intravenous continuous: See weight based protocol attached. 24. Morphine Sulfate 2 mg IV Q4H:PRN pain Hold for somnulance or RR< 12 25. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 17921**] Center NH/RMU Discharge Diagnosis: Acute kidney failure requiring dialysis Non ST Elevation myocardial infarction Diabetes Hypertension Dyslipidemia C-difficile Chronic pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you during your hospitalization at [**Hospital1 18**]. You had a heart attack and received 2 bare metal stents to blocked arteries in your heart. You will need to take Plavix every day for at least one month and possibly longer. Do not stop taking plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] (at [**Hospital1 18**]) tells you it is OK. Your heart is weaker after the heart attack and you have been started on medicines to help the heart pump better and to prevent blood clots from forming in your heart. For your heart failure diagnosis: Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 3 day or 5 lbs in 2 days, follow a low salt diet and restrict your fluidsto 1500 ml/ day or about 6 cups. After the cardiac catheterization, your kidneys stopped working and you were started on dialysis. You will likely need dialysis for a long time and will need to have permanant access placed in your arm to get the dialysis. You will have a kidney doctor at your new dialysis center. You have an infection in your bowel called c difficile again and are on vancomycin to treat this. . We made the following changes to your medicines: 1. STOP taking lasix, diltiazem, labetolol, compazine, zofran, miconazole, kayexelate 2.Increase Duloxetine to 60mg daily 3. Increase levothyroxine to 50 mcg as your TSH was low. You will need to check another TSH in 6 weeks. 4. Change simvastatin to atorvastastin to lower your cholesterol after your heart attack 5. Change NPH to glargine insulin to be taken before breakfast, continue the humalog sliding scale according to blood sugars before meals and at bedtime. 6. Increase warfarin to 5mg daily 7. STOP taking Ativan 8. Cont Epoetin per your nephrologists 9. STOP pantoprazole, take famotidine instead 10. Stop morphine pills, take oxycontin instead to treat your pain. You are on [**1-27**] your normal dose and will increase slowly. 11. Take morphine intravenously as needed for severe pain 12. Increase trazadone to 100 mg at HS, decrease this medicine once pain control is better. . *please continue to not smoke. quitting smoking is the best thing you can do for your health. Followup Instructions: Dr. [**Last Name (STitle) **] [**Name (STitle) 5279**] Cardiovascular Consultants A Department Of [**Hospital 5279**] Hospital 1 [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **], [**Apartment Address(1) **], [**Location (un) 5450**], [**Numeric Identifier 85099**] Phone: ([**Telephone/Fax (1) 84379**] Fax: ([**Telephone/Fax (1) 91919**] Date/Time: [**4-1**] at 11:00am . Primary care: Please make an appt with [**Last Name (un) 18908**] family medicine [**Telephone/Fax (1) 91920**] when pt is leaving rehab. Please stress to pt and family the importance of keeping all physician [**Name9 (PRE) 32723**] to prevent rehospitalization. . Pain Clinic: Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Address: 1 MOUND COURT, [**Location (un) **],[**Numeric Identifier 91921**] Phone: [**Telephone/Fax (1) 91922**] Fax: [**Telephone/Fax (1) 91923**] Monday [**3-31**] at 11:15 AM . Gastroenterology: [**Last Name (LF) **],[**First Name3 (LF) **] B. [**Hospital Unit Name **], [**Location (un) **] [**Doctor First Name **] [**Location (un) 86**] [**Numeric Identifier 718**] Phone:([**Telephone/Fax (1) 2306**] Fax:([**Telephone/Fax (1) 23366**] Completed by:[**2183-3-22**]

Admission Date: [**2128-7-14**] Discharge Date: [**2128-7-19**] Date of Birth: [**2046-11-11**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2836**] Chief Complaint: basic trauma for MVC Major Surgical or Invasive Procedure: [**2128-7-16**]- ORIF left femur fracture History of Present Illness: This patient is a 81 year old male with a history of atrial fibrillation (on coumadin) and hypertension who was transferred from [**Hospital 11560**] [**Hospital3 **] with a distal left femur fracture involving his previous total knee replacement. He was an unrestrained driver going approximately 30 MPH when he had a left headlight to left headlight MVC with moderate vehicle damage. He was brought to [**Hospital 11560**] [**Hospital3 **] complaining only of left knee pain. He had a head and C-spine CT which were negative. He had a distal left femur fracture. His INR was 1.7. His systolic blood pressure varied at the OSH, but remained in the 80s prior to transfer. En route, his systolic blood pressure dropped to the 70s. He received 50 of fentanyl and 4 of morphine prior to transfer, and currently complains only of left knee pain. He did not have an abdominal CT scan prior to transfer to [**Hospital1 18**]. Past Medical History: - Afib on Coumadin - previous back injury - HYPERthyroidism - s/p L TKA Social History: lives alone in [**Location (un) 3844**] during the week and works as a private carpenter and handyman; goes to stay w/dtr and her family on weekends in [**Location (un) 1475**], MA Family History: non-contributory Physical Exam: Discharge Physcial Exam: VS: 98.3 109 116/66 19 997%4L Gen: alert, occasionally confused but easily orients. NAD CV: RRR Pulm: Easy WOB CTAB Abd: Soft NT ND Ext: LLE in ACE and knee immobilizer, DP palp bilat Pertinent Results: [**7-14**] CT abd/pelvis IMPRESSION: 1. Multilevel bilateral rib fractures without pneumothorax. These include at least right anterior second through fifth ribs and left posterior third through fifth ribs. Probable small right upper lung pulmonary contusion. 2. No solid organ injury. 3. Angulated mildly impacted left basicervical femoral fracture. 4. 2.3-cm right thyroid nodule/cyst, to be further assessed by ultrasound. 5. Chronic interstitial changes in the right lung and mild bronchiectasis. Bilateral nodular opacities including a 12-mm nodular opacity in the left upper lobe (2, 32), which could be correlated with prior CT and if needed, follow up in six months to one year is recommended. 6. Trace right pleural effusion. 7. Hypodensities in the liver, spleen, kidneys, most of which too small to fully characterize. 8. Subcentimeter hyperdense lesion in the left hepatic lobe (2, 72), which could represent a small flash-filling hemangioma. 9. Ectatic ascending aorta to 4.5 cm without frank aneurysm. Diffuse atherosclerotic disease. No acute vascular injury. Brief Hospital Course: Mr. [**Known lastname 112367**] was initially admitted to the trauma ICU for neurological checks given concern for delayed head bleed. He remained in the ICU throughout his course, which is summarized by systems below. In brief, he was taken to the OR for ORIF of the left femur fracture; did well postoperatively, and is discharged to rehab on HD 6. Neuro: He did have some episodes of ICU delirium which were managed with PRN haldol and seroqeul. Otherwise pain was well controlled with IV medication that was transitioned to orals as he began to tolerate PO. His confusion improved during the day and with reorientation by family. CV: He was initially hypotensive to the 60's in the ED; hypotension responsed to IVF initially, and then 2u pRBC. He had a bedside echo and was started on a phenylephrine drip. He is on coumadin at baseline for afib; this was held for concern for head bleed. His INR was reversed with 3u FFP on [**7-15**] in anticipation of going to the OR for repair of his femur fracture. He did require pressors immediately postop but these were weaned off on POD1 and at time of discharge he is cardiovascuarly stable. Pulm: He was intubated to go to the operating room for his femur fracture and remained intubated overnight. He also had a bronchoscopy during the OR procedure. He was diuresed postoperatively with albumin and lasix drip. The lasix drip was transitioned to intermittent lasix and his respiratory status improved; he was weaned to room air and remained stable. GI: He was kept NPO until he went to the operating room. Postoperatively diet was advanced and he tolerated well with no issues. GU: A foley catheter was placed in the ED and remained in place until POD2; at this time it was discontinued and he voided without difficulty. Heme: Pt recieved 2u pRBC upon admission. INR was elevated due to home coumadin; 3u FFP to reverse prior to OR. Postop his Hct decreased to 21 and he recieved 2u pRBC; his Hct bumped appropriately to 26 and remained stable throughout the remainder of his course. Coumadin was restarted on [**2128-7-18**]. MSK: Injuries included bilateral rib fractures (L ribs [**12-25**] and R ribs [**2-24**]) and fracture of the left femur. Ortho was consulted in the ED and followed throughout the patient's course. He was taken to the OR with ortho for ORIF of the femur fracture on [**7-16**]; for full details please see the dictated operative report. At discharge he is non-weight bearing on the left lower extremity with an unlocked [**Doctor Last Name **] brace. Physical therapy did see him inpt and recommended rehab. Medications on Admission: Methimazole 2.5mg PO q48 Coumadin 5mg PO daily Sotalol 80mg PO AM Sotalol 40mg PO QPM Digoxin 0.25mg PO daily Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN fever/pain 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Digoxin 0.25 mg PO DAILY Please draw digoxin level before 2nd dose 4. Docusate Sodium 100 mg PO BID 5. Methimazole 2.5 mg PO Q48H 6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain 7. Senna 1 TAB PO BID:PRN constipaiton 8. Sotalol 80 mg PO QAM 9. Sotalol 40 mg PO QPM 10. Warfarin 5 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA) home rx Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: bilateral rib fractures L distal femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the ACS service after your trauma. You may continue to eat a regular diet. You should exercise as much as possible and continue to ambulate. However, you should not bear any weight on your L left. You may take tylenol for pain and narcotic medication as directed. You should also resume your coumadin. Followup Instructions: Follow-up with Orthopedic surgery by [**7-30**] w/ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please call to make an appointment: [**Telephone/Fax (1) 1228**] You should follow up with ACS in [**12-22**] weeks after discharge. Call to make an appointment: [**Telephone/Fax (1) 600**] Completed by:[**2128-7-19**]

Admission Date: [**2129-4-12**] Discharge Date: [**2129-4-16**] Date of Birth: [**2052-7-14**] Sex: M Service: BLOOMGARD HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old gentleman with history of coronary artery disease, ischemic cardiomyopathy, ejection 20 percent, atrial fibrillation, diabetes mellitus with neuropathy, end stage renal disease on hemodialysis. The patient was admitted on [**4-7**] to an outside for failure to thrive and hypotensive. The patient was found to have a large right pleural effusion at the outside hospital. He was also hypoxic to the 70s on 6 liters and thoracentesis revealed [**12-10**] liter of transudative fluid removed. Patient's oxygenation reportedly improved after that. At the outside hospital the patient's left upper extremity antecubital AV fistula was noted to be nonfunctional and a temporary femoral line was placed for dialysis. The patient was transferred to the [**Hospital1 346**] for evaluation of fistula, repair and further medical management. The patient was transferred to the Intensive Care Unit on the [**Hospital Ward Name 516**] of [**Hospital1 346**] on [**2129-4-12**]. Upon transfer his systolic blood pressures were marginal in the 70s. Otherwise the patient was stable and afebrile. The patient was aggressively dialyzed as well as ultrafiltration by nephrology and was transferred to the regular internal medicine floor on [**2129-4-13**]. PAST MEDICAL HISTORY: Coronary artery disease, status post coronary artery bypass graft times three in [**2099**], [**2112**] and [**2121**] at [**Hospital 4415**]. Patient underwent catheterization with no intervention in [**2127-8-10**] at the [**Hospital1 69**]. In [**2127-8-10**] transesophageal echocardiogram showed ejection fraction of about 20 percent, 1+ mitral regurgitation, 2+ tricuspid regurgitation. Patient reportedly with a chronic right lung pleural effusion, chronic atrial fibrillation, status post multiple failed cardioversions. Intermittently anticoagulated but this was limited by a GI bleed which the patient has had in the past related to Barrett's esophagus. Also history of stroke with short term memory loss. History of falls and syncope. History of sick sinus syndrome with pacemaker placed DDI. Also diabetes mellitus with neuropathy and nephropathy. Patient with end stage renal disease on hemodialysis in [**2126-11-9**] on Monday, Wednesday and Friday. Also hypothyroidism. Also gout. Also depression. Also prostatic hyperplasia. Also status post appendectomy. Also reported restrictive and obstructive lung disease on home oxygen. Also history of Legionnaire's disease. SOCIAL HISTORY: Patient lives in [**Hospital3 **]. His wife is alive but demented. [**Hospital **] health care proxy is one of his daughters. Remote tobacco history with history of 100 pack years. Alcohol once to twice per week. ALLERGIES: Cardizem "makes me turn into a puffer fish." MEDICATIONS ON TRANSFER: Prevacid 30 once a day, Zoloft 20 once a day, Synthroid .75 once a day, Neurontin 300 once a day, Renagel 800 t.i.d. on Monday, Wednesday and Friday, Midodrine 10 pre-hemodialysis Monday, Wednesday and Friday. Digoxin .125, Tums 1,000 mg t.i.d., amiodarone 200 t.i.d., Reglan 10 q.i.d., allopurinol 100 q.d., Zebeta 2.5 mg Tuesday, Thursday, Saturday, Sunday, Coumadin 1 mg q.d. which had been held at the outside hospital. PHYSICAL EXAMINATION: On admission temperature 97.1, blood pressure 89/50, heart rate 60, saturating 97 percent on 4 liters nasal cannula. Patient is an elderly gentleman in no apparent distress. Lungs with coarse breath sounds anteriorly. Heart with S1, 2, II/VI systolic murmur. Patient's abdomen was benign. Skin with decubitus ulcer, also skin breakdown on right and left upper extremities as well as right lower extremity. Neuropsychiatric: Patient responds appropriately and answers questions appropriately but with poor recall. Alert and oriented times three. Muscle strength 4 out 5 throughout, decreased sensation to light touch in bilateral lower extremities. LABORATORY DATA UPON TRANSFER: White count 6.6, hematocrit 39, platelets 171. Chemistries within normal limits except for potassium of 5.2, BUN/creatinine 30/5.5, TSH 15, Digoxin level 2.2. SUMMARY OF HOSPITAL COURSE: This 76 year-old gentleman with history of severe coronary artery disease, status post coronary artery bypass graft, severe congestive heart failure and cardiomyopathy, pacemaker, diabetes, end stage renal disease on hemodialysis, transferred from an outside hospital with a nonfunctioning AV fistula used for dialysis. Transiently in the Intensive Care Unit for one day for close monitoring and then transferred to Medicine on [**4-13**]. 1. Congestive heart failure: Ejection fraction estimated at 20 percent per echocardiogram in [**2126**]. Patient's Digoxin was held due to his low blood pressures as well as elevated serum levels. Patient's serum levels should be monitored and consider restarting as an outpatient. Renal followed the patient closely and performed ultrafiltration daily as well as dialysis three times per week for fluid removal for the patient's congestive heart failure. The patient's oxygen saturations remained stable throughout his hospital stay. Clinically the patient initially with jugular venous distention and lower extremity edema. However, this improved with dialysis and ultrafiltration. 2. Blood pressure: Patient with marginal systolic blood pressure in the 70s to 80s on admission. However, blood pressure remained in the 90s to 100s throughout the remainder of his hospital stay. Patient's cortisol was checked and was within normal limits. Patient's blood pressure remained stable and tolerated the hemodialysis and ultrafiltration well. Given the patient's cardiac risk factors we discussed starting low dose ACE inhibitors as well as beta blocker. For this patient, however, given his marginal blood pressures which were very hemodialysis dependent, the patient was not started on one. Recommend outpatient consideration of starting low dose ACE inhibitor on beta blocker. 3. Pulmonary: Patient with congestive heart failure as mentioned above. Also with restrictive lung disease per report. Patient also with stable transudative pleural fluid per report. Patient on home oxygen as well. Patient's oxygen saturation was stable in the mid 90s throughout his hospital stay on low amounts of oxygen via nasal cannula. 4. End stage renal disease: Patient followed by renal consult and team and underwent ultrafiltration q.d. as well as dialysis three times per week which he tolerated well. Patient's AV fistula was found to be clotted and interventional radiology attempted to fix this, however, were unable to. Therefore, patient had a tunneled right internal jugular dialysis catheter placed for access. Patient was evaluated by transplant surgery regarding possible fistula repair or placing a new access site for hemodialysis. Transplant surgery deferred doing this at this time given the patient's skin breakdown over the sites that they would want to do that. Recommend outpatient follow up for possible access procedure in the future. Patient tolerated renal low sodium diet well. Patient also with Nephrocaps and phosphate binders. 5. Dermatology: Patient with skin breakdown on his back, right shin and bilateral upper extremities. These were changed with dressings and monitored closely. 6. Atrial fibrillation: Patient's Coumadin was held due to interventional radiology procedure. Given the patient's history of GI bleed, patient's Coumadin was continued to be held at discharge. Defer to outpatient primary care physician regarding pros and cons of restarting Coumadin with patient likely to undergo re-access in the future. Patient's Digoxin was held as mentioned above. Patient was continued on amiodarone for his atrial fibrillation which he tolerated well. 7. Coronary artery disease, status post coronary artery bypass graft most recently in [**2121**]: Patient's cardiac enzymes negative times three, however, with slightly elevated troponins likely related to chronic end stage renal disease. Patient continued on aspirin. Cardiology was consulted regarding patient's heart issues and stated that the patient could be a candidate for ICD placement due to his low ejection fraction. Medical team discussion with patient and patient decided against this given patient's likely prognosis due to other comobidities. 8. Diabetes mellitus: Patient maintained on insulin sliding scale throughout this hospital stay. This was stable. Continue diabetic diet. 9. Infectious disease: Patient's skin swab from [**4-14**] grew out methicillin resistant staph aureus and patient was placed on precautions. No signs of active infection, however. 10. Fluid, electrolytes and nutrition: Patient maintained on low sodium renal diet. Also proton pump inhibitor. Patient's stools were guaiaced. Patient's hematocrit remained stable. CODE: Code status is full confirmed with the patient as well as his health care proxy, his daughter. Communication daily with the patient as well as his daughters. ACCESS: Peripheral intravenous as well as femoral dialysis catheter placed at the outside hospital on [**4-11**]. Plan to discontinue the femoral dialysis catheter once the right internal jugular tunnel catheter is confirmed to be working properly. CONDITION ON DISCHARGE: Fair, at baseline. DISCHARGE STATUS: To skilled nursing facility. DISCHARGE DIAGNOSES: End stage renal disease on hemodialysis. Coronary artery disease, status post coronary artery bypass graft. Congestive heart failure. Diabetes mellitus. Depression. Hypotension. Pleural effusions. Hyperlipidemia. Skin breakdown. DISCHARGE MEDICATIONS: Pantoprazole 40 once a day, gabapentin 300 mg once a day, allopurinol 100 q.o.d., cevalomir 800 t.i.d., vitamin B, vitamin C, folate, ranitidine 10 mg 30 minutes prior to dialysis, amiodarone 200 t.i.d., Reglan 10 q.i.d. AC, h.s., aspirin 325 q.d., calcium carbonate 1,000 t.i.d., senna b.i.d., colace b.i.d., bisacodyl p.r.n., insulin sliding scale, Synthroid 75 mcg q.d., subcutaneous heparin 5,000 q 12 q.d., Lipitor 10 q.d., sertraline 50 q.d., polyvinylalcohol 1.4 percent ophthalmic drops p.r.n., albuterol MDI p.r.n. FOLLOW UP PLANS: Patient to follow with primary care physician and hemodialysis as outpatient as scheduled. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Name8 (MD) 6906**] MEDQUIST36 D: [**2129-4-15**] 19:05 T: [**2129-4-15**] 20:55 JOB#: [**Job Number 40565**]

Admission Date: [**2109-3-28**] Discharge Date: [**2109-4-4**] Date of Birth: [**2043-5-31**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: This is a 74-year-old male with a complicated medical history who was transferred from [**Hospital **] Hospital with renal failure and metabolic acidosis. He had also complained of odynophagia and difficulty with a severe feeling of thirst. He was transferred to [**Hospital1 346**] for further management of his metabolic acidosis. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post coronary artery bypass graft 17 years ago with a preserved ejection fraction as of [**2109-1-7**]. 2. Type 2 insulin-dependent diabetes mellitus. 3. Chronic renal insufficiency (with a baseline creatinine of 2). 4. Cirrhosis of the liver secondary to alcohol (Child class A) 5. Peripheral vascular disease; status post right-sided below-knee amputation. 6. Head and neck squamous cell carcinoma; specifically in the right mandibular region which was diagnosed in [**2105**]; status post radiation therapy. 7. Hypertension. 8. Paroxysmal atrial fibrillation. ALLERGIES: The patient had no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed heart rate was 104, blood pressure was 94/60, oxygen saturation was 98% on room air, and temperature was 98, and respiratory rate was 18. In general, the patient was very agitated and was not cooperative with the examination. He did not appear to be in acute respiratory distress. Head, eyes, ears, nose, and throat examination revealed his pupils were reactive to light. Extraocular movements were full. Sclerae were muddy and injected. There was no clear icterus or subungual jaundice. The neck revealed no jugular venous distention. The lungs were clear to auscultation anteriorly with decreased breath sounds at the right posterior base. Heart was irregularly irregular and tachycardic. Normal first heart sounds and second heart sounds. There was no third heart sounds or fourth heart sounds appreciated. A 2/6 systolic murmur at the apex was appreciated. The abdomen revealed decreased bowel sounds. Soft, nontender, and nondistended. Liver was palpable four fingerbreadths below the costal margin. Extremity examination revealed there was palmar erythema. The patient was status post right below-knee amputation. There was no pedal edema on the left. Neurologic examination revealed awake, alert and oriented times three. There was no facial droop. The tongue was midline. Extraocular movements were full. Shoulder shrug was equal, [**4-14**] bilaterally. Grimace was symmetric. He had left pronator drift. Otherwise, motor strength was [**4-14**] throughout. PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent laboratory findings on admission revealed an arterial blood gas of 7.10/18/126. White blood cell count was 12., hematocrit was 31.7, and platelets were 124. Chemistry-7 was notable for a potassium of 6.2, bicarbonate was 7, with a creatinine of 6.9, and glucose was 135. Anion gap was calculated at 20. AST was 52, ALT was 25, alkaline phosphatase was 120, and a total bilirubin of 0.3. Creatine kinase was 1018 on admission. Lactate was 0.8. FENa was calculated at 0.8%. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram at the time of admission revealed a rate of 100 and was a normal sinus rhythm at that time, with normal axis and intervals. There were no peaked T waves or ST-T wave changes noted. HOSPITAL COURSE BY ISSUE/SYSTEM: This was a 74-year-old male with an extensive past medical history who was transferred to the [**Hospital1 69**] with severe metabolic acidosis, acute-on-chronic renal failure, history of Child class A cirrhosis, coronary artery disease, and type 2 insulin-dependent diabetes mellitus. 1. METABOLIC ACIDOSIS ISSUES: The metabolic acidosis was felt to be an anion gap acidosis; secondary to either ongoing alcohol abuse (which was an issue for this patient), or possibly diabetic ketoacidosis or starvation ketoacidosis. Diabetic ketoacidosis was not felt to be the leading cause, as his glucose was never high. Nonetheless, he was insulin dependent. His acidosis improved somewhat with aggressive hydration and nutrition; however, never completely normalized during his hospital course. 2. CORONARY ARTERY DISEASE ISSUES: The patient ruled in for a non-Q-wave myocardial infarction and had a transthoracic echocardiogram showing new regional wall motion abnormalities with a dyskinetic left ventricle. He was started on a heparin drip to prevent thrombus. Coumadin was never stated on the patient. 3. RENAL FAILURE ISSUES: The patient had an acute tubular necrosis with a FENa that was less than 1%; however, his creatinine clearance never improved during his hospital stay. Despite aggressive hydration, and renally dosing medications, as well as holding ACE inhibitors and angiotensin receptor blockers, the patient's creatinine never improved. His urine output continued to deteriorate during his hospital course and in the Intensive Care Unit prior to his death. 4. RESPIRATORY FAILURE ISSUES: During his hospital course, the patient had hypoxic respiratory failure requiring intubated and was also quite difficult to ventilate; requiring the use of paralytics. The patient's respiratory course was complicated difficulty clearing secretions by the patient as well as hospital-acquired pneumonia. Sputum cultures did grow out Staphylococcus aureus, and the patient was covered with appropriate antibiotics. 5. ATRIAL FIBRILLATION ISSUES: The [**Hospital 228**] hospital course was also complicated by atrial fibrillation with a rapid ventricular response; requiring atrioventricular nodal blockade with a calcium channel blocker or a beta blocker. 6. DISSEMINATED INTRAVASCULAR COAGULATION ISSUES: The patient did have disseminated intravascular coagulation toward the end of his hospitalization; presumably secondary to profound infection. On the day prior to his death, his urine output continued to be very marginal after aggressive fluid hydration. His maximum urine output was only 40 cc per hour. Sediment continued to reveal a muddy brown cast consistent with acute tubular necrosis; however, his FENa was always less than 1%. His heart rate decreased to the 40s and 50s on the afternoon prior to his death; showing a sinus arrhythmia and ventricular escape beats. There were no ST elevations. His electrolytes were repleted at that time. His overall prognosis was extremely poor because of his renal failure and sepsis which was complicated by disseminated intravascular coagulation. This was communicated to Mrs. [**Known lastname 41304**], the [**Hospital 228**] health care proxy, who stated that Mr. [**Known lastname 41304**] would not have wanted extensive life support. His wife agreed to withdrawing care on [**2109-4-3**], and she stated that he would not have wanted an autopsy done. On [**2109-4-4**], the patient expired. DISCHARGE DIAGNOSES: 1. Renal failure. 2. Pneumonia. 3. Heart failure. 4. Head and neck squamous cell carcinoma. 5. Coronary artery disease. 6. Congestive heart failure. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 8167**] MEDQUIST36 D: [**2110-3-13**] 14:05 T: [**2110-3-14**] 19:26 JOB#: [**Job Number 41305**]

Admission Date: [**2184-4-17**] Discharge Date: [**2184-4-21**] Date of Birth: [**2100-2-6**] Sex: F Service: NEUROLOGY Allergies: Codeine / Morphine Attending:[**First Name3 (LF) 5018**] Chief Complaint: R sided weakness with aphasia Major Surgical or Invasive Procedure: none History of Present Illness: HPI: Patient is a 84 yo right handed walker-dependent women for frequent falls who lives in a nursing home with hx of prior ICH (location unclear) in [**2182**] here from [**Hospital 1110**] Hospital after presenting with aphasia and R sided weakness found to have L IPH. Hx obtained per daughter who was with the patient given that patient unable to express herself. Per daughter, patient had dinner at the daughter's house and was attending her grandson's acapella concert around 7pm. While the daughter was getting the tickets, she walked ahead with her walker and when the daughter looked after buying the tickets, she noticed that a passerby was assisting her mom who seemed to be leaning to the R. She did not fall but she was not able to speak. They grabbed a chair nearby and sat her down and just dragged the chair to the daughter's car who transported the patient to a hospital in [**Location (un) 1110**]. While at [**Location (un) 1110**], she was reported to have R sided weakness with aphasia. Her BP was in 160's/80's and head CT revealed 2X2cm L IPH with some ventricular extension hence patient was transferred here for further care. The daughter does not recall the patient complaining of any headache or nausea. Patient seems to deny having any HA or nausea currently but difficult to assess the extent of her comprehension. Per nursing home, patient walks with a walker at baseline and has mild dementia but is quite oriented at baseline. She is called the "secretary of her [**Doctor Last Name 7594**] [**Doctor Last Name **]/nursing home." The nursing home and the HCP (another daughter) confirms that patient is DNR/DNI. Also, she was recently diagnosed with UTI and started on Amoxicillin yesterday. ROS negative otherwise. Repeat head CT here (10:30pm) compared to [**Location (un) 1110**] (~8pm) appears to be without significant change. Past Medical History: 1. ICH in [**2182**] - ?base of the brain 2. Dementia 3. Hypercholesterolemia 4. GERD 5. hx of pulmonary edema (?) Social History: Lives in nursing home and ambulates with the walker. Daughter [**First Name8 (NamePattern2) 6480**] [**Last Name (NamePattern1) 6382**] is HCP ([**Telephone/Fax (1) 86736**]) and is DNR/DNI. Remote smoking hx - quit before [**2129**]. No EtOH. Used to work for the phone company. Family History: Three daughters - all healthy. Physical Exam: T 98.3 BP 180/99 HR 68 RR 18 O2Sat 96% RA Gen: Comfortable appearing, smiling 84 yo woman, NAD. HEENT: No signs of trauma. Neck: No carotid or vertebral bruit CV: RRR and no murmurs/gallops/rubs Lung: Clear anteriorly Abd: +BS, soft, nontender Ext: Venous stasis skin changes esp. RLE. No edema. Neurologic examination: Mental status: Awake and alert, oriented to self. Non-fluent speech but repetition intact. Although follows simple commands including open/closing eyes, sticking tongue out, showing thumb and wiggling toes, difficult to assess extent of comprehension. Appears to have R/L confusion. Unclear about apraxia whether its comprehension or apraxia. Cranial Nerves: II: Pupils small but reactive (1.5 -> 1mm). Blinks to visual threat bilaterally. III, IV & VI: Extraocular movements intact bilaterally, no nystagmus. V: Reports R/L difference to LT but unclear how. VII: R facial droop - less evident with natural smile. XII: Tongue midline, movements intact Motor: Normal bulk and tone bilaterally. No observed myoclonus or tremor. Severe R pronator drift. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF R 5- 5 5 5 5 5 5- 5- 5 5 5 L 5- 5 5 5 5 5 5 5 5 5 5 Sensation: Appears to have R/L asymmetry to LT and cold but extent is unclear. Reflexes: +2 and symmetric throughout except for dropped ankle jerks. R toe mute but upgoing on L. Coordination and Gait: Deferred. Pertinent Results: [**2184-4-17**] 09:20PM WBC-7.6 RBC-4.86 HGB-14.6 HCT-43.9 MCV-90 MCH-30.0 MCHC-33.2 RDW-13.3 [**2184-4-17**] 09:20PM NEUTS-55.3 LYMPHS-33.2 MONOS-6.8 EOS-3.2 BASOS-1.4 [**2184-4-17**] 09:20PM PLT COUNT-330 [**2184-4-17**] 09:20PM PT-11.8 PTT-24.8 INR(PT)-1.0 [**2184-4-18**] 12:25AM URINE RBC-0-2 WBC-[**7-15**]* Bacteri-RARE Yeast-NONE Epi-0 [**2184-4-17**] EKG: Sinus rhythm. Left ventricular hypertrophy with secondary repolarization changes. [**2184-4-17**] CT HEAD W/O CONTRAST: 1. Unchanged left parenchymal hemorrhage centered in the thalamus, with increased surrounding edema. 2. Unchanged intraventricular hemorrhage and ventricular enlargement. [**2184-4-18**] Chest X-Ray: No pneumonia is seen. [**2184-4-18**] CT Head W/O Contrast: Motion degraded study which reveals no new intracranial abnormalities at this time. [**2184-4-20**]: Chest X-ray: In comparison with study of [**4-18**], there are lower lung volumes but otherwise little change. [**2184-4-20**]: CHEST (PA & LAT): No significant change. Brief Hospital Course: Assessment and Plan at admission: In summary, patient is a 84 yo RHW with mild dementia and hx of prior CNS hemorrhage here with sudden onset of leaning to the R and aphasia without any trauma found to have L intracerebral hemorrhage with some ventricular extension. Patient has severe aphasia but intact repetition. Appears to follow simple motor commands but extent of comprehension difficult to assess. Mild R facial droop and appears to have R sided sensory deficit. Weakness if difficult to detect but has marked R pronator which appears to be from sensory deficit rather than [**Last Name **] problem. Given the location of the bleed (L BG) and no evidence/report of trauma, most likely hypertensive hemorrhage versus amyloid. Although no significant change since OSH imaging, will need to admit to ICU for close observation. RECS: 1. Admit to ICU under Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] with telemetry. 2. Maintain SBP < 160 and HOB > 30 degrees. 3. Keep NPO overnight. 4. DVT PPX with pneumo boots. 5. STAT head CT if change in exam. 6. Follow-up on labs including UA - may need to start on ceftriaxone if +UTI. 7. Further rec's to follow in the morning Hospital Course: #Neuro: Patient admitted to ICU for close monitoring. Head CT on admission showed unchanged left parenchymal hemorrhage centered in the thalamus, with increased surrounding edema, and unchanged intraventricular hemorrhage and ventricular enlargement. Repeat head CT the following morning showed no new intracranial abnormalities. Neuro exam notable for being awake, alert, spontaneous language, able to repeat with paraphasic errors, able to follow most simple commands, occasional word finding difficulties, right sided inattention/neglect, ? right sided field cut/inattention, moves all extremeities well. Transferred to floor on [**4-19**]. PT and OT evaluation recommended rehab. Speech eval recommended intensive speech therapy services for her aphasia. ASA was placed on hold during this hospital stay. Plan is to restart ASA 325 mg daily on [**2184-4-24**]. Neuro exam at dishcarge was significant for:She remained aphasic. Able to name some objects and to repeat with paraphasic errors. Questionable decreased blink to threat on R that was (inconsistent), Right-sided extremitities spastic, strength ranging 4 -4+, toes upgoing #Resp:Oxygen requirement throughout hospital stay: 2LNC. Repeated chest x-rays showed no signs of pneumonia #ID: Started on ciprofloxacin on admission for presumed UTI with positive UA. Urine culture negative. Cipro continued as of day of discharge #CVS: Optimized BP managment. increased dose of metoprolol #F/E/N: Started on NG Tube feeds in the ICU. Swallowing eval on [**4-19**] suggest she should continue primary nutrition via feeding tumbe, begin small amounts of honey thick liquids by tsp and pureed solids, 1:1 supervision for all po intake, Q4 hr oral care. Repeat swallow eval recommended upgrade to nectar thick liquids and ground solids, alternate bites and sips, q6 oral care. #Prophylaxis:DVT prophylaxis with subQ heparin/GI prophylaxis with pantoprazole #Code status:DNR/DNI Medications on Admission: 1. Aricept 10mg bedtime 2. Simvastatin 40mg daily 3. ASA 325mg daily 4. Prilosec 20mg daily 5. Ca2+/D 500 daily 6. Fe2+ 325 daily 7. Vitamin C 500 daily 8. Amoxicillin - started [**4-16**] for UTI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): FOR DVT PROPHYLAXIS AS INPATIENT. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day: ***NOTE: HOLD ASA UNTIL [**2184-4-24**]. [**Month (only) **] RE-START ASA ON [**2184-4-24**]***. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Ciprofloxacin 100 mg Tablet Sig: Four (4) Tablet PO once a day for 4 days: 400 mg PO/NG daily for 4 days. 7. Famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital Discharge Diagnosis: left sided intracerebral hemorrhage Discharge Condition: Neuro exam at dishcarge was significant for: She remained aphasic. Able to name some objects and to repeat with paraphasic errors. Questionable decreased blink to threat on R that was (inconsistent), Right-sided extremitities spastic, strength ranging 4 -4+, toes upgoing Discharge Instructions: You were admitted with a left sided intracerbral hemorrhage. You have had diffculty expressing yourself verbally. After evaluation, you have required feeding through a nasogastric tube as well as small amount of food by mouth. You have been evaluated by physical and occupational therapy as well. You are being transferred to a rehabilitation hospital for intensive speech therapy, further swallowing evaluation, and intensive physical and occupational therapies. During your hospital stay, your aspirin was held. You should restart you aspirin on [**2184-4-24**]. Please follow-up with neurology as listed below. Should you develop any symptoms as listed below or concerning to you, please call your doctor or go to the emergency room. Followup Instructions: Neurologist: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2184-6-9**] 2:00 LOCATION: [**Hospital1 18**] ***Note: Before this appointment, you need your PCP send [**Name Initial (PRE) **] referral to Dr.[**Name (NI) 34043**] office. Also, you must have someone call registration at [**Hospital1 18**] on your behalf at [**Telephone/Fax (1) 10676**] before you can be seen for this follow-up visit. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2184-4-21**]

Admission Date: [**2156-9-19**] Discharge Date: [**2156-9-27**] Date of Birth: [**2095-5-7**] Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamides) / Percocet Attending:[**First Name3 (LF) 8850**] Chief Complaint: Fever, neutropenia, and swollen, painful left elbow Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 61-year-old right-handed woman with glioblastoma multiforme, s/p subtotal resection on [**2156-7-2**], involved-field cranial XRT, and chemotherapy (last taken on [**2156-9-10**]). She developed a fever to 102 F, hypotension to SBP 90s today, and came to our emergency room. Husband first noted left elbow 3-4 weeks ago which resolved in 2 days after application of neosporin (there was a question of spider bite). Then 3 days ago she noted erythema which increased and associated with increasing edema and tenderness. Today, the patient was practically unable to move elbow due to pain. She experienced fever and chills that began yesterday, but she did not take her temperature. Her Review of System is notable for a new dry cough x 6 days. She also developed diarrhea but stopped 3 days ago when she stopped taking Colace. She has fatigue but no SOB, congestion, abdominal pain, dysuria, bright red blood per rectum, or melena. There was no trauma to elbow. There was no recent sick contacts or travel. Regarding her oncologic history, her symptoms began in late [**Month (only) 205**] [**2155**] with headache, word-finding difficulties, memory loss, and confusion. She was found to have a left parietal brain lesion. After subtotal resection on [**2156-7-2**], underwent involved-field XRT with concurrent temozolomid. She also received 1 treatment with CyberKnife radiosurgery to an enhancing lesion in the right occipital lobe, together with temozolomide. In the emergency room, her temperature was 102.6 F, HR 130s (sinus tachycardia), and systolic BP 90s-100s (baseline SBP 120s-130s). Her WBC was 0.3 with no neutrophils or bands. Her U/A showed no WBC but there was nitrates and bacteria. Her serum lactate was 3.9. Blood and urine cultures were sent. Her chest CTA was negative for pulmonary embolism, but there was mild left lung apical patchy ground-glass opacity; there was a question of atelectasis versus pneumonia. She received oxygen at 7 liters via nasal cannula in the emergency room but her systolic BP persisted in 90s-100s. Emergency Department did not start on sepsis protocol because her serum lactate was not > 4 and she was responsive to fluid, despite the elevated temperature, heart rate, and WBC. Past Medical History: Glioblastoma multiforme of left temporoparietal lobe Anxiety Social History: Never smoked, drinks alcohol on rare occasions. Lives with husband. Worked as secretary. Family History: Father had lung cancer. Mother had [**Name (NI) 2481**] disease. Her siblings are all healthy. She has 1 son and 1 daughter, and both of them are healthy. Physical Exam: Physical Examination: Vital Signs: Temperature 102.6 F in Emergency Department; Current Temperature 100.2 F; Heart Rate 108; Blood Pressure 106/56; Respiratory Rate 16; Oxygen Saturation 99% on 2 Liters. Gen: Cushingnoid faced woman, fatigued appearing, otherwise in no acute distress lying in bed HEENT: PERRLA, EOMI, anicteric, pale conjunctival membranes, dry mucous membranes, +scars on scalp from prior neurosurgery Neck: No LAD CV: RRR tachycardic, nl S1, S2 no m/r/g Pulmonary: CTA bilaterally Abdomen: NABS, soft, NT/ND, well-healed vertical [**Doctor First Name **] incision Extremities: LUE elbow has 5-cm area of erythema, warmth, mild fluctuance, and tenderness to palpation. She is unable to abduct at elbow more than 5 degrees secondary to pain. Her lower extremities are cool, without c/c/e. She has 2+ dorsalis pedis pulses bilaterally Neurologic Examination: Her mental status is intact. She is awake, alert, and oriented x 3. Her language is fluent with good comprehension. CN II-XII are intact. Her motor strength is [**4-15**] motor in RUE; LUE examination limited due to pain at elbow. In the lower extremities, she has 4-/5 strength bilaterally at thigh flexors, 5/5 strength at quadriceps, hamstrings, foot dorsiflexion, and plantar flexion. Her reflexes are 2- but her ankle jerks are absent. She has downgoing toes. Sensory examination reveals normal sensory examination. Coordination examination does not reveal dysmetria. Her gait is steady. She does not have a Romberg. Pertinent Results: [**2156-9-19**] 12:10PM WBC-0.3* RBC-4.61 HGB-14.8 HCT-41.3 MCV-90 MCH-32.1* MCHC-35.8* RDW-13.9 [**2156-9-19**] 12:10PM NEUTS-0* BANDS-0 LYMPHS-65* MONOS-35* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2156-9-19**] 12:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL [**2156-9-19**] 12:10PM PLT SMR-LOW PLT COUNT-140* [**2156-9-19**] 12:10PM PT-13.5* PTT-24.5 INR(PT)-1.2 [**2156-9-19**] 12:10PM SED RATE-70* [**2156-9-19**] 12:10PM GLUCOSE-114* UREA N-14 CREAT-0.6 SODIUM-138 POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16 [**2156-9-19**] 12:10PM ALT(SGPT)-35 AST(SGOT)-22 ALK PHOS-88 TOT BILI-0.6 [**2156-9-19**] 01:05PM LACTATE-3.9* [**2156-9-19**] 01:07PM CK-MB-NotDone cTropnT-<0.01 [**2156-9-19**] 01:07PM CRP-67.5* [**2156-9-19**] 01:07PM CK(CPK)-11* [**2156-9-19**] 02:08PM URINE RBC-0 WBC-0 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2156-9-19**] 02:08PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2156-9-19**] 02:08PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.023 L elbow Xray [**2156-9-19**]: Four radiographs of the left elbow demonstrate no joint effusion. No fracture. No cortical fragmentation to suggest osteomyelitis. Regional soft tissues are unremarkable. IMPRESSION: Unremarkable radiographs, left elbow. MRI of L elbow: MR LEFT ELBOW WITHOUT CONTRAST: There is a moderate elbow joint effusion. The bone marrow appears normal in signal intensity characteristics. There is circumferential edema within the subcutaneous tissues about the elbow. There is fluid signal intensity in the region of the olecranon bursa, suggestive of bursitis. There is more confluent high signal intensity surrounding the musculature at the elbow joint. It is not clear if this represents dense edema or frank fluid, as this study is limited without intravenous contrast. Also noted is diffuse increased signal intensity within the musculature about the elbow, suggestive of myositis. IMPRESSION: 1. Moderate elbow joint effusion. 2. Diffuse increased signal intensity within the musculature about the elbow, consistent with nonmyositis. 3. Olecranon bursitis. 4. Edema within the subcutaneous tissues about the elbow, suggestive of cellulitis. CT OF THE CHEST: There are no significant axillary, mediastinal, or hilar lymph nodes. There is a small hypodense area in the left lobe of the thyroid measuring 1.2 x 0.8 cm. Ultrasound could be performed for further evaluation. There is no pericardial effusion. The heart is of normal size. The great vessels are unremarkable. There is no evidence of aortic dissection. There is fluid in the pericardial recess anterior to the aorta, which is unchanged when compared to prior study. The pulmonary artery is normal size. There are no filling defects in the pulmonary artery branches. There is no evidence of pulmonary embolism. The airway is patent to level of subsegmental bronchi. There are subsegmental atelectasis in the right middle lobe and lower lobes. There are emphysematous changes in the lungs. There is a patchy ground-glass opacity in the left upper lobe near the apex that is new when compared to the prior study and of unclear significance. It most likely represents an area of pneumonia. There are no pleural effusions. Limited images of the upper abdomen do not reveal significant abnormality. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Emphysema. 3. Subsegmental atelectasis. 4. Small patchy ground-glass opacity in the left apex of unknown clinical significance. It could representa small focus of pneumonia. It is new when compared to the prior study from [**6-30**], [**2155**]. Attention on follow to confirm resolution is recommended. EKG [**2156-9-25**]: Sinus tachycardia Modest diffuse nonspecific ST-T wave abnormalities Since previous tracing of [**2156-9-19**], sinus tachycardia rate slower and ST-T wave abnormalities are less prominent [**2156-9-26**] 1:20 pm SWAB Source: Left elbow bursa pus. **FINAL REPORT [**2156-10-5**]** GRAM STAIN (Final [**2156-9-26**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2156-9-30**]): STAPH AUREUS COAG +. RARE GROWTH. Please contact the Microbiology Laboratory ([**6-/2457**]) immediately if sensitivity to clindamycin is required on this patient's isolate. 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 + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S PENICILLIN------------ =>0.5 R ANAEROBIC CULTURE (Final [**2156-10-5**]): NO ANAEROBES ISOLATED. BCX [**2156-9-19**]: No growth (final) BCX [**2156-9-20**]: No growth (final) Brief Hospital Course: This is a 61-year-old woman with glioblastoma multiforme, s/p involved-field XRT, surgery, involved-field cranial irradiation, and chemotherapy presented with neutropenic fever, left elbow bursitis/cellulitis, UTI, and possible pneumonia on chest CT. 1. Neutropenic Fever/Hypotension: In the [**Hospital Unit Name 153**], the patient was aggressively fluid resuscitated, and her blood pressure responded without any pressor. Sources of infection included left elbow bursitis/cellulitis, pneumonia, and UTI. In the setting of neutropenic fever, the patient was started on broad spectrum antibiotics with vancomycin, ceftazidime, and azithromycin (for atypical pneumonia), as well as gentamicin x 1 dose in context of continued destabilization and need for double gram negative coverage. Central venous pressure improved to [**6-23**] over the course of 48 hours, and blood pressures stabilized. Patient had no more fever. Patient received stress dose steroids as well as Neupogen. Orthopedics was consulted for her left elbow bursitis/cellulitis. X-ray and MRI did not reveal osteomyelitis. Orthopedics felt that possible bursitis; however, symptoms improved with antibiotics. On transfer to the OMED service, the patient was afebrile and hemodynamically stable. She was continued on Neupogen, vancomycin, ceftazidime, and azythromycin. On [**2156-9-23**], given her enterococcal UTI is pansensitive and the patient no longer neutropenic, vancomycin and ceftazidime were discontinued and cefazolin IV was started to cover both enteroccocus and left elbow cellulitis. Neupogen was discontinued on [**2156-9-24**]. Azythromycin was discontinued after completion of 7 day course on [**2156-9-26**]. Also, on [**2156-9-26**], the left elbow had increased warmth and erythema as well as enlargement of fluid sac. Also, patient's WBC increased despite the discontinuation of Neupogen was disproportionately high with a presence of dohl bodies and toxic granulations on smears suggestive of undertreated or persistant infection. Thus, cefazolin was discontinued, and vancomycin was restarted on [**2156-9-26**]. The left elbow responded well to vancomycin and the fluid sac broke open spontaneously, draining pus. The patient had a PICC line placed in her right arm and was discharged with 10 more days of vancomycin to finish a 2 week course. 2. Hypoxia: The paitnet required O2 supplement temporarily. CXR showed small bilateral pleural effusions and atelectasis. With incentive spirometry use, the patient's sat improved to 95% on RA. 3. Glioblastoma Multiforme: Chemotherapy was held. Continued on Keppra and Decadron. Given on steroids, FS blood glucose was checked 4 times daily and they were mostly in the 100's, not requiring a long acting insulin. 4. Transaminitis: She had elevated AST and ALT from [**2156-7-12**]. Rechecked and was normal. 5. Anxiety: Lorazepam prn helped. 6. Prophylaxis: Sliding scale insulin and finger stick blood glucose given on steroids; PPI, subcutaneous heparin, and bowel regimen were administered as well. 7. FEN: Regular diet 8. Full code: Patient does not want prolonged intubation if M.D.s think poor recovery. Medications on Admission: Decadron 4 mg p.o. TID Keppra 1000 mg p.o. [**Hospital1 **] Protonix 40 mg p.o. [**Hospital1 **] Colace 100 mg p.o. [**Hospital1 **] Lorazepam 1 mg p.o. p.r.n. Percocet 1-2 tablets p.o. p.r.n. G-CSF 300 mcg x 10d, started 2d ago Pentamidine, aerosolized Temodar chemotherapy Discharge Medications: 1. Saline Flush 0.9 % Syringe Sig: Five (5) ml Injection SASH as needed for flushing for 10 days. Disp:*qs for 10 days * Refills:*0* 2. Heparin Flush 100 unit/mL Kit Sig: Three (3) ml Intravenous SASH as needed for iv abx therapy for 10 days. Disp:*qs for 10 days * Refills:*0* 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 7. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous Q 12H (Every 12 Hours) as needed for for cellulitis/bursitis for 10 days. Disp:*qs for 10 days gm* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Left elbow bursititis/cellulitis Urinary tract infection Dehydration Glioblastoma multiforme Discharge Condition: Afebrile, no longer neutropenic, improved left elbow and feeling good. Discharge Instructions: Return to the emergency department or call Dr. [**Last Name (STitle) 724**] if you develop fever, chills, nausea, vomiting, worsening pain or redness in your left elbow, chest pain, shortness of breath, or any other concerning symtpoms. Take your medications as instructed. Keep your follow up appointments. Followup Instructions: Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2156-10-11**] 12:15 Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2156-10-11**] 2:00

