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allergies: patient recorded as having no known allergies to drugs attending: chief complaint: pancreatitis, fever, change in mental status major surgical or invasive procedure: none history of present illness: 70 yo f w/h/o cva, dementia, htn, hypothyroidism presented to osh from nh for fevers, increasing somnolence, abdominal pain, n/v x1. pt was admitted to nwh on w/initial vs 100.3 bp 179/98 hr 91 rr 14 97%ra. fever w/u included cxr-unremarkable, labs notable for amylase/lipase 1078/457 respectively. abdominal u/s w/multiple gall stones. abd ct w/moderate inflammatory changes of ruq>luq areas, minimal peripancreatic inflammation around head/body of pancrease. abd ct c/b 25cc contrast extravasation into l arm. conservative management of pancreatitis, surgery consulted and aggreed to continue conservative management of pancreatitis w/ivf resuscitation, npo and pain control. contrast extravasation also managed conservatively with elevation and ice placement, followed by plastics-no surgical intervention. on pt found to be less responsive, febrile 102 w/tachypnea rr 36 using accessory muscles abg on 3.5lnc 7.45/32/88. icu evaluation at nwh, however no micu beds available. transferred to micu for closer monitoring. past medical history: dementia--baseline a&0 x1 self, does not do own adls, had been ambulating w/walker -htn -cva -s/p fall -s/p orif l intertrochanteric fxr -osteoporosis -depression -hypoparathyroidism social history: lives in sunshine nh in . brother=hcp. at baseline does not to own adls. retired nurse. -no tob or etoh use. family history: unknown physical exam: vs: 103.4 rectally, 182/89 110 24 100%2lnc gen: arousable, not interactive heent: perrl, anicteric sclera, dry mm, cracked tongue, no cervical lad resp: cta b/l antly, no wheezing cv: reg nml s1, s2, no m/r/g abd: soft nd/nt, significantly diminished bs, guarding, no rebound ext: no peripheral edema, warm, 2+dp pulses b/l neuro: arousable, does not follow commands, normal reflexes, downgoing toes b/l pertinent results: imaging: osh: cxr--no pna/ptx/chf abd u/s--limited study due to motion; multiple stones in gb abd ct--moderate inflammatory changes ruq>luq; minimal peripancreatic inflammation around head/body of pancreas . labs: osh : amylase 1078; lipase 457 tbili 1.0, dbili0.3; tn-i<0.01 wbc 24.5 hct 43.0 plt 209 : amylase 482; lipase 156 wbc 18.7, hct 38.6 plt 168 abg 7.43/27/85 4lnc : wbc 19.5 hct 39.8 plt 180; ca 6.3 ph 1.2 abg 7.45/32/88 3.5lnc micro data blood--ngt; urine--e. coli pan sensitive transfer to labs: 10:31pm blood wbc-19.7* rbc-4.00* hgb-13.5 hct-39.7 mcv-99* mch-33.8* mchc-34.0 rdw-13.1 plt ct-233 10:31pm blood pt-15.2* ptt-26.5 inr(pt)-1.4* 10:31pm blood glucose-173* urean-10 creat-0.8 na-135 k-3.7 cl-99 hco3-24 angap-16 10:31pm blood alt-48* ast-57* ld(ldh)-878* alkphos-140* amylase-219* totbili-1.2 10:31pm blood lipase-114* 05:10am blood lipase-109* 03:00am blood lipase-72* 10:31pm blood albumin-3.1* calcium-7.8* phos-2.3* mg-1.7 06:24am blood type-art temp-38 o2 flow-4 po2-101 pco2-30* ph-7.48* caltco2-23 base xs-0 intubat-not intuba comment-nasal 10:53pm blood lactate-2.4* . imaging: cxr: there are no old films available for comparison. the heart is mildly enlarged. there is ill-defined pulmonary vasculature redistribution. the hemidiaphragms are poorly visualized suggesting bilateral pleural effusions. there is bilateral lower lobe volume loss. a focal infiltrate cannot be totally excluded. some mildly dilated loops of bowel are seen in the abdomen. impression: 1. fluid overload with bilateral pleural effusions and vascular plethora. . right upper quadrant ultrasound: limited views of the liver demonstrate no focal or textural abnormalities. small stones and sludge are seen within a nondistended gallbladder. there is no gallbladder wall edema or adjacent pericholecystic fluid to indicate acute cholecystitis. common bile duct measures 4 mm and is not dilated. there is no son sign. no ascites is seen in the right upper quadrant. limited views of the right kidney demonstrate no hydronephrosis or calculi. impression: limited study. cholelithiasis and sludge without evidence of acute cholecystitis. no biliary ductal dilatation. . head ct: 1. no evidence of acute intracranial pathology, including no sign of hemorrhage. chronic small vessel infarction as described above. 2. bilateral prominence of the lateral ventricles out of proportion to the degree of brain atrophy. question is raised of communicating hydrocephalus, which should be correlated clinically. . chest/abd/pelvis ct: 1. overall limited examination; however, no definite evidence of pulmonary embolus to the segmental level. 2. extensive severe pancreatitis with no definite evidence of pancreatic necrosis. no comparison exams are available at our institution limiting assessment for change. due to extensive inflammatory changes, the patient is at risk for sequela of severe pancreatitis including necrosis and vascular complications. 3. bilateral pleural effusions and compression atelectasis with no definite evidence of pneumonia. . echo: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is probably normal (lvef 50-60%) (the inferior wall appears hypokinetic on some views, but not all). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: overall low normal lvef. cannot exclude a regioanl wall motion abnormality due to technical limitations. brief hospital course: . #. fevers: fevers to 103.2 on presentation raised concern for sirs vs. biliary sepsis in the setting of pancreatitis and e-coli uti, elevated lactate, and leukocytosis. she was initially treated with meropeneum empirically for biliary infection possibility. upon improvement of pancreatitis, meropenem changed to cipro for pansensitive e. coli uti on .=, however, she developed another positive ua on this regimen and began spiking fevers again, therefore this was changed to ceftazadime on . blood cultures from the osh and were all negative. a ct chest showed b/l pulm infiltrates, but no pna. she defervesced around . all antibiotics were stopped around .(pnemovac and flu vaccine given at osh) . #. pancreatitis: most likely due to gall stones noted on abd u/s at osh. surgery was consulted and did not feel that the patient was a surgical candidate given her multiple other active medical issues. she was treated conservatively with ivf, npo and pain control. a post pyloric daubhoff was placed by for tube feeding. a repeat ct showed extensive and severe pancreatitis, but no sign of necrosis. she was started on sips with modified diet per speech and swallow on and was tolerating thin liquids and ground diet on . . #. delta ms/dementia: multifactorial in setting of infectious process, resolved with improvement of acute issues. baseline ms per report by patients brother is to self only, not independent in adl's. a head ct was done to rule out acute intracranial processes; it revealed atrophy along with enlargement of the ventricals out of proportion to the degree of atrophy. after transfer to the floor, her mental status stabilized and her brother felt that she returned to her baseline on . . #. tachypnea: the patient required supplemental o2 throughout her stay. she was noted to have worsening pulmonary edema by cxr despite diuresis at the osh. she was diuresised with lasix 40 iv prn with good response. the patient's pcp was ; the patient has no documented history of chf (though no recent echo and on standing lasix as outpatient). bilateral pleural effusions were noted on chest ct (negative for pna or pe). a tte was performed to assess for chf which showed low normal ef. she was also treated symptomatically with nebs. she remained stable on room air since transfer to the floor . #. htn: pt's htn managed with metoprolol; this was initially held due to her tenuous original status w/sirs. restarted as blood pressure increased. . #. code: full, confirmed w/brother=hcp . #. contact: brother as noted above and ; sunrise nh medications on admission: at home) -tylenol 1000mg tid -actonel 35mg -namenda 10mg -emabolex 7.5mg daily -toprol xl 50mg daily -lasix 40mg daily . (on transfer) -lovenox 40mg sc daily -synthroid 60mcg iv daiy -pantoprazole 40mg iv daily -lasix 20mg iv daily (received x1day) -lopressor 5mg iv q6hours x3 days -aspirin 81 mg po daily -colace -senna -zosyn 3.375mg iv q8hrs (day1= received for 3 days total) discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for fever. 2. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). 3. aspirin, buffered 325 mg tablet sig: one (1) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 6. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 7. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). discharge disposition: extended care facility: of discharge diagnosis: pancreatitis pulmonary edema hypertension hypothyroidism fever discharge condition: stable. patient is tolerating thin liquids and ground foods and her medications in applesauce. discharge instructions: please take your medication as directed please call your physician if you develop fever, chills, nausea, vomiting, abdominal pain or diarrhea as these may suggest a serious condition. followup instructions: please follow-up with your surgeon , md on 8:15. his phone number is . . please call for follow-up appointment with your primary care physician weeks after your discharge from the extended care facility. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Other persistent mental disorders due to conditions classified elsewhere Osteoporosis, unspecified Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Acute pancreatitis

allergies: nkda pmh: s/p nephrectomy for metastatic renal ca. has received radiation therapy and up until recetnly had been receiving sutent oral chemotherapy. pt has wide spread bone metastis. pt has rods and pins in spine and left arm. cc: pt had noticed increased wob at home and was at heme clinic for a scheduled blood transfusion and his sob was persistent and worsened. pt was found to be hypoxic with o2 sat 80%. he was sent to the ed and on exam was found to have 2+ pitting edema of both lower extremeties. he was placed on 4lnc with o2 sat's inc to 97%. pt's hct 22 which was down from 29.1. lactate was 2.8. pt sent to micu 7 for further treatment. review of systems: neuro: pt alert and oriented x 3. no c/o pain early in the shift. pt very about all tests and procedures. somewhat anxious about their results. able to move all extremeties. med with oxycontin for back pain at 2200. pt also requested a sleeping pill and received ambien 5mg with good results. resp: pt initially with 4lnc with o2 sat's in the mid to high 90's. pt went for ct scan/ultrasound so cannula was replaced with nrb mask at 100% so that pt would tolerate lying flat on ct table. o2 sat's 100% on the mask. lung sounds with crackles throughout and audible wheezes noted during the night when he was sleeping. pt has been coughing intermittently during the night but unable to raise any sputum. pt states that at home he had been raising green sputum. cv: pt in nsr to st with occ pac's and rare pvc. rates have been 80-100's. bp wnl. dipped to the 80's while sound asleep. when awake bp came back up to 120's. pt had head and chest ct done and leni's to determine if he had pe or dvt's. pt received bicarb drip prior to test d/t receiving dye in ct. pt's hct after 1st transfusion of bld was 22, pt then received 2nd unit. stim test done which was normal. pt started on heparin sc. pt is afebrile. gi: pt states that he doesn't have much of an appetite. pt has been taking sips of water and juice. abd soft/distended with pos bowel sounds. no stool overnight. pt on po protonix. gu: pt voids good amt's of clear yellow urine. skin: intact. access: pt has 2 piv's which are working well. id: pt's wbc 2.9. lactate 1.8. pt receiving vanco and ceftazadine social: pt lives with wife. today they spoke with dr. and it is the pt's wishes to be made a dnr/dni. plan today is to get results of ct scan's and leni's and discuss the results with the pt. monitor pulm status/o2 sat's, use nrb as needed. monitor hct check am labs. Procedure: Non-invasive mechanical ventilation Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Acidosis Unspecified pleural effusion Congestive heart failure, unspecified Unspecified essential hypertension Hyposmolality and/or hyponatremia Acute respiratory failure Secondary malignant neoplasm of brain and spinal cord Long-term (current) use of other medications Glucocorticoid deficiency Knee joint replacement Secondary malignant neoplasm of bone and bone marrow Anemia in neoplastic disease Arthrodesis status Pathologic fracture of other specified site Personal history of malignant neoplasm of renal pelvis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypoxia, hypotension major surgical or invasive procedure: none history of present illness: 56 yo m with widely metastatic renal cell ca on sutent presenting with hypoxia and hypotension. the patient states that approximately 2-3 days ago he awoke in the middle of the night to go to the bathroom and noted significant dyspnea on exertion. his shortness of breath was persistent and slightly worsened until the time of admission. on the day of admission, the patient was seen in oncology clinic for a scheduled transfusion for anemia thought to be associated with sutent myelosuppresion. the patient complained of sob and was found to be hypoxic to the 80's%. he was sent to the ed. the patient denies any recent fevers, chest pain, pleuritic pain or dizziness. he notes a non-productive cough over this time period with increased rle swelling more than lle swelling. the patient's wife notes that his rue also was transiently swollen. the patient describes a small amount of increased shortness of breath when supine. he notes possible sick contacts. in the ed, the patient was hypoxic to 80s% improved on 4l nc with sbp 80. he received approximately 1.5l ns and 1u prbc (for hct 22 down from 29 1 month prior). lactate was noted to be 2.8. cxr revealed a multifocal infiltrate and he received 1 dose of levofloxacin. the patient was felt not stable for cta and he was admitted to the icu for further care. past medical history: --metastatic rcc diagnosed after developing hematuria. s/p debulking nephrectomy in 10/. his disease progressed, and he received radiation to the lumbar spine, left chest wall, and left humerus. mets also to r temporal bone, t10 vertebral body with compression and extension into epidural space. he developed a left humeral pathologic fracture in requiring an im nail procedure. s/p laminectomy and poterior t3-l1 fusion for back pain from spinal met. he started high-dose interleukin-2 therapy in , but his disease continued to progress. he entered the avastin and sorafenib trial on and has had a decrease in size of his lesions. sorafenib had to be held for four weeks because of weight loss. his sorafenib was restarted after gaining some weight but at a reduced dose on . his avastin was held because of excessive proteinuria. he was withdrawn from the study on because of osseous metastases. started sutent , discontinued soon after that and then restarted on at reduced doses due to myelosuppression. cord compression at t10 . he underwent spinal embolization on followed by transpedicular decompression at t10, total laminectomy for excision of tumor at t11, and t3-l1 fusion on . he then received radiation therapy to t10-t11 and t5-t6, completed . -- htn -- gerd -- bilateral knee replacements social history: the patient lives in with his wife. is retired, but previously worked as a combat engineer in the military for 15 years and as a post officer in the post office for 30 years. he smokes approximately 1 pack over the span of 3 days. he reports having smoked one pack per day since the age of 15. he drinks very occasionally. he is married. he has two daughters. family history: brother w/ early heart disease. dm in both mom and dad. mother and daughter both have "thyroid problems." physical exam: 97.8 101 94/53 63 22 98% 4l nc 71.3kg, desats to 80's% with minimal movement. gen: cathectic, pale. nad. integumentary: no rashes or lesions. heent: perrl. cv: rrr. normal s1 and s2. no m/r/g. pulm: bilateral crackles r>l. abd: soft, nontender, nondistended. ext: rle edema 2+, lle edema 1+. back: large thoracic spinal surgical scar. neuro: a&ox3. pertinent results: cta - 1. no evidence of pulmonary embolism or aortic dissection. 2. new extensive multifocal bilateral ground-glass opacity with septal thickening and increase of size of preexisting pulmonary nodules. these findings are most likely secondary to pneumonia, less likely chf. recommend evaluation of pulmonary nodules following resolution of these opacities. 3. extensive bony metastatic disease within the spine, ribs and sternum. ct head - 1. new right cerebellar enhancing 1 cm lesion concerning for a metastatic focus. 2. worsening right frontal bone expansile lytic lesion consistent with bony metastasis. us rue/rle - no evidence of acute deep venous thrombosis in the right upper or right lower extremity. brief hospital course: 56 yo m with metastatic renal cell ca on palliative chemo and xrt with mets to spine with hypoxia and hypotension. # hypoxia. the patient was hypoxic to 80s% on admission to the ed but improved on 4l nc. also hypotensive to sbp 80's. he received approximately 1.5l ns and 1u prbc (for hct 22 down from 29.1 month prior). lactate was noted to be 2.8. cxr revealed a multifocal infiltrate and he received 1 dose of levofloxacin. a cta was negative for pe, but showed multifocal infiltrates consistent with pna. his antibiotics were broaden upon admission to the icu to vancomycin, ceftazidime, and levofloxacin. the patient continued to deteriorate during the next few days with increasing oxygen requirements. he was started on bactrim to cover for possible bactrim given his relative . a family meet was held given his worsening respiratory status that was felt to be a combination of infection, worsening metastatic disease, and bilateral pleural effusion. he and his family decided on cmo and all medications were discontinued. he passed away on at 11:01am. his wife was with him at this bedside. his family declined autopsy. medications on admission: ibuprofen 800 mg--1 tablet(s) by mouth twice a day as needed for pain lisinopril 40 mg--1 tablet(s) by mouth once a day metoprolol succinate 50 mg--1 tablet(s) by mouth daily oxycodone 5 mg--1 tab by mouth every 4 hours as needed for pain oxycontin 80 mg--2 tablet(s) by mouth twice a day protonix 40mg--take one pill each day vitamin b-6 100 mg--3 tablet(s) by mouth once a day sutent 12.5 mg--3 capsule(s) by mouth once a day tums 500 mg-- tablet(s) by mouth four times a day as needed discharge medications: the patient passed away on at 11:01am. discharge disposition: expired discharge diagnosis: respiratory failure discharge condition: the patient passed away on at 11:01am. discharge instructions: the patient passed away on at 11:01am. followup instructions: the patient passed away on at 11:01am. Procedure: Non-invasive mechanical ventilation Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Acidosis Unspecified pleural effusion Congestive heart failure, unspecified Unspecified essential hypertension Hyposmolality and/or hyponatremia Acute respiratory failure Secondary malignant neoplasm of brain and spinal cord Long-term (current) use of other medications Glucocorticoid deficiency Knee joint replacement Secondary malignant neoplasm of bone and bone marrow Anemia in neoplastic disease Arthrodesis status Pathologic fracture of other specified site Personal history of malignant neoplasm of renal pelvis

history of present illness: this 33 and week twin boy was born to a mother on who is 44 years old, gravida 3, para, blood type a negative, antibody negative, unknown group b strep status, hepatitis b surface antigen negative, and rapid plasma reagin nonreactive. prepartum and postpartum history: 1. previous pregnancy notable for in fertilization twin conception with donor eggs. 2. admitted in early - from to - for cervical shortening. at that time, mother received magnesium sulfate and betamethasone. 3. unremarkable course until the morning of delivery on when mother was admitted with premature rupture of membranes. she later developed mild contractions so the decision was made to deliver her by repeat cesarean section under spinal anesthesia. there was no maternal fever. mother did receive intrapartum ampicillin. apgar scores of 8 and 9 in this twin. physical examination on admission: initial physical examination was remarkable for a birth weight of grams, head circumference of 31.5 cm, and a length of 48.5 cm. the infant was pink. soft anterior fontanel. normal faces. intact palate. normal breath sounds. no murmurs. normal s1 and s2. femoral pulses present bilaterally and equal. flat, soft, and nontender abdomen. normal phallus, testes, and scrotum. stable hips. normal perfusion. normal tone and activity. summary of hospital course by system: 1. respiratory: the infant did not have any respiratory issues during the entire stay. has been on room air. 2. cardiovascular: no murmur during the infant's stay. there have been no spells. 3. fluids, electrolytes and nutrition: birth weight of grams. weight on of 1880 grams. the infant started feedings within the first 24 hours of life and is currently on 150 cc/kilogram per day total fluids with feedings at 110 cc/kilogram per day, advancing 15 cc/kilogram twice daily. d-sticks have been stable except for d-sticks yesterday less than 53 and 55. follow-up d- sticks have been normal. voiding and stooling. most recent electrolytes times 24 hours revealed sodium was 141, potassium was 4.5, chloride was 110, and bicarbonate was 22. 4. gastrointestinal: the infant had a maximum bilirubin of 8.8 on day of life three. started on single phototherapy. phototherapy will be discontinued. rebound will be drawn tomorrow. 5. hematology: the infant had an initial hematocrit of 48.6. 6. infectious disease: white blood cell count was 9.8 (16 polys, 0 bands, 78 lymphocytes) and platelet count was 228. the infant did receive ampicillin and gentamicin for 48 hours. when blood cultures were negative, the antibiotics were discontinued. 7. neurology: no issues. 8. sensory: no issues. condition on discharge: good. discharge disposition: to level ii nursery at . primary pediatrician: dr. at . discharge recommendations: 1. feedings: as above. 2. medications: none. 3. will require car seat testing. 4. followup of state newborn screening test which was done on day of life three. 5. immunizations: the infant has not received any immunizations. immunizations recommended: synagis respiratory syncytial virus prophylaxis should be considered from through for infants born between 32 and 35 weeks gestation with two of the following: daycare during respiratory syncytial virus season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or infants with chronic lung disease. in addition, influenza immunization is recommended annually in the fall for all infants once they reach six months of age. before this age (and for the first 24 months of the child's life) immunization against influenza is recommended for household contacts and out of home caregivers. discharge followup: the infant will require followup by pediatrician. discharge diagnoses: 1. prematurity at 33 weeks. 2. twin gestation. 3. physiologic jaundice. 4. status post rule out sepsis. , dictated by: medquist36 d: 16:07:00 t: 16:34:44 job#: Procedure: Enteral infusion of concentrated nutritional substances Other phototherapy 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

past medical history: hypertension. hypercholesterolemia. dilated cardiomyopathy. atrial fibrillation. status post cholecystectomy. status post left optic nerve infarct. status post hernia repair. status post permanent pacer insertion for heart block. allergies: no known drug allergies. preoperative medications: 1. lasix 20 mg p.o. q. day. 2. coumadin 5 mg p.o. q. day. 3. norvasc 5 mg p.o. q. day. social history: the patient lives with his wife. is a retired real estate . the patient drinks three to five alcoholic drinks per week. he is a remote smoker. ho course: the patient was admitted to on , preoperatively for anticoagulation though the patient had stopped his coumadin therapy in anticipation of going to the operating room. laboratory data was significant for a hematocrit of 43.8 and inr of 1.3, otherwise unremarkable. the patient had carotid ultrasound which showed no significant hemodynamic lesion of the right or left carotid artery and the patient was taken to the operating room on , by dr. where he underwent aortic valve replacement and mitral valve replacement and a maze procedure. the aortic valve was a 27 mm pericardial - and the mitral valve was 29 mm mosaic pig valve. total cardiopulmonary bypass time 176 minutes, crossclamp time 90 minutes. the patient was transferred to the intensive care unit on epinephrine infusion. the patient required moderate volume resuscitation postoperatively with labile hemodynamics and on postoperative day number 2 the patient was started on a milrinone infusion to improve his hemodynamics with moderate improvement. electrophysiology service was consulted to increase the rate in his permanent pacemaker to improve his hemodynamics. the patient remained intubated. the patient continued to require volume resuscitation and increase in his inotropic support for low cardiac indices. the patient was started on a heparin infusion as he was found to be in atrial fibrillation when his pacemaker was interrogated. the patient had a transesophageal echocardiogram on postoperative day number 4 which showed an ejection fraction of 40 percent, mild local left ventricular and right ventricular systolic depression, mild tricuspid regurgitation, stable aortic and mitral prosthesis. the patient was started on amiodarone infusion for control of the atrial fibrillation. the patient was still unable to wean from mechanical ventilation, due to his unstable hemodynamics. the patient was started on natrecor to decrease his pulmonary artery pressures. on postoperative day number 5, the patient spiked a fever to 102. he was pancultured. the patient had blood cultures that were drawn from his pa catheter which grew gram positive cocci in pairs and clusters. the line was removed and resited. the blood cultures were eventually one out of four which was coagulase negative staphylococcus. the patient was started on vancomycin. the patient was cardioverted from atrial fibrillation to sinus rhythm with some improvement in his hemodynamics. over the next several days, the patient's milrinone was weaned. the patient remained sedated and intubated. the patient was hemodynamic. the patient had several more episodes of atrial fibrillation all which caused increase in his hemodynamics and required cardioversion. as the patient was unable to be awoken and weaned from the ventilator by postoperative day number 10, it was decided that the patient should undergo a tracheostomy which was done and a number 8 portex trach was placed. the bronchoscopy at that time showed copious thick secretions with edematous mucosa. the sputum subsequently grew out methicillin- resistant staphylococcus aureus. the patient continued to require low dose epinephrine to maintain adequate cardiac output. the patient's sedation was gradually weaned with intermittent increasing agitation and a drop in his hemodynamics. by postoperative day number 17, the patient's epinephrine had been weaned down and he appeared to be tolerating it well. the patient continued on natrecor, however, on postoperative day number 19, it was noted that the patient had dropping mixing his oxygen saturation and appeared to be volume depleted. the patient had all of his lines changed. the patient was found to have a continued drop in hematocrit, and it was realized that the patient had an increasing abdominal distention. the patient had a computerized axial tomography scan of his abdomen which showed a retroperitoneal bleed. the heparin anticoagulation was stopped. a vascular surgery consult was obtained, and it was recommended to continue to treat the patient medically. the measurement of the hematoma was measured at 11 by 11 cm, extending from the right iliacus muscles to the right psoas and then extending superiorly with the displacement of the right kidney anteriorly. the patient had significant abdominal distention at this time with concerns for abdominal compartment syndrome. the patient had continuous bladder pressure monitors which remained relatively stable. however, the patient's creatinine began to rise with concerns for renal perfusion. the patient continued to require blood transfusions. a renal consult was obtained and they felt that the rise in creatinine was due to the patient's acute bleed and volume depletion, and hypotension requiring pressors. on postoperative day number 22, the patient was noted to have a drop in his platelet count. a heparin antibody was sent which was subsequently negative. the patient was transfused platelets as it was felt that he was continuing to have some bleeding from the retroperitoneal hematoma. the patient's creatinine gradually began to decrease over the next several days. critical care consult was obtained for the patient's failure to wean from the ventilator and continued agitation. it was recommended that the patient undergo bronchoscopy and increase some of his ventilator settings. the patient's sputum culture continued to grow methicillin-resistant staphylococcus aureus and the patient was switched from vancomycin to linezolid which resulted in a decrease in his temperature. the patient's epinephrine over the next several days was slowly weaned off. the fentanyl and versed drips which had been used for sedation were slowly weaned off. as the intravenous sedation was weaned off the patient continued to be more awake and more agitated. the ventilator was gradually weaned. the epinephrine was weaned off by postoperative day number 28. the natrecor was weaned off by postoperative day number 30. the patient's pulmonary artery catheter had been removed and his clinical staff indicated that he was tolerating the wean of his inotrope. on postoperative day number 32, the patient was taken to the operating room for an open gastrostomy tube which he tolerated well. the patient has been able to wean off the ventilator with periods of trach collar and at this point it is felt that he is stable for discharge to a rehabilitation facility. condition on discharge: temperature 98.4, pulse 80 av paced, blood pressure 129/58, respiratory rate 25. he is currently on a 50 percent trach mask. neurologically the patient is awake and alert, following commands, unable to evaluate whether or not the patient is oriented, however, he responds appropriately. heart is regular rate and rhythm. breath sounds are coarse bilaterally. abdomen, positive bowel sounds, soft, nontender, nondistended. g-tube site is clean, dry and intact. there is no drainage. the extremities have 1 to 2 plus edema. laboratory data is white blood cell count 6.2, hematocrit 33.7, platelet count 103, sodium 145, potassium 4.9, chloride 112, bicarbonate 25, bun 33, creatinine 1.0 and glucose 92. his sternal incision is clean, dry, well healed and intact. sternum is stable. discharge diagnosis: status post aortic valve replacement, mitral valve replacement and maze procedure. atrial fibrillation. dilated cardiomyopathy. postoperative respiratory failure. postoperative acute renal failure which is resolved. status post tracheostomy. status post open gastrostomy tube placement. status post spontaneous retroperitoneal bleed. methicillin-resistant staphylococcus aureus pneumonia. history of permanent pacemaker. discharge medications: 1. amiodarone 200 mg p.o. once daily. 2. prevacid 30 mg p.o. q. day. 3. lasix 20 mg p.o. q. day. 4. captopril 6.25 mg p.o. t.i.d. 5. clonazepam 1 mg p.o. t.i.d. 6. linezolid 600 mg p.o. b.i.d., the last dose should be . the patient should be receiving humidified oxygen via his tracheostomy to maintain oxygen saturation greater than 92 percent. the patient should be receiving tube feeds and all medications via his percutaneous endoscopic gastrostomy tube. tube feedings should be promod fiber with goal rate of 80 cc/hr. when the patient is sufficiently stable from a respiratory standpoint, he should have a swallowing evaluation to clear him for p.o. intake. fop: the patient should follow up with dr. upon discharge from rehabilitation. he should follow up with his primary care physician, . in two to three weeks and he should follow up with dr. upon discharge from rehabilitation. , m.d. Procedure: Extracorporeal circulation auxiliary to open heart surgery Fiber-optic bronchoscopy Fiber-optic bronchoscopy Excision or destruction of other lesion or tissue of heart, open approach Temporary tracheostomy Open and other replacement of aortic valve with tissue graft Open and other replacement of mitral valve with tissue graft Other gastrostomy Injection or infusion of nesiritide Diagnoses: Other primary cardiomyopathies Pure hypercholesterolemia Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Infection with microorganisms resistant to penicillins Mitral valve insufficiency and aortic valve insufficiency Atrial flutter Pulmonary collapse Methicillin susceptible pneumonia due to Staphylococcus aureus Cardiac pacemaker in situ Urinary complications, not elsewhere classified Mitral valve stenosis and aortic valve stenosis Hemorrhage, unspecified

history of present illness: patient is a 74-year-old man who is transferred from an outside hospital on . he presented to the outside hospital with a history of a couple days of abdominal pain in the right upper quadrant without radiation. the pain had gradually increased. he had no chest pain. no shortness of breath. on the evening of the 24th, patient's abdominal pain actually began to decrease and he fell asleep around 2 a.m. and in the morning he had a normal bowel movement, was not loose and he had juice for breakfast, but developed chills soon thereafter. he called his primary care physician who told him to go to the emergency department. on the way to the emergency department, he developed nausea and vomited some clear fluids. other than that, he did not vomit. he had minimal pain that morning in the lower abdomen bilaterally. he has no prior history of this abdominal pain, no history of bright red blood per rectum, no hematemesis. at the outside hospital, his temperature was 101. chest x-ray was questionable for a right lower lobe infiltrate and the patient was hypotensive. ultrasound of gallbladder was consistent with stones. he had cardiac enzymes, ck 146, troponin .2, pt was 17, inr 1.9, white blood cell count 17, .2 bands, total bilirubin was 6.7, direct bilirubin 3.9, alt 226, ast 204, amylase 41, bicarbonate 18. patient was given levofloxacin, flagyl, tylenol, three liters of normal saline. past medical history: 1. patient had a pacer placed five years ago for bradycardia and heart block. 2. he has a history of hypertension. medications at home: zestril, norvasc. allergies: no known drug allergies. physical examination at emergency room: patient's temperature was 98.4. pulse 105. blood pressure 108/66. respiratory rate 30. saturating 97% on nasal cannula. in general, he appeared uncomfortable. his sclera were mildly icteric. chest: he had bilateral wheezes at bases without crackles or rhonchi. cardiovascularly, he was tachycardic with a regular rhythm. his abdomen was tender in the right upper quadrant with positive sign. he had mild guarding, bowel sounds were present. he was mildly distended. he was not tympanitic. he had no tap tenderness. extremity was warm with no edema. rectal was guaiaced, scant positive loose stool in rectal vault, no masses palpated, nontender. laboratories at this time: white blood cell count 11.4, hematocrit 33, platelets 95,000. chem-7: sodium 140, potassium 2.9, chloride 107, bicarbonate 16, bun 29, creatinine 1.4, glucose 120. arterial blood gases at that time was ph 7.39, pco2 23, po2 89, bicarbonate 14 and a base deficit of 8. alt was 232. ast 185. alkaline phosphatase 96, t bilirubin 5.8, amylase 26, lipase 9. his urinalysis had moderate bilirubin, white blood cells per high powered field. patient's lactate was 4.6. the patient was admitted with presumed cholecystitis/cholangitis septic. the plan at that time was for aggressive resuscitation as well as antibiotics. ampicillin, levofloxacin and flagyl. also at that point, it was being determined whether to take patient to the operating room or to have a percutaneous drainage of his gallbladder. hospital course: the patient was admitted to the surgical intensive care unit. patient was in shock, which seemed to be a combination of septic, as well as cardiogenic shock. patient had a low systemic vascular resistance and also a low cardiac output. therefore, it was deemed safer for the patient to undergo percutaneous drainage of the gallbladder. gastrointestinal was consulted and they recommended possible follow-up endoscopic retrograde cholangiopancreatography if percutaneous drainage of the gallbladder did not resolve the infection. cardiology was also consulted. patient ruled out for myocardial infarction. their recommendation was to follow cardiac index. on , radiology placed a self-locking cholecystostomy tube without complications. patient was aggressively resuscitated with fluids. his blood pressure improved but his cardiac index remained low. he was put on dobutamine drip. on hospital day number two, the patient had a cardiac index of 2.02 and an svr of 960. he had good urine output. his white blood cell count was down to 14.3. gastrointestinal follow-up: still questionable cholangitis without adequate drainage of the common bile duct. a endoscopic retrograde cholangiopancreatography was done on hospital day number three. patient was actually intubated earlier that morning because of respiratory distress. stent was placed. the gallbladder filled with contrast. also with dark cloudy bile was visualized. it was determined that patient needs a sphincterotomy but it was not done at that time because of his coagulopathy, despite ongoing ffp transfusions and vitamin k administration. he was felt to have some underlying liver insufficiency (possibly etoh-related as patient made and drank his own wine). on surgical intensive care unit day number four, patient was given platelets and ffp in order to get the inr below 1.5 and platelets above 50,000. on surgical intensive care unit day number five, the ventilator was weaned and the patient was extubated. he was also transfused one unit of platelets, two units of ffp. during this time, patient is on penicillin day number four, zosyn day number five and gentamicin day number five. surgical intensive care unit day number six, patient was clinically improving. white blood cell count was 10.5. inr at this time was 1.5. patient got a hida scan which failed to light up the gallbladder as well as the duodenum. bilirubin had been steadily rising. so, it was thought that there was an obstructed common bile duct. endoscopic retrograde cholangiopancreatography again was performed on surgical intensive care unit day number seven. stent was occluded and was removed. a 4 mm common bile duct stone was removed. surgical intensive care unit day number eight, total bilirubin decreased to 8.7. on surgical intensive care unit day number eight, patient also began to become irritable and was refusing some treatments. psychiatry was asked to see him. it was their opinion that he was delirious and not capable of making an informed decision. they suggested haldol for his agitation. patient was transferred out of the surgical intensive care unit to the floor on hospital day number nine. he is doing well. his foley was discontinued. his central venous line was discontinued. patient was also less irritable. the one-to-one sitter was discontinued. since coming to the floor, patient's total bilirubin had continued to drop. he has continued to do well and his mental status normalized. on hospital day number ten, he was tolerating a regular diet. he was up out of bed, ambulating. his percutaneous draining continued to drain bile at about 250 cc daily. the patient had had accumulation of peripheral edema due tofluid retention during his septic state. this improved, but later on in his course, he was noted to have clear/ green fluid draining around his cholecystostomy tube (the bile was much darker green). ultrasound showed that the tube was in the gallbladder and there was no biloma. he was continued on antibiotics therefore. on hospital day number 14, he is ready for discharge. he will go home with vna visiting twice a day to change his bile bag, as well as to change his dressing. he will remain on levaquin 500 mg for three weeks. he is being discharged on norvasc and zestril. he is to follow-up with dr. and his pcp. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Endoscopic insertion of stent (tube) into bile duct Trocar cholecystostomy Diagnoses: Unspecified essential hypertension Unspecified septicemia Aortic valve disorders Acute respiratory failure Cholangitis Calculus of gallbladder and bile duct without cholecystitis, with obstruction

service: neurosurgery history of present illness: the patient is a 74 year-old gentleman who fell down a long flight of stairs at a restaurant. circumstances are unclear. the patient was uncooperative and combative, but neurologically intact at the scene. on arrival the patient opened his eyes to command, allergies: tetracycline, strawberries, ciprofloxacin, zovirax and vitamin e. past medical history: according to the wife he has no past medical history. hematomas with no midline shift. a parietal occipital subdural hematoma with pneumocephalus likely related to occipital bone fracture, fracture of the right mastoid, bifrontal and bitemporal contusions. physical examination: his temperature was 96.3. heart rate 76. blood pressure 140/70. he had blood coming from his external auditory meatus. pupils were 2 mm and briskly reactive. he withdrew all four extremities to pain. plantar reflexes, toes down bilaterally. deep tendon reflexes are 2+ throughout. laboratories on admission: white blood cell count 10.8, hematocrit 36.9, platelets 155, ptt 12.3, inr 1.1, sodium 137, k 3.6, chloride 103, co2 23, bun 15, creatinine .7, glucose 123. hospital course: the patient was admitted to the surgical intensive care unit after being initially intubated and sedated in the intensive care unit. the patient's neurological status, pupils were 2 mm and reactive. he had a weak cough and gag. he localized to pain. he appeared to withdraw the upper extremities greater then the lower extremities, but not following commands and no spontaneous movements were noted. he was started on dilantin and a vent drain was placed on the day of admission without complications. the patient had a repeat head ct done on , which showed slight midline shift. the patient was started on mannitol. the patient had an orthopedic consult regarding the c1-c2 question the rotatory subluxation. repeat ct scan of the c spine shows diffuse degenerative changes with no obvious and lanto axial rotatory subluxation. however, the patient will require an mri of the c spine or flexion and extension films when the patient's mental status improves to rule out ligamentous injury. therefore the patient will remain in hard collar. the patient spiked a temperature on to 102.2. his blood cultures from two out of four bottles were positive for gram positive coxae. sputum was also positive for gram positive coxae and staph. the patient was started on oxacillin. the patient was sedated on propofol for periods of agitation. he would open his eyes to painful stimuli. he moved the right arm and leg with no spontaneous movement on the left side. withdraw the left side to pain. pupils are equal, round and reactive to light. on the patient was trached and pegged. neurologically he remained unchanged. he opened his eyes to sternal rub. he withdrew to pain on the left side moving the right side spontaneously and not following commands, not attentive to examiner. the patient was changed from oxacillin to zosyn. the patient's sputum culture from grew out xanthomonas. the patient was then switched to zosyn. the patient had a picc line placed on without complications. he was weaned to trach collar on . the patient was transferred to the step down unit on far nine on . he remained neurologically unchanged and was transferred to the regular floor on . neurologically his mental status was unchanged. he will open his eyes to voice. he moves his right side spontaneously. his left side withdraws to pain. this morning he did follow simple commands by showing two fingers for the first time. he remains on tube feedings at 3/4 strength deliver with 50 grams of promod at 50 cc an hour. his vital signs have been stable. he has been afebrile. he has been evaluated by physical therapy and occupational therapy and found to require rehab. he sats are 96 to 97% on a 40% trach mask and his vital signs have been stable. he does have duoderm intact to the sacrum for a small decubitus and he is tolerating his tube feedings. he will be discharged to rehab and follow up with dr. in one month with repeat head ct at that time. medications on discharge: albuterol one puff inhaler q 4 to 6 hours prn, nystatin oral suspension 5 cc po q.i.d., dilantin 400 mg nasogastric b.i.d., tylenol 650 po q 4 hours prn, zosyn 4.5 grams intravenous q 6 hours, epogen 40,000 units subq once a week. condition on discharge: stable. , m.d. dictated by: medquist36 d: 09:27 t: 10:46 job#: Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Percutaneous [endoscopic] gastrostomy [PEG] Intravascular imaging of intrathoracic vessels Temporary tracheostomy Diagnoses: Pneumonia, organism unspecified Accidental fall on or from other stairs or steps Other septicemia due to gram-negative organisms Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath major surgical or invasive procedure: tracheostomy conversion peg to pej tube history of present illness: 70yo f with als (nonverbal at baseline but hearing is ok and communicates via keypad), ra, and g-tube, with multiple past admissions for aspiration pna admitted for sob. additional sx included subjecive choking, cough and increased secretions which have been difficult to celar. patient reported no fevers or chills and no dysuria. home nebulizer did not help. . in the ed, the pt was afebrile but tachycardic and hypertensive. she was given nebs, decadron and levo/falgyl with some improvement in her sx and vitals. . on the floor she did well. tube feeds were continued. she developed worsening hyponatremia with a stable na of 118. this was managed with salt tabs and fluid restriction. she remained afebrile. she started bipap for the first time on the day she was tx'd to the icu in the early afternoon. her settings were . she tolerated it for a short time during the day and then it was taken off. at 7pm she was in her room and called the nurse to tell her that she felt sob. o2 sat was 88% on ra. prior to this she had been 95% on ra. trigger was called and the ho ordered a cxr that showed blurring of the r hemidiaphragm and increasing rll infiltrate. she was started on bipap nasal mask at 10/5 with 10lpm of oxygen with 93-95% oxygen sats. she was transfered to the icu for further monitoring. past medical history: 1. als - diagnosed in . seen recently in neuro clinic and felt to have a grave prognosis. no longer walking, communicates with keypad as is non-verbal. started on inexsufflator. 2. recurrent aspiration pna. 3. recent distal tib-fib fracture s/p fall 4. recent hospitalization in for pna/uti 5. ra 6. s/p g-tube placement social history: lives at home with her husband, at home. has two daughters nearby that are involved with care. does not smoke or drink. family history: nc physical exam: vs: af, 120/86, 98, 94%10l bipap 10/5 gen: thin, weak appearing woman in nad on bipap heent: pupils dilated at 5mm bilaterally, eomi, op clear, neck supple cv: mild tachycardia, regular rhythm, no m/r/g chest: no crackles nor rhonchi, but some transmitted bipap sounds. prolonged expiratory phase. scattered expiratory wheezes abd: soft, nt, nd, bs present, g tube in place ext: wwp, no c/c/e neuro: non-verbal but makes her needs known. answers yes and no with head nod. no facial asymmetry. shrug . sensation intact to lt. motor: delt/biceps/hip flexors. grip, plantarflexion. dorsiflexion, wrist extension. fasciculations in upper and lower limbs bilaterally. bulk reduced. tone somewhat flacid. no clonus. reflexes 3+ bilaterally. pertinent results: admission labs: 02:45am blood wbc-13.5*# rbc-4.28 hgb-13.0 hct-38.0 mcv-89 mch-30.4 mchc-34.2 rdw-14.4 plt ct-397 02:45am blood neuts-89.8* lymphs-6.9* monos-3.1 eos-0 baso-0.1 02:45am blood plt ct-397 02:45am blood glucose-148* urean-17 creat-0.4 na-129* k-3.9 cl-87* hco3-33* angap-13 06:45am blood calcium-9.5 phos-3.1 mg-1.8 06:45am blood tsh-1.6 06:45am blood cortsol-9.0 . discharge labs: 04:15am blood wbc-12.4* rbc-3.13* hgb-9.9* hct-28.1* mcv-90 mch-31.7 mchc-35.3* rdw-15.3 plt ct-317 04:15am blood plt ct-317 05:00am blood pt-12.7 ptt-35.7* inr(pt)-1.1 04:15am blood glucose-113* urean-14 creat-0.3* na-132* k-4.1 cl-95* hco3-35* angap-6* 04:19am blood alt-13 ast-25 ld(ldh)-130 alkphos-59 totbili-0.2 04:15am blood phos-3.1 mg-1.8 11:58am blood type-art temp-36.8 rates-10/1 peep-5 fio2-50 po2-140* pco2-61* ph-7.39 calhco3-38* base xs-9 comment-ax=96.2 11:58am blood lactate-0.9 02:55am blood lactate-1.8 06:16am blood freeca-1.24 . 06:05am urine color-straw appear-slhazy sp -1.025 06:05am urine blood-sm nitrite-neg protein-neg glucose-neg ketone-15 bilirub-neg urobiln-neg ph-6.5 leuks-neg . clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia. reference range: negative. sputum below: considered colonizer; no fevers, no coughing: gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci. in pairs, chains, and clusters. respiratory culture (preliminary): ? oropharyngeal flora. staph aureus coag +. heavy growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | . uctx no growth bctx no growth . echo: the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). regional left ventricular wall motion is normal. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a small partially echo-filled inferolateral pericardial effusion without evidence for tamponade physiology. brief hospital course: a/p: 70yo f with als and ra who presented with difficulty clearing secretions and coughing. given her known als, previous hx of aspiration pna, and elevated wbc count, this is most likely was a repeat aspiration event. . 1. secretions/coughing: likely aspiration pna as above. as the pt is on chronic prednisone 3mg daily for ra, she was given stress dose steroids in the ed. these were switched to oral prednisone and she was tapered back to her baseline 3 mg daily during this admission. she was treated with levofloxacin/metronidazole 10 day course. received nebulizer tx c albuterol/atrovent. underwent intermittent chest pt with good effect. had sputum gram stain near d/c () with + gs for coag + staph; no fevers, no cough. likely colonizer; sensitivities pending. please follow-up on speciation and sensitivities. . 2. als: the pt was diagnosed in and progression of als is most likely contributing to her repeated aspiration pna. underwent placement of a tracheostomy . sutures around trach need to be removed in 10 days. did well on ventilatory support; was on ps 10/5/fio2 0.4; seemed comfortable. tried on ps 5/5/fi02 0.4 with some success. could consider trach mask trials if pt. wants time off vent. . 3. hyponatremia: the pt has baseline hyponatremia ranging between 120 to 134 with averages in mid 120s. therefore this degree of hyponatremia is baseline for pt. however the etiology of the hyponatremia remains unclear. the pt does not appear particularly hyper or hypovolemic on physical exam making siadh more likely. tsh and cortisol levels wnl. plan to continue salt tabs and bolus free water through pej tube as needed. should have biweekly (at least) sodium levels monitored. . 4. ra: continued prednisone and methotrexate 12.5mg weekly. . 5. fen: peg tube converted to pej tube without complications by gi service. novasource 2.0 @ 40 cc/hr. . 6. depression: continued fluoxetine 20 mg/5 ml solution daily. . 7. ppx: ranitidine 15 mg/ml as well as colace for gi ppx; stopped hep sc on d/c given chronic quadriplegia . 8. code status: full code as per pt and her husband. palliative care consulted and pt. focusing on 1 day at a time and wants full measures at this time. should be readdressed periodically with patient and family. medications on admission: 1. acetaminophen 325 mg 1-2 tablets po q4-6h prn 2. prednisone 3 mg daily. 3. methotrexate 12.5 mg weekly. 4. multivitamin (liquid) 5. folic acid 1 mg daily. 6. ascorbic acid 90 mg/ml drops daily. 7. fluoxetine 20 mg/5 ml solution daily. 8. ranitidine 15 mg/ml . 9. benztropine 0.5 mg daily. discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 2. ascorbic acid 90 mg/ml drops sig: one (1) po daily (daily). 3. fluoxetine 20 mg capsule sig: one (1) capsule po daily (daily). 4. ranitidine hcl 15 mg/ml syrup sig: one (1) po bid (2 times a day). 5. sodium chloride 0.65 % aerosol, spray sig: sprays nasal (2 times a day) as needed. 6. lorazepam 1 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 7. sodium chloride 1 g tablet sig: two (2) tablet po bid (2 times a day). 8. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 11. methotrexate 2.5 mg tablet sig: five (5) tablet po 1x/week (tu). 12. methylphenidate 5 mg tablet sig: one (1) tablet po bid (2 times a day). 13. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 14. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed). 15. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours) as needed. 16. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours). 17. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 18. prednisone 1 mg tablet sig: three (3) tablet po daily (daily). discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary als aspiration pneumonia discharge condition: good discharge instructions: take all medications as instructed. keep appointments with health care providers. rehabilitation as per protocol at pulmonary rehab; can attempt trials off vent if patient desires. settings on discharge: cpap c ps: ps 10/peep 5/fio2 0.4. return to the ed or call your pcp if you experience fevers, chills, shakes, light headedness, dizziness, nausea, vomiting, worsening cough. followup instructions: you should call dr. at to arrange follow up in the next two weeks. please follow up on sputum (coag + staph) for further speciation/sensitivities. patient afebrile, most likely colonization. Procedure: Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Temporary tracheostomy Percutaneous [endoscopic] gastrojejunostomy Diagnoses: Amyotrophic lateral sclerosis Pneumonitis due to inhalation of food or vomitus Retention of urine, unspecified Rheumatoid arthritis Other disorders of neurohypophysis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered ms major surgical or invasive procedure: r subclavian central line placement intubation- no complications. history of present illness: pt is a 51 year old african american woman with pmh sig for htn and hyperlipid with a remote hx of depression who was admitted on after she was found unresponsive by her husband at their home evening. she reportedly went to her room that evening to take a nap, which was not unusual, at around 5pm per her children. her husband checked on her at 8:15 pm and found her unresponsive and (per medical chart)"foaming at the mouth." she reportedly had multiple pill bottles out, but it was unclear at that point how much she had taken. pt psych who went through the pills with the patient's husband, there were approx 70 klonipin tabs missing, in addition to nifedipine and amytriptiline tabs missing. . in the ed, vs hr 60s sbp 110-130s (no temp taken at that time). noted to be very lethargic and vomiting, and subsequently intubated for airway protection. no abg taken prior to intubation. pt given propofol for intubation. pt had ng tube placed, and charcoal was given. labs were notable for a urine tox (+) for benzodiazepines and tcas. abg taken after intubation 7.24/67/304 (vent ac 550 x 15/peep 5/fio2 100%). pt then transferred to the micu. in the micu she remained intubated for obtundation. she was extubated on . she then had a witnessed aspiration and was started on levo and flagyl. . the patient is still unable to give a consistent story of why she is in the hospital. she reports that she fell off of a step stool and hit her head. she also reports that she is in th hospital for her pneumonia. she ademently denies any overdose on her medications as the reason she was admitted. she denies taking too many of her pills. per patient's nurse in the icu, who has been working with her for several days, after she was extubated 2 days ago, she did say that she took too many pills, but since then has also stated that she took too many pills because she was having pain in her foot which she broke one year ago. past medical history: htn hyperchol ? depression/ anxiety s/p surgical repaier for foot ankle fx. c/b staph infection. social history: lives with husband and 3 kids. occ etoh. 3 cig/d x 4 months. no ivdu/no illicit drug use. does not work. family history: dm physical exam: vitals: general: awake and alert. pleasant and talkative. obese. heent: pupils 3mm b/l and reactive. anicteric, pink conjunctivae. no lad. heart: rrr s1 s2; no m/g/r lungs: audible exp wheeze. bronchial bs. no rales or rhonchi on exam. abd: obese, soft, nt, nd, slightly hypoactive bs ext: warm, 1(+) radial/dp pulses b. r foot with well healed scars and 1+ edema. l foot with trace edema. neuro: awake and alert. - oriented x3 - cn ii-12 intact - able to recall objects - unable to spell world or perform serial 7 or 3's. - able to count backwards from 10. - aware of war and current president. states former president was . pertinent results: 10:00pm glucose-128* urea n-11 creat-1.1 sodium-139 potassium-5.7* chloride-104 total co2-27 anion gap-14 10:00pm alt(sgpt)-47* ast(sgot)-60* ck(cpk)-276* alk phos-68 amylase-116* tot bili-0.3 10:00pm lipase-26 10:00pm ck-mb-4 ctropnt-<0.01 10:00pm albumin-4.0 calcium-7.9* phosphate-5.3* magnesium-2.0 10:00pm asa-neg ethanol-neg acetmnphn-6.0 bnzodzpn-neg barbitrt-neg tricyclic-pos 10:00pm urine hours-random 10:00pm urine ucg-negative 10:00pm urine bnzodzpn-pos barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 10:00pm wbc-10.2 rbc-3.94* hgb-11.2* hct-34.3* mcv-87.1 mch-28.3 mchc-32.5 rdw-15.2 10:00pm neuts-82* bands-0 lymphs-14* monos-2 eos-2 basos-0 atyps-0 metas-0 myelos-0 10:00pm plt smr-normal plt count-331 10:00pm pt-13.6* ptt-23.2 inr(pt)-1.2 10:00pm d-dimer-288 10:00pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 10:00pm urine color-straw appear-clear sp -1.016 . . ct of the brain without intravenous contrast: no acute intracranial hemorrhage is identified. there is no mass effect or shift of normally midline structures. the lateral ventricles are symmetric and nondilated. the -white differentiation is preserved. there are tiny basal ganglia lacunes. bone windows demonstrate no evidence of fracture within the surrounding osseous structures. the mastoid air cells are normally pneumatized. there is a small amount of fluid within the ethmoid air cells, and minimal mucosal thickening within the right maxillary sinus. there appears to be proptosis. impression: 1. no acute intracranial hemorrhage or mass effect. 2. minimal mucosal thickening within the maxillary sinus and fluid in the ethmoid sinuses, findings that could possibly relate to mild sinusitis. . . post extubation cxr: the endotracheal tube and ng tube have both been removed. a right subclavian central venous catheter remains in place. there is an unusual sharp turn and a kink seen within the mid portion of the line in the brachiocephalic vein. there is mild cardiomegaly. mediastinal contours are normal. the aorta is slightly unfolded and tortuous. the lungs are clear. pulmonary vasculature is normal. there is no pneumothorax. the osseous structures are unremarkable. impression: mild cardiomegaly with no radiographic evidence of acute cardiopulmonary process. interval extubation. . . brief hospital course: assessment: a 51-year-old female admitted after found down with respiratory failure, question benzo overdose, now stable with a question of delirium. 1. respiratory failure: the patient was intubated for airway protection on admission secondary to question of an overdose. avg on admission was consistent with respiratory acidosis from hyperventilation. the patient had a questionable history of asthma versus copd. she had an audible wheeze, but no wheeze on exam. the patient was continued on her albuterol and atrovent inhalers during her admission. she was extubated after approximately 48 hours. after this, she had a witnessed aspiration for which she was treated with levofloxacin and flagyl for 5 days. her respiratory status markedly improved by the time of discharge and she was requiring no further medications. the patient states that she does not take inhalers at home and therefore these were discontinued on discharge. 2. mental status changes/overdose: on admission, the patient had a positive tox screen for benzodiazepines, which were most concerning for mental status changes. the patient also had positive tox screens for tricyclic acids, which she was known to be taking for sleep. an ekg was done in the icu, which showed mild qt prolongation, which resolved by the time of transfer to a medicine floor. all narcotics were held in both the icu and after the patient was transferred to the medicine floor. mental status improved, however, the patient continued to deny the fact that she overdosed. the patient states after she awoke in the icu, that she had tripped on a stool in her bedroom and that is why she was found down. however, per reports from ems, there were pills all over the patient's bed. the patient states that these pills spilled when husband dragged her across the bed. the patient's story persisted with multiple different interviews by different physicians. the patient was seen by psychiatry, who felt that initially the patient was delirious; however, by the time of discharge, she was no longer delirious and maintained her story that she did not accidentally or intentionally overdose on pills. she states that occasionally she will take extra klonopin when she gets anxious. she was recently given the klonopin for her anxiety by a psychiatrist that she sees in the outpatient. the patient was monitored by psychiatry service throughout her admission, and felt that she did not require an inpatient admission after she was medically stable. her mental status did improve and per her family she was at her baseline at the time of discharge. the patient was not discharged on any narcotics or benzodiazepines and was asked to follow up with her outpatient psychiatrist for further evaluation of the need for antianxiety medications. the patient denied any psych history and states that she was only taking the klonopin on rare occasion. 3. lfts abnormality: patient had elevated lfts on admission, but they trended down to normal on transfer from the icu. it was felt that this may have been due to an element of shock liver, and hypoperfusion while the patient was down. her acetaminophen level was 6. 4. hypertension. patient has an extensive list of blood pressure medications including clonidine 0.2 mg p.o. b.i.d., lopressor 50 mg p.o. b.i.d., nifedipine 30 mg sustained release p.o. once daily., and hydrochlorothiazide 20 mg p.o. once daily. the patient was maintained on this regimen and her blood pressure was well controlled throughout her admission. 5. hyperlipidemia: after her lfts normalized, the patient was restarted on her home dose of lipitor. 6. status post foot surgery: upon further investigation of this, the patient reports that she broke her foot approximately 1 year ago and the incision of the repair became infected. she was on a course of antibiotics and had severe pain. she was receiving pain medication for a while after this procedure, however, she does report that she no longer takes pain medications for it, however, still has pain in her foot. all pain medications were held during this admission due to her mental status changes. the patient also did not request further pain medications during this admission. 7. fen. the patient was maintained on a cardiac diet and her electrolytes were repeated as needed. the patient was a full code during this admission. medications on admission: amitriptyline clonidine lipitor asa nifedipine cr ambien toprol nitro tab hctz tramadol discharge medications: 1. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). 2. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). 3. clonidine hcl 0.2 mg tablet sig: one (1) tablet po bid (2 times a day). 4. nifedipine 30 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 5. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: home discharge diagnosis: benzodiazepine overdose delirium discharge condition: stable discharge instructions: please return to the hospital if you experience shortness of breath, chest pain, severe nausea/vomiting/diarrhea or any other severe symptoms. please return to the hospital or call your doctor if you are feeling any symptoms of depression. please call your doctor is you have any questions about your symptoms. - please go to your follow-up appointment with dr. on at 11am. followup instructions: please follow-up with your psychiatrist on at 11am. please follow-up with your pcp weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Diagnoses: Acidosis Anemia, unspecified Unspecified essential hypertension Poisoning by benzodiazepine-based tranquilizers Accidental poisoning by benzodiazepine-based tranquilizers Other and unspecified hyperlipidemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Other alteration of consciousness

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: found unresponsive at home major surgical or invasive procedure: endotrachial intubation history of present illness: 51 y/o female with pmh significant for seizures who per notes was found down at home by her daughter. report, pt had been lying on the couch all day. she then went to the restroom. when her daughter went to check on her, she was laying on the bathroom and had been incontinent of urine. her daughter was concerned that she could be postictal so she called ems who brought her to the ed for further evaluation. . in the field, the ems fs was 147. the pt received 1 of narcan with little response. on arrival to the ed, her vs were 98 111 142/73 20 100% nrb. there was a concern that the pt was in nonconvolsive status and a stat neuro consult was obtained. speaking to the neuro resident, they did not feel she was in nonconvolsive status. her eyes were not deviated on exam. the pt became very agitated with noxious stimuli. pt was then intubated for airway protection as she was nonresponsive. in the ed, the pt received 10 mg of narcan with some response but she did not wake up entirely or for any prolonged period of time. her toxicology screen was positive for tricyclics and etoh. amphetimines were also seen in her urine. a toxicology consult was obtained. the pt's qrs on her ecg was >100 but other ecg findings and her clinical picture were not felt to be consistent with a tricyclinc overdose. the pt was given bicarb with no change in her ecg or clnical status. pt was then sent to the for further care. . past medical history: 1. cad (mibi with small reversible defect) 2. htn 3. hypercholesterolemia 4. ? h/o sz (? related to etoh) 5. depression (possible suicide attempt ) 6. substance abuse (etoh) social history: lives with husband and 3 kids. occ etoh. 3 cig/d x 4 months. no ivdu/no illicit drug use. does not work. family history: dm physical exam: 98.0 140/83 90 14 100% ac 600/14/.50 gen- sedated and intubated. unresponsive. heent- nc at. perrl. anicteric sclera. mmm. intubated. cardiac- rrr. s1 s2. no m,r,g. pulm- cta anteriorly and laterally. abdomen- obese. soft. nt. nd. positive bowel sounds. extremities- warm. no c/c/e. neuro- sedated. intubated. downgoing toes bilaterally. pertinent results: cxr - low lung volumes. no definite infiltrate. per radiology, ett tube in place. . head ct - very limited due to pt motion. no gross evidence for hemorrhage, mass effect, shift of normally midline structures, or hydrocephalus. density values of the brain parenchyma are grossly within normal limits. -white matter differentiation is grossly intact. visualized osseous structures show no evidence for fracture. . ecg - pt with multiple ecgs in the ed. sinus rhythm. qrs about 125 in all. .. 06:00pm wbc-9.5 rbc-3.56* hgb-9.3* hct-28.2* mcv-79* mch-26.2* mchc-33.0 rdw-18.4* 06:00pm plt count-333 06:00pm pt-12.9 ptt-24.6 inr(pt)-1.1 06:00pm asa-neg ethanol-107* carbamzpn-<1.0* acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-pos 06:00pm alt(sgpt)-28 ast(sgot)-28 ck(cpk)-424* alk phos-72 amylase-150* tot bili-0.2 07:57pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-pos mthdone-neg 11:05pm glucose-123* urea n-11 creat-0.8 sodium-140 potassium-3.3 chloride-106 total co2-28 anion gap-9 11:05pm alt(sgpt)-29 ast(sgot)-27 ld(ldh)-273* ck(cpk)-389* alk phos-67 amylase-146* tot bili-0.3 11:05pm lipase-20 11:05pm ck-mb-5 ctropnt-<0.01 brief hospital course: 51 y/o female with pmh significant for etoh abuse, ? etoh withdrawal seizures, and ? suicide attempt who was found down at home by her daughter. . 1. mental status changes: pt was found down at home per her daughter with a change in mental status. per report, she was basically unresponsive but would respond to noxious stimuli. we considered a wide differential including seizure, ingestion, metabolic, and infection. neuro was consulted but did not believe she was in non-convulsive status. an eeg on showed no seizure activity in the morning. after contacting her pcp, was unclear if she had a true seizure disorder. per pcp's history, her seizures have only been related to withdrawal from etoh. pt was found to have multiple ingestions on her tox screens. her serum tox screen was positive for tricyclics in addition to etoh. pt's urine tox was positive for amphetamines. toxicology was consulted and did not feel her clinical picture was consistent with a tricyclic overdose. they were concerned that she could have taken another depressive medication which is not detected on tox screen. patient was monitored closely. serial ekgs checked. patient's clinical picture was less concerning for infection; she had a very abrupt onset of symptoms, was afebrile during her stay, and her wbc was wnl. a lumbar puncture was not done. patient was extubated soon after arriving in the icu and she was maintaining her o2 sats without difficulty. as patient became more alert, she was able to provide more history. she had a history of depression and etoh use; per patient she was not trying to commit suicide. she would like to enroll in a dual diagnosis program to work on her depression and anxiety as well as her alcoholism. we were unable to discharge patient directly to such a program. she will follow up with her pcp next week and enroll in the partial dual diagnosis program on monday at 9am. in , ma. . 2. seizure disorder- per report, pt has a history of seizures in the setting of etoh withdrawal. neurology evaluated the patient and an eeg showed no evidence of seizure activity. patient was monitored closely for signs and symptoms of etoh withdrawal. on discharge no evidence of withdrawal. . 3. depression - psychiatry was consulted. patient not suicidal. she was discharged to enroll in a dual diagnosis to address her ongoing depression and substance abuse. . 4. cad - patient was continued on a beta blocker, , and asa. . 5. htn - continued on outpatient regimen of toprol, avapro and procardia. . 6. anemia. unclear etiology, appears to be iron deficient. likely related to etoh use. b12 and folate wnl in . stools were guaiac negative. continued on iron supplements. she have anemia follow-up by her pcp next week. medications on admission: 1. toprol xl 200 daily 2. lipitor 80 daily 3. niferex 150 4. ultram 50 tid prn 5. procardia xl 120 daily 6. ntg prn 7. neurontin 300 daily 8. lactulose prn constipation 9. hctz 50 daily 10. ambien 10 qhs prn 11. amytriptyline 125 qhs 12. avapro 300 daily 13. colace 14. compazine discharge medications: 1. metoprolol succinate 100 mg tablet sustained release 24hr sig: two (2) tablet sustained release 24hr po daily (daily). 2. polysaccharide iron complex 150 mg capsule sig: one (1) capsule po daily (daily). 3. atorvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. hydrochlorothiazide 25 mg tablet sig: two (2) tablet po daily (daily). 8. prochlorperazine 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 9. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime) as needed. 10. procardia xl 60 mg tab, sust release osmotic push sig: two (2) tab, sust release osmotic push po once a day. 11. neurontin 300 mg capsule sig: one (1) capsule po once a day. 12. avapro 300 mg tablet sig: one (1) tablet po once a day. discharge disposition: home discharge diagnosis: primary diagnosis: anxiety mental status changes requiring intubation secondary diagnosis: coronary artery disease hypertension depression history of etoh abuse discharge condition: good discharge instructions: please call your primary care physician or return to the hospital if you experience confusion, shortness of breath, chest pain, or have any other concerns. please come to the emergency room if you have any thougths of harming yourself. please resume all your previous medications, except amitriptyline and klonopin. followup instructions: 1. please follow up with dr. next week. () 2. please follow up at the partial dual diagnosis program on monday at 9am. contact - () located at: , ma Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Alcohol detoxification Diagnoses: Tobacco use disorder Unspecified essential hypertension Other convulsions Alcohol abuse, unspecified Poisoning by benzodiazepine-based tranquilizers Accidental poisoning by benzodiazepine-based tranquilizers Dysthymic disorder Other and unspecified hyperlipidemia Acute respiratory failure Iron deficiency anemia, unspecified Obesity, unspecified Lumbago Toxic effect of ethyl alcohol Accidental poisoning by alcoholic beverages Other urinary incontinence

allergies: codeine / morphine attending: chief complaint: chest pain - pressure, heaviness major surgical or invasive procedure: cardiac catherization coronary artery bypass graft x3 (left internal mammary artery -> left anterior descending, saphenous vein graft -> obtuse marginal. saphenous vein graft -> right coronary artery) history of present illness: 74 year old female presented to osh with chest pressure and heaviness. pain lasted 20-25 minutes, denies any associsted symptoms. transferred for further cardiac workup. past medical history: coronary artery disease s/p cabg hypertension diabetes mellitus hyperlipidemia chronic renal insufficiency baseline 1.6 tia aortic stenosis tonsillectomy polio with residual right sided weakness dementia social history: smoked quit 20 years ago etoh 1 watered down port per day lives with son family history: nc physical exam: admission general nad vitals hr 60, rr 17, 197/68 right arm b/p pulm cta cardiac rrr no murmur/rub/gallop neck supple full rom abd soft, nontender, nondistended ext warm well perfused pulses +2 neuro decrease strength rle some confusion re: situation, walks with cane pertinent results: 05:50am blood wbc-11.4* rbc-2.99* hgb-9.4* hct-27.3* mcv-92 mch-31.5 mchc-34.4 rdw-14.3 plt ct-146* 02:25pm blood wbc-7.9 rbc-4.60 hgb-14.6 hct-43.3 mcv-94 mch-31.8 mchc-33.8 rdw-13.3 plt ct-220 04:20pm blood neuts-57.9 lymphs-33.6 monos-5.9 eos-2.2 baso-0.4 05:50am blood plt ct-146* 04:00am blood pt-12.9 ptt-33.9 inr(pt)-1.1 02:25pm blood plt ct-220 02:25pm blood pt-12.3 ptt-30.1 inr(pt)-1.1 05:50am blood glucose-264* urean-12 creat-0.8 na-136 k-3.3 cl-100 hco3-31 angap-8 02:25pm blood glucose-82 urean-17 creat-0.8 na-140 k-3.8 cl-102 hco3-29 angap-13 04:20pm blood alt-29 ast-43* alkphos-68 amylase-46 totbili-0.3 tee conclusions: pre-cpb the left atrium is moderately dilated. mild spontaneous echo contrast is seen in the body of the left atrium. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. there is mild regional left ventricular systolic dysfunction with mild hypokinesis of the inferior wall. the remaining left ventricular segments contract normally. overall left ventricular systolic function is normal. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the ascending aorta. there are simple atheroma in the aortic arch. there are complex (>4mm) atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. brief hospital course: transferred from osh for cardiac catherization which revealed lm and 3 vessel cad and was referred to cardiac surgery. she underwent preoperative work up and on was transferred to the operating room for coronary artery bypass graft surgery. please see operative report for further details. she was transfered to the cardiac surgery recover unit for further hemodynamic monitoring. in the first 24 hours she awoke and was extubated without difficulty. she was alert and following commands but unable to answer questions. on postoperative day 2 she was weaned from iv nitroglycerin and was transferred to 2. she has continued to progress working with physical therapy. neurologically she remains oriented to person not place and time. on postoperative day 4 she was ready for discharge to rehab, but did not get a bed until postop day 6. discharged on . pt. to make all follow-up appts. as per discharge instructions. medications on admission: asa, lovenox, atenolol, glyburide, lipitor, norvasc, oscal, zantac, zoloft, plavix, lisinopril discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 5. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 6. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 7. glyburide 5 mg tablet sig: one (1) tablet po bid (2 times a day). 8. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 9. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 10. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days. 11. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po once a day for 7 days. 12. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 13. haloperidol 1 mg tablet sig: two (2) tablet po bid (2 times a day): 2 mg for 2 days, then 1 mg for 2 days then d/c. discharge disposition: extended care facility: & rehab center - discharge diagnosis: coronary artery disease s/p cabg hypertension diabetes mellitus hyperlipidemia chronic renal insufficiency basline 1.6 tia aortic stenosis tonsillectomy polio with residual right sided weakness dementia 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 pounds in 24 hours or 5 pounds in a week no creams, lotions, powders, or ointments to incisions no driving for approximately one month no lifting more than 10 pounds for 10 weeks please call with any questions or concerns p instructions: dr in 4 weeks () please call for appointment dr in 1 week () please call for appointment dr in weeks () please call for appointment wound check appointment 2 as instructed by nurse () Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries 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 Mitral valve disorders Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Other persistent mental disorders due to conditions classified elsewhere Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Late effects of acute poliomyelitis

maternal history: the mother is a 35-year-old g1, para 0 to 1 woman with past medical history notable for hypertension, nephrolithiasis status post stent placement, and recent sinusitis treated with azithromycin. family history: noncontributory. social history: no illicit substance use. both parents are gi fellows here at . prenatal screens: a positive, dat negative, hepatitis b surface antigen negative, rpr nonreactive, rubella immune, group b strep unknown. antenatal history: by lmp with confirmatory 7.5 week ultrasound. estimated gestational age 28 5/7 weeks at delivery. pregnancy was complicated by preeclampsia, oligohydramnios and growth restriction leading to admission 6 days prior to delivery. treatment with betamethasone, nifedipine and magnesium sulfate with eventual cesarean section under spinal anesthesia. rupture of membranes occurred at delivery and yielded clear amniotic fluid. there was no labor and no intrapartum fever or other clinical evidence of chorioamnionitis. neonatal course: the infant was vigorous at delivery. orally and nasally, bulb suctioned, dried. facial cpap administered for mild to moderate intercostal retractions. apgars were 7 at 1 minute and 8 at 5 minutes. the infant was transferred uneventfully to the nicu on cpap and intubated with surfactant administered at approximately 20 minutes of age. admission physical examination: preterm infant on warmer with moderate respiratory distress. birth weight 940 grams, percentile. ofc 25.5 cm, 25% percentile. length 35th to 5.5 cm, 25th percentile. heart rate 158, respiratory rate 50s-60s. temperature 96.9. bp 49/22, mean 33. sao2 96% in 25% oxygen. heent: anterior fontanel soft, flat, nondysmorphic, palate intact. neck and mouth normal, normal cephalic, red reflex bilaterally with vitreous haze, 2.5 endotracheal tube in place orally. chest: mild to moderate intercostal retractions, fair breath sounds bilaterally, no adventitious sounds. cvs: well perfused, regular rate and rhythm. femoral pulses normal. s1, s2 normal. no murmur. abdomen soft, nondistended, no organomegaly, no masses, bowel sounds active. anus patent. three vessel umbilical cord. gu: normal preterm female genitalia. cns: active, alert, responsive to stimulation. tone appropriate for gestational age and symmetric, moves all extremities symmetrically. gag intact. faces symmetric. integument: normal preterm. musculoskeletal: normal spine, limbs, hips and clavicles. hospital course: 1. respiratory: received her initial dose of surfactant at 20 minutes of age. she was extubated to cpap of 6 cm in 29-35% fio2. a cap gas of 7.33/38 was noted on cpap. she was started on caffeine citrate for apnea of prematurity. on day of life 3, she developed a spontaneous left sided pneumothorax which was treated with a thoracentesis and then chest tube drainage. the infant was reintubated orally and placed back on conventional mechanical ventilation with settings of 18/5 and a rate of 30 and 30% oxygen. the air leak persisted and multiple replacements and manipulations of the left thoracostomy tube were necessary to maintain drainage of the air leak. in spite of these maneuvers, the air leak persisted and on day of life 9, a second chest tube was placed, positioned subpulmonic to relieve reaccumulation of the air leak on the left side. on day of life 9, a persistent airleak was present in the posterior subpulmonic region necessitating a third chest tube on the morning of day 10 of life. on day of life 8, developed atelectasis versus consolidation on the right side. over this period to day of life 10 she required increased ventilatory support. due to issues of inadequate ventilation, she was changed from conventional ventilation to high frequency ventilation on , dol 8. on dol 9, due to acidosis and hypoxemia, various ventilator strategies were tried, but ultimately returned to high frequency ventilation. on the morning of dol 10, she was last tried on conventional ventilation. 2. cardiovascular. access: an umbilical venous catheter was placed upon admission and was utilized for fluid and nutrition administration throughout her hospital stay. on day of life 9, a peripheral arterial line was placed for increasing severity of illness and need for additional monitoring. there was no evidence of a patent ductus or other cardiovascular compromise until day of life 9 when started to become hypotensive requiring volume and vasopressor resuscitation. the baby alternated between periods of tachycardia and sinus bradycardia over the last few days of life. on the morning of she had sinus bradycardia to the 60s and required a short interval of chest compressions and a single dose of epinephrine to improve cardiac output. 3. fluids, electrolytes and nutrition. was maintained n.p.o. throughout her hospital stay. on day of life 8, she was given initial trophic feeding of breast milk which was subsequently discontinued in light of her worsening clinical status. serial electrolytes were monitored and course initially was complicated by hyponatremia, necessitating up to a maximum of 8.8 meq of sodium per kilo in her parenteral nutrition to correct her sodium deficits. over the last 48 hours, developed a metabolic acidosis despite aggressive bicarbonate replacement. she was transiently hyperglycemic in the initial phase of illness, necessitating a decreased glucose infusion rate; however, on day of life 10, likely in the setting of sepsis, she was noted to be significantly hypoglycemic with a glucose of 7. she was treated with multiple boluses of 2 ml/kilogram of d10w infused followed by an increase in her glucose iv infusion rate. subsequent glucoses were in the 60 range. 4. gi. was treated with phototherapy for physiologic unconjugated hyperbilirubinemia and light therapy was discontinued on day of life 8. a rebound was obtained on day of life 9 at 2.6. 5. heme/id. a cbc and blood culture were initially obtained upon admission with initial cbc notable for a white count of 5.9 with 7 polys and 0 bands, 89 lymphs and an absolute neutrophil count of 413. hematocrit 41.8%, 243,000 platelets. received multiple packed red blood cell transfusions. her hematocrit dropped by day of life 6 to 29.6 at which time she received her initial transfusion. on day of life 9 with the return to it was noted that her hematocrit was again in the 30% range and she was again neutropenic with a white blood cell count of 4.2 and 26 polys, 6 bands, 47 lymphs, 280,000 platelets. metas and myelos also present as well as toxic granulation. she received another blood transfusion at this time. on day of life 10, she was noted to be extremely neutropenic with a white blood cell count of 1.6 with 0 neutrophils, 0 bands, 70 lymphs, and 23,000 platelets. due to the persistent neutropenia, was continually on antibiotics. initially, she received a 7 day course of ampicillin and gentamicin for the first 7 days with appropriate gentamicin levels. she was started on vancomycin and gentamicin on day of life 8 for the initial decompensation and concerning cbc as explained above. she was also given oxacillin for her multiple manipulations of the thoracostomy tubes and was started on cefotaxime for broader coverage on day of life 10. the blood cultures remained negative to date. lumbar puncture was performed by dol 7 which ruled out spinal meningitis. 6. neurologic. had an initial head ultrasound on day of life 4 which was normal. it was repeated on day of life 10 and it remained without evidence for intracranial hemorrhage. she received morphine sulfate p.r.n. when intubated and during chest tube insertion. she was started on a fentanyl drip which was escalated to 5 mcg per kilogram and continued to get morphine p.r.n. and fentanyl p.r.n. mostly for procedures. given the persistent hypoxemia and acidemia especially over the final 12 hours of life, discussion with the family ensued regarding the likely neurodevelopmental compromise that may result given the prolonged nature and severity of her metabolic acidosis and hypoxemia. with regard for the futility in continuing to provide medical ervention, the decision was made to discontinue support. t. the parents held the infant as the lines were clamped off and the endotracheal tube was removed. the fentanyl infusion continued. the time of death was 1 p.m. the parents had multiple friends with them at the bedside for support. they declined clergy presence. limited autopsy request obtained for the chest only and the parents will be made aware of any new information that is received. social worker was present as well to assist the family. diagnoses: 1. intrauterine growth restriction, small for gestational age premature infant at 28-5/7 weeks. 2. respiratory distress syndrome requiring surfactant replacement. 3. left pneumothorax. 4. right pulmonary atelectasis versus consolidation. 5. presumed sepsis. 6. severe metabolic acidosis. 7. hyperbilirubinemia. 8. neutropenia. 9. hyperglycemia/hypoglycemia. , Procedure: Insertion of intercostal catheter for drainage 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 Non-invasive mechanical ventilation Arterial catheterization Transfusion of packed cells Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Hyposmolality and/or hyponatremia Extreme immaturity, 750-999 grams Neonatal jaundice associated with preterm delivery 27-28 completed weeks of gestation Septicemia [sepsis] of newborn Other and unspecified atelectasis Other transitory neonatal electrolyte disturbances Interstitial emphysema and related conditions Congenital neutropenia Other acidosis of newborn Fetal growth retardation, unspecified, 750-999 grams

