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allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fever and hypotension major surgical or invasive procedure: placement of a central venous line history of present illness: 71 yo male resident of with multiple medical problems including a history of gastric cancer, who was admitted with hypotension requiring pressors and fever. he reportedly had guaiac positive stools as well. past medical history: hypertension previous cva aphasia bph gastric cancer dvt chf schizophrenia social history: lives at does not smoke or drink alcohol family history: non-contributory physical exam: t 101.3 hr 105 bp 90/50 gen - ill-appearing heent - supple neck, dry mmm, anicteric sclera cv - tachycardic, regular lungs - decreased bs at the bases abd - diffusely tender, distended ext - no le edema neuro - alert, responds to yes/no questions brief hospital course: the patient underwent a ct scan that shwoed evidence of a perforated small intestine which was the suspected source of his sepsis. he was intubated in emergency department in the setting of aggressive volume resuscitation before entire clinical picture was clear. he was also started on vasopressors for blood pressure support inthe setting of hypovolemic shock secondary to sepsis. the patient was seen by surgery for consideration of an operative solution for his sepsis and bowel perforation. however, the patient's family did not want him to undergo surgery. after multiple family meetings in the intensive care unit, the family and health care providers agreed to extubate the patient and make his goals of care comfort only. the vasopressors were discontinued at that time. the patient was transfered to the general medicine wards where he was closely monitored for comfort on a morphine drip. he died the following morning () at 8:55am. the patient's sister and brother were called and both siblings agreed to an autopsy as long as the organs were returned to the body for burial. discharge medications: none discharge disposition: home discharge diagnosis: sepsis secondary to acute peritonitis from a bowel perforation hypovolemic shock requiring vasopressors respiratory distress requiring intubation gastric cancer congestive heart failure schizophrenia discharge condition: deceased Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Other irrigation of (naso-)gastric tube Transfusion of other serum Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Acidosis Congestive heart failure, unspecified Unspecified essential hypertension Unspecified septicemia Severe sepsis Perforation of intestine Unspecified schizophrenia, unspecified Acute respiratory failure Septic shock Personal history of malignant neoplasm of large intestine Hemorrhage of gastrointestinal tract, unspecified Other malignant neoplasm without specification of site

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: large left renal cell carcinoma with tumor thrombus in the inferior vena cava just below the hepatic vessels. major surgical or invasive procedure: left radical nephrectomy with inferior vena cavotomy and complete excision of renal vein with inferior vena caval reconstruction and removal of tumor thrombus. history of present illness: the patient presented to the emergency room with left sided pain and on further workup was noted to have a large left renal mass. further workup revealed inferior vena caval thrombus just below the level of the hepatic vessels in the inferior vena cava and the patient was also noted to have a pulmonary embolus. he and his family fully understand the procedure, alternative therapies, benefits, and risks including death, pulmonary embolism, need for reoperation, myocardial infarction, cva, embolism to other organs, need for long-term ventilation, damage to adjacent organs including spleen or pancreas, need for colon resection. they wished to proceed. past medical history: mr has a past medical history significant for iddm, htn, hyperlipidemia, right-sided claudication (scheduled for angiogram in early ), and depression. in his past surgical history, he has had a cholecystectomy. social history: mr is an ex-smoker of 20 years, with a previous 20-pack year status. he denies any recreational drug use, and intakes alcohol socially. family history: this patient's family history is negative for any genitourinary malignancy; his mother died of brain cancer and his father died of a myocardial infarction at the age of 59. pertinent results: . . echo: conclusions: 1. echogenic structure seen in ivc consistent with thrombus or tumor. this extends upto 4 cm below the junction of the hepatic vein and the ivc. flow is seen around the thrombus. 2. no atrial septal defect is seen by 2d or color doppler. 3. left ventricular wall thicknesses and cavity size are normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). 4. right ventricular chamber size and free wall motion are normal. 5. the ascending aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. 6. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 7. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. 8. there is a trivial/physiologic pericardial effusion. 9. prior to ivc cross clamping portion of the ivc thrombus no longer seen. rv function still appears good. no echogenic structures in the ra or rv. flow present in the main pa, left and right pas. . . cxr : there is no pneumothorax or pleural effusion. mediastinal widening is probably due to vascular engorgement in the supine position. tips of the right internal jugular catheter and endotracheal tube are at the upper margins of the clavicles, both at the thoracic inlet. nasogastric tube passes to the mid stomach. lungs low in volume but grossly clear. heart size normal. mediastinum midline. no significant free subdiaphragmatic gas. . . cxr : left lower lobe atelectasis and bilateral pleural effusion, small on the left and small-to-moderate on the right, which developed after are stable since . heart is normal size. et tube, right supraclavicular central venous line, and nasogastric tube are in standard placements. no pneumothorax. . . cxr : compared with , the tip of the ett appears to have been pulled back somewhat and now projects roughly 5 cm above the carina. the right lung remains grossly clear. there is diffuse haziness overlying the left lung which may be due to a left pleural effusion and associated linear perihilar densities may represent associated atelectasis. the apparent widening of the superior mediastinum is probably secondary to patient rotation to the right, with similar appearances seen on prior films from and . please correlate clinically. . . 9:40 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): sparse growth oropharyngeal flora. . . 9:35 am swab site: rectal source: rectal swab. **final report ** r/o vancomycin resistant enterococcus (final ): no vre isolated. . . 9:35 am mrsa screen site: rectal source: rectal swab. **final report ** mrsa screen (final ): no staphylococcus aureus isolated. . . 8:18 am sputum site: endotracheal **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram negative diplococci. 1+ (<1 per 1000x field): gram positive cocci. in pairs, chains, and clusters. respiratory culture (final ): moderate growth oropharyngeal flora. haemophilus influenzae, beta-lactamase positive. moderate growth. beta-lactamase positive: resistant to ampicillin. . . brief hospital course: mr. was admitted for his procedure on . he was prepared and consented for surgery as per standard. at this time, mr was aware of all potential risks and benefits of his procedure. his family was also aware, and it was noted that his wife is extremely supportive and involved in the situation. in the operating room, total estimated blood loss was approximately 5000 cc. the patient received a total of 6 units of packed red blood cells and 2 units of fresh frozen plasma during the case. there were no major intra-operative complications during the case. . mr then spent 6 days in the icu. over the course of 6 days, he was extubated, had his ngt removed, and his pressors (levophed and neo) were stopped. his anticoagulation medications were held during the duration of his icu care. he recieved supportive care, and was seen by the nutrition team. in addition, the renal team followed him to ensure adequate renal function. during his stay in the icu, he was started on broadspectrum antibiotics for a possible chest infection; the patient had thick copious secretions and a chest xray was obtained. his sputum was found to be gram stain positive, and hence, he was started on levaquin and vancomycin. . once mr was stable, he was transferred to the floor. on the floor, he was re-started on his coumadin with a target inr of 2.0 - 3.0. he appeared to be depressed by members of housestaff and his family. psychiatry was asked to see him, and they advised outpatient follow-up and adjusted his antidepressant medication dosages. . mr was seen by a social worker, where he was able to discuss his recent cancer diagnosis, and his recent surgery. it was felt this visit slightly lifted his spirits, as he began to ambulate more often with encouragement. he was seen by physical therapy to assist with ambulation. . upon discharge, mr was in a stable condition. his staples were removed, his foley removed and his pain under control. his coumadin levels are to be followed by his pcp, . . his family continued to be extremely supportive, with regular visits and discussions with members of housestaff regarding his progress. . he was discharged to a rehab facility. his expected duration of stay at this facility is less than 30 days. medications on admission: ativan 1 mg tablet . avandia 4mg tablet . humulin 70/30 70-30u/ml suspension . humulin n 100u/ml suspension . lisinopril 20 mg tablet . meclizine 12.5 mg tablet . remeron 15mg . simvastatin 40 mg tablet . wellbutrin sr 150mg tablet sustained release . discharge medications: 1. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 2. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 3. bupropion 150 mg tablet sustained release sig: one (1) tablet sustained release po bid (2 times a day). 4. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 5. meclizine 12.5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for vertigo. 6. rosiglitazone 2 mg tablet sig: two (2) tablet po qpm (once a day (in the evening)). 7. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 10. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 11. promethazine 25 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed. 12. coumadin 2 mg tablet sig: one (1) tablet po at bedtime for 1 doses. disp:*1 tablet(s)* refills:*0* 13. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. disp:*20 capsule(s)* refills:*2* 14. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po four times a day as needed for flatulence for 3 days. disp:*12 tablet, chewable(s)* refills:*0* discharge disposition: extended care facility: house rehab & nursing center - discharge diagnosis: renal cell carcinoma. discharge condition: stable. discharge instructions: you are being prescribed a narcotic pain medication. do not drive or operate heavy machinery while taking this medication. it make you drowsy. contact a physician for fever >100.5, bleeding or increasing redness from incisions, difficulty swallowing or breathing, headache, nausea or vomiting, double or blurry vision, or any other concerns. please continue all home medications and those given to you by your surgeon. you are currently receiving coumadin therapy. the target inr range for you is 2.0-3.0. please visit your primary care physician to adjust your coumadin dosage as appropriate and to remain within a therapeutic range. please follow up with your pcp: , . in regards to your recent diagnosis, coumadin levels and antidepressant medications. followup instructions: please arrange a follow-up appointment with dr. calling (. . you should also arrange a follow-up outpatient appointment with a psychiatry service: please call ( outpatient psychiatry service). . please arrange a follow-up appointment with the oncology service - dr may be reached at (. . please follow up with your pcp: , . in regards to your recent diagnosis, coumadin levels and antidepressant medications. Procedure: Venous catheterization, not elsewhere classified Arterial catheterization Nephroureterectomy Transfusion of packed cells Other repair of vessel Other excision of vessels, abdominal veins Incision of vessel, abdominal veins Diagnoses: Pneumonia, organism unspecified Unspecified pleural effusion Unspecified essential hypertension Acute kidney failure, unspecified Atherosclerosis of native arteries of the extremities with intermittent claudication Secondary malignant neoplasm of other specified sites Malignant neoplasm of kidney, except pelvis Pulmonary collapse Iatrogenic pulmonary embolism and infarction Accidents occurring in other specified places Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Cyst of kidney, acquired Other venous embolism and thrombosis of inferior vena cava

allergies: bactrim ds / levaquin / vancomycin hcl / dilantin kapseal / keflex / ciprofloxacin / baclofen attending: chief complaint: altered mental status major surgical or invasive procedure: intubation history of present illness: 36 yo m with h/o t12 paraplegia, ckd, and polysubstance abuse who presents with altered mental status and overdose. per history from his mother, blood pressures had been running 150s-160s at home on his new dose of amlodipine 7.5 mg po daily prescribed by his pcp 12/. she also reported that he was slightly more depressed than usual and had not been going out as frequently. patient was in his usual state of health today until after he ate dinner. his mother heard gurgling and went to his room and subsequently found him with acutely altered mental status, gurgling and moaning, very angry, but able to name the president. mother reports that his previous declines from utis have been similar in their acuity. she called ems to take him to the ed. pt received narcan 2 mg im x1 prior to arrival at ed with little change in mental status. pinpoint pupils noted. per previous discharge summaries, patient has been positive on toxicology screens for benzos, opiates, and cocaine in the past. per mother, metoprolol is available at home, but she keeps it locked up. . in the ed, vs were 96.4 48 177/104 100% on nrb labs sig for initial fs of 130, lactate of 2.0, trop-t of < 0.01, wbc of 11.5, and normal lfts. toxicology screen positive for benzos, opiates, and cocaine. patient triggered for altered mental status and was intubated for altered mental status (described as yelling garbled, unintepretable sounds) with rocuronium and etomidate (succinylcholine not used as can prolong effects of cocaine if used for intubation). patient also received atropine 1 mg iv x1, and cefepime/linezolid for broad uti/meningitis coverage. lp could not be performed b/c patient has rods in his back and would require an ir guided lp. cxr negative for aspiration event, head ct negative for acute intracranial bleed. cardiology and toxicology were consulted. ekg with junctional bradycardia. cardiology thought no need for pacer given lack of hypotension. toxicology thought this could appear to be a mixed ingestion, but did not think it was a beta-blocker or ccb overdose, recommended serial fs, supportive care, and did not recommend glucagon at this time. vs on transfer were: 100% on ac fio2 40% 500 x 15 peep 5. . on the floor, patient is intubated and sedated. iv hydralazine 10 mg x1 was given with good effect on his blood pressure and heart rate (hr up to 55, sbp down to 150/80). past medical history: - t12 paraplegia secondary to mva in - chronic kidney disease, with baseline creatinine of - history of mrsa decubitus ulcers - chronic indwelling foley - recurrent urinary tract infections growing pseudomonas, e. coli, and enterococcus - seizure disorder (last episode in ) - history of c. diff colitis - osteomyelitis in the right hip - chronic back pain - anxiety social history: as per prior discharge summary, patient lives with his mother, who is primary caretaker. a girlfriend, with whom he always stays. unemployed. former heavy alcohol use, quit over 1.5 years prior. occasional prior marijuana. no tobacco use. no other illicits. cocaine positive on toxicology screens in the past admissions. family history: maternal great aunt: dm. maternal uncle: colon cancer. htn. physical exam: initial exam: vs: 100% on ac 500 x 16 fio2 40% peep 5 ga: intubated; biting at tube and fighting restraints; intermittently following commands (squeezing hand) heent: pinpoint pupils minimally reactive to light cardiac: bradycardic. no m/g/r pulm: ctab no wheezes gi: soft +bs no g/rt gu: foley neuro: intermittenly following commands; 2+ reflexes bilaterally (biceps, achilles,plantar); babinski's downgoing bl. extremities: wwp, +dry skin and warm, pulses 2+, bounding; moving all extremities with excellent grip strength bilaterally discharge: vs: 99.5 126/100 80 18 100% ra ga: nad heent: ncat, perrla cardiac: rrr, nl s1s2 no m/g/r pulm: ctab no wheezes gi: soft +bs no g/rt gu: foley in place extremities: wwp, pulses 2+ pertinent results: admission labs: 09:46pm lactate-2.0 08:34pm glucose-117* urea n-22* creat-2.9* sodium-140 potassium-4.5 chloride-105 total co2-22 anion gap-18 08:34pm alt(sgpt)-14 ast(sgot)-24 ck(cpk)-88 alk phos-107 tot bili-0.3 08:34pm lipase-54 08:34pm ctropnt-<0.01 08:34pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-pos barbitrt-neg tricyclic-neg 08:34pm wbc-11.5* rbc-5.27# hgb-15.7 hct-45.4 mcv-86 mch-29.8 mchc-34.6 rdw-13.6 08:34pm neuts-67.1 lymphs-26.5 monos-3.3 eos-2.3 basos-0.7 08:34pm plt count-259 08:34pm pt-13.5* ptt-31.5 inr(pt)-1.2* 08:16pm urine bnzodzpn-pos barbitrt-neg opiates-pos cocaine-pos amphetmn-neg mthdone-neg 08:16pm urine blood-tr nitrite-pos protein-75 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-mod discharge labs: 06:10am blood wbc-7.0 rbc-4.55* hgb-13.5* hct-40.5 mcv-89 mch-29.6 mchc-33.2 rdw-13.6 plt ct-212 06:10am blood plt ct-212 06:10am blood glucose-94 urean-30* creat-2.3* na-139 k-4.9 cl-106 hco3-25 angap-13 05:31am blood ck(cpk)-50 08:53pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-lg micro: 8:53 pm urine source: catheter. **final report ** urine culture (final ): no growth. 8:27 pm urine site: not specified **final report ** urine culture (final ): mixed bacterial flora ( >= 3 colony types), consistent with fecal contamination. imaging: head ct () - no acute intracranial process renal u/s: 1. no renal obstruction or son findings of pyelonephritis/renal abscess. 2. unchanged thickened bladder likely related to underlying neurogenic bladder. brief hospital course: 36 yo m with t12 paraplegia, ckd, and polysubstance abuse who presents with altered mental status and overdose. . # altered mental status: patient admitted to the micu with altered mental status, likely in the setting of toxic/metabolic etiology such as medication/drug overdose. ct head showed no acute process. patient with positive toxicology screens for opiates, benzos, and cocaine (and has been in past admission as well), and is only medically prescribed oxycodone, percocet, and klonopin. of note, oxycodone should only show up in gc/ms toxicology send-out, not in the first pass urine toxicology screen peformed in the ed, indicating patient may have been taking other narcotics other than his prescribed oxycodone. per toxicology, symptoms are not consistent with a pure toxidrome, therefore there are likely multiple substances on board. psychiatry was consulted, and they felt that patient was not actively suicidal, that this overdose was a mistake. he was given an outpatient psychiatry referral and was also provided with substance abuse resources by social work. . # respiratory failure: intubated for airway protection in the setting of altered mental status. cxr appears clear and shows no evidence of pna or aspiration. excellent oxygenation noted on admission abg. pt was successfully extubated on hd #2. . # bradycardia: ekg demonstrates sinus bradycardia and with a junctional rhythm. no evidence of hypotension. be combined ingestion of benzos/opiates resulting in bradycardia. definite concern for reflex in the setting of hypertension, as pt's hr improved with lowering of blood pressure with hydralazine. discussed with cardiology unofficially, no pacer currently required for bradycardia given no evidence of hypotension. bradycardia improved over the course of his micu stay, no events of bradycardia on the floor. was monitored on tele. # hypertension: likely in setting of cocaine overdose versus medication non-compliance. has hypertension with baseline sbps in 150s as outpatient, so well above his current baseline. likely non-compliant with home medications as well. treated as hypertensive emergency given altered mental status with iv hydralazine 5 mg iv q6h goal sbp > 150. b-blockers were held in the micu given concern for cocaine use. was restarted on amlodipine (home medication) while on medical floor with improvement in bp, did not require any prn. . # possible overdose: patient with positive toxicology screen, history of polysubstance abuse and positive tox screens for opiates, benzos, and cocaine in the past. per mother, patient has been more depressed recently. seen by psychiatry as soon as he was extubated; they felt that there was no acute danger of suicide. pt was also seen by social work in the micu. . #. chronic kidney disease: baseline cre at 2.9. medications were renally dosed. . # ?uti: pt with ua suggestive uti on admission, also with altered mental status c/w prior utis so was initially started on cefepime. urine culture came back no growth, a repeat ua was checked which also was c/w uti (however pt with chronic foley), no growth on cx. pt with flank pain (not tenderness; pt without sensation below t12) and possible uti, so renal u/s was done to r/o abscess, pyelo, which was negative. cefepime was dc'ed after 5 days, was given a 2 day course of nitrofurantoin (allergies to keflex, bactrim, cipro) to complete total 7 day course. he will f/u with pcp. . #. seizure disorder: continued keppra (dosed iv while npo). medications on admission: 1. docusate sodium 100 mg po bid 2. senna 8.6 mg po bid 3. bisacodyl 10 mg pr qhs prn constipation 4. levetiracetam 500 mg po bid 5. tolterodine 2 mg po prn bladder spasms 6. pantoprazole 40 mg po bid 7. oxycodone 60 mg sr po q8 8. clonazepam 1 mg po qhs 9. ferrous sulfate 300 mg po bid 10. sevelamer hcl 800 mg po tid with meals 11. ambien 5 mg 1-2 tablets po qhs prn insomnia 12. fluticasone 50 mcg/actuation spray one inhalations 13. oxycodone-acetaminophen 5-325 mg po q4 prn pain 15. amlodipine 7.5 mg po daily (started by pcp) 16. renagel discharge medications: 1. amlodipine 2.5 mg tablet sig: three (3) tablet po daily (daily). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 4. tolterodine 2 mg tablet sig: one (1) tablet po daily (daily) as needed for bladder spasm. 5. bisacodyl 10 mg suppository sig: one (1) suppository rectal (2 times a day) as needed for constipation. 6. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 8. oxycodone 20 mg tablet sustained release 12 hr sig: three (3) tablet sustained release 12 hr po q8h (every 8 hours). 9. clonazepam 1 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 10. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po twice a day. 11. sevelamer hcl 800 mg tablet sig: one (1) tablet po three times a day. 12. ambien 5 mg tablet sig: 1-2 tablets po at bedtime as needed for insomnia. 13. fluticasone 50 mcg/actuation disk with device sig: one (1) inhalation twice a day. 14. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for breakthrough pain. 15. alprazolam 1 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for anxiety. 16. nitrofurantoin macrocrystal 100 mg capsule sig: one (1) capsule po twice a day for 2 days. disp:*4 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: substance abuse/overdose urinary tract infection discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: you were seen in the hospital for an overdose, for which you were medically managed and found to be stable after leaving the intensive care unit. one of the social workers saw you here and provided you with information for follow up treatment. you were also seen by the psychiatrists here who believe you would benefit from seeing a psychiatrist as well, and gave you information to set up an appointment with one of the doctors . you also had symptoms suggestive of a urinary tract infection for which you were treated with a course of intravenous antibiotics. please take oral antibiotics for two more days at home. changes to your medications: start taking nitrofurantoin 100 mg twice a day for two days (start tomorrow morning) followup instructions: department: - adult med when: wednesday at 10:45 am with: , md building: (, ma) campus: off campus best parking: free parking on site please also make an appointment to see a psychiatrist, either one recommended by dr. , the psychiatrist who saw you here, or one closer to home. please also follow up with a substance abuse treatment program, as this will be very important for helping you with your drug use. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Drug detoxification Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Urinary tract infection, site not specified Toxic encephalopathy Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Poisoning by opium (alkaloids), unspecified Poisoning by benzodiazepine-based tranquilizers Accidental poisoning by other opiates and related narcotics Accidental poisoning by benzodiazepine-based tranquilizers Dysthymic disorder Chronic kidney disease, Stage III (moderate) Acute respiratory failure Other specified cardiac dysrhythmias Long-term (current) use of other medications Personal history of noncompliance with medical treatment, presenting hazards to health Altered mental status Accidental poisoning by central nervous system stimulants Lumbago Paraplegia Combinations of opioid type drug with any other drug dependence, continuous Unspecified osteomyelitis, pelvic region and thigh Cauda equina syndrome with neurogenic bladder Poisoning by cocaine Late effect of spinal cord injury Late effects of motor vehicle accident Alcohol abuse, in remission

history of present illness: patient is a 28-year-old male with t12 paraplegia and decubitus ulcers, chronic renal insufficiency, who presented with fever and hypotension. patient is status post recent admission to plastics service from to for treatment of stage iv right greater trochanter necrotizing ulcer and underwent operative procedure including closure to that area. he was also noted to have enterobacter urinary tract infection. patient's wound cultures grew enterococcus and presumptive mrsa. he was treated with linezolid, cefepime, and flagyl, and ultimately discharged on linezolid alone. per the discharge summary, the patient was taking linezolid, however, the patient does not report taking this at home. the patient reports feeling somewhat fatigued three days prior to admission. on the day prior to admission, he noted fever to 104 while at home. he felt slightly nauseous, did not vomit, and denies abdominal pain. he had loose stools for one day, which is unchanged from his baseline. he denied shortness of breath or cough. denied chest pain. denied headache or mental status changes. he denied dysuria. he notes that he has not been straight cathing 4x a day as directed. in the emergency room, the patient was febrile to 103.7, and initially noted to be tachycardic to the 100's with a blood pressure of 128/60. large decubitus ulcers were also noted and a white blood cell count of 12,000 was noted. a chest x-ray and urinalysis were negative. hematocrit was found to be 18. he was transfused 2 units of packed red blood cells. early in the morning, the patient was noted to have an oral temperature of 93.5 with a blood pressure of 64/32 and heart rate in the 70's. he was given 4 liters of normal saline, and his blood pressure improved into the 90's. he had appropriate urine output to this. the patient was also given linezolid at that time. the patient was then transferred to the micu for further treatment of his presumed sepsis. past medical history: 1. t12 paraplegia from mva in . 2. decubitus ulcers stage iv right greater trochanter, stage ii right ischial, stage iii left greater trochanter, stage ii left heel, stage iv coccyx. 3. status post flap closure bilaterally two trochanteric ulcers. 4. recurrent urinary tract infections. 5. chronic renal insufficiency secondary to obstructive uropathy, baseline creatinine of 2.7. 6. seizure disorder with a normal electroencephalogram in . 7. question of clostridium difficile colitis. 8. mrsa. allergies: 1. dilantin, seizing. 2. vancomycin and levofloxacin which gives severe hives. 3. bactrim hives and throat culture. medications on admission: 1. xanax one tid. 2. oxycontin 40 . 3. percocet 1-2 tablets po q4-6h prn. 4. depakote 1,000 . social history: the patient lives in with his mother. denies tobacco. denies alcohol. denies iv drug use. denies hiv risk factors. physical examination: on physical exam, the patient was a thin white male sitting upright in bed in no acute distress. alert and oriented. temperature max 103.7, t current 93.4, pulse of 80, blood pressure 105/63, respirations 16. heent: normocephalic, atraumatic. pupils are equal, round, and reactive to light. extraocular movements are intact. oropharynx was significant for some white patches on the tongue. neck was supple. neck veins were flat. lungs were clear to auscultation and percussion. cardiovascular examination: regular, rate, and rhythm, normal s1, s2, no murmurs, rubs, or gallops. abdominal examination: bowel sounds present, nondistended, and nontender, soft and flat. extremities: warm, wasting noted in the lower extremities, flaccid lower extremities. decubitus ulcers included right and left ulcers over the greater trochanters, ulcer on the coccyx, and also bilateral heel ulcers. neurologic: the patient was alert and oriented times three. cranial nerves ii through xii were intact. absent sensation in the lower extremities. speech was fluent. laboratories on admission: significant for a white count of 12.2, hematocrit 18.4, with 2 units, this increased to 22.4. platelets of 404. chem-7 was significant for a creatinine of 3.8. urinalysis was negative, 0-2 white blood cells, less than 1 red blood cell, and no ketones. blood cultures and urine cultures were drawn on admission. on admission to the micu, the patient was supported with fluids as needed. patient was also started on linezolid and meropenem empirically for presumed sepsis. patient remained stable overnight and on , the patient was transferred from the micu to the medicine firm. summary of hospital course: 1. fever and hypotension, presumed sepsis. although initially the source of infection was not known, patient was started empirically on meropenem and linezolid for presumed sepsis secondary to osteomyelitis. although the patient originally declined mri to evaluate for osteomyelitis on , the patient underwent a mri to evaluate which showed right ischium and right greater trochanter osteomyelitis and also a right greater trochanteric fracture. in addition, there was evidence for a left greater trochanter osteomyelitis, this is evidenced by bone marrow edema as well as enhancement. the patient's wounds were cultured and these revealed coagulase-positive staphylococcus aureus, three colonies. sensitivities on these later revealed that one colony was linezolid resistant mrsa. upon this finding, the patient was switched from linezolid to synercid. in addition, the patient's wound revealed gram-negative rods pansensitive to klebsiella and additionally rare yeast. prior to his change to synercid, the patient did have one spiking temperature on to 101.3. the patient was again cultured. all cultures remained negative on this patient. given the patient's history of recurrent urinary tract infections, an additional source of infection was considered, however, urine cultures were also negative for this patient. the patient remained stable, afebrile with blood pressures in the 110s/60s to the time of transfer to the plastic service on . patient will continue on his antibiotics, meropenem and synercid. 2. chronic renal insufficiency: patient was admitted with a creatinine of 3.8. patient was hydrated and this improved throughout his hospital course, and on the time of transfer to the plastic service, the patient's creatinine was stable at 2.6. this was much improved for this patient and well within the patient's baseline. mri which had been performed had suggested hydronephrosis as a consequence of this on , a renal ultrasound was performed to evaluate the patient's kidneys. renal ultrasound showed mild right hydronephrosis unchanged from prior. in addition to this, there was moderate to severe left hydronephrosis, possibly increased from prior. dr. , the patient's nephrologist, was aware of these results. given the patient's improvement in renal function and the chronic nature of his hydronephrosis, this was not deemed to be an acute inpatient issue. the patient will follow up with dr. further for complete followup of his bilateral hydronephrosis. 3. decubitus ulcers: the ulcers were evaluated and followed by the plastics service. she will need further debridement of these wounds, which will be followed up upon his further hospital course on transfer to the plastics service. 4. osteomyelitis: patient with mri confirmed osteomyelitis, also requiring surgical debridement. the plastics and orthopedic surgery teams are coordinating for a surgical date. by request for surgical planning and further evaluation of the osteomyelitis, in addition to the mri on , a ct scan of the patient's pelvis was obtained on as well as plain films. this again, will be managed further as his hospital course continues on the plastics service. 5. seizures: the patient had a history of seizures last in . the patient was admitted on depakote for seizure prophylaxis, however, valproic acid levels were checked while in house, and these remained consistently low. a trial of iv valproic acid was attempted, however, the valproic acid levels remained low. this is possibly due to a medication which is inducing the t450 system and altering the clearance of valproic acid. as a result, the neurology service was consulted due to his need for change in seizure prophylaxis and also a completed workup given the fact the patient had missed outpatient appointments with neurology due to his admission. they suggested the patient start on keppra. renal dosing for this was considered, and the patient remains on a dose of 750 mg of keppra for seizure prophylaxis. the patient tolerated this change well. there have been no seizures while on service. the neurology team evaluated the patient, and a mri of the patient's head was obtained on . there were no focal abnormalities. the neurologic team signed off on this patient, and the patient should follow up in clinic with dr. or dr. . 6. right shoulder pain: the patient complained of pain in his right shoulder after the ct scan of his pelvis, when he said during movement for this scan, he injured his right shoulder. the patient had an old right shoulder injury as well. patient's shoulder was somewhat swollen, and he had decreased range of motion secondary to pain. on , a shoulder mri was obtained which revealed no bony abnormalities, no soft tissue or ligamentous injury. the patient was given ultram as an additional pain medication in an effort to make him more comfortable. the patient can followup for this right shoulder pain with orthopedics during this hospital course. 7. chronic pain: patient with multiple decubitus ulcers requiring outpatient pain medications. the patient was continued on his oxycodone and also oxycodone acetaminophen prn. the patient was not utilizing any maximum doses of these medications while in-house. 8. anemia: the patient was admitted with a hematocrit of 18. he was transfused 2 units of packed red blood cells. patient's hematocrit increased from this and remains stable at a hematocrit of 28 while on the medicine service. patient's stool was guaiacked, and the patient was guaiac negative. there was no evidence for blood loss anemia was presumed secondary to anemia of chronic disease. the patient was started on epogen shots for further management of his anemia. 9. fen: the patient was taking good po while in house. he occasionally required repletion of magnesium and required phosphate binders. the patient's potassium rose to 5.3 on occasion while in-house. this was deemed to be due to excessive drinking of gatorade, and the patient was encouraged to minimize this intake. 10. psychiatric: patient is followed by social work for psychiatric issues surrounding his diagnosis and paraplegia. the patient declined any further intervention by psychology at this time. this is a summary of hospital course up until when the patient was transferred to the plastic service for further surgical planning for debridement of his wounds and underlying osteomyelitis. on transfer to the plastic service, the patient was stable. he was afebrile and had not been hypotensive for well over a week. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Graft of muscle or fascia Advancement of pedicle graft Advancement of pedicle graft Excisional debridement of wound, infection, or burn Excisional debridement of wound, infection, or burn Other partial ostectomy, other bones Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Acute posthemorrhagic anemia Other convulsions Hydronephrosis Paraplegia Late effect of spinal cord injury Acute osteomyelitis, multiple sites Abscess of anal and rectal regions

of note, this discharge summary will only entail the dates from to the discharge date of . previous to that, the patient was on the medicine service and a discharge summary can be found covering those dates. also, refer to that discharge summary for history of present illness and past medical history in completion. hospital course: 1. decubitus ulcers: in brief, this is a 28-year-old male who is paraplegic t12 from a mva accident in . he presented initially with fever and hypotension and the source was found to be multiple decubitus ulcers in the buttock region. after stabilization on the medicine team, he was transferred to the plastics team for repair of these ulcers. hospital course: the decubitus ulcers entail the bilateral greater trochanters, stage iv, right ischial, stage ii, coccyx, stage iv, and left heel, stage ii. on , the patient was taken to the or for debridement of these decubitus ulcers as well as closure of the ischial ulcer and a gluteal flap was placed for the bilateral trochanter ulcers. he was taken once again to the or on for debridement of the right trochanter wound and readvancement of the gluteal flap. the patient followed a normal postoperative course where he was in the sicu with the exception of prolonged intubation. he was extubated on and it was thought that intubation should be prolonged to maintain sedation to keep the prone position. the prone position was essential for the healing of the ulcers and in prior operations the patient had not been able to comply with this. thus, it was felt that keeping his intubated as long as appropriately possible would aid in the healing. extubation occurred on . the patient was transferred to the floor on . the remaining wounds were initially treated with wet-to-dry dressing changes upon discharge. once granulation tissue was present, the trochanter wounds were placed on high suction vacuum which was changed every three to five days. the sacral wound continued to be changed twice a day with wet-to-dry dressings. this type of wound care will continue as the patient is discharged into rehabilitation. on discharge, all wound sites look healthy with good tissue, no signs of infection. sutures and drains have been removed and the skin is healing well. 2. osteomyelitis: as the patient presented with fever to the medicine team, cultures were taken of these areas in the or. both orthopedics and infectious disease were consulted to evaluate the continued osteomyelitis condition of this patient. cultures of the bones indicated that this patient had mrsa resistant to linazolid and also klebsiella. soft tissue showed the presence of yeast. based on these findings, per id recommendations, the patient was placed on a six week course of meropenem and synercid which he will finish in rehabilitation and completed in-house a two week course of fluconazole. a picc line was placed in the patient's arm prior to discharge for administration of these antibiotics. on discharge, the patient had been afebrile for greater than two weeks. weekly lfts were drawn and within normal limits during the course of antibiotic treatment. 3. renal: the patient is known to have chronic renal insufficiency secondary to his paraplegia. at baseline, he requires straight catheterization. he was transferred to the plastics team with a creatinine of 1.8, although it was documented in his records that he does run as high as 2.3 as baseline at times. in the week prior to discharge, it was noted that his creatinine bumped from 1.8 up to 2.3 and as high as 2.6. a renal consult was obtained. it was thought that this increase was due in part to a foley that was in the patient's bladder during his hospital stay that relieved his baseline hydronephrosis as well as some dehydration. per renal recommendations, the patient was bolused with fluids for a period of 48 hours and continued on maintenance dose. a renal ultrasound was performed which showed mild hydronephrosis of the left kidney. the right kidney was not visualized secondary to the patient's positioning and uncooperative with examination. this was thought to be an improving condition as renal had suspected from his baseline condition. during this time period, his potassium became elevated as high as 5.6. ekgs continued to remain normal. on discharge, potassium was within normal range at 4.6. per renal recommendations, the patient was placed on florinef. he will follow-up with his own nephrologist, dr. , upon discharge. according to renal recommendations, the patient has been receiving weekly epogen shots. also, with the increased creatinine, medication adjustments were made according to renal consults regarding the antibiotics. 4. anemia: of note, the patient received multiple transfusions throughout his hospital stay for low hematocrit secondary to postoperative course. specifically, he received 2 units of packed red blood cells on , 2 units on , 2 units on , and 4 units on . the patient remained stable following these blood transfusions and the last hematocrit was approximately 30. 5. perianal abscess: a perianal abscess was noted on because of the proximity to his flap as well as remaining ulcers. a general surgery consult was obtained. this was closely watched and followed and was noted to spontaneously open in continuity with the anus on . this spontaneous fistulotomy required no operative care and the issue is resolved. 6. seizures: the patient has a history of seizures. he was maintained on keppra 500 b.i.d. this was not an issue during his time on the plastic surgery service. per the medicine discharge note, he is to follow-up with neurology and the clinic for further workup. 7. right shoulder pain: this was previously noted as an issue on the medicine service. the patient had mild right shoulder pain, most likely from the required position that he needed to be in to optimize healing his wounds. he was given appropriate pain medications and he is to follow-up with orthopedics as needed. 8. psychiatric: at times, the patient was found to be withdrawn and occasionally refusing services that would be beneficial to his health. a psychiatry consult was sought on . the psychiatric team was familiar with this patient, calling this episode and adjustment disorder with disturbance of mood and conduct and there were no active issues and care remained optimal. condition on discharge: good. discharge status: the patient will be discharged to rehabilitation for the remaining course of his antibiotics which is 12 days, at which point he can be discharged to home with nursing care. discharge medications: 1. meropenem 1 gram iv q. 12. 2. synercid 400 mg iv q. eight. the patient needs these for 12 more days to complete a six week course. 3. oxycodone 40 mg q. 12 p.r.n. 4. percocet one to two tablets q. four to six hours p.r.n. 5. florinef 0.1 mg p.o. q.d. 6. keppra 500 mg b.i.d. 7. metoprolol 50 mg b.i.d. 8. pepcid 20 mg b.i.d. 9. xanax 0.5 t.i.d. p.r.n. 10. the patient also received an epogen every week as well as b.i.d. heparin 5,000 units. nursing home care: 1. antibiotics will be administered for 12 more days through the picc. vacuumed. 2. vacuum changes are required every three to five days. 3. wet-to-dry dressing changes are needed on the sacral area twice a day. 4. weekly lfts are required to be drawn while the patient is on the antibiotics. follow-up plans: the patient is to follow-up with dr. one week after discharge from rehabilitation center. the patient is to follow-up with his nephrologist, dr. . the patient is to follow-up with the neurology clinic for full workup of seizures of new onset in . the patient is to follow-up with orthopedics as needed for further evaluation of right shoulder pain. dr., 24-143 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Graft of muscle or fascia Advancement of pedicle graft Advancement of pedicle graft Excisional debridement of wound, infection, or burn Excisional debridement of wound, infection, or burn Other partial ostectomy, other bones Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Acute posthemorrhagic anemia Other convulsions Hydronephrosis Paraplegia Late effect of spinal cord injury Acute osteomyelitis, multiple sites Abscess of anal and rectal regions

allergies: bactrim ds / levaquin / vancomycin hcl / dilantin attending: chief complaint: lethargy, nonproductive cough, subjective fevers major surgical or invasive procedure: ir guided hip aspiration history of present illness: 30y/o m with h/o t12 paraplegia mva, h/o mrsa decubitus ulcers, osteomyelitis, psa urosepsis, c diff colitis, and chronic kidney dz presents with nonproductive cough, constipation, and ms changes x1 day. + llq pain, +sob, dark urine. on monday, wound looked purulent; cultures were obtained but cannot be found. on , mother noticed nonproductive cough with louder respirations. had ms changes x2 days - more somnolent, less attentive, not eating well. baseline ms per mom: "argumentative and stubborn." also had l sided abdominal pain, no changes in bm. takes suppositories qod. + bowel/bladder incontinence, has been on foley for about 1 year. no fevers, chills, or night sweats at home. no chest pain, shortness of breath. in , had debridement of infected ischial/greater trochanter decubitus wound. is followed closely by wound care. in , pt's vs were tm 100.2, bp 114/68 (107/54), hr 94 (max 120), 97% ra. wbc 37.7 with 11 bands. rec'd linezolid 600mg iv x1, zosyn 3.375g iv x1, tylenol 1 gram. past medical history: paraplegia secondary to mva chronic kidney disease - baseline cr mrsa decubitus ulcers pseudomonal uti h/o seizure disorder clostridium difficile colitis osteomyelitis in the right hip social history: lives with his mother, who is his primary caretaker. rns come visit 2x/week, and brother also helps. no tobacco. has h/o etoh, none in last 4-5 years. no ivdu. family history: diabetes mellitus - maternal great aunt colon cancer - maternal uncle hypertension no heart disease physical exam: vs: 97.1 123/54 103 20 100% ra gen: pt sleepy, unwilling to answer questions, nad heent: perrl, eomi, dried blood around mouth neck: no jvd, no lad, supple, no stiffness cv: rrr, nl s1/s2, no murmurs pulm: ctab, no wheezes or crackles abd: soft, nt/nd, +bs, no masses ext: flexion contractures in feet; somewhat cool to touch, though + palpable pulses; no edema neuro: sleepy, answers some questions; follows commands, grip strength intact bilaterally; no movement in lower extremities skin: sacral ulcers - 5 in number, no surrounding erythema; gauze protruding from one ulcer, which is deeply punched out pertinent results: admission labs: cbc: wbc-37.7*# rbc-4.46*# hgb-12.0*# hct-40.3# mcv-90 mch-27.0 mchc-29.8* rdw-16.0* diff: neuts-78* bands-11* lymphs-5* monos-6 eos-0 basos-0 atyps-0 metas-0 myelos-0 plt smr-very high plt count-639*# electrolytes: glucose-115* urea n-49* creat-3.3* sodium-138 potassium-4.2 chloride-104 total co2-7* anion gap-31* albumin-3.2* calcium-9.1 phosphate-2.5*# magnesium-2.2 lfts: alt(sgpt)-8 ast(sgot)-14 alk phos-148* amylase-56 tot bili-0.2 lipase-23 lactate-2.0 ua: color-straw appear-cloudy sp -1.015 blood-lge nitrite-neg protein-30 glucose-neg ketone-15 bilirubin-neg urobilngn-neg ph-6.5 leuk-mod rbc-* wbc->50 bacteria-many yeast-none epi-0 granular-* abg: 7.17/20/110 coags: pt-25.0* ptt-86.2* inr(pt)-4.1 head ct: no mass or intracranial hemorrhage cxr: tip of r ij in svc, no ptx, lung fields clear ls spine: no new areas of osteomyelitis brief hospital course: 1. altered mental status: the patient was admitted to the micu with ams and elevated wbc count likely related to uti and bacteremia. his multiple decubitus ulcers were also a potential source, but his blood grew e coli and plastics felt the wounds were clean. the patient improved on zosyn and linezolid while in the micu. other possible etiologies of the patient's ams include overdose and neurologic etiology. head ct was negative on admission and tox screen was positive only for benzodiazepines, which he is taking as an outpatient. the patient's mental status improved dramatically with treatment for his infection and remained at baseline. 2. uti: the patient had an elevated wbc count and had a urine sample which grew pan-sensitive e coli. his blood cultures were also positive for e coli. given a concern for infected decubitus ulcers as well, he was treated with both zosyn and linezolid in the micu with improvement in his clinical status. platics did not feel that his ulcers were infected. on transfer to the floor, the patient's linezolid was discontinued and his zosyn was continued. follow-up cultures were negative. 3. recurrent fevers: pt began spiking temps up to 103 even though uti has resolved. ct pelvis was performed and showed osteo, specifically increased osteo (comp to ) in much of pelvis (ischial tuberocity; inf pubic rami); also new soft tissue ulcers and l hip effusion in close proximity w/ sq infection. consulted ortho for washout and l hip tap. consulted id. no involvement of spine on the scan. daily survailence cxs showed no growth. s/p ir guided tap of l hip : cxs negative, so no urgency for immediate washout. came up with the following plan: d/c pt on abxs (flagyl and cefpodoxime). plan splastics surgery on by dr. . pt will also be seen in clinic. 4. decubitus ulcers: the patient has a long history of mrsa infection of his decubitous wound. plastics saw him in the ed and felt that his wound was not actively infected and recommended a ct pelvis when pt more stable. the patient had a kinair bed for decreased sacral pressure and wound dressing changes with iodoform gauze per plastics. he is scheduled for a flap procedure by dr. on . dressing changes to be continued as outpt. . 4. arf: the patient was admitted with a creatinine of 3.3, over his baseline around , suggesting acute on chronic kidney disease. likely due to prerenal azotemia in the setting of infection as patient appeared dry and his creatinine improved to his baseline with ivf resuscitation. his sevelamer was continued. . 5. elevated inr: the patient was admitted with inr of 4, significantly higher than baseline. repeat measurements were around 1.3. not dic as other coags and fibrinogen are normal. . 6. dysphagia: mother has reported problems with swallowing over the last several days. micu rn reports pt aspirating water. all resolved by time of d/c. able to tolerate regular diet. . 7. anion gap metabolic acidosis: due to infection. resolved. . 8. h/o seizure disorder: continue keppra per outpt regimen . 9. pain: the patient has chronic pain due to osteomyelitis and sacral decubitus ulcers. his pain medications were held given his mental status but were restarted when his mental status improved. medications on admission: oxycodone-acetaminophen tab po q4-6h:prn beclomethasone dipro. aq (nasal) 2 spry nu daily aspirin ec 325 mg po daily sevelamer 800 mg po tid pantoprazole 40 mg po q24h multivitamins 1 cap po daily zinc sulfate 220 mg po daily oxycodone (sustained release) 50 mg po qpm oxycodone (sustained release) 20 mg po q noon oxycodone (sustained release) 50 mg po qam alprazolam 1 mg po tid levetiracetam 500 mg po tid discharge medications: in-hospital medications: oxycodone-acetaminophen tab po q4-6h:prn beclomethasone dipro. aq (nasal) 2 spry nu daily aspirin ec 325 mg po daily sevelamer 800 mg po tid pantoprazole 40 mg po q24h multivitamins 1 cap po daily zinc sulfate 220 mg po daily alprazolam 1 mg po tid levetiracetam 500 mg po tid piperacillin-tazobactam na 2.25 gm iv q6h linezolid 600 mg iv q12h 1. levetiracetam 500 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 2. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). disp:*60 capsule(s)* refills:*2* 3. multivitamin capsule sig: one (1) cap po daily (daily). disp:*60 caps* refills:*2* 4. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 5. sevelamer 800 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 6. 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* 7. bisacodyl 10 mg suppository sig: one (1) suppository rectal qod (). 8. oxycodone 20 mg tablet sustained release 12hr sig: 2.5 tablet sustained release 12hrs po q12h (every 12 hours): in am and hs. 9. oxycodone 20 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po qnoon (). 10. epoetin alfa 4,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday). disp:*1 bottle* refills:*2* 11. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 12. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 13. cefpodoxime 200 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*100 tablet(s)* refills:*0* 14. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*1* 1. levetiracetam 500 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 2. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). disp:*60 capsule(s)* refills:*2* 3. multivitamin capsule sig: one (1) cap po daily (daily). disp:*60 caps* refills:*2* 4. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 5. sevelamer 800 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 6. 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* 7. bisacodyl 10 mg suppository sig: one (1) suppository rectal qod (). 8. oxycodone 20 mg tablet sustained release 12hr sig: 2.5 tablet sustained release 12hrs po q12h (every 12 hours): in am and hs. 9. oxycodone 20 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po qnoon (). 10. epoetin alfa 4,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday). disp:*1 bottle* refills:*2* 11. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 12. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 13. cefpodoxime 200 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*100 tablet(s)* refills:*0* 14. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*1* discharge disposition: home with service facility: discharge diagnosis: primary diagnoses: 1. e coli urinary tract infection 2. bacteremia 3. decubitus ulcers 4. pelvic osteo secondary diagnoses: 1. t12 paraplegia 2. acute on chronic renal insufficiency 3. seizure disorder discharge condition: good discharge instructions: you are discharged to home and will continue all medications as prescribed. please contact your or present to the er if you experience fevers, chills, night sweats, altered mental status or other concerns.please continue taking antibiotics by mouth unless recommended otherwise by infectious disease specialists. followup instructions: please follow-up with your primary care physician, . , within 1-2 weeks after discharge. you should also follow-up with plastic surgeon dr. within the next few weeks prior to or on . provider: , md where: lm disease phone: date/time: 9:00 Procedure: Venous catheterization, not elsewhere classified Arthrocentesis Transfusion of other serum Transfusion of other serum Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Acidosis Anemia of other chronic disease Urinary tract infection, site not specified Acute kidney failure, unspecified Severe sepsis Other convulsions Other specified septicemias Unspecified disorder of kidney and ureter Pressure ulcer, lower back Other and unspecified coagulation defects Paraplegia Chronic ulcer of other specified sites Late effect of spinal cord injury Late effects of motor vehicle accident Acute osteomyelitis, pelvic region and thigh Chronic osteomyelitis, pelvic region and thigh Effusion of joint, pelvic region and thigh

allergies: unknown meds: lithium, seroquel. review of systems: neuro: deeplt sedated overnight for vent management and control of combativeness. as noc progressed, increased doses propofol required. pt placed on ciwa scale, but unable to assess most factors at this time 2nd to intubation. mae well. combative when lightened off sedation. follows no commands and dose not redirect. medicated with 2 doses morphine for ?pain. ativan 0.5mg iv tid. intact gag and cough. intact corneals. perl 2-3mm. cv: sr/st with aggitation, no vea. bp by cuff, low 100s systolic. color pink. skin warm and dry. palp dp and pt pulses bilat. no edema. resp: orally intubated. equal chest expansion. lsc. scant amounts thin yellowish white secretions via ett. on simv. plan to extubate in am. gi: abd. soft, round. + bowel sounds. no vomiting. ogt to lcs with small amount brown drainge. gu: foley with clear yellow urine. heme: stable. pneumo boots. id: afberile. started on ancef endo: no issues. on ssri. skin: lac to lip and forehead sutured during the night. no oozing. edges well-approximated. back intact. small amount bruising from iv and lab sticks. social: mother is wheelchair bound with end stage ms. at home with her. (sister) provided much infor re: hx. several nieces also. family is very involved right now in trying to wake and have funeral for the deceased relative. visitors in tonight and they are unsure when they will be able to come in. mom will probably not be able to visit because of her condition. Procedure: Suture of laceration of lip Closure of skin and subcutaneous tissue of other sites Diagnoses: Alcohol abuse, unspecified Open wound of scalp, without mention of complication Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle Bipolar I disorder, most recent episode (or current) unspecified Open wound of lip, without mention of complication Other alteration of consciousness

history of present illness: the patient is a 37-year-old female involved a motor vehicle collision against a tree. she had positive loss of consciousness. it was unknown whether she was restrained, and she was ethanol intoxicated at the time. there was airbag deployment. the patient was combative at the scene with coma scale of 14. the patient continued to be combative in the emergency room and was intubated for airway protection. past medical history: bipolar disorder. medications on admission: lithium and seroquel. allergies: no known drug allergies. social history: positive ethanol use. positive tobacco use of one pack per day. no drug use. physical examination on presentation: physical examination revealed her temperature was 36.3 degrees celsius, her heart rate was 77, her blood pressure was 136/80, her respiratory rate revealed intubated, and her pulse oximetry was 100%. in general, the patient was combative and confused. coma scale was 14. head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. a scalp laceration measuring approximately 10 cm. a lower lip laceration. the lungs were clear to auscultation bilaterally and equal. cardiovascular examination revealed a regular rate and rhythm. no murmurs. the abdomen was soft, nontender, and nondistended. no ecchymosis. extremity examination revealed no deformity. no tenderness. pulses were 2+ times four. back examination revealed no stepoff. no bruising or tenderness. rectal examination revealed normal tone. guaiac-negative. neurologic examination revealed the patient was combative. she moved all extremities. coma scale was 14. pertinent laboratory values on presentation: laboratories revealed a complete blood count with a white blood cell count of 12.6, her hematocrit was 42.5, and her platelets were 293. chemistry-7 revealed her sodium was 141, potassium was 3.1, chloride was 11o, bicarbonate was 21, blood urea nitrogen was 8, creatinine was 0.7, and her blood glucose was 124. coagulations were within normal limits. serum toxicology screen revealed an ethanol level of 286; otherwise negative. fibrinogen was 240. lactate was 3. amylase was 149. urinalysis was negative. fast examination was negative. pertinent radiology/imaging: a chest x-ray revealed no pneumothorax. no effusions. pelvic x-ray was negative. a head computed tomography was negative. a computed tomography of the cervical spine was negative. a computed tomography of the abdomen and pelvis was negative. concise summary of hospital course: an oral and maxillofacial surgery consultation was obtained, and the patient's forehead and lip lacerations were sutured in the emergency department. the patient was transferred to the surgical intensive care unit for further management, intubated and on the ventilator overnight. the patient was stable on hospital day two and was extubated without difficulties. the patient's cervical spine was cleared, and she was placed on a ciwa scale to monitor for withdrawal. the patient did not require any ativan as she exhibited no signs or symptoms of withdrawal. the patient was transferred to the floor on hospital day two and was stable overnight. on hospital day three, the patient was tolerating a regular diet and ambulating well without difficulty. the patient was passing flatus. the patient's pain was controlled on by mouth medications. a psychiatry consultation was obtained to evaluate the patient for her bipolar disorder and ethanol dependency who recommended that we restart her on her previous psychiatric medications. as there was no evidence of alcohol withdrawal, depression, suicidal ideation, or suicidal intent with the motor vehicle accident she was cleared for discharge from a psychiatric point of view. discharge disposition: the patient was deemed medically stable and was discharged on . discharge diagnoses: 1. forehead laceration. 2. lip laceration. 3. alcohol use. 4. closed head injury. 5. status post motor vehicle collision. 6. bipolar disorder. medications on discharge: 1. cephalexin 500 mg by mouth q.6h. (times three days). 2. percocet one to two tablets by mouth q.4-6h. as needed. 3. tylenol 650 mg by mouth q.4-6h. as needed. discharge instructions/followup: the patient was to follow up with oral and maxillofacial surgery at dental school on , for suture removal and evaluation. the patient was to call telephone number to arrange this appointment. , m.d. 2923 dictated by: medquist36 Procedure: Suture of laceration of lip Closure of skin and subcutaneous tissue of other sites Diagnoses: Alcohol abuse, unspecified Open wound of scalp, without mention of complication Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle Bipolar I disorder, most recent episode (or current) unspecified Open wound of lip, without mention of complication Other alteration of consciousness

allergies: patient recorded as having no known allergies to drugs attending: addendum: the patient was discharged with a prescription for 5 days of lasix 40 mg po qd in light of his tendency to become volume overloaded. he will have his creatinine checked within 1 week and values will be reported to his pcp, . . after 5 days, the patient will see his pcp in follow appointment (which will be 7 days from discharge to re-address whether lasix should be continued). discharge disposition: home with service facility: partners md Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Hemodialysis Venous catheterization for renal dialysis Transfusion of packed cells Injection or infusion of nesiritide Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Hematoma complicating a procedure Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Constipation, unspecified Acute diastolic heart failure Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled Legal blindness, as defined in U.S.A. Partial anomalous pulmonary venous connection

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chf exacerbation major surgical or invasive procedure: cardiac catheterization history of present illness: this is a 70 yo gentleman with type 1 dm, htn, cad s/p mi ', chf, and transferred from for unstable angina and ? cath. he presented to on c/o 5 days if increasing shortness of breath, fatigue, and abdominal discomfort. of note the patient's anginal equivalent is abdominal discomfort. the patient reported stable leg swelling, stable 2 pillow orthopnea, chronic night sweats, and difficult to control sugars. he denies cp, cough, sick contacts, chills, myalgia, med changes, diet changes. at the osh he was found to have a temp to 101 on and started on ceftriaxone/doxy for presumed pna. also he was found to have inf-lat st depressions. he was started on iv nitro, iv lasix before transfer to . while in the hospital the patient had flash pulm edema with desat to the 70's in the setting of an sbp of 180. he had an echo that showed ef 35-40% and severely depressed systolic function and pulomary hypertension. a cardiac cath that showed 3vd (lcx 90% ostial stenosis, rca 90% distal stenosis, lad 90% diffuse disease, with severe depression of systolic function). post-cath he was sent to ccu for further monitoring. past medical history: dm type 1 since age 24 - triopathy cri baseline 1.9 glaucoma legally blind cad s/p nstemi ' (cath at ) chf pvd anemia of chronic disease htn bph hearing loss mrsa osteomyelitis - s/p r 5th toe amputation djd social history: lives with wife in trailer park no tob/etoh/drugs former computer operator family history: dmii physical exam: 98.3/97.1 144/51 (101-144/40-50s) 60s 20s 96%ra i/o=1188/1325 gen: pleasant, nad, comfortable appearing male appearing his stated age, well-nourished heent: perlla, eomi, sclera anicteric, no conjuctival injection, mucous membranes moist, no lymphadenopathy, neg jvd, no carotid bruits : fine crackles at bases r>l cor: rrr, s1 and s2 wnl, no murmurs/rubs/gallops abd: non-distended with positive bowel sounds, non-tender,no guarding, no rebound or masses back: neg cva tenderness ext: no cyanosis, clubbing, edema neuro: alert and oriented x3. vision only to finger count, otherwise cniii-xii are intact. 4/5 strength throughout. pertinent results: osh ua negative ck peak 202 ck-mb peak 8.4 tropi peak 1.39 07:34pm wbc-5.5 rbc-2.76* hgb-8.3* hct-26.1* mcv-95 mch-30.1 mchc-31.9 rdw-13.6 07:34pm neuts-81.5* lymphs-13.1* monos-4.3 eos-0.8 basos-0.3 07:34pm plt count-160 07:34pm glucose-487* urea n-65* creat-1.8* sodium-138 potassium-4.3 chloride-99 total co2-26 anion gap-17 07:34pm alt(sgpt)-12 ast(sgot)-16 alk phos-119* tot bili-0.5 10:16pm ck(cpk)-128 10:16pm ck-mb-7 ctropnt-0.36* cxr - given the presence of kerley b lines and small effusions, the increased interstitial markings could represent asymmetric pattern of interstitial edema. however, differential diagnosis includes other causes, such as infectious and neoplastic etiologies. question nodular opacities, left suprahilar region. left lower lobe collapse and/or consolidation ekg - nsr at 86, nl axis, normal intervals, 1mm st dep ii,iii,avf & 2mm st dep v4-6 echocardiography - ef 35-40% w/ 2+ mr & 2+ tr cardiac catheterization - lad 90% mid vessel stenosis, lcx long 90% ostial stenosis, rca 90% distal stenosis. 06:15am blood wbc-7.6 rbc-3.07* hgb-9.3* hct-28.8* mcv-94 mch-30.3 mchc-32.3 rdw-15.2 plt ct-230 06:05am blood neuts-79.2* lymphs-13.8* monos-5.2 eos-1.4 baso-0.3 06:15am blood plt ct-230 06:05am blood plt ct-234 06:30am blood pt-13.2 ptt-52.4* inr(pt)-1.1 06:15am blood glucose-51* urean-95* creat-3.2* na-132* k-5.0 cl-98 hco3-23 angap-16 07:10am blood fibrino-688* 07:10am blood ret aut-1.8 05:37am blood ck(cpk)-175* 06:26pm blood ck(cpk)-224* 05:37am blood ck-mb-13* mb indx-7.4* ctropnt-0.71* 06:26pm blood ck-mb-15* mb indx-6.7* ctropnt-0.75* 06:05am blood ck-mb-16* mb indx-7.6* ctropnt-0.53* 06:15am blood calcium-8.6 phos-4.0 mg-1.9 06:05am blood calcium-8.4 phos-4.2 mg-2.0 05:00pm blood vitb12-1139* 07:10am blood caltibc-212* ferritn-496* trf-163* 05:00pm blood triglyc-72 hdl-42 chol/hd-2.8 ldlcalc-60 brief hospital course: * cardiovascular ischemia: as discussed above, the patient was transferred from an outside hospital with nstemi (lateral st depressions on ekg). he was maximally medically managed in the cardiac intensive care unit for his coronary artery disease, mi, and congestive heart failure (diastolic dysfunction). he was maintained on asa, metoprolol, a nitro drip, statin, and heparin drip before going to cardiac catheterization. in the cath lab, the following were found: the lad was diffusely diseased with a 90% mid-vessel stenosis. there was subtotal occlusion of the first diagonal branch. the lcx had a long 90% ostial stenosis. the rca had a 90% distal stenosis. limited hemodynamics demonstrated severely elevated right atrial and right ventricular pressures. there was anomalous anatomy of the ivc. it appeared not to empty into the right atrium rather, it looped upwards and joined the svc before the svc emptied into the right atrium. there was difficulty with the swan-ganz catheter and as such, it is not recommended to attempt swan-ganz catheter floatation in any setting other than under fluoroscopy. after this significant disease was identified, the patient was referred to cardiac surgery for cabg. while receiving pre-operative evaluation for this procedure, the patient remained chest pain free. pre-operative evaluation included mra chest in light of cardiac anatomy discussed above, venous ultrasound of the extremities, and carotid studies. troponins reached a peak of 0.75. the patient was transfused as needed to maintained a hct > 30. congestive heart failure: ef at osh 1 year ago was 50%. the cardiac intensive care unit evaluated the patient and believed the patient to have diastolic dysfunction. repeat echo showed an ef of 35-40%. the left atrium was elongated. left ventricular wall thicknesses were normal. the left ventricular cavity was moderately dilated. there was moderate regional left ventricular systolic dysfunction. overall left ventricular systolic function was moderately depressed. resting regional wall motion abnormalities included inferior, inferolateral and inferoseptal hypokinesis. the remaining left ventricular segments contracted normally. right ventricular chamber size and free wall motion were normal. the aortic valve leaflets (3) appeared structurally normal with good leaflet excursion and no aortic regurgitation. no aortic regurgitation was seen. moderate (2+) mitral regurgitation was seen. moderate tricuspid regurgitation was seen. there was moderate pulmonary hypertension. there was no pericardial effusion. with lasix 80 mg, the patient diuresed and there was improvement in his pleural effusions as seen on chest xray. he was weaned off oxygen and at discharge was able to saturate 96% oxygen on room air. rhythym - nsr on tele * hypertension: the patient's blood pressure was initially difficult to control despite being on a nitro drip, beta blocker, hydralazine, nitrate, and dilt. when amlodipine was added, however, the patient's blood pressure responded well and he was able to be weaned off the nitro drip as well as decreasing his beta blocker and hydralazine dose. * renal failure: after cardiac catheterization, the patient experienced dye nephropathy with an acute rise in his creatinine. he was hemodialyzed with good effect. afterward, the patient's renal function was carefully monitored and he received lasix prn to encourage renal output. he responded well to several doses of lasix 80 mg and at discharge, was able to produce around 800 cc's of urine in one day without lasix. the renal service evaluated the patient and expects that renal function will recover slowly and that he will not likely require hemodialysis again. in light of the patient's renal failure, cardiac surgery did not feel comfortable operating. instead, the patient is to follow up with them in three weeks after checking creatinine again. should values be closer to the patient's normal range, cardiac surgery will be reconsidered. * type 1 diabetes - the patient was maintained on a regular insulin sliding scale. * id: the patient remained afebrile during his hospital course. he was treated empirically with ceftriaxone/azithromycin to complete a 7 day course in light of asymmetric right>left pulmonary edema. * glaucoma - the patient was continued on timolol, lumigan, and brimonidine ou medications on admission: lasix 40/20 po alt days isordil 40mg tid lopressor 50mg tid cardiazem 360mg qday cardura 6mg qhs methazolamide 50mg alphagan lamigan timolol asa 325mg qday mvi vit c zinc senna nph 20/10 + riss discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. brimonidine tartrate 0.2 % drops sig: one (1) drop ophthalmic (2 times a day). 3. multivitamin capsule sig: one (1) cap po daily (daily). 4. bimatoprost 0.03 % drops sig: one (1) drop ophthalmic qhs (). 5. ascorbic acid 500 mg tablet sig: one (1) tablet po daily (daily). 6. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 7. atorvastatin calcium 40 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 8. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic qhs (once a day (at bedtime)). 9. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 10. isosorbide dinitrate 20 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 11. amlodipine besylate 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. trazodone hcl 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 13. metoprolol succinate 50 mg tablet sustained release 24hr sig: three (3) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* 14. hydralazine hcl 50 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 15. insulin nph human recomb 100 unit/ml suspension sig: see instructions subcutaneous qam: 20 units every morning. 10 units every night. disp:*1 bottle* refills:*2* 16. continue your regular insulin sliding scale. discharge disposition: home with service facility: partners discharge diagnosis: 3 vessel coronary artery disease, dm type 1, acute on chronic renal failure, glaucoma (legally blind), chf, pvd, anemia of chronic disease, htn, bph, hearing loss, mrsa positive, degenerative joint disease. discharge condition: stable discharge instructions: * please take all of your medications. * please seek medical attention should you experience any of the following: shortness of breath, chest pain, palpitations, sudden weakness, lightheadedness, dizziness, loss of consciousness, fainting, nausea, vomiting, fever, chills * weigh yourself every morning, md if weight > 3 lbs. * adhere to 2 gm sodium diet * see your pcp . within 1 week * please see your cardiothoracic surgeon within 3 weeks as scheduled for you by . make sure to have your creatinine checked before your appointment followup instructions: * please see your pcp . within 1 week of discharge from the hospital. provider: , md where: cardiac surgery lmob 2a date/time: 2:00 Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Hemodialysis Venous catheterization for renal dialysis Transfusion of packed cells Injection or infusion of nesiritide Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Hematoma complicating a procedure Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Constipation, unspecified Acute diastolic heart failure Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled Legal blindness, as defined in U.S.A. Partial anomalous pulmonary venous connection

history of present illness: mr. is a 71-year-old male patient with known 3-vessel disease diagnosed in by cardiac catheterization. at that time, he was referred to dr. for evaluation for cabg. surgery was deferred secondary to a climbing creatinine with a maximum of 5.0 and need for temporary dialysis. mr. has since been seen in our office with hopes for a decreased creatinine and optimized hemodynamics prior to coronary artery bypass grafting and mitral valve replacement/repair. he presented to an outside hospital with anemia. he was transfused with 1 unit of packed red blood cells with flash pulmonary edema and intubation. he was thus transferred to the for ongoing management. his creatinine was below baseline on admission at 1.6, and we were asked to consider surgery at that time. mr. reports dyspnea on exertion, orthopnea, shortness of breath, and weakness. past medical history: type 1 diabetes (diagnosed at the age of 24), chronic renal insufficiency (baseline creatinine of 1.9), glaucoma (legally blind), coronary artery disease (myocardial infarction in ), congestive heart failure, peripheral vascular disease, anemia, hypertension, benign prostatic hypertrophy, hard of hearing, and degenerative joint disease. allergies: question allergy to ace inhibitor's. medications on admission: aspirin 325 mg p.o. once daily, multivitamin, lipitor 80 mg p.o. once daily, protonix 40 mg p.o. once daily, lopressor 50 mg p.o. three times per day, imdur 40 mg p.o. three times per day, amlodipine 5 mg once daily, trazodone 50 mg p.o. once daily, hydralazine 50 mg p.o. three times per day, timolol 0.5 percent 1 drop at bedtime, bimatoprost 0.03 percent 1 drop both eyes at bedtime, and insulin. physical examination on presentation: height of 5 feet 0 inches, weight of 69.9 kilograms. vital signs revealed temperature was 96.0, the heart rate was 63 (in sinus rhythm), the blood pressure was 94/31, the respiratory rate was 16, and 100 percent intubated. in general, flat in bed. intubated, sedated, and in no acute distress. neurologically, responded to painful stimuli. he moved all extremities. respiratory examination revealed fine rales at bilateral bases. cardiovascular examination revealed a regular rate and rhythm. s1 and s2. a positive 2/6 systolic ejection murmur. gastrointestinal examination revealed soft, round, nontender, and nondistended. positive bowel sounds. the extremities were warm and dry. positive red scaly shins without any open areas. laboratory data on presentation: white blood cell count was 8.9, the hematocrit was 30.9, and platelets were 230. pt was 13.9, ptt was 28.8, and inr was 1.2. sodium was 142, potassium was 3.8, chloride was 109, bicarbonate was 25, bun was 38, creatinine was 1.6, and glucose was 245. urinalysis was negative. typed and crossed - o positive. discharge status: to home with visiting nurses to follow. discharge diagnoses: 1. coronary artery disease. 2. status post coronary artery bypass grafting. 3. mitral regurgitation. 4. status post mitral valve repair. 5. type 1 diabetes. 6. chronic renal insufficiency. 7. peripheral vascular disease. 8. anemia. 9. hypertension. 10. benign prostatic hypertrophy. medications on discharge: 1. aspirin 81 mg p.o. once daily. 2. lipitor 40 mg p.o. once daily. 3. colace 100 mg p.o. twice daily. 4. percocet 5/325 one to two tablets by mouth q.6h. as needed (for pain). 5. trazodone 50 mg p.o. at bedtime. 6. methazolamide 50 mg p.o. twice daily. 7. coumadin 2 mg tonight (); to be dosed daily per inr by dr. . 8. norvasc 5 mg p.o. once daily. 9. lasix 20 mg p.o. twice daily. 10. potassium chloride 20 meq p.o. twice daily. 11. brimonidine tartrate 0.15 percent drops 1 drop ophthalmic twice daily. 12. timolol 0.5 percent drops 1 drop bilateral eyes at bedtime. 13. bimatoprost 0.03 percent drops 1 drop both eyes daily. discharge followup: 1. call to schedule an appointment with dr. within four weeks. 2. call to schedule an appointment with dr. within two to four weeks. 3. call to schedule an appointment with dr. within four weeks. 4. visiting nurses daily to draw inr and call results to dr. (telephone number ). , m.d. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Annuloplasty Transfusion of packed cells Injection or infusion of nesiritide Continuous intra-arterial blood gas monitoring Diagnoses: Pneumonia, organism unspecified Other iatrogenic hypotension Anemia of other chronic disease Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Coronary atherosclerosis of native coronary artery Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atrial fibrillation Unspecified glaucoma Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hip fracture and subsegmental pe major surgical or invasive procedure: l hip orif history of present illness: year old female with h/o hypothyroidism, anemia, osteoporosis, multiple falls including and , who presents s/p fall on left hip. per ambulance report, pt was behind her apartment door with walker, when her physical therapist opened the door which hit her, causing her to fall. she landed on left hip. she denies loc, dizziness, palpitations and confusion. x-ray confirmed l hip fracture. . pt taken to or for l orif. intraoperatively she dropped her o2 sats from 100 to 90 and was noted to have an elevated a-a gradient. hip procedure went well without complications. post-operatively, the pt left ventilated on simv and ortho requested transfer to micu for further evaluation and treatment. past medical history: frequent falls , gerd hypothyroidism hearing loss on left b12-deficiency, iron deficiency, anemia osteoporosis t3 compression fracture uti anxiety echo ef>55%, with 1+ ar, normal lv wall motion. social history: social history: - lives in own apartment on - walks with walker - has lifeline - has very actively involved family (niece/hcp) in the area who helps with . she has strong feelings as to how her aunt should be taken care of. - remote tobacco use, no etoh - nok/hcp is patient's niece (is a social worker) - (#1 daughter's room), (#2 cell phone). does not want to work with , rn cm. - pcp is . family history: nc physical exam: vitals: t 99.2 bp 142/65 hr 84 r 26 sat 91% 5lnc * pe: g: elderly female, nad heent: dry mm neck: supple, no jvd lungs: bs bl, diffuse rhonchi cardiac: rr, nl rate. nl s1s2. no murmurs abd: soft, nt, nd. nl bs. no hsm. ext: no edema. neuro: alert, but thinks she's on a ride ("when does this ride stop?") * pertinent results: admission labs: 07:02pm urine color-yellow appear-clear sp -1.017 07:02pm urine blood-tr nitrite-neg protein-neg glucose-neg ketone-15 bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 07:02pm urine rbc-* wbc-0-2 bacteria-few yeast-none epi-0-2 05:40pm glucose-101 urea n-34* creat-1.2* sodium-142 potassium-4.7 chloride-105 total co2-26 anion gap-16 05:40pm calcium-8.8 phosphate-3.8 magnesium-2.0 05:40pm wbc-6.8 rbc-4.26 hgb-12.1 hct-35.6* mcv-84 mch-28.5 mchc-34.1 rdw-13.3 05:40pm neuts-75.1* lymphs-20.4 monos-2.8 eos-1.1 basos-0.6 05:40pm plt count-300 05:40pm pt-12.0 ptt-24.1 inr(pt)-0.9 imaging: admission hip film (): impression: proximal left femoral fracture. admission cxr (): impression: no acute pulmonary process. low lung volumes with right basilar atelectasis. previously identified right retrocardiac nodular density, not clearly visualized in this study. gross path on l hip fx: clinical: fracture left hip. the specimen is received fresh labeled with " " and "left femoral head" and consists of a femoral head measuring 6.5 x 4.5 x 3.8 cm. the additional separate fragment of bone measuring 2.3 x 1.5 x 1.3 cm. the shape of the femoral head is unremarkable, however, there is extensive eburnation across most of the surface. there is mild, focal osteophytic growth on the edge. it is sectioned to reveal large area of hemorrhage measuring up to 3 cm, and the inferior surface of the femoral head is jagged and hemorrhagic. the bone trabecula are firm and no tumors or other mass lesions are noted on sectioning. representative sections are submitted in a-b following decalcification. cta chest (post-op) : impression: 1. single pe visualized in the apical segment of the right lower lobe. 2. small bilateral pleural effusions. associated atelectasis. no other areas of consolidation are visualized. 3. mild/early chf. ct abd/pelvis (): impression: 1. patient is status post orif of the left proximal femur. there is marked streak artifact from this within the pelvis, however, no definite hematomas are identified. 2. bilateral small pleural effusions with associated atelectasis. 3. the gallbladder appears full, and contains sludge. if there is clinical concern for acute cholecystitis, evaluation with ultrasound is recommended. us liver/gb (): impression: gallbladder sludge and pericholecystic fluid. no gallbladder wall edema or other evidence to suggest acute cholecystitis. given the presence of hypoalbuminemia, normal lfts, and the absence of a white count, the gallbladder sludge and gallbladder distention likely reflect a fasting state. cxr : impression: improvement of pulmonary edema. unchanged right pleural effusion. brief hospital course: year old female with h/o hypothyroidism, anemia, osteoporosis, multiple falls including and , who presented s/p mechanical fall with subsequent l hip fx. she was taken to or for l orif. intraoperatively she dropped her o2 sats from 100 to 90 and was noted to have an elevated a-a gradient. hip procedure went well without complications. post-operatively, the pt left ventilated on simv and ortho requested transfer to micu for further evaluation and treatment. in the icu, she was found to have a subsegmental pe and bl pleural effusions. she developed a fever to 101.9, and was treated empirically for hospital-acquired pna with ctz/flagyl (plan for 10 days). she was also started on heparin, and was noted to have had a hct drop of 10 points on , which was stable after transfusion. no obvious source was found and her hct was stable following. during this time (), she was also empirically started on vancomycin for the fevers, but it was d/c'd on . no other etiology for the fevers was found, including negative ruq u/s and ct a/p. once extubated, the patient failed speech and swallow evaluation, but refused ngt placement. a picc line was placed for temporary nutrition via tpn. . 1. pe: the patient was anticoagulated initially with heparin gtt then switched to lovenox. once a peg was placed, the patient was transitioned over to coumadin with lovenox bridge. last inr was 2.1 on , stopped lovenox, discharged on coumadin 3mg po qd, please check inr in 2 days and adjust dose of coumadin as needed. at time of discharge, her sao2 ranged from 92-95 on ra. . 2. id: the patient was treated empirically with ctz and flagyl for a nosocomial/aspiration pna and remained afebrile while on the floor. however, pt's wbc elevated so vanco was added to regimen for a 7 day course. a sputum cx from grew sparse yeast. the foley was changed and a urine sent for culture; the initial sample was contaminated and grew yeast; the second urine cx grew enterococcus resistant to vanco 10,000-100,000 colonies. a repeat urine was sent and the foley was removed; cx grew only yeast. she remained afebrile, with a normal wbc, throughout the remainder of her hospitalization. a pcxr on showed a question of a new l medical base infiltrate; however, in absence of fever and stable wbc, did not treat with abx, followed clinically. there was a concern that the patient may have experienced an aspiration event; however she did not worsen clinically so no further treatment provided other than measures to reduce aspiration risk. . 3. l hip fracture, s/p orif: the patient was followed by orthopedics and did well, cleared for wbat and work with pt/ot; will need pt/ot at rehab when physically able. the patient will f/u with dr. 2 weeks from discharge date (number in discharge paperwork). . 4. delirium/dementia: the patient had a waxing/ mental status. at one point the patient pulled her iv lines including her picc line, occasionally requiring the use of soft restraints for her safety. olanzapine was used on a prn basis for agitation. frequent reorientation was used. pt has periods of apparent lucidity and makes insightful comments and conversation. . 5. fen: the patient failed multiple speech & swallow evaluations. the patient was initially on tpn via the picc line for nutrition. extensive discussions were had with the healthcare proxy regarding options for enteral nutrition. an albumin was 2.7. a peg was placed on and tube feeds were begun and the patient achieved her tf goal. electrolytes were stable. there was concern on that the patient was aspirating some of her tf reflux, despite no residuals when checked; a cxr was unchanged. a day later a repeat cxr showed a question of a new l medial base infiltrate (poor quality film). reglan was started, and tf were restarted at a slower rate. a ppi was also administered. hob kept elevated >30-45 degrees at all times. the patient was followed on a sliding scale insulin regimen with good effect. . 6. hypothyroidism: the patient was initially treated with iv levoxyl since she was npo; a tsh was checked: 8.5, difficult to interpret in an ill, hospitalized patient. a free t4 was wnl, so pt was maintained on same dose of levoxyl. once peg in place, po levoxyl started at same dosing per pharmacy recs. . 7. anemia: stable during remainder of hospitalization. baseline hct appears to be in the low to mid 30s. . . medications on admission: meds on transfer: propofol gtt multivitamins 1 cap po daily olanzapine prn oxycodone 5 mg po q4-6h:prn pain acetaminophen 650 mg po/pr q6h pantoprazole 40 mg po q24h calcium carbonate 500 mg po tid cefazolin 1 gm iv q8h duration: 6 doses docusate sodium 100 mg po bid:prn enoxaparin sodium 40 mg sc q24h levothyroxine sodium 88 mcg po daily senna 1 tab po bid metoprolol 5 mg iv q6h morphine sulfate 1-2 mg iv q4-6h:prn vitamin d 400 unit po daily . allergies: nkda discharge medications: 1. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po bid (2 times a day) as needed for agitation. 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 3. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 4. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 5. coumadin 3 mg tablet sig: one (1) tablet po once a day: via peg. tablet(s) 6. lansoprazole 15 mg susp,delayed release for recon sig: one (1) po daily (daily): via peg. 7. metoclopramide 10 mg tablet sig: one (1) tablet po q6h (every 6 hours): via peg. 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day): via peg, fold for hr<60, sbp<115. 9. outpatient lab work please check inr in 2 days and adjust coumadin level as needed for goal inr . 10. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 11. warfarin 1 mg tablet sig: three (3) tablet po daily (daily) as needed for pe. discharge disposition: extended care facility: at discharge diagnosis: 1. l hip fracture s/p orif 2. pe 3. dementia/delirium 4. pneumonia (resolved) 5. anemia (stable) 6. hypothyroidism discharge condition: fair discharge instructions: -take medications as prescribed -work with physical therapy as able -tube feeds via peg (nothing by mouth until re-evaluation by speech/swallow) -notify your doctor or return to the er for: * fever>101.4 * chest pain, shortness of breath, abdominal pain * other concerns followup instructions: - provider: , md date/time: 1:30 - orthopedics dr. -- call to schedule appointment at a time conveneient for you 2 weeks from your discharge date. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Partial hip replacement Open reduction of fracture with internal fixation, femur Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Esophageal reflux Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Unspecified fall Pneumonitis due to inhalation of food or vomitus Iatrogenic pulmonary embolism and infarction Other closed transcervical fracture of neck of femur