Admission Date: [**2101-6-27**] Discharge Date: [**2101-7-4**] Date of Birth: [**2026-12-7**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[**First Name3 (LF) 1406**] Chief Complaint: Severe epigastric burning - Ruled in for NSTEMI Major Surgical or Invasive Procedure: [**2101-6-30**] Coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the first obtuse marginal artery and the distal circumflex artery. History of Present Illness: 74 year old male with presented to the OSH with severe epigastric burning, improved with sublingual nitroglycerin. He was ruled in for NSTEMI with + troponin (2nd set 1.24, 3rd set 2.0 on Sat PM). Reportedly chest pain free since admission to the OSH. He is transferred to [**Hospital1 18**] for cardiac catheterization and found to have coronary artery disease. He was referred to cardiac surgery for revascularization. Cardiac Catheterization: Date:[**2101-6-27**] Place:[**Hospital1 18**] LMCA: non obstructed LAD: severe ostial stenosis then tapered proximal lesion LCX: severe OM1 and OM2, dominant RCA: occluded Past Medical History: Hypertension Hyperlipidemia Rhabdomylosis [**1-5**] statin GERD CAD s/p cath in [**2074**] with "2 blockages", denied angioplasty or stent, ? MI in the past with stents, details unclear Past Surgical History: s/p appendectomy s/p Hernia repair Social History: - widower, works as a chef, lives alone - 2 daughters - [**Name (NI) 1139**] history: 1 ppd x ~ 50 years, still currently smoking, [**9-14**] cigarettes/day - ETOH: rare - Illicit drugs: denies - daughter [**Name (NI) **] is health care proxy and coming up - independent of ADLs - exercise: walks for exercise Family History: Family History:Father deceased at 58 from MI and Daughter 29 with SVT and AF Physical Exam: Pulse:62 Resp:18 O2 sat:99/RA B/P Right:124/60 Left:119/59 Height:5'9" Weight:170 lbs General: Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [] Neck: Supple [X Full ROM [X Chest: Lungs clear bilaterally [X Heart: RRR [X Irregular [] Murmur [] grade ______ Abdomen: Soft [X non-distended [X non-tender [X bowel sounds + [] Extremities: Warm [X] well-perfused [X] Edema [X] _____ Varicosities: None [x] Neuro: Grossly intact [X] Pulses: Femoral Right: P Left:P DP Right:P Left:P PT [**Name (NI) 167**]:P Left:P Radial Right:P Left:P Carotid Bruit Right: Left: Pertinent Results: [**2101-6-27**] 04:15PM BLOOD Glucose-135* UreaN-17 Creat-0.9 Na-135 K-3.9 Cl-102 HCO3-23 AnGap-14 [**2101-6-27**] 04:15PM BLOOD CK-MB-3 cTropnT-0.11* [**2101-6-28**] 08:30AM BLOOD CK-MB-3 cTropnT-0.13* [**2101-6-29**] 08:10AM BLOOD CK-MB-14* MB Indx-8.0* cTropnT-0.13* [**2101-6-28**] 08:30AM BLOOD Triglyc-183* HDL-41 CHOL/HD-5.7 LDLcalc-157* [**2101-6-27**] 04:15PM BLOOD %HbA1c-5.8 eAG-120 [**2101-7-4**] 10:45AM BLOOD Hct-32.1* [**2101-7-3**] 07:05AM BLOOD WBC-9.9 RBC-3.14* Hgb-9.6* Hct-27.7* MCV-88 MCH-30.7 MCHC-34.8 RDW-14.1 Plt Ct-172 [**2101-7-4**] 10:45AM BLOOD UreaN-21* Creat-0.9 Na-137 K-4.4 Cl-100 [**2101-7-3**] 07:05AM BLOOD Glucose-132* UreaN-18 Creat-0.9 Na-136 K-3.8 Cl-100 HCO3-26 AnGap-14 [**2101-7-2**] 07:40AM BLOOD Glucose-136* UreaN-12 Creat-1.0 Na-139 K-3.8 Cl-101 HCO3-28 AnGap-14 [**2101-6-30**] Echo LEFT ATRIUM: Marked LA enlargement. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. 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: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Mildly dilated descending aorta. Simple atheroma in descending aorta. No thoracic aortic dissection. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild to moderate ([**12-5**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Mild PR. Conclusions PRE-CPB: The left atrium is markedly dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve leaflets (3) are mildly thickened. Mild (1+) central aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-5**]+) mitral regurgitation is seen. POST-CPB: LV systolic function remains normal, estimated EF>55%. The MR [**First Name (Titles) **] [**Last Name (Titles) 7968**] to mild. There is no evidence of aortic dissection. Brief Hospital Course: 74 y/o M with history of HTN, Hyperlipidemia, and CAD s/p PCI in [**2074**] who initially presented to OSH on Friday night with severe epigastric burning. Ruled in for MI with troponins of 1.24 and 2.0. with no EKG changes and was found to have 3VD on cath and was referred for CABG. The patient was brought to the operating room on [**2101-6-30**] where he underwent Coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the first obtuse marginal artery and the distal circumflex artery. See operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. 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. He did have some issues with nausea/ vomiting on POD2 and KUB revealed scattered air within non-dilated loops of large and small bowel and no evidence of bowel obstruction. He was given multiple bowel medications with subsequent bowel movements and resolution of symptoms. The patient was transferred to the telemetry floor for further recovery. He was restarted on half his home dose Zestril with SBP100-130 and he was not started on a statin due to a history of rhabdomyolysis with Lipitor. PCP to determine if/when he should start an alernative statin. Chest tubes were removed POD#4 (left in longer due to serous drainage) and CXR showed questionable loculated left pneumothorax. Follow up lateral decub CXR showed no pneumothorax. 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 to [**Location (un) 582**] at [**Location (un) **] in good condition with appropriate follow up instructions. Medications on Admission: - metoprolol 25 mg [**Hospital1 **] - omeprazole 25 mg daily - Ambien 10 mg qHS prn - ASA 81 mg Discharge Medications: 1. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<100 HR<60. Tablet(s) 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Zestril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Hold for SBP<100. 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital **] Rehabilitation and Nursing Center - [**Location (un) 701**] Discharge Diagnosis: primary diagnosis: non-ST elevation myocardial infarction coronary artery disease secondary diagnosis: hypercholesterolemia hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments [**Hospital Unit Name **] [**Telephone/Fax (1) 170**] Surgeon: Dr. [**Last Name (STitle) **] on [**7-28**] at 1 PM in the [**Hospital **] medical office building [**Hospital Unit Name **] [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 8725**] on [**2101-8-12**] at 2:40 PM Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 69074**] in [**3-8**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2101-7-4**]

Admission Date: [**2191-8-23**] Discharge Date: [**2191-8-27**] Date of Birth: [**2151-6-25**] Sex: M Service: CA/TH [**Doctor First Name 147**] CHIEF COMPLAINT: Occasional palpitations with no shortness of breath or dyspnea on exertion. HISTORY OF PRESENT ILLNESS: The patient was diagnosed at the age of 30 with a murmur. The patient had been followed by echocardiogram and exercise tolerance test serially over the past decade. PAST MEDICAL HISTORY: 1. Mitral regurgitation. 2. Hemorrhoids. 3. Old fracture of left wrist. PAST SURGICAL HISTORY: 1. Sinus surgery in 06/99. 2. Lumbar disk resection in [**2186**]. 3. Vasectomy in [**2183**]. 4. Revision of vasectomy in [**2187**]. ADMITTING MEDICATIONS: Ultram 50 mg tid. ALLERGIES: Aspirin which causes airway problems requiring epinephrine. PHYSICAL EXAMINATION: Initially, pulse 57, blood pressure 142/94, blood pressure 133/84, initial weight 180 pounds. Generally well nourished, muscular young man. Skin: clear. Head, eyes, ears, nose and throat: negative lymphadenopathy, negative jugular venous distention, negative carotid bruits, negative thyromegaly. Chest is clear to auscultation bilaterally. Heart was S1, S2 with a IV/VI systolic murmur. Thrill was palpable at PMI, left anterior chest. Abdomen was nontender, nondistended, positive bowel sounds. Extremities: negative edema or cyanosis, no venous stasis. Varicosities: positive left lower extremities. Neurologic: grossly intact, no focal abnormalities. Cranial nerves II through XII grossly normal. Excellent strength in all four extremities. Pulses were +2 bilaterally, femorals, posterior tibial, and radial. Dorsalis pedis was +1 bilaterally. ADMISSION LABORATORY DATA: White blood cell count 5.4, hemoglobin 14, hematocrit 42, platelets 255,000. PTT 35.6, PT 12.7, INR 1.1. Sodium 140, potassium 4.4, chloride 103, CO2 24, BUN 14, creatinine 1.0, glucose 124. HOSPITAL COURSE: The patient was admitted on [**2191-8-23**] with a diagnosis of mitral valve regurgitation and was transported to the Operating Room for an mitral valve repair. The patient tolerated the procedure well and was transported to the Post Anesthesia Care Unit in stable condition. After the postoperative course, the patient was then transferred to the Cardiothoracic Intensive Care Unit where on postoperative day one, the patient did well and was extubated. The patient was transferred to the floor and continued to do well. On postoperative day two, the patient spiked a temperature to 103 F at which time a chest x-ray was ordered and pan cultures were performed. The chest x-ray showed a right hemidiaphragm with atelectasis in the right lower lobe. On postoperative day three the patient continued to do well, but also continued to have a low grade fever with an average of 100.7 F. The patient's ambulation level increased to a level of between a III and a IV. On postoperative day four, the patient's ambulation level was V and the patient was scheduled for discharge on [**8-27**]. The patient was instructed to continue on [**8-27**] after discharge, to use the incentive spirometry, increase ambulation, and to cough as much as possible to bring up mucus. DISCHARGE PHYSICAL EXAMINATION: Temperature 99.4 F, pulse 78, respiratory rate 20, oxygen saturation 93% on room air, blood pressure 126/80, in 2,000 cc, out 2,600 cc. Cardiovascular: regular rate and rhythm, patent murmur. Respiratory: clear to auscultation bilaterally. Abdomen: soft, nontender, nondistended. Incisions clean, dry, and intact. Extremities: no peripheral edema. Physical Therapy level V. COMPLICATIONS / SIGNIFICANT EVENTS: None, other than low grade temperature. DISCHARGE MEDICATIONS: Percocet one to two tablets po q four to six hours, acetaminophen 650 mg po q four to six hours prn, Lopressor 25 mg po bid, and Ultram 50 mg po tid. DISCHARGE CONDITION: Good and stable. DISCHARGE STATUS: To home. FO[**Last Name (STitle) **]P: Follow-up with Dr. [**Last Name (Prefixes) **] in three to four weeks. PRIMARY DIAGNOSIS: Status post mitral valve repair. SECONDARY DIAGNOSES: 1. History of mitral valve regurgitation. 2. Hemorrhoids. 3. Fracture of left wrist. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern4) 959**] MEDQUIST36 D: [**2191-8-27**] 12:22 T: [**2191-8-27**] 13:30 JOB#: [**Job Number 28545**]

Admission Date: [**2156-1-17**] Discharge Date: [**2156-1-20**] Service: HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old gentleman who reported walking down [**Doctor Last Name **] on an icy driveway this morning and slipped on the ice. His feet went out from under him when he fell backwards striking the occiput on the pavement. He recalls his feet slipping, but does not consciousness for a few seconds. Denies shortness of breath, chest pain, headache, or lightheadedness before the slip and fall. The patient got up and returned to the house, and wanted to rest, but his wife called EMS. He was transported to the Emergency Room for evaluation and treatment. PAST MEDICAL HISTORY: 2. Hypercholesterolemia. PAST SURGICAL HISTORY: Radical prostatectomy seven or eight years ago. MEDICATIONS: 1. Synthroid 50 mcg po q day. 2. Lipitor. ALLERGIES: IV dye. The patient was admitted to the Neuro Intensive Care Unit, where his vital signs were stable. His blood pressure was 133/56. He was in afib. Heart rate was 65. Respiratory rate 19, and sats is 98%. He was in no acute distress awake, alert, and oriented times three, following commands. Speech was fluent, small, superficial mild area of abrasion, contusion in the posterior occiput without laceration. Pupils are equal, round, and reactive to light bilaterally. EOMs full. Smile is symmetric. Face is symmetric. Tongue midline. Neck is supple. Moving all extremities spontaneously. Strength is [**4-19**] in all muscle groups. Sensation is intact to light touch throughout. His reflexes are 2+ throughout, 1+ at the ankles, and toes are downgoing with no clonus. CT scan showed multiple areas of small linear areas of traumatic subarachnoid hemorrhage within the sulci of the inferior frontal lobes bilaterally and an area of intraparenchymal hemorrhage, measures 2 x 2 cm in inferolateral left frontal lobe with a small dural based component and small subdural hematoma with no shift. C spine was cleared radiologically and clinically with no fractures or malalignment. The patient was monitored in the Intensive Care Unit. Had a repeat head CT scan on the morning after admission, which was found to be stable, and the patient was transferred to the regular floor. The patient was transferred to the regular floor, seen by Physical Therapy and Occupational Therapy, and found to be safe for discharge to home. He also underwent a brain MRI to rule out tumor involvement and this was negative.He will follow up with Dr. [**Last Name (STitle) 1132**] in one week with a repeat head CT scan. DISCHARGE MEDICATIONS: 1. Synthroid 50 mcg po q day. 2. Zantac 150 mg po bid. 3. Oxycodone 5 mg po q4h prn for moderate-to-severe headache. CONDITION ON DISCHARGE: Stable. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2156-1-20**] 13:19 T: [**2156-1-20**] 13:19 JOB#: [**Job Number 106929**]

Admission Date: [**2141-10-27**] Discharge Date: [**2141-12-18**] Date of Birth: [**2141-10-27**] Sex: F Service: NEONATOLOG HISTORY OF PRESENT ILLNESS: The 1100 gram product of a 28 and [**1-11**] week gestation, Baby Girl [**Name2 (NI) 4027**] was born to a 37 year-old G unknown, P1 female with prenatal screens after delivery that were A positive, antibody negative, Rubella immune, RPR non-reactive, hepatitis surface antigen negative. Other prenatal information was limited given that the mother undertook no prenatal care. Mother developed acute abdominal pain early on the morning of delivery and called 911, however she deliver precipitously at 3:10 AM prior to the arrival of EMS. The EMTs described the baby as active and breathing well on arrival and a found an Apgar score of 8 minutes without the time being noted. They wrapped the baby in baby towels and transferred the baby by ambulance with mother to the [**Hospital1 69**], where the baby was brought directly to the newborn Intensive Care Unit. On arrival the baby appeared [**Name2 (NI) **] with good spontaneous activity, although she appeared mildly hypotonic. Vital signs were temperature 92.0 F per rectum, heart rate 122, respiratory rate 55, blood pressure 59/27 with a mean BP of 38. Weight was 1.1 kilos which was at the 50th percentile. Length was 34 cm which was at the 15th percentile. Head circumference was 24 cm which was between the 5th and 10th percentile. Valid was consistent with a 29 week gestation pregnancy. Head, eyes, ears, nose and throat: Prominent molding, anterior fontanelle soft and flat. The sutures were mobile. The palate was intact. Respiratory: Only fair air entry was noted bilaterally with mild retractions also noted. Cardiovascular: S1, S2 were of normal intensity, no murmur appreciated. Capillary refill was slightly delayed at two seconds, but overall profusion was good. Abdominal: Soft with normal bowel sounds, no masses or organomegaly noted. A 3 vessel cord was noted. GU: Normal [**Doctor First Name **] female external genitalia. The anus was normally placed. Neurologic: Tone was overall mildly reduced, but was symmetric. Initial dextrose stick was 58. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. RESPIRATORY: Initially intubated with a 3.0 endotracheal tube. The baby was given one dose of Surfactant and was able to be weaned off mechanical ventilation by the second day of life. The baby continued on [**Name (NI) 39000**] through day of life #6. Nasal cannula therapy was discontinued by [**12-9**]. The baby was off of diuretics by [**12-12**]. There have been no episodes of apnea or bradycardia since being off of the diuretics. 2. CARDIOVASCULAR: The baby did not require pressor therapy; however a murmur was noted by [**11-1**]. Echocardiogram revealed a moderate PDA for which Indomethacin was given for one course. The infant was hemodynamically stable thereafter. 3. FLUIDS, ELECTROLYTES AND NUTRITION: Initially NPO, the baby was on TPN by the second day of life. Enteral feedings were started on [**11-2**] and were advanced to maximum calories of PE 30 with ProMod by [**11-15**]. Given good growth, the baby has been on [**Name (NI) 37112**] 24 for the past week and taking it p.o. without difficulty over the last week. Minimum feedings have been 130 cc per kilo per day and the weight on discharge is 2510 grams. 4. GASTROINTESTINAL: Started on phototherapy for hyperbilirubinemia. The baby had a maximum bilirubin total of 11.6 on [**10-29**]. Phototherapy was discontinued by [**11-5**] and the baby had a rebound max bilirubin of 4 on [**11-6**]. 5. HEMATOLOGY: Initial hematocrit was 65.1%. The baby did not receive any transfusions during this admission. The last hematocrit was drawn on [**12-5**] and was 32.5%. The baby has received iron therapy and vitamin E during this admission. 6. INFECTIOUS DISEASE: Initially on Ampicillin and Gentamycin for the presenting history, the child was treated with a seven day course. Blood cultures were no growth [**Name6 (MD) **] the NNP notes. 7. NEUROLOGIC: The initial maternal tox screen was positive for cocaine. There were no other positive screens in follow up testing. Initial head ultrasound done on [**10-30**] was without evidence of hemorrhage. Follow up head ultrasound performed on [**11-28**] showed a left subependymal cyst was considered consistent with an early general matrix hemorrhage. There was no evidence of periventricular leukomalacia. 8. SENSORY: Etiology hearing screen was performed with automated auditory brainstem responses. The baby passed this hearing screen. 9. OPHTHALMOLOGY: Seen on [**11-29**], the baby was felt to have mature retinas bilaterally. Follow up was suggested at eight months. 10. PSYCHOSOCIAL: The [**Hospital1 69**] Social Work Service was involved with the mother. The contact social worker was [**Name (NI) **] [**Name (NI) **] whose page number is [**Numeric Identifier 45010**]. She can also be reached at [**Telephone/Fax (1) 8717**]. DSS was also involved. Ms. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was the case worker and her phone # [**Telephone/Fax (1) 45011**]. A 51-A has been filed. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: The baby is being discharged to home under the mother's care. PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and his clinic phone # [**Telephone/Fax (1) 38541**]. The first appointment with the pediatrician is to be in two days on [**12-20**] at 8:20 in the morning. CARE RECOMMENDATIONS: 1. Feeds at discharge [**Month/Year (2) 37112**] 24 with iron. Also the baby is to receive some supplementary iron sulfate which would be 0.2 milliliters of 25 mg elemental Ferrous Sulfate per ml solution. 2. Care seat testing was passed on [**12-15**]. 3. Newborn screens were sent multiple times. Most recently on [**11-15**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**] Dictated By:[**Last Name (NamePattern4) 45012**] MEDQUIST36 D: [**2141-12-18**] 10:50 T: [**2141-12-18**] 12:05 JOB#: [**Job Number 45013**]

Admission Date: [**2191-12-8**] Discharge Date: [**2191-12-23**] Date of Birth: [**2191-12-8**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 58859**] is an 850 gram product of a 26 and 6/7 weeks gestation born to a 35-year-old gravida 2, para 1 (now 2) mother with prenatal screens blood type O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B negative, group B strep unknown. The pregnancy was complicated by pregnancy induced hypertension. The mother was admitted at 25 weeks for betamethasone and bed rest. Her preeclampsia worsened and she developed thrombocytopenia, so baby boy [**Name (NI) 58859**] was delivered by cesarean section. In the delivery room he was initially limp and apneic. He required positive pressure ventilation and intubation in the delivery room. His Apgar scores were 3 at 1 minute and 7 at 5 minutes of life. He was transferred to the Neonatal Intensive Care Unit for management of his issues or prematurity. INITIAL PHYSICAL EXAMINATION: Birth weight was 850 grams (50th percentile), the length was 33.5 cm (25th percentile), and head circumference was 44.25 cm (25th percentile). In general, baby boy [**Name (NI) 58859**] was an intubated preterm male. Active and in no acute distress. HEENT examination revealed a normocephalic infant with an anterior fontanel that was open and flat with an intact palate. His neck was supple. His lungs had equal breath sounds bilaterally but were coarse. His heart examination revealed a regular rate and rhythm with no murmurs and bilateral 2 plus femoral pulses. His abdomen was soft without organomegaly and had no bowel sounds. His GU examination revealed a normal preterm male. His anus was patent. His clavicles were intact. His hips were stable. His neurological examination revealed slight hypertonia. SUMMARY OF HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY: Baby boy [**Known lastname 58859**] had an initial poor respiratory effort and was thus intubated in the delivery room. He was treated with two doses of Surfactant and did very well; extubating from low settings to CPAP of 6 cm at about 24 hours of life. As he was less than 1000 grams at birth, he was treated with 12 doses of vitamin A. Since extubation he has been quite stable on CPAP 6 cm and less than 30 percent oxygen; primarily in 21 percent. He was bolused with caffeine at the time of his extubation. At the time of this interim summary, he has [**5-4**] apnea of bradycardia spells per day. These seem to be related to thick secretions for which he requires suctioning. 2. CARDIOVASCULAR: Baby boy [**Known lastname 58859**] was hemodynamically stable on admission. He developed a murmur on day of life two and received a single course of indomethacin. Echocardiogram showed his patent ductus arteriosus to be closed. He has had no further murmur or other cardiovascular issues since that time. His blood pressures and perfusion have been normal. 3. FLUIDS, ELECTROLYTES AND NUTRITION: Baby boy [**Known lastname 58859**] was initially held nothing by mouth and started on parenteral nutrition and intravenous fluids at 100 cc/kg per day. His total fluids were gradually advanced to 150 cc/kg per day. On day of life five, he had hyperglycemia with Dextrostix's in the 200 to 300 range. He received a second rule out sepsis for this, but appeared clinically well. No cause of his hyperglycemia was found. He received a single dose of intravenous insulin for a peak blood sugar of 348 with good affect. Blood sugars fell into the 100 range and have been stable between 100 and 150 since that time. Trophic feedings were begun on day of life six and have been successfully advanced to full feedings of breast milk or Special Care 24 calories per ounce at 150 cc/kg per day at the time of this summary, day of life 15. Electrolytes have been stable. Urine output and stooling have been normal. BUN and creatinine were slightly elevated on day of life six with BUN of 26 and a creatinine of 0.6. These had fallen by day of life nine to a BUN of 17 with a creatinine of 0.6. 4. HEMATOLOGIC: Baby boy [**Known lastname 58860**] initial hematocrit was 48.7 percent on admission. He has not required any blood products thus far. Iron and vitamin E were begun on [**12-23**] (day of life 15). His most recent hematocrit was 39.3 percent on day of life six. Bilirubin at 24 hours of life was 4.4; for which he began phototherapy. Bilirubin peaked at 4.5 on day of life six. Phototherapy was discontinued on day of life seven, and a rebound was 2.8. 5. INFECTIOUS DISEASE: Baby boy [**Known lastname 58859**] was delivered primarily for maternal reasons, and was clinically well at delivery, he received a complete blood count and blood culture but was not treated with antibiotics. His initial complete blood count had a white count of 7000 with 31 percent polys and no bands. His platelet count was normal at 218,000. On day of life six, with his sudden increase in blood glucose - that was otherwise unexplained - a complete blood count and blood culture were again sent. Complete blood count at that time had a white count of 7.8 thousand with 30 percent polys and 1 percent bands. Blood cultures remained negative and antibiotics were discontinued after 48 hours. Baby boy [**Known lastname 58859**] has had no further infectious issues at the time of this interim summary. 6. NEUROLOGIC: Baby boy [**Known lastname 58859**] had his first head ultrasound on day of life seven ([**12-15**]). This revealed no intraventricular hemorrhage or other abnormality. He will have a repeat head ultrasound at day of life 30. 7. SENSORY: A hearing screening has not yet been performed but is recommended prior to discharge. Baby boy [**Known lastname 58859**] has not yet had his first ophthalmologic examination, but this will be performed at four to six weeks of life. CONDITION AT TIME OF INTERIM SUMMARY: Stable. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 58861**] of [**Location 50977**]. CARE RECOMMENDATIONS AT TIME OF INTERIM SUMMARY: 1. Feedings are breast milk or Special Care 24 at 150 cc/kg per day; all NG. 2. Medications include caffeine, vitamin A, iron, and vitamin E. 3. Car seat position screen has not yet been performed but should be done prior to discharge. 4. A State newborn screen has been sent. 5. No immunizations have yet been received, but hepatitis B is recommended prior to discharge. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: (1) born at less than 32 weeks gestation; (2) born between 32 and 35 weeks gestation with two of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or (3) with chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach six months of age. Before this age (and for the first 24 months of the child's life) immunization against influenza is recommended for household contacts and out of home caregivers. DISCHARGE DIAGNOSES AT TIME OF INTERIM SUMMARY: 1. Prematurity at 26 and [**5-1**] week gestation. 2. Respiratory distress syndrome. 3. Patent ductus arteriosus - resolved. 4. Feeding immaturity. 5. Hyperbilirubinemia - resolved. 6. Hyperglycemia - resolved. 7. Rule out sepsis - resolved. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**] Dictated By:[**Doctor Last Name 56593**] MEDQUIST36 D: [**2191-12-23**] 17:25:47 T: [**2191-12-24**] 09:24:07 Job#: [**Job Number 58862**]

Admission Date: [**2117-9-14**] Discharge Date: [**2117-9-15**] Date of Birth: [**2043-8-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfonamides / Bactrim / Vancomycin Attending:[**First Name3 (LF) 2297**] Chief Complaint: Reason for MICU admission: Drug reaction Major Surgical or Invasive Procedure: Placement of Central Line History of Present Illness: hpi: 74 yo female presents to ED from [**Hospital 100**] Rehab with pruritic, painful rash over trunk, chest, back, arms, and proximal legs. Patient had been recently admitted to [**Hospital1 18**] for COPD flare requiring brief stay in the ICU, during that admission she was found to have [**3-7**] blood cultures positive for MRSA. She was started on Vancomycin and Gent at that time, Gent later discontinued but Vancomycin continued to complete a two week course after TTE was negative for vegetation. Per report from [**Hospital 100**] Rehab, rash developed on [**2117-9-9**]. Vancomycin was stopped on [**2117-9-10**], but rash continued getting worse with exfoliation and bullae concerning for [**Doctor First Name **]-[**Location (un) **]. In addition, per ED report she had positive blood cultures (GPC in clusters) from [**2117-9-12**] at [**Hospital 100**] Rehab, although the documentation from the HR stated the repeat blood cultures were negative. She was transferred to [**Hospital1 18**] for further management and dermatologic evaluation. . In the ED, she denied fevers, chills, CP, SOB, palpitations, headache, swelling in tongue, throat or wheezing. Vital signs were 96.2 111 125/74 18 100%3L. She was given Sarna lotion, Benadryl, and changed to Linezolid. . Currently she complains of prurutis and pain. Past Medical History: pmhx: 1.COPD - GOLD Stage III with FEV1 32% predicted on PFTs in [**2115**], on home O2 2.Moderate-to-severe aortic stenosis - valve area 0.9 cm, Mean gradient 29mmHg, peak velocity 3.4 on echo in [**8-/2117**] 3.Diastolic CHF 4.Obstructive sleep apnea - No formal sleep study and not on CPAP 5.Achalasia, s/p pneumatic dilatation and botulinum toxin injection of LES 6.Morbid obesity 7.Chronic lower extremity edema 8.S/P cholecystectomy: [**2102**] 9.Chronic low-back pain Social History: 4 children. One adult daughter is deceased at age 47, [**2-5**] to cancer, the remaining daughers are alive. Currently at [**Hospital 100**] Rehab, previously lived alone. remote history of tobacco use for "few years" after she was married, no ETOH. No drug use. Family History: Mother deceased at age 72, [**2-5**] to trauma. Daughter died at age 47 of cancer. Physical Exam: PE: vitals: 97.1 101-120 117/24 29 100%RA GEN: In discomfort, speaking comfortably HEENT: Sclera anicteric, erythematous rash not sparing the nasolabial folds, no stridor or OP swelling, OP clear without lesions NECK: Supple CV: RRR, [**3-9**] sys cres-descres murmur RUSB -> carotids LUNGS: Decreased air movement anteriorally ABDOMEN: Obese, soft, NTND, no HSM EXT: 3+ BL edema SKIN: Exfoliating erythematous rash with evidence of ruptured bullae over chest with dry base, back, anterior thigh, no rash on palms/soles NEURO: AAOx3, CN II-XII intact Pertinent Results: [**2117-9-14**] 06:30AM WBC-26.1* RBC-3.69* HGB-10.5* HCT-32.4* MCV-88 MCH-28.3 MCHC-32.2 RDW-16.1* [**2117-9-14**] 06:30AM NEUTS-92.3* BANDS-0 LYMPHS-4.9* MONOS-2.0 EOS-0.7 BASOS-0.1 [**2117-9-14**] 06:30AM PLT SMR-NORMAL PLT COUNT-292 . [**2117-9-13**] 06:55PM GLUCOSE-114* UREA N-24* CREAT-0.8 SODIUM-134 POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-36* ANION GAP-10 . Pertinent results: CXR: Bedside AP and lateral views labeled "upright, stretcher at 10:00 p.m." are compared with PA and lateral views dated [**2117-8-29**]. Allowing for differences in radiographic technique, motion-blurring and patient positioning, the overall appearance is essentially unchanged. There is evidence of pulmonary hyperinflation with diaphragm flattening, suggestive of underlying obstructive lung disease, but no focal airspace process is seen. The cardiomediastinal silhouette and pulmonary vessels are unchanged with no evidence of CHF. DISH involving the thoracic spine is redemonstrated. . ECHO [**8-/2117**]: Mild LAE, mild LVH, normal function (EF>55%). RV size and free wall motion normal. Mod to severe AS, no AR. trivial MR. . EKG: . UA: small leuks, neg nit, occ bacteria, 0-2 WBC Brief Hospital Course: A/P: 74F Vancomycin for MRSA bacteremia, transferred from [**Hospital 100**] Rehab for worsening rash and persistent bacteremia. . # Rash: On presentation, dermatology was consulted. They believe that it is most consistent with AGEP (acute generalized exanthematous pustulosis), which is a drug hypersensitivity recation. Fever and leukocytosis can acompany this reaction. They recommened supportive care. A biopsy was taken and should be follow up after the patient is discharged. Petrolatum can be applied to entire body surface [**Hospital1 **]-TID to help with healing. Also, ABD pads or other cushioning in intertriginous areas to prevent trauma as well as viscous lidocaine prn oral comfort. She will need suture removal in [**10-17**] days and should follow up at dermatology clinic. ([**Telephone/Fax (1) 1971**] to schedule a follow-up appointment.) The patient was also aggressively hydrated because of the large volume of fluids that she is losing from her skin. . # Bacteremia: Unclear etiology but likely pulmonary; from previous admission. The patient remained afebrile despite growing [**3-7**] blood cultures for gram positive cocci in clusters during that admission. TTE was performed at that time revealing knwon stable AS with a thickened valve but no evidence of vegetation. The patient's vancomycin was stopped on admission and she was started on Linezolid. Repeat blood cultures are pending at the time of discharge. She will need a total of a 14 day course starting from [**9-7**] (ending on [**9-21**]). Medications on Admission: Meds(per last dc summary, needs to be confirmed) Aspirin 325 mg PO DAILY Furosemide 40 mg Tablet PO DAILY Ipratropium Bromide neb Inhalation Q6H Albuterol Sulfate neb Inhalation Q6H Aluminum-Magnesium Hydroxide QID as needed. Miconazole Nitrate Topical [**Hospital1 **] Pantoprazole 40 mg PO Q24H Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q4-6H Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for pruritis. 5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheeze. 8. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for SOB, wheeze. 9. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: [**1-5**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID (3 times a day) as needed. 12. Petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 13. Linezolid 600 mg IV Q12H 14. Morphine Sulfate 2-4 mg IV Q3-4H:PRN pain Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Rash secondary to vancomycin Discharge Condition: stable Discharge Instructions: You were admitted with a rash secondary to an antibiotic that you had taken. During your stay, your antibiotics were changed and you were treated with fluids and aquaphor cream. You will need to continue taking the Linezolid medication to complete a 14 day course (to be completed on [**9-21**]) Followup Instructions: You will be discharged to the MACU at [**Hospital 100**] Rehab for ongoing care. --Please arrange for suture removal in [**10-17**] days. --Please call the dermatology clinic at [**Telephone/Fax (1) 1971**] to schedule a follow-up appointment.

Admission Date: [**2188-7-15**] Discharge Date: [**2188-7-18**] Date of Birth: [**2159-7-30**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: s/p Gunshot wounds to left chest/posterior neck Major Surgical or Invasive Procedure: [**2188-7-15**] FLEXIBLE BRONCHOSCOPY; ESOPHAGOGASTRODUODENOSCOPY History of Present Illness: 28 y/o M s/p GSW with 2 wounds, left chest/axilla region and other to posterior neck. Intubated at the scene and taken to an OSH where a needle decompression of left hemothorax was performed and had chest tube placed. Received 2 units PRBC prior to transport. Once at [**Hospital1 18**] it was noted that not much was draining from the left chest tube and another was placed in the ED. CT scan showed bony damage to clavicle, no great vessel injury. EGD and Bronch in the OR showed no esophageal, tracheal or bronchial injury. Patient arived intubated and sedated. Past Medical History: Unknown Social History: + ETOH, no tob Family History: Noncontirbutory Physical Exam: Temp:97.7 HR: 82 BP: 128/67 RR: 18 O2 Sat:100% @ ACVC 100% 16 x 500, PEEP: 5 GENERAL: intubated and sedated HEENT: C-collar in place RESPIRATORY: chest tubes x 2 present in Left midaxillary line, entry wound in midaxillary line a 3rd interspace CARDIOVASCULAR: pulses equal b/l, RRR GI: S NT/ND NEURO: intubated and sedated, MAE Pertinent Results: [**2188-7-15**] 06:04AM GLUCOSE-97 UREA N-10 CREAT-0.8 SODIUM-141 POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-19* ANION GAP-16 [**2188-7-15**] 06:04AM CALCIUM-8.0* PHOSPHATE-3.5 MAGNESIUM-1.6 [**2188-7-15**] 06:04AM WBC-17.6* RBC-5.00 HGB-14.8 HCT-44.3 MCV-89 MCH-29.6 MCHC-33.4 RDW-14.8 [**2188-7-15**] 06:04AM NEUTS-73* BANDS-1 LYMPHS-15* MONOS-8 EOS-1 BASOS-1 ATYPS-1* METAS-0 MYELOS-0 [**2188-7-15**] 06:04AM PLT COUNT-237 [**2188-7-15**] 06:04AM PT-12.7 PTT-24.7 INR(PT)-1.1 [**2188-7-15**] 04:49AM TYPE-ART PO2-283* PCO2-44 PH-7.28* TOTAL CO2-22 BASE XS--5 [**2188-7-15**] 03:00AM ASA-NEG ETHANOL-281* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG IMAGING: - [**7-15**] (CXR): 1. ET tube and left chest tube in place. 2. Left hemithoracic opacity may represent pleural effusion. 3. Comminuted left clavicular fracture. - [**7-15**] (CT Head): no ICH, L maxillary air-fluid level, no fx - [**7-15**] (CT C-spine): 1. No fx/malalignment of cervical spine. 2. Left clavicle comminuted fx, 3. Nondisplaced fx C7 L lat mass. - [**7-15**] (CT C/A/P): LUL hemorrahage, concern for L subclavian injury, ascending/transverse colon bwl wall thickening. - [**7-15**] (CTA Head/Neck):- AICA/PICA intact, ?Lsc vessel inj - [**7-15**] (MRA neck): - 1. No bone marrow edema is seen in association with the known fracture of the left posterior elements of C7, likely due to the low ratio of bone marrow to cortex. No evidence of ligamentous injury, cord injury, or epidural hematoma. 2. Posterior paravertebral soft tissue edema, R>L 3. No vertebral or ICA intramural hematoma or dissection. [**2188-7-17**] CXR post CT removal : 1. Resolving left upper lobe pulmonary contusion. 2. Probable very small left apical pneumothorax. Brief Hospital Course: He was admitted to the Acute Care team and transferred to the Trauma ICU. His ICU course was as follows: On [**7-15**], the patient was intubated in the field and brought to the ICU. He had 1 left CT placed at the OSH, the other was placed upon arrival to [**Hospital1 18**]. He received 2 units of PRBCs at the outside hospital. A bronch and EGD were down and both negative. The patient was initially on propofol gtt and neo gtt at 0.5. The Neo was discontinued upon arrival to the TICU as his blood pressure was stable. He was given 3L of crystalloid during his EGD and bronch and his uop was adequate. MRA of the neck was performed that did not show any vertebral artery injury and the basilar CT was pulled. His aline was also pulled. On [**7-16**], the patient was extubated and transitioned to dilaudid pca for pain control. He was doing well and was hemodynamically stable. He was transferred to the floor on [**7-16**]. He was transferred to the regular nursing unit in the late afternoon on [**7-16**] with 1 remaining chest tube to water seal. he was noted with some pain control issues requiring continuation of PCA Dilaudid. On the following morning his chest tube output was minimal and the decision was made to pull the chest tube. A post pull chest film was ordered showing a tiny left apical space. He remained without shortness of breath and able to use his incentive spirometer. He was given a regular diet and changed to oral narcotics for pain control which was effective. Social work was consulted due to the nature of his trauma; he was offered assistance from the Center for Violence Prevention and Recovery. He is being discharged to home and will follow up in Acute Care clinic in about 1 week for repeat chest xray. He will also follow up in the [**Hospital **] Clinic in 2 weeks. Medications on Admission: Denies Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: s/p Gunshot wound to left chest and posterior neck Left clavicle fracture Left hemopnuemothorax 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 after a gunshot wound to your left chest and back of your neck. You required that 2 chest tubes be placed into your lung to drain the blood and excess air. You underwent a procedure to check your the inside of your lungs and swallowing pipe which did not sho any abnormalities. You are being discharged to home with the following instructions: *If you notice that you are short of breath, coughing up blood and/or having any difficulty with breathing you should return to the Emergency room immediatley. *Keep the bandage on your left chest in place for at least the next 5 days. It is OK to shower with this bandage just cover it with Saran wrap and tape around the edges of the wrap. *Avoid smoking tobacoo or other illicit drugs. *You should not fly as high altitudes can interfere with the pressure in your lungs. *Because of your broken collar bone you should wear a sling when you get out of bed. Avoid putting full weight on your left arm. *You have been prescribed narcotics for pain - DO NOT drink alcohol, take illicit drugs, drive and/or operate heavy machinery while on the se medications. Take a stool softener and laxative to prevent constipation. Followup Instructions: Follow up in Acute Care clinic next week for a chest xray to evaluate your injuries. Upon discharge please call [**Telephone/Fax (1) 600**] to make this appointment. Follow up in 2 weeks in [**Hospital 5498**] clinic for your clavicle fracture, call [**Telephone/Fax (1) 1228**] upon discharge to make this appointment. Completed by:[**2188-7-18**]