history of present illness: a 68-year-old man with a history of cad, status post cabg, with a history of congestive heart failure and also mitral valve repair, as well as icd placement, presented to outside hospital prior to transfer to - , vomiting, hypertension, and new onset ascites. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Percutaneous abdominal drainage Implant of pulsation balloon Open and other replacement of mitral valve with tissue graft Monitoring of cardiac output by other technique Nonoperative removal of heart assist system Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Coronary atherosclerosis of autologous vein bypass graft Atrial fibrillation Percutaneous transluminal coronary angioplasty status Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Tricuspid valve disorders, specified as nonrheumatic

history of present illness: the patient is a 67-year-old man with a long cardiac history which includes coronary artery bypass grafting in , and , associated with congestive heart failure and an ef of 25-30%. he has also had a mitral valve replacement in the past, as well as an aicd placement in of this year. he presented to the hospital with complaint of and vomiting, as well as increased abdominal girth. he was found to be hypotensive and was admitted to their icu briefly requiring pressors. an echo at the hospital showed an ef of 40% with pa systolic pressures of 25-30, severe mr , as well as hypokinesis of the inferior posterior walls, as well as hypokinesis of the apical septum. the patient was transferred to to discuss treatment of his ascites and possibly redo mitral valve. past medical history: 1) significant for, as stated previously, cabg in , and , with a lima to the lad and saphenous vein graft to the pda in , and a radial graft to the lima to the pda in . 2) congestive heart failure with an ef of 25-30%, with ischemic cardiomyopathy. 3) status post mitral valve repair. 4) chronic atrial fibrillation. 5) sick sinus syndrome, status post pacer in . 6) a v-tach arrest at the time of admission for his sick sinus syndrome. 7) pulmonary hypertension. 8) hypertension. 9) chronic renal insufficiency. 10) gerd. 11) hypercholesterolemia. 12) gout. 13) bronchitis associated with hemoptysis. 14) iron deficiency anemia. past surgical history: 1) significant for coronary artery bypass grafting x 3. 2) mitral valve replacement x 1. 3) appendectomy. 4) right neck mass excision. 5) hernia repair. meds at admission: 1) lasix 120 qd, 2) zaroxolyn 2.5 prn with weight gain, 3) aspirin 325 qd, 4) lopressor 12.5 , 5) plavix 75 qd, 6) prevacid 30 qd, 7) folic acid 1 qd, 8) lipitor 10 qd, 9) imdur 30 qd, 10) hydralazine 10 tid, 11) aldactone 25 , 12) lexapro 10 qd, 13) albuterol prn, 14) atrovent prn, 15) flovent , 16) coumadin 2.5--last taken . allergies: quinidine which causes a rash. social history: lives with his wife in , . occasional alcohol. no history of alcohol abuse. denies tobacco use. physical exam at time of admission: vital signs - temperature 97.4, heart rate 55, blood pressure 129/77, respiratory rate 24, o2 sat 99% on room air. general - pleasant man, sitting upright, speaking in full sentences, in no acute distress. skin - no jaundice or rashes. heent - anicteric, noninjected. pupils equally round and reactive to light. extraocular movements intact. mucous membranes moist. op clear. neck - jvd at angle of jaw, no bruits. no lymphadenopathy. heart - irregularly irregular, iii/vi holosystolic murmur throughout. respiratory - a few vesicular breath sound at bases, otherwise clear. abdomen was distended, nontender, soft, with shifting dullness to percussion, but no fluid wave transmission, no hepatosplenomegaly, positive bowel sounds. extremities - 3+ pitting edema bilaterally up to the knees. neuro - cranial nerves ii through xii grossly intact, no focal deficits. lab data: white count 6.4, hematocrit 34.9, platelets 160, pt 18.5, ptt 39.8, inr 2.3, sodium 138, potassium 4.3, chloride 100, co2 28, bun 25, creatinine 1.3, alt 16, ast 68, ldh 994, alk phos 86, total bili 2.4, albumin 3.9. ekg was afib., paced irregularly with a rate of 63, with axis of -68??????, elevations in v3, and elevation in v2 through 4. hospital course: the patient was treated by the medical service with consultation from heart failure service, as well as cardiology. the cardiac surgery service was consulted as well. the patient was diuresed over the first 10 days of his hospitalization. following that period of time, the patient was evaluated for heart transplant, as it was felt that he may require an lvat during his mitral valve replacement. on the , the patient was brought to the cardiac catheterization lab where an intra-aortic balloon pump was placed prior to his being transferred to the operating room for a redo mitral valve replacement. please see the catheterization lab report for full details. in summary, he had an intra-aortic balloon pump placed prior to surgery. he was then brought directly to the surgical suite, at which time he underwent redo mitral valve replacement with a #27 mosaic porcine valve via a right thoracotomy. the patient tolerated the operation and was transferred from the operating room to the cardiothoracic intensive care unit. please see the or report for full details and summary. the patient was transferred, after redo mvr, with a mean arterial pressure of 82. he was v-paced at a rate of 80. his iv medications included amiodarone at 2 mg/min, epinephrine at 0.03 mcg/kg/min, milrinone at 0.5 mcg/kg/min, levophed at 0.15 mcg/kg/min, and propofol at 10 mcg/kg/min. in the immediate postoperative period, the electrophysiology service was consulted regarding ventricular ectopy. at that time, his internal pacer was increased to a rate of 90 in an attempt to control his ventricular ectopy. the patient did well in the immediate postoperative period. during the first 24 hours, epinephrine was weaned to off, and his amiodarone was decreased to 1 mg/min. on the morning of postoperative day #1, the intra-aortic balloon pump was weaned and ultimately discontinued. during that period, the patient remained hemodynamically stable. neurologically, the patient's sedation was weaned to a point that he was able to move all four extremities and nod appropriately following a quick neuro assessment. the patient was resedated therefore requiring continued ventilatory support. following removal of the intra-aortic balloon pump, the patient's levophed was weaned to off, and on postoperative day #2, the propofol was discontinued, thereby allowing us to wean the patient from the ventilator. the patient was successfully extubated on postoperative day #2. over the next several days, the patient was slowly weaned from his milrinone infusion. on postoperative day #5, the milrinone was successfully discontinued. following the successful discontinuation of the iv milrinone infusion, the patient was transferred to far-2 for continued postoperative care and cardiac rehabilitation. the patient remained on far-2 for an additional three days, during which time his activity level was increased with the assistance of the physical therapist and the nursing staff. on postoperative day #10, it was decided that the patient was stable and ready to be discharged to home with the assistance of visiting nurses. discharge physical exam: vital signs - temperature 98, heart rate 70, v-paced, blood pressure 100/52, respiratory rate 20, o2 sat 95% on room air, weight preoperatively 102 kg, and at discharge 97.3 kg. alert and oriented x 3. moves all extremities. follows commands. respiratory - breath sounds diminished at the bases, otherwise clear to auscultation. cardiac - regular rhythm, s1, s2. right thoracotomy incision with staples, no erythema. abdomen was soft, nontender, positive distention, and positive bowel sounds. extremities were warm and well-perfused with 3-4+ edema bilaterally. lab data: hematocrit 29.3, pt 14.7, inr 1.4, potassium 3.9, bun 21, creatinine 1.3. discharge medications: 1) carvedilol 3.125 mg , 2) aldactone 12.5 mg qd, 3) enalapril 5 mg , 4) amiodarone 400 mg x 1 week, then 400 mg qd x 1 week, then 200 mg qd for 1 month, 5) lasix 80 mg , 6) potassium chloride 20 meq qd, 7) enteric-coated aspirin 325 mg qd, 8) senna 2 tablets , 9) percocet 5/325, 1-2 tabs, q 6 h prn, 10) resume prevacid 30 mg qd. discharge diagnoses: 1) status post redo mitral valve replacement with a #27 mosaic porcine valve via a right thoracotomy. 2) status post coronary artery bypass grafting x 3, , , . 3) congestive heart failure. 4) chronic atrial fibrillation. 5) sick sinus syndrome and ventricular tachycardic arrest. 6) status post aicd permanent pacemaker placement. 7) pulmonary hypertension. 8) hypertension. 9) chronic renal insufficiency. 10) gastroesophageal reflux disease. 11) hypercholesterolemia. 12) gout. 13) bronchitis associated with hemoptysis. 14) iron deficiency anemia. 15) status post appendectomy. 16) status post right neck mass excision. 17) status post hernia repair. condition at discharge: good. fop: 1) he is to have follow-up with dr. in weeks. 2) follow-up with dr. from the heart failure service on at 1:00 pm. 3) follow-up with dr. , his primary care provider, 1 month. 4) he is also to have follow-up in the wound clinic in 1 week. die instructions: the patient is also to have a potassium, bun and creatinine checked by the visiting nurses with results called-in to dr. office on thursday, . , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Percutaneous abdominal drainage Implant of pulsation balloon Open and other replacement of mitral valve with tissue graft Monitoring of cardiac output by other technique Nonoperative removal of heart assist system Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Coronary atherosclerosis of autologous vein bypass graft Atrial fibrillation Percutaneous transluminal coronary angioplasty status Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Tricuspid valve disorders, specified as nonrheumatic

past medical history: 1. coronary artery bypass graft (cabg) in , , and . 2. cardiac catheterization in , during which the patient's left main underwent rotational atherectomy and ptca with stent placement, slowly with evidence of competitive flow, midvessel, after takeoff. 3. status post mitral valve repair in . 4. pacer placement in . 5. aicd placement in for a v tach arrest which was dc cardioverted to sinus rhythm during an admission for chf exacerbation and hemoptysis. the pacer placement was for sick sinus syndrome. 6. chronic atrial fibrillation, ejection fraction 25-40%. 7. pulmonary hypertension. 8. systemic hypertension. 9. hypercholesterolemia. 10. chronic renal failure with a baseline creatinine of 1.3. 11. gout. 12. hemoptysis. 13. gerd. 14. status post appendectomy. 15. status post right neck mass excision. 16. status post herniorrhaphy. 17. iron-deficiency anemia. admission medications: 1. lopressor 12.5 b.i.d. 2. plavix 75 q.d. 3. lipitor 10 q.d. 4. imdur 30 q.d. 5. hydralazine 10 t.i.d. 6. aldactone 25 b.i.d. 7. coumadin 2.5 q.h.s. 8. prevacid 30 q.d. 9. folic acid one q.d. 10. albuterol, atrovent, and flovent inhalers. 11. lexapro 10 q.d. 12. colchicine. 13. lasix 120 p.o. q.d. 14. zaroxolyn 2.5 q.d. medications on transfer from the medicine floor to the ccu: 1. captopril 12.5 t.i.d. 2. aspirin 81. 3. lopressor 12.5 b.i.d. 4. lipitor. 5. zaroxolyn 2.5 q.d. 6. ibuprofen. 7. colchicine. 8. tums. 9. albuterol. 10. atrovent. 11. fluticasone. 12. lexapro. 13. folate. 14. protonix. allergies: quinidine causes a rash. physical examination on admission: vital signs: temperature 97.6, pulse 66, v paced, blood pressure 103/61, respiratory rate 15, oxygen saturation 91% on 2 liters, pulmonary artery pressure 52/27 with a mean of 36, cardiac output 4.1, cardiac index 1.2. no focal neurological deficits. alert and oriented times three. heart: regular heart rate. no rubs or gallops. a positive iv/vi holosystolic mitral regurgitation murmur. extremities: marked lower extremity edema. neck: positive jvd bilateral. lungs: lower one-third lung field crackles. abdomen: soft, nontender, nondistended. heent: no icterus. no pallor. mucous membranes moist. right femoral vein cordis with swan in place. right femoral arterial line. pertinent data on transfer to ccu: hematocrit 33.3, inr 1.6, creatinine 1.2. hospital course: in addition to the above described in the history of the present illness, it should be noted that on a cat scan performed at an outside hospital there is evidently a small mass on one of the patient's kidneys which will need further evaluation after the patient's acute episodes are resolved. after transfer to the ccu, the patient was maintained on a milrinone drip and was started on a lasix drip. over the first two days, he diuresed 8 liters of fluid with improvement in his cardiac index and his pulmonary artery pressures. he was continued on his beta blocker, ace inhibitor, aldactone, zaroxolyn. his plavix and coumadin were held in anticipation of surgery and heparin was not started as the patient was maintaining an inr of 1.6 to 1.8 on his own. a swan-ganz was eventually re-sited to the right ij to allow the patient more mobility. his right femoral arterial line was also re-sited to his right radial artery for the same reason. the rest of this hospital course and discharge status, medications, and diagnoses will be addended by the next intern coming on service. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Percutaneous abdominal drainage Implant of pulsation balloon Open and other replacement of mitral valve with tissue graft Monitoring of cardiac output by other technique Nonoperative removal of heart assist system Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Coronary atherosclerosis of autologous vein bypass graft Atrial fibrillation Percutaneous transluminal coronary angioplasty status Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Tricuspid valve disorders, specified as nonrheumatic

allergies: clindamycin attending: chief complaint: dyspnea major surgical or invasive procedure: dialysis history of present illness: 46 y/o ethiopian male hx t1dm, hiv, esrd (secondary to nephrolithiasis, htn and t1dm) previously on hd since , has been on pd intermittently for several months, most recently started pd 3d pta, last hd , removed 5kg) and peripheral neuropathy presents with dyspnea by ems from dialysis (had pd overnight). pt notes sob since last night, + cough with clear sputum, + pnd. no fever/chills/diarrhea/n/v/dysuria. + abd pain around pd stie with deep inspirationusual sbp 150-180- baseline per omr notes x 2 months. no recent diet or medication changes. . ed course: temp 97.1, bp 215/95, hr 72, sat 99% on 2l, started on nipride drip, titrated to 2mcg/kg/min, bp improved to 177/91. initial k 7.5, hemolyzed, repeat k 5.0. past medical history: - type 1 diabetes - hiv (boosted atazanavir, lamivudine, stavudine), dx'd - esrd on hd, planned change to peritoneal dialysis in near future, on transplant list (clinical study for hiv/solid organ transplant) - recent hospitalizations for serratia bacteremia (presumed source av graft) most recently treated with 6 week course meropenem - history of schistosomiasis - restless leg syndrome - peripheral neuropathy on gabapentin - s/p cholecystectomy social history: moved from in . lives with wife in . works in support services for a law firm. denies any alcohol or iv drug use. quit smoking last year; previous 30 pack-year history. family history: non-contributory. physical exam: t 97.2 hr 72 bp 188/84 rr 12 99% 2l nc general: appears to be more comfrtable, speaks in full sentences, nad heent: anicteric, op clear neck: no lad or difficult to see jv cv: rrr, normal s1, s2 without m/r/g. pulm: crackles way up b/l, no wheezes abd: llq with pd catheter appears clean, although no dressing in place, soft, nd, nd, no hsm ext: 2+ edema nonpitting b/l, 2+ distal pulses neuro: cns ii-xii grossly intact. a/o x 3. skin: no rash pertinent results: 06:25am wbc-4.6 rbc-2.90* hgb-10.6* hct-31.7* mcv-109* mch-36.6* mchc-33.5 rdw-16.5* 06:25am neuts-63.6 lymphs-21.8 monos-6.6 eos-7.6* basos-0.3 06:25am calcium-8.7 phosphate-5.8* magnesium-2.8* 06:25am ctropnt-0.21* probnp-* 06:25am glucose-92 urea n-96* creat-13.2*# sodium-137 potassium-7.5* chloride-97 total co2-24 anion gap-24* . ct w/o contrast: ct of the chest: compared to prior ct from , there is almost mareked improvement in the diffuse bilateral peribronchiolar opacities. since the last exam, there is interval developmen of a wedge-shaped area of consolidation within the left lung base, which may represent a pneumonia, however given its shape cannot exlude infarction. again seen are small bilateral pleural effusions, not significantly changed. the heart and pericardium are unremarkable. small mediastinal lymph nodes are seen which do not meet ct criteria for pathologic enlargement. the visualized upper abdomen is unremarkable. bone windows demonstrate no suspicious lytic or sclerotic lesion. surgical clips are seen adjacent to the right crus of the diaphragm. a right subclavian central venous catheter is seen with tip in the distal svc. impression: compared to the prior ct from , there is marked improvement of the previously noted peribronchiolar opacities within both lungs. however, there is development of a new wedge-shaped opacity within the left lower lobe concerning for pneumonia versus infarction. stable bilateral small pleural effusions. . cta : ct of the chest without and with iv contrast: 10-mm hypodense focus in the left thyroid lobe. no filling defects are noted within the main pulmonary artery and its branches. the previously described wedge-shaped opacity in the left lung base is not seen on the current study. a rounded small pleural- based opacity in the posterior aspect of the left lung base is seen and unchanged when compared to a study dated . the airways are patent to the segmental levels, bilaterally. small mediastinal and axillary lymph nodes, not pathologically enlarged by ct criteria are again noted, unchanged. heart and great vessels are unchanged. no evidence of pericardial effusions. emphysematous changes are again seen. diffuse mild bilateral ground-glass opacities are unchanged when compared to a prior study. the liver demonstrates two small hypodensities measuring 9 mm and 1.7 cm in segment v and viii, respectively previously characterized as hemagioma. bone windows: no suspicious lytic or sclerotic lesions are identified. impression: 1. no evidence of pulmonary embolism. 2. interval resolution of the left lower lobe wedge-shaped opacity. brief hospital course: a&p: 46 yo m hx t1dm, hiv, esrd p/w dyspnea, elevated bp, low grade fevers and cough. . # sob and htn: the patient presented to the ed with fluid overload and hypertensive urgency and was started on a nipride drip. on transition to the inpatient setting he was converted to a labetalol drip to avoid buildup of cyanide biproducts while he awaited hemodialysis. his dyspnea was well controlled on reaching the floor and remained well controlled throughout his hospital stay. his hypertension continued to be an issue following his first dialysis session, despite the removal of 5.2 l of fluid during that session. he was continued on labetalol drip to maintain sbp < 180 with 160 as target. following his second dialysis treatment on hospital day 2, he weighed 57kg, which was considered his new dry weight. for improved bp control, he was started on 20 mg lisinopril per recommendation of the renal team. he also continued his outpatient regimen of 160 diovan and 50 atenolol qd. although his pressure was better controlled, he still had breaks into the 180s and his pressure control will need to be optimized as an outpatient. . renal: the patient had recently transitioned from hemodialysis to peritoneal dialysis, which was apparently insufficient, resulting in fluid overload, hypertension and admission. the patient was discharged with plans to resume hemodialysis at his previous hemodialysis center under the care of his outpatient nephrologist. his next hemodialysis treatment was scheduled for wed. . . hiv: the patient's haart regimen was continued. . anemia: continue epogen at hd. . # fevers: the patient briefly spiked a fever on and underwent non-con ct of the chest. he had increasing cough as well. sputum and blood cultures were negative. the patient's non-con chest ct demonstrated a peripheral wedge shaped opacity, and the patient was started on vancomycin and zosyn, given his relative immunosuppression and his recent hospitalization with full course of levofloxacin. a follow-up cta was done to rule out pe and showed complete resolution of the wedge shaped area, which presumably was simply atelectasis. however, the lung was not entirely clear, and it was felt prudent to continue an day course of iv antibiotics. for this reason, the patient was dosed one gram of ceftazadine and one gram of vancomycin following his dialysis on , and he was written a prescription to receive one gram of vancomycin and one gram of ceftazadine after each of his dialysis sessions on and . (and then the course would end). on the day of discharge, the patient's nasal viral swab returned positive for parainfluenza virus. as discussed with id, the patient's ct and clinical findings could all be explained by parainfluenza virus, but there was also a significant chance for bacterial superinfection. thus, the antibiotic course was planned as described above. . he was also scheduled for followup with his infectious disease physicians on . . medications on admission: gabapentin 100 mg tid atenolol 50 mg po daily valsartan 160mg compazine prn insulin (nph 10 u and regular 5 u qam) tenofovir 300 mg po qsat ritonavir 100 mg p.o. daily atazanavir 300 mg p.o. daily stavudine (zerit) 20 mg po qhd days after hd lamivudine (epivir) 25 mg po after hd on hd days discharge medications: 1. gabapentin 100 mg capsule sig: one (1) capsule po tid (3 times a day). 2. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po qsat (every saturday). 3. ritonavir 100 mg capsule sig: one (1) capsule po daily (daily). 4. atazanavir 150 mg capsule sig: two (2) capsule po daily (daily). 5. stavudine 20 mg capsule sig: one (1) capsule po q24h (every 24 hours). 6. lamivudine 10 mg/ml solution sig: twenty five (25) mg po daily (daily): take orally after hemodialysis on hemodialysis days. . 7. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 8. valsartan 160 mg tablet sig: one (1) tablet po bid (2 times a day). 9. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. prochlorperazine 5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for nausea. 11. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime) as needed. 12. benzonatate 100 mg capsule sig: one (1) capsule po tid (3 times a day) as needed for cough. disp:*20 capsule(s)* refills:*2* 13. insulin nph human recomb 100 unit/ml cartridge sig: per regimen subcutaneous twice a day. 14. ceftazidime 1 g recon soln sig: one (1) intravenous at dialysis for 2 doses: patient should receive 1 gram of ceftazadime administered at his dialysis center after dialysis on and . . disp:*2 doses* refills:*0* 15. vancomycin 1,000 mg recon soln sig: one (1) g intravenous at dialysis for 2 doses: 1 gram, to be given after dialysis at 5/9 and . disp:*2 doses* refills:*0* discharge disposition: home discharge diagnosis: end stage renal disease requiring regular hemodialysis parainfluenza viral infection hiv hypertensive urgency volume overload discharge condition: good discharge instructions: you were admitted with elevated blood pressure and respiratory difficulty which improved with dialysis. however, your blood pressure continues to be elevated at times throughout the day. you will need to work with your clinic physicians to improve your blood pressure. elevated blood pressures for a long period of time with increase your risk of stroke and heart disease. . you have a cough and imaging of your chest showed that you may have a small infection. for this you need to have iv antibiotics (ceftazadine and vancomycin) administered at your next two dialysis sessions on wednesday and friday . you have been given prescriptions for these two antibiotics and your physician at dialysis has been informed. . in addition, you should check your temperature on a daily basis and any time that you feel sick. if you have a temperature greater than 100.4 that does not resolve quickly, you should call your primary care physician. . you had testing for tb during this hospitalization which was negative. one of your tests is still pending. if this test is positive, you will be contact. your physicians at also will have access to these results when you come in for appointments. . you will need regular dialysis. your next dialysis is scheduled for wednesday, at 6:45 am. it is vital that you do not miss . . please keep your other appointments listed in the appointments section. these doctors help with your blood pressure. . you have been started on a new blood pressure medication called lisinopril. you should take this medication as prescribed, and continued taking your other blood pressure medications. followup instructions: dialysis at your regular dialysis center: wednesday, at 6:45 am. . provider: . phone: date/time: 10:00 . provider: , md phone: date/time: 9:10 md, Procedure: Hemodialysis Diagnoses: Pneumonia, organism unspecified End stage renal disease Congestive heart failure, unspecified Polyneuropathy in diabetes Human immunodeficiency virus [HIV] disease Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Unspecified hereditary and idiopathic peripheral neuropathy Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Restless legs syndrome (RLS)

allergies: clindamycin attending: chief complaint: sob, increasing pedal edema major surgical or invasive procedure: intubation, with successful extubation. history of present illness: is a 46-year-old gentleman with h/o dmi, esrd on hd, hiv (vl <50, cd4 393 ), recently diagnosed pe, and multiple ed admissions for htn urgency who presented to the ed with complaints of sob and le that had progressed throughout the evening. sicne 11pm night pta, dyspnea increased and patient sought eval in ed. in , report, patient was 89% ra, and 100% on a 4l nc, appeared comfortable. ekg showed mildly peaked ts, and he was treated with calcium, bicarb, and d50/insulin. approximately 1/2 hour later, patient became acutely dyspneic and tachypneic. repeat ekg showed anterolateral st segment elevations. sbp was in 240s at that time. ekg was reviewed with cardiology attending and cath lab was activated. patient was started on bipap, nitro gtt, nipride gtt, and given lasix 100mg iv. breathing status looked poor, he was intubated using rocuronium for paralysis given esrd. he was given heparin and integrillin boluses for presumed acs. repeact cxr showed acute pulmonary edema. repeat ekg showed that st segment elevations had resolved with bp control. bedside echo was done by cardiology fellow and no wall motion abnormalities were noted. cath was deferred, and patient was admitted to micu for further management. past medical history: - type 1 diabetes - hiv (boosted atazanavir, lamivudine, stavudine), dx'd vl <50, cd4 393 ) - esrd previously on hd, attempted on pd on transplant list (clinical study for hiv/solid organ transplant) - malignant hypertension - hx serratia bacteremia (presumed av graft) tx 6 wks meropenem - hx schistosomiasis - restless leg syndrome - peripheral neuropathy on gabapentin - s/p cholecystectomy - s/p r nephrectomy in secondary renal nephrolithiasis social history: moved from in . lives with wife in . works in support services for a law firm. denies any alcohol or iv drug use. quit smoking last year; previous 30 pack-year history. family history: non-contributory physical exam: t: 98.7; hr 64; bp 120/75; rr 24; o2 sat 100% gen: alert and oriented, ambulating freely heent: ncat. mmm. op clear. neck: supple, no lad. cv: s1s2 rrr. grade ii/vi systolic murmur lungs: ctab abd: nabs. soft, nt, nd. ext: wwp, no cce. 2+ dp pulses bl skin: no rashes/lesions, ecchymoses. pertinent results: echo : shows the left atrium is mildly dilated. the estimated right atrial pressure is 11-15mmhg. there is mild symmetric left ventricular hypertrophy. overall left ventricular systolic function is normal (lvef 60%). there is severe mitral annular calcification. . cxr impression: new air space process in both mid-lungs, most suggestive of early pulmonary edema. . 06:05am type-art temp-35.2 o2-100 po2-188* pco2-60* ph-7.30* total co2-31* base xs-2 aado2-479 req o2-80 intubated-intubated . 05:49am glucose-98 urea n-52* creat-8.8* sodium-136 potassium-7.3* chloride-94* total co2-25 anion gap-24* . 05:49am calcium-9.9 phosphate-11.6*# magnesium-3.5* . 05:49am wbc-12.6*# rbc-3.40* hgb-12.7* hct-36.7* mcv-108* mch-37.3* mchc-34.6 rdw-16.4* neuts-84.8* lymphs-8.5* monos-4.9 eos-1.7 basos-0.1 . 02:05am ck(cpk)-89 02:05am ctropnt-0.26* 02:05am ck-mb-notdone probnp-* brief hospital course: 46m hiv, esrd on hd p/w shortness of breath, intubated for respiratory distress. . # respiratory distress initially presented in an event that appears that most recent event is secondary to acute pulmonary edema. cxr with new pulmonary edema that developed over 1 hour. was emergently intubated and given nitroglycerin gtt. siginficantly improved with dialysis but had focal infiltrate on post-dialysis cxr thought due to pneumonia (as well as fever). thus was initially started on vanc/meropenem that was changed to just vancomycin qhd once sputum culture showed gpcs. was extubated without event on and continued to saturate well, ultimately sating 97% on ra. was continued on vancomycin for presumed cap, was discharge on day 5 of 7 with continued dosing per hd. volume status was continually monitored by i/os and daily weights. he had hd on the day of discharge and tolerated it well. he will continue with his mwf hd where they will monitor both his fluid status and vancomycin dosing. . # benign hypertension no history of cad, ruled out for acs upon admit. transitory ekg changes with admit hypertension, resolved with bp control. on multiple meds with recurrent admits for htn urgency. simplified medications while inpatient. upon discharge his morning antihtn meds included nifedipine cr 30mg, lisinpril 30mg, metoprolol xl 12.5mg. these differed significantly from his admit medications. during his stay, his atenolol and valsartan were discontinued. nifedipine was changed from 90 mg to cr 30 mg and lisinopril was increased from 20 mg to 30 mg. metoprolol 12.5 mg daily was added for additional cardio-protection. we also changed his clonidine to a patch instead of taking po clonidine. he was instructed to follow-up with both his pcp and renal physicians to adjust these medications as needed. . # esrd on hd. appreciate renal input. urgent hd x 3 last week, with total volume decrease of 9kg. this aided greatly in the resolution of his pulmonary edema. he will resume his normal mwf hd this week. his dialysis was peformed while inpatient without incident. discharged on cinacalcet and lanthanum per renal recommendations. . # hiv/aids (vl <50, cd4 393 ) was maintained on his haart medication without interuptions while inpatient. was discharged without altering these medications. . # h/o pulmonary embolus diagnosed and with a newly discovered clot on . supratherapeutic in icu, for which coumadin was briefly held. upon admission to the floor, was restarted on warfarin 4mg po daily. inr was monitored and was therapeutic on discharge. will be followed in hd for continued monitoring and adjustments as need. . # dm type ii controlled - last hba1c 5.7. checked with qac and qhs finger sticks while inpatient. the patient actually did not receive any insulin for 5 days, and did not get any signs or sx of dka. he reports at home that his am fs is 80-90 and then post-prandial goes up to 100-115, after which he then takes his nph. states he takes both long-acting insulin and short-acting with meals. given this, we strongly believe his initial diagnosis of type 1 dm was incorrect and in fact was a very poorly controlled type 2. upon discharge it was recommended that he not take insulin unless his finger sticks were elevated >200. at that point, if his fs >200, he was instructed to call his primary care doctor to seek advice for continued insulin management. given this change, we established follow-up for mr. with the clinic for at 3 pm where this will be addressed. at the recommendation of the np, we also drew c-peptide and insulin antibodies which were pending at time of discharge and will be followed up at . full code medications on admission: 1. warfarin 2 mg tablet sig: three (3) tablets po hs (at bedtime). 2. gabapentin 100 mg capsule sig: one (1) capsule po tid (3 times a day). capsule(s) 3. lanthanum 500 mg tablet, chewable sig: four (4) tablet, chewable po tid (3 times a day). 4. cinacalcet 30 mg tablet sig: two (2) tablet po daily (daily). 5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). 6. atenolol 50 mg tablet sig: two (2) tablet po daily (daily). 7. valsartan 160 mg tablet sig: one (1) tablet po bid 8. prochlorperazine 20mg prn nausea 9. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po qsat (every saturday). 10. ritonavir 100 mg po qd 11. atazanavir 300mg po qd 12. stavudine 20 mg po qd 13. lamivudine 25 po qd 14. metoclopramide 10 mg iv q6h 15. albuterol sulfate 0.083 % q6h 16. clonidine 0.2 mg po bid 17. nifedipine 90 mg po qd discharge medications: 1. lanthanum 500 mg tablet, chewable sig: four (4) tablet, chewable po tid (3 times a day). 2. cinacalcet 30 mg tablet sig: two (2) tablet po daily (daily). 3. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po daily (daily). 4. ritonavir 80 mg/ml solution sig: 1.25 ml po daily (daily). 5. atazanavir 150 mg capsule sig: two (2) capsule po daily (daily). 6. stavudine 20 mg capsule sig: one (1) capsule po q24h (every 24 hours). 7. lamivudine 10 mg/ml solution sig: 2.5 ml po daily (daily). 8. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 9. clonidine 0.2 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qfri (every friday). disp:*4 patch weekly(s)* refills:*2* 10. nifedipine 30 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). disp:*30 tablet sustained release(s)* refills:*2* 11. warfarin 2 mg tablet sig: two (2) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*0* 12. lisinopril 10 mg tablet sig: three (3) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 13. metoprolol succinate 25 mg tablet sustained release 24 hr sig: 0.5 tablet sustained release 24 hr po daily (daily). disp:*15 tablet sustained release 24 hr(s)* refills:*2* 14. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) g intravenous hd protocol (hd protochol). 15. albuterol sulfate 0.083 % (0.83 mg/ml) solution sig: one (1) inhalation inhalation every six (6) hours as needed for shortness of breath or wheezing. 16. prochlorperazine 10 mg tablet sig: 1-2 tablets po twice a day as needed for nausea. 17. gabapentin 100 mg capsule sig: one (1) capsule po three times a day. discharge disposition: home discharge diagnosis: primary: hypertensive crisis, acute respiratory failure secondary to pulmonary edema, pneumonia secondary: esrd requiring hemodialysis, htn, hiv, dm, history of pe on coumadin therapy discharge condition: good. hemodynamically stable and afebrile. discharge instructions: please take all medications as directed. there have been several changes to your medications. first, you have not required insulin during this hospitalization. we reccomend that you do not take insulin unless you notice that your finger sticks are elevated >200. if your sugar is >200, call your primary care doctor and he will advise you what to do with your insulin. we have set you up with diabetes for at 3 pm where this will be addressed. we also changed your blood pressure medications. you should stop taking your atenolol and valsartan. we decreased your nifedipine from 90 mg to 30 mg and increased your lisinopril from 20 mg to 30 mg. we also added metoprolol 12.5 mg daily. we also changed clonidine to a patch which you should change every friday instead of taking clonidine by mouth. your coumadin was decreased from 6 mg daily to 4 mg daily. please follow-up with all outpatient appointments. take daily weights, return to ed or your pcp if you should notice increasing shortness of breath or lower extremity swelling. followup instructions: you should follow-up with your pcp, . after discharge. please call the office at to schedule an . we also scheduled diabetes to better assess your diabetes. you have on friday at 3 pm with dr. . 1. hemodialysis , wednesday and friday. you should have your pt and inr checked to assess whether your coumadin dose is correct. dr. will follow-up on this blood test. 1. provider: , md phone: date/time: 10:45 2. provider: , md phone: date/time: 9:10 3. provider: , md phone: date/time: 9:40 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Injection or infusion of platelet inhibitor Insertion of endotracheal tube Hemodialysis Diagnoses: End stage renal disease Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Human immunodeficiency virus [HIV] disease Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Restless legs syndrome (RLS)

allergies: clindamycin attending: chief complaint: hypertensive crisis, blurry vision major surgical or invasive procedure: hemodialysis history of present illness: 47 yo male with hiv (last cd4 238, viral load 882 in ) on haart, dm, esrd on hd, h/o pe on coumadin (dx ), h/o medication noncompliance, h/o malignant hypertension, who awoke this morning with l eye monocular blurry vision and dysequilibrium with standing. when he first awoke, he was seeing double, worse with r gaze. he also felt as though he was losing his balance when standing, but thinks this is due to the double vision in his l eye. he does have some mild pain in his l eye. he deniess vertigo, pre-syncopal symptoms, syncope, lightheadedness, or le weakness. he had one episode of n/v this am. he also has had a r temporal ha over the past week which is not throbbing and fairly constant. he rates this ha as , but does not wish to take any pain medications for it. he denies slurred speech, cp, sob, abd pain, new weakness or numbness in any of his extremities, brbpr, diarrhea, constipation. he states he has been compliant with taking all of his medications. . in the ed, the pts vitals were: t 99.2, bp 159-204/88-106, hr 80s-90s, r 15-22, sat 93-98% ra. he was noted to have r eye disconjugate gaze and monocular blurry vision. he received lebatolol 5 mg ivx1/10 mg ivx1, valsartan 160 mg po x 1, nifedipine cr 90mg po x1, ativan, and heparin gtt. code stroke was called. ct head and mri head were negative for acute process. he was started on a labetolol gtt. he was seen by neuro and felt to have l 3rd nerve palsy with pupillary sparing. as soon as the pt arrived to the micu, his lebatolol gtt was discontinued as his sbp was 140s. past medical history: - type 1 diabetes - hiv (lamivudine, stavudine), dx'd vl 882, cd4 238 in ) - esrd on hd, attempted on pd on transplant list (clinical study for hiv/solid organ transplant) - pe, on coumadin, diagnosed - malignant hypertension - hx serratia bacteremia (presumed av graft) tx 6 wks meropenem - hx schistosomiasis - restless leg syndrome - peripheral neuropathy on gabapentin - s/p cholecystectomy - s/p r nephrectomy in secondary renal nephrolithiasis social history: moved from in . lives with wife in . works in support services for a law firm. denies any alcohol or iv drug use. quit smoking last year; previous 30 pack-year history. family history: non-contributory physical exam: physical exam on micu admission: vs: temp: 99.2 bp: 141/61 hr: 95 rr: 20 o2sat: 95% 2lnc gen: pleasant, laying flat, comfortable, nad heent: patch over r eye, perrl, l eye unable to adduct or look up/down but able to abduct, anicteric, mmm, op without lesions, no diplopia, clear optic disc margins on left but unable to visualize on r, no hemorrhages on l or r fundoscopic exam neck: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: faint expiratory wheezing at the bilateral bases but no rales/ronchi cv: rr, s1 and s2 wnl, no m/r/g abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: no c/c/e, warm, 1+dp/pt pulses bl skin: no rashes/no jaundice neuro: aaox3. cn ii-xii intact with the exception of the l 3rd cn. 5/5 strength throughout. no sensory deficits to light touch appreciated. no pass-pointing on finger to nose. toes downgoing. pertinent results: admission labs: 09:55am wbc-5.9# rbc-4.03*# hgb-14.1# hct-40.2 mcv-100*# mch-34.9* mchc-35.0 rdw-14.0 09:55am plt count-159 09:55am glucose-120* urea n-54* creat-9.2* sodium-132* potassium-4.7 chloride-91* total co2-27 anion gap-19 07:54pm alt(sgpt)-9 ast(sgot)-11 ck(cpk)-136 alk phos-71 amylase-116* tot bili-0.3 07:54pm lipase-46 09:55am pt-15.0* ptt-30.3 inr(pt)-1.3* . pertinent labs: 09:55am ck(cpk)-139 09:55am ck-mb-19* mb indx-13.7* 09:55am ctropnt-0.29* 07:54pm ck-mb-18* mb indx-13.2* ctropnt-0.43* 03:56am blood ck(cpk)-98 03:56am blood ck-mb-notdone ctropnt-0.56* 03:35pm blood %hba1c-4.9 06:10am blood triglyc-87 hdl-35 chol/hd-3.7 ldlcalc-77 . ekg on admission: sinus rhythm. left atrial abnormality. tall t waves in leads v2-v4. consider acute ischemia or hyperkalemia. compared to the previous tracing of t waves are now upright and more acute. . imaging: chest (portable ap) impression: no acute cardiopulmonary disease. . mra brain w/o contrast impression: 1. normal mra of the head. 2. ventriculomegaly and low-lying cerebellar tonsils as before. 3. minimal amount of chronic microangiopathic changes. . cta head w&w/o c & recons impression: 1. ventriculomegaly and low-lying cerebellar tonsils as before. 2. normal ctp. 3. normal cta of the head and neck. brief hospital course: 47 yo male with hiv (last cd4 238, viral load 882 in ) on haart, dm, esrd on hd, h/o pe on coumadin (dx ), h/o medication noncompliance, h/o malignant hypertension, who presents with hypertensive urgency and left 3rd nerve palsy. . # hypertensive crisis: pt was admitted to the micu. this is likely secondary to medication noncompliance given that pt's bp rapidly normalized after pt received his home bp meds. pt has possible mild resultant cardiac ischemia from this event (positive mb index). he has prior h/o malignant htn in the past, treated with nitro gtts and lebatolol gtts. labetolol gtt was d/c'd once pt came into micu. he was restarted on home medications with few modificaitons and his bp has been well-controlled. he was continued on his home diovan 160 mg po bid, nifedipine cr 60 mg daily, clonidine tts 2 patch qsun, toprol xl 25 mg daily. his lisinopril was increased from 10 mg tid to 20 mg . . # transient 3rd nerve palsy: neurology was consulted and felt his vision changes were likely secondary to 3rd nerve palsy on the l, which is usually caused by dm or htn. there was no pupillary defect nor papilledema or hemorrhages on fundoscopic exam. ophthomology also evaluated the pt and reported resolution of the 3rd nerve palsy. his vision changes had resolved by discharge. pt will follow up with outpatient ophthomology. . # elevated cardiac enzymes: with his elevated cardiac enzymes, he was initially started on heparin gtt. this was likely due to leakage of enzymes from hypertensive emergency as opposed to ischemic event. his elevated tpn is likely due to crf. no had no ekg changes. ck plateaued at 139 and trended down. heparin gtt was stopped given low suspicion and inr near therapeutic for distant dvt. he was continued on his aspirin. . # hypoxia: on admission he was hypoxic wtih mild wheezing at lung bases, likely either to atelectasis vs. volume overload from hypertensive crisis. cxr had no evidence of acute cardiopulmonary process. he was weaned to ra without desaturation and remained on ra for the remainder of his hospitalization. . # n/v: this was likely related to hypertensive crisis as it resolved with bp control. amylase/lipase, lfts were not indicative of an acute processs. his known gastroparesis may have also contributed, and he was continued on his outpatient regimen of reglan. . # esrd: pt cont. to have hemodialysis qmwf. he was continued on lanthanum. . # hiv: he follow ups poorly with both dr. (id) and his pcp, . . per id, given his history of medical noncompliance, his haart medications were held. he will follow up with dr. as an outpatient regarding reinitiation of haart. . # h/o pe: pt was admitted with subtherapeutic inr of 1.3. his coumadin was increased to 5 mg daily and was therapeutic upon discharge. . # ?depression: per his nephrologist dr. & pcp . , there has been some concern for worsening depression/coping, which may be possibly contributing to his medical noncompliance. psychiatry was consulted and felt that he did appear to be somewhat dysthymic but without overt depressive symptoms. pt denies any medical noncompliance. . # restless leg syndrome: pt was continued on neurontin. . # dm: pt was continued on home nph and iss with adqueate control of bs. . # code status: full medications on admission: lamivudine 25 mg qd zerit 20 mg qd ?ritonavir 100 mg daily ?atazanavir 300 mg daily ?tenofovir 100 mg weekly diovan 160 mg nph 10 u qam, 7 u qpm insulin regular 5 u qpm ativan 1 mg tid prn lisinopril 10 mg tid ambien 10 mg qhs prn nifedipine sr 30 mg qd coumadin 4 mg on non-hd days, 5 mg on hd days neurontin 100 mg to tid (depending on how bad restless legs are) catapress 2 patch weekly reglan 10 mg qachs fosrenol 1 gm tid metoprolol succinate 25 mg daily . allergies: clindamycin-rash discharge medications: 1. lisinopril 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 2. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 3. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po once a day. 4. valsartan 160 mg tablet sig: one (1) tablet po twice a day. 5. clonidine 0.2 mg/24 hr patch weekly sig: two (2) patch weekly transdermal qsun (every sunday). 6. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 7. lanthanum 500 mg tablet, chewable sig: two (2) tablet, chewable po tid w/meals (3 times a day with meals). 8. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). 9. gabapentin 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 11. ativan 1 mg tablet sig: one (1) tablet po three times a day as needed for anxiety. 12. ambien 10 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 14. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 15. insulin nph human recomb 100 unit/ml suspension sig: units subcutaneous twice a day: please take 10 units in the morning, 7 units in the evening. 16. insulin regular human 100 unit/ml solution sig: 2-10 units injection four times a day: please take according to attached sliding scale. discharge disposition: home discharge diagnosis: primary: hypertensive emergency cranial nerve palsy . secondary: hiv chronic renal failure, stage v diabetes mellitus type 1 pulmonary embolus discharge condition: stable discharge instructions: you were admitted for dangerously high blood pressure with changes in vision. your vision changes have resolved. neurology and ophthalmology have seen you and ophthalmology recommends outpatient follow up. your lisinopril has been changed from 10 mg three times a day to 20 mg twice a day. your blood pressure has been well-controlled with these medications. . please continue to take your medications except as above. in addition, please take coumadin (warfarin) 5 mg every evening as your inr was noted to be low. please follow up with your primary care physician . to follow your inr and adjust your coumadin dose. in addition, the infectious diseases team recommends that you stop taking your hiv medications for now. please follow up with dr. of infectious diseases regarding when to resume taking these drugs. . if you develop worsening headache, dizziness, lightheadedness, chest discomfort, palpitations, shortness of breath, or any other concerning symptoms, please call your primary care physician . at or go to the emergency department. followup instructions: please follow up with ophthalmology (eye). you have an for tuesday, at 1pm. please confirm your by calling the clinic at(. . please also follow up with dr. of infectious diseases regarding your medications for hiv. you have an for tuesday, at 10am. please confirm your by calling the clinic at (. . please keep the following appointments as well: provider: , : date/time: 9:40 provider: , md phone: date/time: 9:00 provider: , o.d. phone: date/time: 1:00 md, Procedure: Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease End stage renal disease Polyneuropathy in diabetes Long-term (current) use of anticoagulants Personal history of noncompliance with medical treatment, presenting hazards to health Awaiting organ transplant status Asymptomatic human immunodeficiency virus [HIV] infection status Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Gastroparesis Restless legs syndrome (RLS) Third or oculomotor nerve palsy, total

allergies: clindamycin attending: chief complaint: shortness of breath and htn major surgical or invasive procedure: none history of present illness: 46 y/o ethiopian male with a h/o t1dm, hiv, esrd, and peripheral neuropathy who presented to the ed with sob, cough, and pleuritic chest pain. pt states that he was in his usual state of health until he developed a fever (temp to 102 at home), pleuritic chest pain, and sob the night prior to admission. he reports uri symptoms over the past 6 days. his last hd session was the day prior to admission with removal of over 2l of fluid. pt was evaluated in the ed. of note, he had not taken his medications prior to admission. . upon arrival to the ed, vitals were t 99.7 hr 70 bp 227/104 rr 16 and 98%ra. he was given metoprolol 5 mg iv x 1 and hydralazine 10 mg iv x 1. he was also given cefepime 2 grams iv and vancomycin 1 g iv. he was started on a nipride gtt for bp control and transferred to the micu hemodynamically stable. . in icu, he was monitored and continued on nipride gtt for bp control. renal was consulted and he had hd with 3.5 uf. he was also found to have a multifocal pneumonia by ct scan and abx changed to vanco/levo. id was consulted. when off nipride, he was then transferred to medical floor. . on the floor, he currently has no complaints except that cough may be worsening. he denies any fevers, chills, nausea, vomiting, pain. pt in middle of changing dwell for pd and wished to defer further discussion. past medical history: - type 1 diabetes - hiv (boosted atazanavir, lamivudine, stavudine), dx'd - esrd on hd, planned change to peritoneal dialysis in near future, on transplant list (clinical study for hiv/solid organ transplant) - recent hospitalizations for serratia bacteremia (presumed source av graft) most recently treated with 6 week course meropenem - history of schistosomiasis - restless leg syndrome - peripheral neuropathy on gabapentin - s/p cholecystectomy social history: moved from in . lives with wife in . works in support services for a law firm. denies any alcohol or iv drug use. quit smoking last year; previous 30 pack-year history. family history: non-contributory. physical exam: t 98.9 hr 82 bp 197/98 rr 12 98% 2l nc general: wd/wn 46 y/o male in nad. heent: nc/at. perrla. eomi. mmm. op clear. neck: no lad or jvd. cv: normal s1, s2 without m/r/g. pulm: ctab without wheezes or crackles. abd: soft, nd, mild diffuse tenderness. normoactive bs. ext: no c/c/e. neuro: cns ii-xii grossly intact. a/o x 3. skin: no rash pertinent results: ct chest: impression: 1. no pulmonary embolism is seen. 2. diffuse peribronchiolar opacities within both lungs that suggest infectious etiology. 3. small bilateral pleural effusion which is associated with left lower lobe atelectatic changes. . labs on discharge: wbc-6.2 rbc-3.56* hgb-12.8* hct-37.1* mcv-104* mch-35.8* mchc-34.4 rdw-15.3 plt ct-241 glucose-115* urean-45* creat-9.4*# na-137 k-4.2 cl-95* hco3-30 brief hospital course: # sob/pna: etiology most likely to pna and possible volume overload due to missing hd; his sob has improved after removing 2l from hd. on ct chest, he was noted to have diffuse bronchial opacities concerning for infection. in ed, he was started on vanc and cefepime. in micu, continued vanc (dose based on level and re-dose at hd) and started levofloxacin to cover for cap and possible hap given recent admission in . id was consulted and felt this was reasonable and low suspicion for other infectious etiologies. rapid resp panel was negative. he was discharged on a course of po levofloxacin (10 day course) . # htn: pt admitted with htn urgency requiring nipride gtt likely to not taking bp meds for 2 doses prior to admission. once in micu, he was weanned off nipride gtt and transitioned back to home htn meds. for the remainder of hosp course, he was normotensive. . # hiv: followed by dr. as outpatient. recent viral load and cd4 count 393 (and in this range in 1/). he continued his outpatient antiretroviral regimen. on discharge, he will have close follow-up with drs. and . . # esrd: currently attempting to transition pt to pd but pt has been noncompliant with teaching. he continuied on his home hd schedule with outpatient plans to transition to pd. . # t1dm: no active issues. he re-started home insulin regimen and covered with riss (on regular at home) . # fen - renal, diabetic, cardiac healthy diet - monitor lytes . # access - right hd catheter - piv . # code - full code medications on admission: gabapentin 100 mg tid atenolol 50 mg po daily compazine prn insulin (nph 10 u and regular 5 u qam) lamivudine 250 mg po after hd on hd days atazanavir 300 mg po qd ritonavir 100 mg po daily stavudine 20 mg po qhd days after hd ativan prn tenofovir 300 mg po qsat discharge medications: 1. valsartan 160 mg tablet sig: one (1) tablet po bid (2 times a day). 2. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po qsaturday (). 3. levofloxacin 250 mg tablet sig: one (1) tablet po q48h (every 48 hours) for 10 days. disp:*5 tablet(s)* refills:*0* 4. ritonavir 100 mg capsule sig: one (1) capsule po daily (daily). 5. atazanavir 150 mg capsule sig: two (2) capsule po daily (daily). 6. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 7. lamivudine 10 mg/ml solution sig: one (1) po daily (daily). 8. stavudine 20 mg capsule sig: one (1) capsule po q24h (every 24 hours). 9. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 10. atenolol 25 mg tablet sig: two (2) tablet po daily (daily). 11. lanthanum 500 mg tablet, chewable sig: two (2) tablet, chewable po tid w/meals (3 times a day with meals). 12. insulin please continue your home insulin regimen discharge disposition: home discharge diagnosis: primary: pneumonia hiv hypertensive urgency discharge condition: stable, normotensive, afebrile discharge instructions: you had very high blood pressures and also a pneumonia, which is being treated with antibiotics. . please call 911 or go to the emergency room if you have any fevers greater than 100.4, chills, nausea, vomiting, shortness of breath, chest pain, or any other concerning symptoms. . please take all medications as prescribed and attend all follow-up appointments. followup instructions: please attend your appointment with dr. , md phone: date/time: 10:10am in the building . . you also have an appointment with dr. on at 10 am. the location is . please call if you have any questions. . please go to your regular dialysis center on monday for dialysis. you will receive your peritoneal dialysis equiptment from home. . provider: , md phone: date/time: 9:10 provider: . phone: date/time: 10:00 provider: Procedure: Hemodialysis Diagnoses: Pneumonia, organism unspecified End stage renal disease Anemia, unspecified Personal history of tobacco use Human immunodeficiency virus [HIV] disease Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Personal history of noncompliance with medical treatment, presenting hazards to health Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Unspecified hereditary and idiopathic peripheral neuropathy Restless legs syndrome (RLS)

allergies: clindamycin attending: chief complaint: chest pain major surgical or invasive procedure: none history of present illness: 46 y/o ethiopian male hx t1dm, hiv, esrd (secondary to nephrolithiasis, htn and t1dm) presented to the ed complaining of shortness of breath and chest pain. he claims that the chest pain is the same all the time, nonpleuritic, nonpositional, nonradiating, but that his shortness of breath worsens when he lays flat. he notes that the last time he felt this kind of pain, he was found to have a large pleural effusion. the bedside ultrasound was brought over and did not show any evidence of an effusion, and because he is hd dependent, he was sent for a cta, which showed an acute pe as well as evidence of chronic pe's. his pressures were in the 200's systolic, and he was started on a nitroglycerin gtt, with little benefit. otherwise, he was afebrile and with mild respiratory distress to the low 20's. he was seen by renal in the ed (he is followed by dr. as an outpatient) who felt that his hypertension was likely secondary to him missing his am meds, as he had just had hd the day prior to admission. he also had a head ct, prior to initiating heparin gtt to rule out head bleed, and it could not rule out sah given the dye load from the cta. the ed therefore did not start anticoagulation and sent the patient to the for further management of his hypertension, renal failure and pe's. past medical history: - type 1 diabetes - hiv (boosted atazanavir, lamivudine, stavudine), dx'd vl <50, cd4 393 ) - esrd previously on hd, attempted on pd on transplant list (clinical study for hiv/solid organ transplant) - malignant hypertension - hx serratia bacteremia (presumed av graft) tx 6 wks meropenem - hx schistosomiasis - restless leg syndrome - peripheral neuropathy on gabapentin - s/p cholecystectomy - s/p r nephrectomy in secondary renal nephrolithiasis social history: moved from in . lives with wife in . works in support services for a law firm. denies any alcohol or iv drug use. quit smoking last year; previous 30 pack-year history. family history: non-contributory. physical exam: vitals: 98.0 80 % 4lnc general: nad, comfortable heent: jvd to 9cm, perrl, eomi, op clear heart: rrr no m/r/g lungs: ctab no w/r/r abd: soft nt/nd +bs ext: no e/c/c, wwp, 2+ dp pulses neuro: nonfocal skin: warm and dry pertinent results: admit labs: 10:30am wbc-4.5 rbc-3.20* hgb-12.0* hct-34.4* mcv-107* mch-37.6* mchc-35.0 rdw-15.8* 10:30am neuts-60.8 lymphs-26.1 monos-8.1 eos-4.0 basos-1.0 10:30am plt count-203 10:30am glucose-95 urea n-47* creat-9.2*# sodium-137 potassium-6.2* chloride-94* total co2-29 anion gap-20 10:30am alt(sgpt)-24 ast(sgot)-31 ck(cpk)-130 alk phos-153* tot bili-2.3* . cardiac enzymes: 10:30am ctropnt-0.29* 10:30am ck-mb-5 10:30am ck(cpk)-130 08:47pm ck-mb-5 ctropnt-0.23* 08:47pm ck(cpk)-97 . . imaging: : cxr - impression: no acute cardiopulmonary process. . : cta impression: 1. segmental and subsegmental right lower lobe acute pulmonary embolism. 2. stable findings of chronic right lower lobe pe. 3. diffuse and more focal ground-glass opacities, which could represent an infectious process such as viral or atypical pneumonia. pneumocystis pneumonia could also have this appearance in the proper clinical setting. asymmetric pulmonary edema is a less likely consideration. . : head ct: impression: 1. no definite acute intracranial hemorrhage; however, intravascular contrast remains on board from the recent cta pe study, and thus subarachnoid and subtle extra-axial hemorrhage cannot be excluded on this ct. 2. prominent ventriculomegaly, not significantly changed from . 3. low-lying cerebellar tonsils consistent with chiari i malformation. . : head ct: findings: there is no evidence of hemorrhage, mass effect, shift of midline structures, or infarction. the ventricles remain prominently enlarged, unchanged from recent examination. there is stable appearance to low lying cerebellar tonsils as noted on prior exams. soft tissues and osseous structures are unremarkable. perinasal sinuses and mastoid air cells are well aerated. impression: 1. no evidence of hemorrhage. 2. unchanged chiari i malformation and prominent ventriculomegaly . echo: conclusions: the left atrium is mildly dilated. the estimated right atrial pressure is 11-15mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef 60%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets aremildly thickened. there is no mitral valve prolapse. there is severe mitral annular calcification. at least mild (1+) mitral regurgitation is present. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the annular calcification is now severe, and the mitral regurgitation is increased. . discharge labs: brief hospital course: 46 year old ethiopian man with a history of type i diabetes mellitus, ckd stage v on hemodialysis, malignant hypertension, hiv on haart who presented with concomitant severe nausea, vomiting, chest pain and subsequent shortness of breath. the following issues were addressed on this admission: . 1. respiratory distress: initiating event thought to be nausea and vomiting secondary to gastroparesis. patient unable to take anti-hypertensives and combined with sympathetic tone from nausea, vomiting, patient then likely devloped hypertension with systolics to >200's (>250 in emergency room). chest pain secondary to vomiting or possibly ischemia with severe hypertension. shortness of breath appears to have developed secondary to pulmonary edema from severe hypertension. low oxygen requirements even in this setting. patient underwent cta of chest and found to have acute segmental and subsegmental pe's as well as chronic pe's, ultimately not thought to have been responsible for presentation. patient was placed on nitroglycerin drip in er and in the for short time. once nausea controlled, home blood pressure regimen re-initiated with good control. patient dialyzed morning after admission for pulmonary edema. with control of nausea, blood pressure and dialysis, resp distress resolved. no further episodes throughout admission. patient transferred to the floor on hd#2, . see pe below. cardiac enzymes cycled and remained flat, no concerning ecg changes. . 2)pulmonary emboli: patient found to have acute segmental and subsegmental pe in rll and chronic pe. initially unable to rule out head bleed (ct head images affected by contrast dye from cta) and therefore heparin therapy withheld. patient transferred to the floor and had repeat head ct without evidence of head bleed. heparin gtt and coumadin 7.5 mg initiated . coumadin 7.5 mg on , inr then 2.3 on 7/6am. 5mg pm and then inr 4.1 on . coumadin held and inr 3.8 on . given inr>2 x 48 hours on heparin, heparin discontinued on and patient instructed to take no coumadin on evening and have inr checked at scheduled dialysis. dr. will follow inr at dialysis. given script for 2mg coumadin tablets. appears that dosing in past for graft was around daily. . 3)malignant hypertension: as above in #1, patient hypertensive to systolic 250's on presentation. likely secondary to gastroparesis and missing meds with nausea, vomiting. initially on nitro drip in er and quickly weaned once nausea controlled and home anti-hypertensives re-initiated. home anti-hypertensives of lisinopril 20, diltiazem xr 90mg, valsartan 160 and atenolol 100mg daily maintained throughout rest of admission. bp's generally 140-160. . 4. nausea/vomiting/epigastric pain: daily symptoms in setting of dm1 suggested gastroparesis. reglan initiated. gi consulted and recommended reglan. continued throughout admission with good effect. will need to be vigilant for side effects given complex medical issues/regimen. to follow up with dr. . . 5.ckd stage v, on hemodialysis: complicated history, had been on pd, on transplant list. dr. and renal team followed throughout admission. dialysis performed on . patient will get dialysis on . inr check at that time as above. unclear if patient taking lanthanum as outpatient. taking sensipar. here lanthanum 2000mg tid with meals and sensipar 60mg daily continued. to follow up with dr. and dr. for transplant evaluation. . 6. hiv: haart regimen continued. meds given after dialysis on dialysis days. patient to follow up with dr. . . 7 anemia: felt to be result of longstanding esrd. continued epogen w/ hd . 8. peripheral neuropathy: longstanding secondary to dm1. continued gabapentin . 9. type i diabetes mellitus: outpatient regimen continued with good glucose control, generally 90's to 140's. nph 10 qam, 7qpm and regular iss. . 10. patch of alopecia: outpatient dermatology consult as arranged by pcp, . . . 11. finding of chiari i malformation, increased size of ventricles. not cliniically significant on this admission, no acute issues. recommend neurosurgery follow up if patient has not seen at discretion of dr. . patient instructed on all medications including changes and side effects. no coumadin tonight, and check tomorrow at dialysis. follow up instructions provided including with dr. , dr. , dr. , dr. , dr. , dermatology and potentially neurosurgery. see discharge information for details. medications on admission: gabapentin 100 mg tid lanthanum 2000mg tid with meals cinacalcet 60mg daily lisinopril 20mg daily atenolol 100 mg po daily valsartan 160mg diltiazem 90xr daily compazine prn insulin (nph 10 u and regular 5 u qam) tenofovir 300 mg po qsat ritonavir 100 mg p.o. daily atazanavir 300 mg p.o. daily stavudine (zerit) 20 mg po daily lamivudine (epivir) 25 mg po daily (of note haart given after dialysis). discharge disposition: home discharge diagnosis: primary: 1. hypertensive emergency 2. pulmonary emboli 3. respiratory distress 4. gastroparesis secondary: 1.type i dm with complications 2. ckd stage 5 on hemodialysis 3. hiv discharge condition: stable, tolerating po, ambulating, therapeutic on coumadin. discharge instructions: take all medications as prescribed. the new medications are: 1)coumadin, take none tonight, have your inr checked tomorrow at dialysis, and then they will tell you how much to take starting . 2)lanthanum: you should take 2000mg with each meal to help regulate your calcium and phosphorus. 3)reglan(metoclopramide): take this with each meal for your gastroparesis as discussed. continue to take your blood pressure medications, insulin and hiv medications as before, these have not been changed. all your other medications as before. . make sure to follow up with each of the doctors below, as we discussed in detail. . if you have return of nausea, vomiting, shortness of breath, chest pain or develop fevers or any other new concerning symptoms contact your doctor or go to the emergency room. followup instructions: follow up with dr. in dialysis, tomorrow, as scheduled. you must have your inr checked and they will instruct you how much coumadin to take for the rest of the week. . follow up with dr. . call him tomorrow at to set up an for this week. i will tell him about your hospitalization. . follow up with dr. for your hiv medications. his number is . you should call this week to set up an with him. . follow up with dr. on tuesday for your transplant evaluation: provider: , md phone: date/time: 10:50 . follow up with the dermatologist for your hair loss: provider: , md phone: date/time: 10:45 . you can follow up with dr. in clinic for your gastoparesis. she saw you as an inpatient here. her number is . call tomorrow to set up an . you can ask dr. if you have questions. . you may need evaluation by neurosurgery for a possible congenital defect which is not an emergency. (chiari i malformation). let dr. know about this. Procedure: Hemodialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease End stage renal disease Mitral valve disorders Other chronic pulmonary heart diseases Polyneuropathy in diabetes Human immunodeficiency virus [HIV] disease Compression of brain Other pulmonary embolism and infarction Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Gastroparesis Restless legs syndrome (RLS)

allergies: clindamycin attending: chief complaint: high blood pressure major surgical or invasive procedure: hemodialysis on history of present illness: 46 yo m with h/o dmi, esrd on hd, hiv(vl <50, cd4 393 ), recently diagnosed pe, and multiple ed admissions for htn emergency, nausea, and vomiting who presented to with acute onset sob, nausea, and vomiting. patient had been in his usual state of health prior and went to usual hd session where reportedly had the standard amount of uf taken off. that evening, he felt acutely sob with nausea and subsequent vomiting. he denied any associated chest pain, palpitations, lightheadedness, focal numbness or weakness, or changes in vision although he did note headache at that time. . of note, he last took his po meds yesterday afternoon but has since been unable to take po meds due to nausea and vomiting. of note, he has been admitted with similar symptoms 5 times since , three times in last month prior. on recent admission was found to have chronic pes that are of unclear relation, but was started on anticoagulation. on his most recent admission , he was admitted to the icu and was initially managed with nipride gtt which was transitioned to ntg gtt. he was then transitioned to his oral regimen and was discharged with the addition of clonidine patch. he refused to stay until his inr was therapeutic. . in the ed, his initial vitals were signifanct for sbp in 230s. he was given lopressor 5 iv without any change in bp. subsequently given hydralazine 10 iv x 1 followed by hydralazine 20 iv x 2 with minimal improvement in blood pressure. cta was performed for c/o sob which showed new pes in rll but decrease in size of other chronic pes. he was started on a nitro gtt and was transferred to the floor. . on the floor, patient continued to complain of ha and nausea. however, he was able to take valsartan 160 mg po x1. he felt his sob was improved. he was continued on the nitro gtt with sbps remaining in the 200s. renal was consulted but noted that patient was at his new dry weight and did not feel that there was significant volume contribution to current presentation. he received labetolol 20 mg iv x 1 with response in his sbp to 170s. however, required a second dose for return of sbps to 200s with again drop to 170s. he continued to complain of mild ha and nausea but but otherwise denied cp, sob, lightheadedness, numbness, tingling, vision changes, abdominal pain. he was then transferred to the icu for further management. past medical history: - type 1 diabetes - hiv (boosted atazanavir, lamivudine, stavudine), dx'd vl <50, cd4 393 ) - esrd previously on hd, attempted on pd on transplant list (clinical study for hiv/solid organ transplant) - malignant hypertension - hx serratia bacteremia (presumed av graft) tx 6 wks meropenem - hx schistosomiasis - restless leg syndrome - peripheral neuropathy on gabapentin - s/p cholecystectomy - s/p r nephrectomy in secondary renal nephrolithiasis social history: moved from in . lives with wife in . works in support services for a law firm. denies any alcohol or iv drug use. quit smoking last year; previous 30 pack-year history. family history: non-contributory. physical exam: t: 99.6 bp: 166/80 hr: 81 rr: 17 o2 98% 2lnc gen: drowsy but easily arousible. nad heent: no conjunctival pallor. mmm. op clear. mild left ptosis neck: supple, no lad, jvp low. r ij line cdi cv: rrr. ii/vi sys murmur lungs: bibasilar rales. abd: nabs. soft, nt, nd. no hsm. large right flank hernia secondary to nephrectomy unchanged per patient ext: wwp, no cce. 2+ dp pulses bl skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn 2-12 intact except for slight l ptosis and l lower facial droop. preserved sensation throughout. 5/5 strength throughout. pertinent results: 03:13pm glucose-107* urea n-45* creat-10.3*# sodium-136 potassium-5.3* chloride-95* total co2-27 anion gap-19 03:13pm calcium-9.8 phosphate-7.6* magnesium-2.6 03:13pm tsh-3.7 03:13pm wbc-6.4 rbc-2.61* hgb-9.8* hct-28.2* mcv-108* mch-37.4* mchc-34.6 rdw-15.4 03:13pm plt count-253 03:13pm pt-14.9* ptt-90.9* inr(pt)-1.3* 11:45pm glucose-74 urea n-38* creat-8.7*# sodium-137 potassium-5.1 chloride-96 total co2-29 anion gap-17 11:45pm estgfr-using this 11:45pm ck(cpk)-72 11:45pm ck-mb-4 ctropnt-0.36* 11:45pm wbc-6.8 rbc-2.82* hgb-10.2* hct-29.6* mcv-105* mch-36.1* mchc-34.3 rdw-16.1* 11:45pm neuts-64.3 lymphs-23.7 monos-6.5 eos-5.2* basos-0.3 11:45pm pt-14.7* ptt-29.7 inr(pt)-1.3* brief hospital course: the patient was brought to the icu on nitro and labetalol drips for hypertension, and heparin drip for new pe. the nitro drip was weaned without difficulty. the labetalol drip was weaned within the first 24 hours of admission after giving the patient his po blood pressure medications including po propranolol 100mg. the patient received hemodialysis on the morning of . on the morning of the patient's headache and nausea had resolved and he advanced to a regular diet. he had no complaints and was observed overnight for maintenance of blood pressure. he will continue coumadin for his pe and follow-up as an outpatient with his regular doctors. medications on admission: lovenox 60 mg sq daily (per pt, d/c'd by md) coumadin 5 mg qhs gabapentin 100 mg tid lanthanum 2 gm tid cinacalcet 60 mg daily lisinopril 20 mg daily atenolol 100 mg daily valsartan 160 mg prochlorperazine 10 mg q6h prn tenofovir disoproxil fumarate 300 mg qsat ritonavir 100 mg daily atazanavir 300 mg daily stavudine 20 mg daily lamivudine 10 mg/ml solution daily metoclopramide 10 mg tablet qidachs albuterol/ipratropium neb q6h prn clonidine 0.2 mg nifedipine 90 mg daily discharge medications: 1. warfarin 2 mg tablet sig: three (3) tablets po hs (at bedtime). 2. gabapentin 100 mg capsule sig: one (1) capsule po tid (3 times a day). capsule(s) 3. lanthanum 500 mg tablet, chewable sig: four (4) tablet, chewable po tid (3 times a day). 4. cinacalcet 30 mg tablet sig: two (2) tablet po daily (daily). 5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). 6. atenolol 50 mg tablet sig: two (2) tablet po daily (daily). 7. valsartan 160 mg tablet sig: one (1) tablet po bid (2 times a day). 8. prochlorperazine 10 mg tablet sig: two (2) tablet po every six (6) hours as needed for nausea. 9. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po qsat (every saturday). 10. ritonavir 100 mg capsule sig: one (1) capsule po daily (daily). 11. atazanavir 150 mg capsule sig: two (2) capsule po daily (daily). 12. stavudine 20 mg capsule sig: one (1) capsule po q24h (every 24 hours). 13. lamivudine 10 mg/ml solution sig: one (1) po daily (daily). 14. metoclopramide 10 mg iv q6h 15. albuterol sulfate 0.083 % (0.83 mg/ml) solution sig: one (1) inhalation q6h (every 6 hours) as needed. 16. clonidine 0.2 mg tablet sig: one (1) tablet po twice a day. 17. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). discharge disposition: home discharge diagnosis: 1. hypertensive urgency 2. pulmonary embolism . human immunodeficiency virus diabetes hypertension end stage renal disease discharge condition: stable discharge instructions: you were admitted with extremely high blood pressure and new clots to your lungs. your blood pressure is now under better control and are now ready for discharge. you will need to have your inr drawn tomorrow at dialysis to check your coumadin level ! please take your medications as prescribed. . followup instructions: please call dr. at to schedule an within the next month. you will need to have your inr drawn tomorrow at dialysis to check your coumadin level ! . provider: , md phone: date/time: 9:40 . provider: , md phone: date/time: 10:45 Procedure: Hemodialysis Diagnoses: End stage renal disease Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Congestive heart failure, unspecified Human immunodeficiency virus [HIV] disease Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other pulmonary embolism and infarction Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Gastroparesis Restless legs syndrome (RLS)

allergies: clindamycin / ace inhibitors / valsartan attending: chief complaint: fever, rigors major surgical or invasive procedure: transesophageal echocardiogram tunneled catheter removal tunneled catheter placement history of present illness: 49 y/o m with hx of htn, dm, esrd on hd, hiv (cd4 560, hiv vl 116 ), and hx of pe on coumadin since presented to ed with fevers/rigors with today. he reported pain at his site and by report pus was expressed from the catheter site. he was dialyzed completely but spiked temp to 102 and was given vanc and 1gram tylenol. on he was admitted with hematemesis to therapy. of note, recent documentation from transplant that he is now off the kidney transplant list because of medication non-compliance. in the ed, initial vs: 99.6 130 151/79 20 100. cxr wnl. endorsed dry cough. ct abd/pelvis nothing acute. given 1.5l ivf in ed. blood cultures drawn, given zosyn. currently, patient reports lethargy and productive cough of whites sputum although his wife reports he is "always coughing." denies fever prior to today. denies cp, sob, cough, n/v/d, abdominal pain, orthopnea, pnd, orthopnea or doe. ros: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: - type 1 diabetes - hiv: dx'd ; (cd4 560, hiv vl 116 ) - esrd on hd mwf, attempted on pd on transplant list, recently off transplant list for med noncomplaince (clinical study for hiv/solid organ transplant) - pe, on coumadin, diagnosed - malignant hypertension - hx serratia bacteremia (presumed av graft) tx 6 wks meropenem - hx schistosomiasis - restless leg syndrome - peripheral neuropathy on gabapentin - s/p cholecystectomy - s/p r nephrectomy in secondary renal nephrolithiasis - r ij clot social history: quit smoking for yrs, used to smoke for 25 yrs with 0.5ppd, occ drinking, denies illicit drug use, lives with family. moved from in . lives with wife in . family history: denies family history of dm, htn, mi, cva. mother alive in good health. father deceased of unknown cause when pt was young. physical exam: vitals - t: 99.4 bp: 188/80 hr: 91 rr: 18 02 sat: 98%ra general: nad, ill appearing, wrapped in blanket, dilated veins on head visible, minimal movement, short answers to questions heent: normocephalic, atraumatic. marked conjunctival injection. no scleral icterus. pupils equal, minimally reactive, bilateral leukocoria. eomi but with some strabismus at baseline. markedly swollen throat with no lesions or exudate, uvula not visualized. mmm. op clear. neck supple, no lad, no thyromegaly. cardiac: rrr. normal s1, s2. no murmurs, rubs or noted. no s3 or s4. lungs: ctab, good air movement bilaterally. abdomen: nabs. soft, nt, nd. no hsm extremities: no edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn ii-ixx intact. preserved sensation throughout. 5/5 strength throughout. + reflexes, equal bl. normal coordination. gait assessment deferred. psych: flat affect, speech decreased in quantity but with without aphasia or dysarthria, normal attention. pertinent results: hematology 11:15am blood wbc-8.0 rbc-4.28* hgb-12.6* hct-40.9 mcv-96 mch-29.4 mchc-30.7* rdw-17.3* plt ct-232 05:56am blood wbc-15.8*# rbc-3.86* hgb-12.0* hct-37.4* mcv-97 mch-31.1 mchc-32.1 rdw-17.1* plt ct-234 07:00am blood wbc-7.2 rbc-3.96* hgb-11.5* hct-36.8* mcv-93 mch-29.0 mchc-31.2 rdw-17.2* plt ct-297 11:15am blood neuts-90.4* lymphs-4.1* monos-3.0 eos-2.4 baso-0.1 05:45am blood pt-26.3* ptt-33.5 inr(pt)-2.6* 01:15pm blood pt-15.1* ptt-29.9 inr(pt)-1.3* chemistry 11:15am blood glucose-109* urean-17 creat-4.6*# na-133 k-7.0* cl-98 hco3-25 angap-17 05:35am blood glucose-106* urean-17 creat-5.2*# na-139 k-3.9 cl-92* hco3-33* angap-18 07:00am blood glucose-82 urean-28* creat-9.2*# na-137 k-4.0 cl-90* hco3-32 angap-19 07:00am blood calcium-10.5* phos-6.3* mg-2.4 11:15am blood alt-13 ast-62* ck(cpk)-88 alkphos-99 totbili-0.5 04:10pm blood ck(cpk)-34* 12:19am blood ck(cpk)-22* 05:56am blood alt-14 ast-81* ck(cpk)-86 06:15am blood alt-13 ast-15 alkphos-95 totbili-0.4 11:15am blood ck-mb-notdone ctropnt-0.30* 04:10pm blood ck-mb-notdone 04:10pm blood ctropnt-0.40* 12:19am blood ck-mb-notdone ctropnt-0.51* 05:56am blood ck-mb-notdone ctropnt-0.41* micro: blood culture, routine (final ): staph aureus coag +. final sensitivities. _________________________________________________________ staph aureus coag + | erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- 4 r oxacillin------------- 0.5 s trimethoprim/sulfa---- =>320 r anaerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. reported by phone to frost at 2040 on . aerobic bottle gram stain (final ): gram positive cocci in clusters. blood culture, routine (final ): no growth. hiv-1 viral load/ultrasensitive (final ): 143 copies/ml. respiratory viral culture (final ): no respiratory viruses isolated. culture screened for adenovirus, influenza a & b, parainfluenza type 1,2 & 3, and respiratory syncytial virus.. detection of viruses other than those listed above will only be performed on specific request. please call virology at within 1 week if additional testing is needed. respiratory viral antigen screen (final ): negative for respiratory viral antigen. specimen screened for: adeno, parainfluenza 1, 2, 3, influenza a, b, and rsv by immunofluorescence. refer to respiratory viral culture for further information. imaging ct abd - no evidence of diverticulitis or appendicitis. posterior incisional hernia containing large bowel with no evidence of obstruction. status post right nephrectomy. multiple subcentimeter cystic lesions in the left kidney, with imaging features most compatible with lithium toxicity, however, differential includes cystic disease of hemodialysis. dilation of the pancreatic duct measuring up to 6 mm to the level of the ampulla with no discrete mass identified. recommend ercp for further evaluation. stable appearance of diffuse urinary bladder thickening since examination from . cxr - no acute intrathoracic process. right upper extremity veins - . again seen is thrombus within the right internal jugular vein down to the level of the subclavian vein. short segment of non-occlusive thrombus in the right axillary and brachial veins at the axillary and brachial vein confluence. short segment of nonocclusive thrombus in the left axillary vein also at the left axillary and brachial confluence. tte - suboptimal image quality. severe mitral annular calcification with no definite evidence of endocarditis. functional mitral stenosis. preserved biventricular systolic function. mild pulmonary hypertension. compared with the prior study (images reviewed) of , estimated pulmonary artery pressure is higher. tee - no echocardiographic evidence of endocarditis. severe mitral annular calcification. brief hospital course: 49 y/o m with hx of htn, dm, esrd on hd, hiv (cd4 560, hiv vl 116 ), and hx of pe on coumadin since presented to ed with fevers/rigors with today. # hd line infection: patient presented with fever/rigors after on the day of admission. right ij hd catheter was noted to have expressible pus in the tunnel. the catheter site was tender and erythemetous. blood cultures were drawn in the ed. patient was started on vancomycin and zosyn for empiric coverage and admitted to the icu. transthoracic echocardiogram showed no signs evidence of endocarditis. patient was noted to be hemodynamically stable and was transferred to the floor after brief (< 1 day) icu course. after arrival to the floor, patient was initially continued on vancomycin and zosyn until cultures returned as mssa. id was consulted at this time. patient was started on nafcillin 2g iv q4 hours. transesophogeal echocardiogram showed no signs of endocarditis. patient remained afebrile and hemodynamically stable on the nafcillin. on (hospital day 5), patient was taken to ir for re-siting of hd line. left ij hd catheter was successfully placed and infected right ij catheter was removed with no complications. at this time, nafcillin was changed to cefazolin qhd for convenience of the patient after discharge. patient remained hemodynamically stable after treatment of cefazolin with no signs of worsening infection or seeding of infection to secondary sites. daily surveillance blood cultures were negative (after initial on ) at time of discharge. patient was discharged home after , afebrile. cefazolin is to be continued for total 4-week course from line removal (). # esrd on hd: mr. has esrd, recieving hd on mwf schedule. he was previously on the transplant list, however due to non-compliance, he was taken off the transplant list earlier this year. patient's mwf schedule was continued during the admission. right ij hd catheter was removed and left ij catheter placed as above. sevelamer was started while patient was inpatient and continued on discharge. no follow-up arranged as he is seen by his in clinic. # hypertension: poorly controlled, history of malignant htn. on admission, nifedipine cr 60 mg po bid was continued. on transfer to the floor, blood pressure was noted to be elevated and he was started on hydralazine 10 mg po q8h. blood pressures were better controlled, but decision was made to switch from hydralazine to labetalol and attempt was made to titrate this up. patient had periodic emesis (baseline for him) and frequently refused his medications. due to this, systolic blood pressure occasionally reached 200-220, and was given hydralazine iv on a prn basis. prior to discharge, labetalol was discontinued and toprol xl 100mg was started (patient states this was his home dose). bp was well controlled on day of discharge. # ekg changes: ed consulted cards in ed for isolated v2 ste which improved with slower rate. trop positive but with esrd it is not higher than prior values. low likelihood of acs especially given lack of cp. patient was monitored over admission and had no signs or symptoms of acs. # hiv: cd5 560 in , followed by dr. as an outpatient. haart was continued while mr. was admitted to the hospital. infectious disease was consulted due to his high grade mssa bacteremia. mr. was counseled on the importance of medication adherance during his admission. his outpatient id doctor also recommended to stop his arvs on discharge given that he had been refusing some of these medications in the hospital and thought that stopping them at once would help prevent resistance patterns. he is to follow-up with id after discharge. # diabetes - history of diabetes, likely type 1, continued nph while in hospital, but on reduced doses. patient became hypoglycemic overnight due to reduced appetite and evening nph discontinued, but am nph maintained due to type i history. patient discharged home on previous regimen with regular insulin sliding scale. # cough: wheezy and rhonchorous on exam, no cxr infiltrates, appeared slightly hyperinflated, no documented pfts but with smoking history copd is possible. given albuterol prn. # h/o pe: diagnosed by ct in . currently on coumadin as outpatient, but found to be sub-therapeutic on admission. patient also noted to have ij clot on u/s, so placed on heparin gtt. heparin held for ir procedure. prior to discharge, coumadin was restarted with 5mg loading dose then placed on home dose of 2 mg qday. inr was therapeutic on discharge. medications on admission: -docusate sodium 100 mg po bid -tenofovir disoproxil (viread) 300 mg po 1x/week (sa) start: saturday -raltegravir 400 mg po bid -ondansetron 4 mg iv q8h:prn nausea -nifedipine cr 60 mg po bid -lamivudine 100 mg po daily -gabapentin 200 mg po tid -fexofenadine 60 mg po bid:prn congestion -etravirine 200 mg po bid -clotrimazole 1 troc po tid:prn thrush -cinacalcet 90 mg po daily -coumadin 2mg/3mg daily -nph 10 units in am and 7 units in pm daily -riss discharge disposition: home discharge diagnosis: primary diagnosis: indwelling catheter infection (on admission) bacteremia esrd hypertension secondary diagnoses: human immunodeficiency virus infection type 1 diabetes restless leg syndrome peripheral neuropathy discharge condition: hemodynamically stable discharge instructions: you came to the hospital because of fever and chills. you were found to have an infection at the site of your catheter. your catheter was removed and a new one was inserted. you received iv antibiotics in the hospital for the treatment of your infection. you will need to receive 4 weeks of antibiotic therapy to treat your infection--your antibiotics will be given to you at your sessions. during your hospital admission, your blood pressure was elevated and was treated with additional medication to lower it. it is important that you follow-up with your primary care physician, (dr. and infectious disease (dr. physicians after discharge from the hospital. your hiv medications have been stopped. please do not take these after your discharge. please discuss restarting these medications with dr. at your next . it is very important that you take your medications as prescribed. missing just one dose of your blood presure medication will cause your blood pressure to rise. changes in medication: start toprol xl 100 mg by mouth twice a day start sevelamer 1600 mg by mouth with meals stop etravirine stop raltegravir stop lamivudine stop tenofovir disoproxil (viread) please continue all other medications as previously prescribed if you experience fever, chills, lightheadedness, pain at your catheter site, fainting, changes in your mental status or any other symptom that concerns you please call your primary care physician or go to the nearest emergency room for evaluation. followup instructions: an has been made with your pcp for . if you are unable to go, please reschedule the for a more convenient time. additionally, you will be contact by the transplant coordinator for arrangement of an with dr. in early (please cancel your for ) provider: post clinic phone: date/time: 2:50 1. provider: , md phone: date/time: 10:50 -- do not go to this 2. provider: , md phone: date/time: 10:20 3. provider: , md phone: date/time: 3:00 Procedure: Diagnostic ultrasound of heart Hemodialysis Venous catheterization for renal dialysis Diagnoses: End stage renal disease Personal history of tobacco use Human immunodeficiency virus [HIV] disease Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Bacteremia Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Long-term (current) use of anticoagulants Accidents occurring in other specified places Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other and unspecified infection due to central venous catheter Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Unspecified hereditary and idiopathic peripheral neuropathy Restless legs syndrome (RLS)