history of present illness: the patient is a 24 year-old male with a history of asthma presented unresponsive with an episode of emesis requiring intubation on presentation to the emergency room. briefly his immediate family gave a history of ingestion of mdma, ketamine, and ethanol two to three days prior to admission and the ingestion of ghb the night prior to admission. he was found unresponsive by his friends and was driven in to the emergency room and had an episode of emesis with the unresponsiveness requiring intubation for airway protection. in the emergency room charcoal was administered and a foley was placed. he responded to commands after several hours and was admitted to the intensive care unit for further management. past medical history: asthma. medications: serevent and albuterol. allergies: no known drug allergies. social history: single. no tobacco use. history of ethanol use in the past mostly on the weekends. family history: noncontributory. physical examination: afebrile. pulse in the 70s. blood pressure 120/50. sating 95% on room air. in general, awake, alert, oriented, responsive. head, eyes, ears, nose and throat clear. oropharynx no lymphadenopathy. heart was regular with no murmurs. lungs were clear. abdomen was benign with normal bowel sounds. extremities showed no edema. neurologically nonfocal. laboratory: white count 15.3, hematocrit 46.5, platelets 378 with an inr of 1.3. urinalysis was notable for a glucose of greater then 1000, large blood, 21 to 50 red cells, 6 to 10 white cells, occasional bacteria. chem 7 showed a glucose of 128, bun 9, creatinine .9, sodium 143, potassium 3.4, chloride 106, bicarb 25, amylase 58. serum tox screen was negative. urine tox screen was positive for benzodiazepine and amphetamine. chest x-ray showed no infiltrate or acute process. hospital course: mr. was transferred to the intensive care unit after self extubation in the emergency room for further monitoring. he had a stable night with no acute issues. his examination in the morning was benign. a psychiatry/substance abuse consult was called for further evaluation of substance abuse history and potential treatment. he has had similar episodes twice in the past. there was no evidence of suicidal ideation. urine output remained after adequate intravenous fluid rehydration and toleration of po intake. the patient had no complaints. discharge status: afebrile with stable vital signs, asymptomatic with a baseline mental status. discharged to home. follow up with in the clinic for asthma and with the substance abuse program. discharge diagnoses: 1. drug overdose secondary to ghb in combination with mdma, ketamine and ethanol. 2. asthma. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Poisoning by other opiates and related narcotics Home accidents Amphetamine or related acting sympathomimetic abuse, unspecified Toxic effect of ethyl alcohol Poisoning by other and unspecified solid and liquid substances, undetermined whether accidentally or purposely inflicted Poisoning by tranquilizers and other psychotropic agents, undetermined whether accidentally or purposely inflicted Poisoning by analgesics, antipyretics, and antirheumatics, undetermined whether accidentally or purposely inflicted

allergies: penicillins attending: chief complaint: right arm weakness, slurred speech major surgical or invasive procedure: none history of present illness: patient is an 84 year old female nursing home resident with pmh of dvt , htn, gerd, dermatitis. she awoke this morning at 0540 with right arm weakness, slurred and inappropriate speech and bladder/bowel incontinence. she was noted to have said "i think i'm having a stroke". there was no associated fall or trauma. was reportedly aphasic and weak in the right upper extremity initially, but these deficits resolved at some point as noted in the osh records. en route, she reportedly desaturated to 88%, was put on face mask and improved, but required cpr for some reason. it is not known at this time if she was receiving cpr for cardiac arrest or respiratory arrest. . ct at osh showed intracranial hemorhhage. inr was found to be 6.4 (takes coumadin for h/o dvt this year). she was given ffp and transferred. . she was electively intubated at the osh () and arrived here to intubated but not sedated. on initial evaluation by neurology er resident, she was noted to be unresponsive, moving all four extremities spontaneously (l>r), with brain-stem reflexes intact and withdrawing x4 to pain. repeat inr here at at 0830 showed inr of 3.2. patient was given 2 vials of proplex. 3rd inr is pending at this time. . past medical history: dvt , htn, gerd, bipolar, dementia, chronic bladder issues, oa, b/l knee pain with partial knee replacement in past. dermatitis. undocumented, but according to son, has history of "golf-ball sized" meningioma in the left part of brain. was seen by a neurosurgeon last year who did not want to operate. history from chart and partially from son who is unclear on some details of pmh. social history: nh resident. son lives nearby. otherwise unknown. family history: unknown physical exam: t-97.3 bp-118/78 hr-72 rr-12 (vented) o2sat: 100% gen: lying in bed, intubated, vented, sedated. no spontaneous movements. left arm slightly more flexed at elbow than right. no posturing. heent: nc/at, moist oral mucosa. neck: in c-spine hard collar. cv: distant heart sounds. rrr, nl s1 and s2, no murmurs/gallops/rubs lung: slight ronchi bilaterally. no crackels/wheezes. abd: +bs soft, nontender. ext: no edema. no lesions. neurologic examination: mental status: intubated. off propofol, exam shows no response to voice commands. withdraws all four extremities to pain (left greater than right) but no localization of pain. no spontaneous movements. perrla 2-->1 bilaterally. dolls eyes difficult to assess as in hard collar. corneal reflexes present bilaterally. tone moderately rigid in bilateral upper extremities. reflexes 2+ at brachrad/biceps/triceps/patella. plantar response extensor on right, mute on left. . no adventitious movements. . pertinent results: admission labs: 08:30am urine rbc-0-2 wbc-21-50* bacteria-many yeast-none epi- renal epi-0-2 urine hyaline-0-2 08:30am urine blood-sm nitrite-pos protein-tr glucose-neg ketone-150 bilirubin-neg urobilngn-neg ph-6.5 leuk-mod 08:30am urine color-yellow appear-hazy sp -1.018 08:30am pt-30.5* ptt-33.8 inr(pt)-3.2* 08:30am hypochrom-1+ anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 08:30am neuts-84* bands-7* lymphs-6* monos-3 eos-0 basos-0 atyps-0 metas-0 myelos-0 08:30am wbc-14.5* rbc-3.82*# hgb-12.3# hct-33.8*# mcv-88# mch-32.2* mchc-36.5* rdw-13.7 plt count-276 08:30am acetone-moderate 08:30am calcium-9.5 phosphate-1.4* magnesium-1.8 08:30am ck-mb-notdone ctropnt-<0.01 ck(cpk)-42 08:30am glucose-117* urea n-25* creat-0.7 sodium-141 potassium-3.4 chloride-102 total co2-20* anion gap-22* 09:25am freeca-1.19 lactate-0.9 09:25am type-art ph-7.37 intubated-intubated 12:00pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-150 bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 12:00pm urine color-straw appear-clear sp -1.012 12:30pm pt-13.7* ptt-23.9 inr(pt)-1.2* 12:30pm asa-neg* ethanol-neg acetmnphn-9.8 bnzodzpn-neg barbitrt-neg tricyclic-neg 12:30pm tsh-1.3 albumin-4.4 12:30pm ck-mb-4 ctropnt-<0.01 12:30pm alt(sgpt)-22 ast(sgot)-61* ck(cpk)-125 alk phos-81 tot bili-0.5 05:33pm pt-18.0* ptt-29.8 inr(pt)-1.7* 10:14pm pt-22.8* ptt-35.1* inr(pt)-2.3* 10:14pm ck-mb-notdone ctropnt-<0.01 ck(cpk)-72 . admission ct head: ct of the brain without intravenous contrast: a large left frontoparietal intraparenchymal hemorrhage is again noted. there is questionable minimal increase in prominence of the caudal portion of the hemorrhage in comparison with the examination of several hours earlier. the degree of hypodensity surrounding the inferior portion of the hemorrhage also appears minimally increased, consistent with slight increase in edema. the degree of left to right subfalcine herniation is unchanged. there is no hydrocephalus or evidence of transtentorial herniation. bilateral cerebral periventricular white matter hypodensity is consistent with chronic small vessel ischemic change. there is no evidence of extra-axial hemorrhage. . bone windows demonstrate no evidence of fracture within the surrounding osseous structures. the mastoid air cells and visualized portions of the paranasal sinuses are normally pneumatized. . impression: left frontoparietal intraparenchymal hemorrhage, questionably minimally increased along its caudal aspect, without change in degree of mass effect. . ct c spine: 1. no fracture or malalignment seen. 2. extensive degenerative disc disease as well as multilevel djd. . follow up ct: stable left frontoparietal intraparenchymal hemorrhage. no change in degree of mass effect . eeg : abnormality #1: throughout the recording there were frequent bursts of mixed frequency slowing with a generalized distribution. there were also occasional bursts of bitemporal mixed frequency slowing. abnormality #2: background rhythm was usually disorganized. it was often somewhat slow, in the hz range although there were some faster frequencies. the background did react to external stimuli with some apparent alerting. hyperventilation: could not be performed. intermittent photic stimulation: could not be performed. sleep: no normal waking or sleeping morphologies were seen. cardiac monitor: showed a generally regular rhythm. impression: abnormal portable eeg due to the bursts of generalized slowing with additional bitemporal mixed frequency slowing. these findings suggest multifocal subcortical abnormalities. vascular disease is a relatively common cause of such findings. in addition, the background was disorganized and usually somewhat slow, suggesting a concomitant encephalopathy. there were no areas of prominent and persistent focal slowing, and there were no clear epileptiform features. . bilateral lenis: 1. no evidence of acute dvt. 2. evidence of prior dvt of the left popliteal vein. . mri/mra brain: findings: as noted on the prior ct, there is an acute 4 cm left frontoparietal intraparenchymal hematoma. there is a small amount of subdural blood present over the anterior left temporal lobe. there is mass effect upon the atrium of the ipsilateral lateral ventricle. however, there is no significant midline shift or herniation. there are no additional foci of abnormal magnetic susceptibility to indicate other microhemorrhages. there are multiple t2 hyperintensities within the subcortical white matter of both cerebral hemispheres due to chronic microvascular infarct. . this study is slightly limited by patient motion artifact. there is no slow diffusion to indicate an acute infarct. . impression: large intraparenchymal left frontoparietal acute hematoma with a tiny amount of subdural blood along the left middle cranial fossa. . there is no evidence of other microhemorrhages. . no acute infarct. chronic microvascular infarct. . mra: normal brain mra, but limited by motion. . eeg : time samples: throughout the recording, there is continuous slowing of the left hemisphere in the mixed hz delta and hz theta frequency range. there were no clear epileptiform discharges seen throughout the recording. background: over the left hemisphere is more disorganized and represented a lower voltage gradient. the right hemisphere is mildly disorganized but reaches normal alpha frequency ranges. sleep: normal transitions of the sleep architecture were not seen. cardiac monitor: normal cardiac rhythm with a rate of 84 bpm. there was a continuous widespread qrs complex seen. automatic seizure detections: there were no entries in these files. automatic spike detections: there were 103 entries in these files. all entries represent movement and muscle artifact. pushbutton events: there was one pushbutton at the beginning of the recording which represented a system's test. impression: this is an abnormal discontinuous 24-hour long term eeg monitoring due to the presence of continuous slowing over the mixed delta and theta frequency range over the entire left hemisphere. there were no clear epileptiform discharges or seizure activity recorded. a widespread qrs complex was noted. . eeg : time samples: throughout the recording, there is a persistent moderate voltage slowing in the hz delta frequency range and intermittent theta frequency slowing over the entire left hemisphere with left temporal emphasis. as the study progressed, there are initially isolated sharp features over the left temporal region with phase reversing around t3 and runs of semi-rhythmic 5 hz theta frequency slowing in the left central region lasting up to 20 seconds. beginning in the early evening of the recording, there are frequent semi-rhythmic sharp and slow wave and spike slow wave discharges seen phase reversing around f7 and t3, secondarily spreading over the entire left hemisphere. the frequency of these discharges vary between 1 and 2 hz lasting from 1 a.m. to the end of the recording at 10 a.m. on . automatic seizure detections: there are three entries in these files. all events represent fast eye movements. there was no clear seizure activity recorded. automatic spike detections: there were 79 entries in these files. the majority of these entries represent muscle artifact. there were also a few sharp wave discharges over the left temporal region captured. please see above. pushbuttons: there were no entries in this file. sleep: normal transitions of the sleep architecture were not seen. cardiac monitor: there is a normal cardiac rhythm with a rate of 90 bpm. there are prolonged widespread qrs complexes alternating with normal qrs complexes seen. impression: this is an abnormal 24-hour discontinuous eeg telemetry due to the presence of prolonged epileptiform sharp and spike slow wave discharges seen over the left fronto-temporal region spreading over the entire left hemisphere. this finding was persistent for at least nine hours through the end of the recording. additionally, there is continuous delta frequency slowing over the entire left hemisphere. this finding suggests cortical and subcortical structural abnormalities. over the 24-hour eeg recording, there are described discharges over the left hemisphere which became more frequent and persistent but there were no clear seizures recorded. widespread qrs complexes alternating with normal qrs complexes were noted. . eeg : abnormality #1: throughout the recording, there are intermittent bicentral sharp slowing seen independently occasionally followed by a slow wave. abnormality #2: there is increased voltage gradient over the entire left hemisphere with a diffuse mixed theta and delta frequency slowing. there is no clear anterior-posterior voltage gradient on both hemispheres. the background is slow in the hz theta frequency range and disorganized. the superimposed fast activity in the beta frequency range is noted. background: as above. hyperventilation: was not performed due to the patient's clinical condition. intermittent photic stimulation: was not performed because this was a portable study. sleep: normal transitions of the sleep architecture were not seen. cardiac monitor: normal cardiac runs of widespread qrs complexes followed by normal qrs complexes were seen. impression: this is an abnormal portable eeg due to the presence of intermittent, independent, bicentral sharp slowing and sharp slow wave discharges and due to slow and disorganized background rhythms with diffuse theta frequency slowing and increased voltage gradient over the entire left hemisphere. the background slowing suggests cortical/ subcortical dysfunctions and a mild encephalopathy. epileptiform discharges represent most likely cortical dysfunction in central parietal regions. superimposed fast activity is most likely due to medication effect. given the patient's clinical history and eeg findings, eeg monitoring might be of benefit. . ct head : comparison with the prior study of , reveals reduction in the density of the large hemorrhage, but negligible change in its degree of mass effect or surrounding edema. once again, there is considerable compression of the posterior aspect of the body of the left lateral ventricle as well as the atrium. the minimal subfalcine herniation is unaltered. no new area of intracranial hemorrhage is identified. . there is moderate mucosal thickening within the posterior aspect of the left ethmoid sinus, which has evolved since the prior study. the finding likely relates to the intubated status of the patient. . tte : the left atrium is mildly dilated. there is mild (non-obstructive) focal hypertrophy of the basal septum. the left ventricular cavity size is normal. there is mild to moderate regional left ventricular systolic dysfunction with akinesis of the mid antero-septum, distal lv and apex. no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. . brief hospital course: pt. was admitted to the neuro icu. was intubated at the outside hospital. bp was initially maintained below 140 with labetalol iv, and repeat imaging showed stability of the hemorrhage. inr was corrected with ffp and proplex. over the first 24 hours, her exam was felt to be out of proportion with findings on ct. however, she did receive narcotics at the osh and was found to have uti on admission both of which could account for a change in neurological status. propofol was weaned and narcotics held. on day 2 she was noted to be much more awake and following commands. she was able to raise left arm and leg anti-gravity and was noted to be moving all four extremities spontaneously (l>r). her mental status continued to improve and she was transferred to the floor . failed multiple bedside swallow exams and was npo with ng in place. . on the floor mental status continued to improve, although pt. failed a repeat bedside swallow evaluation. aspirin was restarted. she finished a 7 day course of levofloxacin for uti. . on had gtc seizure in the early morning hours. witnessed by physician who reported as upper extremities and face involvement. received 2mg iv ativan without any change. after another 1mg ativan converted to rue and face only. gtc portion estimated to have been about 20 minutes. after another 1+1 ativan she gradually slowed the rue movement but facial twitching continued. was loaded with 1 gram iv dilantin and movements ceased after about an hour. vitals were all initially stable with tachycardia, but became hypotensive in post-ictal period. patient received 5mg ativan and 1gram dilantin in total. she was not on seizure prophylaxis up until this point. was not following any commands but withdrew all four extremities to noxious stim. transferred back to icu for hypotension. dilantin discontinued as she had cyanotic fingertips which was presumably as a reaction to the dilantin (purple glove syndrome). was loaded on depakote and maintained with iv doses qid. was following commands at 24 hours although very somnolent. after 48 hours was more awake and near baseline. was transferred back to the floor . . on the floor depakote was continued, and dose titrated up as levels were low. depakote levels should be checked qod at rehab and dose titrated accordingly. pt. worked with pt and ot who recommended acute rehab. she failed another swallow evaluation. her swallowing was discussed several times with her son and hcp, , who felt that he did not want to subject his mother to a peg tube at this juncture, and was hopeful that with more time she would pass a swallow evaluation. we discussed with him that there was a chance that she may not to regain her swallowing abilities, which he understood, but he maintained that he wanted to give her more time before making the decision to proceed with peg. she should continue to be evaluated by speech and swallow at rehab, and if she continues to fail peg tube will need to be readdressed with him. . neuro exam on discharge was significant for diffuse mild l sided weakness ( in all muscles groups), trace movement of r ankle but 0/5 strength of all muscle groups on the right, and some inattention and perseveration, as well as problems following complex commands. . cvs: cardiovascularly ruled out for mi with serial enzymes. no significant events on telemetry. was hypotensive to 80s/50s and initially did not respond to fluid boluses (3 boluses of 500cc ns each). on arrival to icu received additional 500 cc bolus and pressures corrected to acceptable level. pressors not initiated. ruled out again for mi with serial enzymes. had echo (please see results section) which showed mild to moderate regional left ventricular systolic dysfunction with akinesis of the mid antero-septum, distal lv and apex, ef 35%. she should have a repeat tte when she is more medically stable to f/u these findings. bp stable for several days with no iv boluses required prior to discharge. . resp: intubated at osh. extubated after 48 hours without complications. heme: inr was initially corrected with ffp and proplex. serial inrs were performed and she required a few additional units of ffp over the first 48 hours. she also received some vitamin k sc. inr was stable at 1.0-1.2 after hod #3. . gi: failed multiple swallow evals and ng placed. received tube feeds throughout hospitalization. ppi for prophylaxis. decision for peg . id: had uti on admission which was treated with iv levaquin for 7 days. . renal: no issues this admission. . medications on admission: meds at nh: erythromycin ointment to eyes qhs first 5 days of each month dulcolax sup prn coumadin 4mg po daily namenda 5mg po daily mvi daily remeron 45mg daily mom 30cc daily prn tyelnol 650mg daily prn discharge medications: 1. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed): please administer prior to meals per sliding scale attached. 2. memantine 5 mg tablet sig: one (1) tablet po daily (). 3. multivitamin capsule sig: one (1) cap po daily (daily). 4. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 5. lansoprazole 30 mg susp,delayed release for recon sig: one (1) po daily (daily). 6. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. 7. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 8. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 10. valproate sodium 250 mg/5 ml syrup sig: 7.5 ml po q6h (every 6 hours). discharge disposition: extended care facility: & rehab center - discharge diagnosis: 1) left frontoparietal intraparenchymal hemorrhage 2) generalized tonic-clonic seizure discharge condition: stable, tolerating medications discharge instructions: 1) please return for increasing weakness, trouble speaking, inability to take medications, uncontrolled bleeding, vomiting and fevers. 2) please attend all appointments 3) take all medications as prescribed. followup instructions: your pcp will visit you at your nursing home. please have your nursing home call upon your arrival. . your have a neurology appointment with dr. and his fellow (dr. , wed at 1pm. hospital building . for more details can call # . md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Enteral infusion of concentrated nutritional substances Transfusion of other serum Diagnoses: Other iatrogenic hypotension Esophageal reflux Urinary tract infection, site not specified Other convulsions Intracerebral hemorrhage Benign neoplasm of cerebral meninges Personal history of venous thrombosis and embolism Anticoagulants causing adverse effects in therapeutic use Bipolar disorder, unspecified Pneumonia due to other specified bacteria

allergies: penicillins attending: chief complaint: renal artery stenosis major surgical or invasive procedure: renal artery stent history of present illness: 82 yo f with prior hx of htn, hyperlipidemia, bilateral carotid artery stenosis who was diagnosed with bilateral ras by mra 1 month prior to rising cr. an mra showed bilateral ras with l>r. the left-sided plaque is contiguous with an ulcerated plaque in the aorta. given the severity of her renal artery stenosis, the patient was admitted for stenting. she has been feeling increasing shortness of breath since stopping her diovan and lasix and more severe sob over the past 2 days. the patient also reports no appetite and just eating to "stay alive." she also has nearly no urine output. she denies any constipation/diarrhea/abdominal pain, fevers, chills, cough. past medical history: 1. htn 2. bilateral renal artery stenosis 3. hyperlipidemia 4. prosthetic right eye 5. hx of sjogren's syndrome 6. bilateral carotid artery stenosis s/p cea social history: professor and experimental psychology. lives alone, no husband, no children. hcp is . living will indicated does not want excessive or life-prolonging measures. no tobacco, etoh. family history: mother and father with cad. no renal disease. physical exam: 96.5, 96, 260/90, 22, 93-96% on 2l nc gen- frail, elderly female; tachypneic, sitting at 90 degrees speaking short sentences heent- peerl, op clear, upper dentures in place neck- no jvp cv- rr, no m chest- bilateral crackles way up bilaterally abd- soft, nt/nd, +bs, no abdominal/renal bruits appreciated ext- 1+ edema bilaterally, warm extremities pertinent results: 07:19pm glucose-177* urea n-60* creat-4.0*# sodium-137 potassium-3.9 chloride-102 total co2-21* anion gap-18 07:19pm calcium-8.3* phosphate-4.6*# magnesium-1.8 07:19pm wbc-7.8 rbc-3.37*# hgb-10.0*# hct-30.3* mcv-90 mch-29.6 mchc-33.0 rdw-15.4 07:19pm neuts-85.5* lymphs-8.9* monos-3.5 eos-1.3 basos-0.8 07:19pm hypochrom-1+ 07:19pm plt count-142* 07:19pm pt-13.1 ptt-24.7 inr(pt)-1.1 brief hospital course: pt is an 82 yo f with pvd and severe bilateral renal artery stenosis, severe htn secondary to ras, and who was admitted for renal artery stenting secondary to recent admission for poorly controlled hypertension and chf. during her hospital stay, she developed hypertensive emergency requiring transfer to the ccu with sbp 260 and flash pulmonary edema. she was started on a labetalol drip and diuresed with iv lasix. the renal team agreed with managment. she underwent right renal artery stent x 1 as a salvage attempt for her renal failure. however, this salvage attempt failed and she returned in cardiogenic shock and was made cmo. her code status was determined with the patient and her pcp as the patient expressed that she would never want hemodialysis. all of her lines were removed and she remained unresponsive with 100% nrb and passed away peacefully on while on a morphine drip. medications on admission: atenolol 12.5 mg po qd zocor 40 mg po qd asa 81 mg po qd discharge medications: passed away discharge disposition: expired discharge diagnosis: renal artery stenosis diastolic chf hypertensive emergency death discharge condition: cmo and died during this admission. discharge instructions: none followup instructions: none Procedure: Angioplasty of other non-coronary vessel(s) Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Other and unspecified hyperlipidemia Atherosclerosis of renal artery Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Chronic diastolic heart failure Malignant renovascular hypertension Swelling, mass, or lump in chest

addendum: discharge medications: ceftriaxone 1.0 gm iv q day, prevacid 15 mg per g-tube q day, vitamin c 500 mg per g-tube q day, regular insulin sliding scale, enteric coated aspirin 81 mg per g-tube q day, nepro tube feeds with 60 gm promod with a goal of 45 cc an hour, linezolid 600 mg per g-tube on day six of seven, nystatin 5.0 cc swish and swallow orally qid, norvasc 10 mg per g-tube q day hold for systolic blood pressure less than 90, heparin 5,000 units subcutaneous twice a day, zinc 220 mg per g-tube q day, colace 100 mg per g-tube , nephrocaps one per g-tube daily, epogen 12,000 units iv with dialysis on monday, wednesday, and friday, lisinopril 15 mg per g-tube q day, hold for systolic blood pressure of less than 90, nph 7 units subcutaneous , thiamine 100 mg iv q day, lopressor 25 mg per g-tube twice a day, reglan 25 mg per g-tube qid, albuterol and atrovent nebulizers every four to six hours prn, dulcolax 10 mg per g-tube/pr prn, lactulose 30 cc per g-tube prn. discharge diagnoses: 1. coronary artery disease, status post coronary artery bypass graft times four on . 2. type 2 diabetes. 3. l4-l5 herniated disk. 4. end stage renal disease. 5. hypertension. 6. peripheral vascular disease. , m.d. dictated by: medquist36 d: 08:59 t: 08:00 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Insertion of endotracheal tube (Aorto)coronary bypass of four or more coronary arteries Venous catheterization for renal dialysis Temporary tracheostomy Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Acute respiratory failure Infection and inflammatory reaction due to other vascular device, implant, and graft Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

allergies: nkda current review of systems: neuro: alert, russian speaking only--following commands intermittentlly. mae's. cv: hr 45-60, sinus brady, no ectopy noted. sbp 125-150/70. right quinton cath patent, piv in right hand patent resp: breath sounds clear to coarse, resp rate 20-28. strong productive cough of thick white secretions, requires suctioning approx q2h to help to clear secretions. sats 98-100% on 40% trach mask. renal: anuric, dialyzed on . pt is straight qd, done at 12a today for minimal drops of urine. k+ 4.1 today, creatinine 4.2 gi: abd soft, (+) bowel sounds. peg in place, site benign. tube feeds 3/4 strength nepro at goal of 45cc/hr, residuals <10cc. heme: hct 33.4. sq heparin for dvt prophylaxis id: t. 99.4. wbc 10.4 skin: chest and right leg incis ota, pink and dry, no s/s of infection. right heel with necrotic heel, waffle boots in place. coccyx with stage 2 ulcer, wound bed pink, duoderm gel to wound qd, healing well. social: wife in to visit daily. pt had been screened for rehab, pt's wife only want pt to go to ne , awaiting bed availability a: s/p cabg x 4, hemodynamically stable, resp status improved Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Insertion of endotracheal tube (Aorto)coronary bypass of four or more coronary arteries Venous catheterization for renal dialysis Temporary tracheostomy Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Acute respiratory failure Infection and inflammatory reaction due to other vascular device, implant, and graft Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

history of present illness: this 76-year-old male with a history of type 2 diabetes, chronic renal insufficiency progressed to end stage renal disease, hypertension, peripheral vascular disease, history of chronic abdominal pain, who presented with two days of increasing epigastric pain, shortness of breath, diaphoresis, nausea without vomiting. the patient's symptoms were not relieved by nitroglycerin. the patient also complained of orthopnea and shortness of breath with exertion. the patient had also noticed bilateral lower extremity edema. on presentation, the patient was found to have lateral st depressions on electrocardiogram and was admitted for rule out myocardial infarction. past medical history: type 2 diabetes, benign prostatic hypertrophy, impotence, herniated l4-l5 disc, positive tobacco history, history of abdominal surgery secondary to a world war ii gunshot wound, peripheral vascular disease, cerebrovascular disease, dizziness not otherwise specified, chronic renal insufficiency progressed to end stage renal disease, status post left fistula placement, chronic constipation, and hypertension. allergies: no known drug allergies. medications on admission: lasix 60 mg once daily, glipizide 10 mg twice a day, lipitor 10 mg once daily, avandia 2 mg once daily, epogen 4000 units subcutaneously three times a week, aspirin 325 mg once daily, colace as needed, dulcolax 10 mg suppository as needed, lactulose as needed, nifedipine 120 mg once daily. social history: the patient resides with his wife. is russian-speaking. the patient denied any alcohol. the patient admitted to smoking, 50 pack year history. physical examination: on presentation, the patient had a temperature of 96.3, pulse of 41, blood pressure 142/66, respiratory rate 32, oxygen saturation 92% on 2 liters. general examination: the patient was an ill-appearing, elderly male, in no apparent distress. head, eyes, ears, nose and throat examination: the patient's pupils were equally round and reactive to light. extraocular movements intact. mucous membranes were pink and dry. neck examination: the patient had difficult to assess jugular venous pressure. his neck was supple, without lymphadenopathy. cardiac examination: the patient was in normal rate and rhythm, normal s1 and s2, and no murmurs, rubs or gallops noted. pulmonary examination: the patient had bilateral rales up to one-half of the lung fields, with increased dullness. abdominal examination: the patient had a midline scar, left lower quadrant tenderness. the patient's belly was soft, nondistended, with normal bowel sounds. there was no hepatosplenomegaly or mass palpated. guaiac was negative in the emergency department. on extremity examination, the patient had bilateral lower extremity edema that was 2+, trace dorsalis pedis pulses bilaterally. on neurological examination, the patient was alert and oriented x 3, with cranial nerves ii through xii intact. nonfocal examination. deep tendon reflexes were 2+ bilaterally, with downgoing toes. laboratory data: the patient had a white blood cell count of 11.3, hematocrit of 24.4, and a platelet count of 183. differential revealed 62 neutrophils, 27 lymphs, 8 monos. chem 7 revealed a sodium of 141, potassium of 4.9, chloride of 109, bicarbonate of 14, bun 99, creatinine 5.3, and glucose of 175. the patient's initial ck was 198, with an mb of 5 and a troponin of 1.1. chest x-ray revealed congestive heart failure with right lower lobe atelectasis and small bilateral pleural effusions. a kub revealed stool in the colon. an electrocardiogram was performed in the emergency department, which revealed normal sinus rhythm with a rate of 90, with st depressions that were new and 1 to 2 mm, with t wave inversions in v5 to v6. when the patient arrived on the floor, a second electrocardiogram was done, which revealed bigeminy with a rate of 80s, which went to normal sinus rhythm with a rate of 70s, and depressions laterally. hospital course: this 76-year-old man with multiple cardiac risk factors, originally admitted for abdominal pain, shortness of breath and diaphoresis, was found to have an acute myocardial infarction. 1. cardiovascular. this 76-year-old presented with an acute myocardial infarction. a cardiac catheterization was performed on , and revealed left main and three vessel disease. the patient was referred to cardiothoracic surgery for coronary artery bypass graft. on , the patient received a coronary artery bypass graft x 4 with an saphenous vein graft to the left anterior descending, saphenous vein graft to the obtuse marginal i, saphenous vein graft to the obtuse marginal ii, and saphenous vein graft to the posterior descending artery. the patient's cardiovascular course postoperatively has been hemodynamically stable. the patient has continued on norvasc, lopressor, captopril and aspirin. the patient has ruled out for acute myocardial infarction postoperatively three times in the setting of desaturations. 2. pulmonary. the patient had been reintubated postoperatively three times. initially the patient had a left chest tube for pleural effusions. a bronchoscopy was performed on , for mucous plugging, and the patient required intubation after that. the patient also had left lower lobe infiltrates two days postoperatively. the gram stain revealed gram-positive cocci and neutrophils. this was treated with quinolones and clindamycin. culture eventually grew oral flora. the patient was transferred to the medical intensive care unit on , for copious secretions and failure to wean off the ventilator. the patient had been off the ventilator since , with progressively decreased secretions. the patient required frequent suctioning on the floor. he had been saturating 100% on 40% trach mask since . 3. infectious disease. the hospital course was complicated by pneumonia, as mentioned above. bronchial washings eventually grew out acid-fast bacteria and oral flora. infectious disease was consulted and evaluated the patient, placing him on respiratory precautions with repeat acid fast bacilli smears. infectious disease felt that this was unlikely to be tuberculosis, as chest x-rays were not consistent with primary or reactivation tuberculosis. ppd was placed on , and the result was not reported. the patient also had a urinary tract infection that grew yeast on and . the patient was treated with three days of fluconazole. on , the patient was found to have putrid urine, and cultures were sent, revealing greater than 100,000 colonies of enterococcus. infectious disease was consulted, and recommended switching the patient from a ten day course of vancomycin to linezolid 600 mg twice a day. on , the patient was found to have a large increase in his white blood cell count, and a repeat chest x-ray was obtained. this revealed worsening consolidation at the left base. this was suspicious for a left lower lobe pneumonia, and the patient was started on ceftriaxone 1 gram every 24 hours. the patient was discovered to have hepatitis serologies that revealed exposure to hepatitis b, as he had the hbcab found. the patient was positive for havab for hepatitis a. final culture on the patient's urinary tract infection revealed vancomycin-resistant enterococcus. 4. gastrointestinal. the patient had a history of constipation, and an abdominal ct on revealed no diverticulitis, abscess or obstruction. it did note a distended gallbladder, but no thickening. a left adrenal mass was noted. right upper quadrant ultrasound revealed a common bile duct of 9 mm, with no stone or cholecystitis. hida scan was performed, and was read as negative. the patient presented with increased transaminases with question of induced hepatic injury. there was also a question of tpn vs. congestion vs. hepatic steatosis. a negative abdominal ultrasound was done in workup for the patient's increased liver function tests. 5. renal. the patient did not present with anuria. the patient had a left arteriovenous fistula which was not used secondary to low flow. the patient was originally dialyzed through a temporary quinton catheter. catheter infection x 2 in this line was discovered. the patient had a right internal jugular perma-cath placed on , which continues to work well. the patient receives hemodialysis monday, wednesday and friday. 6. nutrition. the patient was provided with jejunostomy tube feedings, and was tolerating three-quarter strength nepro with 60 grams promod at a goal of 45 cc. 7. endocrine. the patient had a history of insulin-requiring, noninsulin-dependent diabetes. the patient was placed on a regular insulin sliding scale. 8. skin. the patient had required aggressive skin care because of a right sacral decubitus ulcer. the patient had chronic areas. the patient was provided with a kainair mattress, waffle boots, and right upper quadrant wound care. 9. neurology. the patient developed what was thought to be delirium related to the long hospital stay and urinary tract infection. neurology was consulted, and a head ct was performed. the head ct was negative. an electroencephalogram was then ordered, which revealed slow disorganized background with bursts of generalized slowing, suggesting a widespread encephalopathy. thyroid studies were performed, and the patient's tsh was 3.1, with a free t4 level of 1.1. the patient had a normal b12 level and folate level. the patient gradually became more alert as his hospital course continued. disposition: the patient was evaluated by multiple rehabilitation hospitals. he will likely be discharged to rehabilitation. condition at discharge: stable. discharge status: the patient will be discharged to rehabilitation. discharge medications: prevacid 50 mg per gastrostomy tube once daily, vitamin c 500 mg per gastrostomy tube once daily, enteric-coated aspirin 81 mg per gastrostomy tube once daily, nepro tube feeds with 60 grams of promod at 45 cc/hour, linezolid 600 mg per gastrostomy tube twice a day, nystatin 5 cc swish and swallow by mouth four times a day, norvasc 10 mg per gastrostomy tube once daily, zinc 220 mg per gastrostomy tube once daily, colace 100 mg per gastrostomy tube twice a day, nephrocaps one tablet per gastrostomy tube once daily, epogen 12,000 units intravenously with hemodialysis three times per week, lisinopril 15 mg per gastrostomy tube once daily, nph insulin 15 units subcutaneously twice a day, regular insulin sliding scale, lopressor 25 mg per gastrostomy tube twice a day, albuterol and atrovent nebulizers every four to six hours as needed for wheezing, and dulcolax 10 mg per gastrostomy tube/per rectum as needed for constipation. discharge diagnosis: 1. coronary artery disease status post coronary artery bypass graft x 4, acute myocardial infarction 2. type 2 diabetes 3. end stage renal disease on hemodialysis 4. hypertension 5. peripheral vascular disease 6. urinary tract infection 7. pneumonia 8. sacral decubitus ulcer 9. right heel stage iv ulcer 10. widespread encephalopathy , m.d. dictated by: medquist36 d: 01:23 t: 05:51 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Insertion of endotracheal tube (Aorto)coronary bypass of four or more coronary arteries Venous catheterization for renal dialysis Temporary tracheostomy Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Acute respiratory failure Infection and inflammatory reaction due to other vascular device, implant, and graft Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

history of present illness: the patient is a 76 year old russian speaking man with multiple medical problems including type 2 diabetes mellitus and chronic renal insufficiency, progressed to end stage renal disease, hypertension and peripheral vascular disease, who was in his usual state of health until , when he presented with chronic abdominal pain of two days. this pain was associated with shortness of breath and diaphoresis. he was admitted to the medical service for further evaluation. past medical history: 1. type 2 diabetes mellitus. 2. benign prostatic hypertrophy. 3. impotence. 4. herniated l4-l5 disc. 5. tobacco history. 6. world war ii abdominal blast wound surgery. 7. carotid artery disease. 8. dizziness. 9. chronic renal insufficiency progressing to end stage renal disease with a left hand fistula. 10. constipation. 11. hypertension. 12. claudication. allergies: no known drug allergies. medications on admission: 1. lasix 60 mg q.d. 2. glipizide 10 mg b.i.d. 3. lipitor 10 mg q.d. 4. avandia 2 mg q.d. 5. epogen 4000 units subcutaneous three times a week. 6. aspirin 325 mg q.d. 7. colace p.r.n. 8. dulcolax p.r.n. 9. lactulose p.r.n. 10. nifedipine 120 mg q.d. 11. pletal 50 mg b.i.d. physical examination: on arrival, temperature 96.3, blood pressure 140/60, respiratory rate 30, saturating 92%. in general, an elderly man in no acute distress. head, eyes, ears, nose and throat - the pupils are equal, round, and reactive to light and accommodation. extraocular movements are intact. the neck examination revealed no lymphadenopathy. the neck is supple. cardiovascular regular rate and rhythm, s1 and s2. lung examination revealed bilateral rales. abdominal examination revealed midline scar, left lower quadrant tenderness. extremity examination - bilaterally 2+ lower extremity edema. neurologic examination - awake, alert and oriented times three. cranial nerves ii through xii are intact. laboratory data: on discharge, white count 12.6, hematocrit 30.1, platelets 286,000. electrolytes revealed sodium 136, potassium 5.4, chloride 100, bicarbonate 16, blood urea nitrogen 88, creatinine 8.3 predialysis on . magnesium 2.6, phosphorus 7.6. video swallow on , shows no evidence of aspiration but mild rescue with all consistencies. this study was obtained prior to tracheostomy placement. prostate ultrasound shows bilateral benign prostatic hypertrophy with no abscess. peripheral zone calcification of uncertain etiology. hida scan on , shows no evidence of acute cholecystitis. last chest x-ray on , shows small bilateral effusions which are stable since . the lateral decubitus bilateral films show no significant layering. abdominal ct on , shows no evidence of diverticulitis or obstruction. appendix is not identified. there is a distended gallbladder with gallstone but no gallbladder thickening. there is a left adrenal soft tissue mass with attenuation not typical for adenoma although statistically probably an adenoma. bilateral pleural effusions. there is enlarged left pectinate muscle, likely a hematoma. there is a small hyperattenuation focus in the bladder, may be a bladder stone or prostate gland. cardiac catheterization on , shows right dominant system with left main and three vessel coronary artery disease. resting hemodynamics reveal normal left and right sided filling pressures with calculated cardiac index of 2.3 liters per minute per meter square. there is no gradient across the aortic valve. microbiology data - last line culture which was positive shows coagulase negative staphylococcus on , with a groin quinton line which was removed. urine culture shows no growth. c. difficile assay is negative. blood cultures are negative. cultures for gonorrhea and chlamydia are negative. bronchoscopy in , shows clean lungs and all segments without any secretions. hospital course: the patient was admitted initially to the medical service for rule out myocardial infarction protocol after his episode of shortness of breath and diaphoresis. his initial evaluation included renal service evaluation for his emanate dialysis and cardiology evaluation for non q wave myocardial infarction. his cardiology evaluation led to a cardiac catheterization recommendation which showed left main disease with three vessel coronary artery disease with normal systolic function. given this, he was referred to the cardiothoracic service for coronary bypass. the patient received a coronary bypass on , with the following grafts: saphenous vein graft to left anterior descending. saphenous vein graft to om1. saphenous vein graft to om2. saphenous vein graft to posterior descending artery. the patient's postoperative course was extensively complicated with multiple issues. he required intubation three times for persistent respiratory failure which eventually required a tracheostomy tube placement. for nutritional support, he received percutaneous endoscopic gastrostomy tube placement. his issues are being summarized by systems in the following section. on discharge, however, he is on ventilator with a tracheostomy, on dialysis with a permacath access and on tube feeds with percutaneous endoscopic gastrostomy tube. 1. cardiovascular - the patient was taken to the operating room for coronary bypass on , at which time he received a four vessel coronary artery bypass graft. his cardiac performance after the operation throughout hospitalization has remained stable. his rhythm has been in sinus in the 70s with stable blood pressure, being controlled with lopressor, captopril and norvasc. during his respiratory distress episodes, he received rule out myocardial infarction protocol which was negative. on discharge, he is on norvasc, lopressor, captopril and aspirin and is in sinus rhythm. 2. neurological - the patient is reportedly to be alert and oriented prior to his operation, however, there is question of some baseline dementia. after his coronary bypass, he received intubation three times for respiratory distress. at third intubation, he required sedation with ativan while he awaited multiple procedures including tracheostomy, permacath access placement and percutaneous endoscopic gastrostomy tube placement. after being weaned from an ativan drip, he is awake and more responsive, more and more every day. on discharge, he is moving all four extremities. he is not on any sedation or pain medication and is communicative by signs. he is not on any neurological medication, however, responds well with ativan, a small dose p.r.n. should sedation be required. 3. renal - the patient presented to the hospital with chronic renal failure requiring likely dialysis. given his high creatinine and almost no urine output, he has been requiring dialysis throughout his hospitalization. his left av fistula which he had prior to his coronary bypass was found to be low flow and tenuous. for his access, he has been dialyzed through temporary quinton catheters throughout the hospitalization, but prior to discharge has received permanent right ij permacath for further dialysis. on discharge, his dialysis catheter is functioning well. he receives dialysis every two to three days per hemodialysis service. specifications are with the hemodialysis team at . his renal medications include nephrocaps, phoslo, epogen and heparin with dialysis. he has been treated with vancomycin renally dosed for his previous quinton catheter line infection. on discharge, he is afebrile. infectious disease - the patient was reintubated postoperative his coronary bypass on day two for presumed respiratory distress. further evaluation showed a left lower lobe infiltrate. initial gram stain showed gram positive cocci and pmns for which he was treated with quinolone and clindamycin for a complete course of pneumonia. cultures were, however, oropharyngeal flora. his pneumonia has resolved which was evident with bronchoscopy performed in early . on discharge, he is afebrile and oxygenating and ventilating well on a ventilator with small bilateral pleural effusions. the patient has also had two episodes of line catheter tips growing coagulase negative staphylococcus, likely staphylococcus epidermidis. for this, he has been treated for ten days of vancomycin dosed renally per routine vancomycin levels. at discharge, he has finished his vancomycin course and is being discharged without any temporary lines and without any antibiotics. gastrointestinal - the patient presented to the hospital with history of constipation and on preoperative films was shown to have stool in the colon. after the coronary bypass, he continued to remain constipated and required a general surgery consultation. abdominal ct showed no intra-abdominal process, however, showed constipation. since then, he has received a clean out with golytely and after that he receives colace through his gastrostomy tube. on discharge, he is having bowel movements at least once every one or two days. there was also a question of gallbladder infection as raised by infection disease, however, further studies showed no evidence of cholecystitis. this was shown with studies including hida scan. hematology - the patient's hematocrit has been fluctuating in the high 20s and 30s requiring approximately three units of blood throughout his postoperative course, all given during dialysis. nutrition - the patient due to his prolonged hospitalization and intubations has had intermittent nutrition for which he received percutaneous endoscopic gastrostomy tube placement. he is at goal on his tube feeds which are nephro with 60 grams of promod at 45 cc per hour. the nephro tube feeds are three quarter strength. he is being followed by nutrition service. he is on prevacid, vitamin c and zinc. diabetes mellitus - the patient's diabetes mellitus has been controlled with sliding scale insulin through his hospitalization. genitourinary - the patient was shown to have some urethral discharge for which he received genital cultures which were negative including negative for gonorrhea and chlamydia. his rpr test was also negative. urology evaluation included a prostate ultrasound which showed prostatic hypertrophy but no abscess or any other malignant process that could be seen. in summary, the patient presented to the hospital with multiple comorbidities including end stage renal disease, poor respiratory function and coronary disease. his evaluation showed three vessel coronary disease with left main disease and required a coronary bypass. postcoronary bypass course has been for respiratory failure which shows poor respiratory compensation for acidosis likely from his end stage renal disease. this has required tracheostomy tube placement for difficulty weaning from a respirator, percutaneous endoscopic gastrostomy tube placement for poor nutrition and required nutritional support and permanent dialysis catheter placement for nonfunctioning left av fistula and persistent hemodialysis needs. on discharge, he is alert and responsive. he is in bed for multiple days. he is on ventilator at pressure support of 10 with cpap at 35% of fio2 with normal arterial blood gases. he is moving all four extremities and has clean, dry and intact incisions. his access includes a right ij permacath. he is being discharged to rehabilitation for ventilator weaning. discharge medications: 1. aspirin 81 mg per gastrostomy tube q.d. 2. norvasc 10 mg per gastrostomy tube q.d. 3. lopressor 25 mg per gastrostomy tube b.i.d. 4. captopril 50 mg per gastrostomy tube t.i.d. 5. phoslo two tablets per gastrostomy tube q.i.d. 6. epogen 12,000 units with dialysis. 7. heparin 5,000 units subcutaneous b.i.d. 8. ativan 0.5 mg intravenous q6hours p.r.n. 9. colace 100 mg per gastrostomy tube b.i.d. 10. nephrocaps one per gastrostomy tube q.d. 11. prevacid elixir 15 mg per gastrostomy tube q.d. 12. vitamin c 50 mg per gastrostomy tube q.d. 13. zinc 220 mg per gastrostomy tube q.d. 14. insulin sliding scale: for 150-200 give three units, 201-250 given six units, 251-300 give nine units, 301-350 give twelve units. 15. albuterol mdi two puffs q4hours p.r.n. 16. tube feeds three quarter strength nephro with 60 grams promod at 45 cc per hour. allergies: no known drug allergies. follow-up: dr. in two to four weeks. follow-up with hemodialysis as required. disposition: to acute rehabilitation. discharge diagnoses: 1. coronary artery bypass graft times four. 2. end stage renal disease on hemodialysis. 3. respiratory failure on ventilator with tracheostomy. 4. percutaneous endoscopic gastrostomy tube for nutrition. 5. noninsulin dependent diabetes mellitus. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Insertion of endotracheal tube (Aorto)coronary bypass of four or more coronary arteries Venous catheterization for renal dialysis Temporary tracheostomy Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Acute respiratory failure Infection and inflammatory reaction due to other vascular device, implant, and graft Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

discharge condition: stable. discharge medicines: 1. aspirin 325 po qd. 2. plavix 75 po qd. 3. allopurinol 100 mg po qd. 4. zocor 80 mg po qd. 5. lisinopril dose to be dictated as addendum. , Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Insertion of drug-eluting coronary artery stent(s) Intracoronary artery thrombolytic infusion Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Coronary atherosclerosis of autologous vein bypass graft Gout, unspecified Aortic valve disorders Other complications due to other cardiac device, implant, and graft Cervicalgia

medications on admission: 1. procardia xl 30 mg p.o. q.d. 2. allopurinol. 3. hydrochlorothiazide (unclear dose). 4. zocor. 5. ambien. 6. folate. 7. vitamin b. 8. vitamin e. 9. hydralazine (unclear dose). 10. prilosec. allergies: niacin, which causes hypouricemia. elavil, which causes agitation. propanolol, which causes anxiety. questionable history to lipitor, which causes elevated ck's. past medical history: coronary artery disease status post cabg in . at this time, he had a lima to the lad, svg to the d1, a svg graft to the om, and a svg graft to the rca. in , the patient had recurrent chest pain with the d1 and om grafts down. at that time, he had a left main ptca for 80 percent stenosis. in , the patient had recurrent chest pain, and his left main was restented. in , the patient had chest pain, and his svg to the pda was stented. the left main also had some restenosis and that was stented. severe aortic stenosis with a valve area of 0.7. hypercholesterolemia. hypertension. gout. peripheral neuropathy. right total knee replacement. upper gi bleed secondary to nsaid use. nephrolithiasis. social history: the patient does not smoke tobacco. he is married with two children. he works as an architect. family history: is only remarkable for a mi in his mother at age 59 after hiatal hernia surgery. physical examination: temperature 95.1, heart rate of 41, blood pressure 158/68, and he was saturating 97 percent on 2 liters. his exam was only remarkable for a grade harsh systolic ejection murmur at the left mid sternal border. an ekg from the outside hospital showed sinus bradycardia at 50 with a first degree a-v prolongation. there was depressions in i. there were depressions in ii and elevations in iii and f. there is also t-wave flattening in v6 and q waves in iii and f. a potassium was 3.0. ck was 317. mb was 17 and troponin was 0.11 initially. hospital course: patient was monitored after his stenting x5 of the svg to the rca. he was continued on aspirin and plavix. patient denied any subsequent chest pain after the procedure. patient had a peak ck of 1317. his home blood pressure medicines were held, and the patient was started on captopril for blood pressure control. he was not started on a beta blocker as he had some sinus bradycardia. the captopril was titrated up during his hospital stay. his primary cardiologist, dr. can determine if he should remain on this blood pressure medicine in the future, however, given patient's known coronary disease, it is reasonable for him to continue on this as it has a mortality benefit. during the hospital course, he denied any subsequent chest pain. it was thought that his sinus bradycardia was likely secondary to his imi. i will dictate the remainder of the hospital course as an addendum. , Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Insertion of drug-eluting coronary artery stent(s) Intracoronary artery thrombolytic infusion Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Coronary atherosclerosis of autologous vein bypass graft Gout, unspecified Aortic valve disorders Other complications due to other cardiac device, implant, and graft Cervicalgia

allergies: lovastatin / propranolol / elavil / niacin / l-arginine attending: chief complaint: chest pain major surgical or invasive procedure: left/right heart catherization history of present illness: 82 yo m w/ pmhx of dm w/ peripheral neuropathy, htn, hl, chf (ef ~30%) s/p icd, osa, ckd, gout and cad who presented to the ed with chest pain at rest and tachycardia to 140s. approximately at 8:30 pm on the evening of presentation, he developed gradual onset of achy chest pain associated with diaphoresis. he denied palpitations, sob. ems was called and enroute he received sl nitroglycerin without improvement in chest pain and induction of hypotension. . in the ed, initial vitals were 96.7 156 123/87 16 99%ra. he was noted to have signficant st depressions with tachycardia and without tachycadia. troponin trended up to 0.18 and ck to 404 and echo done in ed by the fellow showed no segmental wall motion abnormalities, but ef decreased from prior at 15-20%. integrellin gtt, heparin gtt, asa 325mg , plavix 600mg were initiated and he was taken to the cath lab. . in the cath lab, he received 60mg iv lasix and heparin was discontinued. he received 25mcg fentanyl, 0.5mg versed, 185cc contrast, and 200cc nsb during the procedure. a swan was placed which induced ectopy and broke the svt. lcx had 90% isr and pt received pci w/ a des. he was noted to be presistently hypotensive (sbp 80-90s) and a balloon pump was placed prior to admission to the ccu. . in the ccu, he was chest pain free and his only complaint was his chronic neck and back pain. . on review of systems, he reports recent rhinnitis and non-productive cough not associated with fevers or chills. he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: diabetes, dyslipidemia, hypertension 2. cardiac history: - cabg: , redo in (see further interventions below) - s/p avr (tissue) ' - chf ef: 22-30% -percutaneous coronary interventions: . - cardiac cath, ef 63%, 80% am, 70% rpl, 80% lm, 80% lad, 50% d1, 95% lcx. he underwent a cabg x4 with lima to lad, vg to d1, vg to om and vg to pda . -: cardiac cath for recurrent angina. patent lima to lad and patent vg to rca, occluded vein grafts to d1 and om, 80% lm lesion, attempt at ptcra of lm, unable to pass wire successfully, ptca performed. . -: ptca and stent to lm. echo done at that time showed significant aortic stenosis with of 1.0cm2. . -: cath for atypical chest discomfort and cath revealed patent lm with 40% restenosis. . -: cath: 90% svg to pda and instent restenosis of the stent to the left main. s/p stent placement to the svg to pda and s/p rota and stent to lm. . - cath for continued pain/pre surgery: patent lima and svg to pda, mild as. . - cath/mi: svg to pda totally occluded, high thrombus burden. s/p thrombectomy and 4 stents to pda graft. . -: cath: native cad with occluded rca and lad and 90% lcx. bms to mid cx lesion, patent svg-pda and lima-lad . -pacing/icd: icd other past medical history: chf with ef 30% s/p icd nephrolithiasis gout dm ii w/peripheral neuropathy osa ckd - baseline creatinine 1.5 social history: pt lives with his wife in and is an architect. does not smoke, drink, or use any illicits. he has had numerous transfusions. family history: father - ami in his 80's mother - "enlarged" heart physical exam: vs: afebrile bp=112/43 hr=79 rr= 18 o2 sat= 99% on 5l nc general: wdwn, obese male in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple, unable to visualize jvp 2/2 body habitus. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. + accessory sounds from iabp. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, obese, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. right venous/arterial sheath in place. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral groin sheath in place popliteal 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ popliteal 2+ dp 1+ pt 1+ pertinent results: 06:40am wbc-7.9 rbc-3.60* hgb-9.9* hct-29.7* mcv-83 mch-27.5 mchc-33.4 rdw-15.0 plt ct-150 06:07am pt-12.7 ptt-50.3* inr(pt)-1.1 06:40am glucose-135* urean-35* creat-2.2* na-136 k-4.1 cl-105 hco3-20* angap-15 09:45pm ck(cpk)-200* 09:45pm ctropnt-0.02* 12:50am ck(cpk)-404* 12:50am ck-mb-21* mb indx-5.2 12:50am ctropnt-0.18* 06:07am ck(cpk)-770* 06:07am ck-mb-94* mb indx-12.2* ctropnt-2.08* 01:41pm ck(cpk)-1388* 01:41pm ck-mb-197* mb indx-14.2* 08:27pm ck(cpk)-1221* 08:27pm ck-mb-152* mb indx-12.4* ctropnt-3.50* 04:13am alt-30 ast-106* ck(cpk)-879* alkphos-123* totbili-0.7 04:13am ck-mb-88* mb indx-10.0* ctropnt-3.14* 06:40am alt-21 ast-48* ld(ldh)-427* alkphos-123* totbili-0.6 06:07am %hba1c-7.9* 06:07am triglyc-178* hdl-27 chol/hd-4.6 ldlcalc-60 ekg : probable atrial tachycardia with variable block. borderline intraventricular conduction delay. inferior lead qrs configuration raises consideration of prior inferior myocardial infarction, although it is non-diagnostic. delayed r wave progression with late precordial qrs transition. st-t wave abnormalities. findings are non-specific. clinical correlation is suggested. since the previous tracing of the same date ventricular response is now irregular and slower, precordial lead qrs configuration shows delayed r wave progression but is less suggestive of anterior myocardial infarction and further precordial lead st-t wave changes are present. . tte : the left atrium is dilated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is severe regional left ventricular systolic dysfunction with akinesis of the inferior and inferolateral walls, hypokinesis of the anterior wall and septum. the lateral wall has relatively preserved function. overall left ventricular systolic function is severely depressed (lvef= 25-30 %). with borderline normal free wall function. the ascending aorta is mildly dilated. a bioprosthetic aortic valve prosthesis is present. the prosthetic aortic valve leaflets are thickened. no masses or vegetations are seen on the aortic valve. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . compared with the prior study (images reviewed) of , image quality is better. the aortic prosthesis can be seen and appears to work well. wall motion can be adequately assessd on the current study. . cta chest : 1. no evidence of pulmonary embolism or acute aortic pathology. . 2. coronary artery disease with prior coronary bypass surgery and aortic valve replacement. . cxr : no acute cardiopulmonary process. stable moderate cardiomegaly. . lhc/rhc : comments: 1. selective coronary angiography in this right dominant system demonstrated three vessel disease. the lmca had mild plaquing throughout. the lad had a proximal/ ostial occlusion. the cx had a 90% in stent restenosis in the mid portion of the vessel. the rca was known to be totally occluded and was not visualized. 2. arterial conduit angiography revealed the lima to be widely patent. the svg to the r-pda was widely patent. the svgs from the patients previous cabg were known to be occluded and not visualized. 3. limited resting hemodynamics revealed elevated left and right sided filling pressures. the lvedp was 33 mmhg and the ra a wave was 28 mmhg. the pasp was moderately elevated at 49 mmhg. there was systemic hypotension with an central aortic pressure of 81/50 mmhg. the cardiac index was low at 1.7 l/min/m2. . final diagnosis: 1. three vessel coronary artery disease. 2. moderate left ventricular diastolic dysfunction. 3. moderate pulmonary hypertension. 4. decreased cardic index. 5. systemic hypotension brief hospital course: # coronary artery disease: known 3vcad presenting with nstemi found to have in stent restenosis of left cx (bms placed in ) s/p angioplasty and placement of drug eluting stent. echo showed depressed ef 25%, essentially unchaged from previous. ck's peaked at 1388 with trop 3.5. pt tol cardiac catheterization and placement of intra aortic balloon pump well, right groin with only mild ecchymosis and no hematoma. sbp has been borderline low, 90's-110's, so initiation of ace and metoprolol has been slow. imdur was started for intermittant chest pain that was relieved with sl ntg. currently on full dose aspirin, clopidigrel, atorvastatin and metoprolol succinate. lisinopril was restarted on the day of transfer. pt should increase his metoprolol and lisinopril as tolerated. pt should take aspirin and plavix daily indefinitely to prevent in stent stenosis. hdl 27, ldl 60. . # acute on chronic systolic congestive heart failure: prior ef 25-30% s/p icd placement and iabp for hypotension. now ef 25% after nstemi. high filling pressures in cath lab, rec'd lasix iv x1 and restarted lasix po. currently has no peripheral edema or o2 requirement, needs to be assessed with activity. he should be weighed daily before breakfast and weight gain or more than 3 pounds in 1 day or 6 pounds in 3 days should be reported to provider. needs to follow a 2 gram sodium diet, he has been very non-compliant in the past. fluid restrict to 1500cc/day. he is on spironolactone as before. . # rhythm: on presentation in svt, now in sinus since right heart cath in the lab. . # acute on ckd - baseline creatinine 1.5, elevated to 1.9 on presentation and 2.2 currently. consistent with prerenal state for poor forward flow from acute mi and contrast nephropathy from cardiac catheterization and cta. foley pulled yesterday and replaced for no urine output in 8 hours. he has a history of urinary difficulty but has not been treated in the past. flomax was started and foley will be left in upon transfer. pt has an appt with urologist in 10 days for further evaluate. should have lytes done qod until stable, then weekly thereafter. . # type ii diabetes mellitus with complications, on insulin at home, very non-compliant per son. his sugars are moderately well controlled on 32 units of glargine here (home dose 30 units) with humalog sliding scale. a1c 7.9. need to uptitrate glargine further. . # chronic normocytic anemia - baseline hct 35, admitted above baseline but drifing down after procedures and phelbotomy. currently 29.7 and stable, no signs of bleeding. pt will need colonoscopy if he is not current in last 5 years once clinically more stable. . # gout - continue renally dosing of allopurinol. was taking colchicine 0.6mg at home, renally dosed at 0.3mg daily here. no signs of flare at present. . # chronic neck/back pain - sees orthopedic physician (dr. uses conservative measures at home w/ soft cervical collar and special pillows. was on nabumetome and possibly ibuprofen at home, held because of arf. lidocaine patch was continued. narcotics tend to make pt confused, would use high dose tylenol instead. . comm: - ; . medications on admission: allopurinol 100 mg tablet 1 tablet(s) by mouth once a day amoxicillin 500 mg tablet 4 tablet(s) by mouth x 1 prn as needed for 1 hr prior to dentist bd ultrafine pen needles colchicine 0.6 mg tablet one tablet(s) by mouth twice a day insulin glargine 100 unit/ml cartridge 30 units once a day lidocaine 5 % (700 mg/patch) adhesive patch, medicated apply once a day as needed for apply in morning and remove after 12 hrs lisinopril 5 mg tablet 1 tablet(s) by mouth once a day metoprolol succinate 25 mg tablet sustained release 24 hr one tablet(s) by mouth once a day nabumetone 500 mg tablet one tablet(s) by mouth twice a day simvastatin 80 mg tablet 1 tablet(s) by mouth once a day spironolactone 25 mg tablet 1 tablet(s) by mouth once a day venlafaxine 37.5 mg capsule, sust. release 24 hr 1 capsule(s) by mouth once a day aspirin 325 mg tablet, delayed release (e.c.) 1 tablet(s) by mouth once a day guar gum powder by mouth prn (otc) ibuprofen 200 mg capsule two capsule(s) by mouth twice a day omeprazole 20 mg tablet, delayed release (e.c.) 1 tablet(s) by mouth daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*2* 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*11* 5. insulin glargine 100 unit/ml solution sig: thirty (30) units subcutaneous at bedtime. 6. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). disp:*30 capsule, sust. release 24 hr(s)* refills:*2* 9. fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal daily (daily). disp:*1 bottle* refills:*2* 10. 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:*2* 11. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. benefiber sugar free(guar gum) powder sig: one (1) packet po once a day. 13. effexor xr 37.5 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po once a day. disp:*30 capsule, sust. release 24 hr(s)* refills:*2* 14. lidoderm 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) patch topical once a day: apply to neck or back for total of 12 hours per day. disp:*30 patches* refills:*2* 15. colchicine 0.6 mg tablet sig: 0.5 tablet po daily (daily). 16. ranitidine hcl 150 mg capsule sig: one (1) capsule po daily (daily). 17. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 18. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 19. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for back/neck pain. discharge disposition: extended care facility: for the aged - discharge diagnosis: non st elevation myocardial infarction acute on chronic congestive heart failure acute on chronic kidney disease hypertention urinary retention discharge condition: mental status:confused - sometimes level of consciousness:alert and interactive activity status:ambulatory - requires assistance or aid (walker or cane) discharge instructions: you had a heart attack and required a drug eluting stent be placed in your left circumflex artery. you will need to take plavix every day for at least one year, do not stop taking plavix or miss unless dr. tells you to. this is to prevent the stent from clotting off again and causing another heart attack. you also had trouble urinating after we took out the foley catheter. the catheter was put back in and you will need to keep it in until you see dr. , a urologist, in 10 days. new medicines: 1. flomax: to help shrink the prostate so you can urinate without the catheter. 2. plavix: to prevent the stent from clotting off and causing another heart attack. 3. continue to take aspirin daily along with the plavix. 4. stop taking ibuprofen and nabumetome 5. start taking flonase to stop your runny nose 6. start imdur, a long acting nitroglycerin to prevent chest pain 7. take metoprolol succinate 1 tablet per day and titrate up as tolerated. 8. start taking furosemide to prevent fluid build up. 9. restarted lisinopril at 2.5 mg po daily . weigh yourself every morning, md if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. follow a low sodium diet. followup instructions: orthopedics: provider: , orthopedic private practice phone: date/time: 9:00 . primary care: , m. phone: date/time: please make an appt after you get to your new home. . cardiology: , md phone: date/time: office will call you with an appt. . urology: dr. clinical center, , , . phone:( date/time: at 11:45am. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Implant of pulsation balloon Angiocardiography of right heart structures Insertion of drug-eluting coronary artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Other primary cardiomyopathies Anemia in chronic kidney disease Obstructive sleep apnea (adult)(pediatric) Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Other chronic pulmonary heart diseases Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Atrial flutter Chronic kidney disease, unspecified Cardiogenic shock Long-term (current) use of insulin Other complications due to other cardiac device, implant, and graft Retention of urine, unspecified Automatic implantable cardiac defibrillator in situ Heart valve replaced by transplant Acute on chronic systolic heart failure Knee joint replacement

allergies:nkda. meds:multiple over the counter diet supressents. hx:?viral syndrome approx 2 weeks ago. taking diet surpressents- ?onset of use (per family planning vacation over holiday-?ing onset of diet surpressents). am onset acute dyspnea w progression to cardiac arrest-vf. intubated & defib to st in field-transported to . aggressively rxed in ew. ct head/chest-neg for intracranial hemorrhage & pe. febrile-pan cultured & abx started. progressively deteriorated- requiring pressors & approx 4l fl-to card cath lad-clean c's, but elevated filling pressures-w 30's-rx w lasix & admitted to ccu for further management. echo=sever global lv hk. lv function severly depressed. rv function depressed. 1+mr. social:bu student-2nd year. from ill. parents contact & both present. has 2 other siblings in ill. non smoker & ?limited drinker. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Implant of pulsation balloon Diagnoses: Other primary cardiomyopathies Pulmonary collapse Acute respiratory failure Atrioventricular block, complete Cardiogenic shock Ventricular fibrillation Unspecified condition of brain

history of present illness: the patient is a 19 year old female with no past medical history found dyspneic by her roommate in her dorm room, and subsequently syncopal. the bu police were called, hooked up an automated defibrillator which advised shock. patient was defibrillated. subsequently emt arrived. patient was in complete heart block with slow escape. she was intubated and given epinephrine times four, atropine times three. she subsequently became tachycardiac, again went into ventricular fibrillation, was shocked times two and started on lidocaine bolus and then drip. she was then transported to . in the emergency department patient was given 4 liters of fluid. she was given magnesium and charcoal, 2 gm of iv calcium. her workup included a head ct which was negative. chest ct showed no evidence of pe. subsequently in the emergency department patient was becoming progressively more hypoxic and difficult to ventilate, requiring bagging and continuous suctioning of pink frothy secretions. chest x-ray showed pulmonary edema. she became more hypotensive as well with a nadir blood pressure in the 50s to 60s systolic requiring neosynephrine drip with sedation and paralysis. she became easier to ventilate after that. she was then transferred to the cardiac catheterization lab on 20 mcg per kg of neosynephrine for pa catheterization and intra-aortic balloon pump placement. past medical history: none. allergies: no known drug allergies. medications on admission: adderall which is dextroamphetamine and racemic amphetamine, oral contraceptive pills, ephedrine containing diet medication. social history: the patient is a sophomore at . family history: no history of sudden death. no history of coronary artery disease. physical examination: on admission temperature 96, rising to 99.8; heart rate in the 120s to 130s; blood pressure 50s to 110s systolic, 30s to 70s diastolic; o2 sat ranging from 82% to 92% on 100% o2 and 10 of peep. in general, intubated, sedated, overbreathing the vent. heent charcoal stained, et tube. carotid pulses 2+. thorax coarse bilaterally breath sounds. cardiovascular exam regular tachycardiac, no rv heave, distant heart sounds. extremities warm with no edema. neurological exam intubated, sedated, thrashing about and bucking vent. one episode of extensor posturing. laboratory data: on admission white blood count 9.6, hematocrit 37.7, platelets 381. pt 13.3, ptt 23, inr 1.2. sodium 135, potassium 3.1, chloride 97, bicarbonate 15, bun 11, creatinine 1.2, glucose 238. alt 21, ast 38, alka phos 62, bili 0.4. ck 230, mb 3, troponin less than 0.3. lactate at 10:00 a.m. was 10.1, at 10:38 a.m. was 4.8 and at 4:12 p.m. was 2.0. free calcium was 1.08. urinalysis #1 showed specific gravity of greater than 1.030 with greater than 300 protein, no glucose, trace ketones, no leukocyte esterase, 11 to 20 rbcs, 3 to 5 white blood cells. ua #2 showed similar results. serum tox no aspirin, alcohol, acetaminophen, benzos, no barbiturates, no tricycles. urine tox was positive for amphetamines, otherwise negative. abg #1 was 7.35, 36, 250. patient was put on imv with settings of 500, 14, 100% fio2 and 5 of peep. chest x-ray showed initially mild interstitial edema at 10:00 a.m. and at 4:10 p.m. showed worsening chf and interval placement of a right ij sheath. head ct showed no evidence of acute bleeding or intracerebral hemorrhage. chest ct showed no evidence of pulmonary embolism, patchy bilateral opacities. ekg taken from strips from the emts showed complete heart block with slow junctional escape, then sinus, then v-fib, after shocking back to sinus. ekg on arrival showed sinus tachycardia with normal axis. echocardiogram showed global hypokinesis with severely depressed lvef. left atrium was normal in size. left ventricle mildly dilated. right ventricle normal in size. right ventricular systolic function was somewhat depressed, 1+ mr, no pericardial effusion. the patient was taken to the cardiac catheterization lab where pa cath showed ra mean of 19, rv of 49/12, pa of 43/28, pulmonary capillary wedge pressure of 30 to 31, pa sat of 57%, cardiac index of 1.7. patient was placed on dopamine in the cath lab. neo-synephrine was weaned off and an intra-aortic balloon pump was placed. left sided catheterization showed a right dominant system with normal coronary arteries. impression: the patient is a 19 year old female status post v-fib arrest now in normal sinus rhythm in cardiogenic shock with nonischemic cardiomyopathy of unclear etiology and arrhythmia of unclear etiology. hospital course: 1. cardiovascular. coronaries. there was no evidence of ischemia during initial evaluation and cardiac catheterization showed no evidence of lesions in the coronary arteries. pump. initially the patient was found to be in cardiogenic shock requiring intra-aortic balloon pump and pressors including dopamine and dobutamine with global hypokinesis and ef estimated to be about 20% with depressed cardiac output and cardiac index. on dopamine and dobutamine were slowly weaned. repeat echocardiogram was performed which showed no significant interval change from echocardiogram done on admission. patient's cardiac output and index remained stable off the pressors. the intra-aortic balloon pump was discontinued on . pressures continued to be consistently with mean arterial pressures greater than 70. patient was gradually diuresed with iv lasix and over the course of the next three days achieved a euvolemic volume status. rhythm. the patient was started on an iv amiodarone drip as prophylaxis against further episodes of ventricular fibrillation. after two days there were no episodes of significant ectopy and amiodarone was discontinued and then changed to p.o. amiodarone. from onward patient was no longer having episodes of hypotension, no longer requiring pressors and no longer needed arterial line or pa catheter monitoring and these were discontinued. at this time it is still unclear what the etiology of the cardiomyopathy is. possibilities include viral myocarditis as well as the possibility of drug (ephedrine) induced myopathy. 2. pulmonary. the patient was initially intubated for hypoxic respiratory failure secondary to cardiac arrest. was maintained on a propofol drip for adequate sedation while intubated as patient was often fighting the vent when off sedation. settings were kept on assist control with several episodes of acute desaturation whenever patient was moved. the pulmonary service was consulted and recommended decreasing the tidal volume as well as the fio2 as well as further diuresis, all of which were done. by fio2 had been weaned down to 40% and assist control was changed over to pressure support of 15 and peep of 7.5 with continued adequate oxygenation as well as ventilation. sedation was gradually titrated down and patient continued to have adequate tidal volumes on pressure support. chest x-ray on , showed evidence of left lower lobe opacity consistent with atelectasis. post suctioning and repositioning as well as aggressive chest p.t., these chest x-ray findings resolved and there were no further episodes of desaturation. from the pulmonary edema standpoint patient was started on captopril for afterload reduction which she tolerated well and captopril was increased gradually to 37.5 mg p.o. t.i.d. she continued to have adequate oxygenation and ventilation and no further evidence of pulmonary edema. on she began to develop increasing stridor as well as copious secretions which were becoming more profound. pulmonary consult recommended a tracheostomy which was performed on , by interventional pulmonology. after tracheostomy placement, trials of mask ventilation through the tracheostomy allowed adequate tidal volumes as well as oxygenation and ventilation with simv as backup at night. 3. infectious disease. on initial presentation to the cardiac intensive care unit patient was noted to have a fever of 102.8. blood cultures were sent as well as chest x-ray and urinalysis, none of which grew any bacteria. there was no evidence of infiltrates and no evidence of a urinary infection. antibiotics were started with vancomycin, levofloxacin and flagyl for broad spectrum coverage for possible seeding from line placement in the emergency department. patient continued to be febrile for several days, then running a low grade temperature of about 100 to 100.4 throughout her hospital stay with no further spiking fever. antibiotics were discontinued on day seven. there was no further evidence of bacterial infection with negative blood cultures on repeated occasions as well as negative urinalysis. patient was noted to have some conjunctivitis on the second day of her hospital stay. viral cultures were sent from swabs from the eye and showed no evidence of any viral growth. 4. neuro. the patient suffered a significant amount of hypoperfusion and anoxic brain injury due to the cardiac arrest. for the first four days she was on propofol sedation and neurological status was somewhat difficult to assess. however, after propofol was discontinued, there was very little evidence of purposeful movement, very little withdrawal to pain and patient was not able to follow commands consistently. at times she was noted to have dilated pupils and gaze deviation which resolved on their own. eeg was performed, the results of which seemed consistent with medication related effect versus toxic metabolic injury. there was no evidence of seizure activity. mri showed diffuse anoxic brain injury with multiple areas of cortical white matter infarcts. head ct showed no evidence of edema. however, on funduscopic exam there was some evidence of papilledema. the head of the bed was elevated, but given the mildness of the increased intracranial pressure there was no indication for using diuresis with mannitol or administration of steroids. neurology service was consulted and felt that the overall prognosis for recovery was minimal given the findings on mri as well as the prognosis post cardiac arrest with 93% chance for permanent disability with only about 7% chance of any significant functional improvement. these findings were conveyed to the family who still are maintaining hopes of eventual recovery. 5. fluids, electrolytes and nutrition. the patient was initially started on tube feeds as well as reglan for promotility and colace and senna for a bowel regimen. on , patient underwent percutaneous endoscopic gastrostomy placement by the gastroenterology service without complications. this will be used for further tube feedings. 6. access. initially the patient had a right internal jugular cordis for central access. this was then resited to a left internal jugular cordis on . central access was then discontinued on , as there was no further need for any central access medications or monitoring. arterial line placed on , was continued until , when a-line monitoring was no longer needed. on , a peripherally inserted central catheter was placed for long term access. further hospital course to be dictated at a later date. , m.d. dictated by: medquist36 d: 17:14 t: 17:53 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Implant of pulsation balloon Diagnoses: Other primary cardiomyopathies Pulmonary collapse Acute respiratory failure Atrioventricular block, complete Cardiogenic shock Ventricular fibrillation Unspecified condition of brain

the patient's discharge medications are as follows. discharge medications: 1. amiodarone 400 mg p.o. q. day. 2. captopril 37.5 mg p.o. three times a day. 3. combivent inhaler q. six hours, one to two puffs. 4. reglan 10 mg ng twice a day. 5. metoprolol 37.5 mg p.o. twice a day. 6. heparin 5000 units subcutaneously twice a day. 7. clindamycin 600 mg intravenously q. eight, last dose to be given for aspiration pneumonia. 8. levofloxacin 500 mg p.o. q. 24, last dose , for aspiration pneumonia. 9. tylenol 650 mg p.o. or p.r. q. six hours p.r.n. fever. , m.d. dictated by: medquist36 d: 16:47 t: 17:42 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Implant of pulsation balloon Diagnoses: Other primary cardiomyopathies Pulmonary collapse Acute respiratory failure Atrioventricular block, complete Cardiogenic shock Ventricular fibrillation Unspecified condition of brain