Admission Date: [**2143-12-17**] Discharge Date: [**2143-12-20**] Date of Birth: [**2083-5-22**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin Hcl / Diphenhydramine / baclofen Attending:[**First Name3 (LF) 10435**] Chief Complaint: Shortness of Breath - Outside hospital transfer for pneumonia. Major Surgical or Invasive Procedure: Intubation and mechanical ventilation at outside hospital PICC Line Placement History of Present Illness: Ms. [**Known lastname 31824**] is a 60 year old woman s/p OLT in [**2142**] due to HCV cirrhosis with recurrent hep C (on peg-interferon) and ESRD on dialysis who was admitted to OSH MICU for pneumonia and is now transferred to [**Hospital1 18**] for further management. She was in her usual state of health until the day of admission ([**2143-12-15**]) when she woke up with SOB and cough productive of frothy pink sputum. . In the OSH ED she was febrile to 101.2. CXR showed bilateral infiltrates, new from CXR taken [**12-13**] in ED for evaluation of possible rib fractures s/p fall. The patient subsequently developed respiratory failure requiring intubation. She was started on IV Zosyn and Azithromycin. Her course was complicated by hypotension requiring Levophed, and IV Vancomycin was started. She also developed atrial fibrillation with RVR requiring IV Cardizem. Her RVR resolved and she was weaned off pressors. On HD#3 (day of transfer) she was extubated without difficulty. Her liver [**Month/Day (4) **] coordinator was [**Name (NI) 653**], and agreed to have the patient transferred to [**Hospital1 18**] for further management. . On transfer, initial vitals were T 96.3, HR 98, BP 113/60, RR 16, O2 sat 99% on 2L NC. She denies current SOB, but continues to have occasional cough productive of brown sputum. She also complains of R rib pain, which she attributes to a mechanical fall she sustained 2 days PTA. Past Medical History: -Hep C cirrhosis status post OLT on [**2142-6-13**] complicated by recurrent hep C -End Stage Renal disease on dialysis -Esophageal varices -AFib, status post ablation x2 -EtOH, EtOH abuse -Status post left SFA stent for traumatic AV fistula. -History of recurrent UTI with VRE and ESBL Klebsiella. -Hypothyroidism. -Biliary stricture - ERCP with 3 stents placed on [**10-28**] -Fibromyalgia Social History: She lives alone. Daughter lives 20 minutes away from her; very involved in her care. She denies current ETOH, smoking or drug use. Has hx of ETOH abuse. Family History: Father with heart problems and diabetes Physical Exam: Admission Exam: Vitals: HR 97 120/54 99% 2 liters n/c General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: diminished breath sounds in lower right lung field, no wheezes, rales, ronchi Abdomen: soft, mildly tender, non-distended, bowel sounds present, no organomegaly. Well-healed midline scar. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . Discharge Exam: Vitals: 96.8 128/64 69 18 98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Irregularly irregular S1, S2, no murmurs, rubs, gallops Lungs: CTAB; no wheezes, rales, ronchi; right lower chest tender to palpation Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly. Well-healed midline scar. GU: no foley Ext: warm, well perfused, 2+ pulses Pertinent Results: Admission Labs: [**2143-12-17**] 09:28PM BLOOD WBC-5.5# RBC-3.10* Hgb-9.3* Hct-29.0* MCV-94# MCH-30.1 MCHC-32.1 RDW-18.6* Plt Ct-136* [**2143-12-17**] 09:28PM BLOOD Glucose-125* UreaN-38* Creat-3.5*# Na-136 K-3.4 Cl-93* HCO3-28 AnGap-18 [**2143-12-17**] 09:28PM BLOOD ALT-16 AST-29 AlkPhos-212* TotBili-0.5 [**2143-12-17**] 09:28PM BLOOD Calcium-8.3* Phos-4.3# Mg-2.4 . Discharge Labs: [**2143-12-20**] 04:50AM B1LOOD WBC-2.9* RBC-3.24* Hgb-9.5* Hct-30.3* MCV-94 MCH-29.4 MCHC-31.5 RDW-18.3* Plt Ct-139* [**2143-12-20**] 04:50AM BLOOD Glucose-90 UreaN-30* Creat-3.5*# Na-135 K-4.0 Cl-100 HCO3-25 AnGap-14 [**2143-12-20**] 04:50AM BLOOD ALT-22 AST-39 AlkPhos-194* TotBili-0.6 [**2143-12-20**] 04:50AM BLOOD Albumin-2.9* Calcium-8.2* Phos-1.8* Mg-2.0 . Sirolimus levels: [**2143-12-19**] 04:45AM BLOOD rapmycn-7.4 [**2143-12-20**] 04:50AM BLOOD rapmycn-7.6 . AP Portable CXR [**2143-12-17**]: Mild cardiac enlargement is new, mediastinal venous engorgement is more pronounced and there is persistent pulmonary [**Month/Day/Year 1106**] plethora. Edema in the left lung is mild. On the right side, there are larger areas of perihilar opacification which could be the residual of what was previously more widespread edema, or could be pneumonia or hemorrhage in the right lung. It would be very helpful to have recent prior chest radiographs. Left PIC line ends in the region of the superior cavoatrial junction. No pneumothorax. Pleural effusion, if any, is not appreciable in size. Brief Hospital Course: 60 year old female with a history of hepatitis C complicated by cirrhosis s/p OLT in [**2142**], with recurrent hep C (on peg-interferon), and ESRD on dialysis who was admitted to OSH MICU for pneumonia and transferred to [**Hospital1 18**] for further management. . #Pneumonia: Patient transferred from outside hospital with RML/RLL pneumonia, status-post two-day intubation for respiratory failure. Patient was treated for health care associated pneumonia because of her ongoing dialysis treatments. On arrival to the MICU she was afebrile with stable vital signs, breathing comfortably on NC. She was continued on IV vancomycin from OSH and her zosyn/azithromycin was changed to IV cefepime/flagyl. She was transferred to the liver service. On the floor, the patient breathed comfortably on room air with vast improvement in her cough. She was continued on ipratroprium nebs for dyspnea and incentive spirometry. She was treated with a lidocaine patch to her right chest for rib pain to prevent further splinting. The patient was discharged on vancomycin with hemodialysis and levofloxacin to complete a 14-day antibiotic course. . # Hep C cirrhosis status-post OLT with recurrent hepatitis C: Currently on peginterferon for hepatitis C. On sirolimus and mycophenolate following OLT. Sirolimus levels and LFTs remained stable throughout admission. The patient was continued on single-strength bactrim for prophylaxis. She will follow up in the [**Hospital1 **] clinic upon discharge. . # Atrial fibrillation with rapid ventricular response: The patient has a history of atrial fibrillation, on propafenone, diltiazem, and aspirin 325mg daily s/p ablation x 2. The patient had self-discontinued use of coumadin in [**2141**], as she did not want further blood draws. On admission to the outside hospital, the patient was reported to have rapid ventricular response controlled with IV diltiazem. On the liver service, the patient had several episodes of symptomatic rapid ventricular response with rates to the 120's to 150's. The patient was seen by electrophysiology, who recommended an increase in diltiazem and discontinuation of propafenone. Her rates improved. The patient was discharged on diltiazem 240 ER and ASA 325 daily. She will follow up with her outpatient cardiologist on discharge. . # Hypothyroidism: Stable. The patient was continued on home levothyroxine throughout admission. Medications on Admission: pregabalin 50 mg PO BID propafenone 150 mg TID sulfamethoxazole-trimethoprim 400-80 mg daily mycophenolate mofetil 500 mg [**Hospital1 **] zolpidem 5 mg qHS calcium carbonate 200 mg TID Nephrocaps 1 daily duloxetine 30 mg daily levothyroxine 112 mcg daily omeprazole 40 mg daily Vitamin D3 400 units daily lidocaine-prilocaine 2.5 - 3.5% cream, 1 application PRN graft pain aspirin 325 mg daily diltzac ER 180 mg daily colace 100 mg [**Hospital1 **] PRN peginterferon alfa-2a 135 mcg weekly tylenol 325 mg TID PRN polyethylene glycol 17 gram daily PRN Sirolimus 0.5 mg PO daily Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. peginterferon alfa-2a 180 mcg/mL Solution Sig: One Hundred Thirty Five (135) mcg Subcutaneous 1X/WEEK ([**Doctor First Name **]). 6. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. sirolimus 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO once a day. 12. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. Disp:*30 Capsule, Extended Release(s)* Refills:*0* 13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: to right thorax . Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0* 14. vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous HD PROTOCOL for 10 days. 15. Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO once a day. Capsule(s) 16. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO once a day. 17. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 18. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Tablet, Chewable(s) 19. Tylenol 325 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 20. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Central & [**Hospital3 29991**] [**Hospital3 **] Discharge Diagnosis: Primary diagnosis: Pneumonia Secondary diagnoses: Atrial fibrillation with rapid ventricular response, Hep C cirrhosis s/p OLT with recurrent hepatitis C, Chronic Kidney Disease V - dialysis dependent, hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 31824**], . You were admitted from an outside hospital with a pneumonia. At the outside hospital, your pneumonia required use of a tube to help you breathe for two days. You were started on antibiotics and your pneumonia improved. You were transferred to the ICU at [**Hospital1 18**] for further treatment of pneumonia, and quickly graduated to the regular medical floor. Prior to discharge, you were able to breathe comfortably without the use of oxygen. You will remain on antibiotics for 10 days following discharge. While you were in the hospital, your atrial fibrillation (irregular heart rate) caused your heart to beat rapidly. You were seen by heart specialists, who recommended stopping your propafenone and increasing diltiazem. You were discharged to home. You should follow up with your primary care physician, [**Name10 (NameIs) 2085**], and [**Name10 (NameIs) **] physician as previously scheduled. . The following changes were made to your medication regimen: STOP propafenone CHANGE diltiazem to 240 mg ER by mouth daily Start levofloxacin by mouth for 10 days You will receive vancomycin with dialysis over the next 10 days Followup Instructions: Name: NP[**First Name8 (NamePattern2) 31986**] [**Last Name (NamePattern1) **] Location: [**Hospital3 **], INC Address: 3130 STATE HWY,ROUTE 6, [**Location (un) 31977**],[**Numeric Identifier 31978**] Phone: [**Telephone/Fax (1) 31979**] Appointment: Tuesday [**2143-12-24**] 2:40pm . Department: CARDIAC SERVICES When: FRIDAY [**2144-1-3**] at 10:20 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: [**Hospital Ward Name **] When: WEDNESDAY [**2144-1-8**] at 11:00 AM With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 10438**]

Admission Date: [**2158-9-22**] Discharge Date: [**2158-9-27**] Date of Birth: [**2112-2-13**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 18654**] is a 46-year-old female whose only significant medical history is her paroxysmal atrial fibrillation for seven years. On the day of admission she presented to the [**Hospital1 346**] for an elective ablation of her atrial fibrillation as well as atrial flutter ablation. Her procedure was complicated by hypotension and bradycardia requiring pressors, initially dopamine which led to tachycardia and then was changed to Neo-Synephrine. Originally, these symptoms were thought to be medication related. STAT echocardiogram showed no pericardial effusion, good left ventricular function. The patient subsequently developed right lower quadrant tenderness and an emergent abdominal CT was performed which revealed a retroperitoneal bleed with additional bleeding into the abdomen. A surgical consultation was obtained, and the patient was transferred to the Coronary Care Unit for further management. PAST MEDICAL HISTORY: Significant for atrial fibrillation and atrial flutter. MEDICATIONS ON ADMISSION: Toprol 75 mg p.o. q.d. and Coumadin (which had been stopped a day or two prior to the procedure). ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is married, works as an importer of linens. Denies tobacco. Denies alcohol. PHYSICAL EXAMINATION ON PRESENTATION: The patient was pale and tired but in no acute distress. Vital signs included a blood pressure of 106 to 120s/31 to 60s, pulse 70s to 80s, satting 100% on room air, afebrile. Neck was supple with no jugular venous distention. Cardiac examination revealed a regular rate and rhythm. No murmurs, rubs or gallops. Lungs were clear to auscultation bilaterally. Abdominal examination was soft with slight tenderness in the right lower quadrant, suprapubic. No rebound. Positive bowel sounds. Extremities had no edema. Groin had access sites in the femoral area which was healing. No acute bleed. No hematoma. LABORATORY DATA ON PRESENTATION: Laboratories on admission included a hematocrit of 27.6 (it had been 35.8 on admission that day and had been 33.3 on completion of the electrophysiology study). Chem-7 was within normal limits. INR was 1.5, PTT 23.8. RADIOLOGY/IMAGING: Chest x-ray had no effusions, no congestive heart failure. Abdominal CT had shown a pelvic hematoma extending into the right hemiabdomen and mesentery free intraperitoneal fluid, consistent with hemoperitoneum. HOSPITAL COURSE: 1. ABDOMINAL BLEED: The patient was stable on admission. A central line cordis was inserted, and the patient was transfused 4 units of blood overnight which bumped her hematocrit to 33. She was then observed and given aggressive fluid hydration, and on hospital day two had shown no further decrease in hematocrit. Her blood pressure had remained stable. She was not on any pressors, and she was deemed safe to go to the floor. She was sent to the floor, and her hematocrits were monitored daily until the day of discharge and remained stable that entire time. Her abdominal pain resolved, and it was presumed that any bleeding which had occurred had resolved at the time of discharge. 2. ATRIAL FIBRILLATION/FLUTTER: The patient was in sinus rhythm when she was admitted to the Coronary Care Unit and remained this way until hospital day two when she had an episode of atrial tachycardia documented by electrocardiogram. It was decided through consultation with Dr. [**Last Name (STitle) 73**] to start her on Norpace for this, which was done. Additionally, she was started on Lopressor. Despite this, she continued throughout her hospital stay to have episodes of atrial tachycardia. She was symptomatic from these in that she felt palpitations and lightheadedness, although her blood pressure never significantly dropped. Orthostatics were checked several times, and she would have approximately 10-mm drops in systolic blood pressures going from sitting to standing. On the day of discharge, the patient's hematocrit was stable. She was not orthostatic. At the time of discharge, she was in sinus rhythm and had been so for approximately 18 hours. It was decided through consultation with Dr. [**Last Name (STitle) 73**] that it was okay to send her home. We will send her out on control-released Norpace 200 mg p.o. b.i.d. and metoprolol 25 mg p.o. b.i.d. She will also be sent home on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor and will follow up with Dr. [**Last Name (STitle) 73**] in approximately two to three weeks. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: To home. MEDICATIONS ON DISCHARGE: 1. Norpace (control released) 200 mg p.o. b.i.d. 2. Metoprolol 25 mg p.o. b.i.d. DISCHARGE FOLLOWUP: Followup was with Dr. [**Last Name (STitle) 73**]. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**MD Number(1) 25755**] Dictated By:[**Last Name (NamePattern1) 1213**] MEDQUIST36 D: [**2158-9-27**] 14:46 T: [**2158-9-30**] 04:40 JOB#: [**Job Number 32997**] (cclist)

Admission Date: [**2117-3-30**] Discharge Date: [**2117-4-3**] Date of Birth: [**2037-5-2**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5510**] Chief Complaint: Lower GIB Major Surgical or Invasive Procedure: 4 units of packed red blood cells History of Present Illness: 79 year old female with a past history of hypertension, type 2 diabetes, CAD s/p CABG x 4 and history of lower gastrointestinal bleeding of unclear source who presents to the emergency room with 4 days of "vaginal bleeding." Patient reports that she first noted that she was bleeding on Saturday. It was primarily bright red blood in the toilet bowel with stool with associated fecal urgency. She denies abdominal pain. This is similar to her episode of gastrointestal bleeding in [**2116-5-24**] but not as profuse. The bleeding has continued over the past three days. It is associated with mild left sided chest pressure which is not worse with exertion, dyspnea on exertion, lightheadedness and dizziness. She has not had any nausea, vomiting or hematemasis. She denies melena. She has been eating well until the day of presentation. Her urine output has been normal. Otherwise she has been in her regular state of health. . In the emergency room her initial vitals were T: 98.1 BP: 169/67 HR: 87 RR: 16 O2: 98% on RA. She received one liter of normal saline. She had a CXR which showed no acute process. She had a normal EKG. She had two 20 g IVs placed and one liter of PRBCs was hung. Vaginal exam was within normal limits. Rectal exam showed no external hemorroids and gross blood at the anus. She was hemodynamically stable throughout her time in the ER. She was admitted to the MICU for further management. . Upon arrival to the MICU she denied any complaints. Her lightheadedness, dizziness, chest pain and dyspnea have resolved. Her last bowel movement was morning of admission. She denies nausea, vomiting or abdominal pain. No dysuria or hematuria or decreased urine output. No leg pain or swelling. All other review of systems negative in detail. Past Medical History: Past Medical History: - Coronary Artery s/p CABG [**2107**] - Peripheral Vascular Disease - Stage III chronic kidney disease (baseline creatine 1.3) - Hypertension - Type II Diabetes complicated by retinopathy, nephropathy - Diverticulosis seen on colonoscopy [**5-31**] - s/p toe amputation Social History: She is a retired administrator at [**Street Address(1) 5904**] Inn. She works out at a senior gym three times a week. She does not smoke cigarettes, drink alcohol, or use any recreational drugs. She lives by herself but has family in the area. Family History: Diabetes mellitus-- mother, brother, and sister [**Name (NI) 5905**] mother, father. There is no history of kidney disease. No family history of gastrointestinal bleeding. Physical Exam: On admissions - Vitals: T: 98.4 BP: 136/72 HR: 73 RR: 14 O2: 99% on RA Orthostatics: 122/59 (73); 119/67 (78); 112/55 (69) General: Well appearing elderly female, no acute distress [**Name (NI) 4459**]: Sclera anicteric, moist mucous mebranes, oropharynx clear Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Heart: RRR, s1 + s2, no murmurs, rubs, gallops Abd: soft, non-tender, non-distended, +BS Ext: Warm and well perfused, 1+ pulses, no clubbing, cyanosis or edema Neuro: grossly intact Skin: no rashes or jaundice Pertinent Results: CHEST (PORTABLE AP) Study Date of [**2117-3-30**]: IMPRESSION: No acute pulmonary process. HEMATOLOGY: [**2117-3-30**] 12:55PM BLOOD WBC-9.2 RBC-2.43*# Hgb-7.2*# Hct-21.3*# MCV-88 MCH-30.7 MCHC-34.9 RDW-15.1 Plt Ct-283 [**2117-3-30**] 07:34PM BLOOD Hct-26.6* [**2117-3-31**] 04:10AM BLOOD WBC-8.9 RBC-3.77*# Hgb-11.1*# Hct-31.6* MCV-84 MCH-29.5 MCHC-35.2* RDW-16.2* Plt Ct-207 [**2117-3-31**] 06:44PM BLOOD Hct-30.2* COAGS: [**2117-3-30**] 12:55PM BLOOD PT-13.6* PTT-29.0 INR(PT)-1.2* [**2117-3-31**] 04:10AM BLOOD PT-13.2 PTT-29.3 INR(PT)-1.1 CHEMISTRY: [**2117-3-30**] 12:55PM BLOOD Glucose-298* UreaN-43* Creat-1.4* Na-138 K-4.8 Cl-107 HCO3-23 AnGap-13 [**2117-3-31**] 04:10AM BLOOD Glucose-157* UreaN-33* Creat-1.1 Na-141 K-4.1 Cl-111* HCO3-22 AnGap-12 CARDIAC ENZYMES: [**2117-3-30**] 12:55PM BLOOD CK(CPK)-224* [**2117-3-30**] 12:55PM BLOOD CK-MB-7 [**2117-3-30**] 12:55PM BLOOD cTropnT-0.02* [**2117-3-30**] 07:34PM BLOOD CK(CPK)-208* [**2117-3-30**] 07:34PM BLOOD CK-MB-6 cTropnT-0.01 [**2117-3-31**] 04:10AM BLOOD CK(CPK)-172* [**2117-3-31**] 04:10AM BLOOD CK-MB-5 cTropnT-0.02* Brief Hospital Course: MICU COURSE: Patient presented with a hematocrit of 21 down from her baseline of ~35. Gastroenterology was consulted and reported that this was a likely diverticular bleed given her history of diverticulosis on colonoscopies in the past. She was to be treated conservatively with transfusions and monitoring. She received a total of 4 units of packed red blood cells following admission and had an appropriate HCT bump to 31.6. Serial HCTs on [**2117-3-31**] revealed stabilized of her HCT at ~30 prior to transfer to the floor. Her initial episode of chest pain in the ED was not repeated following resuscitation with PRBCs. She had a rule out for MI with three serial sets of cardiac enzymes with downtrending CKs and normal troponins throughout. Concerning her chronic kidney disease, at presentation she was at her baseline Cr of approximately 1.3 and this fell to 1.1 on morning prior to transfer out of MICU. Given her unknown volume status, her home antihypertensives were initially held and after assurance of stable hemodynamics, she was restarted on lisinopril. Concerning her diabetes, she was managed with a lower dose of lantus given that she was NPO when presenting to the unit. After stabilization of her HCT, she began a diet of clears that was to be advanced as tolerated. In the MICU the patient had no bowel movements and was hemodynamically stable throughout her stay in the MICU. She was feeling well when transferred out of the MICU. . MEDICINE FLOOR COURSE: Patient had several red, guaiac positive BMs on the floor but remained Hd stable and did not receive any further transfusions. On the day of discharge, patient had guaiac postive stools that was brown. Her lisinopril and metoprolol were continued but HCTZ was held. Patient also had her ASA held given GIB with plan to restart when she follows up with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**] next week. She was restarted on her home dose of Lantus on the floor and was managed on an insulin sliding scale. Medications on Admission: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID 3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO daily 4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic TID 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable daily 7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY 8. CALCIUM 500+D 500 (1,250)-200 mg-unit daily 9. Lantus 100 unit/mL Solution Sig: Forty Five (45) units SC at HS. 10. Insulin Sliding Scale Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45) Units Subcutaneous at bedtime. 6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Insulin Aspart Subcutaneous Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: GI bleed requiring blood transfusion Secondary: Diabates, Chronic kidney disease, Coronary artery disease Discharge Condition: stable, afebrile Discharge Instructions: You presented to the hospital with a gastroentestinal bleed. This was felt to be secondary to diverticula (or outpouchings) in your colon. You were initially admitted to the ICU for monitoring and received 4 units of blood. Your blood counts stablaized prior to discharge and you were tolerating a regular diet. . All of your medications were continued except aspirin and hydrochlorothiazide which you should continue to hold until you see Dr. [**Last Name (STitle) 131**] next week. Please keep your appointment with Dr. [**Last Name (STitle) 131**] this [**Last Name (STitle) 2974**]. . Please seek immediate medical attention if you note blood in the stool, dizziness, shortness of breath, chest pain, abdominal pain, vomitting, fevers, chills or any change from your baseline health status. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 131**] at your previously scheduled appointment on [**2117-4-9**]. Call [**Telephone/Fax (1) 133**] if you need to reschedule. Completed by:[**2117-4-4**]

Admission Date: [**2130-7-16**] Discharge Date: [**2130-7-18**] Date of Birth: [**2043-4-12**] Sex: M Service: MEDICINE Allergies: Demerol Attending:[**Last Name (un) 11220**] Chief Complaint: Fall Major Surgical or Invasive Procedure: R IJ central line placement and removal History of Present Illness: History of Present Illness: Mr. [**Known lastname 13639**] is 87M with history of dementia, diastolic CHF (EF%60), HTN who presented s/p fall. The patient was taking a shower at 3AM this morning when her son her a pounding sound. The patient's son found the patient laying on the floor of the shower; unsure if there was LOC. The patient reports that he was in the shower this morning when he slipped and fell; denies hitting his head. Denies any chest pain, denies any shortness of breath. Denies having any light headedness or dizziness. In the ED, initial VS were 91/68 90 RR 34. While in the ED, the patient's only complaint was back pain, which moved after he was transferred off stretcher. The patient was noted to be tachycardic to the 160s by EMS. Of note, as per report, the patient was given Dilt by EMS during transit to [**Hospital1 18**]. The patient was intermittently tachycardic while in the ED with heart rates to the 110s. His pressures dropped as low as the 60s systolic; the patient responded to IVF with pressures recovering to the 90-100s. However, his pressures soon dropped again into the 70s and a R IJ was placed and the patient was started on Levophed. The patient was also initially 86% on RA, and maintained his sats on face mask. The patient also had multiple imaging studies done, with no e/o acute source of infection, or any acute intracranial pathology. Labs notable for white count of 14, lactate of 5.8. EKG with e/o LBBB c/w priors, Scarbossa criteria negative. In total the patient received 3L IVF, and was given Vanc/Cefepime, in addition to being started on Levophed. On ROS, the patient denies having any fevers/chills. Denies any shortness of breath, no trouble breathing. Denies any chest pain. Denies any nausea/vomiting, no abdominal pain. Denies any coughing. Denies any pain or burning with urination. On arrival to the MICU, patient's VS 94.5 124/59 62 24 100% on 50% high flow mask. The patient reports feeling well, without any current complaints. Past Medical History: Patient without regular medical follow up, and self prescribes his own medications. Hypothyroidism Bilateral hypoacusis, s/p bilateral hearing aids Right eye retinal detachment Severe myopia s/p surgery with residual exotropia Atrial flutter Diastolic CHF Dementia HTN Anemia Ezcema Social History: Patient is a retired primary care physician. [**Name10 (NameIs) **] for activities of daily living. He takes care of his wife, who has developed dementia. Lives with his son, who is 57 years old and has dyslexia. Has not smoked for many years. Denies any alcohol consumption or other illicit drug use. Family History: Noncontributory. There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION EXAM: 91/68 90 RR 34 General: elderly gentleman, NAD, laying comfortably in bed, alert and appropriately answering questions, alert and oriented to person, place, time HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, + R sided surgical pupil Neck: supple, JVP not elevated CV: Regular rate and rhythm, soft SEM loudest at RUSB, S1 + S2 Lungs: crackles throughout lung fields, good air movement, no audible wheezes appreciated Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: + foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: dry areas of skin with flaking prominently on head/scalp and lower extremities; 2cm skin abrasion on coccyx, area clean with no e/o drainage Neuro: CNII-XII intact, muscle strength and sensation grossly intact, noted to have resting tremor at baseline, worse with movement Pertinent Results: ADMISSION LABS: [**2130-7-16**] 04:45AM BLOOD WBC-14.5* RBC-4.46* Hgb-13.9* Hct-43.4 MCV-97 MCH-31.2 MCHC-32.1 RDW-14.5 Plt Ct-295 [**2130-7-16**] 04:45AM BLOOD Neuts-87.5* Lymphs-7.3* Monos-1.4* Eos-3.5 Baso-0.3 [**2130-7-16**] 04:45AM BLOOD PT-11.9 PTT-24.8* INR(PT)-1.1 [**2130-7-16**] 04:45AM BLOOD Glucose-291* UreaN-33* Creat-1.7* Na-141 K-3.2* Cl-101 HCO3-19* AnGap-24* [**2130-7-16**] 04:45AM BLOOD ALT-26 AST-35 CK(CPK)-164 AlkPhos-101 TotBili-0.6 [**2130-7-16**] 04:45AM BLOOD cTropnT-0.07* [**2130-7-16**] 04:45AM BLOOD Albumin-4.0 Calcium-9.7 Phos-2.6* Mg-1.8 [**2130-7-16**] 04:49AM BLOOD Lactate-5.8* INTERVAL LABS: [**2130-7-16**] 04:45AM BLOOD CK-MB-3 [**2130-7-16**] 10:19AM BLOOD CK-MB-9 cTropnT-0.17* [**2130-7-17**] 03:28AM BLOOD CK-MB-8 cTropnT-0.09* [**2130-7-16**] 10:19AM BLOOD WBC-14.2* RBC-3.76* Hgb-11.7* Hct-35.6* MCV-95 MCH-31.2 MCHC-32.9 RDW-14.3 Plt Ct-277 [**2130-7-17**] 03:28AM BLOOD WBC-9.5 RBC-3.52* Hgb-10.9* Hct-33.7* MCV-96 MCH-31.0 MCHC-32.3 RDW-14.4 Plt Ct-230 [**2130-7-16**] 10:19AM BLOOD Glucose-176* UreaN-28* Creat-1.1 Na-143 K-3.0* Cl-108 HCO3-24 AnGap-14 [**2130-7-17**] 03:28AM BLOOD Glucose-98 UreaN-23* Creat-0.8 Na-140 K-3.7 Cl-109* HCO3-19* AnGap-16 [**2130-7-16**] 10:19AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.5* [**2130-7-17**] 03:28AM BLOOD Calcium-8.3* Phos-1.9* Mg-2.2 [**2130-7-16**] 04:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2130-7-16**] 10:45AM BLOOD Lactate-1.6 [**2130-7-16**] 10:45AM BLOOD freeCa-1.13 [**2130-7-16**] 05:40AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2130-7-16**] 05:40AM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-1 [**2130-7-16**] 05:40AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2130-7-16**] 05:40AM URINE Hours-RANDOM UreaN-645 Creat-163 Na-24 K-94 Cl-33 IMAGING: ----------- CT C SPINE: 1. No evidence of acute fracture. 2. Extensive degenerative changes in the cervical spine, worse from C2 through C7 levels, with multilevel moderate spinal canal stenosis and neural foraminal narrowing. 3. A 2.3 cm calcified right thyroid lobe nodule. ----------- NCHCT: No evidence of hemorrhage or recent infarction. Old right parietal and frontal infarctions. Severe involutional changes. ----------- CT TORSO: 1. No acute traumatic injury identified in the chest, abdomen and pelvis. 2. Extensive atherosclerotic disease of the thoracoabdominal aorta, with ectasia of the infrarenal aorta measuring 2.7 cm. High-grade stenosis at the right renal artery origin. Extensive coronary arterial calcification. 3. A 4 mm right upper lobe pulmonary nodule. If the patient does not have risk factors for lung cancer, no further followup is required. In the presence of risk factors, followup chest CT in a year is recommended. 4. Mild small airways wall thickening especially in the left lower lobe, suggestive of bronchitis. 5. Cholelithiasis. ---------- ECHO: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is mildly depressed (LVEF= XX %). The right ventricular cavity is mildly dilated with borderline normal free wall function. 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. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild biventricular dilation with mild biventricular global hypokinesis. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2128-4-27**], the severity of tricuspid regurgitation has increased. Estimated pulmonary artery systolic pressures are slightly higher. The right ventricle was probably mildly dilated with borderline systolic function on the prior echo also. Brief Hospital Course: Assessment and Plan: Mr. [**Known lastname 13639**] is 87M with history of dementia, diastolic CHF (EF%60), HTN who presented s/p fall found to have elevated white count and lactate in the ED, as well as some hypotension who was started on Levophed. # Hypotension: The patient was found to be hypotensive in the ED in the settting of elevated lactate and white count. He had been afebrile, as per report, with no clear evidence of source of infection. CXR negative for any acute pulmonary process, UA negative for nitrite/leuks; cultures NGTD at discharge. The patient also had e/o skin abrasion on lower back -- not infected. Lactate initially elevated to 5.8 with acute rise in creatinine as below. Patient initially required levophed which was quickly weaned once in the MICU. He was started on levoquin out of concern for possible respiratory process seen on CT chest, but this was stopped after further review. LENIs were performed for evalaution of possible pulmonary embolism causing his symptoms and were negative. All of the patient's lab abnormalities corrected with IV fluid arguing for hypovolemia rather than sepsis as no source of infection could be identified. . # Acute renal failure: The patient had a baseline creat of 0.9; 1.7 on presentation. Urine lytes suggestive of prerenal, corrected with volume resusitation. . # Troponin leak with atrial flutter and RVR: The patient was noted to have troponin of 0.07; baseline 0.02. No chest pain, peaked at 0.17, cardiology consulted felt related to demand, ECHO unchanged from prior. The patient has previously refused treatment of his tachy-brady syndrome, so no changes were made to his medications. He had no further issues during this hospitalization. . # Elevated CK: likely from small amount of rhabdo due to fall. Was resolving at discharge. . # Hypoxia: The patient was initially noted to be hypoxic in the ED satting 86% on RA. He was transferred to the unit on 50% high flow mask. He was easily weaned to room air. . # S/p fall: The patient fell while in the shower; as per OMR documentation, he apparently has fallen the shower before. Based on history, it seems like this was a mechanical fall. Trauma work up negative. Physical therapy cleared the patient to go home with home PT, home nursing and home safety eval. This plan was discussed extensively with the patient and his son [**Name (NI) **] and both felt it was reasonable and safe. . # Dementia: The patient has history of dementia, independent with his ADLs, but needs assistance with cooking, cleaning, etc. There were no issues with this during the hospitalization. # Diastolic CHF: no evidence of acute failure despite 4 L of fluid resusitation. ECHO unchanged from prior. . # HTN: Stopped his HCTZ at discharge given that it likely caused/exacerbated his dehydration that led to the fall. # Other: A calcified thyroid nodule was seen on his CT spine, and may require outpatient follow-up. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver Admission note. 1. Aspirin 325 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Calcitriol 0.25 mcg PO 1X/WEEK (MO) 5. Thyroid 90 mg PO DAILY 6. potassium citrate *NF* 10 mEq Oral DAILY Aka "Klyte" 7. famciclovir *NF* 500 mg Oral TID 8. Vitamin A Dose is Unknown PO DAILY 9. Thiamine 100 mg PO DAILY 10. Triamcinolone Acetonide 0.1% Cream Dose is Unknown TP Frequency is Unknown Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Thyroid 90 mg PO DAILY 4. Calcitriol 0.25 mcg PO 1X/WEEK (MO) Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Dehydration leading to a fall Dementia Diastolic heart failure, ejection fraction 60% Atrial flutter Hypertension Anemia not otherwise specified Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted after a serious fall at home, and were found to have low blood pressure, fast heart rate and dehydration. You were given intravenous fluids, and these problems resolved. I suspect you fell due to dehydration -- you need to stay better hydrated. You should be urinating several times a day, clear to light yellow in color. If it's darker, you're dehydrated and need to drink more. You are at risk for future falls and as a result need home nursing, home physical therapy and a home safety evaluation. Followup Instructions: 2.3 cm calcified thyroid nodule seen on CT spine. [**Month (only) 116**] require outpatient follow-up. Department: GERONTOLOGY When: WEDNESDAY [**2130-7-26**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**] Completed by:[**2130-7-18**]

Unit No: [**Numeric Identifier 69928**] Admission Date: [**2165-1-2**] Discharge Date: [**2165-1-19**] Date of Birth: [**2165-1-2**] Sex: M Service: NB IDENTIFICATION: Baby boy [**Known lastname **] #1 is a 16-day old former 34- week twin infant who is being discharged from the [**Hospital1 18**] Neonatal Intensive Care Unit. HISTORY: Baby boy [**Known lastname **] was born on [**2165-1-2**] as the 2245-gram product of a 34-week twin gestation to a 32- year-old gravida 2, para 1 (to 3) mother with [**Name (NI) 37516**] of [**2165-2-13**]. Prenatal laboratory studies included blood type O+, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative and group B strep unknown. The pregnancy was notable for spontaneous monochorionic-diamniotic twin gestation and was complicated by an 18-week ultrasound showing growth discrepancy with oligohydramnios of one twin and polyhydramnios of the other twin, consistent with twin/twin transfusion syndrome. Mother was followed closely by the maternal fetal medicine service and underwent amniotic reduction at 18 weeks and again at 26 weeks. Amniotic fluid volumes appeared to equilibrate following the procedure, suggesting the possibility of an inadvertent septostomy. Donor twin, initially labeled as twin A in utero and subsequently found to be nonpresenting, remained growth restricted underneath the 10th percentile but did show appropriate interval growth. Doppler flow studies were reassuring, and fluid has been seen in both bladders and stomachs. Due to the presence of the growth restriction of the donor twin and the twin-twin transfusion syndrome, delivery was scheduled for today at 34 weeks by C-section. Mother had been given a course of betamethasone 2 weeks earlier. She was not in labor at the time of delivery and did not receive intrapartum antibiotics. At delivery, twin #1 emerged vigorous with good tone; requiring only brief blow-by oxygen. Apgars were 8 and 9. The infant was brought to the NICU. PHYSICAL EXAMINATION ON ADMISSION: Weight 2245 grams, 50th to 75th percentile; head circumference 32 cm, 50th to 75th percentile; length 43.5 cm, 25th to 50th percentile. The infant was an active premature infant with moderate respiratory distress and was started on CPAP. Skin was warm and pink. The facies were nondysmorphic. Fontanelles are soft and flat. Ears and nares were normal. Palate was intact. Neck was supple without lesions. Chest was coarse with moderate aeration and moderate retractions and flaring. Cardiac was regular rate and rhythm without murmurs. Abdomen was soft without hepatosplenomegaly and with no masses. Umbilical cord had 3 vessels. Genitalia was that of a normal male with testes descended bilaterally. Anus was patent. Hips and back were normal. Tone and activity were appropriate. HOSPITAL COURSE BY SYSTEMS: 1. RESPIRATORY: The infant exhibited mild-to-moderate respiratory distress syndrome and was treated with CPAP support for 2 days. By day of life #2, the infant was able to be weaned to room air and has remained in room air since that time. The infant did not exhibit apnea of prematurity, and no spells were noted. 2. CARDIOVASCULAR: The infant remained hemodynamically stable throughout admission. A murmur was noted prior to discharge, and this was evaluated with a chest x-ray, EKG and 4-extremity blood pressures; all of which were within normal limits. No further evaluation was performed. 3. FEN: The infant was initially maintained on IV fluids. Enteral feedings were introduced on day of life #2. These were advanced without difficulty to full enteral feedings with a maximum caloric density of 24 calories per ounce. By the time of discharge, the infant is feeding breast milk supplemented to 24 calories per ounce or Similac 24 calories per ounce, all p.o. on an ad lib basis with adequate intake and adequate weight gain. Urine and stool output have been normal. Discharge weight was 2370 gm. 4. GI: The infant did exhibit hyperbilirubinemia of prematurity, treated with phototherapy for 48 hours. Maximum bilirubin level was 11.2 on day of life #5. 5. ID: The infant did undergo a sepsis evaluation following delivery with an unremarkable CBC and a negative blood culture. The infant received 48 hours of antibiotics, which were then discontinued. 6. HEMATOLOGY: Hematocrit at birth was 45.2. Repeat hematocrit on [**1-17**] was 36.2 with a reticulocyte count of 1.3%. The infant has been treated with iron supplementation. 7. NEUROLOGY: The infant has maintained a normal neurologic exam throughout admission. 8. SENSORY: The infant passed the hearing screen prior to discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38832**] [**Hospital 50079**]. CARE AND RECOMMENDATIONS: 1. Diet: Breast milk or Similac supplemented to 24 calories per ounce and then switch to breast feeding. 2. Medications: Fer-In-[**Male First Name (un) **] 2 mg/kg/day. 3. State newborn screening status: Initial State newborn screen on [**1-5**] reported an elevated 17-OH progesterone level. A repeat specimen was sent on [**1-9**], results of which are pending at the time of discharge. Electrolytes were checked at that time, and they were within normal limits. 4. Car seat position screening was performed and passed. 5. Immunizations: The infant received synagis and hepatitis B vaccine [**Date range (1) 69929**]. 6. Immunizations recommended: 1. Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 3 criteria: (1) born at less than 32 weeks; (2) born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or (3) with chronic lung disease. 2. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child's life) immunization against influenza is recommended for household contacts and out-of-home caregivers. 7. Follow-up appointments: The infant will follow up with primary pediatrician 3 days after discharge. A VNA referral will be made. DISCHARGE DIAGNOSES: 1. Prematurity at 34 weeks. 2. Twin gestation. 3. Presumed recipient twin of twin-twin transfusion syndrome. 4. Respiratory distress syndrome. 5. Hyperbilirubinemia of prematurity. 6. Sepsis evaluation. 7. Physiologic murmur. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**] Dictated By:[**Name8 (MD) **] MEDQUIST36 D: [**2165-1-18**] 12:04:01 T: [**2165-1-18**] 12:57:41 Job#: [**Job Number 69930**]

Admission Date: [**2132-4-22**] Discharge Date: [**2132-5-2**] Date of Birth: [**2090-7-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 552**] Chief Complaint: Dyspnea and hypoxia following resection of left renal mass Major Surgical or Invasive Procedure: L nephrectomy Bronchoscopy History of Present Illness: This is a 41 year old man with a PMH significant for Factor V Leiden mutation, who is now POD2 s/p resection of a left renal mass, who had episodes of oxygen desaturation on the floor and for whom a CT showed likely mucus plugging. He was transferred to the [**Hospital Unit Name 153**] for planned bronchoscopy by the interventional pulmonology service. . He originally presented with back pain and in the process of workup for this got an MRI which incidentally showed a 2 cm left renal mass. A CT scan confirmed the presence of the mass. He came to Dr. [**Last Name (STitle) **] for urological follow-up, who scheduled and, on [**4-22**], performed an open partial nephrectomy to resect the mass. This included chest tube placement in the left; the chest tube was pulled [**4-23**]. At midnight [**Date range (1) 62333**], he had a trigger on the floor for hypoxia and fever, with temp 102.2 and O2 saturation of 87% on 3.5L NC. This increased to 92% with 5L NC and use of an incentive spirometer. At that time, the covering MD noted that he was "asymptomatic" without SOB, CP, dyspnea, N/V, chills, or calf pain. An ABG at that time was 7.38/52/74 on 5L NC. . A PE protocol CT chest was ordered stat, and a provisional read showed "Small left pneumothorax... [and] obstructive atelecatsis of the left lower lobe and right middle and lower lobe due to fillings of the lower lobe bronchi, most likely mucous plug." . An EKG done around that time appears to show diffuse T-wave flattening compared to his earlier pre-op EKG but otherwise without diagnostic focal changes. . On the floor today, he continued to be febrile for much of the day, with Tmax of 102.8 at 1415; he continued to require oxygen support of 5L NC with 40% facemask for much of the day, with oxygen saturations in the mid 90s to this. He was also tachycardic to the 110s-120s for most of the day. Past Medical History: Lower extremity DVT in [**2127**], diagnosed with heterozygous Factor V Leiden mutation; on coumadin, followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2805**] Right leg vein stripping for varicose veins, [**2128**] Essential tremor Social History: Professor [**First Name (Titles) **] [**Last Name (Titles) 20367**] at [**University/College **]. Married. Quit smoking in [**2120**], was light smoker before then. 3 glasses of alcohol/month. Denies recreational or IV drug use. Family History: Mother and sister with factor V Leiden mutation; sister w past DVT Physical Exam: General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), ([**Year (4 digits) **] Sounds: Bronchial: , Rhonchorous: diffusely) Abdominal: Soft, Bowel sounds present Extremities: Right: Absent, Left: Absent Skin: Not assessed Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2132-4-22**] 06:09PM GLUCOSE-131* UREA N-10 CREAT-1.3* SODIUM-142 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17 [**2132-4-22**] 06:09PM estGFR-Using this [**2132-4-22**] 06:09PM MAGNESIUM-1.8 [**2132-4-22**] 06:09PM WBC-14.3*# RBC-4.64 HGB-13.8* HCT-39.9* MCV-86 MCH-29.6 MCHC-34.5 RDW-13.9 [**2132-4-22**] 06:09PM PLT COUNT-157 [**2132-4-22**] 06:09PM PT-16.6* PTT-22.0 INR(PT)-1.5* [**2132-4-22**] 11:45AM PT-16.6* PTT-29.3 INR(PT)-1.5* [**2132-4-28**] 06:05AM BLOOD WBC-8.9 RBC-3.39* Hgb-10.1* Hct-29.8* MCV-88 MCH-29.9 MCHC-34.1 RDW-13.8 Plt Ct-191 [**2132-4-27**] 04:30AM BLOOD WBC-11.6*# RBC-3.61* Hgb-10.8* Hct-31.9* MCV-88 MCH-29.7 MCHC-33.7 RDW-13.7 Plt Ct-157 [**2132-4-28**] 06:05AM BLOOD Neuts-82.0* Lymphs-10.2* Monos-5.3 Eos-2.3 Baso-0.1 [**2132-4-28**] 06:05AM BLOOD PT-27.8* PTT-38.2* INR(PT)-2.8* [**2132-4-27**] 05:10PM BLOOD PT-41.8* PTT-51.5* INR(PT)-4.6* [**2132-4-27**] 04:30AM BLOOD Plt Ct-157 [**2132-4-27**] 04:30AM BLOOD PT-35.1* PTT-41.8* INR(PT)-3.7* [**2132-4-26**] 03:28AM BLOOD Plt Ct-154 [**2132-4-28**] 06:05AM BLOOD Glucose-103 UreaN-14 Creat-1.3* Na-141 K-3.1* Cl-104 HCO3-28 AnGap-12 [**2132-4-27**] 05:10PM BLOOD Na-139 K-4.1 Cl-103 [**2132-4-27**] 04:30AM BLOOD Glucose-103 UreaN-16 Creat-1.4* Na-134 K-3.9 Cl-101 HCO3-23 AnGap-14 [**2132-4-26**] 03:28AM BLOOD Glucose-95 UreaN-14 Creat-1.3* Na-141 K-3.9 Cl-102 HCO3-29 AnGap-14 [**2132-4-25**] 04:32AM BLOOD ALT-26 AST-40 AlkPhos-64 Amylase-84 TotBili-1.0 [**2132-4-28**] 06:05AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.3 [**2132-4-27**] 04:30AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.0 [**2132-4-26**] 03:28AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.0 [**2132-4-25**] 12:34PM BLOOD Type-ART pO2-67* pCO2-53* pH-7.40 calTCO2-34* Base XS-5 [**2132-4-25**] 05:54AM BLOOD Type-ART FiO2-100 O2 Flow-15 pO2-52* pCO2-50* pH-7.42 calTCO2-34* Base XS-6 AADO2-630 REQ O2-100 Intubat-NOT INTUBA CTA: IMPRESSION: 1. Given a borderline suboptimal study, there is no pulmonary embolism to the segmental level. 2. Obstruction of the bronchus intermedius and all segmental bronchi of the left lower lobe, likely due to mucus plugging, causing complete collapse of the middle lobe, right lower lobe, and almost all the left lower lobe. 3. New dependent opacities in the left upper lobe, lingula and less in the right upper lobe, could be due to aspiration. 4. Left thyroid hypodensity, should be evaluated by ultrasound if not already known. 5. Extensive post-operative changes of left partial nephrectomy. 6. Small left pneumothorax. Echo The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. IMPRESSION: Suboptimal image quality. Normal global and regional leftventricular systolic function. Mild left ventricular hypertrophy. Right ventricle could not be adequately assessed. Brief Hospital Course: 41 yo M w PMHx of Factor V leiden mutation and DVT, L renal mass sp partial L nephrectomy w post-op complications of fever, hypoxia . #. Hypoxia - [**12-31**] to multiple etiologies. Initially thought to be due to mucus plugging but the due to aspiration vs hospital-acquired pneumonia with ?component of fluid overload. Pt needed to be on bipap w high oxygen requirement which was been weaned down to RA. Pt continues to do well on RA. is sp 7 day course of IV Vanc/Zosyn for HAP. . #. Cdiff colitis - continue oral vancomycin. Will tx for 2 weeks p last abx dose. Low grade temps likely to resolving cdiff colitis. Pt reports that diarrhea is getting better. . #. Hx of L renal mass sp partial nephrectomy - Urology following. Wound site looks good. Path report from nephrectomy shows angiomyolipoma, no cancer. Outpt FU w Dr. [**Last Name (STitle) **] at dc next thursday . #. Hx of Factor V Leiden mutation and DVT - seen by heme preop and coumadin w goal INR of [**12-31**].5 4-6 weeks post op. His INR was supratherapeutic in ICU, so coumadin was held and vitamin K given, Coumadin restarted at low dose. INR on day of dc was 1.9. Discussed w primary hematologist and dc on coumadin alone at 2mg MWF and 1mg T,T, Sat, [**Doctor First Name **] dose and INR check on monday . #. Anemia - likely from post-op blood loss.remained stable throughout hospital stay around 30-31. . #. R flank discomfort - At one point pt complained of R flank pain, likely MSK but was resolved at dc. UA only showed 13 RBC, not concerning for renal stone. pain resolved on its own . # ?CKD- Baseline Cr ~1.2, given young age, nl for pt his age. Cr flucutated but remained around 1.3 at dc. . . Medications on Admission: Home medications: Warfarin 5 mg daily Advil 600 mg prn ("occasionally") Propranolol 20mg, prn ("very occasional" per pre-op med list) for palpitations before presentations Fish oil MVI . Transfer medications: cefazolin 2 g IV q8h acetaminophen 650 pr q4H: prn fever maalox 15-30 po qid:prn heartburn dilaudid PCA 0.25 mg lockout 6 mins, basal 0, 1 hr max 2.5 mg ondansetron 4 mg IV q4H: prn nausea docusate sodium 100 mg po BID diphenhydramine 25-50 mg q6h: prn pruritus or insomnia Discharge Medications: 1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 14 days. Disp:*56 Capsule(s)* Refills:*0* 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 3. Warfarin 2 mg Tablet Sig: use as directed below Tablet PO once a day: take 2mg (1tab) on M, W, F and 1mg on tues, thurs, sat, sun ([**11-30**] tab). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: -SP L partial nephrectomy for renal mass - confirmed to be angiomyolipoma -Healthcare assoicated pneumonia -C diff colitis Discharge Condition: Good Discharge Instructions: -You were admitted to the hospital for partial removal of Left kidney due to a mass, which turned out not be cancer. After surgery you developed complications of mucus plugging and pneumonia. You also developed an infection of your bowel called C diff colitis. You finished the course of IV antibiotics for the pneumonia. You will need to take 2 additional weeks of oral vancomycin for the Cdiff colitis. If at the end of the oral antibiotic course you are still having diarrehea, abdominal pain or fevers, you need to let your doctor know as you may need additional antibiotics. You have hx of factor V leiden mutation which makes you vulnerable to form blood clots especially around surgery, so per your hematologist, you have been placed on coumadin which will be continued for about 4-6 weeks after your surgery. Please follow up with them regarding INR checks and coumadin adjustment Please call your doctor right away or return to ED for fevers, chills, abdominal pain, chest pain, shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] concerning signs of infection at the incision site, worsening diarrhea Followup Instructions: 1. Urology, Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**] Date/Time:[**2132-5-8**] 3:30 2. PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14477**], ph: [**Telephone/Fax (1) 25302**], Appt is on Tuesday, [**5-6**], 9:00 AM 3. Hematology, RN [**Doctor Last Name 9449**], ph: [**0-0-**]. Come to [**Hospital Ward Name 23**] 9, have blood drawn for INR check and [**Doctor Last Name 9449**] will call you with results