allergies: clindamycin / ace inhibitors / valsartan attending: chief complaint: hematemesis major surgical or invasive procedure: upper endoscopy history of present illness: 48 y/o m with hx of htn, dm, esrd on hd, hiv (cd4 count 346, undetectable vl), and hx of pe on coumadin since . presented to ed on with hematemesis. he was feeling well and then became nauseated after his lunch, initially vomitting brown vomit with food particles and then had about 1 cup of bright red and dark red blood. he then felt well, but again after dinner had similar episode with about 1 more cup of bright and dark blood. at that time he presented to the emergency room. he denied abdominal pain, diarrhea, melena, brbpr. he has not had anything like this before. he denies light headedness, chest pain, shortness of breath. he is on asa 325 mg and coumdain for hx of pe. he has not had nsaids or etoh recently. . in the ed, his vitals were 98, 74, 103/60, 24, 96% ra. his hct 38.4 and inr was 1.7. his stools were guiac negative and he refused an ng lavage while there. . overnight, he was admitted to 10. his vitals remained stable throughout the night with tm 99.1, bp 100/50 to 128/76, hr 64 to 74 and 96% on ra. serial hcts were 38.4 to 36.1 to 35.3 to 34.3 (last checked at 445 am today). he was taken to the endoscopy suite and tear was noted in the distal esophagus. one clipped was placed and he was noted to have some bleeding. two subsequent clips were placed and bleeding had stopped. he was transferred to the micu for further monitoring. . on the floor, he is sedated and cannot answer questions. one 18 g iv was placed in addition to his 22 g piv. . review of sytems: per report, unable to obtain due to sedation (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest pain or tightness, palpitations. denied diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: - type 1 diabetes - hiv: dx'd ; (cd4 count 346, undetectable vl) - esrd on hd mwf, attempted on pd on transplant list (clinical study for hiv/solid organ transplant) - pe, on coumadin, diagnosed - malignant hypertension - hx serratia bacteremia (presumed av graft) tx 6 wks meropenem - hx schistosomiasis - restless leg syndrome - peripheral neuropathy on gabapentin - s/p cholecystectomy - s/p r nephrectomy in secondary renal nephrolithiasis social history: quit smoking for yrs, used to smoke for 25 yrs with 0.5ppd, occ drinking, denies illicit drug use, lives with family. moved from in . lives with wife in . family history: noncontributory physical exam: general: snoring, sedated, no acute distress, pupils small approx 2 mm, reactive heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, hd catheter in l subclavian, unused fistula in l arm pertinent results: 11:28am blood wbc-3.9* rbc-3.73* hgb-12.2* hct-38.4* mcv-103* mch-32.8* mchc-31.9 rdw-14.4 plt ct-254 04:45am blood wbc-4.8 rbc-3.35* hgb-11.5* hct-34.3* mcv-102* mch-34.2* mchc-33.5 rdw-14.9 plt ct-267 05:40am blood wbc-4.7 rbc-3.35* hgb-10.7* hct-34.7* mcv-103* mch-32.0 mchc-30.9* rdw-13.8 plt ct-273 03:59am blood wbc-5.9 rbc-3.35* hgb-11.1* hct-34.7* mcv-104* mch-33.0* mchc-31.9 rdw-13.9 plt ct-239 11:35am blood pt-18.7* ptt-32.9 inr(pt)-1.7* 04:45am blood pt-19.5* inr(pt)-1.8* 03:55pm blood pt-26.2* ptt-101.2* inr(pt)-2.5* 11:28am blood glucose-90 urean-38* creat-7.7*# na-130* k-9.6* cl-94* hco3-23 angap-23* 05:40am blood glucose-85 urean-51* creat-12.4*# na-135 k-5.0 cl-92* hco3-26 angap-22* 03:59am blood glucose-73 urean-31* creat-8.1*# na-137 k-4.9 cl-95* hco3-29 angap-18 11:28am blood alt-13 ast-52* ld(ldh)-892* alkphos-103 04:45am blood calcium-10.7* phos-9.3*# mg-2.4 03:59am blood calcium-10.4* phos-5.7* mg-2.3 unilat up ext veins us clip # reason: r/o veinous clot on right arm. please do at bedside if possi medical condition: 48 year old man with esrd on hd, hiv, gi bleed and new forearm swelling reason for this examination: r/o veinous clot on right arm. please do at bedside if possible provisional findings impression: mkjd fri 5:15 pm right internal jugular vein thrombus. ct head w/o contrast clip # reason: ? bleed. medical condition: 48 yo m with h/o malignant htn, iddm, hiv (cd4 count 346, undetectable vl), esrd on hd (mwf, on on transplant list) and pe on coumadin (from , inr 2.2). pt with severe bilateral temporal ha, reports that it is worst ever. no nauea, no visual changes. reason for this examination: ? bleed. contraindications for iv contrast: esrd wet read: jksd wed 8:44 pm no acute intracranial process. final report indication: 48-year-old male with history of malignant hypertension, iddm, hiv, and end-stage renal disease on hemodialysis. patient now with severe bilateral temporal headaches and reports that is the worst ever. comparison: multiple head cts, most recent of . technique: axially acquired images were obtained through the head without contrast. findings: there is no evidence of acute intracranial hemorrhage, large areas of edema, mass, or mass effect. there is no evidence of an acute large vascular territory infarct. there is normal preservation of -white matter differentiation. prominence of the ventricles has remained stable since the previous study of . there is calcification of the tentorium and the falx. visualized paranasal sinuses and mastoid air cells are clear. impression: no acute intracranial process. findings were discussed with dr. at the time of review on . the study and the report were reviewed by the staff radiologist. dr. . dr. approved: 7:51 am brief hospital course: 48 y/o m with hx of dm, htn, esrd on hd, hiv and hx of pe on anticoagulation presents to ed after hematemesis. found to have deep tear. . # hematemesis/ tear: he underwent egd was found to have deep tear and which was clipped. he had mild rebleeding post-procedure but remained stable. he continued iv bid ppi and had 2 pivs for access. hct were stable post procedure and throughout admision. coumadin was held while in the icu, but re-started on . . # mild r hand swelling: pt developed mild r hand swelling on . a rue u/s was done and he was found to have a rij thrombus. the thrombus distended from the right internal jugular vein from its mid portion to the level of the subclavian. he has a rij hd catheter so the possibility of this being the cause was entertained. ir was consulted to see if replacement of the catheter was a viable option but they reccomemended treating medically and follwing up. . # htn: patient currently normotensive, has hx of malignant hypertension. on nifedipine and toprol at home. home meds were held in setting of bleed and being npo, but were re-started after patient was stable. . # esrd: patient on mwf , had shortened session the day of admission in light of his presenting symptoms. electrolytes stable. he was hyperkalemic post procedure, but had no ekg changes and hd was done on his normal schedule. . # dm: given half doses of insulin while npo then when eating returned to sliding scale. . # hiv: pt with nondetectable vl and cd4 349. harrt held while npo, then resumed. . # hx of pe: last pe in , has been anticoagulated since then. in setting of gi bleed, held anticoagulation, but restarted after he was stable. medications on admission: lamivudine 10 ml daily; take after on hd days fexofenadine 60 mg once to twice daily tenofovir disoproxil fumarate 300 mg qweek on saturdays sensipar 90 mg daily regular insulin per sliding scale insulin nph 10u qam and 7u qpm raltegravir 400 mg intelence 200 mg aspirin 325 mg qday metoclopramide 10 mg tid clotrimazole 10 mg prn nifedical xl 60 mg colace 50 qhs coumadin 4mg qdaily neurontin 200 mg tid toprol xl 100 mg discharge medications: 1. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po bid (2 times a day). 2. lamivudine 10 mg/ml solution sig: one hundred (100) mg po daily (daily). 3. raltegravir 400 mg tablet sig: one (1) tablet po bid (2 times a day). 4. etravirine 100 mg tablet sig: two (2) tablet po bid (2 times a day). 5. gabapentin 100 mg capsule sig: two (2) capsule po tid (3 times a day). 6. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po qsat (every saturday). 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain/fever. 8. zolpidem 5 mg tablet sig: 1-2 tablets po hs (at bedtime) as needed for insomnia for 10 days. disp:*20 tablet(s)* refills:*0* 9. reglan 5 mg tablet sig: one (1) tablet po three times a day. disp:*60 tablet(s)* refills:*0* 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 11. cinacalcet 30 mg tablet sig: three (3) tablet po qhs (once a day (at bedtime)). 12. insulin nph human recomb 300 unit/3 ml insulin pen sig: one (1) subcutaneous twice a day: please take 10 units in the am, 7 in the pm. 13. insulin regular human 100 unit/ml cartridge sig: one (1) injection three times a day: per sliding scale. 14. sevelamer hcl 800 mg tablet sig: three (3) tablet po three times a day. disp:*270 tablet(s)* refills:*2* 15. oxycodone 5 mg tablet sig: one (1) tablet po twice a day as needed for pain for 10 doses. disp:*15 tablet(s)* refills:*0* 16. coumadin 1 mg tablet sig: one (1) tablet po once a day: per inr. discharge disposition: home discharge diagnosis: - - tear of esophagus - right internal jugular thrombus - type 1 diabetes - hiv: dx'd ; (cd4 count 346, undetectable vl) - esrd on hd mwf, attempted on pd on transplant list (clinical study for hiv/solid organ transplant) - pe, on coumadin, diagnosed - malignant hypertension - hx serratia bacteremia (presumed av graft) tx 6 wks meropenem - hx schistosomiasis - restless leg syndrome - peripheral neuropathy on gabapentin - s/p cholecystectomy - s/p r nephrectomy in secondary renal nephrolithiasis discharge condition: afebrile, tolerating regular diet, stable discharge instructions: you were admitted with bloody vomit. it was discovered that there was a large tear in your esophagus. this was managed with clips and you never bled again. afterward you developed a terrible headache but a ct scan showed no bleeding in your brain. last, we discovered a clot in your neck vein around your port. with regard to this clot, our plan will be for you to follow up with dr. and determine whether it is appropriate for you to change the site of your catheter. you inr (coumadin number) is 2.5 today and is within the range we want you to be. given the tear in the esophagus, you do have a risks of bleeding on coumadin, but have a risk of clots while not taking coumadin. we discussed this and you were interested in restarting coumadin. . return to the hospital if you have any bleeding with vomiting, any black or tarry stools, high fevers, facial swelling or any symptoms that concern you. . . new medications sevelamer - this medication will help with your phosphate levels that are high because of your kidney disease reglan - you have taken this medication before, use it three times daily to help with your nausea. pantoprazole - this helps reduce stomach acid ambien - you have taken this before; take 5-10 mg each night as needed for sleep. never take more than prescribed. cinicalcet - please take this medication before bedtime. followup instructions: please follow up with your pcp . . you can reach him at . please see him in weeks. please call the gi offices at ( and make an with any gastroenterologist within the next weeks. provider: , md phone: date/time: 8:20 provider: , transplant social work date/time: 10:00 provider: . & phone: date/time: 4:00 Procedure: Hemodialysis Endoscopic excision or destruction of lesion or tissue of esophagus Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Hyperpotassemia End stage renal disease Renal dialysis status Anemia, unspecified Polyneuropathy in diabetes Disorders of phosphorus metabolism Long-term (current) use of insulin Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Awaiting organ transplant status Acquired absence of kidney Gastroesophageal laceration-hemorrhage syndrome Asymptomatic human immunodeficiency virus [HIV] infection status Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled

service: medicine history of present illness: the patient is an 87-year-old female with a history of gastrointestinal bleed in the past, complicated by acute renal failure, duodenitis, gastroesophageal reflux disease, hemorrhoids and colonic polyps, who presented to her primary care physician's office low hematocrit of 19. she was directed to present to the emergency room. she reported having some nausea, but no vomiting and no fevers or chills. she reported one bowel movement that was black and soft. she had recently started aspirin in the past few weeks. she was not taking any non-steroidal anti-inflammatory drugs or steroids. she denied abdominal pain or chest pain. in the emergency room, she was found to have a hematocrit of 22.7, a potassium of 7.3 and a creatinine of 10.2. a nasogastric lavage was negative. she was admitted to the medical intensive care unit for further workup. past medical history: 1. hypertension. 2. anemia. 3. gastroesophageal reflux disease. 4. hypercholesterolemia. 5. history of falls. 6. osteoarthritis. 7. spinal stenosis. 8. hemorrhoids. 9. history of colonic polyps. 10. glaucoma. 11. status post appendectomy. 12. status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 13. gastrointestinal bleed in past complicated by acute renal failure. 14. previous gastrointestinal workup included an esophagogastroduodenoscopy in which showed erythema in the stomach, a polyp in the antrum, an ulcer at the gastroesophageal junction and duodenitis. 15. colonoscopy in showed internal hemorrhoids and polyps in the rectum. medications on admission: lipitor 10 mg p.o. q.d. zoloft 25 mg p.o. q.d. prilosec. aspirin 81 mg p.o. q.d. univasc. allergies: there were no known drug allergies. social history: the patient had no tobacco or alcohol use. she lived in an facility, . physical examination: vital signs included a temperature of 97??????f, a heart rate of 80, respirations of 18, a blood pressure of 150/72 and an oxygen saturation of 97% on room air. in general appearance, the patient was alert and in no apparent distress. on head, eyes, ears, nose and throat examination, the sclerae were anicteric. the mucous membranes were moist. the neck had no lymphadenopathy or bruits. the lungs had bibasilar crackles. the cardiac examination was a normal rate and rhythm with a normal s1 and s2 and a ii/vi systolic murmur at the upper sternal border radiating to the axilla. there were no gallops or rubs. the abdomen was soft, nondistended and nontender with no hepatosplenomegaly and no masses. there were normal active bowel sounds. the extremities had no edema. on neurological examination, the patient was alert and oriented and the examination was grossly nonfocal. laboratory data: the patient had a white blood cell count of 8000, hematocrit of 22.7 and platelet count of 402,000. prothrombin time was 12.8, partial thromboplastin time was 30.2 and inr was 1.1. there was a sodium of 135, potassium of 7.3, bun of 127 and creatinine of 10.2. electrocardiogram: the electrocardiogram showed normal sinus rhythm with left axis deviation and no st or t wave changes. hospital course: 1. hematology: the patient's initial hematocrit was 22.7. she was transfused with four units of packed red blood cells in the medical intensive care unit with post transfusion elevation of the hematocrit to 33, which remained stable throughout the rest of her hospitalization. 2. renal: the patient's admission creatinine was 10.3. during her medical intensive care unit admission, a right quinton catheter was placed and the patient underwent two sessions of hemodialysis. her creatinine trended down throughout her hospitalization. at the time of discharge, her bun was 70 and her creatinine was 4.3 and was trending down independent of any interventions. her renal failure was thought to be due to acute tubular necrosis secondary to gastrointestinal bleeding. given the spontaneous resolution of her renal failure, the renal team decided to stop hemodialysis and her quinton catheter was discontinued on the day of discharge. 3. gastrointestinal: a nasogastric lavage in the emergency room was negative. a rectal tube was placed and did not drain grossly bloody stool throughout her hospitalization. the patient was reluctant to have a workup for gastrointestinal bleeding initially, but finally consented to an esophagogastroduodenoscopy. this showed a hiatal hernia, grade 1 esophagitis and polyps in the duodenal bulb consistent with brunner gland hyperplasia. the gastrointestinal consultation team felt that there were no findings on the esophagogastroduodenoscopy which could explain her severe anemia. they felt that her renal failure was a primary process and that her low hematocrit was due to renal failure. 4. electrolytes: the patient's admission potassium was 7.3. she was treated with calcium gluconate, glucose, insulin and kayexalate with resolution of her hyperkalemia. this did not recur during her hospitalization. at the time of discharge, her potassium was 3.6. 5. cardiovascular: given the patient's severe anemia and possible bleed, her antihypertensives were initially held. she was started back on antihypertensives cautiously. at the time of discharge, she was receiving captopril with strict holding parameters for a systolic blood pressure of less than 110. 6. infectious disease: the patient had a foley catheter while in house and developed a urinary tract infection, which was treated with ciprofloxacin. she was afebrile and without a significantly elevated white blood cell count throughout her hospitalization. impression: the etiology of the patient's severe anemia remains unclear. initially, it was thought that the patient had a significant gastrointestinal bleed which led to renal failure from acute tubular necrosis. however, her esophagogastroduodenoscopy did not show a source that could explain significant bleeding and a low hematocrit. another possibility is that she had a primary renal process which led to severe anemia. the patient will need close follow up of her hematocrit, renal function and potassium. disposition: the patient is being discharged to point. condition on discharge: stable. discharge activity: ad lib with assistance until back to baseline. discharge diet: ad lib. discharge medications: protonix 40 mg p.o. q.d. tums two tablets p.o. t.i.d. zoloft 25 mg p.o. q.d. lipitor 10 mg p.o. q.d. nephrocaps one tablet p.o. q.d. trazodone 25 mg p.o. h.s. p.r.n. for insomnia. captopril 6.25 mg p.o. t.i.d.; hold for systolic blood pressure of less than 110. ciprofloxacin 250 mg p.o. b.i.d. was day one of ciprofloxacin and the patient should complete a three day course for her urinary tract infection. discharge treatments: the patient is to have close monitoring of her hematocrit, renal function and potassium. she is to use pneumoboots, if bedridden. discharge diagnoses: 1. acute renal failure. 2. severe anemia. dr., 12-815 dictated by: medquist36 d: 14:02 t: 16:03 job#: 1 1 1 r Procedure: Other endoscopy of small intestine Hemodialysis Venous catheterization for renal dialysis Diagnoses: Hyperpotassemia Anemia, unspecified Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Unspecified essential hypertension Infection and inflammatory reaction due to indwelling urinary catheter

history of present illness: was born at 30 and 6/7 weeks gestation weighing 1370 grams,at . mother is a 35 year-old gravida 2 para 1 now 2 who developed preterm labor two days prior to delivery. she was admitted to one day prior to delivery and despite treatment with magnesium sulfate labor progressed. mother was also treated with betamethasone and multiple doses of clindamycin. prenatal screens revealed mother is a positive. remaining prenatal screens noncontributory. group b strep was unknown. the infant was born after rapid labor via vaginal delivery on . membranes ruptured just prior to delivery. apgars were 6 and 7. infant's birth weight was 1370 grams. because of lack of bed space at the infant was transferred to on the day of birth where she remained until her transfer to on . problems during hospital stay: 1. respiratory: the infant was initially placed on cpap secondary to apnea and shallow breathing at . she was not thought to have hyaline membrane disease by clinical examination or x-ray. she did require intubation secondary to marked apnea and she remained intubated for less then 24 hours and was subsequently placed on cpap again. the infant was taken off cpap on day of life four and transitioned to nasal cannula and transferred to on nasal cannula. however, because of ongoing significant apneas and bradycardiac episodes, she went off and on cpap a number of times at and ultimately came off cpap on and weaned to room air by . the infant did have ongoing episodes of apnea and bradycardia during the remainder of her stay. however, ultimately it was discovered that when she was made npo for an episode of bloody stools those particular time periods she had no episodes of apnea and bradycardia and for that reason was placed on zantac and reglan with marked improvement. the patient is currently apneic free , other than during feeding. 2. cardiovascular: she has been hemodynamically stable throughout her hospitalizations. she did receive a normal saline bolus times one on day one of life. she has had a murmur heard from approximately day of life seven, which is a soft systolic murmur. echocardiogram was done on day of life ten. there were no structural cardiac defects noted and the murmur was thought to be secondary to peripheral pulmonic stenosis. however, over the last several weeks of her hospital care this murmur is no longer audible. 3. feeding and nutrition: the infant had initially a fair amount of difficulty with major desaturations and bradycardias during feeding. this was thought to be all secondary to immaturity. the patient is currently feeding ad lib demand volumes and breast feeding as well. these episodes have marked decreased. however, because of the major desaturations she has had in the past mom felt more comfortable taking this infant home on a saturation monitor. at the time of discharge the patient weighed 3.455 kilograms and was taking feedings of mother's milk 24 calories per ounce. this was can be reduced over time to 20 calories as good weight gain is demonstrated at home. 4. gastrointestinal: as indicated above when the infant was placed npo for bloody stools and their evaluation, the patient had no episodes of desaturations or apnea of bradycardia. she currently is on reglan and zantac. the patient was treated with phototherapy for three days for jaundice. 5. hematologic: as indicted below the patient had some mild jaundice during her newborn stay. her hematocrit done on the day of discharge is 32.6. she is being discharged home on fer-in- 0.5 cc per day. the patient has not been transfused during her hospital stay. 6. infectious disease: the patient received 48 hours of ampicillin and gentamycin for the first two days of life. repeat sepsis evaluation was performed on day of life twenty five and again on day of life thirty three secondary to increasing spells. in both cases blood counts were reassuring and blood cultures were negative. the infant developed grossly bloody stools on . she had at that time been started on ampicillin and gentamycin. cpc was benign. blood cultures were negative. kub times two were negative and it was thought that the bloody stools were secondary to fissures internally as well as irritated perineum. the infant did well and was restarted on her feeds the following day. throughout the remainder of her hospital stay there were some occasional days where she had some bright red flecks in her stools that were negative by the following day as well as being guaiac negative. there was no allergy to mother's milk. eosinophilia count was normal. we were therefore left once again with the probable diagnosis of some internal fissures or irritation. 7. neurological: the patient has had several head ultrasounds throughout her hospital course all of which have been normal. 8. ophthalmology: she has received several ophthalmologic evaluations the last of which was on . she had immature retinas in zone three bilaterally and will be followed up on the outside at ophthalmology within two weeks of discharge. 9. immunizations: her two month immunizations were given. on she had her first hepatitis b vaccine. on her hemophilus and pneumococcal vaccines. on she had her dtap and polio. 10. retinal exam: last exam on had immature retina, zone 3 ou. discharge medications: poly-vi- 1 cc daily, fer-in- 0.5 cc daily, reglan 0.16 mg q 8 hours prior to feed, zantac 7 mg q 8 hours. discharge plans: the patient is going home on a saturation monitor, sats to be maintained from 92 to 100%, heart rate 80 to 20 prior to alarms being set off. the patient will be seen at by dr. at center on . early intervention referral made. dr. to hve follow up appointment at ophthalmology within the next two weeks. reccomendations: 1. decrease mm to 20 calories as she documents good weight gain at home.. 2. allow to outgrow zantac and reglan over next month. 3 can d'c saturation monitor as infant demonstrates no further episodes during feeding. 4. f/u appointment within next 2 weeks with dr. for immature zone 3 ou. , m.d. dictated by: medquist36 Procedure: Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Anemia of prematurity Retrolental fibroplasia Other preterm infants, 1,250-1,499 grams Abnormality in fetal heart rate or rhythm, unspecified as to time of onset Stenosis of pulmonary valve, congenital

history of present illness: baby girl who was admitted to the neonatal intensive care unit at day of life #10 as a former 30 week premature infant transferred from . she was born on as the 1370 gm product of a 30 week gestation to a 35 year old gravida 1, para 1 mother following progressive preterm labor unresponsive to magnesium sulfate. mother was pretreated with antibiotics and partially treated with betamethasone. her prenatal laboratory data are notable for blood type a positive and group b streptococcus unknown. infant emerged vigorous with apgars of 6 and 7 and a birthweight of 1370 gm. initial physical examination was notable for a birthweight of 1370 and a premature infant nondysmorphic appearing without respiratory distress. hospital course: 1. respiratory - the infant was initially placed on cpap secondary to apnea and shallow breathing. the infant was not thought to have hyaline membrane disease by clinical examination or x-ray. the infant did require intubation secondary to marked apnea; the infant remained intubated for less than 24 hours and subsequently was placed back on cpap. the infant was taken off of cpap on day 4 of life and transitioned to nasal cannula flow. at the time of transfer to the infant was clinically stable on nasal cannula flow at 100 cc of 21 to 30% oxygen with occasional apnea, bradycardiac spells. over the course of the hospitalization at the , the patient has continued to have difficulties with apnea of prematurity with spells varying in frequency and severity. the patient has been on and off of nasal cannula flow as well as cpap secondary to these spells. the infant was placed back on cpap on , day of life #17 and then was transitioned again to nasal cannula or room air on , day of life #30. however, the patient had to be placed on cpap on , day of life #32 secondary to increased spells again. the infant has been maintained on caffeine at 8 to 10 mg/kg/day of caffeine citrate with occasional boluses. the infant does appear comfortable at rest with well aerated breathsounds and no oxygen requirement, so it is not thought that the patient has significant baseline lung disease. a chest x-ray performed on , reveals moderate to normal lung volumes with evidence of mild lung disease of prematurity. the patient has not received any diuretic therapy. 2. cardiovascular - the patient has been largely hemodynamically stable throughout hospitalization. the patient did receive a normal saline bolus times one on day #1 of life. a murmur was heard at approximately day 7 to 8 of life that has been persistent. this is a soft systolic murmur. echocardiogram on approximately day #14 of life revealed a structurally normal heart without a patent ductus arteriosus, but did reveal peripheral pulmonic stenosis. 3. fluids, electrolytes and nutrition - the patient was initially maintained on parenteral nutrition and begun on enteral feeds by day of life #3. these were advanced without difficulty. at the time of this dictation the patient has been tolerating 30 cal/oz breastmilk supplemented with promod at 150 cc/kg/day without issues. urine and stool output are normal and the patient is gaining weight. weight at birth was 1370 gm, weight on the day of admission was 1300 gm and the weight on is 1855 gm. 4. gastrointestinal - the patient was treated with phototherapy for approximately three days for mild physiologic hyperbilirubinemia of prematurity. 5. infectious disease - the patient received 48 hours of ampicillin and gentamicin for the first two days of life, pending clinical course and negative blood cultures. a repeat sepsis evaluation was performed on day of life #25 and again on day of life 33 secondary to the increased spells; in both cases the complete blood counts were reassuring and no antibiotics were given. both blood cultures subsequently became negative. 6. heme - the patient has never been transfused. hematocrit on day of life #25, was found to be 26.8. previous hematocrit was 29 on with a reticulocyte count of 5.1%. given the anemia and the impressive apnea of prematurity several discussions were held with the family and it was decided to begin a two week course of epogen. this was begun on along with supplemental folate and extra fer-in-. hematocrit on was 27.9 with a reticulocyte count of 5.9 and hematocrit on was 28. it is planned the epogen should continue until approximately ; after discontinuation of the epogen, fer-in- should be reduced to normal dosing and folate should be discontinued. 7. neurological - the patient has had a normal neurological examination throughout admission. head ultrasound on day of life #7 was normal. repeat ultrasound on day of life #26 was also normal. the patient received an ophthalmologic evaluation on which revealed immature retinas in zone 2 bilaterally with follow up recommended in three weeks. hearing screening has not yet been performed at the time of this dictation. condition at time of dictation: at the time of this dictation the patient is overall doing well. the patient is presently on cpap of 5 in room air secondary to apnea of prematurity. also on cpap the patient does have occasional spells but only has rare spells on cpap. the patient is hemodynamically stable with a murmur by examination that is thought to be peripheral pulmonic stenosis as documented by echocardiogram. the patient is tolerating 30 cal/oz of breastmilk with supplemental promod in 150 cc/kg/day with normal urine and stool and appropriate weight gain. the patient continues on epogen for anemia. medications: fer-in-, folate, epogen, vitamin e, caffeine diagnosis: 1. prematurity at 30 6/7 weeks 2. apnea of prematurity 3. peripheral pulmonic stenosis. 4. anemia of prematurity 5. sepsis evaluation, resolved , m.d. dictated by: medquist36 Procedure: Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Anemia of prematurity Retrolental fibroplasia Other preterm infants, 1,250-1,499 grams Abnormality in fetal heart rate or rhythm, unspecified as to time of onset Stenosis of pulmonary valve, congenital

allergies: aspirin / ibuprofen attending: chief complaint: ethylene glycol intoxication major surgical or invasive procedure: right femoral hemodialysis catheter placement hemodialysis history of present illness: 50f depression and suicidal ideation presents to osh after family found her confused and "running around". thought that she had overdosed on fioricet, trazodone, paxil, and brought her to ed for further eval. in ed @ osh, noted to be confused, initial abg 7.05/7/137/2 on ra, u/a notable for many rbcs, oxalate crystals, positive barbituates. in consultation with tox, was thought to have ethylene glycol toxicity. started on 150meq bicarb, etoh infusion, and transferred to for further treatment. in ed, given fomepizole 1g, noted to have "fluorescent" urine. initial labs notable for hco3 of 7. seen by renal, and initiated on hemodialysis on arrival to micu. after becoming aroused, pt remembers trying to "end it all" earlier in am around 9-10am, drinking about cup antifreeze. denies any other ingestions (she has run out of her medications). otherwise, cannot remember any other events over the course of the day and first recollection was here at . on ros, has chronic subj fevers/chills, but denies weight loss, has chronic rlq pain abdominal adhesions, otherwise denies cough, chest pain, sob, urinary symptoms, previous suicide attempt. currently denies suicidal ideation. denies melena or hematemesis. of note, vomited fluorescent appearing vomitus during interview. past medical history: - depression - kidney stones - cholecystectomy - appendectomy - diverticulitis - gastric ulcers - kidney stones - partial gastrectomy at 31 - sbo social history: lives with niece , however wants daughter who lives in to be hcp. : 1ppd x 20 years alcohol: denies denies drugs or iv drug use. family history: nc physical exam: vs 106 96/56 16 99% 1l general: nad, caucasian male appearing exhausted heent: anicteric, perrl, , tacky. neck: jvp flat, supple, no lad, no bruits cardiovascular: s1, s2, tachy, no mrg. lungs: diffuse soft rhonchi that clear with cough. abdomen: large vertical scars in midline, soft, mildly tender in rlq. extremities: warm, no cce neuro: skin: no rashes or petechiae pertinent results: 02:30am urine rbc->50 wbc-0-2 bacteria-occ yeast-none epi-0-2 02:30am urine blood-lg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 02:30am urine color-yellow appear-hazy sp -1.009 02:30am pt-10.8 inr(pt)-0.9 02:30am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 02:30am acetone-neg 02:30am albumin-4.8 calcium-9.9 phosphate-2.6* magnesium-2.7* 02:30am alt(sgpt)-14 ast(sgot)-22 alk phos-125* amylase-62 tot bili-0.3 02:30am glucose-131* urea n-6 creat-0.8 sodium-147* potassium-5.1 chloride-118* total co2-7* anion gap-27* 03:24am plt smr-normal plt count-231 03:24am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-2+ microcyt-normal polychrom-normal 03:24am neuts-90* bands-2 lymphs-4* monos-4 eos-0 basos-0 atyps-0 metas-0 myelos-0 03:24am wbc-26.8* rbc-4.71 hgb-15.9 hct-49.3* mcv-105* mch-33.7* mchc-32.2 rdw-13.7 05:36am lactate-4.0* 06:47am type-art po2-78* pco2-23* ph-7.49* total co2-18* base xs--2 brief hospital course: imp: 50f here w/ suicide attempt by ethylene glycol ingestion. . hospital course: # ethylene glycol toxicity: initially the patient had severe metabolic acidosis. she received stat hemodialysis treatment, was started on bicarb drip, and received fomepizole. initial ethylene glycol level here was undetectable. her anion gap closed, and her bicarb normalized. the renal team followed throughout this process with normalization of her gap, they felt there was no need for further need for bicarb or dialysis. . in the setting of an undetectable ethylene glycol level, it was felt that patient had likely metabolized all of the ethylene glycol and that fomepizole no longer played a role. the patient was observed in the micu for renal function and acid base status for greater than 48 hours before being called-out to the floor. . # anemia: the patient's course was complicated by oozing following removal of right groin dialysis catheter. her hematocrit did fall by approximately 3 points, and the patient complained of chronic rlq pain for which there was some concern of retroperitoneal bleed. however, her hematocrit stabilized and later ct abdomen demonstrated no evidence of hematoma. her iron studies and folate level were unremarkable, though her b12 was borderline low. she is to be discharged on daily b12 supplementation. . # suicide attempt: the patient was followed by psychiatry and was watched by a 1:1 sitter throughout the admission. she denied suicidal ideation or intent throughout the admission. she was restarted on her paroxetine and trazodone. she is to be discharged to an in-patient psychiatric facility. . # abdominal pain: the patient's pain appears to be her chronic pain. this pain has been attributed to adhesions related to prior trauma and surgery. as above, a ct abdomen was negative for hematoma. she did have several kidney stones bilaterally, though none obstructing. there was a small hypodensity in her right kidney, which was read by the radiologist to represent either pyelonephritis or ethylene glycol-associated injury. the patient has been afebrile, has had multiple negative urinalyses since her initial u/a demonstrated large blood. the most likely diagnosis for the patient's pain remains her known adhesions, with some component of constipation likely contributing. the patient's pain was controlled with percocet as needed during the admission. she is to be discharged on her home vicodin. . # elevated troponin: the patient had an elevated troponin for unclear reasons on admission. two repeat levels demonstrated normalization. serial ekgs had no concerning changes for myocardial ischemia or infarction. there is no further work-up indicated at this time. . # nicotine addiction: the patient was continued on a nicotine patch daily. . # fen: the patient was maintained on a regular diet. . # prophylaxis: the patient was maintained on sc heparin daily. . # code status: full dr. spoke to pcp and updated her. medications on admission: - paxil - prilosec - vicodin - trazodone - excedrin prn discharge medications: 1. nicotine 21 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). 2. multivitamin,tx-minerals tablet sig: one (1) tablet po daily (daily). 3. paxil 20 mg tablet sig: one (1) tablet po once a day. 4. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 5. vicodin 5-500 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 8. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 9. cyanocobalamin 1,000 mcg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: - discharge diagnosis: ethylene glycol toxicity acute renal failure metabolic acidosis suicide attempt major depression discharge condition: fair discharge instructions: you are being transferred to an in-patient psychiatric facility. please follow up with your primary care physician as below following discharge from that facility. please take all medications as precribed. followup instructions: please follow up with your primary care physician, . , on discharge from your psychiatry care. the number to call for an appointment is . Procedure: Hemodialysis Venous catheterization for renal dialysis Diagnoses: Acidosis Tobacco use disorder Acute kidney failure, unspecified Peritoneal adhesions (postoperative) (postinfection) Major depressive affective disorder, single episode, unspecified Calculus of kidney Toxic effect of other nonpetroleum-based solvents Suicide and self-inflicted poisoning by other and unspecified solid and liquid substances

allergies: aspirin / ibuprofen attending: chief complaint: abdominal pain, hiccups major surgical or invasive procedure: exploratory laparotomy with extensive lysis of adhesions, resection of right colon with ileocolic anastomosis, small bowel resection x2, drainage of retroperitoneal and intra-abdominal abscess history of present illness: ms. is a 54 year old female s/p aortobifemoral bypass graft on after a prior fem-fem crossover graft. she was discharged on to home. 1 day following discharge she began having intractable hiccups, worsening nausea, and worsening abdominal pain. on she reports having 4 episodes of bilious vomiting which has continued since that time. additionally she has been having worsening diffuse abdominal pain. was seen by pcp today who obtain a ct scan at an outside facility. ct scan showed ? of fluid collection vs. dilated small bowel with air fluid level. she was transferred to the ed for further care. of note, she is unsure if she is passing flatus but does reports daily normal bowel movements. past medical history: - cholecystectomy - appendectomy - diverticulitis - gastric ulcers - kidney stones - partial gastrectomy at 31 - sbo pcp . in , ma. past psych: no hospitalizations or formal psychiatric treatment. saw a counselor 15 years ago briefly. no previous suicide attempts (confirmed by daughter). daughter says she would often threaten suicide when frustrated but never came to close to acting out on it. social history: lives with her father and mother after her husband died, denies etoh, smoker, 30 pack/year history of smoking family history: sister-etoh, -diagnosed with bipolar physical exam: vital signs: temp: 98.8 rr: 20 pulse: 96 bp: 137/87 gen: nad, aaox3 heent: anicteric, ngt to lcws with bilious cv: rrr pulm: cta b/l abd: soft, distended. tenderness over the right periumbilcal region without rebound or guarding. ext: edema, warm. large seroma in right groin. pertinent results: 05:40pm wbc-19.6*# rbc-3.10* hgb-9.1* hct-28.9* mcv-93 mch-29.4 mchc-31.6 rdw-15.0 05:40pm neuts-91.2* lymphs-6.4* monos-1.9* eos-0 basos-0.3 05:40pm plt count-623*# 05:40pm pt-13.1 ptt-24.8 inr(pt)-1.1 05:40pm glucose-107* urea n-9 creat-0.7 sodium-140 potassium-3.8 chloride-102 total co2-27 anion gap-15 05:48pm glucose-113* lactate-1.1 na+-138 k+-3.7 cl--101 tco2-28 ct abd/pelvis : 1. large anterior intra-abdominal air and fluid collection concerning for an abscess. 2. focally dilated small bowel loop is concerning for internal hernia and closed loop obstruction. 3. area of of free air and adjacent fluid within the right lower quadrant, separate from the primary abscess. 4. multiple seromas overlying the groin incision sites bilaterally. 5. no appreciable contrast enhancement across the femoral-femoral bypass. 5. status post aortobifemoral bypass, which appears patent, with flow demonstrated in the superficial femoral and profundus branches bilaterally. 6. unchanged mild extra- and intra-hepatic biliary ductal dilatation. right femoral vasc us : 1. occluded femoral-to-femoral bypass graft. 2. large hematoma or seroma within the right groin. 3. normal arterial and venous waveforms within the right common femoral artery and vein. no pseudoaneurysm. kub : 1. dilated central loop of small bowel correlated with findings on ct concerning for partial bowel obstruction. 2. extraluminal air seen in the right lower quadrant corresponding to the findings on ct. 3. air fluid collection seen superior to the dilated loop of small bowel, correlating with fluid collection seen on ct, worrisome for abscess. cxr : picc projects just beyond superior cavoatrial junction. pull back 1 cm. brief hospital course: patient was admitted to the acute care surgery service with intraabdominal abscess. she was taken to the or on hospital day 2 and underwent exploratory laparotomy, debridement, small bowel resection x2 and right hemicolectomy. she tolerated the procedure without complication. post-operatively she spent a short amount of time in the pacu before she was transferred to the floor. she was maintained on iv antibiotics and id was consulted for recommendations regarding long term antibiotics. on the floor, when bowel function returned she was first advanced to clears and then to regular diet, which she tolerated without nausea or vomitting. her foley was discontinued and she voided spontaneously. she ambulated with pt and was cleared for discharge home from a pt perspective. pain was well controlled. at time of discharge pain was well controlled, she was tolerating a regular diet and voiding spontaneously. follow-up was arranged with infectious disease clinic in her town. physical therapy cleared her for discharge home from their perspective. medications on admission: duloxetine 60'', methadone 20'', prilosec 40',trazodone 50', aripiprazole 10', sucralfate 2'', boniva 150 q monthly,symbicort 80-4.5 ''prn sob, plavix 75'; simvastatin 10'; lopressor 12.5''' discharge medications: 1. duloxetine 30 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po bid (2 times a day). 2. aripiprazole 10 mg tablet sig: one (1) tablet po daily (daily). 3. sucralfate 1 gram tablet sig: two (2) tablet po bid (2 times a day). 4. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). 6. methadone 10 mg tablet sig: two (2) tablet po bid (2 times a day). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*45 tablet(s)* refills:*0* 9. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 10. 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* 11. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. ertapenem 1 gram recon soln sig: one (1) intravenous once a day. disp:*30 * refills:*2* discharge disposition: home with service facility: nursing services discharge diagnosis: intra-abdominal and retroperitoneal abscesses with bowel perforation. discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: please call your doctor or nurse practitioner or return to the emergency department for any of the following: *you experience new chest pain, pressure, squeezing or tightness. *new or worsening cough, shortness of breath, or wheeze. *if you are vomiting and cannot keep down fluids or your medications. *you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *you see blood or dark/black material when you vomit or have a bowel movement. *you experience burning when you urinate, have blood in your urine, or experience a discharge. *your pain in not improving within 8-12 hours or is not gone within 24 hours. call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. *any change in your symptoms, or any new symptoms that concern you. please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon. avoid driving or operating heavy machinery while taking pain medications. incision care: *please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *avoid swimming and baths until your follow-up appointment. *you may shower, and wash surgical incisions with a mild soap and warm water. gently pat the area dry. * your staples will be removed at your follow-up appointment. picc line: *please monitor the site regularly, and your md, nurse practitioner, or nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * your md to the emergency room immediately if the picc line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. do not use the picc line in these circumstances.please keep the dressing clean and dry. contact your nurse if the dressing comes undone or is significantly soiled for further instructions. followup instructions: 1) call the acute care clinic at for a follow up appointment in 1 week for staple removal. call dr. office at to schedule an appoitment for the same day. buidling , 2) you must follow-up with infectious diseases: dr. , who has an office in your home-town. please call to make an appoitment to see dr. in 1 week. 3) call dr. , your primary care doctor, for a follow up appointment in weeks. Procedure: Other lysis of peritoneal adhesions Open and other right hemicolectomy Other small-to-large intestinal anastomosis Multiple segmental resection of small intestine Central venous catheter placement with guidance Diagnoses: Perforation of intestine Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other complications due to other vascular device, implant, and graft Seroma complicating a procedure Other retroperitoneal abscess Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)

history of present illness: the patient is a 64 year old male with a history of chronic obstructive pulmonary disease, who presented to outside hospital complaining of intermittent substernal chest pain for five days prior to admission. on , the patient again developed substernal chest pain with radiation to the left arm that lasted for approximately five hours and resolved spontaneously. on , he again developed chest pain that occurred intermittently throughout the day until he was brought to the emergency department that evening. an electrocardiogram in the emergency department demonstrated 2.0 millimeter st segment elevations in leads ii, iii and avf, with persistent pain. the patient received tenecteplase. his chest pain resolved after the administration of tenecteplase with some improvement of his st segment elevations on electrocardiogram. the patient was monitored in the intensive care unit overnight in this outside hospital after receiving tnk. at 7:30 a.m. of , he had two episodes of chest pain with 1.0 millimeter st segment elevations in leads ii, iii and avf again. intravenous nitroglycerin drip was increased and his chest pain again resolved. his lopressor dosage was increased to 25 mg p.o. t.i.d. and an integrilin drip was added to his regimen. the patient was then transferred to for thiolytic therapy after acute myocardial infarction as an indication for cardiac catheterization. past medical history: 1. chronic obstructive pulmonary disease. 2. gout. 3. esophageal stricture. 4. status post carpal tunnel surgery. medications on admission: 1. allopurinol. 2. prilosec. 3. albuterol. 4. theophylline. 5. aspirin. 6. atrovent. 7. lipitor 20 mg p.o. q.d. 8. integrilin drip on transfer. 9. prevacid. 10. intravenous nitroglycerin drip on transfer. allergies: no known drug allergies. family history: father and two brothers died from myocardial infarction at ages between 60 and 80. social history: the patient has a two pack per day tobacco use for many years. he reports occasional etoh use. he denied any recreational drug use. the patient is a retired truck driver who is married with four children. physical examination: on admission, physical examination revealed an elderly gentleman with temperature of 98.6, heart rate 65, blood pressure 130/70, respiratory rate 16, oxygen saturation 98% in room air. the patient arrived to the ccu post catheterization. general examination revealed a lethargic 64 year old male in other distress. head, eyes, ears, nose and throat examination revealed normal extraocular movements with no icterus. jugular venous pressure was 14 to 16 centimeters at 45 degrees of angle in bed. cardiovascular examination revealed normal s1 and s2, no s3, no murmurs noted, and no rubs or gallops. pulmonary examination revealed bilateral diffuse son sounds and expiratory wheezes. there is mild decreased air entry at bilateral bases. abdominal examination revealed the abdomen to be soft, nontender, normoactive bowel sounds, and no hepatosplenomegaly. extremities revealed warm extremities with intact pulses and no pedal edema. the patient had right groin minimal hematoma, status post sheath pull from the catheterization laboratory. central nervous system examination revealed mildly lethargic 64 year old male, arousible with normal extraocular movements and pupils that were equal and reactive to light and 2.0 millimeters bilaterally. the patient was oriented to place. neurological examination was nonfocal with no motor or focal sensory deficits. his deep tendon reflexes were intact throughout with downgoing toes bilaterally. laboratory data: on admission, hematocrit was 39.9, white blood cell count 10.7, platelet count 263,000. chemistries on admission revealed a sodium of 140, potassium 4.2, chloride 101, bicarbonate 30, blood urea nitrogen 14, creatinine 1.4, calcium 10.0, magnesium 2.0 and phosphorus 3.4. albumin was 3.1. cholesterol panel revealed total cholesterol of 151 with hdl 36, ldl 86, and triglycerides 147. liver function tests revealed ast of 25, alt 25, and alkaline phosphatase 123. cpk as measured in outside hospital was 66 with mb index of 7.5 and troponin of 2.0. the second set eight hours later revealed cpk 110, mb positive at 15.6 with a troponin of 5.4. after arrival to status post catheterization, his ck was 97. the patient's electrocardiogram #1 upon presentation to outside hospital emergency department revealed normal sinus rhythm at a rate of 90 beats per minute. his pr interval was 200 milliseconds. there were 2. elevations in leads ii, iii and avf with 1. depressions in leads i, avl. there was t wave flattening in leads v2 and v3 and q waves noted in leads v2 and v3. there were early q waves noted in leads ii and iii. electrocardiogram #2 post lysis administration of tnk revealed a normal sinus rhythm at 70 beats per minute with 0.5 millimeter st segment elevations in leads ii, iii and avf with t wave inversion in leads ii, iii and avf. the patient continued to have pr prolongation at 220 milliseconds. electrocardiogram #3 status post cardiac catheterization and stenting at revealed normal sinus rhythm at 65 beats per minute with normal axis and pr prolongation with pr interval 220 milliseconds. there was 0. elevations in leads ii, iii and avf. hospital course: the patient was transferred directly to the cardiac catheterization laboratory at . his catheterization on , revealed the following hemodynamics: cardiac output by equation was 3.86 with a cardiac index of 1.78. his pulmonary wedge pressure had a mean of 26. his right atrial pressure was 17. his aortic systolic pressure was 105, diastolic pressure was 71. his pulmonary artery pressure was 40/25 with a mean pressure of 32. his right ventricular pressure was 47/25. systolic vascular resistance was measured at 1333 with a pulmonary vascular resistance of , 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 Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Diagnoses: Coronary atherosclerosis of native coronary artery Chronic airway obstruction, not elsewhere classified Gout, unspecified Acute myocardial infarction of other inferior wall, initial episode of care

history of present illness: the patient is a 64 year old male with a history of copd who presented to outside hospital complaining of intermittent substernal chest pain for five days prior to admission. on the patient again developed substernal chest pain with radiation to the left arm that lasted for approximately five hours and resolved spontaneously. on he again developed chest pain that occurred intermittently throughout the day until he was brought to an emergency department that evening. an ekg in that emergency department demonstrated 2 mm st segment elevations in leads 2, 3, avf with persistent pain. the patient received tenecteplase. his chest pain resolved after the administration of tenecteplase with some improvement of st segment elevations on ekg. the patient was monitored in the intensive care unit overnight at the outside hospital after receiving tnk. at 7:30 a.m. on , he had two episodes of chest pain with 1 mm st segment elevations in leads 2, 3 and avf again. intravenous nitroglycerin drip was increased and his chest pain again resolved. his lopressor dosage was increased to 25 mg p.o. t.i.d. and an integrilin drip was added to his regimen. the patient was then transferred to for failed lytic therapy after acute myocardial infarction as an indication for cardiac catheterization. past medical history: copd. gout. esophageal stricture. status post carpal tunnel surgery. medications on admission: included allopurinol, prilosec, albuterol, theophylline, aspirin, atrovent, lipitor 20 mg p.o. q.d., integrilin drip on transfer, prevacid, iv nitroglycerin drip on transfer. allergies: no known drug allergies. family history: father and two brothers died from myocardial infarction at ages between 60 and 80. social history: the patient is a two pack per day tobacco user for many years. he reports occasional etoh use. denied recreational drug use. the patient is a retired truck driver who is married with four children. physical examination: on admission this was an elderly gentleman with temperature of 98.6, heart rate 65, blood pressure 130/70, respiratory rate 16, saturation 98% in room air. the patient arrived in the ccu post catheterization. general exam revealed a lethargic, 64 year old male in no other distress. head, ear, nose, throat and neck exams revealed normal extraocular movements with no icterus. jvp was 14 to 16 cm at 45 degrees of angle in bed. cardiovascular exam revealed normal s1, s2. there was no s3, no murmurs noted, no rubs or gallops. pulmonary exam revealed bilateral diffuse son sounds with expiratory wheezes. there was mild decreased air entry bilateral bases. abdominal exam revealed an abdomen that was soft, nontender with normoactive bowel sounds and no hepatosplenomegaly. extremity exam revealed warm extremities with intact pulses and no pedal edema. the patient had right groin minimal hematoma status post sheath pull from the cath lab. cns exam revealed a mildly lethargic, 64 year old male, arousable with normal extraocular movements, pupils that were equal and reactive to light 2 mm bilaterally. the patient was oriented to place. neurologic exam was nonfocal with no motor or focal sensory deficits. deep tendon reflexes were intact throughout with downgoing toes bilaterally. laboratory data: on admission hematocrit was 39.9, white blood cell count 10.7, platelet count 263. chemistry on admission revealed sodium of 140, potassium 4.2, chloride 101, bicarbonate 30, bun 14, creatinine 1.4. calc, mag, phos were 10, 2.0 and 3.4. albumin was 3.1. cholesterol panel revealed total cholesterol of 151, hdl 36, ldl 86, triglycerides 147. liver function studies revealed ast of 25, alt 25, alkaline phosphatase 123. cpk as measured at the outside hospital, first set was 66 with mb index of 7.5 and troponin of 2.0. the second set eight hours later cpk was 110, mb positive at 15.6 with troponin of 5.4. after arrival to status post catheterization ck was 97. the patient's ecg showed #1 upon presentation to outside hospital emergency department revealed normal sinus rhythm at a rate of 90. pr interval was 200 msec. there were elevations in leads 2, 3 and avf with depressions in leads 1, avl. there was t wave flattening in leads v2 and v3 and q waves noted in leads v2 and v3. there were early q waves noted in leads 2 and 3. ekg #2 post lysis administration of tnk revealed normal sinus rhythm at 70 with 0.5 mm st segment elevations in leads 2, 3 and avf with t wave inversions in leads 2, 3 and avf. the patient continues to have pr prolongation at 220 msec. ekg #3 status post cardiac catheterization and stenting at revealed normal sinus rhythm at 65 beats per minute with normal axis and pr prolongation with pr interval of 220 msec. there were 0. elevations in leads 2, 3 and avf. hospital course: the patient was transferred directly to the cardiac catheterization lab at . his catheterization on , revealed the following hemodynamics. cardiac output by fick equation was 3.86 with cardiac index of 1.78. pulmonary wedge pressure had a mean of 26. right atrial pressure was 17. aortic systolic pressure was 105, diastolic pressure 71. pa pressure was 40/25 with a mean pressure of 32. right ventricular pressure was 47/25. systolic vascular resistance was measured at 1333 with pulmonary vascular resistance of 123. catheterization of the patient's coronary arteries revealed 90% discrete stenosis in the proximal rca, tubular mid-rca stenosis of 70% with normal acute marginal and normal distal rca. left main artery was patent. lad had serial stenosis of the mid-vessel of 50% and 90% respectively with a "moth-eaten" appearance of the lateral lesion suggesting thrombus. first diagonal artery had proximal 90% stenosis. left circumflex artery had mild diffuse disease throughout. rca was dominant with proximal 90% stenosis and mid-vessel 70% stenosis. left ventriculography was not performed. the proximal rca was treated with successful direct stenting. the mid-rca lesion was also treated with direct stenting. the lad lesions were not intervened upon at this time due to the intervention that was performed on the rca already. the patient was discharged to the coronary care unit for monitoring overnight with the understanding that he would go back to the cath lab in one to two days after stabilization from his current imi to receive further stenting of the lad. at the end of cardiac catheterization the patient was noted to have some periorbital swelling and questionable tongue swelling. this was thought to be a dye reaction allergy. the patient was given solu-medrol intravenously and 50 mg of intravenous benadryl. the patient had altered mental status with drowsiness and lethargy after receiving intravenous benadryl. there was a concern for cns bleeding as the patient was status post lytic therapy at the outside hospital with altered mental status status post cardiac catheterization. an emergency head ct was performed which showed no intracranial bleeding. the patient was maintained on integrilin drip and was given oral , 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 Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter Diagnoses: Coronary atherosclerosis of native coronary artery Chronic airway obstruction, not elsewhere classified Gout, unspecified Acute myocardial infarction of other inferior wall, initial episode of care

history of present illness: 72-year-old man with known cad status post a mi in underwent cardiac catheterization on the day of admission and was found to have three-vessel disease with calcified left main and ef of 30 percent by echo done in . the patient had recently stopped digoxin. he is status post dc cardioversion in . woke with palpitations and chest pain radiating to his jaw. called - 1 who on arrival found him to be in a wide complex tachycardia with a heart rate 180s and hypotension. they had to defibrillate him at the scene with 100 joules. he then went into a-fib with a rate of 115 and better hemodynamics. at that time, he was transported to for cardiac catheterization. past medical history: includes cad status post mi times two, a-fib, cva in ' with residual left-sided weakness, hypertension, diabetes mellitus type 2 which is diet- controlled, hypercholesterolemia. patient's catheterization showed a calcified left main, lad with 80 and 90 percent mid lesion, left circumflex with a 60-70 percent lesion in the origin, om-2 with an 80 percent lesion, rca with diffuse disease, rpl with 80 percent lesion. social history: married, lives with wife, remote tobacco history, quit in and occasional alcohol use. allergies: include ampicillin which causes anaphylaxis. medications: 1. aspirin 81 once daily. 2. atenolol 100 once daily. 3. lisinopril 40 once daily. 4. lipitor 10 once daily. 5. coumadin 5 on monday through friday and 7.5 on saturday and sunday. 6. digoxin had been recently discontinued. 7. lasix 20 once daily. 8. amiodarone at 1 mg per hour. laboratory data: ekg showed a sinus rhythm with left bundle branch block, rate of depressions in i, ii and iii, as well as v3-6 and flip ts in avl. chest x-ray shows no congestive heart failure. no significant abnormalities, a tortuous aorta. ua is pending. white count 5.5, hematocrit 41.6, platelets 105, pt 17.8, ptt 32.6, inr 2.0, sodium 142, potassium 4.3, chloride 107, co2 of 27, bun 28, creatinine 1.5, glucose 105, ck 181 and 259, troponin 0.6. physical examination: neurologically alert and oriented times three. moves all extremities with some left-sided weakness. follows commands. respiratory: clear to auscultation bilaterally. cardiovascular: regular rate and rhythm. s1-s2 with no murmur. abdomen: soft, nontender, nondistended with positive bowel sounds. extremities are warm with no edema. pulses: carotid two plus with a soft bruit on the right, two plus with no bruit on the left. radial two plus bilaterally. femoral two plus bilaterally. dorsalis pedis one plus bilaterally. hospital course: the patient was seen by dr. and a plan was made to obtain a carotid duplex, echocardiogram, to stop the coumadin and begin heparin drip and to wait until the patient's inr normalized prior to the patient undergoing surgery. the patient was followed by the medical service preoperatively and ultimately on , he was brought to the operating room at which time he underwent coronary artery bypass grafting times four. please see the or report for full details. in summary, the patient had a cabg times four with the lima to the lad, saphenous vein graft to om, saphenous vein graft to pda with a y to the rplv. his bypass time was 95 minutes with a cross-clamp time of 67 minutes. he tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient was a-paced at a rate of 88. he had a mean arterial pressure of 66 with a cvp of 14. he had epinephrine at 0.02 mcg/kg/min, propofol at 30 mcg/kg/min and nitroglycerin and 0.5 mcg/kg/min. the patient did well in the immediate postoperative period. he remained hemodynamically stable. he was reversed from his anesthesia, weaned from the ventilator and successfully extubated. during this period, he remained hemodynamically stable. postoperative day one, the patient continued to be hemodynamically stable although he did have a high oxygen requirement. during the course of postoperative day one, the patient was weaned from his epinephrine drip. he was also weaned from his nipride drip during which the patient remained hemodynamically stable. on postoperative day two, the patient's swan-ganz catheter was removed. his was on beta blockade as well as hydralazine. his chest tubes were removed and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. once on the floor, the patient had an uneventful postoperative course. his activity level was advanced with the assistance of the nursing staff as well as the physical therapy department. on postoperative day three, his temporary pacing wires were discontinued and he was begun back on his coumadin. on postoperative day five, it was decided that the patient was stable and ready to be discharged to home. at the time of this dictation, the patient's physical exam is as follows. physical examination: vital signs: temperature 98.4, heart rate 68, sinus rhythm, blood pressure 138/72, respiratory rate 18, o2 sat 97 percent on room air. laboratory data: white count 5.9, hematocrit 31, platelets 132, pt 12.7, ptt 18.4, inr 1.0, sodium 138, potassium 3.9, chloride 102, co2 of 27, bun 27, creatinine 1.4, glucose 113. weight preoperatively 92 kg, at discharge 92.4 kg. physical exam: neuro: alert and oriented times three. moves all extremities. follows commands. slightly weak on the left side. respiratory: clear to auscultation bilaterally. cardiovascular: regular rate and rhythm, s1-s2 with no murmurs. sternum is stable. incision with steri-strips open to air, clean and dry. abdomen is soft, non tender, nondistended. positive bowel sounds. extremities are warm and well-perfused with 1-2 plus edema. left leg saphenous vein graft harvest site with steri-strips open to air, clean and dry. both left arm and leg with large ecchymotic areas. condition on discharge: patient's condition at discharge is good. discharge diagnoses: cad status post coronary artery bypass grafting times four with lima to the lad, saphenous vein graft to om and saphenous vein graft to the pda with a jump to the rplv. a-fib. cva. diabetes mellitus. discharge medications: 1. lisinopril 20 mg once daily. 2. aspirin 81 mg once daily. 3. lasix 20 mg once daily. 4. potassium chloride 20 meq once daily. 5. colace 100 mg b.i.d. 6. percocet 5/325, 1-2 tablets q. 4-6 hours p.r.n. 7. amiodarone 400 mg b.i.d. times one week, then 400 mg once daily times one week, then 200 mg once daily. 8. atorvastatin 40 mg once daily. 9. lopressor 25 mg b.i.d. 10. additionally, the patient is to take coumadin as directed by the clinic with a goal inr of two to three. his coumadin dose for monday the 27th, tuesday the 28th, and wednesday the 29th will be 7.5 mg with an inr checked on thursday the 30th, the results to be called to clinic. disposition: patient is to be discharged home with visiting nurses. follow up: he is to have follow-up in the clinic in 2 weeks, follow-up at the clinic on thursday the 30th, follow-up with dr. in 4 weeks, follow-up with dr. in weeks and follow-up with dr. on as previously scheduled. , m.d. Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Atrial fibrillation Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

history of present illness: mr. is a 76-year-old male who was noted to adenocarcinoma of the esophagus on routine surveillance esophagoscopy for known esophagus. at the time of the discovery, the patient was asymptomatic; not having experienced any weight loss or any dysphagia. past medical history: 1. hypertension. 2. gout. 3. mild aortic stenosis. 4. seizures secondary to medications. 5. gastroesophageal reflux disease. past surgical history: past surgical history is significant for nissen fundoplication in . medications on admission: 1. norvasc 10 mg p.o. once per day. 2. lipitor 20 mg p.o. once per day. 3. prevacid 30 mg p.o. once per day. 4. allopurinol 300 mg p.o. once per day. 5. hydrochlorothiazide 25 mg p.o. once per day. 6. glucosamine. 7. potassium chloride. allergies: allergies included atenolol. social history: social history was significant for social alcohol use, and no tobacco use. family history: there is no family history of cancer. mr. father passed away at the age of 42 years of a stroke. physical examination on presentation: initial physical examination revealed mr. was a well-appearing gentleman in no acute distress. his sclerae were anicteric. pupils were equally reactive to light and accommodation. his extraocular muscles were intact. his oropharynx was pink and moist with no lesions. his neck was supple with no thyromegaly or lymphadenopathy. his chest was symmetric with no palpable masses. his lungs were clear to auscultation bilaterally. his heart showed a regular rate and rhythm with a grade 2/6 systolic ejection murmur; consistent with aortic stenosis. his abdomen was soft, nontender, and nondistended. no palpable masses. no guarding. no rebound. no hepatosplenomegaly. cranial nerves ii through xii were intact as was his gross neurologic status. he was alert and oriented to person, place, and time. his range of motion and strength in both the upper and lower extremities were normal. his skin showed no pathology. hospital course: mr. was admitted to the operating room on where he an ivor- esophagectomy. please refer to the dictated operative note for full details of this procedure. the patient was transferred postoperatively to the surgical intensive care unit intubated and on levophed for support of his blood pressure. he had a preoperatively placed epidural for pain control; which at the time contained only narcotic medications. he was transfused 2 units of packed red blood cells intraoperatively and proceeded to receive multiple fluid boluses postoperatively for decreases in urine output. on postoperative day one, he continued to have labile blood pressures and the requirement of pressors (namely levophed) to help maintain this. on postoperative day two, he was found to have some degree of pulmonary deterioration as his pco2 continued to rise. however, his urine output did improve. at this time, mr. also had episodes of atrial fibrillation. on postoperative day three, the levophed drip was turned off as the patient's blood pressure stabilized. with the discontinuation of the levophed, the patient's oxygenation also improved. on postoperative day four, the patient continued to be intubated and sedated but showing improvement in cardiac index as well as improvement in urine output. he continued with his dilaudid epidural at this time. tube feeds were started on postoperative day five by jejunostomy tube with the patient receiving impact with fiber at 30 cc per hour. later on postoperative day five, the patient was found to have a worsening po2, for which lasix was given. the patient's blood pressure remained stable, and with diuresis the patient's oxygenation improved. on postoperative day six, the patient continued to require further diuresis as he would occasionally have oxygen desaturations on turning. his tube feeds were raised to 40 cc per hour on this day. also during this time, the patient was found to have a pneumonia by chest x-ray, and a sputum culture was positive for klebsiella which was pan-sensitive. he remained intubated and stable over the next number of days. mr. continued to be intubated and sedated with active diuresis and was started on levofloxacin for his pneumonia. he did require occasional suctioning for desaturations as he respiratory status continued to fluctuate. the patient was concurrently followed in consultation by the cardiology service due to his atrial fibrillation and previously existing aortic stenosis. the patient remained intubated and sedated on postoperative day 17. at this time, he was continuing on his tube feeds as well as levaquin for pneumonia. at this time, he was not following commands. due to the prolonged course of intubation, on postoperative day 17, a tracheostomy was performed on the patient. he tolerated the procedure well. he was started on coumadin on postoperative day 19 due to his prolonged atrial fibrillation. at this time, his tube feeds were running at his goal nutritional rate. over the ensuing days, the patient began to slowly follow commands as given to him by the surgical team and physical therapy. his respiratory status remained stable via tracheostomy tube, and the patient was continued on levaquin. on postoperative day 27, mr. a bedside swallowing evaluation; however, this study could not be evaluated as the patient refused to swallow liquids given to him. he was elevated by physical therapy on multiple occasions who deemed him to require a stay in an acute rehabilitation facility in order to build strength and mobility and to gain independence with activities of daily living. by on postoperative day 29, his respectively and hemodynamic status were stable and improved enough for transfer to the regular patient floor. the patient was tolerating his tube feeds without nausea or vomiting, and return of bowel function was indicated by bowel movements. at this time, the patient continued to receive daily doses of coumadin with intravenous heparin for anticoagulation due to his atrial fibrillation. by postoperative day 30, the patient was deemed stable and ready for transfer to an acute care rehabilitation facility where he could continue to receive tracheostomy care as well as tube feeds. the patient will require remaining nothing by mouth at this time and will require daily inr checks as he is receiving daily coumadin until his inr has reached a therapeutic level; per his prolonged and continued atrial fibrillation. at this time, the heparin drip may be discontinued. discharge disposition: the patient was to go to an acute care rehabilitation facility. discharge diet: the patient is nothing by mouth at this time and is receiving impact with fiber (full strength) at 80 cc per hour. discharge activity: the patient's activity is to be restricted, and he require extensive help with physical therapy and occupational therapy to regain strength and mobility as well as independence with his activities of daily living. medications on discharge: 1. levofloxacin 500 mg via jejunostomy tube once per day. 2. reglan 10 mg via jejunostomy tube three times per day. 3. zantac 150 mg via jejunostomy tube once per day. 4. lopressor 12.5 mg via jejunostomy tube twice per day. 5. regular insulin sliding-scale. 6. acetaminophen liquid 650 mg jejunostomy tube q.4-6h. as needed. 7. nph insulin 20 units subcutaneously q.12h. 8. coumadin (dose to be adjusted per the patient's inr which need to be continually checked on a daily basis). discharge instructions/followup: the patient was to follow up with dr. . the physician should be called in order to schedule an appointment (date and time). , m.d. dictated by: medquist36 Procedure: Other total gastrectomy Other enterostomy Fiber-optic bronchoscopy Temporary tracheostomy Bronchoscopy through artificial stoma Diagnoses: Esophageal reflux Unspecified essential hypertension Gout, unspecified Atrial fibrillation Aortic valve disorders Pneumonia due to Klebsiella pneumoniae Malignant neoplasm of cardia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fevers, rigors, respiratory distress major surgical or invasive procedure: intubation and mechanical ventilation transfusions history of present illness: 79 yo male discharged from on after undergoing apical-aortic conduit surgery through a left thoracotomy for a heavily calcified aortic valve that could not be repaired conventially. his post-op course was c/b atrial fibrillation and brachial plexopathy. he was discharged to rehab. he presented to hospital with sob, shaking chills, and respiratory distress. he was initially alert and able to reponded to bipap. per the icu attending, he acutely desaturated to ~70% with a blood pressure of ~60 systolically. he was initially on bipap, then intubated. his pressure responded to levophed and iv fluids. a foley was placed drained cloudy urine, per report. he was given lasix for crackles on exam, precipitating further hypotension. an echo was done there showing an ef of ~10%, patent conduit, and heavily calcified aortic valve. blood and urine cultures were drawn before pt transferred to for further management. of note, pt's incision wound appeared erythematous. ros positive for recent diarrhea better on flagyl despite c. dif negative. past medical history: 1. apical-aorta conduit surgery 2. aortic stenosis, valve area 0.5 cm2 3. aortic valvuloplasty 4. cad s/p cabg with lima to dlad, svg to ramus, svg to diag, svg to drca with last cath at with occluded svg-drca s/p stent, otherwise open grafts and occluded natives 5. paroxysmal atrial fibrillation 6. supraventricular tachycardias 7. prostate cancer s/p radiation 8. radiation cystitis- with significant hematuria over past year with hx of cauterization and 3way foley irrigations and no hematuria off asprin. social history: - retired engineer- lives in with wife- tobacco, rare etoh family history: unremarkable. physical exam: vs: 100.9, 107/42, 71 gen: intubated and sedated cor: iii/vi systolic murmur at 6th intercostal space left midclavicular line, ii/vi diastolic murmur at llsb chest: cta anteriorly, no wheezes abd: +bs, s, nt, nd ext: 2+/2+ pitting edema brief hospital course: mr. is a 79 year old male with severely calcified aortic valve s/p recent unconventional correction by apical-aortic conduit (apex of heart to descending aorta), transferred from an outside hospital intubated with sepsis, found to have an aortic thrombus. he was intubated and started on pressors. from the standpoint of infection, mr. was initially thought to be septic since he had a positive ua at the osh. his blood cultures revealed mrsa and he was started on vanco. the infectious disease team was consulted and felt that his conduit was seeded, so the patient would now need lifelong suppressive treatment. he was also given gentamycin for synergy and once a 7 day course had elapsed and his blood cultures were negative, rifampin was initiated. with his supertherapeutic inr, haptoglobin, ld, and fibrin split products were obtained and were not consistent with disseminated intravascular coagulation. it was thought that the high inr was secondary to malnutrition and vitamin k deficiency. his initial transthoracic echocardiograms revealed an aortic thrombus. this was thought likely due to forward flow from stenotic aorta in setting of retrograde flow from conduit, despite supratherapeutic inr. surgery was not thought to be an option given operative risk and thrombus will reform given etiology the dual flow state. mr. was hypotensive with upper extremity bp is about 15 points lower than lower extremity. he required levophed for about 2 weeks and it was eventually weaned. his cortisol stimulation test was not consistent with adrenal insufficiency. his blood pressure responded well when he was given blood products, which seemed to indicate that he was intravascularly depleted but that he was total body overloaded. of note, mr. developed hematuria, requiring placement of a three way foley for irrigation. the urology service provided advice on treatment of his radiation cystitis. he had several clots were drawn out each day from the foley. he also was transfused on several occassions. mr. arrived with a history of atrial fibrillation and was initially in h/o af, then nsr following dc cardioversion. he then intermittenly went back into atrial fibrillation. after a long course aspiration pneumonia requiring reintubation, mr. developed worsening multiorgan failure. his renal failure and respiratory failure progress and not only did he require ventilation but increasing amounts of 2 pressors. mr. son and wife were present for a family meeting. they determined that aggressive, heroic efforts were not his wishes. the wanted to stop these measures since they seemed unlikely to improve his outcome. shortly thereafter, the patient was extubated. he expired the same evening. medications on admission: na discharge medications: none discharge disposition: expired discharge diagnosis: na discharge condition: na discharge instructions: na followup instructions: na Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Diagnostic ultrasound of heart Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other electric countershock of heart Arterial catheterization Other incision of pleura Transfusion of packed cells Irrigation of other indwelling urinary catheter Infusion of vasopressor agent Diagnoses: Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Acute posthemorrhagic anemia Severe sepsis Atrial fibrillation Personal history of malignant neoplasm of prostate Infection with microorganisms resistant to penicillins Methicillin susceptible Staphylococcus aureus septicemia Rheumatic heart failure (congestive) Acute and chronic respiratory failure Pneumonitis due to inhalation of food or vomitus Infection and inflammatory reaction due to other vascular device, implant, and graft Other and unspecified coagulation defects Irradiation cystitis Late effect of radiation Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Embolism and thrombosis of thoracic aorta