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: history of stroke major surgical or invasive procedure: minimally invasive pfo closure history of present illness: ms. is a 43 year old female who suffered a stroke in . workup at that time revealed patent foramen ovale/atrial septal defect. she was subsequently placed on warfarin. a recent echocardiogram from showed an atrial septal defect with left to right flow. her lvef was estimated at 60%. she now presents for surgical intervention. of note, warfarin was discontinued five days prior to admission. in addition, she had been on antibiotics for mildly productive cough. past medical history: atrial septal defect/patent foramen ovale, history of stroke in , ulcerative colitis, raynauds disease, history of thrombophlebitis, s/p ex-lap for ovarian torsion social history: denies tobacco. admits to only rare etoh. she works with computers. she is married. family history: denies premature coronary artery disease. physical exam: vitals: bp 100/64, hr 72, rr 20, sat 98% on room air general: well developed, well appearing female in no acute distress heent: oropharynx benign, neck: supple, no jvd, heart: regular rate, normal s1s2, no murmur or rub lungs: clear bilaterally abdomen: soft, nontender, normoactive bowel sounds ext: warm, no edema, no varicosities pulses: 2+ distally neuro: nonfocal pertinent results: 04:59pm blood wbc-7.3 rbc-3.86* hgb-10.7* hct-31.1* mcv-81* mch-27.6 mchc-34.3 rdw-14.7 plt ct-234 04:59pm blood pt-13.0 ptt-26.4 inr(pt)-1.1 04:59pm blood glucose-91 urean-14 creat-0.8 na-141 k-3.5 cl-105 hco3-28 angap-12 05:50am blood wbc-4.0 rbc-2.84* hgb-8.0* hct-23.8* mcv-84 mch-28.3 mchc-33.7 rdw-15.6* plt ct-148* 05:50am blood glucose-91 urean-13 creat-0.6 na-139 k-4.2 cl-107 hco3-26 angap-10 discharge chest x-ray: stable bilateral small pleural effusions, right greater than left. brief hospital course: ms. was admitted the day before surgery for routine preoperative workup. warfarin was discontinued five days prior to admisstion. preoperative evaluation was unremarkable and she was cleared for surgery. on , dr. performed a minimally invasive pfo closure. for further surgical details, please see seperate dictated operative note. following the operation, she was brought to the csru for invasive monitoring. she initially experienced bradycardia and temporarily required neo and fluid boluses to maintain hemodynamics. within 24 hours, she awoke neurologically and was extubated. her hemodynamics and heart rate gradually improved, and neo was weaned without difficulty. low dose beta blockade was initiated and she transferred to the sdu on postoperative day two. her hematocrit ranged between 22-24%. she remained in a normal sinus rhythm, heart rate ranging between 50-60 beats per minute. low dose beta blockade was not advanced due to intermittent bradycardia and her systolic blood pressure remained in the 80-100 mmhg range. given that she remained asymptomatic, no blood transfusions were given. the rest of her postoperative course was unremarkable and she was discharged to home on postoperative day four. she will no longer require warfarin anticoagulation. medications on admission: warfarin - stopped asacol canasa discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 3. ibuprofen 600 mg tablet sig: one (1) tablet po every hours as needed for pain. disp:*50 tablet(s)* refills:*0* 4. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po once a day. disp:*30 tablet(s)* refills:*0* 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. hydromorphone 2 mg tablet sig: one (1) tablet po every hours as needed for pain. disp:*30 tablet(s)* refills:*0* 7. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 8. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: hospice and vna discharge diagnosis: patent foramen ovale - s/p surgical closure, postoperative anemia, bradycardia, history of stroke in , ulcerative colitis, raynauds disease, history of thrombophlebitis, s/p ex-lap for ovarian torsion discharge condition: good discharge instructions: patient may shower, no baths. no creams, lotions or ointments to incisions. monitor wounds for signs of infection. please call with any concerns or questions. followup instructions: cardiac surgeon, dr. in weeks - call for appt. local pcp, . in weeks - call for appt. local cardiologist, dr. in weeks - call for appt. Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Other and unspecified repair of atrial septal defect Transfusion of packed cells Diagnoses: Anemia, unspecified Other specified cardiac dysrhythmias Ostium secundum type atrial septal defect Personal history of other diseases of circulatory system Ulcerative colitis, unspecified Raynaud's syndrome

discharge status: home with home physical therapy, home occupational therapy evaluation, and home nurses' aide evaluation. medications on discharge: 1. prilosec 20 mg p.o. b.i.d. 2. multivitamin with trace minerals 1 tablet p.o. q.d. 3. baclofen 5 mg p.o. t.i.d. p.r.n. 4. bactrim-ss 1 p.o. q.d. 5. thorazine syrup 100/ml 0.5 cc t.i.d. p.r.n. hiccups. 6. peridex swish-and-swallow 15 cc p.o. b.i.d. 7. nystatin swish-and-swallow 5 cc p.o. q.i.d. 8. neutra-phos 2 packets p.o. t.i.d. 9. magnesium oxide 800 mg p.o. b.i.d. 10. albuterol meter-dosed inhaler 1 puff q.i.d. p.r.n. 11. compazine 10 mg p.o. q.6h. p.r.n. 12. ativan 0.5 mg one to two tablets p.o. p.r.n. 13. ritonavir 100 mg p.o. b.i.d. 14. amprenavir 150 mg 8 p.o. b.i.d. 15. didanosine 400 mg p.o. q.d. 16. lamivudine 150 mg p.o. b.i.d. 17. stavudine 40 mg p.o. b.i.d. discharge diagnoses: 1. human immunodeficiency virus. 2. history of hodgkin disease, in remission. 3. non-hodgkin lymphoma. discharge followup: follow up with dr. and dr. for further treatment of his non-hodgkin lymphoma. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Insertion of endotracheal tube Fiber-optic bronchoscopy Hemodialysis Biopsy of bone marrow Closed [endoscopic] biopsy of bronchus Closed [percutaneous] [needle] biopsy of kidney Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Acute kidney failure, unspecified Hematoma complicating a procedure Candidiasis of mouth Human immunodeficiency virus [HIV] disease Other malignant lymphomas, unspecified site, extranodal and solid organ sites Herpes simplex with other specified complications

past medical history: 1. human immunodeficiency virus diagnosed in . most recent viral load of 19,000 in of this year. 2. possible history of pcp, unclear. his antiretroviral medications were discontinued on 5.5 cycles of ddavp between and with remission for 2.5 years. 3. non hodgkin's lymphoma, status post fine needle aspiration of cervical lymph node on which revealed monoclonal b cell infiltrates, cd-10 positive consistent with non hodgkin's lymphoma, either small, non cleaved cell of large cell histology. 4. ppd negative two years ago 5. perianal papillomatosis, status post laser surgery 6. cryptosporidium medications: 1. solu-medrol 1 mg per kg 2. levofloxacin 250 mg q day 3. allopurinol 4. haldol prn 5. ddavp social history: alienated from his family because of his sexual preferences. he is originally from . physical exam on : vital signs: temperature 100.1??????, blood pressure 1128/76, pulse 88, respiratory rate 24. general: somnolent, but able to respond to questions and follow commands, stating he is hungry and thirsty. thin gentleman. head, ears, eyes, nose and throat: pupils equal, round and reactive to light. extraocular muscles are intact. anicteric sclerae. mouth dry with cracked lips and small lesions on the tongue. no parotid enlargement noted. neck: dressing on right side of neck, no lymphadenopathy, possible left axillary lymphadenopathy, no jugular venous distention. heart: tachycardic, regular rhythm, no murmurs, rubs or gallops. lungs: occasional wheezes heard. abdomen: soft, positive bowel sounds, nondistended, 2+ pedal pulses. neurologic: nonfocal, not formally tested. buttocks: skin tear secondary to rectal tube without exudate or erythema. admission labs : white blood cell count 12.6, hematocrit 32.7; differential 51% neutrophils, 31.8 lymphocytes, 3.8 monocytes, bicarbonate 10. bun 185, creatinine 13.6, glucose 96, ldh 751, cks 155, lactate 5.1, calcium 10.8, phosphorus 8.2, magnesium 3.8. urinalysis revealed large blood, nitrite positive, protein greater than 300, trace ketones, bilirubin negative, urobili 0.2, greater than 1000 red blood cells, 4 white blood cells, occasional bacteria. csf revealed 0 white blood cells. ultrasound nephromegaly with increased echogenicity, no obstruction/23/100/13/-11 uric acid. labs on upon transfer to the floor: white blood cell count 6.1, hematocrit of 19, platelets 52. labs on : white blood cell count 13.7, hematocrit 26.5, platelets 64. sodium 150, potassium 3.3, chloride 106, bicarbonate 23, bun 63, creatinine 2.7, glucose 170, calcium 8.5, phosphorus 6.6, magnesium 1.5, albumin 3... , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Insertion of endotracheal tube Fiber-optic bronchoscopy Hemodialysis Biopsy of bone marrow Closed [endoscopic] biopsy of bronchus Closed [percutaneous] [needle] biopsy of kidney Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Acute kidney failure, unspecified Hematoma complicating a procedure Candidiasis of mouth Human immunodeficiency virus [HIV] disease Other malignant lymphomas, unspecified site, extranodal and solid organ sites Herpes simplex with other specified complications

service: oncology history of present illness: this is a 45-year-old gentleman with a history of hiv for 15 years and hodgkin's disease diagnosed in , status post five and a half cycles of abvd in and with remission for the last two and a half years. in of this year, he had swelling over his right episodic fevers, night sweats, cough, shortness of breath, wheezing and episodic chest pain. he was admitted in for dyspnea and cough and treated for pneumocystis carinii pneumonia with bactrim double strength two t.i.d., although a bronchoalveolar lavage was negative for pneumocystis carinii pneumonia. he was discharged after two days with lower dose bactrim for frontal and maxillary sinus mucosal disease on ct since that discharge, the patient had been experiencing nausea, decreased p.o. intake with a 25 pound weight loss in three weeks, night sweats, a cough with bloody sputum and dysuria with dark urine color. on , a fine needle aspiration of his left cervical node revealed monoclonal infiltrate with b cells positive for cd10 antigen, consistent with non-hodgkin's lymphoma (small, noncleaved and large cell histology). the final is pending. the patient was admitted on in acute renal failure and with the above symptoms. on admission, his creatinine was 13.6 and his uric acid was 21.1. platelet count was 136,000. hematocrit was 32.7. prothrombin time was 14.7, partial thromboplastin time was 28.1 and inr was 1.4. the patient was admitted to the medical intensive care unit, where he was started on hemodialysis via a right internal jugular catheter and was intubated for airway protection. a renal ultrasound revealed massive homogeneous enlargement of the kidneys and a bronchoscopy for his recurrent hemoptysis revealed a large clot/vascular mass in his right bronchus intermedius with spill-over blood in the left bronchus. on , a lumbar puncture was performed which was negative for malignant cells. a renal biopsy revealed diffuse infiltrative disease of the kidneys with lymphoproliferative disorder consistent with lymphoma. the patient was started on methylprednisolone 1 mg/kg q.d. intravenously and allopurinol 150 mg q.d. on , he was transfused blood for a low hematocrit with the hematocrit coming up to 30. his last day of hemodialysis was on . another bronchoscopy was done on , which revealed a large clot in his bronchus intermedius with clear left airways. on , the patient was still intubated and sedated on a morphine and lorazepam drip with low grade fevers and requiring high doses of peep. another rigid bronchoscopy was done on , which revealed the clot in his bronchus intermedius and pathology revealing no endobronchial lesions. an echocardiogram was done on with a normal ejection fraction of 60%. on , the patient was still intubated and sedated after being agitated on . his sputum was negative for acid fast bacilli and pneumocystis carinii pneumonia. he had some low grade fevers and mild systolic hypertension. he was also treated for presumed pneumonia with levofloxacin during his medical intensive care unit stay. for his coagulopathy, the patient received estrogen, ddavp and vitamin k. finally, he was extubated on and transferred to the oncology floor for planned low dose cyclophosphamide and vincristine. in addition, a head ct scan on was negative for a mass lesion. past medical history: 1. hiv: this was diagnosed in . the patient's last cd4 count was 324 with a viral load of 19,000 in . there was a possible history of pneumocystis carinii pneumonia, although this was unclear. the patient was on antiretroviral therapy until this admission. 2. hodgkin's disease: this was diagnosed in and the patient was status post five and a half cycles of abvd between and with remission for two and a half years. 3. non-hodgkin's lymphoma : this was status post fine needle aspiration of cervical lymph node on , which revealed monoclonal b cell infiltrates and cd10 positive, consistent with non-hodgkin's lymphoma of either small cell, noncleaved cell or large cell history. 4. ppd: this was negative two years ago. 5. perianal papillomatosis: this was status post laser surgery in . 6. cryptosporidium. medications on transfer: allopurinol 150 mg p.o. q.d. d5w 100 cc/hour intravenously continuous. levofloxacin 250 mg p.o. q.d. protonix 40 mg intravenous q.d. nephrocaps one tablet p.o. q.d. solu-medrol 60 mg intravenous q.d. estrogen 35 mg intravenous q.d. calcium acetate two tablets p.o. t.i.d. allergies: there were no known allergies to medications. family history: the patient's mother died of leukemia in her 60s. an aunt also died of leukemia. social history: the patient was a homosexual with a current partner. did not smoke. he drank occasional alcohol. he had never used intravenous drugs. he was a chemist at . he played basketball on the gay league. he was originally from and had been alienated from his family because of his sexual identity. physical examination: on , upon transfer, vital signs revealed a temperature of 100.1??????f, a blood pressure of 128/76, a pulse of 88 and a respiratory rate of 24. in general, the patient was a somnolent thin gentleman who was able to respond to questions and follow commands, stating that he was hungry and thirsty. on head, eyes, ears, nose and throat examination, the pupils were equal, round and reactive to light. the extraocular muscles were intact. the sclerae were anicteric. the mouth was dry with cracked lips and small lesions on the tongue. the patient was unable to open his mouth widely due to dryness. no parotid enlargement was noted. on examination of the neck, there was a dressing on the right side of the neck. there was no lymphadenopathy. there was a question of left axillary lymphadenopathy. there was no jugular venous distention. the heart was tachycardic with a regular rhythm and no murmurs, gallops or rubs. the lungs had occasional wheezes heard throughout. the abdomen was soft and nondistended with positive bowel sounds and diffuse tenderness throughout. there was tender splenomegaly. the extremities had no edema. there were 2+ pedal pulses. the neurological examination was nonfocal, not formally tested. in the buttocks, there was a skin tear secondary to a rectal tube. laboratory: laboratory studies on admission on included a white blood cell count of 12,600 with a hematocrit of 32.7 and platelet count of 136. prothrombin time was 14.7, inr was 1.4 and partial thromboplastin time was 28.1. differential revealed 61% neutrophils, 31.8% lymphocytes, 3.8% monocytes, 2.2% eosinophils and 1.2% basophils. there was a sodium of 129, potassium of 6.2, chloride of 93, bicarbonate of 10, bun of 185, creatinine of 13.6 and glucose of 96. uric acid was 21.1. ldh was 751. ck was 151. calcium was 10.8. phosphorus was 8.2. magnesium was 3.8. lactate was 5.1. urinalysis revealed large blood, nitrite positive, proteins of greater than 300, trace ketones, bilirubin negative, urobilinogen of 0.2, greater than 1000 red blood cells, 4 white blood cells and occasional bacteria. cerebrospinal fluid revealed no white blood cells, 120 red blood cells, p of 0, l of 0, gram stain negative, protein of 48, glucose of 66. laboratory studies on transfer on revealed a white blood cell count of 6100, hematocrit of 19 and platelet count of 52,000. prothrombin time was 13.2, partial thromboplastin time was 24.7 and inr was 1.2. fibrinogen was 395. there was a sodium of 144, potassium of 3.6, chloride of 102, bicarbonate of 23, bun of 70, creatinine of 2.6 and glucose of 130. alt was 134, ast was 93, alkaline phosphatase was 79, total bilirubin was 1.1, albumin was 2.9, calcium was 8.2, phosphorus was 5.0, uric acid was 14.4 and magnesium was 1.5. sputum showed 2+ gram-positive cocci in pairs and rods. radiology: a renal ultrasound revealed nephromegaly, increased echogenicity and no obstruction. a chest x-ray showed a question of early developing pneumonia. a ct scan of the chest on showed marked enlargement of the cortices of the kidneys bilaterally, consistent with a pattern of acute renal failure, although an infiltrative process such as lymphoma could not be ruled out. pulmonary nodular densities were superimposed over the consolidation in the lung bases. it was recommended that the patient have a follow up chest ct scan to further evaluate this nodules after resolution of the pneumonia. a ct scan of the pelvis on showed massive nephromegaly bilaterally and increased echogenicity without obstruction, consistent with medical renal disease. a ct scan of the abdomen on showed marked enlargement of the cortices of the kidneys bilaterally, which was consistent with a pattern of acute renal failure, although an infiltrative process such as lymphoma could not be ruled out. pulmonary nodular densities were superimposed over the consolidation in the lung bases. it was recommended that the patient have a follow up chest ct scan to further evaluate these nodules after resolution of the pneumonia. a chest x-ray on showed substantial clearing of both lungs and resolution of the right sided pleural effusion with minimal residual right basilar atelectasis. a chest x-ray on showed left lower lobe atelectasis. a chest x-ray on was a normal chest x-ray. a ct scan of the head without contrast on showed no acute intracranial process with no change from prior study. a chest ct scan without contrast on showed interval resolution of bilateral small pleural effusions and posterior atelectasis with apparently new multiple sub-centimeter pulmonary nodules in the bilateral lungs. this could represent lymphoma. nonspecific, patchy, ground glass opacities in the right upper lobe could represent an infectious process, hemorrhage or tumor infiltration and there was a large subscapular hematoma compressing the left kidney with moderate perirenal fat stranding. bone marrow biopsy: a bone marrow biopsy done on showed bone marrow involvement by lymphoma. microbiology: urine culture of showed no growth. blood culture of also showed no growth. cerebrospinal fluid culture on showed no growth, no polymorphonucleocytes and no microorganisms. urine culture on showed no growth. hiv nucleic acid was 24,494 copies on . blood culture on showed no growth. sputum gram stain on showed no microorganisms. respiratory culture showed oropharyngeal flora. there was no acid fast bacilli seen on direct or concentrated smear; acid fast culture pending. urine culture on showed no growth. sputum culture on showed gram-positive cocci in pairs. blood culture on showed no growth. stool culture on was negative for clostridium difficile toxin. sputum on showed 4+ gram-negative rods, 4+ gram-positive cocci in pairs, chains and clusters and 4+ gram-positive rods. respiratory culture on showed no predominance of these respiratory pathogens: s. pneumonia, h. flu and m. catarrhalis with no acid fast bacilli; acid fast culture was pending. urine culture on showed no growth. bronchoalveolar lavage revealed 1+ gram-positive cocci in pairs and 1+ gram-negative rods. acid fast culture was pending. acid fast smear was negative. legionella culture was negative. fungal culture revealed albicans as the presumptive identification. pneumocystis carinii pneumonia was not seen with no nocardia isolated. sputum culture on showed 2+ multiple organisms, consistent with oropharyngeal flora. bronchoalveolar lavage viral culture on showed herpes simplex virus type 1 with respiratory syncytial virus negative. catheter tip wound culture showed no significant growth. urine culture on showed no growth. sputum culture on showed 2+ gram-positive cocci in pairs and 2+ gram-positive rods. respiratory culture showed oropharyngeal flora with no acid fast bacilli on direct or concentrated smear. acid fast culture was pending. blood culture on showed no growth. stool culture on was c. difficile negative. stool culture on was microsporidium negative, isospora negative, clostridium difficile negative, cryptosporidium negative and giardia negative. bone marrow gram stain on showed no microorganisms and no growth. acid fast culture was pending. fungal culture showed no fungus isolated. koh showed no fungal elements seen. pcp was not done. blood culture on showed no growth. urine culture on showed no growth. sputum culture on showed 1+ gram-positive cocci in pairs with no fungus isolated. sputum viral culture on showed herpes simplex-like cytopathic effect; culture confirmation pending. impression: the patient is a 45-year-old hiv positive gentleman with a history of hodgkin's disease in remission, now with a new diagnosis of non-hodgkin's lymphoma by cervical node and renal biopsies, who presented with acute renal failure, likely due to autotumor lysis syndrome, requiring a medical intensive care unit admission and hemodialysis. the patient also had hemoptysis, which appeared to be resolving once he reached the floor. hospital course: 1. hematology/oncology: on , the patient received his first dose of cyclophosphamide and vincristine as well as packed red blood cells for a hematocrit drop to 19. while he was receiving this, he experienced transient chest tightness associated with a cough, which resolved spontaneously after one to two minutes. he finished receiving his chemotherapy and blood at a slower rate. the patient continued to receive methylprednisolone 1 mg/kg intravenous q.d. for several days; this was then changed to p.o. prednisone and slowly tapered off. his allopurinol was continued throughout his hospitalization and raised to a dose of 300 mg p.o. q.d. once his renal function was normal. his tumor lysis laboratory values were followed and improved, as did his uric acid. he had a bump in his white blood cell count after his first day on the floor because he received an extra dose of methylprednisolone by mistake. the patient received a total of four units of packed red blood cells for his hematocrit of 19. it was unclear why his hematocrit had dropped to 19 on this day, since his hemoptysis was decreasing. later on, once a chest ct scan was done showing a renal hematoma, it was thought that this might have been the source secondary to the renal biopsy that was done recently. his stools were guaiac tested and were all negative throughout his hospitalization. a smear was reviewed at the beginning of his stay and no signs consistent with hemolysis, such as schizocytes, were seen. his prothrombin time, partial thromboplastin time and inr normalized, making consumptive coagulopathy less likely. through the days after chemotherapy, his counts started to trend downward. his calcium acetate was increased to three tablets t.i.d. with meals for an increase in his phosphorus and he was given repletion for a low calcium. his intravenous fluids on were increased to 150 cc/hour of d5w with bicarbonate to alkalinize his urine. on , a urinalysis showed large blood in the urine but no red blood cells, so it was decided to check a ck to look for myoglobinuria. his ck was found to be elevated at 4820. this was thought to be secondary either to lymphoma infiltrating muscle or liver and it was decided to do a gallium study for further staging. a bone marrow biopsy and aspiration were done on , revealing negative cultures but findings consistent with non-hodgkin's lymphoma infiltrating the bone marrow. on , the patient tripped and fell and banged his head. his platelet count was 50,000 that day, so a head ct scan was done showing no bleed. his liver function tests were elevated on with an alt of 125, ast of 308 and alkaline phosphatase of 124, suggesting possible liver etiology to his increased ck. on , he was started on neupogen subcutaneously for a low white blood cell count status post chemotherapy. on , dr. returned from vacation and saw the patient, having not seen him since the medical intensive care unit. it was decided that the patient would need six cycles of chop chemotherapy. he may substitute the doxorubicin with daunoxome because it is less cardiotoxic and the patient has already received abvd for hodgkin's disease in the past. because of bone marrow involvement, the patient will need intrathecal therapy with ara-c times four treatments. it was decided that allopurinol should stay for ten days post chemotherapy and that g-csf should be given for at least ten days to increase his counts. he has an appointment with dr. to begin chemotherapy on at 3 pm. on , the patient was transfused two units of packed red blood cells for a hematocrit of 26 in preparation for discharge. 2. renal/fluid, electrolytes and nutrition: the patient's renal function continued to improve throughout his hospitalization stay. on the day after transfer to the floor, the creatinine was 2 and the sodium and potassium were stable. aggressive intravenous fluids were continued with d5w and three ampules of bicarbonate. the patient was continued on calcium acetate and nephrocaps. his foley catheter was discontinued on . the renal team continued to follow the patient while on the floor. his nephrocaps were discontinued and changed to a multivitamin with trace minerals because the patient was no longer on hemodialysis. his calcium, magnesium and potassium were occasionally low and these were repeated as necessary. his elevated ck was thought not to be due to rhabdomyolysis since it was normal on admission and it would need a much higher level if it was rhabdomyolysis. other possibilities for its etiology include the renal biopsy going through a muscle or lymphoma infiltrating muscle or liver. it was fractionated on with a normal mb and an electrocardiogram was done, which was unchanged. the troponin was less than 0.3. myoglobulinuria was negative, again confirming the unlikelihood of rhabdomyolysis. his renal function continued to improve. on , the patient's creatinine was 1.1. a chest x-ray on revealed a subscapular left kidney hematoma on ct scan, probably secondary to his renal biopsy and this would explain the drop of hematocrit to 19 on the day that he was transferred to the floor. his renal function continued to improve with a creatinine of 0.6 on . intravenous fluids were discontinued on . the patient's ck continued to remain high, going as high as approximately 7000 during this admission. at this time, this seems to be slowly trending down with the ck on of 5228. it has not seemed to cause the patient any problems such as muscle spasms or pain. 3. infectious disease: the patient was afebrile on transfer to the floor. his chest x-ray after reaching the floor was much improved as compared with the last one showing resolved pneumonia. he was continued on levaquin for a total of ten days and this was discontinued on . three acid fast bacilli smears were negative, so precautions were discontinued. his oral thrush was treated with nystatin swish and swallow and peridex. his levaquin dose was increased to 500 mg p.o. q.d. as his renal function improved. on , bactrim ss one p.o. q.d. for pneumocystis carinii pneumonia prophylaxis was started. on , an infectious disease consultation was requested because of the growth of herpes simplex virus i on culture of his bronchoscopy aspiration on . the lungs did sound congested and wheezy that day. their initial impression was that he clinically looked well and that the herpes simplex virus i was most likely a contaminant. on , the patient was restarted on his antiretroviral therapy. this was held off for the first few days because of his nausea and vomiting from chemotherapy, but once this resolved he was restarted. on , the patient spiked a fever in the evening and he was started on ceftazidime intravenously. there was no change on chest x-ray and his blood cultures and urine cultures were negative. the source of this temperature was unclear. also had recurrence of his hemoptysis and it was decided, with the infectious disease team's input and approval, to start the patient on intravenous acyclovir. his stools were negative for cryptosporidium, giardia, isospora and microsporidium as well as being negative for clostridium difficile twice. acyclovir was started at 350 mg intravenous every eight hours. this is also bone marrow depressing, so we will watch his counts as he is on acyclovir. his repeat sputum culture was negative for fungus, but viral cultures were showing herpes simplex virus-like effects again. the patient had been neutropenic in the last few days and this was likely secondary to the chemotherapy, plus or minus the effect of the acyclovir. however on , his counts seem to be coming up with the help of neupogen. the plan is to complete a ten day course of acyclovir for herpes simplex i. we will switch to p.o. on discharge. the question remains as to whether to continue him on ceftazidime, which is an intravenous medication for his neutropenia, until his absolute neutrophil count is greater than 500 and he is afebrile. when the patient was first transferred to the floor on , his hemoptysis seemed to be resolving. he required oxygen by nasal cannula for only a couple of days and then was on room air doing well. occasionally, he experienced some wheezing and he was started on albuterol metered dose inhaler and albuterol and atrovent nebulizer p.r.n. the hemoptysis was dark brown in coloration, but improving. he was continued on levaquin for a total of ten days to treat his pneumonia. on the evening of , the patient had increased congestion, cough and wheezing at night with a slight decrease in his oxygen saturation. he received two nebulizer treatments. a chest x-ray showed increased vascularity, so intravenous fluids were decreased a little bit to 100 cc/hour instead of 150 cc/hour. on , the patient had recurrent bright red hemoptysis and a pulmonary consultation was requested with a repeat chest ct scan ordered to see if there was any source for this recurrent hemoptysis. he was no longer coagulopathic at this point. the pulmonary service thought that his hemoptysis was most likely due to an infectious etiology, possibly herpes simplex virus versus pneumonia. other possibilities included post extubation versus anti-gbm versus vasculitis. however, the patient refused a repeat bronchoscopy on because he wanted to let his body heal. he did feel clinically improved on the following day. albuterol metered dose inhaler was changed to a standing dose of q.i.d. his chest ct scan showed some pulmonary nodules, possibly consistent with lymphoma, and some right upper lobe ground-glass opacities, possibly consistent with infection. the patient was started on acyclovir as noted above. it would be a good idea to repeat the chest ct scan after the acyclovir treatment is done to look for any resolution. his hemoptysis did continue to improve after the exacerbation. he did have recurrent hiccups throughout his hospitalization stay with thorazine being given every day and raised to 50 mg t.i.d. on . on , the patient was given baclofen for his hiccups, which seemed to work more effectively than the thorazine, so he might consider either one of these as an outpatient if his hiccups do continue. 4. gastrointestinal: the patient had diarrhea at the beginning of his floor stay. he was sent for cultures, ova and parasites and clostridium difficile and these were all negative. he did have some nausea, which was treated with compazine b.i.d., compazine p.r.n. and ativan. this resolved s his diet increased. he advanced his diet to regular with a good appetite throughout his stay on the floor. disposition: the plan is for the patient to receive his gallium scan today, , in and then to be transferred to . he has a follow up appointment with dr. on , which is a tuesday, at 3 pm to receive his first cycle of chop. discharge medications: 1. multivitamin with trace minerals one p.o. q.d. 2. prilosec 20 mg p.o. b.i.d. 3. allopurinol 300 mg p.o. q.d. with last dose on . 4. peridex swish and swallow 15 cc p.o. b.i.d. 5. nystatin swish and swallow p.o. q.i.d. 6. compazine 15 mg p.o. b.i.d. 7. neupogen 300 mcg subcutaneous q.d. with last dose on . 8. acyclovir, dose pending infectious disease recommendations. 9. bactrim ss one p.o. q.d. 10. ritonavir 100 mg p.o. b.i.d. with am and pm meals. 11. amprenavir 150 mg eight p.o. b.i.d. for a total of 1200 mg b.i.d. 12. didanosine (videx) 400 mg p.o. q.d. 13. lamivudine 150 mg p.o. b.i.d. 14. stavudine 40 mg p.o. b.i.d. 15. thorazine 50 mg p.o. t.i.d. in pill or syrup. 16. baclofen 10 mg p.o. q.d. p.r.n. for hiccups. 17. magnesium oxide 800 mg p.o. b.i.d. 18. prednisone 5 mg p.o. q.d. times two days and then discontinue. 19. albuterol and atrovent nebulizers p.r.n. 20. albuterol metered dose inhaler q.i.d. p.r.n. 21. robitussin ac 10 ml every four hours p.r.n. 22. percocet 5 mg p.o. p.r.n. every six hours. 23. compazine 10 mg intravenous p.o. every six hours p.r.n. 24. ativan 0.5 to 1 mg p.o. p.r.n. 25. serax 15 to 30 mg p.o. h.s. p.r.n. 26. tylenol 650 mg p.o. every four to six hours p.r.n. 27. kvl solution 1:1:1 ratio swish and spit t.i.d. p.r.n. condition on discharge: stable. discharge status: the pt was originally scheduled to be discharged to , but there were apparent insurance complications and pt was not approved for rehab stay. he was subsequently discharged to home w/ pcp f/u. discharge instructions: the patient will follow up with dr. on tuesday, , at 3 pm. the patient is also to receive daily physical therapy while at rehabilitation. discharge diagnoses: 1. hiv. 2. non-hodgkin's lymphoma. 3. history of hodgkin's disease. 4. resolving hemoptysis. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Insertion of endotracheal tube Fiber-optic bronchoscopy Hemodialysis Biopsy of bone marrow Closed [endoscopic] biopsy of bronchus Closed [percutaneous] [needle] biopsy of kidney Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Acute kidney failure, unspecified Hematoma complicating a procedure Candidiasis of mouth Human immunodeficiency virus [HIV] disease Other malignant lymphomas, unspecified site, extranodal and solid organ sites Herpes simplex with other specified complications

history of present illness: the patient is a 45-year-old man with a history of hiv and hodgkin's disease in remission with newly diagnosed non hodgkin's lymphoma and a recent admission meningitis in . recently discharged to rehab on . he returns with fever to 104. he was started on vancomycin, ticarcillin at and transferred to bed . his lymphomatous meningitis in resulted in omaya being placed on . he received intrathecal ara-c on and systemic non hodgkin's lymphoma. he developed a third nerve palsy and other cranial nerve deficits with lymphomatous meningitis. currently patient denies headache, neck stiffness, photophobia, cough, sore throat, nausea, vomiting, diarrhea, abdominal pain, dysuria and chest pain. his only complaint other than fevers, increasing lower extremity weakness. he was initially admitted to the medical intensive care unit. his csf was sampled and found to have no white cells, normal protein and glucose and negative gram stain. however, second csf gram stain had gram positive cocci. patient was started on acyclovir, ampicillin, vancomycin and ceftriaxone. past medical history: significant for non hodgkin's lymphoma diagnosed with renal and bone marrow involvement, hiv diagnosed in , hodgkin's disease in remission diagnosed , tumor lysis syndrome , history of cryptosporidium, history of lymphomatous meningitis and pcp . medications: on admission include bactrim single strength one tablet po q day, didanosine 400 mg po q day, lamivudine 150 mg po bid, stavudine 40 mg and amprenavir 1200 mg , baclofen 5 mg tid, nystatin swish and swallow 5 cc qid, allopurinol 300 mg , morphine prn, colace 100 mg po bid, compazine prn, thorazine syrup prn, prevacid 30 mg po q day, albuterol mdi one puff qid prn, acyclovir 600 mg q 8 hours, ritonavir 100 mg . allergies: no known drug allergies. social history: he is a chemist. occasional alcohol use. denies tobacco use. physical examination: on admission his temperature was 101.2, pulse 124, respirations 20, blood pressure 140/90. generally he is awake and alert, in no acute distress. heent: extraocular movements full, mucus membranes were dry, sclera were anicteric. neck supple, no lad. lungs with coarse breath sounds bilaterally. abdomen was soft, no tenderness, positive bowel sounds. cardiac exam as regular, tachycardic with no murmurs, rubs or gallops appreciated. extremities were thin and warm with no edema. neurologic exam, he was alert and oriented times three with normal language and attention. cranial nerves significant for right third nerve palsy with ptosis left facial. motor exam, upper extremity was 4/5 strength distally and lower extremities were throughout bilaterally. sensory exam, decreased distal sensation in both lower extremities and dysmetria on finger nose finger bilaterally. laboratory data: on admission, white count 12.4, hematocrit 28.2, platelet count 220,000, sodium 124, potassium 3.6, chloride 95, co2 23, bun 11, creatinine 0.3. his lfts were within normal limits. head ct showed no intracranial pathology, vp shunt in the right lateral ventricle. chest x-ray showed no evidence of pneumonia, no pneumothorax or no effusion. hospital course: the patient is a 45-year-old man with history of hiv, complicated by a lymphomatous meningitis, presenting with fever. hospital course was remarkable for steady progression and decline in his functioning and mental status. he was continued on multiple antibiotics, started on decadron as well as intrathecal chemotherapy. he was briefly made npo because of aspiration events. he eventually developed a left lower lobe infiltrate, was continued on multiple antibiotics, remained full code initially and was followed closely by his family attending. id was also involved, making multiple recommendations as was hematology/oncology. however, inspite all of our efforts, the patient died on . previous to this, he had been made dnr/dni. discharge condition: deceased. dr., 11-970 dictated by: medquist36 d: 10:15 t: 12:24 job#: Procedure: Spinal tap Incision of lung Diagnoses: Pneumonia, organism unspecified Hyposmolality and/or hyponatremia Acute respiratory failure Cachexia Other and unspecified coagulation defects Asymptomatic human immunodeficiency virus [HIV] infection status Lymphocytic choriomeningitis Other malignant lymphomas, lymph nodes of multiple sites

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transferred from outside hospital for coronary and carotid cath major surgical or invasive procedure: carotid cath coronary cath history of present illness: 64 yr old hypertensive, diabetic male with cad s/p cabg ' and b/l carotid disease transferred from osh after an episode of chest pain and aphasia. he was in his usoh until when at noon he developed substernal chest "burning" while sitting at his office. he noticed that his speech was slurred and "the words wouldn't come out." when his wife called him she noted that his words "made no sense" "he was saying nonsense." she thought he might have been hypoglycemia and gave him some coke, after which his symptoms improved. they called ems and were taken to hospital. a head ct was (-) for bleed and trop-i+ 0.87. ck 200. he received 2 doses of 1 mg/kg lovenox and was transferred to . he had lad stent in . a few days later, he has rca stented and has myoclonic jerk, not seizure in the cath lab per neurology attending ros: (-) sob/palp/edema/n/v/weakness/numbness/ha. past medical history: ##cad s/p cabg in with ef 50% by lvg. he has chest pain with lifting boxes. lima>>lad, svg>>diag - ett thal for 2 minutes with hr 130, 2 mm horizontal lateral st depressions. ##non-insulin dependent diabetes mellitus x 10 years. ##hypertension ##hypercholesterolemia ##stroke/tia with no residual defects. carotid u/s in with right ica occlusion and left 80-99% stenosis. followed by dr. (cardiology) and dr. (vasc ). ## b/l claudication social history: quit smoking 25 years ago. no etoh. works as a mechanic. lives with wife. 2 adopted children. family history: mother mi at 60 physical exam: temp: afebrile bp:120/82 hr:60 rr:12 o2:99 ra gen: nad, a/o x 3 heent: pearla. eomi. op w/o lesions. cv: rr. soft ii/vi systolic murmur at llsb. jvd flat. sternotomy incision c/d/i. pulm: cta b/l abd: s/nt/nd ext: no edema. s/p vein graft incision c/d/i. 1+dp/pt neuro: motor at all flexors/extensors. sensation: gi to light touch and pinprick. intact. ftn intact. cnii-xii: gi pertinent results: at osh: na:138, k:4.3, bun:20, cr:1.4, inr:0.9, wbc:10.1 hgb:14.6, plt:171 ecg: nsr at 56. qs in iii, f. j-pt elevation in v1, v2, ii, f. lateral twi (dynamic). nl axis/intervals. cxr: no cp processes : chronic right occipital cortical infarct, chronic deep white matter infarction due to small vessel disease, small lacunar infarct in left thalamus. cath : 1. significant native coronary artery disease. 2. severe bilateral internal carotid artery disease. 3. arterial disease in the left subclavian and bilateral vertebrals 4. successful placement of self-expanding stent in left ica. 5. successful employment of accunet distal embolic protection. 6. self-limited, brief myotoclonus event. comments: 1. limited coronary angiography demonstrated a right dominant system with left main and severe native vessel disease. the lmca had an ostial 60% lesion. the proximal and midvessel lad had diffuse calcific disease. the distal lad filled via a lima which was not selectively engaged. the d1 branch was totally occluded. the lcx had mild diffuse disease. the rca and bypass grafts were not successfully engaged. 2. limited resting hemodynamics revealed a central blood pressure of 132/57 mmhg and a left cfa pressure of 101/67 mmhg. the mean gradient was 3 mmhg. 3. retrograde access of the left common femoral artery was obtained for selective carotid, vertebral, and coronary angiography. the thoracic aorta had a type i arch. the bilateral subclavian arteries had mild proximal disease. the left subclavian artery had a 50% lesion in the origin with a peak to peak gradient of 20 mmhg. 4. the right vertebral artery was small and diminutive with a total occlusion at the base of the skull before entering the brain. the left vertebral artery was large and was noted to have a 60% origin lesion and filled the basilar and the cerebellar arteries. the contralateral pca filled from the vertebral but the ipsilateral (left) pca was not seen. 5. the right common carotid artery was without disease but the ica was totally occluded. the left common carotid artery was without disease but the ica had diffuse tubular 80% disease. the left ica filled the ipsilateral aca and mca as well as the contralateral aca and mca via a large acom. 6. successful placement of a x 40 mm acculink stent in the left ica postdilated with a 4.5 mm balloon. final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (see ptca comments). 7. transient, self-limited myoclonic event during postdilation which was though not likely to represent seizure activity. 8. successful perclose of the left femoral arteriotomy site at the conclusion of the procedure without complications. cath at osh : "multiple tight stenoses of the proximal lad and proximal d1. proximal d2 occluded. rca proximally occluded. lima to lad patent, svg to diag could not be visualized and was presumed occluded. left carotid patent, right carotid occluded." cardiac cath 1. three vessel coronary artery disease. 2. rotation atheterectomy of the proximal lad. 3. unsuccessful attempt at ptca/stenting of the d1. comments: 1. selective coronary angiography revealed a right dominant system. the rca was not injected. the svgs and the lima were not injected. the lmca had a 60% ostial stenosis. the proximal lad 80% calcific stenosis. the distal lad was filling via a lima (there was competitive flow). the d1 had a 80% calcific stenosis at the origin. the lcx had mild diffuise disease. 2. unsuccessful attempt at ptca/stenting of the d1 due to inability to cross despite using multiple wires. rotational atherectomy was performed in the lad in an attempt to modify the lad lesion and allow crossing inro the d1 (see ptca comments). carotid series : reason: known carotid atherosclerosis, pre-op for stenting. findings: duplex evaluation was performed of both carotid arteries. significant plaque was identified on the right. there is no flow in internal carotid artery including power doppler technique. of note there is no study for comparison. on the left, significant mostly soft appearing homogeneous plaque is identified in the internal carotid artery. of note it appears to extend fairly distally in the cervical internal carotid artery. on the right, peak systolic velocities are 52, 72 in the cca, eca respectively. on the left, in the internal carotid artery the peak systolic over diastolic velocity is 361/123. in the remainder of the vessel the peak systolic velocities are 54, 584 in the cca, eca respectively. the ica-cca ratio is 6. this is consistent with an 80-99% stenosis. 05:48pm glucose-97 urea n-18 creat-1.2 sodium-143 potassium-4.0 chloride-105 total co2-28 anion gap-14 05:48pm alt(sgpt)-32 ast(sgot)-29 ck(cpk)-168 05:48pm calcium-9.3 phosphate-3.2 magnesium-1.8 05:48pm wbc-7.5 rbc-4.46* hgb-14.0 hct-40.8# mcv-92 mch-31.4 mchc-34.3 rdw-13.0 05:48pm plt count-195# 05:48pm pt-13.2 ptt-32.6 inr(pt)-1.1 brief hospital course: 64 y.o. male with cad status post cabg, history of tia with bilateral carotid stenosis presents s/p episode of chest pain and aphasia with borderline elevation in tn-i and non-specific ant/lateral st-t wave changes. he was admitted for coronary and carotid cath.patient had cardiac catheterization on and was discovered to have severe bilateral internal carotid artery disease and also arterial disease in the left subclavian and bilateral vertebrals. successful placement of self-expanding stent in left ica and successful employment of accunet distal embolic protection. patient was admitted briefly to ccu for observation overnight. he did well and has no neurological events. his blood pressure was kept between 120-140. he did well and was discharged the following day medications on admission: glipizide xl 5, fish oil 1000mg, ca 600 , mvi, garlic pill 1250, loratadine, asa 325, atenolol 50, metformin 1000mg, nexium 40 daily, lisinopril 5 tid, lipitor 20, zetia 10, doxazosin 4. coumadin was d/c'd 3 months ago discharge medications: 1. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). disp:*60 tablet, chewable(s)* refills:*2* 4. multivitamin capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 5. omega-3 fatty acids 120-180-1.8 mg-mg-unit capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 6. fexofenadine hcl 60 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 7. glipizide 5 mg tab, sust release osmotic push sig: one (1) tab, sust release osmotic push po daily (daily). disp:*30 tab, sust release osmotic push(s)* refills:*2* 8. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*9* 9. atorvastatin calcium 40 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: coronary artery disease carotid artery stenosis discharge condition: stable discharge instructions: please return to the hospital or call your doctor if you have chest pain/shortness of breath/dizziness/blur vision or if there are any concerns at all please take all your prescribed medication followup instructions: please call dr. , tomorrow to schedule an appointment Procedure: Left heart cardiac catheterization Left heart cardiac catheterization Coronary arteriography using a single catheter Coronary arteriography using a single catheter Percutaneous angioplasty of extracranial vessel(s) Percutaneous insertion of carotid artery stent(s) Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atherosclerosis of native arteries of the extremities with intermittent claudication Aortocoronary bypass status Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Personal history of tobacco use Other and unspecified hyperlipidemia Old myocardial infarction Unspecified disorder of kidney and ureter Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Aphasia Examination of participant in clinical trial Myoclonus

her past medical history was remarkable for an astrocytoma requiring and a vp shunt with resulting abdominal adhesions. past obstetrical history is remarkable for infertility and this pregnancy was assisted via in fertilization with di/di twins resulting from the reduction of triplets to twins. the pregnancy was otherwise unremarkable until the day of admission, , when the mother was admitted with hypertension and proteinuria. the infant was delivered without difficulties, had apgar scores of eight and eight. she emerged with a cry and was warm, dry, suctioned and stimulated. she was admitted into the neonatal intensive care unit at secondary to prematurity. physical examination on admission: weight: 2,160 grams. vital signs: blood pressure 65/33 with a mean of 43, heart rate 140-160s, respiratory rate 30s to 50s in room air. general: the patient was in no apparent distress with the eventual development of mild grunting. heent: normocephalic, atraumatic. the anterior fontanelle was soft and flat, open. normal facies. normal set ears. intact palate. chest: clear to auscultation bilaterally without any crackles or wheezes. no grunting, flaring, or retracting initially; however, grunting did develop subsequently. cardiovascular: regular rate and rhythm, normal s1, s2. no murmurs, rubs, or gallops. abdomen: soft, flat, nontender without hepatosplenomegaly. normal cord. normal female external genitalia. stable hips. normal tone and activity. hospital course: 1. cardiovascular: baby girl was initially given a 10 cc per kilogram normal saline infusion secondary to relative hypotension and hypoperfusion. she subsequently required no cardiovascular support and has had no episodes of dysrhythmia, hypotension, or hypertension. it has been noted on multiple occasions that she has a murmur which is soft and is audible in both axillae. she has a normal chest x-ray with a normal cardiac silhouette, normal ecg, normal four extremity blood pressures and passed a hyperoxia test without difficulty. it is likely that her murmur is consistent with a pps murmur and as such she should require no further workup. she is currently cardiovascularly stable with heart rates in the 150s to 160s. 2. respiratory: baby girl was admitted to the neonatal intensive care unit without any signs or symptoms of respiratory distress. however, she did transiently develop some grunting which rapidly resolved. she had no evidence of surfactant deficiency or pneumonia and has remained respiratorily stable without any difficulties. she is currently breathing in the 40s to 50s, is completely comfortable and is not currently being followed with oximetry. she has had no difficulties with apnea of prematurity as well. 3. fluids, electrolytes, and nutrition: baby girl was initially made n.p.o. on admission and iv fluids were started at 80 cc per kilogram per day of d10w via peripheral iv. she was started on feeds rather rapidly and advanced quite quickly to full feeds at current volume of 150 cc per kilogram per day of pe or mother's milk 20 calorie per ounce. she is currently feeding both p.o. and pg. she did have one day where she fed completely by mouth; however, on the day of this dictation, , she has required some pg feeding and is currently working on reaching full p.o. feeds and ad lib feeding. she is currently supplemented with iron sulfate. she has had no difficulties with electrolyte instability, has had no difficulties as well with voiding or stooling. 4. hematologic/infectious disease: baby girl was admitted without any concerns regarding sepsis. she received a screening cbc which was remarkable for a white count of 12,500, hematocrit 37%, and platelet count of 301,000. her differential was benign. her blood culture drawn at the time of admission was sterile. she is currently without any signs or symptoms of sepsis. baby girl was also followed for hyperbilirubinemia of prematurity and had a peak bilirubin of 7.4 and has required no phototherapy. of note, baby girl has not received hepatitis b vaccine number one and will instead receive this at her primary care pediatrician's office. 5. social: baby girl parents have been kept up to date regarding their daughter's progress. they are well informed and they have received support from social work in the person of . they continue to be well involved with the care of their daughter. the primary care pediatrician for the twins will be dr. , pediatrics. , m.d. dictated by: medquist36 Procedure: Enteral infusion of concentrated nutritional substances Diagnoses: Observation for suspected infectious condition Twin birth, mate liveborn, born in hospital, delivered by cesarean section Neonatal jaundice associated with preterm delivery Other preterm infants, 2,000-2,499 grams 33-34 completed weeks of gestation Hypotension, unspecified Transitory tachypnea of newborn

infant born at 34 4/7 weeks to 33 yo g1 a+, ab-, gbs ?, hbsag-, rpr-nr woman. past medical history remarkable for astrocytoma requiring v-o shunt with resulting abdominal adhesions. past ob history remarkable for infertility. ivf di/di twins resulting from reduced triplets. otherwise unremarkable antepartum until today when admitted with hypertension and proteinuria. c/s under spinal anesthesia. emerged with cry. apgars 8, 8. exam remarkable for preterm infant in no distress with vital signs as noted, pink color, soft af, nl facies, intact palate, no gfr, clear breath sounds, no murmur, flat soft n-t abdomen without hsm, nl external genitalia, stable hips, nl tone/activity, fair perfusion. preterm asymptomatic newborn- without evident sepsis risk except prematurity- delivered for maternal indications. no clinical evidence for surfactant deficiency. will require close respiratory monitoring. relatively low risk for apnea of prematurity. given persistence of low blood pressure, will insert iv and bolus with normal saline. will follow cardiovascular status closely. will check blood glucose and follow temperature and bilirubin, given prematurity. in view of relative absence of sepsis risk factors, will not check cbc unless concerns for infection raised. family is aware of current status and immediate plan of care. primary pediatrician is pediatrics. Procedure: Enteral infusion of concentrated nutritional substances Diagnoses: Observation for suspected infectious condition Twin birth, mate liveborn, born in hospital, delivered by cesarean section Neonatal jaundice associated with preterm delivery Other preterm infants, 2,000-2,499 grams 33-34 completed weeks of gestation Hypotension, unspecified Transitory tachypnea of newborn

discharge status: fair. condition on discharge: stable. discharge diagnosis: seizure. dr., 12-664 dictated by: medquist36 d: 07:56 t: 07:47 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Other pulmonary insufficiency, not elsewhere classified Atrial fibrillation Other convulsions Pneumonia due to Pseudomonas Hyperosmolality and/or hypernatremia Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

allergies: pcn on arrival to icu, pt with hct of 15, inr 1.7. received total of 8 units ffp, 7units prbc's and 1 pack of platelets. initially hemodynamically unstable, also requiring neo to maintain bp. large amt of blood out from oropharynx (approx 900cc). ent in to evaluate pt, oropharynx repacked. current review of systems: neuro: arousable to name, attempting to open eyes (unable d/t swelling). pupils 3mm bilat and briskly reactive. impaired corneals. (+) cough, gag not assessed d/t packing in mouth. mae's, right arm slighlty weaker. withdrawing ble's off the bed. propofol off since 4a. c-collar in place, logroll precautions maintained cv: hr initially 70's-80's afib, now in 50's junctional. pt with permanent pacemaker ?mode and settings. on neo to keep map's >65, weaned to off at 4:30am. skin warm to touch, pale. multiple ecchymotic areas on chest, arms and back. hands/feet cool to touch, pulses via doppler. tlcl in right groin, left groin with small hematoma from attempted line in ew. left and right knees swollen and ecchymotic. cpk's being cycled, 1st set negative resp: breath sounds clear, suctioned for large amts of thick bloody secretions, now brown in color, small amts. vent settings: a/c 600 x 12, 5 peep, 50% fi02. abg wnl. gi: abd soft, hypoactive bowel sounds. ogt to lws, 450cc brown drainage out since 9pm. small formed stool. npo maintained. renal: urine clear yellow, approx 30-40cc/hr. creatinine 2.1 today. k+ and calcium repleted heme: hct 15 on arrival, received 7 units prbc's, 8 units ffp, 1pack plts and 10mg vit k. at 4a, hct 24, inr 1.4. sicu ho aware--no further transfusions at this time. id: afebrile. started on clinda endo: blood sugars 228-288, regular insulin given per sliding scale Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Temporary tracheostomy Percutaneous (endoscopic) jejunostomy [PEJ] Diagnoses: Acute posthemorrhagic anemia Acute kidney failure, unspecified Atrial fibrillation Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Cardiac arrest Accidental fall on or from other stairs or steps Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

allergies: pcn sicu course: oropharynx packed by ent on day of admission, packing removed on without incident. repeat head ct 24 hours post fall was without significant change. pt was extubated on , went in to resp failure within 12 hours d/t weak cough and no gag-- and was reintubated. on pt underwent bedside trach c/b asystolic arrest & cpr. pt weaned from vent on , tolerating trach collar at 50%. peg placed in interventional radiology today without difficulty. current review of systems: neuro: awake and alert, agitated at times, haldol prn with effect. , purposeful--pulling at 02 and lines. not f/c's. med with roxicet prn for generalized discomfort. pupils 3mm bilat and briskly reactive. passy-muir valve trial done, pt at present. c-spine cleared radiologically--unable to do mri d/t permanent pacemaker. cv: hr 115-130's afib at start of shift. received extra 5mg iv lopressor at 8a, repeated at 9a and 10a with improvement in hr briefly to low 100's. on return from peg placement, hr still in 120's, bp stable. ? chf--low u/o and i/e wheezes. sicu ho aware--40mg iv lasix given with fair diuresis resp: as above--inspir/expir wheezes with crackles in bases posteriorly. fair cough, congested-suctioned for small amts of thick blood tinged secretions. tolerating trach collar at 50%. renal: fair response to lasix. k+ 5.8 prior to lasix--also received 30gm kayexalate enema. caclcium repleted. creatinine 2.4 today. foley changed today gi: peg placed today, npo. belly soft, (+)bowel sounds. large stool after kayexalate enema heme: hct stable at 28. remains on sq heparin id: afebrile, on levaquin for uti. endo: blood sugars 130-150 today, continues on sliding scale regular insulin--? start nph when tolerating tube feeds at goal skin: lacs to forehead and chin receiving wet to dry dsg changes tid, multiple skin tears to bilat forearms-edematous and reddened, moderate amt of serous weeping. right thigh with firm area on lateral thigh, tapped on for fluid, cx results pending. abrasions to right knee dry and scabbed. old chest tube site on left with mod amt of serosang drainage, straps and dsd. buttocks pink but intact. nystatin powder to groin for yeast. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Temporary tracheostomy Percutaneous (endoscopic) jejunostomy [PEJ] Diagnoses: Acute posthemorrhagic anemia Acute kidney failure, unspecified Atrial fibrillation Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Cardiac arrest Accidental fall on or from other stairs or steps Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

history of present illness: the patient is an 80-year-old male who fell down a flight of about approximately 10 stairs. he was able to press his lifeline and was found by ems at the bottom of the stairs. the patient was intubated at the scene by ems and had a head ct on arrival that was positive for right subdural hematoma with minimal mass effect. he did have significant facial trauma with severe epistaxis and multiple facial fractures. hospital course: the hospital course was complicated by prolonged intensive care unit stay, rapid atrial fibrillation and acute renal failure. a peg and trach was done and the trach was complicated by an asystolic arrest. the patient was seen by both the neurosurgical service, renal service, as well as the cardiology service. the patient's atrial fibrillation was eventually rate controlled with diltiazem. his renal function range during his hospital course rose from a low of 2.1 to a high of about 3.4. his hospital course was further complicated by respiratory failure and inability to wean from the vent. the patient did tolerate trach collar for a short course, however, secondary to left lower lobe collapse and decreasing two sets required to be put back on cpap. the patient was also noted throughout the course of his admission to have guaiac positive stools. he was also seen by gastrointestinal who declined any intervention at this time. he is on protonix 40 mg per g-tube q.d. past medical history: 1. coronary artery disease, status post coronary artery bypass graft x4 and myocardial infarction 2. chronic atrial fibrillation 3. diabetes mellitus with retinopathy, neuropathy, nephropathy 4. transient ischemic attack, status post cea 5. history of falls, status post pacer past surgical history: 1. status post coronary artery bypass graft 2. status post pacemaker 3. status post cea allergies: the patient has an allergy to penicillin. the patient is being discharged to rehabilitation. on discharge, he is stable. he is afebrile. his blood pressure ranges from 110 to 120 systolic. he is weight controlled in the 60s to 70s. he is on cpap with an fio2 of 40% and pressure support of 5 and a peep of 5. he has received two doses of ddavp for uremic platelet dysfunction. on exam, he is alert and follows commands. his pupils equal, round and reactive to light. his heart is irregular with a 3 out of 6 systolic ejection murmur. he has coarse breath sounds bilaterally. his abdomen is soft, nontender and he has 2+ upper extremity edema and 1+ lower extremity edema. discharge medications: 1. diltiazem 45 mg per j-tube q8h 2. vitamin c 500 mg per g-tube q.d. 3. zinc 220 mg per g-tube q.d. 4. kaltostat to right knee, right upper extremity, right lower extremity and left thigh areas with tegaderm changed b.i.d. 5. normal saline dressing to chin b.i.d. 6. mvi 1 cap per g-tube q.d. 7. lasix 100 mg per g-tube q8h 8. protonix 40 mg per g-tube q.d. 9. epogen 5000 units subcutaneous monday, wednesday, friday 10. haldol 2 mg per g-tube q hs prn 11. nph 12 units subcutaneous b.i.d. 12. regular insulin sliding scale 0 to 180 nothing, 181 to 220 2 units, 221 to 250 4 units, 251 to 300 6 units, 301 to 350 8 units, greater than 850 m.d. 13. heparin 5000 units subcutaneous b.i.d. the patient's bun and creatinine have been slightly rising in the last few days and will need them rechecked in two days. his urine output needs to be followed closely and his lasix adjusted accordingly. he does receive nepro tube feeds 0.75 strength of 50 cc per hour. he does have a c-collar on that is on for week five of six. the c-collar may be discontinued in one week. he does require suctioning and chest pt. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Temporary tracheostomy Percutaneous (endoscopic) jejunostomy [PEJ] Diagnoses: Acute posthemorrhagic anemia Acute kidney failure, unspecified Atrial fibrillation Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Cardiac arrest Accidental fall on or from other stairs or steps Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

history of present illness: this is an 80-year-old male with multiple medical cardiac problems, including hypertension, coronary artery disease, chronic renal insufficiency, status post coronary artery bypass graft, noninsulin dependent diabetic with retinopathy, neuropathy with a long history of falls, pacer, carotid occlusion, transient ischemic attacks, atrial fibrillation and status post right caa who presented to the emergency room on , status post a fall down 10 stairs with questionable loss of consciousness. the patient pushed his lifeline and was found by ems. the patient was intubated in the field with severe epistaxis upon arrival and questionable 2 units of blood loss in the field. the patient was seen in the trauma bay with severe nasal bleeding, evaluated by anesthesia for tube placement and found to have tube in place with pooling of blood in the posterior pharynx. patient with multiple contusions on his face. the patient was emergently brought to the ct scanner where he was shown to have a small left tentorial hematoma with a moderate sized subdural hematoma with a lower density collection extending over the parietal bone. there was no significant midline shift. he had a bilateral comminuted nasal bone fracture and possible fracture involving the medial wall of the right maxillary sinus. no evidence of cervical spine fracture. the patient was scanned for abdomen and pelvis which showed a 4.3 cm infrarenal abdominal aortic aneurysm without rupture. there was no intraabdominal or intrathoracic injury. there was a left groin hematoma involving the adductor muscles. the patient's nares were packed in the trauma bay. there was adequate control of bleeding at this time. physical exam on admission: general: the patient was intubated, sedated, multiple facial injuries, hematomas and nasal bleeding, posterior pharyngeal blood pooling. there was no obvious stepoff or deformity or cervical spine or of the head. head, ears, eyes, nose and throat: pupils were equal, round and reactive to light. tympanic membranes were clear bilaterally. the trachea was midline. chest: without crepitus, clear, breath sounds bilaterally. abdomen: soft, nontender. extremities: warm and dry with good pulses. the right forearm was with ecchymosis. rectal: negative. admission labs: white blood cell count of 10, hematocrit of 20.3, platelets of 138. coagulation studies were pt of 14.5, ptt of 32.5, inr of 1.4. fibrinogen was 225. urine was negative. chemistry showed a sodium of 139, potassium of 3.9, chloride of 97, bicarbonate of 23, bun of 75, creatinine of 2.6, glucose of 268, initial ck of 110. initial digoxin level was 0.8. imaging: initial imaging as noted above. hospital course: the patient was admitted to the sicu for intracranial bleed, nasal bleed and decreased hematocrit with associated hypotension. the patient had his right nares packed with an inflated foley catheter by ears, nose and throat. clamp traction was removed by ears, nose and throat on the 19th in the a.m. there was minimal oral secretions with drainage at the left nares on this day. the patient was started on clindamycin for the multiple facial fractures. on the 20th, the patient remained intubated and sedated, moving his right arm on the bed with questionable continued left arm weakness, moving both extremities in the bed. on the 20th, the patient's hematocrit was to 28 with platelets at 66 and inr of 1.3. the patient had x-rays of the right shoulder and bilateral knees without evidence of fracture. on the 21st, the patient continued to have no further changes on neurologic exam, continued with thick bloody brown oral secretions. his hematocrit remained stable, finishing his third dose of vitamin k. platelets at this point were at 107. at this point, the patient was weaned off propofol with purposeful movements of all four extremities. there was a weak gag and cough. pupils were 3 mm and reactive to light. the patient was started on intravenous lopressor for occasional rates in the 80s. on the 22nd, the patient was weaned to a pressure support of 15 and peep of 5 with several apneic times. he was placed on full vent support overnight. packing in the right nares remained in place through the 25th. on the 24th, the patient was extubated with difficulty with significant wheezing and inability to clear secretions. the patient was acidotic with hypercarbia. the patient was re-intubated due to difficult ventilation at this time. the patient also had periods of rapid atrial fibrillation at this point that resolved on their own. on the 24th, the patient was started on tube feeds. the patient's mental status throughout this course remained somewhat tenuous with purposeful movements, left greater than right, nodding to questions yes or no, moving both his lower extremities in the bed with attempts to get out of bed. full mental status was not clear. due to continued elevated blood sugars, the patient was started on an insulin drip at 1 unit per hour. there was discussion of another attempt to wean to extubate. on the 27th, the patient was on pressure support of 5, peep of 5, but this was not tolerated with hypercarbia returning. on the 29th, the discussion of trach and peg was raised with the family. the family discussed this issue and on the 30th it was determined that a trach and peg would be done on the 31st. during a bed side trach, the patient began bleeding copious amounts into his trachea with desaturation. the patient desaturated significantly with elevated heart rate and dropping blood pressure until the patient became asystolic approximately one minute. chest compressions were performed with efforts to clear the airway. the patient did receive epinephrine and atropine. the patient was revived and started on an esmolol drip for rate control and neo-synephrine for pressure support. the patient remained in atrial fibrillation with esmolol drip required and then discharged with intravenous lopressor for rate control. on the first, the patient's neurologic status seemed to be similar to pre-tracheostomy with opening eyes spontaneously, grimacing to procedures and nodding yes or no to questions. the patient remained off all antibiotics at this time. during the tracheostomy, the patient was noted to have a left pneumothorax and a left chest tube was placed. the patient's issue at this point continued to be his atrial fibrillation with intravenous lopressor needed for rate control. there was a discussion with cardiology regarding management of chronic atrial fibrillation and question of starting amiodarone. after discussion as to whether a tee would be necessary prior to chemical conversion and discussions with the family, it was felt that a tee would not be prudent at this time and chemical cardioversion with amiodarone would not be performed. rate control would be performed with beta blockers or calcium channel blockers as needed. it was deemed that the patient was not a candidate for anticoagulation for obvious reasons. on the 6th, the patient was converted to p.o. lopressor and remained on a trach collar with q 2 to 4 hour suctioning. it was deemed appropriate to be transferred to the medical surgical floor for continued care. however, on the evening of transfer, the patient returned to rapid atrial fibrillation with continued copious secretions with suctioning and significant nursing care required. therefore, the patient was transferred back to the intensive care unit for rapid atrial fibrillation and nursing care. the patient has remained in the intensive care unit getting q2h suctioning with clear occasionally blood tinged secretions. he was started on a diltiazem drip on his second sicu admission with conversion of intravenous diltiazem to p.o. diltiazem on the 7th without difficulty. he has remained in good rate control on p.o. diltiazem. on the day of dictation, the patient remained stable without continued episodes of atrial fibrillation. discharge medications: 1. heparin subcutaneous 5000 units b.i.d. 2. insulin sliding scale 3. natural tears 4. aspirin 325 mg p.o. q day 5. diltiazem 60 mg p.o. q6h 6. bactrim 7. albuterol metered dose inhaler 1 to 2 puffs q6h prn 8. haldol 2 mg intravenous q6h prn 9. nystatin powder to affected areas prn 10. dilaudid 0.25 mg intravenous prn 11. epogen 5000 units subcutaneous monday, wednesday, friday 12. nph insulin 12 units subcutaneous b.i.d. 13. protonix 40 mg intravenous q day 14. nepro with promod at 40 cc an hour discharge instructions: the patient will be going to an acute rehabilitation facility for continued pulmonary care. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Temporary tracheostomy Percutaneous (endoscopic) jejunostomy [PEJ] Diagnoses: Acute posthemorrhagic anemia Acute kidney failure, unspecified Atrial fibrillation Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Cardiac arrest Accidental fall on or from other stairs or steps Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

past medical history: cad/cabg; afib- on dig; pacer; recent sdh; nasal bleed -intubation -> trach for failure to wean c/b vent associated pnx; tia's s/p cea; recurrent pneumonia; cri; type 2 dm with triopathy. allergies: pcn pt was recently in s/p fall and sdh. hospital course c/p tracheal bleed, ptx and asystolic arrest with bedside trach. he also had multiple episodes of rapid afib controlled with dilt. he was d/c'ed to . rehab course was c/b recurrent fevers, gnr in urine and sputum. on he had a tonic/clonic seizures for which he was started on dilantin. eeg showed no seizure activity at that time. cxr showed lll infiltrate and he was treated with ceftaz and cipro. code status was discussed with his dauther and pt was made dnr. he was d/c'ed back to . he had been doing relatively well until when he began spiking temps to 102, decreased mental status, with mod- lg amt of brbpr with formed stool. hct 30 ->25, creat 1.8 -> 2.9 with marked decrease in u/o over the week. stool was positive for c.diffand started on flagyl. he looked better but bun/creat increased to 83/4.4 (he is not a dialysis canidate by pt's own request). this am pt had 3 grand mal seizures. pt was transfered back to for further evaluation. review of systems: resp-pt has a trach and is vented on psv 10/peep 5. he is being for white secretions q2-3h. she also has alot of oral secretions. neuro: pt has had no evidence of seizures since admission. on admission he was unresponsive to stimuli but has seemed to wake more. he has made no effort to communicate or follow commands but he looks and focuses, as well as tracks you in the room. he moves r>l upper extremites. when turning he fights by stiffining to avoid turning. cardiac: b/p 118-130/50's, hr 100's afib. with rare pvc's. k+ 4.3 renal: pt arrived on the unit with a 3-way foley from (they were giving ampho bladder irrigations for yeast). he also has a purulent discharge from his meatus, this drainage was cultured. the foley was changed to a 2 way foley. u/o 50-100cc/hr. bun 88, creat 4.5. renal ultrasound done. gi: pt has a peg, site looks good. he has hypoactive bowel sounds with green liquid stool that was (+) for c.diff at . he is currently npo but nutrition consult recommended ultracal with goal of 75 cc/hr. id: pt is on iv flagyl for c.diff. he has been afebrile 97.0-98.0, wbc's 11.1 with no bands. lines: pt had a picc line in right brachial that was placed by ir on . the site was reddened and since he was having fevers the picc was d/c'ed with tip cultured, a #20a was started in left lower arm and the iv team will place a new picc in left brachial when he has been cleared from bacterimia. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Other lavage of bronchus and trachea Diagnoses: Acute kidney failure with lesion of tubular necrosis Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Other convulsions Pulmonary collapse Other specified cardiac dysrhythmias Acute bronchitis Tracheostomy status

service: micu history of present illness: the patient is an 80-year-old male with a past medical history significant for diabetes type 2, coronary artery disease, transient ischemic attacks, chronic renal insufficiency, atrial fibrillation, who was transferred to from his acute renal failure and seizure x 4. the patient had been recently admitted to in secondary to a fall which resulted in development of a subdural hematoma. his course was complicated by a difficult bedside tracheostomy with significant bleeding and a pneumothorax. the patient also experienced an episode of asystole at this time, as well as rapid atrial fibrillation was treated with diltiazem and digoxin, and he was discharged to in with a tracheostomy in place. at the rehabilitation hospital, the patient was noted to have gram-negative rods in urine and sputum, and was treated with ciprofloxacin and ceftazidime for a full course. he was also noticed to have an increased tsh, and was started on synthroid. on the first of , the patient was noted to have an episode of tonic/clonic seizures. he was therefore admitted back to the hospital. he was started on dilantin, with a goal of a free dilantin level between 1 and 1.5, to be maintained over six months. an electroencephalogram was checked at that time, which was within normal limits. the patient was also noted to have a left lower lobe infiltrate, and was started on a course of ceftazidime. the patient's pulmonary function improved significantly over the course of the hospital stay, and at the time of discharge, he was tolerating tracheostomy mask trials for approximately two to three hours each afternoon. the patient's atrial fibrillation was well controlled on diltiazem as well as digoxin. the patient had a picc line placed for antibiotic therapy, and was discharged back to rehabilitation on the . at the rehabilitation hospital, the patient continued to improve significantly. according to the patient's family and doctor, the patient's mental status continued to improve to the point where he was able to have short conversations with a passey-muir valve, and appeared to be both alert and oriented. the patient was even to the point of making decisions with his family regarding his medical treatment. however, on , the patient experienced a temperature spike to 102 degrees, and was found to be hypotensive. this was associated in a decrease in mental status, and the patient was thought to be septic, possibly secondary to a picc line infection. over the course of the day, the patient had one episode of bright red blood per rectum, as well as a small drop in his hematocrit, for which he was transfused two units of packed red blood cells. he was also noted to have a bump in his creatinine from his baseline of 1.8 to 2.9, associated with decreased urinary output. sputum cultures from that day grew acinetobacter, and the patient was started on a combination of ciprofloxacin and ceftazidime antibiotic therapy. in addition, stool cultures from that day were positive for c. difficile toxin, and the patient was started on intravenous flagyl as well as intravenous vancomycin. over the course of the next two days, the patient continued to decompensate. his creatinine rose steadily, and the patient developed acute renal failure, which was thought secondary to acute tubular necrosis secondary to hypoperfusion during his septic episode. there was no response in his urinary output to lasix or intravenous hydration. the patient was found to have yeast growing in his urine, and was started on amphotericin b bladder lavages twice a day. the patient's pulmonary function also continued to worsen, and an ultrasound of the chest wall revealed a small left pleural effusion. multiple discussions were held between the patient's doctor and his health care proxy, his daughter, , who made her wishes known that she felt it was very important that the patient remain at and not have to be taken back to the hospital. however, on the evening prior to admission, the patient had four episodes of tonic/clonic seizures and ceased producing any urine. at that point, the daughter felt like it was important that the patient receive further medical care, and he was transferred from to . past medical history: diabetes mellitus type 2, coronary artery disease, status post coronary artery bypass graft, status post multiple transient ischemic attacks, status post carotid endarterectomy, atrial fibrillation, pacemaker placement, status post recent subdural hematoma in , recurrent pneumonias, chronic renal insufficiency. medications on admission: digoxin 0.125 mg by mouth once daily, protonix 40 mg by mouth once daily, epogen 5000 units subcutaneously monday, wednesday and friday, vitamin k 10 mg by mouth once daily, synthroid 25 mcg by mouth once daily, dilantin 100 mg by mouth three times a day, heparin subcutaneously 5000 units twice a day, free water boluses 100 mg per nasogastric tube once daily, ciprofloxacin 200 mg intravenously twice a day, ceftazidime 1 gram every 24 hours, flagyl 500 mg every eight hours, vancomycin 1 gram intravenously once daily, amphotericin b bladder washings twice a day. allergies: penicillin. social history: the patient is currently a resident of . his primary care physician is . . his health care proxy is his daughter, . physical examination: general: the patient is an elderly, fair-appearing male, cachectic, unresponsive. vitals: afebrile, blood pressure 90s/60s, heart rate 98, respiratory rate 26 to 28, oxygen saturation 98%. head, eyes, ears, nose and throat: normocephalic, atraumatic, pupils equal, round and reactive to light, mild scleral icterus, dry mucous membranes. neck: supple, no lymphadenopathy. cardiovascular: heart rate irregularly irregular, normal s1 and s2, ii/vi systolic ejection murmur heard at the left sternal border, no jugular venous distention. lungs: diffuse rhonchi bilaterally, decreased breath sounds bilaterally, crackles at bilateral bases. abdomen: positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly. extremities: multiple ecchymoses over all four extremities, 2+ pulses in upper extremities, 1+ pulses in lower extremities, no cyanosis, clubbing or edema. genitourinary: the patient had a foley in place, red candidal rash over entire groin and sacral area, no sacral ulcers or decubitus ulcers. neurological: the patient was unresponsive. he was able to move all four extremities. reflexes 1+ in biceps, patellar, achilles tendons. laboratory data: white blood cell count 11.1, hematocrit 30.0, platelets 378. sodium 133, potassium 4.3, chloride 97, bicarbonate 23, bun 88, creatinine 4.5, glucose 86. alt 18, ast 46, alkaline phosphatase 422, ldh 227, total bilirubin 4.5, direct bilirubin 2.4, lipase 34, amylase 26, dilantin 3.8, free dilantin 1.7, albumin 2.3. calcium 8.1, magnesium 2.1, phosphate 4.4, vancomycin 24.6, digoxin 1.5. reticulocyte count 1.6. urinalysis: moderate blood, nitrite negative, 100 protein, 35 red blood cells, 16 white blood cells, occasional bacteria. urine electrolytes: sodium 83, creatinine 23, potassium 20, chloride 72, urea 242. head ct: slightly reduced size of left subdural hematoma, otherwise no other intracranial acute pathology. chest x-ray: small lung volumes, small left pleural effusion, small left lower lobe consolidation which appears stable if not improved compared to his chest x-ray at time of last discharge. pacemaker wires in appropriate positions. right picc line with tip in the superior vena cava. tracheostomy in place. hospital course: the patient is an 81-year-old gentleman with a history of multiple past medical problems, who was transferred from for acute renal failure thought secondary to a hypotensive episode and seizure x 4. 1. pulmonary: the patient was brought in with a tracheostomy in place and on a ventilator. his initial ventilator settings were pressure support, 15 and 5, with tidal volumes of 430, respiratory rate of 15, and fio2 of 40%. his initial arterial blood gas at the time of admission was 7.34/38/87. the patient was thought to be stable from a pulmonary perspective at the time of admission. there was no specific acute new process noted on chest x-ray, and the patient had minimal sputum production at the time of admission. he had been treated empirically with ceftazidime and ciprofloxacin for a possible pulmonary infection. since the patient had been experiencing fevers even on these medications, it was determined that the best course of action would be to stop all antibiotic therapy which had no particular indication and to follow the patient clinically. therefore, ceftazidime and ciprofloxacin were discontinued. over the course of the hospital stay, the patient did well from a pulmonary perspective. he continued on pressure support at 15 and 5, and was placed on fimv at night to avoid any apneic episodes. the patient also tolerated tracheostomy mask trials for approximately two to three hours during the course of each day. however, on the 22nd, the patient suddenly experienced acute shortness of breath associated with a decrease in his oxygenation. his fio2 was bumped from 40% to 70%, and his oxygen saturation was maintained. a chest x-ray was obtained, which demonstrated complete white-out of the left lung. the patient underwent a bronchoscopy which revealed a tracheobronchitis, minimal secretions, no evidence of mucous plugging or other endobronchial lesion. the patient was also evaluated by ultrasound to determine the presence and/or size of a pleural effusion. however, ultrasound demonstrated only a very small amount of fluid at the left lung base. a chest x-ray obtained following the bronchoscopy demonstrated significant return of air fields in the left lung, suggesting that the patient had likely had an episode of mucous plugging leading to left lung collapse, which was revealed on a chest x-ray of a white-out. putting the patient back on positive pressure ventilation as well as having a bronchoscopy enabled the patient to expand his left lung. therefore, the patient was started on levofloxacin 250 mg intravenously every 24 hours to treat the underlying infection which prompted this process, and the patient's current tracheostomy mask trials will be discontinued until the patient has cleared the infection and is able to tolerate them once again. at the time of discharge, the patient was stable from a pulmonary perspective. he had good saturations on an fio2 of 40%. he will complete a 14 day course of levofloxacin to treat his underlying pulmonary infection. he is to be returned to with ventilator settings pressure support, 15 and 5, tidal volumes of approximately 400, respiratory rate of approximately 15, and fio2 of 40%. 2. cardiovascular: the patient has a history of atrial fibrillation and is on digoxin therapy. however, the patient was noted to be tachycardic, with heart rates in the upper 90s to low 100s over the course of the admission. therefore, the patient was started on diltiazem, which was titrated up to 45 mg per nasogastric tube three times a day. at this dose, the patient's heart rate was maintained in the 60s, and the patient's blood pressure remained stable over the course of the hospital stay. the patient had no further cardiovascular issues. 3. renal: at the time of admission, the patient had a creatinine of 4.5, which had been trending up over the past three days. the patient's urinary electrolytes suggested this was not a pre-renal pattern, and in addition the patient did not respond to intravenous therapy hydration. a renal ultrasound was obtained to evaluate for a post-obstructive process. there was no evidence of any hydronephrosis, stones, or any obstructing lesion on either side. therefore, it was felt that the patient was most likely experiencing renal failure secondary to an intrinsic renal etiology. his urinary sediment was examined, which was not consistent with any particular renal process. however, discussion with the patient's doctor revealed that urinary sediment obtained from that hospital was consistent with acute tubular necrosis. therefore, it was felt that the patient was experiencing acute renal failure secondary to acute tubular necrosis, which was most likely prompted by his hypotensive episode during his initial sepsis on the 16th. the patient did not have indication for dialysis at the time of admission, however, a long discussion was held with the health care proxy, , regarding the patient's wishes for dialysis, since the patient was unable to respond at this time. the patient's daughter stated that she felt that the patient would not wish to be on dialysis for a long time, however, if it was something that could treat an acute process and could be stopped perhaps further down the road, it might be a treatment that the patient would wish for himself. however, a final decision was not made and will require further discussion with the family. over the course of the hospital stay, the patient's urinary output picked up significantly, and his creatinine began to drop. at the time of discharge, the patient had well over 30 cc of urine output per hour, and his creatinine was continuing to trend downward. 4. infectious disease: at the time of admission, the patient had a questionable presentation of sepsis. he had currently been on four different intravenous antibiotics as well as amphotericin b bladder washings. the patient had received three days of bladder washings, and therefore these were discontinued. the patient's foley was changed, and a urine sample was resent and showed no sign of yeast. the patient had a documented c. difficile toxin positive test at . therefore, the patient's flagyl was continued in an effort to complete a 14 day course to treat this infection. however, the remainder of the patient's antibiotics, including ceftazidime, ciprofloxacin, and vancomycin, were discontinued, as there was no clear indication of what they were treating, and it was felt like multiple antibiotics might be contributing to a drug fever. once the antibiotics were discontinued, the patient's fever quickly defervesced, and the patient appeared much better. in addition, the patient's picc was removed, and the tip was cultured, which showed no growth. a urethral swab was obtained at the time of admission, also demonstrating no growth at the time of discharge. the patient remained well, however, on the fourth hospital day, developed a decreasing saturation associated with an increased oxygen need. bronchoscopy at that time revealed a tracheobronchitis and an x-ray revealed an increase in the left lower lobe consolidation. therefore, the patient was started on levofloxacin 250 mg intravenously every 24 hours in an attempt to treat a tracheobronchitis vs. pneumonia. the patient is to complete a 14 day course of this therapy. over the course of the hospital stay, the patient's white blood cell count increased mildly in association with his increased need for oxygen. however, the patient remained afebrile over the course of the hospital stay. 5. neurological: the patient developed seizures diagnosed ni the past month secondary to the developed of left subdural hematoma following his fall. at the time of the past discharge, the patient had a therapeutic dilantin level and had demonstrated no seizure activity. however, in the setting of sepsis and acute renal failure, the patient experienced four episodes of seizure prior to admission. following the time of admission, the patient had no further seizure activity. approximately 24 hours after admission, the patient's mental status began to clear, and he returned nearer to his baseline. the patient was loaded with dilantin in the emergency department, and an effort was made to determine why the patient's free dilantin level was low at the time of admission, as well as to determine the appropriate dilantin dose. discussion with neurology and pharmacy revealed that the patient was most likely having poor absorption of his dilantin through the gastrointestinal tract, even though tube feeds were being held before and after the elixir was given. therefore, at the suggestion of pharmacy, the patient was switched from dilantin elixir to dilantin crushed tablets in order to obtain better absorption. in addition, the patient's dilantin dose was increased from 100 three times a day to 150 in the morning, 100 in the afternoon, and 150 mg at night. a free dilantin level is to be checked on the 28th to determine the efficacy of this change in dilantin therapy. 6. fluids, electrolytes and nutrition: the patient has a percutaneous endoscopic gastrostomy tube in place. he was nothing by mouth at the time of admission, but was started on tube feeds when tolerated. he quickly reached his tube feed goal of 75 cc/hour of ultracal tube feeds. the patient remained hemodynamically stable over the course of the hospital stay. his electrolytes were checked on a daily basis and replaced as needed. 7. gastrointestinal: the patient demonstrated an elevated alkaline phosphatase and total bilirubin at the time of admission. a right upper quadrant ultrasound was obtained in order to evaluate for cholangitis or other biliary tract disease. gallstones were noted in the gallbladder, and there was some mild thickening of the gallbladder wall, however, no stones were noted to be obstructing the ducts, and there was no ductal dilatation. therefore, it was felt that the elevation in alkaline phosphatase and total bilirubin was secondary to the patient's passing a stone, which did not cause an obstruction. the patient's laboratory values were noted to decrease over the course of the hospital stay. the patient had no further gastrointestinal issues. 8. endocrine: the patient has a history of hypothyroidism, and is on synthroid therapy. a tsh and t4 were not checked while the patient was in hospital, as it was felt that his acute illnesses would cloud the appropriateness of the synthroid therapy. therefore, the patient needs to have his tsh and t4 followed up when he returns to . the patient also has a history of diabetes mellitus. he was controlled on finger sticks four times a day and a regular insulin sliding scale. 9. hematology: the patient has a history of anemia of chronic disease. his epogen 5000 units subcutaneously monday, wednesday and friday was continued while the patient was in the hospital. condition at discharge: the patient was discharged to in stable condition. he had a picc line placed at prior to discharge. discharge status: stable. discharge diagnosis: 1. acute renal failure secondary to acute tubular necrosis 2. seizure disorder 3. pneumonia, left vs. tracheobronchitis 4. s/p atalectasis, left lung 5. subdural hematoma, chronic 6. respiratory insufficiency, chronic dr. dictated by: medquist36 d: 22:36 t: 00:00 job#: Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Other lavage of bronchus and trachea Diagnoses: Acute kidney failure with lesion of tubular necrosis Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Other convulsions Pulmonary collapse Other specified cardiac dysrhythmias Acute bronchitis Tracheostomy status