Admission Date: [**2190-3-3**] Discharge Date: [**2190-3-6**] Date of Birth: [**2120-12-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5810**] Chief Complaint: Bloody Emesis Major Surgical or Invasive Procedure: EGD History of Present Illness: This is a 69 year old male with a history of HTN, gastric ulcers, HLD and old CVA who woke up this morning feeling weak, dizzy and diaphoretic. He then went to the bathroom and had some bloody emesis and bloody bowel movements. He does not describe melena rather bloody appearing stools. He called [**Company 191**] who advised a call to EMS, and he was tranferred to the ED. He was in his usual state of health prior to this. No recent infections or bowel movement changes. . Of note patient reports that he had an upper GI bleed similar to this in the late 70s early 80s which was due to an ulcer possibly related to EtOH. At that time he required 6 U of PRBC. . In the ED, initial vs were: 97.3 82 142/94 20 100. An NG tube was placed that revealed about 200cc of coffee ground emesis with some bright red blood. The BRB cleared after 200cc NS was flushed. He was given 1L of normal saline and protinix IV x 40mg. Two 18G PIV were placed. His vitals at the time of transfer were: 89 139/92, 16, 100% RA . On the floor, patient was mildly tachycardic ranging from 87-130. He was not complaining of anything. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: hypertension, not treated possible diabetes Social History: Married, with two daughters and a son. Retired, used to work as a manager of a manufacturing plant. Tobacco use was 1ppd x approx 40yrs, now 1ppwk. Used to be a heavy drinker x 40yrs, now EtOH only once a month. No drug use. Family History: DM, CAD in parents, brother. Children healthy. No strokes or seizures. Physical Exam: Physical Exam on Admission: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress, NGT in place HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, one non tender freely mobile LN in the L ant cervical chain Lungs: Coarse breath sounds, rhales and rhonchi on right. 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, no bruits ascultated. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on Admission: [**2190-3-3**] 11:05AM BLOOD WBC-7.9# RBC-4.29* Hgb-11.8* Hct-37.9* MCV-88 MCH-27.4 MCHC-31.1 RDW-15.4 Plt Ct-232 [**2190-3-3**] 11:05AM BLOOD PT-13.9* PTT-21.5* INR(PT)-1.2* [**2190-3-4**] 04:05AM BLOOD Glucose-114* UreaN-21* Creat-0.9 Na-142 K-3.6 Cl-113* HCO3-22 AnGap-11 [**2190-3-3**] 11:05AM BLOOD ALT-40 AST-52* CK(CPK)-134 AlkPhos-68 TotBili-0.9 Labs on Discharge: [**2190-3-6**] 08:05AM BLOOD WBC-5.9 RBC-4.11* Hgb-11.6* Hct-34.1* MCV-83 MCH-28.2 MCHC-34.0 RDW-15.2 Plt Ct-206 [**2190-3-6**] 08:05AM BLOOD Glucose-91 UreaN-14 Creat-1.0 Na-142 K-3.3 Cl-108 HCO3-24 AnGap-13 Microbiology: HELICOBACTER PYLORI ANTIBODY TEST (Final [**2190-3-5**]): POSITIVE BY EIA. [**2190-3-4**]: Blood Cx x2: no growth to date Studies: EGD ([**2190-3-3**]): Erythema and petechiae in the stomach body compatible with gastritis. Ulcer in the duodenal apex (injection) Otherwise normal EGD to third part of the duodenum Brief Hospital Course: This is a 69 year old male with a history of gastric ulcers, HTN, HLD old CVA without deficits who had bloody emesis on morning of admit. Hematemesis: On admission, 2 large bore PIVs were placed and PPI drip was initiated. NGT tube was placed and revealed about 200cc of coffee ground emesis with some bright red blood. The BRB cleared after 200cc NS was flushed. The patient's Hct fell from a baseline of 41 to a nadir of 29. He was transfused a total of 3 units pRBCs. He underwent EGD which showed gastritis and a non-bleeding ulcer in the duodenal apex which was injected with epinephrine. The patient's antihypertensive medications were held and he briefly needed NTG gtt for hypertension after volume repletion. The patient had a single episode of temperatures to 101 during the time of transfusion. Blood culutres yielded no growth prior to discharge. Following EGD, general surgery was consulted who felt no surgical intervention was necessary. Hematocrit stabilized and the patient required no further transfusions. The patient'as diet was advanced and he tolerated PO intake. He was switched to PO PPI [**Hospital1 **]. After positive H. polyri antibody test, treatment for H. pylori was initiated with Amoxicillin, Clarithromycin and PPI x 10 days. He will follow up in [**Hospital **] clinic after discharge. ECG changes: On the day of arrival, the patient had mild ST depressions inferior/laterally which resolved with pRBC transfusion and were not assoicated with CE leak. They were likely related to demand in setting of bleed. Miocardial infarction was ruled out by negative cardiac biomarkers. HTN: Antihypertensives were transiently held in the setting of GI bleed and re-started prior to discharge. Hyperlipedemia: Atorvastatin was held in acute setting and re-started after EGD. Medications on Admission: Atorvastatin 40mg daily lisinopril 30mg daily sildenafil 25mg prn sex aspirin 325mg daily Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. 3. 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:*0* 4. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 8 days. Disp:*32 Capsule(s)* Refills:*0* 5. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 8 days. Disp:*16 Tablet(s)* Refills:*0* 6. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*10 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Gastritis, Upper GI bleed Secondary: Hypertension, Hyperlipidemia 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 because you developed lightheadedness, dizziness, vomited blood and had bleeding from below. Tests performed at the hospital showed that you had a bleed from your stomach or small intestine. An endoscopy was performed to look for the source or bleeding and located an ulcer, which was injected with epinephrine to help stop bleed. After the procedure, you were observed closely to make sure you did not have a repeat bleed. However, your red blood cells remained stable and there was no evidence of further bleeding. You tested positive for bacteria known as H. pylori, which causes ulcers in the small intestine. We prescribed you medicine to eracidate this bacterium. You are now ready to be discharged home. We made the following changes to your medicaitons: 1. We prescribed you Pantoprazole 40mg [**Hospital1 **]. Please make sure to take this medicine as directed to prevent repeat bleeds. Do not stop it unless told specifically to do so by your doctor. 2. We started you on Amoxicillin 1 gram twice a day. Please take it for 8 more days, for a total of 10 days of antibiotics. 3. We started you on Clarithromycin 500mg twice a day. Please take it for 8 more days, for a total of 10 days. 4. We stopped your Aspirin. Please do not take that medicine until told otherwise by your doctor. Please continue to take all your other medications as prescribed. You have follow-up appointments with your GI doctor and in [**Hospital 1944**] clinic (see below). If you develop any of the concerning symptoms, such as dizziness, lightheadedness, changes in vision, bleeding from below or vomiting blood, black stools, worsening abdominal pain, please return to the Emergency Department right away. Followup Instructions: You have the following follow-up appointments: Appoitment #1 MD: Dr. [**First Name (STitle) **] [**Name (STitle) **] Specialty: [**Hospital3 **] Post [**Hospital **] Clinic Date/ Time: [**Last Name (LF) 2974**], [**3-12**] at 10:30am Location: [**Hospital3 **], [**Hospital Ward Name 23**] Clinical Center, [**Apartment Address(1) **] North, [**Location (un) 830**], [**Location (un) 86**] Phone number: [**Telephone/Fax (1) 250**] Special instructions for patient: This appointment is for follow up to your hospitalization. You will then be connected to your Primary Care provider after this visit. Appointment #2 MD: Dr. [**First Name (STitle) **] [**Name (STitle) **] Specialty: Gastroenterology Date/ Time: Tuesday, [**3-16**] at 2:00pm Location: [**Last Name (LF) **], [**First Name3 (LF) 452**] Bldg [**Location (un) **], [**Location (un) 86**] MA Phone number: [**Telephone/Fax (1) 463**] Completed by:[**2190-3-9**]

Admission Date: [**2104-1-25**] Discharge Date: [**2104-2-1**] Date of Birth: [**2045-12-2**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 10370**] Chief Complaint: CC: elevated blood sugar Major Surgical or Invasive Procedure: PICC Renal Artery Stent History of Present Illness: 56 yo M with history of renal cell cancer s/p nephrectomy and renal transplant in [**2101**], hypertension who presents with 2 days of general malaise, weakness, nausea, polyuria, polydipsia, and chills. Pt notes 1 week h/o nonproductive cough. Denies fever, CP, or SOB. Pt was seen in renal clinic today where he was noted to have a glucose of >500. On arrival to [**Name (NI) **], pt found to have glucose >900, T 99.1, BP 236/108. In ED given 10 units of SC insulin x2 and then started on insulin gtt. Pt had a h/o DM while on Prograf in [**2101**]. Not currently treated for DM. Pt was transferred to the MICU and was placed on an insulin drip with better sugar control was transferred to the floor. Past Medical History: Renal cell ca s/p L nephrectomy [**2093**] s/p cadaveric renal transplant [**8-7**] diabetes mellitus type 2 asthma- not treated, hospitalized as child s/p left AV graft h/o ciguatera poisening from barracuda ingestion nasal polyps hypertension DM type 2 Barrett's esophagus mild pulmonary hypertension trivial MR Social History: married, works in nutrition at [**Hospital1 18**] remote tob hs, no EtOH, no IVDA Family History: mother with renal disease Physical Exam: VS: Tm 98.4 Tc98.1 86 68-96 BP 170/39 150-204/39-82 RR 19 SaO2 96, 95-97 RA I/O 5300/750 Gen: well appearing male in NAD HEENT: dry MM, PERRL, EOMI, No JVD CV: rrr, SEM II/VI greatest RUSB Chest: CTA b/l Abd: soft, NT/ND, +BS Ext: no edema, strong DP/PT pulses Neuro: A&Ox3 Pertinent Results: [**2104-1-25**] 09:15PM GLUCOSE-732* UREA N-18 CREAT-1.8* SODIUM-134 POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-19* ANION GAP-21* [**2104-1-25**] 06:49PM GLUCOSE-931* K+-6.1* [**2104-1-25**] 06:30PM GLUCOSE-837* UREA N-20 CREAT-1.8* SODIUM-127* POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-23 ANION GAP-20 [**2104-1-25**] 06:30PM CK(CPK)-294* [**2104-1-25**] 06:30PM CK-MB-4 cTropnT-0.03* [**2104-1-25**] 06:30PM CALCIUM-10.7* PHOSPHATE-2.3* MAGNESIUM-2.3 [**2104-1-25**] 06:30PM WBC-4.5 RBC-5.35 HGB-13.8* HCT-43.2 MCV-81* MCH-25.8* MCHC-31.9 RDW-13.7 [**2104-1-25**] 06:30PM NEUTS-67.6 LYMPHS-26.6 MONOS-4.7 EOS-1.2 BASOS-0.1 [**2104-1-25**] 06:30PM HYPOCHROM-3+ MICROCYT-1+ [**2104-1-25**] 06:30PM PLT SMR-NORMAL PLT COUNT-168 LPLT-2+ [**2104-1-25**] 06:30PM PT-12.4 PTT-25.0 INR(PT)-1.0 [**2104-1-25**] 01:14AM GLUCOSE-692* [**2104-1-25**] 01:14AM UREA N-19 CREAT-1.8* SODIUM-134 POTASSIUM-3.7 CHLORIDE-94* TOTAL CO2-30 ANION GAP-14 [**2104-1-25**] 01:14AM ALT(SGPT)-30 AST(SGOT)-19 TOT BILI-0.5 [**2104-1-25**] 01:14AM ALBUMIN-3.7 CALCIUM-10.4* PHOSPHATE-2.1* [**2104-1-25**] 01:14AM rapamycin-14.6* [**2104-1-25**] 01:14AM URINE HOURS-RANDOM CREAT-41 TOT PROT-207 PROT/CREA-5.0* [**2104-1-25**] 01:14AM WBC-4.2 RBC-5.52 HGB-14.0 HCT-44.1 MCV-80* MCH-25.3* MCHC-31.7 RDW-13.3 [**2104-1-25**] 01:14AM PLT SMR-NORMAL PLT COUNT-167 [**2104-1-25**] 01:14AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.036* [**2104-1-25**] 01:14AM URINE BLOOD-TR NITRITE-NEG PROTEIN->300 GLUCOSE->1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0 LEUK-NEG [**2104-1-25**] 01:14AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 <BR> CXR in ED: No active lung disease. <BR> ECHO: The left atrium is moderately dilated. There is probably moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal. Right ventricular systolic function is normal. The aortic valve leaflets are mildly thickened. The study is inadequate to exclude significant aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no pericardial effusion. <BR> CXR [**1-26**] (after unsuccessful SC/IJ line attempts): Cardiac silhouette and mediastinum is within normal limits. No pneumothoraces are identified on either side. No parenchymal opacities are seen. There is no evidence for gross pulmonary edema. <BR> RUE US: No evidence of right upper extremity DVT. <BR> Renal Artery Cath: 1. Significant renal artery stenosis of the transplanted kidney. 2. Normal central blood pressure. 3. Successful stenting of transplant renal artery. 4. Successful Perclose Proglide closure of right femoral artery. 5. Successful Angioseal closure of left femoral artery. <BR> Renal US: Normal appearance of transplant kidney. No evidence of hydronephrosis. <BR> V/Q Scan: Low likelihood for pulmonary embolism. <BR> Abdominal/Pelvic CT: 1. No evidence of intra-abdominal hematoma. 2. Status post left nephrectomy, with a residual soft tissue nodule of unclear etiology. If there is a neoplasm and any concern for recurrence, comparison to prior studies could be helpful if available. 3. Renal transplant in the right lower quadrant, with delayed excretion of contrast from prior catheterization procedure. 4. Bibasilar atelectasis. Brief Hospital Course: Mr. [**Known lastname **] was initially treated for severe hyperglycemia in the ICU, and once stable, transferred to the [**Location (un) **] Chief Medicine Service for further evaluation of his symptoms and underlying medical problems. During his admission, he was noted to have severe HTN, and received surgical intervention for his renal artery stenosis. He was also noted to be hypoxic on finger pulse oximetry to 85% RA, leading to a workup for causes of this hypoxia which was most likely [**2-7**] venous/arterial mixing of blood in his extremities due to b/l shunts and grafts. SaO2 as measured on his ear was much improved. His creatinine levels rose slightly after the procedure, with concern for renal toxicity from surgical contrast. CT scan was remarkable for a small soft tissue mass in the area of his L nephrectomy, with concern for malignancy. Renal team recommended f/u with repeat CT scan in three months. <BR> 1) Hyperosmolar Nonketotic Hyperglycemia: Upon initial presentation to the [**Name (NI) **], pt. had glucose of 837. He had been symptomatic for hyperglycemia for past several weeks (polydipsia, polyuria, malaise). Pt was not on medications for DM2 prior to admission. In [**2100**], he was noted to be hyperglycemic, but this was thought to be [**2-7**] his Prograf and this medication was changed. Random glucose in [**Month (only) 1096**] had been measured at 214. His hyperglycemia was likely exacerbated by his steroid medications. Other possibilities included viral syndrome or bacterial bronchitis, although blood and urine Cxs were negative. There was also a possibility that the renal artery stenosis, combined with mild dehydration, could have lead to a pre-renal azotemia that compounded the underlying hyperglycemia. <BR> The pt. was aggressively hydrated in the ICU and started on an insulin drip until glucose levels returned to baseline. He was then transferred to the floor with a RISS and followed by the [**Last Name (un) **] endocrine service for modifications to his sliding scale. Prior to d/c, pt. was educated about the use of insulin and symptoms of hyper/hypoglycemia. <BR> 2) HTN: Pt. stated that his BP has not been well controlled for a long time, and that the loss of his R kidney had originally been due to HTN. He was on an extensive list of medications for bp at home, including amlodipine, clonidine, lisinopril, valsartan, furosomide, and metoprolol. These medications were optimized when possible, and hydralazine and nitro prn were also added to his regimen. Metoprolol was switched to labetalol in consult with the renal service out of concern for a paradoxical interaction between his beta-blocker and the alpha-agonist. It was thought that the beta-2 agonism and alpha-1 antagonism effects of labetalol would avoid the risk of unopposed alpha-2 vasoconstriction. When his pressures remained elevated to the 190s on this aggressive regimen, interventional cardiology was consulted to evaluate his known renal artery stenosis. <BR> A renal artery stent was placed on [**1-30**], at which time it was determined that the stenosis had occluded 90% of the renal artery, with a 30mmHg pressure gradient across the stenosis. His bps were much improved the next day, and he was able to come off of the nitro. Gradually, he was also taken off of his [**Last Name (un) **], ACE-I, and hydralazine as SBPs remained 120s-140s out of concern for preserved renal function. <BR> 3) Hypoxia/SOB: The pt. complained of chest tightness upon admission, and was ruled out for MI with three sets of cardiac enzymes, EKGs, and telemetry. He had an ECHO which did not show any acute processes. His symptoms resolved without intervention. Once out of the ICU, the pt. was noted to have mild SOB on occasion in the AM, stating he found it easier to breathe when sitting upright. His O2 sats as measured on his fingers were typically lowest overnight and in the AM, down to 85% on room air, and ranging from 89-97% on 4LPM via nasal cannula. His O2 sat did not drop appreciably upon ambulation. Ddx for his SOB was considered to be infectious/PNA/PCP [**Last Name (NamePattern4) **]. fluid overload vs. cardiac vs. PE vs. OSA/obestity-hypoventilaion syndrome. He stated that IV fluids made his SOB worse, but CXR showed no acute process and physical exam showed clear lung sounds throughout. The pt. was monitored with telemetry and EKGs to monitor cardiac activity. The pt. was evaluated for PE w/ a V/Q scan (CTA contraindicated given decreased renal function). Blood/urine cultures were obtained and negative at 48 hours, without evidence for an infectious process. An ABG showed hypercapnea, hyperoxemia, and a normal pH and A-a gradient. The level of hyperoxemia did not correlate with the SaO2 as measured on the pulse oximeter on his fingers bilaterally. An oximeter was applied to his ear, which indicated an SaO2 in the middle-to-high 90s on RA, which better fit his clinical picture. <BR> A sleep study from the medical record had remarked about his nocturnal hypoxia and symptoms concerning for OSA. Pt. was not using CPAP/BiPAP at home as had been recommended. He was started on BiPAP prior to discharge, with improvement in his oxygenation and symptoms. <BR> 4) Anemia: The pt. had a fall in hematocrit from 35.9 -> 29.6 on the day following his cath. This was concerning for a femoral or RP bleed, which was ruled out with a non-contrast CT. Crit remained constant after the initial drop, and the retic count was appropriately elevated. <BR> 5) OSA: Pt previously had a sleep study at [**Hospital1 **] showing very bad OSA. He has pHTN, daytime sleepiness, and apnea/[**Last Name (un) 6055**] [**Doctor Last Name 6056**] breathing while sleeping. He was started on BiPAP while in hospital and scheduled for follow-up in the sleep clinic. <BR> 6) S/P Renal Transplant: Pt was continued on his home doses of CellCept, Rapamune, and prednisone while in hospital. His rapamycin trough was found to be within the therapeutic range. His creatinine rose gradually on the days following his stent placement, which was concerning for contrast toxicity. The rise was gradual, however, and pt. was not thought to be in renal failure or have the need for HD. He will need creatinine levels monitored as an outpt. <BR> 7) Soft Tissue Mass: A 14mm x 8mm soft tissue mass in the area of the pt's L nephrectomy was seen on CT. This could be old scarring, but given pt.'s Hx of RCC, could be malignancy. No CT scan was available for comparison, so pt. was recommended to repeat the CT in three months. <BR> 8) FEN: Pt. was monitored with daily lytes, and repleted as necessary. He was kept on a Cardiac/Diabetic diet. RISS was initiated as described above. <BR> 9) Access: Given difficultly of placing peripheral lines and need for hydration/medications/procedure, pt. had a PICC placed. It was removed prior to discharge. <BR> 10) Code: Pt was FULL CODE on this admission. Medications on Admission: - Diovan 320 mg a day - metoprolol 100 twice a day - lisinopril 40 a day - Norvasc 5 daily - Lasix 40 mg a day - clonidine 0.3 twice a day - Rapamune 4 mg a day - Bactrim single strength MWF - CellCept [**Pager number **] twice a day - baby aspirin - prednisone 5 mg daily Discharge Medications: 1. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*2* 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). Disp:*12 Tablet(s)* Refills:*2* 3. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 9. 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* 10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) Subcutaneous twice a day: Take 24 U in the morning. Take 22 U in the evening. Disp:*1 qs* Refills:*0* 11. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: Use per sliding scale. Disp:*1 qs* Refills:*0* 12. Insulin Needles (Disposable) 29 X [**1-7**] Needle Sig: Four (4) Miscell. four times a day. Disp:*1 qs* Refills:*2* 13. Lab Work Sig: One (1) once a day: On [**2104-2-4**] please go to the lab and have your CBC, Chem-10, drawn and faxed to Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) 5717**] [**Name (STitle) 21867**]10 = sodium, potassium, chloride, bicarbonate, bun, creatine, magnesium, calcium, phosphate. Disp:*1 time* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Hyperosmolar Nonketotic Hyperglycemia, Diabetes Mellitus Type 2, Renal Artery Stenois, Hypertension, Sleep Apnea <BR> Secondary: s/p renal transplant Discharge Condition: stable stable Discharge Instructions: -please continue with medications as prescribed -please attend all of your appointments -if symptoms of nausea, vomiting, headaches, shortness of breath, chest pain/palpitations, leg swelling, or any other concerning symptoms occur, please come back to the ED immediately -if you start to feel symptoms of increased thirst, increased urination, dizziness, weakness, or fatigue, check your blood sugar levels. If you are having trouble controlling your blood sugar, please call the [**Hospital **] clinic or your primary doctor. You will need to schedule the following appointment with your primary doctor: CT scan of your abdomen and pelvis in 3 months. Provider: Followup Instructions: You have the following appointments scheduled: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2104-2-20**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2104-2-5**] 8:30 AM [**Last Name (un) **] Diabetes with Dr. [**Last Name (STitle) 978**] on [**2104-2-5**] at 4:00pm [**Last Name (LF) **],[**Name8 (MD) **] MD, SLEEP CLINIC Phone:[**Telephone/Fax (1) 6856**] Date/Time:[**2104-2-5**] 3:00 PM You will need to schedule the following appointment with your primary doctor: CT scan of your abdomen and pelvis in 3 months. Provider:

Admission Date: [**2189-11-14**] Discharge Date: [**2189-11-20**] Service: MEDICINE Allergies: Sulfasalazine / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Dyspnea, cough Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is an 84 yo M with PMH of CVA w/residual weakness, CAD s/p stent, h/o COPD, h/o aspiration PNA and chronic pleural effusion/LLL collapse presenting with worsened dyspnea and cough over two weeks. He reports that symptoms started two weeks ago with increased dyspnea and a "head cold" and progressed to a productive cough. He denies any fevers, does endorse 8 pound weight gain and some increased leg edema. He has also been using his nebulizer treatments more frequently as well increased from QHS to TID. . Of note he was recently admitted from [**Date range (1) 94557**] and treated with course of Vanc/Zosyn for HAP/aspiration pneumonia. In addition, his wife was recently admitted with GPR bacteremia with growth of Corynebacterium Diptheria on [**3-27**] blood culture bottles with concern from ID consult of infection rather than contamination. . VS on arrival to the ED T99.4 BP 138/86 HR 84 RR 16 97% on 4L NC. He had a CXR which showed stable LLL effusion with stable LLL consolidation. He was given levofloxacin and flagyl to treat aspiration pneumonia. While in the ED he had acute episode of tachycardia, likely Afib with rate in the 140's-150's with associated drop in blood pressure to 101/37. He was given 500ml NS and diltiazem 10mg IV x2, with improvement in HR to the 120's. He was admitted to the ICU [**1-24**] concern for persistent tachycardia with borderline blood pressure. Past Medical History: 1. Type 2 DM 2. Ulcerative colitis s/p ileostomy and colectomy 3. Hypertension 4. CAD s/p stent (90's) 5. s/p CVA X3 (94, 95, 96) 6. Prostate ca s/p XRT on Hormone therapy 7. Paget's disease 8. GERD 9. Esophageal ulcer and stricture 10. Venous stasis 11. Anxiety 12. Bladder Cancer secondary to prostate ca therapy 13. Macular Degeneration 14. Pulmonary Embolism [**2170**] 15. Anemia 16. Hyperlipidemia 17. Hearing Loss 18. Melanoma Social History: Patient lives at [**Hospital **] [**Hospital **] Nursing Home. Wife was in the ICU. No smoking, EtoH or IVDU. Has local sons. Family History: NC Physical Exam: ADMISSION PHYSICAL: VS: T98.3 HR 132 BP 149/64 RR 24 95% 3L NC Gen: alert, resting comfortably in NAD HEENT: NC AT, dry mucous membranes CV: irregularly irregular Lungs: breath sounds diminished at bases L> R, scattered ronchi, no wheezing Abd: distended, nontender, ileostomy, no rebound or guarding, normoactive bowel sounds Ext: 1+ pitting edema in RLE, trace LE edeam LLE, DP's palpable bilaterally Pertinent Results: Admission Labs: WBC-10.9 RBC-3.58* Hgb-10.2* Hct-30.7* MCV-86 MCH-28.4 MCHC-33.2 RDW-15.3 Plt Ct-295 Neuts-88.7* Lymphs-5.5* Monos-4.1 Eos-1.4 Baso-0.3 PT-12.5 PTT-23.8 INR(PT)-1.0 Glucose-248* UreaN-34* Creat-2.1* Na-135 K-5.3* Cl-93* HCO3-30 AnGap-17 Calcium-8.9 Phos-3.2 Mg-1.3* Lactate-2.6* . Labs on discharge: WBC-10.6 RBC-3.17* Hgb-8.7* Hct-27.1* MCV-86 MCH-27.6 MCHC-32.2 RDW-14.4 Plt Ct-316 BLOOD Glucose-202* UreaN-36* Creat-1.9* Na-137 K-3.9 Cl-95* HCO3-35* AnGap-11 BLOOD Calcium-9.2 Phos-3.1 Mg-1.9 . Studies: [**2189-11-14**] CXR - CONCLUSION: 1. Stable left basal effusion and left lower lobe consolidation. 2. Atelectasis at the right lung base. 3. Increased density and trabeculation in the right humerus is unchanged and most likely related to Paget's disease. Brief Hospital Course: 84 yo M with PMH of CVA w/residual weakness, CAD s/p stent, h/o COPD, h/o aspiration PNA and chronic pleural effusion/LLL collapse presenting with worsened dyspnea and cough over two weeks, with new Afib w/RVR in the ED. MICU Course: Mr. [**Known lastname **] was admitted to the MICU with worsening and cough for 2 weeks in the setting of Afib with RVR. His SOB was in the setting of new onset afib and an 8lb weight gain and it was believed to due to afib. He was started on PO Diltiazem 15mg PO QID but he had converted back to sinus rhythm by the time he arrived in the ICU. He was continued on low dose Diltiazem for control of his afib. His amlodipine was stopped due to borderline hypotension in the setting of afib. He was continued on his home COPD regimen of Spiriva and Atrovent and also treated with Albuterol. He is being discharged on albuterol PRN. Sputum and blood cultures were obtained and were negative. Urine legionella was ordered and was negative. He was given an insulin sliding scale for his diabetes. His blood pressure stayed in the 120s-130s/50s and heart rate remained in the 70s throughout his MICU stay. . # GI Bleed: The patient was transferred to the floor. He had been started on a heparin drip and coumadin because of his A fib. He began to pass blood and maroon stool through his ostomy, and thus his heparin and coumadin was stopped. His HCT nadired at 25.9 and gradually increased without blood transfusion to 27.1. His HCT on admission was 30.7. The maroon stool resolved and the patient was passing only brown stool and no blood for the last 3 days prior to discharge. The goals of care were discussed with patient and he did not want aggressive care and he did not want a colonoscopy to investigate the source of the bleeding. . #Dyspnea/cough: The patient's dyspnea and cough were likely due to his COPD exacerbation in conjunction with his chronic lung disease. He has known pleural effusion and long standing emphysema. His atrial fibrillation likely exacerbated his dyspnea by causing some mild pulmonary edema. The patient has CHF and had an 8 lb weight gain before admission suggesting an element of heart failure. He was treated for a COPD exacerbation with prednisone 60mg x 3 days. He was given spiriva, atrovent, and albuterol PRN and was discharged on these medications. The patient is at high risk for aspiration and understands the risk of aspiration but has decided to eat a regular diet. His oxygen saturation was 99% on 2L at the time of discharge. Please use humidified oxygen as pt requests this for comfort given that pt has very dry throat. . # Afib w/RVR - He presented in A fib with RVR in the ED. He was placed on diltiazem. He was in NSR in the unit and has been since. He should be continued on the diltiazem. His amlodipine was stopped. . # CKD - The patient renal function slightly worsened while in the hospital with a creatinine of 2.1 from a baseline of 1.9. He was given 1L of NS given that this was thought to be prerenal. His creatinine returned to his baseline of 1.9 prior to discharge. The patient was continued on metolazone. . # Type 2 DM - The patient had several days of high blood sugars, at times greater than 500, in the setting of being on prednisone. His NPH was increased during this time. He was discharged on his home regimen of NPH. His glipizide was held while in the hospital and restarted on discharge. . # Hypertension - The patient has been normotensive since admission. He was on amlodipine as an out patient and is now on diltiazem. . # Skin Ulcer - The patient has a stage II cocyx ulcer which should be cared for as follows: clean with wound cleanser and pat dry. Use no sting barrier to wipe peri wound tissue and let dry. Then apply wound gel and cover with Allevyn foam dressing which should be changed q 3 days. The patient should be turned q2hrs and as needed. He should also be getting up out of bed to his chair. Sitting time should be limited to 1 hr at a time with a 4 inch foam cushion. He also has skin tears between his thumb and first finger bilaterally which should be cared for as follows: on hands bilaterally between thumbs and first finger has skin tears. Apply aquaphor and 4 x 4 to cover. This should be changed daily. Medications on Admission: Amlodipine 5 mg Tablet PO DAILY Multivitamin One (1) Tablet PO DAILY (Daily) Acetaminophen 1000mg QHS Omeprazole 20 mg PO DAILY Clopidogrel 75 mg Tablet PO DAILY Simvastatin 20 mg PO DAILY Bicalutamide 50 mg PO DAILY Tiotropium Bromide 18 mcg One (1) Cap Inhalation DAILY Ditropan 10mg daily FerrouSul 325mg daily Glipizide 5 mg [**Hospital1 **] Ocuvite zaroxyln 2.5mg daily Wellbutrin 37.5mg [**Hospital1 **] Atrovent nebs TID NPH 8 unis SC QAM Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO at bedtime. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Ditropan XL 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2* 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Ocuvite Tablet Sig: One (1) Tablet PO once a day. 11. Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 12. Bupropion 75 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Other 8 units sc qAM 14. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 15. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) cap Inhalation three times a day. 16. humalog sliding scale pls resume prior scale Finger sticks [**Hospital1 **] <60 give [**Location (un) 2452**] juice or [**12-24**] amp of D50 and call physician 60-249 do nothing 251-300 4 units 301-350 6 units 351-400 8 units >400 give 10 units and call physician 17. Diltiazem HCl 30 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day): hold for HR<60 or SBP<100. 18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation q4hrs as needed for shortness of breath or wheezing. 19. Procrit 10,000 unit/mL Solution Sig: One (1) dose Injection every 2 weeks. 20. Dextromethorphan Poly Complex 30 mg/5 mL Suspension, Sust.Release 12 hr Sig: One (1) dose PO every six (6) hours as needed for cough. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **] Discharge Diagnosis: Primary diagnosis: A fib COPD exacerbation GI bleed . Secondary diagnosis: DM Ulcerative colitis s/p ileostomy and colectomy HTN CAD s/p stent CVA x3 Prostate cancer Bladder cancer Paget disease GERD Esophageal ulcer and stricture Venous stasis Anxiety Macular degeneration Pulmonary embolism Anemia Hyperlipidemia Hearing loss Melanoma Discharge Condition: Stable. Oxygen at 2 liters which is his baseline. Slightly decreased BS at bases of his lungs with some crackles. Cough. Afebrile. Discharge Instructions: You were admitted to the intensive care unit with Atrial fibrillation. This lead to some difficulty breathing. You were also found to have a COPD exacerbation which was treated with prednisone. You now are only requiring your baseline amount of oxygen of 2L. Being on the prednisone caused your blood sugars to be high but they have greatly improved. Because of your A fib you were started on a blood thinner which caused you to bleed into your ostomy bag. You decided that you did not want anything invasive done by gastroenterology. Your anticoagulation was stopped and you understand the risks of not being anticoagulated. Please return to the hospital if you develop blood in your ostomy, worsening shortness of breath, or any other new concerning symptom. Followup Instructions: Please follow up with a physician at your nursing facility. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2189-11-20**]

Admission Date: [**2108-3-27**] Discharge Date: [**2108-4-7**] Service: Vascular CHIEF COMPLAINT: Right first toe gangrene. HISTORY OF PRESENT ILLNESS: This is a 78-year-old black female with right first toe gangrene refractory to conservative treatment x1 month with a history of right calf claudication x1 year. She denies rest pain. She claudicates at least 8 feet. Underwent arteriogram on [**2108-3-8**] which demonstrated a left common iliac with severe stenosis. Right common iliac with diffuse disease. Right external iliac, common femoral, and SFA were totally occluded. The right popliteal reconstitutes below the knee level. The right tibioperoneal trunk and PT are occluded. The right AT is attenuated, but refuses a DP with distal stenosis. The right peroneal reconstructs proximally, but is attenuated. REVIEW OF SYSTEMS: Positive for angina at rest, relieved with nitroglycerin. The last episode was two weeks prior to initial assessment which was on [**2108-3-8**]. Frequency is infrequent. She does complain of dyspnea with walking. She denies recent congestive heart failure, PND, orthopnea, or edema. She does have a history of CVA with no reoccurrence of symptoms. The patient is now admitted for elective revascularization. ALLERGIES: None. MEDICATIONS: 1. Enteric coated aspirin 325 mg q day. 2. Coumadin 3 mg q day. 3. Keflex 500 mg q8h. 4. Potassium chloride 200 mg [**Hospital1 **]. 5. Digoxin 0.125 mg q day. 6. Pravachol 80 mg q day. 7. Trental 400 mg [**Hospital1 **]. 8. Lasix 20 mg q day. 9. Lopressor 75 mg [**Hospital1 **]. 10. Captopril 25 mg tid. 11. NPH 52 units plus 14 of R q am and NPH 16 units plus 7 of R at dinnertime. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Chronic atrial fibrillation. 3. Acute myocardial infarction in [**2103**]. 4. Congestive heart failure with an ejection fraction calculated 25-30% distal by echocardiogram in 04/96. 5. Insulin dependent diabetes. 6. Hypertension. 7. Hypercholesterolemia. 8. Cerebrovascular accident in the [**2085**] that manifested as right sided weakness which resolved over 24 hours. 9. History of cataracts. 10. History of fatty liver disease diagnosed by ultrasound with no ductal obstruction secondary to elevated LFTs, ALT 245, AST 108, alkaline phosphatase 91, total bilirubin 0.7. PAST SURGICAL HISTORY: 1. Cardiac catheterization in [**2100**], three vessel disease. 2. A repeat cardiac catheterization in [**2107-10-25**] showed severe left ventricular systolic-diastolic dysfunction, pulmonary wedge pressure 22, left end diastolic pressure 27. Cardiac index 2.6, ejection fraction of 24%. Right coronary artery was dominant. Left main trunk was patent. AD was totally occluded in mid portion, left circumflex 70% at mid portion, right coronary artery 70% at origin, and 50% mid stenosis. No intervention. 3. Cholecystectomy secondary to stones. 4. Remote right ureteroscopy with stent placement in [**2102-12-2**]. 5. Bilateral cataracts. 6. Appendectomy remote. SOCIAL HISTORY: She lives with her family and ambulates with a cane or walker. She denies alcohol or smoking. PHYSICAL EXAMINATION: Vital signs: 97.9, 142/72, 73, and 18, and 96% O2 saturation on room air. Chest examination: lungs are clear to auscultation. Heart is a regular rhythm. There are no murmurs, rubs, or gallops. Abdominal examination: Obese, nontender, and nondistended, bowel sounds diminished x4, no bruits. Vascular examination: Carotids without bruits. Left brachial artery site of angio without hematoma, clean, dry, and intact. Pulse examination shows brachioradial arteries on the left side 1+, 2+, ulnar 2+, femorals are absent on the left, popliteals absent on the left. Dorsalis pedis and posterior tibial pulses are absent. The patient has 1+ femorals on the right with no pulses palpable distal to the femorals on the right. Neurologically she is grossly intact. HOSPITAL COURSE: The patient was admitted to the preoperative holding area on [**2108-3-28**], and she underwent a right axillofem bypass which was complicated by intraoperative ischemic ST changes. Transesophageal echocardiogram showed essentially only lateral minimal wall motion and with lateral wall being akinetic to hypokinetic. The patient was admitted to the SICU, intubated for continued vasopressor and respiratory support. The patient required dobutamine at 3 mcg/kg/min for pressor support, IV Heparin was begun, serial enzymes were obtained. Postoperative hematocrit was 35.7 which drifted to 31.3. BUN and creatinine remained stable at 19 and 0.4. Initial CK was 105 with a MB of 1 and troponin less than 0.30 .................... troponins remaining flat. Cardiology was requested to assist in patient management and management of her paroxysmal atrial fibrillation. Recommendations were continue hydration, hold diuresis. They could increase her metoprolol to 75 tid. Echocardiogram was obtained which showed an ejection fraction of 10%. Patient was transferred after extubation to the VICU for continued monitoring and care. By postoperative day three, her diet was advanced to tolerated. She continued with aggressive pulmonary toilet. Her Swan was discontinued, and she remained in the VICU for continuing monitoring and surveillance. Physical Therapy to see the patient and felt that she would require rehabilitation once she is medically stable. As she continued to have episodes of atrial fibrillation/flutter, which eventually was controlled with increasing her beta blockade. The patient required manipulation of her ACE inhibitors and beta blockers to improve her rate control. She remained on perioperative Levaquin while lines were in place. She was transferred to the regular nursing floor on postoperative day number eight. Often blood pressure systolically is 120-150, and they felt from their standpoint that she was at a bed at rehabilitation, they can be discharged from their standpoint. Remaining hospital course is unremarkable. At the time of discharge, lungs were clear, dry, and intact. She had a functioning axobifem graft. The patient should follow up with Dr. [**Last Name (STitle) 1391**] in two weeks time. She is then to followup with her primary care physician once discharged from rehabilitation. DISCHARGE MEDICATIONS: 1. Acetaminophen 325 mg [**2-2**] q4-6h prn as indicated. 2. Protonix 40 mg q day. 3. Pravastatin 80 mg q day. 4. Digoxin 250 mcg q day. 5. Metoprolol 50 mg tid. 6. Aspirin 81 mg q day. 7. Lasix 40 mg [**Hospital1 **]. 8. Coumadin 3 mg q day. 9. Captopril 50 mg tid. 10. Insulin-sliding scale in six insulin doses. Please see enclosed flow sheet. DISCHARGE INSTRUCTIONS: Patient's INR should be monitored on a continual basis until she is in a steady therapeutic state for her atrial fibrillation with a goal INR 2.0-2.5. Patient should follow up with Dr. [**Last Name (STitle) 1391**] in two weeks. DISCHARGE DIAGNOSES: 1. Aortoiliac disease status post axillobifemoral bypass. 2. Myocardial infarction by enzymes, stable. 3. Diabetes controlled. 4. Blood loss anemia corrected. 5. Paroxysmal atrial fibrillation rate controlled. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2108-4-5**] 20:17 T: [**2108-4-6**] 04:31 JOB#: [**Job Number 92911**]