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 79 year old white male with shortness of breath. major surgical or invasive procedure: apical-aortic conduit history of present illness: 79-year-old male with known cad and severe as with valve area 0.5 cm2 who is s/p two balloon aortic vavuloplasties. the most recent in had temporary relief, but he had an increase in symptoms 3-4 weeks post intervention and he returns with another chf exacerbation at osh. his shortness of breath improved after diuresis with lasix, and he was admitted for cardiac eval pre-op for aortic valve replacement. past medical history: - aortic stenosis, valve area 0.5 cm2 - aortic valvuloplasty - cad s/p cabg with lima to dlad, svg to ramus, svg to diag, svg to drca with last cath at with occluded svg-drca s/p stent, otherwise open grafts and occluded natives - paroxysmal atrial fibrillation - supraventricular tachycardias - prostate cancer s/p radiation - radiation cystitis- with significant hematuria over past year with hx of cauterization and 3way foley irrigations and no hematuria off asprin. social history: - retired engineer - lives in with wife - tobacco, rare etoh family history: unremarkable. physical exam: admission exam: bp 119/55, p 73, r 26 o2sat 100%ra gen: pleasant elderly man, nad heent: mmm, clear op neck: flat jvd chest: ctab no wheezes, occasional bilteral basilar crackles cv: rrr, 2-3/6 systolic murmur loudest rusb- +radiation to neck abd: soft nt/nd +bs ext: trace edema bilaterally, dp pulses 2+ bilaterally pertinent results: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 09:16am 6.1 4.63 12.3* 38.7* 84 26.5* 31.7 16.6* 156# basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 05:58am 19.2* 2.3 chemistry renal & glucose glucose urean creat na k cl hco3 angap 05:58am 95 26* 0.9 137 4.0 101 31* 9 chemistry totprot albumin globuln calcium phos mg uricacd iron 05:58am 7.7* 3.4 1.8 brief hospital course: mr. was admitted on and underwent cardiac cath which revealed: a heavily calcified aorta, 70% stenosis of lmca, 80% proximal lad ., 50% ., 90% mid rca stenosis, with a patent stent in the rca svg, a patent ramus svg, and a patent lima ->lad. an echo showed: severe valvular as with of 0.5 cm2 with severe global lv dysfunction and an lvef of %. he had moderate pulmonary hypertension and moderate rv dysfunction. he had moderate mr, trace ai, and mild tr. dr. was consulted. the high risk nature of the surgery was discussed at length with the patient and he wanted to proceed. a chest ct was obtained and the aortic calcification made it impossible to replace the aortic valve conventionally. on he underwent an apical-aortic conduit with an 18mm valved conduit through a l thorocotomy. the total bypass time was 90 mins. he tolerated the procedure well and was transferred to the csru on amiodorone, milrinone, levophed, and propofol. he was extubated on pod#1, and his milrinone and levophed were weaned. he was in and out of afib. he was transiently on epi., and all of his drips were weaned by pod#5. his chest tube was d/c'd on pod#5 and he was transferred to the floor on pod#6. he had some right arm weakness and swelling and this was felt to be a brachial plexus injury as his head ct was negative. he had diarrhea and this decreased on flagyl despite a negative c. diff. culture. he continued to progress and was anticoagulated and on pod#11 he was discharged to rehab in stable condition. medications on admission: lasix 40 mg po q m/w/f digoxin 0.125 mg po alt. w/ 0.25 mg qd kdur 20 mg po qd amiodorone 200 mg po qd lipitor 80 mg po qd discharge medications: 1. amiodarone hcl 200 mg tablet sig: two (2) tablet po bid (2 times a day) for 5 days: then decrease to 400 mg po qd for 7 days, then decrease to 200 mg. po qd. 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po once a day for 7 days. 5. lisinopril 10 mg tablet sig: one (1) tablet po once a day. tablet(s) 6. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. tablet(s) 7. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 7 days. 8. coumadin 1 mg tablet sig: one (1) tablet po once a day: inr goal 2-2.5. tablet(s) 9. miconazole nitrate 2 % cream sig: one (1) appl topical (2 times a day): apply to affected areas. 10. lasix 20 mg tablet sig: one (1) tablet po twice a day for 7 days. 11. lipitor 10 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: rehab unit at - discharge diagnosis: aortic stenosis. discharge condition: good. discharge instructions: follow medications on discharge instructions. you may not drive for 4 weeks. you may not lift more than 10 lbs for 3 months. you should shower, let water flow over wounds, pat dry with a towel. followup instructions: make an appointment with dr. for 1-2 weeks. make an appointment with dr. for 2-3 weeks. make an appointment with dr. for 4 weeks. Procedure: Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angioplasty of other non-coronary vessel(s) Decortication of lung Open and other replacement of aortic valve with tissue graft Arteriography of other intra-abdominal arteries Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Coronary atherosclerosis of autologous vein bypass graft Cardiac complications, not elsewhere classified Atrial fibrillation Systolic heart failure, unspecified Primary pulmonary hypertension Mitral valve insufficiency and aortic valve stenosis Stricture of artery Pleurisy without mention of effusion or current tuberculosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sob major surgical or invasive procedure: cardiac catheterization history of present illness: 87 y/o woman w/ h/omi and cad, presented on transfer from osh after presenting there with sob, chf, pulmonary edema. diuresed well w/lasix, ruled out for mi. had diagnostic cath at osh revealing 3vd, 90%rca, occluded lad and pda. presented for repeat cath and likely intervention. past medical history: cad dm carotid stent htn anemia social history: no tobacco or etoh currently family history: htn physical exam: deferred. pertinent results: 07:02pm type-art po2-128* pco2-57* ph-7.19* total co2-23 base xs--6 08:24pm calcium-6.2* phosphate-4.4 magnesium-1.3* 08:24pm ck(cpk)-20* 08:24pm glucose-220* urea n-30* creat-0.7 sodium-139 potassium-4.1 chloride-111* total co2-15* anion gap-17 08:38pm lactate-5.7* 08:38pm type-art po2-135* pco2-30* ph-7.29* total co2-15* base xs--10 09:04pm type-art po2-249* pco2-22* ph-7.12* total co2-8* base xs--20 brief hospital course: the patient was admitted directly to cath lab. cardiac catheterization complicated by lad dissection s/p stenting, severe systolic ventricular dysfunction, cardiogenic shock, moderate pericardial effusion without echocardiogeaphic evidence of tamponade. pt was dependent upon pressors post-cath upon arrival to icu and acutely decompensated within 30 minutes of arrival there. despite aggressive resucitative efforts, intubation, and emergent pericardial drainage of <100cc sanguinous material, the pt had refractory pea/v fib arrest. time of death 20:57 . interventional attending, daughter and grand-daughter present at bedside. medications on admission: colace protonix lopressor imdur glyburide meclizine aspirin vitamin b12 levoxyl vitmain c iron nph insulin digoxin lasix amiodarone discharge medications: none discharge disposition: expired discharge diagnosis: cardiac arrest discharge condition: expired Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours 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 endotracheal tube Pericardiocentesis Angiocardiography of right heart structures Cardiopulmonary resuscitation, not otherwise specified Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Cardiac complications, not elsewhere classified Unspecified disease of pericardium Cardiogenic shock Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Ventricular fibrillation Aneurysm of coronary vessels

allergies: no known allergies / adverse drug reactions attending: chief complaint: angina major surgical or invasive procedure: : cabgx4 lima-> lad, rsvg-> diagonal, posterior descending artery, obtuse marginal : right atrial lead placement history of present illness: 60yo man with known coronary disease (ami in and lcx ). doing well until last week when he developed angina initially with exertion then progressed to rest angina. each episode was releived with sl ntg, no episode lasting more than 5 minutes. he presented to cardiologist for treatment. he was admitted to mwmc, a cardiac catheterization revealed 3 vessel disease. he was transferred to for coronary bypass grafting. cardiac catheterization: date: place: mwmc -lad- chronic total occlusion proximally(distal filling via collaterals) -rca- chronic total occlusion of non-dominant rca 90% -lcx- new complex 90% stenosis of prox lcx involving the bifurcation of the lcx proper and large om2. old stent in lcx is widely patent -mod lv systolic dysfx, with anterior, apical, and infero-apical ak and reduced ef 30% lvedp 36mmhg no valvular dz past medical history: cad-(ami , lcx ) cardiomyopathy- ef 35-45% depending on study ventricular tachycardia s/p aicd atrial flutter s/p ablation hypertension dyslipidemia insulin dependent diabetes mellitus obesity conduction disease-lafb peripheral vascular disease s/p right fem- bypas left leg claudication right thigh tumor s/p radiation and excision 's social history: race: caucasian last dental exam: lives with: wife occupation: owns company tobacco: 2ppd x20 yrs quit etoh: occaisional family history: father died 50yo cirrhosis, mother died 42yo mi physical exam: pulse: 58 resp: 16 o2 sat: 97%-ra b/p right: 124/76 left: height: 5'" weight: 259 lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema -none varicosities: none . well healed right vein harvest site. neuro: grossly intact pulses: femoral right: +2 left:+2 dp right:+2 left:+2 pt : +2 left:+2 radial right: +2 left:+2 carotid bruit none right: +2 left:+2 pertinent results: : prebypass the left atrium is dilated. no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no spontaneous echo contrast is seen in the body of the right atrium. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity is severely dilated. there is moderate regional left ventricular systolic dysfunction with hypokinesis of the apex and septum. overall left ventricular systolic function is mildly depressed (lvef=30-35%). the estimated cardiac index is depressed (<2.0l/min/m2). focal abnormalities are seen in the mid and apical anteroseptal wall, apical anterior wall, mid and apical inferoseptal wall, apical inferior wall. no thrombus was seen in lv apex. right ventricular chamber size and free wall motion are normal. the descending thoracic aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened with focal calcification of the non-coronary cusp which moves poorly. there is a minimally increased gradient consistent with minimal aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. there is no mitral valve prolapse or flail segments. there is no pericardial effusion. postbypass the patient is a-paced and on a phenylephrine infusion. biventricular systolic function is unchanged. mitral regurgitation remains mild-to-moderate. the thoracic aorta is intact post decannulation. 05:00am blood wbc-10.9 rbc-3.73* hgb-11.2* hct-31.7* mcv-85 mch-30.1 mchc-35.4* rdw-13.9 plt ct-114* 05:00am blood glucose-151* urean-19 creat-0.7 na-135 k-3.9 cl-100 hco3-28 angap-11 05:00pm blood alt-66* ast-55* ld(ldh)-206 alkphos-73 totbili-0.3 brief hospital course: the patient was admitted to the hospital and brought to the operating room on where the patient underwent coronary artery bypass graft x 4. see operative note for details. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the electrophysiology team was consulted now due to non capturing atrial lead after permanent pacemaker was initially interrogated and epicardial wires were removed. ventricular lead and icd were functioning appropriately. the right atrial lead was revised on without complication. he is to follow up the device clinic at in 2 weeks - operative note was given to patient to bring to follow up appointment. the patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. lisinopril was restarted for better blood pressure. the patient was transferred to the telemetry floor for further recovery. chest tubes were discontinued without complication on post operative day 3. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 4 the patient was ambulating freely, the sternal and pacer pocket wound was healing and pain was controlled with oral analgesics. he is to continue on 1 week of antibiotics per ep s/p atrial lead placement. the patient was discharged home with vna services in good condition with appropriate follow up instructions. all follow up appointments were arranged. medications on admission: lisinopril 20' atenolol 100' vytorin qhs fenofibrate 200' asa 325' ntg-sl/prn insulin-nph 22u qam/24u qpm- followed by insulin- humalog ss mvi calcium 600' plavix - last dose: allergies: nkda discharge medications: 1. fenofibrate 160 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 2. simvastatin 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 3. ezetimibe 10 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*1* 4. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*100 tablet(s)* refills:*0* 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 7. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*65 tablet(s)* refills:*0* 9. 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* 10. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 7 days. disp:*28 capsule(s)* refills:*0* 11. lasix 40 mg tablet sig: one (1) tablet po once a day for 7 days. disp:*7 tablet(s)* refills:*0* 12. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po once a day for 7 days. disp:*7 tablet, er particles/crystals(s)* refills:*0* 13. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 14. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 15. nph insulin human recomb 100 unit/ml suspension sig: one (1) subcutaneous twice a day: take 22 units in am and 24 units in pm. disp:*qs 1 month * refills:*0* 16. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease cad-(ami , lcx ),cardiomyopathy- ef 35-45% ventricular tachycardia s/p aicd , atrial flutter s/p ablation , hypertension, dyslipidemia,insulin dependent diabetes mellitus, obesity, conduction disease-lafb, peripheral vascular disease s/p right fem- bypas , left leg claudication, right thigh tumor s/p radiation and excision 's discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with percocet incisions: sternal - healing well, no erythema or drainage leg left - healing well, no erythema or drainage. 1+ edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr on at 1:45pm cardiologist: dr. on at 3:30pm ep clinic at in weeks: call for appointment - wound check appointment in medical office building date/time: 12:00 please call to schedule appointments with your primary care dr. in weeks follow up with clinic to be arranged by patient **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Implantation of automatic cardioverter/defibrillator lead(s) only Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atherosclerosis of native arteries of the extremities with intermittent claudication Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Other specified forms of chronic ischemic heart disease Long-term (current) use of insulin Mechanical complication of automatic implantable cardiac defibrillator Automatic implantable cardiac defibrillator in situ Obesity, unspecified Personal history of irradiation, presenting hazards to health Chronic total occlusion of coronary artery Body Mass Index 35.0-35.9, adult Left bundle branch hemiblock

history of present illness: the patient is a 67-year-old woman with a known congenital bicuspid aortic valve who has now developed a critical stenosis. she presents with a presyncopal episode. the patient had a transthoracic echocardiogram in which demonstrated an increased peak aortic gradient of 77 mmhg. following a second presyncopal episode, the patient underwent cardiac catheterization in which showed a calculated aortic valve area of 0.7 cm2 and a relatively preserved ejection fraction of 50%. the patient subjectively reports progressive fatigue and mild dyspnea on exertion times several months. no shortness of breath, chest pain, paroxysmal nocturnal dyspnea, or orthopnea. past medical history: 1. bicuspid aortic valve. 2. asthma. 3. factor deficiency. 4. hypertension. 5. hypercholesterolemia. 6. polymyalgia rheumatica. 7. osteoarthritis. 8. status post appendectomy. 9. status post left knee arthroscopy. 10. status post left donor nephrectomy. 11. status post tubal ligation. 12. status post incisional hernia repair. 13. left bundle-branch block. allergies: penicillin (gives swelling). contrast dye (gives hives). medications on admission: 1. prednisone 6 mg p.o. q.d. 2. fosamax 70 mg p.o. every thursday. 3. singulair 10 mg p.o. q.d. 4. hydrochlorothiazide 12.5 mg p.o. q.d. 5. combivent as needed. 6. advair as needed. 7. vitamin e. 8. vitamin c. 9. calcium. 10. multivitamin supplement. physical examination on presentation: the patient was an elderly woman in no acute distress. head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. pupils were equal, round, and reactive to light. extraocular movements were intact. sclerae were anicteric. the throat was clear. the neck was supple without lymphadenopathy or masses. the chest was clear to auscultation bilaterally. cardiovascular examination revealed a regular rate and rhythm with a 3/6 systolic ejection murmur. the abdomen was soft, nontender, and nondistended, without masses or organomegaly. extremities were warm. not cyanotic and not edematous times four. neurologic examination was intact. pertinent laboratory values on presentation: admission laboratories revealed complete blood count with a white blood cell count of 9.1, hematocrit was 35.9, and platelets were 311. chemistries revealed sodium was 140, potassium was 4, chloride was 103, bicarbonate was 28, blood urea nitrogen was 16, creatinine was 0.7, and blood glucose was 108. alt was 37, ast was 26, alkaline phosphatase was 56, total bilirubin was 0.2. prothrombin time was 12, inr was 1, and partial thromboplastin time was 37.3. urinalysis was negative. radiology/imaging: a chest x-ray showed no acute process. hospital course: the patient was admitted for semi-elective aortic stenosis repair. preoperatively, the patient was evaluated for her factor deficiency and was cleared by the hematology/oncology service in order for surgery. they investigated the past records surrounding her past surgeries; including her donor nephrectomy as well as knee arthroscopy, and made the suggestion for a bioprosthetic valve to be preferential. they also remarked that postoperative bleeding may be a significant complication. they did note, however, that she had tolerated her past surgeries very well. on , the patient underwent aortic valve replacement (minimally invasive) with a 21-mm - valve. the patient tolerated the procedure well and was transferred to the postanesthesia care unit with levophed and propofol drips. there was some bleeding in the case, and the patient was transfused 9 units of fresh frozen plasma and 1 unit of packed red blood cells in the operating room. in the unit, the patient was started on a nitroglycerin drip and propofol was increased. the patient was extubated in the evening on postoperative day zero. on postoperative day one, the patient had her nipride drip weaned off as well as beginning moving to the chair with assistance. here, it was noted that she had an approximately 20-beat run of ventricular tachycardia which was asymptomatic and spontaneously resolved. the patient was sleeping while this occurred. on the following days on the floor, the patient continued to work with physical therapy in regaining her strength and mobility. on the evening on postoperative day three, the patient had another short 7-beat run of ventricular tachycardia. again, she was sleeping and symptomatic. cardiology was consulted for evaluation and had no changes in management to recommend. the patient stayed on the floor and worked again with physical therapy and was ambulating quite well. on the evening on postoperative day six, the patient again had two short runs of ventricular tachycardia of approximately 6 beats and 4 beats while she was sleeping. the patient was clinically asymptomatic. the electrophysiology service was consulted and had no further recommendations. they stressed only continuing beta blockade with metoprolol as we were doing. on the evening on postoperative day seven, the patient had a short run of supraventricular tachycardia. again, the patient was asymptomatic. discharge disposition: on postoperative day eight, the patient was discharged to home tolerating a regular diet, adequate pain control on oral pain medications, and having no more presyncopal events. physical examination on discharge: physical examination on discharge revealed the patient was in no acute distress. the chest was clear to auscultation bilaterally. no sternal click. no drainage from the incision site. a regular rate and rhythm without murmurs, rubs, or gallops. there was 1+ pedal edema bilaterally. pertinent laboratory values on discharge: laboratories on discharge revealed complete blood count with white blood cell count of 11, hematocrit was 31.6, and platelets were 333. chemistry panel revealed sodium was 141, potassium was 4.7, chloride was 100, bicarbonate was 30, blood urea nitrogen was 19, creatinine was 0.9, and blood glucose was 91. magnesium was 2.1. medications on discharge: 1. aspirin 325 mg p.o. q.d. 2. percocet 5/325 p.o. as needed. 3. colace 100 mg p.o. b.i.d. 4. prednisone 6 mg p.o. q.d. 5. singulair 10 mg p.o. q.h.s. 6. lasix 20 mg p.o. b.i.d. (times seven days). 7. potassium chloride 20 meq p.o. b.i.d. (times seven days). 8. lopressor 25 mg p.o. b.i.d. 9. combivent 1 to 2 puffs inhaled q.4-6h. as needed. 10. oxazepam 5 mg to 10 mg p.o. q.h.s. as needed. condition at discharge: condition on discharge was good. discharge status: discharge status was to home with . discharge diet: discharge diet is cardiac. discharge instructions/followup: 1. the patient should follow up with cardiology (dr. in one to two weeks. 2. the patient should follow up with dr. in four weeks; address the need for diuretics and cardiac medications. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Monitoring of cardiac output by other technique Diagnoses: Polymyalgia rheumatica Unspecified essential hypertension Asthma, unspecified type, unspecified Aortic valve disorders Paroxysmal ventricular tachycardia Congenital insufficiency of aortic valve Acquired absence of kidney Syncope and collapse Congenital factor XI deficiency

history of present illness: this is a 26 year old male with no past medical history who was found unresponsive in a parked running car. there was no trauma or evidence of motor vehicle accident. the second passenger was found in the same condition. he was in respiratory distress but able to saturate 15% on 15 liters face mask. he was unable to be intubated secondary to a straight type of clenched jaw. blood glucose at the scene was 137. he was given narcan and versed without response and brought to the . in the emergency department, his pupils were pin point. he was intubated and cord temperature was noted to be 91 degrees. he was given a bear hugger and warm saline. blood pressure was 110/60. electrocardiogram showed sinus bradycardia with a prolonged q-t approximately 500 milliseconds. he was suspected to be a ghb overdose and toxicology screen was positive for cocaine, amphetamines and benzodiazepines. chest x-ray showed an aspiration pneumonia versus pneumonitis and he was given a dose of clindamycin and ceftriaxone. while in the emergency department, he self extubated and was initially kept on oxygen, however, secondary to continued vomiting and inability to protect his airway, he was reintubated and brought to the medical intensive care unit. physical examination: on examination, temperature was 101.2, pulse 99 and regular, blood pressure 142/65, oxygen saturation 100% on ventilator. head, eyes, ears, nose and throat - the pupils are 3.0 millimeters bilaterally and reactive. the neck was supple. lungs revealed coarse anterior breath sounds. heart was regular rate and rhythm, normal s1 and s2, no murmurs. the abdomen was soft, nontender, nondistended, with normoactive bowel sounds. extremities showed no edema. multiple tatoos, warm and dry. no damage. gcs was 3.0 and sedated. laboratory data: white blood cell count 12.5, normal differential, hematocrit 41.6, platelet count 243,000. coagulation studies within normal limits. chem7 was within normal limits. carboxyhemoglobin was 0.3. lactate was 2.6. urine toxicology was positive for benzodiazepines, cocaine and amphetamines. electrocardiogram showed sinus bradycardia at 53 beats per minute, normal axis, q-tc of 500 milliseconds but no st elevations or depressions. chest x-ray showed a left middle lobe opacity and head ct was negative for hemorrhage. hospital course: the patient was brought to the medical intensive care unit for further monitoring after his overdose. a toxicology consultation was obtained in the emergency department and was felt most likely to be a polypharmacy overdose including ghb. given supportive care overnight on the ventilator and kept sedated on propofol. the following morning he was able to take deep total breath and after lightening the sedation he was extubated. at that time, he admitted to cocaine, alcohol and ghb overdose. he had one history of a similar overdose approximately six years ago. an electrocardiogram was rechecked and showed normalization of the q-t interval. given that he was afebrile, no productive sputum, no cough, and chest x-ray showed resolution of the left upper lobe opacity, it was felt most likely aspiration pneumonitis as opposed to pneumonia. he showed no evidence of infection and antibiotics were discontinued. on hospital day, after being observed for an additional 24 hours after extubation with normal hemodynamics and respiratory function, he was discharged to home. he was given the number for clinic for follow-up and to start counseling about the dangers of further overdose. condition on discharge: good. discharge status: to home. discharge diagnoses: 1. acute respiratory failure. 2. overdose. 3. aspiration pneumonitis. medications on discharge:: none. follow-up: given the telephone number for clinic to follow-up with primary care physician. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Alcohol abuse, unspecified Cocaine abuse, unspecified Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Amphetamine or related acting sympathomimetic abuse, unspecified Toxic effect of unspecified alcohol Poisoning by other specified drugs and medicinal substances, undetermined whether accidentally or purposely inflicted

allergies: dristan cold attending: chief complaint: hemoptysis major surgical or invasive procedure: bronchoscopy percutaneous gj tube placement radiation therapy history of present illness: 72yo woman with h/o newly diagnosed metastatic cancer (lung vs esophageal primary) with mass compressing the esophagus and left hip met presented with hemoptysis, melana, tachycardia. cancer diagnosed 3 weeks prior after patient noted progressive dysphagia. pt seen by dr. as outpatient who felt patient was not an operative candidate for curative resection. patient was started on weekly taxol/ and xrt treatment(palliative chemo regimen). egd showing nonulcerated submucosal mass. patient also treated for h. pylori . three days prior to presentation the patient noted onset of a nonproductive cough without fevers, chills, chest pain. on the morning of admission at 1am, she awoke with cough productive of bloody sputum. later that morning she passed a large loose black stool x 2. she has had poor po intake for the past week secondary to mass limited her ability tolerate solid food. when she presented earlier today to clinic, she complained of dizziness/lightheadedness and was found to be tachycardic and orthostatic, and was referred to the ed for further evaluation. in the ed, hr 128, bp 151/49, and hct noted to be 29.5 (baseline 36-39), inr also elevated to 1.5. she developed a transfusion reaction with fever. she was pretreated with benadryl and tylenol, and then transfused one unit prbc. she also received 3l ns. gi service was consulted and reported that endoscopy would put the patient at further risk for bleeding due friable esophagus secondary to xrt, and limited therapeutic benefit in face of bleed due to tumor or radiation. thoracic surgery consulted and recommended palliative esophageal stenting after acute bleed resolved, but not acute surgical management of tumor burden. today , patient stable to be called out of icu setting to regular medical floor to be followed by the oncology team. past medical history: cancer- esophageal vs lung, mets to left hip hypertension hypercholesterolemia pvd s/p bypass basal cell skin ca h/o polio as a child h. pylori h/o heartburn social history: widowed x 2 with 4 grown children tob: 1/2ppd x 40yrs, quit 12yrs ago etoh: occasional illicits: none family history: mother d. chf father d. mi 1 brother d. leukemia 1 brother d. cva 1 brother 1 sister with cad physical exam: physical exam on admission : t 97.7 hr 118 bp 123/45 rr 16 95% 2lnc gen: comfortable, lying in bed, nad heent: perrl, anicteric, mmm with blood in op neck: supple, no lad cv: tachycardic, regular rhythm, no m/r/g resp: decreased breath sounds with crackles r base to 1/2 up gi: +bs, soft, nt, nd, no masses, no hsm, vertical midline scar back: nt rectal: little stool in vault, guiaic negative skin: no rashes neuro: cn ii-xii intact, motor and sensation intact grossly physical exam on transfer to omed : vs: t 98.8 hr 126 bp 143/67 rr 18 o2 93% on gen: elderly f sitting in bed with faint voice nad, nasal canula o2 on. heent:perrl. eomi. mm dry. no cervical/ supraclavicular lad cv: tachycardic, regular. no m/r/g. some mild tenderness over lower right anterolateral ribs, mostly over intercostal muscles lungs: decreased bs lower r lung. no crackles. abd: hypoactive bs. soft. nt, nd. no palpable hsm. extr: warm pt 2+ b/l. no palpable cord. no asymmetry. no edema back: nontender. skin: dry. no visible rashes. neuro: cn 2-12 grossly intact, toes downgoing. no focal motor or sensory deficits noted. labs: pertinent results: endoscopic ultrasound (): a 35 x 41 mm heterogeneous mass with irregular borders was identified at 28 cm on the oposite site from the aorta in the mediastinum. the mass could not be traversed with an eus endoscope. no adenopathy was noted. fna x 3 with a linear endoscope was performed--> cytology consistent with non-small cell carcinoma. egd (): a submucosal mass 31 to 28 cm which could be traversed with an endoscope with resistance. chest x-ray(): extensive consolidation in right middle and right lower lobes and to a lesser degree in the right upper lobe and posterior segment of left lower lobe. these findings may be due to massive aspiration, infectious pneumonia, or pulmonary hemorrhage. a more chronic process such as bronchoalveolar cell carcinoma cannot be excluded. follow up radiographs and clinical correlation suggested. ct(): 1) hyperenhancing focus superior to the esophageal mass which abuts the carina, right main stem bronchus and esophagus which could reflect hemorrhage. 2) large lower esophageal mass displacing the left atrium. 3) mediastinal and right hilar adenopathy. 4) extensive alveolar opacities most pronounced in the right lower lobe which could reflect aspiration or hemorrhage. 5) unremarkable aortic bypass graft with no evidence of aortoenteric fistula. transthoracic echo : ef 60%. normal lv. trivial mr. l effusion. brief hospital course: 72yo woman with newly diagnosed metastatic nonsmall cell cancer (esophageal vs lung primary) presenting with hemoptysis, melana, tachycardia. 1. hemoptysis: the patient initially presented with hemoptysis and the ddx included esophageal tumor invading trachea or bronchi, lung cancer, pneumonia vs. aspiration from ugib. her ct scan on admission was concerning for a hemorrhagic lesion, and cxr for an aspiration event. treatment options were limited per thoracic surgery. she was transfused 4 units prbc to maintain a hct >30, and hct stabilized on the second day of admission. the patient suffered a tranfusion reaction consisting of tachycardia, tachypnea, and decreased oxygen saturation that resolved with benadryl and tylenol. she was pretreated for all subsequent transfusions. she had one treatment of xrt ; chemotherapy was held. she underwent bronchoscopy on the second day of admission which showed extrinsic compression of bronchi, blood in the rll c/w aspiration. patient continued to cough up sputum with dried blood, felt to be from aspiration. transferred to the floor in stable condition. 2. melena: patient presented with apparent ugib by history, but was guiaic negative on exam. gi was consulted and initially deferred endscopy unless emergent given risk of bleeding with friability of gastroesophageal mucosa secondary to xrt and limited therapeutic options. the ddx included esophageal tumor, mucositis secondary to xrt, pud, esophagitis, - tear. all services agreed that most likely etiology was tumor. hct remained stable after prbc transfusion. she was continued on iv protonix. diet was advanced to clears on hospital day 2, but she tolerated little in the way of a po diet given the tumor burden on her esophagus. - continue to guaic stools. - will request repeat endoscopy from gi tomorrow to evaluate if tumor has grown. 3. squamous cell cancer of unknown primary source (lung vs esophageal): the patient's palliative treatment regimen consisted of xrt and weekly chemo on admission. she received one xrt treatment on . chemotherapy has been held per dr. and dr. . - will continue to address with dr. when/if plan to resume chemotherapy. - will request dr. continues to discuss prognosis with family. 4. coagulopathy, inr 1.5 on admit: coagulopathy was thought to be nutrional given the patient's poor po intake. a dic panel was negative. tranfusion of ffp was attempted but failed due to tranfusion reaction. as the patient's level of coagulopathy was not so severe as to cause spontaneous bleeding, she was treated with sq vitamin k and monitored. inr has remained stable 1.4-1.5 since admit. 5. tachycardia: the patient presented with tachycardia that was felt to be due acute blood loss causing hypovolemia. she ruled out for mi. echocardiogram showed normal lv function and no pericardial spread of disease causing pericardial effusion. she was fluid rescuscitated but continued to be tachycardic. it was then felt that her tachycardia may be associated with the low grade fevers she experienced and anxiety. she continued in sinus rhythm with hr 100-120s on transfer to the floor. on the third night of admission, she developed acute pulmonary edema secondary to 4-5 liters ivf boluses for treatment of tachycardia. she was subsequently diuresed approximately 3 liters and her oxygenation and tachypnea improved by later that day. - continue aggressive diuresis, goal negative 500cc-1l. 6. arf: creatitine on admission was 1.1 from baseline 0.6, and was thought to be prerenal associated with her acute blood loss. it resolved by the second day of hospitalization after fluid rescusitation. 7. htn: patient has a history of htn treated with hctz. she was normotensive on admission. anti-hypertensives have been held out of consideration for continued blood loss. in the icu, the patient has continued to be normotensive to mildly hypertensive with sbp 140-150s during her hospitalization. - monitor blood pressure. consider resuming anithypertensives if hct remains stable. 8. pulmonary: aspiration pneumonia: on admission, a large rll infiltrate was noted on cxr that was concerning for aspiration pneumonitis, pneumonia, lymphangetic spread versus hemorrhage. today of antibiotics (levofloxacin/clindamycin) for possible aspiration pneumonia. her wbc has improved. she continues to have occasional low grade fevers. cxr today not sig changed from yesterday - continue to monitor respiratory rate, fever and wbc count. - continue nasal canula, wean o2 as tolerated. chf: pulm edema likely related to ivf boluses, improving with diuresis. 9. nutrition: on admission, the patient was kept npo. her diet has been advanced to clears, however she is taking little po per report of icu team. - continue mainenance ivfs. - once pt stabilized, will discuss with thoracic surgery the possibility of palliative esophageal stent. 10. pain: continue to manage pain with fentanyl patch and morphine iv for breakthrough 11. dispo: per icu team, the patient is full code. her son, , is designate health care proxy. we will continue to address code status given prognosis is poor. medications on admission: 1. /taxol 2. lipitor 10mg daily 3. asa 4. hctz 12.5mg daily 5. folate 6. mvi 7. xalatan eye drops 8. fentanyl patch discharge medications: 1. fentanyl 50 mcg/hr patch 72hr sig: one (1) patch 72hr transdermal q72h (every 72 hours). 2. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 3. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): per gj tube. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 5. morphine sulfate 10 mg/5 ml solution sig: five (5) mg po q6h (every 6 hours) as needed. 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 7. phenergan 12.5 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea. 8. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po twice a day. discharge disposition: extended care facility: of discharge diagnosis: metastatic adenocarcinoma of unknown primary icd-9 199 pelvic metastatic disease pulmonary hemorrhage melena volume depletion acute blood loss anemia esophageal compression with dysphagia hematemesis discharge condition: stable. ambulating well with assistance. tube feeds via gj tube are at goal. patient is afebrile. discharge instructions: call dr. if you have a fever > 101.4, lightheadedness, dizziness, trouble breathing or blood in your stool or black stool. followup instructions: follow up with dr. : provider: , md where: hematology/oncology phone: date/time: 9:00 provider: ,hem/onc hematology/oncology-cc9 where: hematology/oncology phone: date/time: 9:00 md Procedure: Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Transfusion of packed cells Other radiotherapeutic procedure Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Hypopotassemia Pneumonitis due to inhalation of food or vomitus Malignant neoplasm of bronchus and lung, unspecified Blood in stool Hematemesis Other and unspecified coagulation defects Secondary malignant neoplasm of bone and bone marrow Stricture and stenosis of esophagus Secondary malignant neoplasm of other digestive organs and spleen

history of present illness: the patient is an 84-year-old female with a known history of coronary artery disease, status post a myocardial infarction twelve years ago, who presented to the emergency department with chest pain. the patient reported that her chest pain developed last evening when she was at rest. she took three sublingual nitroglycerin tablets with subsequent resolution of her chest pain; however, her chest pain returned later in the evening, and she presented to the emergency department. upon presentation to emergency department, the patient was given sublingual nitroglycerin as well as lovenox 60 mg at 9 p.m., aspirin, and morphine. the patient subsequently had recurrence of her chest pain at approximately 2 a.m. and was noted to have st depressions in v4 through v6, ii, iii, and avf. her initial laboratories were borderline positive with a troponin of 0.16, creatine kinase of 159, and mb positive at 32. therefore, she was transferred from to the emergency department. in the emergency department, a cardiology consultation was obtained, and the patient was complaining of chest pain which resolved with administration of morphine. the patient was noted to have a borderline blood pressure of approximately 90 systolic and was treated with 500 cc of normal saline bolus. a 2b3a inhibitor was not given because the patient had a hematocrit of 28 and was noted to be guaiac-positive on physical examination. the patient also reported bright red blood per rectum, presumed to be her hemorrhoids, for approximately one week prior to admission. a repeat electrocardiogram obtained upon arrival showed some improvement in her st depressions. review of systems: review of systems was positive for longstanding lightheadedness which is worse in the morning and relieved by lying down. the patient denied any current shortness of , radiation of her chest pain, or any associated nausea or vomiting. the patient reported never having chest pain similar to this prior to this episode. past medical history: 1. coronary artery disease, status post myocardial infarction twelve years ago. 2. hypertension. 3. diabetes. 4. history of transient ischemic attack four years ago with binocular blindness. 5. status post cholecystectomy. 6. history of large subdural hematoma ten years ago, status post drainage at nimmock. 7. bright red blood per rectum since . allergies: the patient has no known drug allergies, but reports that aspirin upsets her stomach. medications on admission: aggrenox (dipyridamole 200 and 25) 1 tablet p.o. q.d., insulin 24 units subcutaneous q.d., lasix 20 mg p.o. q.d., isosorbide 10 mg p.o. t.i.d., irbesartan 150/hydrochlorothiazide 12.5 1 tablet p.o. q.d. social history: the patient denied any tobacco or alcohol use. physical examination on presentation: vital signs revealed afebrile, blood pressure of 95/50, pulse of 80, satting 99% on 4 liters nasal cannula. in general, comfortable, in no acute distress. head, eyes, ears, nose, and throat revealed mildly dry mucous membranes. jugular venous distention at 11 cm. cardiovascular revealed a regular rate and rhythm. no murmurs, rubs or gallops. lungs revealed occasional wheezes bilaterally. the abdomen was soft, nontender, and nondistended, positive bowel sounds. extremities revealed no edema, 2+ dorsalis pedis and posterior tibialis pulses. rectal revealed guaiac-positive brown stool. pertinent laboratory data on presentation: laboratory values revealed a white blood cell count of 12.8, hematocrit of 26.3, platelets of 302. sodium of 142, potassium of 3.9, chloride of 108, bicarbonate of 24, blood urea nitrogen of 21, creatinine of 1.1, glucose of 155. ptt of 36.3, pt of 17.4, inr of 1.2. creatine kinase of 281, mb of 59, with an index of 21. calcium of 7.8, magnesium of 1.6, phosphorous of 2.7. albumin of 2.9. radiology/imaging: electrocardiogram revealed normal sinus rhythm at 89 beats per minute, q waves in v1 through v3, 1-mm st elevations in v4 through v6, st depressions in i, ii, and avr, and avl. hospital course: the patient is an 84-year-old female with known coronary artery disease who presented with unstable angina who is now chest pain free status post nitroglycerin drip and heparin with no subsequent administration of a 2b3a inhibitor given her recent bright red blood per rectum and hematocrit of 26. 1. cardiovascular: the patient was continued on her nitroglycerin drip as well as heparin drip and started on a low-dose beta blocker. her aspirin was continued; however, her aggrenox was discontinued, and the patient was treated with 1 unit of packed red blood cells given her low hematocrit. her blood pressure was monitored closely; however, the patient did not require any further boluses to maintain her blood pressure. the patient was sent to catheterization later in the day which revealed 3-vessel disease with total occasional of the left circumflex, 90% left anterior descending artery which was stented, 80% middle right coronary artery which was stented and which was felt to be the culprit lesion. her pulmonary artery saturation was noted to be 40%, with a wedge of 36. therefore, an intra-aortic balloon pump was placed. the patient was diuresed with 60 mg of lasix in the catheterization laboratory and sent to the coronary care unit. upon arrival in the coronary care unit, the patient was stable without any complaints of further chest pain. therefore, the patient was felt to have suffered a non-q-wave myocardial infarction secondary to a right coronary artery culprit lesion and was noted on catheterization to have severe 3-vessel disease, however, was not felt to be a surgical candidate. therefore, the patient was continued on aspirin, plavix, and lipitor. a 2b3a inhibitor continued to be held given her history of bright red blood per rectum. a beta blocker was held until the intra-aortic balloon pump was removed. however, the patient was started right away on a low-dose ace inhibitor which was titrated up as tolerated. on the day following her catheterization, the intra-aortic balloon pump was weaned, and the patient tolerated this without difficulty. it was subsequently removed on , and the heparin drip was discontinued. the patient was maintained on telemetry over the remainder of her hospital stay and had no arrhythmic events. her swan-ganz catheter was discontinued once the patient was felt to have effectively diuresed, and lopressor and captopril were started back and titrated up as tolerated. a transthoracic echocardiogram was obtained which demonstrated a mildly dilated left atrium, with a normal left ventricular wall and cavity size, but with hypokinesis of the anterior and anteroseptal walls of the left ventricle, and overall moderately depressed ventricular systolic function. the right ventricular chamber size and free wall motion were noted to be normal. the patient demonstrated 2+ mitral regurgitation and borderline pulmonary artery systolic hypertension without any evidence of pericardial effusion. at the time of discharge, the patient was tolerating administration of zestril and atenolol with adequate blood pressure response. she was referred to follow up with her cardiologist associated with her primary care physician at the . 2. infectious disease: the patient was noted to have a positive urinalysis and mild fever at the time of admission. a urine culture was obtained, and the patient was started on ciprofloxacin 500 mg p.o. b.i.d. the patient did not demonstrate any symptoms of a urinary tract infection during her hospital stay. she completed a 5-day course of ciprofloxacin for treatment of her urinary tract infection, and subsequently remained afebrile, and her white blood cell count normalized. she had no further infectious disease issues throughout the remainder her hospital stay. 3. hematology: the patient was noted to have a low hematocrit and bright red blood per rectum at the time of admission. she was treated with one unit of packed red blood cells in the emergency department prior to catheterization. on the day following her catheterization, the patient was once again given a single unit of packed red blood cells, and subsequently her hematocrit remained stable. she was recommended to follow up with her primary care physician to arrange for an outpatient colonoscopy. otherwise, the patient's hematocrit remained stable, and she remained hemodynamically stable throughout the remainder of her hospital stay. 4. gastrointestinal: the patient was maintained on a regular diet which she tolerated without difficulty. she complained of constipation and was started on dulcolax suppository with good effect. 5. endocrine: the patient had a history of diabetes mellitus and was placed on a regular insulin sliding-scale during her hospitalization. once the patient was able to eat a regular diet she was switched back to daily insulin injections at her prior dose of 24 units per day. she was encouraged to follow up with her primary care physician soon after discharge to check her sugar control. condition at discharge: the patient was evaluated by physical therapy and occupational therapy, who determined that the patient was safe to go home. condition at discharge/status: therefore, she was discharged to home on in stable condition. discharge followup: she was to follow up with her primary care physician, . (telephone number ) who will refer her to a local cardiologist for further followup. medications on discharge: 1. lisinopril 10 mg p.o. q.d. 2. aspirin 325 mg p.o. q.d. 3. lipitor 10 mg p.o. q.d. 4. atenolol 25 mg p.o. q.d. 5. plavix 75 mg p.o. q.d. times 30 days. 6. insulin 24 units subcutaneous q.a.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 Angiocardiography of left heart structures Implant of pulsation balloon Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Cardiogenic shock Old myocardial infarction

allergies: percocet=hallucinations meds at home: allopurinol, lopressor, digoxin, protonix, , coumadin. pt awake and alert, mso4 pca for incisional pain with good effect. pt states he is sore all over. moves well in bed with help. lopressor(x3) for afib to 160. ekg and cardiology consult done. hr down to 95 with occ. pvcs. mgso4 and kcl repleted. hct 28.4. inr 2.0. multiple boluses of ivf for low u/o. bp 110-160. maintainence fluid at 150cc/hr. 2l nc with sats 98%. pt coughs and deep breaths well. clear lungs, rr 14. ngt to low suction draining bile. abd. is obese, no bowel sounds or flatus. abd. binder intact. incisional dressings dry. jp drains putting out large amt. sero-sanginous fluid. famotidine given. urine output low. pneumboots on. pt is afebrile on kefzol. pt lives with his mother on called and was updated. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Arterial catheterization Excisional debridement of wound, infection, or burn Other open incisional hernia repair with graft or prosthesis Initial insertion of single-chamber device, rate responsive Initial insertion of transvenous lead [electrode] into ventricle Size reduction plastic operation Diagnoses: Other postoperative infection Atrial fibrillation Paroxysmal ventricular tachycardia Incisional hernia without mention of obstruction or gangrene Unspecified sleep apnea Long-term (current) use of anticoagulants Disruption of external operation (surgical) wound Alcohol withdrawal delirium

history of present illness: the patient was admitted for elective hernia repair to be done via component separation. the patient has a history of hypertension, sleep apnea, and atrial fibrillation. he was admitted to the ssu house staff on status post surgery, and received 4500 cc of lactated ringer's and three units of packed red blood cells. the patient was extubated postoperative and found to be in rapid atrial fibrillation as high as 170. he had episodic rapid afibribillation after surgery with his colectomy done on , which was treated with oral and intravenous beta blockers. the patient also had asymptomatic bradycardia at that time. he was recommended for pacemaker placement by cardiology, but this never occurred. he was transferred to the surgical intensive care unit today for postoperative management of right ventral hernia repair. past medical history: significant for hypertension, sleep apnea, atrial fibrillation. past surgical history: ileal bypass, colectomy, knee arthroscopy, right hemicolectomy. medications: allopurinol, lexapro, lopressor, accupril, doxazosin, protonix, , coumadin. allergies: percocet, .................. physical examination: the patient was lethargic, obese male, complaining of painless cough. vital signs: temperature 97.3, heart rate 126 to 156, respiratory rate 14, blood pressure 150/89, oxygen saturation 100% on 2 liters. head, eyes, ears, nose and throat: extraocular movements intact, pupils equal, round and reactive to light and accommodation, nasogastric tube in place. neck: supple. lungs: clear to auscultation bilaterally. heart: irregularly irregular, tachycardia, s1 and s2. abdominal binder in place. - drain with serosanguinous output. extremities: no cyanosis, clubbing or edema. neurologic: the patient is alert and oriented x 3, moving all extremities. laboratory data: white blood count 12, platelets 255. sodium 141, potassium 3.8, chloride 113, bicarbonate 19, bun 10, creatinine 1.2, glucose 134. magnesium 1.2. hospital course: the hospital course was complicated. the delirium and agitation associated with possible alcohol withdrawal were treated with ativan and haldol, as well as prolonged intubation. on , ativan dose was revised. on , it was noted that the patient was disoriented, also likely due to narcotics. therefore, narcotics were held until mental status was clear. an electroencephalogram was checked to rule out hypercarbia as a possibility. the patient's signs of alcohol withdrawal were treated with oral librium, continued as needed ativan as per ciwa scale. on , arterial blood gas was normal. the patient was noted to have increased output per his - drains for the first few days post-surgery. large fluid output was noted on at approximately greater than 2 liters per day. total parenteral nutrition was started on , with continued fluid management as well. the patient was continued on prolonged intubation on bipap. noted was a high - drain output, likely secondary to significant abdominal wall lymphedema seen in the operating room previously. meanwhile, for total parenteral nutrition use, the patient was started on a regular insulin sliding scale. on , hematocrit was noted to be stable, with electrolytes stable, and inr was normalizing. it was still noted that source of high - drain output was probably due to abdominal wall lymphedema. discontinue intravenous ancef. on , the patient was noted to be in improved mental status. on , the patient was also noted to have increased stable scrotal edema, for which elevation and scrotal support were continued. on , it was noted that small amounts of drainage from the center left area of the transverse abdominal incision, and persistent large amounts of scrotal edema. also on , it was recommended that the patient would be discontinued from total parenteral nutrition and continue tube feeds and a pureed diet. encourage ambulation and out of bed. on , the abdominal wound had a central area of skin necrosis, as well as turbid fluid drainage. this was consistent with an abdominal midline incision dehiscence. the patient was scheduled to go back to the operating room on for wound incision and drainage. on , to address the infected abdominal wound, a debridement, irrigation and washout, removal of mesh was done, with subsequent vac placement, as well as placement of four new - drains, with old - drains removed. estimated blood loss was minimal, with a soft tissue specimen sent for culture and pathology. there were no complications during surgery. postoperatively, the patient was sent to the post-anesthesia care unit intubated. the patient restarted total parenteral nutrition as well as tube feeds. zosyn was continued, with serial cultures. results of wound cultures showed enterococci as well as staphylococcus aureus. cultures showed +2 polys, +2 gram-positive cocci, +1 gram-positive rods. on , the patient was returned again for repeat incision and drainage of the abdominal wound, as well as for a vac change. the patient was stable. the patient was transferred back to the intensive care unit. repeat incision and drainage was done for increase of necrotic tissue noted in the wound. the patient had four vac changes in total by the time of discharge. on , the patient had vacuum-assisted closure. he was awake, alert, and oriented, interactive. on , it was noted a stage ii sacral decubitus ulcer. duoderm was applied. the patient was kept off his back, with frequent turning, optimal nutrition, and continued duoderm dressings. on , the patient was also extubated without complications, and the patient was transferred to the floor on the same day, without complications, tolerating an oral diet, as well as sufficient pain management. on , electrophysiology service was consulted regarding the patient's episodes of atrial fibrillation and bradycardia. they recommended pharmacologic therapy including beta blocker (metoprolol). this was initiated. the patient was sent back to the operating room for vacuum-assisted closure change again, with no complications. the patient continued to be followed by the electrophysiology fellow and staff. his digoxin was continued to be held concerning frequent episodes of alternating tachyarrhythmias and a bradycardia including a seven beat episode of ventricular tachycardia at 11 p.m. on . in the meantime, the patient was able to ambulate out of bed, followed closely by physical therapy. pain was controlled with oral dilaudid. on , continued to taper total parenteral nutrition. caloric counts were obtained for adequate nutrition. recommended ambulation four times a day. intravenous zosyn was continued. on , the patient had another vacuum-assisted closure apparatus change at the bedside. - drains were still in place and draining. on , discussed with eps the possibility of instituting a pacemaker for definitive management of tachy/brady arrhythmia. on , one of the - drains was pulled out mistakenly. it was decided that the - drains did not need to be reinserted. electrocardiogram done on showed mild left ventricular systolic dysfunction, +3 mitral regurgitation, and decreased left ejection fraction of 30 to 40%, down from previously 55% in . on , it was noted that the patient was cleared for procedure of vvi pacer implantation, which was successfully performed without complications. the patient was continued on intravenous antibiotics, a sling was placed on the left arm, and head of the bed elevated 45 degrees. metoprolol was changed to 50 mg by mouth three times a day, zestril 2.5 mg by mouth once daily was added, as well as digoxin 0.25 mg once daily was added for noting of left ventricular systolic dysfunction. metoprolol was adjusted for prophylactic rate control. recommendation was that coumadin could be restarted on , with heparin subcutaneously to be continued until therapeutic inr could be reached. the patient was screened for rehabilitation for network. condition at discharge: stable. discharge disposition: the patient will be discharged to acute rehabilitation with telemetry services at network on . discharge diagnosis: 1. ventral hernia. 2. status post hemicolectomy. 3. incision and drainage, vac changes. 4. atrial fibrillation, tachy/brady syndrome discharge medications: 1. miconazole nitrate powder. 2. albuterol sulfate 0.83 mg/ml inhalation every six hours as needed for shortness of breath. 3. heparin subcutaneously 5000 units every eight hours until therapeutic inr of 2.3 is reached. 4. acetaminophen 325 mg one to two tablets every four to six hours as needed for pain. 5. zosyn 4.5 mg vial one vial every six hours. 6. dilaudid 2 to 4 mg one tablets by mouth every four to six hours as needed for pain. 7. lisinopril 2.5 mg by mouth once daily. 8. metoprolol 50 mg by mouth three times a day. 9. coumadin 7.5 mg by mouth daily at bedtime. 10. protonix 40 mg by mouth once daily. 11. digoxin 0.25 mg by mouth once daily. note: if the patient is not able to be given zosyn, possible to give augmentin 500 mg by mouth three times a day. discharge instructions: the patient is to follow up with dr. , telephone number , within one week, and to call for an appointment. , m.d. dictated by: medquist36 d: 09:39 t: 09:40 job#: Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Arterial catheterization Excisional debridement of wound, infection, or burn Other open incisional hernia repair with graft or prosthesis Initial insertion of single-chamber device, rate responsive Initial insertion of transvenous lead [electrode] into ventricle Size reduction plastic operation Diagnoses: Other postoperative infection Atrial fibrillation Paroxysmal ventricular tachycardia Incisional hernia without mention of obstruction or gangrene Unspecified sleep apnea Long-term (current) use of anticoagulants Disruption of external operation (surgical) wound Alcohol withdrawal delirium

service: neonatology history of present illness: is the former 2.725 kilogram product of a 34 and week gestation pregnancy born to a 22 year-old g2 p0 now 1 woman. prenatal screens: blood type a positive, antibody negative, negative, group beta strep status unknown. medical history: significant for insulin dependent diabetes since 7 years of age. obstetrical history: notable for a previous pregnancy resulting in an intrauterine fetal demise at 20 weeks. this membranes occurring on . she presented to hospital with ruptured membranes. she was treated with intravenous ampicillin. the infant was born by forceps assisted vaginal delivery for concern for fetal heart rate decelerations and tachycardia. apgars were 9 at one minute and 9 at five minutes. he was admitted to the neonatal intensive care unit for further management. physical examination on admission to the neonatal intensive care unit: weight 2.725 kilograms 75th percentile. length 48 cm 75th percentile. head circumference 31 cm 50th percentile. pink in room air with a saturation of 100% active and alert. head, eyes, ears, nose and throat occipital molding. anterior fontanel soft and flat. facial bruising across eyebrows, ears and right cheek. palette intact. chest clear to auscultation,equal breath sounds. no grunting, flaring or retracting. cardiovascular, grade soft systolic murmur at the left upper sternal border, mildly vibratory at the left lower sternal border. pulses +2 and equal. +2 femoral pulses. abdomen soft, minimal bowel sounds. genitourinary, normal phallus, testes descending, palpable bilaterally. patent anus. musculoskeletal, stable hips. extremities well profuse. neurological, symmetric tone and reflexes. hospital course/pertinent laboratory data: 1. respiratory: remained in room air throughout his entire neonatal intensive care unit admission. he did not have any episodes of spontaneous apnea or bradycardia during his admission. 2. cardiovascular: the murmur noted at admission persisted throughout his hospitalization. on he had a chest x-ray, electrocardiogram and four point bps. all of these were within normal limits. as he seemed uncompromised by the murmur no further workup was undertaken at this time. 3. fluids, electrolytes and nutrition: maintained normal serum glucoses. he was initially on intravenous fluids. enteral feeds were started on day of life number one and gradually advanced to full volume. he required supplement pg feeds through . since that time he has been entirely ad lib po taking in a minimum of 130 cc per kilo per day. his discharge weight is 2.95 kilograms with a length of 49.5 cm and a head circumference of 32.5 cm. 4. infectious disease: due to the prolonged rupture of membranes and his prematurity was evaluated for sepsis. a complete blood count had a white count of 15,000 with a differential of 27% polys, 0% bands. a blood culture was obtained prior to starting intravenous ampicillin and gentamycin. blood culture was no growth at 48 hours and the antibiotics were discontinued. 5. gastrointestinal: required treatment of unconjugated hyperbilirubemia with phototherapy. his peak serum bilirubin occurred on day of life number three with a total of 13.4 mg per deciliter. he was treated with phototherapy for approximately 96 hours. his rebound bilirubin on was 10 mg per deciliter. 6. hematological: hematocrit at birth was 43.4%. did not require any transfusions of blood products during admission. 7. neurological: has maintained a normal neurological examination throughout admission and there were no concerns at the time of discharge. 8. sensory: audiology, hearing screening was performed with automated auditory brain stem responses. passed in both ears. condition on discharge: good. discharge disposition: home with parents. the primary pediatric care to be provided by pediatric associates of in , , , . phone number . fax number . care and recommendations at the time of discharge: 1. feeding ad lib po enfamil 20 with iron. 2. no medications. 3. a car seat screening positioning test was passed on . state newborn screening was performed on day of life number three and on the day of discharge. there have been no notification of abnormal results to date. hepatitis b vaccine was administered on . immunizations recommended, synagis rsv prophylaxis should be considered monthly from through for infants who meet any of the following criteria: born at less then 32 weeks. born between 32 and 35 weeks with plans for day care during rsv season, with a smoker in the household or with preschool siblings or with chronic lung disease. influenza immunizations should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age the family and other care givers should be considered for immunization against influenza to protect the infant. discharge diagnoses: 1. prematurity at 34 and week gestation. 2. infant of an insulin dependent diabetic mother. 3. suspicion for sepsis ruled out. 4. unconjugated hyperbilirubinemia. 5. cardiac flow murmur. dr., 50-622 dictated by: medquist36 Procedure: Enteral infusion of concentrated nutritional substances Other phototherapy Circumcision 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 Neonatal jaundice associated with preterm delivery Other preterm infants, 2,500 grams and over Routine or ritual circumcision Undiagnosed cardiac murmurs Syndrome of "infant of a diabetic mother"

allergies: morphine / erythromycin base / valium / robaxin / penicillins / felbatol / phenobarbital / thorazine / sulfa (sulfonamides) attending: chief complaint: confusion, spell in er major surgical or invasive procedure: intubation extubated history of present illness: 51 year old man with history of temporal lobe epilepsy as well as a history of nonepileptic spells that resemble seizures, as well as a psychotic disorder who presented on for feelings of confusion while sitting at a cafe, which he described as "feeling seizurey," and a spell he had in the er for which he was intubated. he is followed by dr. , and had earlier in the day told dr. that he had been hearing voices. the patient also reports feelings of "uncontrollable crying in the absense of emotion," which he also refers to as "brain tears" while sitting in a cafe a book. this sensation lasted two hours, and then his right eye closed; he at that point felt "seizurey," and he called an ambulance because he felt as if he were about to have a seizure. he was brought to where in the er he had a witnessed spell which was observed by dr. and dr. of the neurology service. dr. description is as follows: "when i went to evaluate patient, i noted the his head was extended back, eyes fixed upwards, eye lids fluttering repetitively. the rate and frequency of the fluttering was not regular. it would cease if you held the patient's eye lids open. it would stop if you held up eyes to blink to threat or to test corneal reflex. at that same time, both of his arms were flexed in and rigid. patient would actively resist movement of the arms. legs were extended and rigid. when noxious stimuli was used, rate of patient's eye lid fluttering would change. there was a brief withdrawal of the bilateral lower extremities. ed completed dilantin 1 gram. patient then began to have convulsive activity. head was extended and jerking. arms were flexed in and stiff. resisted opening. legs were shaking symmetrically but shaking was dysrhytmic. if you held one of the legs, shaking could be stopped and would start up again at a faster frequency when you let leg go. babinski testing made shaking stop. ed gave him another 2 mg of ativan. several minutes after that, shaking stopped. about one hour after patients arrival, called emergently to room as "actively seizing". dr. (chief resident) and i went to evaluate patient. ed staff had given another 4 mg of ativan. arms again in and stiff, actively resisting opening. legs shaking, both frequency and amplitude of movement varying. would blink to threat and stop eye lid fluttering with confrontation. patient moved to red zone for possible intubation. however, maintaining o2 sats in high 90s with nonrebreather. dr. and i arranged for emergent eeg to assess if activity had electrographic correlate. while being manipulated by ed staff for ivs, patient would cry out, spit, puff cheeks. while tech putting on leads, patient had generalized shaking. no electrical correlate seen by myself nor by eeg fellow. during remainder of eeg, patient was calm but not yet oriented or alert. shortly before 8pm, ed docs called to patient's room again for recurrent convulsions. i was at bedside. patient was tachycardic, but with respiratory rate in 20s, oxygen saturation in high 90s on the non-rebreather. ed staff planning to intubate patient. i argued that seizures were not clinically consistent with epileptic seizures, that eeg did not show ongoing epileptiform activity, and that patient was protecting airway at that time." the er attending dr. was worried about the patient's risk of aspirating and despite neurology input that this was not in fact a seizure, the patient was intubated and transferred to the neuro icu after receiving more ativan. the following day, he was extubated and transferred to the floor. per dr. , the spell had lasted over twenty minutes. interview at that time reveals recent psychosocial stressors including being evicted from his apartment. past medical history: -pt has extensive psych history-please see d/c summary from for excellent summary, including complex social history. -temporal lobe epilepsy from omr diagnosed in by dr. . see d/c summary from . -multiple admissions for seizures from - with no electrographic correlate. -syphilis in late 's social history: patient lives in , desribes himself as writer. he does not report any recent etoh, tobacco, or drug use. family history: no known history of seizures physical exam: admission physical exam by dr. : physical exam: most recent vitals post intubation: tc: still awaiting rectal temp by ed nurse bp: 81/30 after intubation meds and propofol hr: 89 rr: 14 o2sat: 100% on vent rest of exam is pre intubation: gen: wd/wn,uncomfortable, diaphoretic. heent: nc/at. anicteric. mmm. neck: supple. no masses or lad. no jvd. no thyromegaly. no carotid bruits. lungs: cta bilaterally. no r/r/w. cardiac: rrr. s1/s2. no m/r/g. abd: soft, nt, nd, +nabs. no rebound or guarding. no hsm. extrem: warm and well-perfused. no c/c/e. neuro: mental status: eyes open at times, but eyelids fluttering. will not alert to examiner. not following commands. no verbal output. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 4 to 3 mm bilaterally. blinks to threat bilaterally. iii, iv, vi: +oculocephalic reflex bilaterally. v, vii: facies symmetric. viii: unable to assess. ix, x: +gag. : unable to assess. xii: tongue midline without fasciculations. motor: normal bulk. tone in arms and legs mostly rigid, with patient actively resisting limb movements. grimaced and had increased respiratory rate in upper extremities after noxious stimuli. withdrew to noxious in the lower extremities bilaterally. sensation: grimaced and had increased respiratory rate in upper extremities after noxious stimuli. withdrew in lower extremities to noxious. reflexes: patient's arms and legs both rigid; unable to elicit reflexes. toes downgoing bilaterally. coordination: unable to assess. gait: unable to assess. when evaluated on the floor: general: awake, alert, and cooperative with exam in no acute distress. heent: normocephalic, no scleral icterus noted, clear oropharynx with moist mucus membranes neck: supple, with no jvd or carotid bruits appreciated pulmonary: lungs clear to auscultation bilaterally without wheezes, rhonchi or rales cardiac: regular rate and rhythm, with no murmurs abdomen: soft, nontender, with normoactive bowel sounds, no masses or organomegaly noted. extremities: warm with no edema and good pulses throughout skin: no rashes or lesions noted. neurologic: mental status: the patient is awake, alert, and oriented x 3. able to relate history without difficulty. language is fluent with intact repetition and comprehension, and speech is normal rate, tone and volume. patient was able to register 3 objects and recall at 30 seconds and at 5 minutes. the patient had good knowledge of current events. there was no apraxia. cranial nerves: olfaction not tested. pupils equal, round and reactive to light bilaterally, and visual fields intact to confrontation bilaterally with no hemineglect. no ptosis is noted, and fundoscopic exam revealed sharp discs and venous pulsations. extra-ocular muscles were intact without nystagmus. sensation was intact to light touch over face. no facial asymmetry was noted, and hearing was intact to finger-rub bilaterally. palate and uvula elevate at midline. there is strength in trapezii and sternocleidomastoids bilaterally. tongue protrudes in midline, with no fasciculations. motor: normal bulk, tone throughout. no tremor, asterixis or drift. delt bic tri wrf wre ffl fe io ip ham ta l 5 5 5 5 5 5 5 5 5 5 5 5 5 r 5 5 5 5 5 5 5 5 5 5 5 5 5 sensory: no deficits to light touch, pinprick, vibratory sense, proprioception throughout. no extinction to dss. coordination: normal finger to nose and heel to shin, with no dysmetria. no dysdiadochokinesia noted on rapid alternating hand movements or finger tapping. reflexes: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. the patient had downgoing toes on plantar response bilaterally. gait: normally based, with normal arm swing. able to walk in tandem without difficulty. romberg absent. pertinent results: 04:45pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 04:45pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-50 bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 03:58pm alt(sgpt)-36 ast(sgot)-25 ld(ldh)-164 alk phos-84 tot bili-0.4 03:58pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 03:58pm wbc-8.6 rbc-4.71 hgb-14.9 hct-39.7* mcv-84 mch-31.6 mchc-37.5* rdw-13.1 03:58pm plt count-206 eeg during spell: findings: note: at the beginning of the record, the patient presented in the video for less than five seconds clonic flexion of both arms synchronously with fast breathing. during this episode there were no eeg correlations except movement artifact noted. background: is a low voltage hz alpha frequency rhythm with normal anterior-posterior voltage gradient. there is a superimposed beta frequency activity seen throughout the record. hyperventilation: could not be performed due to the patient's clinical condition. intermittent photic stimulation: could not be performed because this was a portable study. sleep: normal transitions of the sleep architecture were not seen. cardiac monitor: a sinus tachycardia with a rate between 100 and 120 were seen. impression: this is a normal portable eeg. there were no clear epileptiform activities recorded, especially no epileptiform features during the clinical presentation of clonic flexion of both arms. beta frequency activity was seen and this is likely a medication effect. a sinus tachycardia was noted. brief hospital course: the patient was admitted initially to the icu and soon afterwards extubated and transferred to the floor the following evening. his spell was proven by eeg to have been nonepileptic, and despite the fact that this patient has known epilepsy, his recent spell was considered to be psychiatric in nature, possibly in response to recent stressors in his life. physical therapy was consulted to help him out of bed, as he reported feeling "unsteady" on his feet after his brief icu stay. his medications were not adjusted, and he was monitored clinically for further spells. physical therapy felt that his difficulty with walking was not physiologic, and the primary team felt that as his anxiety improves, his walking will likely improve. of note, he takes a total of 8 mg ativan each day at home; dr. prescribes him for 6 mg per day (split dosing). he has follow up with dr. in the near future and should keep his appointment. he was seizure-free on the day of discharge and his physical exam was completely unchanged from the previous day. medications on admission: medications prior to admission: 1. trileptal . ativan 2 mg po tid 3. seroquel 100 mg po qid 4. effexor xr 150 mg po bid 5. zantac 300 mg po qhs discharge medications: 1. oxcarbazepine 300 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 2. oxcarbazepine 300 mg tablet sig: one (1) tablet po qafternoon (). 3. oxcarbazepine 300 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 4. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day) as needed. 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 6. venlafaxine 75 mg tablet sig: two (2) tablet po bid (2 times a day). 7. quetiapine fumarate 300 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 8. lorazepam 1 mg tablet sig: two (2) tablet po tid (3 times a day): or as directed. discharge disposition: home discharge diagnosis: nonepileptic spell temporal lobe epilepsy nonepileptic spell complex partial seizure disorder discharge condition: no signs of seizure good followup instructions: f/u with pmd as previously scheduled; follow up with dr. in weeks provider: , md where: ks building (/ complex) behavioral neurology unit phone: date/time: 2:30 provider: , md where: ba ( complex) neurology/ 503 phone: date/time: 3:00 provider: , md where: neurology phone: date/time: 11:00 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Other convulsions Tachycardia, unspecified Conversion disorder Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p vt arrest major surgical or invasive procedure: cardiac catheterization s/p minivision lad stent intubation r arterial line placement history of present illness: mr. is a 52 yo male with significant pmh significant for htn, smoking, who collapsed and hit his head at work this afternoon. the fall was witnessed by his collegue. there is no report of chest pain, sob, or any other symptoms prior to his fall. he was found to be breathing when he was found down. he was given 5 minutes of cpr with no respirations. paramedics arrived, he was found to be in vf (no strips available)and was shocked. he remained in a ventricular rhythm with a rate of 20, and then converted spontaneously to sinus rhythm. patient had agonal respirations at the time of the arrest. he was brought to where he was found to have posturing. the patient was given ativan, versed, and nitro and a ct of the head was done which suggested subdural hematoma vs. meningioma. ekg showed st elevations in 1, avl, v2-v6. the patient did not receive asa, heparin, or integrilin for concern for a possible intracranial bleed. he was transferred to for cardiac catheterization and closer monitoring. in the cath lab he was found to have occluded lad after d1 & s1 and 1 subbranch with long subtotal occlusion with collateral filling of distal vessel. minivision stent was placed into d2. hemodynamic parameters as follows: co 6.5, ci 3.3 and pcwp 23. past medical history: hypertension social history: the pt is a ceo/cpa in . he is an 80 pack year smoker, no alcohol. married, has 1 son. illicit drugs. family history: possible cad physical exam: vitals t 98.8 bp 137/89 ar 88 rr 20 02 sat 100% vent settings: ac fio2 0.5 tv 650 rr 20 peep 5 gen: pt sedated; not responsive to sternal rub or pain heent:perrla, ett in place lungs:course breath sounds heart:distant heart sounds abdomen: soft, nt/nd, +bs extremities: no edema, 2+ dp/pt pulses neuro:does not respond to pain stimuli pertinent results: laboratory results: 08:01pm hgb-12.5* calchct-38 o2 sat-98 08:01pm glucose-105 lactate-0.8 k+-3.4* 08:01pm type-art tidal vol-880 o2-100 po2-371* pco2-49* ph-7.26* total co2-23 base xs--5 aado2-305 req o2-56 intubated-intubated 09:08pm o2 sat-99 09:08pm type-art tidal vol-700 o2-100 po2-437* pco2-37 ph-7.35 total co2-21 base xs--4 aado2-251 req o2-48 intubated-intubated 10:34pm pt-13.1 ptt-36.7* inr(pt)-1.1 10:34pm plt count-330 10:34pm calcium-7.9* phosphate-2.3* magnesium-1.7 10:34pm ck-mb-35* mb indx-9.0* ctropnt-0.73* 10:34pm glucose-146* urea n-20 creat-1.0 sodium-140 potassium-4.7 chloride-110* total co2-22 anion gap-13 04:06pm ck 1048* 05:45am ck 1011*1 04:06pm ckmb 15* mbi 1.4 05:45am ckmb 17* mbi 1.7 . ekg: nl sinus rhythm, st elevations in 1, avl, v2-v6, reciprocal st depressions in iii, avf, t wave inversions laterally, lafb . relevant imaging: 1)cardiac catheterization (): 1. selective coronary angiography in this right dominant system revealed severe two vessel coronary artery disease. the lmca had diffuse mild disease. the lad was totally occluded after d1 and s1. the distal lad was a small diffusely disease vessel that filled via right to left collaterals. the first diagonal was severely diffusely disease. the second diagonal was a large vessel with a large subbranch with a long subtotal occlusion; this vessel filled distally via collaterals. the lcx had a 30% proximal and a 50% mid occlusion. 2. left ventriculography was deferred. 3. hemodynamics revealed elevated left and right sided filling presures. the lvedp was 23 mmhg. the rvedp was 16 mmhg. there was pulmonary artery hypertension. pulmonary artery pressure wa 41/21 mmhg with a mean of 30 mmhg. cardiac index was perserved at 3.25 l/min/m2. 2)c,t,l-spine ct (): no evidence of fracture or malalignment. 3)ct head (): there is a 5-mm hyperdensity along the right frontal falx of uncertain etiology. there is no evidence of hemorrhage, mass effect, shift of normally midline structures, hydrocephalus, or infarction. the density values of the brain parenchyma are within normal limits and the -white matter differentiation is preserved. the ventricles and sulci are normal in size. the surrounding osseous and soft tissue structures are unremarkable. the imaged portions of the paranasal sinuses are well-aerated. 4)mri/mra head (): study is limited due to patient motion artifact. however, the major vessels of the circle of appear patent. there do not appear to be any large areas of intracranial atherosclerotic disease. the right vertebral artery is dominant. there appears to be a fetal origin to the right posterior cerebral artery. brief hospital course: mr. is a 52 yo male with htn who is now s/p anterolateral stemi and vf arrest s/p lad stent, and s/p intubation. he was extubated following cardiac catheterization. he remained stable thereafter, but did have some residual short term memory deficits. 1)stemi: the patient had evidence of an anterolateral stemi and subsequent vfib arrest. he was taken to the cath lab where he was found to have occluded lad after d1 & s1 and 1 subbranch with long subtotal occlusion with collateral filling of distal vessel. a minivision stent was placed into the mid-lad. the patient was maintained on asa 325 mg, lipitor 80mg, plavix 75mg daily x 1 month, lisinopril 10 mg qd, and metoprolol titrated to 50mg tid. the patient was made a follow up appointment with dr. , cardiologist. 2)pump: the patient had an echo 2 days after pci and vf arrest which showed an ef~ 30% with an akinetic apex. although the pcwp 23 on cardiac cath, the patient was diuresed during his hospitalization and was euvolemic on exam by time of discharge. given the akinetic apex found on echo and increased risk of clot formation, the patient was started on a heparin drip as a bridge to coumadin. upon discharge the patient's inr was 1.4. he was discharged on lovenox sq and coumadin. he was told to have his inr checked on friday and have the results faxed to dr. office. 3)rhythm: the patient is s/p vfib arrest secondary to an anterolateral stemi. he stayed in normal sinus rhythm throughout his hospitalization. his metoprolol was titrated up to 50mg tid. 4)fall: the patient is s/p posterior head trauma prior to the vf arrest. head ct head showed a 5-mm hyperdense focus along anterior falx. differential included meningioma vs. bleed. this focus was thought to be stable after the patient was therapuetic on heparin. neurosurgery was involved throughout and recommended follow-up in weeks with an outpatient ct and appointment with dr. . ct of the c- t- and l-spine ruled out fracture. 5)short term memory: the patient's stm deficit was thought to be secondary to anoxic brain injury from poor perfusion during the vfib arrest. it was stable to slightly improved by the time of discharge. both neurology and psychiatry were consulted. they recommended follow up in the clinic for further testing. a follow up appointment was made with dr. for this purpose. 6)leukocytosis: the patient's leukocytosis was attributed to the recent stemi. the patient was clinically asymptomatic and over the course of the hospitalization. ua and cxr were negative for uti and pna respectively. the leukocytosis slowly improved and was wnl by discharge. medications on admission: none discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 5. warfarin 2.5 mg tablet sig: three (3) tablet po hs (at bedtime). disp:*90 tablet(s)* refills:*2* 6. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. lovenox 80 mg/0.8 ml syringe sig: one (1) injection subcutaneous twice a day for 3 days. disp:*6 injections* refills:*0* 8. outpatient lab work please check pt, ptt, inr please call in results to dr. ( fax (. discharge disposition: home with service facility: visiting nurse discharge diagnosis: primary diagnosis: st elevation mi with stent placement v-fib arrest new systolic dysfunction (ef 30%) with apical akinesis meningioma . secondary diagnosis: hypertension discharge condition: safe for discharge home. discharge instructions: 1. please continue to take your lovenox as instructed for three additional days. . 2. please have your coumadin level (inr) checked on friday and the results sent to dr. office phone(. . 3. please take all medications as prescribed. most importantly, you must take your aspirin and plavix every day. please do not miss . failure to take these medications can result in stent closure which could be life threatening. . 4. if you develop any chest pain, shortness of breath, lightheadedness or dizziness, or any other concerning symptoms, please contact your doctor or report to the nearest er. followup instructions: 1. please contact dr. office (cardiologist) to follow up phone: date/time: 3:20. please have your coumadin level checked this friday at his office. . 2. please contact dr. , md, phd: date/time: 1:00 clinic. . 3. please follow up with dr. from neurosurgery in weeks with a head ct. please call to make these arrangements after discharge. . 4. previously scheduled appointments: provider: , m.d. phone: date/time: 12:00 md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours 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 endotracheal tube Arterial catheterization Angiocardiography of right heart structures Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Acute myocardial infarction of anterolateral wall, initial episode of care Paroxysmal ventricular tachycardia Cardiac arrest Anoxic brain damage Benign neoplasm of cerebral meninges Ventricular fibrillation

allergies:nkda. pmh:htn-wo med. crf:smoker-80pk/yr. fh cad-mother. ?cholesterol level. social:married. 1 son. ceo of ?accounting firm. present hx:collapsed @ work. struck head. ?pulseless w agonal respirations. cpr wo breaths administered by co-workers for approx 5min. paramedics-vf shocked x1 to slow vent rhythm w conversion to sinus rhythm. intubated. transported to . ct head-?sm subdural hematoma vs meningioma. posturing. ekg-anterior/lateral ste. ekg ghgs not rxed due to head ct. transported to for card cath. decided signif ste required rx. card cath-pci w placement minivision stent to prox lad. integrillin started. admitted to ccu for further management/support. o:neuro=easily agitated. does not respond appropriately to verbal commands. moves r/l arms non-purposefully (rises & lowers). ?posturing r arm. moves r/l legs on bed. cervical collar on. versed/fent added for agitation/com- fort. pulm=intubated/vented. settings adjusted to sats/abgs. breath sounds=course throughout. sx-thick brown secretions. cv=hemody stable. becomes hypertensive w tachycardia w agitation. lopressor to start in am. intregillin infusing-to be dced 1500 . discussed artic sun w cardiac fellow-over 6hr time frame. gi=npo. ogt placed. drainage-brownish liquid. gu=foley. adeq uo. hydrating w d51/sns x2l. access=peripheral x1. r fem venous introducer. r radial aline. id=afebrile @ present. skin=wo breakdown. social=wife/son present-events discueed w mds. labs=mg/calcium replaced. a:a/lstemi c/b vf arrest. p:contin present management. ?neuro consult. ?aspiration (ett sx & ogt drainage simular). support family as indicated. ?ss consult. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours 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 endotracheal tube Arterial catheterization Angiocardiography of right heart structures Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Acute myocardial infarction of anterolateral wall, initial episode of care Paroxysmal ventricular tachycardia Cardiac arrest Anoxic brain damage Benign neoplasm of cerebral meninges Ventricular fibrillation

discharge medications: 1. albuterol 90 microgram inhaler, one to two puffs q. four as needed. 2. multivitamin once a day. 3. ascorbic acid 500 mg once a day. 4. miconazole powder applied twice a day. 5. hydrocortisone 0.5% cream applied twice a day. 6. colace 100 mg twice a day. 7. bisacodyl 10 mg once a day. 8. metoprolol 100 mg three times a day. 9. atrovent two puffs inhalation four times a day. 10. amlodipine 5 mg once a day. 11. ceftazidime 2 grams intravenously every eight hours for ten days. 12. vancomycin one gram intravenously every 12 hours for ten days. 13. protonix 40 mg once a day. discharge diagnoses: 1. pneumonia/pneumonitis, aspiration. 2. anemia. 3. delirium. 4. decubitus ulcer. 5. thyroid mass. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage 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 Percutaneous [endoscopic] gastrostomy [PEG] Closed [endoscopic] biopsy of bronchus Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Pulmonary collapse Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Infection and inflammatory reaction due to other vascular device, implant, and graft Esophageal hemorrhage

history of present illness: this patient is a 66 year old female who presented with light-headedness, dizziness, hematemesis, to an outside hospital on , and was found to have a hematocrit of 15.0 and workup was consistent with an upper gastrointestinal bleed. the patient was transfused a total of sixteen units of packed red blood cells and four units of fresh frozen plasma at the outside hospital. at the outside hospital, the patient underwent esophagogastroduodenoscopy on , which revealed grade iv esophagitis, bleeding ulcer 3.0 centimeters proximal to the gastroesophageal junction and this bleeding ulcer was cauterized and injected. at the outside hospital, the patient continued to bleed actively with falling hematocrit and underwent esophagogastroduodenoscopy two more times. on , esophagogastroduodenoscopy revealed a spurting visible vessel in the distal esophagus and 9cc of epinephrine were injected. on , esophagogastroduodenoscopy revealed old blood in the fundus and the distal esophagus was injected a third time. at the outside hospital, the patient was intubated for airway protection as she was noted to have hematemesis with likely aspiration. the patient was extubated briefly but reintubated after another episode of hematemesis. the patient was transferred to on , for further management of her upper gastrointestinal bleed and respiratory status. past medical history: 1. gastroesophageal reflux disease. 2. malaria. 3. filariasis. 4. thyroid surgery. medications on transfer: 1. octreotide. 2. reglan. 3. protonix. 4. levaquin. 5. clindamycin. physical examination: on admission, in general, the patient is an obese woman, intubated and sedated. head, eyes, ears, nose and throat is normocephalic and atraumatic. the pupils are equal, round, and reactive to light and accommodation. the oropharynx is with endotracheal tube in place. heart - regular rate and rhythm, s1 and s2, no murmurs, rubs or gallops. lungs - decreased breath sounds bilateral lower lobes, coarse upper airway sounds. abdomen is obese, soft, nontender, nondistended, normal bowel sounds. extremities - 2+ pulses throughout, no cyanosis, clubbing or edema. neurologically, the patient is sedated, responsive to sternal rub. pertinent diagnostic studies on admission: white blood cell count was 10.0, hematocrit 30.2, platelet count 230,000. sodium 142, potassium 3.6, chloride 108, bicarbonate 27, blood urea nitrogen 13, creatinine 0.5, glucose 114, calcium 7.9, phosphate 3.2, magnesium 1.7. alt 10, ast 10, alkaline phosphatase 60, total bilirubin 1.0. prothrombin time 13.9, inr 1.3, partial thromboplastin time 24.6. chest x-ray showed the endotracheal tube in proper position, patchy alveolar opacity in the right lung, opacity with air bronchograms in the left retrocardiac region, differential diagnosis multifocal aspiration, pneumonia, asymmetric pulmonary edema. electrocardiogram showed normal sinus rhythm at 71 beats per minute, no st-t wave changes, normal axis, normal intervals. hospital course: 1. upper gastrointestinal bleed - the patient's hematocrit remained stable in the low 30.0s and high 20.0s throughout her hospital stay. the patient did not require a repeat esophagogastroduodenoscopy and she remained guaiac negative with no signs or symptoms of active bleed. the patient did receive one unit of packed red blood cells on , for a slowly decreasing hematocrit to 27.0 over several days. her hematocrit responded appropriately to this one unit of packed red blood cells and she did not require further transfusions. the patient was maintained on proton pump inhibitor throughout her hospital stay. octreotide was continued until , when it was stopped with gastroenterology approval. 2. respiratory distress - the patient was transferred here intubated and sedated. the patient was difficult to wean from the ventilator likely due to a combination of bilateral atelectasis, bilateral pleural effusions, pneumonia, pulmonary edema. the patient also was found to have a right pneumothorax on . no instrumentation had been performed on that side, and chest x-rays from the previous days had not shown a pneumothorax. likely, it was a side effect of being intubated on the ventilator as well as due to underlying chronic lung disease. a chest tube was placed on the right with good results. the patient's bilateral pleural effusions were decreased with diuresis as well as on the right side with the placement of the chest tube. right pleural fluid was serosanguinous with 400 white blood cells, 50% polys, total protein 2.9, glucose 107, ldh 515, gram stain negative. the patient was started on ceftriaxone on , for her left lower lobe consolidation as well as spiking fever. on , the patient's pleural fluid and the blood culture bottle was positive for gram positive cocci. the patient was afebrile and continued on the ceftriaxone. chest x-ray on , showed that the pneumothorax had resolved. on , the patient was extubated and her oxygen saturation remained in the 90s on nonrebreather face mask. the patient briefly required cpap via face mask as she clinically was requiring great effort for breathing. the patient was started on albuterol and ipratropium nebulizers q4hours, standing dose. on , the patient was switched from ceftriaxone after five days to ceftazidime and vancomycin for increased white blood cell count and fever to 102 degrees with continued left lower lobe consolidation. these antibiotics were chosen to cover broadly for pneumonia pathogens including pseudomonas as well as hospital line infection from her central line. on , chest x-ray showed increased pulmonary edema, and the patient was clinically with crackles bilaterally in the lungs two thirds of the way up. the patient was restarted on lasix p.r.n. with a goal of minus one to two liters each day. the patient responded very well to diuresis and pulmonary edema decreased significantly. the patient's lasix dose was decreased on . with good diuresis as well as treatment of the pneumonias and pneumothorax, the patient was weaned slowly on oxygen from nonrebreather face mask after extubation to nasal cannula by . on , vancomycin and ceftazidime were discontinued as the patient had received six days of these antibiotics as well as five days of ceftriaxone and was clinically stable with no signs or symptoms of infection. the same day the patient's arterial line and central line were removed. 3. mental status changes - the patient initially transferred here sedated. after extubation and weaning of sedation, the patient remained responsive but clearly confused and disoriented. the patient's tsh and free t4 were within normal limits. head ct on , was negative for an acute process. psychiatry was consulted and the patient was started on haldol 4 mg and then increased to 6 mg q.h.s. the patient also responded well to haldol p.r.n. for agitation. the patient also received ativan 2 mg once for agitation with good effect. the patient's mental status changes were gradually improved on a daily basis and by , she was conversant and appropriate. the patient was not yet back to her high baseline mental status, but no further workup was deemed necessary. the patient's mental status changes were thought to be due to the fact that she was intubated for several weeks, on propofol. also, in the intensive care unit setting, the patient was likely very sleep deprived, contributing to somnolence and agitation intermittently. 4. cardiovascular - the patient with no known cardiac history but with pulmonary edema which contributed to difficulty to wean from ventilator as well as from oxygen after extubation. echocardiogram on , revealed a mildly dilated left atrium, mild symmetric left ventricular hypertrophy with normal cavity size, normal left ventricular wall motion, hyperdynamic left ventricular systolic function, ejection fraction of greater than 75%, right ventricular chamber size and free wall motion normal. aortic root was mildly dilated, ascending aorta moderately dilated. mitral and aortic valves were within normal limits. no pericardial effusion. the patient was diuresed effectively with lasix. the patient's heart rate and systolic blood pressure increased after extubation to a heart rate in the 100 to 130 range, and systolic blood pressure in the 170 to 200 range. this is of unknown cause although possibly related to the recent extubation. the patient was started on nitroglycerin drip on , which was discontinued on . the patient was also started on a diltiazem drip and then switched to an esmolol drip after the diltiazem did not affectively control the patient's heart rate. the nitroglycerin and esmolol drips effectively controlled the patient's heart rate and blood pressure but they remained labile. possibly contributing to this were her frequent nebulizer treatments with albuterol. another important factor contributing to the patient's systolic blood pressure and heart rate elevation was anxiety and agitation as mentioned above. the patient was started on metoprolol three times a day via her nasogastric tube with good effect and both the nitroglycerin and esmolol drips were tapered to off. the patient's cardiac vital signs also stabilized as her agitation decreased and her mental status improved. currently, her heart rate and blood pressure are well controlled on metoprolol 100 mg three times a day. 5. liver function - the patient's liver function tests were within normal limits on admission. on , the patient was noted to have increased alt to 106, ast 84, ldh 306, alkaline phosphatase 158, total bilirubin 0.5, amylase 63, lipase 106. the patient denied any abdominal pain at this time or other symptoms. the patient underwent ultrasound of the abdomen that day which had a normal gallbladder, normal liver, normal biliary tree and normal kidneys. also found mild ascites and bilateral pleural effusions persisting. the patient's liver function tests normalized within two days and the etiology of this transient increase in liver function tests was thought to be possibly drug related. 6. fluids, electrolytes and nutrition - the patient was provided nutrition via nasogastric tube and tube feeds were as per nutrition consultation recommendations. on , the patient was evaluated by the speech and swallow consultation and found to be grossly aspirating. they recommended a gastric feeding tube. that day the patient's daughter was and consented for this procedure on the patient's behalf. gastroenterology was and planned gastric feeding tube placement on , or . the patient's potassium and magnesium were repleted as needed throughout her hospital stay. the patient was diuresed throughout the second half of her hospital stay due to pulmonary edema with good effect. 7. prophylaxis - the patient was started on subcutaneous heparin on , after hematocrit continued to be stable and gastroenterology consultation agreed. the patient was also maintained on proton pump inhibitor throughout her hospital stay. 8. code status - full. 9. communication - the patient was intubated and not mentally competent to make decisions on her own behalf. the patient's husband, friend , and daughter , were involved in the patient's care and were updated frequently by the medical team. 10. access - the patient had a left subclavian central line which was eventually removed on , as the patient no longer needed to receive medications via the line. disposition: the patient was screened for rehabilitation facility and approved awaiting a bed. condition on discharge: stable. discharge diagnoses: 1. esophageal ulcer. 2. pneumonia. 3. pneumothorax. 4. respiratory distress. 5. pulmonary edema. 6. hypertension. medications on discharge: to be determined by the inpatient regular team. follow-up plans: the patient to be transferred to rehabilitation facility with follow-up with primary care physician. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage 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 Percutaneous [endoscopic] gastrostomy [PEG] Closed [endoscopic] biopsy of bronchus Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Pulmonary collapse Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Infection and inflammatory reaction due to other vascular device, implant, and graft Esophageal hemorrhage