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: wheezing major surgical or invasive procedure: none history of present illness: the patient is a 46 year old male with pmh of asthma and morbid obesity, who presented to an osh on with complaint of wheezing and doe x 2 days. patient reports onset of sob, wheezing, and fevers on . his pcp had prescribed amoxicillin, but patient denied any improvement in his symptoms. on presentation to the osh, the patient was noted to be in respiratory distress, with a room air o2 sat of 91%. abg was noted to be 7.34/53/69. he was placed on a 50% face mask, and he was administered prednisone, levofloxacin, and bronchodilators. he was transferred to for further management. past medical history: 1. asthma- no history of intubation. last flare ~7 years ago. 2. htn 3. morbid obesity social history: the patient lives with his wife, children, and mother-in-law. quit smoking on . he smoked 1.5 packs per day x 20-30 years. he drinks alcohol occasionally. denies illicit drug use. family history: nc physical exam: vs: t: 100.4 bp: 154/64 hr: 101 rr: 20 o2 sat: 95% on 50% face mask general: obese male lying in bed in mild respiratory distress. patient is able to speak in full sentences heent: mmm. oropharynx clear. neck: supple. no lad. cvs: distant heart sounds, tachy. no murmurs appreciated. lungs: diffuse insp and exp wheezes throughout, moderate air movement. abd: obese, soft, nt, +bs. extr: no c/c/e. warm. pertinent results: wbc hgb hct mcv plt ct 10.5 14.1 40.5 91 293 neuts bands lymphs monos eos 78.4* 16.9* 4.0 0.3 0.3 glucose urean creat na k cl hco3 113* 12 0.8 138 3.7 100 30* calcium phos mg 8.6 3.7 2.2 ua (): color appear sp straw clear 1.025 blood nitrite protein glucose ketone bilirub urobiln ph leuks neg neg tr neg neg neg neg 6.5 neg micro: : influenza a dfa: pos sputum () gram stain (final ): pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): multiple organisms consistent with oropharyngeal flora. respiratory culture (pending): blood cx x 2 (): pending urine cx (): pending radiology: chest (portable ap) 10:54 am large size habitus of patient, but no evidence of chf or acute infiltrates on portable single view examination. chest (portable ap) 6:06 am hypoventilation involving the lower lobes. no evidence of active congestion or infiltration. no evidence of pleural effusion or pneumothoraces. ekg: sinus tach 107. nl int, nl axis. q iii. no st/tw changes. brief hospital course: 46 year old male with pmh of asthma, htn, and morbid obesity, admitted to micu on with wheezing/sob. 1) asthma exacerbation/influenza a: the patient was admitted to the micu for management of his respiratory distress. he was placed on bipap overnight on . he was treated for an asthma exacerbation with steroids and bronchodilators. he continued on levofloxacin for treatment of tracheobronchitis. on , the patient spiked a temperature of 102.4 his nasopharyngeal aspirate came back positive for influenza a. the patient was maintained on continous nebulizers, which have been tapered to q 4 hours. since the patient did not tolerate bipap, so he was placed on nasal cpap (12-15 cm h2o) for likely obstructive sleep apnea. in addition, the patient was administered wellbutrin and a nicotine patch to assist with smoking cessation. given improvement in his respiratory status, the patient was transferred to the medical floor. 2) smoking cessation: the patient was srtarted on wellbutrin and nictoine patch. 3) osa: he was placed on nocturnal cpap 12-15 cm h2o with a nasal mask. patient's pcp (dr. ) has been contact and outpatient sleep study was recommended. 4) htn: captopril was titrated as necessary and the dose was converted to lisinopril at the time of discharge. 5) steroid-induced hyperglycemia. glycemic control was maintained with riss. 6) fen: low na diet. medications on admission: medications on admission: azmacort albuterol avalade amoxicillin guiafenescin discharge medications: 1. fexofenadine hcl 60 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 2. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 6 days. disp:*6 tablet(s)* refills:*0* 3. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours) for 2 weeks. disp:*14 tablet, delayed release (e.c.)(s)* refills:*0* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 5. ipratropium bromide 0.02 % solution sig: one (1) inhalation q4h (every 4 hours). 6. albuterol sulfate 0.083 % solution sig: one (1) inhalation q4h (every 4 hours). 7. bupropion hcl 150 mg tablet sustained release sig: one (1) tablet sustained release po qd (). disp:*30 tablet sustained release(s)* refills:*2* 8. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. montelukast sodium 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. fluticasone propionate 110 mcg/actuation aerosol sig: four (4) puff inhalation (2 times a day). disp:*1 inhaler* refills:*2* 11. lisinopril 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 12. nicotine 14 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). disp:*7 patch 24hr(s)* refills:*0* 13. prednisone 20 mg tablet sig: three (3) tablet po once a day for 2 days: 0n and . disp:*6 tablet(s)* refills:*0* 14. prednisone 50 mg tablet sig: one (1) tablet po once a day for 2 days: on and . disp:*2 tablet(s)* refills:*0* 15. prednisone 20 mg tablet sig: two (2) tablet po once a day for 2 days: on and . disp:*4 tablet(s)* refills:*0* 16. prednisone 10 mg tablet sig: three (3) tablet po once a day for 2 days: and . disp:*6 tablet(s)* refills:*0* 17. prednisone 20 mg tablet sig: one (1) tablet po once a day for 2 days: and . disp:*2 tablet(s)* refills:*0* 18. prednisone 10 mg tablet sig: one (1) tablet po once a day for 2 days: and . disp:*2 tablet(s)* refills:*0* 19. respitory therapy please supply 1 cpap machine with all accessories necessary for daily overnight use. 20. oxygen please supply continuous oxygen @ 2l nasal canula. * pt is hypoxic at rest 89% (ra) and desaturates to <88% (ra) on ambulation. 21. cpap settings please set cpap @ 12 cm and 10 l/minute 02 in-line for nightly use. discharge disposition: home with service facility: respiratory solutions discharge diagnosis: 1. asthma exerbation 2. tracheobroncitis 3. obstructive sleep apnea 4. hypetension discharge condition: good discharge instructions: 1. call 911 or go to the nearest er if you experience increased shortness of breath, chest pain, fevers, chills, or feel unwell. followup instructions: 1. please call your primary care physician and pulmonologist, dr. , to follow up on your recent admission in the next 1-2 weeks @ . 2. you are schedule to see dr. on , at 2:00 pm for sleep study @ 2:00 pm on center; call ( for questions. md Procedure: Non-invasive mechanical ventilation Diagnoses: Unspecified essential hypertension Unspecified sleep apnea Morbid obesity Chronic obstructive asthma with (acute) exacerbation

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: morbid obesity major surgical or invasive procedure: open roux-en-y gastric bypass open cholecystectomy history of present illness: the patient is a 47-year-old gentleman with a bmi of 61 and a weight of 463 pounds. he has been on multiple supervised diets with a maximum of 125 pounds weight loss with regain. he has recently been evaluated by program and deemed a suitable candidate for weight loss surgery. he has comorbid conditions including hypertension, sleep apnea, gastroesophageal reflux disease, dyslipidemia and asthma. he is familiar with complications including mortality of 1%, complications of 10%, reoperation of 5%. he fully understands the risks of tracheostomy and ventilator dependence given his longstanding history of smoking. he is familiar with complications including leaks, internal hernias, external incisional hernias, stenosis, internal hernias, retained stones, abscesses, infections, bleeding, malnutrition, excess skin and hair thinning. he agrees to diet, exercise, support group and lifelong medical follow-up. past medical history: 1. asthma 2. bronchitis 2. htn 3. morbid obesity social history: quit tobacco , 30 pack-year history social etoh no other drug use family history: nc physical exam: nad, a&ox3 perrl heent wnl neck supple no masses or thyromegaly no cervical lad chest ctab rrr no mrg. no jvd abd obese, soft ntnd with nl bs. no surgical scars. full arom ue and le pertinent results: hct-36 brief hospital course: pt was admitted through same day admission and taken to the or with dr. for an open gastric bypass with cholecystectomy, see operative report for details. he tolerated the procedure well and was extubated in the or. due to the length of the operation, his morbid obesity, and his history of obstructive sleep apnea, it was decided to keep mr. in the pacu overnight. he experienced some elevated heart rate and blood pressure on pod#0 that was treated with iv lopressor with good effect. he otherwise had an uneventful first night and was transferred to the surgical floor on the morning of pod#1. his ng tube was removed and he was advanced to a stage i diet. nutrition and physical therapy were both consulted. on pod#2 the foley catheter was removed. a methylene blue swallow test was done which was negative. he was advanced to a stage ii diet which he tolerated well. he was ambulatory with physical therapy. on pod#3 he was advanced to a stage iii diet which he tolerated well. by the time of discharge on pod #5 he was ambulating well, saturating well on room air, and tolerating a stage 3 diet well. medications on admission: hctz 25' singulair 10' albuterol prn flovent 110" zyrtec 60" protonix 40' ambien prn lisinopril 20' asa centrum buproprion sr 150' discharge medications: 1. flintstones complete 30-200-3 mg-unit-mcg tablet, chewable sig: one (1) tablet, chewable po once a day. disp:*30 tablet, chewable(s)* refills:*2* 2. zantac 15 mg/ml syrup sig: ten (10) ml po once a day for 1 months. disp:*qs for 1 month ml* refills:*0* 3. roxicet 5-325 mg/5 ml solution sig: ml po every hours as needed for pain for 1 months. disp:*250 ml* refills:*0* 4. roxicet 5-325 mg/5 ml solution sig: ml po every hours as needed for pain for 1 months. disp:*250 ml* refills:*0* 5. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. bupropion 75 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 9. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). discharge disposition: home discharge diagnosis: morbid obesity hypertension obstructive sleep apnea gerd asthma gout bronchitis dyslipidemia discharge condition: stable discharge instructions: call your surgeon or go the er if you experience: -chest pain or shortness of breath -fevers greater than 101.5 degrees, chills -persistent nausea and vomiting -severe abdominal pain -inability to pass gas or stool -redness or foul-smelling drainage at wound medications: resume your usual home medications. take the roxicet (oxycodone/acetaminophen liquid) as prescribed for pain. in addition, you will need to take liquid zantac (acid-reducer) for 1 month and a chewable multivitamin every day. diet: stay on a stage iii diet until follow-up. do not self-advance your diet. do not chew gum or drink out of a straw. activity: you may resume your usual activities. however, you should not lift anything heavier than lbs for the next 6 weeks. wound care: you may shower as you normally would, but no swimming or bathing until after follow-up. the white paper strips over the incisions will fall off on their own in about a week. you can cover the incisions with a dry gauze if they are draining, otherwise no dressing is needed. followup instructions: provider: , md phone: date/time: 12:45 provider: , ma, rn, ldn phone: date/time: 1:30 Procedure: Non-invasive mechanical ventilation Cholecystectomy High gastric bypass Diagnoses: Esophageal reflux Unspecified essential hypertension Gout, unspecified Asthma, unspecified type, unspecified Personal history of tobacco use Other and unspecified hyperlipidemia Unspecified sleep apnea Morbid obesity Chronic cholecystitis

allergies: phenergan attending: chief complaint: sustained vt and unresponsiveness major surgical or invasive procedure: intracardiac defibrillator placement history of present illness: 52m with history hypertension, narcotics dependence and gastric bypass presented to with several days of nausea, vomiting, and diarrhea. there he was given zofran for nausea after which became unresponsive, noted to be in polymorphic ventricular tachycardia. he was shocked and loaded on amiodarone and then started on amiodarone drip 1mg/min and trasnferred to . on arrival he was alert, oriented. then had episode of vt and became unresponsive shocked with 200j, got another 150 amio gtt and then was changed to lidocaine drip 3mg/min, repleted k 40iv and 40 po. still having occasional 8-10 beat runs of vt in the ed. patient is also complaining of intermittent chest pain he describes as "irritating" localized to the area around the pacer pads. he received morphine, toradol and rectal aspirin in the ed. he has no recollection of the events surrounding his episodes. he denies any recent or remote episodes of chest pain but does endorse some dyspnea on exertion while climbing stairs. he does have a history of narcotic dependence and was recently on dilaudid 16mg q4h for pain following a complicated right knee replacement. he reports that he has since weaned himself down to 3-4mg po q4h. he also reports that he recently stopped taking his enoxaprin for dvt ppx 3 days ago. . in the ed, initial vitals were 98.6 62 144/94 18min 100%4l past medical history: 1. asthma 2. bronchitis 2. htn 3. morbid obesity 4. gout 5. obstructive sleep apnea 6. bronchitis social history: quit tobacco , 30 pack-year history social etoh dependence on prescribed narcotics family history: non-contributory physical exam: admission physical exam: general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. neck: supple cardiac: rr, normal s1, s2. no m/r/g. no s3 or s4. lungs: pacer pads in place. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. extremities: no c/c/e. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: radial 2+ dp 2+ left: radial 2+ dp 2+ pertinent results: cardiac labs: 12:43am blood ck(cpk)-49 07:07am blood ck(cpk)-51 01:32pm blood alt-12 ast-20 alkphos-109 totbili-0.4 04:29am blood ck(cpk)-68 05:53am blood ck(cpk)-33* 07:31pm blood ctropnt-<0.01 08:39pm blood ctropnt-<0.01 12:43am blood ck-mb-2 ctropnt-<0.01 07:07am blood ck-mb-2 ctropnt-<0.01 04:29am blood ck-mb-3 ctropnt-<0.01 05:53am blood ck-mb-3 ctropnt-<0.01 cardiac cath: 1. selective coronary angiography of this co-dominants system demonstrated single vessel coronary artery disease. the lmca was large in caliber, with minimal luminal irregularities. the lad was mildly calcified, with diffuse mild luminal irregularities. a large diagonal branch with luminal irregularities was noted. the distal lad wraps slighter aorund the apex, with slow flow consistent with microvascular dysfunction. the lcx was large in caliber, with dlow flow consistent with microvascular dysfunction. it supplies a large om2, lpl, and modest lpda. a large caliber, patent ramus was noted. the rca supplyinga modest caliber rpda and several rv branches was demonstrated. proximal to mid difuse diease with serial 75% stenoses with timi 2 slow flow (similar to lad and lcx) demonstrated. 2. limited resting hemodynamics revealed normal left ventricular filling pressures, with an lvedp of 12 mmhg. there was mild systemic hypertension, with a central aortic pressure of 140/93 mmhg (mean of 113 mmhg.) 3. limited femoral angiography demonstrated mild profunda plaquing iwht arteriotomy stie at the sfa/pf bifurcation. closure device not attempted. final diagnosis: 1. single vessel coronary artery diease, but diffuse slow flow consistent iwth diffuse microvascular dysfunction. 2. in the absence of symptoms and sentiment that vt was not ischemia induced, no intervention performed at this time, with plan for further evaluation of ischemia. 3. normal lv diastolic function. 4. mild systemic hypertension. . echo: the left atrium is moderately dilated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. there is mild to moderate global left ventricular hypokinesis more prominent inferior wall severe hypokinesis (lvef = 40 %). no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the ascending aorta is moderately dilated. the aortic arch is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. trace aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: mild left ventricular cavity enlargement with global hypokinesis c/w diffuse process (toxin, metabolic, cannot exclude multivessel cad). dilated thoracic aorta. mild mitral regurgitation. compared with the report of the prior study (images unavailable for review) of , the findings are new. . nuclear stress test: no ischemic ecg changes noted and no anginal type symptoms reported with persantine infusion. appropriate hemodynamic response. nuclear report below: 1. probably normal myocardial perfusion. inferior wall defect most consistent with attenuation. 2. increased left ventricular cavity size. moderate systolic dysfunction with global hypokinesis. brief hospital course: 52 year old man with a history of gastric bypass, narcotics dependence, and recent knee replacement who became unresponsive in outside hospital's emergency department secondary to polymorphic ventricular tachycardia following administration of zofran for nausea and vomiting. . # ventricular tachycardia: possible etiologies considered were ischemia, electrolyte abnormalities, medication effects, hypoxia, and metabolic causes. an echo revealed global hypokinesis. although catheterization revealed a narrowing of the rca, nuclear stress test did not show any reversible or nonreversible defects to suggest ischemia or infarction. the medical records, recent and remote past ekgs, and clinical presentation were reviewed, and it was concluded that the patient's hypokalemia, hypomagnesemia in the setting of two qt-prolonging medications contributed to development of vt. all qt-prolonging medications were held, and his electrolytes were repleted. given the risk that the patient's ventricular tachycardia might return, an icd was placed. the patient tolerated the procedure well. at the time of discharge, the patient still required two days of antibiotics to complete his course. . # acute systolic dysfunction according to echo, the patient's ef was 38% with global hypokinesis. the patient showed no evidence of fluid overload and seemed euvolemic upon discharge. the patient was started on 5 mg lisinopril. . # coronary artery disease the patient's catheterization showed 80% rca lesion, and the stress test showed inferior small reversible defect attributed to attenuation. no plans for intervention. the patient will continue on a beta-blocker and aspirin and be started on a statin. . # narcotics dependence/chronic pain: the patient has a history of significant narcotics dependence. he required 2mg iv dilaudid every 2 hours to prevent withdrawal symptoms. he expressed a desire to wean from narcotics and it is likely that an attempt at self-weaning prompted his initial complaints of nausea and vomiting. psychiatry was consulted, and they recommmended continuing current doses of ativan and dilaudid. the patient would also benefit from inpatient detoxification, and the patient agreed. unfortunately, the patient did not have insurance to cover such treatment. instead, he was provided enough medication to last until he could follow up with his primary care physician, intends to perform a slow taper. medications on admission: albuterol nebulizers prn tid metoprolol 25 mg dilaudid 16mg po q4 --> 3-4mg po q4, 2 mg 1-2 tabs q 4 hours prn neurontin 400mg one po tid x 14 days lunesta 3mg one tab at hs tums prn phenergan 25 mg pr q 4 hours x 10 doses only () ventolin 2 puffs qid flovent hsa 110 one puff xanaflex 6mg q 8 hours as needed for spasm tussionex tsp q 12 hours (normally one tsp) for cough augmentin x 10 days 400 mg on ( ) xoma 350 one tab tid as needed for spasm (should be finished) celexa 40 mg once daily lorazepam 1 mg 2 tabs tid discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. polyethylene glycol 3350 17 gram/dose powder sig: one (1) packet po daily (daily). 4. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. simvastatin 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) vial inhalation three times a day as needed for shortness of breath or wheezing. 8. cephalexin 500 mg tablet sig: one (1) tablet po three times a day for 2 days. disp:*6 tablet(s)* refills:*0* 9. hydromorphone 4 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 10. lorazepam 1 mg tablet sig: two (2) tablet po every six (6) hours as needed for anxiety. 11. flovent hfa 110 mcg/actuation aerosol sig: one (1) puff inhalation twice a day. 12. ventolin hfa 90 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation four times a day. 13. celexa 10 mg tablet sig: three (3) tablet po once a day. discharge disposition: home discharge diagnosis: ventricular tachycardia/torsades de pointes related to prolonged qt interval narcotic dependence acute systolic dysfunction 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 had nausea and vomiting and developed a dangerous rhythm called ventricular tachycardia or torsades de pointes that required a shock to restore a normal rhythm. we were concerned that this could happen again so we implanted an internal cardiac defibrillator (icd) that will shock you again if the rhythm reoccurs. please keep the dressing over the incision site until sunday , you can then take off the gauze dressing, leave the tape strips in place. you can then shower, don't get soap over the incision site. you will return here in 1 week to get the wound checked. you will need to take an antibiotic for 24 hours after you go home to prevent an infection at the icd site. call dr. right away if the icd fires. this feels like a very strong kick in the chest. you should avoid any medicines that make you more prone to ventricular tachycardia, we gave you list of these medicines. other medication changes are: 1. stop taking phenergan, gabapentin, xoma, lunesta, xanaflex, augmentin and tussionex 2. take cephalexin three times a day for 2 days to prevent an infection at the pacer site 3. start taking lisnopril to lower your blood pressure and help your heart pump better 4. start simvastatin to lower your cholesterol 5. take dilaudid 4mg for pain every 4 hours, decrease to 3mg every 4 hours on monday with further decreases per dr. 6. increase lorazepam to 2mg every 6 hours as needed for anxiety with further decreases per dr. . . we found that your heart function was also weaker than it was a year ago. we did not see any evidence of fluid overload here but you should monitor yourself for swelling in the legs, trouble breathing and a bothersome cough. weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 1 day or 5 lbs in 3 days. followup instructions: department: cardiac services when: thursday at 9:30 am with: device clinic building: sc clinical ctr campus: east best parking: garage department: surgery when: wednesday at 2:00 pm with: , rd,ldn building: sc clinical ctr campus: east best parking: garage department: surgery when: wednesday at 2:30 pm with: , md building: sc clinical ctr campus: east best parking: garage name: , address: ,, , phone: appointment: thursday 4:30pm department: cardiac services when: wednesday at 3:20 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage please call registration at to complete your insurance information. thanks. Procedure: Coronary arteriography using two catheters Left heart cardiac catheterization Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Diagnoses: Other primary cardiomyopathies Other chronic pain Coronary atherosclerosis of native coronary artery Tobacco use disorder Unspecified essential hypertension Hypopotassemia Opioid type dependence, continuous Paroxysmal ventricular tachycardia Knee joint replacement Drug withdrawal Disorders of magnesium metabolism Long QT syndrome Heart disease, unspecified Bariatric surgery status

allergies: penicillins attending: addendum: mr. was not discharged on as he was not offered a bed. his weekend was uneventful. on his sutures were removed. he is being discharged today in stable condition. discharge disposition: extended care facility: - md, Procedure: Fasciotomy Open reduction of fracture with internal fixation, tibia and fibula Transfusion of packed cells Open reduction of fracture with internal fixation, other specified bone Diagnoses: Thrombocytopenia, unspecified Acute posthemorrhagic anemia Defibrination syndrome Other specified cardiac dysrhythmias Retention of urine, unspecified Traumatic compartment syndrome of lower extremity Closed fracture of pubis Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle Closed fracture of acetabulum Fat embolism Closed fracture of shaft of tibia alone

allergies: penicillins attending: chief complaint: s/p mvc major surgical or invasive procedure: : orif left tibia with 4 compartment fasciotomies : orif left posterior wall acetablar and closure of fasciotomies. history of present illness: mr. is a 19 year old who was involved in a single car accident on . he stated that he felt dizzy, was unlocking his seatbelt and lost control of his car. he hit a guardrail and was ejected from the car. he was taken to hospital for evaluation and then taken by to for evaluation. past medical history: migraines social history: lives with parents in school family history: stable physical exam: upon admission alert/oriented cardiac: svt but hemodynamically stable chest: lungs clear bilaterally abdomen: soft non-tender non-distended extremities: left hip posterior dislocation, pain with rom, lower leg swollen tense pressure 73, sensation intact, + movement brief hospital course: mr. presented to the via transfer. he was evaluated in the trauma bay by the orthopaedic and trauma surgical teams. he was noted to be in svt by remianed hemodynamically stable. he was taken to the operating room for left compartment syndromes and he underwent fasciotomies and an left tibia nail. he tolerated the procedure well, was extubated and transferred to the trauma icu. in the icu he remianed stable. cardiology was consulted for the svt episodies. he was transferred to the floor on . on he was again taken to the operating room. he underwent a posterior wall acetabular fracture orif and closure for the left tibia fasciotomies. also in the operating room he under went an echo per cardiology, which was essentially normal. on a cta was done because of concern for a pe because of transient hypoxia. the cta findings were consistent with fat emboli. medicine was consulted and they recommended supportive management. on he was transfused with 2 units of packed red blood cells due to post operative anemia. today, 6/8/7, his hct is 25.4. the remainder of his hospital course was without incident. his pain was well controlled. his labs and vitals remained stable. he is being discharged today in stable condition. medications on admission: fioricet discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for fever/pain. 2. enoxaparin 30 mg/0.3 ml syringe sig: one (1) subcutaneous q12h (every 12 hours) for 4 weeks. 3. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day) as needed. 4. hydromorphone 2 mg tablet sig: 1-2 tablets po q3-4h (every 3 to 4 hours) as needed for pain. 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. discharge disposition: extended care facility: - discharge diagnosis: s/p mvc left tibia fracture compartment syndrome left posterior wall acetabular fracture post-operative anemia discharge condition: stable discharge instructions: continue to be touchdown weight bearing with posterior hip dilocation precautions. continue your lovenox as instructed keep your incisions clean and dry your sutures/staples can come out 14 days after your surgery or at your follow up appointment. if you notice any increased redness, driange, or swelling, or if you have a temperature greater than 101.5 please call the office or come to the emergency department. physical therapy: activity: as tolerated right lower extremity: full weight bearing left lower extremity: touchdown weight bearing treatments frequency: sutures/staples can be removed 14 days after surgery or at your follow up appointment you may apply a dry sterile dressing daily of as needed for comfort or drainage followup instructions: please follow up with dr. in 2 weeks, please call to schedule that appointment. please follow up with your primary care physcian for a stress test as per cardiology. md, Procedure: Fasciotomy Open reduction of fracture with internal fixation, tibia and fibula Transfusion of packed cells Open reduction of fracture with internal fixation, other specified bone Diagnoses: Thrombocytopenia, unspecified Acute posthemorrhagic anemia Defibrination syndrome Other specified cardiac dysrhythmias Retention of urine, unspecified Traumatic compartment syndrome of lower extremity Closed fracture of pubis Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle Closed fracture of acetabulum Fat embolism Closed fracture of shaft of tibia alone

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: melena, hypotension major surgical or invasive procedure: esophagogastroduodenoscopy (egd) history of present illness: mr. is a 67 yo m with history of multiple myeloma, paroxysmal atrial fibrillation, and prior known duodenal ulcer who presented to an outside hospital with one day history of melena and hypotension to sbp in the 80s at home. he had chemotherapy with valcade and dexamethasone at three days prior to admission. at osh, he was guaiac positive, and his hct was found to be 22 down from a baseline in the mid 30s per his wife. was transfused two units of packed red cells and a cordis was placed. patient also complained of chest pain on presentation and had dynamic st depressions in the lateral leads. he was given nitro and blood with resolution of his symptoms. patient was transferred to for further management. in the ed, initial vs were: 97.0, 99, 128/89, 20, 100% 10l nrb. patient was given a iv bolus and started on a ppi drip. he had a negative ng lavage but was again guaiac positive. repeat labs here showed hematocrit of 24.8 (he did not bump his hematocrit after the two units given at the osh). ekg here showed atrial fibrillation without any st changes. gi was consulted, and he was admitted to the icu for further management. on transfer, vitals were 107, 122/76, 14, 99% 2l nc. in the micu, the patient received a total of 4 units which he tolerated well without complaints. his chest pain completely went away when he received blood products. patient had 18 hours of diarrhea after taking his chemo on friday but did not notice any blood at that time. he did have three hours of melena on saturday night but has had no further bms since. no abdominal pain, nausea, vomiting, constipation. no change in po intake, difficulty breathing or dyspnea on exertion. past medical history: multiple myeloma on chemo paroxysmal afib cad s/p ptca in htn h/o gastric ulcer tias hypercholesterolemia pfo with asd on echo with right to left & left to right shunts presumed diagnosis of amyloid angiopathy h/o ich while on warfarin (no longer anticoagulated) social history: he is married and his wife is his hcp. denies smoking, etoh or drugs. family history: uncle: died of mi in 70's father: leukemia, mi at age 65 also aml uncle: died of mi in 40's physical exam: on transfer in the er temp:97.0 hr:99 bp:128/89 resp:20 o(2)sat:100 normal constitutional: comfortable heent: normocephalic, atraumatic; pale conjunctiva oropharynx within normal limits chest: clear to auscultation cardiovascular: tachy regular rate and rhythm, normal first and second heart sounds abdominal: soft, nontender, nondistended pertinent results: admission labs: 06:25am blood wbc-15.0*# rbc-2.87*# hgb-8.8*# hct-24.8*# mcv-87 mch-30.8 mchc-35.5* rdw-16.5* plt ct-214 06:25am blood neuts-85.7* lymphs-10.0* monos-4.0 eos-0.1 baso-0.1 04:09am blood hypochr-normal anisocy-1+ poiklo-1+ macrocy-1+ microcy-1+ polychr-1+ spheroc-2+ ovalocy-1+ schisto-occasional 06:25am blood pt-12.3 ptt-19.4* inr(pt)-1.0 06:25am blood glucose-128* urean-72* creat-1.6* na-139 k-3.9 cl-105 hco3-25 angap-13 01:46pm blood calcium-7.9* phos-2.8 mg-2.5 01:46pm blood alt-19 ast-15 ck(cpk)-63 alkphos-66 totbili-1.3 06:25am blood ctropnt-0.02* 01:46pm blood ck-mb-4 ctropnt-0.05* 03:20pm blood ck-mb-4 ctropnt-0.05* 08:42pm blood ck-mb-3 ctropnt-0.06* 04:09am blood ck-mb-3 ctropnt-0.05* 08:08pm blood ck-mb-3 ctropnt-0.04* . ecg study date of 6:22:00 am atrial fibrillation with rapid ventricular response. diffuse non-specific st-t wave flattening. compared to the previous tracing of the lateral ischemic appearing t wave abnormalities are no longer recorded. however, pseudonormalization cannot be excluded, given the rapid rate. atrial fibrillation has appeared. followup and clinical correlation are suggested. intervals axes rate pr qrs qt/qtc p qrs t 105 0 84 362/440 0 -3 134 . egd normal esophagus. edematous, erythematous antral fold noted consistent with inflammation and possibly underlying ulcer. a single non-bleeding 2 mm ulcer was found in the stomach body. otherwise normal egd to third part of the duodenum brief hospital course: mr. is a 67 yo male with history of paroxysmal atrial fibrillation, coronary artery disease, hypertension and multiple myeloma s/p recent chemo. he has a known duodenal ulcer and presented with melena and hypotension (sbp 80's) to an outside hospital. there he was found to have a hematocrit of 22 down from his baseline in the mid 30's. he also complained of chest pain with lateral st depressions noted on ekg that resolved when he received nitroglycerin and 2 units prbcs. . icu course: he was transferred to . on initial evaluation in the emergency room he had a hematocrit of 24 despite the 2 units prbcs from the outside hospital and was noted to be in atrial fibrillation with a ventricular rate greater than 100. he was started on a ppi drip and admitted to the icu for further management. while in the icu, his atrial fibrillation was controlled with metoprolol iv and reinstitution of his sotalol. the patient had one further episode of chest tightness that resolved with nitrates as he received an additional 4 units of prbc's with his hematocrit stabalizing in the low 30's. he was ruled out for an mi and remained stable from a cardiac standpoint after that single episode. he had no further melena or guaiac positive stools in the icu and underwent egd on with the results as noted above. on transfer to the hospital floor on , he had a transient episode of hypotension with a pressure of 85/58 when he was transferring from the stretcher to the bed, which was attributed to the patient having restarted his home dose of labetalol on the evening of transfer. his labetalol was subsequently held (until the day of discharge) and his blood pressure stabalized. . # gi bleed: egd: edematous, erythematous antral fold noted c/w inflammation and possibly underlying ulcer; single non-bleeding 2 mm ulcer was found in the stomach body. the patient was treated with a total of 6 units of prbcs with stabalization of his hematocrit. his intravenous pantoprozole was changed to po and the patient's diet was advanced. on the 4th and 5th hospital days following transfer from the icu, the patient had an episode of black tarry stool on each day. in consultation with the gi service, these episodes were felt to be due to old blood from his initital upper gi bleed. his hematocrit and blood pressure remained stable over the course of these two days with no further evidence of new bleeding. . # chest pain: the patient's episode of chest tightness was felt to be demand ischemia related to gi bleed superimposed on atrial fibrillation and rapid ventricular response. pain improved with sl nitroglycerin and blood transfusions. his troponins remained flat and he ruled out for an mi. he has been continued on his statin. the hospital course was reviewed with the patient's primary cardiologist and the patient will follow up with him on . . # atrial fibrillation: the patient has paroxysmal atrial fibrillation treated with sotalol and labetalol. his rapid ventricular response at the outside hospital appeared related to hypovolemia and ischemia from his gi bleed. his rate has been controlled with single doses of metoprolol iv when in the icu and reinstitution of his sotalol. he converted to nsr by hospital day 4. on the last hospital day, he has been restarted on a lower dose of his labetalol (in addition to sotalol) to prevent further rapid ventricular response, but his dose is limited by his earlier hypotensive episodes. the patient is anticoagulated with low dose aspirin and aggrenox, but these were held during his gi bleed. he received a single dose of each on the 4th hospital day just prior to having two further guaiac positive, melenic stools. although, the stools are thought to be from old blood and the patient's hematocrit has remained stable, his anticoagulation was discontinued. this has been discussed with his primary cardiologist by phone, and the patient will see him in follow up on to address restarting low dose aspirin and aggrenox. . # multiple myeloma: last chemo with velcade and decadron at . the patient was continued on bactrim and acyclovir prophylaxis and he will follow up with dr. at the on where he will be evaluated and the decision whether or not to proceed with chemotherapy will be made. . # hypertension: he takes numerous antihypertensives at home including amlodipine, tekturna, labetalol, clondine and losartan. these had been held in the setting of his hypotension and gi bleeding and only clonidine and labetalol have been reinstituted at the time of discharge. he will follow up with his cardiologist on and his pcp on to reinstitute these medications as tolerated. medications on admission: aggrenox 200 mg-25 mg amlodipine-atorvastatin 10 mg-80 mg daily aliskiren 300 mg daily sotalol af 120 mg daily labetalol 400 mg clonidine 0.1 mg furosemide 80/40 mg daily aspirin low-strength 81 mg chewable daily (takes ) losartan 100 mg daily folic acid 1 mg daily vitamin d 50,000 unit qweek nitroglycerin 0.4 mg sublingual prn multivitamin 1 daily amlodipine besylate 5mg daily dexamethasone -- unknown strength revlimid -- unknown strength valcade unknown sig bactrim -- unknown strength qmonday wednesday friday acyclovir unknown daily discharge medications: 1. sotalol 80 mg tablet sig: 1.5 tablets po daily (daily). 2. simvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po qmowefr (monday -wednesday-friday). 4. acyclovir 400 mg tablet sig: one (1) tablet po daily (daily). 5. clonidine 0.1 mg tablet sig: one (1) tablet po twice a day. 6. omeprazole 40 mg tablet, sig: one (1) tablet, po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 7. labetalol 100 mg tablet sig: one (1) tablet po bid (2 times a day): do not take if your pulse is less than 50 beats per minute. disp:*60 tablet(s)* refills:*2* 8. folic acid 1 mg tablet sig: one (1) tablet po once a day. 9. vitamin d 50,000 unit capsule oral 10. multivitamin oral 11. take your chemotherapy medicines as directed by your oncologist these include revlimid, dexamethasone, and velcade discharge disposition: home discharge diagnosis: upper gastrointestinal bleed from gastric ulcers atrial fibrillation coronary artery disease hypercholesterolemia multiple myeloma tias s/p intracranial hemorrhage on warfarin for afib presumed amyloid angiopathy patent foranen ovale with asd on echo with righ to left and left to right shunts discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted with a bleeding ulcer that required intensive care because your blood pressure was low. you were treated with blood transfusions and a new medicine to decrease your stomach acid production. your anemia and low blood pressure caused you to have chest pain from your heart disease and caused your heart to beat fast from your atrial fibrillation (afib). the blood transfusions and heart medicine helped to stop the chest pain. there are no signs that you had a heart attack. in the setting of your bleeding, your blood thinners for your afib and heart disease were stopped. you will work with your cardiologist to decide the right time to restart your blood thinners. because your blood pressure has been low, we have stopped most of your high blood pressure medicines. do not take your losarten, amlodipine, tekturna (also called aliskiren), or lasix until advised to restart these medications by your doctors. do not take your aggrenox or low dose aspirin. you should avoid taking any aspirin, ibuprofen or drugs containing aspirin or nsaids (motrin or aleve)unless you have asked one of your doctors. you were taking caduet - a combination blood pressure and statin, but you will take only atorvastatin now. followup instructions: hematology oncology name: dr. when: monday at 1pm cardiology name: dr. when: wednesday at 1pm department: primary care name: dr. when: thursday at 12 pm address: 199 route 101 , , phone: department: div. of gastroenterology when: wednesday at 3:30 pm with: , md building: ra (/ complex) campus: east best parking: main garage Procedure: Other endoscopy of small intestine Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Acute posthemorrhagic anemia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Percutaneous transluminal coronary angioplasty status Chronic kidney disease, Stage III (moderate) Ostium secundum type atrial septal defect Multiple myeloma, without mention of having achieved remission Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Amyloidosis, unspecified

history of present illness: the patient is a 58-year-old white gentleman with no significant past medical history who had the worst headache of his life along with positive nausea and vomiting since 7 p.m. on the day of admission. the patient states he took aspirin and ibuprofen and went to sleep. the pain worsened over the next few hours, and the patient presented to emergency room where he was found to have a subarachnoid hemorrhage on computed tomography looking like a right middle cerebral artery distribution. the patient denies weakness of extremities, visual changes, dizziness, or lethargy. the patient reports having consumed several shots of southern comfort on the afternoon of admission. past medical history: the patient denies. past surgical history: the patient denies. medications on admission: aspirin and ibuprofen which he took on admission. allergies: the patient denies any known drug allergies. social history: the patient quit smoking 10 months ago. he does drink daily; he has a few shots per day. pertinent laboratory values on presentation: laboratories revealed the patient's white blood cell count was 10, his hematocrit was 41.4, and his platelets were 227. chemistry-7 was pending at the time of this dictation. his inr was 0.9. physical examination on presentation: vital signs revealed the patient's heart rate was 70, his blood pressure was 168/90, and his respiratory rate was 20. his pupils were equal, round, and reactive to light and accommodation. the extraocular movements were full. the lungs were clear. cardiovascular examination revealed a regular rate and rhythm. no murmurs. the abdomen was soft and nondistended. extremity examination revealed no edema. cranial nerves ii through xii were intact. neurologically, the patient was alert, awake, and oriented times three. the patient was conversant with appropriate speech. he followed commands bilaterally. pupils were equal, round, and reactive to light and accommodation. the extraocular movements were full. no nystagmus. the visual fields were full to confrontation. the neck was supple. no pronator drift. muscle strength was in the upper and lower extremities. the toes were downgoing. no dysmetria. the face was symmetric. the tongue was midline. brief summary of hospital course: the patient was admitted to the neurology intensive care unit and was started on nimodipine 60 mg by mouth q.4h. and morphine as needed for pain. neurologic checks were performed every hour with gastrointestinal prophylaxis. he was to keep his blood pressure less than 130. he was to go to angiogram later on in the day. on the morning of the patient's temperature maximum was 98.9 degrees fahrenheit. his blood pressure was 134/64 with a heart rate of 78. his hematocrit was 41.4, his white blood cell count was 10.6, and his platelets were 227. his sodium was 141. his potassium was 4.1. his prothrombin time was 12. his partial thromboplastin time was 20.4. his inr was 0.9. the patient was alert, awake, and oriented times three. the pupils were equal, round, and reactive to light at 2.5 mm to 2 mm. the face was symmetric. an arterial line was placed. on the patient had an angiogram done which was negative. postoperatively, his vital signs were stable. his blood pressure was 126/63, his heart rate was 57, his respiratory rate was 17, and his oxygen saturation was 97% on 2 liters. the patient was alert, awake, and oriented times three. he was following commands. the extraocular movements were full. no drift. his strength was in both the upper and lower extremities. no hematoma. his dorsalis pedis pulses were 2+ bilaterally. he was kept on best rest. his systolic blood pressure was less than 130s. the patient remained in the intensive care unit in stable neurologic condition. the patient stayed in the intensive care unit until . he remained neurologically intact. he had a repeat angiogram on which showed no definite aneurysm; however, there was an irregularity at the origin of the posterior communicating artery. he had no complications. postoperatively, he had a mild headache. his vital signs remained stable. after the angiogram the patient wanted to be discharged home and talked about leaving against medical advice. however, dr. did speak with the patient and told him there was no definite source of hemorrhage; however, the angiogram showed mild evidence of cerebral vasospasm, and he was advised to stay in the hospital. the patient did decide to stay. however, on the patient wanted to leave the hospital and did leave against medical advice. he was told to follow up with dr. and again reminded that our advice would be to remain in the hospital in order to insure that the vasospasm visualized on angiography did not become symptomatic. , m.d. dictated by: medquist36 Procedure: Arteriography of cerebral arteries Arteriography of cerebral arteries Arterial catheterization Diagnoses: Subarachnoid hemorrhage Personal history of tobacco use

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p stab wound to left post axilla,left flank region splenic injury major surgical or invasive procedure: s/p exploratory laparotomy s/p splenectomy history of present illness: 36 yo male s/p stab wound to left post chest/left flank, unresponsive at scene with intermitt combativeness; intubated at scene. past medical history: hepatitis b & c social history: currently homeless; resides in shelter. has girlfriend who is reportedly pregnant family history: noncontributory physical exam: gen- unresponsive heent- eomi neck- + jvd; trachea midline, cervial collar in place chest - + crepitus left chest cor- tachycardic abd- flat, soft skin- diaphoretic neuro- responds to pain pertinent results: 11:34pm lactate-3.2* 11:06pm glucose-119* urea n-8 creat-0.8 sodium-141 potassium-3.8 chloride-108 total co2-21* anion gap-16 11:06pm alt(sgpt)-44* ast(sgot)-54* alk phos-67 amylase-29 tot bili-0.5 11:06pm lipase-23 11:06pm albumin-3.8 calcium-8.7 phosphate-3.4 11:06pm wbc-7.4 rbc-4.17* hgb-12.8* hct-36.9* mcv-89 mch-30.6 mchc-34.5 rdw-14.2 11:06pm plt count-177 11:06pm pt-13.0 ptt-28.0 inr(pt)-1.1 brief hospital course: patient admitted to trauma service; intial chest xray revealed small left pneumothorax, chest tube placed. patient taken to or on for exploratory lap and splenectomy, he recived 4 units fresh frozen plasma and 2 units packed red cells in or. postoperative course stable. began clear liquids, diet advanced as tolerated. changed to oral pain medication. chest tube removed without complication. stab wounds and chest tube site dressed with dry sterile dressings. ex lap incision staples remained in place, to be taken out at trauma clinic in 1 week. prior to discharge was vaccinated w/ pneumovax, meningococc, h.flu vaccinations & given rx for amox 3g to take if fever. medications on admission: unknown discharge medications: 1. percocet 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours. disp:*30 tablet(s)* refills:*0* 2. amoxicillin 500 mg capsule sig: six (6) capsule po once for fever >101: if you develop fever take all 6 tabs immediately and go to emergency department. disp:*6 capsule(s)* refills:*0* discharge disposition: home with service facility: , discharge diagnosis: s/p stab wound s/p splenectomy discharge condition: stable discharge instructions: *should you develop fever over 101 degrees you should take the 6 amoxacillin tabs prescribed for you and go to nearest emergency room immediately. avoid heavy lifting or any strenuous activities for next weeks. be sure to keep your followup appointment with trauma clinic. avoid contact with people who may have a cold. followup instructions: follow up in trauma clinic in 2 weeks , call for an appointment Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Exploratory laparotomy Total splenectomy Transfusion of packed cells Diagnoses: Unspecified viral hepatitis C without hepatic coma Cocaine abuse, unspecified Assault by cutting and piercing instrument Traumatic pneumothorax without mention of open wound into thorax Lack of housing Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta Injury to spleen without mention of open wound into cavity, unspecified injury Injury to other intra-abdominal organs without mention of open wound into cavity, retroperitoneum Open wound of axillary region, without mention of complication Open wound of abdominal wall, lateral, without mention of complication

history of present illness: is the former 27 and week gestation premature infant born to a 34 year- old, gravida ii, para i now ii mother. this is his second . he was transferred to on day of life #55 for a bowel resection. his initial perinatal history was significant for delivery by cesarean delivery secondary to maternal bleeding and concern for a placental abruption. mother was beta- complete at the time of delivery. prenatal screens were blood type a positive, antibody negative, rubella immune, rpr nonreactive, hepatitis b surface antigen negative, group beta strep status unknown. the mother was delivered under general anesthesia. apgars were 2 at 1 minute, 6 at 5 minutes and 7 at 10 minutes. he was admitted to the nicu following elective intubation in the delivery room. physical examination: upon readmission to the nicu on , weight was 3 kg. general: active and vigorous, somewhat fussy but overall comfortable. near term infant. mild edema of the extremities and scrotum. skin: warm and dry, mildly jaundiced. heent: fontanel soft and flat. eyes slightly icteric. ears and nares normal. neck supple, no lesions. chest: coarse, well aerated, mild stridor, mild retractions. cardiovascular: regular rate and rhythm, no murmur. abdomen full, soft, active bowel sounds. surgical incision clean and dry. no masses. genitourinary: normal male. testes palpable bilaterally. mild edema. anus patent. extremities, hips and back normal. neuro: appropriate tone and activity, intact grasp, coordinated suck. hospital course: by systems including data from both and admissions: 1. respiratory: initially had respiratory distress syndrome and was treated with surfactant, conventional ventilation for 9 days and then c-pap for one month. he was then transitioned to nasal cannula. he was reintubated for the operating room on and was extubated on . he was treated for apnea of prematurity with caffeine. at the time of discharge, he is in room air, breathing comfortably with a respiratory rate of 30 to 60 breaths per minute. 2. cardiovascular: treated for a patent ductus arteriosus (pda) with indocin times one course. last echo with normal cardiac antomy and no pda. had mild hypotension following his surgery on that was treated with volume and renal dose dopamine. upon readmission to the , he had some transient hypertension with systolic blood pressures greater than 100. a renal ultrasound was performed and was normal. the hypertension was thought to be related to the onset of a narcotic abstinence syndrome which was treated with neonatal morphine. at the time of discharge, his baseline heart rate is 130 to 150 beats per minute with a recent blood pressure of 95/38 mmhg with a mean arterial pressure of 59 mmhg. no murmurs have been noted. 3. fluids, electrolytes and nutrition: initially was n.p.o. and transitioned to full volume enteral feeds. he had necrotizing enterocolitis diagnosed at 5 weeks of age, after presenting with bloody stools and pneumatosis by x-ray. he was treated with 14 days of bowel rest and intravenous zosyn. feedings were reinitiated after the period of bowel rest but he had almost immediate feeding intolerance with abdominal distention. a barium enema was performed on revealing a tight stricture in the transverse colon. he was also noted to have recurrence of pneumatosis at that time. he was transferred to and treated for an additional 14 days of antibiotics and bowel rest. he underwent an end-to-end anastomosis surgical repair on . enteral feeds were restarted on postoperative day number 7 and gradually advanced. at the time of transfer back to , he was on 30 ml per kg per day of breast milk. he was able to transition to full volume feedings and, at the time of discharge, is ad lib p.o. feeding or breast feeding. when p.o. feeding the expressed breast milk with 4 calories per ounce of similac powder is added. a broviac catheter was placed on and removed on . weight at the time of discharge is 3.355 kg which is 50th percentile for corrected post menstrual age of 41 weeks; length 50.5 cm; head circumference 35 cm. due to persistent hypoglycemia, infant had an evaluation for - performed with genetics consultation while he was at . no definitive results were returned and some studies are still outstanding. 4. infectious disease: as previously noted, received two 2 week courses of intravenous antibiotics in concert with treatment for necrotizing enterocolitis. he also was noted to have copious endotracheal secretions and was treated for presumed tracheitis with a trached aspirate culture positive for staphylococcal aureus. he received a 7 day course of unasyn ending on . 5. hematology: had a mild coagulopathy discovered on routine preoperative labs at . hematology was consulted. was treated with ffp and cryoprecipitate perioperatively with resolution of the coagulopathy. the suggested diagnosis was a coagulopathy attributed to chronic inflammation. most recent hematocrit on was 31% with a reticulocyte count of 2.9%. 6. gastrointestinal: as previously noted, had necrotizing enterocolitis requiring bowel resection for a stricture. his incision is healing well. also has a direct hyperbilirubinemia, likely related to tpn cholestasis. an abdominal ultrasound was within normal limits. his most recent liver function tests were obtained on with an alt of 232, ast of 176; total bilirubin 11.7 mg/dl; direct 8.4 mg/dl; indirect 3.3 mg/dl. will be followed by the pediatric surgery team at . his appointment is scheduled for . 7. neurology: had normal head ultrasounds on and . he was treated for narcotic abstinence syndrome with neonatal morphine from to . 8. sensory: audiology: hearing screening was performed with automated auditory brain stem responses. passed in both ears on . ophthalmology: has had mild retinopathy of prematurity with stage i disease in zone 2. most recent eye examination was on and showed immature retina in both eyes with the occurrence of the multiple capillary hemangiomas and a slightly exophthalmic examination. was re-examined by dr. who felt that there was no evidence of acute hemangioma in the ocular region. follow-up eye examination is due the week of . 9. integumentary: has had emergence of multiple capillary hemangiomas. at the time of discharge, there are 3 on his abdomen, 1 in the inguinal area, 1 on the right leg, 1 on the left lower lip. there is also a small, approximately pea-sized mass in the left lower mandibular area. an ultrasound was performed on with the opinion being that this is a lymph node. 10. psychosocial: social work has been involved with this family. the contact social worker is and she can be reached at . condition on discharge: good. discharge disposition: home with the parents. primary pediatrician: dr. , pediatrics, , , , , phone number . care and recommendations: at the time of discharge: 1. feeding ad lib breast feeding or p.o. feeding expressed breast milk, fortified to 24 calories per ounce with 4 calories of similac powder. 2. medications: a. ferrous sulfate 0.6 ml p.o. once daily, 25 mg per ml dilution. b. goldline baby vitamins or equivalent infant multi-vitamin supplement, 1 ml p.o. once daily. 3. car seat position screening was performed. was observed in his car seat for 90 minutes without any episodes of oxygen desaturation or bradycardia. 4. immunizations: hepatitis b vaccine on . synagis on . pediarix on . pneumococcal vaccine on . hemophilus influenza b vaccine on . 5. immunizations recommended: synagis rsv prophylaxis should be considered from through for infants who meet any of the following three criteria: (1) born at less than 32 weeks; (2) born between 32 weeks and 35 weeks with two of the following: day care during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease. 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. 6. state newborn screens: - several amino acids out-of-range, repeat normal, final sent . 7. follow-up appointments scheduled or recommended: a. appointment with dr. , primary pediatrician, within 5 days of discharge. b. pediatric surgery at on . c. pediatric ophthalmology week of . discharge diagnoses: 1. prematurity at 27 and 1/7 weeks gestation. 2. status post respiratory distress syndrome. 3. status post chronic lung disease. 4. status post apnea of prematurity. 5. status post patent ductus arteriosus. 6. necrotizing enterocolitis. 7. status post bowel resection for colonic stricture. 8. status post staphylococcal aureus tracheitis. 9. direct hyperbilirubinemia. 10. retinopathy of prematurity. 11. multiple capillary hemangiomas. , Procedure: Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Diagnoses: Other specified conditions originating in the perinatal period Retrolental fibroplasia Neonatal hypoglycemia Hemangioma of skin and subcutaneous tissue Unspecified fetal and neonatal jaundice Diaper or napkin rash Acute tracheitis without mention of obstruction

history of present illness: the patient is a 75-year-old woman with a history of smoking and without other risk factors for coronary artery disease who was transferred for . the patient was in her usual state of health until 1 p.m. on the day of admission when while cooking she experienced a bilateral shoulder ache with radiation to her epigastrium. this was associated with nausea and diaphoresis. she denied shortness of breath or palpitations. at the emergency department, the patient was found to have anterior st elevations in leads v2 through v4 on her electrocardiogram. she was treated with intravenous heparin and nitroglycerin; after which her blood pressure fell from 120/55 to 58/38 which was resolved to a systolic blood pressure in the 80s with dopamine treatment. she was then transferred to the to the coronary care unit. it should also be noted that she was thrombolysed at . the patient denied chest pain on arrival to , and it was unclear as to when the chest pain resolved. past medical history: 1. question of cerebrovascular accident with lacunar infarction. 2. hypertension in the past but not for about six years. social history: the patient has a 100-pack-year smoking history and is still smoking. she denies alcohol or drug use. family history: a sister passed away for a myocardial infarction in her 50s. physical examination on presentation: temperature was 95.8 degrees fahrenheit, her blood pressure was 82/54, her heart rate was 90, and her respiratory rate was 19. general physical examination revealed the patient appeared pale. the lung examination was normal. cardiovascular examination was normal. the extremities were cool but without edema. pertinent radiology/imaging: an electrocardiogram revealed a sinus rhythm at 78 beats per minute with q waves in v1 and v2. there were 1-mm st elevations in v1, and 2-mm st elevations in v2 through v4, and 1-mm st elevations in leads in i and avl. she was also noted later to have an accelerated junctional rhythm with continued st elevations in leads v2 through v4. later on, she had q waves in v1 through v5, i, and avl with continued st elevations in v2 through v5. pertinent laboratory values on presentation: the patient's white blood cell count was 17.6, her hematocrit was 43, and her platelets were 246. creatine kinase was around 3000 with a troponin of 16. brief summary of hospital course by issue/system: 1. st-elevation myocardial infarction issues: the patient was admitted to the coronary care unit and taken initial to the cardiac catheterization laboratory for persistent hypotension on arrival which revealed a pulmonary capillary wedge pressure of 30. she had a 99% lesion of the left anterior descending artery which was stented, and a 90% lesion to the right coronary artery which was stented, and a 60% lesion in the first obtuse marginal which was stented. there were no acute events after return from the catheterization laboratory. the patient required a blood transfusion of 1 unit of packed red blood cells. she was continued on a heparin drip. she was started on plavix 75 mg by mouth and aspirin. she was also started on captopril, metoprolol, and lipitor. the patient initially returned from the catheterization laboratory with an intra-aortic balloon pump which was discontinued soon after her return to the coronary care unit. the patient returned to the catheterization laboratory two days later for stenting of her right coronary artery and her left circumflex artery. she was hemodynamically stable throughout her cardiac catheterization. it should be noted that on telemetry the patient had some episodes of nonsustained ventricular tachycardia and short runs of bigeminy. however, she was without chest pain throughout the entire hospitalization. an echocardiogram done following all the interventions revealed overall left ventricular systolic function was moderately depressed with regional wall motion abnormalities; including akinesis at the apex, anteroseptal, and anterior walls. a small patent foramen ovale was noted to be present. her ejection fraction was 35% to 40%. the patient continued to be heparinized secondary to her low ejection fraction and was initiated on coumadin. the patient was unable to tolerate a beta blocker secondary to a low blood pressure; however, she was continued on aspirin, plavix, lipitor, and lisinopril. given the abnormalities on telemetry, there was a question of whether or not the patient would need implantable cardioverter-defibrillator placement in the future. she was to follow up with dr. in one month for an electrophysiology study. 2. hematologic issues: the patient was noted to be anemic during her hospitalization with an unknown etiology. hemolysis laboratories were negative. a computed tomography of the pelvis was negative for bleeding and guaiac was negative. she was to continue to have her hematocrit levels checked -weekly to verify stability and was encouraged to have an outpatient gastroenterology workup. discharge diagnoses: 1. coronary artery disease; status post inferior myocardial infarction. 2. anemia of unknown etiology. major surgical/invasive procedures performed: cardiac catheterization with stent placement on and . medications on discharge: 1. aspirin 325 mg by mouth once per day. 2. plavix 75 mg by mouth once per day. 3. lipitor 10 mg by mouth at hour of sleep. 4. protonix 40 mg by mouth once per day. 5. lisinopril 12.5 mg by mouth once per day. 6. coumadin 5 mg by mouth at hour of sleep (with possible adjustments based on inr). 7. lovenox 40 mg subcutaneously q.12h. (to be continued until inr is therapeutic with a goal of greater than 2). discharge instructions/followup: 1. the patient was instructed to follow up with her primary care doctor (dr. on . 2. the patient was instructed to follow up with her new cardiologist (dr. ) on . 3. the patient was instructed to follow up with dr. in one month for an electrophysiology study. 4. the patient was instructed to have her inr and hematocrit levels drawn by the services. 5. the patient was instructed to continue on a cardiac healthy diet with low sodium. condition at discharge: condition on discharge was stable. , m.d. dictated by: medquist36 d: 19:21 t: 03:30 job#: Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Implant of pulsation balloon Transfusion of packed cells Insertion of drug-eluting coronary artery stent(s) Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute myocardial infarction of other anterior wall, initial episode of care Cardiac complications, not elsewhere classified Hematoma complicating a procedure Other chronic pulmonary heart diseases Systolic heart failure, unspecified Hypotension, unspecified

see fhp for detailed pmh, hpi, and allergies o-ms:a/o/x/3. very pleasant and cooperative with care. resting comfortably throughout night. denies pain cv/heme: hr 60s, nsr with pacs and pvcs, runs of aivr and reprefusion beats and missed beats. lopressor ordered and held till am. k and mg stable and not requiring repletions. iabp 1:1 with fair to poor aumentation secondary to arrhythmias, unloading fair to poor as well. maps 80s to 90s. captopril given and toleratating well, could withstand increase today. arriving with pa tracing appearing to be in ra, prior to transport in pa, cards fellow and resident notified, mvo2 sent and 49%(66%). cards fellow declining to advance and no cxr ordered. right groin site with pressure dsg applied in cath lab intact, serosang ooze on 4x4 between folds, no further expansion noted around site, hct 36(40), transfused with 1uprbcs thus far without incident. troponin at osh .3 and this am 16 and ckmbs since admitted 3031(2989)/389(417) with ams pending. heparin re-started at 4am for iabp protection at 500u/hr and no bolus. resp: bss clear with crackles at bases, o2sat on ra 93%. placed on 4ls and sating 99-100%. occasional dry cough but not expectorating anything. denies sob. otherwise no other issues. gu/gi:since diuresed in cl, uos remain brisk, 200-400cc/hr. additional 40mg of lasix given prior to blood and pt currently 1.5l(-) for los. bun/creat stable. abd soft with (+) bss. given sips of water and soda overnight and tolerating well. no further nausea. id: tm 98.9 po. wbc 17 on admission, am pending. ucx pending. no other issues.. Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Implant of pulsation balloon Transfusion of packed cells Insertion of drug-eluting coronary artery stent(s) Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute myocardial infarction of other anterior wall, initial episode of care Cardiac complications, not elsewhere classified Hematoma complicating a procedure Other chronic pulmonary heart diseases Systolic heart failure, unspecified Hypotension, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dysphagia and weight loss major surgical or invasive procedure: pericardiocentesis gastric feeding tube placement by interventional radiology history of present illness: 60 yo f with newly diagnosed metastatic nsclc was admiteed from clinic for worsening dyphagia, dehydration, neutropenia, and arf. mrs. presented to clinic today for an unscheduled urgent visit due to an inability to swallow and extreme fatigue. she has chronic low-back pain and was also unable to take her percocet today. her nutrition has been worse over the last couple of days and her husband fears she has lost even more weight (98 lbs 10 days ago). otherwise, she has had no fevers at home, no chills or night sweats. constipation remains an issue as she has not had a bowel movement in about 3 days. past medical history: 1. smoked until 2 weeks ago, on nicotine patch until . 2. rheumatoid arthritis 3. pci to lad in (95% lad, 40%rca, 50% pda) 4. hypercholesterolemia 5. htn social history: lives w/ her husband of 38 . has daughter and son. smoked 1ppd for 40 , quit 3 weeks ago. drinks about 10 drinks per week. works for her sons asphalt company doing office work. family history: cad in brother/sister brother w/ prostate cancer physical exam: vital signs: temperature 96.6, blood pressure 142/86, pulse 102, oxygen saturation 96% on room air, weight is 90 pounds, height is 61 inches. ecog performance status is 2. in general, ms. is a thin, pleasant 60- year-old woman in no acute distress. heent: pupils are equal, round, and reactive to light. sclerae are anicteric. neck is supple with approximate 1-cm bilateral cervical lymph nodes. heart: tachycardic rate, regular rhythm with no appreciable murmurs, rubs, or gallops. lungs are clear to auscultation bilaterally with no wheezes or crackles. abdomen is soft, nontender, nondistended with normoactive bowel sounds. extremities: there is no edema, clubbing, or cyanosis. pertinent results: 11:53am urea n-77* creat-2.8*# sodium-131* potassium-3.8 chloride-91* total co2-30* anion gap-14 11:53am alt(sgpt)-32 ast(sgot)-31 ld(ldh)-300* alk phos-77 tot bili-0.5 dir bili-0.1 indir bil-0.4 11:53am albumin-4.1 calcium-9.6 11:53am cea-5107* 11:53am wbc-1.4*# rbc-3.96* hgb-13.1 hct-36.8 mcv-93 mch-33.0* mchc-35.5* rdw-12.2 11:53am neuts-8* bands-1 lymphs-52* monos-31* eos-3 basos-0 atyps-5* metas-0 myelos-0 11:53am plt smr-low plt count-85*# echo conclusions: the left atrium is normal in size. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is a large, circumfirential pericardial effusion with pericardial thickening (2.0-3.0 cm anteriorly from subcostal view). there is respiratory variation in the mitral and tricuspid inflow that is non-diagnostic. there is right atrial and right ventricular early diastolic invagination without definite collapse. there appears to be occasional, prolonged rv free wall diastolic invagination (respiratory change?) that likely represents early tamponade. impression: large circumfirential pericardial effusion with probable early tamponade. echo conclusions: left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is a small pericardial effusion subtending primarily the right atrial and right ventricular free wall. there are no echocardiographic signs of tamponade. no right atrial diastolic collapse is seen. no right ventricular diastolic collapse is seen. compared with the findings of the prior report (tape unavailable for review) of , the pericardial effusion is smaller. brief hospital course: # dysphagia: pt with known significant lad compressing the esophagus. this has caused substantial weight loss and is likely contributing significantly to her weakness as she was unable to take po's. gi was consulted for placement of peg tube for initiation of tube feeds. they performed egd however were unable to pass the scope past the upper esophagus due to stricture likely from external source. ir was then called and they placed peg tube under flouroscopy. attempted to start using the peg tube 24 hours after placement with 4 boluses per day of nutritional supplement. with this method pt had residuals of 100 and was requesting use of pump. she was then started on cycling which was adjusted until she was able to tolerate with minimal residuals. she was also started on reglan and erythromycin for enhamced gi motility. pt continued to have problems with nausea and phlegm production. gi was reconsulted in reagrds to possible esophageal stent for comfort measures. pt decided against esophageal stent and patient was discharged home on cycling tube feeds, tolerating it well with reglan. . # pericardial effusion: pt had a small pericardial effusion seen on recent ct scan. she developed progressive sob in the setting of aggressive hydration for her arf due to dehydration. cxr showed small bilateral effusion with pulmonary edema. at this point she was diuresed with minimal effect. her sob and o2 requirement continued to worsen. repeat cxr now showed moderate szized effusion on the left with increase size of silhoutte of heart. pulsus was 15 at this time. she was then sent for echo which demonstrated large pericardial effusion with tamponade physiology. pt was tachycardic but bp stable at this time. cardiology was consulted and patient was sent to the west for urgernt pericardiocentesis. they drained the effusion and performed a balloon pericardiotomy. after the drainiage her heart rate decreased and patient clinicallyy improved however still required o2. after the procedure she was monitored in the ccu for 1 day then on the floors by cardiology for 2 more days. follow up echos showed no evidence of reacculmulation 5 days later. . # volume status: pt was very dry at admission & labs c/w prerenal. rec'd aggressive iv hydration. now with pleural effusion in the setting of pericardial effusion. pleural effusion was present on discharge. disucussed possibility of thoracentesis, pt refused and wanted to go home. . # arf: pt presented with creatinine of 2.8 and bun of 77. her baseline creatinine was 0.8. her fena at this time was <1% and renal failure felt to be secondary to dehydration. she was aggressively hydrated with gradual improvement in her renal function. after several days creatinine had returned to baseline. . # hypoxia: pt with bilateral effusion left greater then right. also likely has lymphangetic spread of the tumor. disucussed possibility of tapping the effusion but the pt refused. also not sure if tapping would help with hypoxia anyway given lymphangetic spread. pt sent home with o2 for comfort. . # cad: no chest pain during stay. was on bb for most part. had stop for for short period when pt was hypotensive. did not restart statin as would have no benefit to patient in short term. . # hyponatremia: was likely due to volume depletion, this resolved with ivf. . # non-small-cell lung ca: did not actively treat as inpatient. however started on tarceva prior to discharge. . # pt had isolated fever on after pericardiocentesis. she was emipirically started on levo/vanco. blood cultures and ua thus far negaitve. since pt had been afebrile otherwise we stopped the abx. . # dispo- discharged home with vna services and likely transition to hospice. medications on admission: inderal, benicar, lipitor, percocet one tablet q.6h. p.r.n. discharge medications: 1. fentanyl 25 mcg/hr patch 72hr sig: one (1) patch 72hr transdermal q72h (every 72 hours). disp:*10 patch 72hr(s)* refills:*2* 2. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed. disp:*qs * refills:*2* 3. lidocaine-diphenhyd--mag- 200-25-400-40 mg/30 ml mouthwash sig: 15-30 ml mucous membrane every four (4) hours as needed for mouth pain. disp:*qs * refills:*2* 4. lorazepam 0.5 mg tablet sig: 1-2 tablets po every six (6) hours as needed for nausea/anxiety: please take 0.5mg qhs and then use q6hr prn otherwise. disp:*120 tablet(s)* refills:*1* 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 6. metoclopramide hcl 10 mg tablet sig: one (1) tablet po qid (4 times a day). disp:*120 tablet(s)* refills:*2* 7. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. disp:*60 tablet(s)* refills:*2* 8. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-20 mls po q6h (every 6 hours) as needed. disp:*qs ml(s)* refills:*2* 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 10. docusate sodium 150 mg/15 ml liquid sig: fifteen (15) ml po bid (2 times a day). disp:*900 ml* refills:*2* 11. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: mls po q6h (every 6 hours) as needed. disp:*qs ml(s)* refills:*2* 12. oxygen pt requires 4l of continuous oxygen via nc 13. probalance liquid sig: four (4) cans po once a day. disp:*120 8 oz cans* refills:*2* 14. tube feed supplies pt will need a tube feed pump, pole, and g tube supplies(tubing, bag for tube feeds, etc.) discharge disposition: home with service facility: healthcare hospice discharge diagnosis: non-small cell lung cancer dehydration dysphagia due to lymphadenopathy pericardial effusion with tamponade discharge condition: stable, tolerating tubefeeds and small amounts of pos, breathing comfortably discharge instructions: take all medications as instructed. please contact dr. if you develop fever/chills, worsening shortness of breath, worsening pain, or other concerning symptoms. followup instructions: you will need to follow-up with dr. and dr. please call their office at to set up an appointment for next thursday. md Procedure: Enteral infusion of concentrated nutritional substances Pericardiocentesis Percutaneous [endoscopic] gastrostomy [PEG] Pericardiotomy Transfusion of packed cells Transfusion of platelets Closed [endoscopic] biopsy of esophagus Diagnoses: Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Secondary malignant neoplasm of other specified sites Constipation, unspecified Secondary malignant neoplasm of brain and spinal cord Malignant neoplasm of bronchus and lung, unspecified Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Stricture and stenosis of esophagus

history of present illness: is the former 880 gram product of a 26 and week gestation pregnancy to a 39-year-old g3, p1, now 2 woman. prenatal screens - blood type a positive, antibody negative, rubella immune, rpr nonreactive, hepatitis b surface antigen negative, group beta strep status unknown. this baby is now 44 days old with corrected post menstrual age of 32 and 4/7 weeks gestation. the mother's pregnancy was complicated by cervical shortening and preterm labor starting at 23 weeks gestation. she was admitted to the and treated with betamethasone on the day of delivery. there was unstoppable preterm labor and progressive cervical dilatation. the mother was treated with intravenous antibiotics. the baby was by spontaneous vaginal delivery and was vigorous at delivery. he was given blow-by oxygen and electively intubated. apgars were 6 at 1 minute and 9 at 5 minutes. he was admitted to the neonatal intensive care unit for treatment of prematurity. physical examination: physical examination on admission to the neonatal intensive care unit: weight 880 grams, length 32.5 cm, head circumference 24.5 cm. general: appropriate for gestational age, preterm infant. pink and well perfused. head, ears, eyes, nose and throat: anterior fontanel soft and flat. ears, eyes, nose and mouth normal. neck: supple without masses. clavicles normal to palpation. chest: breath sounds equal. fair aeration. cardiovascular: regular rate and rhythm. no murmur. perfusion normal. normal pulses. abdomen: soft, nondistended, nontender. three-vessel umbilical cord. genitourinary: normal preterm male. anus patent. spine: straight. normal sacrum. skin: warm and dry. color pink. extremities: normal. neurologic: appropriate activity. tone and strength for 26 weeks gestational age. summary of hospital course by systems: respiratory: was treated with 3 doses of surfactant. his initial ventilatory settings were peak inspiratory pressure of 23/positive end expiratory pressure of 5 and intermittent mandatory ventilatory rate of 25 and 50% fraction of inspired oxygen. he weaned to low ventilator settings and on day of life 2 was extubated to continuous positive airway pressure. his chest x-ray showed pulmonary interstitial emphysema in the left lung. he developed a left pneumothorax and was reintubated and placed on high frequency oscillatory ventilation. his respiratory disease worsened until day of life 8 when he was on a mean airway pressure of 13 and fraction of expired oxygen of 1.0. he had persistence of the left pneumothorax. he was given a 10-day course of intravenous decadron with improvement in his respiratory status. on day of life 12 he was again extubated to continuous positive airway pressure but was reintubated for excessive apnea and right lung collapse. he was again placed on the high frequency oscillatory ventilator and day of life no. 16 had recurrence of his left pneumothorax, again requiring placement of the left thoracostomy tube. he was gradually weaned from the high frequency oscillator/ ventilator and was extubated to continuous positive airway pressure on day of life 27, . he has remained on continuous positive airway pressure since that time. the pulmonary interstitial emphysema of the left lung has resolved. at the time of discharge he is on continuous positive airway pressure of 6 cm of water pressure, baseline oxygen requirement is 25%. he has intermittent episodes of apnea of prematurity and is treated with caffeine citrate. cardiovascular: has maintained normal heart rates and blood pressures. an echocardiogram was performed on , that showed a patent foramen ovale versus atrial septal defect. no patent ductus arteriosus and right ventricular pressure less than half left ventricular pressure at the time of discharge. his baseline heart rate is 150 to 170 beats per minute with a recent blood pressure of 74/46 mm on day 3 with a mean arterial pressure of 57 mm of hg. no murmurs have been noted. fluids, electrolytes and nutrition: was initially npo and maintained on intravenous fluids. he had a percutaneously inserted central catheter for parenteral nutrition. enteral feeds were started on day of life no. 12 and gradually advanced to full volume. he had been received 140 ml per kg per day of breast milk fortified to 30 calories per ounce with beneprotein with the onset of his incarcerated hernia on . he was made npo and started on total parenteral nutrition, iv fluids of 10% glucose with 2.6% amino acids, 2 meq of sodium and 2 meq of potassium per 100 ml to run at 130 ml per kg per day iv. tpn runs at 6.8 ml per hour and intralipids at 3 grams per kg per day runs at 0.9 ml per hour. weight on the day of discharge is 1.415 kg. infectious disease: the placental pathology showed acute funisitis and chorioamnionitis. initial white blood cell count was 6300 with 46 polymorphonuclear cells and 2 band neutrophils. blood culture was obtained prior to initiating intravenous ampicillin and gentamycin. the antibiotics were continued for 10 days. on , due to vital sign instability, was again evaluated for sepsis. a blood culture was obtained and he received 3 days of vancomycin and gentamycin. the antibiotics were discontinued with negative blood cultures. with the onset of his incarcerated hernia on , he had blood cultures sent at 5 a.m. and 6 p.m. both blood cultures showed no growth to date. he is currently being treated with ampicillin and gentamycin. hematological: hematocrit at birth was 48.7%. has received 3 transfusions of packed red blood cells. is blood type a positive. gastrointestinal: was treated for unconjugated hyperbilirubinemia with phototherapy. peak serum bilirubin was 4.2/0.5. left inguinal hernia was noted first on day of life 17. on , the hernia was unable to be reduced without great difficulty requiring sedation with fentanyl. he was evaluated by the pediatric surgical team from . attending dr. plan surgical repair of the hernia on . neurology: has had two normal head ultrasound on , and . he has maintained a normal neurological examination. he was treated with fentanyl through day of life 29. endocrine: due to his treatment with a course of decadron, is being treated with stress steroids in anticipation of his surgery. the plan is for 3 doses of hydrocortisone 0.5 mg per kg iv q.8 hours for 3 doses. sensory: audiology, hearing screening has yet been performed. ophthalmology: eyes were most recently examined on , showing immature retinas to zone 2 with a repeat examination in 2 weeks. psychosocial: the parents are very involved and visit daily. condition on discharge: stable. discharge disposition: transferred to for surgical repair of the left inguinal hernia. name of primary pediatrician: dr. , , . care recommendations at discharge: 1. npo. iv fluids at 130 ml per kg per day of total parenteral nutrition, 10% glucose, 2.6 amino acids with 2 of sodium, and 2 of potassium per 100 ml at 6.8 ml per hour, 20% intralipids at 0.9 ml per hour. 2. medications: hydrocortisone 0.7 mg iv q.8 hours x3 doses. caffeine citrate 9 mg iv q.24 hours, due at 1300 hours daily. ampicillin 200 mg iv q.8 hours due at 2 p.m., 10 a.m. and 6 p.m. daily, gentamycin 4 mg iv q.24 hours due to 6 p.m. daily. 3. car seat position screening recommended prior to discharge. 4. state newborn screens were sent on , and with results normal. 5. immunizations received: hepatitis b vaccine was administered on . follow up appointments: surgical repair of hernia at . . discharge diagnoses: 1. prematurity at 26 and 3/7 weeks gestation. 2. left pulmonary interstitial emphysema. 3. left pneumothorax, recurring x1. 4. respiratory distress syndrome. 5. suspicion for sepsis ruled out x3. 6. apnea of prematurity. 7. anemia of prematurity. 8. unconjugated hyperbilirubinemia. 9. left inguinal hernia with incarceration. , md Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Thoracentesis Non-invasive mechanical ventilation Arterial catheterization Other phototherapy Prophylactic administration of vaccine against other diseases Transfusion of packed cells Umbilical vein catheterization Circumcision Bilateral repair of inguinal hernia, not otherwise specified Diagnoses: Esophageal reflux Need for prophylactic vaccination and inoculation against viral hepatitis Single liveborn, born in hospital, delivered without mention of cesarean section Extreme immaturity, 750-999 grams Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Chronic respiratory disease arising in the perinatal period Primary apnea of newborn Neonatal bradycardia Anemia of prematurity Other specified conditions originating in the perinatal period Retrolental fibroplasia Routine or ritual circumcision 25-26 completed weeks of gestation Ostium secundum type atrial septal defect Interstitial emphysema and related conditions Late metabolic acidosis of newborn Bacteremia of newborn Inguinal hernia, with obstruction, without mention of gangrene, bilateral (not specified as recurrent) Allergic gastroenteritis and colitis

history of present illness: the patient is a 63 year old male with a history of coronary artery disease, status post coronary artery bypass grafting to the posterior descending artery and left anterior descending artery on . mitral valve replacement also on , who was transferred to the c-medicine service for placement of a ddd pacemaker after he was found to be in complete heart block with a junctional escape rhythm post coronary artery bypass grafting. past medical history: please refer to dictation dated by the cardiothoracic surgery service. medications on admission: please refer to dictation dated by the cardiothoracic surgery service. social history: please refer to dictation dated by the cardiothoracic surgery service. hospital course: the patient was admitted to the c-medicine service and underwent ddd pacemaker placement without complication. his amiodarone, which was started in consultation with the electrophysiology service on the , was continued and converted to 200 mg daily to start on . the patient will continue on a regimen of his amiodarone and anticoagulation, and follow up with the electrophysiology clinic in one month for consideration of further control of his rhythm. co artery disease: the patient is status post coronary artery bypass grafting with no ischemic symptoms. he will continue on aspirin, beta blocker and lisinopril. the patient will follow up with dr. in approximately two weeks. status post mitral valve replacement: the patient continues on coumadin 4 mg daily and will be discharged on lovenox 60 mg subcutaneously twice a day until he is fully anticoagulated. neurologic: the patient had delirium status post multiple medications postoperatively. a head ct was performed on which showed old infarctions in the region of the left caudate, right internal capsule and right cerebellar hemisphere as well as atrophy out of proportion to age. the patient was evaluated by physical therapy and occupational therapy with regard to home safety, and felt that he would be safe at home as long as family was observing him and closely involved. his posterior delirium was clearing at the time of discharge but, if this persists, given his history of strokes in the past, the patient was advised to seek formal neurologic follow-up as referred by his primary care physician in . pulmonary: the patient has a history of mild chronic obstructive pulmonary disease and will continue on an albuterol meter dose inhaler as needed. the patient will need outpatient pulmonary function tests given the initiation of amiodarone, if these were not already done. gastrointestinal: the patient will need follow-up of his liver function tests on amiodarone, by his primary care physician. endocrine: the patient will need his tsh followed while on amiodarone, by his primary care physician. anticoagulation: the patient will be discharged on coumadin 4 mg daily to crossover with lovenox 60 mg subcutaneously twice a day for his mitral valve replacement. diion: the patient will be discharged to home on to follow up with cardiothoracic surgery, dr. , in approximately two weeks, to follow up with his primary care physician in , dr. , in one week, and to follow up with neurology as referred by dr. . discharge medications: coumadin 4 mg p.o.q.d. lovenox 60 mg s.c.b.i.d. while becoming anticoagulated. lopressor 12.5 mg p.o.b.i.d. lisinopril 5 mg p.o.q.d. aspirin 81 mg p.o.q.d. albuterol meter dose inhaler two puffs q.6h.p.r.n. amiodarone 200 mg p.o.q.d. discharge diagnoses: coronary artery disease, status post two vessel coronary artery bypass grafting. atrial fibrillation. delirium , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Insertion of endotracheal tube Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Open and other replacement of mitral valve Implant of pulsation balloon Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Urinary tract infection, site not specified Cardiac complications, not elsewhere classified Atrial fibrillation Atrioventricular block, complete Primary pulmonary hypertension Drug-induced delirium Subendocardial infarction, subsequent episode of care