Admission Date: [**2194-12-29**] Discharge Date: [**2195-1-1**] Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1271**] Chief Complaint: Subarachnoid hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 89yo M presents as transfer from [**Hospital **] hospital with SAH. Pt was having lunch with his wife when he fell and struck his head. Pt was unconscious, but was reportedly alert and moving all extremities. He later deteriorated and required intubation through his tracheostomy. He was transferred to [**Hospital1 18**] for further management. Past Medical History: PMHx: esophageal cancer Social History: LIVES WITH WIFE Family History: Family Hx: unknown Physical Exam: On admission: PHYSICAL EXAM: GCS 9T E: 3 V: 1T Motor 5 O: T: BP:112/76 HR: 82 R 16 O2Sats 98 HEENT: laceration to left forehead Neuro: intubated via tracheostomy, sedation recently initiated w/ propofol, EO to voice, non-verbal, pupils [**3-12**] bilaterally, cough and gag in tact, following simple commands, moving all extremities, toes equivocal bilaterally On discharge - he is awake and alert o x 3/ non verbal at baseline due to laryngectomy and tracheostomy stoma. His pupils are [**4-13**] bilaterally, EOMI, no facial and tongue is midline. His motor strength is near full throughout and somewhat effort dependent. His facial laceration / abrasion is clean / sutures intact. He is attentive and follows commands readily. Pertinent Results: [**2194-12-29**] CTA CT HEAD: There is evidence of subarachnoid hemorrhage in bilateral frontal and right parietal lobes. Small amount of blood is also seen in bilateral lateral ventricles. There is no hydrocephalus or midline shift. Note is made of soft tissue swelling in the left preseptal and facial soft tissues. There is no acute intracranial infarction. Ventricles and sulci appear age appropriate. Bilateral vertebral artery and intracranial carotid artery calcifications are seen. CTA HEAD: Atherosclerotic changes are seen in bilateral vertebral and cavernous and supraclinoid ICAs. There is no significant stenosis, occlusion, dissection or aneurysm formation. IMPRESSION: Mild increase in Subarachnoid and intraventricular hemorrhage as described above with left preseptal and facial soft tissue swelling. Pattern of hemorrhage is compatible with history of trauma. CTA head reveals no significant vascular stenosis or aneurysm formation. [**2194-12-30**] CT BRAIN FINDINGS: Subarachnoid hemorrhage overlying both cerebral hemispheres, right greater than left, is not significantly changed in quantity compared to the previous study from [**12-29**], [**2194**]. IMPRESSION: 1. No significant interval change in the overall quantity of subarachnoid hemorrhage overlying the cerebral hemispheres, right greater than left. Similarly, the quantity of intraventricular hemorrhagic extension is not significantly changed, allowing for redistribution. Decrease in the previously noted left temporal extra-axial hemorrhage. ( se 2, im 14) 2. No acute large vascular territorial infarction. [**2194-12-29**] CXR Final Report REASON FOR EXAMINATION: Evaluation of the patient with intracranial hemorrhage. Portable AP radiograph of the chest was reviewed with no prior studies available for comparison. The patient is after tracheostomy placement with the tip of tracheostomy being 4.5 cm above the carina. There is a pacemaker in the left hemithorax with its leads terminating in the expected location of right atrium and right ventricle. The assessment of the cardiac silhouette demonstrates mild cardiomegaly. There is also presence of the mediastinal shift to the left, most likely due to left lower lobe atelectasis, partially imaged. Patient is in mild interstitial edema. Bibasilar atelectasis is seen as well. Infectious process in the lung bases cannot be entirely excluded. Followup after diuresis to assess the remaining opacities that might potentially worrisome for infection is recommended. Brief Hospital Course: Pt was seen and examined in the emergency room for LOC and SAH/IVH after transfer from [**Hospital **] Hospital. He had a tracheostomy in place related to history of esophageal cancer. On arrival to the outside hospital he was stable and then deteriortated. He was then connected to a ventilator for support and transferred to [**Hospital1 18**]. (PLEASE NOTE: HE IS NOT ABLE TO BE INTUBATED DUE TO LARYNGECTOMY / HE MUST HAVE A TRACH PLACED FOR VENTILATION IF NEEDED) He was seen and admitted to the ICU after trauma clearance. He was placed to trach mask the following am and tolerated this well. Repeat imaging on [**12-30**] was stable and he was transferred to the step down unit. On [**12-31**] he remained stable and was transferred to floor status. He tracheostomy was removed and his stoma is well healed and remains intact. He was seen by PT OT ST and cleared for discharge to rehab facility. The family is aware and agrees with this plan. Medications on Admission: unkown Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. repaglinide 2 mg Tablet Sig: One (1) Tablet PO TIDAC (3 times a day (before meals)). 6. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 14. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 18. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Ondansetron 4 mg IV Q8H:PRN N/V 20. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 21. Morphine Sulfate 2-4 mg IV Q4H:PRN pain hold for sedation 22. CefazoLIN 1 g IV Q8H facial laceration Duration: 7 Days Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: subarachnoid hemorrhage loss of consciousness intraventricular hemorrhage tracheostomy / old secondary to esophageal cancer facial lacerations 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: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed. Followup Instructions: ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**]. As always, please call your primary care physician for an appointment to be seen. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2195-1-1**]

Admission Date: [**2145-1-28**] Discharge Date: [**2145-1-29**] Date of Birth: [**2095-4-21**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Transfer from [**Hospital **] Medical Center with a spontaneous SubArachnoid Hemmorhage Major Surgical or Invasive Procedure: External ventricular drain placed emergently [**2145-1-28**] History of Present Illness: Patient is a 49M in his usual state of health, when 3-4 days prior to admission began to report headache. He was seen by his physician who diagnosed him with migraine headaches. On [**1-27**], he was found by his son to be unresponsive. When he arrived home from work on date of admission his family found him to be "not quite right".EMS activated and brought pt to [**Hospital 15096**] medical center where CT imaging of the brain revealed the Subarachnoid hemorrhage with marked hydrocephalus and mass effect. Clinical deterioration progressed requiring endotracheal intubation for airway protection. Past Medical History: Asthma Social History: Married, resides with his wife who is supportive. Family History: Non-contributory Physical Exam: visible or audible respirations. Eyes and mouth open. No peripheral pulses detected, No Carotid upstrokes. No spontaneous movements. EVD, foley catheter and IV sites secure. Pertinent Results: [**2145-1-28**] 05:00AM BLOOD WBC-15.1* RBC-4.89 Hgb-15.3 Hct-43.2 MCV-88 MCH-31.4 MCHC-35.5* RDW-13.1 Plt Ct-325 [**2145-1-27**] Neuts-85.9* Lymphs-10.0* Monos-3.6 Eos-0.3 Baso-0.2 [**2145-1-28**] Plt Ct-325 [**2145-1-28**] PT-13.2 PTT-24.3 INR(PT)-1.1 [**2145-1-28**] Glucose-178* UreaN-11 Creat-0.8 Na-145 K-4.2 Cl-110* HCO3-29 AnGap-10 [**2145-1-28**] 05:00AM BLOOD Phenyto-9.5* [**2145-1-27**] 11:34PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: At [**Hospital1 18**], Head CT showed obstructive hydrocephalus d/t colloid cyst in foramen of [**Last Name (un) **]. Right ventricular drain was placed. Initial clinical exam details unresponsiveness, absent appendicular responses. MRI showed extensive bihemispheric infarcts and persistent hydrocephalus of left lateral ventricle. Bilateral ventricular drains were placed. Pt continued on Dilantin and Nicardipine with no improvement in his neurologic exam. CT showed On [**2145-1-28**] an increased hypodensity within the parafalcine frontal lobes, and in the distribution of the posterior circulation, consistent with evolving infarction that is seen on the MR performed hours earlier. Regions of hypodensity include bilateral thalami. During the 3:00pm hours pts ICP was noted to climb. There was a lengthy family meeting with Stroke Neurology, Neurosurgery and family to discuss the patients grave illness and poor prognosis. After this meeting, the family decided to make pt [**Name (NI) 9036**] measures only. A Morphine infusion was started for [**Name (NI) **]. The patient was extubated and expired on [**2145-1-29**] @12:15am. Please refer to Death certificate for final time designation. Medications on Admission: Albuterol Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Sub Arachnoid Hemmorage Colloid Cyst Hydrocephalus Discharge Condition: poor Discharge Instructions: To morgue for transfer to Funeral Home of family's designation. Followup Instructions: None Completed by:[**2145-1-29**]

Admission Date: [**2150-12-5**] Discharge Date: [**2150-12-14**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2009**] Chief Complaint: Dyspnea Reason for MICU Admission: Hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 59386**] is a [**Age over 90 **] yo F with history of HTN, SVT, hx cholangitis/E.coli bacteremia ([**2-10**]), freq UTIs, who presents from her nursing home with acute dyspnea, hypoxia to low 80's on RA, and fever to 102. She was recently hospitalized for LLL PNA and D/C'd on [**12-1**] on a course of levofloxacin and flagyl. She was changed at the nursing home from levofloxacin to cefpodoxime for better facility acquired coverage, but has no sputum cx data to date. She also had a urine cx sent on [**12-3**] at the NH which is no growth to date. Per nursing home staff, she had been doing well for the last 2 days (no O2 requirement) until 9am this morning when she was found to be confused and lethargic and an O2 sat was in the low 80s and did not respond to nasal cannula. She was also found at that time to have a fever to 102. On interviewing the patient, she denies chest pain, shortness of breath, abdominal pain or urinary sx. She reports R ear pain. . In the ED, her VS were T 99.8 BP 155/96 HR 160 (sinus) O2 84% on 4L. CXR showed a worsening LLL PNA compared to [**11-30**], U/A showed > WBC. She received CTX, azithro, and vanco as well as 2L IVFs which brought her HR to 115. On transfer she was satting 98% on NRB. After discussions w/ family members - she remains DNR/DNI - plan for abx, supplemental O2, no pressors, no line, and if worsens or in increased distress plan to switch focus to comfort. . ROS: Other than above, pt unable to provide further hx. . Past Medical History: --History of SVT --hyperthyroidism --htn --b12 deficiency --h/o cholangitis s/p ERCP --Macular degeneration --s/p TAH BSO --s/p nephrectomy --s/p appendectomy --s/p hip hemiarthroplasty Social History: Pt lives at [**Hospital1 **] at [**Location (un) 55**]. Denies tobacco, etoh. Reportedly a retired math teacher (7th and 8th). Played the organ in church for years. Originally from upstate [**State 5887**], married in [**2070**] and moved to [**Location (un) 86**] at that time. Widowed since [**2126**]. She is a non-smoker, no EtOH, no illicit drugs. Son = HCP = [**Name (NI) **] [**Name (NI) 59386**] [**Telephone/Fax (1) 59387**]. Daughter ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 59388**] -[**Telephone/Fax (1) 59389**]) lives in [**Location **] and is ill with COPD and home oxygen. Patient has close friend who identifies herself as her "daughter" though admits that she is not related, her name is [**Name (NI) 32400**] [**Name (NI) 7756**] [**Telephone/Fax (1) 59390**]. Son [**Name (NI) **] gives permission to speak with [**Location (un) 32400**] but says that he should be the first contact. [**Name (NI) **] family and friend [**Name (NI) 32400**], patient normally alert, fully oriented and coherent. Family History: Non-contributory. Physical Exam: Vitals: T: 98.0 BP: 141/71 HR: 115 RR: 35 O2Sat: 99% on NRB GEN: Respiratory distress with use of accessory muscles HEENT: surgical pupils b/l, MM dry, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: Tachycardic, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs decreased BS at bases, L > R. No crackles, wheezes or rhonchi. ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: Awake, answers simple questions. moving all extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. . Pertinent Results: Other labs/interpretation: Resp cx: GRAM STAIN (Final [**2150-12-7**]): >25 PMNs and <10 epithelial cells/100X field ? OROPHARYNGEAL FLORA. YEAST, SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. MRSA . . UA [**12-5**] >50wbc, mod bact, UCx [**12-5**] >100K yeast UA [**12-7**] 6wbc, no bacteria, UCx [**12-7**]: >100K yeast . . Imaging/results: [**2150-12-5**] CXR: Increasing left lower lobe infiltrate and pleural effusion is concerning for progression of pneumonia. The remainder of the study is relatively unchanged. . [**2150-12-7**] Unchanged area of worsening right basilar area of consolidation and stable appearance of left basilar consolidation. Unchanged slight volume overload and bronchial wall thickening. . [**12-10**]: Increased right pleural effusions, bilateral basilar consolidations unchanged. Pulm vasc congeston. Brief Hospital Course: [**Age over 90 **] year old female with h/o SVT, HTN, recent admission with LLL PNA (discharged [**12-1**] on levo/flagyl), admitted from [**Hospital1 1501**] with acute onset hypoxia/dyspnea/fevers 102, CXR with worsening LLL PNA, which has now progressed to b/l PNA, clinical evidence of aspirartion. Afebrile and mostly stable, but episodes of clinical deterioration. . . Pneumonia, admitted with acute hypoxic resp failure, much improved. CXR with progressive infiltrates, LLL->now bilateral (infection vs fluid). Acuity suggests component of aspiration pneumonitis. Has resp and oral secretions, aspirating oral secretions, but has trouble bringing up tracheal secretions (weak cough) and requires deep suctioning. No fevers. White count finally coming down. She will be treated to complete a 14 day course of vanc/zosyn. . Given likely aspiration risk, she had multiple swallow evaluations, with evidence of aspiration. Based on family discussion, there is a goal of primarily comfort for patient, with thin liquids, despite risk of aspiration. If there is evidence of significant coughing, further evaluation or discussions regarding goals of care should continue with her family. . . Pleural effusions: developing over 3days, likely due to tachycardia and fluid. Diuresis for the most part was deferred further, given minimal oral intake. . . Leukocytosis: She had a leukocytosis that worsened, likely due to pneumonia. This had resolved by [**2150-12-12**]. . Atrial fibrillation, with intermittent tachycardia: While in the ICU, she had evidence of tachycardia, possibly atrial fibrillation, which broke with IV metoprolol. She continued to have intermittent episodes of tachycardia throughout her stay, likely sinus tachycardia in the setting of mucous plugging and anxiety. She was maintained on IV lopressor, and transitioned on d/c to oral lopressor. . Contaminated UA: UA/UCx on admission wtih >100K yeast, foley removed, 1 dose diflucan in MICU, but repeat UCx again >100K yeast, though UA less WBC 50->6. No treatment pursued. . . Encephalopathy: She had evidence of intermittent confusion, consistent with delirium, due to ICU stay, pneumonia. She gradually improved, though remains off her baseline. . . HTN: Well controlled on metoprolol . . PUD. cont PPI . . OA/shoulder pain: lidocaine patch, no narcotics, esp given aspiration risk . . FEN/proph: HLIV, monitor lytes, soft diet with honey thick liquids per speech only when awake, otw NPO, strict aspiration precautions, TEDs/SCDs, heparin [**Hospital1 **], PPI . . Dispo/Code status: DNR/DNI. Goals of care defined with goal toward comfort, based on family meeting between geriatrics service and her family (son, daughter, daughter in law). They would like her to return to her nursing home. A do-not-rehospitalize order will likely need to be discussed on return to [**Hospital1 599**]. . [**First Name8 (NamePattern2) **] [**Known lastname 59386**] is HCP(wife [**Doctor First Name **] [**Telephone/Fax (1) 59387**], c [**Telephone/Fax (1) 59391**]. Daughter ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 59388**] - [**Telephone/Fax (1) 59389**]) lives in [**Location **] (but is ill). Medications on Admission: 1. Metoprolol Tartrate 12.5 mg po bid 2. Docusate Sodium 200mg po bid 3. Acetaminophen 1g q8hr 4. Prilosec 20mg po q24hr 5. Cefpodoxime 100mg po bid 6. Metronidazole 500 mg po bid 7. MVI with iron 8. Remeron 15mg po qhs 9. [**Last Name (un) 7139**]-128 5% eye gtt 4x daily to each eye . Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Pneumonia, bilateral Aspiration, chronic Pleural effusions Atrial fibrillatoin Encephalopathy Discharge Condition: Stable. Prognosis is poor. Discharge Instructions: You were admitted secondary to pneumonia that is likley secondary to aspiration. You were treated for pneumonia with antibiotics. . We had extensive discussion with you and your family regarding the risk of aspiration depending on what type of food/liquids you consume but you will be allowed to eat food with aspiration precautions. . Your doctor will discuss future plans for rehospitalization with your family. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] on return to [**Hospital1 599**].

Admission Date: [**2148-8-6**] Discharge Date: [**2148-8-9**] Date of Birth: [**2079-12-19**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 4691**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Laparoscopic cholecystectomy ([**2148-8-8**]) ERCP with sphincterotomy and balloon sweep ([**2148-8-6**]) History of Present Illness: The patient is a 68-year-old male who is transferred to [**Hospital1 18**] from [**Hospital **] Hospital with chief complaint of abdominal pain. He was brought to [**Hospital **] Hospital by supervisors at his group home. He reports dull pain in the midepigastrum At [**Hospital1 **] he had a lipase of greater than 4000 and an US which demonstrated gallstones and slude, with no evidence of cholecystitis. Past Medical History: Past Medical History: 1. h/o CHF, MR 2. DM2 3. GERD 4. h/o diverticulitis 5. [**Location (un) 805**] syndrome, Mental retardation 6. HTN 7. h/o SBO (last in [**10-22**]) 8. Impulse control d/o 9. Depression Past Surgical History: s/p colectomy (reason unclear) Social History: Lives in a group home. Family History: Non-contributory. Physical Exam: 99.3 F 86 113/63 16 97% RA Pain [**4-22**] GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: well healed midline incision, soft, mildly distended, mildly tender in midepigastrum, no RUQ pain, no [**Doctor Last Name **] sign, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No LE edema, LE warm and well perfused Pertinent Results: [**2148-8-6**] 12:20AM BLOOD WBC-15.7* RBC-3.71* Hgb-12.7* Hct-37.2* MCV-100* MCH-34.4* MCHC-34.2 RDW-14.0 Plt Ct-168 [**2148-8-6**] 10:14AM BLOOD WBC-11.4* RBC-3.18* Hgb-11.6* Hct-32.5* MCV-102* MCH-36.4* MCHC-35.6* RDW-14.0 Plt Ct-143* [**2148-8-7**] 01:47AM BLOOD WBC-8.5 RBC-3.60* Hgb-11.8* Hct-36.8* MCV-102* MCH-32.8* MCHC-32.0# RDW-13.7 Plt Ct-151 [**2148-8-8**] 05:30AM BLOOD WBC-5.7 RBC-3.60* Hgb-12.3* Hct-36.7* MCV-102* MCH-34.1* MCHC-33.5 RDW-13.7 Plt Ct-160 [**2148-8-6**] 12:20AM BLOOD ALT-57* AST-77* AlkPhos-155* TotBili-0.9 [**2148-8-6**] 10:14AM BLOOD ALT-40 AST-45* AlkPhos-112 Amylase-724* TotBili-0.7 [**2148-8-6**] 07:10PM BLOOD ALT-56* AST-91* AlkPhos-170* Amylase-562* TotBili-2.1* [**2148-8-7**] 01:47AM BLOOD ALT-93* AST-165* AlkPhos-247* Amylase-356* TotBili-2.6* DirBili-2.4* IndBili-0.2 [**2148-8-7**] 01:47AM BLOOD ALT-93* AST-165* AlkPhos-247* Amylase-356* TotBili-2.6* DirBili-2.4* IndBili-0.2 [**2148-8-8**] 05:30AM BLOOD ALT-68* AST-66* AlkPhos-272* Amylase-85 TotBili-1.1 [**2148-8-9**] 06:00AM BLOOD ALT-73* AST-57* AlkPhos-221* TotBili-0.9 [**2148-8-9**] 08:33AM BLOOD ALT-70* AST-54* AlkPhos-207* TotBili-0.8 [**2148-8-6**] 12:20AM BLOOD Lipase-1890* [**2148-8-6**] 10:14AM BLOOD Lipase-793* [**2148-8-6**] 07:10PM BLOOD Lipase-450* [**2148-8-7**] 01:47AM BLOOD Lipase-244* [**2148-8-8**] 05:30AM BLOOD Lipase-36 Brief Hospital Course: The patient was initially admitted to the unit because of concern for hypotenstion in the ED. His SBPs were never lower than the 80's but a central line was placed prior to his leaving the ED. His pressures responded to fluid resuscitation and he never required pressors. The patient was taken to ERCP on the day of admission, the results of which are listed below. He tolerated the procedure well and was transferred to the floor. His labs were checked the next day and his lipase was decreasing. He was taken for laparoscopic cholecystectomy the following day. His diet was then advanced as tolerated and his pain was controlled with PO pain meds. He was ready for discharge on HD4. His foley catheter was removed and the patient voided. RUQ/Liver US ([**2148-8-6**]) - Intra and extrahepatic biliary dilation with intraductal sludge. Choledocholithiasis cannot be excluded due to limitations of visualization. ERCP or MRCP could be used for further evaluation. Gallbladder distention with sludge and wall thickening. Imaging findings suggest cholecystitis. Clinical correlation is recommended as son[**Name (NI) 493**] [**Name2 (NI) 515**] sign was negative; HIDA could be performed to better evaluate for cholecystitis if clinically appropriate. Trace ascites. CXR ([**2148-8-6**]) - Multifocal opacities, worrisome for infection. Right internal jugular central line with tip at cavoatrial junction. Pulmonary vascular congestion. Cardiomegaly, which may be in part due to pericardial fluid. ERCP ([**2148-8-6**]) - A moderate diffuse dilation was seen at the main duct with the CBD measuring 13 mm. The intrahepatic ducts were also dilated. The cystic duct filled with contrast. Successful sphincterotomy. Biliary sludge was seen exiting the ampulla along with very dark, almost black, bile. Otherwise normal ercp to third part of the duodenum. Medications on Admission: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Align 4 mg Capsule Sig: One (1) Capsule PO once a day. 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Discharge Medications: 1. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*40 Capsule(s)* Refills:*0* 10. Align 4 mg Capsule Sig: One (1) Capsule PO once a day. 11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 13. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Sympomatic choledocholithiasis Discharge Condition: Mental Status: Clear and coherent (Baseline mental retardation) Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-22**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please call the Acute Care Surgery clinic at [**Telephone/Fax (1) 600**] to arrange for a follow-up appointment in [**1-17**] weeks. The clinic is located on the [**Location (un) 10043**] of the [**Hospital **] Medical Building at [**Last Name (NamePattern1) 12939**].

Admission Date: [**2100-8-18**] Discharge Date: [**2100-8-23**] Date of Birth: [**2057-1-23**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: Multinodular goiter Major Surgical or Invasive Procedure: Total thyroidectomy History of Present Illness: The patient is a 43 year old woman who has had a history of hypothyroidism,here for total thyroidectomy for MNG.She had an increasing thyroid swelling since a couple of years,and showed up at Dr[**Name (NI) 10946**] clinic. The goiter went basically from her chin down to her sternum. She was diagnosed with MNG and was planned for a total thyroidectomy. Past Medical History: hypothyroidism Social History: She works as a hotel manager. Prior smoker and quit in [**2098**]. Drinks alcohol rarely per hospital records. Denies illicit drug use. Family History: No history of thyroid disease, diabetes, heart disease, or COPD. Father's side of family has had uterine cancer and other cancers of unknown etilogy. Physical Exam: General: Alert and oriented x3, Obese female with large neck swelling, no distress, appears comfortable. Eyes: Anicteric sclerae. Extraocular movements normal. ENT: Normal external appearance. Oropharynx is without lesions. Neck: incision with steri strips clean dry intact,no erythema, positive edema. Cardiovascular: Regular, borderline tachycardic, [**1-16**] SM at LUSB. Respiratory: Normal to inspection, percussion, and auscultation. GI: Normal bowel sounds. Abdomen not distended or tender. No hepatomegaly. Neurologic: Normal deep tendon reflexes. No tremor. No spasms. Vulvar exam: erythematous vulva with redness extending out to inner thigh. underlying skin - moist with concern for wheeping from the wound. No vaginal discharge noted. Extremities:[**12-12**]+ pitting edema present bilaterally, warm, no clubbing. Pertinent Results: [**2100-8-18**] 08:50PM BLOOD WBC-12.7* RBC-2.75* Hgb-8.8* Hct-26.6* MCV-97 MCH-31.9 MCHC-33.0 RDW-13.5 Plt Ct-213 [**2100-8-18**] 08:50PM BLOOD PT-13.7* PTT-30.2 INR(PT)-1.2* [**2100-8-18**] 08:50PM BLOOD Plt Ct-213 [**2100-8-18**] 08:50PM BLOOD Glucose-154* UreaN-10 Creat-0.6 Na-140 K-4.0 Cl-108 HCO3-22 AnGap-14 [**2100-8-18**] 08:50PM BLOOD Calcium-8.2* Phos-4.6* Mg-1.6 [**2100-8-18**] 09:49PM BLOOD Lactate-0.9 [**2100-8-18**] 09:49PM BLOOD Type-ART Temp-35.9 Rates-14/ Tidal V-500 PEEP-5 FiO2-40 pO2-149* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2100-8-19**] 03:52AM BLOOD WBC-11.6* RBC-2.46* Hgb-7.9* Hct-25.4* MCV-103* MCH-32.0 MCHC-31.0 RDW-14.1 Plt Ct-193 [**2100-8-19**] 05:54AM BLOOD WBC-13.4* RBC-2.88* Hgb-9.1* Hct-27.4* MCV-95# MCH-31.6 MCHC-33.2 RDW-14.2 Plt Ct-228 [**2100-8-19**] 03:52AM BLOOD Plt Ct-193 [**2100-8-19**] 05:54AM BLOOD PT-13.0 INR(PT)-1.1 [**2100-8-19**] 05:54AM BLOOD Plt Ct-228 [**2100-8-19**] 03:52AM BLOOD Glucose-686* UreaN-8 Creat-0.4 Na-110* K-3.4 Cl-88* HCO3-17* AnGap-8 [**2100-8-19**] 05:54AM BLOOD Glucose-139* UreaN-11 Creat-0.5 Na-139 K-4.0 Cl-107 HCO3-21* AnGap-15 [**2100-8-19**] 01:50PM BLOOD CK(CPK)-375* [**2100-8-19**] 08:16PM BLOOD CK(CPK)-448* [**2100-8-20**] 04:03AM BLOOD CK(CPK)-482* [**2100-8-19**] 01:50PM BLOOD CK-MB-9 cTropnT-<0.01 [**2100-8-19**] 08:16PM BLOOD CK-MB-9 cTropnT-<0.01 [**2100-8-20**] 04:03AM BLOOD CK-MB-9 cTropnT-<0.01 [**2100-8-19**] 05:54AM BLOOD Calcium-7.4* Phos-5.1* Mg-2.3 [**2100-8-19**] 08:16PM BLOOD Calcium-7.7* [**2100-8-19**] 03:52AM BLOOD PTH-12* [**2100-8-19**] 05:54AM BLOOD PTH-14* [**2100-8-19**] 05:53AM BLOOD Type-ART pO2-113* pCO2-45 pH-7.38 calTCO2-28 Base XS-1 [**2100-8-19**] 04:28AM BLOOD freeCa-1.11* [**2100-8-19**] 05:53AM BLOOD freeCa-1.06* [**2100-8-20**] 04:03AM BLOOD WBC-10.3 RBC-2.37* Hgb-7.5* Hct-22.7* MCV-96 MCH-31.6 MCHC-33.1 RDW-14.2 Plt Ct-122* [**2100-8-20**] 03:41PM BLOOD Hct-24.0* [**2100-8-20**] 04:03AM BLOOD Glucose-93 UreaN-8 Creat-0.5 Na-137 K-3.8 Cl-104 HCO3-20* AnGap-17 [**2100-8-20**] 03:41PM BLOOD Calcium-8.0* Brief Hospital Course: 43 year old female with diagnosis of a massive goiter is status post total thyroidectomy on [**2100-8-18**]. Intraoperatively patient was intubated and transferred to the intensive care unit for observation as there were concerns that the patient may not be able to maintain her airway due to preoperatively concerns that the thyroid was compressing the airway. Over the night of her operation she became hypotensive with systolic blood pressure to the 80s and she was started on Dopamine drip this was ultimately thought to be related to hypocalcemia. She was infused with 250 ml of albumin to which her systolic blood pressure responded and she was successfully weaned off dopamine drip and was extubated on [**2100-8-19**] and on room air. On [**2100-8-20**] she was transferred out of the intensive care unit to the surgical inpatient unit.Of note, she was noted to have extensive vulvar irritation and erythema while in the intensive care unit and Gynecology were consulted and provided recommendations. On [**2100-8-21**] she her oxygen saturation was in the mid 90s on Room air during the morning,and then triggered at noon time for O2 Sat of 85% Room air. Patient had no dyspnea and was asymptomatic. She was placed on 1 to 4 liters via nasal cannula to maintain her O2 sats. However patient continued to have an O2 Sat 90% on 3 liters nasal cannula. Therefore a chest xray was done which was negative for pneumonia and chest scan was done and was negative for pulmonary embolism. She was diuresed with Lasix intravenously. She continued to have low grade temperature 99 up to 100.2, an electrocardiogram and continued to be tachycardic, although denied dyspnea or chest pain. On [**9-28**] she continued to have decrease Oxygen saturation, mid 90's on 40-50% shovel mask. She received Lasix 20 mg intravenous and diuresed well. Overnight she was ordered for blood transfusion for a hematocrit of 22 which was stopped due to a rise in temperature from 99.2 to 100.2. She was expectorating green and brown sputum and a sputum culture was obtained. She has some intermittent productive sputum but otherwise is dry and per the patient this is usually worse during the night. A sputum culture and repeat chest Xray PA/Lat was done to rule out pneumonia. The patient continued to have no dyspnea, no respiratory distress and the oxygen was subsequently weaned to 40% and her O2 sats 92% to 94%room air. She was started empirically on Levofloxacillin but has no evidence of lower respiratory tract infection. The pulmonary team were consulted for etiology of hypoxia and recommendations. The patient will follow-up with Pulmonology Outpatient for a bubble study. The patient has no nausea or emesis and diet was advanced from clears to regular which was tolerated well. Her pain was well controlled with oral analgesia. She is ambulating independently with a steady gait. The neck incision with steri strips is clean, dry and intact without erythema, there is edema in the neck. She will follow-up with Dr. [**Last Name (STitle) **] on [**2100-8-26**] for her postoperative visit. She will be discharged home on Levothyroxine, Calcium carbonate and Calcitriol. She will follow up with primary care provider and gynecology in [**12-12**] week. Medications on Admission: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily) Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*60 Tablet, Chewable(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*20 Capsule(s)* Refills:*2* 5. Aluminum-Calcium Packet Sig: One (1) Packet Topical TID (3 times a day) as needed for vulvar pruritis. Disp:*20 Packet(s)* Refills:*0* 6. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for vulvar pruritis. Disp:*2 tubes* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Multinodular goiter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the General Surgery Inpatient Unit and underwent a total thyroidectomy.Your tissue was sent to pathology and you should have your results in 1 week. Please monitor your neck incision for any drainage, swelling or redness. Please seek immediate attention if you develop shortness of breath or increase neck swelling. Please notify Dr. [**Last Name (STitle) **] office if you have any questions or concerns. You have steri strips on your neck incision, please keep clean and dry. These steri-strips will fall off on their own, please do not remove them. You may shower but avoid swimming or bathing. Please take Tylenol for pain as directed. Please do not drink alcohol or drive while taking this medication as it may cause drowsiness. Do not take more than 4000 mg of acetaminophen (Tylenol) in a 24 hour period. Please monitor for signs and symptoms of hypothyroidism: watch for numbness or tingling around mouth or legs, confusion, muscle spasm,or changes in level of conciousness, these could be signs of low calcium which can happen after thyroid surgery. Please monitor for signs and symptoms of Hyperthyroidism: Anxiety, irritability, trouble sleeping Weakness (in particular of the upper arms and thighs, making it difficult to lift heavy items or climb stairs), Tremors (of the hands, Perspiring more than normal, difficulty tolerating hot weather Rapid or irregular heartbeats, Fatigue,Weight loss in spite of a normal or increased appetite, Frequent bowel movements. If you experience any of these signs or symptoms please contact Dr. [**Last Name (STitle) **] office [**Telephone/Fax (1) 9**]. Your follow-up appointment with Dr. [**Last Name (STitle) **] is scheduled for Thursday [**2100-8-26**] at 11:00 A.M. You will be given a prescription for Ciprofloxacin to treat your respiratory infection, please take 500mg twice a day for 2 weeks, please take all antibiotics as prescribed. Please follow-up with the Pulmonary Clinic ([**Telephone/Fax (1) 3554**] as an Outpatient for a Bubble Study. Please resume your home medication. Please schedule an appointment with your primary care provider for monitoring of your thyroid level. You will be given a prescription for Calcium Carbonate(Tums)and Calcitriol please take as directed. Followup Instructions: Your follow-up appointment with Dr. [**Last Name (STitle) **] is scheduled for Thursday [**2100-8-26**] at 11:00 A.M.([**Telephone/Fax (1) 84720**] [**Street Address(2) **]., [**Location (un) **] Division: General Surgery Please schedule an appointment with Pulmonary Clinc for Bubble study [**Telephone/Fax (1) 612**] Please schedule follow-up appointment with primary care provider [**Last Name (NamePattern4) **].[**Last Name (STitle) **] in 2 weeks. Please schedule follow-up appointment with Gynecology in 1 week. Completed by:[**2100-8-24**]

Admission Date: [**2177-11-13**] Discharge Date: [**2177-11-21**] Date of Birth: [**2101-12-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3276**] Chief Complaint: Chest pain, SOB. Major Surgical or Invasive Procedure: Arterial line Central venous line History of Present Illness: 75 year-old man with history of stage IV non-small cell lung ca with mets to spine diagnosed [**9-22**], HTN, AF, CRI, who presents with pleuritic chest pain and dyspnea for one day. The patient states that he received his first round of chemotherapy of [**Doctor Last Name **]/taxol 4 days prior to admission. He felt well one day prior to admission, but then began feeling unwell today. He stated that he had a productive cough, chills, fatigue and well as bilateral plerutic CP with taking a deep breath. He denied dyspnea. He denied N/V/D or poor po intake - eating eggs and bacon. Temp at home 100.4; referred to ED by heme/onc fellow. The pt was BIBA. Enroute the patient c/o CP and was given nitro with drop in BP to 70's. . In the ED, the patient vomited once. He had a chest CT, neg for PE. CT abd/pelvis neg. Due to the ? of PNA with fever and WBC 16.8, the pt received levo, cefepime - did not yet receive vanc. The patient remained hypotensive with SBP's 70-90's despite repeat fluid boluses - total 2L. An IJ was placed and neo was started. The patient was also found to be in afib with RVR HR 130-170. He received IV diltiazem x with improvement in HR to 100's. He was then switched to a diltiazem drip. The patient was not cardioverted as he had been in afib for 10+ years. VS were temp 99.0 HR 105 SBP 105/50 RR 20 SAo2 100% NC. Past Medical History: # stage IV adenocarcinoma of the lung dx [**2177-10-21**] by bronchoscopy, MRI [**10-26**] with bony mets to T11, 50-75% narrowing of spinal canal and mild to moderate spinal cord compression, s/p radiation on [**10-28**] - started clinical trial with Pacitaxel, Carboplatin, Anamorelin vs. placebo at [**Company 2860**], day 1 was [**2177-11-11**] # DM2 # Atrial fibrillation # HTN # chronic renal failure # Anemia # Hyperlipidemia # COPD Social History: -Tob: quit in [**2166**], approx 150 pk yrs, + asbestos exposure -EtOH: quit in [**2166**] -Illicits: None -Living situation: lives alone, no children but his extended family is very close to him -Occupation: used to be a [**Doctor Last Name 9808**] operator Family History: No family history of lung cancer Physical Exam: Physical Exam at Admission VS: 98.9 HR 92 Bp 112/77 RR 12 SaO2 96%RA Gen: NAD, flushed, Aox3 easily able to relate history HEENT: right IJ in place, mild JVD, no LAD, benign OP CV: RRR, no MRG PULM: mild bilateral crackles, good air movement, no labored breathing ABD: soft, NT/ ND EXT: warm well perfused . Physical Exam at Discharge VS: 97.7, 112/68, 106, 16, 95%RA In general patient is alerat and oriented, in NAD Neck is supple and non-tender with no LAD Heart exam shows irregular rate and rhythm. No m/r/g. Chest exam is clear to auscultation bilaterally in posterior fields Abdomen is non-tender with normal bowel sounds Extremities shows no lower pitting edema; they are warm and well perfused Pertinent Results: [**2177-11-13**] 04:40PM BLOOD WBC-16.8* RBC-3.86* Hgb-11.4* Hct-33.6* MCV-87 MCH-29.5 MCHC-34.0 RDW-14.0 Plt Ct-313 [**2177-11-13**] 04:40PM BLOOD Neuts-95.4* Lymphs-3.2* Monos-0.7* Eos-0.7 Baso-0.1 [**2177-11-14**] 05:11AM BLOOD PT-15.5* PTT-31.7 INR(PT)-1.4* [**2177-11-13**] 05:00PM BLOOD Glucose-163* UreaN-24* Creat-1.4* Na-130* K-4.8 Cl-95* HCO3-22 AnGap-18 [**2177-11-13**] 05:00PM BLOOD CK(CPK)-31* [**2177-11-14**] 05:11AM BLOOD LD(LDH)-344* CK(CPK)-34* TotBili-0.9 [**2177-11-13**] 05:00PM BLOOD cTropnT-<0.01 [**2177-11-14**] 05:11AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2177-11-13**] 05:00PM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8 [**2177-11-14**] 05:11AM BLOOD Hapto-345* . CXR: Interval worsening of the left upper lobe opacity and left subpulmonic effusion. There is a large left hilar mass, better appreciated on prior CT study. . Head CT: No acute intracranial process. Lucency involving the inner table of the left occipital bone may represent venous [**Doctor Last Name **] or arachnoid granulation, although metastatic disease cannot be excluded. Opacification of the left mastoid air cells and middle ear opacification may represent mastoiditis in the correct clinical context. . CTA Chest: Extensive left hilar tumor masses with lesions narrowing the left upper segmental branches without evidence of PE. Brief Hospital Course: MICU Course: Mr. [**Known lastname 1007**] was admitted to the MICU with likely post-obstructive PNA with elevated WBCs, productive cough and fever. A CTA showed a lung mass but no clear infiltrate and was negative for PE. ECGs initially were without ischemic changes and troponins were negative. He was started on Vancomycin and Zosyn. He had a thoracentesis which showed an exudate, cytology pending at time of transfer. He initially required Levophed for blood pressure but was able to be weaned off on [**2177-11-16**]. He was never intubated. He was feeling well the day after admission and asymptomatic with regards to the hypotension. Cultures were all negative. . He also had Afib with RVR on presentation. He was initially managed with Diltiazem gtt in the ED, then put on standing Diltiazem in the MICU. He was transitioned to Metoprolol which was titrated up to 75 mg PO TID. He had some occasional episodes of rapid heart rate which were controlled with additional doses of Metoprolol. He was loaded with Digoxin 0.25mg PO X 3 and then put on standing Digoxin of 0.125mg PO qday. His rate was better controlled on transfer but occasionally required additional Metoprolol for HR>120s. An ECG showed some T wave inversions compared to admission his cardiac enzymes were negative. He never complained of chest pain. He had an echocardiogram which showed moderate pericardial effusion without signs of tamponade.There was possible but not confirmed pericarditis causing his symptoms and ECG findings. . He developed neutropenia with an ANC of 540 on the day of transfer. He had been started on Neupogen on [**2177-11-18**]. He was afebrile at this time and continued on broad-spectrum antibiotics. He was transfused 2 units PRBCs over his course in the ICU for a hematocrit of 23.9 on [**2177-11-14**]. He was continued on standing Zofran and Ativan for post-chemotherapy nausea and was continued on his clinical trial medication of anamorelin. He was put on an insulin sliding scale for a diagnosis of diabetes for which he was not taking medication. . He was transferred to the Oncology service on [**2177-11-19**] with a controlled heart rate in the 100s-120s, hemodynamically stable and asymptomatic. . FLOOR COURSE: He was transferred to OMED service and maintained on metoprolol for rate control. He was monitored on telemetry and although he remained in atrial fibrillation, his ventricular rate was well-controlled on metoprolol 75 mg Q6H. His antibiotics were switched to levofloxacin, and he was discharged to complete a seven day course for presumptive CAP. He was seen by physical therapy who recommended discharge to home with home PT. He remained on the floor for two nights. There were no concerning episodes on telemetry and he was afebrile without chest pain or cough. He was no longer neutropenic at time of discharge. Neupogen was stopped. Medications on Admission: Fluticasone-Salmeterol 250/50 mcg disk, 1 disk [**Hospital1 **] Tiotropium Bromide 18mcg 1 cap qday Enalapril 10mg PO qday- not taking Simvastatin 20mg PO qday Albuterol 90mcg [**1-15**] puff q6hours PRN Atenolol 75mg PO daily Colace 100mg PO BID Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) Zofran 8 mg [**Hospital1 **] Ativan 1mg [**Hospital1 **] Hydrocodone as needed Tramadol as needed Discharge Medications: 1. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed: nausea. 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Anamorelin Sig: One (1) DAILY (Daily) for 3 weeks: study drug, take as directed. 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 12. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Pneumonia Atrial fibrillation with rapid ventricular response hypotension secondary to afib/dehydration Neutropenia . Secondary: # Stage IV adenocarcinoma of the lung # DM2 # Atrial fibrillation # HTN # Chronic renal failure # Anemia # Hyperlipidemia # COPD Discharge Condition: Vital signs stable, afebrile, tolerating POs, ambulatory Discharge Instructions: You presented to the hospital for low blood pressures and trouble breathing likely due to a pneumonia. You were treated with antibiotics and pressors in the ICU and your blood pressure improved. During this time, occasionally you had a rapid heart rate due to atrial fibrillation and you were started on medications, digoxin and metoprolol, to control your heart rate. . Please take all medications as prescribed. New medications: digoxin, toprol XL, levofloxacin Discontinued medications: atenolol . Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, abdominal pain, sweating, fevers, chills, bleeding, or other concerning symptoms. Followup Instructions: You should schedule an appointment with Dr. [**Last Name (STitle) 3274**] for next week on Tuesday or Thursday. You said you had already called his office to set this up prior to discharge. Call his office at ([**Telephone/Fax (1) 3280**] with any questions. . Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2177-12-2**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 5068**] Date/Time:[**2177-12-4**] 1:00 Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2177-12-24**] 10:10 [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**] Completed by:[**2177-11-22**]

Admission Date: [**2180-5-3**] Discharge Date: [**2180-5-6**] Date of Birth: [**2134-6-21**] Sex: M Service: CTS HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 34589**] is a 45-year-old male with a past medical history remarkable for chronic relapsing pericarditis secondary to severe variant rheumatoid arthritis. The patient has been experiencing severe pleuritic chest pain which had been controlled on 10 mg of prednisone; however, this had recently increased to 20 mg to control these recurrent flares. Since the symptoms stemming from the relapsing pericarditis has required the use of prednisone while other symptoms such as aching in the hands and feet have been well controlled on colchicine and methotrexate, the Cardiothoracic Surgery Service was consulted to evaluate this patient for pericardiectomy. PAST MEDICAL HISTORY: 1. Severe variant rheumatoid arthritis. 2. Gastritis. 3. History of Helicobacter pylori. 4. Status post back surgery. MEDICATIONS ON ADMISSION: (Medications at home included) 1. Prednisone 7.5 mg p.o. once per day. 2. Methotrexate 15 mg p.o. every week. 3. Colchicine 0.6 mg p.o. twice per day 4. Duragesic patch 50 as needed. 5. OxyContin 40 mg p.o. four times per day as needed (for pain). 6. Centrum. 7. Nexium. 8. Stool softeners. ALLERGIES: PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent laboratories as of [**2180-5-5**] revealed white blood cell count was 10.5, hematocrit was 30.8, and platelets were 175. Sodium was 143, potassium was 4.4, chloride was 107, bicarbonate was 27, blood urea nitrogen was 11, creatinine was 0.7, and blood glucose was 120. Magnesium was 2.3. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed vital signs with a temperature of 99.2, heart rate was 80 (sinus), blood pressure was 140/72, respiratory rate was 18, and oxygen saturation was 96% on room air. The patient is a well-developed and well-nourished male in no apparent distress. Sclerae were anicteric. Mucous membranes were moist. No evidence of oral ulcers. No evidence of cervical lymphadenopathy. Cranial nerves II through XII were intact. The chest was clear to auscultation bilaterally. The sternal dressing was intact. No evidence of extending erythema. No serosanguineous drainage was noted. The sternum showed no signs of click to palpation. Cardiovascular examination revealed a regular rate and rhythm. No murmurs, no rubs, and no click noted. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. No evidence of inguinal lymphadenopathy. No hepatosplenomegaly was noted. Extremity examination revealed no evidence of edema. No rash was noted. HOSPITAL COURSE: The patient is a 45-year-old male with a long history of severe variant rheumatoid arthritis who underwent a subtotal pericardiectomy for recurrent pericarditis. The patient's intraoperative course as well as postoperative course were uncomplicated. The patient was taken to the Cardiothoracic Surgery Recovery Unit immediately postoperatively for close monitoring. The patient was promptly extubated. The patient maintained good oxygen saturations status post extubation and remained in a normal sinus rhythm while maintaining good pressure without any pressors. By postoperative day two, the patient's condition continued to advance; demonstrating ambulation greater than five minutes without evidence of shortness of breath. By postoperative day three, the patient achieved proper physical therapy status criteria for discharge and the decision was made to discharge the patient in good condition from the hospital without services. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharge status was to home. DISCHARGE DIAGNOSES: Status post subtotal pericardiectomy. MEDICATIONS ON DISCHARGE: 1. Prednisone 7.5 mg p.o. once per day. 2. Aspirin 325 mg p.o. once per day. 3. Metoprolol 25 mg p.o. twice per day. 4. Fentanyl patch. 5. Oxycodone 80 mg p.o. twice per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was requested to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in four weeks after discharge. 2. The patient was to follow up with Dr. [**Last Name (STitle) 19634**] in one to two weeks. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name8 (MD) 11079**] MEDQUIST36 D: [**2180-5-5**] T: [**2180-5-5**] 15:45 JOB#: [**Job Number 34590**] cc:[**Numeric Identifier 34591**]