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status, sepsis major surgical or invasive procedure: none. history of present illness: mrs. is an 85 year old woman with a history of pvd, mild dementia and cad who presented to accompanied by her daughter with 1 day of altered mental status. the patient was in her usual state of health until 1 day prior admission. her daughter noted that she was calling out for people who were not there. she denies having had any cough or diarrhea. she was brought to the ed where she was found to have positive ua, lactate of as high as 7.5. her temperature was noted to be 102 rectally. in the ed, she was given vancomycin and ceftriaxone. a pre- line was placed in ed, and 1.5l ns were administered. ngt placement was attempted. on arrival to the micu the patient had no complaints. she coughed up some rust-colored sputum which, according to her daughter, was from an ng tube placement attempt. past medical history: 1. diabetes, diet controlled. 2. coronary artery disease, status post right coronary artery stent in . 3. chf; echo in showed ef=55%, enlarged left atrium, moderate lvh, mild ms, moderate mr, moderate systolic pa hypertension 4. dementia 5. hypertension. 6. cerebrovascular accident with residual aphasia. 7. depression. 8. anxiety. 9. cri with baseline cr 1.5-1.6 10. anemia (baseline hct 34) 11. multiple myeloma 12. gout 13. ?raynaud's disease 14. h/o gallstones but has gallbladder past surgical history: 1. s/p amputation of left 5th toe and right 3rd toe, 2. status post left total hip replacement. 3. status post l4 vertebral plasty on . 4. status post left ankle fracture reduction. 5. status post appendectomy. 6. status post cesarean section times two. 7. status post traumatic amputation of the fourth right digit. 8. : angioplasty of superficial femoral artery, popliteal artery, tibioperoneal trunk and proximal posterior tibial artery social history: she lives on one floor of a three floor home with her daughter. she is somewhat independent of her adl's (ie: can prepare her own breakfast) but relies on her daughter for a lot of assistance. she has two children, a grand-daughter and a great-grandchild. she is a retired hairdresser. she denies tobacco or alcohol history. . family history: father with cad in his 70's physical exam: tmax: 96.2 tcurrent: 95.3 bp: 109/45 (100s-130s/40s since levo off) p: 66 (60s-70s) r: 18 99% 4lnc i/o: 4967 in/156 cc uop total (10-16 cc/hr) cvp: 15 gen: pleasant elderly woman in bed in no apparent distress. heent: mmm, sclerae anicteric. neck: left ij in place. cv: normal s1/s2, rrr. iii/vi hsm at lsb/ pul: cta bilaterally no wheezes, rales or rhonchi abd: soft, nt, nd, +bs ext: 1+ le edema bilatereally neuro: awake, alert, oriented to hospital. pertinent results: ucx : urine culture (final ): klebsiella oxytoca. > 100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella oxytoca | ampicillin/sulbactam-- => 32 r cefazolin------------- => 64 r cefepime-------------- <=1 s ceftazidime----------- 16 i ceftriaxone----------- 4 s cefuroxime------------ => 64 r ciprofloxacin--------- 1 s gentamicin------------ 8 i imipenem-------------- <=1 s levofloxacin---------- 1 s meropenem-------------<=0.25 s nitrofurantoin-------- 32 s piperacillin/tazo----- => 128 r tobramycin------------ 8 i trimethoprim/sulfa---- => 16 r renal u.s. 2:03 pm 1. no evidence of renal abscess. 2. scarring in the upper pole of the right kidney consistent with chronic change due to prior infection. 3. moderate-to-large bilateral pleural effusions. 11:10pm wbc-2.4*# rbc-3.73* hgb-10.0* hct-30.0* mcv-80* mch-26.9* mchc-33.4 rdw-17.2* 11:10pm neuts-56.2 bands-0 lymphs-36.3 monos-6.5 eos-0.3 basos-0.6 11:10pm hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 11:10pm plt smr-normal plt count-310 11:10pm glucose-227* urea n-56* creat-2.1* sodium-134 potassium-6.0* chloride-98 total co2-21* anion gap-21* 11:10pm alt(sgpt)-14 ast(sgot)-54* ck(cpk)-59 alk phos-85 amylase-99 tot bili-0.7 11:10pm lipase-74* 11:10pm ctropnt-0.08* 11:10pm calcium-9.1 phosphate-5.7* magnesium-2.4 11:45pm pt-14.9* ptt-21.9* inr(pt)-1.3* 01:02am lactate-7.5* 03:00am ld(ldh)-471* 11:45pm urine color-yellow appear-hazy sp -1.011 11:45pm urine blood-sm nitrite-pos protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-mod 11:45pm urine rbc-0 wbc- bacteria-mod yeast-rare epi- trans epi- brief hospital course: 85 year old woman with history of cad, presents with ams and sepsis, found to have mrsa urinary infection. . 1) urosepsis: pt with fever, tachycardia, low bps, and elevated lactate on admission and code sepsis was called. resusitated with ivfs and placed on levophed x 1 day. was subsequently weaned off of levophed with stable bps during remaining hospital course. most likely source was uti given positive ua and recent urinary tract infection. pt has had e.coli and klebsiella in the past, both sensitive to fluoroquinolones. pt received vanc/ctx in ed. in micu, vancomycin d/c'd and was continued on levaquin. on transfer to floor, urine culture with mrsa, vancomycin restarted and levaquin d/c'd. picc placed for outpt iv vancomycin treatment for total of 14 days. vancomycin trough level while in hospital therapeutic at 11.0. . 2) cardiac: h/o chf, cad, htn. pt has tendence to get volume overloaded and symptomatic chf when her diuretic +/- her ace are held. however, given low bp requiring pressors on admission, ace-i, bb, and lasix were held. once bps were more stable, all three were readded without event. asa was also continued. . 3) acute renal failure: likely acute on chronic secondary to prerenal state. pt's cr peaked to 2.0 while in house, has since dropped back to baseline after ivfs. . 4) dm - diet controlled as outpt. hiss with qid fs. . 5) anemia - baseline hct in upper 20s low 30s. iron studies were consistent with anemia of chronic disease. . 6) s/p amputation of l 5th toe and r 3rd toe - wound care continued. . 7) access - picc. . 8) communication - with pt's daughter . . 9) ppx - heparin sq. . the pt was discharged to a rehab facility for pt/ot and to finish her 14 day course of iv vancomycin for mrsa urinary infection. medications on admission: amitriptilyine 25 mg qday asa 81 mg qday colace 100 mg fosamax 70 mg qwk metoprolol 25 mg ranitidine 150 mg timolol eye drops zestril 10 mg qday furosemide 40 mg qday 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. heparin (porcine) 5,000 unit/ml solution sig: five (5) ml injection q8h (every 8 hours). disp:*150 ml* refills:*2* 3. amitriptyline 25 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 4. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 6. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) gram intravenous q48h (every 48 hours) for 10 days. disp:*5 gram* refills:*0* 10. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po qhs prn as needed for confusion, agitation. disp:*30 tablet, rapid dissolve(s)* refills:*0* discharge disposition: extended care facility: - discharge diagnosis: mrsa urinary infection urosepsis diabetes mellitus type ii cad s/p rca stent chf htn s/p cva c residual aphasia depression anxiety cri discharge condition: stable. discharge instructions: please take all of your medications as instructed. you will need to complete a 2 week course of iv vancomycin for treatment of urinary infection. return to the hospital if you experience any of the following symptoms: altered mental status, fevers, chills, night sweats, burning on urination, increased urinary frequency, shortness of breath, chest pain. please take your weight daily. you will need to follow-up with your primary care doctor within 1 week of discharge. you are being discharged to a rehab facility to get additional physical therapy and to complete your course of iv antibiotics. followup instructions: please follow-up with your primary care doctor within 1 week of discharge. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Anemia of other chronic disease Coronary atherosclerosis of native coronary artery Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Gout, unspecified Other chronic pulmonary heart diseases Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Septic shock Multiple myeloma, without mention of having achieved remission Late effects of cerebrovascular disease, aphasia

allergies: sulfamethoxazole/trimethoprim / codeine / antihistamines attending: chief complaint: weakness, diarrhea major surgical or invasive procedure: left subclavien central line placement right arm picc line placement history of present illness: pcp: . and , . . hpi: ms. is an 82yo woman with h/o afib, copd, recent hospitalization with shortness of breath, (treated for pneumonia with levofloxacin for 10d (ended 3d ago) and copd flare with prednisone 5d course), and chronic low back pain on oxycontin who presented to the er today feeling drowsy and with diarrhea. very poor historian. she has not had fever at home. there are several calls to by her son, after which , np called an ambulance to bring her in today. . per notes and er staff there are questions of whether her son has been giving her more than her prescribed oxycotnin versus taking it himself (or selling). per notes the patient has been refusing all of her meds except oxycontin all week, and her son has been giving her extra doses. she has also been quite sleepy all week. denies dysuria, cough, sob, abd pain. . in the er the patient was noted to be afebrile and in afib with rvr at 160. cards was called and recommended dilt drip. she received 3lns and was given potassium repletion and was started on a dilt drip, which was able to bring her heart rate to 100-120s with an sbp of 100s. o2 sat 97-100% on 2lnc. she had a wbc of 28. cxr was performed and revealed her prior pna seen on cxr 3w ago. ua was negative for infection. stool was not sent. blood cultures were drawn and she was given a dose of ctx and azithro to cover for possible cap before it was noted that her infiltrate was unchanged from prior. . ros: denies ha, states diplopia lasting a few seconds at a time for last "month or so", lower back pain which is worse since they lowered her oxycontin dose, not wearing bottom dentures because gums are swollen and sore. no dysuria. . past medical history: - chronic low back pain on oxycontin with oxycodone for breakthrough - htn - cad with rca stent: pmibi in showed mild, reversible perfusion defects of the apical portions of the inferior and inferolateral walls. normal left ventricular cavity size and systolic function. - chf due to valvular disease: mod ar and as with severely thickened av, mild mr deformity and annular calcification. . - rheumatic heart disease followed by dr. : echo : left atrium mildly dilated. symmetric left ventricular hypertrophy. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). aortic valve leaflets are severely thickened/deformed. aortic valve stenosis. (2+) aortic regurgitation. mitral valve leaflets are moderately thickened. the mitral valve shows characteristic rheumatic deformity. there is severe mitral annular calcification. there is thickening of the mitral valve chordae. there is mild mitral stenosis. mild (1+) mitral regurgitation is seen. pulmonary artery systolic hypertension. compared with the findings of the prior report (tape unavailable for review) of , the pulmonary hypertension is worse, and the mitral regurgitation may be better. . - tachy-brady syndrome s/p dual chamber pacer - panic disorder - copd: last pfts showed tlc 2.76 (72%), dlco 39%pred, fvc 1.61 (75%) with fev1 1.18 (83%) and fev1/fvc 111% pred. - restrictive lung disease with scoliosis - s/p tah/bso - multinodular goiter - hyperlipidemia - chronic leg edema with venous stasis social history: lives with son. his lives upstairs. smokes 1ppd for about 65yrs. no etoh. family history: siblings with "heart conditions" and "cancer" physical exam: t 96.0 hr 95, bp 96/33, rr 18, o2 100% on 2lnc gen: confused but answers questions heent: ncat, perrl, r side of mouth with droop (no photos to compare), mm dry neck: no lad cor: irreg irreg, ii/vi systolic and diastolic murmurs heard throughout precordium pulm: cta l lung, r base with crackles abd: soft, ntnd, no hsm, hyperactive bs ext: 2+ pitting edema ble (per pt at baseline), dps faintly palp bilat neuro: able to move eyebrows bilat, able to puff out cheeks bilat, pt will not smile for me. bilat dorsi/plantarflexion, bilat hip flexor (cannot raise leg off of bed but can with bent knee and foot on bed) gu: foley catheter in place with concentrated brown urine in bag pertinent results: wbc-28.1*# rbc-4.56 hgb-11.9* hct-36.1 mcv-79* mch-26.1* mchc-32.9 rdw-15.7* plt count-380 - neuts-93.6* bands-0 lymphs-2.4* monos-3.4 eos-0.4 basos-0.1 pt-29.4* ptt-36.2* inr(pt)-3.0* glucose-100 urea n-61* creat-1.3* sodium-131* potassium-3.8 chloride-94* total co2-21* calcium-8.8 phosphate-3.9 magnesium-2.2 ck(cpk)-1431* ->799 ck-mb-29* -> 20 ctropnt-0.04* ->0.03 lactate-1.9 -> 1.1 urine blood-neg nitrite-neg protein-neg glucose-neg ketone-tr bilirubin-sm urobilngn-1 ph-6.5 leuk-neg markedly limited study. there is still persistent opacity at the medial right lung base which may be the residual of prior infection or recurrent disease. no significant edema. . ekg: afib at 150, nl axis, st depression in ii, iii, f, downsloping st depression in v5-6. st depressions decreased in size on repeat at rate 123 . . brief hospital course: 82yo woman with cad, rheumatic valve disease, copd, afib, tachy-brady syndrome s/p pacer, recent hospitalization where she was treated for pneumonia with levo and copd flare with prednisone. . micu course: # sirs/diarrhea: the patient was admitted overnight to the micu, where she was found to be afebrile, in atrial fibrillation with rvr, hypotensive with systolic bp in the 80s-90s, confused and clearly dehydrated. she was hydrated with normal saline aggressively overnight, including 250cc boluses x 3 and a continuous ns iv drip at 250cc per hour. cxr showed only persistence of her known prior pneumonia. blood cultures were drawn and were pending. stool cultures were sent for general bacterial infection as well as c diff toxin and she was started on flagyl empirically and placed on contact precautions for presumed c diff given her recent antibiotic exposure. on the morning after admission, the patient was much improved hemodynamically. her urine output and blood pressure had recovered to normal values and her acute renal failure as well as hyponatremia both resolved after overnight hydration with ns. # afib with rvr: she was continued on her sotalol and was initially on a diltiazem drip for her atrial fibrillation, however given her hypotensionand the fact that this was not adequately controlling her hr this was stopped. her heart rate improved somewhat with hydration, dropping from the 140s to the 100-120s. at approximately 4am, the patient spontaneously converted to nsr and was atrial paced at a rate of 70. after this time, her sbp remained in the 100-120s. # cad: her initial ekg at rate 150s showed marked st depression in ii, iii, f and v5-6. on repeat ekg at rate of 120s, st depressions were still present but smaller. after the patient converted to nsr and was atrial paced at 70 st depressions resolved in ii, iii, and f but remained (although only 1-2mm) in v5-v6. notably the patient has known reversible inferior and inferolateral defects seen on pmibi in which were not intervened upon. she ruled out for mi with cardiac enzymes and was started on full dose aspirin. her statin was continued, but ace was held and no bb was started given hypotension. # social: repeated conversations were had with the patient's son, , who called the micu 6 times in 20 minutes from the time his mother was assigned a bed and the time she was settled in with nursing staff. he appeared angry and paranoid by phone, stating that the pt would say he was abusing her, that he believed his was overdosing the patient on her oxycontin and that the two of them were whispering about him and plotting against him. he also said he had to tell the patient right away that he was moving out and not paying her rent. the patient's also phoned, saying that is mentally ill and becomes more unstable when the patient is in-house. social work was called. plan was to call , who is very familiar with the pt and per her recommendation to contact elder services, as it is likely the patient is either being given too much oxycontin or that this is being taken from her. called patient relations on the morning following admission, and from our patient relations office also suggested we involve elder services. # confusion: the patient was oriented x 1 on arrival ot micu. she has an unclear baseline. possible that pt has ms change in setting of infection, versus use of oxycontin/oxycodone as well as valium. her oxycontin dose was halved and on the day following admission she was still somnolent. we switched to low dose immediate release oxycodone only. this raises suspicion of possible theft of her medications at home. her valuim was held, and she displayed no signs of withdrawal while in the micu. mental status was somewhat improved after overnight hydration and flagyl, however she remained oriented x 1 only on call-out to the floor. # valvular chf: due to history of rheumatic heart disease. we held her home lasix while in micu due to dehydration and aggressively hydrated her. on the morning following admission she was still satting 100% on 2lnc and had developed only mild crackles at her bilateral bases. her jvp had increased to about 8 and further hydration was held, as she was felt to be replete by exam, blood pressure and urine output. . medical floor course . # atrial fibrillation the patient converted to nsr in the micu. she was continued on sotalol and electrolytes were repleted. she remained in nsr until her cardiorespiratory arrest and death. . # c diff colitis she was started on po flagyl for presumed c diff colitis in the micu. her c diff toxin was positive. she continued with profuse watery diarrhea for the first several days while on the medical floor. given the fluid losses, she was given volume resuscitation with normal saline. after 4 days of po flagyl, the patient's overall condition was somewhat improved. though still with profuse watery diarrhea and diffuse abdominal pain, her mental status was improved such that she was oriented x 2 (name and location) and her white blood cell count was declining as well. she was switched to po vancomycin given her risk for serious complications and recurrence of c diff per her age, micu admission, and co-morbidities. over the next several days the patient's white blood cell count increased and her abdomen was increasingly painful and tender to palpation. she was also increasingly somnolent. her stools did decrease as well. on her white blood cell count increased dramatically despite treatment with po vancomycin. given further worsening of her abdominal examination, general surgery was consulted. she was started also on iv flagyl (in case po meds were not reaching the colon). a ct scan was ordered with po contrast to evaluate for possible perforation and or pancolitis / megacolon. iv fluids were also bolused as well given clinically hypovolemic state and worsening acute renal failure on laboratory studies. the ct scan was delayed by attempts to have the po barium contrast for the study ingested (concerns re: aspiration and risks to place a ngt in her hypercoaguable state). as the day progressed on , the medical team was notified by nursing that the patient's rr was increasing to 30-40s. . # code blue when the medical team arrived the patient was confused, tachypneic, with cool distal extremeties and feet, and weak, thready pulses. her blood pressure was systolic 70s / doppler (despite cuff measurement of systolic 110s). an abg was obtained which showed a severe metabolic acidosis. as the team was preparing for enhanced intravenous access, the patient's breathing shallowed and then she stopped breathing. a code blue was called. the patient's airway was secured open and venitlated with the ambu-bag. after several breaths the patient vomited and aspirated a large volume of dark brown liquid. this was suctioned and resuscitation was continued. soon therafter the patient lost a pulse and she entered into a pea arrest. cpr was initiated, and epinphrine, atropine, bicorbonate, amiodarone, vasopressin were administered. an et tube was placed via anesthesia. the patient was shocked 3 times. fluids were being infused as rapidly as possible and dopamine was also infused. surgery placed a left subclavien central line for access. after 25 minutes approximately, the patient's pulse did not restart and the code was terminated. the time of death was 1:45pm. the chief cause of death was considered cardiopulmonary arrest from progressive metabolic acidosis, likely from toxic megacolon and/or bowel perforation. the son ) was present at the beginning of the resuscitation, and left soon thereafter. he was contact via telephone approximately 1 hour after the code was terminated. the patient's grandson also was contact; he and his wife arrived at the hospital for viewing. could not be contact again to obtain permission for the post-mortem examination. . # neglect concern regarding neglect was raised during the patient's initial presentation. per records, the np had several conversations with the son about her deteriorating clinical state. despite the np's recommendations, the son refused to bring her to the hospital. after several days and no improvement, the np called ems herself. social work was consulted and eldery services became alerted to the case. investigations were ongoing at the time of death regarding elderly neglect / abuse. . # coagulopathy the patient presented to the medical floor with an elevated inr. she takes coumadin at home for atrial fibrillation; it is possible that the levofloxacin increased her inr. the inr did not trend down over several days. this was considered secondary to c diff colitis (overtaking normal bowel flora). it is also possible that hypotension on the day of death contributed to hepatic dysfunction. haptoglobin and fibrinogen were checked to evaluate for dic, but were found to be wnl. medications on admission: - asa 81 mg po qday - atorvastatin 20mg po qday - bisacodyl 10mg po qday prn (per d/c sum bottle not with her) - citalopram 30mg po qday (per dc summ from 1week ago however pt's med bottle says 20mg) - diazepam 2-4mg po q8hrs prn - colace 100mg po bid - advair 250-50 1 inhalation (per d/c sum, not with her) - furosemide 20 mg po qday - lactulose 30ml po q8hrs prn (per d/c sum) - lisinopril 10mg po qday - oxycontin 20mg po qam, 10mg po qnoon prn, 10mg po qhs (bottle not with her) - oxycodone 5mg po q8hrs prn (bottle not with her) - ranitidine 150mg po bid - sotalol 120mg po bid - warfarin 2.5mg po qhs - ferrous sulfate 325mgpo qday (not on d/c summary but pt has bottle with her) discharge medications: none discharge disposition: expired discharge diagnosis: c diff colitis copd s/p pneumonia atrial fibrillation discharge condition: deceased discharge instructions: expired followup instructions: none Procedure: Venous catheterization, not elsewhere classified Cardiopulmonary resuscitation, not otherwise specified Diagnoses: Pneumonia, organism unspecified Acidosis Other chronic pain Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Hyposmolality and/or hyponatremia Severe sepsis Chronic airway obstruction, not elsewhere classified Atrial fibrillation Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Intestinal infection due to Clostridium difficile Multiple involvement of mitral and aortic valves Cardiac pacemaker in situ Dehydration Lumbago Chronic diastolic heart failure Venous (peripheral) insufficiency, unspecified Nontoxic multinodular goiter

allergies: sulfamethoxazole/trimethoprim / codeine / antihistamines attending: chief complaint: shortness of breath major surgical or invasive procedure: ep study, pacer placement history of present illness: 80 yo f h/o rheumatic heart dz mitral stenosis, as, ar, cc: shortness of breath ********** hpi: pt is a 79 y/o female with rheumatic heart disease, rapid atrial-fibrillation, strong smoking history, and copd who presents with shortness of breath. she had a recent admission for jaw/chest pain where found to have only a 40% proximal lad lesion but was noted to be in rapid afib and was discharged on diltiazem for rate control. she was discharged with of hearts monitor. she was subsuquently seen by dr. in cardiology clinic where she was again found to be in rapid a-fib, with a rate near 150; admission for cardioversion was discussed at length, but the patient refused, so she was started on metoprolol 50mg , aspirin, and warfarin. . the pt continued to have sob and palpitations so she sought further care in . the pt denies any chest pain. in the ed, the pt briefly required non-invasive ventilatory support for the sob. cxr showed pulmonary edema. ecg revealed a-fib at 140's-150's with st depressions v4-v6 and trop leak to 0.24 c/w demand ischemia. iv dilt was started in the , cardiology consultant recs and the pt was transferred to the medicine floor. . on the medicine floor, the telemetry showed a-fib with rates to 150's, with periods of asystole lasting for a couple of seconds, during which the pt reported dizziness and nausea. the pt was transferred to the ccu for further monitoring and management. the plan at the ccu was to place a temporary pacer wire so that rate control therapy could be safely started once a back-up rhythm could be guaranteed by the temporary pacer. venous cannulation was unable to be acheived at the bedside. however, during the attempts to place the venous cannula, the pt converted to sinus rhythm at 70-80 bpm. . past medical history: coronary artery disease multinodular goiter constipation h/o atypical chest pain chronic bronchitis chronic low back pain s/p tah-bso cigarette smoking hypercholesterolemia panic disorder social history: lives with son, denies etoh. smoker (current) ppd x 60 yrs.. family history: non-contributory physical exam: pe t bp hr rr o2sats gen: nad, breathing with mask heent: perrl and a, eom intact, moist mucous membranes, neck: no masses, +jvd b/l, no carotid bruits lungs: decr. breath sounds at bases, wheezes throughout, no crackles heart: irreg rate, nl s1/s2, no m/r/g abd: soft, nt/nd, +bs ext: no cyanosis, clubbing, min. symmetric le edema, 2+ rad/dp pulses neuro: a&ox3, non-focal pertinent results: cath : taxus to 80% rca lesion . cath : rhc: pa 25/15. pcwp 15. co/ci/svr = 5.35/3.65/942 1.0. mean gradient 22. mitral area 2.0 gradient 8. 3+ ai, 2+ mr rca: patent lad: 40% proximal discrete lcx: patent . cxr : pulmonary edema congestive heart failure. . echo : conclusions: the left atrium is elongated. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). regional left ventricular wall motion is normal. the ascending aorta is mildly dilated. the aortic valve leaflets are severely thickened/deformed. there is moderate aortic valve stenosis. mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. the mitral valve shows characteristic rheumatic deformity. there is moderate thickening of the mitral valve chordae. there is a minimally increased gradient consistent with trivial mitral stenosis. moderate to severe (3+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (tape reviewed) of , the severity of mitral regurgitation has increased and the estimated pulmonary artery systolic pressure is higher. the transaortic valve gradient is also increased. . 08:29pm ctropnt-0.20* 08:29pm wbc-10.4# rbc-3.65* hgb-10.4* hct-31.4* mcv-86 mch-28.6 mchc-33.1 rdw-14.6 08:45am glucose-118* urea n-28* creat-1.1 sodium-140 potassium-4.0 chloride-104 total co2-22 anion gap-18 08:45am calcium-9.6 phosphate-4.5 magnesium-1.8 08:45am ctropnt-0.24* 08:45am ck(cpk)-124 03:10am ck-mb-5 ctropnt-0.04* probnp-6646* 03:10am digoxin-<0.2* 03:10am pt-14.7* ptt-27.6 inr(pt)-1.4 brief hospital course: a/p: 79 yo f with valvular heart failure as area 1.0 gradient 22, ms area 2.0 gradient 8, 3+ai, 2+mr, copd and rapid afib, presenting with sob/chf exacerbation. the pt was found to be in rapid a-fib on admission, developed long symptomatic ventricular pauses with rate control therapy, pacemaker was placed successfully in order to safely rate control. . # rhythm: the pt described symptoms of increased fatigue and sob on admission. she was noted to be in rapid afib. she was initially rate controlled with dilt and metoprolol on the medicine floor. however, the pt was noted on the telemetry to have periods of seconds of asysole, during which she felt light-headed and nauseous. the pt was transferred to the ccu for more intensive monitoring. attempted placement of catheter for temporary pacer was not successful, though pt converted to nsr. the pt was counseled regarding the benefits of permanent pacemaker so that the heart rhythm could be more successfully controlled, and she was amenable to this solution. the device was implanted successfully without complications. in terms of medical therapy amiodarone for rate control and to attempt maintenence of sinus rhtyhm. for medical therapy, beta blocker and digoxin were used for rate control. amiodarone was added to maintain sinus rhythm, but was later discontued after the pt developed symptoms of mental status changes which may have been at least partly exacerbated by the amio. anti-coagulation for stroke prophylaxis was pursued with coumadin with a heparin bridge. . 2. chf: pt was initially found to be in acute chf with pulmonary edema on cxr and increased o2 needs. this was assessed to be a-fib with rvr in setting of significant valvular heart disease. pt had low bp 90-120/40-50, when she was in rapid a-fib and on several bp meds, isordil, lisinopril 40, lasix 100 iv. the pt was diuresed gently and gradually brought to euvolemic state with medical therapy. echo was repeated to evaluate for any changes since the previous echo in may and revealed no significant changes. . 3 cad: the pt did have a slight troponin elevation which peaked at 0.24. this was likely secondary to demand ischemia in setting of rapid afib and low bp that she had on hd#1. the were so symptoms of anginal pain. no area at risk per cath . asa, plavix, lipitor were continued. . 4. mental status changes: in the post-operative setting, after the device was placed, the pt devloped symptoms of acute delirium. she had fluctuating levels of consciousness as well as some agitation, particulalrly developing at night. the delirium was thought to be to post-operative setting, multiple medications including opiates, benzodiazepines, amiodarone, as well as a tenuous baseline status. the medication regimen was simplified and over the subsequent couple of days, the pt returned to her baseline mental status. . 5. fen: na-restricted diet, fluid restriction. 6. chronic lbp: continue oxycodone/oxycontin. 7. ppx: anti-coagulated. 8. code: full. 9. dispo: the physical therapist evaluated the patient and recommended rehab. the physician team as well as the nursing staff impressed upon the pt that rehab was the safer option than returning home. the pt remained adamant that she wished to return home without rehab. medications on admission: 1. coumadin, though pt was not therapeutic on admission 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin calcium 20 mg tablet sig: one (1) tablet po daily (daily). 3. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 4. diazepam 2 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. 5. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 6. furosemide 20 mg tablet sig: 0.5 tablet po daily (daily). 7. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 8. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 9. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 10. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day). 11. oxycodone 20 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po qam (once a day (in the morning)). 12. oxycodone 10 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po midday (). 13. oxycodone 10 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po qpm (once a day (in the evening)). 14. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 15. isosorbide mononitrate 30 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 16. cardizem cd 240 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po once a day. discharge medications: 1. medical supply one hospital bed. pt weight 48 kg. height 5 foot 3 inches 2. commode one commode 3. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 4. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 6. ranitidine hcl 150 mg capsule sig: one (1) capsule po once a day. 7. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. lasix 20 mg tablet sig: one (1) tablet po once a day. 9. toprol xl 50 mg tablet sustained release 24hr sig: three (3) tablet sustained release 24hr po once a day. disp:*90 tablet sustained release 24hr(s)* refills:*0* 10. warfarin 2.5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*14 tablet(s)* refills:*0* 11. outpatient lab work please have you inr check blood test on . discharge disposition: home with service facility: vna discharge diagnosis: atrial fibrillation chf exacerbation discharge condition: good discharge instructions: please take all medicines as directed below. please weigh yourself daily and call your doctor if your weight increases by more than 3 lbs. restrict your fluid intake to less than 1.5 l daily. followup instructions: provider , md where: phone: date/time: 2:00 provider , m.d. where: cardiac services phone: date/time: 2:45 . electrophysiology device clinic, cardiac services 1:30 pm . . provider fern, where: phone: date/time: 10:20 Procedure: Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Non-invasive mechanical ventilation Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Tobacco use disorder Unspecified pleural effusion Unspecified essential hypertension Acute kidney failure, unspecified Acquired coagulation factor deficiency Chronic airway obstruction, not elsewhere classified Atrial fibrillation Rheumatic heart failure (congestive) Mitral valve insufficiency and aortic valve stenosis Sinoatrial node dysfunction Backache, unspecified Delirium due to conditions classified elsewhere

history of present illness: this is a 76-year-old female with previous history of hypertension, atrial fibrillation and sick sinus syndrome status post pacemaker who originally presented to an outside hospital with acute pancreatitis secondary to gallstone. she was treated at the outside hospital with intravenous fluids and was put npo for bowel rest. however, she subsequently developed worsening shortness of breath even though her pancreatitis was being adequately treated. the thinking at that point was congestive heart failure versus pneumonia versus ards. her hypoxia was slowly worsening and she was thus transferred to the on a regular floor. she was originally being managed with antibiotics and diuresis. however, on the second day of admission, the patient became severely hypoxic with o2 saturations of about 60% to 70% on 100 nonrebreather. she had a transthoracic echocardiogram which revealed an ejection fraction of 65%, thus leaving the most likely explanation to be ards. the patient was transferred to the medical intensive care unit where she was intubated. on the day of intubation, which was , she was also started on two pressors, levophed and vasopressin. at the same time, there was a rising suspicion of worsening of her pancreatitis which could have lead to her ards. because of this, she was started on a 10 day course of imipenem. on the following day, she was found to have a low cortisol a.m. level, so she was started on hydrocortisone 100 mg tid for renal insufficiency. imaging studies at this point revealed the following: head ct was negative for a bleed. chest ct showed ards and abdominal ct revealed no evidence of abscess or necrosis in the pancreas. on , the patient had urine culture and sputum cultures growing yeast and she was started on a five day course of fluconazole which she completed without complications. the patient's respiratory status slowly improved and after about 10 days of intubation, decision was made to try to extubate her. however, she appeared difficult to extubate and appeared sedated. this situation, however, improved and finally on , she was extubated. at this point, she was transferred to our care on the regular medical floor. past medical history: 1. hypertension 2. atrial fibrillation 3. sick sinus syndrome, status post pacemaker 4. status post mitral valve replacement home medications prior to admission to outside hospital: 1. atacand 2. lipitor 3. digoxin 4. zoloft 5. coumadin 6. lasix medications upon transfer to our floor: 1. coumadin 500 mg qd 2. digoxin 0.125 mg qd 3. zoloft 100 mg qd 4. erythropoietin 10,000 units 3x a week 5. heparin intravenous gtt 6. regular insulin sliding scale 7. lactulose 30 ml q6h prn 8. dulcolax pr q hs prn allergies: no known drug allergies. social history: she lives alone and is widowed. her son is very involved in her care. there is no use of tobacco or alcohol. family history: noncontributory. physical exam: vital signs: temperature 97.6??????, blood pressure 125/62, pulse 74, respiratory rate 20 with saturations 97 on 4 liters nasal cannula. general: this is a chronically ill appearing woman smiling. head, ears, eyes, nose and throat: pupils equal and reactive to light. extraocular movements intact. oropharynx is clear. mucous membranes appear dry. neck: there is no lymphadenopathy. jugular venous pressure elevated to about 9 cm. respiratory: difficult to fully assess secondary to deconditioning, however there are crackles about of the way up. cardiovascular: regular rate, 4/6 systolic ejection murmur best heard at the left upper sternal border. there is a also a holosystolic murmur best heard at the right upper sternal border. abdomen: soft, nontender, nondistended with hyperactive bowel sounds, no mass and no liver edge. extremities: lower extremities are puffy without pitting edema and 2+ pulses. neurologic: mental status alert and oriented to place, but not to time. comprehension appears intact. language is fluent. the patient is somewhat somnolent. cranial nerves are intact. motor and sensory difficult to test secondary to patient's noncompliance. there were no focal abnormalities. laboratories on transfer: white count 13.1, hematocrit 26.6, platelets 235. sodium 136, potassium 4.4, chloride 102, bicarbonate 27, bun 24, creatinine 0.5, glucose 128, pt 12.9 with inr of 1.2, ptt 50.2. alt 18, ast 31, alkaline phosphatase 73. total bilirubin 0.6, amylase 126, lipase 361, calcium 7.8, phosphorus 3.5, magnesium 1.4. her last arterial blood gas and fio2 of 50% showed ph 7.45, pco2 45, po2 109. brief hospital course upon transfer: 1. cardiovascular: the patient was deemed to be slightly volume overloaded. when she experienced the hypertensive episode in the medical intensive care unit, she received over 11 liters of fluid to maintain hemodynamic instability. as a consequence, she has been volume overloaded ever since then, but has been able to ............ diurese without requiring administration of lasix. we therefore continued this and patient was about 500 to 700 cc negative every day. her blood pressure remained in the range of systolic 110 to 130 and diastolic 60 to 70. we therefore did not restore her outpatient atacand. we continued her on lipitor and digoxin. her rhythm remained to be chronic atrial fibrillation. in this context, we also started coumadin. she was originally receiving 5 mg of coumadin, but after three days of that there was no significant improvement in her inr. we therefore increased the dose of coumadin to 7.5. she will require close follow up of her inr until it reached a therapeutic level between 2.5 and 3.5. 2. gastrointestinal: the patient's pancreatitis was considered clinically resolved by the time she was admitted to our service. she had no complaints of abdominal pain, nausea, vomiting or any other signs to indicate a recurrence of infection. she had received several days of tpn in the intensive care unit as well as a day of tube feeds. she was receiving the tube feeds through a catheter placed in her jejunum. for the first two hospital days on the floor, she continued to receive tube feeds through the jejunal tube. tpn, however was discontinued. on hospital day #3 on the regular medical floor, she was started on clear fluids after consultation with the gastroenterology service. she tolerated this very well with no episodes of nausea or vomiting. she was therefore advanced to full liquids and this subsequently was advanced to a diet as tolerated. the patient is very well on solid foods without complaints of nausea, vomiting, abdominal pain or diarrhea. in addition to this, she had a speech and swallow study which revealed intact swallowing apparatus. the study was performed given lengthy medical intensive care unit stay and possibility of damage to the swallowing apparatus following 12 days of intubation. 3. pulmonary: ards had resolved during her medical intensive care unit stay. the patient had a very low oxygen requirement and subsequently was saturating 97% to 98% on room air. her respiratory exam continued to have occasional crackles bilaterally at the bases which was attributed to a resolution of her ards. 4. anemia: the patient has been mildly anemic, however clear etiology for this anemia was not reached. her hematocrit slowly increased from about 25 to 30 without any transfusions. stool guaiac was checked and was negative. 5. neurology: the patient's mental status has been of concern following her extubation. she remains very somnolent most of the time, not oriented to be place. in addition, her speech was very labored, sometimes not intelligible. upon careful neurological examination, there was no focal weakness or any cranial nerve abnormalities that were detected. she received a non contrast ct of the head which showed no intracranial bleed. we therefore felt that her mental status was mostly resolved for prolonged intensive care unit stay and did not require further investigation at this point. it is quite likely that her mental status will slowly improve with time. discharge condition: stable discharge status: discharge to in acute care rehabilitation. discharge diagnoses: 1. pancreatitis 2. ards discharge medications: 1. zoloft 100 mg po qd 2. digoxin 0.125 po qd 3. lipitor 10 mg po qd 4. erythropoietin 10,000 units 3x a week 5. coumadin 7.5 mg po qd 6. tylenol 325 to 650 po q 4 to 6 hours prn 7. lactulose 30 ml po q6h prn 8. dulcolax 10 mg prn q hs 9. heparin intravenous ............ guideline scale , 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 Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Diagnoses: Anemia, unspecified Unspecified essential hypertension Candidiasis of other urogenital sites Atrial fibrillation Heart valve replaced by other means Alkalosis Sinoatrial node dysfunction Acute pancreatitis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fevers, ataxia, altered mental status major surgical or invasive procedure: vp shunt tapped. history of present illness: 40 yo m resident of group home with brain tumor dx at age 15 and resultant hydrocephalus s/p left side vp shunt (last drained one week previous), who presented with gait instability and multiple falls over the last two days. of note the pt had his vp shunt drained one week prior to development of sx. over the last two days, the pt has had unsteady gait (beyond baseline) and became verbally agitated. the pt was placed in restraints for protection and given haldol and ativan. the pt was subsequently brought to the ed where he was noted to have a cough and found to have a fever to 103.7 along with hr of 120s, bp of 82/60 and sao2: 90% ra ->95%2l. he presented to osh where a head ct was found to be without change, ua was negative and cxr was negative for pna. lactate was 1.0. he received 2l ivf as well as ceftriaxone, tylenol, haldol, and ativan and transferred to for further work up. . in the ed, the pt was found to be unresponsive to painful stimuli to intermittently arousable at time of arrival. gcs score was 8. vs was significant for hr: 86, bp: 90/70, rr: 18, 97% ra. the pt was seen by neurosurgery who tapped his shunt (3000/1600cc) and started him on abx including 2g cftx, vancomycin 1gm iv x1, ampicillin 1g q8, acyclovir 800mg iv x1, 5mg haldol, 2mg ativan. fsg: 103. lactate 1.0 . in the ccu, the pt was resting comfortably in nad. he was arousable with verbal/physical stilumi and followed commands (by ) as rn. he was without significant complaint. he just wanted to be left alone so he could sleep. past medical history: 1. cerebellar tumor, s/p resection , ependymoma per dr. note (followed by dr. . exam at baseline shows trunkal ataxia, old 3rd and 4th cranial nerve palsies and left ophthalmoplegia, scanning speech. 2. meningitis, c/b deafness 3. s/p vp shunt for hydrocephalus 4. seizure disorder - no seizures for years, no one is clear on what type/how many seizures he has had, he is on depakote but not on antiepileptic doses. 5. ?depression vs bipolar, psychosis, with multiple psychiatric hospitalizations following tumor resection 6. idiopathic insomnia, sleep walks, had a sleep study at 7. h/o traumatic brain injury--was closed head injury beating on , also with leg fracture at that time social history: pt lives in a group home. as per mother, the pt walks with a wide gait due to ataxia and has baseline line weakness on the right side. the pt also has tremors at baseline and is clumsy. speech wise, the pt is articulate enough to understand however his verbal comprehension is difficult and the pt requires a letter board for comprehension. visually, the pt has poor visual acuity and poor peripheral vision (he has glasses but does not always wear them at baseline). however she has not seem him in two weeks and is therefore difficult to make any assessment as to any acute changes. however the mother was informed, the pt has been sleeping more than usual. from what she knows this is how he presented in when he had to have his shunt revised. tob: admits to smoking cigars/day. etoh: none illicit drugs: none family history: unknown physical exam: vs: tc: 99.5 (100.2 on arrival), bp: 99/60, hr: 76, rr: 18, sao2: 100% on 50% flow; 92% on ra gen: young, well nutritioned, well appearing male in nad. sleeping comfortably. arousable with verbal/physical stimuli. tired and unclear if pt is appropriately responding (woken up from sleep at mn). of note, the pt did have a wet productive cough during exam. heent: pupils unable to be assessed without pt cooperation, anicteric, mmm cv: rrr, s1, s2, no m/r/g chest: cta anteriorly, laterally, pt uncooperative with posterior exam abd: soft, nt, nd, bs+ ext: wwp, no c/c/e neuro: unable to assess without cooperation. pertinent results: studies: head ct at osh: no change shunt series at osh: ok, no disconnection . head ct : stable appearance of a vp shunt without evidence of acute mass effect or hemorrhage. post-operative changes in the cerebellum with suboccipital craniotomy. . skull ap and lat : the visualized portions of the shunt along the left side of the neck, left chest, and entering into the abdomen terminating into the right upper quadrant appears intact. there is only a small portion of the shunt within the mid neck that is not visualized due to technique. . abd/pelvic ct : a large area of consolidation in the right lung base likely representing a pneumonic process or aspiration. no acute pathology visualized in the abdomen or pelvis. . csf : protein:11 glucose:91, wbc:1, rbc: 4, poly: 0, lymph: 10, gs: neg. . micro: urine culture: : no growth . : blood cultures from and have shown no growth on . : csf fluid: no pmns, no organisms, no growth . cbc: 12:40pm blood wbc-11.7*# rbc-4.28* hgb-14.2 hct-40.2 mcv-94 mch-33.3* mchc-35.4* rdw-12.7 plt ct-160 12:40pm blood neuts-65 bands-20* lymphs-6* monos-7 eos-0 baso-0 atyps-2* metas-0 myelos-0 05:28am blood wbc-9.2 rbc-3.90* hgb-12.5* hct-36.0* mcv-93 mch-32.0 mchc-34.6 rdw-12.5 plt ct-141* 05:50am blood wbc-5.9 rbc-3.96* hgb-13.0* hct-36.6* mcv-93 mch-32.8* mchc-35.5* rdw-12.6 plt ct-149* 05:50am blood neuts-76.4* lymphs-17.8* monos-3.9 eos-1.4 baso-0.5 06:05am blood wbc-4.1 rbc-4.09* hgb-13.1* hct-39.2* mcv-96 mch-32.1* mchc-33.4 rdw-12.8 plt ct-156 . coags: 12:40pm blood pt-15.0* ptt-31.0 inr(pt)-1.3* 05:50am blood pt-12.7 ptt-27.0 inr(pt)-1.1 . sma 7: 12:40pm blood glucose-107* urean-22* creat-1.2 na-139 k-4.2 cl-105 hco3-22 angap-16 05:50am blood glucose-89 urean-10 creat-0.9 na-144 k-4.3 cl-110* hco3-27 angap-11 06:05am blood glucose-88 urean-11 creat-0.8 na-145 k-4.5 cl-111* hco3-25 angap-14 05:50am blood calcium-8.5 phos-2.6* mg-1.7 . lfts: 12:40pm blood alt-51* ast-45* alkphos-45 amylase-119* totbili-0.3 12:40pm blood lithium-1.2 valproa-12* 12:40pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr- neg tricycl-neg 12:43pm blood lactate-1.0 brief hospital course: a/p: 40yo m with hx of brain tumor s/p resection with left sided vp shunt (revision in ) who presents with fevers, falls and altered ms. . #. id: given his presentation including fevers, falls and altered mental status, the most significant concern was for an infectious process, possibly meningitis. patient was initially admitted to the micu for close monitoring; however, the next day, patient had stabilized clinically and was sent for management on the floors. . the csf was tapped on admission in the ed and he was empirically started on acyclovir, vancomycin, ceftriaxone and ampicillin. however the csf did not demonstrate any acute infection, the abd ct on the other hand demonstrated a large area of consolidation in the right lung base suggestive of a pna. as the pt lives in a group home, past/current exposures to resistant organisms were not initially clear. although it is not a nh, and he has not had recurrent hospitalizations, given his acute illness, his antibiotic regimen was changed to vancomycin, zosyn and azithromycin. the following day, the director of the group home was contact and it became clear neither he nor his room (house) mates nor those who work with them had any significant contact with health workers making infections with resistant organisms even less likely. his antibiotic regimen was therefore narrowed to ceftriaxone and azithromycin the following day. and since he lost iv access on , the antibiotic regimen was changed to oral levofloxacin. his wbc count trended down from his initial presentation and has has been afebrile while on the floor for >72 hours. . the patient had a speech and swallow evaluation to assess his capability for swallowing his food. it was felt that the patient was an aspiration risk given data from his video swallowing study. hence, it was felt that his pneumonic infiltrate could be an aspiration event. as such we have discharged him to finish 5 more days of levofloxacin and flagyl - course to end on . . a repeat evaluation was completed on - and again patient was felt to be an aspiration risk for thin liquids. the patient was not willing to drink thickened liquids in place of thin. a discussion was caried out with the patient, his health care provider, and father regarding the risks of continued po intake of thin liquids. all of the above agreed that they would be willing to accept the risk of aspiration with thin liquids at this time for his quality of life, but would reassess should any further aspiration events occur. the patient and his family/providers were told and agreed to avoid straw use to decrease the risk of aspiration. . #. vp shunt management: currently without evidence of csf infection. patient was seen by neurosurgery and at this time, there were no urgent shunt issues to address. . #. seizure do: most likely due to his previous brain tumor and resection with subsequently development of hydrocephalus and shunt placement. he was cont. on depakote 250mg . #. depression/psychosis/insomnia: patient was cont. on outpt meds ---lithium 600mg ---klonopin 5mg once daily--> this was the dosage given to the admitting team -> however upon confirmation with health care aides, this was changed to 0.5mg daily. ---melatonin 3mg once daily ---zydis wafer prn for agitation. . on admission, his medicines were at therapeutic levels. . #. pain: neurontin for pain and acetominophen prn for pain/fever . #. ppx: patient was maintained on hep sub q tid for dvt ppx and ppi (pt takes ranitidine as outpt). #. communication: (mother): cell: / other son's home where she will be until wed : medications on admission: allergies: nkda . medications on transfer: from note previously left by dr. . was contact but unable to verify med list at the time. 1. ec asa 81mg once daily 2. lithium 600mg 3. klonipin 5mg once daily 4. depakote liquid 250mg 5. melatonin 3mg once daily 6. ranitidine 150mg 7. neurontin 600mg tid 8. mvi 9. ibuprofen prn discharge medications: 1. ranitidine hcl 15 mg/ml syrup sig: one (1) po bid (2 times a day). disp:*1 100ml* refills:*2* 2. lithium carbonate 150 mg capsule sig: four (4) capsule po bid (2 times a day). disp:*80 capsule(s)* refills:*2* 3. clonazepam 0.5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 5. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 5 days. disp:*5 tablet(s)* refills:*0* 6. flagyl 500 mg tablet sig: one (1) tablet po three times a day for 5 days. disp:*15 tablet(s)* refills:*0* 7. multivitamin capsule sig: one (1) cap po daily (daily). 8. melatonin 3 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 9. gabapentin 300 mg capsule sig: two (2) capsule po tid (3 times a day). disp:*100 capsule(s)* refills:*2* 10. depakene 250 mg/5 ml syrup sig: five (5) ml po twice a day. disp:*1 qs* refills:*2* discharge disposition: extended care discharge diagnosis: aspiration pneumonia discharge condition: ambulating with wide based gait articulating coherent phrases afebrile satting well on room air discharge instructions: please finish the course of antibiotics. . please call your primary care provider or come back to the emergency department if you experience any fevers, shortness of breath or other concerning symptoms. . please follow instructions regarding eating from speech and swallow evaluation completed at . followup instructions: please call your primary care provider for follow up. we would recommend follow up in the next 7-10 days. please do so sooner if your symptoms start to get worse. md Procedure: Ventriculopuncture through previously implanted catheter Diagnoses: Obstructive hydrocephalus Other convulsions Pneumonitis due to inhalation of food or vomitus Presence of cerebrospinal fluid drainage device

history of present illness: a 37-year-old male status post assault with mental status changes and right open tibia/fibula fracture. past medical history: (significant for) 1. resection of brain tumor at age 15 with resultant cognitive deficits. 2. history of seizure disorder. 3. idiopathic insomnia. 4. restless leg syndrome. 5. ataxia. past surgical history: significant for previously mentioned brain tumor resection in . medications on admission: folic acid 1 mg p.o. q.a.m., vitamin b 100 mg p.o. q.a.m., peri-colace p.r.n., lithium carbonate 600 mg p.o. b.i.d., requip 0.75 mg p.o. t.i.d., .................... syrup 15 cc b.i.d., trazodone 100 mg p.o. q.h.s., neurontin 300 mg p.o. q.a.m. and 600 mg p.o. q.h.s., mirapex 0.25 mg p.o. b.i.d. allergies: the patient has no known drug allergies. physical examination on admission: gcs 3; the patient was initially responsive at the scene and then gcs dropped to 5 in front of the paramedic team. vital signs in the trauma bay were blood pressure of 110/palp, pulse of 110, 96% to 99% on 100% face mask, and temperature of 99.8. head and neck examination was significant for pupils which were pinpoint bilaterally, tympanic membranes were clear bilaterally. neck was supple with midline trachea. the chest was clear to auscultation bilaterally without crepitus. cardiac examination revealed a regular. abdomen was soft, nontender, and nondistended. the pelvis was stable. rectal examination was normal tone and guaiac-positive. extremity examination showed an obvious open right tibia/fibula fracture and palpable distal pulses. back examination did not show any stepoff. laboratory on admission: his trauma series was negative. the patient's toxicology screen was positive for an ethanol level of 188. radiology/imaging: ct of the head was negative for acute injury. ct of the abdomen and pelvis was also negative. hospital course: the patient was intubated for airway control due to agitation and mental status changes. he was seen by the orthopaedic surgery service who took him to the operating room on hospital day one for open reduction, internal fixation and debridement of his right open tibia/fibula fracture. the patient went the surgical intensive care unit postoperatively and remained intubated until postoperative day two. he was extubated without difficulty and remained hemodynamically stable. he was placed on lovenox for deep venous thrombosis prophylaxis postoperatively. the patient went to the floor on postoperative day three. his mental status was improved; although, per reports, did not quite return to baseline. on the floor hie had one episode of agitation where psychiatry was called to evaluate. the patient was put in restraints and given a one-to-one sitter. he was also started on p.r.n. haldol. the patient did very well after this. sitter was discontinued in one day. psychiatry continued to follow and were concerned about his mental status not returning completely to baseline. they recommended a repeat head imaging, which was obtained and showed no change from his admission head ct. it was felt that it was reasonable for this patient with a history of cognitive deficits from tumor resection with blunt head trauma (although, head ct was negative for serious injury) to take a while to return to mental status. it was felt that he was okay to be discharged to a cognitive or neurologic rehabilitation facility. the patient remained afebrile on the floor. he was on kefzol perioperatively, because the orthopaedic team felt he had some erythema around his right lower extremity incision and wanted him to remain on p.o. keflex for a short course. medications on discharge: 1. trazodone 100 mg p.o. q.h.s. 2. neurontin 300 mg p.o. q.a.m. and 600 mg p.o. q.h.s. 3. .................... syrup 15 cc p.o. b.i.d. 4. zantac 150 mg p.o. b.i.d. 5. multivitamin 1 tablet p.o. q.d. 6. requip 0.75 mg p.o. t.i.d. 7. lovenox 30 mg subcutaneous b.i.d. times six weeks. 8. lithium 600 mg p.o. b.i.d. 9. haldol 1 mg p.o. q.4h. p.r.n. for agitation. 10. keflex 500 mg p.o. q.i.d. times four days. 11. boost 1 can p.o. t.i.d. 12. percocet one to two tablets p.o. q.4-6h. p.r.n. 13. colace 100 mg p.o. b.i.d. 14. dulcolax p.r.n. condition at discharge: he was discharged in stable condition. discharge diagnoses: 1. right open tibia/fibula fracture, status post assault. 2. status post open reduction, internal fixation. discharge instructions: the patient was given instructions to follow up with the clinic in approximately two weeks. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Debridement of open fracture site, tibia and fibula Open reduction of fracture with internal fixation, tibia and fibula Diagnoses: Toxic encephalopathy Other extrapyramidal diseases and abnormal movement disorders Assault by unspecified means Insomnia, unspecified Toxic effect of unspecified alcohol Open fracture of shaft of fibula with tibia Poisoning by other and unspecified solid and liquid substances, undetermined whether accidentally or purposely inflicted Lack of coordination Personal history of malignant neoplasm of brain

allergies: nkda neuro: awake and alert on admission, now sedated on fent and versed cv: sbp now 110-120s, hr 80s-90s. team talked to cardiology ie how far to reverse his inr. resp: intubated, will remain so at least overnight for rescoping in the am. a/c 600x14, 100%, 5 peep. 02 sats 100%. gi: scoped as above, will be rescoped tomorrow. follow hct, inr, ca++. gu: foley to be incerted, he did urinate 400cc light colored urine. soc: his mother and sister called. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other endoscopy of small intestine Other endoscopy of small intestine Insertion of endotracheal tube Endoscopic control of gastric or duodenal bleeding Other endovascular procedures on other vessels Arteriography of other specified sites Transfusion of packed cells Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Heart valve replaced by other means Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Hemorrhage of gastrointestinal tract, unspecified Gastroesophageal laceration-hemorrhage syndrome Cellulitis and abscess of hand, except fingers and thumb

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: melena major surgical or invasive procedure: ir embolization (coil) of left gastric artery egd x 3 history of present illness: 53 yo m with h/o st. on transferred from where he presented with melena mixed with brbpr since 2 am morning of . patient reports not feeling well for 2 days prior to presentation - decreased po intake and emesis x 1 (non-bloody non-bilious). then he was awoken at 2 am morning of admission with melenous bm. had about 7 bms before arrival at icu. patient reported feeling lightheaded and diaphoretic. his inr one week prior to presentation was in the therapeutic 2.5-3.5 range. he also complained of lower abdominal cramping discomfort that he developed the night prior to admission, non-radiating. denied nsaids use. on presentation to the osh bp 80/palp, pulse of 68. inr was 4.89, hct 28.4. he was transfused 2 unit p rbcs, given 2 units ffp, vit k 10 mg sc, protonix 40 mg iv once, and transferred here. inr here 2.5. hct 23.4. . on the review of systems, he denies chest pain, nausea, vomiting, fevers, chills, abdominal pain, urinary urgency, frequency or dysuria. he complains of mild lower back pain. past medical history: 1. endocarditis, s/p st. av placement in 2. htn 3. hyperlipidemia 4. panic attacks/anxiety 5. s/p vasectomy 6. wisdom teeth removal 7. had a colonoscopy/egd in ri in "normal" per patient. social history: divorced. lives with parents. currently unemployed and applying for ssi/disability. previously worked as a chef. has three daughters ages 27, 19 and 18. mother is next of . tobacco: none for many years. alcohol: occasional etoh. ivdu denies. family history: father had a bleeding ulcer. no family history of colon cancer. physical exam: admission exam vs: 98.3; 86/59; 65; 16; 100 % on ra general: alert and oriented x 3; anxious appearing; lying in bed heent: nc, at, no scleral ictrus, perrl, conjunctiva slightly pale, mmm neck: supple, no lad cv: regular, mechanical s2, no m/r/g pulm: cta bilaterally abd: + bs, soft, nt, nd extr: no c/c/e pertinent results: 12:15pm pt-24.6* ptt-30.5 inr(pt)-2.5* 12:15pm plt count-230 12:15pm neuts-72.7* lymphs-21.0 monos-4.2 eos-1.3 basos-0.8 12:15pm wbc-7.0 rbc-2.72* hgb-8.2* hct-23.4* mcv-86 mch-30.3 mchc-35.2* rdw-14.3 12:15pm glucose-117* urea n-38* creat-0.6 sodium-143 potassium-4.3 chloride-115* total co2-21* anion gap-11 05:42pm alt(sgpt)-11 ast(sgot)-13 ld(ldh)-169 alk phos-31* tot bili-0.5 04:37pm albumin-2.4* calcium-6.5* 05:48pm lactate-0.5 09:01pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 09:01pm urine color-yellow appear-clear sp -1.020 egd : findings: esophagus: other there was a moderate sized hiatal hernia present about 38 centimers from the incisors. at the base of the hernia sac there was a 6 mm pigmented protuberence that resembled - tear. the area was injected with 7 cc's total of a 1:10,000 epi solution. the injections were performed in a four quadrant distribution. there was very good hemostasis and no evidence of further bleeding. 7 1 cc.epinephrine 1/ injections were applied for hemostasis with success. stomach: contents: there was a large fundic clot present. repeated attempts to aspirate the clot were unsuccessful. a orogastric lavage using and tube was then performed and small amounts of clot were removed. despite these manuevers the entire clot could not be fully cleared. erythromycin 250 mg iv was given in an attempt to facilitate gastric removal of the clot. we also switched to the endoscope with the largest suction channel that we had available to facilitate clot removal. duodenum: other there was no evidence of active bleeding in the duodenum. there was no evidence of any mucosal abnormalities to suggest a bleeding source in the duodenum. impression: there was a moderate sized hiatal hernia present about 38 centimers from the incisors. at the base of the hernia sac there was a 6 mm pigmented protuberence that resembled a - tear. the area was injected with 7 cc's total of a 1:10,000 epi solution. the injections were performed in a four quadrant distribution. there was very good hemostasis and no evidence of further bleeding. (injection) blood in the fundus there was no evidence of active bleeding in the duodenum. there was no evidence of any mucosal abnormalities to suggest a bleeding source in the duodenum. egd : findings: esophagus: normal esophagus. stomach: other large blood clot encompassing entire fundus. we were able to suction approximately 500 cc of clot material and liquid blood. duodenum: normal duodenum. impression: large blood clot encompassing entire fundus. we were able to suction approximately 500 cc of clot material and liquid blood. egd : findings: esophagus: normal esophagus. stomach: excavated lesions two superficial ulcers ranging in size from 2 mm to 4 mm were found in the stomach body. erythematous mucosa with patchy bluish areas and small erosions was noted along the posterior wall of gastric body along the lesser curvature. no active bleeding was noted. duodenum: normal duodenum. impression: superficial ulcers and surrounding gastritis in the posterior wall of gastric body along the lesser curvature. recommendations: sulcrafate suspension one gram four times daily continue ppi twice daily repeat upper endoscopy in 8 weeks. blood cx : no growth urine cx , : no growth h pylori ab: negative cxr : indication: fever. there has been interval extubation. the heart is upper limits of normal in size. there has been near complete resolution of left basilar atelectasis and interval decrease in size of a small left pleural effusion. there are no new areas of consolidation to suggest pneumonia. brief hospital course: 53 yo m with h/o st. aortic valve, on coumadin, who presents with melena, borderline hypotensive. . 1. ugi bleed - patient was admitted to the icu and seen immediately upon arrival to the icu by gi. gi began to perform an egd to investigate cause of bleeding. passing of the scope was difficult due to patient continually vomiting blood. they sucked out about 500cc of blood and clot. gi was able to visualize a hyperpigmented lesion next to an existing hiatal hernia that resembled tear. there was a very large clot in the fundus as well and they chose not to dislodge it. he was given a dose of erythromycin to later remove the clot. there was a concern that there was bleeding underneath the clot. he was transfused a total of 4 prbc's in the icu at and 2 units of ffp. upon repeat scope the next day () the clot in the fundus was still present and enlarged. since his hct was stable but not responding to the transfusion of prbc's appropriately, it was decided to involve ir for possible embolization of the left gastric artery. on , the patient underwent angiography via ir and the left gastric artery was coiled. no active bleeding was seen at this time. afterwards, the patient was stable and returned to the icu. he was tx'ed out of the icu on . within hours of arrival to the floor, he developed melena. the gi team took him back for an egd which revealed the following: findings: esophagus: normal esophagus. stomach: excavated lesions two superficial ulcers ranging in size from 2 mm to 4 mm were found in the stomach body. erythematous mucosa with patchy bluish areas and small erosions was noted along the posterior wall of gastric body along the lesser curvature. no active bleeding was noted. duodenum: normal duodenum. impression: superficial ulcers and surrounding gastritis in the posterior wall of gastric body along the lesser curvature. recommendations: sulcrafate suspension one gram four times daily continue ppi twice daily repeat upper endoscopy in 8 weeks. his hct remained stable and he had no further issues with bleeding during his hosp stay. 2. fever: on , the patient spiked a temperature of 101 and blood cultures, sputum culture, and urine culture were drawn along with a stat cxr. he was found to have a swollen right hand at the site of a previous peripheral iv lock. he was initially given iv vanco and then was subsequently changed to iv cefazolin when blood cultures remained negative. he completed a course of po dicloxacillin and his cellulitis completely resolved. he had no further fevers. all culture data was negative. . 3. st. jude's valve: patient's anticoagulation was reversed in the setting of his life-threatening bleed. once his hematocrit stabilized, anticoagulation was restarted. he was maintained on a heparin gtt and coumadin was started. his hematocrit remained stable. once his inr reached 2.3, decision was made to discharge the patient on lovenox for the remainder of his bridge. he is to have his inr drawn the day after discharge to continue coumadin dose adjustment. . 4. anxiety: patient has a history of anxiety with panic attacks. he has taken klonopin prn for this in the past and required a few doses while in house for mild anxiety. . 5. hypertension: patient's blood pressure was well controlled on atenolol 25 mg po qd. he was not sure what dose of beta blocker he normally takes at home. . 6. hypercholesterolemia: patient was continued on his home dose of atorvastatin. medications on admission: lipitor 20 mg po qd celexa (off lately) baby asa coumadin 5/7.5 mg alternating daily vicodin prn atenolol ? dose lasix ? dose clonazepam ? dose discharge medications: 1. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 2. enoxaparin 80 mg/0.8 ml syringe sig: one (1) injection subcutaneous (2 times a day): until inr greater than or equal to 2.5. disp:*10 injection* refills:*0* 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 4. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. warfarin 5 mg tablet sig: two (2) tablet po hs (at bedtime) as needed for mechanical : please discuss with dr. to determine your dose for tuesday night. disp:*10 tablet(s)* refills:*0* 6. sucralfate 1 g tablet sig: one (1) tablet po qid (4 times a day): take this 1 hour apart from any of your other medications and 1 hour before meals. disp:*120 tablet(s)* refills:*2* 7. clonazepam 0.5 mg tablet sig: one (1) tablet po bid:prn. discharge disposition: home discharge diagnosis: upper gi bleed st. jude's valve hand cellulitis discharge condition: good, no further bleeding, hematocrit stable, tolerating regular diet discharge instructions: please call your doctor or go to the emergency room if you experience temperature > 101, abdominal pain, blood in your stool, chest pain, shortness of breath, dizziness, or other concerning symptoms. please take the lovenox injections until your inr is greater than or equal to 2.5. you are to follow closely with your doctor of your inr until then. please take 10 mg of coumadin tonight. you will have your inr checked tomorrow and should discuss with dr. how much coumadin to take on tuesday night. please stop taking your aspirin. please take all medications as prescribed. followup instructions: please have your blood drawn at dr. office tomorrow to check your inr. please follow-up with dr. on at 11:20 am. phone . please call to confirm your follow-up egd scheduled for at 11:00 am with dr. . phone: . Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other endoscopy of small intestine Other endoscopy of small intestine Insertion of endotracheal tube Endoscopic control of gastric or duodenal bleeding Other endovascular procedures on other vessels Arteriography of other specified sites Transfusion of packed cells Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Heart valve replaced by other means Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Hemorrhage of gastrointestinal tract, unspecified Gastroesophageal laceration-hemorrhage syndrome Cellulitis and abscess of hand, except fingers and thumb

history of present illness: baby is a 2.8 kilogram product of a 36 week gestation, born to a 30-year-old gravida 4, para 3 to now 4. pregnancy was complicated by a discovery of a maternal intrahepatic mass. the maternal prenatal screens were complete and unremarkable, for a gbs status that was unknown. there were no sepsis risk factors. to allow for further evaluation of mother's intrahepatic mass and after fetal lung maturity test suggested lung maturation, the mother underwent pitocin induction. the infant was born by vaginal delivery. there was a nuchal cord noted at delivery but the patient did extremely well with apgars of . he was sent to the newborn nursery where he was noted to have persistent tachypnea. the patient was then admitted to the neonatal intensive care unit for evaluation. physical examination: on admission, the patient was well perfused and well saturated in room air, was in general mild respiratory distress, manifested predominantly by tachypnea and mild subcostal retractions. there was notable facial bruising with bruising under both eyes and scleral hemorrhages. the anterior fontanel was soft and flat, the palate was intact. the skin was without lesions. the clavicles were intact. the chest was clear to auscultation bilaterally. cardiovascular, there was a regular rate and rhythm without murmur noted, pulses were 2+ and symmetrical. the abdomen was soft, nontender, with no masses noted. the gu exam was significant for a normal male anatomy with the testes descended bilaterally. the hips were stable. neurologic exam was non focal and appropriate for age. hospital course: 1. respiratory: the patient was admitted on day of life #1 and went from room air to a c-pap of 6 and over the course of the next 24 hours developed increased work of breathing with tachypnea to the 80's to 100's and increase in fio2. on day of life #2 the patient was intubated and was given one dose of surfactant. the patient remained intubated less than one day and was successfully extubated to a nasal cannula o2 for which on day of life #3 he was requiring approximately 200 cc of flow. the nasal cannula was weaned gradually over the next two days and by day of life #5 the patient was in room air. the patient remained tachypneic with intermittent drifts in saturations predominantly with feeds over the course of the next day and a half. however, between day of life #7 and day of life #8 there was no significant drifts in saturations, the patient remained stable with saturations greater than 94% in room air and had no drifts or spells noted for greater than 24 hours on the day of discharge. a chest x-ray that was done when the patient was intubated was consistent with mild surfactant deficiency and patient responded very well to the dose of surfactant. 2. cardiovascular: the patient had a murmur noted approximately on day of life #1, it was a very soft flow murmur and remained intermittent for the first couple days of life at which time it disappeared by day of life #4 and was not heard from day of life #4 to the day of discharge. 3. fluids, electrolytes & nutrition: the patient was npo initially on the first day of life and remained on iv fluids for a total of two days at which point when the patient came off nasal cannula was advanced on feedings from day of life #2 to day of life #3. by day of life #3 he was on full feeds ad lib with a minimum of 60 cc/kg/day and by day of life #5 was taking well over 100 cc/kg/day without any distress. 4. gi: patient was noted to have mild jaundice. the highest bilirubin was noted to be 5.1 on and the patient was followed clinically and never required phototherapy. 5. hematologic: the patient had a cbc drawn on the first day of life and as part of a sepsis rule out had a white count of 15 with a hematocrit of 44.3, a platelet count of 328,000, differential showed 74 polys, 0 bands and 22 lymphs. 6. id: cbc was benign. blood culture was no growth after 48 hours. the patient was started initially on ampicillin and gentamycin but was taken off antibiotics at 48 hours. 7. neurologic: the patient had a normal neurologic exam and no ultrasound was deemed necessary. 8. sensory: the patient did have audiology screening. a hearing screen was performed with an automated auditory brain stem response and the patient passed. condition on discharge: good. discharge disposition: to home. primary pediatrician: , m.d., phone # and fax #. the office was contact and i personally spoke with , one of the nurses, and updated him about baby hospital course and notified him that we would be faxing this discharge summary as soon as it became available. care & recommendations: 1. feeds: feeds at discharge were enfamil 20 with iron, ad lib and patient was taking greater than 140 cc/kg/day ad lib at the time of discharge. 2. medications: none. 3. state newborn screening status: initial screen was normal. 4. immunizations received: patient did receive hepatitis b prior to discharge. 5. immunizations recommended: a) synagis rsv prophylaxis should be considered from through for those infants who meet any of the following three criteria: 1) born at less than 32 weeks; 2) born between 32 and 35 weeks with plans for daycare during rsv season, with a smoker in the household, or with preschool siblings; or 3) with chronic lung disease. b) immunizations recommended, influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach 6 months of age. before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. follow-up: the family has already called and set up an appointment to see dr. next week on monday, . discharge diagnosis: 1. appropriate for gestational age preterm male newborn. 2. sepsis, ruled out. 3. respiratory distress syndrome, resolved. 4. physiologic hyperbilirubinemia. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances 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, 2,500 grams and over Other specified maternal conditions affecting fetus or newborn