history of present illness: the patient is a 63-year-old male with history of coronary artery disease, myocardial infarction, ptca, chronic atrial fibrillation, and transient ischemic attacks who developed chest pain in the beginning of of this year. the pain resolved spontaneously but reoccurred on when the patient developed persistent chest pain. after approximately 12 hours of discomfort, the patient went to the campus where an ekg showed atrial fibrillation without ischemic changes. cpk at that time was 1510, with a 7.6 index and troponin greater than 50. the patient was taken for cardiac catheterization at that time which showed significant two vessel disease and an ejection fraction of approximately 30%. following catheterization, the patient was referred for surgical intervention with the cardiothoracic team at . past medical history: the past medical history includes congestive heart failure, two myocardial infarctions, hypertension, bladder cancer, ptca, mild chronic obstructive pulmonary disease, transient ischemic attacks in with a clot visualized in the atrium, and significant smoking history. past surgical history: the past surgical history revealed cholecystectomy, cystography, trigger finger release, ptca, tonsillectomy, testicle removal, and nasal septoplasty. preoperative medications: albuterol 2 puffs b.i.d., lovenox 3 mg subq. b.i.d. following the discontinuation of his coumadin which he had been taking for atrial fibrillation, lipitor 10 mg q.d., lopressor 100 mg b.i.d., aspirin 325 mg q.d., prilosec 40 mg q.d., multivitamin, folate, thiamine, and nicoderm patch. allergies: ativan causes mental status changes, librium causes paranoid delusions and confusion. physical examination: the patient presented with a blood pressure of 133/84. the patient was in no apparent distress and had no complaints. the skin was intact without evidence of rashes or breakdown. the head was normocephalic, atraumatic with intact cranial nerves. the throat was clean. there was no jugular venous distention, lymphadenopathy, or bruits evident. the chest was clear to auscultation bilaterally. the heart revealed normal s1 and s2 with an irregularly irregular heartbeat. the abdomen was soft, nontender, and nondistended with present bowel sounds. the extremities were warm and well perfused without peripheral edema. neurologic examination was nonfocal and grossly intact. hospital course: the patient was admitted to the cardiothoracic service on , following cardiac catheterization and placement of intra-aortic balloon pump. the patient was taken to the operating room on and underwent a cabg times two: to the posterior descending artery and the left anterior descending artery. the patient also had mitral valve replacement with a 31 mm st. jude's valve. the patient tolerated the procedure well and was transferred to the cardiothoracic intensive care unit in a stable condition. on postoperative day #1, the patient was afebrile with stable vital signs. weans were begun on the intra-aortic balloon pump and the ventilator. on postoperative day #2, the patient was extubated but continued on the intra-aortic balloon pump. the patient postoperatively had been in a normal sinus rhythm of approximately 70 beats per minute. the postoperative ekg showed 1:1 av conduction with a pr interval of approximately 0.22. in the middle of the day, strips showed sinus rhythm with a complete av block. the patient was afterwards paced but a strip of several seconds was obtained which showed complete absence of p waves, absent qrs, and absent pacer spiking. electrophysiology consult was obtained at this time and the patient was increased on the v lead sensitivity to improve the pacing of the patient's heart rate and anticoagulation was done for the patient's persistent atrial fibrillation. on postoperative day #2, the patient's intra-aortic balloon pump was discontinued and the patient tolerated this well. the patient continued to have a junctional escape rhythm in the 30s upon repeated attempts to discontinue the pacemaker and observe the patient's intrinsic rhythm. the patient's amiodarone was converted to 200 mg p.o. q.d. under the direction of the electrophysiology service. the patient was transferred to the floor on and continued to do well on the floor. the patient was placed on heparin drip for anticoagulation while coumadin was held pending possible placement of pacemaker. the patient's heart continued to be ventricular paced at a rate of 80. the patient continued to improve over the following few days and worked well with physical therapy. the patient was noted to ambulate without difficulty. on , the patient's demand pacing was decreased to a rate of 40. the patient was noted to become tired and more lethargic as his rhythm remained in the low 40s. the pacer was then increased back to a rate of 60-80 and the patient improved symptomatically. the patient also had some brief episodes of nausea during the day on which responded well to zofran medication. he was given thorazine for hiccups and had slow advancement of diet. on , the patient was afebrile with stable vital signs. the patient was seen by the ep service and was felt to be ready for dc cardioversion and placement of pacemaker. the patient had a urinalysis which showed 11 white blood cells in the urine and subsequently the patient was started on ciprofloxacin for possible urinary tract infection. urine culture done from this sample grew no bacteria. it was felt at this time the patient was stable for transfer to the electrophysiology service for dc cardioversion and placement of pacemaker. the patient was stable from a medical and surgical standpoint. discharge status: transferred to the electrophysiology service and then to rehabilitation versus home. discharge condition: stable. discharge medications: reglan 10 mg p.o. t.i.d., ciprofloxacin 500 mg p.o. b.i.d. x 7 days total, captopril 6.25 mg p.o. b.i.d., lasix 20 mg p.o. b.i.d., kcl 20 meq p.o. b.i.d., coumadin 5 mg p.o. q.d. after ep procedure, prilosec 40 mg p.o. q.d., amiodarone 400 mg q.d. through and then 200 mg p.o. q.d., combivent mdi 2 puffs q. 4 hours p.r.n., tylenol 650 mg q. 4-6 hours p.r.n., colace 100 mg p.o. b.i.d. p.r.n. die instructions: the patient is to be transferred to the electrophysiology service for cardioversion and placement of pacemaker. the patient was to take the medications as outlined above. the patient is to be discharged to rehabilitation versus home based upon his performance following placement of pacemaker. the patient is to follow up with the ep service as directed by that service. the patient is to follow up with the cardiothoracic service of dr. in approximately two weeks. the patient is to call said office in order to establish followup appointment. the patient's amiodarone dose should be switched to 200 mg p.o. q.d. on . , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Insertion of endotracheal tube Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Open and other replacement of mitral valve Implant of pulsation balloon Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Urinary tract infection, site not specified Cardiac complications, not elsewhere classified Atrial fibrillation Atrioventricular block, complete Primary pulmonary hypertension Drug-induced delirium Subendocardial infarction, subsequent episode of care

history of present illness: mr. is a 64 year old man with a past medical history of coronary artery disease, status post coronary artery bypass grafting times two with mitral valve replacement with a st. jude valve in , who presented to the emergency room on complaining of abdominal pain which he had been having since his heart surgery in . the patient reported that his abdominal pain was increasing in severity, persisting for a longer amount of time and was more intense. it was postprandial. he reported diarrhea. he reported that the pain was associated with bowel movements. physical examination: on physical examination, the patient had a temperature of 97.9, heart rate 77, blood pressure 144/78, respiratory rate 18 and oxygen saturation 99%. head, eyes, ears, nose and throat: unremarkable. neck: supple without lymphadenopathy. cardiovascular: irregular with a loud s1 and ii/vi systolic ejection murmur. lungs: clear to auscultation bilaterally. abdomen: diffusely tender with diminished bowel sounds. neurologic: nonfocal. past medical history: 1. atrial fibrillation for years, resistant to cardioversion. 2. , inferior myocardial infarction with angioplasty time two. 3. , cerebrovascular accident times two. 4. congestive heart failure. 5. asthma. 6. , myocardial infarction, congestive heart failure and rib fractures. 7. , coronary artery bypass grafting times two, mitral valve replacement with st. jude valve and dual pacemaker. 8. , cardioversion. 9. , cholecystectomy. 10. , patient found to have a solitary lung nodule. allergies: the patient is allergic to benzodiazepines, which cause a paradoxical reaction. medications on admission: aspirin 81 mg p.o.q.d., lisinopril 10 mg p.o.q.d., lopressor 12.5 mg p.o.b.i.d., amiodarone 200 mg p.o.q.d., coumadin 2.5 alternating with 5 mg p.o.q.h.s., ambien p.o.q.h.s.p.r.n., albuterol meter dose inhaler two puffs b.i.d. laboratory data: a kub demonstrated dilated loops of bowel. an abdominal ct showed no bowel wall thickening; it did show dilated loops of bowel and no diverticulosis. hospital course: the patient was admitted to the vascular service with a presumptive diagnosis of mesenteric ischemia. he underwent an abdomen angiogram on and had angioplasty of his superior mesenteric artery, with decreased abdominal pain. on , the patient was seen by the thoracic surgery service because he had been previously noted to have a left upper lobe lesion by chest x-ray in . a ct scan revealed a t2n2 left upper lobe lesion and possible right rib metastases on recent bone scan. thoracic surgery recommended consulting medical oncology. on , the patient complained of increasing abdominal pain and was found to have evidence of obstruction. he underwent an by dr. on , with pathology results confirming a carcinoid tumor. on postoperative days two through four, the patient was noted to be doing well, with an oxygen saturation of 99% on three liters nasal cannula. however, some rales were noted on examination. on , the patient was noted to have an increased respiratory rate to 30 and rales on examination, which was treated with albuterol nebulizers with some relief. a chest x-ray revealed mild congestive heart failure. his oxygen saturation decreased to 87% to 91% on three liters and respiratory rate was in the 30s to 40s. he was treated with lasix with some improvement. he was ruled out with cyclic cardiac enzymes. on and 20, , the patient was not noted to improve. he was transferred to the surgical intensive care unit on and treated with clindamycin and ciprofloxacin as per infectious disease on . on , the patient was started on vancomycin and, by , the patient was noted to be much improved, feeling well, with decreased shortness of breath. he still had a cough which was productive of clear sputum. he denied fever, chills, chest pain, nausea, vomiting or diarrhea. he was tolerating a small amount of oral intake, but this was limited secondary to his oxygen needs. on a 15 liter nonrebreather mask, the patient's oxygen saturations were 91% to 96%. please note that the transfer to the surgical intensive care unit was in order to allow utilizing continuous positive airway pressure to improve oxygenation and gain alveolar recruitment. on , the patient was found to have a systolic blood pressure in the 70s to 80s. this responded to gentle hydration and return to 104/40. his oxygen saturation was 92% to 96% on high flow humidified oxygen at 15 liters per minute. his heart rate was 85 in atrial fibrillation. at this time, the patient was transferred to the vascular intensive care unit. on , the patient was postoperative day 12, hospital day 16. he reported that he felt okay, although he appeared to be in mild respiratory distress. he was able to speak in full sentences. he was afebrile with stable vital signs. his oxygen saturation was 86% to 94% on 15 liters high flow humidified oxygen. cardiology was consulted regarding the pulmonary consultation's recommendation of discontinuing amiodarone. this was recommended secondary to a rare occurrence of amiodarone causing pulmonary infiltrates in an acute manner. on , the patient was postoperative day 13 and hospital day 17. he reported that he had had a good previous night, with no complaints. his oxygen saturation was 95% on 60% oxygen by face mask. his blood pressure range was 88/46 to 110/56. his examination demonstrated an irregularly irregular heart rhythm with an s1 present. his lungs were clear on the right with some end-expiratory rhonchi on the left. his sputum culture had grown out hemophilus influenzae, beta lactamase negative. it was decided to continue the amiodarone at this time. the patient's liver function tests, which had been previously elevated, were trending down, with his ast at 124, down from 352, alt 148, down from 265, alkaline phosphatase 161, down from 177 and total bilirubin 0.4, down from 1.1. his pneumonia appeared to be clinically improving and he had a decreased oxygen requirement. on , postoperative day 15 and hospital day 19, the patient was doing very well, with no complaints. he was afebrile and his vital signs were stable. his oxygen saturation was 95% on three to four liters by nasal cannula. his lungs were clear to auscultation bilaterally. on , the patient's antibiotic regimen was changed to oral levaquin 500 mg daily after pulmonary recommended this change. on postoperative day 17, hospital day 21, the patient was doing well, with no complaints. he was able to walk with assistance. he was afebrile with stable vital signs. his respiratory rate was 18 and he was breathing at 97% on three liters nasal cannula. his prothrombin time was 13.3, partial thromboplastin time 58.8, inr 1.2, sodium 134, potassium 4.6, chloride 102, bicarbonate 25, bun 15, creatinine 0.8 and glucose 118. his heparin drip was increased at this time to 1,200 units/hour. his coumadin dose was increased to 7.5 mg at bedtime. on , the patient was doing well, with no complaints. he was postoperative day 18, levaquin day four. he was afebrile with stable vital signs. his oxygen saturation was 98% on two liters per nasal cannula. his heart was irregular. his lungs had an occasional crackle but were otherwise clear. his abdomen was soft, nontender, nondistended, with normal active bowel sounds. his incision was clean, dry and intact with steri-strips. his appropriate was 13.8, partial thromboplastin time 79.2 on 1,200 units/hour of heparin and inr was 1.3. discharge medications: levaquin 500 mg p.o.q.d. times nine days. lopressor 12.5 mg p.o.b.i.d. zantac 150 mg p.o.b.i.d. coumadin 7.5 mg p.o.q.h.s. heparin 1,200 units/hour. enteric coated aspirin 325 mg p.o.q.d. percocet one to two tablets p.o.q.4-6h.p.r.n. pain. discharge diet: low sodium with three cans of boost plus per day. condition at discharge: fair. discharge status: to rehabilitation. discharge diagnosis: status post , , of carcinoid tumor. pneumonia, resolving. coronary artery disease, status post coronary artery bypass grafting times two and st. mitral valve replacement in . atrial fibrillation, chronic, with pacemaker. cerebrovascular accident times two in , symptoms have resolved. asthma. mild chronic obstructive pulmonary disease. , m.d. dictated by: medquist36 Procedure: Angioplasty of other non-coronary vessel(s) Open and other right hemicolectomy Other small-to-large intestinal anastomosis Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Atrial fibrillation Aortocoronary bypass status Malignant neoplasm of other parts of bronchus or lung Chronic obstructive asthma, unspecified Stricture of artery Unspecified intestinal obstruction Malignant neoplasm of ileum

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catherization coronary artery bypass graft x3 (saphenous vein graft -> left anterior descending, saphenous vein graft -> right coronary artery, saphenous vein graft->posterior lateral branch) history of present illness: 71 year old male with new onset chest pain. he was awoken from sleep at approximately 2am with chest "burning" in the left parasternal area, that radiated to his left jaw, relieved with sl ntg at and then reoccured. was transferred for further cardiac management. he denied sob or diaphoresis, but did admit to some mild nausea with his chest pain. he denies any prior history of chest pain or chest pressure in the past. he does admit to some mild sob while walking up stairs as well as calf pain when walking distances. past medical history: - type ii dm - htn - hypothyroidism - hyperlipidemia - depression - gerd - tias - s/p right carotid endarterectomy - s/p hip replacement - s/p left mastectomy 3 years ago for breast cancer (breast cancer diagnosed after patient noted bleeding from left nipple) social history: patient lives with his wife in southern . formerly operated a bed and breakfast. - quit smoking 50 years ago, smoke 1 ppd x 6-8 years - occasional etoh use, 1-2 times/month - no recreational drug use family history: father- mi at age 63 mother- mi at age 80 physical exam: vitals t 97.7, bp 132/51, hr 77, rr 18, o2 sat 99% on 4l gnl: nad, alert and oriented x 3 heent: perrla, anicteric, mmm, jvp to angle of jaw; well healed right carotid endarterectomy scar along right neck cv: rrr, normal s1 + s2, no murmurs, rubs or gallops chest: left mastectomy scar, well healed resp: clear to auscultation bilaterally, no wheezes or crackles abd: soft, nontender, nabs, no hepatosplenomegaly extremities: no cyanosis, or clubbing; 1+ le edema on shins; dt/pt intact, feet warm, hairless lower legs skin/nails: no rashes/no jaundice/no splinters neuro: aaox3 discharge vitals 98.1, 70 sr, 130/70, 20, 99% ra gen a/ox3 nad cards rrr lungs ctab abd +bs inc sternum stable ext no edema pertinent results: cxr lung volumes are preserved following extubation. mild enlargement of the postoperative cardiomediastinal silhouette is comparable. lungs are clear and there is no pleural effusion or pneumothorax. tee pre-cpb no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. 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 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. post-cpb normal biventricular systolic function. no other changes from pre-cpb findings. thoracic aorta appears intact. 04:28am blood wbc-10.6 rbc-2.62* hgb-7.9* hct-22.4* mcv-86 mch-30.0 mchc-35.1* rdw-15.0 plt ct-246 10:00am blood wbc-9.2 rbc-3.70* hgb-11.0* hct-32.4* mcv-88 mch-29.8 mchc-34.1 rdw-14.0 plt ct-180 04:28am blood plt ct-246 02:34am blood pt-13.0 ptt-24.9 inr(pt)-1.1 10:00am blood plt ct-180 10:00am blood pt-15.3* ptt-70.7* inr(pt)-1.4* 04:28am blood glucose-118* urean-37* creat-1.6* na-136 k-4.5 cl-101 hco3-25 angap-15 10:00am blood glucose-195* urean-32* creat-1.4* na-140 k-4.9 cl-107 hco3-21* angap-17 12:01pm blood alt-15 ast-32 alkphos-41 amylase-39 totbili-0.4 brief hospital course: presented to with chest pain and then transferred to for cardiac management. he ruled in for stemi and then underwent cardiac catherization which revealed 3 vessel coronary artery disease. he underwent cardiac surgery preoperative workup and went to the operating room for coronary artery bypass graft surgery. please see operative report for further details. he was transferred to the cardiac surgery unit on insulin, propofol, and neosynephrine. in the first 24 hours he awoke neurologically intact, extubated without difficulty, and weaned off vasopressors. he continued to progress and was transferred to 2 on post operative day 1. he continued to progress except for elevated blood sugars and returned to the cardiac surgery recovery unit for blood glucose management and insulin drip. he was transitioned back to nph and regular insulin sliding scale with controlled blood sugars. he was transferred to 2 were he continued to progress and was ready for discharge with vna services on postoperative day 5. plan for continued glucose monitoring and follow up with dr . medications on admission: celexa 20mg po daily ritalin 10mg po bid glyburide 5mg po bid synthroid 175mcg po daily trazadone 100mg po daily guaifenesin 600mg po bid insulin nph 20 units qam/25 units qpm insulin regular 5 units qam/ 10 units qpm lisinopril 20mg po daily terazosin 5mg po qhs rosigilitazone 4 mg po daily lovastatin 20mg po daily prilosec 20mg po daily hyoscyamine 0.375 po daily aspirin 325mg po daily discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). for 5 days 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. levothyroxine 175 mcg tablet sig: one (1) tablet po daily (daily). disp:*175 tablet(s)* refills:*2* 4. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. methylphenidate 10 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. glyburide 5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. metoprolol tartrate 50 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*90 tablet(s)* refills:*2* nph insulin resume home dosing varying scale regular insulin continue with sliding scale as prior to admission trazadone 100mg once daily guaifenisin 600mg twice a day hytrin 5mg once daily rosiglitazone 4mg twice a day zocor 20mg once daily prilosec 20mg daily hyoscyamine 0.375mg once daily discharge disposition: home with service facility: vna alliance nh and discharge diagnosis: cardiac catherization coronary artery bypass graft x3 (saphenous vein graft -> left anterior descending, saphenous vein graft -> right coronary artery, saphenous vein graft->posterior lateral branch) discharge condition: good discharge instructions: 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 poiunds in 24 hours or 5 pounds in one week no creams, lotions, powders, or ointments to incisions no driving for one month no heavy lifting (10 pounds) for 10 week call with any questions or concerns followup instructions: dr. in ct surgery clinic in 4 weeks. please call for an appointment. wound check appointment 2 as instructed by nurse () Procedure: (Aorto)coronary bypass of three coronary arteries Extracorporeal circulation auxiliary to open heart surgery Left heart cardiac catheterization Coronary arteriography using a single catheter Angiocardiography of right heart structures Transfusion of packed cells Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Esophageal reflux Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Diastolic heart failure, unspecified

history of present illness: a 78-year-old gentleman, followed by dr. , who has been having several months of substernal chest pain and shortness of breath, usually relieved with sublingual nitroglycerin. recently, the pain has increased to weekly and currently almost daily. the pain is with exertion, but not at rest, and is always relieved with one sublingual nitroglycerin. he has no complaints of orthopnea, paroxysmal nocturnal dyspnea, or lightheadedness. he underwent a cardiac catheterization on which demonstrated severe three-vessel disease, a 70% lesion in the lad, a 100% occlusion of the left circumflex, and a 100% occlusion of the rca; ejection fraction was 47%. the patient was booked for the or on for coronary artery bypass grafting. past medical history: 1) insulin dependent diabetes mellitus, 2) coronary artery disease, status post mi in , 3) hypertension, 4) hyperlipidemia, 5) former smoker, 6) status post right inguinal herniorrhaphy. meds at admission: 1) nph insulin 24 u in the morning, 14 u in the evening, 2) regular insulin 14 u in the morning, 12 u in the evening, 3) lopressor 50 mg po bid, 4) zestril 80 mg po qd, 5) benicar 40 mg po qd, 6) avandia 4 mg po qd, 7) zocor 80 mg po q pm, 8) flomax 0.4 mg po bid, 9) imdur 30 mg po qd, 10) hydrochlorothiazide 12.5 mg po qd, 11) proscar 5 mg po q pm, 12) aspirin 325 mg po qd. allergies: no known allergies except to shellfish. exam at admission: this was a moderately obese gentleman in no acute distress. his neck was supple without lymphadenopathy. he had no bruits. his chest was clear. his heart had a regular rate and rhythm without murmurs. his belly was soft, nondistended, nontender. extremities were warm and well-perfused with mild pedal edema. brief hospital course: the patient was brought to the operating room on and underwent a four-vessel cabg with lima to lad, saphenous vein graft to the om-1, to the pd and the diagonal. he did very well in the or and was weaned and extubated postoperatively in the csru. his urine output was adequate, and his blood sugars were elevated, and an insulin drip was started. he was otherwise alert and oriented, moving all of his extremities, with somewhat labile blood pressure. he was a-paced with a heart rate of 80 with an underlying rhythm of 40s in sinus brady. he continued to require a nitroglycerin drip to maintain his blood pressures adequately low. by postop day #1, the patient was doing well. the nitroglycerin was weaned off. he was delined and transferred to far-2. on the floor, he was doing well until postoperative day #3, when he complained of sudden onset of chest pain in the lower sternal area. on examination, he was found to have a sternal click with some scant serous drainage from the lower part of the incision. he was placed on sternal precautions, and his pain was controlled, and serial exams were performed throughout the day. throughout the course of the day, he continued to develop worsening wheezing despite nebulizer treatments. the decision was ultimately made to take the patient back to the or for reclosing of his sternal dehiscence which was carried out on . the patient tolerated the procedure well and came out on low-dose of neo-synephrine. he remained intubated, and a chest tube had to be inserted when his postoperative x-ray demonstrated a large effusion on the left. his vent was weaned, and his nitroglycerin drip was dc'd, and the patient was extubated on postop day #2 without complication. he had been empirically started on levofloxacin and vancomycin while we waited for the cultures to come back. all intraoperative cultures were negative. the patient was started on his oral cardiac meds. he was fed a diet. his insulin schedule was restarted while the insulin drip was weaned off. his sternal wound had a constant infusion of 1% betadine. by postop day #4, the patient was still having periods where he was requiring a nitroglycerin drip, despite being treated with hydralazine, lisinopril, lopressor and lasix. we changed his lopressor to atenolol po which is what he was taking preoperatively, and this seemed to have a better effect with him. his chest tubes and foley were discontinued on postop day #4. his subsequent icu course was notable for marginal respiratory status. on postop day #5, the patient was noted to have an unstable sternum with drainage from the sternal wound, nonpurulent in nature. his white count which had been elevated prior was on its way down, however; and, the patient had remained afebrile. the decision was made to observe with serial exams before deciding if the patient needed to go to the operating room. fortunately, over the next several days, the patient remained afebrile, his white count continued to decline, and he was improving. his cultures ultimately grew out mrsa from the sputum, but everything else had been negative. vancomycin was continued. on postop day #9, he was doing well. he was off all drips, oral lopressor. his respiratory status was good, and he was transferred to the floor where he had a relatively uneventful course with the exception of a few episodes of atrial fibrillation for which he was started on amiodarone. these episodes of paf all occurred within the same 48-hour period, and he has been in sinus ever since achieving adequate levels of amiodarone. the incision stopped draining fluid on postop day #15, although he still had a small click. white count and creatinine continued to normalize, and a picc was placed for iv vancomycin and levofloxacin. physical therapy had seen the patient and recommended that he be discharged to rehab when he was medically cleared. on postoperative day #16, his respiratory status was somewhat worsened, and a chest x-ray was obtained which demonstrated a left effusion that had been increasing in size. placement of a cook catheter in the left chest was attempted unsuccessfully, and a 28 french chest tube was placed in instead which was successful in draining approximately 100 cc of serosanguineous fluid immediately, followed by approximately 200 since insertion. his chest x-ray and his respiratory status improved, and the chest tube was removed approximately 48 hours later. he continued to do well, be maintained on oral medications, but was still unable to ambulate very well. the patient is being discharged to a rehab facility on in stable condition. discharge diagnoses: 1) coronary artery disease. 2) new onset atrial fibrillation. 3) status post coronary artery bypass graft x 4. discharge examination: neck was supple without lymphadenopathy or bruits. his chest was clear anteriorly with diminished breath sounds at the bases. his heart had a regular rhythm and rate. his abdomen was soft, nontender, nondistended. his incisions were all clean, dry and intact. he had 1+ pedal edema. his extremities were warm and well-perfused. discharge medications: 1) tamsulosin 0.4 mg q hs, 2) finasteride 5 mg po qd, 3) simvastatin 80 mg po q hs, 4) rosiglitazone 4 mg po qd, 5) percocet 1-2 tabs po q 3-4 h prn, 6) ipratropium bromide 0.2 mg/ml solution 1 neb inhalation q 6 h prn wheezing, 7) colace 100 mg po bid, 8) potassium chloride tablets 20 meq po bid for 5 days, 9) lasix 40 mg po bid for 5 days, 10) zantac 150 mg po qd, 11) aspirin 325 mg po qd, 12) guaifenesin codeine cough syrup ml po q 6 h as needed, 13) insulin 24 u nph, 14 u regular subcu q am, 14) insulin 14 u of nph, 12 u of regular subcutaneous q pm, 15) heparin 5,000 u subcu , 16) lopressor 75 mg po bid, 17) amiodarone 400 mg po tid x 1 week, then 400 mg po bid x 2 weeks, then 400 mg qd x 2 weeks, then 200 mg thereafter. the patient is to see dr. in 2 weeks. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Other repair of chest wall Local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified pleural effusion Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Other and unspecified angina pectoris Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Old myocardial infarction Disruption of external operation (surgical) wound

allergies: sulfa (sulfonamides) attending: chief complaint: chest pain major surgical or invasive procedure: cardiac cath with balloon angioplasty to left circumflex artery bronchoscopy with lavage and biopsy lumbar puncture brain biopsy with right sided craniotomy history of present illness: this is a 43 year old recently discharged from after admission for pcp pneumonia, unknown brain mass, seizures who presented with an episode of substernal chest pain today at 3 am. he describes the pain as associated with nausea, vomit and worse on inspiration and radiated to the l arm and jaw. . in the ed, ekg with st elevations on ii-iii-avf- i-avl v4-v5-v6. patient was given aspirin 325, heparin, plavix 300 and morphine. patient was taken to the cath lab. lmca normal lad 70% ulcerated stenosis with timi 3 flow, d1 is to lcx ulcerated thrombotic stenosis in the distal lcx with timi 2 flow rca normal. balloon angioplasty was done on cx lesion. . on ccu arrival, vs 108/69 hr 97 patient complaining of sub-sternal chest pain, . patient stated that it was similar to the pain he had when he came in. no new ekg changes compare to ekg post cath, st elevation in precordial leads improving. the chest pain did not respond to 2 sublingual nitro, so nitro drip was started and morphine 2mg x2 was given obtaining pain relief. the pt was eventually transferred to the medical in a stable condition. past medical history: 1. hiv, last cd4 125 on , hiv vl 3 384 copies/ul. on haart. dx 2. anal condyloma 3. history of oral hsv 4. eczema of skin over hips 5. pcp pneumonia currently treated. 6. unknown brain lesion right temporal lesion social history: lives with roommate. works as a mechanic. quit smoking about 4 months ago. no etoh. no ivdu. no other substances. family history: noncontributory physical exam: vs bp 109/59 hr 98 sats 100 on ra gen: patient in moderate distress heent: no jvd, no lad lungs: clear to auscultation bilaterally cv: rrr, s1-s2 normal, no murmurs, no gallops abdomen: bs+, soft non tender, non distended extremities: no edema, groin site clean, sheath still in. distal pulses + pertinent results: admission labs: 09:05am plt smr-normal plt count-244 09:05am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 09:05am neuts-91* bands-1 lymphs-2* monos-5 eos-1 basos-0 atyps-0 metas-0 myelos-0 09:05am wbc-24.7*# rbc-4.46* hgb-14.3 hct-40.2 mcv-90 mch-32.0 mchc-35.5* rdw-16.0* 09:05am ck-mb-15* mb indx-9.7* 09:05am ctropnt-0.10* 09:05am ck(cpk)-154 09:05am glucose-146* urea n-22* creat-0.9 sodium-134 potassium-4.1 chloride-98 total co2-23 anion gap-17 10:21am hgb-12.5* calchct-38 o2 sat-95 10:21am type-art po2-103 pco2-34* ph-7.38 total co2-21 base xs--3 01:15pm pt-12.7 ptt-28.9 inr(pt)-1.1 01:15pm plt count-230 01:15pm wbc-20.5* rbc-4.11* hgb-12.6* hct-34.9* mcv-85 mch-30.6 mchc-36.0* rdw-16.1* 01:15pm triglycer-101 hdl chol-52 chol/hdl-2.6 ldl(calc)-61 01:15pm calcium-7.6* phosphate-3.6 magnesium-1.3* cholest-133 01:15pm ck-mb-202* mb indx-16.1* ctropnt-2.41* 01:15pm alt(sgpt)-65* ast(sgot)-128* ck(cpk)-1252* alk phos-59 01:15pm glucose-142* urea n-17 creat-0.6 sodium-133 potassium-4.1 chloride-102 total co2-18* anion gap-17 05:54pm plt count-201 05:54pm calcium-8.0* phosphate-3.4 magnesium-2.3 05:54pm ck-mb-465* mb indx-16.8* ctropnt-7.87* 05:54pm ck(cpk)-2766* 05:54pm glucose-123* urea n-14 creat-0.6 sodium-129* potassium-4.2 chloride-98 total co2-22 anion gap-13 08:00pm hct-32.6* relevant labs/studies . cardiology: cath hemodynamics: elevated left heart filling pressures with preserved ci co 4.64, ci 2.88 pcw 20 pa 39/7 mean 16 lv 97/11 25 rv 39 end 12 left ventriculography: no mitral regurgitation, anterolateral and inferoapical hypokinesis lvef ~45% . coronary angiography: right dominant lmca normal lad 70% ulcerated stenosis with timi 3 flow, d1 is to lcx ulcerated thrombotic stenosis in the distal lcx with timi 2 flow rca normal . impression: final diagnosis: 1. two vessel coronary artery disease. 2. midly depressed systolic ventricular function. 3. moderately elevated left heart filling pressure. 4. mildly depressed cardiac output. 5. successful balloon angioplasty of the distal cx lesion. . echocardiogram: 1. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. trivial tr and mr . echo: () the left atrium is normal in size. 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 mildly depressed (ejection fraction 40-50 percent) secondary to severe hypokinesis of the posterior and lateral walls. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , posterior and lateral hypokinesis now present. . imaging: ct chest, w&w/o contrast (): there is a 4.8 x 2.8 cm consolidative opacity within the left upper lobe with surrounding nodularity and ground-glass opacity, as described above. the differential for this includes a consolidative pneumonic process, though given the patient's history of hiv, atypical organisms such as aspergillus or tb should also be considered. neoplasm is also on the differential, and followup evaluation should be obtained after treatment to evaluate for resolution. . mr head with gado/adc (): signal abnormalities in the right temporal and occipital lobes, likely represent either evolving acute brain ischemia, an infiltrative process such as lymphoma, or inflammatory process. . sinus rhythm. severe right axis deviation *** lateral infarct - possibly acute *** tall r waves in lead v1, v2 - consider posterior wall myocardial infarct no change from previous . pathology: brain biopsy encephalitis, chronic, mild. occasional microglial nodules at -white junction. no diagnostic toxoplasma gondii or multinucleated cells (e.g. hiv encephalitis changes) identified. scattered gram-positive cocci isolated and in pairs, not directly associated with microglial nodules. note: this brain biopsy includes neocortex and a small amount of underlying subcortical white matter. it is largely normal. several small microglial nodules are present at the -white junction in the several levels prepared from the tissue. microglia are increased near the nodules. the nodules lack multinucleated cells that would be diagnostic for hiv encephalitis. they also lack diagnostic viral inclusions (including the inclusions of pml), giant cells, or toxoplasma organisms. the acid fast stain is negative for bacilli and the gms silver stain lacks fungi or yeast forms. the tissue gram stain shows infrequent gram-positive cocci scattered over the tissue, sometimes near sites of pathology and sometimes in otherwise normal brain. while the lack of secondary tissue changes to many of these organisms suggests they may be a staining contaminant, the culture prepared from this same brain tissue did grow rare coagulase negative staphylococcus. clinical correlation is advised. based on the h&e and lack of staining in afb and gms stains, the main differential diagnoses for the microglial nodules at the -white junction would be hiv encephalitis and treated toxoplasmosis. additional stains are pending for other viruses. the results will be issued in an addendum. . brief hospital course: pt is a 43yo male with history of hiv, pcp pneumonia, seizures who was found to have a brain mass. the pt initially presented to the ed with complaints of chest pain, underwent a cardiac workup which revealed a postero-lateral stemi. the pt underwent a cardiac catheterization with poba to left circumflex. he was transferred to the medicine team for evaluation of the brain mass. the pt underwent a brain biopsy which revealed no evidence of lymphoma or focal infection. the brain biopsy was significant for some gram positive cocci which were thought to be a contaminant. the pt was recommended close follow-up with his primary care provider and neurology for results of pending studies. . cardiac: ischemia the pt has no known past cardiac history. he presented with acute onset chest pain and was noted to have inferolateral st elevations with a ck peak of 5864, mb>500 and troponin-t of 9.83. he was immediately referred to the cardiac catherization lab. his cardiac cath revealed a right dominant circulation with two vessel coronary artery disease. the lmca was without flow limiting disease. the lad had an ulcerated lesion in the mid segment with 70% stenosis and timi 3 flow. the d1 was totally occluded. the lcx had a proximal 40% stenosis and the distal segment had an ulcerated thrombotic stenosis with timi 2 flow after om3. resting hemodynamics demonstrated mildly elevated right heart filling pressure and moderately elevated left heart filling pressure (rvedp 15 mmhg, lvedp 26 mmhg, mean pcwp 20 mmhg). there was mild to moderate pulmonary arterial hypertension. the calculated co was 4.7 l/min with a ci of 2.9. left ventriculography demonstrated anterolateral and inferoapical hypokinesis. the calculated ef was 45%. the distal cx thrombotic lesion was angioplastied using a maverick and a voyager balloon with lesion reduction from 95% to 10%. the final angiogram showed timi iii flow with no dissection but embolization in a small branch of the om. no stents placed given brain lesion and risk of bleeding with plavix and integrilin. in the post-cath period the pt developed repeat episode of chest pain, described as "sharp", "14/10" and focal over cardiac apex. his ekg was without change from previous with exception of v1 with t-wave flattening/inversion. the chest pain resolved with 1mg iv morphine sulfate. the pt was noted to have one subsequent episode of chest pain on the day of the brain biopsy which was not associated with any new or acute ekg changes (unchanged compared to previous). the pt's pain was relieved with 1 sl nitro and 1mg iv morphine. the pt was maintained on a beta-blocker, aspirin, ace inhibitor and statin (low dose, on haart). in the post-cath period and was discharged on these medications. his dose of beta-blocker was decreased prior to discharge in light of low pressure. the pt was instructed to follow-up as an out-pt with dr. in cardiology. . cardiac: pump the pt was noted to have an ejection fraction of 40-50% on echo and 45% on cardiac catheterization. the cardiac cath was also significant for an elevated wedge pressure in 20's, severe hypokinesis of posterior and lateral walls, trivial mitral regurgitation and no effusion. . cardiac: rhythm the pt was noted to be in normal sinus rhythm on telemetry. . renal: the pt has a baseline creatinine of 0.6-0.9 and the pt continued to be in this range during the hospitalization. . leukocytosis: the pt was noted to have an elevated white count of 24.3 but no bands or fever on admission. the wbc count decreased to within normal limits on subsequent lab readings the same day and it was thought that the pt may have had transient leukocytosis secondary to acute mi. the pt was not noted to be febrile during the hospitalization and all his cultures showed no growth to date. . hiv: the pt was on anti-retroviral medications on admission. he had the following counts: absolute cd4 (342), absolute cd8 (967) and a cd4/cd8 ratio of 0.4. the pt's hiv viral load by rt-pcr was 562 copies/ml. on admission he was on a regimen of efavirenz, emtricitabine and tenofovir disoproxil fum and primaquine. he was maintained on his regimen while admitted in the hospital. he was discharged with instructions to follow-up with his primary care provider as an . . pcp : the pt was noted to have a cxr significant for a worsening of consolidation in the left upper lobe with cavitation. it was thought that this may represent worsening of pneumonia or a hemorrhage from a recent biopsy (which showed no aspergillus or fungal elements). the was placed on tb precautions until tb was ruled out with acid fast smears from induced sputum and a bronchoalveolar lavage which revealed pneumocystis carinii on immunofluorescence testing. the pt was initiated on a 17 day course of primaquine-clindamycin. the pt was subsequently noted to have x3 negative afb smears, however afb were noted to grow on culture. the samples were sent to the state of lab for tb probe and the preliminary results, (infection control) were negative. the pt was subsequently taken off precautions and was instructed to follow-up with dr. for the final report. the pt also underwent testing for rapid respiratory viral antigen test in which no respiratory viral antigens were detected. however, the culture confirmation was pending at the time of discharge and will need to be followed by dr. . dr. was informed of these pending results. . infectious diseases work-up: the pt was noted to have negative tests for legionella urinary antigen, fungus (, biopsy and bronchoalveolar lavage), rpr (), toxoplasma antibodies (igg, igm) and cryptococcal antigen. the following laboratory tests were pending at the time of discharge and will need to be followed as an out-patient: induced sputum afb culture, afb culture (brain biopsy) and csf acid-fast bacillus. . seizures: the pt was noted to have new-onset seizures during his last hospitalization. he was started on keppra and was noted to have a non-specific hypodensity in the right temporal lobe on ct. during that admission the pt had an eeg that showed the unknown hypodensity to be a likely source of his seizure activity. on discharge after his last hospitalization the pt was also informed of state law requiring 6 months of no seizures prior to driving again, and was instructed to make arrangements to inform his place of employment. when the pt was admitted on he was not noted to have any focal deficits. the pt underwent a planned brain biopsy which showed no diagnostic toxoplasma gondii or multinucleated cells, scattered gram-positive cocci isolated and in pairs, not directly associated with microglial nodules (the nodules lacked multinucleated cells that would be diagnostic for hiv encephalitis), the acid fast stain was negative for bacilli and the gms silver stain lacked fungi or yeast forms, tissue gram stain showed infrequent gram-positive cocci scattered over the tissue, sometimes near sites of pathology and sometimes in otherwise normal brain. while the lack of secondary tissue changes to many of these organisms suggested they may be a staining contaminant, the culture prepared from this same brain tissue did grow rare coagulase negative staphylococcus. clinical correlation was advised. after discussion with the attending, dr. and the infectious diseases team, it was thought that the coag negative staph likely represented a contamination (especially in light of a delay between collection and processing of the brain biopsy specimen). a decision was made to discharge the patient on his haart regimen, cardiac medications and pcp pneumonia treatment. no treatment was indicated based on clinical correlation (no mental status changes, no signs of meningitis or clinical signs of infection).the pt was instructed to follow-up with dr. who will discuss the final results of the biopsy (brain) and pending microbiology studies. . fen: the pt was maintained on a cardiac and heart healthy diet. . code: full code . communication: , health care proxy (sister) . medications on admission: 1. emtricitabine 200 mg capsule sig: one (1) capsule po qhs (once a day (at bedtime)). 2. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 3. efavirenz 600 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 4. prednisone 20 mg tablet sig: one (1) tablet po qd () for 2 days. disp:*3 tablet(s)* refills:*0* 5. clindamycin hcl 300 mg capsule sig: one (1) capsule po four times a day for 17 days. disp:*68 capsule(s)* refills:*0* 6. primaquine 26.3 mg tablet sig: two (2) tablet po daily (daily) for 17 days. disp:*17 tablet(s)* refills:*0* 7. 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* 8. keppra 750 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 9. keppra 500 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* discharge medications: 1. primaquine 26.3 mg tablet sig: one (1) tablet po daily (daily) for 3 days. disp:*3 tablet(s)* refills:*0* 2. clindamycin hcl 150 mg capsule sig: two (2) capsule po q6h (every 6 hours) for 3 days. disp:*12 capsule(s)* refills:*0* 3. emtricitabine 200 mg capsule sig: one (1) capsule po hs (at bedtime). 4. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po hs (at bedtime). 5. efavirenz 600 mg tablet sig: one (1) tablet po hs (at bedtime). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 7. keppra 500 mg tablet sig: one (1) tablet po three times a day: please take with 750mg tablet twice daily for total dose of 1250mg twice daily. disp:*90 tablet(s)* refills:*2* 8. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 11. metoprolol tartrate 25 mg tablet sig: one (1) tablet po once a day: hold for sbp<100, hr<60. disp:*30 tablet(s)* refills:*2* 12. tylenol 325 mg tablet sig: 1-2 tablets po twice a day as needed for headache for 2 weeks. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: intracranial lesion unspecified pcp pneumonia acid bacilli pna posterolateral stemi s/p balloon angioplasty to distal lcx discharge condition: good. patient is afebrile, hemodynamically stable. patient has known intracranial lesion with arranged plans for biopsy. additionally, the patient is noted on discharge to have recurrent episodes of sharp chest pain. these episodes are without new ecg changes, although ecg demonstrates persistent, slowly resolving posterior and lateral st segment elevations. it is known that the patient is being discharged without complete resolution of his pain symptoms and does not require repeat admission unless the patient's symptoms are increasing in severity or duration and/or the patient demonstrates new ecg changes. discharge instructions: please take all medications as prescribed . please keep all outpatient appointments that are arranged for you. the numbers of the healthcare providers involved in your care are being provided to you. please call the offices of any of these providers if you have any questions. . please return to the hospital if you experience repeat seizures, headaches, nausea, vomiting, chest pain that does not self resolve after a few minutes or is increasing in duration or intensity, shortness of breath or any other concerning symptoms. . there has been a change to your medications. please read teh attached list carefully. . you have scheduled for a follow-up appointment with dr. who will discuss the results of all pending labwork when you meet him. followup instructions: provider: . (who performed the procedure on your heart) date/time: at 1:30 p.m. phone:(. the doctor's office is located in . if you are unable to make it to his office for follow up, you should contact the cardiology department at at: and arrange a follow up with any available cardiologist. it is imperative that you maintain follow up with a cardiologist after your heart attack (myocardial infarction). . provider: , md phone: date/time: 4:30 . provider: , m.d. phone: date/time: 1:30pm. it is very important that you make it to this appointment . provider: , md. phone: date/time: at 11:20am. it is very important for you to follow with your pcp regarding pending microbiology and lab studies. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Open biopsy of brain Transfusion of platelets Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Other convulsions Human immunodeficiency virus [HIV] disease Pneumocystosis Acute myocardial infarction of other lateral wall, initial episode of care Unspecified causes of encephalitis, myelitis, and encephalomyelitis

discharge status: home with parents. name of primary pediatrician: dr. , at . care and recommendations: 1. feeding at discharge is enfamil 20 calories per ounce p.o. ad-lib, minimum 100 cc per kilogram per day. 2. medications: none. 3. car seat position screening: 4. state newborn screen was sent on day of life three; results are pending. 5. immunizations: the infant received hepatitis b vaccine on . a rebound bilirubin level is recommended for . 6. immunizations recommended: 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 care givers. 7. follow-up appointment with primary pediatrician on . discharge diagnoses: 1. prematurity at 35 weeks. 2. status post rule out sepsis with antibiotics, ruled out. 3. status post respiratory distress. 4. indirect hyperbilirubinemia. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Laryngoscopy and other tracheoscopy Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Other preterm infants, 2,000-2,499 grams 35-36 completed weeks of gestation Carrier or suspected carrier of group B streptococcus

history of present illness: baby boy is a 35 and 0/7 week, 2210-gram, male product of a 24-year-old gravida 3, para 2, now 3, mother (serologies - o positive, antibody negative, hepatitis b surface antigen negative, rapid plasma reagin nonreactive, rubella immune, group b strep status unknown). the baby was via spontaneous vaginal delivery after preterm labor. rupture of membranes was seven hours prior to delivery. mother did receive antibiotics one hour prior to delivery. the infant emerged with a spontaneous cry and received bulb suction and blow-by oxygen. apgar scores were 8 and 9. physical examination on presentation: notable for an awake, 2210-gram, infant. length was 43.5 cm. in general, this was a well-developed male. anterior fontanel was soft and flat. the facies were symmetric. palate was intact. the neck was supple without cleft of masses. his chest was symmetric. his heart was regular in rate and rhythm and without murmurs. his lungs had poor aeration. he had some grunting, flaring, and retracting. his abdomen was soft and nondistended. he had a 3-vessel cord, and no hepatosplenomegaly. his extremities were all intact, warm, and well perfused. genitourinary: male with testes descended bilaterally. the anus appeared patent. his back was without a sacral dimple. his hips were stable without clicks or clunks. he had a symmetric moro. he had a positive grasp and did have a suck. summary of hospital course by issue/system: 1. respiratory: the patient was initially placed on continuous positive airway pressure, but due to work of breathing was intubated and received one dose of surfactant. he was extubated within 24 hours to room air and has remained on room air since with comfortable breathing. 2. cardiovascular: the patient has remained cardiovascularly stable. he has had no murmurs and no blood pressure instability. 3. fluids/electrolytes/nutrition: the baby was initially nothing by mouth on d-10-w. feedings were initiated on day of life one. he has been taking by mouth ad lib enfamil 20, taking approximately 130 ml/kg per day. initial electrolytes were 140, 4.9, 107, and 23 with an initial dextrose stick of 75. he did have a second dextrose stick that was 220. at that point in time, he was weaned from d-10-w to d-5-w, and a follow-up dextrose was 115. the next day, his dextrose stick was 63. he has had no further problems with hyperglycemia. 4. gastrointestinal: the infant admitted with indirect hyperbilirubinemia which peaked on day of life two with a total of 12.5 and a direct of 0.3. he was placed on double phototherapy. phototherapy was discontinued on . his most recent bilirubin was~7. 5. hematologic: the infant's initial hematocrit was 47.5. he has received no blood transfusions during his stay. 6. infectious disease: the infant had an initial complete blood count notable for a white count of 11.7 with 0% bands and 30% segmented neutrophils. a blood culture was sent, and he was treated with antibiotics empirically for 48 hours until blood cultures were negative. he showed no further signs of infection. 7. sensory: a hearing screen was performed with automated auditory brain stem responses. passed both ears. condition at discharge: stable. discharge disposition: to home. primary pediatrician: care and recommendations: 1. feedings at discharge: enfamil 20 by mouth ad lib. 2. medications: fer-in- 0.2 ml by mouth daily. 3. car seat position screening should be completed prior to discharge. 4. state newborn screen was sent on . the results are pending at this time. 5. hepatitis c vaccination was received on . immunizations recommended: synagis respiratory syncytial virus prophylaxis should be considered from through for infants who meet any of the following three criteria: (1) at less than 32 weeks gestation; (2) between 32 and 35 weeks gestation with 2/3 of the following: plans for day care during respiratory syncytial virus season, with a smoker in the household, neuromuscular disease, airway abnormalities, or with school-age siblings; and/or (3) with chronic lung disease. influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers to protect the infant. discharge instructions/followup: primary pediatrician ..................... discharge diagnoses: 1. prematurity at 35 weeks. 2. respiratory distress syndrome; resolved. 3. hyperglycemia; resolved. 4. sepsis evaluation negative. 5. hyperbilirubinemia; resolved. dr., 50-477 dictated by: medquist36 d: 14:39 t: 17:53 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Laryngoscopy and other tracheoscopy Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Other preterm infants, 2,000-2,499 grams 35-36 completed weeks of gestation Carrier or suspected carrier of group B streptococcus

history of present illness: baby boy is a 35 and 0/7 week, 2210-gram, male product of a 24-year-old gravida 3, para 2, now 3, mother (serologies - o positive, antibody negative, hepatitis b surface antigen negative, rapid plasma reagin nonreactive, rubella immune, group b strep status unknown). the baby was via spontaneous vaginal delivery after .................... preterm labor. rupture of membranes was seven hours prior to delivery. mother did receive antibiotics one hour prior to delivery. the infant emerged with a spontaneous cry and received bulb suction and blow-by oxygen. apgar scores were 8 and 9. physical examination on presentation: notable for an awake, 2210-gram, infant. length was 43.5 cm. head circumference was ..................... in general, this was a well-developed male. anterior fontanel was soft and flat. the facies were symmetric. ..................... palate was intact. the neck was supple without cleft of masses. his chest was symmetric. his heart was regular in rate and rhythm and without murmurs. his lungs had poor aeration. he had some grunting, flaring, and retracting. his abdomen was soft and nondistended. he had a 3-vessel cord, and no hepatosplenomegaly. his extremities were all intact, warm, and well perfused. genitourinary .................... male with testes descended bilaterally. the anus appeared patent. his back was without a sacral dimple. his hips were stable without clicks or clunks. he had a symmetric moro. he had a positive grasp and did have a suck. summary of hospital course by issue/system: 1. respiratory: the patient was initially placed on continuous positive airway pressure, but due to work of breathing was intubated and received one dose of surfactant. he was extubated within 24 hours to room air and has remained on room air since with comfortable breathing. 2. cardiovascular: the patient has remained cardiovascularly stable. he has had no murmurs and no blood pressure instability. 3. fluids/electrolytes/nutrition: the baby was initially nothing by mouth on d-10-w. feedings were initiated on day of life one. he has been taking by mouth ad lib enfamil 20, taking approximately 130 ml/kg per day. initial electrolytes were 140, 4.9, 107, and 23 with an initial dextrose stick of 75. he did have a second dextrose stick that was 220. at that point in time, he was weaned from d-10-w to d-5-w, and a follow-up dextrose was 115. the next day, his dextrose stick was 63. he has had no further problems with hyperglycemia. his most recent weight is ..................... 4. gastrointestinal: the infant admitted with indirect hyperbilirubinemia which peaked on day of life two with a total of 12.5 and a direct of 0.3. he was placed on double phototherapy. phototherapy was discontinued on day of life .................... his most recent bilirubin is .................... on ..................... 5. hematologic: the infant's initial hematocrit was 47.5. he has received no blood transfusions during his stay. 6. infectious disease: the infant had an initial complete blood count notable for a white count of 11.7 with 0% bands and 30% segmented neutrophils. a blood culture was sent, and he was treated with antibiotics empirically for 48 hours until blood cultures were negative. he showed no further signs of infection. 7. sensory: a hearing screen was performed with automated auditory brain stem responses. the results are ..................... condition at discharge: stable. discharge disposition: to home. primary pediatrician: care and recommendations: 1. feedings at discharge: enfamil 20 by mouth ad lib. 2. medications: fer-in- 0.2 ml by mouth daily. 3. car seat position screening should be completed prior to discharge. 4. state newborn screen was sent on . the results are pending at this time. 5. hepatitis c vaccination was received on . immunizations recommended: synagis respiratory syncytial virus prophylaxis should be considered from through for infants who meet any of the following three criteria: (1) at less than 32 weeks gestation; (2) between 32 and 35 weeks gestation with 2/3 of the following: plans for day care during respiratory syncytial virus season, with a smoker in the household, neuromuscular disease, airway abnormalities, or with school-age siblings; and/or (3) with chronic lung disease. influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers to protect the infant. discharge instructions/followup: primary pediatrician ..................... discharge diagnoses: 1. prematurity at 35 weeks. 2. respiratory distress syndrome; resolved. 3. hyperglycemia; resolved. 4. sepsis evaluation negative. 5. hyperbilirubinemia; resolved. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Laryngoscopy and other tracheoscopy Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Other preterm infants, 2,000-2,499 grams 35-36 completed weeks of gestation Carrier or suspected carrier of group B streptococcus

allergies: bactrim ds / sulfa (sulfonamides) attending: chief complaint: shortness of breath, left leg swelling major surgical or invasive procedure: none. history of present illness: 62yo woman with history of hypertension presented to clinic on day of admission with multiple complaints including chest pain radiating to her left shoulder, shortness of breath on exertion, cough, and worsening lle swelling and pain x 2 days. on initial exam, her vitals were stable: t 97.7, bp 126/84, p65, rr10 98%ra. her exam was notable for lle swelling and warmth. she was sent to the ed for further evaluation. in the ed, her evaluation was notable for the following: clear chest film; cta demonstrating bilateral pe's; lle leni with extensive dvt in left common femoral, superficial femoral, and popliteal veins, also extending into greater saphenous; also found to have acute coagulopathy, anemia, and thrombocytopenia. she was also found to have brbpr. gi was consulted, and recommended to perform bowel prep in anticipation of colonoscopy in am. surgery was consulted as well, and agreed with plan for anticoagulation for pe's and further investigation for gi bleeding by gi. . on interview on the floor she is alert, oriented, very pleasant, and in no distress. she confirms that over the past several days she has had exertional dyspnea, chest pain (described as dull pressure, , mid-sternal with radiation to bilateral shoulders, not clearly pleuritic) and worsening lle swelling and pain. she also reports several recent bouts of upper respiratory symptoms after exposure to her grandson who is an infant in daycare (reportedly had rsv bronchiolitis recently). otherwise, she denies any fever, chills, n/v, lymphadenopathy, night sweats, unintentional weight loss, abdominal pain/increased girth, or pruritus. she does report one episode of brbpr on day prior to admission after having bowel movement. ros otherwise negative. she also reports a worsening dry cough since she has been in the hospital. she did not have a flu shot. she does not report any long plane/car trips, no prolonged bed-rest. she notes that the swelling in her l leg has improved since being in the hospital. past medical history: hypertension osteopenia h/o pneumonia liver hemangioma psoriasis rosacea diverticulosis social history: lives in , ma and summers on . married, two adult children. retired. no etoh/drugs/tobacco. very active involved in re-modelling her house. babysits her grandson once per week. prior to onset of multiple viral illnesses last fall she did the treadmill for 25 mins at speed 3.3 3-4 times per week. family history: father and mother with heart disease. father had a triple a. htn. no blood clots. father nieces with stomach cancer. aunt with lung cancer but was a smoker. physical exam: 99.6, 92, 124/61, 18, 99% 2l nc . gen a/o, no distress, speaking in full sentences, no accessory resp muscle use heent moist mm, anicteric neck supple, from, no meningeal signs, no jvd, no lymphadenopathy cv rrr, no m/r/g resp cta with decreased breath sounds in bilateral bases l>r abd obese, soft, nabs, nt, no hepatosplenomegaly extr asymmetric 2+ edema and erythema in lle neuro grossly non-focal pertinent results: 06:50pm wbc-11.7*# rbc-3.75* hgb-11.4* hct-31.8* mcv-85 mch-30.2 mchc-35.7* rdw-13.7 06:50pm neuts-81.0* lymphs-13.3* monos-3.7 eos-1.6 basos-0.3 06:50pm plt smr-very low plt count-61*# lplt-2+ 06:50pm pt-15.9* ptt-44.8* inr(pt)-1.4* 06:50pm fibrinoge-65* 06:50pm caltibc-281 haptoglob-248* ferritin-192* trf-216 06:50pm homocystn-12.4 06:50pm glucose-119* urea n-27* creat-1.1 sodium-136 potassium-3.7 chloride-101 total co2-23 anion gap-16 06:50pm alt(sgpt)-30 ast(sgot)-24 ld(ldh)-333* ck(cpk)-276* alk phos-82 amylase-38 tot bili-0.5 06:50pm ck-mb-3 06:50pm ctropnt-<0.01 05:30am d-dimer-8945* cta chest: 1. extensive bilateral pulmonary emboli, with probable developing infarction in the left lingula. 2. left pelvic vein clot from imaged portion of common femoral to the confluence of the common iliac veins, likely the source of pulmonary emboli. no definite extension to the right common iliac vein or ivc. 3. large hemangioma in liver. 4. colonic diverticulosis without diverticulitis. 5. left adnexal cyst, unusual in a postmenopausal patient. this should be further evaluated with pelvic ultrasound on a nonemergent basis. leni: extensive acute dvt within the entire left lower extremity deep venous systems. no right dvt. ecg: sinus rhythm. non-specific junctional st segment depressions. compared to the previous tracing this finding is new. tte: the left atrium is elongated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the aortic arch is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the left ventricular inflow pattern suggests impaired relaxation. there is borderline pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. pelvic us: fibroids, follicular activity left ovary, right ovary not seen, thrombus in the left iliac vein brief hospital course: 1) dvt/pe: patient was started on anticoagulation with heparin for extensive pe/dvt (lle). this was continued despite bleeding. once the bleeding has stabilized, she was started on coumadin. she was discharged on a lovenox bridge to coumadin. in terms of workup for cause of this thrombosis, pt had a pelvic us to further evaluate mass since on ct as potential malignancy. but there was no evidence of ovarian malignancy. she was up to date on other cancer screening. factor v leiden and prothrombin gene mutation were pending at time of discharge. the rest of the hypercoagulable workup will have to be done once acute thrombosis resolves. the left leg swelling improved throughout the admission. pt was instructed to keep the leg wrapped most of the day. and to keep it elevated when lying in bed or sitting. .. 2) gi bleed: flex sig showed diverticulosis so this bleeding was secondary to that. pt did have blood loss anemia requiring transfusions. during the last 5days of the admission, there was no clinical bleeding and her hct was stable to slightly improving. aspirin was held. verapamil was also held and not restarted as pt's bp was well controlled in house. .. 3) htn: as above, verapamil was held. .. 4) coagulopathy: on admission, pt had thromboctyopenia, low fibrinogen. this was felt to be due to consumption and factors improved once anticoagulation was started. there was no evidence of frank dic. .. 5) pneumonia: several days into the admission, pt developed a low grade temperature and cough. though this was most likely due to pulmonary infarction, levaquin was started for pneumonia. pt's cough improved with this and she completed a 5d course of levaquin before discharge. medications on admission: aspirin 81 mg betamethasone valerate 0.1 % to skin metrogel 1 % to skin multivitamin qd verapamil hcl cr 240 mg qd viactiv 500-100-40 mg-unit-mcg 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. warfarin 1 mg tablet sig: five (5) tablet po once a day. disp:*150 tablet(s)* refills:*0* 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. disp:*30 tablet(s)* refills:*0* 4. enoxaparin 80 mg/0.8 ml syringe sig: one (1) syringe subcutaneous q12h (every 12 hours) for 1 weeks. disp:*14 syringe* refills:*0* discharge disposition: home with service facility: discharge diagnosis: deep venous thrombosis pulmonary embolism diverticular hemorrhage pneumonia discharge condition: good. discharge instructions: take medications as prescribed. you should not take aspirin or verapamil until you are reassessed by dr. . do not take a multivitamin or anything else with vitamin k as that will counteract the coumadin. for the next week, you can do basic daily activities but avoid anything that requires prolonged standing, sitting (with legs not elevated) ie driving, or walking. you can continue to use the leg wrap during the night and part of the day. as your swelling improves, you should not continue to need that. followup instructions: you will have your inr checked on monday with results sent to dr. . he will instruct you on whether you need to continue lovenox and how to adjust your coumadin dose. please ask the vna which lab the blood will be sent to. please follow up with dr. late next week or early the following week. Procedure: Flexible sigmoidoscopy Diagnoses: Pneumonia, organism unspecified Thrombocytopenia, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Diverticulosis of colon with hemorrhage Other pulmonary embolism and infarction

code: full allergies: sulfa Procedure: Flexible sigmoidoscopy Diagnoses: Pneumonia, organism unspecified Thrombocytopenia, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Diverticulosis of colon with hemorrhage Other pulmonary embolism and infarction

history of present illness: after her arrest and transferred to the medical intensive care unit, the patient was followed for a number of conditions. 1. with regards to infectious disease, the patient continued to be covered for her high-grade candidemia. in addition, she was covered with broad-spectrum antibiotics to cover other possible infectious contributions to her illness. 2. she continued to remain dependent on ventilator and could not be successfully weaned without developing marked respiratory distress. 3. gi. she continued to be followed by the gi team, who remained concerned that her elevated lfts represented hepatic candidiasis or a potential biliary obstruction. unfortunately, the patient was not stable enough to undergo mri examination of her abdomen, and this remained an unanswered question. 4. neurology. after her arrest, the patient never regained meaningful interactions with her caretakers or her family. at various times she appeared very uncomfortable, and a decision was ultimately made to focus treatment on her comfort. after extensive discussions with the family about her ongoing issues and her grim prognosis, the decision was made to defer further aggressive measures and focus care on her comfort. in accordance with these wishes, the patient was extubated on , and weaned from all antibiotics and blood pressure supporting medicines. shortly thereafter, the patient expired. time of death: 1:30 am on . cause of death: 1. cardiac arrest. 2. sepsis. no autopsy was performed per the family's request. discharge status: deceased. discharge diagnoses: 1. candidemia. 2. sepsis. 3. anemia. 4. tachycardia. 5. electrolyte abnormalities. 6. hepatitis. 7. acute cholecystitis. 8. pancreatitis. 9. status post pulseless electrical activity arrest. 10. tophaceous gout. 11. hypothyroidism. discharge medications: none. follow-up plan: none. , md dictated by: medquist36 d: 10:28 t: 11:49 job#: Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Endoscopic sphincterotomy and papillotomy Endoscopic dilation of ampulla and biliary duct Other cholecystotomy Diagnoses: Acute kidney failure with lesion of tubular necrosis Acute and subacute necrosis of liver Unspecified septicemia Acute respiratory failure Defibrination syndrome Disseminated candidiasis Acute pancreatitis Calculus of gallbladder with acute cholecystitis, without mention of obstruction Gouty tophi of other sites, except ear

history of present illness: this is an 81-year-old with no significant past medical history who is transferred from hospital for anemia, melena, acute renal failure and rule in myocardial infarction. this is an 81-year-old with no medical history except for tophaceous gout who was in her usual state of excellent health until three days prior to admission when after lunch, she laid down because she did not feel well. she sleeps in a different room from her husband, with whom she lives. when he asked her later that evening how she was, she said she was fine. the next day, she continued to remain in bed. he offered her some juice, which she drank, but she was slowly becoming more confused and lethargic. on the third day, she was barely arousable and incoherent. he called ems who found her to be "incontinent of urine." she was taken to hospital where she was lethargic, oliguric and confused. she had a rectal temperature of 87 degrees. her pulse was 80 with a systolic blood pressure of 72-135. she was found to be guaiac positive with a fingerstick of 38. her white blood cell count was 17.1, 87% neutrophils, 14% bands, 4% lymphocytes and 2% monocytes. her hematocrit was found to be 16.1. he platelet count was 100,000. her chem-7 revealed a sodium of 148, potassium 4.8, chloride 118, bicarbonate 15, bun 83 and creatinine 2.5. her ck was 499 with an mb of 60 and an index of 12. her inr was 2.6. blood cultures times two were negative. a head ct was performed which showed enlarged ventricles, but was otherwise negative. she was resuscitated and given two units of packed red blood cells. she was warmed to a rectal temperature of 94 and transferred to for further care. on arrival, her temperature was 98 and she had a systolic blood pressure in the low 100s. she received more blood products and vitamin k and was admitted to the medical intensive care unit. past medical history: tophaceous gout. medications: advil 1 tablet q.d. allergies: no known drug allergies. social history: no tobacco or alcohol use. never visited a doctor. lives with her husband in . does the banking, and shopping and cooking. is very active at home, taking care of her husband of the past 60 years. family history: a sibling with diabetes. physical examination: this is an ill-appearing elderly woman who had a temperature of 98 rectally, a blood pressure of 106/50. pulse of 87. respiratory rate of 28 and an oxygen saturation of 100% on 100% nonrebreather. she was normocephalic, atraumatic with a 2 mm right pupil and a 1 mm sluggish left pupil. she had anicteric sclera. her mucous membranes were dry. she had upper dentures and dried blood on her upper palate above her dentures. her neck had no masses. her chest was clear except with good air movement except for decreased breath sounds at the right base. her heart was regular in rate and rhythm with no murmurs. her abdomen was moderately distended without rebound or guarding and good bowel sounds. her back had no overt lesions. she had a fluctuant mass along her right thorax extending from her axilla to her iliac crest without erythema. she had large gouty tophi and joint disease of bilateral hands and feet. she had 2+ anasarca. she had 2+ bilateral radial and dorsalis pedis pulses. she had ischemic discoloration of her right second finger, left second to fourth digits in all ten toes bilaterally. she had numerous ulcerations on her feet. her gout involved the small joints of her hands, as well as both her elbows and both her knees. on neurological exam, she was awake and responded to voice, but did not answer questions. her extraocular movements were intact and she was moving all her extremities, as well as withdrawing to pain. laboratory data on arrival: white blood cell count of 15.9, hematocrit of 24.9, a platelet count of 117,000, inr of 2.6, an arterial blood gas of 7.41, 28 and 114. a negative toxicology screen and a chem-7 consistent with that of the outside hospital. albumin is 3.1, ast of 749 with alt of 437. alkaline phosphatase of 269 and a total bilirubin of 1.9. her tsh was 6 with a free t4 of 0.7. her cortisol was 55. amylase and lipase revealed a 123 and 405. her ck was 485. it peaked at 1064 and then returned to . her troponin peaked at 1.4. electrocardiogram revealed normal sinus rhythm at 90 beats per minute with low voltage in the limb leads. she had normal axis, normal intervals and no acute st changes. chest x-ray showed low lung volumes and bilateral pleural effusions, right greater than the left, with associated collapse of her right lower lobe and right middle lobe. abdominal ct revealed a large right and a moderate left pleural effusion, as well as ascites. she also had a right subcutaneous fluid collection. she had a uterine fibroid. her bowels appeared normal as did her liver and gallbladder. she had atrophic kidneys with scattered cysts. she had normal pancreas, spleen and adrenals. hospital course: on admission to the medical intensive care unit, she was resuscitated with two units of ffp, 1 mg of intravenous vitamin k, intravenous fluids and she was started on antibiotics, mainly vancomycin, ceftriaxone and flagyl. she did not require pressors at any point during her stay. the main initial differential included ttp, although, her coags were abnormal and she had a negative lupus anticoagulant and anticardiolipin antibodies, so that diagnosis was excluded. the main concerns then were either sepsis leading to dic or massive gastrointestinal bleed leading to dic. she spent six days in the intensive care unit where she was persistently obtunded and guaiac positive. however, she was hemodynamically stable and was easily weaned off all supplemental oxygen and remained with a good blood pressure. multiple blood cultures were negative. she had a single urine culture on presentation that had 10-100,000 pansensitive e. coli, but all subsequent urine cultures were negative. her necrotic toes were cultures and grew out polymicrobial gram positive cocci and gram negative rods. she was given the diagnosis of sepsis of unknown etiology with complications of dic and multisystem organ failure, namely acute renal failure, shock liver, acute myocardial infarction, altered mental status and digital necrosis. she also had gross anasarca. given her altered mental status, mr of her head was performed which revealed chronic microvascular infarct, but was negative for anoxic brain injury or major infarct. an lumbar puncture was negative with normal protein and glucose and negative cultures. an electroencephalogram was consistent with toxic metabolic encephalopathy. her b12, folate and rpr were all normal. her arterial blood gases remained within normal limits. her white blood cell count fell to approximately 13. her inr improved with vitamin k and ffp. she initially had a lactate of 3.9 that dropped to 1.9. her hematocrit remained stable at about 26-28. her platelets remained low in the 80,000s. her creatinine peaked at 3.9 and then slowly dropped to approximately 1.4. her bicarbonate improved from 17 to 25. her transaminases returned to . her alkaline phosphatase stabilized in the 300-400 range. numerous consultations were obtained including a cardiology that stated that her myocardial infarction was likely in the setting of severe anemia and sepsis. an echocardiogram revealed severe apical hypokinesis with decreased systolic function and a small effusion with fiber and deposits on the cardiac surface. cardiology recommended no anticoagulation given her anemia and guaiac positive stools. they recommended keeping her hematocrit about 30 and the use of a beta-blocker if she became hypertensive or tachycardic, neither of which happened during her stay. hematology was also consulted regarding her coagulopathy. they felt it was consistent with dic and was not ttp. they recommended vitamin k supplementation which improved her inr. she did, however, have a persistently elevated ptt despite having a negative lupus anticoagulant and anticardiolipin antibody. the renal service was consulted and diagnosed her with atn with muddy brown casts. he creatinine slowly improved from a peak of 3.9 to 1.4. her anasarca improved with diuresis. she did not require hemodialysis. a rheumatology consult stated that she had chronic gout with no apparent acute flare of any joints. she was unable to receive colchicine or nsaids due to her acute renal failure and would not have benefited from allopurinol at that time. her right elbow was causing her some discomfort and was tapped twice during her stay. both times, it was negative for infectious arthritis, but did reveal crystals suggestive of gout. the vascular surgery service was consulted and continues to follow her throughout her stay with regard to the gangrene of her toes. her lower extremities were elevated and received wound care. amputations were recommended when she was medically stable. her toes were never a cause of her sepsis and never look infected. they were debrided as necessary. they became very well demarcated and healed nicely. the gastrointestinal service was consulted. they felt that she most likely had pancreatitis and were uncertain what the initial cause of her sepsis or her massive gastrointestinal bleed was. they recommended transfusions, following her guaiac and no ng suction. they stated that neither esophagogastroduodenoscopy nor colonoscopy could be done until six weeks after her myocardial infarction unless she demonstrated active bleeding. however, her hematocrit remained stable after her initial transfusion. after six days in the unit, she was transferred to the floor. there was a concern that her mental status were due to the morphine and ativan she was receiving because of her extreme pain during dressing changes. during her stay in the unit, she was nearly constantly crying or screaming. on the floor, she remained hypothermic with an alkaline phosphatase of about 500. her white blood cell count increased to about 26. her stool culture was negative for c. difficile times three. she was changed from ceftriaxone to ceftazidime and remained on broad spectrum coverage. she continued to have excellent saturations and blood pressures. her only focal sign remained abdominal pain. an ultrasound was unhelpful. a second ct was obtained which showed a large gallbladder that was not inflamed with a large gallstone. there was no pericholecystic fluid or biliary dilatation or obstruction. during this time, she had been started on tube feeds. however, she had an episode of nausea and vomiting with aspiration and so she was made npo and tpn was started via a picc. due to the concern for cholecystitis, a hida scan was performed which showed no uptake. this was consistent with acute cholecystitis and there was a potential that this could have been the triggers setting off her sepsis. a gallbladder drain was placed by interventional radiology as general surgery consulted and stated that she was far too ill to undergo surgery. her viral culture was negative. in the continued search for a source of her sepsis, her pleural effusion was tapped. it was transudate and the cultures were negative. her ascites was also tapped. her serum to ascites albumin gradient was 1.1. she had 1700 white blood cells with 60% polys and a negative gram stain and cultures. at that point, she had received adequate coverage for bacterial peritonitis with ceftriaxone and then ceftazidime. after the gallbladder drain was placed. her white blood cell and alkaline phosphatase started to decrease, but after a few days, her total bilirubin, white blood cell count and alkaline phosphatase once again started to rise for unclear reasons. a ggt was checked to insure that the alkaline phosphatase was of liver source and it was very elevated. she also had a mild lipase leak at this point from 45 to 71. there was a concern for gallstone pancreatitis or cholangitis. she continued to have melena throughout this time. a magnetic resonance cholangiopancreatography was performed which showed pancreatitis and no biliary dilatation, but raised the question of a mass in the head or uncinate process of the pancreas and also a question of duct disruption. as her alkaline phosphatase continued to rise, from the 500s to the 1000s and her total bilirubin increased to 2.2 and her lipase increased to 123, an endoscopic retrograde cholangiopancreatography consult was obtained. the endoscopic retrograde cholangiopancreatography fellow recommended a cholangiogram as an initial first step. this was done injecting dye through her gallbladder drain. this revealed a distal common bile duct obstruction, question stenosis versus stone with no duodenal filling and mild dilatation of her hepatic and common bile ducts. also during this time, other sources of infection were being sought and an mri of her feet were done, which were negative for infection. as above, her right elbow joint was also tapped and was negative for septic arthritis. after the cholangiogram revealed obstruction, an endoscopic retrograde cholangiopancreatography was performed which revealed no pus or masses but did reveal ampullary stenosis. a sphincterotomy was performed. on the floor, after her endoscopic retrograde cholangiopancreatography, she developed post endoscopic retrograde cholangiopancreatography pancreatitis and her lipase rose to 163. she had increasing abdominal tenderness and became slightly more confused. prior to the endoscopic retrograde cholangiopancreatography, her mental status had greatly improved, although, she still was not speaking, she was alert. after the endoscopic retrograde cholangiopancreatography, a third abdominal ct with intravenous contrast was obtained to evaluate for potential endoscopic retrograde cholangiopancreatography induced perforation of the intestine or for pancreatic mass given the question raised on the magnetic resonance cholangiopancreatography done earlier. abdominal ct number three revealed pancreatitis with no hemorrhage or significant necrosis and no pancreatic mass. she had no signs of perforation secondary to her endoscopic retrograde cholangiopancreatography and no bowel ischemia. after the endoscopic retrograde cholangiopancreatography, her total bilirubin dropped to normal, however, her alkaline phosphatase continued to increase from the 1100s to the 1700s. as she slowly recovered from her endoscopic retrograde cholangiopancreatography pancreatitis, not only did her alkaline phosphatase continue to rise, but she developed a direct hyperbilirubinemia again. at this point, she began growing from her blood and her urine. she received 24 days of broad spectrum antibiotics at this point. her antibiotics were stopped and her tpn was stopped as well. her picc line was removed. she was started on fluconazole. right around this time, she developed dysarthria and a facial droop that was unclear if it was new. a repeat mri with gadolinium was the same as her previous. the repeat was done on and it showed no changes from the mri on . a repeat electroencephalogram was normal. over a few days, her dysphonia improved. she remained on her fluconazole. surveillance blood cultures were negative. a repeat cholangiogram showed normal biliary tree and flow. this cholangiogram was performed as her alkaline phosphatase had continued to rise from the 1700s to the . a repeat bile culture grew yeast. her white blood cell count remained stable between 16 and 20,000 throughout this time. she was restarted on tube feeds as her post endoscopic retrograde cholangiopancreatography pancreatitis was improving. an ophthalmology consult was obtained to evaluate for fungal eye disease secondary to her candidemia. she had no evidence of fungal eye disease. after she developed candidemia and with her increasing alkaline phosphatase, her creatinine bumped from 1.4 to 1.6. despite her positive cultures, she continued to improve in terms of mental status, abdominal pain, and renal function. however, since her bile culture had grown out , her gallbladder drain was removed. after it was pulled, she had leakage of her ascites out of the cutaneous fistula tract that had led to her gallbladder. the ascitic fluid was tinged brown with concern for bile spillage into the peritoneal cavity. over the afternoon after her gallbladder drain was pulled, she demonstrated increasing abdominal tenderness and guarding that was new. this was discussed with the gastrointestinal and radiology services who stated that she should be started on broad spectrum antibiotics to cover potential secondary bacterial peritonitis, although, she was most likely suffering from a chemical peritonitis secondary to bile spillage. fluid was sent for gram stain culture and fungal culture. radiology stated that in the presence of ascites, the site of her gallbladder drain in the gallbladder wall was less likely to close off immediately after the catheter was pulled, but should close with time. they recommended supportive care through this peritonitis. later that evening, she was noted to be bradycardic on telemetry. a code was called. she underwent pea arrest and was transferred to the medical intensive care unit after she was resuscitated. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Endoscopic sphincterotomy and papillotomy Endoscopic dilation of ampulla and biliary duct Other cholecystotomy Diagnoses: Acute kidney failure with lesion of tubular necrosis Acute and subacute necrosis of liver Unspecified septicemia Acute respiratory failure Defibrination syndrome Disseminated candidiasis Acute pancreatitis Calculus of gallbladder with acute cholecystitis, without mention of obstruction Gouty tophi of other sites, except ear