Admission Date: [**2117-4-5**] Discharge Date: [**2117-4-8**] Date of Birth: [**2043-7-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: left-sided chest pain and new left-sided pleural effusion Major Surgical or Invasive Procedure: None History of Present Illness: 73 y/o woman with PMH notable for malignant melanoma admitted with left-sided chest pain and new left-sided pleural effusion on [**2117-4-6**] s/p thoracentesis w/ 1000cc drainage of hemorrhagic fluid c/w metastatic effusion. Overnight she developed recurrent left chest/shoulder pain while ambulating to the bathroom and an increase in her oxygen requirement. On the am of transfer to the [**Hospital Unit Name 153**] she developed acute tachycardia to 170s while ambulating to the bathroom and progressive hypoxia with sat in mid 90s on 5L facemask. Repeat CXR obtained at that time demonstrated increasing left pleural effusion. EKG showed SVT at a rate of 130. ABG was 7.29/64/77 on 5L facemask, RR of 22. She was transferred to the [**Hospital Unit Name 153**] for closer monitoring and consideration of non-invasive ventilation. . On arrival to the [**Hospital Unit Name 153**], she received 1L NS bolus. She noted her SOB was improved but continued with left shoulder/chest pain. . Past Medical History: HTN malignant melanoma (see below) . Oncologic history (per OMR): Ms. [**Known lastname 32058**] [**Last Name (Titles) 1834**] shave biopsy of a left eyebrow skin lesion revealing a 1.3 mm thick, [**Doctor Last Name 10834**] level IV, non-ulcerated melanoma with 15 mitoses per high-powered field in 12/[**2112**]. In [**12/2113**], she [**Year (4 digits) 1834**] wide local excision and left parotid sentinel lymph node biopsy. There was no sentinel lymph node biopsy involvement with melanoma. Wide local excision revealed residual melanoma extending to 4.5 mm thick, [**Doctor Last Name 10834**] level IV with evidence of microsatellitosis. She did not receive adjuvant therapy. She [**Doctor Last Name 1834**] punch biopsy of a right forearm lesion in [**2115-5-24**] revealing microinvasive melanoma, [**Doctor Last Name 10834**] level II, 0.22 mm, extending to the peripheral specimen margins. She [**Doctor Last Name 1834**] wide local excision in [**2115-6-23**] revealing focal residual melanoma in situ, completely excised. On her three-year followup scans in [**3-1**], her torso CT revealed multiple lung nodules with a large left hemidiaphragm lesion measuring 7.9 x 6.3 x 3.7 cm. Biopsy was positive for melanoma. Considered for IL2 therapy but not a candidate [**1-25**] PFTs. Plan for chemotherapy. Social History: Lives with husband. Daughter is [**Name8 (MD) **] RN at [**Hospital1 **], very involved in care. Quit smoking. No alcohol. Family History: NC Physical Exam: GENERAL - ill-appearing female in NAD, in mild respiratory distress, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple LUNGS - decreased BS bilat, L>R, fair air movement, resp minimally labored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), no calf tenderness NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-27**] throughout, sensation grossly intact throughout, cerebellar exam and gait deferred Pertinent Results: [**2117-4-5**] 07:18PM LACTATE-1.6 [**2117-4-5**] 12:10PM GLUCOSE-145* UREA N-17 CREAT-0.7 SODIUM-139 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-28 ANION GAP-14 [**2117-4-5**] 12:10PM estGFR-Using this [**2117-4-5**] 12:10PM WBC-12.2* RBC-4.15* HGB-12.2 HCT-35.1* MCV-85 MCH-29.5 MCHC-34.8 RDW-14.5 [**2117-4-5**] 12:10PM NEUTS-88.4* LYMPHS-6.8* MONOS-3.9 EOS-0.6 BASOS-0.3 [**2117-4-5**] 12:10PM PLT COUNT-308 [**4-5**] CTA IMPRESSION: 1. No pulmonary embolism. 2. Marked interval increase in size of metastatic lesions at the left lung base, now associated with a large, and likely malignant, left pleural effusion. The right paraesophageal mass has also increased in size with other small bilateral pulmonary nodules again noted. [**4-7**] CXR : Large left and small right pleural effusion, unchanged. Streaky right perihilar opacities, could be atelectasis. Dense LLL opacity likely a combination of known mass atelectasis and effusion. Widened right lower paramediastinal region part of it is likely due to known paraesophageal mass. Brief Hospital Course: 73 yo F with metastatic melanoma with acute presentation of malignant pleural effusion s/p thoracentesis with short-interval reacummulation concerning for hemothorax from melanoma. #. Respiratory Distress, hypercapnic/mild hypoxia - [**1-25**] effusion, space occupying lesion, underlying COPD, respiratory depression from narcotics. Possible PE but unable to anticoagulate [**1-25**] hemorrhagic effusion. In setting of hemothorax from melanoma there are few options for treatment. Any further drainage would like result in another quick reexpansion. Given there is no treatment to stop the bleeding, placing a permanent drain or pleurex cath is not indicated. Patient's family chose to transition Ms. [**Known lastname 32058**] to comfort measures with morphine. Patient died on the AM of [**4-8**] from respiratory failure. . #. Metastatic Melanoma - Mets to pleural space, likely hemorrhagic, prognosis poor. As a result, family chose to transition patient to comfort measures. Medications on Admission: At home: - atenolol 50 mg daily - caltrate 600 mg daily - multivitamin daily - asa 81 mg daily - hctz/lisinopril 12.5/10 mg daily - compazine/zofran prn . On transfer: Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Aspirin 81 mg PO DAILY Docusate Sodium 100 mg PO BID HYDROmorphone (Dilaudid) 0.5 mg IV Q4H:PRN Heparin 5000 UNIT SC TID Ipratropium Bromide Neb 1 NEB IH Q6H Multivitamins 1 TAB PO DAILY Ondansetron 4-8 mg IV Q8H:PRN nausea Prochlorperazine 10 mg IV Q6H:PRN Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Expired Discharge Diagnosis: Patient passed away [**4-8**] Discharge Condition: Patient passed away [**4-8**] Discharge Instructions: Patient passed away [**4-8**] Followup Instructions: Patient passed away [**4-8**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2117-4-8**]

Admission Date: [**2144-2-27**] Discharge Date: [**2144-3-5**] Date of Birth: [**2079-5-27**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 618**] Chief Complaint: Found down by family, stuporous. Major Surgical or Invasive Procedure: Intubation (outside) Placement of oraogastric tube (outside) History of Present Illness: Mr. [**Known lastname **], "[**Last Name (un) **]", is a 64-year-old man transferred from [**Hospital3 **] after being found down and description of intracerebral hemorrhage on NCHCT, on a background of chronic hypertension. He was last seen at baseline by his son, [**Name (NI) 5758**] [**Name (NI) **], [**Name (NI) **]., on Monday evening. On Tuesday morning he was seen by his neighbor who described him as lethargic and as having slurred speech. The neighbor came back to Mr. [**Known lastname 94143**] door about ten minutes later and Mr. [**Known lastname **] did not respond or open his door as he normally would. On Wednesday his family tried to call and when they could get no response, decided to visit. His daughter arrived and knocked, then called to him when the door didn't open. She asked how he was and he said "Okay" and clearly recognized that it was his daughter. [**Name (NI) **] then started to mumble, then did not respond. This was at about 6 p.m., and given their concerns they forced their way in before 7 p.m. Mr. [**Known lastname **] was on the floor of his living room. It looked as if he had fallen, was lying on his back and likely hit the sofa with his head on the upper left side, deflecting it to the right. He opened his eyes to voice and was mumbling, sometimes saying things. He could not move when asked, but lifted up his shirt and said he had chest pain. There were no other apparent injuries, but he had been incontinent of urine. EMS took him to [**Hospital3 **]. Upon arrival his family say that he was no longer coherent or opening his eyes. He was intubated given his mental status and concern for aspiration (his family tell us). Non-contrast head CT scan revealed left sided intraparenchymal hemorrhage dissecting into the left thalamus and ventricles (see Imaging below). He was transferred on propofol to [**Hospital1 18**] for further management. At [**Hospital1 **] he was given 1.5 L NS, fentanyl/Versed, etomidate, Ativan. CT head, C-spine and chest x-ray were performed (see below). CK was 5374 (with normal CK-MB index). He had a leukocytosis with predominant neutrophils, some bands (22.5, 85 %, 5%). [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] note: Patient denied pain, said "it was light out", unable to get up. They noted that he was difficult to understand. Patient reported high cholesterol. In the ED he was continued on propofol and nicardipine was started to control blood pressure. Review of systems negative except as above. Past Medical History: - Hypertension, 20 years, on HCTZ monotherapy, per family - Hiatus hernia - Cardiomegaly per family, likely concentric hypertrophy in context of hypertension - Nasal polyps, s/p surgery - Recent extraction of all teeth in last couple of months - Anxiety (takes Klonopin) - Dyslipidemia, per patient at [**Hospital1 **] (as stated in their note) - Family deny diabetes Social History: Lives alone. Retired barber. 40-50 pack years, current smoker of 1 ppd. Some alcohol, but not for 8 years. Family History: Hypertension in many family members, both [**Name2 (NI) **]. Mother had 'small stroke'. Father with coronary disease. Physical Exam: Exam on Discharge: Mr [**Known lastname **] is drowsy at times, but will wake to full alertness. He is oriented to self, year and hospital. He mumbles (worse after hemorrhage), but language itself is normal. He does not easily follow midline commands (poke out tongue, smile), but will follow appendicular commands. He has a mild right facial droop with generally decreased facial expression. He has significant ataxia, with a mild right upper motor neuron pattern of weakness, worse in the arm than the leg. Weakness seems, prima facie, much worse in the context of ataxia. Sensation is intact. Coordinated appendicular movements are slow but accurate. Exam on Admission: Appearance: Appears stated age, well kept and likely BMI ~ 26. Intubated and sedated. Son, daughter and wife present at bedside. Vitals: Afebrile, 174/82 mmHg, 48 BPM and regular, 16 breaths, 99%, intubated, CMV: FiO2 0.5, 550 cc, rate 16, PEEP 5 cmH2O Respiratory pattern/ventilator settings: Will overbreathe vent. when sedation off. On CMV. Primary Survey/Evidence of Trauma: Contusion at junction of parietal and occipital bones on left, no skin breakage, no other trauma noted. Evidence of Chronic or Systemic Illness: Darker pigmentation on face, ? acanthosis nigricans. Trophic changes at feet. No surgical incisions. Evidence of Drug Ingestion/Use: None. Nuchal Rigidity Neck tone normal. HEENT: Otherwise NC, intubated, with OG. Neck: Supple. No bruits. Some secretions audible in upper airway. Lungs: CTA bilaterally/vent. sounds. Cardiac: RRR. Enlarged PMI. Normal S1/S2. No M/R/G. Abdominal: Soft, NT, BS+ Extremities: Warm and well-perfused. Peripheral pulses 1+. Neurologic: Eye Response: When propofol off will open eyes to command, but not spontaneously. Motor Response: Will move feet, but not lift from bed. Will squeeze both hands, stronger on left, but can make thumbs up on right. Will nod when touched on either side. Verbal Response: Mouthed hello on command and daughter thought he mouthed 'hey baby' to his daughter during exam. Optic Fundi: Miotic pupils. Not examined. Pupillary Responses: Pupils miotic at 1.5 mm with small symmetric reaction. Spontaneous Eye Movements: Made eye contact briefly before closing eyes. Will look to right and left. Gaze conjugate. Corneal Responses: Present bilaterally. Remaining Cranial: Face symmetric. Hearing grossly intact - follows verbal commands. Gag intact when sedation light. Respiratory Pattern Overbreathing vent. when sedation lowered. Skeletal Muscle Tone: Tone normal throughout. Motor Responses: As above. Can move both feet, squeeze left hand and seems weaker on right. No whole limb antigravity movements noted. Myotatic Reflexes: B T Br Pa Ac Left 2 1 2 2 0 Right 0 0 0 1 0 Cutaneous Reflexes: Toes go down bilaterally. Sensory Responses: Can move hand or foot that is touched to command for both feet and hands. Pertinent Results: On Admssion: [**2144-2-27**] 12:47AM BLOOD WBC-17.2* RBC-5.07 Hgb-14.9 Hct-43.1 MCV-85 MCH-29.3 MCHC-34.5 RDW-15.9* Plt Ct-202 [**2144-2-27**] 04:15AM BLOOD Neuts-73.1* Lymphs-19.2 Monos-6.1 Eos-1.2 Baso-0.4 [**2144-2-27**] 12:47AM BLOOD PT-13.1 PTT-24.6 INR(PT)-1.1 [**2144-2-27**] 04:15AM BLOOD Glucose-75 UreaN-11 Creat-0.5 Na-143 K-2.4* Cl-117* HCO3-18* AnGap-10 [**2144-2-27**] 04:15AM BLOOD ALT-19 AST-75* LD(LDH)-243 CK(CPK)-3625* AlkPhos-39* TotBili-0.4 [**2144-2-27**] 12:47AM BLOOD Lipase-22 [**2144-2-27**] 12:47AM BLOOD cTropnT-<0.01 [**2144-2-27**] 04:15AM BLOOD CK-MB-27* MB Indx-0.7 [**2144-2-27**] 08:52AM BLOOD CK-MB-37* MB Indx-0.6 cTropnT-<0.01 [**2144-2-28**] 03:53AM BLOOD CK-MB-6 [**2144-2-27**] 04:15AM BLOOD Albumin-2.5* Calcium-5.2* Phos-1.6* Mg-1.4* Cholest-147 [**2144-2-27**] 04:15AM BLOOD %HbA1c-6.2* eAG-131* [**2144-2-27**] 04:15AM BLOOD Triglyc-79 HDL-28 CHOL/HD-5.3 LDLcalc-103 [**2144-2-29**] 06:10AM BLOOD TSH-0.86 [**2144-2-27**] 12:47AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2144-2-27**] 04:24AM BLOOD Type-ART Rates-20/16 Tidal V-550 PEEP-5 FiO2-50 O2 Flow-9.3 pO2-99 pCO2-37 pH-7.43 calTCO2-25 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2144-2-27**] 12:50AM BLOOD Glucose-107* Lactate-2.1* Na-143 K-3.8 Cl-99* calHCO3-26 [**2144-2-27**] 12:50AM BLOOD Hgb-14.9 calcHCT-45 O2 Sat-55 COHgb-2 MetHgb-0 [**2144-2-27**] 04:24AM BLOOD freeCa-1.12 [**2144-2-27**] 12:47AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2144-2-27**] 12:47AM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2144-2-27**] 12:47AM URINE RBC-35* WBC-4 Bacteri-NONE Yeast-NONE Epi-0-2 [**2144-2-27**] 12:47AM URINE CastHy-0-2 [**2144-2-27**] 12:47AM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG On Discharge: [**2144-3-5**] 06:05AM BLOOD WBC-17.9* RBC-5.24 Hgb-15.0 Hct-43.8 MCV-84 MCH-28.7 MCHC-34.3 RDW-15.4 Plt Ct-327 [**2144-3-5**] 06:05AM BLOOD Neuts-63.6 Lymphs-23.1 Monos-7.9 Eos-2.8 Baso-2.5* [**2144-3-5**] 06:05AM BLOOD Glucose-108* UreaN-17 Creat-0.7 Na-132* K-3.6 Cl-92* HCO3-28 AnGap-16 [**2144-3-2**] 07:20AM BLOOD CK(CPK)-569* [**2144-3-5**] 06:05AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.0 EKG [**2144-2-27**] Sinus rhythm with increase in rate as compared with previous tracing of [**2144-2-27**]. The ischemic appearing ST-T wave abnormalities have improved but may represent pseduonormalization in the context of increase in rate. The initial forces in lead V2 are consistent with prior anteroseptal infarction. Followup and clinical correlation are suggested. Rate PR QRS QT/QTc P QRS T 84 162 90 386/428 59 -2 87 Non-Contrast Head CT [**2144-2-27**] FINDINGS: There is a similar moderate-sized left thalamic hemorrhage with surrounding edema which extends into the occipital horns of the bilateral lateral ventricles and the body of the left lateral ventricle. Possible small foci of subarachnoid/cortical hemorrhage are noted in the right frontal lobe and unchanged. No increase in the size or new focus of hemorrhage is appreciated. There is a minimal amount of rightward shift of midline structures, though the basal cisterns are preserved. Periventricular white matter hypodensity is likely related to chronic small vessel ischemia. The ventricles and sulci are normal in size. Elsewhere in the brain, [**Doctor Last Name 352**] matter/white matter differentiation is preserved. There is a small air-fluid level within the right maxillary sinus. The mastoid air cells are clear. IMPRESSION: Similar appearance of left thalamic hemorrhage with extension into the bilateral occipital horns and body of left lateral ventricle and possible small foci of subarachnoid/cortical hemorrhage in the right frontal lobe. There is minimal rightward shift of midline structures also unchanged. Though the hemorrhage may relate to hypertension or fall, underlying vascular/neoplastic etiology cannot be excluded and further workup as clinically indicated. CT C-Spine IMPRESSION: 1. No acute cervical fracture or malalignment. 2. Multilevel degenerative changes, with likely chronic uniform vertebral height loss at C5 and C6. 3. Partially-imaged brain demonstrates bilateral intraventricular hemorrhage, compatible with the known left thalamic hemorrhage. Duplex Renal Ultrasound IMPRESSION: 1. Normal sized kidneys, without evidence of renal artery stenosis. 2. Mildly elevated renal arterial resistive indices could relate to underlying chronic kidney disease. CT Head [**2144-3-4**] IMPRESSION: 1. Similar appearance of left thalamic hematoma and surrounding edema with extension to the body of the left lateral ventricle and 3rd ventricle and bilateral occipital horns of the lateral ventricles. F/u as clinically indicated. 2. No new interval hemorrhage. 3. Stable mild rightward shift of midline structures. Chest X-ray [**2144-3-5**] IMPRESSION: Marked improvement of previously identified congestive pattern. No new parenchymal infiltrates and only a plate atelectasis remaining on the left base. Brief Hospital Course: Mr. [**Known lastname **] was intubated prior to arrival given vomiting, concern for aspiration and stupor. He was admitted to the Neurology ICU service for monitoring and blood pressure control, given intraparenchymal hemorrhage with intraventricular extension. Intraventricular extension was limited to the posterior horns of the lateral ventricles, the ventricular system remaining patent, so ventricular drain placement was not necessary. He was transferred to the floor service when stabilized and extubated where the primary issues became blood pressure control, monitoring for pneumonia given persisting leukocytosis, physical therapy and his dysphagia. Intraparenchymal Cerebral Hemorrhage Typical location and historical features for hypertensive etiology. Given location and appearance, underlying mass, amyloid and traumatic seem much less likely. Blood pressure was controlled and the hemorrhage remained stable. Treatment of hypertension will be important for reducing the risk of subsequent hemorrhage. A statin was started given his lipid profile. Aspirin is safe to continue as prophylaxis. Hypertension Mr. [**Known lastname 94143**] antihypertensive regimen was broadened and increased during the admission. Amlodipine was started. HCTZ was increased to 50 mg daily, then decreased again to 25 mg owing to hypokalemia, with carvedilol initiated to help control blood pressure further. Valsartan is at maximum dose and hydralazine was also added at 10 mg every six hours. The latter [**Doctor Last Name 360**] is less ideal for home use given potential rebound and likely non-compliance given four times daily dosing. We would recommend caution in uptitrating carvedilol given heart rate and concomitant use of amlodipine (concern for heart block). Clonidine patch and long-acting nitrates might also be considered. Mr. [**Known lastname 94143**] blood pressure was improved after diuresis with Lasix 20 mg IV also, after receiving fluid in excess of urine output (not hypotonic given cerebral edema) earlier in the admission. Doppler ultrasound of the renal arteries was performed. Aldosterone level was not checked given that hypokalemia was explained by HCTZ use. Hypokalemia Increased and decreased with hydrochlorothiazide dosing, to which this was attributed. Serum potassium has been around 3.5 on the present 25 mg of HCTZ. This should be monitored in rehabilitation to determine whether supplement is necessary. Leukocytosis Initially attributed to stress-related demargination of neutrophils, but then persisted. This, is conjunction with prior aspiration, along with a hazy left base on portable film raised concern for pneumonia. He remained afebrile, but was treated with ceftriaxone for possible aspiration-related pneumonia. He remained afebrile and further evidence of clinical or radiographic pneumonia did not develop. WBC increased on the day of discharge, but this was attributed to an increase in eosinophils that were not present at admission, suggesting mild allergic reaction to ceftriaxone. Nonetheless, given no other evidence of allergy and this short course due to finish after four more doses, we recommend continuing this medication to complete the course, with the last dose of [**2144-3-9**]. Question of Pneumonia See leukocytosis. Relative Eosinophilia There is no absolute eosinophilia, but has been a relative increased in this cell line since admission. This may represent a mild allergic response to ceftriaxone. Please check CBC with differential to see that this does not climb further. Drowsiness Given peri-thalamic hemorrhage, some decreased level of arousal is not uncommon and this will often improve over several days. Klonopin was a home medication that was used at uncertain dose in the home setting, so this was titrated during the admission. He presently is taking 0.5 mg TID, which can likely be tapered to 0.25 mg TID then off over the next few days. Hyponatremia Mild hyponatremia on discharge that is attributable to mild SIADH in the context of intracerebral hemorrhage. This is just under the normal range, 132 versus 133, and has been stable, so no specific intervention seems warranted at this time. Elevated CK Attributed to rhabdomyolisis given immobility at home - it is likely that he was in the same position for about 36 hours. This trended down and we stopped checking this when in the normal range for African-American males (< ~ 800). Prediabetic State A1c was mildly elevated. Continued monitoring for diabetes is indicated. We did not initiate treatment during the admission. Myocardial Ischemia Suggested by EKG (see above), but may be prior. Enzymes were negative. Medications on Admission: - HCTZ, dose unknown - Klonopin - Total of [**2-28**], maybe more medications per family. Pharmacy, [**Company 25282**] in [**Location (un) 5110**] dispensed Klonopin, Zoloft, Trazodone. Family will bring list in a.m. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Primary Intracerebral Hemorrhage Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You came to the hospital after being found confused at home by your family. You went to an outside hospital where you were noted to have vomiting and were very drowsy and you were therefore intubated. CT scan of your head revealed that there was bleeding in your brain. You were transferred to [**Hospital1 771**] and initially monitored in the intensive care unit until it was clear that bleeding had stopped. We attribute this intracerebral hemorrhage to high blood pressure. We got your blood pressure under better control. This process of progressively controlling your blood pressure will need to continue at rehabilitation. Please stay in regular touch with your primary care physician so that this can be watched closely. You will also need to see Dr. [**Last Name (STitle) **] in [**Hospital 878**] Clinic, before which you will need an MRI (ordered at [**Hospital1 18**]) and laboratory test (prescription attatched). Followup Instructions: Please follow up in [**Hospital 878**] Clinic with Dr. [**Last Name (STitle) **]: [**Name6 (MD) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2144-4-28**] 7:30 Please see your primary care doctor immediately after dishcarge from rehabilitation. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Admission Date: [**2132-12-31**] Discharge Date: [**2133-1-27**] Date of Birth: [**2076-5-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: Progressive signs of dizziness, visual difficulties, unsteady gait Major Surgical or Invasive Procedure: Right-sided high frontal stereotactic biopsy, CT-guided target point, definition and MRI-guided intraoperative imaging. History of Present Illness: The patient is a 56-year-old male with a history of colon cancer, as well as testicular cancer, who presents with progressive signs of dizziness, visual difficulties, unsteady gait for approximately 12 months. He was worked up including an MRI scan that showed a brainstem lesion. He was referred to the brain tumor clinic for consideration of a biopsy. The patient has been followed at the [**Hospital6 **] at [**Location 10050**]. He had been treated for a number of medical issues. He was examined by Dr. [**Last Name (STitle) 66170**] whose physical exam reportedly showed bilateral facial numbness and swaying, and a MRI of the head was preformed. This demonstrated expansion of the brainstem without significant contrast enhancement. The patient was thus considered to have a brainstem glioma and started on Decadron. The patient now presents for a surgical opinion. In the office, the patient complains about dizziness, blurred vision, double vision, occasional headaches, and unsteady gait. He feels better with medications. He takes at baseline 2 Tylenol a day. Has a history of arthritis in the lower back, otherwise, he reports that the numbness in his hands has disappeared since starting the Decadron. The patient has tapered his Decadron to a dose of 2 mg p.o. b.i.d. The patient is otherwise feeling himself stable. He was told that he had a left lazy eye at baseline, but the patient is not quite sure about the symptoms. He denies otherwise any extreme fatigue, weight loss or other symptoms. Past Medical History: Hypertension Hypercholesterolemia Sigmoid colon cancer [**2125**] Testicular cancer s/p Left orchiectomy and was found to be a germ cell tumor T1, N0.was treated with adjuvant chemotherapy no radiation. Hemorrhoids Recurrent bouts of thrush Social History: He is a high school graduate. He is an electrician. He is divorced. He has no other people in the household. He has a 40-pack-year history of smoking. He drinks about three drinks a week, and he denies any recreational drug use. Family History: His mother died at 63 of a heart attack. His father died at 44 after a MVA. He has two sisters 58 and 54, the 54-year-old has gallbladder stones. Other than that, they both are healthy. There are two brothers, one brother at 47 who has hypertension and two daughters that are in good health. Physical Exam: GENERAL: He is alert, pleasant, middle-aged man in no acute distress. Weight was 170 pounds, height was 74 inches, blood pressure was 154/90, pulse of 96, respirations 20, temperature of 97.4. HEENT: The patient did have a head tilt to the left. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or rubs. LUNGS: Clear to auscultation. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: The patient is awake, alert and oriented. He has bilateral reactive pupils. Eye movements are full and we cannot detect a clear deficit of a particular muscle, at current, the patient has no diplopia. Visual fields seem to be fully intact. He has non-exhaustible end gaze nystagmus with rotatory component. Face is symmetric. Tongue is midline. No fasciculations. He has a hoarse voice. He has full strength bilaterally. He has intact sensation and symmetric reflexes. The patient does not have any memory problems, blackouts, nausea, concentration, or speech problems, as well as hearing problems. On motor examination, he was [**4-24**] bilaterally, normal tone, no drift. I found no evidence of any weakness in his hands. Upper sensory, he was intact to light touch throughout, and he was intact to pinprick over in the hands Reflexes were 2+ throughout. Cerebellar: He had bilateral intention tremor in the hands as well as finger tapping and rapid alternating movements were fine. Foot tapping and heel-knee-shin was normal. Gait: He had a wide based gait, he is unable to toe tandem or heel walk. Pertinent Results: [**2132-12-31**] 09:40AM GLUCOSE-116* LACTATE-1.2 NA+-132* K+-4.0 CL--95* [**2132-12-31**] 09:40AM TYPE-ART PO2-83* PCO2-35 PH-7.50* TOTAL CO2-28 BASE XS-3 INTUBATED-INTUBATED VENT-SPONTANEOU COMMENTS-RM AIR [**2132-12-31**] 09:48AM PT-11.1* PTT-21.2* INR(PT)-0.8 [**2132-12-31**] 09:48AM PLT COUNT-241 [**2132-12-31**] 09:48AM WBC-17.9* RBC-4.30* HGB-12.2* HCT-34.0* MCV-79* MCH-28.4 MCHC-35.9* RDW-17.9* [**2132-12-31**] 09:48AM GLUCOSE-115* UREA N-16 CREAT-0.5 SODIUM-133 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-16 [**2132-12-31**] 11:21AM freeCa-1.12 [**2132-12-31**] 11:21AM HGB-11.1* calcHCT-33 O2 SAT-97 CARBOXYHB-1 [**2132-12-31**] 11:21AM GLUCOSE-129* LACTATE-1.7 NA+-133* K+-3.9 CL--98* . Pathology [**2132-12-31**]: MIDDLE CEREBELLAR PEDUNCLE/PONS STEREOTACTIC BRAIN BIOPSY (including intraoperative smear): DIFFUSELY INFILTRATING FIBRILLARY ASTROCYTOMA. WHO ([**2126**]) grade II out of IV. . Brief Hospital Course: 56 M with PMH sigmoid and testicular ca in [**2125**], HTN, COPD, admitted for new diagnosis pontine glioma s/p posterior fossa decompression and necrotizing pna. . # Pontine glioma: 56 year-old man initially seen and discussed in brain tumor clinic. Patient taken to OR on [**12-31**] for brainstem lesion biopsy under general anesthesia. Postoperatively stayed in the PACU 6 hours then transferred to floor. On postop day one patient demonstrated difficulty of swallowing which he failed his speech and swallow evaluation. Patient kept NPO, started IV fluids. On [**2133-1-2**] patient taken back to OR for a suboccipital chiari decompression. Patient tranferred to neuro ICU for hemodymanic and neurologic monitoring. Due to postoperaive respiratory secretion extubated on [**2133-1-4**] after bronchcospy. . Brain stem biopsy pathology result is significant for infiltrative astrocytoma. Radiation oncology decided not to perform radiation mapping and to hold off for another several weeks before planning to start XRT, since patient has a slow growing glioma, and XRT could exacerbate pna. Patient known by Dr [**Last Name (STitle) 4253**] will follow up with him as scheduled. Patient was transferred to Step-down unit on [**2132-1-7**]. His speech continued to become more articulate and clear, and his mental status continued to become more clear. The patient stated that his dizziness has improved. . # Necrotizing pneumonia: Patient has a known pulmonary process that been followed in [**Hospital 669**] [**Hospital **] hospital in MA. In house repeat CT of the chest significant for left lower lobe, consolidative opacity, with central area of necrosis, an air-fluid level, and low-attenuation material. Additionally, there are several areas within the right and left lungs peripherally, with patchy opacity and tree-in-[**Male First Name (un) 239**] opacities, concerning for multifocal opacity. There is also a wedge-shaped opacity in the right lower lung zone, some of which may represent atelectasis.There is a 3.3 x 2.6 cm nodule with multiple foci of calcification within the left lower lobe. Attempt to obtain images from [**Hospital **] hospital regarding pulmonary lesions for comparison, [**Name (NI) 653**] with MEdical records to sent ua CD images. Medicine and interventional pulmonary services recommended continue antibiotics, and follow up with chest CT with and with out contrast in 4 weeks in pulmonary clinic. In the mean time [**Name (NI) 653**] with Dr [**First Name (STitle) **] at the [**Hospital **] hospital regarding tranfering him over to VA regarding his known pulmonary process, and colon carcinoma for further work up which he was agreed with the transfer. . Pleural fluid culture grew out positive to MSSA, GNR, [**Female First Name (un) 564**] albicans, staph coag neg. BAL culture grew out Stenotrophomonas maltophila and Klebsiella sensitive to almost all abx tested. ID was consulted and created antibiotic regimen of clindamycin, bactrim, ceftriaxone, to be continued for 4-6 weeks. Levo was completed for 2 weeks (last date [**2133-1-27**]). Patient should be reassessed to refine abx regimen within 2-4 weeks. The patient greatly improved on suctioning and chest PT, maintaining >95% RA on the floor. . The following labs will need to be followed up after discharge: LFTs, mycolytic/fungal cx, Cdiff x3, legionella urinary antigen . # Urinary retention: Patient had no urine output after foley was d/ced. Straight cath released 980 ml of urine. After 2 days of straight caths, patient recovered normal urination, and does not have a foley upon discharge. . # Skin lesions: Dermatology consulted in reference to his left deltoid skin lesion, non-bleeding which is present for 5 year according to patient. Dermotalogy recommended excision of the lesion to rule out melanoma once acute issues resolved with Derm Surgery ([**Telephone/Fax (1) 2977**]). . # Anemia: Patient's Hct was around 25 during admission. . # HTN: Controlled. Diltiazem and captopril were continued as per her outpt regimen. . # Access: Picc placed [**2133-1-9**]. Medications on Admission: The patient is a 56 y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] with a PMH significant for sigmoid and testicular cancer in '[**25**], HTN, and COPD who was admitted to the neurosurgery service on [**2132-12-31**] with a new diagnosis of a pontine mass after 1yr of progressive dizziness and ataxia. He underwent a stereotactic bx on [**12-31**] showing a low grade glioma and received a palliative posterior fossa expansion on [**1-2**]. . Routine pre-op CXR revealed multiple opacities and a 3x3 cm well demarcated cavitary lesion with an air/fluid level in left posterior lung. Following his surgery, he was extubated w/out event but required reintubation later that evening [**1-22**] desaturation. On [**1-3**], a chest CT was done which showed a multifocal pneumonic process with LLL necrotizing PNA. He underwent a bronch on [**1-4**] with BAL revealing MSSA and stenotrophamonas and was started on Levofloxacin (now d10/14), Vanco (since d/c), and Clinda (d10/42) at this time. Bactrim (d5/14) was added on [**1-8**] when BAL grew stenotrophamonas. . During this time, he has been intermittantly hypoxic with thick secretions requiring frequent suctioning. Over the past 2d, he has been afebrile and his secretions have cleared appreciably. He has maintained his O2 sats on 4L NC. Other than this, the patient has been intermittantly hypertensive requiring the addition of captopril to his outpatient regimen. He has also failed numerous speech and swallow evaluations requring NG tube feeds to maintain his nutritional status. From an oncologic standpoint, his pontine lesion is not amenable to resection and the plan is to initiate palliative radiation therapy. Per neurosurgery, his prognosis is extremely poor. Finally, the patient has requested transfer to the [**Location 1268**] VA system over the past several days as he has received much of his care at this hospital. Discussions are still ongoing to facilitate this transfer. . PMH: 1. Colon cancer 2. testicular cancer 3. Hemorrhoids 4. Hypertension. 5. Thrush. 6. Hypercholesterolemia. . Transfer Meds: Acetaminophen Albuterol Bisacodyl Captopril Clindamycin Dexamethasone Diltiazem Docusate HSQ Sulfameth/Trimethoprim Oxycodone Nystatin Nicotine Patch Levofloxacin Lansoprazole Ipratropium ISS . PE: 97.0 (98.5), 124/72, 81, 21, 95% 4L NC Gen: Cachetic [**Male First Name (un) 4746**] sitting up in a chair in NAD HEENT: MMM, PERRLA, EOMI, O/P clear w/ NGT in posterior oropharynx Neck: No LAD, No JVD CV: RRR, S1/S2 wnl, -M/R/G appreciated Lungs: Decreased breath sounds bilaterally L>R w/ coarse inspiratory sounds bilaterally and anteriorly, -wheezes appreciated, dullness to percussion at the L base Abd: S/NT/ND, +BS Ext: -C/C/E, 2+ peripheral pulses bilaterally Neuro: CN 2-12 grossly intact, dysarthric, strength 5/5 in the RLE, on the LLE he has decreased dorsal flexion in the foot/flexion and extension at the knee/flexion at the hip, mildly decreased L grip strength compared to R hand ================ Micro: - Sputum [**1-3**]: E. coli (pan-sensitive), Coag + staph (pansensitive) - BAL [**1-4**]: Stenotrophamonas (sensitive bactrim), Coag + staph (MSSA), sparse GNR - MRSA/VRE swab: negative ================ CTA [**2133-1-9**]: 1. Some improvement in the consolidation in the left lower lobe, although the large 4-cm cavitary lesion with an air-fluid level persists, consistent with slight overall improvement in necrotizing pneumonia. 2. New small cavitary lesion in the left upper lobe, possibly related to aspiration. Of note, the patient has a small hiatal hernia. 3. Improvement in some of the ground-glass opacities in the right middle and upper lobes, with persistent 4-mm lung nodule. 4. Similar slightly prominent right hilar and mediastinal lymph nodes. 6. No evidence of pulmonary embolism. 7. Similar calcified lung mass, possibly a hamartoma, although metastatic colon cancer cannot be excluded. . CT Head ([**2133-1-9**]): No definite change in the mass effect associated with the brainstem glioma. Interval development of a small left frontal region subdural collection. . CXR [**2133-1-10**]: No interval change. Persistent opacity at the left base. There is a 3.6-cm parenchymal opacity within the left base as well which is also unchanged. There is no evidence for overt pulmonary edema. The lines and tubes are stable in position. ================ A/P: 56 yo M admitted for dizziness/weakness. Found to have a pontine glioma now s/p posterior fossa decompression complicated by necrotizing PNA and multiple episodes of hypoxia requiring MICU level care. Called out to medicine service for further management of his infection and pulmonary status. . # Hypoxia: He has been stable over the past few days w/ better maintained SpO2. He has improved in the past w/with deep suctioning. Chest CT c/w necrotizine PNA. He is on levo ([**1-9**] -> 2 weeks), and clinda ([**1-9**] -> 6 weeks). Bactrim was started on [**1-8**] (x 2 weeks): BAL + for stenotrophamonas. - wean O2 as tolerated on the floor - Per thoracic staff ([**2133-1-10**]) pt will need CT guided drain placement this week; ? if best to schedule PEG at same time to minimize procedures - continue levaquin, clindamycin, and bactrim for full course - will need repeat CT in 1 month - continue nebs prn - continue aggressive pulmonary toilet - incentive spirometry on the floor . # Lung nodule. Chest CT from the VA on [**8-25**] demonstrated 2 lesions in LLL (anterior and posterior) both of which were felt to be stable compared to prior CT [**2-/2127**]. - await old films being mailed from the VA - f/u IP/thoracic recs . # Brainstem glioma. Prognosis estimated at a couple of months per neurosurg. ? palliative radiation - continue Decadron [**Hospital1 **] per neurosurgery - continue prn pain meds - Neurosurg following - pt full code - monitor CN exam, mental status, and strength exams . # Anemia. 4pt Hct drop on [**2133-1-9**], transfused on [**1-11**] w/ appropriate Hct elevation and has been stable overnight - repeat Hct when called out to floor - guaiac stools x3 then d/c if negative - transfuse for Hct < 25 - continue PPI while on decadron . # HTN. BP well controlled on current regimen - Continue diltiazem and captopril - monitor BP and titrate prn . # Left deltoid lesion. - f/u in Dermatologic surgery clinic on [**2133-1-15**] at 11am . # Communication: VA Chief - [**Telephone/Fax (3) 66171**]. Mrs. [**Name (NI) 66172**] (aunt) [**Telephone/Fax (1) 66173**] is HCP. . # FEN. TF's through NGT (failed video swallow again on [**2133-1-12**]) - continue aspiration precautions - patient has decline PEG placement x2 per notes in chart - will reevaluate patient's wishes once transferred to floor; would be best to place PEG when placing drainage so as to minimize procedures - replete lytes prn . # Access: PICC line placed [**2133-1-9**] . # PPX. SC heparin, PPI, bowel regimen, ISS while on decadron, replete lytes . # Code: Full . # Dispo: Patient would like to be transferred to [**Location 1268**] VA. [**Name (NI) 1094**] aunt has a scheduled meeting today with Dr. [**Last Name (STitle) **] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: Hold for lose stool. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-22**] Puffs Inhalation Q6H (every 6 hours). 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4-6H (every 4 to 6 hours) as needed. 11. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO BID (2 times a day). 13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-22**] Drops Ophthalmic PRN (as needed). 14. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours): Started on [**1-2**] Total of 14 days then d/c. . Discharge Disposition: Extended Care Facility: VA Discharge Diagnosis: Right brainstem lesion Discharge Condition: Neurologically stable Discharge Instructions: Monitor suboccipital staple sites for drainage, erthyma, swelling, fever greater than 101.5, seizure activity, visual changes, weakness, numbness or any other neurologic symptoms that may be concerning. Keep your all appointments as sheduled. Followup Instructions: Follow up with Dr [**Last Name (STitle) **] in 10 days from [**1-2**] for wound check and staple removal or can be removed at the [**Hospital **] hospital. Follow up with Dr [**Last Name (STitle) 4253**](neurooncology) and Dr [**Last Name (STitle) 3929**](Radiation oncology) in brain tumor clinic on [**2133-1-26**] at 1300 [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) **]. Follow up with Pulmonary Clinic in 4 weeks with a Chest CT with and without contrast. Follow up with Dr [**First Name (STitle) **], Dermatologic surgery clinic([**Telephone/Fax (1) 2977**]for left deltoid lesion on [**2133-1-15**] at 1100. Follow up with VA infectious disease for possible repeat CT chest in 4 weeks. Completed by:[**2133-1-27**]