history of present illness: ms. is a 19 year-old female brought in by ambulance after having been found unresponsive by her boyfriend at home. she had a history of alcohol abuse with hospitalizations as far back as at for alcohol intoxication requiring intubation and a four day micu stay. per her father the patient went to her first alcoholics anonymous meeting on and per her boyfriend the patient binges on alcohol two to three times a week. the boyfriend met the patient at approximately 2:45 in the afternoon and the patient had become very intoxicated. neither family member or the boyfriend were aware of when she initially became intoxicated. she complained of feeling groggy, vomited once and then told her boyfriend she wanted to lie down. she became unresponsive and was unarousable. ems was called and she was brought to the emergency room. at that time she was intubated for airway protection, charcoal was given by mouth. serum alcohol was sent and it was 518 and she was admitted to the intensive care unit. past medical history: depression, anxiety, mild asthma with one hospitalization for asthma as a child. medications: 60 mg once daily, paxil 20 mg once daily, ritalin 80 mg once daily, neurontin 200 mg twice a day. allergies: penicillin causing hives. keflex causes nausea. zithromax causes hives. social history: she is a student at community college. she has been using alcohol there for several years. she states marijuana use. physical examination: her vital signs were 114/61, pulse 106, sating 99% on room air in the emergency room. heent pupils were 4 mm bilaterally, slightly short reactive. no scleral icterus. lungs were clear to auscultation bilaterally. cardiovascular regular rate and rhythm. no murmurs, rubs or gallops. abdomen soft, nontender, nondistended with no response to deep palpation. her extremities were cool, but there were palpable pulses peripherally. neurologically, she responded only to painful stimuli. she did not open eyes to command. she did not exhibit corneal reflex, no gag reflex. she moved all extremities spontaneously, but infrequently. laboratory: sodium 144, potassium 3.6, chloride 108, bicarb 23, bun 12, creatinine 0.4, glucose 103, anion gap 13, white count 14.3, hemoglobin 14.4, hematocrit 43.0, platelet count 279, alcohol level 518, serum tox screen was otherwise negative. urine tox screen was otherwise negative. urinalysis showed no epithelial cells. no evidence of urinary tract infection. a urine pregnancy test was negative. acetone was negative. serum osmolality was 419. hospital course: 1. the patient was admitted to the micu for ventilation and airway protection. her course overnight was unremarkable having received hydration, thiamine, folate and multi vitamins. she remained intubated and sedated until mid morning at which point in time she awoke and removed her endotracheal tube. the next morning she was transferred to the medical floor and received prophylaxis for alcohol withdraw using a ciwa scale with ativan. 2. psychiatry: addictions consult as well as psychiatric consult were obtained to rule out suicidality. she was found to be not suicidal. addictions consult was continued and efforts were made at placement at facilities to treat both her depression and her underlying alcoholism. she is presently medically cleared for discharge and is awaiting a bed. 3. fluids, electrolytes and nutrition: adequate fluids were provided throughout the hospitalization. she was able to eat and tolerate po intake. medications on discharge: thiamine 50 mg po q day, folate 1 mg po q day, multi vitamin 1 mg po q day, ibuprofen 600 mg po t.i.d. prn pain and trazodone 50 mg po q.h.s. prn, 60 mg po b.i.d. prn, albuterol meter dose inhaler two puffs q 4 hours prn. discharge diagnoses: 1. depression. 2. alcohol dependence. 3. history of asthma. 4. anxiety. condition on discharge: stable. dr., 11-889 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Asthma, unspecified type, unspecified Dysthymic disorder Other and unspecified alcohol dependence, continuous

history of present illness: this is a 37-year-old male with cardiac risk factors of mild hypercholesterolemia who had his first myocardial infarction on of this year of the left anterior descending artery (proximally). the patient had been doing well after discharge. he had been discharged on plavix, aspirin, and coumadin. on the day of admission, he had been exercising on his bike for 20 minutes when 20 minutes after exercise he experienced chest pressure, some shortness of breath, and diaphoresis. he immediately recognized the symptoms and went by ambulance to where electrocardiogram showed an anterior st elevation myocardial infarction with elevation in v1 through v6. the patient received nitroglycerin, morphine, aspirin, and heparin and was transferred within one hour to for cardiac catheterization. catheterization showed a total occlusion of the left anterior descending artery at the area of the stent placement. a balloon angioplasty was performed at the site without complications, and the patient was sent to the coronary care unit. past medical history: (the patient's past medical history was significant for) 1. mild hypercholesterolemia; treated with zocor. 2. the patient also had an echocardiogram on which showed moderate regional left ventricular systolic dysfunction with an ejection fraction of 30% and anteroseptal, anterior, and apical kinesis. medications on admission: the patient's home medications were enalapril 10 mg p.o. once per day, lopressor 25 mg p.o. twice per day, zocor 20 mg p.o. once per day, coumadin 5 mg p.o. once per day, aspirin 81 mg p.o. once per day, folic acid 3 mg p.o. once per day, and plavix. allergies: there were no known drug allergies. social history: social history was significant for no tobacco use. no intravenous drug use. occasional alcohol. the patient had been following a regular exercise course. he is a business manager at . family history: family history was significant for no early cardiovascular disease. two brother are healthy. one sister with diabetes mellitus. physical examination on presentation: physical examination revealed vital signs with temperature of 98.3, heart rate was 81, blood pressure was 105/71, respiratory rate was 20. in general, the patient was awake and alert, in no acute distress. head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. extraocular muscles were intact. no increased jugular venous pressure. cardiovascular examination revealed a regular rate and rhythm with no murmurs and a fourth heart sound. the abdomen was soft and benign. lungs were clear to auscultation anteriorly. extremities revealed the patient had a femoral sheath in the right groin with no hematoma and 2+ palpable dorsalis pedis pulses. pertinent laboratory data on presentation: laboratories showed white blood cell count was 15,000, hematocrit was 35.9, platelets were 207. inr was 3.3, ptt was greater than 150. creatine kinase was 137, and potassium was measured at 3.5. arterial blood gas showed ph of 7.25, pco2 was 45, and po2 was 180, with a bicarbonate of 21. the latest total cholesterol tests from showed a total cholesterol of 174, and high-density lipoprotein was 42, low-density lipoprotein was 108, triglycerides were 119. radiology/imaging: electrocardiogram measured at showed sinus rhythm with a rate of 81, 3-mm st elevations in i, avl, and v2 through v6; 2-mm st depressions in ii, iii, and avf. electrocardiogram taken after cardiac catheterization at showed sinus rhythm at a rate of 89, p-r prolongation, decreased st elevations in v2 through v6, and resolved abnormalities in ii, iii, and avf. a chest x-ray showed no pulmonary edema. hospital course: the patient did well. the patient was started on plavix, integrilin, zocor, aspirin, beta blocker, and ace inhibitors. serial creatine phosphokinases and troponin i were done with a peak creatine phosphokinase of 1112 and a peak troponin of greater than 50. the patient was taken back for catheterization and evaluation for brachy therapy. the catheterization revealed no significant hyperplasia within the stent; and therefore brachy therapy was not performed. a repeat echocardiogram on showed an ejection fraction of 30%, hypokinesis of the anterior free wall and septum, and dyskinesis of the apex. a left ventricular mass or thrombus could not be excluded. due to this patient's unusual situation of in-stent thrombosis while on coumadin, aspirin, and plavix, hypercoagulability studies were pursued. a lupus anticoagulant test was performed and was found to be negative. the right femoral catheter was removed on . this procedure was significant for the fact that 70 minutes of pressure had to be held at the site before bleeding stopped. in addition, the patient had a vagal episode with a heart rate down to the 50s and systolic blood pressure down to the 80s. he was given 0.5 mg of atropine and a 500-cc bolus of normal saline with improvement. on , the patient was exercising increasing pain in the right groin area where the catheter had been removed. the patient was given pain medications, and a cat scan showed a hematoma without retroperitoneal bleed, and the patient was instructed to limit his movement to and from the bathroom. medications on discharge: 1. metoprolol 25 mg p.o. b.i.d. 2. zestril 10 mg p.o. q.d. 3. aspirin 325 mg p.o. q.d. 4. plavix 75 mg p.o. q.d. 5. zocor 20 mg p.o. q.d. 6. folic acid 3 mg p.o. q.d. 7. coumadin 5 mg p.o. q.d. condition at discharge: the patient's condition on discharge was good. discharge followup: the patient was instructed to follow up with his cardiologist. discharge diagnoses: in-stent re-thrombosis with resulting st elevation anterior wall myocardial infarction. , m.d. dictated by: medquist36 Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Diagnostic ultrasound of heart Diagnoses: Coronary atherosclerosis of native coronary artery Acute myocardial infarction of other anterior wall, initial episode of care Hypopotassemia Other complications due to other cardiac device, implant, and graft

history of present illness: the patient is a 37-year-old man with mild hypercholesterolemia, currently being treated only with exercise who presented to on complaining of crushing substernal chest pain that radiated to the left arm. the patient had been running that day and after one quarter mile of his normal six mile run, he was forced to stop, as the symptoms developed. specifically, he had chest pain and felt a little lightheaded. he denies nausea, vomiting, diaphoresis at that time or dizziness at that time. he was then able to flag down another runner who was able to contact the emergency medical services and have him brought to the hospital. at , an electrocardiogram was obtained and the findings were as follows: st segment elevations in the lateral limb leads, one in avl and lateral anterior leads v2 through v5. he received oxygen, intravenous nitroglycerin, beta blocker, lopressor 5 mg x1, lipitor and a heparin drip. he was then transferred to the for emergency cardiac catheterization. the patient reports having had a similar episode of chest tightness that had resolved after running five days before presentation. he had been in his normal state of health before then. at cardiac catheterization, a total occlusion of the proximal left anterior descending artery was found. the patient underwent percutaneous transluminal coronary angioplasty and a stent was placed. an intra-aortic balloon pump was also placed because the patient's wedge pressure was 26 mmhg and he then he was transferred to the coronary care unit. physical examination on presentation: vital signs: temperature 98.0??????, heart rate 75, blood pressure 113/83, respiratory rate 18, oxygen saturation 98% on 3 liters nasal cannula. general: he is a thin, well developed, well nourished hispanic man lying comfortably in bed. head, ears, eyes, nose and throat: pupils were equal, round and reactive to light and accommodation. extraocular movements were intact. he had anicteric sclerae and a clear oropharynx. heart: regular rate and rhythm, normal s1, normal s2, no murmurs, rubs or gallops. neck: supple, full range of motion, no cervical adenopathy, no thyromegaly, no jugular venous distention. lung: the patient had good effort, normal excursion, clear to auscultation bilaterally. abdomen: normoactive bowel sounds. the abdomen was soft, nontender, nondistended. there were no masses appreciated. extremities: there was no clubbing. there was no cyanosis. there was no edema. left groin intra-aortic balloon pump catheter was in place. he had right venous and arterial sheaths in place. laboratory examination on presentation: white blood cell count 15.5, hematocrit 36.2, platelet count 214, inr 2.0. electrolytes: sodium 143, potassium 4.1, chloride 111, bicarbonate 19, blood, urea and nitrogen 16, creatinine 0.9, glucose 121. cardiac enzymes as follows: on , the creatine phosphokinase was 5177. on , it was 7255.on , the creatinine was phosphokinase was 4273. on , it was 1553. the mb isozyme creatine phosphokinase was as follows: on it was 246. on it was 147. on in the evening it was 86. hospital course: the patient was admitted to the coronary care unit where he received aspirin, plavix, integrilin, heparin drip following removal of the sheath, metoprolol and lipitor. in the coronary care unit, the patient remained chest pain free, had good urine output an the intra-aortic balloon pump was removed on . the patient was transferred to c-med on . examination at that time was essentially unchanged, except there was no femoral hematoma bilaterally and the distal pulses were 2+ bilaterally. there was no cyanosis, clubbing or edema. there was no calf tenderness. the patient had a low grade temperature t-max of 100.4?????? after being transferred to the c-med service. he had a urinalysis which was negative. chest x-ray was negative and blood cultures which did not grow anything. the fever subsided by the afternoon of . again, the patient was chest pain free during the entire stay. the patient was evaluated on by the physical therapy service. their findings were that all goals were achieved and that further inpatient therapy was not warranted. discharge condition: good discharge status: home discharge diagnosis: acute myocardial infarction, status post percutaneous transluminal coronary angioplasty with stent placement discharge medications: 1. lisinopril 10 mg in the morning 2. enteric coated aspirin 325 mg daily 3. plavix 75 mg x30 days. there are 26 days remaining. 4. pravastatin 20 mg in the evening 5. folate 1 mg daily 6. colace 100 mg twice daily 7. metoprolol 75 mg every 12 hours 8. warfarin 5 mg in the evening follow up: the patient is to follow up with his guard medical associates primary care physician, . . the patient is to have his inr level checked during that visit. , m.d. dictated by: medquist36 d: 14:29 t: 15:12 job#: Procedure: Insertion of non-drug-eluting coronary artery stent(s) Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Left heart cardiac catheterization Coronary arteriography using a single catheter Implant of pulsation balloon Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Acute myocardial infarction of other anterior wall, initial episode of care

addendum: most recent development included a hematocrit drop to 26, that is from 28 yesterday. the following laboratory studies were ordered: total bilirubin, to rule out possible hemolysis. dr., 12-749 dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Injection or infusion of platelet inhibitor Coronary arteriography using a single catheter Diagnostic ultrasound of heart Other electric countershock of heart Angiocardiography of right heart structures Right heart cardiac catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified pleural effusion Unspecified essential hypertension Acute myocardial infarction of other anterior wall, initial episode of care Atrial fibrillation Rheumatic heart failure (congestive) Multiple involvement of mitral and aortic valves Acute diastolic heart failure

history of present illness: this is a year old caucasian female with a past medical history significant for hypertension and atrial fibrillation. she presented with anterior myocardial infarction to the ccu status post catheterization. the patient states that saturday morning while preparing some breakfast, she began to have substernal pain described as crushing sensation. she states that she has a history of gastroesophageal reflux disease and that she took tums. the pain was not relieved. ems was called and the patient was brought to the emergency department. in the emergency department, the patient was given nitroglycerin, lopressor 5 mg q5 times three. she had diffuse st elevations in leads v2 through v3. at that time, she was admitted to the c-medicine and nothing was done due to the resolution of st changes. on , the patient began to have chest pain once again described as substernal and crushing. ck showed 713, up from 52, the first laboratory value. a catheterization was done and showed mild disease in left main coronary artery and moderate proximal disease in left anterior descending with total occlusion after d2 with faint left to left collaterals. there were elevated right and left heart filling pressures with moderate pulmonary hypertension with a markedly depressed cardiac output. at that time, the patient was given intravenous milrinone for the decreased cardiac output. a stent was deployed in occluded left anterior descending. the patient arrived at the ccu at approximately 3:00 p.m. upon arrival, the patient was found to be alert, with no apparent distress. she did not complain of shortness of breath. she did, however, complain of palpitations. at that time, a chest x-ray was ordered and it showed worsening congestive heart failure marked by cephalization and pleural effusion. past medical history: 1. migraine. 2. uterine cancer. 3. iron deficiency anemia. 4. atrial fibrillation. 5. hypertension. 6. aortic stenosis. 7. gastroesophageal reflux disease. 8. osteoarthritis of the right knee. medications on admission: 1. clonidine 0.2 mg. 2. amiodarone 100 mg once daily. 3. cardizem 300 mg once daily. 4. hydrochlorothiazide 50 mg once daily. 5. ranitidine 75 mg once daily. 6. diovan 80 mg once daily. past surgical history: hysterectomy and lymphectomy. family history: significant for mother with coronary artery disease. social history: the patient lives alone at admiral living facility. no alcohol or tobacco use. review of systems: positive history of migraines. positive hearing loss. no history of nasal congestion. positive dryness of mouth secondary to medications. the patient has a positive history of aortic murmur, positive palpitations, positive leg edema in both extremities, no dyspnea. lungs - no history of shortness of breath, no recent history of bronchitis or pneumonia, no history of chronic obstructive pulmonary disease. abdominal - positive history of constipation, melanotic stools occasionally, no diarrhea, no weight loss, however, recent weight gain of three pounds. genitourinary - no history of frequency, no history of dysuria, no hematuria. positive history of uterine cancer with hysterectomy. extremities - positive history of leg edema. upper extremities showed bruising. hematology - positive history of anemia. no history of hemophilia. neurologically, no decrease in sensation, no history of numbness or tingling sensation in extremities. physical examination: vital signs revealed temperature 97.2, pulse 85, blood pressure 137/74, oxygen saturation 91% on four liters, pulmonary arterial pressure 54/22. head, eyes, ears, nose and throat examination - the pupils are equal, round, and reactive to light and accommodation. extraocular movements are intact. the pharynx is normal, pink. tongue nonmottled. the heart is irregular s1, s2, heart rhythm, grade iii murmur second intercostal space. lungs - positive rales heard anterolaterally. abdominal examination showed no tenderness, nondistended, positive bowel sounds. extremities - right groin site negative hematoma, no bruit was noted. negative tenderness. good posterior tibial and dorsalis pedis pulses in both feet. neurologically, cranial nerves ii through vi, vii through xii are intact. hearing aid present in the right ear. sensory intact. motor throughout. reflexes + throughout upper and lower extremities. laboratory data: white blood cell count 12.4, hemoglobin 9.0, hematocrit 30.1, platelet count 39,900, mcv 76.0. ck 666, ck mb 76, troponin 2.19. this was up from 1.95 with earlier laboratory study. sodium 133, potassium 3.1, chloride 93, bicarbonate 32, blood urea nitrogen 23, creatinine 0.6, glucose 156. liver enzymes were as follows: alt 17, ast 52, alkaline phosphatase 61, total bilirubin 2.0, calcium 9.7, phosphorus 3.0, magnesium 2.2. urinalysis was done and it was negative. chest x-ray showed fluffy infiltrates, right pleural effusion, cardiomegaly. catheterization results were as follows: left main coronary artery showed mild disease. left anterior descending showed moderate proximal disease, total occlusion after d2 with faint left to left collaterals. d2 has 50% stenosis. left circumflex showed moderate diffuse disease. right coronary artery nondominant. right atrial pressure is mean 15, aortic pressure 132/82, pulmonary artery 50/25, right ventricular pressure 50. electrocardiogram showed st elevations in anterior leads, v2 and v3. hospital course: rales on lung examination and pleural infiltrates on chest x-ray. she also showed jugular venous distention of about seven centimeters on the right atrium. we also continued the integrilin that she was started on in the catheterization laboratory and continued aspirin and nitroglycerin drip. metoprolol was discontinued because of decreased cardiac index. the patient was continued on milrinone for decreased cardiac output until 8:00 a.m. she was then started on digoxin because of history of atrial fibrillation and decreased cardiac output. she was given one unit of blood secondary to hemoglobin of 9.0. valsartan was discontinued and the patient was started on captopril 12.5 mg three times a day for post myocardial infarction protocol. the patient received 80 mg potassium secondary to laboratory value of 3.1. she was diuresed once more with 20 mg of lasix. she responded well putting out approximately two liters. she was found to be confused overnight and was started on seroquel. the next morning she was found to be awake, alert and oriented times three. digoxin was discontinued and amiodarone was increased to 200 mg p.o. three times a day for rate control. this was secondary to a heart rate in the one teens. beta blocker was increased to 12.5 mg and captopril was increased to 50 mg p.o. three times a day. on , the patient was found to have a nosebleed after sitting up and using the bathroom. it was believed that this was due to a vasovagal response. the patient responded well to pressure. no other events of bleeding during her stay. oxygen was turned off and heparin was stopped for one hour and then restarted. the patient was given coumadin at 6:00 p.m. secondary to being high risk of thrombus formation, anterior myocardial infarction and also a history of atrial fibrillation. a transthoracic echocardiogram was done and it showed left atrium moderate dilatation. it also showed moderate regional left ventricular systolic dysfunction with focal akinesis. she had an ejection fraction of 30 to 35%. also found was 1% aortic regurgitation and 1+ mitral regurgitation. on , the patient was taken for transesophageal echocardiogram guided cardioversion secondary to conversion of atrial fibrillation into atrial flutter. the patient tolerated conversion well, was given 200 joules and is now in sinus rhythm. the patient was found to be acceptable to go to rehabilitation tomorrow by physical therapy consultation. the patient is to follow-up with dr. , her primary care physician, , at 10:30 a.m. directions are given in page one that will accompany discharge summary. the patient is to follow-up with dr. , her cardiologist, on , seven at 1:30 p.m. discharge diagnosis: acute myocardial infarction. , m.d. dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Injection or infusion of platelet inhibitor Coronary arteriography using a single catheter Diagnostic ultrasound of heart Other electric countershock of heart Angiocardiography of right heart structures Right heart cardiac catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified pleural effusion Unspecified essential hypertension Acute myocardial infarction of other anterior wall, initial episode of care Atrial fibrillation Rheumatic heart failure (congestive) Multiple involvement of mitral and aortic valves Acute diastolic heart failure

history of present illness: the patient is a 39 year old male pedestrian struck after a convenience store robbery by an automobile. he had a gcs of 3 at the scene. he was sent to after noted to have a large subarachnoid hemorrhage at an outside hospital. he was immediately intubated at the scene and received tetanus and kefzol at the outside hospital. past medical history: unknown. past surgical history: unknown. medications at home: unknown. allergies: unknown. social history: unknown. physical examination: temperature on admission was 97.4, heart rate 80, blood pressure 119/65, oxygen saturation 100 percent on his vent. in general, the patient had a gcs of 3. head, eyes, ears, nose and throat - the face is stable. the patient was intubated. he had a repaired laceration on the right temporal parietal region of his head. his pupils were three and two millimeters and sluggishly reactive. trachea was midline. chest was clear to auscultation bilaterally. the heart was regular rate and rhythm. the abdomen showed a right inguinal laceration. his abdomen was soft and nondistended. pelvis was stable. the patient had decreased rectal tone and he was guaiac negative. his back showed abrasions in the sacral and lumbar areas but no deformities. extremities - right leg was bandaged and reportedly had an open fracture. films performed on admission included chest x-ray which showed a right clavicle fracture and a left pneumothorax. pelvic x-ray was negative. head ct showed extensive tentorial subarachnoid hemorrhage with edema. neck ct was negative from the outside hospital. chest ct showed a left pneumothorax, sternal fracture and right clavicular fracture. ct of his face showed a right mandibular, left mandibular condyle and left zygomatic arch as well as left zygomatic temporal junction fracture and also a nasal fracture. ct of the abdomen from the outside hospital was negative. right tibia fibula film was performed and that showed a fracture. hospital course: the patient was immediately admitted to be placed in the intensive care unit. a left chest tube was placed to decompress his pneumothorax. this eventually had to be replaced as the tube was kinked and was not decompressing his pneumothorax. neurosurgery was involved for treatment of his subarachnoid and it was deemed necessary to place an interventricular drain as his head ct indicated that there was high likelihood of herniation otherwise particularly on a repeat head ct the morning after his admission. oromaxillofacial surgery was also involved secondary to his facial injuries but indicated that they would wait until the patient was stabilized before attempting any sort of surgical correction. orthopedics was also consulted with regards to his severe fibular fracture. they also declined correction until such time the patient was stabilized. the thoracic surgery team was also consulted regarding the sternal fracture and question of pneumopericardium which they evaluated and indicated that there was no pneumopericardium and the sternal fracture was stable from a surgical point of view. over the course of the next 24 hours as stated, repeat head ct showed increased intracranial swelling and the interventricular drain was placed for decompression. the patient was also given mannitol to decrease intracranial pressures. he received approximately two doses and due to increased serum osmolarity and hypernatremia, this treatment was no longer available to decrease intracranial pressure. over the course of the next 24 hours, the patient's intracranial pressure continued to rise and a family meeting was convened at which time surgery and in particular craniotomy versus medical management versus making the patient comfort measures only was presented. the family declined surgery indicating that they did not wish that a craniotomy be performed and that they would discuss that night medical management versus making the patient comfort measures only. the following morning the patient's family arrived and decided to allow the patient to be comfort measures only and allow his organs to be donated for transplantation. it is now , and the patient was declared dead by dr. . the patient was taken to the operating room by the transplant surgery staff and organ procurement was performed on a delayed cardiac. discharge diagnoses: subarachnoid hemorrhage, intracerebral edema. right tibia fibular fracture. sternal fracture. right clavicular fracture. right mandible, left mandibular condyle, left zygomatic arch, left zygomatic temporal junction and nasal fractures. left pneumothorax. coma. hypernatremia. hypokalemia. diabetes insipidus. , Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Intravascular imaging of intrathoracic vessels Transfusion of packed cells Diagnoses: Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Hypopotassemia Closed fracture of sternum Unspecified fracture of ankle, open Traumatic pneumothorax without mention of open wound into thorax Hyperosmolality and/or hypernatremia Closed fracture of malar and maxillary bones Closed fracture of mandible, multiple sites Other and unspecified open wound of head without mention of complication Street and highway accidents Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration Injury to other and multiple intra-abdominal organs, with open wound into cavity Closed fracture of clavicle, unspecified part Closed fracture of nasal bones

history of present illness: mr. was a 63 year old man who was found in his bathroom around noon on the day of admission. he was found to be minimally responsive to questions. after he was transferred to the , he progressively got worse in his mental status and could only respond to noxious stimuli. initially, he was brought to a local hospital where a ct confirmed a large bleed inside his brain. cervical spine was cleared and the patient was intubated before being transferred to the . neurologic examination at the time of admission: the patient was unresponsive and could only respond with withdrawal to deep noxious stimuli. he did not respond to any other stimulation. his cranial nerve examination revealed severe papilledema with pupils one to two mms bilaterally. the tone of his musculature was normal in all limbs and no rigidity was noted. his reflexes were spread and crossed in the lower extremity, especially when it was applied to the right patella. no reflexes could be seen on the left. his toes were upgoing on both sides. hospital course: at the time of admission, cat scan of his head showed a large, acute, intracranial hemorrhage with surrounding edema centered in the left basal ganglion. the area of acute hemorrhage measured six by four cms. the edema extended anteriorly to the left frontal lobe. this created a mass effect on the left lateral ventricle and there was a rightward shift of the midline by approximately one cm. no skull fracture was noticed. mr. condition gradually deteriorated and on , the patient's status was changed to comfort measures only. he expired a little later that day. dr., 13-279 dictated by: d: 08:30 t: 03:34 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Tobacco use disorder Unspecified essential hypertension Aortocoronary bypass status Intracerebral hemorrhage Old myocardial infarction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain major surgical or invasive procedure: laprascopic cholecystectomy history of present illness: 76yo m with pmhx of prostate ca(radiation) who presented with 1 wk h/o abdominal pain, fevers and chills. ercp performed earlier shows evidence of dilated cbd with stones. no relation of abdominal pain to eating habits. no anorexia. no change in bowel habits. no chest pain or shortness of breath. past medical history: diabetes prostate ca treated with radiation social history: noncontributory family history: noncontributory physical exam: gen: alert and oriented times three heent: mildly icteric, eomi, op pink cv: rrr rep: ctab abd: soft nt nd obese no sign ext: no clubbing cyanosis or edema neuro: grossly intact pertinent results: 09:15am blood wbc-6.5 rbc-5.36 hgb-16.3 hct-46.6 mcv-87 mch-30.5 mchc-35.0 rdw-14.8 plt ct-283 04:36am blood wbc-10.6 rbc-4.84 hgb-14.6 hct-41.8 mcv-86 mch-30.2 mchc-35.0 rdw-14.1 plt ct-303 09:15am blood plt ct-283 01:10pm blood pt-13.3 ptt-27.6 inr(pt)-1.1 04:36am blood glucose-123* urean-10 creat-0.8 na-138 k-4.5 cl-103 hco3-31* angap-9 09:15am blood urean-12 creat-1.0 na-138 k-5.2* cl-102 hco3-28 angap-13 09:15am blood alt-216* ast-122* alkphos-429* amylase-69 totbili-2.7* dirbili-1.5* indbili-1.2 07:00pm blood alt-137* ast-41* alkphos-264* amylase-49 totbili-1.8* 07:10am blood alt-112* ast-41* ck(cpk)-80 alkphos-198* amylase-44 totbili-1.7* 09:50am blood alt-83* ast-30 alkphos-159* totbili-1.5 04:36am blood alt-84* ast-50* ld(ldh)-161 alkphos-126* amylase-31 totbili-1.2 dirbili-0.6* indbili-0.6 07:20am blood alt-50* ast-29 alkphos-101 totbili-1.3 07:00pm blood lipase-49 07:20pm blood ck-mb-2 ctropnt-<0.01 07:10am blood ck-mb-2 ctropnt-<0.01 07:00pm blood calcium-8.9 phos-3.2 mg-1.9 04:36am blood albumin-3.0* calcium-8.4 phos-4.0 mg-1.7 09:15am blood %hba1c-6.8* 09:15am blood psa-3.9 brief hospital course: patient was admitted to ercp service with dr. on . after two days of recovery from the sphincterotomy with a good downward trending of his liver function tests, the patient was then brought to the operating room for completion cholecystectomy. the plan was then to perform a laparoscopic cholecystectomy so he was transferred to purple with dr. . during the procedure, the disection was difficult so dr. was consulted and worked in conjunction with dr. to complete the procedure. a follow up ercp was performed on where a stent was placed in common bile duct. there was a filling defect that appeared like air bubles versus stones within the gallbladder. the common bile duct, common hepatic duct and right and left hepatic ducts, biliary radicles, cystic duct and gallbladder were filled with contrast and well visualized. on an open cholecystectomy for retained gallbladder with cholecystitis following attempt at laparoscopiccholecystectomy was performed without difficulty. the patient had a brief event immediatly post operatively where there was an air leak in the endotrachael tube which had to be removed. pulseox went from 99 to 89. the patient was successfully mask ventilated with o2 sat at 96% three minutes later. the patient awoke alert and oriented following verbal commands. ck-mb times three were done and normal. the remainer of the hospital course was unremarkable. the patient was discharged on with jp out but staples still in. these will come out back home in south america. the patient was discharged in good condition: afebrile, tolerating regular diet, ambulating without difficulty and pain well controlled on oral medications. discharge medications: 1. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 2. percocet 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours. disp:*35 tablet(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*30 capsule(s)* refills:*0* 4. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 5. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). discharge disposition: home discharge diagnosis: cholecystitis hypovolemia diabetes gerd asthma s/p appendectomy s/p myocardial infarction prostate ca osteoarthritis otosclerosis discharge condition: good: afebrile, tolerating regular diet, ambulating without assistance, pain well controlled on oral medications. discharge instructions: 1. please monitor for the following: fever, chills, nausea, vomiting, inability to tolerate food/drink. if any of these occur, please contact your physician . 2. please remove your staples on . followup instructions: provider: , . call to schedule appointment see your primary care physician when returning home. please remove your staples on . Procedure: Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Endoscopic retrograde cholangiopancreatography [ERCP] Other partial cholecystectomy Laparoscopic partial cholecystectomy Diagnoses: Esophageal reflux Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Personal history of malignant neoplasm of prostate Asthma, unspecified type, unspecified Calculus of gallbladder and bile duct with other cholecystitis, with obstruction

allergies: penicillins attending: chief complaint: shortness of breath major surgical or invasive procedure: none history of present illness: 75 yo m with h/o cad s/p imi in with ptca of the rca, chf ef 30%, and recent endocarditis on vanco who presented with sob to , transferred here for concern for valvulopathy. he was found to have o2 sats in the 60s at the nh and b/t le edema. he was sent to osh ed where he improved on bipap and nitro gtt. at osh his cxr showed pulmonary congestion, but he also received levofloxacin (3% bands). . in the ed the nitro gtt was stopped when he became hypotensive to 70s/30s. peripheral dopamine was started and a r scl tlc was placed. he recieved gentamycin 80 mg. the dopamine gtt was quickly weaned off. . of note, patient had his icd battery changed on . approx 2 weeks later he reported chills, anorexia, and nausea. he presented to his pcp where blood cultures were drawn. these were reportedly positive for staph and pt was started on vancomycin. other records suggest that he was admitted on for endocarditis. the details of this are not available. . ros: he reports "trouble cathching breath". pt denies fever or chills. denied headache, congestion, cough. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, or abdominal pain. no dysuria. has chronic arthritis. no myalgias. no rash. past medical history: pcp , cardiologist - cad s/p prior imi with ptca of the rca, recathed in after a positive stress test and was found to have no progression - chf with ef 30% - inferior and apical hypokinesis - left bundle branch block and documented nonsustained vt - + ep studys/p -v icd placement in - mild-moderate mr in - s/p pacemaker placement - hypertension - hyperlipidemia - diet controlled dm - former smoker, quit 33 yrs ago - arthritis - s/p appendectomy - hydrocele repair - gout - "-repair of cerebral aneurysm" of carotid art social history: he is widowed and a retired machinist from polaroid. he drinks rare alcohol. he lives at center. former smoker, quit 33 yrs ago. family history: non-contributory physical exam: vitals: t: 101.8 p: 77 bp: 127/50 rr: 29 sao2: 100% on 70% open face mask general: awake, alert, mild resp distress. heent: perrl, eomi, sclera anicteric. mmm, op without lesions neck: supple, jvd to level of jaw. no carotid bruits appreciated, 2+ carotid pulses pulm: lungs with exp wheezes, distant breath sounds, occ crackles cardiac: rrr, distant s1/s2, no m/r/g appreciated abdomen: soft, nt/nd, + bs, no hepatomegaly noted. ext: trace edema b/t, warm skin: no osler nodes, splinter hemorrhages. l arm with 1 cm healing abrasion neurologic: alert & oriented x 3. pertinent results: admission labs: 10:50pm type-art po2-98 pco2-56* ph-7.36 total co2-33* base xs-3 intubated-not intuba 10:50pm o2 sat-96 04:55pm genta-2.8* vanco-18.4 12:00pm urine color-yellow appear-clear sp -1.007 12:00pm urine blood-mod nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 12:00pm urine rbc-0-2 wbc-0-2 bacteria-rare yeast-none epi-<1 07:25am type-art po2-89 pco2-59* ph-7.33* total co2-33* base xs-2 02:25am lactate-1.4 02:25am hgb-9.2* calchct-28 o2 sat-88 02:15am pt-14.7* ptt-29.8 inr(pt)-1.3* 01:55am glucose-145* urea n-33* creat-2.1* sodium-139 potassium-5.0 chloride-100 total co2-30 anion gap-14 01:55am ck(cpk)-58 01:55am ctropnt-0.06* 01:55am ck-mb-notdone probnp-* 01:55am tsh-0.36 01:55am cortisol-17.5 01:55am vanco-19.9 01:55am digoxin-0.2* 01:55am wbc-12.9* rbc-3.18* hgb-8.9* hct-27.7* mcv-87 mch-28.1 mchc-32.3 rdw-16.7* 01:55am neuts-67.8 bands-0 lymphs-9.2* monos-21.9* eos-0.6 basos-0.5 01:55am plt smr-very low plt count-72*. . microbiology: blood cultures from no growth abscess culture: no growth to date . <b>ekg: : v-paced, nl pr interval, lbbb, lad admission: nsr, 1st degree avb, lbbb, lad, no qs. . <b>radiologic data: cxr : mild-to-moderate chf. more confluent opacity in the right lower lobe could represent asymmetric pulmonary edema; however, a developing pneumonia cannot be excluded. . cxr : there has been interval placement of a right subclavian central venous catheter with the tip in the svc. there is no evidence of pneumothorax. . cardiac cath : 1. coronary angiography of this right-dominant system revealed no hemodynamically significant cad. the left main, lad, and left circumflex were without hemodynamically significant lesions. the right coronary artery had mild luminal irregularities throughout its length without hemodynamically significant lesions. 2. resting hemodynamic measurements revealed borderline elevation of the pulmonary artery systolic pressure at 30mmhg. the lvedp was within normal limits at 11mmhg. the ci was within normal limits at 3.6 l/min/sq.m. there was no mitral stenosis. there was no gradient on pullback across the aortic valve. 3. left ventriculography revealed global hypokinesis with an ejection fraction estimated at 35%. there was no mitral regurgitation. final diagnosis: 1. no hemodynamically significant coronary artery disease. 2. moderate systolic ventricular dysfunction. . osh: ejection fraction of 30% with inferior and apical hypoakinesis and mild to moderate mitral regurgitation . : 1. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is moderate to severe global left ventricular hypokinesis. overall left ventricular systolic function is moderately depressed. lvef 2. the aortic valve leaflets are severely thickened/deformed. there is moderate to severe aortic valve stenosis. trace aortic regurgitation is seen. 3. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. 4. no evidence of endocarditis or abscess is seen. . tee : conclusions: no spontaneous contrast or thrombus is seen in the body of the left atrium or left atrial appendage. a patent foramen ovale is present. a left-to-right shunt across the interatrial septum is seen at rest. overall left ventricular systolic function is moderately depressed. there are simple atheroma in the descending thoracic aorta. there are simple atheroma in the abdominal aorta. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. no masses or vegetations are seen on the aortic valve. there is moderate aortic valve stenosis. mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are structurally normal. no mass or vegetation is seen on the mitral valve. mild to moderate (+) mitral regurgitation is seen. no vegetation/mass is seen on the pulmonic valve. there is no clot or endocarditis on the pacer wire. there is no pericardial effusion. impression: no echocardiographic signs of endocarditis. there is no clot or endocarditis on the pacer wire. moderate aortic stenosis with mild to moderate aortic regurgitation. a pfo is present with left to right flow. moderately depressed systolic function (ef 30-35%). brief hospital course: <b>assessment and plan: 75 yo m with h/o cad s/p imi in with ptca of the rca, chf ef 30%, and recent endocarditis on vanco who presented with sob to , transferred here for concern for valvulopathy. . endocarditis: no records were initially available from the osh. he was maintained on vancomycin (pcn allergy) which was renally dosed. he also received a tte and a tee which showed no evidence of vegetation or abscess. his old picc line was removed and culture was sent. his wbc count trended down from 12.9 - 7. his osh records were obtained on , which showed that he had staph hominis bacteremia and an report that raised the question of aortic valve endocarditis and ai. the actual ocho images were not able to be reviewed. all blood cultures obtained were negative for growth. he will continue on vancomycin for a 6 week course (through ). ep was consulted; they feel that he does not need pacer wires changed at this time, however would consider changing the wires should he develop recurrent fevers or + blood cultures. he is to continue his vancomycin to be dosed by outpatient oncology clinic at med ctr. dr. will also follow his troughs. his goal trough is 15-20. . ischemic cardiomyopathy: there were no ekg changes concerning for ischemia. his initial troponin was 0.06. he was continued on his asa, statin, beta blocker. his ace was held for his renal insufficiency. he did not have any chest pain or other concerning symptoms during his admission. . chf: performed here showed an ef 30-35%: cxr on admission was consistent with chf exacerbation, and his bnp was . the patient initially appeared labored with his breathing. he was given lasix and his oxygenation and ventilation improved. he diuresed well. there was a question of whether some of his symtoms were due to his ai. an abg was normal. we continued his digoxin, bblocker, and statin. . rhythym: he did have 1st degree avb which was confirmed on multiple ekgs. it did not progress, and he remained asymptomatic. his amiodarone was continued. . ai: apparently new over the last month. it was unclear whether it was thought due to endocarditis. echp here did not show any evidence of infection or vegetation. this issue remained stable during admission. . fever: likely due to endocarditis as above. cxr was without infiltrate. lue extremity was erythematous. fluctuance was detected on exam. surgery was consulted for possible i+d. the picc line was removed. his fevers resolved and he did not experience any more during admission. surgery drained his left elbow abscess without complications. his abscess fluid was cultred and was no growth upon discharge. cultures remained negative, and his wbc trended down. . cellulitis: the patient has a recent history of cellulitis of the l forearm, with a fluid collection that was previously drained and grew enterobacter, for which he was treated with levofloxacin x 10 days. he was found to have a reaccumulation of fluid over his l forearm during this admission which was drained by surgery; the fluid was sterile. . renal failure: his creatinine remained elevated. his medications were renally dosed. it was unclear what his baseline cr was. his epoetin was continued. his allopurinol was held. . anemia: per old records, his anemia was chronic and ill defined. we continued his outpatient epoetin. there were no signs of active bleeding. he was re-started on protonix per old records indicating history of gastritis. he was maintained on iron replacement. he was given 2 units prbcs during admission with appropriate response. . thrombocytopenia: old records indicated a chronically low count, thought to be due to mds, although it was not proven definitively. his platelet count remained in the 50-60's. he has an outpatient hematologist who plans to pursue an outpatient bm biopsy for work up of possible mds. . arthritis: we continued his steroids and plaquenil. . diabetes mellitus: we kept him on an insulin sliding scale. . hypothyroidism: we continued synthroid at 25 mcg. . code: he was full code during admission. medications on admission: vancomycin 1.25 g q40h levothyroxine 25mcg daily amiodarone 50mg daily digoxin 0.125 mg daily lasix 40mg daily toprol xl 100mg daily lipitor 10mg daily captopril 2.5mg three times per day hydroxychloroquine 200mg daily allopurinol 300mg daily folic acid 1mg twice a day prednisone 2.5mg twice a day for arthritis multivitamin 1 tablet daily iron sulfate 325 daily epogen 40,000 qweek discharge disposition: home with service facility: hospital discharge diagnosis: primary diagnosis: chf exacerbation secondary diagnoses: cellulitis cad cri arthritis discharge condition: good- afebrile with normal wbc count. discharge instructions: during this admission you have been treated for chf exacerbation. please continue to take all medications exactly as prescribed. you should adhere to a low salt diet. you should weigh yourself every day; if you note a >3 pound weight gain in 2 days you should call dr right away. if you notice increasing shortness of breath, fatigue, fevers, night sweats, chest pain, or other symptom that is concerning to you, please seek immediate medical attention. you are to take vancomycin through . pleaseis take 1g iv every morning from . on , please have a vancomycin trough level prior to your am dose. goal trough 15-20. if level <20, continue with daily qam dosing. if level >20, please call dr. office to determine proper schedule. check follow up blood cultures 10 days after last dose of vancomycin. please call dr. with any questions. followup instructions: dr : (cardiology) monday at 2:00 pm. ( . provider: clinic phone: date/time: 11:30 provider: , m.d. phone: date/time: 12:00 . Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Transfusion of packed cells Aspiration of skin and subcutaneous tissue Infusion of vasopressor agent Diagnoses: Thrombocytopenia, unspecified Anemia of other chronic disease Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Mitral valve insufficiency and aortic valve insufficiency Chronic kidney disease, unspecified Rheumatic heart failure (congestive) Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Bacteremia Cellulitis and abscess of upper arm and forearm Old myocardial infarction Automatic implantable cardiac defibrillator in situ Acute and subacute bacterial endocarditis Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus

discharge medications: synthroid 100 micrograms po q.d., vitamin e 400 units po q day, protonix 40 mg po q.d., colace 100 mg po q.d., miconazole powder b.i.d. to affected areas. regular insulin sliding scale, nph 18 units subq b.i.d., haldol 1 to 2 mg po intravenous im q 2 to 4 hours prn agitation. tylenol 650 mg po q 4 to 6 hours prn. benadryl 25 mg po q 4 to 6 hours prn. the patient will follow up with her outpatient psychiatrist dr. in two weeks. the patient will also follow up with her primary care physician . in one to two weeks after discharge from rehab. , m.d. dictated by: medquist36 Procedure: 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 Suture of artery Other incision of skin and subcutaneous tissue Diagnoses: Pneumonia, organism unspecified Acidosis Urinary tract infection, site not specified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hematoma complicating a procedure Acute pancreatitis Other psychotropic agents causing adverse effects in therapeutic use Poisoning by other specified psychotropic agents

history of present illness: the patient is a 53-year-old female with a history of bipolar disorder, diabetes mellitus, who was referred from mental health for accidentally taking two 900 mg tablets of lithium the night before presentation. the patient reported one day history of vomiting and shortness of breath as well as body aches. the patient was unable to give an elaborate history beyond that of her concern that she had had too much lithium. the patient had revealed that she had taken too much lithium in the past, and felt much the same as she did when she presented. the patient had no history of chest pain, fever, cough, but did note shortness of breath especially with climbing stairs. in the emergency department, a foley catheter was placed, drawing 50 cc of urine. an arterial blood gas was performed, revealing a ph of 7.31, with a pco2 of 60 and a pao2 of 68. oxygen saturations were in the mid-80s. chest x-ray showed bilateral basilar opacities with pulmonary vascular congestion. the medical intensive care unit was called for assessment for invasive monitoring of the patient and to monitor waxing and mental status in the setting of elevated lithium level. past medical history: 1. bipolar disorder 2. morbid obesity 3. hypothyroidism 4. sleep apnea 5. diabetes mellitus medications: lithium 600 mg every morning and 900 mg every evening, trazodone 100 mg by mouth daily at bedtime, synthroid, glucophage, glucotrol, lasix, accupril and hydrochlorothiazide. allergies: stelazine, norpramin social history: the patient is divorced, lives with her fiance. the patient admits to a brief smoking history as a teenager. physical examination: temperature 99, heart rate 70s to 80s, blood pressure 134/86, oxygen saturation 80% supine and 92% sitting up. on general examination, the patient was an alert, obese female, in mild distress. the patient was oriented to place, date and situation. head, eyes, ears, nose and throat examination revealed pupils equal, round and reactive to light, extraocular movements intact. thorax revealed bibasilar rales to the mid-lung fields. cardiac examination revealed regular rate and rhythm, normal s1, s2, and a ii/vi systolic murmur. abdominal examination revealed an abdomen that was soft, obese, nontender, nondistended, with normal bowel sounds. extremity examination revealed 1+ peripheral edema. neurological examination revealed a patient that was alert, somewhat inattentive. the patient was tremulous. there were scattered myoclonic jerks. the patient had 3+ reflexes throughout, with one to two beats of clonus at the ankles. laboratory data: the patient had a sodium of 134, potassium 4.5, chloride 99, bicarbonate 30, bun 52, creatinine 3.4 with a baseline of 0.9, and glucose of 77. the patient had a lithium level of 2.6. the patient had a white blood cell count of 14.9 with a hematocrit of 34.7 and platelets of 268. serum toxicology screen was negative for aspirin, etoh, acetaminophen, benzodiazepines, barbiturates, and tricyclic antidepressants. urinalysis revealed positive nitrites, 3+ protein, moderate blood, red blood cells, and white blood cells. an initial ck was 20. chest x-ray: cardiomegaly with congestive heart failure. electrocardiogram: normal sinus rhythm, normal axis, nonspecific st/t wave changes in v1 and avf. hospital course: the patient is a 53-year-old female with a history of bipolar disorder, diabetes mellitus, who presented with a one day history of vomiting and shortness of breath as well as a history of ingestion of 1800 mg of lithium the evening before presentation. the patient was admitted to the medical intensive care unit to monitor her waxing and mental status as well as her ability to maintain her airway. 1. pulmonary: the patient presented with acute on chronic respiratory acidosis. it was suspected that the acute component was likely related to cns depression with lithium overdose. the chronic component appeared to be secondary to her obesity and obstructive sleep apnea. the patient was admitted to the medical intensive care unit for supplemental oxygen, monitoring of her respiratory status, and possible need for intubation. the patient was also suspected to be in congestive heart failure, and was diuresed as well. the patient did require a brief intubation secondary to a neck hematoma that developed after central line attempt. this was done prophylactically for airway protection. the patient was quickly extubated as the hematoma resolved. the patient was also subsequently found to have a pneumonia and was successfully treated with a ten day course of levofloxacin and vancomycin. the patient showed improvement in her oxygen saturation over the course of the admission, and was transferred from the intensive care unit to the regular medicine floor on . she routinely had an oxygen saturation of 93 to 95% on room air. 2. cardiovascular: the patient was ruled out for myocardial infarction by serial cks. 3. neurologic: patient with changes in mental status, likely secondary to lithium overdose. her lithium level was elevated to 2.6. she was obtunded, tremulous, with mild ataxia. she had barbiturates present in her urine. toxicology was consulted and recommended holding all of the patient's psychotropic medications as well as recommending dialysis for removal of lithium. the patient was started on hemodialysis secondary to increased lethargy, worsening acid/base status, and the presence of toxic levels of lithium. she tolerated this well. the patient's lithium level steadily trended downwards to the point of being undetectable. the patient's mental status gradually returned to her baseline. psychiatry had been consulted and recommended that there was no acute indication for pharmacotherapy of her bipolar disorder. they recommended haldol and ativan for agitation. the patient had infrequent episodes of agitation in the evening, requiring haldol. 4. renal: the patient presented with oliguric acute renal failure after lithium overdose. this was thought to be secondary to acute tubular necrosis related to hypovolemia as well as lithium toxicity. the patient required hemodialysis both to remove toxic levels of lithium as well as for worsening acid/base status. a first attempt at a hemodialysis line placement resulted in a right neck hematoma. a second line placement attempt led to a femoral artery puncture which required vascular surgery repair. the patient became hemodynamically unstable, requiring a short interval on pressors secondary to this complication. the patient returned quickly to hemodynamic stability. the patient's creatinine was elevated on presentation and required ongoing hemodialysis. however, the patient gradually showed improvement in her creatinine, which came down to 1.3. the patient also began to have excellent urine output, up to 1500 cc/day. at that point, the renal service did not feel that the patient needed ongoing hemodialysis, nor was it felt that she needed to continue to receive erythropoietin. 5. gastrointestinal: the patient had a nasogastric tube placed upon admission to the medical intensive care unit. she received tube feeds for the initial intensive care unit stay. however, the patient began to have evidence of increasing abdominal tenderness with an elevated lipase, suggesting pancreatitis. the patient had an abdominal ct which was negative for pancreatic pseudocyst or for pancreatic inflammation. however, the patient continued to have an increasing lipase and was therefore placed on bowel rest with nasogastric tube placement. the patient's white blood cell count was likewise elevated. however, the patient's lipase gradually decreased while on bowel rest, as did her white blood cell count. her abdominal tenderness resolved, and she was gradually started on sips of clear fluids. she tolerated this well. the patient had a swallow study in the intensive care unit, which revealed some evidence of aspiration. she did not have any evidence of aspiration as her diet was advanced. she was eventually able to tolerate a full diet. 6. endocrine: patient with history of diabetes, on oral hypoglycemics at home. the patient was started on nph and regular insulin sliding scale in the intensive care unit. this was continued as the patient was transferred to the floor. the patient had finger stick blood sugars checked four times a day. she showed excellent glycemic control while in-hospital. 7. hematology: patient with evidence of anemia upon presentation. she had further blood loss secondary to a complicated central line placement. her hematocrit eventually stabilized. because of the possibility of chronic renal insufficiency, the patient was given erythropoietin. her hematocrit was monitored closely while in the hospital. she did have evidence of resolving normocytic anemia, which was likely not multifactorial. the patient may require an outpatient colonoscopy at some point to evaluate possible gastrointestinal losses. 8. infectious disease: the patient presented with evidence of urinary tract infection and was initially treated with ciprofloxacin. the patient later was found to have a pneumonia, which was successfully treated with a ten day course of levofloxacin and vancomycin. the patient was afebrile, with a gradually normalizing white blood cell count upon transfer to the general medical floor. the patient's elevated white blood cell count was attributed to pancreatitis, and as her lipase resolved, her white blood cell count also decreased. she was carefully monitored for any signs of infection. she did have evidence of funguria on a repeat urine culture. the patient had a foley, which was changed. urine culture was rechecked after the foley change. this urine culture was pending at the time of this discharge summary. condition on discharge: good. discharge medications: synthroid 100 mcg by mouth once daily, vitamin e 400 units by mouth once daily, protonix 40 mg by mouth once daily, heparin subcutaneously 5000 units three times a day, colace 100 mg by mouth once daily, miconazole powder to affected areas twice a day, regular insulin sliding scale, nph 18 units subcutaneously twice a day, tums two by mouth with meals three times a day, haldol 1 to 2 mg by mouth, intravenously or intramuscularly every two to four hours as needed for agitation, tylenol 650 mg by mouth every four to six hours as needed for pain, benadryl 25 mg by mouth every four to six hours as needed for itching. discharge diagnosis: 1. lithium overdose 2. acute renal failure 3. pancreatitis 4. pneumonia 5. urinary tract infection 6. normocytic anemia 7. diabetes mellitus 8. hypothyroidism 9. bipolar disorder 10. obesity 11. sleep apnea , m.d. dictated by: medquist36 Procedure: 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 Suture of artery Other incision of skin and subcutaneous tissue Diagnoses: Pneumonia, organism unspecified Acidosis Urinary tract infection, site not specified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hematoma complicating a procedure Acute pancreatitis Other psychotropic agents causing adverse effects in therapeutic use Poisoning by other specified psychotropic agents

history of present illness: baby boy is the 2.04 kg product of a 34 and week gestation born to a 36-year-old g3, p2, now 3 mother. prenatal screens - blood type a negative, antibody negative, rpr nonreactive, rubella immune, hepatitis surface antigen negative, and gbs unknown. this pregnancy was reportedly unremarkable with normal afp and ultrasound. no amniocentesis. mother presented this morning with pre-prom at approximately 5 a.m. mother was admitted for induction of labor. labor progressed gradually although recurrent fetal decelerations required discontinuation of pitocin and treatment with amnioinfusion via iupc. the infant was eventually delivered by stat cesarean section for prolonged fetal decelerations. after placement of spinal anesthesia, mother was found to be fully dilated and progressed to forceps assisted vaginal delivery. nuchal cord was present. at delivery the infant emerged with moderate tone and spontaneous cry requiring only drying and stimulation. apgars were7 and 8. physical examination: weight 2.040 kilograms, 50th percentile; length 47 cm, 50th to 75th percentile; head circumference 30.5 cm, 25th to 50th percentile. warm, dry, premature infant, mildly reduced spontaneous activity in no acute distress. skin warm and pink. no rashes. positive bruising over scalp. fontanel soft and flat. positive caput. sutures appropriate, no split. red reflex bilaterally present. ears and nares normal. neck supple. no lesions. chest: coarse breath sounds. moderately aerated. mild tachypnea, minimal retractions. positive pectus. cardiovascular: regular rate and rhythm. no murmurs. femoral pulses 2+. abdomen: soft. no hepatosplenomegaly. three-vessel cord. no masses. genitourinary: normal preterm male. testes palpable in inguinal canal bilaterally. anus patent. extremities: hips normal. shallow sacral dimple present on the bottom. neurologic: appropriate tone, mildly reduced activity, intact grasp, weak suck. summary of hospital course by systems: respiratory: has remained in room air without any issues. he has a history of occasional desaturations, one with apnea documented on . no further issues. the infant has not received any methylxanthine's. cardiovascular: he has been cardiovascularly stable. heart rate in the 130s to 150s. blood pressure had been 60/47 with a mean of 51. fluids, electrolytes and nutrition: birth weight was 2.040 kg. discharge weight is grams up 5 from previous day. the infant was initially started on 80 cc per kg per day. enteral feedings were started on day of life no. 1. the infant is currently receiving a 140 cc per kg per day of breast milk or special care 20 calorie doing a combination of oral feeding and gavage feeding. the infant has remained euglycemic throughout his hospital course. his most recent set of electrolytes were on with sodium of 139, potassium of 5.2, chloride of 103, total co2 was 24. gastrointestinal: his peak bilirubin was on day of life 3 and it was 12.1/0.5. his most recent bilirubin is ... phototherapy was discontinued on with a rebound bilirubin on of 7.6. hematology: hematocrit on admission was 52.8. the infant has not required any blood products. infectious disease: cbc and blood culture obtained on admission. cbc was benign with the exception of a low thrombocytopenia, platelet count of 104. repeat was 102 twelve hours later. most recent platelet count was on of 133. of note maternal platelets were 336,000 just prior to delivery. cbc: he had a white count of 21.3, 50 polys, 0 bands, 44 lymphs. he received 48 hours of ampicillin and gentamycin with a nature culture at which time antibiotics were discontinued. neurologic: the infant has been appropriate for gestational age. the infant has been appropriate. sensory: hearing screen has not yet been performed but should be performed prior to discharge. condition on discharge: stable. discharge disposition: to . name of primary pediatrician: not yet identified although it will be in the group. care recommendations: 1. continue advancing feeds as necessary to maintain weight gain. 2. medications: not applicable. 3. car seat position screening has not yet been performed. 4. state newborn screen was sent on , and should have been sent prior to discharge on . 5. immunizations received: the infant has not received any immunizations to date. discharge diagnoses: 1. premature infant born at 34 weeks. 2. rule out sepsis with antibiotics. 3. mild hyperbilirubinemia. 4. apnea bradycardia of prematurity. , Procedure: Enteral infusion of concentrated nutritional substances Other phototherapy Umbilical vein catheterization Diagnoses: Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Neonatal jaundice associated with preterm delivery Primary apnea of newborn Neonatal bradycardia Other preterm infants, 2,000-2,499 grams 33-34 completed weeks of gestation

past medical history: 1. coronary artery disease times twenty years. 2. history of myocardial infarctions times two in and . 3. gastroesophageal reflux disease. 4. hypertension. 5. hyperlipidemia. 6. elbow fracture. allergies: the patient has no known drug allergies. medications: 1. aspirin. 2. prevacid 15 mg q.d. 3. corgard 20 mg po q.d. 4. mevacor 40 mg po q.d. 5. nitroglycerin p.r.n. physical examination: examination revealed the following: blood pressure 130/80, heart rate 72, afebrile. general: the patient was in no apparent distress. heent: examination was within normal limits. there were no bruits. no jvd. chest: examination was clear to auscultation bilaterally. heart: examination revealed regular rate and rhythm without murmurs. abdominal: abdomen was nontender, nondistended, no masses present. extremities: no edema, pulse present bilaterally. laboratory data: laboratory data revealed the following: hematocrit 34, wbc 6.8, platelet count 173,000, sodium 145, potassium 4.6, bun 14, creatinine 1.1, inr 1.9,. chest x-ray performed on showed low lung volumes and retrocardiac opacification, which could indicate atelectasis. hospital course: given the symptoms of chest discomfort and back pain, the patient underwent cardiac catheterization on . the catheterization showed two-vessel coronary artery disease with significant branch-vessel disease in a third artery. left ventricular function was slightly depressed with estimated ejection fraction of 51%. there was an unsuccessful attempt to revascularize the left circumflex due to the inability to cross the lesion. a surgical approach was recommended. on the patient underwent a coronary artery bypass graft times four with left internal mammary artery to left anterior descending coronary artery, reverse saphenous vein graft from the aorta to the right posterior descending coronary artery, reverse saphenous vein graft from the aorta to the obtuse marginal coronary artery, in sequence with the right posterolateral coronary artery. the procedure was without complications. please see the full operative note for details. the patient was transferred to the intensive care unit in satisfactory condition. the patient had a postoperative fever of 101.1. the patient was started on lasix, lopressor, and aspirin. given persistent low-grade fever, blood cultures were obtained, as well as urine culture, which were all negative. on postoperative day #1, the patient was transferred to the regular floor. he remained in stable condition with sinus rhythm. the patient was treated by the physical therapist daily. on postoperative day #4, the patient went into atrial fibrillation. he was symptomatic in that he felt his heart beating away. heart rate was in the 160s. the patient was treated with iv lopressor and the standing dose of lopressor was increased accordingly. the patient eventually converted to sinus rhythm. chest tubes were removed. on postoperative day #6, the patient experienced palpitations while walking with the physical therapist. the heart rate increased to 200 and he was in a rhythm that was most consistent with supraventricular tachycardia. he was treated with iv lopressor. he reverted spontaneously to sinus rhythm. this episode of supraventricular tachycardias occurred one more time and lasted a few minutes. the patient again converted spontaneously into sinus rhythm. no more episodes of supraventricular tachycardia were recorded. the patient remained at least twenty-four hour without any changes in the rhythm. the patient was discharged to home on postoperative day #7 in stable condition. the patient was cleared by the department of physical therapy. he showed good oxygenation levels on room air. he was tolerating a regular diet. the incision was clean, dry, and intact without any significant of infection. condition on discharge: stable. discharge disposition: home. discharge diagnoses: 1. three vessel coronary artery disease status post coronary artery bypass graft. 2. history of myocardial infarction times two. 3. hypertension. 4. hypercholesterolemia. discharge medications: 1. aspirin 325 mg po q.d. 2. prevacid 15 mg po q.d. 3. corgard 20 mg po q.d. 4. mevacor 40 mg po q.d. 5. levofloxacin 500 mg po q.d. for a total course of five days. 6. percocet one to two tablets po q.4h.p.r.n. pain. 7. colace 100 mg po b.i.d. 8. lasix 20 mg po b.i.d. times seven days. 9. potassium chloride 20 meq po b.i.d. times seven days. discharge instructions: 1. the patient is to follow up with his surgeon, dr. in approximately six weeks. 2. the patient is to follow up with his primary care physician, . in approximately one to two weeks. 3. the patient is to follow up with his cardiologist in approximately three to four weeks. , m.d. dictated by: medquist36 Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Diagnostic ultrasound of heart Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Cardiac complications, not elsewhere classified Personal history of tobacco use Mitral valve insufficiency and aortic valve insufficiency Old myocardial infarction

allergies: penicillins attending: addendum: the patient was given a prescription for protonix 40mg po bid for 1 month for his ugib. he has outpatient follow up with gi in 2 weeks. discharge disposition: home with service facility: homecare md Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Insertion of temporary transvenous pacemaker system Insertion of drug-eluting coronary artery stent(s) Transposition of cranial and peripheral nerves Insertion of two vascular stents Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on two vessels Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Acute myocardial infarction of other inferior wall, initial episode of care Hemorrhage of gastrointestinal tract, unspecified

allergies: penicillins attending: chief complaint: chest pain, transferred from osh for stemi major surgical or invasive procedure: cardiac catheterization s/p cypher stenting of lcx and om1 history of present illness: 83 y/o man with "on and off" chest pain for several weeks who presented to hospital today complaining of pain that was persistent. his ecg showed inferior st elevations with reciprocal changes. while at , his exam was consistent with chf, as well as cxr. he was given iv lasix, heparin, integrelin, plavix loaded. he was additionally noted to be bradycardic to hr 39. he was given atropine 1 mg twice without response. his bp was 74 systolic, so peripheral dopamine was started, and he was sent to for intervention. . in cath here he was found to have 90% occlusion of the l cx, as well as diffuse disease of a dominant om1 - cypher stents to both. there was also 90% mid vessel rca lesion (non-dominant vessel). . pcwp was 25. past medical history: - cva (hemorrhagic) x 2: and - not on asa due to this; no known residual deficits - retroperitoneal fibrosis with mult sbo from this and chronic pain - dm2 on oral agents only - htn 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: blood pressure was 132/64 mm hg while supine. pulse was 73 beats/min and regular, respiratory rate was 20 breaths/min. generally the patient was well developed, well nourished and well groomed. the patient was oriented to person only. . there was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. the neck was supple with jvp of 8 cm. the carotid waveform was normal. there was no thyromegaly. the were no chest wall deformities, scoliosis or kyphosis. the respirations were not labored and there were no use of accessory muscles. the lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. . palpation of the heart revealed the pmi to be located in the 5th intercostal space, mid clavicular line. there were no thrills, lifts or palpable s3 or s4. the heart sounds revealed a normal s1 and the s2 was normal. there were no rubs, murmurs, clicks or gallops. . the abdominal aorta was not enlarged by palpation. there was no hepatosplenomegaly or tenderness. the abdomen was soft nontender and nondistended. the extremities had no pallor, cyanosis, clubbing or edema. there were no abdominal, femoral or carotid bruits. inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. . pulses: right: carotid 2+ femoral 2+ dp 2+ left: carotid 2+ femoral 2+ dp 2+ pertinent results: 11:00am calcium-7.9* phosphate-4.1 magnesium-1.6 11:00am ctropnt-2.73* 11:00am ck(cpk)-534* 11:00am estgfr-using this 11:00am glucose-310* urea n-32* creat-1.4* sodium-131* potassium-3.6 chloride-99 total co2-18* anion gap-18 06:58pm plt count-312 06:58pm ck-mb-291* mb indx-11.5* 06:58pm ck(cpk)-2535* 06:58pm potassium-4.6 08:54pm pt-11.4 ptt-22.3 inr(pt)-1.0 08:54pm plt count-302 08:54pm wbc-17.0* rbc-3.54* hgb-10.0* hct-29.9* mcv-85 mch-28.3 mchc-33.5 rdw-14.1 . imaging/studies: cardiac catheterization: comments: 1. coronary angiography in this right dominant system demonstrated an lmca with mild proximal disease. the lad had minimal luminal irregularities. the lcx was a dominant vessel with diffuse disease; the mid-lcx had an average 90% stenosis with evident thrombus, the dominant om had severe diffuse disease and evident thrombus as well; both the lcx and om had timi ii slow flow. the rca was a small nondominant vessel wtih a 90% lesion in its mid segment. 2. limited resting hemodynamics revealed normal systemic arterial pressure (on dopamine gtt). right sided filling pressures were mildly elevated. 3. peripheral angiography demonstrated a 95% lesion in the right external iliac artery at the bifurcation with the internal iliac artery. 4. pci: successful ptca and stenting was performed of the av cx with a 3.5x18 mm cypher stent postdilated to 3.75 mm with an nc balloon. successful ptca and stenting was performed of the om1 with a 3.0x33 mm cypher stent which was postdilated with a 2.5 mm nc balloon. final angiography revealed 0% residual stenosis, no dissection, and timi 3 flow in both vessels. (see ptca comments). final diagnosis: 1. two vessel coronary artery disease. 2. acute inferior myocardial infarction, managed by acute ptca of the lcx. 3. successful ptca and stenting of the av cx and om1 was performed with drug eluting stents. . echocardiogram: the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is mildly dilated. no masses or thrombi are seen in the left ventricle. overall left ventricular systolic function is mildly depressed with inferior and infero-lateral akinesis, ef = 40-45%. there is no ventricular septal defect. there is focal hypokinesis of the apical free wall of the right ventricle. the aortic root is mildly dilated at the sinus level. 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. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is severe pulmonary artery systolic hypertension, pasp = 63. there is no pericardial effusion. brief hospital course: mr. is an 83 year old male with a past medical history significant for htn, dm ii, hemorrhagic cva x 2, and retroperitoneal fibrosis who presented with stemi. . 1. stemi: mr. presented to an osh with chest pain. he was found to have st elevations in the inferior leads with reciprocal changes. he was transferred to for cardiac catheterization. his troponin peaked at 2.73 pre-catheterization. he underwent successful cypher stenting of the lcx and om1. catheterization also demonstrated 90% lesion of the rca mid-segment which was nondominant and a 95% lesion in the right external iliac artery at the bifurcation with the internal iliac artery. echocardiography demonstrated an ef of 40-45%, mild dilatation of the left ventricular cavity is mildly dilated with inferior and infero-lateral akinesis. his post-catheterization course was complicated by a bump in creatinine and chf, as well as hematemesis in the setting of integrilin, heparin, plavix and aspirin use (see below). he was continued on his beta-blocker which was increased for improved heart rate and pressure control. high-dose statin therapy was initiated. at home, he is on an ace inhibitor which was held in the setting of rising creatinine. . 2. chf: volume overload was likely secondary to recent stemi with mildly depressed lv function. chf was managed with aggressive diuresis and his beta blocker was continued. he had no oxygen requirement at discharge. echo as above. . 3. creatinine elevation: mr. creatinine increased from 1.4 to 1.9 post-catheterization. baseline was unknown. this acute rise was most likely secondary to contrast nephropathy. his ace inhibitor was held, but can be restarted as an outpatient. mr. was instructed to have lab work after discharge. his pcp, . will monitor the results. . 4. ugib: the patient had one episode of guiaic (+) maroon-colored emesis that occurred post-catheterization in the setting of integrilin, plavix, asa and recent heparin bolus. colostomy contents were guiaic negative. integrilin was stopped and aspirin was decreased to 81mg. plavix was continued given his recent stenting. his pre-transfer hct at the osh was 35.2. post-emesis hct dropped to 26.7. he received 1 unit of prbcs with an appropriate response in hct and remained stable for the remainder of his hospitalization. repeat hct was 29.9, then 26.7 post-cath and post-emesis. he was instructed to have a cbc after discharge. results will be faxed to dr. . he is scheduled for outpatient gi follow up in 2 weeks. . 5. dm ii: glyburide and metformin were initially held. he was managed with sliding scale insulin only until the day prior to discharge when glyburide was restarted. we continued to hold metformin given his elevated creatinine, but this may be restarted on an outpatient basis after blood work is reviewed by dr. . . 6. rp fibrosis: fentanyl patch was continued per home regimen. medications on admission: atenolol 100 lisinopril 10 hctz 25 metformin glipizide 5mg daily fentanyl patch 100 mcg zantac discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. fentanyl 100 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 5. glipizide 5 mg tablet sig: one (1) tablet po once a day. 6. zantac 150 mg tablet sig: one (1) tablet po twice a day as needed for heartburn. disp:*60 tablet(s)* refills:*0* 7. metoprolol tartrate 100 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: primary: 1. stemi 2. chf 3. acute renal failure 4. upper gi bleed . secondary: 1. htn 2. dm ii 3. retroperitoneal fibrosis s/p colostomy 4. hemorrhagic cva x 2 discharge condition: stable. afebrile. tolerating po. ambulates with assistance. chest pain free. discharge instructions: you were admitted to the hospital because you had a heart attack and required cardiac catheterization. you should return to the er or call your doctor if you experience any of the following symptoms: fever > 101.4, chest pain, shortness of breath, numbness/weakness/dizziness or any other concerning symptoms. . please take all medications as prescribed. you should not take your metformin (also called glucophage) until you follow up with dr. . . please follow up with all appointments as instructed. . during this admission, you underwent cardiac catheterization and stenting. please carry the stent information card in your wallet at all times. followup instructions: 1. chem-7 and cbc check on wednesday (to be drawn by vna), results should be sent to dr. (fax: , phone: ). metformin and ace-i to be restarted as indicated by laboratory data. 2. the following appointment with gasteroenterology at (, - , ) has been made for you. provider: , md phone: date/time: 2:00. 3. a cardiology follow up appointment has been made for you. provider: , md phone: date/time: 9:40 Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Insertion of temporary transvenous pacemaker system Insertion of drug-eluting coronary artery stent(s) Transposition of cranial and peripheral nerves Insertion of two vascular stents Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on two vessels Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Acute myocardial infarction of other inferior wall, initial episode of care Hemorrhage of gastrointestinal tract, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 25 y/o male with hx of closed head injury as teenager, cocaine od, lumbar spine surgery was transferred from an outside hospital with c6 lamina fracture and ? c5 fracture. pt slipped and fell in puddle of water, hitting head as he fell down reports immediate neck right shoulder pain, no loc no loss of bowel or bladder sensation major surgical or invasive procedure: acdf c6-7 history of present illness: 25 y/o male with hx of closed head injury as teenager, cocaine od, lumbar spine surgery was transferred from an outside hospital with c6 lamina fracture and ? c5 fracture. pt slipped and fell in puddle of water, hitting head as he fell down reports immediate neck right shoulder pain, no loc no loss of bowel or bladder sensation past medical history: closed head injury as teenager, cocaine od, lumbar spine surgery in . social history: currently prisoner went to jail on for violating a restraining order according to patient. smokes 1.5ppd, drinks 6-12 beers per day last drink ; uses coccaine occassionaly family history: non contributory physical exam: t:98.0 bp:128/70 hr: 68 r 18 o2sats 97% gen: awake on icu bed conversant heent: pupils: eoms neck: in collar lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: toes cool no injuries. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. motor: d b t fe ff ip q at g r 4+ 4+ 4+ 4+ 4+ 5 5 5 5 5 l 5 5 5 5 5 3 3 3 3 0 sensation: intact to light touch decreased on left leg, normal senation in pubic area and penis reflexes: b t br pa ac right 2 2 2+ left 2 2 2+ no clonus propioception intact toes mute rectal exam normal sphincter control per er and trauma resident pertinent results: 06:30am plt count-264 06:30am neuts-64.9 lymphs-26.4 monos-5.9 eos-0.9 basos-1.8 06:30am wbc-9.0 rbc-5.04 hgb-16.5 hct-46.2 mcv-92 mch-32.7* mchc-35.6* rdw-13.0 06:30am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 06:30am phosphate-4.6* magnesium-2.4 06:30am estgfr-using this 06:30am estgfr-using this 06:40am glucose-100 lactate-1.5 na+-144 k+-3.8 cl--108 tco2-23 06:40am glucose-100 lactate-1.5 na+-144 k+-3.8 cl--108 tco2-23 06:40am ph-7.40 comments-green top brief hospital course: mr was admitted to the trauma icu he underwent cervical,thoracic, lumbar mri: showing: large disc protrusion at c6/7 extending from just left of midline rightward into the right neural foramen. this disc protrusion results in compression of the right anterolateral aspect of the spinal cord. 2. small disc protrusions at t2/3 and t7/8. 3. degenerative disc changes and protrusions as described at l3/4, l4/5, and l5/s1. it was felt that his c6/7 disc was the one that causing the majority of his symptoms, on he underwent a acdf with allograft plate c6-7. post operatively he was full in strength in his right arm with continued neck pain. on post operative day 1 he was moving all extremities with good strenght though was hesitent to move left leg at times though when pushed he had full strength. his pain medication was weaned and he was placed for a physical therapy consult. he was tolerating a regular diet and voiding without difficulty. medications on admission: none discharge medications: percocet colace discharge disposition: extended care discharge diagnosis: c6-7 hnp with c7 pedicle fracture discharge condition: neurologically stable discharge instructions: ?????? do not smoke ?????? keep wound(s) clean and dry / no tub baths or pools for two weeks from your date of surgery ?????? if you have steri-strips in place ?????? keep dry x 72 hours. do not pull them off. they will fall off on their own or be taken off in the office ?????? no pulling up, lifting> 10 lbs., excessive bending or twisting ?????? limit your use of stairs to 2-3 times per day ?????? have a family member check your incision daily for signs of infection ?????? you are required to wear cervical collar asinstructed ?????? you may shower briefly without the collar / back brace unless instructed otherwise ?????? take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? do not take any anti-inflammatory medications such as motrin, advil, aspirin, ibuprofen etc. unless directed by your doctor ?????? increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation call your surgeon immediately if you experience any of the following: ?????? pain that is continually increasing or not relieved by pain medicine ?????? any weakness, numbness, tingling in your extremities ?????? any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? fever greater than or equal to 101?????? f ?????? any change in your bowel or bladder habits please return to the office in ____________days for removal of your staples/sutures ( if your sutures are under the skin you will not need to be seen until the follow up appoinment followup instructions: please call to schedule an appointment with dr. in 6 weeks you will need xrays (ap/lat) prior to your appoinment Procedure: Other cervical fusion of the anterior column, anterior technique Repair of vertebral fracture Fusion or refusion of 2-3 vertebrae Diagnoses: Tobacco use disorder Cocaine abuse, unspecified Fall from other slipping, tripping, or stumbling Closed fracture of C5-C7 level with anterior cord syndrome