history of present illness: baby boy is the 28 and 5/7 weeks gestational infant born to a 35-year-old g1, p0, now 1 mom. prenatal screens - o negative, antibody negative, rpr nonreactive, rubella immune, hepatitis surface antigen negative, gbs unknown with an estimated date of confinement of . this pregnancy was uncomplicated until premature rupture of membranes on . mother received one dose of betamethasone, followed by dose of interpartum antibiotics with precipitous delivery at 4:47 on the afternoon. he required intubation in delivery room. apgars of 6 and 7. transferred to the newborn intensive care unit for management of prematurity. physical examination: weight 1280 grams, 70th percentile; length 38 cm, 50th percentile; head circumference 26.5 cm, 45th percentile. anterior fontanel open and flat. puncture lesions x 2 with some bleeding from scalp lead. positive molding and facial bruising with edema. orally intubated. breath sounds diminished and coarse throughout. regular rate and rhythm without murmurs. 2 + peripheral pulses including femorals. abdomen benign without hepatosplenomegaly. normal male genitalia for gestational age. testes high in scrotum bilaterally. skin warm and well perfused. appropriate tone and strength. active and responsive. summary of hospital course by systems: respiratory: was intubated in the delivery room for surfactant deficiency. he received a total of 2 doses of survanta and was weaned to extubatable settings within 24 hours of age. he was extubated to room air. he remained stable in room air until day of life 14 when he required some nasal cannula oxygen. he had been receiving caffeine for apnea of prematurity until day of life 27. he was stable on nasal cannula oxygen until the onset of current clinical situation (see renal) requiring him to be intubated on day of life 27 () with associated severe respiratory acidosis. due to poor ventilation as well as poor lung expansion, he was placed on hfo with a max map of 18=9. he was changed to simv on and currently on 24/5 x 34 21-25% fio2. his most recent blood gas on these settings was a ph of 7.40, pco2 of 40, po2 of 97, bicarb 26, base xs 0. his most recent cxr demonstrates poor lung inflation with 7 rib expansion cardiovascular: his cardiovascular status has been stable throughout hospital course. no history of a murmur. no history of a murmur. his heart rate range from 150 to 160 and his means are mid to high 60s. he had an echocardiogram performed on . there was no intercardiac thrombus noted. he had good biventricular function. a patent foramen ovale was present. otherwise structurally normal. gastrointestinal/ genitourinary: birth weight was 1280 grams. discharge weight is 2.080 kg. we are basing fluids on 1.915 grams. after birth, he was initially started on 100 cc per kg per day of d10w starter pn. enteral feedings were initiated on day of life no. 3. he advanced to full enteral feedings by day of life 9. he was tolerating full enteral feedings until , with the onset of these current renal issues (see below) . he was made npo. he is currently received parenteral nutrition of d12.5 with 3 of sodium chloride and one of potassium chloride. he also has peripheral arterial line in with normal saline with one unit of heparin. on the morning of : his sodium was 138, potassium is 3.6, chloride is 102, total co2 was 27. a repeat in the evening showed a potassium of 2.7 (nicu on 7north called and will remake fluids containing 3 meq of k cl. urine, electrolytes from , showed sodium of 70, potassium of 7, chloride of 54, albumin was 37.4, creatinine was 4. renal: the infant presented on day of life 27, , with frank blood in urine. at that time a renal ultrasound was performed and the renal ultrasound showed an echogenic enlarged right kidney with reversed diastolic flow. the right kidney measured approximately 5.3 cm and the left kidney measured approximately 4.7 liters. at that time images of the aorta and inferior vena cava were not obtained. repeat renal ultrasound on , showed marked enlarged and echogenic right kidney which measured approximately 5.9 cm. the arterial flow present to the right kidney showed high velocity and reversed diastolic flow. the left kidney measured approximately 4.6 cm and had high velocity flow with reversal in diastole as well. there was a small amount of ascites. the gallbladder was filled with sludge. the ivc had a very narrow portion just proximal to the confluence of the hepatic vein. distal to this was a large clot measuring approximately 1 cm in diameter. the ivc clot most likely accounts for the abnormal findings in both kidneys and the patient's hematuria. the study was limited by the patient's overlying bowel gas and the fact that he was on high frequency ventilation. his most recent abdominal ultrasound was done on . the findings of this ultrasound were once again showed a large clot in the ivc below the liver. the clot does not involve the intrahepatic portion of the ivc. flow was present both proximal and distal to the clot, however the origins of the renal veins were not identified. both kidneys remained small with decreased cortical medullary differentiation. the right kidney is somewhat smaller since the prior study currently measuring 5.5 cm in length compared to 5.9 cm. ivc clot currently measures approximately 2.8 x 0.7 x 1.2 in size. there is persistent high resistance arterial flow within the right renal artery as well as within segmental and internal arteries with diminished diastolic flow. the amplitude of the intrarenal wave forms was also dampened. the resistive indices measure between 0.83 and 1.0 on the right. venous flow was identified within the right kidney, especially in the region of the hilum. a renal vein was identified draining into the retroperitoneum on the left side. the flow within the main renal artery and within the renal parenchyma is more normal than that on the right. the resistive indicates with the left renal parenchyma range between 0.68 and 0.84. the renal service has been consulted and following; the attending is dr. . after the patient presented with gross hematuria, concern for renal vein thrombosis, and poor urine output, a foley catheter was placed. the foley is now out. his most recent bun was 23 and creatinine was 0.6 that was on . he had a peak bun of 81 with a creatinine of 0.9. peak bilirubin was on day of life 4 of 6.3/0.4. the infant received phototherapy for a total of one week and that issue has since resolved. hematology: hematocrit on admission was 56.1. in setting of renal vein thrombosis, infant had crit of 26.7% and received prbc transfusion. the infant has received in total of 40 per kg packed red blood cells since dol #27 with the most recent blood transfusion being on . his most recent hematocrit was 37.9 on . his blood type is a positive, direct coombs' negative. in light of all the concerns for intravascular clots pt, ptt were obtained and his most recent levels - he had a pt of 13.4, and ptt of 36.7 on . his d-dimer at that time was 7638. in the setting of bilateral renal vein thrombosis and ivc clot with concern for further spread, hematology service was consulted. he was started on lovenox on . we have been unsuccessful in reaching therapeutic levels. his most current level was today and it was 0.1. dr. is the attending. since his acute current illness, his platelet count was monitored. his lowest plt count was 98 and this has remained stable and currently 148. no platelet transfusions were required. of note, in the setting of ivc/renal venous thrombi, a hematological work-up was sent on both parents and pending at the time of this dictation. infectious disease: with the onset of hematuria and decompensation of his respiratory status. a cbc and blood culture obtained. the infant was started on vancomycin and gentamycin which was then changed to cefotaxime and vanc (levels of 6.9 and 26.6). he was changed to cefotaxime and oxacillin on . the plan is to treat him for one week with antibiotics. his blood culture from is no growth to date. his cbc's have all been normal except for one shifted cbc on with wbc of 0.0 (22p10b) neurologic: initial head ultrasound on was within normal limits. prior to starting lovenox, a repeat hus was done and was within normal limits. on , a another hus was performed and demonstrated bilateral hemorrhages in the subependymal regions as well as significantly larger bleed in the region of the right thalamus. there was mild dilatation of the lateral ventricles and third ventricle. the third ventricle was displaced to the right. the thalamic bleed measures approximately 1.4 x 1.8 x 1.8 cm in size. the fourth ventricle is small but otherwise appears normal. several foci punctuate regions of hyperechogenicity are identified within the chrono radiata on each side which may represent small hemorrhages. no other abnormality. neurology was consulted-- dr. is the attending neurologist. neurology thought that infant might have internal cerbral clots with secondary hemorrhagic component; as a result they recommended obtaining a mrv at restarting lovenox. the infant is now being transferred to for mrv and possible lovenox to be restarted. sensory: hearing screen has not been performed. ophthalmology: eye exams have not been done at this time. psychosocial: a social worker has been involved with the family and can be reached at . the family has been kept up to date and are appropriately concerned. condition on discharge: guarded. discharge disposition: to level iii. name of primary pediatrician: dr. . discharge diagnosis: preterm male born at 28 and 5/7 weeks gestation corrected to 33 weeks. status post respiratory distress syndrome. rule out sepsis. bilateral renal vein thromboses ivc thrombosis. bilateral subependymal hemorrhage and right thalamic hemorrhage r/o sinus venous thrombosis , dictated by: medquist36 d: 20:04:00 t: 03:09:37 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Other phototherapy Transfusion of packed cells Umbilical vein catheterization Transfusion of other serum Insertion of indwelling urinary catheter Diagnoses: Acidosis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Other preterm infants, 1,250-1,499 grams 33-34 completed weeks of gestation Other venous embolism and thrombosis of inferior vena cava Other venous embolism and thrombosis of renal vein Intraventricular hemorrhage unspecified grade Phlebitis and thrombophlebitis of intracranial venous sinuses Congenital anemia

history of present illness: please note that the patient has a discharge summary dating , with addendum that adequately describes his course prior to this current admission which was on . this patient has had a long and complicated course and history of present illness will be presented in that context. this is an 83 year old right handed man without any significant past medical history as he did not present himself to medical attention, had initially presented with right hemiplegia and dysarthria and had been found to have a left parapontine ischemic stroke in the setting of severely compromised posterior circulation including bilateral vertebral stenoses and midbasilar stenosis. he had been discharged on , to a rehabilitation facility. reportedly his blood pressure which usually was systolic of 160 to 200 dropped to 130 and he had worsening symptoms of right hemiplegia and also in terms of left sided symptoms. for this reason, he was transferred to for further evaluation. medications on admission: 1. plavix 75 mg p.o. q.d. 2. aspirin 81 mg p.o. q.d. 3. magnesium oxide 400 mg p.o. b.i.d. for four doses which he had not completed. 4. tylenol 650 mg q6hours p.r.n. pain. social history: the patient used to live alone on a farm until his previous hospitalization. allergies: no known drug allergies. family history: noncontributory. physical examination: on readmission on , systolic blood pressure is in the 170s and diastolic blood pressure is in the 80s. heart rate is in the 60s and regular. the patient is lying in bed somnolent, hard collar in place, family by bedside. the heart is regular rate and rhythm. the lungs are clear to auscultation bilaterally. positive bowel sounds. neurological examination on readmission revealed the patient is dysarthric and somnolent but fairly arousible, can say his name but does not know the date (question inattentive/frustrated) or what hospital. the patient is fluent. the rest of the examination was not completed due to the patient's disinterest. on cranial nerve examination, the patient had pupils equal, round and reactive to light. extraocular movements were intact. right facial droop. right tongue deviation. hearing was intact to finger rub. sternocleidomastoid and trapezius were not tested. motor examination - flaccid right side, only moves toes to noxious stimuli, question spasms, right side has significantly more strength. notably deltoids 5-/5, biceps , and distal upper extremities have 5-/5 finger extensors and finger flexors. wrist extensor and flexors were full strength. iliopsoas was 5-/5. quadriceps was , hamstring was 5-/5 and the remainder of all the muscle groups were essentially full strength either or 5-/5. there was also question of patient's interest and effort during this part of the examination. sensory - the patient denies any decrease in sensation to light touch and cold touch, question of inattention. the patient was areflexic on the right upper extremity with 1+ deep tendon reflex on the left upper extremity at biceps and triceps. he had 1+ patellar reflexes bilaterally. achilles tendon reflex could not be elicited and he had upgoing toes bilaterally. coordination - finger-nose-finger within normal limits on the left. gait - the patient is bed bound. hospital course: as mentioned above, the patient has had a long and complicated course. i will address his course in summary highlighting each physical system. 1. neurologic - a magnetic resonance scan was done with stroke protocol that showed extension of restricted diffusion in the left parapontine region with new restricted diffusion in the left cerebellum and a minimal restricted diffusion on the right. he was admitted to the intensive care unit with heparin drip and was coumadinized initially. his neurological course has had many turns. in summary, head of bed was kept flat and when we would either try to increase the inclination of the head of the bed, he would get symptoms including nausea and loss of strength on the left. his strength on the right side remained minimal, only able to wiggle toes and occasionally wiggle fingers. his strength on the right was also waxing and with good strength on some days as described in the initial examination and on other days he would not give his best effort. at least one time we did a repeat imaging because we were concerned that he may have had further extension of infarct but we did not find any new findings beside what has already been mentioned above. the patient has been kept anticoagulated for neurological reasons through heparin drip and has been tried to be coumadinized to goal at multiple times. at times, the coumadin has been stopped either because the patient needed an interventional radiology procedure or needed percutaneous endoscopic gastrostomy tube to be placed. at this time, he is still on heparin drip with coumadin being administered to goal. after an episode of pulmonary edema on the morning of , after administration of fresh frozen plasma to reverse supratherapeutic inr that will be described below in the cardiovascular section, an angiogram was done by dr. to determine possibility of angioplasty of posterior circulation, however, on this angiogram, there was evidence of total occlusion of the basilar artery with evidence of collaterals being formed from the pica and possible collateral blood flow from the left meningeal vasculature. given this situation, there was no indication for any further intervention and no angioplasty was done. this was discussed extensively with the family. from a neurological point of view, we are going to manage him conservatively with gentle challenge of his posterior circulation by increasing the inclination of his bed and hoping he does not get any symptoms. there have been talks of possible involvement of neurosurgery by dr. to ask whether there would be any neurosurgical procedure that could be done that would enhance blood flow to the posterior circulation. at this time, this consultation is in progress and we will likely contact dr. for his formal opinion on the issue. also from a neurological standpoint, we have kept his blood pressure always more than 160 systolic but we have revisited this issue as discussed below in the next section. 2. cardiac - initially we had kept the patient's blood pressure in the 160s to 180s to enhance flow to the posterior circulation. however, on , he was found to be diaphoretic, tachypneic with rate of 40s and stat electrocardiogram was done that showed evidence of st wave elevation and reciprocal depression in the precordial leads and with evidence of t wave inversion in the lateral leads. a stat cardiology consultation was called and this was felt to be flash pulmonary edema due to the fact that he had recently been transfused with one unit of fresh frozen plasma for an supratherapeutic inr of 5.2. he was managed in the cardiac unit for a day and was transferred after being given intravenous lasix and diuresed. he did pretty well from a cardiac standpoint and we used p.o. lopressor 12.5 mg from time to time to control his blood pressure. we also had started midodrine 10 mg t.i.d. in the hopes of preventing him from getting orthostatic hypotension. after this episode on , midodrine was stopped. the patient had another congestive heart failure exacerbation with flash pulmonary edema on chest x-ray on the morning of . cardiology was again involved and he was transferred to the subacute coronary care unit. he was again found to be diaphoretic with tachypnea in the 40s and systolic blood pressure 220/110. he was initially managed with a nitroglycerin drip and he is going to be transferred back to the floor with lopressor 37.5 mg b.i.d. and nitroglycerin patch 0.2 mg between 9:00 a.m. and 11:00 p.m. and lasix 20 mg q.o.d. that will be further described in the present medication section. we had a long discussion with the cardiology team and they felt that the patient was going to continue having subendocardial ischemia that would cause flash pulmonary edema and similar episodes to the one he had on , and . however, if we did not control his blood pressure adequately, a decision has been reached that we will tightly control his blood pressure between 150 and 160. the cardiology team also feels that should he have another of this congestive heart failure exacerbation, decision will then have to be made as to whether he will benefit from cardiac catheterization. the cardiology team is going to be following the patient on the floor. 3. fen - a percutaneous endoscopic gastrostomy tube was placed through which he has received tube feeds, promote with fiber. the patient had significant morbidity from percutaneous endoscopic gastrostomy tube placement, having subcutaneous emphysema that took a couple of weeks to resolve. the patient had two episodes of bleeding from the percutaneous endoscopic gastrostomy tube site and hemostasis was achieved by surgicel on both occasions. interventional radiology was involved on the first bleed and general surgery was curb-sided on the second occasion and they agreed with the plan to use surgicel to achieve hemostasis. it is presumed that because of this intermittent percutaneous endoscopic gastrostomy tube site bleed into the stomach through the tube, he has been guaiac positive. the percutaneous endoscopic gastrostomy tube was advanced to a jejunostomy tube because there was some concern that he may be aspirating. 4. orthopedic - the patient was diagnosed with a type ii odontoid fracture and as per orthopedics, we have kept him in the hard collar which he does not tolerate very well. he is scheduled to see dr. , , on , for reassessment on this issue. if the patient is still in house, please call his office on , and determine follow-up care. 5. other - there were long discussions with the family and the patient was made dnr/dni after a family meeting. there was another family meeting that was arranged to decide on the interventional radiology angioplasty procedure. at this meeting, dr. from interventional radiology was present and we provided explanation on the reasons why this was being done. , of the patient, was appointed as principal spokesperson and health proxy for the patient. his contact numbers are home and his beeper . 6. psychiatry - the patient was started on citalopram 20 mg q.d. because after several discussions, we noted that the patient had a depressed affect. psychiatry was consulted and they agreed with the plan. in summary, the patient is going to be managed conservatively with hopes of formation of collateral flow to his posterior circulation and he will be managed more aggressively from a cardiology standpoint with possible cardiac catheterization if family decides to go ahead with the procedure. please note that hematocrit has been stable in the low 30s ranging between 30.0 and 32.0. medications at present: 1. lopressor 37.5 mg b.i.d. 2. aspirin 81 mg q.d. 3. lipitor 10 mg q.d. 4. citalopram 20 mg q.d. 5. colace 100 mg t.i.d. 6. lasix 20 mg q.o.d., hold for systolic blood pressure less than 150. 7. dulcolax per tube/pr 10 mg p.r.n. 8. coumadin 5 mg q.h.s. 9. nitroglycerin patch 0.2 mg between 9:00 a.m. and 11:00 p.m., take off for systolic blood pressure less than 150. 10. tube feed promote with fiber 20 cc/hour, at goal 80 cc/hour. at lower volumes, it will be complimented by normal saline so that the patient gets total of 80 cc/hour of fluid. 11. lansoprazole 30 mg q.d. follow-up: the patient's follow-up will be determined when the patient is going to be discharged. there will be an addendum that will be dictated when discharge process will be initiated. , m.d. dictated by: medquist36 Procedure: Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Percutaneous [endoscopic] gastrojejunostomy Diagnoses: Subendocardial infarction, initial episode of care Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Pneumonitis due to inhalation of food or vomitus Emphysema (subcutaneous) (surgical) resulting from procedure Occlusion and stenosis of basilar artery with cerebral infarction Other gastrostomy complications Closed fracture of cervical vertebra, unspecified level

allergies: iodine; iodine containing / thimerosal / shellfish / lidocaine-epinephrine / adhesive tape attending: chief complaint: atrial fibrillation major surgical or invasive procedure: - sternotomy/full maze procedure/removal of left atrial appendage. history of present illness: 58-year-old female who was diagnosed with supraventricular tachycardia roughly 19 - 20 years ago and paroxysmal atrial fibrillation, which developed roughly six years ago. since that time, she has failed multiple medical management attempts, which include sotalol, nadolol, flecainide, and now amiodarone. she has also failed cardioversion, pulmonary vein isolation, and tachycardia ablation. she has frequent or worsening symptoms with her atrial fibrillation. she is now referred for a maze procedure. a past cardiac catheterization from showed no coronary artery disease and a past transesophageal echocardiogram from showed no aortic regurgitation, trivial mitral regurgitation, and no left atrial mass. original plan for mini- maze changed to sternotomy for insurance requirements. past medical history: 1. gerd 2. fibromyalgia 3. atrial fibrillation x 15y, on toprol xl and flecainide social history: social history is significant for the absence of current tobacco use. there is no history of alcohol abuse. family history: there is no family history of premature coronary artery disease or sudden death. physical exam: pulse: 78 occ. irreg. resp: o2 sat: b/p right: 154/99 left: 137/95 height: 64" weight: 200# general: skin: dry intact some ecchymotic aread near recent acupuncture sites heent: perrla eomi anicteric sclera, op unremarkable neck: supple full rom no jvd chest: lungs clear bilaterally fine bibasilar rales heart: rrr irregular murmur none abdomen: soft non-distended non-tender bowel sounds + obese, no hsm/ cva tenderness extremities: warm , well-perfused edema none varicosities: none ble superficial spider veins neuro: grossly intact, mae strengths, nonfocal exam pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 1+ left: 1+ radial right: 2+ left: 2+ carotid bruit right: none left: none pertinent results: echo pre-bypass: the left atrium is mildly dilated. no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no mass/thrombus is seen in the left atrium or left atrial appendage. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. post bypass biventricular systolic function is unchanged. the left atrial appendage has been ligated. aorta is intact post decannulation. echocardiography report , portable tte (complete) done at 9:54:12 am final referring physician information , c. , status: inpatient dob: age (years): 59 f hgt (in): 64 bp (mm hg): 99/53 wgt (lb): 240 hr (bpm): 81 bsa (m2): 2.12 m2 indication: pericardial effusion icd-9 codes: 423.9, 424.0, 424.2 test information date/time: at 09:54 interpret md: , md test type: portable tte (complete) son: doppler: full doppler and color doppler test location: / 6 contrast: none tech quality: adequate tape #: 2009w051-0:00 machine: vivid echocardiographic measurements results measurements normal range left atrium - long axis dimension: *4.1 cm <= 4.0 cm left atrium - four chamber length: 5.2 cm <= 5.2 cm left atrium - peak pulm vein s: 0.8 m/s left atrium - peak pulm vein d: 0.9 m/s right atrium - four chamber length: 4.7 cm <= 5.0 cm left ventricle - septal wall thickness: 0.8 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 0.7 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.7 cm <= 5.6 cm left ventricle - systolic dimension: 3.2 cm left ventricle - fractional shortening: 0.32 >= 0.29 left ventricle - ejection fraction: >= 55% >= 55% aorta - sinus level: 3.5 cm <= 3.6 cm aorta - ascending: 3.1 cm <= 3.4 cm aorta - arch: *3.3 cm <= 3.0 cm aortic valve - peak velocity: 1.6 m/sec <= 2.0 m/sec mitral valve - e wave: 1.0 m/sec mitral valve - a wave: 0.7 m/sec mitral valve - e/a ratio: 1.43 mitral valve - e wave deceleration time: 183 ms 140-250 ms tr gradient (+ ra = pasp): *29 to 38 mm hg <= 25 mm hg findings this study was compared to the prior study of . left atrium: normal la size. right atrium/interatrial septum: normal ra size. no asd by 2d or color doppler. the ivc was not visualized. the ra pressure could not be estimated. left ventricle: suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. overall normal lvef (>55%). right ventricle: normal rv chamber size and free wall motion. abnormal septal motion/position. aorta: normal diameter of aorta at the sinus, ascending and arch levels. aortic valve: mildly thickened aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. no ms. trivial mr. tricuspid valve: normal tricuspid valve leaflets. mild tr. indeterminate pa systolic pressure. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. no ps. normal main pa. pericardium: trivial/physiologic pericardial effusion. general comments: left pleural effusion. conclusions the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there is abnormal septal motion/position. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. impression: no pericardial effusion. normal global and regional biventricular systolic function. compared with the prior study (images reviewed) of , the findings are similar. electronically signed by , md, interpreting physician 11:55 brief hospital course: mrs. was admitted to the on for a full maze procedure. she ws taken to the operating room where she underwent a sternotomy with a full maze procedure. please see operative note for details. postoperatively she was taken to the intensive care unit for monitoring. within the next few hours, mrs. awoke neurologically intact and was extuubated. on postoperative day one, she was transferred to the step down unit for further recovery. she was gently diuresed towards her preoperative weight. the physical therapy was consulted for assistance with her postoperative strength and mobility. on ms. had c/o fatigue and shortness of breath. hct was 20- re check 21. given 2 uprbc and stat echo revealed no effusion. hct stabilized and symptoms resolved. hct 26.9 on and ms/ was claered for d/c to home. dr. will follow her couamdin dosing for afib. d/c'd to hoome on home dose of 5mg coumadin. inr 1.7 on day of discharge. medications on admission: amiodarone 400 mg once daily diltiazem 240 mg once daily nexium 40 mg once daily pravachol 40 mg once daily coumadin 5 mg daily (last dose 6/29) ambien 10 mg at bedtime aspirin 325 mg daily calcium with vitamin d 600 mg and 200 units twice daily magnesium oxide 500 mg once daily claritin 10 mg as needed iron sulfate 325 mg once daily skelaxin 800 mg qhs flonase prn vitamin b complex daily discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. warfarin 1 mg tablet sig: five (5) tablet po daily (daily): take 5mg sun and monday dose per dr. based on inr. 5. pravastatin 20 mg tablet sig: two (2) tablet po daily (daily). 6. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 7. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily). 8. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 9. metaxalone 800 mg tablet sig: one (1) tablet po bid (2 times a day). 10. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 11. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 7 days. disp:*7 tablet(s)* refills:*0* 12. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po daily (daily) for 7 days. disp:*7 tab sust.rel. particle/crystal(s)* refills:*0* 13. esomeprazole magnesium 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po bid (2 times a day). 14. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 15. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed for nasal congestion. 16. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. disp:*80 tablet(s)* refills:*0* 17. outpatient lab work inr check monday and call to dr. for couamdin titration discharge disposition: home with service facility: vna discharge diagnosis: atrial fibrillation s/p full maze procedure gerd discharge condition: good discharge instructions: 1) monitor wounds for signs of infection. these include redness, drainage or increased pain. in the event that you have drainage from your sternal wound, please contact the at (. 2) report any fever greater then 100.5. 3) report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) no lotions, creams or powders to incision until it has healed. you may shower and wash incision. gently pat the wound dry. please shower daily. no bathing or swimming for 1 month. use sunscreen on incision if exposed to sun. 5) no lifting greater then 10 pounds for 10 weeks from date of surgery. 6) no driving for 1 month or while taking narcotics for pain. 7) call with any questions or concerns dr. will manage your coumadin dosing. followup instructions: please follow-up with dr. in 1 month. ( please follow-up with dr. in 2 weeks. please follow-up with dr. in weeks. dr in weeks ( Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Excision or destruction of other lesion or tissue of heart, open approach Excision, destruction, or exclusion of left atrial appendage (LAA) Diagnoses: Anemia, unspecified Esophageal reflux Unspecified pleural effusion Atrial fibrillation Other and unspecified hyperlipidemia Long-term (current) use of anticoagulants Unspecified hereditary and idiopathic peripheral neuropathy Myalgia and myositis, unspecified Acquired absence of both cervix and uterus

allergies: lasix / diuril / keflex / iodine attending: chief complaint: dyspnea, renal failure, anemia, fluid overload major surgical or invasive procedure: bronchoscopy history of present illness: 76 year old female with h/o ipf on chronic prednisone, copd with trach, chf, mechanical mitral valve, pacemaker, and anemia who presents with several days of worsening dysypnea, peripheral edema, and fatigue. she reports difficulty walking very short distances due to sob and lightheadness frequently. she reports pillow orthopnea that remains unchanged from baseline. she reports frequent productive cough that occasionally is bloody, last bloody sputum was this morning. she reports frequency of cough and sputum production is same as baseline. she believes she has had an unknown amount of weight gain. peripheral edema fluctuates in severity. she denies changes in bowel habits and denies changes in urination. she denies changes in appetite, denies fever, chills, chest pain, nausea, vomiting, abdominal pain, melena, and brbpr.she denies sick contacts and recent travel. in the ed, labs were significant for hct 14, inr 10, creatinine 2.1. had peripheral edema on exam. she was ordered for 2 units prbcs (not given due to difficult crossmatch), crossmatched 4 units. also given 5mg po vitamin k. she was not given lasix or ffp. most recent vitals 85 113/49 23 100% 5l. . in the micu, she was noted to be short of breath and had brown, guaiac positive stool. . review of systems: (+) per hpi (-) denies fever, chills, night sweats,denies headache, sinus tenderness, rhinorrhea or congestion.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. past medical history: - s/p mechanical mitral valve repair -sinus node dysfunction s/p ddd pacemaker placement - atrial flutter s/p ablation and cardioversion - congestive heart failure, last echo lvef= 40-45% moderate to severe tricuspid regurgitation - chronic obstructive pulmonary disease: 4lo2 trach at home at rest - idiopathic pulmonary fibrosis on chronic prednisone - chronic kidney disease; baseline creatinine 1.3-1.6 on urean-40* creat-1.1 - anemia due to mechanical valve and chronic kidney disease - hypertension - hypercholesterolemia - hypothyroidism - meniere??????s disease (hoh) - spinal arthritis - breast cancer radical mastectomy right breast . partial left . - s/p hysterectomy - s/p nasal embolization for refractory epistaxis social history: -smoked 36 years, quit in . -denies alcohol use. -no ivdu. -requires assistance with all adls and iadls -uses walker at baseline. -housekeeper 2x /week in past. -peapod for groceries. -hha twice a week and for assitance with showers. -husband does . -husband family history: father had polymyositis and coronary artery disease; mother had metastatic bone cancer. she has several cousins with breast cancer. physical exam: vitals: t:98.3 bp:119/51 p:86 r:13 spo2:100% general: alert, oriented, short of breath, difficulty finishing sentences heent: sclera anicteric,pale conjuctiva, no tenderness, increased pigmentation bilateral cheeks, dry oral mucosa, oropharynx clear, perrl neck: supple, jvp not elevated, no lad cv: tachycardia, normal s1 loud mechanical s2, no rubs,no gallops lungs: slight use of accessory muscles,decreased breath sounds bilaterally l>r, crackles in r lung, large healed scar on r chest in mammary region from radical mastectomy abdomen:refused gu: foley rectal: refused ext: cap refill <2 sec, +2 pitting edema upper and lower extremities pertinent results: 02:24pm wbc-13.6*# rbc-1.49*# hgb-4.6*# hct-14.2*# mcv-95 mch-30.6 mchc-32.1 rdw-17.5* 02:24pm plt count-240# 02:24pm neuts-92.1* lymphs-4.3* monos-2.0 eos-1.4 basos-0.1 02:24pm pt-86.1* ptt-53.0* inr(pt)-10.0* 02:24pm glucose-254* urea n-72* creat-2.1* sodium-138 potassium-5.4* chloride-97 total co2-29 anion gap-17 02:24pm ctropnt-0.13* 03:20pm iron-13* 03:20pm caltibc-329 haptoglob-122 ferritin-64 trf-253 03:20pm ck-mb-3 probnp-1495* 03:20pm alt(sgpt)-20 ast(sgot)-23 ld(ldh)-405* ck(cpk)-48 alk phos-48 tot bili-0.3 08:36pm ret man-15.1* 10:03pm urine rbc-0 wbc-1 bacteria-none yeast-none epi-0 10:03pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 10:03pm urine osmolal-335 10:03pm urine hours-random urea n-451 creat-71 sodium-39 potassium-44 chloride-29 . day of discharge: wbc rbc hgb hct mcv mch mchc rdw plt ct 11.4* 3.32* 9.7* 30.1* 91 29.3 32.3 16.7* 169 . pt ptt inr(pt) 20.4* 47.3* 1.9 . glucose urean creat na k cl hco3 angap 87 76* 1.7* 152 3.1* 109* 28 18 . anemia work-up retic: 6.6 caltibc hapto ferritn trf 329 122 64 253 . lfts: alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 30 28 72 492* 0.4 . tfts tsh: 12 ft4: 1.1 images: chest ap: low lung volumes with known idiopathic pulmonary fibrosis. while a subtle superimposed acute consolidation in the lung bases is difficult to exclude, it would be highly coincidental and is felt less likely with the increased opacity likely due to crowding. cxr (): findings: as compared to the previous radiograph, there is no relevant change. status post sternotomy, status post valvular replacement. the external and internal pacemaker with leads are visible. unchanged evidence of a right basal opacity with a predominantly reticular pattern, that might, in part be, fibrotic. these are likely to be related to the known history of idiopathic pulmonary fibrosis. there is no evidence of fluid overload on the current image. no pleural effusions. no parenchymal opacities have newly occurred. . ct torso: impression: 1. emphysema and pulmonary fibrosis with mild bibasilar consolidations, worse on the right than the left, likely reflecting atelectasis, although superimposed pneumonia cannot be excluded. 2. status post right mastectomy. 3. cholelithiasis in a nondistended gallbladder with mild wall edema/pericholecystic fluid likely reflects either chf or hypoproteinemia. 4. diverticulosis without diverticulitis. 5. no evidence of intra-abdominal free air or organized fluid collection. 6. indistinct pancreatic head; correlate with pancreatic enzymes if clinical concern for pancreatitis. . ruq us 1. sludge and stones in the gallbladder neck without other findings to suggest acute cholecystitis. if there is continued clinical concern, a hida scan may be more definitive in the exclusion of acute cholecystitis. 2. dilated hepatic veins consistent with diastolic dysfunction . ct head 1. no acute intracranial abnormality. 2. small vessel ischemic disease and diffuse cerebral atrophy. . pathology: bronchial lavage: atypical. atypical squamous cells. bronchial cells and inflammatory cells. . colonic polyp, distal ascending/proximal transverse (biopsy): 1. fragments of adenoma with focal high grade dysplasia. . micro: 2:47 pm stool consistency: not applicable source: stool. **final report ** clostridium difficile toxin a & b test (final ): reported to and read back by @ 0550 on . clostridium difficile. feces positive for c. difficile toxin by eia. 2:27 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive cocci. in pairs and clusters. 3+ (5-10 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive rod(s). 1+ (<1 per 1000x field): gram negative diplococci. 1+ (<1 per 1000x field): budding yeast with pseudohyphae. smear reviewed; results confirmed. respiratory culture (final ): moderate growth commensal respiratory flora. 1:09 am urine source: catheter. **final report ** urine culture (final ): yeast. ~7000/ml. brief hospital course: 76 y.o woman with pmh of ipf,copd,anemia, mechanical mitral valve,and pacemaker presents with worsening dyspnea, acute renal failure, and fluid overload. #. anemia: on admission hemoglobin of 4.6 and hematocrit of 14.2 from a hgb 10 and hct 33.1 within the last several weeks. hemolysis labs negative, and rectal exam showed guiac positive brown stool. her anemia was believed to be secondary to a gi bleed. she was transfused 4 units total with appropriate hct response, and her hct/hgb ramined stable. she underwent egd/colonoscopy which showed esophageal and fundal varices and a large polyp in the colon, concerning for malignancy which was believed to be the source of bleeding. on biopsy, this lesion was found to be an adenoma with high grade dysplasia. gastroenterology believed that it would be possible to perform a transluminal resection but that the procedure would have high risk of perforation and death. after a goals of care discussion with the health care proxy, , and the gastroenterology team it was decided that though the adenoma is high risk for malignancy, she will likely succumb to her severe pulmonary disease in the next 1-5 years and removal of the mass is not in line with her goals of care. she was started on nadolol for esophageal varaces. outpatient issues: -- obtain 2x weekly hcts and transfuse for hct <21 -- continue fe supplementation and epo administration . #. hypoxemic respiratory failure: the patient presented on 5l trans-trach from a baseline of 4l at home in the setting of known ipf, copd, and chronic heart failure. her dyspnea was attributed to anemia vs fluid overload from chf, and remained stable in-house and gradually improved upon discharge from the icu. there was low suspicion for a copd or ipf exacerbation. she was given iv torsemide for diuresis with her packed red cell transfusions, and her home bumex was held in-house. her home prednisone and nebulizers were continued in-house. related to her shortness of breath, she occassionally coughed up "blood balls", which she attributed to bloodly mucous originating at her catheter site. these were inconsistent, and associated with epistaxis, and we believed that there was a component of bloody post-nasal drip contributing, exacerbated by the fact that she was on a heparin gtt for her heart valve. the total blood loss from these episodes was essentially non-contributory. on the floor, she continued to be dyspneic at times. she was found to have evidence of a rul hap, so she was started empirically on vancomycin and cefepime. she developed progressive respiratory distress and returned the micu where she was intubated. she underwent broncheoalveolar lavage which was culture negative and her antibiotics were discontinued on . she continued to be intermittently diuresed but it was stopped when her creatinine bumped from 1.8 to 2.7. she was extubated and returned to the medical floor with o2 sats 95% on 2lnc the thought is that her respiratory distress was likely due to a mucus plug and pulmonary edema. after two days on the medical floor, she pulled out a nasogastric tube which had been used for tubefeeds, aspirated and developed respiratory distress with hypoxia and acidemia. she was transferred to the micu for a third time where she was again intubated. out of concern for hcap the pt was started on vanc/. due to increasing wbc and decreased stool output there was also concern for c.diff, which ultimately was positive, and the pt was started on flagyl/po vanc. the pt's respiratory status improved and she was successfully extubated. vancomycin was discontinued on with plan to complete a total of 8d of meropenem. outpatient issues: -- continue meropenem thru . -- ongoing discussion regarding replacement of transtracheal catheter. . #clostridium difficile: the pt was found to have a rising wbc, episodes of hypotension and decreased stool output. she was empirically started on iv flagyl and po vanco which were continued when stool culture was positive for c.diff. pt had subsequent decreased in wbc to normal with improvement in loose stools. outpatient issues: -- plan to complete po vancomycin 125mg po q6hrs as well as flagyl 500mg q8hrs; end date . . #anticoagulation: patient anticoagulated due to presence of mechanical valve. patient presented with an inr of 10 for unclear reasons. she received 5mg po vit k, and her inr down-trended to the sub-therapeutic range and she was started on a heparin gtt for her mechanical mitral valve. she experienced epistaxis and coughed up bloody mucus in the setting of a slightly supratherapeutic ptt which resolved with decreasing her heparin gtt. she was kept on a heparin drip for bridging on the medicine floor. when the decision was made to pursue endomucosal resection of her adenoma, her warfarin was discontinued, however given this was put on hold, the pt was restarted on coumadin . at time of discharge patient remained on hep gtt as well as coumadin 3mg daily; inr on day of discharge 1.9 outpatient issues: -- continue hep gtt and coumadin until inr therapeutic (2.5 - 3.5). . #volume status/acute renal failure. patient with oscillating renal function in house. peak cr 2.8 from a baseline of ~1.4, likely secondary to hypovolemia as well as renal hypoperfusion anemia. urine lytes showed were consistent with hypovolemia. initially bumex was held and she was given iv hydration. creatinine increased from 1.8-2.7 in the setting of diuresis (as above) and bumex was held. during hospital stay patient was intermittently diuresised and prior to discharge restarted on po bumex 5mg daily with creatinine of 1.7. weight at time of discharge: 62.4kg ; sating >95% on 5l nc. outpatient issues: -- pleae continue bumex 5mg po daily; monitor weights daily as well as renal function; may consider increasing bumex to or transitioning to iv if weight increases >3lb . # esophageal varices. newly diagnosed. patient placed on nadolol 10mg daily. . # hypertension. patient largely hypotensive to normotensive in house. decision made to hold home amlodipine 5mg daily as well as spironolactone 50mg at time of discharge. outpatient issues: -- close hemodynamic monitoring; plan to re-initiate anti-hypertensives if needed. . # pulmonary fibrosis. patient with transtracheal o2 catheter as well as use of chronic steriods as an outpatient. during 1st intubation transtracheal cath was removed. in house patient received stress dose steriods which were weanted to home prednisone 10mg daily at time of discharge. outpatient issues: -- continue chronic prednisone; consider need for pcp continue discussion re replacement of transtracheal cath . # hypernatremia. patient noted to be intermittently hypernatremic when npo/intubated. received free water boluses thru ngt as well as iv d5 with improvement. na at time of discharge 152 outpatient -- continue monitoring of electrolytes; encourage po intake and adminster d5w if needed (however by cautious in setting of known diastolic chf). # goals of care: on a goals of care discussion was held with the patient's hcp . the decision was made to forgo aggressive management of the colonic adenoma as her life expectancy with idiopathic pulmonary fibrosis (which she has suffered with for ~8 years) is now less than 5 years and likely less than one. the family wanted the patient to remain full code and to have aggressive management of her pulmonary disease. # code: full # hcp . . transitional issues =================== health care associated pneumonia treatment -- continue on meropenem for planned 8d course, end date . c. difficile infection -- continue on flagyl and po vanc for planned 10d course; end date: . congestive heart failure -- continue po bumex 5mg daily; monitor weights as well as renal function with weekly chem 10 panel . mitral valve replacement; goal inr 2.5 - 3.5 -- continue hep gtt until bridged with coumadin, 3mg daily, to a therapeutic inr . colonic polyp; gi bleed -- please check twice weekly hematocrit check with plan to transfuse if <24 . arrythmia -- restarting home dofetilide on discharge; primary cardiologist aware. . hypernatremia -- patient with improved po intake in days leading up to discharge however sodiums borderine in 140s-150s. please monitor closely to ensure patient does not need additional free water to correction of electrolyte abnormality. . pcp : consider starting pcp prophylaxis given chronic steroid use. discussed with the patient's pulmonologist, . patient has been on it in the past, but when she was on higher doses of po steroids (~20 mg) chronically. left kidney mass was seen on ct abdomen which is new since and will need follow up ultrasound and monitoring. medications on admission: 1.amlodipine 5 mg po daily 2.fexofenadine 60 mg tablet po bid 3.levothyroxine 112 mcg tablet po daily 4.omeprazole 20 mg capsule, delayed release po bid 5.multivitamin one tablet po daily 6.tiotropium bromide 18 mcg capsule, w/inhalation device one cap inhalation daily 7.atorvastatin 20 mg tablet one tablet po daily 8.docusate sodium 100 mg capsule one capsule po bid 9.dofetilide 125 mcg capsule one capsule po q12h 10.albuterol sulfate 90 mcg/actuation hfa aerosol inhaler two puff inhalation q4h (every 4 hours)prn dyspnea. 11.cholecalciferol (vitamin d3) 1,000 unit tablet two tablet po daily 12.fluticasone 110 mcg/actuation aerosol two puff inhalation 13.morphine 15 mg tablet extended release one tablet 14.morphine 10 mg/5 ml solution po q4h prn dyspnea. 15.calcium carbonate 200 mg calcium (500 mg) tablet 16.warfarin 5 mg one tablet po 4x/week (,mo,we,fr). 17.warfarin 2 mg one tablet po 3x/week (tu,th,sa). 18.epogen 20,000 unit/ml one injection once a week. 19.guaifenesin 600 mg tablet extended release one tablet extended release po twice a day. 20.bumetanide 5 mg tablet 21.prednisone 10 mg tablet sig: please follow attached taper instructions. tablet po once a day: on , take 40mg (4 tablets once daily). on , take 30mg (3 tablets once daily). on , take 20mg (two tablets once daily). on and onwards, take 10mg per day (one tablet once daily). 22.ferrous sulfate 325 mg (65 mg iron) one tablet po once a day. 23.spironolactone 50mg added discharge medications: 1. outpatient lab work please obtain twice weekly hematocrits, inr (inr goal 2.5 - 3.5) 2. outpatient lab work please obtain twice weekly chemistry panels (sodium, potassium, chloride, bicarb, bun, creatinine, mag, calcium, phosp) to monitor for hypernatremia and chronic kidney insufficiency 3. bumetanide 1 mg tablet sig: five (5) tablet po once a day. 4. sodium chloride 0.9% flush 10 ml iv prn line flush temporary central access-icu: flush with 10ml normal saline daily and prn. 5. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm: goal inr 2.5 - 3.5. 6. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours): to end . 7. prednisone 10 mg tablet sig: one (1) tablet po once a day. 8. fexofenadine 60 mg tablet sig: one (1) tablet po twice a day. 9. levothyroxine 112 mcg tablet sig: one (1) tablet po once a day. 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 11. multivitamin capsule sig: one (1) capsule po once a day. 12. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) inhalation once a day. 13. atorvastatin 20 mg tablet sig: one (1) tablet po once a day. 14. dofetilide 125 mcg capsule sig: one (1) capsule po twice a day. 15. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) inhalation every four (4) hours as needed for shortness of breath or wheezing. 16. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1) tablet po once a day. 17. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 18. morphine 15 mg tablet extended release sig: one (1) tablet extended release po once a day as needed for pain: hold for sedation, rr< 12. 19. morphine 10 mg/5 ml solution sig: po every four (4) hours as needed for shortness of breath or wheezing. 20. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po twice a day. 21. epogen 20,000 unit/ml solution sig: one (1) injection once a week: please administer on monday. 22. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 23. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours): to end . 24. heparin (porcine) in d5w intravenous 25. nadolol 20 mg tablet sig: 0.5 tablet po once a day. 26. meropenem 500 mg recon soln sig: five hundred (500) mg intravenous every eight (8) hours for 3 days: to end . discharge disposition: extended care facility: for the aged - macu discharge diagnosis: gi bleed secondary to colonic lesion health care associated pneumonia acute on chronic kidney insufficiency copd 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 ms it was a pleasure taking care of you. you were admitted to for evaluation of gi bleed and while in house you developed respiratory compromise requiring intubation. . regarding the gi bleed, you were seen by our team of gi doctors who performed a colonscopy. during the procedure a colonic lesion was seen and a plan was devised to proceed for excisional biopsy. you were transfused rbcs as needed and your blood counts were monitored closely. after discussion with your family the decision to undergo biopsy was deferred to the outpatient setting. . while in house your breathing became labored on several occassions which required intubation twice. the cause of the distress included aspiration and possible pneumonia. you were started on antibiotics with a plan to complete an 8d course. your transtracheal catheter was removed with plan to discuss replacement as an outpatient. at time of discharge you were oxygenating well using supplemental oxygen delivered by nasal cannula. also you were noted to have an infection in your gi tract and were started on antiobiotics to eradicate this bacteria. prior to discharge you were feeling much improved and the decision was made to transition to a nursing facility/rehab where you can work to optimize strength, mobility and nutrition. . changes to your medications: start 10mg nadolol daily for gastric varices continue meropenem until continue vancomycin and flagyl until stop spironolactone and amlodipine until told otherwise change coumadin to 3mg daily (goal inr 2.5 to 3.5) change bumex to 5mg daily (previously 5mg twice a day) again it was a pleasure taking care of you. please contact with any questions or concerns. followup instructions: department: west clinic when: tuesday at 8:45 am with: , md building: de building ( complex) campus: west best parking: garage Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of large intestine Diagnoses: Pneumonia, organism unspecified Anemia in chronic kidney disease Anemia of other chronic disease Abnormal coagulation profile Congestive heart failure, unspecified Long-term (current) use of steroids Acute posthemorrhagic anemia Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Obstructive chronic bronchitis with (acute) exacerbation Acute on chronic diastolic heart failure Personal history of malignant neoplasm of breast Personal history of tobacco use Atrial flutter Other and unspecified hyperlipidemia Heart valve replaced by other means Chronic kidney disease, Stage III (moderate) Acute respiratory failure Blood in stool Intestinal infection due to Clostridium difficile Unspecified hearing loss Cardiac pacemaker in situ Anticoagulants causing adverse effects in therapeutic use Hypovolemia Hyperosmolality and/or hypernatremia Benign neoplasm of colon Diseases of tricuspid valve Other respiratory abnormalities Attention to tracheostomy Inhalation and ingestion of food causing obstruction of respiratory tract or suffocation Neoplasm of uncertain behavior of stomach, intestines, and rectum Esophageal varices without mention of bleeding Foreign body in respiratory tree, unspecified Idiopathic pulmonary fibrosis M?ni?re's disease, unspecified Spondylosis of unspecified site, without mention of myelopathy Acquired absence of breast and nipple

69 year old african-american femaleadmitted to the hospital with epistaxis on and to micu a on @ ~0000h. she complained of nose bleed on and off for past 3 weeks and it increased . to er for right nare packing. nose continued to bleed. a-p balloon placed by ent and no further bleeding noted from her nose. hct 28.3. noted that patient takes coumadin regularly. past medical history of anemia, chf, copd, htn, ppm, pulmonary fibrosos, mvr, s/p mastectomy ', hyperlipidemia, transtracheal tube placement. allergies: lasix and diuril. neuro - alert and oriented. no complaints of pain. slept. see flowsheet for further details. cardiac - rhythm sb with frequent v-pacing and pvc's. pvc's became frequent at ~2330h. blood sent to lab to check mg and potassium. mg noted to be 1.8. magnesium sulphate 2 grams iv given. pvc's now noted to be rare. see flowsheet for further details. resp - o2 @ 2l via transtracheal tube. o2 sats stable. lungs clear although diminished to bases. transtracheal tube flushed and pt was able to expectorate moderate amount thick sanguinous secretions x2. see flowsheet for further details. gi - abdomen soft, nontender and nondistended. bowel sounds present. see flowsheet for further details gu - foley insitu. noted to have decreased urine output during the evening. urine noted to be dark red. ho notified and order received to give 250cc ns iv bolus x1. urine output continued to be decreased after bolus. foley flushed with 60cc ns and 100cc amber - blood tinged urine promptly returned. see flowsheet for further details. access - saline lock 20gauge x2 in left arm. eent - no further bleeding noted from nose. hct remains stable. Procedure: Control of epistaxis by anterior nasal packing Diagnoses: Mitral valve disorders Congestive heart failure, unspecified Acute posthemorrhagic anemia Unspecified acquired hypothyroidism Personal history of malignant neoplasm of breast Acute respiratory failure Postinflammatory pulmonary fibrosis Other emphysema Long-term (current) use of anticoagulants Epistaxis Tracheostomy status

allergies: lasix / diuril attending: chief complaint: epistaxis major surgical or invasive procedure: nasal packing history of present illness: 69yo with hx of mvr (mechanical), anemia of chronic disease (transfusion-dependent), copd/emphysema and ipf with trans trach on home o2 presented 5 days ago with epistaxis that had been intermitent over last 3 weeks prior to admission which has been chronic issue while on coumadin with negative work up. in ed was packed by ent with bilateral packings which required continuous o2 monitoring and stay in the micu, she was monitored and ir guided emolization was considered, but pt declined the required general anesthesia for an elective procedure with risk of stroke as well from emolization. now bleeding has slowed down with minimal packing and she feels better, but still with right sided facial pain/pressure from the packing and possible nerve injury. also stay complicated by conjunctivitios stable on e-mycin eye drops. no other shortness of breath or pain or other symptoms except constipation with pain meds. she is anxious to be about transfer to floor and increased ambulation so she can go home. past medical history: 1. chronic obstructive pulmonary disease. the patient uses 4 liters of oxygen at home. pulmonary function tests on showing fev1 of 1.39l (80%), fev1/fvc 75%, dlco of 17.34 (25% decrease since ) 2.idiopathic pulmonary fibrosis. 3. frequent nose bleeds--no etiology other than coumadin despite extensive work ups 4. placement of transtracheal oxygen cath due to o2 contrib. to epistaxis. has needed recanulation x1 5. anemia due to mvr, cri-- baseline 30 6. mvr (metal) replaced in due to acute mr 7. hypertension. 9. hypercholesterolemia. 9. hypothyroidism. 10. mrsa/vre colonization (negative swabs for both in ) 11. sinus node dysfunction s/p ddd in 12. congestive heart failure with echocardiogram with an ef of 40%, mild global hypokinesis, mitral valve regurgitation with trivial mitral regurgitation, 3+ tricuspid regurgitation, mild pulmonary artery systolic hypertension. 13. meniere's disease, tinnitus, diminished hearing bilaterally. 14. breast cancer treated with radical mastectomy of right breast. no chemotherapy. no radiation therapy. 15. spinal arthritis. 16. myopia, corrected with glasses. 17. cataracts. social history: the patient lives in with her husband. the patient works in human resources for the state of promoting diversity. the patient has a 36 pack year history of smoking, having smoked 1 ppd from the ages of 14 to 50. quit with the help of acupuncture. the patient uses alcohol occasionally. no ivdu. family history: there is no known history of bleeding or clotting disorders. there is a family history of muscle cramps. her father had polymyositis and her mother had cancer. physical exam: vs: hr 53 bp 131/52 sat 100% on 4l transtracheal o2 gen aao, nad heent perrl, mmm, ecchymosis right peri-nasal area, bilateral packing in place without blood, transtracheal cath in place for o2 chest ctab with occasional bibasilar crackles r>l, and occasional end exp wheezes bilaterally, +right sided scar cv rrr, mechanical s1, nl s2 abd soft nt, slightly distended, +bs ext no edema, 2+dp pulses bilaterally neuro cn ii-xii intact sensation, but with mildly decreased right motor muscle strength pertinent results: 04:15pm glucose-108* urea n-26* creat-1.4* sodium-149* potassium-4.3 chloride-112* total co2-33* anion gap-8 04:15pm iron-55 04:15pm caltibc-312 vit b12-1587* folate-greater th ferritin-633* trf-240 04:15pm wbc-4.2 rbc-2.89* hgb-9.1* hct-28.3* mcv-98 mch-31.6 mchc-32.3 rdw-15.1 04:15pm neuts-74.8* lymphs-15.2* monos-4.9 eos-4.9* basos-0.1 04:15pm plt count-114* 04:15pm pt-20.2* ptt-50.0* inr(pt)-2.6 11:45pm hct-27.1* 11:45pm pt-18.4* inr(pt)-2.1 brief hospital course: 69f with copd, ipf, htn, on coumadin for mvr here with epistaxis s/p packing and control of bleeding. 1)epistaxis: initially required nasal packing by ent which required continuous o2 monitoring, but remained stable and although embolization was considered, it was not done because patient did not want elective intubation which would have been required for the procedre and with the risk of stroke with embolization this procedure was deferred. the packing was eventually removed and an absorbable intranasal packing was placed and nares kept moist with ocean spray and vaseline. she did have occasional episodes of minimal epistaxis which was managed with courses of afrin and supportive measures and her hematocrit remained stable after 3 total units of blood transfusions. she was continued on ancef while packing remained in place. she did have some pressure headaches from the packing which was stable on percocet and dilaudid as needed. 2)s/p mvr: for severe mitral regurgitation 6 yrs ago-- stable for now-- initially coumadin held and reversed with vitamin k and 2units of ffp and eventually she was restarted on coumadin with goal inr around 2.5-3.0 as her risk of bleeding is significant. during her stay she was bridged with heparin until inr was therapeutic. 3)anemia: acute on chronic with blood loss anemia on top of anemia of chronic disease with baseline hematocrit around 30. she was transfused total of 3units of prbc and her hematcrit remained stable above 30 during the rest of her stay, she was also restarted on her home epogen regemin. 4)copd/ipf: stable at baseline home o2 via trans-tracheal catheter. drainage from trans-tracheal catheter was managed by interventional pulmonary team with periodic strippings and bronchoscopies as above. otherwise she was continued on her home doses of albuterol, combivent and inhaled steroids. 5)chf: 40% ef, but stable and euvolemic-- continued on home bumex and 6)hypothyroid: stable on home thyroid meds medications on admission: coumadin 7 x6 days and 12mg x1 day bumex 1mg qd levoxyl 112mcg qd lipitor 20mg qd cozaar 50mg qd quinine 260bid tums flovent combivent mucinex dm 600bid discharge medications: 1. bumetanide 1 mg tablet sig: one (1) tablet po daily (daily). 2. levothyroxine sodium 112 mcg tablet sig: one (1) tablet po daily (daily). 3. atorvastatin calcium 20 mg tablet sig: one (1) tablet po daily (daily). 4. losartan potassium 50 mg tablet sig: one (1) tablet po daily (daily). 5. quinine sulfate 325 mg capsule sig: one (1) capsule po hs (at bedtime). 6. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bidwm (2 times a day (with meals)). 7. fluticasone propionate 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 8. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed. 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 11. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 12. guaifenesin 100 mg/5 ml syrup sig: ten (10) ml po q4h (every 4 hours). 13. sodium chloride 0.65 % aerosol, spray sig: two (2) spray nasal qid (4 times a day). disp:*1 bottle* refills:*2* 14. warfarin sodium 1 mg tablet sig: seven (7) tablet po at bedtime. 15. epoetin alfa 4,000 unit/ml solution sig: one (1) injection injection qmowefr (monday -wednesday-friday). 16. outpatient physical therapy please continue to follow up with your pulmonary and respiratory therapists for care of your trans-tracheal catheter and stripping as you need to for diagnosis of copd and interstitial lung disease 17. erythromycin 5 mg/g ointment sig: 0.5 inch ophthalmic four times a day for 4 days. disp:*qs tube* refills:*0* 18. oxymetazoline hcl 0.05 % aerosol, spray sig: one (1) spray nasal (2 times a day) for 3 days. disp:*1 bottle* refills:*2* discharge disposition: home discharge diagnosis: epistaxis blood loss anemia anemia of chronic disease chronic anticoagulation for mitral mechanical valve chornic pulmonary obstructive disease interstitial pulmonary fibrosis discharge condition: good, ambulating without difficulty and breathing comfortably on 2l of oxygen via tran-tracheal catheter discharge instructions: please call your pcp or return if you have any increase in bleeding from your nose, shortness of breath or pain. please continue all your medications as prescribed. followup instructions: please see your pcp days. please have your inr checked in the next 2 days and get your trans-tracheal catheter followed by ip as you have been prior to admission. please follow up with your ent dr within the next month. provider: call where: none cardiac services phone: date/time: 9:00 provider: , pt, ccs where: rehab services (dyspnea) phone: date/time: 10:15 provider: call where: none cardiac services phone: date/time: 9:00 Procedure: Control of epistaxis by anterior nasal packing Diagnoses: Mitral valve disorders Congestive heart failure, unspecified Acute posthemorrhagic anemia Unspecified acquired hypothyroidism Personal history of malignant neoplasm of breast Acute respiratory failure Postinflammatory pulmonary fibrosis Other emphysema Long-term (current) use of anticoagulants Epistaxis Tracheostomy status

allergies: lasix / diuril / keflex / iodine attending: chief complaint: shortness of breath. major surgical or invasive procedure: none. history of present illness: mrs. is a 74 yo woman with pulmonary fibrosis and copd on transtracheal home oxygen (3-4l) and chronic prednisone (10mg po daily) who was admitted to the micu on for worsening dyspnea and hypoxia after elective bronchoscopy earlier that day. she was admitted in (~6 wks prior to this admission) to an osh for exacerbation of her shortness of breath and was discharged to a rehab facility. previously, she had been the primary caretaker for her ill husband, and reports being able to perform household chores and climb the stairs in her house, though believes this "wore her out." . because of the six weeks of worsening dyspnea and two days of increased cough productive of prurulent sputum (which coincided with an episode of prolonged epistaxis c/w prior history, though patient denies any link to her sob), she was scheduled for elective bronchoscopy on day of admission. per ip notes, there was no bloody secretions in the airways, minimal clear secretions and no endobronchial lesions. pt was monitored post procedure without event and was transferred back to the rehab where she and her husband have been living for the last 2 months. on return to rehab, husband was concerned that she was increasingly sob and o2 sats dipped into the 70s. husband spoke with dr. who recommended returning to the ed for evaluation. . in the ed, initial vs were: t 100.1 p 101 bp 141/54 r 24 o2 sat 96%. patient underwent a cxr which was essentially unchanged with possible retrocardiac opacity. she was given vanc/levofloxacin, albuterol and ipratropium for possible pna. cultures/coags were not sent as she was a difficult stick. hct was notably down from recent baseline and was positive with brown stool. pt denied any brbpr or hematemesis and was given iv ppi. she was cross matched for blood and gi was notified. pt was ultimately admitted to the icu for tachypnea and o2 requirement. . on arrival to the icu, pt was tachypneic but completing full sentences and not appearing to be in any distress. there were no events and she was transferred to the floor the next day. on the floor, she is resting comfortably on 4l, speaking full sentences, though becoming sob with minimal exertion (such as sitting forward for lung exam) and with occasional cough. she denies any dizziness, chest pain, palpitations, nausea, or vomiting. . review of sytems: she was denying cp, palpitations, pnd, orthopnea, lightheadedness, tingling, numbness, nausea, vomiting, diarrhea or brbpr. she has baseline dark stools due to iron replacement and this remains unchanged. she denies fevers, uri or congestion but reports general decline in resp status over the last 6 wks and feels sob has gradually worsened with some increased cough with scant hemoptysis since episode of epistaxis. past medical history: #s/p nasal embolization for refractory epistaxis #s/p mechanical mvr in ' due to acute mr #sinus node dysfunction s/p ddd pacemaker placement in #aflutter s/p ablation in and cardioversion (maintained on dofetilide, followed by ) #chf: last echo lvef 40-45%, 4+ tr #copd: on 2-4l o2 at home via transtracheal oxygen cath #idiopathic pulmonary fibrosis on chronic prednisone 10mg daily #cri; baseline creatinine 1.3-1.6 #anemia due to mvr and cri; baseline hct 30-35 #hypertension #hypercholesterolemia #hypothyroidism #meniere??????s disease (hoh) #spinal arthritis #breast cancer treated with radical mastectomy of right breast in . no chemo or xrt. partial left . #s/p hysterectomy social history: since mid she has been in rehab, sharing a room with her husband. she has two step- children. she smoked for ~ 36 years, but quit in . social alcohol. no ivdu. prior to hospitalization in (patient has been in rehab since that time): housekeeper 2x /week. peapod for groceries. hha twice a week since discharge along with hha for assitance with showers. husband does . since entering rehab, patient requires assistance with all adls, iadls and uses walker at baseline. no falls + visual aides - dentures - hearing aides family history: parents are deceased, father had polymyositis, mother with metastatic bone ca. her mother died of metastatic bone disease. her father died of coronary artery disease. she has no siblings. she has several cousins with breast cancer. physical exam: on admission: general: nad, mildly tachypneic, oriented heent: sclera anicteric, mmm, exopthalmos neck: supple, no lad lungs: dry velcro rales at bases bilaterally, no congestion, rhonchi or wheezes cv: regular rate and rhythm, gr 3 sem over rusb abdomen: soft, nt/nd, nabs, no rebound or guarding ext: warm, 2+ pulses, no edema on transfer to floor: vitals: t: 95.8 bp: 130/70 p: r: 20 o2: 100% general: alert, oriented, no acute distress, sitting watching television and eating breakfast heent: sclera anicteric, mmm neck: supple, jvp 7-8 cm, no lad lungs: decreased air entry throughout, dry crackles bilaterally, more pronounced at bases. cv: regular rate and rhythm, accentuated s1, s2, no murmurs, rubs, gallops appreciated abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: on admission: 09:40pm wbc-14.0* rbc-2.79*# hgb-8.1*# hct-26.2*# mcv-94 mch-28.9 mchc-30.8* rdw-17.5* 09:40pm neuts-92.0* lymphs-5.8* monos-1.4* eos-0.6 basos-0.4 09:40pm plt count-323# 09:40pm glucose-182* urea n-36* creat-1.7* sodium-140 potassium-4.0 chloride-100 total co2-29 anion gap-15 10:03pm hgb-8.7* calchct-26 10:03pm glucose-178* lactate-2.6* k+-4.0 01:35am urine rbc-0-2 wbc-0-2 bacteria-few yeast-none epi-0-2 01:35am urine blood-neg nitrite-neg protein-25 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 01:35am urine color-yellow appear-clear sp -1.013 04:31am ck-mb-notdone ctropnt-0.09* 04:31am ck(cpk)-62 . echo the left atrium is normal in size. 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 mildly depressed (lvef= 45 %). there is no ventricular septal defect. the right ventricular cavity is mildly dilated with depressed free wall contractility. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. a bileaflet mitral valve prosthesis is present. the mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the report of the prior study (images unavailable for review) of , the lvef is slightly lower. . ct chest: 1)severe emphysema combined with pulmonary fibrosis is most likely due to the syndrome of combined pulmonary fibrosis and emphysema (cpfe)with no acute pathology. 2)stable enlarged mediastinal lymph nodes and severe cardiomegaly brief hospital course: ***discharged to rehab and she can be reached at *** 74 y/o f with pmhx of end stage lung disease who presents with subacute worsening in baseline hypoxia and anemia. # dyspnea: the etiology of mrs. acute worsening of her chronic dyspnea was not clear, but the differential at admission included bronchospasm s/p bronch, acs, respiratory infection, ipf flare, acute anemia, and chf. she was weaned back to baseline o2 within an hour in icu. she was clinically euvolemic with tte unchanged, troponin peak 0.09, which trended down; ekg changes in absence of symptoms thought to be due to lvh with strain in the setting of acute hematocrit drop. given the history of increased cough and sputum production with no acute process on chest ct, sputum positive for gpc and gnr (likely colonization, but possibly bronchitis), she was treated empirically for copd exacerbation with levofloxacin (completed 6 day course) and rapid prednisone taper to chronic 10mg dose. we would recommend a discussion regarding goals of care and long-term progression of her disease with her primary team during follow-up. . # anemia: hematocrit 24.7 on admission. patient is maintained on chronic ferrous sulfate and epoetin for anemia of chronic disease with a history of transfusion requirements at times of bleeding, including epistaxis. stools were guaiac positive, but there was no evidence of active bleeding on admission, the patient was hemodynamically stable, and she has no history of brisk gi bleed. given poorly compensated resp status, she was transfused 1 rbc unit in the icu, and she bumped 24-->27. stable coags. she was seen by ent, who felt there was no need for intervention and recommended nasal saline. she was also seen by gi, but declined egd and colonoscopy to evaluate for source of bleeding. during the admission there was no evidence of active bleeding and her hct remained stable at 25, with slow upward trend. epoetin was due (but not given) . . # anticoagulation (s/p mechanical mvr in 99): inr was 2.3 on admission. baseline warfarin dose is 5mg. icu re-started coumadin at 2.5 mg given that patient received levofloxacin in the ed. on the floor, the patient was covered with lmwh given subtherapeutic inr, and warfarin dose was increased to baseline 5mg. dofetilide was continued at home-dose. . # af/aflutter s/p pcm for sick sinus node: pt followed by dr. , maintained on dofetilide, anticoagulated with coumadin. her heart rate remained ~80 throughout the admission. . # systolic chf: baseline ef 40-45%, though denies any symptoms of volume overload and appears clinically dehydrated on exam with mildly elevated creatinine. continued spironolactone and held bumex initially given that patient was hypovolemic-euvolemic on exam. patient continued to appear euvolemic throughout admission, and bumex was restarted at 2mg po bid upon discharge. . # hypertension: amlodipine 5mg daily was continued and patient remained normotensive throughout admission. . # hypercholesterolemia: atorvastatin was continued at 20mg daily. . # hypothyroidism: levothyroxine 112mcg daily was continued. . # code: full medications on admission: albuterol inhaled amlodipine 5mg daily bumex 3mg dofetilide 125mcg epoetin alfa 20,000 weekly fexofenadine 60mg fluticasone inhaled levothyroxine 112 mcg daily lipitor 20mg tablet daily morphine 3-5mg prn sob prednisone 10mg daily salmeterol 50 mcg spironolactone 50mg daily tiotropium 18 mcg daily warfarin vitamin d colace ferrous sulfate 325mg daily mucinex miv tums discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. warfarin 2 mg tablet sig: 2.5 tablets po once daily at 4 pm: this should be adjusted based on your inr. 3. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 4. fexofenadine 60 mg tablet sig: one (1) tablet po bid (2 times a day). 5. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 6. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 7. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 8. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 10. multivitamin tablet sig: one (1) tablet po daily (daily). 11. dofetilide 125 mcg capsule sig: one (1) capsule po q12h (every 12 hours). 12. spironolactone 25 mg tablet sig: two (2) tablet po daily (daily). 13. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 14. morphine 10 mg/5 ml solution sig: 2.5 po q4h (every 4 hours) as needed for sob. 15. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 16. prednisone 10 mg tablet sig: one (1) tablet po daily (daily): please confirm that this is patient's baseline dose (before hospitalization). if not, please adjust to prehospitalization dose. 17. bumetanide 1 mg tablet sig: two (2) tablet po bid (2 times a day). 18. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 19. guaifenesin 600 mg tablet sustained release sig: two (2) tablet sustained release po bid (). 20. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q2h (every 2 hours) as needed for sob. 21. enoxaparin 60 mg/0.6 ml syringe sig: one (1) subcutaneous q 24h (every 24 hours): please discontinue once inr is therapeutic between 2.5-3.5 for at least 2 days. 22. weight please obtain weight monday, wednesday, friday at same time each day. if weight changes >3lbs, please notify md; bumex dose may need to be adjusted. 23. outpatient lab work please check inr every 2 days and adjust warfarin dose as needed to maintain inr between 2.5-3.5. 24. epoetin alfa 20,000 unit/ml solution sig: one (1) injection once a week: please adjust dose recommended by dr. before hospitalization. 25. outpatient lab work please check hematocrit, sodium, potassium, bun, and creatinine weekly. 26. insulin sliding scale please monitor patient's blood sugars and manage with humalog insulin on a sliding scale. the scale used in the hospital is included in the discharge paperwork. discharge disposition: extended care facility: discharge diagnosis: primary: copd exacerbation secondary: idiopathic pulmonary fibrosis chronic obstructive pulmonary disease anemia chronic kidney disease heart failure, systolic dysfunction atrial flutter hypertension hyperlipidemia hypothyroidism discharge condition: hemodynamically stable, satting 99-100% on 4l transtracheal. ambulating with o2 sats >90% on 6l. 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 icu and then the medicine floor at for your worsened shortness of breath. the bronchoscopy and chest ct did not show any evidence of pneumonia or any new changes. you were treated with bronchodilators, steroids, and antibiotics. you were also transfused 1 unit of red blood cells because your red blood cell count was low (hct 24.7) on admission. *you should continue your medications from before hospitalization and should see your cardiologist and pulmonologist, as listed below. the only change to your medication is to: continue bumex 2mg twice a day. if you start to drink more fluids, gain more than 3lbs, or notice significant swelling in your legs, you should talk to dr. or dr. about increasing the dose. *weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: dept: cardiology dr. hospital - phone: ( when: wednesday at 3:30 pm dept: pulmonary hospital- , phone: ( someone will call you about an appointment with dr. . if you don't hear from someone within 2-3 days, you should call the number above. dr. phone: date/time: 11:40 Procedure: Closed [percutaneous] [needle] biopsy of kidney Diagnoses: Anemia of other chronic disease Congestive heart failure, unspecified Long-term (current) use of steroids Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Obstructive chronic bronchitis with (acute) exacerbation Atrial flutter Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Heart valve replaced by other means Chronic systolic heart failure Long-term (current) use of anticoagulants Cardiac pacemaker in situ Nonspecific abnormal findings in stool contents Precipitous drop in hematocrit Epistaxis Tracheostomy status Other dependence on machines, supplemental oxygen

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fall with acute onset aphasia major surgical or invasive procedure: none history of present illness: hpi: 83 year old female with apparently sudden-onset aphasia this morning at 7:45 pm. she apparently sustained a fall in the early part of the day on but has been ambulatory and verbal. she was brought by ambulance to for stroke work-up. past medical history: two cva - one hemorrhagic, one likely ischemic - resulted in minor speech difficulty and gait abnormality social history: regular alcohol user/abuser family history: not obtained physical exam: vs: t afebrile hr 61 bp 157/78 rr 14 sat 100 on ra pe: neuro ms: patient awake. eyes open spontaneously. nods to name. mute. patient nods head "no" to all questions. does not follow commands. perll eomi face symmetrical no evidence of neglect. blinks to confrontation. at least 3/5 strength in both ue and lower extremities however patient is not cooperative with exam. there are bilateral babinski reflexes. pertinent results: 10:40am wbc-6.7 rbc-2.96* hgb-9.7* hct-29.4* mcv-99* mch-32.9* mchc-33.2 rdw-13.3 10:40am neuts-82.0* bands-0 lymphs-10.7* monos-6.4 eos-0.7 basos-0.1 10:40am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 10:40am plt smr-normal plt count-253 10:40am pt-13.2 ptt-24.7 inr(pt)-1.2 08:22pm pt-13.6* ptt-27.3 inr(pt)-1.2 11:30am urine color-yellow appear-clear sp -1.020 11:30am urine blood-mod nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-0.2 ph-8.0 leuk-neg 11:30am urine rbc-* wbc-0-2 bacteria-occ yeast-none epi-0 10:40am glucose-96 urea n-9 creat-0.5 sodium-122* potassium-4.2 chloride-86* total co2-25 anion gap-15 10:40am calcium-9.1 phosphate-2.9 magnesium-1.7 brief hospital course: patient was admitted to the sicu for close neurological monitoring secondary to subdural hematoma.she was also evaluated by neurology service.she was extubated on hospital day #2, she also received 2 units prbc for hematocrit of 25, which rose to 32. she was followed with head ct which were stable. she was transferred to the floor. diet and activity were advanced. she was seen by ot and pt and was recommended for home pt. medications on admission: lisinopril baby asa discharge medications: 1. phenytoin sodium extended 100 mg capsule sig: two (2) capsule po bid (2 times a day). disp:*120 capsule(s)* refills:*2* 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 3. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: partners discharge diagnosis: left subdural hematoma with mild midline shift and ventricle effacement. discharge condition: neurologically stable discharge instructions: report any headache, vision changes, vomiting, weakness, numbness, difficulty of walking or any other neurologic concerns. do not drive. followup instructions: follow up with dr in 4 weeks with head ct.call for an appointment and scheduling your head ct prior to follow up at . have pcp dilantin level every week. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Transfusion of packed cells Diagnoses: Unspecified essential hypertension Alcohol abuse, unspecified Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Fall from other slipping, tripping, or stumbling

allergies: patient recorded as having no known allergies to drugs attending: addendum: discharged to rehab on discharge disposition: extended care facility: md Procedure: Closed reduction of dislocation of hip Open reduction of fracture with internal fixation, other specified bone Diagnoses: Congestive heart failure, unspecified Closed fracture of one rib Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Contusion of lung without mention of open wound into thorax Street and highway accidents Closed fracture of C5-C7 level with unspecified spinal cord injury Closed fracture of acetabulum M?ni?re's disease, unspecified Injury to spleen without mention of open wound into cavity, hematoma without rupture of capsule Closed dislocation of hip, unspecified site

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: left hip pain major surgical or invasive procedure: s/p closed left hip reduction s/p orif left acetabular fx history of present illness: mr. is a 65 year-old gentleman who was involved in a motor vehicle accident, resulting in a comminuted posterior wall left acetabular fracture, c5-6 anterior body fracture and c7 facet and lamina fracture. he now presents for operative fixation. past medical history: menireres diseae congestive heart failure s/p l4-5 fusion social history: non-contributory family history: non-contributory physical exam: afebrile, all vital signs stable gen: alert and oriented, no acute distress lungs: cta bilaterally abd: benign spine: tenderness to palpation over cervical and thoraic regions extremities: left lower incision: no swelling/erythema/drainage dressing: clean/dry/intact +/fhl/at +silt 2+ pulse, moves toes pertinent results: operative report , k. **not reviewed by attending** name: , unit no: service: date: date of birth: sex: m surgeon: , preoperative diagnoses: acetabular fracture, posterior wall, significantly comminuted. postoperative diagnoses: acetabular fracture, posterior wall, significantly comminuted. procedure: open reduction internal fixation of left posterior wall acetabular fracture. indications for procedure: mr. is a 65 year- old gentleman who was involved in a motor vehicle accident, resulting in the above injury. he now presents for operative fixation. special considerations: this is an extremely difficult case. the posterior wall was comminuted in at least 5 major parts with significant amounts of moderate impaction requiring subchondral grafting. the case merits billing under modified 22 considerations. the case was made difficult given the amount of comminution and need for impaction grafting and the need for double plating of the posterior wall, in addition to placement of lag screws to secure fixation. procedure in detail: the patient was brought to the operating room and after successful induction of general anesthesia, he was placed in the supine position and then transferred to the lateral decubitus position with the left side up. after prepping and draping the gluteal region and leg, the fracture was exposed via a approach. the external rotators were identified, tagged and cut. the quadratus was preserved. the sciatic nerve was visualized and protected throughout the procedure by keeping the knee flexed and the hip extended. there were significant amounts of hematoma given the dislocated nature of the joint during the trauma. the fracture fragments of the posterior wall were identified and were found to be numerous. they were preserved with their attachments in order to preserve the vascularity. the amount of clot and interposed soft tissue was aggressively debrided and the wound was lavaged with pulsed irrigation. there were significant amounts of longitudinal impaction which was elevated with a and then grafted with 30 cc of cancellous chips. single layer of fracture fragments were reduced and held in position with k wires and then with lag screws of the 3.5 mm cortical variety. subsequently, two 3.5 mm reconstruction plates were contoured and applied to the posterior wall in a buttress manner. fluoroscopy in the ap as well as oblique and anteriorly were used to confirm that the fixation was appropriate. no screws were angled into the joint. the patient's range of motion and stability was acceptable. the wound was then copiously irrigated and closed in layers with vicryl sutures. ethibond sutures were used to repair the external rotators. staples were placed in the skin. the wound was covered with sterile dressings. the patient will be given postoperative precautions and touch-down weight bearing only. dr. was present for the entire procedure. , md dictated by: 09:50pm type-art po2-83* pco2-52* ph-7.34* total co2-29 base xs-0 intubated-not intuba 09:50pm lactate-4.5* 09:50pm hgb-12.4* calchct-37 09:50pm freeca-1.18 08:04pm glucose-248* urea n-21* creat-1.1 sodium-138 potassium-3.4 chloride-100 total co2-28 anion gap-13 08:04pm calcium-8.1* phosphate-2.4* magnesium-1.3* 08:04pm wbc-18.5* rbc-3.61* hgb-12.1* hct-32.8* mcv-91 mch-33.5* mchc-36.8* rdw-13.1 08:04pm plt count-223 05:40pm urine hours-random 05:40pm urine bnzodzpn-neg barbitrt-neg opiates-pos cocaine-neg amphetmn-neg mthdone-neg 05:40pm urine color-straw appear-clear sp -1.050* 05:40pm urine blood-lg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-0.2 ph-5.0 leuk-neg 05:40pm urine rbc-* wbc-0-2 bacteria-none yeast-none epi-0 05:36pm ph-7.28* comments-green top 05:36pm glucose-196* lactate-3.1* na+-141 k+-3.5 cl--101 tco2-30 05:36pm hgb-12.4* calchct-37 o2 sat-97 carboxyhb-1.2 met hgb-0.6 05:36pm freeca-1.10* 05:25pm urea n-21* creat-1.1 05:25pm amylase-36 05:25pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 05:25pm wbc-18.3* rbc-3.65* hgb-12.1* hct-32.8* mcv-90 mch-33.1* mchc-36.9* rdw-12.7 05:25pm plt count-210 05:25pm pt-11.7 ptt-23.1 inr(pt)-1.0 05:25pm fibrinoge-251 brief hospital course: mr. presented to the emergency department from an outside hospital s/p mva as an unrestrained passenger. he was evaluated by the orthopaedics department and found to have a fracture to his left posterior acetabular wall, c6-6 vertebral body fx and c7 facet and lamina fxs. the hip was internally reduced in the ed. she was then admitted and consented for surgery. on , he was prepped and brought down to the operating room for surgery to his left lower extremity. intra-operatively, he was closely monitored and remained hemodynamically stable. he tolerated the procedure well without any difficulty or complication. post-operatively, he was extubated and transferred to the pacu for further stabilization and monitoring. he was then transferred to the floor for further recovery. on the floor, he remained hemodynamically stable with his pain controlled. he progressed with physical therapy to improve his strength and mobility. he continues to make steady progress without any incidents. he was discharged to a rehabilitation facility in stable condition. he was instructed to call drs. and offices at for a follow up appointments in 2 weeks. medications on admission: hctz discharge medications: 1. enoxaparin 40 mg/0.4 ml syringe sig: one (1) subcutaneous q 24h (every 24 hours) for 4 weeks. 2. insulin regular human 100 unit/ml solution sig: per riss injection asdir (as directed). 3. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 4. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 6. dolasetron mesylate 12.5 mg iv q8h:prn nausea 7. lorazepam 0.5-1 mg iv q4-6h:prn discharge disposition: extended care facility: discharge diagnosis: left hip dislocation left acetabular fx c5-6 ant body fx c7 facet and lamina fx discharge condition: stable discharge instructions: keep the incision/dressing clean and dry. you may apply a dry sterile dressing as needed for drainage or comfort. if you have skin staples, they can be removed 2 weeks after surgery. if you are experiencing any redness, swelling, pain, or have a temperature >101.5, please call your doctor or go to the emergency room for evaluation. resume all of your home medication and take all medication as prescribed by your doctor. continue your lovenox injections as prescribed for anticoagulation. continue to wear your c-collar for 2 weeks until your follow up appointment with dr. , please call for an appointment. please call dr. office @ for a follow up appointment in 2 weeks. feel free to call our office with any questions or concerns. followup instructions: please call drs. and offices @ for follow up appointments in 2 weeks. Procedure: Closed reduction of dislocation of hip Open reduction of fracture with internal fixation, other specified bone Diagnoses: Congestive heart failure, unspecified Closed fracture of one rib Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Contusion of lung without mention of open wound into thorax Street and highway accidents Closed fracture of C5-C7 level with unspecified spinal cord injury Closed fracture of acetabulum M?ni?re's disease, unspecified Injury to spleen without mention of open wound into cavity, hematoma without rupture of capsule Closed dislocation of hip, unspecified site