Admission Date: [**2136-2-3**] Discharge Date: [**2136-2-19**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: 1. Dyspnea 2. Hemoptysis Major Surgical or Invasive Procedure: none History of Present Illness: Mr [**Known lastname 46286**] is a [**Age over 90 **]yo man with history of sCHF (EF 20-25% [**4-/2135**]), complete heart block s/p pacer, AS s/p AVR (St. [**Male First Name (un) 923**] porcine valve, [**10-7**]), Afib s/p cardioversion on warfarin, HTN, and GERD who presents with 1-2 week history of progressive fatigue, weakness, and dyspnea on exertion, as well as new onset hemoptysis in setting of supratherapeutic INR. . Patient was in his usual state of health until two weeks prior to presentation when he developed slight DOE and increased lower extremity edema, felt to be mild exacerbation of CHF by his PCP. [**Name10 (NameIs) **] lasix dose was increased from 20mg daily to 40mg daily with some effect. However, 1-2 weeks prior to presentation patient reported increasing fatigue, weakness, and SOB. He developed dyspnea with only several steps around his apartment. He denied dyspnea at rest, orthopnea or PND. Denied any fever or chills, but reported >1 week of rhinorrhea, nasal congestion, and a terrible cough productive of white phlegm. The morning of presentation ([**2136-2-3**]) he noted bright red blood mixed in with his phlegm; he could not fully quantify the amount though likely less than 1 tsp at a time. Patient reported several episodes of recurrent hemoptysis, prompting presentation to the [**Hospital1 18**] ED for further evaluation. . In the emergency department, initial VS were T: 96.4 HR: 80 BP: 120/73 RR: 16 O2%: 100% on an unknown amount of oxygen. Exam was notable for blood in oropharynx, crackles and decreased breath sounds on right. Stool was guiac negative. Labs were notable for INR of 6.8, WBC 11.8 with 87.0% N, HCT 39.1. Difficult to obtain blood draws per ED report, and several samples hemolyzed. CXR demostrated whiteout of right lung fields, as well as left sided effusion. EKG showed AFib with intermittent pacing, no ischemic changes. Bedside echo to exclude severe MR [**First Name (Titles) 3**] [**Last Name (Titles) 46296**] of right-sided effusion was limited study, but showed only mild MR. [**Name13 (STitle) **] ordered for vitamin K 10 units IV, 2 units FFP and profilnine. Also received vanco 1gm IV, zosyn 4.5mg IV, oseltamivir. Admitted to MICU for ongoing evaluation and management. On arrival to ICU, patient had an O2 sat > 94 on NRB, though became dyspneic with desats to 80s when NRB removed. He reports no recent changes in medications (other than increase in lasix dose), no sick contacts, no recent change in diet. Most recent INR reported in our system was 1.9 on [**2135-12-21**] (per OMR notes), and patient's goal INR has been 2-2.5. Past Medical History: Complete heart block s/p pacer Aortic stenosis s/p AVR (St. [**Male First Name (un) 923**] porcine valve, [**10-7**]) Atrial fibrillation s/p cardioversion Systolic congestive heart failure, EF 25-30% on TTE [**4-10**] HTN GERD s/p ORIF "right leg" Cholecystectomy Cataract removal BPH s/p TURP Carpal tunnel syndrome s/p release Allergic rhinitis L hip OA s/p THR [**9-8**] Dementia dx [**2127**] h/o rhabdomyalysis Right lower extremity radiculopathy and sacroiliitis Venous insufficiency Social History: Patient divorced. Lives alone. Has Meals-on-Wheels 5 days per week, also has someone come into to clean. No home nursing other than scheduled INR checks. Daughter has accompanied him to recent health care visits. Former smoker, quit years ago. No EtOH or illicit drug use. Family History: Non-contributory. Physical Exam: ADMISSION EXAM: VS: 95.7 72 122/58 25 97% on NRB GEN: awake, alert, oriented, elderly male in NAD, able to speak in full sentences, hard of hearing HEENT: EOMI, sclera anicteric, MMM, OP with blood NECK: supple, no cervical LAD, JVD to mandible PULM: decreased breath sounds right lung with scattered crackles, diffuse expiratory wheezes bilaterally, decreased breath sounds at left base, also with scattered crackles CARD: irregularly irregular, systolic murmur ABD: bowel sounds present, soft, NT, ND, no guarding or rebound tenderness, no hepatosplenomegaly EXT: warm, well-perfused, radial/PT/DP pulses 2+ bilaterally, 1+ edema to knees bilaterally, compression stockings in place SKIN: warm, dry NEURO: AAOx3, CN 2-12 grossly intact, moving all four extremities PSYCH: calm, appropriate . DISCHARGE EXAM: VS: T 97.8 BP 90/50 HR 76 O2 Sat 96 2L NC GEN: Awake, alert, oriented, elderly, cachectic male in NAD, able to speak in full sentences, hard of hearing HEENT: EOMI, sclera anicteric, MMM, OP with blood NECK: supple, no cervical LAD, no JVD PULM: Good movement of air throughout, course expiratory ronchi L>R, improved CARD: irregularly irregular, 2/6 systolic murmur RUSB ABD: Flat, bowel sounds present, soft, NT, ND, no guarding or rebound tenderness, no hepatosplenomegaly EXT: warm, well-perfused, radial/PT/DP pulses 2+ bilaterally, no LE edema, pneumo-boots in place SKIN: warm, dry NEURO: AAOx3, CN 2-12 intact (sensorineural hearing loss bilat), moving all four extremities, strength 5/5 PSYCH: Appropriate, Pertinent Results: ADMISSION LABS: [**2136-2-3**] 06:35PM BLOOD WBC-11.8*# RBC-4.44* Hgb-13.1* Hct-39.1* MCV-88 MCH-29.4 MCHC-33.4 RDW-15.2 Plt Ct-425# [**2136-2-3**] 06:35PM BLOOD Neuts-87.0* Lymphs-7.6* Monos-3.2 Eos-1.8 Baso-0.4 [**2136-2-3**] 06:35PM BLOOD PT-59.8* PTT-43.0* INR(PT)-6.8* [**2136-2-4**] 02:42AM BLOOD Glucose-105* UreaN-21* Creat-0.8 Na-134 K-4.1 Cl-98 HCO3-24 AnGap-16 [**2136-2-4**] 02:42AM BLOOD CK(CPK)-50 [**2136-2-4**] 02:42AM BLOOD CK-MB-4 cTropnT-0.03* proBNP-9700* [**2136-2-4**] 02:42AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.8 [**2136-2-3**] 06:42PM BLOOD Glucose-101 K-6.5* [**2136-2-3**] 06:42PM BLOOD Hgb-13.3* calcHCT-40 . DISCHARGE LABS: . MICRO: [**2-8**] Sputum Cx: upper respiratory contamination [**2-7**] Sputum Cx: upper respiratory contamination [**2-6**] Sputum Cx: GRAM STAIN (Final [**2136-2-6**]): <10 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2136-2-8**]): SPARSE GROWTH Commensal Respiratory Flora. [**2-5**] Blood Cx: negative to date [**2-4**] Rapid Viral Screen/Cx: negative 3/5 Blood Cx: negative [**2-4**] Urine Legionella: negative [**2-4**] Sputum Cx: commensal respiratory flora . IMAGING: [**2136-2-3**] Echo: The left atrium is dilated. The right atrium is dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. LV systolic function appears depressed. The right ventricular cavity is dilated with depressed free wall contractility. A bioprosthetic aortic valve prosthesis is present. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Moderate symmetric LVH with deoressed systolic function. Dilated and depressed right ventricle. At least mild mitral regurgitation (not likely to be severe however). Bioprosthetic AVR - limited study and gradients not assessed. Compared with the prior study (images reviewed) of [**2135-4-21**], this was an on-call, limited, study. Findings are broadly similar. . [**2136-2-3**] CXR: New confluent patchy alveolar opacification of the right hemithorax likely represents alveolar hemorrhage given clinical context. . Chest CT [**2136-2-13**]: 1. Left hilar mass with associated atelectasis of the lingula and anterior segment of left lower lobe and bronchial stenosis of the segmental bronchi is likely to be accessible bronchoscopically. 2. Bilateral bronchocentric pulmonary opacity with smooth septal thickening in the right lung likely reflects aspiration. 3. Bilateral moderately large nonhemorrhagic pleural effusions. 4. Moderately severe aortic annular, valvular and mitral annular calcification and mild-to-moderate coronary artery atherosclerotic calcification. 5. Right atrial and pulmonary arterial enlargement consistent with pulmonary hypertension. CXR: [**2136-2-18**] One view. Comparison with the previous study done [**2136-2-17**]. Patchy bilateral pulmonary opacities are again demonstrated. There are bilateral pleural effusions as well. These findings are essentially unchanged, as are the mediastinal structures. The left heart border is partially obscured. A bipolar transvenous pacemaker remains in place. IMPRESSION: No significant change. Brief Hospital Course: Mr. [**Known lastname 46286**] is a [**Age over 90 **]yo man with history of sCHF (EF 20-25% [**4-/2135**]), complete heart block s/p pacer, AS s/p AVR (St. [**Male First Name (un) 923**] porcine valve, [**10-7**]), Afib s/p cardioversion on warfarin, HTN, and GERD who presented with 1-2 week history of progressive fatigue, weakness, and dyspnea on exertion, as well as new onset frank hemoptysis in setting of supratherapeutic INR with CXR demonstrating almost complete alveolar opacification of the right lung. His hospital admission is sumarized by problem below. # Hypoxemic Respiratory Distress: Initially admitted to the MICU and was found to have almost complete opacification of the right lung and a left pleural effusion. He was treated with Vancomycin and Levofloxacin for presumed pneumonia for nearly 14 day course. Also given a steroid pulse in case asthma/emphysema were at play, as patient does have a smoking history, but no documented COPD. Echo showed an EF of 25-35%, so given concern for CHF exacerbation, he was diuresed aggressively and did require bipap and a nitro gtt briefly. When his respiratory status improved to saturations of >94 on 5 L NC he was transfered to the medical floor. Given persistant pleural effusion and hypoxemia, despite aggressive diuresis, IP was consulted for both diagnostic and therapeutic thoracenteisis. They felt these were not amenable to drain as minimal fluid on ultrasound. He had a Chest CT which demonstrated a new large mass in his left lung (5cm x 5cm) obstructing the bronchus to the lingula concerning for malignancy. Pulmonary was consulted to discuss further work up of this mass, and the patient and his daughter decided not to pursue a biopsy at this time. Palliative care was consulted as well. Ultimately, the patient would like to be home and is willing to go to rehab with plans to transition to home with hospice. His respiratory status remained quite tenuous throughout his hospitalization. He was diuresed aggressively with improvement in oxygenation. However, he was then noted to be hypotensive with SBPs in the low 70s. Of note, normal SBPs are in the 90s. The patient was completely asymptomatic. His blood pressure improved with a 250 cc bolus and holding further diuresis. The following day, the patient triggered for respiratory distress that was consistent with flash pulmonary edema which improved with morphine. He was continued on his home lasix regimen of 40 daily as this appeared to balance his respiratory status with his blood pressure with a goal fluid balance of even to -250 cc. He remained normotensive for 48 hours prior to d/c and his respiratory status remained stable for 24 hours prior to discharge to the MACU. He will continue to need supplemental oxygen as this was unable to be weaned completely off. His volume status should be watched carefully as he has proven to be quite tenuous -- too much volume and he goes into respiratory distress, too little volume and he is hypotensive. # Hemoptysis: In setting of elevated INR to 6.8 (on warfarin for afib). He was reversed with vitamin K. Treated for presumed pneumonia. Also [**Month/Year (2) 46296**] may be lung mass near bronchi, however work up deferred per patient request. Resolved and restarted on coumadin without incident. INR goal 2-2.5. # Goals of Care: Numerous discussion with patient and daughter were had regarding patient's goals of care. Given his likely terminal illness from his lung mass, the patient and daughter felt they did not want further workup of this. Both the pulmonary team and paliative care aided in this discussion. Both patient and daughter were in favor of intubation if the patient needed, only for the short term. He was DNR, but not DNI. They were both told that he will likely go into respiratory distress again given his finely balanced fluid status. If this were to occur, they were both in favor of coming back to the hospital if needed. # Elevated Troponin: During respiratory distress, patient's troponin was elevated to 0.09 with flat CKs. EKG showed a paced rhythm. Given this likely demand ischemia, patient was started on aspirin and atorvastatin. Further care should be directed in the outpatient. # Aspiration: CT findings were suggestive of aspiration though video swallow studied did not show aspiration. His diet was therefore advanced. #. Acute on Chronic Systolic CHF: EF 25-30% this admission in setting of decompensated heart failure. Diuresed as above. Could not wean patient off of oxygen completely. On day of discharge, patient was ~95% on 2 liters. #. Atrial fibrillation s/p cardioversion, AV node ablation: Patient was in Afib, and ventricularly paced with rate in 70s. Patient was supratherapeutic in terms of INR on admission and was given Vit K in the ED due to hemopytsis. Goal INR was 2-2.5. for atrial fibrillation. Patient with porcine valve. The patient was rate controled on metoprolol throughout admission. Coumadin restarted and INR 1.8 at time of discharge. Continued SQ heparin while patient was < 2.0. # Hyponatremia: As low as 129. Most likely hypovolemic from aggressive diuresis. It resolved on the floor. #. HTN: Patient's baseline sbp is in the high 80s-90s and at times in the 100s. Given these low blood pressures, diuresis could not be overly aggressive. He will be d/c'd on lasix 40 mg daily (as above). Lisinopril 2.5 mg was held due to low bps. Metoprolol was continued with intermittent holding in setting of low blood pressures. Low BP felt secondary to diuresis along with systolic heart failure. #. GERD: Home omeprazole was continued throughout admission. #. Osteoarthritis: Tramadol was continued throughout his admission. Medications on Admission: Furosemide 40mg daily Lisinpril 2.5mg daily Metoprolol succinate 25mg daily Omeprazole 20mg daily Potassium chloride 20 mEq daily Tramadol 50mg TID prn pain Urea 40% cream applied to left shin daily Warfarin 5mg daily, 7.5mg Friday Calcium carbonate 500mg TID Colace 100mg PO BID prn constipation Vitamin D2 400 units daily Ferrous sulfate 325mg daily MVI daily Senna 2 tabs daily prn constipation Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pain. 3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. multivitamin, stress formula Oral 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation Q6 hours PRN as needed for shortness of breath or wheezing. 8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation: Do not take if you're having loose stools or diarrhea. 9. warfarin 5 mg Tablet Sig: One (1) Tablet PO QM/W/T/TH/SAT/SUN. 10. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Friday only. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**12-4**] ampulettes Inhalation Q2H (every 2 hours) as needed for sob, wheeze. 12. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a day. 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Hold for BP < 100. 14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for Constipation: Hold for loose stool. 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily): Hold for bleeding. 16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day): Continue until patient ambulating. 17. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 18. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day: PLEASE HOLD IF SBP < 100. 19. Urea 40 40 % Lotion Sig: One (1) application Topical twice a day as needed for rash: Apply to left shin. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. Congestive heart failure exacerbation 2. New obstructive lung mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. [**Known lastname 46286**], It was a pleasure taking care of you while you were an inpatient at the [**Hospital1 69**]. You were admitted to our medical intensive care unit on [**2136-2-3**] for severe shortness of breath. While here, you were treated with antibiotics, steroids, and diuretics for a possible pneumonia, COPD exacerbation, and congestive heart failure exacerbation respectively. You improved with this therapy in the ICU and were transfered to the medical floor. You're antibiotics and steroids were discontinued and we continued to diurese for a CHF exacerbation. On [**2136-2-13**] a CT scan was taken that demonstrated a new mass in your left lung. This was discussed with you and your daughter [**Name (NI) **] by both the medicine and pulmonary teams and you decided that a biopsy would not be prudent at this time. On [**2136-2-19**] your respiratory status improved and were felt ready to be dischargee to an inpatient rehabilitation facility. Please note the following instructions: more than 3 lbs. 2. Please use combivent and albuterol nebulizers as needed for shorteness of breath You should continue your home medications with the following important changes: 1. STOP lisinopril 2.5 mg daily 2. Change metoprolol Succinate 25 mg daily to metoprolol tartrate 12.5 mg [**Hospital1 **] due to several low blood pressures. 3. Stop potassium supplementation 4. Start Atorvastatin 80 mg daily 5. Start Aspirin 81 mg daily Followup Instructions: -Please call PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], for an appointment when patient leaves rehab. -Also, please go to the following upcoming appointents: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2762**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2136-3-26**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2136-4-18**] 2:00

Admission Date: [**2106-3-22**] Discharge Date: [**2106-3-27**] Date of Birth: [**2038-3-14**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: angina Major Surgical or Invasive Procedure: [**2106-3-22**] CABG x5 (LIMA to LAD, SVG to RAMUS, SVG to OM, SVG to PDA, sequentially to PLB) History of Present Illness: 68 yo male with angina and abnormal ETT referred to [**Hospital1 18**] for cardiac cath. Past Medical History: NIDDM HTN elev. lipids prior GI bleed on ASA ( w/u revealed vascular ectasias in small bowel) anemia bacterial prostatitis [**8-26**] Social History: teaching consultant with PHD in organic chemistry lives with wife in [**Name2 (NI) **],staying here with daughter(GI physician) never used tobacco occasional ETOH Family History: father died of MI at 75 Physical Exam: 5' 7" 160# appears younger than stated age lying flat for exam in cath lab skin unremarkable, wears glasses neck supple with full ROM, and no cartotid bruits appreciated CTAB anterolaterally RRR distant heart sounds, no murmur abd soft, NT, ND extrems warm, well-perfused, no edema or varicosities noted neuro grossly intact, unable to assess gait 2+ bil. fem/DP/PT/radials Pertinent Results: [**2106-3-26**] 05:20AM BLOOD WBC-8.1 RBC-2.72* Hgb-8.2* Hct-24.2* MCV-89 MCH-30.3 MCHC-34.1 RDW-13.5 Plt Ct-171 [**2106-3-26**] 05:20AM BLOOD Plt Ct-171 [**2106-3-26**] 05:20AM BLOOD Glucose-127* UreaN-34* Creat-1.1 Na-133 K-4.1 Cl-96 HCO3-30 AnGap-11 [**2106-3-26**] 05:20AM BLOOD ALT-18 AST-26 AlkPhos-48 TotBili-0.6 Co[**Last Name (STitle) 77854**]ons PRE-CPB:1. The left atrium is normal in size. No spontaneous echo contrast is seen in the left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). 4. Right ventricular chamber size and free wall motion are normal. 5. The aortic root is mildly dilated at the sinus level. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Dr. [**Last Name (Prefixes) **] and [**Doctor Last Name **] were notified in person of the results POST-CPB: On infusion of norepi, nitroglycerine, propofol. Preserved LV systolic function with LVEF= 55%. Trace MR. Aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2106-3-22**] 15:05 RADIOLOGY Final Report CHEST (PA & LAT) [**2106-3-26**] 9:48 AM CHEST (PA & LAT) Reason: eval for pleural effusions [**Hospital 93**] MEDICAL CONDITION: 68 year old man s/p CaBG REASON FOR THIS EXAMINATION: eval for pleural effusions HISTORY: Status post CABG, to evaluate for pleural effusion. FINDINGS: In comparison with study of [**3-24**], there is little overall change in the appearance of the heart and lungs. Opacification at the left base with blunting of the costophrenic angle persists. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: FRI [**2106-3-26**] 12:05 PM Brief Hospital Course: Admitted on [**3-22**] and underwent cabg x5 with Dr. [**Last Name (STitle) 1290**]. He noted poor graft targets and elected to have the pt. start plavix and imdur postoperatively.Transferred to the CVICu in stable condition on phenylephrine, nitroglycerin and propofol drips. Extubated later that day and transferred to the floor on POD #1 to begin increasing his activity level.Transfused for Hct 22.Chest tubes and pacing wires removed without incident. He was gently diuresed toward his preop weight. Beta blockade was titrated. One episode of vomiting on POD #3 as well as generalized pruritis, without rash. sarna lotion applied. LFTs normal and pt. tolerating food.Cleared for discharge to daughter's home with VNA servies on POD #5. Pt. is to make all followup appts. as per discharge instructions. Medications on Admission: ASA 81 mg ( started 2 weeks prior to cath) toprol XL 25 mg daily lotrel 5mg/20 mg daily prandin 0.5 mg QID metformin 500 mg TID lipitor 10 mg dialy omeprazole 40 mg daily (plavix 300 mg [**3-14**], 75 mg [**3-15**]) Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for poor grafts. Disp:*30 Tablet(s)* Refills:*2* 2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*1* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*1* 4. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day for 5 days. Disp:*5 Packet(s)* Refills:*1* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 6. 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* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 8. Repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO TIDAC (3 times a day (before meals)): take if eating. Disp:*90 Tablet(s)* Refills:*1* 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 13. 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* 14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*2 bottles* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 3765**] Home Discharge Diagnosis: CAD s/p cabg x5 NIDDM HTN elev. lipids prior GI bleed ( on ASA- w/u showed vascular ectasias in small bowel) anemia bacterial prostatitis [**8-26**] Discharge Condition: good Discharge Instructions: SHOWER daily and pat incisions dry no lotions, creams or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness, drainage, or weight gain of more than 5 pounds in [**5-26**] days Followup Instructions: see Dr. [**Last Name (STitle) **] in 2 weeks see Dr. [**Last Name (STitle) 1290**] Thursday [**4-22**] at 12:45 PM [**Telephone/Fax (1) 170**] see PCP as soon as you return to NY Completed by:[**2106-3-27**]

Admission Date: [**2160-6-7**] Discharge Date: [**2160-6-23**] Date of Birth: [**2098-11-23**] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: Patient is a 61-year-old woman transferred from [**Hospital 1474**] Hospital with known bilateral subdural hematomas. The patient was in her usual state of health until today on the 17th when she had a sudden onset of headache after coughing. She was taken to [**Hospital 1474**] Hospital, where she was intubated for airway protection, although neurologically stable. She was transferred to [**Hospital3 **] for further management. She is on Coumadin for a history of valve surgery. Her INR at the outside hospital was 10.5. She was given 1 unit of fresh-frozen plasma and 5 mg of vitamin K. PAST MEDICAL HISTORY: 1. Hypertension. 2. Ventricular pacer. 3. Question of valve surgery. PHYSICAL EXAMINATION: On physical exam, she is in AF, heart rate 77, blood pressure was 208/49. She was intubated, sedated, awakened to examiner, attentive. She has antigravity strength in both upper and lower extremities. She withdraws to pain bilaterally. Her pupils were symmetric and reactive at 2.5. Her face was symmetric and her toes were downgoing. LABORATORIES AT OUTSIDE HOSPITAL: White count was 8.8, hematocrit 36.2, platelets 286. Sodium 139, potassium of 4.2, chloride of 105, CO2 24, BUN 12, creatinine 0.7, glucose 147. CT scan at the outside hospital showed right sided subdural hematoma which was about 5 mm at the greatest thickness. Also a chronic subdural hematoma with slight effacement of the right lateral ventricle. She was admitted to the Neurosurgical Intensive Care Unit. On [**2160-6-8**], the patient had an episode of desaturation with frothy sputum thought to be secondary to fluid overload from blood products to correct INR. The patient remained intubated. Pupils were symmetric. She localizes pain bilaterally moving the legs to command. Spiked a temperature to 102.6. Her sputum had gram-positive cocci in pairs and clusters. She was started on Vancomycin for pneumonia. She had positive blood cultures on [**2160-6-13**] with gram-positive cocci pairs and clusters. On [**2160-6-11**], the patient was seen by the EPS service for a question of problem with her pacemaker. They recommended to getting an echocardiogram and continuing her current medications, and just continuing to monitor her condition. She continued to spike to 102, and on [**6-15**], she had positive blood cultures with gram-positive cocci. Was started back on Vancomycin. On [**6-16**], the patient had a PICC line placed without any problems. The patient continued to be awake to voice, attentive, and following commands, moving arms and legs spontaneously and purposefully. She remained in the Intensive Care Unit, and patient was extubated on [**2160-6-18**]. She tolerated extubation well, and she was transferred to the regular floor on [**2160-6-19**], where she has remained stable from respiratory and neurologic standpoint. She is awake, alert, and oriented times three, moving all extremities. Still had some left upper extremity weakness which she has had right along. She has been followed by Physical Therapy and Occupational Therapy, and found to be safe for discharge to rehabilitation. Pulmonary wise, she is on room air. Tolerating room air fine without difficulty breathing. She has been restarted on her anticoagulation after repeat head CT scan shows stable size of the subdural hematoma with no change in that she is currently on 850 units of IV Heparin and 5 mg of Coumadin. Her INR today on [**2160-6-23**] is 1.9 with a PTT of 91.5 currently going at 850 an hour of Heparin. DISCHARGE MEDICATIONS: 1. Vancomycin 1 gram IV q24h. 2. Ipratropium bromide inhaler one nebulizer q6h prn. 3. Albuterol one nebulizer q6h prn. 4. Lasix 40 mg IV bid. 5. Levofloxacin 500 mg po q24h. 6. Metoprolol 75 mg po bid. 7. Nystatin oral suspension 5 cc po qid. 8. Fluticasone propionate 110 mcg two puffs [**Hospital1 **]. 9. Albuterol two puffs q6h prn. CONDITION ON DISCHARGE: Stable. FOLLOW-UP INSTRUCTIONS: She will follow up with Dr. [**Last Name (STitle) 1132**] with a repeat head CT scan in two weeks. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2160-6-23**] 09:37 T: [**2160-6-23**] 09:39 JOB#: [**Job Number 28697**]

Admission Date: [**2179-7-16**] Discharge Date: [**2179-7-19**] Date of Birth: [**2102-1-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: SOB Major Surgical or Invasive Procedure: s/p Bronch and stent removal History of Present Illness: 77M with tracheal malasia Past Medical History: COPD, home O2, TBM, OA, diverticulosis, nephrolithiasis, MRSA, asbestosis, GERD Social History: sormer insulation (asbestos) worker minimal smoking history Family History: none Physical Exam: AVSS Course with wheezes Pertinent Results: [**2179-7-16**] 08:11PM TYPE-ART PO2-180* PCO2-57* PH-7.36 TOTAL CO2-34* BASE XS-5 [**2179-7-16**] 08:11PM O2 SAT-97 [**2179-7-16**] 08:03PM GLUCOSE-110* UREA N-14 CREAT-0.9 SODIUM-140 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-32 ANION GAP-12 [**2179-7-16**] 08:03PM CALCIUM-9.0 PHOSPHATE-4.5 MAGNESIUM-2.0 [**2179-7-16**] 08:03PM WBC-13.0*# RBC-3.79* HGB-11.6* HCT-34.5* MCV-91 MCH-30.5 MCHC-33.5 RDW-14.4 [**2179-7-16**] 08:03PM PLT COUNT-190 Brief Hospital Course: Pt taken to OR for stent removal and clean out. Post op admitted to CSRU on vent. Kept on vent overnight and wean and extubated in AM. Diet advanced. CXR showed patent airways with minimal consolidation. Medications on Admission: Capsaicin Dilt Colace Nexium [**Doctor First Name **] Advair Xopenex Levofloxacin Lopressor Prednisone Spiriva Tylenol Codeine Guaifenesin Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* As above Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: TBM Discharge Condition: stable Discharge Instructions: Continue IS, coughing, and deep breathing. Followup Instructions: F/U with Dr. [**Last Name (STitle) **] in [**12-13**] wks F/U with Dr. [**Last Name (STitle) 952**] in 2 wks Completed by:[**0-0-0**]

Admission Date: [**2158-12-13**] Discharge Date: [**2158-12-13**] Date of Birth: [**2091-4-21**] Sex: M Service: SURGERY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 974**] Chief Complaint: unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: 67 M with extensive PMH found unresponsive by family, found to have SDH with midline shift and uncal herniation, transferred here for further management Past Medical History: Esophageal varices, GIB, h/o MI x 2, h/o lung ca Brief Hospital Course: The patient was admitted to the trauma ICU. After discussion with the family, given the patient's ICH, midline shift, and uncal herniation, further aggressive treatment was felt to be futile. He was made CMO and expired the night of [**2158-12-13**]. Discharge Disposition: Expired Discharge Diagnosis: SDH, uncal herniation Discharge Condition: expired

Admission Date: [**2108-3-22**] Discharge Date: [**2108-4-3**] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 17813**] Chief Complaint: seizures Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [**Age over 90 **] year old woman with a recent cardiopulmonary arrest of unknown etiology and seizures who has been transferred from [**Hospital1 **] [**Location (un) 620**] for further management of suspected status epilepticus. This history was obtained from discussion with her son [**Name (NI) 333**] and from review of the medical record. On [**2108-2-18**] she was found down at her residence and was noted to be bradycardic, hypotensive, hypothermic, and lethargic. She was transported to an ED at Upstate [**Location (un) **] Hospital in NY where she had a cardiopulmonary arrest and was intubated and resuscitated. The intubation was difficult and she was found to have a mediastinal mass (multinodular goiter with papillary microcarcinoma, which was removed). She had a complicated hospital course with hospital-associated pneumonia, lung collapse s/p bronchoscopy, sepsis, corneal abrasion/chemosis, perioperative anemia from blood loss, and then confusion. She was started on quetiapine initially for suspected ICU-related delirium. However, she started showing clinical signs of seizures (sudden behavioral arrest, blank stare, eye deviation to the left and down) which resolved with low dose of lorazepam. Despite reportedly unremarkable head imaging, she was thought to potentially has PRES (unclear what the blood pressure measurements were at the time). She was started on Levetiracetam 750 mg [**Hospital1 **] for seizure prevention. An EEG done at that time reportedly suggested potential epileptiform foci but no seizures were seen. She was discharged to a rehab but per her family did not return to her prior highly functional baseline mental status. On [**2108-3-21**], she was even more lethargic than usual and did not respond promptly to sternal rub. She was observed as having right face and right shoulder twitches with associated bowel/bladder incontinence which ceased with diazepam 2.5 mg given twice. She had a normal blood sugar of 81 at that time and otherwise normal vital signs after the episode. She was transferred to [**Hospital1 **] for further management where she was given two loading doses of Fosphenytoin 500 mg with some improvement in the focal motor activity. Neurology was consulted there and recommended increasing Levetiracetam to 1000 mg [**Hospital1 **] and continuing Phenytoin. She had an unremarkable NCHCT. She was found to have a UTI and was started on Ceftriaxone on [**3-21**]. She was thought to potentially have pneumonia as well, but chest imaging did not reveal an infiltrate so this was stopped. An EEG was obtained which potentially showed frequent left parasagittal epileptiform discharges, so she was transferred to [**Hospital1 18**] for further care. Prior to transfer per her son, he [**Name2 (NI) 15598**]'t notice any more motor activity but she was not very arousable (she would only briefly open her eyes to voice). Past Medical History: [] Neurologic - Seizures (s/p cardiac arrest, ? hypoxic brain injury), Recent ? Posterior Reversible Leukoencephalopathy Syndrome (clinical diagnosis at onset of seizures) [] MSK - Left hip fracture (s/p ORIF) [] Cardiovascular - Recent cardiac arrest, HTN, HL, reportedly CAD [] Pulmonary - Recent hypoxic respiratory failure [] Endocrine - Multinodular goiter with papillary carcinoma (s/p resection, discovered during difficult intubation) [] Ophthalmologic - Corneal abrasion/chemosis Social History: Until recently living independently, driving. Now at [**Hospital3 4103**] on the [**Doctor Last Name **]. No tobacco, ETOH, or illicit drug use. Family History: Ovarian cancer (mother) Physical Exam: General: NAD, lying in bed comfortably. Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity, no meningismus Cardiovascular: RRR, no M/R/G Pulmonary: Equal air entry bilaterally, no crackles or wheezes Abdomen: Soft, NT, ND, no guarding Extremities: Warm, no edema, palpable radial/dorsalis pedis pulses Skin: No rashes or lesions Neurologic Examination: - Mental Status - Alert, Oriented to self and year, but no year or city. She follows commands. - Cranial Nerves - [II] PERRL 3->2 brisk. VF full to threat. [III, IV, VI] Tracks to the left but has difficult crossing midline to the right. [V] Corneals present bilaterally. [VII] No facial asymmetry at rest. [XII] Tongue midline. - Motor - No tremor or asterixis or myoclonus currently. She has full strength on the left side of her body, with decreased strengh on the right, but moving at least against gravity. - Sensory - Response to noxious all four extremities. - Reflexes =[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc] L 2 2 2 2 2 R 2 2 2 2 1 Plantar response extensor bilaterally. - Gait - Unable to assess. Brief Hospital Course: Neuro: Mrs. [**Known lastname 110651**] was very sleepy while in the ICU, and her EEG was showing PLEDs. She was started on keppra and dilantin. Her PLEDs improved, and her mental status continued to slowly improved. Upon transfer to the floor, she had no further clinical seizures. Her mental status was improving daily, and she was back to having full conversations on the day of her discharge. we stopped her dilantin and increased the keppra in order to create a balance between her level of drowsiness and seizure control. We decided not to treat the actual PLEDs, as she was clinically improving. CV/Resp: She did not have any further acute issues during her stay. We continued her anti-hypertensive medications. FEN/GI: She was initially too sleepy to eat on her own and therefore was placed on tube feeds. She took her own tube out on [**4-1**], and as she was awake enough, we decided not to replace it and allow her to PO. We advanced her diet to soft + thin liquids based on the recommendations of speech therapy, and she tolerated it well. She needs to continue to work on her diet, and she needs supplmentation with ensure. ID: She received 7 days of ceftriaxone for her UTI, she was afebrile, and had no further complications. We kept her foley in because she developed a bed sore, and we did not want the area to become wet. The foley can come out once the area has healed. Medications on Admission: Transfer Medications: LEV 1000 [**Hospital1 **] NovoLog sliding scale Lovenox 40 SC Mag PRN PHT 100 q8h CTX 1g daily, ASA 325 Nexium 20 [**Hospital1 **] APAP 650 q6h prn Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID (2 times a day). 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Seizures Discharge Condition: Condition: good Mental status: Alert, oriented to self and year, fluctuates in terms of orientation to day/city. Ambulatory: currently bed bound. Discharge Instructions: Dear Mrs. [**Known lastname 110651**], It has been a great pleasure taking care of you. You were admitted to our neurology/epilepsy service because you were having seizures after you had your cardiac arrest. Your EEG did show that you were having a lot of epileptic discharges, you were placed on two medications, and we only kept you on one of them, which was enough to control the seizures. You also had a urinary tract infection which we treated. Your mental status continued to improve dramatically. You required a feeding tube through your nose initially, but you were able to start eating by mouth soon after and therefore did not need it anymore. Followup Instructions: Our neurology clinic will contact you for a follow up appointment.

Admission Date: [**2105-8-11**] Discharge Date: [**2105-8-12**] Date of Birth: [**2034-12-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2817**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: None History of Present Illness: 70yo man w/ h/o CAD s/p CABG, h/o afib, ETOH cirrhosis, DM, who presented to an OSH on [**2105-8-4**] w/ a perforated small bowel, underwent enterectomy & end-ileostomy on [**2105-9-5**], post-op course complicated by renal failure, ileus, worsening hepatic failure and mental status changes. He is being transferred to [**Hospital1 18**] for evaluation of his multi-organ failure--there was question of him having hepatorenal syndrome. Summary of OSH Course: - Pt p/w abd pain. Initially treated conservatively w/ IVF and levo/ flagyl. However, his pain persisted and lactate up to 6.1. - Pt went for ex lap, which reportedly revealed perforated small bowel. He underwent enterectomy w/ end ileostomy. - Post-op he was extubated. However, he had increasing respiratory distress and required intermittent Bipap. On day of transfer, he was requiring persistent Bipap due to hypoxemia: ABG 7.48/30/68--on 50% Fi02 on Bipap. He was intubated prior to transfer to [**Hospital1 18**]. - Pt described as having MS changes w/ possible hepatic encephalopathy. He reportedly Opened eyes, responded "intermittently" to voice. - He developed acute renal failure of unclear cause. His bumped from 0.48 to 1.58 post-op. OSH was unable to be measure crt on last day or two of his OSH stay [**1-17**] elevated bili. Renal US w/ no hydro (per erport). - Pt described as having post-op ileus for which an NGT placed. He was started on TPN b/c ileus. - LFTs notable for Tbili 20.8, up from 6.8 on admission. Direct bili 14.9. AST 85, ALT 49. INR 2.1. Alb 2.4. - Pt noted to have ascites w/ bacteroides uniformis (few) and rare clostridium species (not perfringens) growing in it. - Cdiff test positive from [**2105-8-4**]--day of pt's admission, suggesting he had it prior to presenting. - Pt treated with flagyl/levo from outset of hospital stay ([**8-4**]) and zosyn was added (? [**8-11**]) - Had afib w/ rates up to 140s. Was getting dig for this. - Trop 0.11. EKG unchanged from prior. - Pt developed hypotension. He was started on levophed. Serum cortisol 22.1 (unclear if random level). Lactic acid 2.9 prior to transfer. - Plt 29K (chronically low--for years) - Pt noted to have coagulopathy w/ INR 2.1 - Got re-intubated by EMS, AC 550x10/5/100%; on levophed, Past Medical History: - CAD s/p CABG - DM - ETOH cirrhosis - Colon cancer s/p resection & radiation - Chronic thrombocytopenia & ? leukonpenia - Group B strep sepsis of unknown source in [**4-20**] - AAA - HTN - Hypercholesterolemia -GERD -Esophagitis - Echo [**6-22**] (OSH) nml LV function, LVH & biatrial enlargement. Mild MR, Mild to mod TR, mild to mod PAH. (EF 64% on MIBI [**6-22**]) - EGD [**6-22**] showed "diffuse mild inflation at GE junction--not biopsied--and gastritis. - Colonscopy rectal polyp (rsected Social History: Married. Lives w/ wife on [**Name (NI) **]. Works 3day/wk in butcher shop. Has grown kids. Drinks 4 gins /day. Former smoker Family History: nc Physical Exam: VS: T: 95.6 HR: 105 BP: 117/62 (on 0.25 levophed) Sat: 92% on AC 550x14, 5, 100% Gen: NAD, when sedation wears off pt follows one step commands & shakes his head "no" when asked if he is in pain. HEENT: NCAT, PERRL, sclera icteric Neck: Supple, no LAD, no JVD CV: distant hrt sounds; nml S1/S2, no m/r/g Resp: course breath sounds b/l anteriorly Abdomen: Distended but Soft, absent BS, NT, vertical ~midline surgical incision w/ areas open space where fluid is leaking out (?[**Last Name (un) 12949**] fell out in those areas), fluid draining appears serosanguinous. Ostomy draining serosainguinous fluid Ext: No c/c/e. DP pulses are 2+ bilaterally Neuro: A + O x 3, CN II-XII grossly intact, Motor [**4-20**] both upper and lower extremities Skin: Pink, warm, no rashes Brief Hospital Course: 70 year-old man with CAD s/p CABG, PAF, reported cirrhosis from ETOH abuse, and chronic thrombocytopenia, POD#7 s/p enterectomy & end-ileostomy for small bowel perforation, who is transferred with multiorgan failure. . # Shock: Pt presented from OSH already on one pressor with evidence for multisystem organ failure including ARF. Had been intubated prior to transport. On arrival pt rapidly decompensated with hypotension refractory to IVF and eventually maxed out on 4 pressors. He was treated broadly with antibiotics, daptomycin, ceftazadime, PO vancomycin, IV flagyl. His lactate continued to elevated and he stopped making urine. A family meeting was held during the day when pt's pressures could not be maintained on max presssors and fluids. The decision was made not to withdraw care but it was agreed that CPR would not be indicated. The patient passed away with his family present at [**2026**]. Medications on Admission: Dig 0.25mg Toprol Xl 50mg ASA 81 PRotonix 40mg ? Glyburide Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Sepsis Multiorgan failure Discharge Condition: Expired Discharge Instructions: expired Followup Instructions: expired

Admission Date: [**2116-12-6**] Discharge Date: [**2116-12-10**] Date of Birth: [**2063-1-24**] Sex: M Service: MEDICINE Allergies: Compazine Attending:[**First Name3 (LF) 7591**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: intubation/extubation History of Present Illness: HPI: This is a 53 year-old gentleman with HCV cirrhosis and refractory lymphoblastic lymphoma/ALL on rituximab and prednisone who presents with altered mental status. His mother found him this morning with increased lethargy and complaining of diffuse back pain. The back pain was unchanged from his usual back pain, secondary to his ALL, and was not relieved by morphine or methadone. He was recently admitted to the BMT service from [**11-27**] until [**12-1**] for fevers and progressive ALL. Infectious work-up was unremarkable and his fevers were atrributed to a reaction to platelet transfusion. Of note, he had another admission earlier in [**Month (only) **] at which point he developed a strep viridans line infection (from PICC line)-- the PICC line was removed, he was treated with a course of PCN G which was changed to augmentin at his last admission with the last dose due either yesterday or today. After finding him this morning, his mother brought him back to 7 [**Hospital Ward Name 1826**] today for readmission and an ambulance was called from there to bring him to the ED. . In the ED, initial vitals were T 98.3, BP 122/83, HR 100, RR 12, 100% on 4L. He was sleepy but A+O x3. Pt was noted to be very uncomfortable, complaining of back pain. While in the ED, he became more delirious, writhing around in bed, refusing pain medications, and perseverating on wanting to get out of bed to urinate. Pt was intubated for CT head and abdomen. Spiked temp to 101.8 rectally but remained hemodynamically stable. He was given ceftriaxone, vanco, and acyclovir for empiric meningitis coverage. LP was deferred given platelet count of 14. CT head was negative and CT abdomen was notable for slightly worsened ascites, new bibasilar opacities. Attempts to place OGT and foley were unsuccessful and patient was noted to only have 40cc of UOP while in the ED. . ROS: Unable to obtain. Past Medical History: <b>HEMATOLOGIC/ONCOLOGIC HISTORY:</b> Mr. [**Known lastname 2479**] was diagnosed with lymphoblastic lymphoma in [**2116-1-31**]. He presented to [**Hospital1 18**] on [**2115-12-30**] with complaints of diffuse myalgias and arthralgias. A CT scan demonstrated multiple enlarged portahepatis lymph nodes (largest 1.5 x 2.7 cm)and portacaval lymph nodes (largest 1.9 cm x 3.4 ) as well as multiple mildly enlarged paraaortic lymph nodes, the largest measuring 1.2 x 1.9cm. On [**2116-1-6**], he underwent a CT-guided fine-needle aspiration of a portahepatis lymph node which was nondiagnostic. A bone marrow biopsy was obtained on [**2116-2-26**], demonstrating involvement by high-grade B-cell lymphoproliferative disorder. Tumor cells were diffusely positive for pan B cell markers CD20 and PAX-5, with co-expression of CD10 and bcl-2. TdT staining was equivocal, with predominantly cytoplasmic staining and a rare cell with dim nuclear staining. MIB-1 staining showed an overall proliferation index of 50-60%, with focal areas with a higher fraction. The differential diagnosis was felt to include lymphoblastic lymphoma/leukemia (precursor B-cell lymphoma/leukemia) or a blastic transformation/progression of a mature B cell lymphoma. It was noted that a definitive diagnosis would require flow cytometry and molecular studies, which could not be performed because there were no blasts in the peripheral blood and a marrow aspirate could not be obtained (dry tap). However, the peripheral blood sample was sent for immunophenotyping, which demonstrated a new population of CD34 positive cells and a small population of CD19 positive cells in the "blast" gait, without expression of TdT. It was felt that these findings should be interpreted with caution since no blasts were identified on a corresponding peripheral smear. Given his significant liver dysfunction and other medical co-morbidities, the initial treatment regimen chosen for the patient consisted of R-CHOP, which was initiated on [**2116-3-4**]. He received a second cycle of chemotherapy on [**2116-3-24**], consisting of R-CHOP without vincristine, which was held secondary to neuropathy. Modified Hyper-CVAD Course A was given on [**2116-4-10**], with a second course given on [**2116-5-15**] and a third course on [**2116-6-22**]. Course B was not given due to his history of hepatic cirrhosis. Of note, the patient has known retinal involvement by his lymphoma, for which he is followed by Dr. [**Last Name (STitle) **] of ophthalmology. A liver biopsy on [**5-8**] and repeat bone marrow biopsies on [**6-12**] and [**7-19**] have shown no evidence of recurrent lymphoma. The patient presented on [**2116-10-15**] with myalgias, headache, mental status changes, and fevers. A CBC showed a WBC of 7.2 with 14% blasts. A bone marrow biopsy demonstrated marked fibrosis and relapsed acute lymphoblastic leukemia/lymphoma. He was treated with rituximab 500mg, given in three doses of 100mg, 200 mg, and 200mg on [**10-9**] - [**10-11**]. In addition, he was treated with rituximab 375mg/m2, cyclophosphamide 750mg/m2, doxorubicin 20mg/m2, and dexamethasone 20mg from [**10-19**]- [**10-21**]. The patient was noted to have recurrence of peripheral blasts on [**2116-11-9**], with a bone marrow biopsy on [**2116-11-11**] showing residual leukemia in the marrow. After extensive discussion, he opted to continue palliative chemotherapy with rituximab and prednisone. Rituximab was started on [**2116-11-16**] at 100mg, with plans to continue threrapy with 200mg daily on [**11-17**] and [**11-18**]. <br> <b>ADDITIONAL MEDICAL HISTORY:</b> 1. Hepatitis C, not treated. 2. Hepatic cirrhosis. 3. History of intravenous drug use. 4. History of depression. 5. Chronic lower back pain. 6. Status post tonsillectomy and adenoidectomy. 7. Lipomectomy. 8. Steroid-induced diabetes mellitus Social History: The patient is currently living with his mother and his brother, [**Name (NI) 2259**]. [**Name2 (NI) **] has two children and four grandchildren. He is a recovering heroin addict who used IV drugs for over 30 years before becoming clean, but he admits that he intermittently uses illegal drugs, most recently in early [**Month (only) 359**] (cocaine) and did heroin ~5 years ago. He Currently smoke [**2-2**] cigarretes/day and has history of ~20 pack-year. He denies alcohol use. He formerly worked in housing construction as roof constructor. Family History: The patient's father died of lung cancer at 78. His maternal grandmother died of colon cancer 78. His sister died of leukemia. He has 2 brothers and 2 sisters who are healthy as well as 2 children. He is separated Physical Exam: Vitals: T: 101.1 BP: 87/50 HR: 71 RR: 23 O2Sat: 100% Vent settings: AC 600/14 PEEP 5 FiO2 100% GEN: intubated HEENT: PERRL (4-->2mm), sclera anicteric, no epistaxis or rhinorrhea, MMM, ET tube in place NECK: No JVD, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, diminished breath sounds at the left anteriorly, no W/R/R ABD: Distended, +BS, difficult to assess HSM, +fluid wave EXT: No C/C/E, no palpable cords NEURO: opens eyes to voice, does not consistently follow commands. Moves all 4 extremities spontaneously. Plantar reflex downgoing. SKIN: Scattered ecchymoses on LUE (by PICC line) and abdomen. No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2116-12-6**] 08:25AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-1+ [**2116-12-6**] 08:25AM NEUTS-25* BANDS-1 LYMPHS-21 MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* NUC RBCS-15* OTHER-48* [**2116-12-6**] 08:25AM GLUCOSE-211* UREA N-26* CREAT-0.6 SODIUM-140 POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15 [**2116-12-6**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2116-12-6**] 09:00PM GLUCOSE-133* LACTATE-2.3* NA+-137 K+-5.1 CL--115* [**2116-12-6**] 09:00PM TYPE-ART PEEP-5 O2-60 PO2-92 PCO2-31* PH-7.43 TOTAL CO2-21 BASE XS--2 INTUBATED-INTUBATED [**12-8**] DIC labs + Tbili: 5.1 Alb: LDH: [**Numeric Identifier 35002**] Dbili: 0.8 Fibrinogen: 463 Plt: 24 CXR (s/p intubation): Although on the frontal view, the electronic measurement of the distance from the ET tube tip to the carina is less than 6 cm, the tip is above the upper margin of the clavicles, and it is probably 3 cm above optimal placement, with the discrepancy explained by marked patient kyphosis. Aside from mild plate-like atelectasis at the base of the left base, lungs are clear. There is no pleural effusion. Heart size is normal. . CT abd/pelvis: Slightly worsened ascites. No change in splenomegaly, cholelithiasis, portal lymphadenopathy. Bibasal opacities new since [**Month (only) 359**], could be due to atelectasis, pneumonia, aspiration. . CT head: No evidence of acute intracranial abnormalities. MR with gadolinium would be more sensitive for intracranial infections or masses. . KUB: Non-specific bowel gas pattern without free intraperitoneal air. . CXR PA and lat: Interpretation is limited by patient rotation and kyphotic angulation. However, there is no evidence of pleural effusion or focal consolidation. Allowing for change in positioning, the study is overall not significantly changed since [**2116-11-27**]. There is a focus of linear atelectasis at the left lung base. Wedge compression deformities of two low thoracic vertebral bodies are unchanged. Brief Hospital Course: Patient was a 53 year-old male with a history of relapsing refractory ALL on prednisone and rituximab and HCV cirrhosis who presents with fever, altered mental status, and hypotension. Patient was hypotensive, started on pressors, given IVF, worsened in the setting of adrenal insuffiency, and synthetic hepatic dysfunction. Patient was intubated. Once infectious etiology was eliminated, patient's dim prognosis was discussed with family and a determination was made to make the patient CMO. Patient was extubated and started on morphine drip. Patient, due to high drug tolerance, continued to have pain and was responsive on morphine drip. Patient was transferred from the [**Hospital Unit Name 153**] to BMT floor for CMO continuation. Patient continued to show signs of discomfort and sedatation was switched to dilaudid and ativan drip. Patient expired at 7:20 pm on [**2116-12-10**] secondary to respiratory failure from relapsing refractory ALL in the presence of the family. The proxy, [**Name (NI) **] [**Name (NI) 2479**], the patient's son, consented to a full autopsy. Medications on Admission: Amoxicillin-Pot Clavulanate 500-125 mg PO Q8H Lantus 50u daily Humalog ISS Gabapentin 300 mg PO HS Lactulose 30 ML PO QID Lorazepam 0.5 mg Tablet PO Q4H Filgrastim 480 mcg/1.6 mL Q24H Acyclovir 800 mg PO Q8H Methadone 30mg PO QAM , 20mg PO NOON , 30mg PO QPM Mirtazapine 30 mg PO HS Morphine 15 mg PO Q4H prn Nystatin Suspension 5 ML PO QID prn Omeprazole 20 mg PO DAILY Prednisone 20 mg PO daily Spironolactone 100 mg PO DAILY Allopurinol 300 mg PO DAILY Furosemide 40 mg PO DAILY Acetaminophen 650 mg PO Q4H prn Discharge Medications: expired --- none Discharge Disposition: Expired Discharge Diagnosis: lymphoblastic lymphoma / ALL HCV cirrhosis Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2116-12-10**]