history of present illness: patient is a 56-year-old male with past medical history of type 1 diabetes since the age of 4 who presents to the hospital on with nausea, vomiting, and hyperglycemia. patient was found to be in diabetic ketoacidosis with a blood pressure of 72/50, spo2 of 77% with blood sugars greater than 400, and kussmaul's breathing. initial abg on admission 7.04/13/158. potassium was 7.6, anion gap was 34. ekg revealed wide qrs complexes. blood sugars spiked to 1234. patient was aggressively volume resuscitated with seven liters and osh q.d. initial ck was 332 with an mb of 15.5. troponin 2.93 rose to 52.3. patient started on insulin drip and sent to the cath lab, which revealed 90% occlusion of mid left anterior descending and 30% occlusion of d2. patient was stabilized and transferred to for stent. a cypher stent was placed in the d2, pixel stent in the lad. pcwp at that time was 7.0. patient sent to the cardiac care unit for recovery. denied chest pain. positive for shortness of breath on 100% nonrebreather, diaphoretic, positive nausea postop. past medical history: 1. type 1 diabetes since age 4. 2. multiple admissions for dka. 3. on insulin pump for around 10 years. 4. status post partial gastrectomy. 5. bipolar disorder. allergies: no known drug allergies. medications at home: 1. insulin pump. 2. luvox 200 mg p.o. q.d. 3. trazodone 50 mg q. h.s. 4. zestril 5 mg p.o. q.d. 5. ativan 0.5 mg p.r.n. social history: positive tobacco one pack per day; lives with father; unemployed. family history: positive for cerebrovascular accident and coronary artery disease; father-cad status post coronary artery bypass graft. admission vital signs: afebrile, 100.3; pressure 147/58, heart rate 97, respirations 20 at 95% on 100% nonrebreather. physical examination: general: alert and oriented times three; lying in bed; unable to speak in complete sentences; tachypneic; no acute distress. heent: anicteric; pupils equal, round, reactive to light; extraocular movements intact; mucous membranes dry. neck: supple; no bruits; no jugulovenous pressure appreciated. regular rate, normal s1, s2, no murmurs, rubs, or gallops. respirations: diffuse crackles bilaterally; prolonged inspiratory and expiratory; no wheezes appreciated. abdomen: soft, nontender, nondistended; positive bowel sounds times four; no hepatosplenomegaly. extremities: warm; no clubbing, cyanosis, or edema; 2+ pulses the dorsalis pedis, posterior tibial, and femoral; no bruits. neuro: alert and oriented times three. cranial nerves ii-xii grossly intact. right groin: status post catheter removal; no hematoma; clean, dry, and intact. laboratory data on admission: abg 7.5/41/86 on 100% nonrebreather. wbc 19.8, sodium 138, potassium 3.6, chloride 101, bicarbonate 30, bun 28, creatinine 0.6, glucose 287, anion gap 27. ck is trended 2.93, spike of 52.3 and then post cath 39.02. chest x-ray revealed patchy, diffuse bilateral infiltrates consistent with possible adult respiratory distress syndrome or viral process. due to hypercarbic respiratory failure patient was intubated for airway protection and placed on ac. hospital course: 1. cardiovascular: pump post cath echo revealed an ejection fraction of 35%. initially held off anticoagulation because of decreasing platelets, negative antibody, and heparin drip was initiated on . at time of discharge patient was using lovenox 60 mg subq b.i.d. with bridge to coumadin 5 mg p.o. q.d. goal inr of 2 to 3. patient informed to have vna fax results to primary care physician, . , for target goal. patient will need follow-up echo in one month time to reassess ejection fraction at that time. anticoagulation might be discontinued. given his low ejection fraction, electrophysiology evaluation was obtained, performed a signal average ecg revealing a short qrs duration of 109 milliseconds. felt that patient will need to follow up with cardiology and have a stress test with t wave alternans at for appointment. 2. rhythm: patient remained on telemetry throughout hospital stay. normal sinus rhythm without aberrancy. 3. coronary artery disease: patient was weaned off nitro after catheterization. completed 18 hours of integrilin therapy. started on plavix, aspirin. beta blocker and ace were titrated as hemodynamically tolerated. cardiac enzymes trended down and blood pressure was successfully managed. 4. pulmonary: due to increasing tachypnea and chest x-ray concern for ards, patient was intubated for airway protection. patient improved with progressive diuresis on hospital day six. patient was extubated with good gas exchange. aggressive pulmonary physical therapy was initiated as well as albuterol and combivent. at the time of discharge patient was satting 97% on room air. given prescriptions for rescue inhalers as well as vna assistance for chest pt as needed. 5. infectious diseases: blood cultures and urine cultures remained negative. negative for legionella or rsv viral strands and fungal strands. sputum was positive for methicillin-resistant staphylococcus aureus. respiratory precautions were initiated. patient finished nine-day course of vancomycin 1 gram iv q. 12 and was discharged with flagyl 500 mg p.o. q.d. and levofloxacin 500 mg p.o. q.d. times 14 days. he was afebrile throughout hospital course with leukocytosis trending down. 6. endocrine: patient initiated on insulin drip. consult was obtained. per recommendations glargine 12 units q. h.s. with humalog. sliding scale was initiated. blood sugars remained in adequate control. at time of discharge the patient was scheduled with a follow-up appointment on at with dr. as well as vision screen at that time. patient informed to record blood sugars and bring them to his follow-up appointment. 7. renal: creatinine at baseline is 0.6 throughout hospital course. received mucomyst post-procedure dye load without creatinine bump. 8. psychiatric: the patient initiated post intubation luvox 50 mg titrated up to 100 mg p.o. q.d. discussed with psychiatrist, dr. , at to follow up at discharge. discharge medications: 1. lovenox 60 mg subq q. 12 times seven days. 2. warfarin 5 mg p.o. q.d. titrating to inr 2 to 3, faxing results to pcp . . 3. aspirin 325 mg p.o. q.d. 4. plavix 75 mg p.o. q.d. times nine months. 5. insulin glargine 12 units subq q. h.s. with humalog sliding scale recommendations. 6. metronidazole 50 mg p.o. t.i.d. times 14 days. 7. levofloxacin 50 mg p.o. q.d. times 14 days. 8. fluvoxamine 100 mg p.o. q.d. 9. albuterol. 10. ipratropium one to two inhalations q. 6 p.r.n. shortness of breath or wheezing. 11. atorvastatin 10 mg p.o. q.d. 12. zestril 20 mg p.o. q.d. 13. toprol xl 100 mg p.o. q.d. 14. nitroglycerin 0.3 mg sublingual q. 5 minutes times three p.r.n. chest pain. discharge instructions: 1. patient will check his inr on friday, , and monday, , titrating inr to 2 and 3. will fax results to dr. . 2. patient to call cardiology at for an appointment in two weeks. 3. patient to follow up with on at 10 o'clock for eye exam and appointment with dr. . 4. patient discharged with vna nursing for respiratory and medication instruction as well as administration of lovenox. discharge status: discharged home with vna services, chest pain free, shortness of breath free. discharge condition: stable. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours 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 endotracheal tube Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Insertion of drug-eluting coronary artery stent(s) Diagnoses: Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute myocardial infarction of anterolateral wall, initial episode of care Pneumonitis due to inhalation of food or vomitus Methicillin susceptible pneumonia due to Staphylococcus aureus Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Bipolar I disorder, most recent episode (or current) unspecified

history of present illness: this is a 34-year-old female with no significant past medical history who was transferred from hospital. the patient reported having a severe headache with repeated nausea and vomiting the evening prior to admission after having sexual intercourse. the headache and nausea persisted throughout the night. the patient called the primary care and was directed to the emergency room. a head ct at the outside hospital revealed a subarachnoid hemorrhage. the patient denied weakness of any extremities, dizziness, speech or visual disturbance. past medical history: malaria three years ago, denies hypertension, diabetes. past surgical history: she had a benign breast tumor excised. she does not take any medication. no drug allergies. social history: occasional etoh, nonsmoker. physical examination: the patient was awake, alert and oriented times three, followed commands. pupils were equal and reactive to light and accommodation. eoms were full, visual fields full by confrontation. no pronator drift. sensation intact. toes downgoing bilaterally. muscle strength 5/5 bilaterally. gross hearing intact. neck with mild stiffness. chest was clear. abdomen soft, nondistended. cardiac: regular rate and rhythm. extremities: no edema. laboratories: white count was 9.0, hematocrit 37.8, platelets 208,000. sodium 139, potassium 3.5, chloride 104, bicarbonate 26, bun 10, creatinine 0.6. pt 13, ptt 23 and inr 1.1. the patient was admitted to the neurosurgery service, started on nimodipine 60 mg q.4h. her blood pressure was kept less than 130. she was started on gi prophylaxis, was to get a cta overnight and was kept n.p.o. on the the patient's cta showed no obvious aneurysm in place. her headache was improving. she only had one episode of nausea, however did have neck stiffness, no pronator drift. she went for a formal angiogram , showed evaluation intracranial vascular demonstrated no definite aneurysm or vascular malformation and followup in five to seven days was recommended to exclude a thrombosed tiny aneurysm. the patient was monitored in the icu until and she was sent to a step-down unit, where she received q.1h vital signs. the patient remained awake, alert, continued to complain of a headache but otherwise following commands and moving all extremities. on she had an mri exam of her cervical spine, which showed no evidence of abnormal flow voids to indicate arteriovenous malformation, findings indicating a subarachnoid hemostasis in the prepontine region, no evidence of spinal stenosis. on the patient was transferred to the regular surgical neurologic floor. she continued to have a normal neurologic exam. the patient had a repeat cerebral angiogram on 13th, which was negative again. she continued to remain fully alert and oriented. her angiogram site in the right groin was clean, dry and intact, no hematoma. she had a positive pedal pulse in that foot. on the patient was to be discharged with followup instructions to return if she developed a worsening headache, fevers, chills. she was to return in 30 days for an mri to rule out any further development of an aneurysm. she was given a prescription for percocet one to two p.o. q.4-6h p.r.n. for pain. , m.d. dictated by: medquist36 Procedure: Arteriography of cerebral arteries Arteriography of cerebral arteries Diagnoses: Subarachnoid hemorrhage Headache Personal history of malaria

history: baby was born on at 11:15 p.m. as the 1845 gm product of a 35 4/7 weeks gestation pregnancy to a 29 year old gravida 1 para 0-1 mother. maternal prenatal laboratory studies were notable for blood type b positive, hepatitis b surface antigen negative, rpr nonreactive, rubella immune and group b strep unknown. prenatal history was notable for preeclampsia treated with magnesium sulfate. the infant was delivered by spontaneous vaginal delivery approximately two hours following spontaneous rupture of membranes. there were no perinatal risk factors for infection. the infant was born vigorous with apgar scores of 8 and 9 and was brought to the regular nursery after a brief period of transitioning in the neonatal intensive care unit. the patient did well in the regular nursery and was discharged to home on with a weight of 1805 gm. bilirubin on was 11/0.3 and on was 12.9/0.4. the patient was breastfeeding with supplements of formula or expressed breast milk following breastfeeding. the patient was urinating and stooling regularly. on , the patient returned for a bilirubin check; bilirubin was found to be 15 and the patient was then admitted. hospital course: the patient was admitted to the newborn nursery and placed on double phototherapy. breastfeeding was continued with supplemental formula or expressed breast milk following each feed. urine and stool output remained normal throughout. bilirubin in am had decreased to 11.2. phototherapy was continued for another 12 hours and then discontinued at 6 p.m. on . a rebound bilirubin 12 hours later in the morning on was further decreased at 9.7/0.3. the infant's weight on admission was 1780 gm and it increased to 1795 on and then was 1805 gm at discharge on . from a cardiovascular and respiratory standpoint, the infant remained stable throughout admission without any evidence of distress. from a hematologic standpoint, the hematocrit on admission was elevated at 67.9. it was repeated on , and was more appropriate at 62.7 with a reticulocyte count of 1.6. with regards to routine health care maintenance, a hepatitis b vaccine had been given on . hearing screen was passed bilaterally on . physical examination at discharge: weight is 1805 gm. the infant is active and comfortable in no distress. the infant is mildly jaundiced throughout. the fontanelles are soft and flat. the palate is intact. ears and nares are patent. chest is clear to auscultation without grunting, flaring or retracting. heart exam is regular rate and rhythm without murmurs. abdomen is soft without hepatosplenomegaly or masses. extremities are warm and well-perfused. genitalia are that of a normal male. tone and activity are normal. disposition: the infant is being discharged to home with mother. the infant will follow up with primary pediatrician at community health center in one day. the infant will continue breastfeeding with supplemental expressed breast milk following each feed. the infant is not being discharged on any medications. discharge diagnoses: hyperbilirubinemia, resolving. prematurity, 35 4/7 weeks. small for gestational age with birth weight of 1845 gm. , md Procedure: Other phototherapy Diagnoses: Neonatal jaundice associated with preterm delivery

history of present illness: baby delivered at 27 5/7 weeks gestation weighing 1335 gm and was admitted to the intensive care nursery for management of respiratory distress and prematurity. mother is a 39 year old gravida 4, para 1, now 2 woman with estimated date of delivery . prenatal screens included blood type b negative, antibody screen negative, rpr nonreactive, rubella immune, hepatitis b surface antigen negative and group b streptococcus unknown. mother's obstetrical history is notable for tab times two and normal spontaneous vaginal delivery of a term male in . delusional disorder diagnosed in which is currently treated with seroquel and prolixin. this pregnancy complicated by prolixin and seroquel usage as above and onset of preterm labor on day of delivery with progression to delivery by cesarean section for breech presentation. the membranes were ruptured at delivery for clear fluid. there was no maternal fever or fetal tachycardia. the mother received antibiotics about 45 minutes prior to delivery. the infant emerged with good respiratory effort, was dried, bulb suctioned, given oxygen and then cpap by bag and mask for moderate retractions. was intubated around 4 minutes of age in the delivery room for respiratory distress. apgar scores were 7 and 8 at 1 and 5 minutes respectively. physical examination: physical examination on admission revealed weight 1335 gm (75th to 90th percentile), head circumference 26.5 cm (75th to 90th percentile), length 39.5 cm (75th percentile). anterior fontanelle slightly full but soft with intact palate. moderate chest retraction with decreased breathsounds bilaterally and scattered coarse crackles, well perfused with regular rate and rhythm, normal femoral pulses. no murmur. abdomen, soft, nondistended, no organomegaly, no masses, three vessel cord. patent anus. normal male genitalia with testes in canal bilaterally. active and responds to stimulation with tone appropriate for age. hips normal. hospital course: respiratory - placed on conventional ventilation on admission with maximum support required, pressures of 24/6, rate of 25, fio2 30%. received three doses of survanta for respiratory distress syndrome. weaned to cpap on day of life #2 and remained on cpap until day of life 33. he then required supplemental oxygen via nasal cannula until day of life #66 (). he has remained in room air since with respiratory rate of 30s to 50s with mild baseline subcostal retractions. had apnea of prematurity treated with caffeine citrate. the caffeine citrate was discontinued on day of life #53 (). the last bradycardia was on . cardiovascular - received two normal saline boluses following admission for low mean blood pressures, that required dopamine to maintain blood pressure for the first 24 hours of life and has not required any blood pressure support since. he has remained hemodynamically stable. a heart murmur was noted on day of life #3, an echocardiogram showed a normal heart structure with a very small patent ductus arteriosus that was not hemodynamically significant. fluids, electrolytes and nutrition - was initially npo on intravenous dextrose and then total parenteral nutrition. enteral feeds were started on day of life #3 and then stopped shortly after for bilious aspirates and distended bowel loops that resolved. feeds were restarted again on day of life #7 and advanced to full feeds by day of life #19 without problems. the caloric density was gradually increased to a maximum of 30 cal/oz of promod for good growth. needed nasogastric feedings until when he began to take all of his formula by bottles. at discharge he is feeding about every four hours, adlib amount of enfamil 24 with iron with very good weight gain. discharge weight 3500 gm. length 50 cm. head circumference 33 cm. gastrointestinal - was treated with phototherapy for indirect hyperbilirubinemia, peak bilirubin total 10.3, direct .3. hematology - infant's blood type is b positive, direct coomb's negative. the infant did not receive any blood transfusions during this hospitalization. the most recent hematocrit on was 28.8% with a reticulocyte count of 7%. lowest hematocrit was and that was 24.5%. infectious disease - received 48 hours of ampicillin and gentamicin following admission for rule out sepsis. the complete blood count was benign and the blood culture was negative. received 48 hours of vancomycin and gentamicin around one week of life for rule out sepsis with negative blood culture and normal complete blood count. he has not had any further episodes of infection. neurology - head ultrasound was done times three all showing no intraventricular hemorrhage, no periventricular leukomalacia. he does have a left choroid plexus cyst, which is a benign finding. sensory - audiology, hearing screening was performed with automated auditory brain stem responses. the infant passed both ears. ophthalmology, eyes were examined most recently on , revealing mature retinal vessels and follow up examination was recommended at 8 months of age. psychosocial - the mother has visited often and is comfortable taking care of . contact social worker for any questions is . and she can be reached at . condition on discharge: 74 day old, former 27 weeker, now 38 weeks corrected age. discharge disposition: discharged home with parents. primary pediatrician: , m.d., phone #. care/recommendations: 1. feeds - enfamil 24 with iron adlib. 2. medications - fer-in- 0.3 cc p.o. once a day. 3. carseat position screening, passed carseat test. 4. state newborn screens have been followed most recently on and are normal. 5. immunizations received - received first hepatitis b immunization on . he has not received the second dose. received two month immunizations that included dtap, hib, ipv, and pcv7 on . received synagis on . immunizations recommended - synagis respiratory syncytial virus 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 and 35 weeks with plans for daycare during respiratory syncytial virus season, with a smoker in the household or with preschool siblings; or 3. with chronic lung disease. influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age the family and other caregivers should be considered for immunization against influenza to protect the infant. follow up appointments scheduled/recommended: 1. the parents are to call pediatrician on monday, and arrange for appointment for early in the first week of discharge. 2. has been made. 3. early intervention had been made to minutemen early intervention program, . 4. ophthalmology examination recommended with pediatric ophthalmology at 8 months of age. 5. needs second hepatitis b immunization. discharge diagnosis: 1. appropriate for gestational age 27 5/7 weeks preterm male. 2. respiratory distress syndrome, resolved. 3. hypertension resolved. 4. chronic lung disease. 5. apnea of prematurity resolved. 6. patent ductus arteriosus. 7. indirect hyperbilirubinemia. 8. sepsis, ruled out times two. 9. left choroid plexus cyst. 10. anemia of prematurity. , m.d. dictated by: medquist36 d: 15:39 t: 15:54 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Other phototherapy Prophylactic administration of vaccine against other diseases Audiological evaluation Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Chronic respiratory disease arising in the perinatal period 27-28 completed weeks of gestation Primary apnea of newborn Patent ductus arteriosus Anemia of prematurity Other preterm infants, 1,250-1,499 grams

allergies: celexa attending: chief complaint: urosepsis major surgical or invasive procedure: history of present illness: hpi: 87-year-old male w pmh significant for cad, cri, afib, b sdh requiring craniotomy, and dementia who was transferred from for possible percutanouus decompression of gallbladder for cholecystitis in association with sepsis. . pt was in his usual state of health until 2 days prior to admission to osh when he developed bilateral lower back discomfort, generalized weakness, and f/c. in ed at on , pt found to have temp of 104.9 with ?rigors, uti +/- ? lll pna given dirty ua and possible lll infiltrate on cxr. pt given ceftriaxone, azithromycin and levo and 2l ns. he was then in shock c sbps in 70s on arrival to the floor and was transferred to the icu where he recieved 6l ivf. blood pressure stabilized transiently. within the same day the pts cr bumped from 1.8 to 2.6 (felt to be secondary to atn/sepsis) and his ast/alt increased from the 40s to the 500s (felt to be due to shocked liver). further fluid resuscitation was aborted due to high cvp and chf picture on cxr. the pt was hypoxemic and placed on nrb, felt to be secondary to fluid overload. intubation was never required. the pt was also in nsr on admission and converted back into a fib. on hd2 at the osh, the pt again became hypotensive with sbp in 70s, requiring pressure support with levophed. on the pt's wbc increased from 4 on admission to 46 and his bands increased from 5% on admission to 25%. blood cultures grew gnrs( sensitive to ceftazidime and resistant to ceftriaxone) and urine culture grew e coli. the patient was switched to ceftazidime. . also on hd2 at the osh, the pt complained of right lower quadrant pain, and a ruq ultrasound was performed that showed: cholecystitis with contracted gallbladder with thickening and edema but no stone/ductal dilatation. as the pt was having diarrhea, there was also a concern for c diff so flagyl was added. finally, one dose of gentamicin was given for double coverage for gram negative sepsis. pt was transferred to for percutaneous placement of cholecystostomy tube to decompress the gallbladder. . in the micu at , levofloxacin was discontinued, and blood cx/ua/cxr were repeated. pt was transferred on nrb--satting at 100%, which was quickly changed to 6lnc. cxr revealed lll infiltrate with probable associated small l pleural effusion. blood cx thus far reveals gram neg rods in the anaerobe cx, multidrug resistant including to ctx, cefazolin, amp, gent, fluoroquinolones, bactrim. initially the pt was on levophed but this was held as his sbp was in the 100s. ivf was also held given pts cvp was 18. pt was given lasix 20 mg iv x1 with improved oxygenation. hida scan was performed which revealed normal gallbladder filling, and surgery did not think this is c/w cholecystitis. as there was concern after pts platelets had been 140 on admission to osh and dropped to 61 here, dic panel was ordered and was negative, asa held. amiodarone was increased for tachycardia. . prior to transfer to the floor, the pt was noted to be hemodynamically improved with sbp of 120, slightly tachy in afib with hr in 100s-120s, oxygenating well on 6l nc, afebrile, cr down to 2, alt down to 453, ast down to 286. past medical history: past medical history: - cva - atrial fibrillation on amiodarone - coronary artery disease - chronic right-sided subdural hematoma. - subdural hematoma bilaterally status post craniotomy for a right-sided subdural. - bph s/p turp in - dememtia - glaucoma - crf( cr 1.0-1.4 at baseline) social history: social: patient lives with wife at home, no tobacco /etoh use. his son is involved in his care family history: family: noncontributory physical exam: on exam at admission: t m/c 97.4 hr 106-126 afib bp 96-136/73-99 (117/99) cvp 3-11 rr 18-26 sat 90-96% 6l nc i; 1640 o: 2215 gen- alert elderly man, agitated, talking loudly, not oriented heent- anicteric, slightly dry mm, poor dentition neck: supple, r ij line with dried blood on dressing cv- irregularly irregular, distant heart sounds, no r/m/g resp- ctab anteriorly but lll rales noted posteriorly abdomen- soft, ntnd, nabs, no palpable hsm, no palpable masses extremities- no edema, dp/pt 2+ b/l, l wrist restraint and l arterial line in place gu: foley with light yellow urine collected (now dc'd) neuro- confused, agitated, uncooperative in performing cn exam, moving all 4 extrem skin: large eccymosis on l forearm pertinent results: 02:06pm glucose-100 urea n-58* creat-2.0* sodium-144 potassium-4.1 chloride-113* total co2-20* anion gap-15 02:06pm alt(sgpt)-532* ast(sgot)-438* ld(ldh)-227 alk phos-131* tot bili-0.8 02:06pm albumin-2.5* calcium-8.0* phosphate-3.5 magnesium-2.0 02:00pm urine hours-random creat-90 sodium-less than 02:00pm urine osmolal-532 02:00pm urine color-yellow appear-clear sp -1.018 02:00pm urine blood-lg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-tr 01:50am fdp-10-40 01:28am type-art temp-36.8 rates-/21 o2 flow-12 po2-107* pco2-34* ph-7.31* total co2-18* base xs--8 01:28am lactate-3.7* 01:16am glucose-68* urea n-48* creat-2.2*# sodium-141 potassium-4.7 chloride-111* total co2-17* anion gap-18 01:16am lipase-14 01:16am ck-mb-notdone ctropnt-0.06* probnp-* 01:16am albumin-2.7* calcium-8.2* phosphate-4.4# magnesium-1.9 01:16am wbc-46.2*# rbc-4.31* hgb-13.1* hct-40.3 mcv-94 mch-30.3 mchc-32.4 rdw-15.5 01:16am neuts-82* bands-10* lymphs-1* monos-7 eos-0 basos-0 atyps-0 metas-0 myelos-0 01:16am hypochrom-normal anisocyt-1+ poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal burr-3+ how-jol-occasional 01:16am plt smr-very low plt count-70*# 01:16am pt-15.8* ptt-34.3 inr(pt)-1.6 01:16am fibrinoge-687* 10:15am blood wbc-10.2 rbc-3.81* hgb-11.1* hct-35.3* mcv-93 mch-29.1 mchc-31.5 rdw-16.4* plt ct-229 10:15am blood plt ct-229 10:15am blood glucose-122* urean-21* creat-1.2 na-146* k-4.1 cl-109* hco3-34* angap-7* 09:26am blood alt-90* ast-41* alkphos-194* totbili-0.9 04:54am blood alt-183* ast-112* ld(ldh)-186 alkphos-277* totbili-1.9* 06:39pm blood ck-mb-2 ctropnt-<0.01 10:15am blood calcium-8.0* phos-2.5* mg-2.1 10:17am blood lactate-2.3* 03:00am blood heparin dependent antibodies- microbiology: 1:45 am blood culture **final report ** aerobic bottle (final ): no growth. anaerobic bottle (final ): gram negative rod(s). identification and sensitivities performed on culture # from . 1:35 am blood culture **final report ** aerobic bottle (final ): no growth. anaerobic bottle (final ): reported by phone to at 4:58a . escherichia coli. final sensitivities. trimethoprim/sulfa sensitivity available on request. warning! this isolate is an extended-spectrum beta-lactamase (esbl) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. consider infectious disease consultation for serious infections caused by esbl-producing e. coli and klebsiella species. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- =>64 r cefepime-------------- r ceftazidime----------- r ceftriaxone----------- r cefuroxime------------ =>64 r ciprofloxacin--------- =>4 r gentamicin------------ =>16 r imipenem-------------- <=1 s levofloxacin---------- =>8 r meropenem-------------<=0.25 s piperacillin---------- =>128 r piperacillin/tazo----- <=4 s tobramycin------------ 8 i abd u/s (): impression: 1. no evidence of biliary ductal dilatation. 2. mild persistent gallbladder wall edema in a nondistended gallbladder, which could represent sequelae of concurrent illness or intrinsic liver disease. cxr (): impression: small left pleural effusion with a patchy opacity in the left lower lobe likely consolidations/atelectasis. 2) right basilar atelectasis. hida scan (): impression: no evidence of acute cholecystitis. normal gallbladder study. brief hospital course: a/p: 88yo m with h/o afib, bilateral subdural hematomas requiring craniotomy, dementia, transferred from osh where he had been treated for sepsis growing gnr from blood, uti, , lll pna. pt was transferred for tx of presumed acalculous cholecystitis, however here pt is negative for cholecystitis and continuing tx of uti/pna/post-sepsis/. . # s/p septic shock: patient initially hypotensive and briefly required levophed to maintain adequate blood pressures. lactate elevated and overall picture c/w sepsis. interventional radiology and surgery were consulted during the patient's stay and did not believe the patient had acute cholecystitis and therefore did not feel that percutaneous drainage was necessary. other etiology could be from lll pna. normal response to cortisol stim test. etiology most likely secondary to urosepsis as urine cx positive for e. coli. at outside hospital had been treated with ceftazidime as inital cultures showed susceptibility. however cultures obtained here grew out e coli resistant to ceftazidime so patient was started on meropenem which the e coli was sensitive to. flagyl was given for several days as organisms had been growing in anaerobic bottle but was discontinued several days prior to discharge. patient to complete a 14 day course that will be completed on . a picc line was placed prior to discharge so that patient could finish this course after discharge. pt has been afebrile, normotensive, with no pressors or fluid boluses needed in the days prior to discharge. wbc within normal limits prior to discharge but had been as high as 46.2. . . #uti: likely cause of urosepsis as noted above and was treated as previously mentioned. patient initially had foley catheter in place. patient voiding well since catheter removed. . #lll pna: likely cap as pt had this infiltrate upon arriving at osh. patient treated with a course of azithromycin during his stay . #chf: pt with h/o chf and ef of 30% on tte from , bnp of 60k here but baseline unknown. pt was likely volume overloaded on transfer given aggressive hydration. once normotensive ivf were discontinued and several doses of lasix were given for diuresis. patient no longer volume overloaded clinically and has maintained good oxygen saturations. . # acalculous cholecystitis: likely not acute cholecystitis. on us at osh there was gallbladder wall edema and thickening but no stones. repeat us done here did not reveal evidence of cholecystitis or biliary obstruction. hida on revealed complete filling. pt seen by both surgery and ir, who agreed that no evidence of acute cholecystitis. . #transaminitis: lfts now resolving as perfusion improving suggesting shock liver at time of transfer from osh. statin initially held for potential liver toxicity but restarted once improved lfts. would recommend that patient have lfts rechecked as outpatient. . # atrial fibrillation/ tachycardia: pt with h/o paroxysmal afib previously on amiodarone. pt was in nsr initially on admission to osh, but converted into afib at osh and has been in afib while here but with good rate control. amiodarone stopped and patient started on metoprolol with good effect while still in afib. no coumadin or heparin given recent subdural hematomas and concern that patient may be at risk for falls. patient reverted back to nsr during admission so amiodarone was restarted. metoprolol was stopped as patient not tachycardic and son reports h/o hypotensive episodes in the past. . # thrombocytopenia: platelets dropped below 70 during course of admission, likely secondary to hit i versus sepsis. pt without purpura or anemia, making ttp less likely. hit type ii unlikely given negative hit ab. peripheral smear showed only burr cells attributable to liver disease or more likely uremia. sc heparin and aspirin were held while platelets low but restarted once normalized. patient's platelets returned to prior to discharge. . # acute renal failure: likely related to hypotension/atn. fena less than 1% on admission. cr 1.0 on , up to 2.8 at osh. cr improved during admission and returned to baseline. while in arf medications had been renally dosed. . # dementia: patient initially experienced sundowning overnight requiring sitter. increased home dose of zyprexa. patient's mental status improved significantly in the days prior to discharge and he was at baseline as per son. continued home aricept. . #decreased anion gap: patient has had decreased anion gap during admission. would recommend following as outpatient, potentially with spep to r/o hyperproteinemia. . # cad- continued aspirin once platelets normalized as noted above. . #bph- started on finasteride during admission with good effect. . # communication - (son) . # code- apparently full code -will address code status with son . # access- patient initially had r ij catheter. this was removed and picc line was placed. . # ppx- pneumoboots, hold heparin until hit negative, ppi medications on admission: medications on admission: aricept 10 qd folic acid 1 qd amiodarone 200 zyprexa 2.5 qd asa 325 qd protonix 40 qd lescol 80 qd colace 100 kcl 20 timolol ditropan xl 10 qd ceftaz genta x1 azithro 500 qd levaquin 500 qd discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed. 3. donepezil 10 mg tablet sig: one (1) tablet po hs (at bedtime). 4. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po hs (at bedtime). 6. olanzapine 5 mg tablet, rapid dissolve sig: two (2) tablet, rapid dissolve po daily (daily). 7. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 8. heparin sodium (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day): until mobile. 9. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 10. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). 11. meropenem 1 g recon soln sig: one (1) gram intravenous q8h (every 8 hours) for 1 weeks: for e coli urosepsis, resistant to most other antibiotics. 12. timolol maleate 0.25 % drops sig: one (1) drop ophthalmic (2 times a day). 13. folic acid 1 mg tablet sig: one (1) tablet po once a day. 14. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times a day). discharge disposition: extended care facility: of discharge diagnosis: urosepsis pneumonia discharge condition: hemodynamically stable, breathing comfortably on room air with o2 sats in mid-90s%, afebrile discharge instructions: please continue to take all medications as prescribed and follow up with your doctors. with the healthcare team at the rehabilitation facility. return to the nearest emergency room if you have shortness of breath, chest pain, confusion, or any other concerning symptoms. followup instructions: please follow up with your primary care physician within one week of discharge from acute rehabilitation. please bring a copy of your discharge paperwork so that you physician is updated on your hospital stay. please have you physician perform follow up blood work including chemistries, complete blood count, and liver function tests. Procedure: Venous catheterization, not elsewhere classified Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Thrombocytopenia, unspecified Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Acute and subacute necrosis of liver Severe sepsis Atrial fibrillation Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other persistent mental disorders due to conditions classified elsewhere Septicemia due to anaerobes Septicemia due to escherichia coli [E. coli]

history of present illness: an 87-year-old male who was found by the visiting nurses to be orthostatic today. he was admitted after falls recently and had been seen at . he denied any other complaints. on evaluation at the outside hospital, hospital, his head ct showed bilateral subdural hematoma measuring 2.2 cm on the right and 1.0 cm on the left. past medical history: significant for a stroke in the past, atrial fibrillation which was recently diagnosed, coronary artery disease and chronic right-sided subdural hematoma. medications on admission: proscar, zoloft, amiodarone, buspar, protonix and flomax. physical examination: general: awake, alert and oriented times three. vital signs: pulse 99. blood pressure 141/61. heart rate 94. respirations 20. 97% on room air. cardiac: regular rate and rhythm. chest: clear bilaterally. abdomen: soft and nontender. neurologic: he is awake and alert. left pupil was , right was , round and reactive. cranial nerves ii-xii were intact. his strength was 5- throughout except for his grip on his left side was 4. sensation was intact. laboratory data: white count 7.5. hematocrit 46.4. platelets 278. sodium 143. bun 14. creatinine 1.3. glucose 88. inr was 1.1. hospital course: the patient was admitted to the neuro step- down unit where he was seen by dr. . he was found to be awake, alert, attending the examiner, oriented to the year and conversant with good attention. he was moving all extremities without any drift. he felt the right-sided fluid collection appeared to be separated and would need a craniotomy to get the best drainage and best results. he spoke with the patient's son who he wanted medical therapy initially and not to have surgery at this time to see how he did being treated medially. so, he remained in the neuro step-down unit where his vital signs and neuro checks were monitored every 1 hour. his inr was kept less than 1.3, and his platelets were kept greater than 100. he was noted to be quite orthostatic by both nursing and physical therapy. his flomax was stopped thinking that perhaps that could cause some of his orthostatics, and he was well-hydrated. he remained in atrial fibrillation while he was here, and cardiology was to see him. initially, they had thought of trying to convert him with cardioversion. however, they decided to favor medical treatment with increasing his amiodarone to 200 b.i.d. and lopressor 50 mg p.o. b.i.d. his rate did become more controlled from the 110s down to 90s to low 100s. on the morning of , he was found to only lift his left arm off the bed briefly, and he was antigravity with his left leg. his strength was definitely diminished on the left side, and he had full strength on the right. given his new left-sided hemiparesis kind of symptoms, he got a stat head ct. the head ct showed both subdural collections demonstrating layering phenomenon as well as apparently more acute hemorrhage within the components. the right convexity hemorrhage faced nearly all the adjacent cortical sulci. there was less sulci effacement on the left side. the ventricular system was compressed, but no appreciable shift. abnormal midline structures were noted. the surrounding ostia and soft tissue structures were within normal limits. the family was spoken to and given his motor changes. he was brought emergently to the operating room and underwent a craniotomy for drainage of a right subdural hematoma. postoperatively, he was awake, alert and oriented times three. he was monitored in the recovery room overnight. his strength seemed to be 5 to 5- bilaterally, and he had a subdural drain in place. he had a head ct on which showed overall decreased size of his right-sided subdural hematoma. his left side had remained stable. he was noted to have a left drift on examination. he was transferred to the neuro step-down unit that day, and he has remained neurologically intact following commands, awake, alert, tolerating a regular diet. he had a foley placed at the hospital prior to him being transferred here, and he had complained of a traumatic placement of that and had some hematuria on arrival here. he had the foley removed twice for trials of him to be able to void spontaneously, which has not worked. so, now he does have foley re-inserted, and that should remain in place for approximately a week until another trial period can be assessed. currently, he is being seen by physical and occupational therapy. i do not have an assessment at this time, but we feel that he will most likely need acute rehabilitation facility for strengthening and gait assistance and assistance with activities of daily living. he is tolerating a regular diet. he has minimal complaints of headaches, and he is moving all extremities well. discharge instructions: he is to keep his staples dry, do not get them wet. he should watch staples for redness, drainage, swelling. they should be removed at the rehabilitation facility on , . he should not do any heavy lifting. he should follow up with a head ct in two weeks with dr. . discharge diagnoses: 1. subdural hematoma bilaterally status post craniotomy for a right-sided subdural. 2. atrial fibrillation status post cerebrovascular accident. 3. coronary artery disease. 4. orthostasis. discharge medications: 1. timolol maleate 0.25 drops one drop ophthalmic b.i.d. 2. clorazepate potassium 3.75 two tablets p.o. once daily 3. sertraline 50 mg 0.5 tablets p.o. daily. 4. lopressor 50 mg one tablet p.o. b.i.d. 5. finasteride 5 mg tablet p.o. daily. 6. buspirone 10 mg tablets p.o. b.i.d. 7. amiodarone 200 mg one tablet p.o. b.i.d. 8. tylenol 325 two tablets every four hours as needed. 9. protonix 40 mg pi once daily 10. heparin 5000 subcu t.i.d. 11. dilantin 100 mg two tablets every 12 hours. 12. lopressor 25 mg half tablet p.o. t.i.d. 13. tylenol with codeine 300/30 mg p.o. every 4-6 hours. 14. oxybiotin 5 mg one tablet p.o. t.i.d. 15. bacitracin ointment to his meatus q.i.d. 16. colace 100 mg tablets p.o. b.i.d. , dictated by: medquist36 d: 10:45:16 t: 11:10:36 job#: Procedure: Incision of cerebral meninges Incision of cerebral meninges Diagnoses: Coronary atherosclerosis of native coronary artery Atrial fibrillation Personal history of other diseases of circulatory system Subdural hemorrhage Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Orthostatic hypotension Contusion of face, scalp, and neck except eye(s) Other fall

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: perforated esophagus major surgical or invasive procedure: perforated esophagus after wretching s/p thoracotomy, repair of esophageal perforation, g-j tube placement. history of present illness: mr. is a 43-year-old gentleman with a prior history of reflux disease who has been off proton pump inhibitors for the last 6 months. at approximately 06:00 p.m. on the fifth, the patient was eating supper and developed a meat impaction of the distal esophagus. this caused him to retch with the acute onset of left chest pain and hematemesis. he was seen in emergency room where a gastrografin swallow showed prompt extravasation of contrast towards the left chest. this was confirmed with a ct scan, confirming the diagnosis of boerhaave syndrome of spontaneous esophageal rupture. past medical history: gerd social history: +tob, +etoh 5x/wk family history: n/a physical exam: admit pe vs: 97 121 190/90 18 96%@2l distressed cta-b tachy nd, tender to palp. firm pertinent results: 10:00pm blood wbc-14.3* rbc-3.75* hgb-11.7* hct-33.6* mcv-90 mch-31.3 mchc-34.9 rdw-12.6 plt ct-349 04:06am blood wbc-11.2* rbc-3.96* hgb-12.1* hct-35.8* mcv-91 mch-30.6 mchc-33.8 rdw-12.8 plt ct-306 05:34am blood wbc-13.2* rbc-4.20* hgb-12.8* hct-37.0* mcv-88 mch-30.4 mchc-34.5 rdw-12.7 plt ct-563* 10:00pm blood neuts-91.5* bands-0 lymphs-5.8* monos-2.5 eos-0.1 baso-0.1 10:00pm blood pt-14.3* ptt-25.6 inr(pt)-1.4 03:09am blood pt-13.5* ptt-28.2 inr(pt)-1.2 04:07am blood plt ct-342 12:44am blood plt ct-415 10:00pm blood glucose-102 urean-15 creat-0.9 na-142 k-3.2* cl-110* hco3-22 angap-13 04:06am blood glucose-102 urean-10 creat-0.9 na-141 k-4.0 cl-107 hco3-25 angap-13 05:34am blood glucose-144* urean-15 creat-0.7 na-141 k-3.8 cl-108 hco3-24 angap-13 05:34am blood alt-30 ast-29 ld(ldh)-182 alkphos-54 amylase-201* totbili-0.5 04:07am blood calcium-7.9* phos-2.5*# mg-1.3* 05:34am blood calcium-8.5 phos-3.3 mg-2.0 post-op cxr (): satisfactory postoperative appearance with a faint right basilar density. chest ct (): minimal hickening at the distal esophagus as it crosses the diaphragm. no definite peri-esophageal fluid collection is seen; no significant fluid collection is seen within the esophagus. cxr (): the heart size and mediastinal contours are unchanged. two left-sided chest tubes are in unchanged position. a tiny left apical pneumothorax is stable in appearance. a small left-sided pleural effusion and atelectasis within the left lower lobe are unchanged. no new opacities are seen within the lungs. brief hospital course: pt was transferred from hospital with a gastrgraffin swallow and ct suggesting an esophageal rupture. his initial constellation of syptoms began with wretching after a meal, and included vomitting and feeling steak stuck in his throat, followed by hematemesis and the acute onset of chest, abd as well as back pain. he was taken emergently to the or in the morning of for the above procedure. the operation itself was without complication or finding necessitate a change in preop dx; however, during intra-op egd, an esophageal flap was identified. a g and j tube were placed intraoperatively for considerations of post-op management. post-operatively, he was transferred to the sicu intubated, and stated on amp/levo/flagyl. he was extubated on pod#1, and started on jejunal tube feeds on pod#2, and an ent consult was obtained for the esophageal web. he remained stable in the sicu and was transferred to the floor on pod#3. he tolerated his tube feeds well, and the chest tubes were kept to sxn until pod#5; cvl was also removed n pod#5. of note, upon his transfer to the floor, the j and g tubes were reversed, such that he was getting tfs in the g and the j was to gravity; the situation was recognized and corrected with no apparent sequelae (the ngt and was removing all feeds from stomach). the ngt was removed by pt on pod#7, but g-tube remained to gravity, no issues. on pod#8, the chest tubes were put to air seal, all po meds were changed to the j-tube and he was freely ambulating and tolerating tfs at goal; also on this day, his intra-operative cultures came back + for pseudomonas, and he was transitioned from levo to cipro. cm was able to obtain home services for his feeds and drains. on pod#11, pt was considered stable for discharge home, and all necessary services were arranged. medications on admission: none discharge medications: 1. tube feeding replete w/ fiber at______/hr for ______/ hours. ____cans/day 2. tube feeding pump tube feeding pump for cycled jejunostomy feedings 3. iv pole iv pole 4. tube feeding bags tubefeeding bags # 30. refill x1 5. syringes 60cc catheter tip syringes #20, refill-1 6. tubefeeding pump, pole, j/g tube supplies 7. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4-6h (every 4 to 6 hours) as needed. disp:*600 ml(s)* refills:*0* 8. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 2 weeks. disp:*42 tablet(s)* refills:*0* 9. ciprofloxacin 250 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 2 weeks. disp:*28 tablet(s)* refills:*0* 10. ampicillin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 2 weeks. disp:*56 capsule(s)* refills:*0* 11. lansoprazole 30 mg susp,delayed release for recon sig: one (1) dose po bid (2 times a day). disp:*60 dose* refills:*2* discharge disposition: home with service facility: home therapies discharge diagnosis: gastroesophogeal reflux disease, perforated esophagus after wretching s/p thoracotomy, repair of esophageal perforation, g-j tube placement. discharge condition: good, improving discharge instructions: call dr. office for: fever, chest pain, sshortness of breath, nausea, vommitting, constipation, abdominal pain, diarrhea; or seek more immediate medical attention at a convenient ed. you should not restart your home medications you were taking pre-operatively, and you should likewise remain npo with tube feeds for the next 3 weeks (as per vna). you may shower but absolutely not bath or immerse yourself in water, with careful drying of the incision sites and covering of the chest tubes. the chest tubes will remain covered with gauze at all times. crush your medications as shown, and administer through j-tube. your g-tube should remain to gravity at least until your follow-up appt. followup instructions: call cr. office for appointment in weeks, after swallow studies. . tube feeding monitoring with vna. tubefeeding care provided by home therapies- . presriptions for tube feeding supplies to be faxed to . Procedure: Other enterostomy Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Incision of mediastinum Other gastrostomy Suture of laceration of esophagus Other repair of esophagus Diagnoses: Esophageal reflux Diaphragmatic hernia without mention of obstruction or gangrene Hematemesis Mediastinitis Perforation of esophagus

history of present illness: baby girl is the third of triplets, a former 1340-g, 31-1/7 week female, admitted to the newborn intensive care unit for management of prematurity. mother is a 28-year-old gravida 1, para 3 prenatal screens: o positive, antibody negative, rapid plasma reagin nonreactive, rubella immune, hepatitis b surface antigen negative, group b strep unknown. this pregnancy was achieved via in fertilization. mother was admitted with a history of vaginal bleeding the triplets were in vertex/vertex/breech positions. biophysical profile was 8/8 times three. she was transferred to the floor for observation. she received one dose of betamethasone and developed cramping. examination was noted to be 4 cm dilated. she was started on magnesium sulfate and progressively labor led to a cesarean section under combined epidural anesthesia. rupture of membranes was at delivery. this baby required vigorous stimulation and brief bag and mask ventilation for a heart rate of about 80, improving by one minute. the baby received blow by oxygen and suctioning and went to the newborn intensive care unit with blow by oxygen. apgar scores were 7 at 1 minute and 8 at 5 minutes. physical examination on presentation: examination on admission revealed a premature female with mild respiratory distress. temperature of 97.3, heart rate of 168, respiratory rate of 64, blood pressure of 41/29, with a mean of 39. birth weight was 1340 g (25th percentile). discharge weight was g. admission length was 39 cm (25th percentile). head circumference was 38.5 cm (40th percentile). discharge length of 42.5 cm. discharge head circumference of 31.5 cm. anterior fontanel was soft and flat, nondysmorphic, intact palate, normal red reflex. ou fair aeration, coarse breath sounds. no murmur. normal pulses. soft abdomen. a 3-vessel cord. no hepatosplenomegaly. normal female genitalia. patent anus. no sacral dimple. no hip click. normal tone for age. hospital course by system: 1. respiratory: the baby required intubation and received two doses of surfactant and was extubated by day of life two to room air. she continued to do well on room air with no further issues with respiratory distress. the baby exhibited one quickly self-resolved episode of apnea and bradycardia soon after extubation and has had no further issues with apnea and bradycardia of prematurity. did not require any methylxanthine treatment. 2. cardiovascular: the infant did not require any boluses or pressor support during transition. she has been hemodynamically stable with a soft intermittent murmur. 4- extremity blood pressures, chest radiograph and electrocardiogram were within normal limits on . murmur was thought to be probably a flow murmur. blood pressure was stable at 63/30s with mean in the 40s. 3. fluids/electrolytes/nutrition: the baby initially had peripheral intravenous line with maintenance intravenous fluids. enteral feedings introduced on day of life one. she advanced to full enteral feedings of pe-20 by day of life eight at 150 cc/kg caloric density was increased to pe 28 calories per ounce with promod. as her weight and oral intake improved and her p.o. improved, caloric density was decreased, and she was switched over the enfamil 26 calories per ounce, for discharge. this was achieved by concentrating the enfamil to 24 calories per ounce plus 2 calories per ounce of corn oil (which is 0.5 cc per 60 cc of formula which equals two additional calories per ounce). the baby was also receiving supplemental iron 0.2 cc p.o. q.d. which is a 2 mg/kg per day. siblings were on the same dose at home. the baby is currently feeding all orally and doing well. 4. nutrition laboratory: the nutrition laboratories were on with a sodium of 143, potassium of 5.3, chloride of 106, bicarbonate of 25, blood urea nitrogen of 22, creatinine of 0.5. alkaline phosphatase of 197, albumin of 3.7. calcium of 10.8. phosphorous of 6.8. at that time, her hematocrit was 34.2. 5. gastrointestinal: the baby did exhibit some indirect hyperbilirubinemia with a peak bilirubin on day of life two of 5.2/0.4. she responded to phototherapy, and her rebound bilirubin on day of life four was 2.6/0.2. 6. hematology: admission hematocrit was 45. last hematocrit was on and was 30.2, with a reticulocyte count of 3.6%. the baby did not require any blood products during this admission. 7. infectious disease: because of her respiratory distress, the baby had an initial sepsis evaluation with a white blood cell count of 6.9 (17 polys and 1 band), platelets of 263,000, and a hematocrit of 45, and 13 nucleated red blood cells. she had a blood culture sent and was started on a 48-hour course of ampicillin and gentamicin. her clinical course had improved by 48 hours, and cultures remained negative. antibiotics were stopped. she has had no further issues with infection. 8. neurology: the baby had a head ultrasound on (which was day of life 11) which showed no intraventricular hemorrhage. she was clinically appropriate for gestational age. 9. sensory: she passed her audiology screening. ophthalmology eye examination on showed mature retinas with plans to follow up in eight months. 10. psychosocial: the parents have been visiting and looking forward to transitioning triple number iii home to joint her siblings. condition at discharge: condition on discharge was stable. discharge disposition: home with family. pediatrician: primary pediatrician is dr. , , (telephone number ; fax number ). care recommendations: 1. feeds: continue enfamil 26 with iron ad lib. 2. medications: fer-in- 0.2 cc p.o. q.d. (which equals 2 plus mg/kg per day). 3. car seat screening: passed. 4. state newborn screening: serial state screens were sent and were within normal range. no concerns. immunizations received: none to date. the plan was to have all three triplets receive their immunizations after discharge, as number iii is not big enough to receive hers at this time. immunizations recommended: synagis respiratory syncytial virus 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 and 35 weeks with plans for day care during respiratory syncytial virus season, with a smoker in the household, or with preschool siblings; or (3) with chronic lung disease. influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age, the family and other care givers should be considered for immunization against influenza to protect the infant. followup appointments: 1. follow up with primary care pediatrician within three to five days. 2. was following this family. discharge diagnoses: 1. premature triple number iii of iii born at 31-1/7 weeks gestational. corrected gestational age of 35-2/7 weeks at the time of discharge. 2. status post respiratory distress syndrome. 3. status post indirect hyperbilirubinemia. 4. status post rule out sepsis with antibiotics. 5. status post apnea and bradycardia of prematurity. 6. anemia of prematurity. dr. , a. f. dictated by: medquist36 d: 17:27 t: 18:42 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Observation for suspected infectious condition Anemia of prematurity Other preterm infants, 1,750-1,999 grams Unspecified fetal and neonatal jaundice Other multiple birth (three or more), mates all liveborn, born in hospital, delivered by cesarean section Abnormality in fetal heart rate or rhythm, unspecified as to time of onset

*allergies: iodine ** please see admit note/fhp for admit info and hx. neuro: pt very pleasant, sleeping most of shift, easily arousable, follows commands, answers simple questions but unable to fully determine orientation (difficult to understand). able to sxn mouth w/ yankaur, assist w/ turns, make needs known. haldol . ? baseline dementia. cardiac: v-paced w/ rare pvc's, hr 50-59, sbp 100-145. hct 25.7, k 4.2 (received kayexalate yesterday). resp: remains on a/c 40%/500/12/5, o2sat 100%, rr 12-22, ls coarse throughout, sxn q3-4h for mod-copious thick yellow secretions. no c/o difficulty breathing. gi/gu: soft diet, deflate trach for meds and meals (7cc's). +bs, no stool this shift, abd obese/non-tender. urine out foley yellow/clear, 30-40cc/hr. id: temp 98.2-98.4, wbc 4.3. ciprofloxacin and vanco for pna. iv sites wnl. psychosocial: daughter visited in evening, will most likely return to rehab today or tomorrow. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute kidney failure, unspecified Cardiac pacemaker in situ Chronic obstructive asthma, unspecified Dehydration Diverticulosis of colon (without mention of hemorrhage) Chronic respiratory failure Dependence on respirator, status

allergies: iodine attending: chief complaint: found unresponsive major surgical or invasive procedure: none history of present illness: patient is an 83 yo f with a history of copd, ventilator dependence who was found today at rehab to be off the ventilator. cpr was initiated (though no documented loss of pulse) and patient was reattached to the ventilator. records are limited but report that the patient was unresponsive and possibly hypoxic (though numbers not documented). . on arrival to the ed she had sinus brady at 50 bp 132/22 rr 20 100% in the ed the patient was found to have altered mental status (unclear baseline) as well as a leukocytosis and cxr concerning for pneumonia. therefore, was treated with levofloxacin 750 mg iv, metronidazole 500mg iv, vancomycin 1g iv. past medical history: 1. anemia - on aranep; iron studies from c/w aocd. nl spep. no upep sent. 2. l hiatal hernia 3. copd, vent dependent for > 4years 4. htn 5. cad: h/o mi; no recoerds availble; ef unknown 6. h/o gib 7. diverticulosis 8. h/o mssa 9. chronic asthma 10. history of admissions altered ms in the setting of overmedication and pna: pseudomonas and mssa in sputum (no infiltrate on cxr; no leukocytosis) 11. single lead guidant meridien pacemaker for symptomatic bradycardia social history: lives at , no h/o tobacco, no etoh, no ivdu. at baseline needs assistance to commode family history: nc physical exam: pe: (last wt at rehab 205.7) gen: obese woman in no acute distress with trach in place and attached to ventilator heent: perrl, eomi, mmm, no lad cv: rrr no murmurs lungs: coarse breath sounds throughout, occasional wheezing, with rhonchi centrally, trach in place abd: soft, diffusely tender, nd, + bs, per ed guaiac + and negative ext: moving all 4 extremities equally, good 2+ pulses in all four extremities, trace edema bilaterally neuro/psych: would not tolerate plantar reflexes, ue 2+ biceps reflexes. unable to assess sensation. could not say last name, date of birth. follows all commands. cannot assess speech secondary to trach, also with out teeth. pertinent results: admission labs: 09:45pm blood wbc-13.3*# rbc-3.12* hgb-8.7* hct-28.2* mcv-90 mch-27.9 mchc-30.9*# rdw-16.5* plt ct-119* 09:45pm blood neuts-93.8* lymphs-3.0* monos-2.9 eos-0.2 baso-0.1 09:45pm blood pt-14.2* ptt-27.3 inr(pt)-1.3* 09:45pm blood glucose-113* urean-34* creat-1.9* na-141 k-4.3 cl-109* hco3-22 angap-14 09:45pm blood ck(cpk)-81 06:44am blood alt-23 ast-33 ck(cpk)-74 alkphos-88 totbili-0.3 09:45pm blood ck-mb-notdone ctropnt-0.18* 06:44am blood ck-mb-notdone ctropnt-0.20* 04:18pm blood ck-mb-7 ctropnt-0.18* 09:45pm blood calcium-9.0 phos-4.4 mg-1.8 06:44am blood albumin-3.1* calcium-9.2 phos-4.0 mg-1.8 iron-18* cholest-116 06:44am blood caltibc-191* ferritn-384* trf-147* 06:44am blood triglyc-39 hdl-64 chol/hd-1.8 ldlcalc-44 09:45pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 11:48pm blood lactate-0.9 02:44am blood type-vbg temp-37.4 rates- tidal v-500 peep-5 fio2-50 po2-38* pco2-68* ph-7.25* caltco2-31* base xs-0 intubat-intubated comment-axillary=9 discharge labs: 02:58am blood wbc-4.3 rbc-2.87* hgb-8.1* hct-25.7* mcv-90 mch-28.2 mchc-31.5 rdw-16.4* plt ct-93* 10:02am blood hct-25.9* 09:45pm blood neuts-93.8* lymphs-3.0* monos-2.9 eos-0.2 baso-0.1 02:58am blood plt smr-low plt ct-93* 02:58am blood glucose-81 urean-31* creat-2.0* na-142 k-4.2 cl-112* hco3-24 angap-10 02:58am blood alt-17 ast-21 ld(ldh)-172 alkphos-86 totbili-0.4 02:58am blood calcium-8.7 phos-3.7 mg-1.8 04:18pm blood ck-mb-7 ctropnt-0.18* non-contrast head ct scan. findings: there is no hemorrhage, mass effect, shift of the normally midline structures or major vascular territorial infarct. the -white matter differentiation is preserved. mild periventricular white matter hypodensities are consistent with chronic microvascular ischemia. the overlying soft tissues and osseous structures are unremarkable. incidental note is made of bony nonfusion of the posterior arch of c1. there is opacification of the left mastoid air cells without osseous destruction. the visualized nasopharynx appears normal and symmetric. impression: 1. opacification of the left mastoid air cells. 2. no hemorrhage or mass effect. echo: general comments: suboptimal image quality - poor echo windows. suboptimal image quality - poor parasternal views. suboptimal image quality - poor apical views. suboptimal image quality as the patient was difficult to position. suboptimal image quality - body habitus. suboptimal image quality - ventilator. conclusions: the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. overall left ventricular systolic function is low normal (lvef 50%) secondary to hypokinesis of the inferior and posterior walls. there is no ventricular septal defect. the right ventricular cavity is dilated. right ventricular systolic function appears depressed. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen. there is no pericardial effusion. renal ultrasound: portable renal ultrasound indication: 83-year-old woman with acute renal failure. rule out obstruction. findings: the bedside study is markedly limited by patient's body habitus and inability to cooperate. limited views of the right and left kidneys were obtained. a right kidney measures 8.7 cm, left kidney was not measured. no hydronephrosis is detected on these limited views. several simple cysts are noted bilaterally, measuring up to 2 cm in size. impression: markedly limited study. no hydronephrosis. several simple cysts. cxr: chest one view: cardiac size, mediastinal and hilar contours are unchanged. persistent elevated left hemidiaphragm. left-sided pacemaker with intact lead terminating over the right ventricle. persistent small bilateral pleural effusions. persistent vascular congestion and multifocal airspace opacity predominantly in the lower lobes. there is no pneumothorax. impression: essentially unchanged radiographic chest; likely mild chf and multifocal pneumonia. microbiology: 11:30 pm blood culture site: arm #1. aerobic bottle (final ): reported by phone to at on .. staphylococcus, coagulase negative. isolated from one set only. sensitivities performed on request.. of two colonial morphologies. anaerobic bottle (preliminary): corynebacterium species (diphtheroids). isolated from one set only. . sputum culture: staph aureus coag + | acinetobacter baumannii | | ampicillin/sulbactam-- =>32 r cefepime-------------- =>64 r ceftazidime----------- =>64 r ciprofloxacin--------- =>4 r erythromycin---------- 4 i gentamicin------------ <=0.5 s <=1 s imipenem-------------- 8 i levofloxacin---------- =>8 r oxacillin-------------<=0.25 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s . brief hospital course: 83 yo f with chronic ventilator dependence secondary to copd who presents after being found unresponsive. history of unresponsiveness: per report the patient was quite unresponsive at rehab and required cpr. however, the patient had improving mental status as the course progressed. she now appears to be somewhat close to her baseline. additionally was off the vent when found which may have caused now able to have some level of interaction. however, per report was difficult to arouse when off the ventilator, suggesting likely hypoxia secondary to difficulty mentating. additionally, though patient may have an element of infection that may be causing some mild encephalopathy. no other signs of unresponsiveness while hospitalized. pneumonia: no increased ventilator requirements, but did have questionable infiltrate on cxr and secretions concerning for infection. sputum cultures showed mssa and acinetobacter that were resistent to cipro. given this the patient was changed from vancomycin/ciprofloxacin to bactrim. - recommend 8 additional days of bactrim po. copd/ vent dependence/asthma: patient has chronic history of vent dependence. also with co2 retention on previous abgs. - continue albuterol, combivent, flovent as per rehab dose. cardiac: - pump: echocardiogram showed low normal ef with regional wall motion abnormalities likely consistent with known cad and mi. no echo was available - cad: has history of cad by report and an mi at another hosptital. given this it is unclear why the patient is not on a statin, aspirin, ace-inhibitor and possibly a beta-blocker. will start toprol xl, statin for now. will need to readdress the need for aspirin with rehab doctors. - has enzyme leak, but does have last trop .11 and worsening renal function. no signs of acute coronary syntrome. - rhythm: from ecg and cxr it appears that the patien thas a single lead in the ventricle. from records, it appears that the pacer was placed for persistent bradycardia. on interrogation by ep, there was no signs of pacer malfunction. however, there is no record of ventricular activity in the pacemaker and will not accurately record the information. ok to start beta-blocker for risk reduction given that the patient has a pacemaker for a back-up rate. acute renal failure: has elevation of creatinine up from baseline. cause is unclear as to her current worsening of renal failure. initial labs showed a picture more consistent with pre-renal etiology (fena 0.5%) but now showed intrarenal causes (fena 1.2%). urinalysis did not show signs of overwhelming atn, though the patient may have had some mild hypoperfusion/hypoxia surronding the unresponsive episode. regardless the renal function is stable now and electrolytes were normal. -labs should be followed every 2-3 days to ensure that renal function is improving and that electrolytes remain normal. history of gi bleed : guaiac positive in ed. does have known history of diverticulosis/itis and this could be cause of trace guaiac positive stools. currently above baseline, but will follow hct. patient had decreased hct to 25 at time of discharge. however, a repeat hct was stable and the patient did not have signs of ongoing bleeding. hypertension: hypertensive in ed, but bp range from 100s to 180s in icu initially. however bp improved and outpatient meds were started. however, hydralazine was restarted at a lower dose given initial low bp as well as desire to start metoprolol xl for risk reduction given known cad. can increase hydralazine as bp tolerates. anemia: per report, has anemia of chronic disease. unclear from records if patient is on both aranesp and iron. iron studies show replete iron stores. code status: full code medications on admission: haldol 0.5 mg aranesp 60 mcg sc qweek (wednesday) temovate tid albuterol q4 h prn isordil 10 mg tid hydralazine 20 mg q 8hr feosol 325 mg daily nexium 40 mg daily colace 100 mg combivent 6 puffs qid flovent 110 mcg ferrlecit mwf 62.5 mg iv discharge medications: 1. haloperidol 1 mg tablet sig: one (1) tablet po bid (2 times a day). 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 3. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: six (6) puff inhalation every six (6) hours. 4. hydralazine 10 mg tablet sig: one (1) tablet po q6h (every 6 hours). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. flovent hfa 110 mcg/actuation aerosol sig: one (1) inhalation twice a day. 7. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q 4h as needed. 8. isosorbide dinitrate 10 mg tablet sig: one (1) tablet po tid (3 times a day). 9. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 10. metoprolol succinate 25 mg tablet sustained release 24 hr sig: 0.5 tablet sustained release 24 hr po daily (daily). 11. iron (ferrous sulfate) 325 (65) mg tablet sig: one (1) tablet po once a day. 12. bactrim ds 160-800 mg tablet sig: one (1) tablet po twice a day. 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 14. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. discharge disposition: extended care facility: hospital discharge diagnosis: pneumonia acute renal failure copd with chronic ventilator dependence coronary artery disease discharge condition: improved respiratory status discharge instructions: you were admitted after being found unresponsive. while at you were diagnosed with pneumonia and worsening renal function. for this you were treated with antibiotics and were given fluids. please take all medications as prescribed followup instructions: please follow up with pulmonary and cardiology as needed md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute kidney failure, unspecified Cardiac pacemaker in situ Chronic obstructive asthma, unspecified Dehydration Diverticulosis of colon (without mention of hemorrhage) Chronic respiratory failure Dependence on respirator, status

allergies: iodine neuro: pt is alert and oriented x1, opens eyes spontaneously-perrl 3mm/brisk bilaterally. answers simple questions by nodding head, follows commands consistently. able to lift bue and moves ble on bed. bilateral soft wrist restraints maintained for safety of tubes/lines. at times noted to become agitated with stimulation, but otherwise appears to be comfortable and nods head "no" when asked if in pain. no seizure activity noted. afebrile. resp: pt has trach which has audible leak at times and tends to be positional-dr. aware. vent settings are cmv/50%/500/12/5, no changes made this shift. lung sounds are essentially coarse throghout, suctioned for small amts of thick creamy secretions to moderate amts of thick tan secretions. bilateral chest expansion noted, rr 12-20 and spo2 95-100%. cv: hr 50's-60's v-paced with occasional pvc's. sbp upon arrival to micu 180's with stimulation, however quickly decreased to 140's without intervention once pt was settled. current sbp range has been 109-130's and maps >60. palpable radial/dp pulses. pt has #20 piv and left brachial midline. midline noted to be clotted upon arrival from ed-attempted to instill tpa without success as of yet. gi/gu: abdomen soft, bowel sounds present x4. no stool this shift. pt is npo at this time. indwelling foley catheter secure and patent with adequate amts of clear yellow urine per hour. ua and c&s sent. integ: skin on back and buttocks grossly intact, however pt is noted to have areas on left forearm that appear to be healing scabs-no breaks in skin noted. social: no contact from family this shift. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute kidney failure, unspecified Cardiac pacemaker in situ Chronic obstructive asthma, unspecified Dehydration Diverticulosis of colon (without mention of hemorrhage) Chronic respiratory failure Dependence on respirator, status

allergies: iodine attending: chief complaint: altered ms. major surgical or invasive procedure: none history of present illness: 81y/o f w/ copd, chronically vent dependant, htn, resident of , was transferred to for concern of altered mental status (not herself, incoherence, confusion, not communicating), diffuse face and limb spasm, twitching. decreased po intake (unable to feed herself), no fevers, no sob, or respiratory distress. md, her co2 higher than normal. vs there were t:96.4, hr: 66, bp: 118/90 r: 20. noted cr to increase to 1.4, hyperkalemic to 5.8 which was treated today with 60gm of kayexalate. . in ed started on 1 l ns and transferred up to micu. past medical history: 1. anemia 2. hiatal hernia 3. copd, vent dependant for 4years 4. htn 5. cad: h/o mi 6. h/o gib 7. diverticulosis 8. h/o mrsa 9. chronic asthma social history: lives at , no h/o tobacco, no etoh, no ivdu. family history: nc physical exam: t:97.1, hr: 78, bp: 136/63, r: 30 vent: ps 12, peep 5, tv: 423 rr: 23 gen: alert, talkative, engaging, nad, diffuse body twitching, no overt fasiculations. heent: eomi, perrl, mm dry, tongue fasiculations, neck: no lad cv: rrr, no m/r/g pulm: left side with crackles and mild wheezes, right cta abd: bs present, soft, nd, patient very ticklish with exam. surgical scars appreciated ext: b/l lower ext pitting edema l>r. dp/pt 1+ b/l neuro: diffuse body twitching, no chvosteks, left side of body strenght greater than right, 3-4/5 strenght. moves all extremities, cn ii-xii grossly intact. pertinent results: abg: 7.35/67/88. 138 97 49 <67 ca-8.7 phos-4.1 mag-2.2 4.9 36 1.4 3.7> <105 22.9 freeca-1.20 ua: normal alt(sgpt)-33 ast(sgot)-40 ck(cpk)-50 alk phos-85 amylase-115* tot bili-0.1 ck-mb-notdone ctropnt-0.08* iron-39 caltibc-286 vit b12-753 folate-12.3 ferritin-160* trf-220 head ct: impression: 1. relatively mild age-related involutional changes. 2. hypodensities in the white matter, likely chronic small vessel ischemic disease. 3. no evidence of intracranial hemorrhage or acute process. . ecg: sinus bradycardia with primary av conduction delay, normal axis, no std or ste, nml qrs interval. prwp u/s of left lower extremity: impression: limited exam. no evidence of left lower extremity dvt. cxr: impression: bibasilar opacities, which may represent pneumonia, aspiration, and/or effusions. brief hospital course: a/p:81y/o f with copd- chronically vent dependant, htn, p/w altered mental status and difusse body twitching. 1. altered mental status: was likely multifactorial given that she had a pneumonia, was extremely anemic and was on multiple medications that could cause confusion. we started treatment with broad spectrum antibiotics and on day 2 of admission was narrowed down to levofloxacin 250mg. on day two of admission, patient was given her morning medications which included neurontin, celexa and clonidine. within 40min she became lethargic and very difficult to arouse. she had been on trach collar at the time and was immediately placed back on mechanical ventilation given the thinking that she may have become hypercarbic. oxygenation was 100% the entire time. team tried to gas patient but refused and would not allow any blood draws. nurse then brought the medications to our attention and medications were discontinued. her mentation improved and maintained itself throughout the day. she was also transfused one unit of packed red blood cells. the infection, anemia and medications all contributed to her change in mental status but the medication seemed to be the likely culprit. her lfts were normal, her ecg did not have any evidence of mi, enzymes were flat, ua was normal, not uremic, her gas was not far from her baseline, glucose normal as well as ca/mg/phos, no evidence of seizure. the celexa, neurontin and clonidine should not be restarted. . 2. myoclonus: iron defficiency vs. hypercarbia vs. medications. patient was transfused with one unit of red cells, medications were stopped as above and the infection is being treated. unclear as to which intervention stopped the myoclonus but it has gone. . 3. copd/asthma: c/w fluticasone and combivent. . 4. htn: norvasc and clonidine were stopped. hctz was restarted on discharge. patient normotensive, norvasc not restarted. . 5. anemia: -has chronic anemia, on aranesp. patient transfused two unit of packed red blood cells. hct stable. . 6. acute renal insufficiency: -ns fluid hydration was given, urine lytes showed feurea: >50%. cr was stable x3, ? whether she had medication induced atn or whether this is chronic renal insufficiency. uop was normal. . 7. thrombocytopenia: -platelets stable. chronic thrombocytopenia. follow up with pcp for further work up. . 8. left lower ext edema: u/s was performed, no evidence of dvt. . 9. fen: sp/sw recommended soft diet with thin liquids, medications in apple sauce . 10. full code per family. . medications on admission: 1. seroquel 12.5mg qhs (d/c'd ) 2. celexa 10mg daily 3. aranesp 60mg weekly 4. clonidine 0.3mg 5. coalce 100mg 6. combivent 2p qid 7. hctz 25mg daily 8. flovent 110mcg 2p 9. protonix 40mg daily 10. neurontin 200mg 11. norvasc 5mg daily 12. ecasa 81mg daily 13. clobetasol cream 2% prn 14. mom prn 15. tylenol prn discharge medications: 1. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours). 2. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. aranesp 60 mcg/ml solution sig: one (1) injection once a week. 6. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. 7. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 8. levofloxacin 250 mg tablet sig: one (1) tablet po once a day for 8 days. discharge disposition: extended care facility: hospital discharge diagnosis: 1. anemia 2. pneumonia 3. myoclonus 4. altered mental status 5. acute renal insufficiency secondary 1. copd, vent dependant 2. chronic asthma 3. htn discharge condition: stable, discharge instructions: please take all your medications as prescribed and keep all your recommended appointments. please seek medical attention or call your primary care physician if you develop: chest pain, shortness of breath, lethargy, confusion, or other concerning symptoms. followup instructions: 1. please follow up with your primary care physician . within 2 weeks. please call to set up an appointment. per recommendations of speech and swallow specialist. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Thrombocytopenia, unspecified Anemia, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Chronic obstructive asthma, unspecified Drug-induced delirium Chronic respiratory failure Tracheostomy status Myoclonus Dependence on respirator, status

allergies: iodine attending: chief complaint: melena major surgical or invasive procedure: colonoscopy egd placement of right internal jugular catheter history of present illness: 81y/o f on chronic mechanical ventilation x 4 years for copd, receives all care at , h/o lgib per pts daguhter in the past (last admit to for gib last year; tics on colonoscopy), who presented from jmh after an episode of melena starting at 11:30 pm last night associated with rlq pain. she was hd stable in our ed (afebrile, hr in 70s; bp 136/76--> 110/70 without associated increase in hr). initial was 22 (pt w/ h/o anemai on aranesp; hct 22.9 during her only admit to on --> up tp 28 after 1 u prbcs on on discharge). in the ed she passed large quantities of melena (total of bms; last 200 cc of melena at 8 am). ngl negative per ed. she received a total of 2u prbcs. had difficulty with establishing a good iv access: has 322 on l foot; #18 at lac and l ej. unbale to repeat blood work after transfusion. pts' bp dropped to the lowest of 88/56--> responded to ivfs (1l ns). a ct abd/pelvis was performed due to a c/o rlq pain (read p). ngt removed, pt transferred to for further work up and management. got anzemet 12.5mg x1, lidocaine viscous, pantoprazole 40mg, levo/flagyl in the ed. gi notified in the ed. . pt was recently admitted for altered mental status thought to be multiple causes including mssa and psa pneumonia, meds, and anemia. she was discharged to complete a total of 10 day course of levofloxacin on . past medical history: 1. anemia - on aranep; iron studies from c/w aocd. nl spep. no upep sent. 2. l hiatal hernia 3. copd, vent dependant for 4years 4. htn 5. cad: h/o mi; no recoerds availble; ef unknown 6. h/o gib 7. diverticulosis 8. h/o mssa 9. chronic asthma 10. recent admit for delta ms in the setting of overmedication and pna: pseudomonas and mssa in sputum (no infiltrate on cxr; no leukocytosis) social history: lives at , no h/o tobacco, no etoh, no ivdu. family history: nc physical exam: pe t 98.4 bp 118/43 p 72 r 20 o2 99% on trach collar fio2 35% 15 l/min gen: nad, a&ox3 heent: trach in place, perrl, mmm pulm: mild crackles and wheezing cvs: rrr; s1/2; at rusb abd: obese; acanthosis nigrans; s/nt/nd/+bs x 4 ext: no c/c/e skin: no rashes pertinent results: 09:32pm hct-23.3* 05:33pm lactate-0.9 04:58pm glucose-103 urea n-38* creat-1.2* sodium-141 potassium-3.7 chloride-108 total co2-26 anion gap-11 04:58pm ld(ldh)-145 ck(cpk)-43 04:58pm ck-mb-4 ctropnt-0.08* 04:58pm calcium-7.5* phosphate-3.2 magnesium-1.5* 04:58pm wbc-8.6 rbc-2.74* hgb-7.9* hct-22.7* mcv-83 mch-28.9# mchc-34.9# rdw-15.6* 04:58pm neuts-85.0* lymphs-11.0* monos-2.3 eos-1.5 basos-0.2 04:58pm hypochrom-1+ poikilocy-2+ microcyt-1+ 04:58pm plt count-175 04:58pm ret aut-1.9 02:10pm urine color-straw appear-clear sp -1.015 02:10pm urine blood-mod nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 02:10pm urine rbc-12* wbc-3 bacteria-occ yeast-none epi-0 01:10pm type-art temp-37.8 po2-147* pco2-51* ph-7.33* total co2-28 base xs-0 comments-axillary 01:10pm glucose-95 na+-139 k+-4.2 01:10pm hgb-8.3* calchct-25 o2 sat-98 01:10pm hgb-8.3* calchct-25 o2 sat-98 01:10pm freeca-1.09* 05:20am urine color-straw appear-cloudy sp -1.013 05:20am urine blood-lg nitrite-pos protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-mod 05:20am urine rbc-* wbc-* bacteria-many yeast-none epi-0 05:20am urine 3phosphat-mod 03:32am glucose-113* urea n-46* creat-1.3* sodium-144 potassium-3.8 chloride-110* total co2-25 anion gap-13 03:32am wbc-12.8*# rbc-2.81* hgb-7.4* hct-23.9* mcv-85 mch-26.2* mchc-30.8* rdw-15.2 03:32am neuts-86.6* lymphs-10.6* monos-2.1 eos-0.5 basos-0.1 03:32am hypochrom-3+ microcyt-1+ 03:32am plt count-217# 03:32am pt-13.5* ptt-23.6 inr(pt)-1.2* 03:28am hgb-7.7* calchct-23 01:10pm blood type- temp-35.7 rates-/19 po2-38* pco2-71* ph-7.28* calhco3-35* base xs-3 intubat-not intuba 03:21am blood wbc-7.7 rbc-2.79* hgb-8.1* hct-23.8* mcv-86 mch-29.2 mchc-34.2 rdw-15.4 plt ct-95* 05:15pm blood hct-25.7* 05:23am blood wbc-6.9 rbc-2.89* hgb-8.7* hct-24.2* mcv-84 mch-30.0 mchc-35.8* rdw-15.3 plt ct-99* 05:23pm blood hct-27.0*# 05:17am blood wbc-7.7 rbc-2.36* hgb-7.0* hct-20.2* mcv-86 mch-29.8 mchc-34.8 rdw-15.3 plt ct-104* 07:30pm blood hct-25.5* 11:08am blood hct-25.5* 04:52am blood wbc-8.5 rbc-3.04* hgb-8.9* hct-25.6* mcv-84 mch-29.3 mchc-34.9 rdw-15.0 plt ct-113* 05:40pm blood hct-27.1* plt ct-103* 11:23am blood hct-27.7*# plt ct-133* 04:25am blood wbc-7.7 rbc-2.67* hgb-7.7* hct-22.1* mcv-83 mch-28.9 mchc-35.0 rdw-15.3 plt ct-119* 05:30pm blood hct-26.7* plt ct-118* 10:03am blood hct-21.4* plt ct-131* 03:52am blood wbc-6.4 rbc-3.28* hgb-9.1* hct-27.0* mcv-83 mch-27.8 mchc-33.7 rdw-15.4 plt ct-133* 11:14pm blood hct-28.7* 06:48pm blood hct-26.1* 05:00am blood wbc-6.5 rbc-3.55*# hgb-9.9*# hct-28.5* mcv-80* mch-27.8 mchc-34.6 rdw-16.1* plt ct-175 09:32pm blood hct-23.3* 05:17am blood neuts-82* bands-0 lymphs-11* monos-2 eos-4 baso-0 atyps-1* metas-0 myelos-0 04:52am blood neuts-79* bands-1 lymphs-6* monos-9 eos-4 baso-0 atyps-1* metas-0 myelos-0 04:25am blood neuts-78.6* lymphs-15.8* monos-2.9 eos-2.3 baso-0.3 03:52am blood neuts-78.1* lymphs-15.3* monos-3.1 eos-2.9 baso-0.5 05:00am blood neuts-79.2* lymphs-15.7* monos-2.8 eos-2.1 baso-0.3 05:17am blood hypochr-normal anisocy-1+ poiklo-normal macrocy-normal microcy-1+ polychr-1+ 04:52am blood hypochr-1+ anisocy-1+ poiklo-1+ macrocy-normal microcy-1+ polychr-1+ spheroc-2+ ovalocy-1+ stipple-1+ 04:25am blood hypochr-1+ poiklo-3+ microcy-1+ 03:52am blood hypochr-1+ poiklo-2+ microcy-1+ 05:00am blood anisocy-1+ poiklo-2+ microcy-1+ 03:21am blood plt ct-95* 03:21am blood pt-11.7 ptt-25.9 inr(pt)-1.0 05:23am blood plt smr-low plt ct-99* 05:23am blood pt-12.1 ptt-27.4 inr(pt)-1.0 05:17am blood plt smr-low plt ct-104* 05:17am blood pt-12.0 ptt-26.2 inr(pt)-1.0 04:52am blood plt ct-113* 04:52am blood pt-12.1 ptt-25.3 inr(pt)-1.0 05:40pm blood plt ct-103* 11:23am blood plt ct-133* 04:25am blood plt ct-119* 04:25am blood pt-13.7* ptt-27.9 inr(pt)-1.2* 05:30pm blood plt ct-118* 10:03am blood plt ct-131* 03:52am blood plt ct-133* 03:52am blood pt-13.6* ptt-23.9 inr(pt)-1.2* 05:00am blood plt ct-175 05:00am blood pt-12.8 ptt-27.6 inr(pt)-1.1 03:21am blood glucose-113* urean-29* creat-1.2* na-141 k-4.3 cl-105 hco3-33* angap-7* 05:23am blood glucose-109* urean-23* creat-1.0 na-141 k-3.6 cl-102 hco3-36* angap-7* 05:23pm blood k-4.0 05:17am blood glucose-113* urean-25* creat-1.1 na-144 k-4.1 cl-108 hco3-32 angap-8 03:00pm blood k-4.3 04:52am blood glucose-114* urean-19 creat-1.1 na-140 k-4.1 cl-108 hco3-29 angap-7* 04:25am blood glucose-83 urean-17 creat-1.0 na-141 k-4.0 cl-111* hco3-26 angap-8 03:52am blood glucose-78 urean-19 creat-0.9 na-145 k-3.8 cl-110* hco3-27 angap-12 05:00am blood glucose-83 urean-29* creat-1.1 na-142 k-4.4 cl-109* hco3-27 angap-10 03:21am blood calcium-8.7 phos-3.7 mg-1.6 05:23am blood calcium-8.0* phos-3.5 mg-1.9 05:17am blood calcium-7.4* phos-4.1 mg-1.7 03:00pm blood mg-2.0 04:52am blood calcium-7.9* phos-3.9 mg-1.8 04:25am blood calcium-7.3* phos-3.0 mg-1.8 03:52am blood calcium-7.9* phos-3.1 mg-1.9 05:00am blood calcium-8.0* phos-3.1 mg-2.6 04:52am blood triglyc-74 01:10pm blood type- temp-35.7 rates-/19 po2-38* pco2-71* ph-7.28* calhco3-35* base xs-3 intubat-not intuba abdomen/pelvis ct: 1. there is extensive colonic diverticulosis. there is nonspecific stranding within the pericolonic fat at numerous locales, especially in the descending and sigmoid regions. given the multifocality of this finding, it is nonspecific. acute diverticulitis and sequela from prior episodes of diverticulitis are considered. 2. numerous exophytic soft tissue nodules of the kidneys bilaterally, some of which are hyperdense and likely represent hyperdense cysts. however, given that iv contrast was not administered, it is not possible to assess for the presence or absence of carcinoma. 3. calcified pleural plaques bilaterally, consistent with prior asbestos exposure. 4. calcified granulomas versus tiny foci of barium within the lung bases bilaterally. 5. bronchiectasis at the left lung base as described. 6. coronary artery calcifications. 7. fatty infiltration of the liver. cxr: there is continued marked elevation of the left hemidiaphragm. the tracheostomy tube and ng tube remain in place. the previously identified mild congestive failure has been improving. there is continued patchy opacity in the right lower lobe indicating atelectasis versus pneumonia. there is no evidence of pneumothorax. brief hospital course: 81 yo f with h/o lgib, vent dependent for 4 years due to copd, chronic anemia of unclear etiology; h/o cad, admitted to the w/ melena and initial hct of 23. pt received a total of 6 units of prbc transfusion during the course of her hospital stay. initial ng lavage and egd were negative. ct scan showed diffuse diverticulosis in the colon. colonoscopy was done 3 times secondary to inadequate prep. it showed diverticuli throughout the colon with polyps in the sigmoid colon. biopsy was deferred at this time risk of bleeding. gi should f/u with the patient in months to biopsy the polyp. pt was d/c'd to hospital on hd #7, hemodynamically stable with hct of 24. of note, pt's copd was treated with alb/atrovent mdi's and flovent. patient pulled of ventilator on day #2 and had o2 sat of 100 on fio2 35% with 15 l/min. initial admission also showed dirty ua which was treated with cipro and later switched to bactrim on day #3 in light of culture and sensitiviy. 1. lgib: in the , pt was hypotensive to 80/56 and was resuscitated with fluid and transfused 2 units prbc. ng lavage was negative. at the , pt was taken for tagged rbc scan, which was negative. c.diff and lactate, decreasing the likelihood of infectious or ischemic etiologies. lft's were also negative. ct scan revealed diffuse diverticulosis of the colon. colonoscopy the following morning was unrevealing because bowel prep was inadequate. egd showed gastritis of antrum with no bleeding. pt had been reluctant to drinking golytely for bowel prep. on the third day, pt passed large melena, and a second tagged rbc scan was done, which again shows no bleeding site. hct dropped from 27 to 22, pt was transfused 2 more units of prbc. on the fifth hospital day, pt passed maroon blood, hct dropped from 25 to 20 and pt was transfused 2 more units. pt was prepped for colonoscopy again, but gi was unable to see b/c prep was inadequate. pt was put on tpn starting on hd#4 and continued to receive golytely for third colonoscopy on hd 6. colonoscopy revealed diverticuli throughout the colon and polyps in the sigmoid colon. biopsy was deferred in the setting of possible bleeding. gi will do colonoscopy and biopsy in months. pt is hemodynamically stable with hct at 24 upon discharge. she should refrain from taking aspirin for one month given gib. 2. chronic vent with h/o copd: pt disconnected ventilator tubing on hd #2 and stayed on trach collar with 15 l/min fio2 35% throughout the hospital course. o2 sat around 100% most of the time. secretions were monitored, showing yellow, thick mucous. sputum culture positive for pseudomonas and staph aureus, but was not treated given lack of clinical evidence of infection (no leukocytosis or fever). cxr on admission was clear without infitrates. pt was on alb/atrovent mdis and flovent throughout her course of stay. in the future, can consider olympic button and removal of trach collar if continuing to do well. 3. uti: pt's u/a was dirty on admission. cipro was started empirically while waiting for culture. on hd #3, urine culture grew proteus sensitive to bactrim and resistant to cipro. abx was promptly changed from cipro to bactrim. bactrim was d/c'd after 5 days upon discharge on 4. anemia: pt has a mixed picture of aocd based on iron studies and concurrent blood loss. pt received 6 units of prbc (2 in the ed and 4 at ). iron supplementation was continued on discharge. 5. h/o cad: pt reported multiple strokes and heart attack many years ago. aspirin was hold in the setting of lgib. ecg showed no evidence of ischemia. medications on admission: 1. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours). 2. fluticasone 110 mcg 2 puffs 3. docusate sodium 100 mg 4. aspirin 81 mg tablet daily 5. aranesp 60 mcg/ml injection weekly 6. hydrochlorothiazide 25 mg daily 7. protonix 40 mg daily 8. ferrous sulfate 325 mg po qd discharge disposition: extended care facility: hospital discharge diagnosis: lgib secondary to diverticulosis discharge condition: stable followup instructions: f/u with gi in months for colonoscopy biopsy of polyps in sigmoid colon. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Colonoscopy Transfusion of packed cells Diagnoses: Acidosis Anemia of other chronic disease Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Unspecified essential hypertension Acute posthemorrhagic anemia Old myocardial infarction Chronic obstructive asthma, unspecified Diverticulosis of colon with hemorrhage Chronic respiratory failure Tracheostomy status Dependence on respirator, status

allergies: iodine attending: chief complaint: gastrointestinal bleeding major surgical or invasive procedure: none history of present illness: 81y/o f w/ copd, chronically vent dependant, htn last admitted to for melena w/negative egd and colonoscopy demonstrating diverticuli throughout the colon and polyps in the sigmoid colon. her mininumum bp that admission was 88/56 and she required 4u prbc. today, she presented through the ed from her nursing home w/a seven point crit drop over one week; her triage vs were notable for hypothermia to 35c. ngtl in ed negative. r femoral line was place for iv access. gi was called from the ed and will see the patient in the morning. she was also found to have a uti on u/a and started on levaquin. . further history is difficult to elicit due to trach and difficulty communicating. past medical history: 1. anemia - on aranep; iron studies from c/w aocd. nl spep. no upep sent. 2. l hiatal hernia 3. copd, vent dependant for 4years 4. htn 5. cad: h/o mi; no recoerds availble; ef unknown 6. h/o gib 7. diverticulosis 8. h/o mssa 9. chronic asthma 10. recent admit for delta ms in the setting of overmedication and pna: pseudomonas and mssa in sputum (no infiltrate on cxr; no leukocytosis) social history: lives at , no h/o tobacco, no etoh, no ivdu. family history: nc physical exam: pe: 100.1(warming blanket on) 71 127/66 17 100% gen: well appearing, obese woman in no acute distress with trach in place and attached to ventilator heent: perrl, eomi, oropharynx dry, no lad cv: rrr no murmurs lungs: coarse breath sounds throughout, occasional wheezing, no rhonchi or rales, trach in place abd: soft, diffusely tender, nd, + bs, guiaic + dark melanotic stool in the ed ext: moving all 4 extremities equally, good 2+ pulses in all four extremities pertinent results: 06:40pm ctropnt-0.11* 06:40pm wbc-4.4 hct-21.0* 10:00pm blood hct-26.9* 03:46am blood wbc-6.5 rbc-3.05* hgb-9.0* hct-26.8* mcv-88 mch-29.5 mchc-33.6 rdw-17.7* plt ct-116* 12:30pm blood hct-26.5* 09:05pm blood ck-mb-notdone ctropnt-0.14* 03:21am blood ck-mb-notdone ctropnt-0.11* brief hospital course: the patient was admitted to the micu due to her vent dependence although she was hemodynacmically stable in the ed. in the icu, she was transfused 2 units of prbc's and her hct was stable at 27 over the remaining hospital stay. she did not have any more melanotic or guiaic positive stools after her first admission day. she was started on cipro for her uti and gi consult recommended an outpatient scope and pill endoscopy, as her egd was unrevealing. she had a previous hospitalization for gi bleeding last year with no known cause at discharge. while in the icu she was kept on her previous vent settings of ac 18, tv 500, fio2 40 and peep 5. she was discharged back to in stable condition. medications on admission: aranesp 40ug qfri fleet enema qd dulc 10 pr qd tylenol vit c folvent 110 x 4 aspirin 81mg qd combivent 4 puffs q4 nexium 40 qd haldol .5mg isordil 10mg tid feosol 325 qd hydral 10mg q8 colace ferrlecit 62.5 qm,w,fri discharge disposition: extended care facility: hospital discharge diagnosis: urinary tract infection gastrointestinal bleeding discharge condition: stable and improved discharge instructions: you will be discharged home today. you should continue to take your previous medications as prescribed. you will also be prescribed an antibiotic for your urinary tract infection that you should take for its full course. if you should develop any more blood in your stools, lightheadedness, nausea, vomiting, fever, chills or back pain followup instructions: follow up with your pcp in the next 1-2 days. follow up with gi for a colonoscopy and pill endoscopy. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Transfusion of packed cells Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Acute posthemorrhagic anemia Chronic obstructive asthma, unspecified Hemorrhage of gastrointestinal tract, unspecified Chronic respiratory failure Tracheostomy status