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 52m with acute onset of syncope, diaphoresis and weakness. major surgical or invasive procedure: three vessel coronary artery bypass grafting(left internal mammary to left anterior descending, vein grafts to obutuse marginal and posterior descending arteries) history of present illness: this 52m was in his usual state of health and experienced an acute episode of syncope, diaphoresis, and weakness which was followed by chest pain which radiated to his l arm and lasted 15-30 mins. he presented to the mwmc ed and had anterolateral ekg changes and a + ett. he underwent cardiac cath which revealed: 50% lm ., 99% lad ., 80% rca ., and a 40% lvef. he was transferred to for cardiac surgery. past medical history: htn ^chol. depression anxiety hernia repair vasectomy social history: lives with wife. cigs: none, smokes cigars. etoh: 1-2 bottles of wine/wk. family history: + cad, mother is s/p cabg, brother and father had mi physical exam: wdwn in nad avss heent: nc/at, perla, eomi, oropharynx benign neck: supple, from, no lymphadenopathy or thyromegaly, carotids 2+=bilat. without bruits lungs: clear to a+p cv: rrr without r/g/m, nl s1, s2 abd: +bs, soft, nontender, without masses or hepatosplenomegaly ext: without c/c/e neuro: nonfocal pertinent results: 06:35am blood wbc-9.6 rbc-3.51* hgb-10.7* hct-31.3* mcv-89 mch-30.6 mchc-34.4 rdw-12.9 plt ct-164 04:21am blood pt-14.0* ptt-34.7 inr(pt)-1.2* 06:35am blood glucose-91 urean-14 creat-0.9 na-137 k-4.4 cl-99 hco3-32 angap-10 radiology final report chest (portable ap) 11:33 am chest (portable ap) reason: ? ptx medical condition: 52 year old man with cad s/p cabg s/p tubes pull reason for this examination: ? ptx study: ap chest, . history: 52-year-old man status post cabg with coronary artery disease. findings: comparison is made to the previous study from , . endotracheal tube, swan-ganz catheter, nasogastric tube, and mediastinal drains have been removed. median sternotomy wires are present. no pneumothoraces are identified. there are no signs of focal consolidation. the cardiac size is enlarged. there is some atelectasis at the lung bases, most consistent with the poor inspiratory effort. dr. cardiology report echo study date of patient/test information: indication: intraoperative tee for cabg status: inpatient date/time: at 13:07 test: tee (complete) doppler: full doppler and color doppler contrast: none tape number: 2006aw2-: test location: anesthesia west or cardiac technical quality: adequate referring doctor: dr. r. measurements: left ventricle - inferolateral thickness: 1.0 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 5.2 cm (nl <= 5.6 cm) left ventricle - ejection fraction: 35% (nl >=55%) aorta - valve level: 2.6 cm (nl <= 3.6 cm) aorta - ascending: 2.6 cm (nl <= 3.4 cm) interpretation: findings: left atrium: no spontaneous echo contrast in the body of the laa. all four pulmonary veins identified and enter the left atrium. 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: wall thickness and cavity dimensions were obtained from 2d images. normal lv wall thickness. normal lv cavity size. moderate regional lv systolic dysfunction. moderately depressed lvef. lv wall motion: regional lv wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; right ventricle: normal rv chamber size. mild global rv free wall hypokinesis. aorta: normal aortic root diameter. focal calcifications in aortic root. normal ascending aorta diameter. simple atheroma in aortic arch. simple atheroma in descending aorta. aortic valve: mildly thickened aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. no ms. physiologic mr (within normal limits). tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets with physiologic pr. pericardium: trivial/physiologic pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. no tee related complications. the patient was under general anesthesia throughout the for the patient. conclusions: pre-cpb no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is mild lv global hypokinesis. there is moderate to severe hypokinesis of the septum and apex. overall ef is about 35%. right ventricular chamber size is normal. there is mild global right ventricular free wall hypokinesis. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. physiologic mitral regurgitation is seen (within normal limits). there is a trivial/physiologic pericardial effusion. post-cpb the patient is receiving epinephrine by infusion. there remains mild biventricular systolic dysfunction. the focal wall motion abnormalities, namely moderate to severe septal and apical hypokinesis remain. overall ef may be slightly improved to 35 to 40%. no other change from pre-cpb findings. electronically signed by , md on 13:20. brief hospital course: the patient was transferred to the csru from mwmc on a heparin drip. he was in stable condition and on he underwent cabgx3(lima->lad, svg->pm, pda). cross clamp time was 61 mins, total bypass time was 81 mins. he tolerated the procedure well and was transferred to the csru on epi and propofol in stable condition. he was extubated on the post op night and had his chest tubes d/c'd on pod#2 and was transferred to the floor. his epicardial pacing wires were d/c'd on pod#3 and he was discharged to home in stable condition on pod#4. medications on admission: heparin gtt asa 325 mg po daily lisinopril 20 mg po daily clonazepam 0.5 mg po tid wellbutrin 150 mg po bid hctz 25 mg po daily protonix 40 mg po daily lipitor 80 mg po daily mso4 2-4 mg sc prn 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:*100 tablet, delayed release (e.c.)(s)* refills:*2* 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 4. clonazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*0* 5. bupropion 150 mg tablet sustained release sig: one (1) tablet sustained release po bid (2 times a day). disp:*60 tablet sustained release(s)* refills:*0* 6. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 6-8 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 7. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days. disp:*14 tablet(s)* refills:*0* 8. potassium chloride 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* 9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease - s/p cabg, hypertension, hypercholesterolemia, depression, anxiety discharge condition: good discharge instructions: patient may shower, no baths. no creams, lotions or ointments to incisions. no driving for at least one month. no lifting more than 10 lbs for at least 10 weeks from the date of surgery. monitor wounds for signs of infection. please call with any concerns or questions. followup instructions: cardiac surgeon in weeks, dr. - call for appt. local pcp, . in weeks - call for appt. local cardiologist, dr. in weeks - call for appt. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Dysthymic disorder

*allergies: lipitor (rash) *access: 18g and 20g piv's on l arm ** please see admit note/fhp for admit info and hx. neuro: pt sleeping off and on, easily arousable, moves self in bed, no c/o pain, a&ox3. cardiac: nsr w/o ectopy, hr 74-87, sbp 121-147. x1 episode of a.flutter yesterday, was treated x3 w/ iv lopressor, now taking sm standing dose po. hct stable @ 29.4 (transfuse for <26), plan for endoscope today. na 146, now has d5 1/2ns @ 100cc/hr. resp: 2l nc, desat to 88 if removed. this shift, o2sat 97-99, rr 18-26, ls clear throughout, no cough and/or sputum noted. gi/gu: was on clear liquid diet, npo after midnight for scope today. +bs, no stool this shift, abd soft/non-tender. urine out foley yellow/clear 25-140cc/hr. id: temp 96.8-97.7, wbc 11.8. no abx @ this time. iv sites wnl, skin intact. psychosocial: fam visited in evening, will call again today for updates. Procedure: Other endoscopy of small intestine Transfusion of packed cells Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Coronary atherosclerosis of unspecified type of vessel, native or graft Atrial flutter Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Hypovolemia Accidents occurring in unspecified place Unspecified analgesic and antipyretic causing adverse effects in therapeutic use

allergies: lipitor attending: chief complaint: melena major surgical or invasive procedure: endoscopy history of present illness: 83f w/ cad s/p cabg, anemia, who reports "fainting and waking up incontinent of black liquid stool". she got up, cleaned up in bathtub, but continued to have a couple more episodes of small liquid, black stool yesterday. her last bm was this day of adm. she also notes some lightheadedness, + nausea and diaphoresis. she does take aspirin and aleve 4 pills daily x 4-5 days for back pain. . in ed, 98.4, 102, 166/78. she was in nad, abd benign, euvolemic, melena on rectal. ng lavage negative. ekg unchanged. . in the unit, she reports feeling well with no chest pain, sob, lhd, dizzyness, abd pain. per daughter, pt has never had seizure like activity, syncope, gib bleed before. she has never had a colonoscopy. she received 2 u prbc so far. past medical history: 1. venous insufficiency. 2. cad status post acute mi . 3. hypertension. 4. cataract os. 5. hyperlipidemia. 6. dysfunctional uterine bleeding. 7. cystocele complicated by mixed incontinence. 8. anemia. 9. djd, right knee. past surgical history: 1. status post cataract extraction, os. 2. status post excision of cyst, right knee. 3. status post cabg, four vessels. . gynecologic history: gravida 3, para 2, two vaginal deliveries. menarche in her teens. menopause at age 53. last pap smear 5/. last mammogram 2/. . social history: she grew up in . she is widowed. she worked as a stitcher but was mostly a housewife. no tobacco use. she did smoke but quit many years ago. social alcohol use, no drug use. family history: positive for diabetes in her sister. positive for cad in her brother, questionable malignancy in an aunt. family history of hypertension. physical exam: vitals: 98.7 115/78 85 16 100% 2lnc heent: perrl, eom intact, mm moist pulm: ctab heart: well-healed midline scar, rrr, hsm lpsa abd: soft, nt/nd, normoactive bs ext: no edema, +dp blaterally; hypersensitive to light touch neuro: aaox3 rectal: guaiac positive, black stool in rectal vault pertinent results: labs on discharge: wbc-11.8* hct-29.4* plt ct-221 . pt-12.3 ptt-21.2* inr(pt)-1.0 . glucose-139* urean-15 creat-0.8 na-146* k-3.9 cl-114* hco3-25 . . endoscopy: esophagus: mucosa: normal mucosa was noted in the whole esophagus. stomach: excavated lesions there were 3 ulcers found in the pre-pyloric area ranging from 3mm to 1cm. all ulcers had clear bases. there was no active bleeding noted. duodenum: mucosa: normal mucosa was noted in the first part of the duodenum and second part of the duodenum. impression: normal mucosa in the whole esophagus; ulcer in the pre-pylorus normal mucosa in the first part of the duodenum and second part of the duodenum; otherwise normal egd to second part of the duodenum brief hospital course: 83 y/o f hx cad s/p cabg now with 10 point hct drop and melanotic stools concerning for gib . # gib: she presented with likely ugi source in the settig of taking aspirin, plavix, and nsaids. she received 2uprbcs and hct remained stable in 28-30 without need for further transfusions. endoscopy showed three well healed pre-pyloric ulcers with no active bleeding. h pylori was checked and pending at discharge. she was advised to stop all nsaid use. aspirin was restarted at discharge. she will need repeat endoscopy 6 weeks after discharge. . # syncope: suspect hypovolemia and orthostasis in setting of blood loss although in the micu, pt was not orthostatic (after reciving fluids and blood in ed). pt was ruled out with 2 sets of cardiac enzymes and was monitored on tele. on the morning after admission to micu, pt developed svt (aflutter) to 140-150s which slowed with 3 doses of metoprolol 5mg iv. ekg after iv metoprolol was sinus with pvcs and apcs. pt was started on metoprolol 12.5mg tid which will need uptitration (pt was on atenolol 75mg daily at home) . # cad: s/p cabg. patient was still taking plavix although her cabg was 1.5 years ago. her primary cardiologist, dr. , confirmed that she should no longer be on plavix any more. this was clarified with patient. she can still continue aspirin. . # arf: baseline 0.9, now 1.2. suspect prerenal azotemia and improved with fluids/blood . # htn: bp meds intially held in setting of gib. by day of discharge, she restarted bb and acei. . # hypersensitivity in le: unclear etiology; ?rsd or restless leg, but not an active issue during this admission. . # fen: diet was advanced after endoscopy. . # ppx: pneumoboots, ppi . # access: piv x 2 . # code: full, discussed with patient and hcp medications on admission: - aspirin 81 mg once daily - atenolol 75 mg once daily - enalapril 5 mg once daily - furosemide 20 mg once daily - plavix 75 mg once daily (per daughter, not sure of taking) - simvastatin 80 mg once daily, - nitroglycerin p.r.n. - calcium with vitamin d t.i.d. - mvi - aleve and tylenol prn discharge medications: 1. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. disp:*60 capsule, delayed release(e.c.)(s)* refills:*2* 2. aspirin 81 mg tablet sig: one (1) tablet po once a day: please start taking this on thursday, . 3. atenolol 25 mg tablet sig: three (3) tablet po once a day. 4. enalapril maleate 5 mg tablet sig: one (1) tablet po once a day. 5. lasix 20 mg tablet sig: one (1) tablet po once a day. 6. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 7. hexavitamin tablet sig: one (1) cap po daily (daily). 8. calcium + vitamin d 600-200 mg-unit tablet sig: one (1) tablet po once a day. 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po at bedtime for 1 doses. discharge disposition: home discharge diagnosis: primary: - duodenal ulcers - atrial flutter - anemia: gi bleed - htn secondary: - cad s/p mi - hyperlipidemia - djd discharge condition: well discharge instructions: you came in with blood in your stool and a fainting episode. you received two units of blood in the emergency department and were admitted to the icu. your blood levels stabilized. you underwent an egd which showed three ulcers in your duodenum. these were not bleeding. please continue to hold your plavix. you can restart your aspirin on thursday, . we also are starting prilosec 20mg twice daily. please take this at least until your repeat egd and colonoscopy in weeks. we restarted all your other medications (except the plavix). . please monitor for any dizziness, bloody or black stools, or abdominal pain. if so, please stop your aspirin and return to the emergency department. please contact your pcp if you experience chest pain, shortness of breath, constipation/diarrhea. . please followup with your pcp to see if you have h. pylori. . please do not take advil, motrin, aleve, or other nsaids. . please take metoprolol 25mg x1 tonight at 7pm. then you can resume your atenolol normally in the morning. followup instructions: please followup with gi: dr. on monday, . please arrive at 9:30am. plan for a pickup at around 12:30. your appointment is on the : entrance, . you will receive information by mail regarding your preparation for the egd and colonoscopy. number: . please followup with your pcp, . on tuesday, at 11:15am. . provider: , md date/time: 11:30 provider: , : date/time: 11:15 Procedure: Other endoscopy of small intestine Transfusion of packed cells Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Coronary atherosclerosis of unspecified type of vessel, native or graft Atrial flutter Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Hypovolemia Accidents occurring in unspecified place Unspecified analgesic and antipyretic causing adverse effects in therapeutic use

history of present illness: ms. is an 82-year-old woman who had a positive exercise tolerance test and was referred for cardiac catheterization; which showed a 70% proximal lad lesion with a 70% proximal circumflex lesion, a 90% mid circumflex lesion and a 60% rca lesion with 1+ mr and an ef of 60%. she was then referred to cardiac surgery for coronary artery bypass grafting. the patient is a same-day admit to the operating room for coronary artery bypass grafting. past medical history: 1. low back pain. 2. arthritis. 3. hypertension. 4. hyperlipidemia. 5. cyst removal. 6. bladder prolapse. 7. mi in . 8. thalassemia. 9. status post cataract surgery. 10. venous stasis. allergies: the patient states an allergy to lipitor. medications at home: include norvasc 5 mg daily, zocor 80 mg daily, aspirin 325, vasotec 20 b.i.d., atenolol 100 daily. family history: brother with an mi at an unknown age. social history: remote tobacco; quit 49 years ago. lives in a retirement community. rare alcohol use. review of systems: no fevers, weight changes. no nausea, vomiting, diarrhea or constipation. however, does have a baseline poor appetite. positive frequency and nocturia. no diabetes. no tias. no cva. a poor exercise tolerance due to back pain. laboratory data: white count 7.2, hematocrit 30.4, platelets 201. inr 1.1. sodium 136, potassium 3.9, chloride 103, co2 of 26, bun 13, creatinine 0.8, glucose 112. alt 10, ast 18, alkaline phosphatase 54, total bilirubin 0.4. discharge status: the patient is to be discharged home with visiting nurses. discharge followup: she is to have followup with dr. in 2 to 3 weeks after discharge. the patient is to call for an appointment. she is also to have followup with dr. 4 weeks after discharge. the patient is also to call dr. office for an appointment. discharge diagnoses: 1. status post coronary artery bypass grafting x4; with a left internal mammary artery to the left anterior descending, saphenous vein graft to right coronary artery, saphenous vein graft to diagonal with a sequential graft to the obtuse marginal. 2. hypertension. 3. hypercholesterolemia. 4. low back pain. 5. arthritis. 6. thalassemia. 7. bladder prolapse. 8. status post cataract surgery. 9. status post cyst removal. 10. venous stasis. condition on discharge: good. discharge medications: include simvastatin 80 mg daily, lasix 20 mg daily x2 weeks, colace 100 mg b.i.d., potassium chloride 20 meq daily x2 weeks, aspirin 81 mg daily, percocet 5/325 one to 2 tablets every 4 to 6 hours as needed for pain, atenolol 75 mg daily and plavix 75 mg daily. , md Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Mitral valve disorders Unspecified essential hypertension Other and unspecified hyperlipidemia Old myocardial infarction Other thalassemia Venous (peripheral) insufficiency, unspecified

allergies: lipitor attending: chief complaint: tachycardia major surgical or invasive procedure: cardioversion history of present illness: 84 year old female with history of atrial flutter, cad s/p cabg , htn presents with asymptomatic tachycardia. patient was previously discharged from hospital on after being admitted on for asymptomatic tachycardia. patient was noted to be in atrial flutter on previous admission that converted back to sinus with fluid administration alone. during her previous admission, patient was seen and evaluted by ep who reccomending continuing current management without change in medications. please see previous discharge summary for furthur discharge info. it appears that 2 days after discharge patient was back in atrial flutter (ie since ) looking at ob/gyn note in omr with hrs in 140s. patient has regular vna services at home, and this morning vna thought that the patient was in afib with heart rate in the 140s. at that time patient with stable bp 112/70. as per vna patient is patient was completely asymptomatic, afebrile, without chest pain or shortness of breath. non specific ecg changes. . patient was transported to our ed for further eval. on arrival to ed her vitals were t 97.1 bp 129/70 hr 143 rr 18 98% ra. patient was in atrial flutter. cardiology was consulted. patient was given iv diltiazem 10 mg x 2 and iv metoprolol 5 mg x 2 per verbal ed signout. patient then dropped her pressures to 88/46 with no change in heart rate and was given total of 3 liters of ns boluses per ed verbal signout. . on arrival to micu her symptoms were t 96.9 hr 140s bp 109/73 rr 15 99% ra. patient denies any fever, chills, nightsweats, cough, cold, chest pain, shortness of breath, pnd, orhtopnea, abdominal pain, dysuria, hematuria, blood in stool or urine, weakness, numbness. her diarrhea has resolved. stable chronic back pain. no other complaints. past medical history: atrial flutter s/p dc cardioversion in , flutter ablation cad s/p cabg x 4 (lima->lad, svg->dm2, svg->om1, svg->pda) cad, s/p prior mi hypertension hyperlipidemia djd, right knee pud (healing pre-pyloric ulcer on egd ) sigmoid diverticulosis anemia peripheral neuropathy chronic lower back pain cystocele complicated by mixed incontinence thallasemia chronic venous insuffiency dub djd, right knee. s/p cataract surgery left eye s/p excision of cyst, right knee social history: widowed. has 2 children living nearby. previous smoker, but quit many years ago. occasional alcohol. family history: positive for diabetes in her sister and cad in her brother. physical exam: vital signs: t 96.9 hr 140s bp 109/73 rr 15 99% ra. general appearance: elderly woman in no distress. pleasant, following commands, able to give history. heent: mmm neck: jvp 8 cm. lungs: fine crackles at right > left lung bases. heart: irregularly irregular, normal s1 and s2, tachycardic abdomen: +bs, soft, ntnd. extremities: trace edema in ble. pertinent results: labs on admission: . hematology: 02:30pm blood wbc-8.4 rbc-5.41* hgb-10.9* hct-35.4* mcv-65* mch-20.1* mchc-30.7* rdw-16.2* plt ct-283 02:30pm blood neuts-59.3 lymphs-29.2 monos-7.3 eos-3.9 baso-0.4 02:30pm blood pt-22.0* ptt-26.1 inr(pt)-2.1* . chemistry: 02:30pm blood glucose-120* urean-23* creat-1.2* na-141 k-4.4 cl-101 hco3-29 angap-15 06:19am blood calcium-8.8 phos-3.1 mg-2.0 02:30pm blood ck-mb-notdone ctropnt-<0.01 02:30pm blood ck(cpk)-74 . ekg narrow complex supraventricular tachycardia, most likely a-v nodal re-entrant tachycardia. compared to the previous tracing of supraventricular tachycardia is new. read by: , intervals axes rate pr qrs qt/qtc p qrs t 143 0 76 326/471 0 16 128 . cxr since , mild interstitial edema is new. prior sternotomy for cabg was performed. there is no significant pleural effusion. heart size is top normal. the aorta is tortuous and calcified. there is no focal area of consolidation. minimal indentation on the right tracheal wall could be due to a thyroid nodule, should be evaluated by if not already known. . cxr portable semi-upright radiograph of the chest: the patient is rotated to the left which limits evaluation of the heart size. the aorta is tortuous and calcified. the hilar contours are unremarkable. there are low lung volumes bilaterally. small amount of left pleural effusion is noted. impression: limited study, but no acute intrathoracic pathology. brief hospital course: 84f w cad (s/p cabg), a-fib and a-flutter (s/p dccv and cavotrunkal isthmus ablation), admitted with asymptomatic tachycardia after discharge on for same issue. . # rhythm - patient with a history of atrial flutter s/p dc cardioversion in , and subsequent empirical cti ablation in the setting of noninducible svt. she was in atrial flutter with hr 140s on admission, therapeutically anticoagulated. coumadin was held and heparin gtt started. ep saw her and recommended cardioversion. she had been therapeutic on her coumadin for the past 8 weeks. cardioversion was successful after one 200 j shock. she was subsequently hemodynamically stable with wandering atrial pacemaker in the 80s. amiodarone was started at 200mg tid, and coumadin was restarted at 1mg (half home dose because of known interaction with amiodarone). she will need outpatient pfts for baseline on amiodarone as well as regular inr checks / coumadin dose adjustments. her amiodarone will be tid for 5 days, then for 14 days, then once a day. . # coronaries - patient with a history of cad s/p cabgx4 in . no acute issues. pt discharged on aspirin 81mg daily, toprolxl 150mg daily. enalapril reduced to 5mg po daily due to increased creatinine. simvastatin switched to pravastatin 80mg daily due to interaction with amiodarone. . # pump ?????? she had chronic systolic congestive heart failure (lvef=30-35% on tte in 8/). she initially appeared euvolemic. after receiving 3 l of fluid in the ed, she developed acute respiratory distress several hours after her cardioversion. bp was elevated to 200/120, she was transferred back to the ccu overnight. shortness of breath improved with iv lasix, and she was thought to have had flash pulmonary edema. pt's symptoms resolved and she was restarted on home medications and sent back to the regular cardiology floor. . # acute renal failure - cr on admission was 1.2, up from baseline of 0.9-1.0, likely pre-renal from recent diarrhea and poor forward flow from heart failure. ace inhibitor was held, then restarted on a lower dose (enalapril 5mg daily). . # thalassemia - low mcv and normal serum iron level were consistent with a known diagnosis of thalassemia. hematocrit on admission was 35 which is relatively stable. . # hyperlipidemia - discharged on pravastatin. . # thyroid nodule- seen on cxr, needs follow up as out pt. tsh was 1.7 at baseline before starting amiodarone. . pt will be discharged home with vna. cardiology and pcp follow up are planned, as well as a thyroid and pfts. her pcp will be following her inr. medications on admission: warfarin 2 mg daily aspirin 81 mg tablet daily metoprolol succinate 150 mg daily enalapril maleate 10 mg tablet daily simvastatin 80 mg daily furosemide 40 mg daily gabapentin 300 mg daily lidocaine 5 %(700 mg/patch) patch daily omeprazole ec 20 mg capsule daily nitroglycerin 0.3 mg sl prn lorazepam 0.5 mg qhs prn for insomnia calcium-cholecalciferol (d3) 500 (1,250)-200 mg-unit estradiol 0.01 % (0.1 mg/g) cream vaginal multivitamin daily discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. metoprolol succinate 100 mg tablet sustained release 24 hr sig: 1.5 tablet sustained release 24 hrs po daily (daily). 3. enalapril maleate 5 mg tablet sig: one (1) tablet po daily (daily). 4. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*2* 5. pravastatin 20 mg tablet sig: four (4) tablet po daily (daily). disp:*120 tablet(s)* refills:*2* 6. amiodarone 200 mg tablet sig: one (1) tablet po as directed: take one pill three times a day through , then take one pill twice a day for 2 weeks, then take one pill once a day. disp:*51 tablet(s)* refills:*2* 7. furosemide 40 mg tablet sig: one (1) 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. gabapentin 300 mg capsule sig: one (1) capsule po q24h (every 24 hours). 10. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: adhesive patch, medicateds topical daily (daily). 11. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 12. calcium carbonate 500 mg (1,250 mg) tablet sig: one (1) tablet po daily (daily). 13. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. discharge disposition: home with service facility: vna discharge diagnosis: atrial flutter . coronary artery disease hypertension hyperlipidemia discharge condition: hemodynamically stable discharge instructions: you were admitted to the hospital with asymptomatic tachycardia (heart rate into 140's). you were found to have an arrhythmia called atrial flutter. you were treated with cardioversion. . you should follow up with your physicians as detailed below. you should have your inr checked regularly. you should have your lung function tested and have your thyroid function followed while on amiodarone. . we changed your medications as follows: 1. started amiodarone, the dose will be three times a day through , then twice a day for 2 weeks, then once a day there after 2. changed simvastatin 80mg daily to pravastatin 80mg daily due to interactions w amiodarone 3. decreased your warfarin to 1mg po daily . if you have chest pain, shortness of breath, lightheadedness, dizziness or any other concerns, please call your physician . followup instructions: you will be contact for outpatient pulmonary function tests for baseline levels on amiodarone therapy. . provider: phone: date/time: 1:45 thyroid to eval for nodule. . provider: , md phone: date/time: 11:15 . provider: , md phone: date/time: 11:30 . provider: , md phone: date/time: 3:30 @ Procedure: Other electric countershock of heart Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Aortocoronary bypass status Atrial flutter Other and unspecified hyperlipidemia Unspecified hereditary and idiopathic peripheral neuropathy Acute on chronic systolic heart failure Other thalassemia Venous (peripheral) insufficiency, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: unresponsiveness major surgical or invasive procedure: intubation history of present illness: 56 yo spanish speaking male who gets regular care at , was in usoh notable for etoh abuse, until morning of admit. he was working as a painter and started to feel ill, complaining of diaphoresis while working in the heat. he went to his girlfriend's place of work where he was witnessed to have a small nosebleed and then became weak and fell to the floor. ems found him unresponsive but with stable vital signs per report (paperwork missing). . in the ed was initially given narcan without effect. finger stick was 100. he became agitated and was given fentanyl and ativan. after this he was noted to have a generalized seizure with eyes rolling back and limbs stiffening. his breathing became apneic, although he had good o2 sats. he was intubated for airway saftey and sedated when he began grabbing at lines. neuro assessed, but already sedated. ct of head was neg for bleed. lp done and was normal. etoh blood level 319. per ed notes, loaded with dilantin and transferred to . admsision labs notable for anion gap of 21, lactate 2.5, ketones in the urine, normal csf, mcv of 101. abg: 7.37/45/177 in , pt had a repeat abg on ac with a fio2 of 40% which showed an improved pao2. a repeat cxr did not reveal evidence of aspiration pna. he was extubated and started on a valium and ativan ciwa scaleneurology saw pt and felt that it was unclear whether pt actually had a seizure but that an eeg was not indicated. dilantin was held and he was started on thiamine. pt denies complaints currently except is hungry. no anxiety, palpitations, diaph, cp, sob, n/v, abd pain. past medical history: etoh abuse, hypertension, ? volvulus or sbo in past social history: drinks 2 large bottles (? 1l each) of bicardi daily. unclear if hx of withdrawl or seizures in past. smokes 2 ppd x40 years. no illicit drug use. lives with girlfriend family history: father and brother with stroke physical exam: upon transfer to floor: t99.2 tm 100.9 at 2pm 75 126/77 19 99%ra i/o 24: 3013/2200 gen: nad thin male, tremulous, no diaphoresis heent: pupils reactive, neck supple, op clear cv: regular, s1s2, no m/r/g pulm: clear bilat, no wheeze, no crackles abd: think, soft, well healed periumbilical midline incision. ext: no edema. 2+ dp pulses neuro: aao x 3, tremulous, nl ftn htn, strength and sensation to light touch intact b/l le and ue. rhomberg not assessed as pt incontinent of liquid brown stool upon standing. pertinent results: 01:20pm wbc-6.0 rbc-3.85* hgb-13.5* hct-38.8* mcv-101* mch-35.1* mchc-34.8 rdw-13.0 01:20pm neuts-59.5 lymphs-33.0 monos-6.7 eos-0.7 basos-0.2 01:20pm pt-12.4 ptt-24.0 inr(pt)-1.0 01:20pm glucose-88 urea n-18 creat-1.0 sodium-139 potassium-3.7 chloride-98 total co2-20* anion gap-25* 01:20pm blood albumin-4.5 calcium-9.6 phos-3.6 mg-1.9 01:20pm alt(sgpt)-22 ast(sgot)-84* ck(cpk)-354* alk phos-86 amylase-40 tot bili-0.8 01:20pm lipase-23 04:32am blood ck(cpk)-252* 01:20pm blood ck-mb-3 ctropnt-<0.01 04:32am blood ck-mb-2 ctropnt-<0.01 04:32am blood vitb12-377 folate-19.9 01:20pm blood asa-neg ethanol-319* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 05:49pm blood type-art po2-177* pco2-45 ph-7.37 calhco3-27 base xs-0 02:16pm blood lactate-2.5* . 02:44pm cerebrospinal fluid (csf) protein-37 glucose-66 02:44pm cerebrospinal fluid (csf) wbc-0 rbc-0 polys-0 lymphs-100 monos-0 . 01:32pm urine color-amber appear-clear sp -1.019 01:32pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-15 bilirubin-neg urobilngn-8* ph-7.0 leuk-neg 01:32pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg . imaging: ct head no acute intracranial pathology including hemorrhage, fracture, or mass. cxr the tip of the endotracheal tube is identified at thoracic inlet. a nasogastric tube terminates in the gastric fundus. the lungs are clear. the heart and mediastinum are within normal limits. no pneumothorax is identified. . ekg technically difficult study sinus tachycardia at 102 bpm left axis deviation - anterior fascicular block possible old inferior infarct possible old anterior infarct consider left ventricular hypertrophy clinical correlation is suggested . micro data: csf **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. blood, urine and stool cultures were all negative. brief hospital course: 56 yo male with hx of heavy etoh use presents with obtundation after working in the heat. in the ed his blood etoh level was 319 and he experienced a possible seizure. he was intubated for airway compromise, now extubated and is being transferred to the floor for management of alcohol withdrawal. . 1. s/p resp failure secondary to etoh withdrawl seizures: the patient was intubated and admitted to the for airway protection and periods of apnea peri-seizure. there was no evidence of aspiration pna on repeat chest xrays. he was extubated within 1 day and did well from this standpoint and was therefore transferred to the floor. . 2. etoh abuse and w/d-the patient was maintained on standing valium while in the . on transfer to the floor, the patient appeared tremulous but hd stable. he was changed from standing valium to prn valium on as his ciwa scale remained low. he was maintained on mvi, thiamine, folate. he was seen by the addictions specialist and agrees to attend aa meetings. . 3. obtundation/ms change: secondary to etoh intoxication, volume depletion, and alocholic/starvation ketoacidosis. the ketones in his urine and elevated mcv would indicate poor nutrition and starvation ketosis. the seizure likely related to etoh. id work up including cxr, ua, lp was negative for source of infection. the patient was mentating at his baseline within one day of being transferred to the floor. . 5. ? seizures: the patient received a dilantin load in ed, however neurology saw the patient and advised to hold on further doses. etiology likely related to etoh withdrawal. per neurology, it was not clear whether this event was a seizure. no eeg was needed per neurology. . 5. diarrhea-? ivf with no solid foods eaten. resolved on its own. all stool studies were negative. 7. anemia: macrocytic, b12, folate normal. most likely etoh suppression. hct was stable during admission. . 8. thrombocytopenia: has low plts at baseline:120's. he was on subq heparin, which was d/c'd in , when his platelet count dropped to 86 from 102. we suspect the low platelets are likely to alcohol abuse, much less likely hit. the platelet count stabilized at 115, near his baseline, at discharge. he will need to have his bloodwork checked by his pmd after discharge. . 9. ppx-pneumoboots, eating . 10. fen-advanced diet as tolerated, repleted lytes prn . 11. htn: while initially normotensive, his blood pressure became more elevated during the latter part of his admission. he will need to resume his outpatient antihypertensive . 12. code: full . 13. comm: sister , iend medications on admission: one pill for htn, unclear what it is discharge medications: 1. outpatient lab work your platelet count was low - probably related to your alcohol intake. please have your regular dr. . at ) recheck your blood work (platelet count) when you see her next 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 capsule* refills:*2* discharge disposition: home discharge diagnosis: respiratory failure, resolved alcohol intoxication alcohol withdrawal seizure dehydration, resolved starvation and alchoholic metabolic acidosis, resolved thrombocytopenia, stable anemia, stable discharge condition: stable and improved discharge instructions: please seek immediate medical attention if you experience fever greater than 101f, shaking chills, severe nausea or vomiting, chest pain, shortness of breath, seizures or other symptoms of concern to you. please avoid drinking alcohol. you have been given a list of spanish speaking aa centers and other resources to help stop drinking alcohol. please take your medications as directed. please resume your outpatient medication for high blood pressure. followup instructions: please follow up with aa as planned. please follow up with your pcp . as needed. if you wish to find a new pcp you can call at to make an appointment. please have your blood work rechecked by your pcp . . Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Acidosis Thrombocytopenia, unspecified Anemia, unspecified Other convulsions Acute respiratory failure Alcohol withdrawal Acute alcoholic intoxication in alcoholism, continuous Effects of hunger

past medical history: 1. hypertension. 2. angina. 3. myocardial infarction. past surgical history: hernia repair in the past. family history: pertinent for coronary artery disease and myocardial infarction in her family as well as a brother who had stomach cancer and her mother had complications from a hysterectomy. social history: she smoked cigarettes, one-half a pack per day, for 50 years, stopped approximately 10-12 years prior to admission. she does not drink alcohol. admission medications: 1. atenolol. 2. dexamethasone. 3. nitrostat. 4. multivitamin. 5. calcium. allergic: the patient is allergic to aspirin and it has made her bleed in the past. review of systems: negative for a skin rash, head, eyes, ears, nose and throat symptoms, other than the history of present illness, neck, cardiovascular, pulmonary, gastrointestinal, genitourinary, or musculoskeletal symptoms. her weight at the time of admission was 92-94 pounds and her height was 5' 2". physical examination on admission: the vital signs were within normal limits with a blood pressure of 190/94 consistent with hypertensive disease, but she was on atenolol, heart rate 72. the neck was supple. no carotid bruits noted. no lymphadenopathy. the cardiac examination revealed a regular rate and rhythm. the lungs were clear. the abdomen was soft. the extremities showed no clubbing, cyanosis or edema. the neurological examination revealed that she was awake, alert, and oriented times three. no right or left confusion or finger agnosia. language was fluent, good comprehension, naming and repetition. cranial nerve examination revealed that the pupils were equal and reactive to light, 3 mm to 2 mm bilaterally equal. the extraocular movements were full. visual field examination showed an incongruous left-sided field cut, worse in the left eye than the right. the funduscopic examination revealed sharp disk margins bilaterally with spontaneous venous pulsations. the face was symmetric. facial sensation was intact. the tongue was midline. palate up in the midline. sternocleidomastoid and upper trapezius were strong. the motor examination showed a drift of the right upper extremity but no pronation. her muscle strength was in all muscle groups except for the right iliac psoas which was 4+/5. muscle tone was normal. the deep tendon reflexes were 2+ bilaterally except for absence of bilateral ankle jerks. her right great toe is equivocal while the left is downgoing. the sensory examination was intact to touch and proprioception and gait was hemiparetic in the right leg. she did not have a romberg at that time. hospital course: due to the clinical findings, the patient was seen as an outpatient previously by dr. and, therefore, admitted and taken to the operating room on the morning of where under general endotracheal anesthetic the patient underwent a right occipital craniotomy and excision of tumor. frozen section at the time raised the question of it being a metastatic lesion as opposed to the previous thought of it being a primary brain tumor. the patient tolerated the procedure quite well overnight in the pacu and was subsequently transferred to the floor. however, on the floor, on at 9:30 p.m. the patient experienced a syncopal episode. she got up to go to the bathroom with the help of her daughter and began to feel weak at that time. her vital signs were checked and considered stable when she was seen and it was considered that she probably had a likely vasovagal episode. her hematocrit at the time was 29.2, white count 14.3, platelets 245,000. however, her sodium was 129 with potassium of 4.4, chloride 96, c02 23, bun and creatinine within normal limits, and blood sugar 298. ck 80 and ck mbs were pending at that time and were unremarkable when completed. due to the hematocrit of 29.2, a decision was made to transfuse if the hematocrit fell less than 29 and the patient remained stable then until later on , at which time she complained of an episode of chest discomfort which was accompanied by ekg changes in the evening. she stated that she was brushing her teeth at around 9:00 p.m. in the evening, at which point she began to experience squeezing epigastric discomfort, in intensity, radiating to the left arm and accompanied by shortness of breath, lightheadedness, and diaphoresis. she was seen in consultation by the cardiology service for this and she was placed on telemetry with cycling of the cardiac enzymes at that time. her course was subsequently complicated by some coffee ground emesis and drainage on a ng tube and she was seen by the gi service for an upper gi bleed. she subsequently underwent endoscopy which identified the source of bleeding on endoscopy. she was transferred to the surgical icu for stabilization. hematocrit at that time was 30.9, platelets 127,000, white count 12.6. the chem-7 was within normal limits. pt 13.5, inr 1.3, ptt 26.1 and cpk of 59. she remained neurologically intact, awake, alert, and oriented times three. the pupils were equal and reactive. she was following all commands and moving all extremities. she was subsequently stabilized in the unit and later transferred back out to the floor on . the patient then was seen in consultation by the thoracic surgery service after a ct scan of the chest and abdomen revealed lung masses as well as an adrenal mass. this raised the question of a high likelihood of a metastatic lung lesion as the primary source of the brain tumor and arrangements were made for the patient to undergo a fine-needle aspiration and biopsy at a subsequent hospitalization. the remainder of this patient's postoperative hospitalization was otherwise essentially unremarkable. she was subsequently discharged home on the afternoon of with follow-up to see dr. in the clinic in approximately one weeks time. she was given a tapering dose of steroids as well as a prescription for analgesics. arrangements were made for further follow-up with the consulting services. condition on discharge: stable and improved. , m.d. dictated by: medquist36 Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Endoscopic control of gastric or duodenal bleeding Other irrigation of (naso-)gastric tube Other irrigation of (naso-)gastric tube Diagnoses: Acute gastric ulcer with hemorrhage, without mention of obstruction Anemia, unspecified Coronary atherosclerosis of native coronary artery Secondary malignant neoplasm of brain and spinal cord Old myocardial infarction Other diseases of lung, not elsewhere classified Other malignant neoplasm without specification of site Other acute and subacute forms of ischemic heart disease, other

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fatigue, chest pain major surgical or invasive procedure: avr/cabg on history of present illness: 81 y/o female with exertional chest pain and fatigue. she's had known as, followed by echo, recent increase in symptoms. past medical history: htn obesity hypercholesterolemia complete heart block s/p ppm chronic anemia gerd recurrent ventral hernia narcolepsy agorophobia fractured ribs s/p mva s/p right carotid stent s/p ppm placement s/p hernia repair social history: remote smoker denies etoh wodowed, lives with friend retired family history: non-contributory physical exam: cor: gr iv/vi systolic murmur abd: + large ventral hernia 1+ peripheral edema pre-operative exam otherwise unremarkable pertinent results: 05:31am blood hct-25.6* 03:36am blood wbc-12.2* hct-26.8* 05:43am blood plt ct-200 05:25am blood glucose-102 urean-29* creat-1.2* na-133 k-4.7 cl-99 hco3-25 angap-14 brief hospital course: admitted on due to anemia. gi workup revealed duodenitis (by egd) and diverticulosis and rectal polyp (by colonoscopy). carotid ultrasound: : 40-59% and 60-69% stenosis she was taken to the or on where she underwent an avr (# 21mm pericardial valve), and a cabg x 1 (svg>rca) post-operatively she was taken to the cardiac surgery recovery unit, and was weaned from mechanical ventilation and extubated the day of surgery. she was noted to be undersensing her p waves by her permanent pacemaker, and the ep service was following her for this. she also has an elevated threshold for her ventricular lead. she was transferred to the telemetry floor on pod # 2, her chest tubes were removed, and she has remained hemodynamically stable. her epicardial wires were removed on pod # 3 her creatinine peaked at 1.8 on pod # 3, but has dropped to 1.2 today, pod # 6. she has progressed slowly with ambulation and physical therapy, but has remained hemodynamically stable throughout her post-op course. she is ready to be discharged to rehab today to continue with increasing mobility/physical therapy. medications on admission: benicar/hctz 40/25 daily norvasc 5mg qd crestor 10mg qd asa 325 mg qd acidophilus cipro protonix 40mg qd discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. rosuvastatin 5 mg tablet sig: two (2) tablet po daily (daily). 5. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 6. ferrous gluconate 300 mg tablet sig: one (1) tablet po daily (daily) for 1 months. 7. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 months. 8. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). 9. norvasc 5 mg tablet sig: one (1) tablet po once a day. 10. lasix 20 mg tablet sig: one (1) tablet po once a day. 11. potassium chloride 10 meq tablet sustained release sig: two (2) tablet sustained release po once a day. discharge disposition: extended care facility: ledge discharge diagnosis: s/p avr(#21 pericardial)cabgx1(svg->rca) pmh: htn, ^chol, chb s/p ppm, anemia, gerd, recurrent ventral hernia, obesity, narcolepsy discharge condition: good discharge instructions: keep wounds clean and dry. ok to shower, no bathing or swimming. take all medications as prescribed. call for any fever, redness or drainage from wounds followup instructions: provider: clinic phone: date/time: 11:00 provider: . phone: date/time: 11:30 Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Esophagogastroduodenoscopy [EGD] with closed biopsy Transfusion of packed cells Closed [endoscopic] biopsy of rectum Artificial pacemaker rate check Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Hyposmolality and/or hyponatremia Aortic valve disorders Other and unspecified hyperlipidemia Other complications due to other cardiac device, implant, and graft Iron deficiency anemia, unspecified Duodenitis, without mention of hemorrhage Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Other abnormal blood chemistry Fitting and adjustment of cardiac pacemaker Diverticulosis of colon (without mention of hemorrhage) Benign neoplasm of rectum and anal canal Ventral, unspecified, hernia without mention of obstruction or gangrene

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transfer from hospital in , ct/referring dr. and dr. major surgical or invasive procedure: cabg x 3, maze, iabp placement on history of present illness: mr. is a 64 yo gentleman who suffered a vf arrest while at a casino. a subsequent cardiac catheterization revealed three vessel disease. he was transferred to for surgial evaluation. past medical history: pmh: cardiomyopathy, dm, cri, mi, cad, chf, +chol, chronic afib, htn, pancreatitis, bile duct tumor psurgh: bile duct tumor removal cholecystectomy social history: 50 pack year smoking history but quit 20 yrs ago, no etoh x 20 yrs, retired, used to work for ge, lives independently with his wife. family history: mother died of an unknown cancer. father died of an mi at 65. brother had an mi at 66. another brother had a cabg at 55. he has 2 healthy children. physical exam: vitals: p: 106 bp: 142/98 r: 16 sao2: 93% on ra general: awake, alert, nad although tearful at times when discussing his near death heent: nc/at, perrl, eomi without nystagmus, ? scleral icterus noted, mmm, no lesions noted in op neck: supple, no jvd appreciated pulmonary: lungs cta bilaterally, breathing comfortably cardiac: irreg irreg, 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: no rashes or lesions noted. neurologic: -mental status: alert, oriented x 3. able to relate history without difficulty. -cranial nerves: ii-xii intact pertinent results: 06:25am blood hct-33.1* 06:25am blood pt-29.9* ptt-40.5* inr(pt)-3.1* 06:25am blood glucose-63* urean-24* creat-1.5* na-138 k-4.7 cl-98 hco3-34* angap-11 05:05am blood wbc-7.0 rbc-3.43* hgb-10.1* hct-31.0* mcv-90 mch-29.6 mchc-32.7 rdw-14.2 plt ct-299 09:00am blood pt-32.0* inr(pt)-3.4* 05:05am blood pt-29.9* inr(pt)-3.1* 05:10am blood pt-29.5* ptt-36.9* inr(pt)-3.1* 09:00am blood glucose-159* urean-30* creat-1.8* na-135 k-4.8 cl-98 hco3-30 angap-12 05:05am blood glucose-124* urean-36* creat-2.2* na-135 k-4.8 cl-95* hco3-30 angap-15 05:10am blood glucose-45* urean-32* creat-2.0* na-133 k-4.4 cl-92* hco3-31 angap-14 06:50am blood urean-28* creat-1.7* k-4.1 brief hospital course: mr. was brought to the operating room on and underwent a coronary artery bypass grafting times three, rf maze, and balloon placement. this procedure was performed by , md. he was hypotensive and required the placement of a balloon pump before he was transferred to the surgical intensive care unit. his epineprhine was weaned to off and his iabp was weaned and removed on pod #2. he was extubated on pod #2. he remained in atrial fibrillation. he was transferred to the floor on pod #4. he was started on heparin and coumadin for a fib. he was seen by for his dm and elevated blood sugars and was restarted on his metformin and glyburide as well as set up for post op follow up and teaching. he was seen in consultation by electrophysiology for his preoperative v fib arrest. they recommended tee and possible ep study. tee on showed an laa thrombus, precluding an ep study, he will follow up as an outpatient.also on he developed a fever to 103. he was pancultured and placed on vanco and cipro empirically. his creatinine began to rise and his ace inhibitor was dc'd. he subsequently remained afebrile, his creatinine began to normalize, and his blood sugars improved. he was ready for discharge home on . medications on admission: home medications: coumadin 2.5 mg daily enalapril 20 mg po daily dig 0.25 atenolol 25 mg po daily lipitor 20 mg po daily glyburide 10 mg po daily hctz 12.5 mg po daily ranitidine 300 mg po daily creon 10,000 tid metformin 1000 mg po bid viagra prn . meds on transfer: heparin drip stopped asa clonidine 0.1 mg po tid furosemide 40 mg po daily ssi glargine 20 u daily metop 50 mg po bid pantoprazole 40 mg po daily discharge medications: 1. potassium chloride 20 meq packet sig: one (1) po once a day for 7 days. disp:*7 pkts* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(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. 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* 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 6. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. amylase-lipase-protease 33,200-10,000- 37,500 unit capsule, delayed release(e.c.) sig: one (1) cap po qidwmhs (4 times a day (with meals and at bedtime)). disp:*120 cap(s)* refills:*0* 8. furosemide 40 mg tablet sig: one (1) tablet po once a day for 7 days. disp:*7 tablet(s)* refills:*0* 9. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 10. warfarin 1 mg tablet sig: one (1) tablet po once (once) for 2 doses: check inr with results to dr. . disp:*90 tablet(s)* refills:*0* 11. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). disp:*270 tablet(s)* refills:*0* 12. coumadin 1 mg tablet sig: one (1) tablet po once a day: check inr . take as directed by dr. for inr goal of . disp:*30 tablet(s)* refills:*0* 13. glyburide 5 mg tablet sig: 0.5 tablet po dinner (dinner): hold for blood sugar less than 80. disp:*30 tablet(s)* refills:*0* 14. glyburide 5 mg tablet sig: one (1) tablet po breakfast (breakfast): hold for blood sugar less than 80. disp:*30 tablet(s)* refills:*0* 15. lancets 16. glucose test strips discharge disposition: home with service facility: homecare discharge diagnosis: cad dm cri chronic af htn discharge condition: good discharge instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no driving for 1 month no lifting > 10# for 10 weeks followup instructions: with dr. in weeks with dr. in weeks with dr. in weeks make an appointment for education classes at @ make an appointment with , np or dr. , or dr. at for 1 , and also amke an appointment with vision network at the same number. make an appointment with dr. for 1-2 weeks Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Diagnostic ultrasound of heart Diagnostic ultrasound of heart Excision or destruction of other lesion or tissue of heart, open approach Implant of pulsation balloon Nonoperative removal of heart assist system Diagnoses: Other primary cardiomyopathies Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Unspecified pleural effusion Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Chronic kidney disease, unspecified Paroxysmal ventricular tachycardia Other and unspecified hyperlipidemia Old myocardial infarction Long-term (current) use of anticoagulants Family history of ischemic heart disease Personal history of malignant neoplasm of other gastrointestinal tract Other specified diseases of pancreas Diabetes with unspecified complication, type II or unspecified type, uncontrolled

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain, hypotension, fever. major surgical or invasive procedure: : icp monitor placement : successful placement of an 8 french percutaneous right transhepatic internal-external biliary drain (pct). : removal of temporary hd cathteter and placement of tunneled ij hd cathterer in interventional radiology. history of present illness: mr is a 67 year old male who is s/p whipple surgery in for biliary versus pancreatic cancer, who presented to osh with dyspnea and fevers. had an episode of ruq abdominal pain earlier in day that resolved. no nausea or vomiting. no diarrhea. originally thought to be in chf at osh and treated with lasix 40mg iv, and was also thought to have an infiltrate on cxr concerning for pna. however, labs at osh showed elevated lfts and bilirubin 2.6. an abdominal us and mrcp were done, which showed mildly dilated intra-hepatic ducts that could be consistent with prior whipple. he then became febrile and hypotensive with sbps in the 60s requiring a dopamine drip. transferred to for evaluation of possible cholagitis. past medical history: pmhx: 1. cad s/p cabg with svg to pl of cx, svg to om branch, lima to lad. there were no bypassable targets in rca territory. 2. ckd (baseline cr 1.4-1.8 in ) 3. chronic atrial fibrillation ? of s/p maze or pvi on coumadin at home 4. pancreatic ca vs biliary ca s/p whipple in 's 5. dm 6. hyperlipidemia 7. cardiac risk factors include coronary artery disease, diabetes, and dyslipidemia. 8. pancreatitis . pshx: bile duct tumor removal, cholecystectomy social history: 50 pack year smoking history but quit 20 yrs ago, no etoh x 20 yrs, retired, used to work for ge, lives independently with his wife. family history: mother died of an unknown cancer. father died of an mi at 65. brother had an mi at 66. another brother had a cabg at 55. he has 2 healthy children. physical exam: on admission: vs: 98.7 130 76/39 20 95 gen: ill-appearing man, answering questions heent: mmm, scleral icterus cv: irregular, tachycardic lungs: course bs abd: softly distended, non-tender with deep palpation ext: no c/c/e pertinent results: on admission: 09:34pm type-art po2-104 pco2-23* ph-7.38 total co2-14* base xs--9 intubated-not intuba 09:34pm lactate-8.2* 09:12pm lactate-7.7* 09:00pm glucose-265* urea n-51* creat-3.3*# sodium-137 potassium-3.3 chloride-100 total co2-16* anion gap-24 09:00pm alt(sgpt)-776* ast(sgot)-1722* alk phos-252* tot bili-3.4* dir bili-2.2* indir bil-1.2 09:00pm lipase-38 09:00pm ctropnt-0.08* 09:00pm ck-mb-17* 09:00pm albumin-3.2* calcium-7.3* phosphate-2.7 magnesium-0.9* 09:00pm urine hours-random 09:00pm urine gr hold-hold 09:00pm wbc-18.8*# rbc-3.43* hgb-9.8* hct-30.5* mcv-89 mch-28.6 mchc-32.2 rdw-14.4 09:00pm neuts-89* bands-0 lymphs-1* monos-1* eos-0 basos-0 atyps-0 metas-9* myelos-0 09:00pm hypochrom-occasional anisocyt-occasional poikilocy-1+ macrocyt-occasional microcyt-occasional polychrom-1+ stippled-1+ bite-occasional elliptocy-1+ 09:00pm plt smr-low plt count-112*# 09:00pm pt-29.6* ptt-37.5* inr(pt)-2.9* 09:00pm urine color-yellow appear-clear sp -1.009 09:00pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg . imaging: abd/pelvic ct w/contrast: 1. probable 1.4-cm distal cbd stone/debris. 2. two ovoid foci of high-attenuation in the pancreatic neck raising possibility of hemorrhagic lesions vs partially calcified lesion. no pancreatic ductal dilatation. differential considerations include hemorrhagic metastases versus hemorrhagic pseudocyst vs amorphous calcification/debris in pancreatic duct, although no ductal dilatation. further evaluation with mrcp is advised. 3. mediastinal and retroperiteonal lymphadenopathy, raising the possibility of an underlying hematological/lymphomatous malignancy vs. metastases, although not typical presentation for pancreatic metastases. close interval followup and further clinical evaluation is recommended. . echocardiogram: the left atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the 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. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: suboptimal image quality. mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. compared with the prior study (images reviewed) of , biventricular systolic function is improved. . head ct: there are a number of small foci of diminished density within the white matter of both cerebral hemispheres, most evident in the left frontal periventricular white matter and more distinctly within the left lentiform nucleus, and to a lesser extent, the right lentiform nucleus. there is a probable punctate focus of diminished density within the right cerebellar hemisphere. while nonspecific in etiology, given patient age, chronic small vessel infarction would appear the most likely diagnosis. there is no hydrocephalus or shift of normally midline structures. there is mild peripheral cerebral atrophy. there is heavy atherosclerotic calcification of the cavernous internal carotid arteries, and to a moderate extent, the distal vertebral arteries at the level of the foramen magnum. the surrounding osseous and extracranial soft tissues reveal mild air-fluid levels within the sphenoid sinus, as well as mild bilateral ethmoid sinus mucosal thickening, likely representing effects of intubation. multiple metal staples are seen in the right frontal scalp, at the site of the former bolt insertion. conclusion: no intracranial hemorrhage. probable chronic small-vessel infarction. . bilat lower ext veins: no deep venous thrombosis involving the right or left lower extremity. . tube cholangiogram/chalnagiography: cholangiogram performed through the existing biliary catheter showed the catheter to be in a satisfactory position and draining well. there was no evidence of any bile duct obstruction seen. a minor adjustment was made to the catheter position by pushing it in by about a centimeter. brief hospital course: the patient was transferred from an osh and was admitted to the general surgical service in the sicu on for spetic shock and cholangitis. in the emergency department, he was made npo and intubated, intensive fluid rescusitation was initiated, a foley catheter was placed, initially started on levophed and neomycin in ed changed to neo and vassopressin for pressure support, lines placed, and started on empiric iv vancomycin and zosyn. abdominal ct revealed high density material in the cbd and projecting over the pancreatic neck and body, question of stones, calcification. mild biliary dilation, without other acute abnormalities to explain patients clinical condition. cardiology consulted; felt that ekg changes and troponin leak indicative of likely demand ischemia due to septic picture. recommended echo, diuresis, hold off on cardioversion. patient takes coumadin at home for history of atrial fibrillation, arriving with inr 2.9. recieved a total of 8 units of ffp in preparation for percutaneous transhepatic biliary drain (ptbd) placement in interventional radiology. on , the patient underwent percutaneous transhepatic cholangiogram, placement of an 8 french internal-external locking right percutaneous biliary drain, and post-tube placement cholangiogram. ptbd was placed to gravity drainage. transfer to inpatient unit occurred on . . neuro: upon return from or for ptc placement, he was noted to have fixed and dilated right pupil. he was intubated, sedated and still hemodynamically very unstable so a head ct was unable to be obtained at this point. neurology and, subsequently, neurosurgery were consulted for evluation of pupilary findings. an icp monitor bolt placed with an opening icp of 20mm. when re-examined the next morning, pupils were small and reactive. on , the bolt was removed, and a head ct performed, which showed no intracranial hemorrhage, but probable chronic small-vessel infarction. he remined neurologically intact. the patient received fentanyl prn in the sicu with good effect. when transferred to the inpatient floor, he was nolonger experiencing any pain, and did not require pain medications other than acetaminophen prn. . cv: upon admission, the patient required three pressors to maintain hemodynamic stablitiy. cardiology was consulted for uncontrolled atrial fibrillatio, and the patient was started on a diltiazen drip. weaned off pressors on . diltiazem was transitioned to metorpolol with the patient ultimately stable on 125mg po bid. warfarin was restarted on , but discontinued on . held for tunneled hd catheter placement. coumadin restarted at 2mg in the evening. pt/inr should be checked daily at rehab facility until therapeutic; inr goal 2.5 with a therapeutic range of . once on the floor, the patient's other anti-hypertensive and diuretic medications were restarted. he remained cardiovascularly stable. . pulmonary: upon admission, the patient was intubated and placed on mechanical ventilation for need of aggressive fluid rescusitation and hemodynamic instability. he became fluid overloaded, which responded well to cvvh diuresis, with resultant improvement in respiratory status. he was extubated on without problem. thereafter, the patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. . gi/gu/fen: upon admission, the patient was made npo with iv fluids. on , he was started on cvvh after placement of a temporary hd catheter. on , he was negative 1300ml via cvvh diuersis. he was doing very well with cvvh with up to 20kg of fluid removed, close to dry weight. began recovering some renal function with excellent urine output, albeit with lasix. overall, he tolerating continuous renal replacement therapy (crrt) well. he had experienced respiratory alkalosis on , which compensated with metabolic acidosis crrt fluid changed to bb32. a dobhoff was placed, and tubefeeds started on , which were continued until , when discontinued and the dobhoff removed. the patient underwent a swallow evaluation, and was started on a renal diet on /201, which he tolerated. patient's intake and output were closely monitored, and iv fluid was adjusted when necessary. electrolytes were routinely followed, and repleted when necessary. renal felt that the patient was experiencing acute renal failure in the context of a history of mild chronic renal insufficiency and acute spetic shock. it is expected that hemodialysis will be a temporary intervention, and that recovery to baseline can be expected. final renal recomemendations were enclosed with the patient's discharge inforamtion. the ptbd was capped on , which was well tolerated without abdominal pain, nausea, vomiting or fever. he will be discharged with the capped ptbd. in 1 month, the patient will have a repeat ptbd cholangiogram with possible diliation as an outpatient. potential discontinuation of the ptbd will be determined at future follow-up with dr. . . id: admitted with septic shock, with blood culture at osh with strep bovis/clostridium clostriforme, blood cultures here were negative. was started on meropenem/vancomcyin. infectious disease service consulted. bile cultures with polymicrobial organisms. changed to ceftriaxone and flagyl. then changed to unasyn alone to treat the s. bovis, clostridium, and the bacteroides in the bile culture. the patient's white blood count and fever curves were closely watched for signs of infection. staples on scalp from previous bolt removed prior to discharge. . endocrine: given his acute renal failure, home metformin was stopped, and the patient was placed on an insulin regimen. the diabetes service was consulted. the patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. at the time of discharge, the patient was receiving lantus 20units qhs plus sliding scale insulin with good glycemic control. . hematology: while hospitalized, the patient received 10 units of ffp, most of which were given initially upon admission to correct his inr before emergent ptbd placement. other units were given prior to invasive procedures, such as tunneled hd catheter placement. he received 1 unit prbcs on for a hct 23.0/hgb 7.4 during cvvh. he was started on erythropoietin as part of his dialysis regimen. pre-discharge hct 23.9 /hgb 8.1 on for which one unit was transfussed during dialysis prior to discharge. . prophylaxis: the patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. . at the time of discharge, the patient was doing well, afebrile with stable vital signs. the patient was tolerating his renal diet, ambulating, voiding without assistance, and was not experiencing any significant pain. he was discharged to an extended care facility with inhouse hd capabilities for rehabilitation. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: asa 81 mg daily lisinopril 5mg daily metformin 1000 mg creon protonix 40 mg daily simvastatin 40 mg daily amlodipine 10 mg daily coumadin 2mg daily lopressor 100 mg bumetanidine 2 mg daily discharge medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for eye irritation. 2. amlodipine 10 mg tablet sig: one (1) tablet po once a day. 3. amylase-lipase-protease 60,000-12,000- 38,000 unit capsule, delayed release(e.c.) sig: two (2) cap po tid w/meals (3 times a day with meals). 4. metoprolol tartrate 50 mg tablet sig: 2.5 tablets po bid (2 times a day). 5. bumetanide 2 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. acyclovir 5 % ointment sig: one (1) appl topical asdir (as directed). 8. lantus 100 unit/ml solution sig: twenty (20) units subcutaneous at bedtime. 9. insulin lispro 100 unit/ml solution sig: 2-16 units subcutaneous as directed per humalog insulin sliding scale. 10. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 11. coumadin 2 mg tablet sig: one (1) tablet po qevening. discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary: 1. cholangitis 2. septic shock secondary to strep bovis and clostridium clostridiiforme bacteremia 3. demand ischemia - resolved 4. anisocoria with elevated intra-cranial pressure - resolved 5. acute renal failure in the context of mild chronic renal insufficiency and septic shock. expect resolution with temporary hemodialysis. . secondary: 1. type ii dm 2. atrial fibrillation 3. cad discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: 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 lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. avoid driving or operating heavy machinery while taking pain medications. please follow-up with your surgeon and primary care provider (pcp) as advised. ptbd care: *please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *the drain is capped. call the doctor, nurse practitioner or nurse if you expereince fever, abdominal pain, nausea, vomiting. *wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide with a sailine rinse, pat dry, and place a drain sponge. *keep the insertion site clean and dry otherwise. *avoid swimming, baths, hot tubs; do not submerge yourself in water. *make sure to keep the drain attached securely to your body to prevent pulling or dislocation. monitor the hemodialysis catheter site for redness, swelling, increased pain, or drainage from the insertion site. follow care instructions as advised by your dialysis nurse. followup instructions: please call ( to arrange a follow-up appointment with dr. (pcp) in weeks. . please call ( to schedule a follow-up appointment with dr. (surgery) in 3 weeks. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Arterial catheterization Other cholangiogram Percutaneous hepatic cholangiogram Intracranial pressure monitoring Magnetic removal of embedded foreign body from cornea Diagnoses: Acute kidney failure with lesion of tubular necrosis Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Severe sepsis Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Hypopotassemia Other and unspecified hyperlipidemia Acute respiratory failure Alkalosis Septic shock Long-term (current) use of anticoagulants Streptococcal septicemia Cholangitis Obstruction of bile duct Personal history of malignant neoplasm of other gastrointestinal tract Anisocoria Chronic kidney disease, Stage II (mild)

history of present illness: the patient is a 37 year old gravida 3, para 2-0-1-3, status post vaginal delivery of a 9 pound male infant on at . she suffered a severe laceration up to her posterior fornix and was noted to have continuous bleeding during the repair so she was packed and observed and her hematocrit subsequently went from 36 to 17 and she had a fibrinogen of 61, inr 1.5, ptt 40.6. she was transfused one unit of packed red blood cells and was hemodynamically stable but the pack fell out and on speculum examination, an arterial bleed was noted. she was repacked and transferred to for further care. here, her hematocrit was 26 so the decision was made to do supportive care and only take her to the operating room for worsening bleeding. she was hemodynamically unstable with edema unchanged, complaining of dizziness and shortness of breath. she denied chest pain, abdominal pain, nausea or vomiting. in the emergency room, she got normal saline and was started on one unit of packed red blood cells and was given tylenol for a temperature of 100.0 f. she was then transferred to the intensive care unit where she was observed and given a total of 6 units of packed red blood cells and 6 units of fresh frozen plasma. she was also given vitamin k to help her inr. her hematocrit was followed q. six hours and prior to discharge her hematocrit was 33. on , the patient was taken to the operating room for an examination under anesthesia and removal of the vaginal pack, at which time one small area of bleeding was noted at the episiotomy site and one stitch was placed at that point and excellent hemostasis was noted. the patient was sent to the postpartum floor for recovery. postoperative day one, the patient was doing very well, ambulating and tolerating p.o. her foley catheter was removed and she was voiding spontaneously. on the following day, she continued to do better with increasing ambulation and her infant was discharged from to her hospital room and the baby was rooming-in. the patient resumed breast feeding. she was discharged on , ambulating, tolerating p.o. with very minimal vaginal bleeding which would be expected for someone who has recently had a vaginal delivery. physical examination: on admission, generally sleepy but arousable. pale. vital signs with temperature 99.0 f.; heart rate 100; blood pressure 113/68; o2 saturation 100% on two liters. heent: pupils equally round and reactive to light. extraocular muscles are intact. pulmonary: clear to auscultation bilaterally. cardiac: tachycardic without murmurs. abdomen soft, nontender, with good bowel sounds. extremities with no cyanosis; one plus pitting edema bilateral lower extremities. neurologically, alert and oriented times three. five out of five strength bilaterally. laboratory: on admission, white blood cell count 19.1, hemoglobin 9.1, hematocrit 26.4, platelets 175, inr 1.7, fibrinogen 91. sodium 136, potassium 3.7, chloride 106, bicarbonate 21, bun 8, creatinine 0.4, glucose 99. calcium 7.9, magnesium 1.2, phosphorus 3.7, amylase 243, ast 27, alt 9, alkaline phosphatase 84. past medical history: 1. hyperthyroidism. 2. status post cyst removal in , ovarian. 3. migraine headaches. medications: multivitamin. allergies: to sulfa which causes a rash. social history: denies tobacco, alcohol or drug use. she lives with her husband. a five year old daughter. baby is named . discharge instructions: 1. she was given pelvic rest precautions. 2. she was told to follow-up with her primary ob/gyn for her postpartum check. discharge medications: 1. prescription for a breast pump. , m.d. dictated by: medquist36 Procedure: Removal of vaginal or vulvar packing Diagnoses: Postpartum coagulation defects, delivered, with mention of postpartum complication Other immediate postpartum hemorrhage, delivered, with mention of postpartum complication Anemia of mother, delivered, with mention of postpartum complication

history of present illness: mr. is a 57-year-old male who had an abnormal ekg which ultimately lead to work up including cardiac catheterization, transthoracic echocardiogram and a ct scan ultimately showing a bicuspid aortic valve with aortic regurgitation and an ascending thoracic aneurysm with secondary left ventricular hypertrophy. th has never had any chest pain, shortness of breath or dyspnea. no history of congestive heart failure or palpitations. no lower extremity edema. no prior history of mi or cva. no diabetes in the past. cardiac catheterization data was unavailable at initial presentation as a resultant fax to dr. office. past medical history: 1. he has no prior surgical history. 2. he had a heart cath 18 years ago for a "congenital disease" which is not otherwise specified. 3. benign heart murmur for which he gets prophylaxis with antibiotics over his lifetime. 4. no history of major depression and anxiety. 5. no hypertension. 6. he is on accupril for his aortic insufficiency. 7. no history of coronary artery disease. he has clean coronaries by recent preoperative cardiac catheterization. 8. no history of gastroesophageal reflux disease. 9. no history of dyslipidemia or diabetes. outpatient medications: 1. paxil 20 mg p.o. q. day. 2. accupril 10 mg p.o. q. day. 3. multivitamin occasionally. 4. he is not taking any aspirin. his cardiologist is dr. at the in , . dr. is his pcp in the region. allergies: he has no known drug allergies except for just some seasonal allergies. last dental exam was done on which showed no evidence of caries or risk. no need for tooth extraction. family history: he has a son who has a prior history of repair with aortic aneurysm resection. his son has a history of congenital bicuspid aortic valve which related in aortic stenosis which required his procedure. social history: patient's occupation is a probation officer. he lives with his wife. has three grown children. uses minimal alcohol. only tobacco history was that of cigars. physical examination: in general well appearing, active, well-nourished, well-developed, age appropriate male. no rashes were present on the skin. head, eyes, ears, nose and throat: pupils are equal, round and reactive to light and accommodation. extraocular muscles intact. no jugular venous distention, no bruit. no cervical lymphadenopathy. his precordium was quiet. lungs were clear. abdomen was soft. extremities were unremarkable. neurological is nonfocal. ese findings, he was sent for evaluation by dr. who deemed the patient an appropriate candidate for aortic valve replacement as well as resection of the ascending aortic aneurysm and the non-coronary sinuses. on , the patient was admitted to the hospital and went to the operating room where he underwent an aortic valve repair with a 27 mm - pericardial tissue valve. also had resection of an ascending aortic aneurysm and of the non-coronary sinus. a 26 mm tube graft was accordingly placed. dr. was then attending surgeon with dr. being the assistant. the patient pericardium was left open with a right radial a line and right ij swan-ganz catheter, two ventricular and two atrial pacing wires. there was mediastinal and right pleural tubes that had been placed. he was in sinus rhythm. he came off the pump without any difficulty. postoperatively he was rapidly extubated. he did well from a hemodynamic standpoint. he had excellent blood pressure control. strips were weaned the following day and started on an oral regimen of lopressor. he was diuresed accordingly. he otherwise is out of bed ambulating. he was transferred to the floor. his wires were removed. his foley catheter had been discontinued. he is tolerating a diet ultimately by postoperative day #3. the patient passed a level 5 ambulatory status after having completed stairs without any assistance. the patient was eager to actually go home. given the fact that he had done markedly well postoperative, his wounds looked excellent, lungs were clear, lower extremities were not edematous and the fact that he asked for analgesia and was ambulating up stairs without difficulty, it was thought that the patient was appropriate for discharge to home without service. medication on discharge: 1. paroxetine 20 mg p.o. q. day. 2. percocet one to two tabs p.o. q. four to six p.r.n. 3. ibuprofen p.r.n. 4. tylenol as needed. 5. aspirin 325 mg p.o. q. day. 6. lasix 20 mg p.o. b.i.d. times seven days. 7. k-dur 20 meq p.o. b.i.d. to be taken for the seven days that he is on lasix. 8. lopressor 12.5 mg p.o. b.i.d. 9. accupril will be held until he is seen by dr. at follow up in the . 10. continue his multivitamins. discharge disposition: will be sent home without services. he did well postoperatively and had no other issues to speak of. , m.d. dictated by: medquist36 d: 10:29 t: 11:39 job#: Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Open and other replacement of aortic valve with tissue graft Resection of vessel with replacement, thoracic vessels Diagnoses: Anxiety state, unspecified Congenital insufficiency of aortic valve Thoracoabdominal aneurysm, without mention of rupture Cardiomegaly Personal history of affective disorders

history of present illness: the patient is a 77-year-old gentleman with an extensive history of coronary artery disease (status post multiple myocardial infarctions) who was transferred from an outside hospital for cardiac catheterization. the following history is per the patient's daughter; as the patient only speaks portuguese. she reports that the patient had increasing shortness of breath with exertion over the week prior to admission. at 1 o'clock a.m. on the morning of admission, the patient awoke from sleep with acute shortness of breath. he decided to present to an outside hospital. at approximately 7 o'clock a.m., while driving to the hospital, the patient developed chest pain. at the outside hospital, the patient was pain free after receiving oxygen. he was found to have a troponin of 76.3, a creatine kinase of 501, and a ck/mb of 20.8. the patient was given a heparin bolus, and the decision was made to transfer the patient to for cardiac catheterization. at that time, the heparin was discontinued and the patient was started on integrilin. other laboratories from the outside hospital included a potassium of 3.9, creatinine of 1.4, and a hematocrit of 39. his arterial blood gas at the outside hospital was 7.46/38/69 on 3 liters nasal cannula. electrocardiogram revealed sinus tachycardia at approximately 110 beats per minute. axis was approximately was 30 degrees. the patient had poor r wave progression. there were a few changes from previous studies. past medical history: 1. hypertension. 2. type 2 diabetes mellitus. 3. hypercholesterolemia. 4. status post myocardial infarction times two; (a) in , the patient had a posterior/inferior myocardial infarction with a cardiac catheterization showing 70% left anterior descending artery, 98% left circumflex, and diffuse right coronary artery disease. the patient had stenting of the left circumflex and the right coronary artery. (b) in , the patient had an inferoseptal myocardial infarction with cardiac catheterization showing 70% stenosis in the middle of the left anterior descending artery, 40% stenosis in the second diagonal, and 70% in-stent restenosis in the left circumflex which was intervened on. (c) a redo catheterization in showed diffuse proximal and mid disease in the left anterior descending artery which was stented. (d) the patient subsequently underwent redo catheterization in when he was found to have left anterior descending artery 50% narrowing prior to the stent, the left circumflex stent was widely patent, and the right coronary artery stent was widely patent. 5. peripheral vascular disease. allergies: no known drug allergies. medications on admission: 1. lopressor 50 mg by mouth twice per day. 2. pepcid 40 mg by mouth once per day. 3. neurontin 100 mg by mouth three times per day. 4. lasix 40 mg by mouth once per day. 5. lipitor 10 mg by mouth once per day. 6. moexipril 15 mg by mouth once per day 7. xanax 0.5 mg by mouth twice per day. 8. glyburide 5 mg by mouth twice per day. social history: the patient is a pleasant portuguese-speaking gentleman who is married and lives with his wife. is a retired box maker. the patient has an extensive tobacco history of one pack per day for approximately 60 years. he quit smoking in . no history of alcohol or drug abuse. physical examination on presentation: physical examination on admission revealed his temperature was 99 degrees fahrenheit, his blood pressure was 103/59, his heart rate was 78, his respiratory rate was 22, and his oxygen saturation was 96% on 4 liters nasal cannula. in general, the patient was a mildly obese male in no acute distress with labored breathing. head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. extraocular movements were intact. the mucous membranes were moist. neck examination revealed increased jugular venous pulsation at approximately 12 mm to 14 cm at 30 degrees. positive right carotid bruit. cardiovascular examination revealed normal first heart sounds and second heart sounds. a regular rate. there was a crescendo-decrescendo murmur with radiation to the axilla. the lungs were clear to auscultation anteriorly. there were bibasilar crackles. no wheezes. the abdomen was soft, nontender, and nondistended. positive bowel sounds. no hepatosplenomegaly. extremity examination revealed 1 to 2+ pitting edema to the patellas bilaterally. dorsalis pedis pulses were 2+ bilaterally. pertinent laboratory values on presentation: laboratories on admission revealed his white blood cell count was 10.9, his hematocrit was 35.6, and his platelets were 197. his prothrombin time was 13.4, his partial thromboplastin time was 39.3, and his inr was 1.2. his sodium was 137, potassium was 4.3, chloride was 101, bicarbonate was 27, blood urea nitrogen was 22, creatinine was 1.4, and his blood glucose was 285. his calcium was 9, his magnesium was 1.5, and his phosphorous was 3.4. creatine kinase was 370. ck/mb was 14. troponin was 3.72. concise summary of hospital course by issue/system: 1. cardiovascular issues: cardiac catheterization revealed two patent left anterior descending artery overlapping stents. the left circumflex was patent with very distal upper branch disease and a large first obtuse marginal. the right coronary artery and the av groove was patent including proximal stents. there was an eccentric 40% mid right coronary artery lesions. the left anterior descending artery was stented with a 3.25 x 18 cypher, and the right coronary artery was stented with a 3 x 13-mm hepacoat stent. the patient received 20 mg of intravenous lasix in the catheterization laboratory with approximately 700 cc of urine output. following the catheterization, the patient completed an 18-hour course of integrilin. throughout the admission, he was also continued on an aspirin, plavix, an ace inhibitor, a beta blocker, and a statin. (a) rhythm: the patient was in a sinus rhythm throughout the admission. he was monitored continuously on telemetry. (b) myocardium: the patient had a congestive heart failure exacerbation on admission to the hospital with increasing shortness of breath, lower extremity edema, and exercise intolerance over the week prior to admission. he had a good diuresis in the catheterization laboratory following 40 cc of intravenous lasix. the patient continued to have a good diuresis over the first one day of admission. his shortness of breath resolved, and he felt much better. the patient had previously had a poor left ventricular ejection fraction of 20% to 30% on previous echocardiograms. therefore, a repeat echocardiogram was performed on . this revealed a mildly dilated left atrium. the right atrium was normal in size. the left ventricular cavity was severely dilated. there were multiple left ventricular wall motion abnormalities including; mid anterior/akinetic, mid anterior septal/akinetic, mid inferoseptal/akinetic, mid inferior/akinetic, mid inferolateral/akinetic, anterior apex/akinetic, septal apex/akinetic, inferior apex/akinetic, lateral apex/akinetic, and apex/dyskinetic. the right ventricular chamber size and free wall motion were normal. the aortic root was mildly dilated as was the ascending aorta. there was no aortic valve stenosis. there was trace aortic regurgitation. mild-to-moderate 1 to 2+ mitral regurgitation was seen. there was borderline pulmonary artery systolic hypertension. the estimated left ventricular ejection fraction was less than 20%. given the patient's history of multiple myocardial infarctions and very decreased left ventricular ejection fraction, pacemaker placement was discussed. it was determined that this would not be done as an inpatient, but the patient was to follow up with electrophysiology. 2. type 2 diabetes mellitus issues: the patient was continued on an insulin sliding-scale throughout his admission with good blood sugar control. 3. renal issues: the patient's creatinine was slightly elevated at 1.4 prior to catheterization. following catheterization, he received intravenous hydration and mucomyst times two. subsequently, his creatinine decreased and was 1.3 at the time of discharge. 4. hypercholesterolemia issues: the patient was continued on a statin throughout his admission. 5. hypertension issues: the patient was continued on his ace inhibitor and beta blocker. he had good blood pressure control throughout the admission. 6. pulmonary issues: following diuresis on admission, the patient's shortness of breath greatly improved. on the day of discharge, he was saturating in the mid 90% range on room air. in addition, he was able to walk around the unit without becoming short of breath. condition at discharge: condition on discharge was stable. discharge status: the patient was discharged to home. discharge diagnoses: 1. type 2 diabetes mellitus. 2. hypercholesterolemia. 3. hypertension. 4. peptic ulcer disease. medications on discharge: 1. aspirin 325 mg by mouth once per day. 2. plavix 75 mg by mouth once per day. 3. famotidine 40 mg by mouth once per day. 4. gabapentin 100 mg by mouth three times per day. 5. atorvastatin 10 mg by mouth once per day. 6. alprazolam 0.5 mg by mouth twice per day. 7. moexipril 15 mg by mouth once per day 8. toprol-xl 50 mg by mouth once per day. 9. glyburide 5 mg by mouth twice per day. 10. lasix 40 mg by mouth once per day. 11. nitroglycerin 0.3 mg sublingually one tablet as needed (for chest pain). discharge instructions/followup: 1. the patient was instructed to follow up with primary care physician (dr. who also manages the patient's cardiac issues in approximately one week. 2. the patient was instructed to follow up dr. on at 1 o'clock p.m. , m.d. dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Insertion of drug-eluting coronary artery stent(s) Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Systolic heart failure, unspecified Chronic obstructive asthma, unspecified

discharge status: the patient is discharged to cardiac rehabilitation program. the patient is walking without assistance, not on oxygen and pain free. discharge disposition: full code. admission medications: 1. moexipril 15 mg p.o. q. day. 2. metoprolol xl 50 mg p.o. q. day. 3. glyburide 5 mg p.o. twice a day. 4. lasix 40 mg p.o. q. day. 5. insulin 75/25, 80 units subcutaneously q. a.m. and 66 units subcutaneously q. p.m. 6. aspirin 325 mg p.o. q. day. 7. plavix 75 mg p.o. q. day. 8. pepcid 40 mg p.o. q. day. 9. neurontin 100 mg p.o. three times a day. 10. lipitor 10 mg p.o. q. day. 11. alprazolam 0.5 mg p.o. twice a day p.r.n. 12. sublingual nitroglycerin 0.3 mg p.o. p.r.n. discharge medications: 1. enteric coated aspirin 325 mg p.o. q. day. 2. plavix 75 mg p.o. q. day. 3. pepcid 40 mg p.o. q. day. 4. lipitor 10 mg p.o. q. day. 5. fenestra 5 mg p.o. q. day. 6. regular insulin sliding scale. 7. glyburide 5 mg p.o. twice a day. 8. nitroglycerin sublingual 0.3 mg p.r.n. chest pain. discharge instructions: 1. the patient is to follow-up with his cardiologist, dr. , in two to four days. 2. he is also to follow-up with dr. from urology and call for an appointment. 3. he is also to follow-up with dr. , his primary care physician in two weeks. , m.d. Procedure: Venous catheterization, not elsewhere classified Non-invasive mechanical ventilation Pulmonary artery wedge monitoring Other genitourinary instillation Insertion of indwelling urinary catheter Other transurethral excision or destruction of lesion or tissue of bladder Transurethral clearance of bladder Injection or infusion of nesiritide Diagnoses: Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Other pulmonary insufficiency, not elsewhere classified Unspecified septicemia Septic shock Injury to bladder and urethra, without mention of open wound into cavity Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Other specified types of cystitis