Admission Date: [**2199-2-10**] Discharge Date: [**2199-2-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: Intubation History of Present Illness: [**Age over 90 **] y/o F extensive PMH including CHF, A Fib on coumadin, chronic thromboembolic PHTN who presents with hematemesis. Patient's caretaker noticed her coughing up bright red blood (quarter size clots) today and consequently brought her to the ED for evaluation. Vitals on presentation were 97.5 88 99/62 18 85. On evaluation patient produced large amounts of hematemesis and required intubation for desaturation and airway protection. She was given 40 mg protonix, 10 mg IV vitamin K and 2 L of NS. Her labs were significant for HCT of 20 and creatinine 5.3. BP ranged from 87-114/54-64. She was transferred to the MICU for management of upper GI bleed. . Patient was recently discharged [**2199-2-8**] from the [**Hospital1 1516**] service home with hospice following a complicated hospital course. Patient presented with shortness of breath secondary to CHF exacerbation, was aggressively diuresised but developed hematemesis and worsening renal failure. Her renal failure did not improve and her bleeding source was never found. During the admission bloody material came from her mouth, but it was not clear whether it was emesis or cough. There was concern for malignancy based on prior CT showing thyroid mass and LAD, but a follow-up non-contrast chest CT did not suggest new pathology. ENT did not visualize any bleeding source down to the glottis level. GI was consulted but GI and primary team agreed that risks of EGD outweighed benefits unless Hct unstable. Prior to discharge she did have grossly apparent dark red blood in her bowel movements suggestive of GI etiology. Patient was also treated for kleibsella UTI during the admission. Due to her increasingly difficult-to-manage systolic and diastolic CHF, combined with increasingly severe renal failure and unknown source of bleed decision was made for comfort focus and she was discharged home with hospice. Past Medical History: Risk factors: no HTN, DM, HL no prior CABG or PCI Probable CAD (focal wall motion abnormality & fixed perfusion defect) Congestive heart failure, systolic and diastolic, chronic Atrial fibrillation on coumadin Valvular disease: 2+ MR & 4+ TR . Chronic thromboembolic PHTN with RV failure, s/p IVC filter [**2185**] CKD (cr 2-2.6) pancytopenia Peripheral vascular disease h/o ischemic colitis h/o LGIB Gout/pseudogout: followed by rheum Dr. [**Last Name (STitle) **]. h/o h. pylori positive gastritis s/p TAH/BSO OA vs rheumatoid arthritis Social History: Lives in her own home with a 24hr home health aide, [**Last Name (STitle) 802**] [**Name (NI) **] involved and lives nearby. She has a remote history of smoking. Denies ETOH. Family History: Denies significant family history. Physical Exam: Initial PE: General Appearance: Well nourished, No acute distress, Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t) Absent), (S2: No(t) Normal, Distant, No(t) Loud, No(t) Widely split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic), Distant heart sounds Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath Sounds: No(t) Clear : , Crackles : Few, No(t) Bronchial: , No(t) Wheezes : , Diminished: , No(t) Absent : , No(t) Rhonchorous: ), Periodic breaething Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, No(t) Tender: , Obese Extremities: Right lower extremity edema: 1+ edema, Left lower extremity edema: 1+, No(t) Cyanosis, No(t) Clubbing Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand Skin: Warm, No(t) Rash: , No(t) Jaundice Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds to: Tactile stimuli, No(t) Oriented (to): , Movement: Non -purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Not assessed Pertinent Results: [**2199-2-10**] 11:02AM HCT-24.2* [**2199-2-10**] 03:30AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010 [**2199-2-10**] 03:30AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2199-2-10**] 03:30AM URINE RBC-[**10-26**]* WBC-21-50* BACTERIA-FEW YEAST-RARE EPI-[**2-8**] [**2199-2-10**] 03:22AM TYPE-ART RATES-18/ TIDAL VOL-400 PEEP-5 O2-100 PO2-37* PCO2-49* PH-7.32* TOTAL CO2-26 BASE XS--1 AADO2-644 REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED [**2199-2-10**] 02:09AM COMMENTS-GREEN TOP [**2199-2-10**] 02:09AM LACTATE-3.4* K+-3.9 [**2199-2-10**] 02:09AM HGB-6.7* calcHCT-20 O2 SAT-62 [**2199-2-10**] 02:00AM PT-18.6* PTT-36.9* INR(PT)-1.7* [**2199-2-10**] 01:50AM GLUCOSE-177* UREA N-138* CREAT-5.3* SODIUM-134 POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-27 ANION GAP-18 [**2199-2-10**] 01:50AM estGFR-Using this [**2199-2-10**] 01:50AM WBC-5.2 RBC-2.31* HGB-6.3* HCT-20.0* MCV-86 MCH-27.0 MCHC-31.3 RDW-19.2* [**2199-2-10**] 01:50AM NEUTS-67.3 LYMPHS-25.1 MONOS-5.6 EOS-1.8 BASOS-0.2 [**2199-2-10**] 01:50AM PLT COUNT-151 CXR [**2199-2-10**] Comparison is made to the prior study from [**2199-2-10**]. Endotracheal tube terminates 21 mm above the carina which is acceptable. Nasogastric tube courses below the diaphragm but the tip is not seen, presumed in the stomach. The heart is markedly enlarged. There is patchy consolidation at both lung bases as well as in the perihilar region. There may be superimposed congestive failure. There are small bilateral pleural effusions. Brief Hospital Course: [**Age over 90 **] y/o F CHF, A Fib on coumadin, chronic thromboembolic PHTN who presents with hematemesis. Patient recently discharged home with hospice [**2199-2-8**] from [**Hospital1 1516**] service following complicated admission with CHF exacerbation, renal failure and hematemesis. . # Hematemesis: Significant upper GI bleed with hematocrit drop 20 from most recent HCT of 25. Etiology most likely esophagitis, gastritis versus peptic ulcer disease. Prior EGD [**2193**] demonstrates gastritis (history of h. pylori). Patient given 10 mg IV vitamin K in ED. Patient home hospice/DNR/DNI prior to admission, unfortunately unable to reach HCP at time of presentation and thus she was intubated in the emergency department. HCP was out of the country. Her [**Last Name (LF) 802**], [**Name (NI) **] was the only family available by phone. Based on extensive documention in OMR no central line, pressors or extreme aggressive measures. We spoke with the hospice nurse involved in the case as well as available family and decision was made not to initiate any further invasive procedures. . # Positive Ua: Patient oliguric with multiple prior positive cultures for KLEBSIELLA and is most likely colonized. Patient treated last admission for Klebsiella with ceftriaxone. Abx were held as most likely is colonized. Patient hypotensive secondary to hypovolemia/blood loss and unlikely sepsis. . # CHF: Severe diastolic dysfunction and TR. Recent admission with aggressive diuresis. This was monitored. # Atrial fibrillation: Currently irregular rate. Patient is not anticoagulated based on goals of care. . # CKD: Baseline renal insufficiency worsened last admission, continues to climb. Lytes within normal limits. No further labs were drawn after it was decided not to pursue further monitoring. . # Goals of care: Patient recently discharged home with hospice however was brought into ED for evaluation. Most likely caretaker felt overwhelmed at home. Unfortunately, we are unable to reach patient's HCP for further direction. Touched base with primary providers, hospice nurse, and available family. Confirmed that pt and HCP had decided on DNR/DNI, no furthe treatment was initiated. - DNR, no aggressive measures such as central access, pressors . # FEN: pRBC, replete electrolytes, NPO # Prophylaxis: pneumoboots # Access: peripherals X 2 # Communication: Patient # Code: DNR # Disposition: ICU pending goals of care discussion . Contact: [**Name (NI) **] (not HCP) ([**Telephone/Fax (1) 109254**]) [**Hospital 269**] Hospice [**Telephone/Fax (1) 32042**] [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) **] *** On [**2199-2-13**], after BPs falling over prior 48 hours, pt. went into intermittent asystole. Pupils were fixed, no heart or breath sounds. Once asystolic, ventilator was turned off. Physical exam repeated without change. Time of death was 04:45. Her [**Last Name (LF) 802**], [**Name (NI) **] was notified and the family did not choose to pursue autopsy. Medications on Admission: 1. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:*30 Capsule(s)* Refills:*2* 2. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for indigestion. Disp:*500 ML(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. Disp:*60 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* 5. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*2 inhalers* Refills:*3* 6. Home oxygen Home oxygen, at 1-6L/min, pulse dose for portability 7. Morphine 10 mg/5 mL Solution Sig: One (1) mL PO every [**3-12**] hours as needed for pain and/or respiratory distress. Disp:*100 mL* Refills:*0* 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Compazine 5 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for nausea. Disp:*60 Tablet(s)* Refills:*2* 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:*500 mL* Refills:*2* 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Medications: Pt. expired Discharge Disposition: Expired Discharge Diagnosis: 1. GI Bleed 2. Hypotension/Hypovolemia Discharge Condition: Pt. expired Discharge Instructions: Pt. expired Followup Instructions: Pt. expired

Admission Date: [**2184-10-22**] Discharge Date: [**2184-11-9**] Date of Birth: [**2120-5-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6169**] Chief Complaint: Word finding difficulty Major Surgical or Invasive Procedure: Craniotomy and drainage History of Present Illness: Pt is a 64 y/o male with a h/o AML/MDS, DM2, and COPD who presented to clinic today for a routine visit with a complaint of a difficulty finding words over the past week. He states this came on suddenly. The primary trouble is with finding words to describe what he wants to say, not actually articulating the words. He denies any other neurologic symptoms, including weakness (no stumbling, dropping items), loss of sensation, or other confusion. Mr. [**Known lastname **] displays understanding of his current situation and location. He denies any specific symptoms, including fever/chills, headache, shortness of breath, chest pain/pressure, nausea/vomiting, diarrhea/constipation, melena/hematochezia, dysuria/hematuria, nosebleeds, and rashes. Hhis speech prompted the team in the clinic to investigate these symptoms, and an MRI/MRA demonstrated a left parietal fluid collection. In terms of his AML, Mr. [**Known lastname **] was treated with LODAC in [**2182**] and subsequent to that has been on hydrea and donazol and has been transfusion dependant. He is currently on hydroxyurea only. Past Medical History: 1.)AML, converted from MDS 2.)DM-2 3.)COPD Social History: Mr. [**Known lastname **] lives alone. His sister lives about one block from him and is very supportive. He uses [**Company 107361**] the ride to get to his [**Hospital1 107362**] clinic visits. He lived in [**State 15946**] for many years where he worked at a VA. He also has worked as a taxi driver. He smoked for many years but quit around 30 years ago. Family History: Non-contributory. Physical Exam: t 98.4, bp 114/68, hr 88, rr 14, spo2 95%ra gen- thin older male, appears frustrated and slightly confused heent- anicteric sclera, op clear with mmm neck- no jvd, no lad, no thyromegaly cv- rrr, s1s2, no m/r/g pul- moves air well, occasional wheeze, no rales/rhonchi abd- soft, nt, nad, nabs, no organomegaly extrm- decreased bulk/normal tone, no c/c/e, warm dry neuro- a&ox3 (knows situation, knows having trouble finding words); language: pt has naming difficulties, cannot find name for pen, chair; affect: approriately frustrated; cn: eomi, perrl, facial motion/sensation intact/symmetric, tongue midline and without fasiculations; motor: [**4-21**] distal strength all extrm, 4+/5 in le with hip flexion, [**4-21**] LE knee flexion/extension, ue [**3-22**] proximal strenght, [**4-21**] distal, no pronator drift; sensation intact to light touch throughout; reflexes +2 and symmetric patellar, ankle, biceps; finger to nose normal, rapid alternating movements normal. Pertinent Results: [**2184-10-22**] 09:05AM BLOOD WBC-22.4* RBC-3.40* Hgb-10.3* Hct-30.0* MCV-88 MCH-30.2 MCHC-34.3 RDW-14.1 Plt Ct-6*# [**2184-10-29**] 12:30AM BLOOD WBC-15.5* RBC-3.20* Hgb-9.8* Hct-28.9* MCV-90 MCH-30.6 MCHC-33.8 RDW-14.4 Plt Ct-82* [**2184-11-9**] 05:45AM BLOOD WBC-14.9* RBC-2.87* Hgb-8.7* Hct-25.9* MCV-91 MCH-30.5 MCHC-33.7 RDW-14.7 Plt Ct-27*# [**2184-11-9**] 05:45AM BLOOD Glucose-83 UreaN-29* Creat-0.5 Na-140 K-4.2 Cl-100 HCO3-34* AnGap-10 [**2184-11-9**] 05:45AM BLOOD Calcium-10.2 Phos-4.6* Mg-2.3 Brief Hospital Course: 64 y/o male with AML progressed from MDS currently being treated with hydroxyurea who was admitted for a word finding difficulty and was found to have a subdural bleed in the setting of platelets of six. 1.)Subdural bleed -- The patient was initially brought up to a platelet level of 50 and observed in the bone marrow unit. On the second day of admission, he experienced a sudden, severe headache and had a stat head CT, showing no definite change in the size of the lesion or the degree of midline shift, yet due to his symptoms, neurosurgery was consulted. They felt it appropriate to take Mr. [**Known lastname **] to the OR where the subdural bleed was drained; subsequent pathology demonstrated clotted blood. He was kept in the neurosurgical ICU for two days where he did well with no post-operative complications and was then sent back to the bone marrow unit for further care. By his return to BMT, his speech and confusion had greatly improved, and his family members agreed that he was back to his baseline. Throughout the remainder of the admission, he continued to experience a slight headache, much improved from admission, that was well relieved by 5mg of oxycodone. His word-finding symptoms did not recur. The main challenge was maintaining his platelets at a an appropriate level due to his underlying myelodysplastic syndrome. Per the neurosurgery team, his goal for platelets was around 50 for three weeks; at the time of discharge, he will require an additional week of platelets at this level, usually achievable by giving two bags of platelets each morning, checking a post transfusion count 30-60 minutes thereafter. After this week has finished, he will be maintained at his prior level, getting transfusion two to three times per week at [**Hospital1 1388**] hematology clinic under the care of Dr. [**First Name (STitle) 1557**]. He will follow-up with his hematologist, Dr. [**First Name (STitle) 1557**], for his AML in one week and with Dr. [**Last Name (STitle) 739**], a neurosurgeon, in two weeks (he will get a repeat CT scan at that time). 2.)AML -- Mr. [**Known lastname **] is being treated with hydroxyurea and transfusions as needed. His WBC at [**Hospital1 18**] ranged between 12 and 28, generally around 14. His goal hematocrit was over 25, and he generally required one unit of packed RBC's every three to four days. Platelet requirements have been described above. 3.)Type two diabetes -- The prednisone Mr. [**Known lastname **] takes makes his blood sugars somewhat difficult to control, however, a regimen of Humalog 75/25 with 45 units every morning and 25 units at night seemed to work the best. He was also covered with a routine regular insulin sliding scale for excessively high values (usually starting at 2 units of regular insulin for a glucose of 150-200, and going up by two units of insulin for every 50mg/dl of blood glucose increase). 4.)COPD -- Mr. [**Known lastname **] was maintained on Advair 250/50, one puff twice a day. He was also given an albuterol inhaler for shortness of breath/wheezing that he rarely needed. He became wheezier in the middle of the admission, and was given twice daily scheduled albuterol nebs to which he responded well. We would recommend continuing these for two more days, then stopping them, leaving him on only Advair and as needed albuterol inhalers. 5.)Fever -- One week prior to discharge, Mr. [**Known lastname **] had a temperature to 101. His blood and urine cultures were negative. Clinically and radiographically, his most likely source was pulmonary, although the chest x-ray did not demonstrate an obvious pneumonia. He was treated with levofloxacin, and will finish his course with seven more days of antibiotics. Medications on Admission: Humalog 75/25 40 units sc every AM and PM Furosemide 20mg po daily Advair 250/50 one puff twice daily Hydroxyurea 1000mg po once daily Pantoprazole 40mg po daily Prednisone 15mg po daily Discharge Medications: 1. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Forty Five (45) Units Subcutaneous qAM. 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb Inhalation twice a day. Disp:*qs qs* Refills:*2* 3. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) Ml Intravenous DAILY (Daily) as needed. Ml 14. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Twenty (20) Units Subcutaneous qPM. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Subdural hematomoa Secondary: Acute Myelogenous leukemia/Myelodysplastic syndrome Diabetes -- type two COPD Discharge Condition: Fair, with improved sx, stable hematoma, requiring frequent platelet transfusions. Discharge Instructions: Please return to the emergency department for fevers/chills, shortness of breath, chest pain, severe headaches, confusion, speech difficulties. Follow up as below. Take medications as prescribed. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **] on [**11-19**] at 11:30. Please call [**Telephone/Fax (1) 107363**] for questions. Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Where: [**Hospital6 29**] HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2184-11-15**] 12:30 Please call Dr. [**Last Name (STitle) 739**], your neurosurgeon, at [**Telephone/Fax (1) 1669**] to be seen in two weeks. When you call, please remind them you will need another CT-scan of your head prior to the visit.

Admission Date: [**2182-5-20**] Discharge Date: [**2182-5-30**] Date of Birth: [**2119-6-30**] Sex: M Service: MEDICINE Allergies: Lasix / Betalactams / Haldol / Ceftriaxone Attending:[**First Name3 (LF) 10370**] Chief Complaint: Tachypnea, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 61 yo Russian-speaking man w/anoxic brain injury and with hx of DMI, s/p cadaveric kidney transplant([**2175**]), h/o CVA and chronic aspiration (multiple admissions for aspiration PNA - last [**3-19**]), CABG in [**2170**], widespread tracheomalacia with trach stent, and recent admission to the ICU from [**Date range (2) 21579**] for PNA, stent removal and tracheostomy. He was treated for aspiration PNA with Vanc, Levo, Flagyl and then switched to Cefepime and Azithro to complete a 10 day course. He was also given Cipro x 7 days for a UTI. He was discharged with a dobhoff feeding tube and on tube feeds. He was found today at rehab to be hypoxic to the mid-80s. Suction was attempted but did not show improvement and he was sent to [**Hospital1 18**] ED. . In the ED, initial vs were: T100.4 HR102 BP163/93 RR24 O2sat96. Patient was given Vanc, Cefepime, Azithro and Solumedrol 125mg IV x 1. He was given Kayexalate PR for potassium of 5.7 and aspirin for troponin of 0.62. He was seen by IP due to possible air leak as he was pulling tidal volumes of 200. The plan was to replace his trach once in the ICU. . On the floor, he appears comfortable, unable to answer questions, not following commands. Past Medical History: - Cadaveric renal transplant in [**2175**] - CVA-residual right hemiparesis - DM Type I - HTN - Hx non-QMI and Vfib arrest [**2169**] with anoxic brain injury - CAD/CABG [**2170**] - Swallow study-showed silent aspiration - hx of aspiration pneumonia - tracheomalacia after long intubation requiring trach stent and button complicated by site cellulitis and granulation tissue requiring cryoptherapy. Social History: Lives with wife. Former endocrinologist in [**Country 532**]. Has homemaker who comes in 5 times a week. Has 3 daughters who visit him. Family History: No history of lung disease Physical Exam: General: Awake, in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Course breath sounds bilaterally, left sided rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + foley with brown sediment Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: TRANSTHORACIC ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with inferior/inferolateral akinesis/hypokinesis and apical septal akinesis/dyskinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. . Compared with the prior study (images reviewed) of [**2181-11-16**], left ventricular sysotlic function is now more significantly impaired. Focal apical septal hypokinesis was present previously. Inferolateral /inferior akinesis is new (there may have mild inferior hypokinesis previously). . . CXR: BEDSIDE FRONTAL RADIOGRAPH OF THE CHEST: Bilateral airspace opacities which are more confluent in the left lung, worrisome for pneumonia. Distended azygous contour, could represent volume overload with part of the RUL opacity representing early edema. There is no pleural effusion or pneumothorax. Heart size is normal. Median sternotomy wire and mediastinal clips from prior CABG are present. Tracheostomy tube is in standard location with the tip terminating 3 cm above the carina. . IMPRESSION: Multifocal pneumonia with mild volume overload. . . [**2182-5-20**] 05:35AM BLOOD cTropnT-0.62* [**2182-5-20**] 02:40PM BLOOD CK-MB-23* MB Indx-6.7* cTropnT-1.47* proBNP-[**Numeric Identifier 21580**]* [**2182-5-20**] 11:01PM BLOOD CK-MB-14* MB Indx-5.1 cTropnT-1.70* [**2182-5-21**] 04:36AM BLOOD CK-MB-12* MB Indx-4.7 cTropnT-1.79* [**2182-5-21**] 01:59PM BLOOD CK-MB-7 cTropnT-1.36* [**2182-5-20**] 05:35AM BLOOD Glucose-415* UreaN-65* Creat-2.4* Na-146* K-5.7* Cl-106 HCO3-21* AnGap-25* [**2182-5-20**] 02:40PM BLOOD Glucose-405* UreaN-75* Creat-2.7* Na-146* K-4.9 Cl-111* HCO3-23 AnGap-17 [**2182-5-20**] 11:01PM BLOOD Glucose-170* UreaN-68* Creat-2.4* Na-149* K-4.9 Cl-115* HCO3-23 AnGap-16 [**2182-5-21**] 04:36AM BLOOD Glucose-66* UreaN-67* Creat-2.2* Na-151* K-4.7 Cl-117* HCO3-23 AnGap-16 [**2182-5-24**] 05:38AM BLOOD Glucose-98 UreaN-36* Creat-1.1 Na-144 K-3.8 Cl-107 HCO3-31 AnGap-10 [**2182-5-20**] 02:40PM BLOOD CK(CPK)-345* [**2182-5-20**] 11:01PM BLOOD CK(CPK)-277 [**2182-5-21**] 04:36AM BLOOD CK(CPK)-254 [**2182-5-23**] 05:27AM BLOOD CK(CPK)-70 [**2182-5-20**] 05:35AM BLOOD tacroFK-14.6 [**2182-5-21**] 04:36AM BLOOD tacroFK-5.4 [**2182-5-23**] 05:27AM BLOOD tacroFK-7.2 [**2182-5-24**] 05:38AM BLOOD tacroFK-4.9* [**2182-5-30**] 06:09AM BLOOD WBC-4.5 RBC-3.87* Hgb-9.9* Hct-30.9* MCV-80* MCH-25.7* MCHC-32.2 RDW-17.2* Plt Ct-249 [**2182-5-30**] 06:09AM BLOOD Glucose-290* UreaN-30* Creat-1.1 Na-145 K-4.7 Cl-108 HCO3-30 AnGap-12 [**2182-5-27**] 07:38PM BLOOD ALT-23 AST-19 LD(LDH)-231 CK(CPK)-33* AlkPhos-58 TotBili-0.4 [**2182-5-28**] 05:50AM BLOOD CK-MB-NotDone cTropnT-1.05* [**2182-5-25**] 08:45AM BLOOD CK-MB-NotDone cTropnT-1.81* [**2182-5-23**] 05:27AM BLOOD CK-MB-NotDone cTropnT-1.58* [**2182-5-22**] 04:03AM BLOOD CK-MB-5 cTropnT-1.35* [**2182-5-21**] 01:59PM BLOOD CK-MB-7 cTropnT-1.36* [**2182-5-21**] 04:36AM BLOOD CK-MB-12* MB Indx-4.7 cTropnT-1.79* [**2182-5-20**] 02:40PM BLOOD CK-MB-23* MB Indx-6.7* cTropnT-1.47* proBNP-[**Numeric Identifier 21580**]* [**2182-5-20**] 05:35AM BLOOD cTropnT-0.62* [**2182-5-30**] 06:09AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9 [**2182-5-23**] 05:27AM BLOOD Triglyc-114 HDL-55 CHOL/HD-2.8 LDLcalc-76 [**2182-5-28**] 02:36PM URINE Color-Yellow Appear-SlHazy Sp [**Last Name (un) **]-1.015 [**2182-5-28**] 02:36PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose->1000 Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-TR [**2182-5-28**] 02:36PM URINE RBC->50 WBC-[**4-12**] Bacteri-FEW Yeast-FEW Epi-0-2 MICRO: [**2182-5-29**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2182-5-28**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2182-5-28**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2182-5-22**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2182-5-22**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [**2182-5-20**] URINE Legionella Urinary Antigen -FINAL INPATIENT [**2182-5-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST} INPATIENT [**2182-5-20**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2182-5-20**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI} EMERGENCY [**Hospital1 **] [**2182-5-20**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] [**2182-5-20**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2182-5-27**] FINDINGS: Despite repeated image acquisition, the study is limited by patient motion. Hyperdensity projecting over the left inferolateral frontal lobe (3:20) is likely a bone-related artifact in the setting of motion. Otherwise, there is no evidence of acute intracranial hemorrhage, mass effect, edema or major vascular territorial infarct. The prominent ventricles and sulci are unchanged in size or configuration. There is no shift of normally midline structures. Moderate periventricular and subcortical white matter hypodensities are compatible with known chronic microvascular ischemic disease. Lacunar infarcts in the basal ganglia are unchanged. There is persistent moderate opacification of the left sphenoid sinus. IMPRESSION: 1. No evidence of an acute intracranial process on motion-limited evaluation. 2. Moderate chronic microvascular ischemic disease with numerous lacunar infarcts. 3. Unchanged moderate opacification of the left sphenoid sinus without evidence of acute sinusitis. Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [**2182-5-28**] FINDINGS: In comparison with the study of [**5-24**], there has been placement of a right PICC line that extends to the lower portion of the SVC. There is increased aeration at the left base with minimal residual atelectasis. Nasogastric tube has been removed. Tracheostomy tube remains in place. Brief Hospital Course: 62 year old man with history of multiple strokes, type one diabetes, and recurrent aspiration PNA s/p tracheostomy who presents after witnessed aspiration event with hypoxia, diabetic ketoacidosis, and NSTEMI. . #. Hypoxia: This was most likely due to an acute aspiration event given his history and witnessed aspiration. He was initially covered with broad spectrum antibiotics although culture grew out sparse commensals and imaging was thought to be more consistent with atelectasis and volume overload than pneumonia so antibiotics were stopped after two days. He was given bumex boluses to maintain fluid balance a negative fluid balance until this volume overload resolved. His hypoxia resolved after this. . #. NSTEMI: Patient with EKG changes, elevated cardiac biomarkers with troponinT peaking at 1.8, and transthoracic echo with new wall motion abnormalities. He was started on aspirin 325mg daily and high dose statin initially. A heparin drip was continued for 48 hours. He was started on low dose beta blocker and subsequently on clopidogrel. The cardiology service was consulted and after discussion with the family the plan was for in-patient cardiac catheterization. He was transfered to the cardiology service for this. After discussion with the patient's wife it was decided not to pursue cardiac catheterization due to the patient being 5 days post medically treated NSTEMI and the complications that could arise with this procedure. [**Hospital 21581**] medical management was pursued. . #. CHF: Patient was found to be volume overloaded on admission. This was thought to be the cause of his initial hypoxia and was probably caused by his NSTEMI given the new wall motion abnormalities and depressed EF of 35-40% (previously 55%) on TTE. He was treated with bumex boluses and his volume overload resolved. After resolution of the acute episode he remained euvolemic and did not need further duiresis. . # Diabetic Ketoacidosis: In the emergency department, he had hyperglycemia, an anion gap in the twenties, and ketones in the urine on admission. The precipitant was thought to be cadiac ischemia. Patient treated with insulin gtt with closure of anion gap and return to normoglycemia. [**Last Name (un) **] was consulted regarding glargine and insulin sliding scale dosing. He had several episoded of hypoglycemia on his home dose of glargine that were atributed to poor PO intake. Glargine was subsequently decreased to 10 units at bedtime and his ISS was changed to humalog and adjusted for meals. He then had episodes of hyperglycemia and his HSS was adjusted further. . # Positive blood culture: He had one out of 2 sets of blood cultures growing coag negative staph on [**5-20**] (with subsequent negative blood cultures) and another [**2-9**] sets positive for coag negative staph from [**5-29**] that came back after he was discharged. This information was reported verbally to his nurse and by fax to [**Hospital **] Hospital [**Hospital1 8**] where he is currently. . #. Acute renal failure: He was found to have an elevated creatinine of 2.2, up from his baseline of 1.1-1.3. This was thought to be pre-renal azotemia in the setting of dehydration with osmotic diuresis due to DKA and poor forward flow due to his NSTEMI and acute CHF exacerbation. His renal function returned to baseline with gentle IVF initially and then with diuresis. His medications were renally dosed and nephrotoxic medications (enalpril) were held. The renal transplant team was consulted given his history of cadevaric renal transplant in [**2175**]. Once his renal function returned to his baseline enlapril was re-started without complications. . #. Altered mental status: Patient was found to have acute mental status change after he was transfered to the cardiology service from the ICU. This was thought to be due delirium as the patient was waxing and [**Doctor Last Name 688**] between agitation and somnolence. A CT head was done to evaluate for an intracranial process causing his AMS but this was negative. Infectious work up was also negative. After reviewing patient's record it had been mentioned in past discharge summaries that the patient had similar episodes after long hospitalizations. He was treated with low dose zyprexa prn which he received few doses of. His MS [**First Name (Titles) 21299**] [**Last Name (Titles) 21582**]r and he was back to his baseline on the day of discharge. . #. Immunosuppression: s/p cadaveric renal transplant [**2175**]. His tacrolimus level was monitored closely in the setting of acute renal failure. He was continued on his home dosage for a goal of [**4-13**]. The renal transplant service was consulted. He was continued on cellcept and prednisone. He was continued on bactrim. . #. Recurrent UTI: He recently completed a course of cipro for a UTI. Urine culture grew out E.coli that was pan-resistant except to nitrofurantoin (contraindicated in renal insufficiency) ceftriaxone, ceftaz (allergy) and cefepime. He completed a 7 day course of cefepime. Medications on Admission: Medications from prior d/c summary: 1. Mycophenolate Mofetil 500mg PO BID 2. Pravastatin 20 mg Tablet PO qday 3. Fluvoxamine 100mg PO BID 4. Aspirin 81 mg Tablet qday 5. Docusate Sodium suspension 100mg PO BID 6. Senna 8.6 mg Tablet 1 tab [**Hospital1 **] PRN constipation 7. Prednisone 4mg PO qday 8. Sulfamethoxazole-Trimethoprim 800-160 mg qMWF 9. Metoprolol Tartrate 25 mg Tablet PO TID 10. Albuterol Sulfate neb q2H PRN wheezing 11. Insulin Glargine 100 unit/mL Solution 25 unit SC qHS 12. Bisacodyl 5 mg tab PO qday PRN constipation 13. Docusate Sodium 100 mg Capsule PO BID 14. Enalapril Maleate 20 mg Tablet PO qday 15. Lansoprazole 30 mg Tablet,Rapid Dissolve, PO qday 16. Ipratropium Bromide 0.02 % Solution inhalation q6H 17. Tacrolimus 3mg PO qPM, 4mg PO qAM 19. Polyethylene Glycol 3350 17 gram/dose Powder PO qday PRN constipation 20. Quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS 21. Morphine 2-4 mg Intravenous Q6H PRN as needed for pain. 23. Lorazepam 0.5-2 mg Injection Q4H (every 4 hours) PRN agitation. 24. Ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12 hours) for 7 days: Last dose [**2182-5-20**]. . Discharge Medications: 1. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution [**Month/Day/Year **]: 2.5 ML PO BID (2 times a day). 2. Pravastatin 80 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day. 3. Fluvoxamine 50 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times a day). 4. Aspirin 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: Ten (10) ML PO BID (2 times a day) as needed for constipation. 6. Senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Prednisone 1 mg Tablet [**Month/Day/Year **]: Four (4) Tablet PO DAILY (Daily). 8. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 9. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3 times a day). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Day/Year **]: One (1) neb Inhalation Q2H (every 2 hours) as needed for wheezing. 11. Bisacodyl 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day as needed for constipation. 12. Enalapril Maleate 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily). 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 14. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 15. Tacrolimus 1 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO QPM (once a day (in the evening)). 16. Tacrolimus 1 mg Capsule [**Last Name (STitle) **]: Four (4) Capsule PO QAM (once a day (in the morning)). 17. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 18. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 19. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Ten (10) units Subcutaneous at bedtime. 20. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: One (1) units Subcutaneous four times a day: per sliding scale. 21. Polyethylene Glycol 3350 17 gram Powder in Packet [**Last Name (STitle) **]: One (1) packet PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital-[**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis: NSTEMI Secondary Diagnosis: Cadaveric renal transplant in [**2175**] - CVA-residual right hemiparesis - Hx NSTEMI and Vfib arrest [**2169**] with anoxic brain injury - Swallow study-showed silent aspiration - hx of aspiration pneumonia - tracheomalacia after long intubation requiring trach stent and button complicated by site cellulitis and granulation tissue requiring cryoptherapy. - recurrent aspiration PNA s/p tracheal stent removal and tracheostomy Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the [**Hospital1 18**] because you were breathing fast and you oxygen was low. You were initially admitted to the intensive care unit were they treated you for pneumonia. Upon further testing you were found to have had a small heart attack. We treated you with the appropriate medications for this. Your heart attack caused acute systolic heart failure that we treated with diuretics. This resolved with treatment and your heart funtion remained stable. We spoke with your family about doing a cardiac catheterization but this was not pursued as you had already been treated medically. You also had a UTI and were treated with antibiotics. You were found to be agitated and disoriented at times but this improved. The diabetes doctors saw [**Name5 (PTitle) 17773**] and made changes to your insulin treatment. You should follow the new sliding scale that was provided. Medication Changes: INCREASE: Pravastatin to 80 mg daily INCREASE: Aspririn to 325 mg daily START: Clopidogrel 75 mg daily Followup Instructions: Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2182-6-20**] 9:00 Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2182-6-20**] 9:30 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2182-6-20**] 10:00 [**2182-6-21**] 02:20p [**Doctor Last Name **]-CC7 [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY (SB)

Admission Date: [**2116-12-5**] Discharge Date: [**2116-12-9**] Date of Birth: [**2047-5-8**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2090**] Chief Complaint: Episodic confusion, left-sided weakness, left-sided neglect, and headache Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [**Known lastname 67988**] was diagnoses in [**8-13**] with GBM by stereotactic brain bx and started on decadron and keppra. She received XRT by 8 weeks and temazolamide for 3 weeks, discontinued due to rash. Keppra was also discontinued at this time ([**2116-10-24**]). MRI post XRT showed that the R. temperal parietal mass was stable and a decadron taper was begun, reducing the dose from 6 to 4 to 2mg daily over 2 weeks. Her decadron was increased to 2mg [**Hospital1 **] on [**11-30**]. On [**12-4**], Mrs. [**Known lastname 67988**] almost fell, was caught by her husband who noted that her legs were intertwined. She was also confused for 1-2 minutes, but had no post-ictal confusion or incontinence. That night, she had another 5 minute episode of sharp, sudden-onset headache over her right eyebrow, confusion, and falling. Head CT outside on [**2116-12-4**] did show a 9 mm midline shift and when compared to an MRI of the head done on [**2116-11-30**] at [**Hospital1 **], there was only a 2-3 mm shift and review of the head CT also showed signs of tight uncus with increased swelling, although no frank herniation. On arrival, she continued to be disoriented and had a [**10-18**] right-sided headache. She vomited twice. She was admitted to the ICU. Past Medical History: 1. hypertension 2. cervical spine surgery (at [**Hospital3 3765**] in [**Location (un) 1514**], MA) 3. hysterectomy for uterine fibroids 4. basal carcinoma, left side of nose (1st dx'd 20 yrs ago and excised then 5 yrs ago required Mohs x3 as plastic surgeon reports cancer and grown into deep structures of the face) 5. eczema well controlled with topical corticosteroids 6. carpel tunnel 7. seasonal allergies; allergy to dust, cats and feathers 8. normal colonscopy approx 3 yrs ago Social History: Lives with husband in in-law apartment in daughter's home. 40 pack year history smoking cigarettes, no ETOH, or illicit drug use. Family History: Mother had DM2 and died of vulvar/rectal ca. Father died of CAD. Physical Exam: PHYSICAL EXAMINATION: VITALS: 97.4/99.1 p 68(53-71) 117/44(86/35-140/65) 17(19-21) 96% on 3L GENERAL: She is alert, pleasant elderly lady in no acute distress. CARDIOVASCULAR: She had regular rate and rhythm. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation bilaterally. ABD: SNTND, +BS EXTREMITIES: No clubbing, cyanosis, or edema. NEUROLOGICAL EXAMINATION: MS: Orientation: [**Hospital3 **], [**2116-11-8**] (no date) Attn: Months of year backwards: "[**Month (only) 1096**], [**Month (only) **], [**Month (only) **], stop" Memory: Registration intact, Recall 0/3 at 5min Language: Fluent, good comprehension and repetition. No dysarthria, appropriate prosody, naming intact Fronto-Parietal: Calculation intact, no apraxia, slight left neglect, clock draw shows good planning, cannot copy cube or intersecting pentagons Coordination: She had normal appendicular coordination. Gait: Deferred CN: I: Not tested II: R. anisocoria (stable since birth), both reactive to light, sharp disc margins III,IV,VI: EOMI, no nystagmus, does not completely bury V,VII: Facial strength, sensation intact/symmetrical VIII: Hearing intact to finger rub b/l IX,X: Palate elevation midline [**Doctor First Name 81**]: SCM/Trap full strength XII: Tongue midline, no fasciculations Motor: Normal bulk/tone b/l. No abnormal movements/tremors. Quite mild l. hemiparesis, [**5-13**] deltoid and triceps, tibialis anterior. No drift. Reflexes: 2 right/left at biceps,triceps,brachioradialis,patellar,achilles Coordination: Slight delay on finger-nose, normal [**Doctor First Name **] Gait: Deferred Pertinent Results: [**2116-12-9**] 06:25AM BLOOD WBC-8.6 RBC-3.52* Hgb-11.5* Hct-34.2* MCV-97 MCH-32.8* MCHC-33.7 RDW-17.0* Plt Ct-203 [**2116-12-8**] 06:20AM BLOOD WBC-6.2 RBC-3.38* Hgb-11.1* Hct-32.8* MCV-97 MCH-32.7* MCHC-33.7 RDW-17.3* Plt Ct-199 [**2116-12-7**] 04:58AM BLOOD WBC-8.4 RBC-3.10* Hgb-10.7* Hct-29.8* MCV-96 MCH-34.5* MCHC-36.0* RDW-17.8* Plt Ct-181 [**2116-12-6**] 03:00AM BLOOD WBC-6.6 RBC-3.55* Hgb-12.0 Hct-33.9* MCV-95 MCH-33.8* MCHC-35.5* RDW-17.8* Plt Ct-179 [**2116-12-4**] 11:00PM BLOOD WBC-6.1 RBC-3.59* Hgb-12.3 Hct-34.3* MCV-95 MCH-34.3* MCHC-35.9* RDW-18.1* Plt Ct-186 [**2116-12-9**] 06:25AM BLOOD Plt Ct-203 [**2116-12-9**] 06:25AM BLOOD Glucose-76 UreaN-18 Creat-0.7 Na-141 K-4.0 Cl-103 HCO3-28 AnGap-14 [**2116-12-9**] 06:25AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2 [**2116-12-8**] 06:20AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.3 [**2116-12-9**] 06:25AM BLOOD Osmolal-297 [**2116-12-8**] 09:21PM BLOOD Osmolal-295 [**2116-12-6**] 03:00AM BLOOD Phenyto-10.2 [**2116-12-5**] 04:12PM BLOOD Phenyto-13.6 Brief Hospital Course: Ms. [**Known lastname 67988**] was admitted to the ICU on [**12-4**]. The patient was loaded with Decadron 10 mg and then put on Decadron 4mg q6hrs. She was also loaded with Dilantin because of the history of the seizures and the Keppra was increased to 750 twice a day, frequent neuro checks were done and a repeat MRI of the brain was considered and neurosurgery was consulted. Mannitol 20% was begun 25g IV q6hrs, checking serum Na and osms prior to each dose. Headache was managed with toradol q6 hrs. Neurosurgery discussed potential surgical options with the family, and they decided on no neurosurgical intervention at this time. While in the ICU, her clinical condition improved, and she became more oriented. Her left-sided neglect and left-sided weakness persisted. On [**12-7**], Ms. [**Known lastname 67988**] was transferred to the floor. Mannitol was weaned to 12.5mg [**Hospital1 **] with the last dose the morning of [**12-9**]. PT/OT were consulted who cleared her for home with services and a rolling walker. She will have follow-up with Dr. [**Last Name (STitle) 724**] in the brain tumor clinic. Medications on Admission: Keppra 500po [**Hospital1 **] Decadron 4mg po daily Famotidine 20mg po daily Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Decadron 4 mg Tablet Sig: 1.5 Tablets PO every six (6) hours. Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Gliobastoma multiforme Seizures Discharge Condition: Stable. Baseline left superior field cut, left nasolabial fold flattening, left hemiparesis, left neglect. Discharge Instructions: Please take all of your medications as directed. Please return to the Emergency Room if you experience headaches, visual changes, lethargy, speech or language problems, new weakness, nausea, or vomiting. Followup Instructions: Please call Dr.[**Name (NI) 6767**] office at [**Telephone/Fax (1) 1844**] to schedule follow up. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]