history of present illness: the patient is a 77 year old, portugeuse speaking male, who presented to the emergency department as a transfer from an outside hospital, complaining of left sided chest pain, non radiating, associated with dyspnea. the patient reports similar symptoms approximately one week prior to this presentation. at that time, the patient ruled in for a myocardial infarction with positive enzymes, peak ck of 501. he underwent coronary catheterization and stent placement to the left anterior descending and right posterior descending artery coronary arteries. his post hospital course was complicated by congestive heart failure exacerbation. with this current episode, the chest pain and shortness of breath resolved after administration of oxygen, 325 mg of aspirin and sublingual nitroglycerin times two. most improvement was noted with oxygen therapy via non rebreather mask. the patient was then able to be weaned to nasal cannula oxygen. chest x-ray and clinical examination at an outside hospital were consistent with congestive heart failure. there, the patient received lasix 40 mg intravenous and morphine sulfate. he was started on heparin and nitroglycerin drip at hospital and transferred to for further evaluation. on further questioning, the patient reports waking up at approximately 3:30 a.m. on the day of admission, complaining of shortness of breath. he has had shortness of breath with some dyspnea at rest since his discharge from the hospital last week. however, overall, he has been less dyspneic than prior to his last admission. he also reports vague left sided chest pressure, unable to rate, no radiation to neck, jaw or shoulders. no associated nausea, vomiting, diaphoresis. he has stable two pillow orthopnea at baseline. no paroxysmal nocturnal dyspnea, ascites, lower extremity swelling or edema. he does report non compliance with a sodium restriction diet since discharge. past medical history: ischemic cardiomyopathy with an ejection fraction less than 20% on echocardiogram 9/. coronary artery disease, status post myocardial infarction times three. myocardial infarction in 4/97, , . status post multiple percutaneous transluminal coronary angioplasty with stent to left anterior descending, left circumflex, right coronary artery. status post stents one week prior to this most current admission to left anterior descending and right posterior descending artery. congestive heart failure. hypertension. gastroesophageal reflux disease. peripheral vascular disease. insulin dependent diabetes mellitus with neuropathy. hypercholesterolemia. anxiety. allergies: no known drug allergies. medications on admission: moexipril 15 mg p.o. q. day. ....................50 mg p.o. q. day. glyburide 5 mg p.o. twice a day. lasix 40 mg p.o. q. day. insulin 75/25, 80 units q. a.m., 66 units q. p.m. aspirin 325 mg p.o. q. day. plavix 75 mg p.o. q. day. famotidine 40 mg p.o. q. day. neurontin 100 mg p.o. three times a day. lipitor 10 mg p.o. q. day. alprazolam 0.5 mg p.o. twice a day prn anxiety. sublingual nitroglycerin prn chest pain. social history: the patient is married, portugeuse speaking, retired box-maker. reports one pack per day tobacco history times six years, having quit in . denies any alcohol or intravenous drug use. physical examination: upon admission, vital signs showed temperature of 98.4; heart rate 93 and regular; blood pressure 137/97; respiratory rate of 64; oxygen 96% on two liters nasal cannula oxygen. general appearance: well developed, obese, white male, comfortable, slightly labored breathing, no acute distress. head, eyes, ears, nose and throat: normal cephalic, atraumatic. pupils are equal, round, and reactive to light and accommodation. extraocular movements intact. sclera anicteric. conjunctiva non injected. oral mucosa moist. oropharynx clear. neck: supple. no masses or lymphadenopathy. positive right carotid bruit. unable to assess jugulovenous pressure. chest: bilateral crackles, one third the way up both lung fields, coarse in nature. cardiovascular: regular rate and rhythm. s1 and s2 heart sounds, auscultated. positive two to three out of six crescendo/decrescendo holosystolic murmur heard best at the apex with radiation to the axilla. abdomen: soft, obese, nontender, nondistended, positive bowel sounds. no hepatosplenomegaly. genitourinary: foley catheter in place, draining bright pink to red tinged urine. extremities: no clubbing, cyanosis or edema. 1+ dorsalis pedis/posterior tibial pulses bilaterally. laboratory data: cbc showed white blood cell count of 9.7; hemoglobin of 11.2; hematocrit of 36.3; platelets 287. coagulation profile showed pt of 13.2, ptt of 29, inr of 1.2. serum chemistry showed sodium of 141; potassium of 4.1; chloride of 105; bicarbonate 26; bun 30; creatinine 1.6 (baseline of 1.3 to 1.4.) cardiac enzymes showed ck of 119, ck mb of 2.1; mb index of 1.8; troponin i at outside hospital 17.10. electrocardiogram from outside hospital showed sinus tachycardia at 104 beats per minute; left axis deviation; left atrial enlargement; q waves noted in v1 and v2, with widened qrs; t wave inversions noted in leads 1 and avl. electrocardiogram at , while the patient was pain free, was consistent with the electrocardiogram at . also demonstrated flattening of the t waves in v5 through v6. coronary catheterization on showed an 80% right posterior descending artery and hazy 70% proximal left anterior descending lesion. the right posterior descending artery was injected with a balloon and had a stent placed. no residual of timi-iii flow. the left anterior descending was predilated with a balloon; stented with a cyper stent with an overlap of the distal portion of the previous stent; no residual timi-iii flow. resting hemodynamics showed elevated right and left filling pressures. pulmonary capillary wedge pressure was 28; left ventricular end diastolic pressure of 33. echocardiogram from showed ejection fraction of less than 20%; dilated; left ventricle severely dilated with severe left ventricular function; resting regional wall motion abnormalities, including mid to distal inferior, inferolateral, septal, anterior akinesis with apical akinesis/dyskinesis. one to two plus mitral regurgitation was noted. borderline pulmonary artery systolic hypertension. chest x-ray from showed pulmonary edema, consistent with congestive heart failure. hospital course: problem #1: coronary artery disease: the patient had a known history of coronary artery disease, status post a myocardial infarction one week prior to his admission. it was felt that his elevated troponin value on this most recent admission, on , was likely residual from his myocardial infarction the prior week. however, in order to completely rule out for myocardial infarction, his cardiac enzymes were cycled. he had a flat cardiac enzyme times three sets. initially, he was continued on aspirin, plavix, lipitor, oxygen, metoprolol. ace inhibitor was held in light of his worsening renal function and hematuria. initially, the plan was to titrate up the patient's metoprolol xl to a higher dose for greater beta blockade. however, he was unable to titrate up the dose, secondary to hypotension. on the evening of , the patient had an episode of decreased oxygen saturation and hypotension. as a result of this, he was transferred to the medical intensive care unit. electrocardiogram at the time of his sustained hypotension was suggestive of a demand ischemia with anterolateral st depressions. he transiently required pressor therapy for blood pressure support. throughout his medical intensive care unit stay, his beta blocker and ace inhibitor were held. cardiac enzymes from the time of this event were relatively flat with a slight troponin leak but not significant enough to have the patient rule in for myocardial infarction. again, it was felt that his troponin leak and electrocardiogram changes were secondary to demand ischemia. the patient was transferred out of the intensive care unit on . once he was on the floor, beta blocker and ace inhibitor therapy continued to be held in light of his relative hemodynamic instability and relative hypotension. on , the patient was cleared for cystoscopy by c-med cardiology fellow. perioperative prescriptions included the continuation of plavix and aspirin through the perioperative period. specifically, aspirin and plavix should not be stopped as the patient had recent stent placement. the recommendation was also made to hold the ace inhibitor, lasix and beta blocker therapy to the perioperative course and to restart ace inhibitor and beta blockade after surgery as the patient's blood pressure tolerated, with systolic blood pressure 110 to 120. the patient was then transferred to the and the medicine service pending cystoscopy. his further coronary and cardiac issues status post will be dictated as a separate addendum to this report. problem #2, congestive heart failure: the patient had an echocardiogram on with last ejection fraction less than 20%. on admission, he had evidence of congestive heart failure exacerbation clinically and based on his chest x-ray. he was diuresed with lasix intravenous prn. input and output, daily weight and fluid restriction were followed. he also continued a restricted sodium diet. initially, his ace inhibitor, moexipril was held in light of his elevated creatinine. however, it was restarted on hospital day number three. as described above, the patient had an acute hypoxic episode with sustained hypotension and, pending this, he was transferred to the medical intensive care unit for further evaluation. there for blood pressure he required dopamine pressor support; beta blocker and ace inhibitor therapy were held. in order to resuscitate the patient during his hypotensive episode, he received over one and a half liters of intravenous fluid. this resulted in a second congestive heart failure exacerbation. he was diuresed in the medical intensive care unit. he came up to the regular medicine floor with his heart failure relatively well compensated. he continued to be on aspirin, ace inhibitor and undergo gentle diuresis with intravenous lasix. on , the patient had an episode of hypotension. he responded to a fluid bolus. in light of his hemodynamic instability, lasix, beta blocker, ace inhibitor therapy were held. problem #3, hematuria: the patient underwent dramatic foley catheter insertion at an outside hospital. upon presentation, he was noted to have gross hematuria. urology consultation was obtained. they recommended initiating continuous bladder irrigation as well as renal ultrasound. renal ultrasound was within normal limits. the patient could not be taken off his aspirin and plavix anti platelet therapy in light of his recent coronary stent, approximately one week prior to admission. throughout his hospital course, he was continued on continuous bladder irrigation with frequent urology follow-up. his urine remained pink-tinged for the first ten days of his hospital course. his urine began to clear somewhat and the patient underwent a trial of time off continuous bladder irrigation and removal of his foley catheter. however, this was complicated by an inability of the patient to void. this then required further urology follow-up and replacement of foley catheter. status post replacement of his foley catheter, the patient drained several 100 cc of dark, red, blood tinged urine with several large clots. he was, therefore, continued again on continuous bladder irrigation. he continued to have persistent hematuria. his hematocrit values were monitored with serial blood draws. he required several blood transfusions to keep his hematocrit greater than 30. ct scan of the abdomen and pelvis was obtained to rule out any upper urinary tract abnormality and it was negative. -max 5 mg p.o. q. day was added to his medication regimen. on , the patient underwent cystoscopy by the urology service. results of cystoscopy and the patient's postoperative course will be dictated as a separate addendum to this report. problem #4, acute on chronic renal failure: the patient had a history of baseline chronic renal insufficiency with a baseline creatinine of 1.3 to 1.4. upon admission, however, his creatinine value was elevated to 1.6. it was felt that this is likely secondary to poor forward flow, due to his congestive heart failure state. initially, ace inhibitor therapy was held. his creatinine value decreased somewhat as he was diuresed and his congestive heart failure was better compensated. status post his episode of hypotension requiring medical intensive care unit admission, the patient had a second bump of his creatinine, also postulated to be secondary to poor forward flow/hypo perfusion. as his cardiac issues were further managed, his creatinine value returned closer to his baseline. problem #5: septic shock: as detailed above, on the evening of , the patient had an episode of hypoxia with oxygen saturation values in the low 80's, accompanied by decreased systolic blood pressure to 60's over 30's. he failed to respond to 1,700 cc of fluid bolus. he was symptomatic with this blood pressure, complaining of dizziness and light headedness. he was evaluated by the medical intensive care unit team and was transferred to the intensive care unit for further therapy. their swan-ganz catheter placement showed elevated filling pressures but also demonstrated a peripheral vascular resistance of 533, consistent with distributive shock. at this time, the patient was also noted to be febrile with a white count as well as a lactate level. it was felt that he was in septic shock with suspected genitourinary source, given his history of multiple instrumentation the last couple of weeks with admission. he started on levophed for blood pressure support. he was pan cultured. data from urine culture was not available as it was misprocessed by the laboratory. blood cultures failed to grow out any organism. he was covered empirically with zosyn. anti hypertensive therapies were held in light of his hemodynamic insufficiency. cortisol level was checked and it was low, indicative of a slightly adrenal suppressed state. status post pressor support and fluid resuscitation, along with antibiotic therapy, the patient's blood pressure improved. he was transferred out to the floor on . there, however, he remained relatively hypotensive for him; therefore, his antihypertensive drugs were not restarted. problem #6, diabetes mellitus: throughout admission, the patient maintained labile blood glucose levels. initially, his insulin regimen was cut in half, compared to his home dose regimen, as he had several evenings of being n.p.o. in prep for possible procedures. however, even with this lower dose regimen, he had episodes of hypoglycemia requiring dextrose and juice administration. he was continued on a consistent carbohydrate diet with four times a day finger stick blood glucose testing, as well as regular insulin sliding scale. his oral hypoglycemic glyburide 5 mg p.o. twice a day was continued. multiple changes in his insulin regimen were undertaken during this admission. please refer to the following addendum to this report for the patient's current insulin dosage at the time of discharge. problem #7, code status: full. please note that the remainder of the hospital course as well as his discharge instructions, and the diagnoses will be dictated as a separate addendum to this report. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Non-invasive mechanical ventilation Pulmonary artery wedge monitoring Other genitourinary instillation Insertion of indwelling urinary catheter Other transurethral excision or destruction of lesion or tissue of bladder Transurethral clearance of bladder Injection or infusion of nesiritide Diagnoses: Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Other pulmonary insufficiency, not elsewhere classified Unspecified septicemia Septic shock Injury to bladder and urethra, without mention of open wound into cavity Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Other specified types of cystitis

history of present illness: the patient is an 87-year-old female who was a pedestrian struck by a car at approximately 40 miles per hour. she had a loss of consciousness documented approximately 20 minutes. she was intubated at the scene and was transferred to emergency department via life flight. she was hypotensive during transport and was given intravenous fluids. past medical history: unknown at the time of presentation. per family, hypertension. past surgical history: rhinoplasty times two. medications on admission: the patient takes a hypertensive medication, the name of which is unknown. allergies: the patient has no known drug allergies. physical examination on presentation: the patient arrived intubated with sedation and perlitic medications on board. vital signs revealed her temperature was 97, her blood pressure was 120/69, her heart rate was 50, her respiratory rate was 18, intubated with 100% saturation. her head, eyes, ears, nose, and throat examination showed periorbital swelling of the left eye with a sluggish pupillary reaction to light, from 4 mm to 3 mm. the right eye was reactive to light from 3 mm to 2 mm. the patient had an obvious laceration across her left eyelid which superficial in nature. she had a large central forehead laceration with tissue deficit and rectalis muscle exposure. there were no obvious stepoffs of her facial bone. her tympanic membranes were clear bilaterally. the tongue was midline. airway was confirmed with visualization of the tube through the cords. she had a regular rate and rhythm. there were no murmurs. she had clear breath sounds to auscultation bilaterally. there were no obvious deformities of her chest. the abdomen was soft, nontender, and nondistended. there were positive bowel sounds. however, there were multiple superficial abrasions across her belly; consistent with "road rash." her pelvis appeared stable to palpation. the cervical and thoracolumbosacral spine had no obvious deformities or stepoff. she was guaiac-negative with good rectal tone. there were obvious deformities of the bilateral lower extremities with ecchymoses and swelling of both knees. she had 2+ radial pulses bilaterally, and 2+ femoral pulses bilaterally, and she had 2+ dorsalis pedis pulses bilaterally. pertinent laboratory values on presentation: white blood cell count was 14, her hematocrit was 22, and her platelets were 181. chemistry-7 was unremarkable. the patient had an inr of 1.2. pertinent radiology/imaging: a computed tomography on admission showed no intracranial hemorrhage. a computed tomography of the cervical spine showed degenerative changes; no acute changes. a chest computed tomography was negative. an abdominal and pelvic computed tomography showed superior and inferior rami fracture with right pelvic hematoma and a right sacral ala fracture. thoracolumbosacral films showed a l1 compression fracture. bilateral femur films showed a right tibia/fibula fracture, a right pubic fracture, and a left tibial plateau fracture. summary of hospital course: the patient was transferred to the surgical intensive care unit in an intubated condition. she required neurologic checks and serial hematocrit checks. on hospital day two, it was noted that her hematocrit had reached a level of 26.5, and she received 2 units of packed red blood cells. she was re-scanned to determine where the bleeding was coming from, and it was found that she had bilateral intraventricular hemorrhages and a parietal subarachnoid hematoma. it was also noted that the pelvic hematoma, though initially small, was expanding in size. angiography of the pelvic arteries was performed, and one small arterial branch was embolized with gelfoam. neurosurgery was monitoring for evaluation of her intracranial head bleeds. tight blood pressure control, as well as glycemic control, and inr parameters were maintained while the patient was in the intensive care unit. a follow-up head computed tomography showed no increase in the bleeding. the patient was awakened each day from sedation and was found to be moving all extremities. neurosurgery also assisted the clearance of her cervical spine, and a magnetic resonance imaging of the entire spine was obtained. her cervical spine was subsequently cleared. as the patient was going to the operating room for orthopaedic repair, bolt was placed for intracranial pressure monitoring on hospital day three and was taken out on hospital day six. the intracranial pressure was noted to be within normal limits. no operative intervention was found to be needed for the patient's intracranial hemorrhage. orthopaedics was consulted for the patient's multiple pelvic and lower extremity fractures. they recommended open reduction and internal fixation of these fractures. this occurred on hospital day four, as the patient's hemodynamic status needed to be stabilized. in addition, her neurosurgical issues took precedence at that time. on , on hospital day four, the patient went to the operating room for open reduction/internal fixation of bilateral tibial plateau fractures as well as open reduction/internal fixation of the left intercondylar lateral femur fracture. please see the operative report for full details. the operation occurred without any complications, and intracranial pressure was monitored with bolt as mentioned previously. as the patient was unable to be anticoagulated given her pelvic and intracranial bleeding, and inferior vena cava filter was placed on hospital day three. a week out from her injuries, and when it was determined her intracranial hemorrhage was stable, the patient was able to be started on lovenox for anticoagulation, and the inferior vena cava filter was discontinued on (on hospital day 13). per orthopaedics, the patient is in braces to both extremities on a continuous passive motion machine bilaterally. she was to be nonweightbearing for an extended period of time, which will be determined specifically at her outpatient appointment with her orthopaedic doctor (dr. ) in two weeks after discharge. there was no operative repair of her pelvic fractures. plastic surgery was consulted for repair of her deep facial lacerations which included a central forehead laceration with tissue deficit and exposure of the rectalis muscle. the repair of this occurred in the operating room at the same time that the orthopaedic procedure was taking place with galea undermining and suturing of the laceration. she also had sutures placed at the bedside over her left eyelid with good approximation and repair. an ophthalmology consultation was obtained given the left periorbital swelling and asymmetry of the left pupil. this was thought to be due to a direct blow to the orbit region rather than any intracranial etiology. ophthalmology documented corneal abrasions, no entrapment, and recommended prophylactic antibiotic ointments and eyedrops. a spinal service consultation was obtained for evaluation of the patient's l1 compression fracture. the magnetic resonance images of this region were reviewed. the patient was fitted for a lumbosacral brace, which she is to wear at all times except when she is supine. in addition, the spinal service was consulted for the patient's right upper extremity weakness which was thought to be related to her cervical stenosis and spondylosis. this right upper extremity weakness was brought to the doctors' attention after the patient was extubated. it was thought that it is an acute-on-chronic exacerbation. recommendation was made for the patient to consider cervical decompression at a future date when she is fully recovered from this current incident. the orthopaedic spine doctors spoke with the patient about this. as they were following her for her lumbar fracture, they will be able to readdress this issue when she sees them for followup. the patient was extubated on hospital day seven; however, this proved to be unsuccessful, and the patient needed reintubation approximately two hours later due to coughing and subjective feeling of being unable to breathe. a chest x-ray was performed, and it was thought that the patient was too fluid overloaded to sustain spontaneous breathing. she was aggressively diuresed and then successfully extubated on hospital day ten. while in the intensive care unit, the patient became febrile and was pan-cultured. it was determined that she had a urinary tract infection which was positive for pseudomonas. the patient was started on levofloxacin, and the foley was changed, and she became afebrile. condition at discharge: the patient was discharged in stable condition. at the time of discharge, she was hemodynamically stable. alert and oriented times three. eating solid foods, though of a soft consistency; as she is edentulous. she is nonweightbearing of the lower extremities and had a foley in place. discharge disposition: to an extended care facility. discharge instructions/followup: 1. the patient was to be nonweightbearing for a lengthy period of time; to be determined by her orthopaedic (dr. with whom she will follow up with two weeks after her discharge date. 2. the patient was instructed to continue with continuous passive motion machine of the bilateral lower extremities and wear her braces to her bilateral lower extremities. 3. given her nonweightbearing status, she will be discharged with a foley. 4. the patient was instructed to follow up with plastic surgery for evaluation of her central forehead wound and eyelid laceration. this should occur in two weeks with dr. (telephone number ). 5. the patient was instructed to follow up in orthopaedics with dr. for evaluation of her bilateral leg fractures; status post open reduction/internal fixation. she was to see him in two weeks. she was to call telephone number for an appointment. 6. the patient was instructed to follow up in spine surgery with dr. . he will evaluate the healing of her l1 compression fracture and a future need for cervical surgery. she was to call telephone number in three to four weeks for an appointment. 7. the patient was instructed to follow up in neurosurgery with dr. in one month. she will need to have a head computed tomography prior to this appointment. she may call telephone number for an appointment. 8. there was no scheduled appointment with the trauma clinic; however, if the patient has questions or concerns she may call telephone number for an appointment. discharge diagnoses: 1. right superior and inferior pubic rami fractures. 2. right sacral ala fracture. 3. right tibia/fibula fracture; status post open reduction/internal fixation. 4. left lateral tibial plateau fracture; status post open reduction/internal fixation. 5. left lateral femoral condyle fracture; status post open reduction/internal fixation. 6. multiple rib fractures. 7. l1 compression fracture. 8. bilateral intraventricular hemorrhage; stable. 9. subarachnoid hemorrhage in the parietal region; stable. 10. central forehead wound with rectalis muscle exposed and tissue deficit; repaired by plastic surgery. 11. left eyelid laceration; repaired by plastic surgery. 12. right upper extremity weakness; acute-on-chronic in origin. 13. cervical spondylosis/stenosis. 14. urinary tract infection (pseudomonas); status post antibiotic treatment for 10 days. medications on discharge: 1. bacitracin ointment applied to wounds twice per day. 2. albuterol nebulizer 1 to 2 puffs q.6h. as needed. 3. artificial tear ointment apply 1 to 2 drops in eyes as needed. 4. lovenox 30 mg subcutaneously q.12h. 5. colace 100 mg by mouth twice per day. 6. tylenol 650 mg by mouth q.4-6h. 7. metoprolol 50 mg by mouth three times per day. 8. hydralazine 25 mg by mouth q.6h. 9. combivent nebulizer 1 nebulizer q.6h. as needed. 10. erythromycin ointment 0.5 inches to the left eye four times per day. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Interruption of the vena cava Enteral infusion of concentrated nutritional substances Arteriography of femoral and other lower extremity arteries Other surgical occlusion of vessels, lower limb arteries Open reduction of fracture with internal fixation, tibia and fibula Open reduction of fracture with internal fixation, femur Linear repair of laceration of eyelid or eyebrow Closure of skin and subcutaneous tissue of other sites Transfusion of packed cells Diagnoses: Urinary tract infection, site not specified Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Closed fracture of lumbar vertebra without mention of spinal cord injury Closed fracture of condyle, femoral Subarachnoid hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Closed fracture of pubis Injury to unspecified pelvic organ, without mention of open wound into cavity Injury to iliac artery Other specified open wounds of ocular adnexa

pmh- htn.atenalol 50 mg qd carotid stenosis no allergies reported. ros: pt mae's to command; nodding head; mouthing words at times & gesturing. pupil noted to be unequal with l>r , and right pupil nonreactive. corneals impaired. +gag/cough; able to open eyes(left w/difficulty d/t edema.) opthalmolgy consult ordered. ? foreign body in eye. also facial ct to be done when stable to travel. pt able to nod 'yes' to pain in both le's and + sensation in le's. pt gesturing to take ett out. prn pain med with caution d/t drop in bp with sedation meds. cvs- labile bp..see careview. bp drifts into 70's/systolic and responds to volume to 120-130/. bp to 160-170 when pt most awake & stimulated. hr rmains in 40's sb w/o ectopy regardless of bp. cvp by lsc introducer is . ivf infusing at 100cc/hr. pt has required 3l fluid to maintain bp >100 sytolic. heme-adm hct 22>>>40 after 4u pc's>>>27.5. 1u pc's infused. serial hcts ordered. pelvic binder placed(sheet secured tightly with hemostats. pt nable to travel to ct/radiology d/t hemodynamic instability ? d/t bleeding. pt to angiography @ 1900. ..coags wnl resp- full vent support with ac 40% 600 x14 5peep with adequate gas exchange and mild met acidosis(-4) and lactate of 4. breath sounds are clear and decreased at bases. no secretions at this time. renal- adeqaute u/o via foley; initially pink tinged..now clearing. bun/creat wnl electrolytes repleted id- initial temp 93.3(checked by all methods). bear hugger placed; temp to 98.5 by 1800. kefzol ordered. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Interruption of the vena cava Enteral infusion of concentrated nutritional substances Arteriography of femoral and other lower extremity arteries Other surgical occlusion of vessels, lower limb arteries Open reduction of fracture with internal fixation, tibia and fibula Open reduction of fracture with internal fixation, femur Linear repair of laceration of eyelid or eyebrow Closure of skin and subcutaneous tissue of other sites Transfusion of packed cells Diagnoses: Urinary tract infection, site not specified Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Closed fracture of lumbar vertebra without mention of spinal cord injury Closed fracture of condyle, femoral Subarachnoid hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Closed fracture of pubis Injury to unspecified pelvic organ, without mention of open wound into cavity Injury to iliac artery Other specified open wounds of ocular adnexa

discharge medications: versed q.6h., fentanyl q.4h., vancomycin. immunizations: infant has not received immunizations to date. , dictated by: medquist36 d: 05:37:37 t: 06:40:16 job#: Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Diagnoses: Congestive heart failure, unspecified Single liveborn, born in hospital, delivered by cesarean section Observation for suspected infectious condition Patent ductus arteriosus Other specified conditions originating in the perinatal period Other specified congenital anomalies of heart Other respiratory problems after birth Congenital mitral insufficiency Hypotension, unspecified Ostium secundum type atrial septal defect Cellulitis and abscess of foot, except toes Down's syndrome Persistent fetal circulation

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transfer from osh for hypotension major surgical or invasive procedure: s/p r ureteral stent placement history of present illness: 39 yo f w/ h/o nephrolithiasis presented to osh with r flank pain associated with n/v/f/c and was found to have stone in r ureter. she underwent ureteral stent placement and postoperately she was developed fever to 102 with rigors. she rapidly developed hypotension unreponsive to fluids and eventually requiring pressors. she also had evidence of dic, arf and respiratory distress requiring nrb mask to keep o2 sats in mid-90s. she was given cipro, gent, and zosyn, and was transferred to for further w/u. past medical history: 1. kidney stone ~4 years ago 2. depression with psychotic features social history: remote h/o tobacco, quit age 20. no h/o etoh or ivdu. lives with parents in , ma. family history: mom with h/o colon ca and cyst in brain, still a+w. physical exam: t 99.4, bp 115/50, p 82, rr 34, o2 sat 95% 2l i/os: 2475 / 5390 gen: young female, flat affect, breathing moderately labored with full sentences heent: perrl, anicteric sclera, dry mm clear op neck: supple, no lad/ masses, no jvp noted cv: rrr, nl s1, s2 i/vi sem pulm: decreased bs at bases o/w clear abd: soft, nt/nd + bs extr: no c/c/e, 2+ pedal pulses pertinent results: cxr - 1. removal of endotracheal and nasogatric tubes since the prior examinations. 2. progressive consolidation of the left upper lobe or a portion of it, with air bronchograms, consistent with pneumonic consolidation. 3. persistent left lower lobe atelectasis or consolidation with a small adjacent pleural effusion. 4. continued patchy infiltrates in the right lung. 5. considerable improvement in the degree of bilateral predominantly alveolar diffuse opacities. 03:43am freeca-1.01* 03:43am glucose-201* lactate-3.4* na+-137 k+-3.4* 03:43am type-art po2-69* pco2-30* ph-7.33* total co2-17* base xs--8 04:12am fibrinoge-351 04:12am pt-17.8* ptt-42.2* inr(pt)-2.0 04:12am plt count-124* 04:12am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 04:12am neuts-91* bands-1 lymphs-3* monos-5 eos-0 basos-0 atyps-0 metas-0 myelos-0 04:12am wbc-27.3* rbc-3.12* hgb-9.7* hct-29.5* mcv-95 mch-31.2 mchc-33.0 rdw-14.1 04:12am cortisol-140.9* 04:12am tsh-1.1 04:12am albumin-2.9* calcium-6.7* phosphate-2.3* magnesium-1.7 04:12am lipase-9 04:12am alt(sgpt)-33 ast(sgot)-31 ld(ldh)-206 alk phos-57 tot bili-0.4 04:12am glucose-197* urea n-20 creat-1.1 sodium-141 potassium-3.6 chloride-115* total co2-15* anion gap-15 04:40am fdp-80-160* 05:26am type-art temp-37.0 rates-/32 o2-100 po2-79* pco2-23* ph-7.36 total co2-14* base xs--10 aado2-629 req o2-100 intubated-not intuba 05:30am urine voidspec-requisitio 07:18am cortisol-121.2* 07:18am cortisol-122.6* 07:49am o2 sat-98 07:49am lactate-3.2* 07:49am type-art po2-128* pco2-28* ph-7.36 total co2-16* base xs--7 02:56pm wbc-26.7* rbc-3.15* hgb-9.9* hct-29.3* mcv-93 mch-31.4 mchc-33.8 rdw-14.7 02:56pm plt count-96* 03:12pm freeca-1.12 03:12pm o2 sat-97 03:12pm glucose-97 lactate-2.2* 03:12pm type-art po2-108* pco2-31* ph-7.36 total co2-18* base xs--6 05:04pm urine rbc-420* wbc-26* bacteria-none yeast-none epi-0 05:04pm urine blood-lge nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-sm 05:04pm urine color-ltamb appear-hazy sp -1.020 05:46pm o2 sat-77 05:46pm type-mix po2-38* pco2-32* ph-7.36 total co2-19* base xs--6 ct abd pelvis: 1. bilateral pleural effusions with some associated bibasilar atelectasis. 2. ascites within the peritoneal cavity, in the pelvis and adjacent to the liver and gallbladder. 3. a right-sided ureteric stent is present, extending from the right renal pelvis to the bladder. no hydronephrosis identified bilaterally. a hypodense lesion is seen in the right kidney, likely representing a renal cyst. 4. there are no discrete focal fluid collections with areas of rim enhancement to suggest abscesses or othersignificant signs of infection. cxr: improving multifocal pulmonary opacities, most likely due to provided history of pneumonia and ards brief hospital course: course: she was admitted to for treatment of sepsis, presumed urinary source. she was initially treated with zosyn and cipro, agressive iv hydration and pressor support. she was intubated secondary to hypoxic respiratory failure on , felt to be likely ards. urology was consulted and requested stu which revealed a well positioned ureteral stent without hydro or extravasation of contrast. she responded to treatment initially with wbc decreasing from 35.2 at maximum to 14.2 on . a urine culture from osh grew e-coli and abx changed to ceftriaxone on . she then spiked a fever to 101.8-102.2 on and and wbc began to rise again. all cultures, including c-diff remained negative. antibiotics changed to vanco, gent, ceftriaxone to treat possible vap. on , successfully extubated with decreasing o2 requirement. currently afebrile, hd stable of pressors, oxygenating well on 2l n/c and awaiting transfer to floor. 1. respiratory failure - patient extubated on and doing well with decreasing o2 requirement. remains mildy tachypneic but comfortable. pleural fluid without growth to date. o2 was weaned over next few days. ultimately changed to levoquin po as wt ct came down. pcp to follow up bld cx. 2. leukocytosis - wbc rising from 14 on to 29.9 today with 10% bands yesterday. source not entirely clear as blood, sputum, urine cultures ngtd. pneumonia possible. no diarrhea to suggest c-diff. abx cont and then changed once wbc ct improved. cxr and ua did not show an explanation for the course. 3. urosepsis - ecoli grew in urine culture from osh. hd stable and now afebrile. recommended cont abx. 4. nephrolithiasis: pt now with ureteral stent and ? passage of stone. urology following. recent abd ct demonstrates ureteral stent is in good location with no hydronephrosis, delay in excretion or extravasation of fluid. no need for intervention currently. urology f/u as outpt 5. renal function - back to baseline. 6. psychiatry pt will be started back on fluoxetine and clozaril now that she is successfully extubated cont clozaril at 25mg/day and titrate up to 125 mg per psych with f/u . 7. anemia - hct stable. will need a repeat diff as outpt. 8. f/e/n - taking good clears now. encourage po diet. has had some vomiting after drinking so monitor for signs of swallow dysfuncion s/p intubation. repleted k+ 9. dispo - home afebrile improved 10. full code medications on admission: prozac 40 mg po qd clozaril 175 mg po qd discharge medications: 1. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for 2 weeks. disp:*qs 1* refills:*0* 2. fluoxetine hcl 20 mg capsule sig: two (2) capsule po daily (daily). disp:*30 capsule(s)* refills:*2* 3. lidocaine hcl 2 % solution sig: five (5) ml mucous membrane tid (3 times a day) as needed: for motuh discomfort. disp:*30 ml(s)* refills:*0* 4. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*7 tablet(s)* refills:*0* 5. clozapine 25 mg tablet sig: three (3) tablet po hs (at bedtime): increase by 25 mg(one tablet) each day until at 175 mg dose (7 tablets). disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: 1. uretral stone 2. sepsis 3. respiratory distress/pneumonia 4. depression with psychotic features 5. anemia discharge condition: good discharge instructions: if you have fever/chills, shortness of breath, difficulty urinating, chest pain, please call your pcp or come to the ed. followup instructions: please call your pcp dr for a f/u appt in 1 week. will need repeat cbc with diff (atypical cells seen on last diff), follow up on blood cx results done at . wed. 11:45 am psychiatry: dr. (please call for an appt in weeks, message left that you would need an appt) dr. . wood () pls call for appt in weeks, message left by pscyh attending Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Thoracentesis Arterial catheterization Diagnoses: Pneumonia, organism unspecified Acidosis Anemia, unspecified Urinary tract infection, site not specified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Pulmonary collapse Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Septic shock Calculus of kidney Infection and inflammatory reaction due to other genitourinary device, implant, and graft Major depressive affective disorder, single episode, severe, specified as with psychotic behavior

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypoxia major surgical or invasive procedure: central line placement history of present illness: pt presented to ed on with fever to 102.5 at 2 days after vaporization of prostate by dr. at . pt states that he has had mild dysuria, denies hematuria. he was discharged from with a foley and bactrim. . pt states that he had no significant symptoms other than the fever. did start feeling "woozy" the night prior to transfer, describes lightheadedness but no vertigo. has dull suprapubic abdominal pain, does not radiate. denies recent cough, denies sob or cp/pressure. has had muscle aches. no recent travel, no known sick contacts. denies recent diarrhea; had bm on am of transfer, no blood. . on arrival to the ed, t was 102.7, satting 92% on ra, hr 102. blood cultures sent, pt given 2l ns, levo, vanco, azithromycin, admitted to floor. urology has been following in hospital, feel that abx for the pna will cover uti, feel no acute urological issues. on the am of transfer, pt became hypotesnive to 80s, responded to 2l ivf, bp up to 110s. pt was noted to be tachypneic but was not complaining of sob. abg on ra was 7.44/26/62 with lactate 2.4 (up from 1.9 earlier), abg on 5l was 7.46/26/55. pt was transferred to for further management. past medical history: - h/o prostate ca, s/p external beam rt years ago, now treated with lupron - h/o urinary retention s/p laser vaporization of prostate 2d pta - hypertension - anxiety - depression social history: lives in since the death of his mother. married, no children. has a cat. denies present or past tobacco, drinks 1 glass wine/week, no ivdu. used to work as a security guard and car salesperson. family history: noncontributory; has one sister, poor relationship with her; no children or other siblings, both parents deceased physical exam: admission exam: vs: tm 102.2 tc 102.2 112/71 102 30 93% 5l nc gen: appears tachypneic heent: mm dry, eomi, perrl neck: jvp flat, no lad cv: tachycardic, regular, nl s1/s2, no m/r/g pulm: occasional end-expiratory wheezes, breathing shallowly, bibasilar crackles, e->a change at l base abd: soft, suprapubic tenderness, no rebound or guarding, +bs ext: well-healed scars over knees; 1+ pitting pretibial edema, 2+ distal pulses neuro: 5/5 strength bilaterally, cn ii-xii intact pertinent results: admission labs: 06:16pm blood wbc-17.5* rbc-4.66 hgb-13.0* hct-38.9* mcv-83 mch-27.8 mchc-33.3 rdw-15.4 plt ct-299 03:48am blood pt-12.8 ptt-30.8 inr(pt)-1.1 06:16pm blood glucose-136* urean-22* creat-1.5* na-138 k-3.8 cl-105 hco3-20* angap-17 06:16pm blood calcium-9.3 phos-2.8 mg-1.8 06:20am blood caltibc-146* vitb12-446 folate-10.6 ferritn-629* trf-112* 04:45pm blood hapto-227* 03:59am blood type-art po2-71* pco2-27* ph-7.47* calhco3-20* base xs--1 06:15pm blood lactate-2.0 03:59am blood lactate-1.9 11:54am blood lactate-2.4* discharge labs: cultures: 6:16 pm blood culture **final report ** aerobic bottle (final ): pseudomonas aeruginosa. final sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- <=1 s ceftazidime----------- <=1 s ciprofloxacin--------- =>4 r gentamicin------------ 8 i imipenem-------------- 2 s meropenem------------- 1 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ 8 i 7:30 pm urine site: catheter **final report ** urine culture (final ): pseudomonas aeruginosa. 10,000-100,000 organisms/ml.. of two colonial morphologies. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- <=1 s ceftazidime----------- 2 s ciprofloxacin--------- =>4 r gentamicin------------ =>16 r imipenem-------------- 2 s meropenem------------- 4 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ =>16 r radiology: chest, two views: there are no comparisons. the cardiac contour appears enlarged. there are low lung volumes. no definite pulmonary vascular congestion, pleural effusion, or pneumothorax. on the lateral view, there appears to be an opacity posteriorly, most likely in the left lower lobe. impression: findings likely represent a left lower lobe pneumonia indication: left lower lobe pneumonia, hypoxic, tachypneic, tachycardic. please evaluate pulmonary embolus. comparisons: none. mdct acquired axial images of the chest were acquired with and without iv contrast. ct pe protocol. ct of the chest with and without iv contrast: there is no evidence of pulmonary embolism. evaluation beyond second order vessels is limited by atelectasis. bilateral pleural effusions are seen, with associated atelectasis/consolidation, worse on the left. no pathologically enlarged mediastinal lymphadenopathy is identified. there is evidence of atherosclerotic disease with calcification seen within the aorta as well as coronary vessels. bone windows: no suspicious lytic or blastic lesions are identified. degenerative changes, including loose body, seen in the right shoulder. multiplanar reformatted images confirm the axial findings. impression: 1. no evidence of pulmonary embolism. 2. lower lobe atelectasis and consolidation with effusions, worse on the left side. findings consistent with pneumonia. 3. atherosclerotic disease with marked calcifications seen within the aorta and coronary vessels. . ct abd/pelvis : per report by radiology, bilateral renal cysts; no evidence of renal abscess on ct scan. brief hospital course: the patient was admitted for hypotension, hypoxia, and fevers. he was initialyl admitted to the floor but was then shortly transferred to the icu for sepsis. he was found to have urosepsis with pseudomonoas and was treated with zosyn. he was then transferred back to the floor and was gently diuresed. . # hypoxia: the patient was initially admitted with mild hypoxia which quickly worsened with from fluid boluses for his hypotension resulting in pulmonary edema. he was also thought to have an pneumonia, though this was later thought to be atlectasis. there was concern given his recent surgery and hypoxia that he could have a pe, therefore a ct angio was preformed which showed no evidence of pe. his flu dfa negative, legionella neg. abg showed worsening respiratory alakalosis. at his worst, he required 10 l nc to maintain his o2 sats. he was gently diuresed and on discharge, was no longer hypoxic. he may need an echo as an outpaitent to evaluate for cardiomyopathy. # sepsis: the patient had pseuodomonal urosepsis likely related to his recent prostate insturmentation. he was fluid recucxiteec in the and responded well to antibiotics. he will continue a course of zosyn for a total of 14 days ending on . # continued fevers: the patient continued to have low grade temps after dc from the icu. a fever workup ensued. he had diarrhea which was cdiff neg x2 witn the 3rd pending, though he was started on flagyl for emperic treatment. ultrasound of his kidneys showed a cyst vs. abscess, therefore a ctu was done. the ct showed no evidence of abscess. # s/p prostate vaporization for urinary retention: initially urology was consulted who felt that there was no acute urologic issue. his foley was changed on admission once his ua was foind to be positive. i spoke with dr. about this and he suggested that the foley be removed and the patient try to void. he underwent a voiding trial here. he was able to pass urine, though was incontinent. his pvr was 300. this needs to be checked daily. he will follow up with dr. , his urologist within 1 week. # acute renal failure: the paitent does not have a history of renal failure. his cr was 1.5 on admission and he was felt to be prerenal with a fena <1%. his cr initially decreased then increased, likely to contrast induced nephropathy. he recieved another dye load on , thereore needs his chem 7 checked on monday ro follow his cr. medications on admission: ambien 5mg qhs celexa 10mg daily imipramine 25mg daily terazosin 2mg qhs verapamil sr 240mg daily protonix 40mg daily ancef/bactrim/diflucan x 1 day peri-procedure discharge medications: 1. acetaminophen 500 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. 2. albuterol sulfate 0.083 % solution sig: one (1) inhalation q4h (every 4 hours) as needed for sob, wheezing. 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day): dc when paitent is more active. 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for sleep. 6. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 7. terazosin 1 mg capsule sig: two (2) capsule po hs (at bedtime). 8. pramoxine-mineral oil-zinc 1-12.5 % ointment sig: one (1) appl rectal (2 times a day). 9. ativan 0.5 mg tablet sig: one (1) tablet po at bedtime as needed for anxiety. discharge disposition: extended care facility: landing discharge diagnosis: urosepsis discharge condition: good, foley in place. discharge instructions: continue all your medications call your pcp with any fevers followup instructions: urology: you have an appointment with dr. on feburary tuesday 21 at 11:00, ma, phone for directions. fax: pcp: . will see you in the rehab. md Procedure: Venous catheterization, not elsewhere classified Diagnoses: Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Severe sepsis Depressive disorder, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Acute respiratory failure Septic shock Malignant neoplasm of prostate Septicemia due to pseudomonas

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: mental status changes major surgical or invasive procedure: cardiac catherization mitral valve replacement with 27-mm st. porcine valve. exploration for bleeding/tamponade.cauterization of bleeding vessel from sternum.debridement of mitral annulus. sternal debridement sternal debridement. bronchscopy dressing change in the operating sternal debridement and omental flap closure and bilateral pectoralis advancement flaps. evacuation of hematoma and ligation of bleeder. cardioversion evacuation of hematoma. picc line placement in ir tracheostomy (#8 portex) history of present illness: 71 year old male admitted to outside hospital for mental status changes. blood and urine culture +. tee revealed 2-3 cm mass on anterior mitral valve leaflet and smaller vegetation on posterior leaflet. also left atrial appendage thrombus. ct head showed acute/subacute r pca infarct without hemorrhage, developed atn from gentamycin. he was started on antibiotics and transferred for surgical work up. past medical history: mitral valve endocarditis stroke atn urosepsis cri hypertension anxiety depression prostate cancer s/p radiation c. diff colitis social history: lives in landing nursing home. never married, no children. denies present or past tobacco, denies etoh, no ivdu. used to work as a security guard and car salesperson. family history: noncontributory; has one sister, poor relationship with her; no children or other siblings, both parents deceased physical exam: admission no acute distress alert oriented moving all extremeties equally perrla no carotid bruits lungs clear to auscultation card rrr abdomen soft, nontender ext no edema palpable distal pulses pertinent results: time taken not noted log-in date/time: 11:44 am tissue site: valve-bicuspid (mitral) mitral valve vegitation. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram positive cocci. in pairs. reported by phone to dr 1400 . tissue (final ): enterococcus sp.. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ <=2 s penicillin------------ 4 s vancomycin------------ <=1 s anaerobic culture (final ): no anaerobes isolated. 06:01am urine color-yellow appear-clear sp -1.020 06:01am urine blood-mod nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-0.2 ph-6.5 leuks-tr 06:01am urine rbc-* wbc-0-2 bacteri-occ yeast-rare epi-0 09:16am blood freeca-1.17 07:13pm blood freeca-1.15 09:15am blood o2 sat-98 09:16am blood glucose-88 na-138 k-4.2 07:13pm blood lactate-1.4 k-2.8* 06:48pm blood wbc-21.6* rbc-2.87* hgb-8.8* hct-26.4* mcv-92 mch-30.7 mchc-33.4 rdw-15.9* plt ct-408 03:37am blood wbc-17.9* rbc-3.21* hgb-9.8* hct-28.4* mcv-88 mch-30.4 mchc-34.4 rdw-16.8* plt ct-392 04:48am blood wbc-25.6* rbc-3.45* hgb-10.2* hct-29.9* mcv-87 mch-29.7 mchc-34.3 rdw-16.5* plt ct-196 05:07am blood wbc-6.7 rbc-3.56* hgb-10.0* hct-30.1* mcv-85 mch-28.0 mchc-33.1 rdw-19.4* plt ct-234 02:09am blood neuts-82.8* bands-0 lymphs-8.2* monos-4.3 eos-4.3* baso-0.4 03:59am blood neuts-82.9* lymphs-9.7* monos-5.4 eos-2.0 baso-0 02:09am blood hypochr-1+ anisocy-occasional poiklo-2+ macrocy-occasional microcy-normal polychr-occasional ovalocy-1+ burr-1+ stipple-occasional 06:48pm blood plt ct-408 02:09am blood pt-13.7* ptt-24.7 inr(pt)-1.2* 04:49pm blood pt-12.9 ptt-31.5 inr(pt)-1.1 06:25am blood plt ct-251 01:51pm blood fibrino-126* 01:31am blood ret aut-2.0 04:32am blood glucose-136* urean-58* creat-1.5* na-149* k-4.3 cl-112* hco3-26 angap-15 02:40am blood glucose-34* urean-30* creat-1.2 na-146* k-3.9 cl-111* hco3-26 angap-13 01:45am blood glucose-145* urean-39* creat-1.7* na-138 cl-105 hco3-21* 02:01am blood glucose-129* urean-27* creat-2.3* na-138 k-4.7 cl-103 hco3-19* angap-21* 02:14am blood glucose-108* urean-15 creat-1.6* na-142 k-4.0 cl-114* hco3-22 angap-10 05:07am blood glucose-82 urean-14 creat-1.9* na-137 k-4.0 cl-105 hco3-24 angap-12 06:55pm blood alt-37 ast-35 ld(ldh)-274* alkphos-41 amylase-38 totbili-0.2 09:41pm blood alt-17 ast-27 alkphos-35* amylase-75 totbili-0.5 05:07am blood alt-16 ast-29 ld(ldh)-247 alkphos-32* totbili-0.3 06:55pm blood lipase-33 09:41pm blood lipase-42 12:52pm blood ck-mb-3 ctropnt-1.08* 04:32am blood mg-3.1* 02:13am blood calcium-9.1 phos-1.5* mg-2.0 03:13am blood calcium-8.3* phos-4.7* mg-2.7* 06:25am blood calcium-8.4 phos-4.0 mg-2.3 12:49am blood caltibc-70* ferritn-901* trf-54* 04:49pm blood %hba1c-5.8 -done -done 06:24am blood vanco-14.1 unilat up ext veins us right 5:32 pm unilat up ext veins us right reason: r/o dvt pt has line in and rt arm swelling medical condition: 71 year old man with picc in r and increased swelling. reason for this examination: r/o dvt indication: picc in right arm. increased swelling. rule out dvt. right upper extremity ultrasound: grayscale, spectral, and color doppler analysis of the right internal jugular vein, subclavian vein, axillary vein, brachial veins, cephalic vein, and basilic vein was performed. picc catheter is seen in one of the brachial veins. there is normal flow, compressibility, augmentation, and waveforms in the right jugular vein, axillary vein, and brachial veins. no evidence of thrombus in the basilic or cephalic veins. impression: no evidence of right upper extremity dvt. medical condition: 71 year old man s/p mvr reason for this examination: please place picc indication for exam: this is a 71-year-old man status post mvr, needs iv access. radiologists: the procedure was performed by drs. and , the attending radiologist who was present and supervising throughout the procedure. procedure and findings: since no suitable veins were visible, ultrasound was used to identify the right basilic vein, which was patent and compressible. the right arm of the patient was then prepped and draped in standard sterile fashion. after injection of 5 cc of 1% lidocaine, 21-gauge needle was advanced into the right basilic vein under ultrasonographic guidance. hard copies of the images before and after the venipuncture were obtained. a 0.018 guidewire was then advanced through the needle into the distal part of the svc under fluoroscopic guidance. the needle was then exchanged for a 5 french micropuncture sheath. based on the markers in the guidewire, it was decided that a length of 43 cm would be suitable. the line was then trimmed to this length and advanced over the wire into the distal part of the svc. the wire and the peel-away sheath were then removed. the line was flushed, heplocked and statlocked. a dressing was applied, and final fluoroscopic image of the chest demonstrated tip of the catheter to be located in the distal part of the svc. the patient tolerated the procedure well. impression: successful placement of a 43 cm long double lumen line with the tip in the distal part of the svc. the line is ready for use. technique: ct of the chest, abdomen and pelvis with iv contrast. 130 ml of nonionic contrast were administered. nonionic iv contrast was used due to rapid bolus necessary for this study. ct chest: the patient is status post median sternotomy and near complete removal of the sternum. there is interval placement of an omental flap and closure of the skin. no evidence of new hematoma. a small fluid collection near the left cardiophrenic angle measuring 45 x 22 mm (2:38) appears to be slightly smaller than the previous study from , and also more hypodense. the findings are consistent with a resolving hematoma. the vessels supplying the flap are patent. tiny pericardial effusion unchanged. severe coronary artery calcifications and stents in the coronary arteries. calcifications of the aorta. large bilateral pleural effusions with associated atelectasis, similar to . et tube is located 1-1.5 cm from the carina and could be withdrawn approximately 1 cm. a feeding tube with the tip in the stomach. right ij cordis catheter within the upper right brachiocephalic vein. ct abdomen: small amount of free fluid in the abdomen with simple characteristics. no evidence of hematoma within the abdomen. the liver, spleen, and adrenal glands are within normal limits. the proximal portion of the pancreatic duct is slightly dilated measuring 8 mm, but the distal pancreatic duct is unremarkable. this is of unknown clinical significance. multiple hypodense areas in the kidneys bilaterally, likely representing cysts. some of the hypodense areas are too small to be characterized. no retroperitoneal lymphadenopathy. multiple surgical clips in the regions of the harvesting of the omentum. small periportal nodes do not meet ct criteria for pathology. multiple nodules in the subcutaneous tissues in the anterior abdominal wall, likely from medication injection. ct pelvis: there is malposition with the foley catheter likely with the balloon in the urethra. (2:123.) the rectum, urinary bladder, distal ureters, intrapelvic bowel loops are unremarkable. small amount of simple free fluid in the pelvis. bone windows: there are degenerative changes of the spine, but no suspicious lytic or blastic lesions. healing fracture of the right twelfth rib. impression: 1. no reason to explain dropping hematocrit. 2. resolving left cardiophrenic hematoma. 3. viable flap. 4. large bilateral pleural effusions and associated atelectasis. the pleural effusions have simple characteristics and are unchanged since prior study. 5. hypodense areas in the kidneys likely representing cysts, but some are too small to be characterized. 6. mild dilatation of the central portion of the pancreatic duct measuring up to 8 mm of unclear significance. correlate with history of simple ascites. be sinus bradycardia with left atrial abnormality but consider also ectopic atrial rhythm low qrs voltage prolonged q-tc interval clinical correlation is suggested since previous tracing of , sinus tachycardia absent read by: , w. intervals axes rate pr qrs qt/qtc p qrs t 49 0 94 546/514 0 11 28 mri head impression: 1. right occipital lobe lesion as described above, of uncertain etiology. the intense restricted diffusion may suggest a small involving infarction with surrounding hemorrhage. given the patient's history of sepsis, an abscess is also possible. 2. areas of susceptibility artifact seen scattered throughout both cerebral hemispheres suggestive of amyloid angiopathy. multiple cavernomoas is an alternative diagnosis. 3. subgaleal fluid collection over the left temporal bone- etiology uncertain. 4. mr no stenosis or aneurysm centrally. evaluation for a mycotic aneurysm is unsatisfactory, as there is no clear visualization of the distal intracranial arterial vasculature, which is the usual locale for mycotic aneurysms. tee pre-bypass: the left atrium is normal in size. no thrombus/mass is seen in the body of the left atrium. a patent foramen ovale is present. a left-to-right shunt across the interatrial septum is seen at rest. left ventricular wall thicknesses and cavity size are normal. the remaining left ventricular segments contract normally. the right ventricular cavity is mildly dilated. there is mild global right ventricular free wall hypokinesis. the ascending aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. the aortic valve leaflets are mildly thickened. mild (1+) aortic regurgitation is seen. a bioprosthetic mitral valve prosthesis is present. the motion of the mitral valve prosthetic leaflets appears normal. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is a small pericardial effusion with no evidence of tamponade. brief hospital course: 71 year old male admitted from outside hospital with mitral valve endocarditis, r pca infarcts, and atn for preop evaluation. he underwent preoperative workup including cardiac catherization and infectious disease consult. cardiac catherization mild single vessel coronary artery disease. he received hydration and creatinine was monitored closely. on he was brought to the operating room and underwent mitral valve replacement #27mm porcine valve. please see operative report for further details. he was transferred to the cardiac surgery recovery unit requiring vasopressors and blood products. he returned to the operating room that evening due to bleeding and widened mediastinum. he returned to the csru and postoperative day 1 he was weaned from vasopressors and sedation. he awoke and responded to voice, weaned to pressure support. on postoperative day 2 he was extubated, chest tubes removed, and transferred to the floor. he continued to progress but on postoperative day 4 he was in atrial fibrillation with hypotension and returned to the csru for monitoring and vasopressors. he continued to be in and out of atrial fibrillation and sternal click noted with no drainage. then on postoperative day 8 there was sternal drainage, erythema, and tenderness. he became asystolic, intubated, and returned to the operating room for reexploration . he returned to with open chest on nimbex. plastic surgery was consulted, vac dressing was placed until he was ready for sternal closure. he was weaned off pressors and underwent flap closure . he required returns to the operating room for sternal exploration due to bleeding. he has continued to progress since sedation was weaned and he underwent a tracheostomy due to failure to wean from the ventilator. neuro: required nimbex while chest open, discontinued with closure. weaned off sedation, and has been improving. he is alert, follows commands, and tramadol for pain control pulmonary: he was extubated pod 2 and then reintubated due to cardiac arrest. do to failure to wean he required prolonged ventilation, he had a tracheostomy placed # 8 portex without complications. in addition he has had pigtails placed for pleural effusions which are now removed. he has since been able to tolerate trach collar during the day and rested on the ventilator overnight. he cont cardiac: has been in and out of atrial fibrillation, now in normal sinus rhythm. he has required vasoactive medications during icu stay for blood pressure support with b/p stable off pressors. renal: baseline creatinine was 1.9 with a peak to 2.3, now 1.5. medications adjusted due to renal clearance and has been slowly diuresed. nutrition: has been receiving tube feeds via ng and now dobhoff. he passed his swallow evaluation on for a full diet, but given his poor po intake, he remains with tube feeds. heme: received multiple blood products due to coagulopathies and falling hematocrit. hct was stable at d/c. plastics: on went to operating room due to sternal drainage, he underwent mediastinal exploration with sternal debridement and chest open underwent sternal wound debridement and vac dressing placed . he remained on nimbex while chest open. he returned to the operating room for sternal debridement and omental flap closure and bilateral pectoralis advancement flaps and nimbex discontinued. due to bleeding he returned to the operating room multiple times for reexploration of chest and washout. jp have been removed by plastics and sternum has staples that are to be maintained for four weeks. id: enterococcal mitral valve endocarditis with septic emboli, mitral valve replaced and valve tissue culture + enterococcus received vancomycin, fluconazole,levoquin, ampicillin and ceftriaxone based on increased wbc and culture data. antibiotics dc'd on , as he finished his 6 weeks course.he will follow up with id in 2 weeks. white count at the time of discharge is 18, down from 24, and will need to continue to be followed. medications on admission: ativan 0.5 q6h prn citalopram 20mg daily mvi buspar 10mg twice a day teraozosin 2mg at bedtime vitamin c 500mg twice a day colace senokot 2 tabs twice a day protonix 40mg daily kcl 10 meq twice a day ampicillin 2gm iv q6h heparin 5000units sq three times a day discharge disposition: extended care facility: - discharge diagnosis: mitral valve endocarditis hypertension anxiety depression prostate cancer s/p radiation c. diff colitis discharge condition: fair discharge instructions: 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 no lifting more than 10 pounds for 10 weeks please call with any questions or concerns Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other bronchoscopy Atrial cardioversion Reopening of recent thoracotomy site Reopening of recent thoracotomy site Temporary tracheostomy Control of hemorrhage, not otherwise specified Local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] Local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] Attachment of pedicle or flap graft to other sites Open and other replacement of mitral valve with tissue graft Other repair of omentum Diagnoses: Mitral valve disorders Other postoperative infection Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Cardiac complications, not elsewhere classified Atrial fibrillation Disruption of internal operation (surgical) wound Hematoma complicating a procedure Sepsis Hemorrhage complicating a procedure Cardiac arrest Intestinal infection due to Clostridium difficile Iatrogenic cerebrovascular infarction or hemorrhage Mediastinitis

history of present illness: this is a 56-year-old g3, p3 who has noticed an increasing vaginal bulge in of this year. but did notice an increase in urinary frequency, nocturia, and urgency. she had no change in her bowel habits, and is not sexually active. preoperative physical examination showed a stage ii pelvic organ prolapse mostly cystocele. the decision was made to proceed with an anterior-posterior colporrhaphy. past medical history and past surgical history: uterine suspension and total abdominal hysterectomy, left salpingo-oophorectomy in , three right breast biopsies all benign, tonsil and adenoidectomy, and appendectomy, irritable bowel syndrome, pernicious anemia, migraine headaches. past ob history: three full term normal spontaneous vaginal deliveries. the first one was complicated with postpartum hemorrhage. last pap smear was which was within normal limits. psychosocial history: she denies any tobacco or alcohol use. medications: vitamin b12 q month, fosamax 50 mg q week, celexa 40 mg q day. allergies: penicillin, sulfa, clindamycin, and ivp dye. family history: mother died of breast cancer at age 52. father has diabetes, heart disease, peripheral vascular disease. hospital course: the patient was brought to the operating room for same-day admission for anterior-posterior colporrhaphy. the procedure was without complications, except for a difficult intubation. the estimated blood loss was 200 cc. intraoperative findings included a grade ii-iii cystocele, a grade ii rectocele, and a normal vaginal cuff. in the immediate postoperative period, there was noted to be continuous bleeding from the vagina. removal of the vaginal pack showed vigorous bleeding from two areas in the vagina surgical incision. she was taken back to the operating room where, under a second general anesthesia, these two bleeding points were suture ligated with excellent hemostasis. the estimated blood loss from the second procedure was 50 cc. postoperatively, because of the difficult intubation and the result of pharyngeal edema, the decision was made to keep the patient intubated and in the micu in order to optimize airway management. the patient did well hemodynamically in the micu and was extubated successfully on postoperative day one. the patient's vital signs were stable with excellent o2 saturations. the patient was transferred to the regular gyn floor on postoperative day one. her pain was well controlled with im demerol and was rapidly converting to po percocet once the patient began tolerating a regular po diet. on postoperative day #2, the patient had a slight temperature elevation up to 101.9. the patient at this time was passing flatus, ambulating freely, voiding spontaneously with no complaints of frequency. the patient had a chest x-ray was within normal limits. she had a urinalysis sent which was negative and the urine culture was also subsequently negative. her white count was 7.4. the patient was started on levaquin, rather than chance a pneumonia. the patient did well until the day of discharge (levaquin day #2). the day of discharge, the patient began complaining of a generalized rash (nonitchy). inspection of this rash describes the lesions as macular appearing rashes. the decision was made at this point to stop her levaquin. no additional antibiotic was started as her cultures have been negative to date, she has been afebrile and the white count was not elevated. the patient will be discharged to home with the following medications: percocet, motrin, and reglan. the patient's condition on discharge is good and the patient is discharged to home. , m.d. dictated by: medquist36 d: 00:20 t: 11:31 job#: Procedure: Repair of cystocele and rectocele Suture of laceration of vagina Diagnoses: Hemorrhage complicating a procedure Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Irritable bowel syndrome Pernicious anemia Edema of pharynx or nasopharynx

history of present illness: she is a 62-year-old female with a past medical history significant for mitral valve prolapse, borderline elevated cholesterol, and early menopause. negative for hypertension or diabetes with a positive family history in that her father expired from a mi at the age of 63, who was in her usual state of health until five days prior to admission when she noticed epigastric pressure radiating into her neck after exercising and lasting approximately five minutes. on day of admission, again, patient after exercising noted some same epigastric pressure, but much more severe and radiating into neck and bilaterally into the shoulders. not associated with any nausea or vomiting, but associated with some diaphoresis. patient presented to emergency room, where an ekg revealed st elevations in v3 and v4. patient was given aspirin, plavix, started on a nitroglycerin gtt., heparin gtt., and patient became chest pain free with resolution of st elevations. patient was secondarily started on integrilin gtt. and transferred to the hospital for a catheterization. review of systems: the patient was free of any headache, vision changes. no uri symptoms. no cough, no shortness of breath, no abdominal pain, no nausea, vomiting, diarrhea, or constipation, no edema, no dysuria, no numbness, tingling, or weakness. no hematuria. no hematochezia, hematemesis, hemoptysis. past medical history: 1. mitral valve prolapse. 2. borderline hypercholesterolemia. 3. early menopause. allergies: 1. sulfa. 2. penicillin. medications: 1. e-vista unknown dose. 2. multivitamins daily. 3. aspirin 81 mg one p.o. q.d. family history: significant for a father who expired at the age of 63 from myocardial infarction. social history: the patient resides with her husband and son. she does not smoke tobacco. she consumes two glasses of wine per week. otherwise, no other drugs. the patient does exercise regularly. physical examination: patient's temperature was 96.4. her blood pressure is 140/90. pulse was 84. satting at 98% on room air. generally, she is a well-appearing female in no acute distress completing full sentences without development of shortness of breath. heent is normocephalic, atraumatic. extraocular movements are intact. oropharynx is clear with no lesions or exudates noted. neck is supple with no jvd, no lymphadenopathy. heart is regular rate and rhythm with no murmurs, normal s1, s2, no clicks or gallops. lungs are clear to auscultation bilaterally with no wheezes, crackles, or rales. abdomen is mildly obese, soft with good bowel sounds, nontender, and nondistended with no masses palpated, or hepatosplenomegaly. groin bilaterally are free of any bruits. her extremities are free of any clubbing, cyanosis, or edema. dorsalis pedis 2+ bilaterally. neurologic examination: cranial nerves ii through xii are intact. strength is and symmetric. reflexes are 2+ throughout. toes are downgoing. data from : white count 10.3, hematocrit 38.0, platelet count is 225. ekg from revealed normal sinus rhythm at 60, normal axis. she was noted to be leftward from old ekg. normal intervals. new st elevations of 2 mm in v3 through v4, t-wave inversions in lead iii. hospital course by systems: 1. for st elevation mi, patient was continued on her nitroglycerin gtt., aspirin, plavix, heparin, and integrilin. the patient was taken to the catheterization laboratory emergently, where a cardiac catheterization was performed. the results of the catheterization were as follows: patient had one vessel coronary artery disease in the lad that revealed tubular 90% mid vessel lesion, but otherwise angiographically was normal. patient had mild systolic ventricular dysfunction, mild diastolic ventricular dysfunction, her lvedp was 18. her right sided filling pressures were normal at 10 ml hg. patient was stented in the mid lad and the procedure was performed without complications. post catheterization the patient was weaned off her nitroglycerin gtt., but was maintained on heparin. approximately four hours post catheterization, patient continued to have vagal responses with hypotension into the 90/50 range, and nausea and emesis. later she complained of back pain. patient underwent an emergent noncontrast ct of her abdomen and pelvis, which revealed a large extraperitoneal hemorrhage displacing the urinary bladder to the left tracking along the right psoas muscle. patient was emergently brought up to the floor and was transfused 2 units of blood in the setting of a hematocrit drop from 36.1 to 31.7. during infusion of blood, patient was noted to hypotense to 70/40, and developed some dizziness. she was put in the reverse trendelenburg. a femoral line was placed. patient was given aggressive hydration with fluid and was transferred to the ccu. in the ccu, the patient received another unit of blood. her hematocrit stabilized at approximately 34-35. patient had no further evidence of bleeding. she had no further episodes of hypotension. patient also underwent an ultrasound of her femoral arteries which revealed no evidence of pseudoaneurysm. the patient was maintained in the ccu for 24 hours, where q.4h. hematocrits were drawn and remained stable in the 34-35 range. she was then transferred to the floor for medical management. 2. cad: for coronary artery disease secondary prevention, the patient was maintained on aspirin 325 mg q.d. she was also started on a statin, lipitor 40 mg one p.o. q.d. she was initially maintained on captopril, and on date of discharge changed to lisinopril 5 mg one p.o. q.d. and she was maintained on metoprolol 50 mg one p.o. b.i.d. patient had good blood pressure control in the range of 130s/70-80s with pulse mostly in the 70s-80s. repeat ekgs were performed on the floor, which revealed no acute st-t wave changes or resolution of elevations that were seen on ekg during her st elevation mi. the patient had no further episodes of chest pain, shortness of breath, or epigastric pain during her hospitalization. 3. heme: patient's hematocrit throughout her hospitalization post transfusion of 3 units remained stable in the 34-35 hematocrit range. her hematocrit on discharge was 34.4. 4. thrombocytopenia: during her hospitalization, the patient's platelet count nadired to 144, and it was felt that this thrombocytopenia was likely secondary to consumption in the setting of retroperitoneal bleed. a hit antibody was sent and was pending at the time of discharge. this will need to be followed up by the patient's primary care physician. platelet count did stabilize at 152 and there were no further episodes of thrombocytopenia noted. patient had no evidence of bleeding. 5. gi: patient was maintained on a bowel regimen as well as zofran for nausea. by the time of discharge, patient had no nausea x24 hours, 6. code: patient was a full code. medications on discharge: 1. aspirin 325 one p.o. q.d. 2. plavix 75 mg one p.o. q.d. 3. atorvastatin 40 mg one p.o. q.d. 4. metoprolol 25 mg one p.o. b.i.d. 5. lisinopril 5 mg one p.o. q.d. follow-up plans: patient is to followup with her primary care physician within one week of discharge. she has advised me that she has a cardiologist located in the same building as her primary care physician, she would like to followup with this cardiologist. she is advised that she should follow up with a cardiologist within two weeks of discharge. patient is to continue her current medication regimen and her metoprolol and/or lisinopril may need to be titrated up for continued hypertension outpatient. discharge condition: stable. she is stable on room air. she is able to ambulate with physical therapy without difficulty. she is tolerating a regular diet without development of any nausea or emesis. she has had no further evidence of abdominal pain, epigastric pain, chest pain, or shortness of breath. her hematocrit and platelet count has stabilized. , m.d. dictated by: medquist36 Procedure: Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Transfusion of packed cells Insertion of drug-eluting coronary artery stent(s) Diagnoses: Thrombocytopenia, unspecified Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Hematoma complicating a procedure Hypotension, unspecified Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure

allergies: codeine / penicillins attending: chief complaint: ventricular fibrillation major surgical or invasive procedure: 1. cardiac catheterization 2. aicd placement. history of present illness: 53yo m with no known heart disease, history of narcotic and alcohol abuse on methodone presented to with syncope. he had had recurrent syncopal events over the last 4 days prior to admission but refused medical attention. he was found to be in ventricular fibrillation. he was defibrillated and intubated. he awoke with conversion to sinus rhythm. was agitated. (initial k 2.7, initial abg at 7.40/47/326.)he pulled out his et tube, became progressively obtunded with more ventricular ectory and was reintubatd. he was treated for recurrent bouts of ventricular tachycardia with iv amiodarone, magnesium and potassium, as well as ativan and pavulon. drug screen was positive for benzodiazepine, tetrahydrocannabinol and was negative for etoh. he developed vf again on amiodarone and with k 3.0 requiring another defibrillation. he had subsequent addition of lidocaine with stabilization of ventricular ectopy. weaning was attempted next am when he began to develop ventricular ectopy. echo showed anterior septal hypokinesis with ef 30-40%. his peak ck was 5675 post defibrillation past medical history: 1. gerd 2. hypothyroidism 3. hepatitis b and c positive 4. pvd 5. partial gastrectomy in 6. appendectomy in . social history: marijuana use significant etoh use prior heroin use family history: nc physical exam: physical examination: gen: short obese male with long unkempt hair asleep but easily arousable, nad. pt conversing in full sentences without accessory muscle use. heent: eomi, anicteric, mmm, op clear cv: rrr, s1, s2, distant heart sounds, no murmurs, rubs, gallops appreciated chest: improved but persistent bilateral wheezing. right subclavian line in place without significant erythema, induration or tenderness on palpation. large white abd pad over left chest, clean dry intact. minimal tenderness over site. abd: obese, soft, nt, nd ext: wwp, +1 non-pitting edema with some tenderness, ?trace pt. multiple areas of echymosis (pt unclear how he got them) without skin breakdown. pertinent results: 05:51pm wbc-9.9 rbc-4.49* hgb-12.9* hct-40.5 mcv-90 mch-28.7 mchc-31.7 rdw-15.4 05:51pm plt count-173# 05:51pm glucose-114* urea n-7 creat-0.6 sodium-138 potassium-3.9 chloride-105 total co2-28 anion gap-9 05:51pm alt(sgpt)-78* ast(sgot)-258* ld(ldh)-639* ck(cpk)-8324* tot bili-2.5* 05:51pm ck-mb-61* mb indx-0.7 ctropnt-0.03* 05:51pm tsh-9.6* 05:51pm hbsag-negative hbs ab-positive 05:51pm hcv ab-positive 05:51pm triglycer-62 hdl chol-28 chol/hdl-2.7 ldl(calc)-35 05:55pm pt-14.7* ptt-32.1 inr(pt)-1.4 07:14pm -negative 07:58pm urine color-amber appear-hazy sp -1.015 07:58pm urine blood-lg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-sm urobilngn-8* ph-6.5 leuk-tr 07:58pm urine rbc->50 wbc-0 bacteria-0 yeast-none epi-0 09:29pm type-art po2-152* pco2-43 ph-7.43 total co2-29 base xs-4 . . abd us: "echogenic liver consistent with fatty infiltration. other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on the basis of this study. no focal liver lesions are identified. the additional finding of splenomegaly is suggestive of intrinsic liver disease." . . tte: "1. the left atrium is mildly dilated. 2. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). 3. the aortic root is mildly dilated." . . hip x-ray: "1) status post right femoral head resection with acetabular screws as described. no significant change. 2) degenerative disease of the left hip, no obvious fracture but due to osteopenia, subtle fractures may be missed and if clinical suspicion persists, an mri could be helpful." . . cardiac cath: "1. coronary arteries had no flow limiting disease. 2. severe diastolic ventricular dysfunction." . . cxr: "status post icd placement with single lead in the right ventricle. no evidence of pneumothorax" . . brief hospital course: a/p: 53yo m with significant alcohol use, narcotic abuse and no significant cardiac history presents with recurrent ventricular arrhythmia s/p vf arrest in the setting of positive tox screen, hypokalemia and hypomagnesemia. he is transferred for ep evaluation s/p vf cardiac arrest and ef 30-40%. . 1. cv: a). coronaries: pt was without prior history of cad, however he had a high ck on admission which was most likely due to his repeated cardioversions. however with vf and new chf, ischemic causes were ruled out with cardiac catheterization. the cath demonstrated clean coronaries confirming our suspicion regarding the origin of the high ck. the patient was continued on acei (lisinopril 5mg once daily), and bb (atenolol 50mg once daily) and was started on asa. . b). pump: on admission, the patient was clinically found to have significant chf. tte at showed ef 30-40%. cardiac cath demonstrated clean coronaries, making ischemic causes unlikely. this is possibly due to alcohol induced, infectious (hiv pending, hcv positive), narcotic induced, familial, infiltrative or idiopathic or his arrhythmia. this is unlikely to be due to thyroid (tsh of 11 but normal free t4), or hemochromoatosis (normal iron studies). sarcoidosis also can not be excluded but is unlikely given the rest of his clinical history, exam and normal ca. and esr also were wnl. pt was continued on acei and bb during his hospital stay as above. after correction of his electrolytes, and repeated dccv, he was back in nsr and his chf appeared to resolve as well. . c). rhythm: pt presented with vfib arrest in setting of positive thc, bzd with hypokalemia and hypomagnesemia. this is most likely secondary to electrolyte imbalance from substance abuse. his electrolytes were repleted and the pt was started on amiodarone 400mg tid. he also received an aicd after his cardiac catheterization without any complications. he wa monitored on telemetry during his hospital stay and remained in nsr to sinus tach. at time of discharge, the amiodarone was discontinued as he now had an aicd implanted. in addition, given his hx of thyroid disorder and unknown pulmonary function (but requiring fluticasone and albuterol), amiodarone was deemed unsafe/unnecessary in this setting. at time of discharge he was sent home on clindamycin qid for 6days for prophylaxis (the patient has an allergy to pcn). . . 2. pulm: pt was intubated at osh after his episodes of vfib arrest. he was acutely agitated after conversion to nsr and self extubated himself. he progressively became obtunded with more ventricular ectopy requiring re-intubation at osh. at , he was extubated without complication. after extubation, he was found to have significant wheezing on exam but improved with ih and nebulizers. the patient was continued on fluticasone with albuterol nebulizers. in addition, he was given guaifenesin prn for mucous secretions. at time of discharge, he was given additional prescriptions for the fluticasone and albuterol ih and given explicit instructions to both him and his wife on how to use the ih and spacers effectively. the patient was also instructed to follow up with his pcp regarding and sleep study. . . 3. substance abuse: the patient has a significant substance abuse history and was admitted with positive bzd and thc (cannabinoids) on tox screen. pt also was found to have lft changes consistent with chronic alcohol disease. he was continued on his standing valium 5mg as well as methadone 120mg qd with oxycodone for break through pain (outpatient regimen). his wife and the methadone clinic was contact regarding this regimen which was confirmed. he was monitored on a ciwa scale but did not require additional bzd or additional pain control. . . 4. id: pt had occasional temperature spikes earlier in hospital course and was started on azithromycin for bronchitis. this was switched to cipro 500mg on . he finished a 5day course of abx and was afebrile, without any focal signs of sx of infections. he was discharged on clindamycin qid for 6days (for prophylaxis s/p aicd placement). . . 5. hypothyroidism: continued synthroid dose. . . 6. ms: the patient experienced an episode of vfib arrest with ? period of anoxia. secondary to this significant event, he was found to have some short term memory loss. however at time of discharge, he was found to be fuctional with all adl and iadl. after evaluation by pt and ot, he was cleared to go home with outpatient pt and services. his wife reports there is still some baseline disturbances, but believes he is improving slowly with time. . . 7. fen: folate, thiamine, mvi supplements. replete lytes as above. . . 8. ppx: pt was continued on heparin sub q tid for dvt prophylaxis throughout his hospital course. colace and senna was also given for bowel regimen given opiate use with dulcolax prn. . . 9. code: full code. . medications on admission: synthroid 0.05mg qd valium 2mg protonix 40 methadone 120 qd discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 3. levothyroxine sodium 50 mcg tablet sig: one (1) tablet po daily (daily). 4. methadone hcl 40 mg tablet, soluble sig: three (3) tablet, soluble po qd (). 5. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. diazepam 5 mg tablet sig: one (1) tablet po q12h (every 12 hours). 7. alprazolam 1 mg tablet sig: 0.5 tablet po tid (3 times a day) as needed. 8. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 9. multivitamin capsule sig: one (1) cap po daily (daily). 10. oxycodone hcl 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*10 tablet(s)* refills:*0* 11. colace 100 mg capsule sig: capsules po twice a day. disp:*30 capsule(s)* refills:*2* 12. fluticasone propionate 110 mcg/actuation aerosol sig: two (2) puffs inhalation twice a day. disp:*1 inhaler* refills:*2* 13. albuterol 90 mcg/actuation aerosol sig: inhalation every 4-6 hours as needed for shortness of breath or wheezing. disp:*1 inhaler* refills:*2* 14. clindamycin hcl 300 mg capsule sig: one (1) capsule po four times a day for 6 days. disp:*24 capsule(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: 1. ventricular fibrillation cardiac arrest 2. sleep apnea 3. sick euthyroid 4. hypertension 5. history of polysubstance abuse 6. hepatitis b and c postive discharge condition: good discharge instructions: please take all your medications as listed on the following page. please follow up with your doctors. please call your doctor or return to the hospital if you have chest pain/lightheadedness/shortness of breath or if there are any concerns at all please do not drive for at least 6 months. followup instructions: pcp: your pcp: , a. for an appointment within 2 weeks. you need to be evaluated with a outpatient sleep study for sleep apnea. please also have your pcp arrange for an outpatient pfts as well as repeat thyroid studies. cardiology: 1. device clinic where: cardiac services phone: date/time: 3:00 2. please call ( to shedule an appointment with dr. , the cardiologist, within one month of your discharge md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Drug detoxification Automatic implantable cardioverter/defibrillator (AICD) check Diagnoses: Congestive heart failure, unspecified Unspecified acquired hypothyroidism Unspecified viral hepatitis C without hepatic coma Peripheral vascular disease, unspecified Alcohol abuse, unspecified Hypopotassemia Unspecified sleep apnea Ventricular fibrillation Disorders of magnesium metabolism Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta Cannabis dependence, continuous Alcoholic cardiomyopathy Bronchitis, not specified as acute or chronic Amphetamine and other psychostimulant dependence, continuous