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: cabg x 4 () history of present illness: 63 y/o male w/ sudden onset of chest pain. taken to ed at , + ekg changes, taken to cath lab there where he was found to have signifiacnt 3vcad, pci/stent placed to rca (for acute imi). he was transferred to for cabg. past medical history: diverticulosis social history: recently quit smoking married. lives w/wife denies etoh family history: non-contributory physical exam: unremarkable upon admission pertinent results: 06:15am blood wbc-11.8* hct-21.2* 06:20am blood wbc-12.6* rbc-2.45* hgb-7.6* hct-21.8* mcv-89 mch-31.1 mchc-34.9 rdw-14.3 plt ct-270 06:20am blood plt ct-270 06:20am blood glucose-112* urean-16 creat-0.8 na-137 k-4.4 cl-99 hco3-32 angap-10 patient/test information: indication: aortic valve disease. coronary artery disease. hypertension. left ventricular function. mitral valve disease. valvular heart disease. status: inpatient date/time: at 11:48 test: tee (complete) doppler: full doppler and color doppler contrast: none tape number: 2007aw210-0:0 test location: anesthesia west or cardiac technical quality: adequate referring doctor: dr. measurements: left atrium - long axis dimension: *5.4 cm (nl <= 4.0 cm) left atrium - four chamber length: *5.4 cm (nl <= 5.2 cm) left ventricle - septal wall thickness: *1.3 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: *1.3 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 4.7 cm (nl <= 5.6 cm) left ventricle - systolic dimension: 3.3 cm left ventricle - fractional shortening: 0.30 (nl >= 0.29) left ventricle - ejection fraction: 40% to 45% (nl >=55%) aorta - valve level: 2.1 cm (nl <= 3.6 cm) aorta - ascending: *3.5 cm (nl <= 3.4 cm) interpretation: findings: left atrium: moderate la enlargement. no spontaneous echo contrast or thrombus in the body of the laa. all four pulmonary veins identified and enter the left atrium. right atrium/interatrial septum: normal ra size. no spontaneous echo contrast in the body of the ra. no asd by 2d or color doppler. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. mild symmetric lvh. normal lv cavity size. mild-moderate regional lv systolic dysfunction. lv wall motion: regional lv wall motion abnormalities include: basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; remaining lv segments contract normally. right ventricle: mildly dilated rv cavity. normal rv systolic function. aorta: normal aortic diameter at the sinus level. mildly dilated ascending aorta. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: three aortic valve leaflets. mildly thickened aortic valve leaflets. no as. trace ar. mitral valve: mildly thickened mitral valve leaflets. moderate mitral annular calcification. mild thickening of mitral valve chordae. no ms. trivial mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets with physiologic pr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. no tee related complications. the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope. the patient was under general anesthesia throughout the procedure. conclusions: pre-bypass: the left atrium is moderately dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no spontaneous echo contrast is seen in the body of the right atrium. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild to moderate regional left ventricular systolic dysfunction with basal and mid inferior and inferior septal hk. the remaining left ventricular segments contract normally. the right ventricular cavity is mildly dilated. right ventricular systolic function is normal. 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. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is no pericardial effusion. post-bypass overall lv systolic fuction now appears normal. lvef > 55%. there appears to be improvement of the inferior wall. study ortherwise unchanged from prebypass. brief hospital course: mr. was admitted from on (where he was admitted for stemi). he underwent pre-operative workup, including echo, remained on cardiac monitoring, and diuresed for some systolic chf. he was taken to the or on for cabg x 4 (please see operative report for details of operation). post-operatively, he was taken to the csru, was weaned from vasoactive gtts & mechanical ventilation. he was transferred to the telemetry floor on pod # 1, and has remained hemodynamically stable. his hematocrit has been low post-op (21), but as he has remained asymptomatic, and tolerating his beta blockers, it was decided not to transfuse him. he was started on iron and vitamin c. he has progressed well from a physical therapy standpoint, and is ready to be discharged home. medications on admission: none at home discharge medications: 1. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 6 days. disp:*24 capsule, sustained release(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 5. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. ferrous gluconate 300 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 9. furosemide 40 mg tablet sig: one (1) tablet po twice a day for 7 days. disp:*14 tablet(s)* refills:*0* 10. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: cad discharge condition: good discharge instructions: shower daily, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no lifting > 10# for 10 weeks no driving for 1 month p instructions: with dr. in weeeks with dr. in weeks with dr. in 4 weeks md Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Cardioplegia Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Atrial fibrillation Systolic heart failure, unspecified Acute myocardial infarction of other inferior wall, initial episode of care

allergies: penicillins attending: chief complaint: shortness of breath major surgical or invasive procedure: echo cardiac cath cardiac cath history of present illness: this is a year old woman with a history of diabetes mellitus, coronary artery disease status post coronary artery bypass graft and pci in who presents with exertional angina, doe and pnd with + stress test for cardiac cath. pt c/o 3-4 weeks of progressive doe and increased sob. pt previously able to walk and do house work, however now unable to do chores around the house. states no sob at rest, but gets sob with minimal exertion. she was seen by her cardiologist on , dr. , who noted angina, shortness of breath, pnd, and orthopnea, worsened since her last visit. she had a stres test on showing lv dilation with exertion. pt direct admit for cardiac catheterization on . ros: pt also reports that she felt week and feel 2-3 weeks ago. states did not lose conciousness, however, fall not witnessed by anyone. denies any residual weakness from the fall. past medical history: 1. coronary artery disease status post myocardial infarction in ;3vd status post coronary artery bypass graft with saphenous vein graft to left anterior descending, saphenous vein graft to left anterior descending, saphenous vein graft to obtuse marginal-1 and obtuse marginal-2. status post pci to the vein graft with lad under the care of dr. in . old q waves inferiorly 2. diabetes mellitus type 2. 3. hypertension. 4. mild as on cath in 99 social history: the patient lives alone in in with a granddaughter involved. the patient was full code. there is no history of ethanol or tobacco use. family history: non contributory physical exam: t a. , bp 102/67, hr 70, rr 20, o2 sat 94%ra gen: pleasant spanish elderly female. able to speak in full sentences, but dyspnic after a sentence heent: perrl, mmm, jvp up to the angle of jaw. no carotid bruits chest: crackles upto middle of lung fields bilaterally cvr: nl s1, s2. ii/vi early systolic murmor heard best over left upper sternal border. no change with valsalva. no radiation to carotids. abdomen: soft, nt, +bs ext: 1+ femoral pulses bilaterally. popliteal/dp/pt pulses non palpable. right 1st metatarsal-tarsal joint tender. +erythema, no warmth to touch. neuro: communicative, grossly intact pertinent results: echo: dilated, ef 15%, severe global lv hypokinesis, 2 x 1.2 cm globular thrombus in lv. cath 1) native vessels. - severe native three vessel coronary artery disease. the lmca with no signifiant lesion. - the lad was diffusely diseased with narrowing to 50% in the proximal vessel and then serial 80-90% lesions in the mid and distal vessel. - the lcx was diffusely diseased with serial 90% lesions in the proximal segment. the lcx supplied a large, bifurcating om1 that had diffuse luminal irregularities and a focal 80% lesion at the bifurcation. - the rca was diffusely diseased with an 80% ostial narrowing and serial 90% lesions in the proximal and mid vessel. 2) grafts - the svg->lad had 90% in-stent restenosis in the proximal segment(cypher stent -> no residual stenosis) and an 80% tubular stenosis in the distal graft just prior to the touchdown (cypher stent -> negative 20% residual stenosis) - the svg->om was known to be totally occluded. 3) hemodynamics - mean ra pressure of 13 mmhg and a mean pcwp of 17 mmhg. the cardiac output was severely reduced at 2.5 l/min with an svr of 2592 dynes-sec/cm5. there was also evidence of pulmonary hypertension with pa pressures of 72/23/40 mmhg and a pvr of 736 dynes-sec/cm5. left ventricular filling pressures were not obtained due to the patient's known lv clot. cath 1) coronary arteries -the lad had severe proximal and midvessel disease with distal competitive filling via the svg-lad. lcx as above cath . - the rca was not selectively engaged. - the svg-lad had no angiographically apparent, flow-limiting disease. 2) resting hemodynamics revealed central hypertension with blood pressure 170/82 mmhg. pa systolic pressures were elevated at 39 mmhg. mean pcwp was 11 mmhg. cardiac index was 1.9 l/min/m2 by fick. 3) successful treatment of lcx with three overlapping cypher drug-eluting stents after rotational atherectomy. final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow. 04:30pm blood wbc-7.0 rbc-4.89 hgb-13.5 hct-42.0 mcv-86 mch-27.7 mchc-32.2 rdw-14.5 plt ct-257 04:30pm blood pt-13.9* ptt-22.5 inr(pt)-1.2 04:30pm blood glucose-124* urean-27* creat-1.4* na-138 k-5.4* cl-103 hco3-22 angap-18 09:37pm blood ck(cpk)-27 10:30am blood ck-mb-notdone ctropnt-0.09* 04:30pm blood calcium-8.5 phos-3.0 mg-2.0 05:35am blood triglyc-126 hdl-34 chol/hd-3.5 ldlcalc-61 05:35am blood tsh-2.5 brief hospital course: a/p the pt is an elderly cuban woman w pmh of dm, cad s/p mi and cabg,who presents for coronary angiography due to + stress test and continued symptoms of angina and chf. 1) cad - pt with h/o mi, s/p cabg and pci with 3 weeks of doe and sob and +stress test revealing fixed inferior and lateral wall perfusion defects and lv dilation. pt admitted for cath . pt's creatinine was 1.5 on admission and pt received mucomyst and bicarb hydration prior to cath on . pt also had an echo done prior to cath, which showed a 2x1 cm thrombus in lv. at cath, lv cavity was not entered. pt had 2 stents placed in svg->lad graft. pt was transferred to ccu post cath and was taken back to cath on and had 3 stents placed in lcx. pt denied any cp, orthopnea or pnd after the procedures. 2) chf - pt volume overloaded on exam, elevated jvp and bibasilar crackles. doe may have been secondary to cad vs. chf. pt was initially diuresed with iv lasix on the floor. echo was remarkable for global hypokinesis and a thrombus in lv cavity. hemodynamics at cath on were pcw 18, pa 62/21, co (fick) 2.43 and ci 1.63 at cath and pt transferred to ccu. pt required milrinone 0.28mcg/kg/min iv infusion and nesiritide 0.01mcg/kg/min. during the cath on , svg -> lad stenosis was opened with 2 cypher stents. on she underwent a second cardiac cath where lcx lesions were stented open with 3 cypher stents. pt was gently diuresed -1l day one and -400 cc day 2 in the icu. pt was weaned off milronone and niseritide and was transferred back to floor after 2 days in ccu. hemodynamics on cath , pa 45/20, pcw 11, co 4.7, ci 3.1. post ccu pt was diuresesed with lasix on the floor. she had some sob with exertion however denied cp, orthopnea and pnd. 3) cri - creatinine on admission 1.5. the renal insuff on presentation may have been a combination of cri secondary to dm as well as pt being prerenal due to severly depressed co seen on first pci. creatinine 0.9 post cath , in setting of post cath hydration. her creatinine was 1.2 on which maybe near her baseline creatinine. acei was held since pt had received 2 dye loads. she should have potassium and creatinine checked on . and pcp can restart the acei when pt is seen on monday . 4) lv thrombus - pt with a 2x1 cm thrombus on echo . consideration was given to oral coumadin anticoagulation as outpt, in addition to asa and plavix. after speaking with dr. , given pt's age and recent fall 3 weeks ago, plan is to continue to anticoag with asa and plavix and hold off on coumadin. 5) dm - glipizide was held in patinet and pt was covered with riss. her sugars remained in 100-210 range. 6) htn - pt was switched over to lopressor 50 po bid (taking atenelol 50 po qd outpt) and acei was continued initially. lisinopril was held post cath since pt had received 2 dye loads in 2 days. pcp can restart on . 7) dispo - pt was evaluated by physical therapy prior to discharge. medications on admission: 1. lisinopril 10 mg p.o. q. day. 2. glipizide 5 mg p.o. q. day. 3. atenolol 50 mg p.o. q. day. 4. pantoprazole sodium 40 mg p.o. q. day. 5. isosorbide mononitrate 60 mg p.o. q. day. 6. furosemide 40 mg p.o. q. day. 7. aspirin 81 mg p.o. q. day. discharge medications: 1. toprol xl 100 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. disp:*30 tablet sustained release 24hr(s)* refills:*2* 2. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (once a day). 3. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. atorvastatin calcium 20 mg tablet sig: one (1) tablet po qd (once a day). 5. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day). 6. imdur 30 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. 7. glipizide 5 mg tablet sig: one (1) tablet po once a day. 8. lasix 20 mg tablet sig: three (3) tablet po once a day. discharge disposition: extended care facility: hospital discharge diagnosis: 1. coronary artery disease a)status post myocardial infarction in ; 3vd status post coronary artery bypass graft with saphenous vein graft to left anterior descending, saphenous vein graft to left anterior descending, saphenous vein graft to obtuse marginal-1 and obtuse marginal-2. b) status post pci to the vein graft with lad under the care of c) status post pci x 2 in . 2 stents placed in svg->lad graft, 3 stents placed in lcx. 2. diabetes mellitus type 2. 3. hypertension. 4. chf 5. cri (baseline creatinine ~1.2) discharge condition: fair discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: 1500 cc please call your pcp if you have shortness of breath. also if you have chest pain take one sublingual nitroglycerin. if pain is not relieved take another tablet in 5 minutes and call 911. followup instructions: provider: follow up with your pcp, . , m. () on monday @ 11:30am. Procedure: Combined right and left heart cardiac catheterization Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Coronary arteriography using two catheters Pulmonary artery wedge monitoring Transfusion of packed cells Injection or infusion of nesiritide Insertion of drug-eluting coronary artery stent(s) Insertion of drug-eluting coronary artery stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Aortocoronary bypass status Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other and unspecified angina pectoris Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other complications due to other cardiac device, implant, and graft Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled

allergies: demerol / morphine / penicillins attending: chief complaint: left shoulder pain left arm pain right leg pain major surgical or invasive procedure: : irrigation & debridement of open right tibia fracture, external fixation placement of right lower extremity : flexible bronchoscopy, esophagogatroduodenoscopy, right thoracotomy, repair of tracheal laceration, intercostal pedicled muscle flap. : intramedullary nail, right tibia, orif of right tibia, removal of external fixator, incision & drainage of open wound, right lower leg; application of vac dressing history of present illness: : this 60 year old african american female pedestrian was struck by a car and found with altered mental status and multiple fractures. she was transported by ems to hospital. a right open tib/fib fracture was identified as well as a left humurus fracture. the patient was electively intubated due to polytrauma and mental status changes, although hemodynamically stable. patient was transported to via for additional care. past medical history: osteogenesis imperfecta depression hypertension hysterectomy social history: this 60 year old african american female denies alcohol use, tobacco use and use of recreational drugs. no history of physical abuse. the patient does not work, is on disability and lives with her sister in , ma. she also recieves family support from a nephew. she has 2 daughters who live in , and her husband died 4 years ago. family history: noncontributory physical exam: vs: bp 152/101, hr 80, rr 12, spo2 100%, patient intubated upon arrival. constitutional: intubated, sedated head/eyes: left periorbital ecchymosis. ear/nose/throat: tympanic membranes clear bilaterally. dried blood in nares. chest/respiratory: clear to auscultation bilaterally, good color. cardiovascular: regular rate & rhythm. gastrointestinal/abdominal: soft, fast negative. positive rectal tone. genitourinary/flank/pelvic: stable musculoskeletal/extremities/back: right open tibula/fibula fracture skin: multiple abrasions pertinent results: 07:58pm wbc-16.0* rbc-2.46* hgb-7.8* hct-22.9* mcv-93 mch-31.5 mchc-33.9 rdw-13.8 07:58pm plt count-177 07:58pm pt-14.1* ptt-31.2 inr(pt)-1.2* 07:58pm fibrinoge-160 05:41pm type-art po2-236* pco2-33* ph-7.32* total co2-18* base xs--8 comments-green top 04:06pm glucose-170* lactate-2.4* na+-144 k+-3.2* cl--120* tco2-18* 04:04pm urea n-13 creat-0.7 04:04pm amylase-83 radiology final report chest (pa & lat) 10:56 am chest (pa & lat) reason: interval change medical condition: 60 year old s/p trauma, tracheal repair reason for this examination: interval change ap upright and lateral film indication: status post trauma. tracheal repair. assess interval change. comparisons: . a right-sided picc line is again seen with its tip within the mid to distal svc. there is mild blunting of the left posterior pleural surface which is essentially unchanged. the lungs are clear. the pulmonary vascularity is normal. there is no pneumothorax. impression: no significant interval change compared to . the study and the report were reviewed by the staff radiologist. dr. dr. approved: 8:57 pm radiology final report tib/fib (ap & lat) right 2:59 pm tib/fib (ap & lat) right; lower extremity fluoro without reason: tibia nailing history: tibial nailing. fluoroscopic assistance provided to the surgeon in the or without the radiologist present. 15 spot views were obtained. no fluoro time was recorded on the electronic requisition. views demonstrate steps related to placement of an intramedullary rod and interlocking screws traversing a tibial fracture. fibular fractures are also present. skin staples noted. dr. approved: mon 7:16 pm brief hospital course: upon arrival to , ortho-trauma, neurosurgery, thoracic surgery and plastic surgery consults were obtained for multiple injuries. she underwent surgical repair of open right tibia/fibula fracture with external fixation on by dr. . she recovered in the pacu, remained intubated, and was transferred to trauma surgical intensive care unit. on she underwent repair of tracheal rupture by dr. , which included placement of 3 chest tubes and a cervical collar. the patient remained intubated and recovered well in the pacu. she was then transferred back to trauma surgical intensive care unit. physical therapy and occupational therapy were consulted on , and have followed her throughout her admission. she was extubated on . gentamycin and cefazolin were started post-operatively, as well as anticoagulation. a picc line was placed by interventional radiology for intravenous access. acute pain service was consulted and an epidural was placed. her pain was controlled through epidural analgesia and intravenous dialudid via patient controlled analgesia. pca dialudid was continued until when she was transitioned to oral dilaudid, which she has tolerated well. the tracheal injury prohibited further intubation for surgical orif of tibula/fibula fracture. on , spinal clearance was obtained. on 2 chest tubes were removed, and the remaining chest tube was left to water seal. on she recieved orif of the right tibula/fibula under spinal anesthesia, removal of ex-fix and placement of wound vac by dr. . plastic surgery is consulted regarding the wound vac of the right lower extremity, and for closure of the leg flap. she is projected to have closure of the flap during the middle of the week of decemeber 11th. on she was touch down weight bearing on rle and the drain was d/c by thoracic surgery. the vac dressing remained in place. on , she had her picc line tpad with success. on orthopedics changed the vac dressing and she continued to wait for a flap. on the pca was stopped and she tolerated oral pain medication well. on , there were no issues. on , the vac was changed again by orthopedics. on , she was preoped for flap placement on rle. pt saw her as well and thought patient had great rehab potential when eligable. the patient ended up going to the or on for rle gastro flap with full thickness skin graft. please see operative note for full details. she had no intra or postoperative complications. on , there were no major issues as her pain was well controlled. the jp drain put out 29cc of serosang fluid. on , the remained in place the jp continued to drain serosanguinous fluid. on , she there were major issues and her pain was well controlled with po tylenol. she remained on bed rest and on , we changed the dressing. the wound was intact and looked good. occupational therapy saw here on and recommended ot and rehab 3 hours per day 5-7 days/week to maximize patient function. she also stared a dangle protocol at 5 minutes tid and the jp remained in. on , we changed the dressing again and took out the jp. she was advanced to a 15 minute dangle protocol tid and was due for discharge to spaling facility this afternoon. medications on admission: home meds reported: ambien, depression meds, hypertension meds. no doses or names of medications provided. discharge medications: 1. ipratropium bromide 0.02 % solution sig: one (1) nebulizer inhalation q6h (every 6 hours) as needed for wheezing. 2. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed for wheezing. 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 4. labetalol 200 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for hr < 65, or sbp < 110. 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for hr < 60, sbp < 110. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 8. hydromorphone 2 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* discharge disposition: extended care facility: - discharge diagnosis: open right comminuted displaced tib/fib fracture tracheal rupture left proximal humerus fracture left zygomatic arch fracture left parietal skull fracture c2 spinous process fracture trace pneumomediastinum discharge condition: stable discharge instructions: do not bear weight on your left arm. you may touchdown weight bear on your right lower extremity. please continue to dangle the right lower extremity for 30 mintutes tid. continue to increase this time for three times a day. followup instructions: follow up appointment with your throacic surgeon, dr. , in 2 weeks, call # for appointment. follow up with plastic surgery clinic on for outpatient management of left zygomatic fracture electively, call for an appointment. dr. is the attending md. follow up with your orthopedic surgeon, dr. in 2 weeks, call # for an appointment. follow up with the trauma clinic as needed, call if you have any concerns. Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Graft of muscle or fascia Other repair and plastic operations on trachea Debridement of open fracture site, tibia and fibula Debridement of open fracture site, tibia and fibula Application of external fixator device, tibia and fibula Open reduction of fracture with internal fixation, tibia and fibula Transfusion of packed cells Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances Systemic to pulmonary artery shunt Other immobilization, pressure, and attention to wound Open reduction of fracture without internal fixation, tibia and fibula Full-thickness skin graft to other sites Diagnoses: Anemia, unspecified Unspecified essential hypertension Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Traumatic subcutaneous emphysema Closed fracture of malar and maxillary bones Closed fracture of surgical neck of humerus Open fracture of shaft of fibula with tibia Open wound of trachea, without mention of complication Closed fracture of vault of skull without mention of intracranial injury, with concussion, unspecified Unspecified fracture of ankle, closed Osteogenesis imperfecta

allergies: pcn hpi: pt developed sob, diaphoresis, nausea x 3 day history, then developed chest heaviness in addition to above, went to pcp, admitted to . pt ruled in for mi. echo showed ef 40%, +mitral regurg. on ntg, levonox s/c, aggrestat. last evening pt developed audible wheezes, increased anxiety, abg showed resp acidosis, pain meds given w/ some relief, stat cxr showed chf- given total 90mg iv lasix. ntg titrated. ekgs unchanged. sats decreased 92% placed on nc and nrb 100%. transfered to ccu. arrived in the ccu on ntg 150mcg, aggrastat @ 11cc. c/o of generalized aches and pains. ho in to assess pt. cardiology in to assess. given mso4 2mg ivp for pain c/o with good effect. vss. review of systems: neuro: a+ox3. generalized pain. rec'd mso4 2mg x1 (see above). bilat foot drop. walks w/ cane + leg brace on l. cardiac: sr 80s. sbp 90s-110s. on ntg @ 150mcg. aggrastat @ 11cc. started on ivf d5.45ns@75cc/hr. hard to palpate pedal pulses. no further c/o of pain post mso4 dose. ?to go to cath lab today. resp: ls expiratory wheezes, coarse. o2 6l humidified. sats 91-93%. slight sob noted. cxr rll pneumonia. gi/gu: foley patent, clear yellow urine. abd soft, distended. +bs. npo. skin: intact. id: afebrile. on levo po and cefriaxone iv. plan: monitor cks, lytes. monitor vs. medicate for pain relief. monitor resp status. con't abx. ?cath lab today? keep npo until cardiology makes decision re cath lab. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Unspecified essential hypertension Cardiac complications, not elsewhere classified Ventricular fibrillation Lumbago Acute myocardial infarction of inferoposterior wall, initial episode of care

history of present illness: the patient is a 63-year-old male experiencing substernal chest pain and diaphoresis on after exercise. on the patient experienced markedly increased chest pain and shortness of breath, worsening with exertion. the patient was admitted to emergency room on for right lower lobe pneumonia and positive troponin. ekg at that time showed lateral lead st depression. echocardiogram showed ejection fraction of 40% with inferior and posterior wall motion abnormality and mild mr. past medical history: significant for hypertension, chronic back pain and left foot drop. cath at the time showed the left main were normal, lad 90%, mid section occluded, left circumflex 80% occluded, rca 100% occluded. medications: home medications included protonix 40 mg po q d, aspirin 325 mg po q d, lopressor 12.5 mg po tid, diovan 80 mg po q d, lovenox 100 mg subcu , colace, humibid 1200 mg po bid, valium 5 mg po q 4-6 hours prn, albuterol nebs. hospital course: the patient was taken by dr. to the or and underwent cabg times three on with lima to lad, svg to om and svg to pda. postoperatively the patient did well. however, the patient was extubated and went off drips without any incidents. however, we did decide to keep the patient in the icu for two extra days because of his pre-op pneumonia. the patient was on ceftriaxone since the day of admission and postoperatively the patient did well, afebrile and was able to transfer to the floor on postoperative day #2. the only complication is patient experienced atrial fibrillation on postoperative day #2, was started on amiodarone and was rate controlled with lopressor. the patient's vital signs were stable, was never hypotensive and on the floor patient underwent physical therapy and was ambulating at level with assistance. the rest of the postoperative course was unremarkable and upon discharge the patient's lungs were clear to auscultation, the incision was clean, dry and intact, no drainage, no pus. heart was normal sinus rhythm and sternum was stable. upon discharge his white count was 12.2, hematocrit 29.2, bun 30, creatinine .9. discharge medications: ceftriaxone 1 gm iv q d times 6 days, amiodarone 400 mg po tid times 6 days, then 400 mg po bid times one week, then 400 mg po q d, lopressor 12.5 mg po bid, albuterol nebs q 4-6 hours prn, lasix 20 mg po bid times 10 days, potassium chloride 20 meq po bid times 10 days, valium 5 mg po q 4-6 hours prn, percocet 1-2 tablets po q 4-6 hours prn, aspirin 81 mg po q d, protonix 40 mg po q d, lovenox 100 mg subcu . upon discharge patient was stable and afebrile. the patient will be discharged to a rehab facility and told to follow-up with dr. in weeks. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Unspecified essential hypertension Cardiac complications, not elsewhere classified Ventricular fibrillation Lumbago Acute myocardial infarction of inferoposterior wall, initial episode of care

allergies: patient recorded as having no known allergies to drugs attending: addendum: the patient was started on gcsf on . he will continue it for 8 doses per modified protocol. discharge disposition: home md Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Hemodialysis Insertion of other (naso-)gastric tube Esophagogastroduodenoscopy [EGD] with closed biopsy Arteriography of other intra-abdominal arteries Arteriography of other intra-abdominal arteries Arteriography of other intra-abdominal arteries Transfusion of packed cells Injection or infusion of cancer chemotherapeutic substance Closed [aspiration] [percutaneous] biopsy of spleen Diagnoses: Anemia, unspecified Tobacco use disorder Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Hypopotassemia Nausea with vomiting Hypotension, unspecified Loss of weight Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Disorders of magnesium metabolism Splenomegaly Burkitt's tumor or lymphoma, lymph nodes of multiple sites Diarrhea of presumed infectious origin Mood disorder in conditions classified elsewhere Duodenitis, with hemorrhage Ulcer of esophagus with bleeding Other diseases of spleen Unspecified disorder of gallbladder Jaundice, unspecified, not of newborn

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: luq pain x 1 month, w/u at major surgical or invasive procedure: ct-guided biopsy history of present illness: 56m w/minimal pmhx who p/w gradual onset luq dull pain/"pushing" x ~1 month. some radiation to l flank, worse lying down, slightly relieved w/walking. he presented to the system, where initial dx included constipation, treated with laxatives with no relief of pain. currently the patient reports 7/10 intensity abdominal pain. at the va: ldh 726, ct showed massive lad in retrocrural nodes into upper abdomen involving celiac nodes; concerning for lymphoma. he was prepared for biopsy of the area, but was unable to complete procedure secondary to discomfort (?chest pain). he was discharged yesterday and presents to to transfer his care to this facility. pt states he does not want to go back to va for any care. pt also notes nausea, "dry heaves" ~4-5x in past 2 weeks. +anorexia, ~30 lbs unintentional wt loss over past 6 wks. +feverishness, +ns +chills. profound fatigue and generalized weakness. constant diarrhea x 2 yrs, taking frequent "stool hardener" ?kaopectate, which he recently self-d/c'd. no current bowel problems. past medical history: arthroplastic surgery on knee. no history of cad social history: lives with wife and 2 daughters in area. he smoked 1.5 ppd x 40 years, "quit 4 days ago." works as a letter carrier, but has taken sick for past week. approximately 6 drinks per week. family history: daughter with leukemia, diagnosed . she receives care in . no other family history of malignancy. physical exam: pe: vs t98.7, p72, bp 161/75, r18, spo2 95% ra gen: alert, oriented male in no distress. appears slightly older than stated age. heent: pharynx clear, poor dentitions. no cervical lymphadenopathy. cv: no jvd. s1 s2 with no murmurs. lungs clear. chest: no lesions. abd: nontender over cm, no hsm by palpation or percussion. nonobese. guaiac negative stool per er report. ext: no c/c/e x4. pertinent results: 02:30pm glucose-84 urea n-17 creat-0.8 sodium-141 potassium-4.6 chloride-101 total co2-28 anion gap-17 02:30pm alt(sgpt)-15 ast(sgot)-20 ck(cpk)-52 alk phos-107 amylase-24 tot bili-0.4 02:30pm lipase-16 02:30pm ck-mb-notdone ctropnt-<0.01 02:30pm wbc-9.9 rbc-4.12* hgb-12.4* hct-35.9* mcv-87 mch-30.2 mchc-34.7 rdw-12.5 02:30pm plt count-302 ct abdomen: in the upper abdomen, there is a large heterogenous mass consistent with confluent adenopathy measuring up to 9.4 x 7.8 cm. it surrounds the aorta and celiac axis with tethering of the left gastric artery. a 3.1 x 1.9 cm periportal node is also seen. 1. large heterogenous splenic mass. heterogenous bulky retroperitoneal adenopathy surrounding the aorta and celiac artery. areas of necrosis are seen. these findings are concerning for lymphoma. 2. left renal exophytic cyst. possible right renal cyst. pathology: overall, the findings are of a high grade, non-hodgkin b-cell lymphoma. given the high proliferation fraction, the differential diagnosis includes a high grade diffuse large b-cell lymphoma versus an atypical burkitt lymphoma. cytology: overall, findings are of a high-grade cd10-positive b-cell lymphoma. differential includes atypical burkitt's vs large b-cell lymphoma. ct chest: impression: 1) right hilar lymphadenopathy measuring 17 mm in diameter, as well as slight prominence other bilateral hilar nodes. in the clinical setting of lymphoma, involvement of lymphoma in the right hilar nodes is suspected. correlative fdg pet or gallium imaging may be helpful. 2) calcified subcarinal node, with multiple calcified granulomas, representing prior granulomatous infection. 3) non-calcified pulmonary nodule measuring less than 5 mm in diameter, as described above, probably related to the prior granulomatous infection, however, please follow up these lesions on future ct scans. 4) gynecomastia. 5) interval development of small amount ascites, measuring 43 hounsfielunits, which raises the possibility of hemoperitoneum following recent biopsy. : tte: conclusions: 1.the left atrium is mildly dilated. 2. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). 3.right ventricular chamber size and free wall motion are normal. 4.the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. 5.the mitral valve leaflets are structurally normal. no mitral regurgitation is seen. 6.there is no pericardial effusion. : bone marrow biopsy- normocellular marrow for age with multiple lymphoid aggregates : ct abdomen: there has been interval decrease in the size of the splenic lesion. previously, it measured 11.5 x 11.1 cm and now measures 10.0 x 8.6 cm. it is now more heterogeneous in appearance with low attenuation areas consistent with necrosis. small amount of higher attenuation fluid is noted at the inferior margin of the spleen consistent with peri-splenic hematoma. the retroperitoneal mass of bulky adenopathy involving the proximal abdominal aorta and left diaphragm has also decreased in size. previously, it measured 9.4 x 7.8 cm and now measures 7.6 x 6.6 cm. areas of low attenuation are also seen consistent with necrosis. : gastrointestinal mucosal biopsies, two: a. esophagus: 1. active esophagitis, with ulceration. 2. no viral inclusions or tumor seen. 3. methenamine silver stain of the esophagus (slide a) is negative for fungi, with satisfactory control. . b. duodenum: 1. acute duodenitis, with multiple crypt abscesses and focal loss of villi. 2. no viral inclusions or tumor seen. 3. immunostain of the duodenum (slide b) is negative for cytomegalovirus, with satisfactory control. some reagents are not approved for diagnostic use. note: possible causes of the duodenal inflammation include infection and drug injury. :ct abdomen: gallbladder is slightly prominent but demonstrates no secondary signs of cholecystitis. there is a stable appearing,predominantly hypodense lesion within the spleen measuring 8.2 x 7.0 cm. this appears unchanged in size and appearance in the interval. a large paraesophageal soft tissue mass measures 6.5 x 5.5 cm and is grossly unchanged in appearance as well. pancreas and adrenal glands are normal in appearance : ct sinus: impression: minimal ethmoid sinus thickening. evidence of prior right maxillary surgery. otherwise, negative study. : ct abdomen:impression 1. no evidence for splenic, perisplenic, or intra-abdominal hemorrhage. 2. unchanged size and appearance of the splenic hypodense lesion, and peri- splenic fluid collection. 3. unchanged soft tissue mass in the lesser sac, which is presumably a mass of matted lymph nodes. brief hospital course: the patient is a 56 yo male with burkitt's lymphoma. #burkitt's lymphoma - the patient presented to the va with 5-6 day history of luq pain and constipation. a ct scan at wr was notable for lymphadenopathy concerning for neoplastic disease. a repeat ct abdomen on admission was notable for extensive lad, splenomegaly with a splenic lesion. on , ct guided core biopsy of spleen was notable for b cell lymphoma - dlbl vs burkitts. ct chest was done for staging which was notable for enlarged r hilum ln. he then had a baseline tte which suggested an lvef of >55%. a bone marrow biopsy was done which suggested t cell dominant lymphoid profile. there was a small population of cd10 co-expressing b cells; given the known history of a cd10 positive b-cell lymphoproliferative disorder, the findings are suspicious and minimal involvement of the marrow cannot be entirely excluded. he was started on ivfs with amps of bicarb + bicarb tablets for goal urine ph >7 and allopurinol. when his urine ph was greater than 7, he was given his first dose of cytoxan 400 mg iv (). he was given anzemet/decadron prior to chemo for antinausea prophylaxis. in the pm of day 1, he was given his first dose of vincristine 2mg iv x1. the medications were separated in time because he was considered high risk for tls because his ldh was 1100 and rising and he had burkitts with a large tumor burden. tls were checked q3 hours. on day 2, he was given 1600 mg cytoxan in the morning and 80 mg iv doxurubicin in the evening. his ldh increased to max 2900 on day 2 of modified protocol. he did not develop evidence of hyperkalemia, hyperphosphatemia, hyperuricemia, or hypocalcemia. his bicarbonate in his blood rose to 43, so the bicarb in his fluids was decreased. the frequency of tls labs was decreased to q6hours. on day 3, he received it cytarabine + hydrocortisone with no complications and 400 mg iv cytoxan with no complications. on day 4 and 5, he received 400 mg cytoxan with no complications, hematuria, etc. on day 5, he received the second dose of it cytarabine with hydrocortisone with no complications. over the first few days of chemo, the patient also required intermittent doses of lasix to maintain a stable weight and limit bipedal edema. on day 7, the patient noted an increase in his luq pain; a repeat ct of the abdomen showed necrosing tumor decreasing in size. he received his second dose of vincristine on day 7. he tolerated the vincristine well without peripheral numbness/tingling or constipation. on day 8, the patient had continued increased luq pain so he was started on a morphine pca. on day 9 he was started on ivfs with bicarb for goal urine ph >7.0. on day 10, he got methotrexate 6 gm iv. on day 11, he started leucovorin rescue. his 24 hour mtx level was 1.87. on day 12, he was neutropenic. he spiked to 102.4 overnight so he was started on cefepime, blood cultures/urine cultures were sent which were negative. a few hours after having a fever, he started to have profuse watery diarrhea ~2l in 8 hours. flagyl was added for possible c.diff. stool cultures, cdiff and cmv were sent which were negative (cdiff negative x 3). the patient was also started on ciprofloxacin for double gram negative coverage. by mid morning of day 13, the patients blood pressures had decreased to 70s-80s/40s-50s and his hr increased to 120s. he also had episodes of projectile vomiting-nonbloody. he was also started on neupogen (per protocol) and b/c the patient was neutropenic and there was concern of typhilitis. he was given over 5 liters ns bolus with no increase in pressures. he was then transferred to the for further management of his hypotension. an a-line was placed and he was started on levophed once in the unit. another 2l of ns were administered and the levophed was weaned off. ct abdomen was performed with oral contrast (through ngt b/c pt unable to tolerate contrast) due to concern for abdominal source, especially typhlitis. his ct abdomen demonstrated some mild wall thickening in the cecum. he remained febrile and vancomycin was started. he again remained febrile with negative cultures so caspofungin was started. repeat kubs were unremarkable, without free air. on day 14, he had coffee ground emesis overnight and guaic + stools so he was started on iv ppi. the coffe ground emesis resolved, but the patient continued to have 1-2l /day watery diarrhea (no infectious etiology had was found) so octreotide was started. the patient continued to have diarrhea with decreased po intake so tpn was started. after days of octreotide, the patients diarrhea decreased to episodes per day. repeat stool studies were again negative. the patients anc began to rise on day 17. he was no longer neutropenic by day 18 so the neupogen was stopped. the vanco and cefepime were also stopped because he was no longer febrile. because the patient was no longer neutropenic, he was able to have an egd which was notable for grade 1 esophagitis and diffuse nodularity of the mucosa of the duodenom. the path from the biopsies were consistent with crypt abscess from drug vs infection. cmv and fungal cultures were negative from the biopsies. it was felt that the etiology of the diarrhea was methotrexate induced. the patient was still afebrile so the caspo was stopped. over the next few days, the patients wbc count increased despite stopping neupogen. by day 21, his wbc increased to 49. flow was sent on the blood and it was found to not be consistent with burkitts. in the setting of such a high wbc, there was concern for cdiff toxin b even though cdiff a was negative x >3 so stool was sent for toxin b and the patient was started on po vanco in addition to flagyl. tgg was also sent to evaluate for celiac sprue. this test was also negative. a repeat abdominal ct was done which was notable for stable mass in spleen, stable paraortic lymph nodes and no thickening of wall of small bowel. the patients diarrhea began to slow down to 2-3 stools per day and his wbc trended down. on day 26, his wbc was 17.6, his t. bili was 1.7, he had only stools per day so it was decided to start part b of modified protocol (ivac). he was given 75% dose of etoposide and ara-c, 100% dose of ifosfamide in light of his elevated bilirubin. the patient was also started on mesna with the ifosfamide. baseline cerebellar check was only notable for minimal intention tremor with finger to nose testing. the patient's cerebellar exam remained stable throughout and s/p the 4 doses of ara-c. he tolerated the 5 days of chemo well. his course was complicated only by minimal nausea decreased with anzemet and ativan. on day 8, the patient received it mtx with no complications. his anc on discharge was 1170. he refused 1 unit prbc prior to discharge. #luq pain - the patients pain was well controlled with po pain meds until after his first round of chemo. the pain then increased and he required a morphine pca for pain control. the pca was stopped in the setting of the patient's acute mental status changes while he was hypovolemic/hypotensive. when he was transferred back to 7 , he was started on a fentanyl pca for pain control. this did not decrease his pain, so he was changed back to a morphine pca. the morphine pca gave him good relief. prior to discharge, he was changed to ms contin and po msir for breakthrough pain. #acute renal failure - in the setting of the patient's hypotensive episode, his creatinine increased to a max of 1.4. his bun increased to 24. his fena was 1.4%. it was felt to be secondary to volume depletion (prerenal). the patient's uo remained 50-100 cc/hour. due to concern for methotrexate toxicity (completed on ) and mtx level 0.36 on , especially in light of sepsis and potential third spacing of mtx, iv leucovrin was increased and hemodialysis was started. his methotrexate level decreased appropriately, and no further hemodialysis was required. #hyperbilirubinemia - in the setting of the diarrhea, hypotension, the patients bilirubin also started to rise. it was mostly direct by fractionation. a ruq ultrasound was normal and had normal venous flow. the patients peak bilirubin was 8.1 with direct bili of 5.7 on day . hepatitis a, b and c serologies were sent which were negative. the etiology of the hyperbilirubinemia was unknown, and with negative us and ct scan it was felt to be secondary to septic gallbladder (although peaked several days after the episode of hypotension occurred) vs methotrexate effect. the patient remained on actigall 600 mg throughout the admission. his bilirubin trended down to normal on the actigall. #altered mental status - on day 13, in the setting of the diffuse watery diarrhea and hypotension, the patient became lethargic. it was felt that the ativan given for his nausea and his morphine pca could be contributing to his altered mental status so both of these were held. the patients neuro exam was nonfocal during the episode. the patients lethargy resolved after stopping these meds and after aggressive hydration. #depression - the patient has a history of several major depressive episodes. he has been hospitalized at least 2 times for "breakdowns". he was admitted on celexa 40 mg daily and wellbutrin 200 mg . throughout the admission, he remained down with a flat affect. his celexa dose was increased to 60 mg daily with improvement in his mood. he was also seen by psychiatry who felt that he should be maintained on celexa and wellbutrin. #fen - the patient remained on tpn from day 17 until discharge. his electrolytes were repleted as needed. #code - full. medications on admission: meds @ home: wellbutrin 200 mg po bid, celexa 40 mg po qd, colace 100 mg po bid, mvi 1 tab po qd, percocet 1-2 tabs q4-6h. discharge medications: 1. 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* 2. citalopram hydrobromide 20 mg tablet sig: three (3) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 3. bupropion hcl 100 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 4. acyclovir 200 mg capsule sig: two (2) capsule po q8h (every 8 hours). disp:*180 capsule(s)* refills:*2* 5. ursodiol 300 mg capsule sig: two (2) capsule po bid (2 times a day). disp:*120 capsule(s)* refills:*2* 6. levofloxacin 250 mg tablet sig: two (2) tablet po q24h (every 24 hours) for 10 days. disp:*20 tablet(s)* refills:*0* 7. zolpidem tartrate 5 mg tablet sig: 1-2 tablets po hs (at bedtime) as needed. disp:*45 tablet(s)* refills:*0* 8. morphine sulfate 15 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). disp:*60 tablet sustained release(s)* refills:*0* 9. lorazepam 0.5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for nausea. disp:*30 tablet(s)* refills:*0* 10. morphine sulfate 15 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for breakthru pain. disp:*24 tablet(s)* refills:*0* 11. filgrastim 480 mcg/1.6 ml solution sig: one (1) injection q24h (every 24 hours): please inject 480 mcg subcutaneously x 6 days. disp:*10 ml* refills:*0* 12. chlorhexidine gluconate 0.12 % liquid sig: one (1) ml mucous membrane (2 times a day). disp:*60 ml(s)* refills:*2* 13. vancomycin hcl 250 mg capsule sig: one (1) capsule po four times a day for 7 days. disp:*28 capsule(s)* refills:*0* 14. flagyl 500 mg tablet sig: one (1) tablet po three times a day for 7 days. disp:*21 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: burkitt's lymphoma discharge condition: stable discharge instructions: please take all medications as prescribed. if you have fevers, chills, sweats, nausea, vomiting, abdominal pain, increased diarrhea, you should call dr. office or come to the emergency department. temperatures of 100.4 and above should be considered a fever while your white count is low. followup instructions: provider: , md where: hematology/bmt phone: date/time: 2:30 Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Hemodialysis Insertion of other (naso-)gastric tube Esophagogastroduodenoscopy [EGD] with closed biopsy Arteriography of other intra-abdominal arteries Arteriography of other intra-abdominal arteries Arteriography of other intra-abdominal arteries Transfusion of packed cells Injection or infusion of cancer chemotherapeutic substance Closed [aspiration] [percutaneous] biopsy of spleen Diagnoses: Anemia, unspecified Tobacco use disorder Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Hypopotassemia Nausea with vomiting Hypotension, unspecified Loss of weight Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Disorders of magnesium metabolism Splenomegaly Burkitt's tumor or lymphoma, lymph nodes of multiple sites Diarrhea of presumed infectious origin Mood disorder in conditions classified elsewhere Duodenitis, with hemorrhage Ulcer of esophagus with bleeding Other diseases of spleen Unspecified disorder of gallbladder Jaundice, unspecified, not of newborn

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status major surgical or invasive procedure: central line placement history of present illness: 68 yo male with esrd on dialysis, htn, l bka, cad, presents with fevers (tm 103.8 per ems at ), rigors, hypotension (90/60s in field, 100/52 in ed) and altered mental status. in the ed, got 1 gm tylenol pr and ampicillin/sulbactam and vancomycin for suspected sepsis secondary to decubitus ulcer. after 2 l ns, his bp did not improve. he was started on neosynephrine drip which improved his bp to low 100's/60. a left subclavian was placed after it was not possible to thread a femoral guidewire. he was noted to have stage 2+ sacral decubitus ulcers. heel does not look infected. last hd on monday and usually dialyzes m, w, f in . . ros: intermittent nausea/nbnb emesis over last couple weeks, non-productive cough x 2-3d, back pain at site of ulcer, mild diarrhea, 30 lbs weight loss over unspecified amount of time, denies fever, hematochezia, sob, cp, hematuria past medical history: esrd s/p l bka htn cad dm social history: sh: lives at home with his sister, but has been staying at since . previously smoked 4 packs/day x 20 years, but quit in . drinks occasionally. since his recent bka he has required more help with adls mr. has lived alone at home in , but more recently his sister has stayed with him, occasionally replaced by other siblings. he has vna to help with meals. family history: brother with mi at 70s. pt has 3 brother, 4 sisters physical exam: physical exam: vs: 98.4 93/64 93 11 100% gen: nad, somnolent heent: perrl, mm dry cv: tachy, rr, nl s1/s2, no m/r/g appreciated lungs: diffusely rhonchorous but sub-optimal exam abd: + bs, s/nt/slight distension, no hsm ext: 2+ radial pulse, l bka, well healed lateral surgical incision of r ankle, 3 toes on r foot neuro: arousable, oriented to person, place, not date; cn ii-xii intact, mafe, no rigidity skin: r gluteal stage ii-iii ulcer, dry, w/o exudate or bogginess lines: r sc dialysis catheter, l sc placed , r arterial a-line pertinent results: 10:18pm lactate-2.1* k+-4.1 10:18pm hgb-9.9* calchct-30 10:10pm glucose-272* urea n-30* creat-4.7* sodium-141 potassium-4.1 chloride-99 total co2-27 anion gap-19 10:10pm wbc-14.8* rbc-3.51* hgb-9.6* hct-30.7* mcv-87 mch-27.4 mchc-31.3 rdw-17.9* . 04:28am blood ck(cpk)-128 02:37am blood mg-1.8 06:00am blood calcium-7.8* phos-4.0 mg-2.2 02:19am blood caltibc-94* ferritn-1861* trf-72* 11:59am blood wbc-13.1* rbc-3.16* hgb-9.5* hct-28.7* mcv-91 mch-30.0 mchc-33.1 rdw-18.7* plt ct-253 02:37am blood wbc-11.2* rbc-3.11* hgb-9.2* hct-28.3* mcv-91 mch-29.5 mchc-32.4 rdw-18.6* plt ct-258 04:59pm blood wbc-13.6* rbc-3.57* hgb-10.0* hct-30.4* mcv-85 mch-28.0 mchc-32.9 rdw-17.4* plt ct-215 08:20pm blood wbc-13.1* rbc-2.79* hgb-7.8* hct-23.1* mcv-83 mch-28.1 mchc-34.0 rdw-17.4* plt ct-246 03:45am blood wbc-16.1* rbc-3.04* hgb-8.6* hct-24.9* mcv-82 mch-28.2 mchc-34.4 rdw-17.1* plt ct-237 09:06am blood pt-21.4* ptt-77.2* inr(pt)-2.1* 02:37am blood plt ct-258 02:37am blood pt-17.5* ptt-57.5* inr(pt)-1.6* 07:33pm blood ptt-62.6* 11:59am blood pt-15.4* ptt-150* inr(pt)-1.4* 01:36am blood pt-13.3* ptt-98.8* inr(pt)-1.2* 09:30am blood esr-23* 02:37am blood glucose-55* urean-12 creat-2.6*# na-139 k-4.0 cl-104 hco3-29 angap-10 01:36am blood glucose-209* urean-23* creat-4.4* na-136 k-4.4 cl-102 hco3-24 angap-14 03:45am blood alt-9 ast-14 ld(ldh)-167 alkphos-58 amylase-23 totbili-0.3 02:17am blood ck-mb-9 ctropnt-1.08* 03:19pm blood ck-mb-10 mb indx-18.5* ctropnt-1.18* . micro: blood culture aerobic bottle-final; anaerobic bottle-final {prevotella species} inpatient blood culture aerobic bottle-final; anaerobic bottle-final inpatient catheter tip-iv wound culture-final negative. 04:01am blood ck(cpk)-111 03:46pm blood ck(cpk)-154 . echo : conclusions: the left atrium is moderately dilated. left ventricular wall thicknesses and cavity size are normal. there is mild to moderate regional left ventricular systolic dysfunction with focal akinesis of the inferior and inferolateral walls and hypokinesis of the anterolateral wall. the remaining left ventricular segments contract normally. right ventricular chamber size is normal with focal basal free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. an eccentric jet of mild to moderate (+) mitral regurgitation is seen directed along the lateral wall. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: regional left and right ventricular systolic dysfunction c/w cad (lv and rv infarction). mild-moderate mitral regurgitation. pulmonary artery systolic hypertension. . : impression: successful placement of 28 cm (23 cm tip-to-cuff length) angiodynamics even more hemodialysis catheter. the catheter tip is in the right atrium. the catheter is ready to employ. . brief hospital course: a/p: 69 yo m w/ esrd, htn, dm p/w fever, hypotension from line sepsis. . 1. sepsis: the pt initially presented to the icu with sepsis requiring pressors. the suspected source was the hd catheter and this was pulled. the patient was covered with broad spectrum empiric antibiotics. the blood cultures showed prevotella 1/4 bottles, which was clearly no confirmatory for line infection, although no other definitive source was identified and line infection was most likely. the antibiotics were changed to vanc/unasyn which was continued until which was a 14 day course. a new hd line was placed on . . 2. cardiac: a. ventricular tachycardia: on , the pt was being prepared for discharge to rehab and he was noted to have episodes of non-sustained ventricular tachycardia noted on telemetry monitor. the patient has ef 35% and known scar. ep was consulted and in their estimation, the patient was not a candidate for icd given the esrd and infection risk. metoprolol was continued. he will be monitored on tele at the acute rehab facility for one more week. . b. atrial fibrillation: the patient was noted to have episodes of atrial fibrillation, although he mostly remained in sinus rhythm. anticoagulation was started on with heparin bridge and coumadin. he was monitored for bleeding given that he had a significant bleed from his sacral decubitis ulcer requiring transfusion after debridement. metoprolol was continued as well. amiodarone was started for maintenence of nsr. this was started at 200 mg tid and should be continued at this frequency for three more weeks after discharge. then frequency should be decreased to once per day after that. at discharge, his inr was 2.6. at the nursing facility, the patient will continue to have daily pt/inr until his inr is stable. he will follow up with dr. in electrophysiology. . b. chf, ef 35%: on echo, the patient was noted to have ef 35%. he remained euvolemic after the sepsis had resolved. fluid control was with dialysis. low dose lisinopril was started towards the end of his hospital stay. . c. cad: the pt was noted to have ecg changes and elevated cardiac ezymes while in the icu. per cardiology, this was thought secondary to demand ischemia, medical management was recommended. the pt was treated with aspirin, beta blocker, started on high dose statin. however, the ck bump was quite unremarkable with a peak of merely 154, which suggests minimal myocardial damage. . 3. anemia: patient had bleed from sacral decubitus ulcer after debridement. his last transfusion was . hematocrit was followed while on anticoagulation. . 4. depression: mood was depressed with decreased speech production and lack of interest in conversation. ssri was started, but will take several weeks to reach effect. . 5. esrd/hd: on monday/wednesday/friday schedule for hemodialysis. last hd in hospital was . . 6. dm2: the patient was on glargine and ssi for additional coverage. he had recurrent episodes of hypoglycemia, so his am glargine was decreased from 14 units to 10 units, then 8 units. he still had a brief hypoglycemic episode on 8 units. it is recommended to continue on 5 units after discharge and increase dose again if necessary. medications on admission: lactulose 30 ml multivitamin qd vitamin c 500 mg zinc 220 mg qd metoprolol 25 mg q6 dulcolax suppository pr qhs nepro 60 ml qid heparin sq tid renagel 40 tid colace 200 mg qhs fentanyl 100 mcg q 72 last dilaudid 4 mg q4 prn moderate pain and prior to hd dilaudid 8 mg q4 prn severe pain prostat 30 ml qid asa 325 mg qd iron 325 mg qd prozac 20 mg qd lipitor 80 mg qd nephro vite qd prilosec 20 mg qd senokot 2 tabs discharge medications: 1. ascorbic acid 500 mg tablet : one (1) tablet po bid (2 times a day). 2. zinc sulfate 220 (50) mg capsule : one (1) capsule po daily (daily). 3. acetaminophen 325 mg tablet : 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for fever. 4. b complex-vitamin c-folic acid 1 mg capsule : one (1) cap po daily (daily). 5. atorvastatin 40 mg tablet : two (2) tablet po daily (daily). 6. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 7. silver nitrate applicators misc : one (1) misc topical daily (daily) as needed. 8. surgifoam powder : one (1) mucous membrane prn (as needed). 9. trazodone 50 mg tablet : 0.5 tablet po hs (at bedtime) as needed. 10. metoprolol tartrate 25 mg tablet : one (1) tablet po tid (3 times a day). 11. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 12. thiamine hcl 100 mg tablet : one (1) tablet po daily (daily). 13. senna 8.6 mg tablet : 1-2 tablets po bid (2 times a day) as needed. 14. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day) as needed. 15. amiodarone 200 mg tablet : one (1) tablet po three times a day. tablet(s) 16. warfarin 2.5 mg tablet : one (1) tablet po at bedtime: dose to be adjusted per inr. 17. metoclopramide 10 mg tablet : 0.5 tablet po tid (3 times a day). 18. fluoxetine 20 mg capsule : one (1) capsule po daily (daily). 19. heparin lock flush (porcine) 100 unit/ml syringe : one (1) ml intravenous daily (daily) as needed: to each port. 20. insulin glargine 100 unit/ml solution : five (5) units subcutaneous qam. 21. insulin lispro (human) 100 unit/ml solution : 0-10 units subcutaneous four times a day: per sliding scale. 22. outpatient lab work please draw pt/inr daily 23. lisinopril 5 mg tablet : one (1) tablet po daily (daily). 24. roho cushion for stage 4 pressure ulcer, per wound care discharge disposition: extended care facility: - discharge diagnosis: primary: 1. sepsis, presumed secondary to hd line infection, s/p removal 2. non-sustained ventricular tachycardia 3. atrial fibrillation 4. non-st elevation mi 5. acute blood loss anemia secondary to decubitus ulcer 6. sacral decubitus ulceration 7. peripheral vascular disease s/p bka on left in at 8. delirium 9. depression 10. malnutrition . secondary: 1. esrd on hemodialysis 2. diabetes mellitus type 2, controlled with complications 3. cad with ischemic cardiomyopathy discharge condition: hemodynamically stable, normal sinus rhythm, tolerating pos, afebrile. discharge instructions: if you have any fevers, chills, confusion, light-headedness or passing out, chest pain, or any other concerning symptoms, please call your doctor or return to the emergency room. . you have been started on new medications including coumadin which is a medicine to thin the blood to prevent strokes since you have atrial fibrillation which can lead to strokes. you have also been started on a medicine called amiodarone which is to prevent abnormal heart rhythms since you have had episodes of an abnormal heart rhythm. you should be taking amiodarone three times per day for three more weeks (total of four weeks), then frequency should be decreased to once per day. you should be monitored on telemetry for one more week after you have been discharged from the hospital (total of two weeks). followup instructions: amiodarone should be taken three times daily for three more weeks, then frequency should be decreased to once daily. patient should be on telemetry for one more week after discharge from the hospital. . coumadin was started in hospital. frequent inr necessary and dose should be adjusted accordingly. . low dose lisinopril has been started for heart failure. dose should be slowly increased as tolerated. . please call your primary care physician to establish follow-up appointment within 1-2 weeks after you leave rehab. , a. . please also follow up with: provider: , m.d. phone: date/time: 3:00 Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Other incision with drainage of skin and subcutaneous tissue Incision with removal of foreign body or device from skin and subcutaneous tissue Nonexcisional debridement of wound, infection or burn Nonexcisional debridement of wound, infection or burn Transfusion of packed cells Infusion of vasopressor agent Diagnoses: End stage renal disease Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Acute posthemorrhagic anemia Unspecified septicemia Unspecified protein-calorie malnutrition Severe sepsis Atrial fibrillation Paroxysmal ventricular tachycardia Other specified forms of chronic ischemic heart disease Hemorrhage complicating a procedure Septic shock Long-term (current) use of anticoagulants Pressure ulcer, lower back Infection and inflammatory reaction due to other vascular device, implant, and graft Pressure ulcer, heel Delirium due to conditions classified elsewhere Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Below knee amputation status

history of present illness: this is a 51 year old male patient who noticed to have chest pressure a few hours prior to admission. he presented to an outside hospital emergency department about 3:00 in the afternoon and was found to have elevated st segments. he was started on integrilin at that time and was transferred to for emergency cardiac catheterization. this revealed left main and severe three vessel coronary artery disease with a left ventricular ejection fraction of greater than 55 percent and was referred for emergency coronary artery bypass grafting. past medical history: significant for nephrolithiasis status post stone extraction as well as ankle surgery. preoperative medications: accupril, metoprolol 100 mg po bid, lipitor 20 mg po q d, vitamin e, and aspirin daily. allergies: the patient states no known drug allergies although he does note an upset stomach with erythromycin. physical examination: upon admission to the hospital was unremarkable as were his laboratory values with the exception of elevated cpks and troponins. hospital course: the patient was taken emergently to the operating room due to his findings in catheterization laboratory of a 95 percent left main coronary artery stenosis, as well as a 90 percent to 95 percent left anterior descending coronary artery lesion. 80 percent proximal left circumflex and an occluded right coronary artery. the patient was taken to the operating room with dr. where he underwent coronary artery bypass graft times three. the patient had an intraaortic balloon pump placed preoperatively due to his anatomy. postoperatively he was transported from the operating room to cardiac surgery recovery unit in good condition on propofol and phenylephrine drips. on postoperative day #1, he was weaned from mechanical ventilation, successfully extubated. he remains on neo- synephrine for the next day or so due to some hypotension, his cardiac function remained good with a cardiac index of greater than 3. his intraaortic balloon pump was weaned and subsequently discontinued on postoperative day #1. the patient did require some intravenous fluid boluses for hypotension. on postoperative day #2, the patient had some atrial fibrillation and was placed on amiodarone because of this. he was also begun on lopressor at that time and begun with diuresis. the following day the patient had converted back to normal sinus rhythm. had remained hemodynamically stable. had his neo-synephrine drip weaned to off and was tolerating beta blocker and diuresis. postoperative day #3, he was transferred from the intensive care unit to the telemetry floor. his metoprolol had been increased. his - drain in his leg had been removed and he had begun ambulation and cardiac rehabilitation. the patient subsequently on the telemetry floor had another episode of atrial fibrillation that was short lived on , early in the morning that was self limiting. his lopressor was increased and he has not had any further episodes of atrial fibrillation. he remains on amiodarone and metoprolol for this. physical examination: today, , is as follows: the patient is afebrile. he is in normal sinus rhythm with a rate in the mid 70's. his blood pressure is 120/74. room air oxygen saturation is 96 percent. neurologically he is grossly intact with no apparent deficits. his pulmonary examination - his lungs are clear to auscultation bilaterally. coronary examination is regular rate and rhythm. his abdomen is soft, nontender, nondistended. his extremities are warm without edema. his sternal incision as well as his right leg incisions are all clean and dry with no erythema, no drainage. the steri-strips are intact. discharge medications: lopressor 100 mg po bid, lasix 20 mg po bid times seven days, potassium chloride 20 meq po bid times seven days, zantac 150 mg po bid, aspirin 325 mg po q d, plavix 75 mg po q d times three months. lipitor 20 mg po q d, percocet 5/325 po q four hours prn pain. the patient is also to continue on amiodarone 400 mg po tid times one week, then decrease to 400 mg po bid times one week, then decrease 400 mg po q d times one week, and then decrease to 200 mg po q d for the remaining week. this is the tentative plan for amiodarone loading unless it is altered or until it is discontinued by the patient's primary cardiologist, dr. . the patient is also going home with of hearts cardiac monitor for his amiodarone loading and this will be transmitted to the electrophysiology service here at . condition on discharge: good. the patient is to follow up with is primary care physician, . in one to two weeks. he is to follow up with his primary cardiologist, dr. also in one to two weeks and to follow up with dr. in approximately five to six weeks. condition on discharge: good. discharge diagnoses: 1. coronary artery disease status post emergent coronary artery bypass graft. 2. postoperative atrial fibrillation. , Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Injection or infusion of platelet inhibitor Left heart cardiac catheterization Implant of pulsation balloon Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Other and unspecified hyperlipidemia

history of present illness: the patient is a 69-year-old man with a history of alcohol abuse who presented on with lethargy, abnormal labs, dehydration and a low blood pressure. the patient has long history of alcohol abuse with question liver disease. he also had a prior gi bleed in the past but is not known to have varices. he initially presented to emergency room on with complaints of weakness, trouble ambulating and requesting detox placement. he was discharged to for detox. upon arrival at , labs were drawn which revealed severely elevated liver function tests. this included an ast of 99, alt 32, alkaline phosphatase 496, total bilirubin 16.4, albumin 1.6. it also showed that he had a hematocrit of 22.2. the patient was managed for approximately 1?????? days with a ciwa scale, received 1-2 doses of serax. he was also started on levaquin for a question of pneumonia. however, on the evening of , the patient was found to be hypotensive and more lethargic. he was then transferred back to the emergency room for further evaluation and management. in the emergency room, a central line was placed and he was given aggressive iv fluid and rehydration including intravenous potassium chloride and potassium phosphate. a rectal was guaiac negative and ng lavage was also negative for gi bleed. a diagnostic paracentesis was performed which yielded only about 10-15 cc of straw colored fluid. this fluid was negative for suggestion of spontaneous bacterial peritonitis. the patient had a blood pressure in the 70-80 range systolic and was felt to be too unstable for the general medical floor and was transferred to the micu on the . past medical history: alcohol abuse with apparent liver disease. history of withdrawal with delirium tremens but no history of seizures. history of gi bleed, presumably secondary to gastritis. prostate cancer status post resection . pancreatitis. chronic hypocalcemia. status post fracture and open reduction and internal fixation of his left arm. coronary artery disease. cardiac catheterization showed an ef of 50%, mild to moderate single vessel disease of the left circumflex artery, 50% stenosing lesion was noted at the mid section of the artery. hypertension. medications: on transfer from , multivitamin, folate, thiamine, protonix, calcium carbonate, magnesium oxide, levaquin 500 mg, lasix, serax. allergies: aspirin. social history: the patient is married. he is a retired telephone repairman. he has a history of alcohol abuse, drinking at least 1?????? cups of brandy a day. his last drink was reportedly on . he also smoked ?????? pack per day times 30 years. physical examination: temperature 97.1, pulse 88-99, blood pressure 70/42-117/64, respiratory rate 26, o2 saturation 99% on four liters nasal cannula. the patient is a cachectic elderly african american male in no acute distress. he is lethargic. he is alert and oriented times two. heent: pupils equal, round and reactive to light and accommodation, there is positive scleral icterus. his oropharynx is clear. neck is supple. chest, bibasilar crackles without wheezing anteriorly. cardiovascular exam is regular rate and rhythm, no murmurs are appreciated. abdomen, positive bowel sounds, very distended. liver edge palpable about 5 cm below the right costal margin and nontender. tympanic abdomen. guaiac negative rectal exam. extremities, trace edema in both feet. neuro exam, alert and oriented times two but lethargic. does not cooperate with full neuro exam but moves all extremities. laboratory data: white blood cell count 16.0, hematocrit 23.7, platelet count 298,000, mcv 100, 74 neutrophils, 4 bands, 20 lymphs, 1 mono, 11 nucleated red cells, inr 1.4, ptt 35.5, sodium 139, potassium 3.0, chloride 106, co2 21, bun 19, creatinine 1.2, glucose 112, albumin 2.0, calcium 7.4, magnesium 2.1, phosphorus 0.6, alt 32, ast 112, alkaline phosphatase 523, total bilirubin 20.4, direct bilirubin 14.8, indirect bilirubin 5.6, amylase 210, lipase 213. chest x-ray, heart size within normal limits, low lung volume, no evidence of chf. blunted right costophrenic angle. no obvious pneumonia. abdominal ultrasound, no obvious evidence of cholecystitis. there is positive sludging and stones noted. no intra or extra hepatic ductal dilatation is noted. peripheral blood smear, target cells, poikilocytes, nucleated red cells, few teardrops, reticulocytes, no schistocytes seen. ekg, atrial tachycardia at 115, normal axis, short pr interval, long qtc, superior t wave, t wave inversions in v1, biphasic in leads v2 through v3, t wave flattening in 3, l. hospital course: the patient was admitted for management of his apparent fulminant liver failure. ct scan of his abdomen was performed after admission. this revealed bilateral pleural effusions, diffuse fatty liver, no intra or extra hepatic ductal dilatation, patent portal and hepatic veins, diffuse colonic thickening which appears to be consistent with pancolitis with some involvement of the terminal ileum. gallbladder shows some stones and sludging but no wall thickening. there is a small amount of fluid around the tail of the pancreas with no overt radiographic evidence of pancreatitis. diverticula were also noted. there is a moderate amount of free fluid in the pelvis. there is not an overt amount of ascites fluid. there is increased attenuation in the right lobe of the liver. the liver service was consulted as well as the surgical service to comment on the patient's liver failure as well as abdominal distention. the liver service felt that this was most likely consistent with a picture of fulminant alcoholic hepatitis. they did note that it is not uncommon to see mildly elevated transaminases in the presence of severely elevated alkaline phosphatase and total bilirubin. there were initial discussions regarding performing an mrcp vs an ercp. by the patient's amylase and lipase had decreased significantly. at that point, the liver service suggested holding off on performing an mrcp. it was also felt that the patient would likely not tolerate an mrcp given his history of claustrophobia. if he required sedation for the procedure, he likely would have required intubation for airway management. the liver service also felt that ercp was likely not indicated in his case regardless given the severity of his liver failure. it was felt that if he had the unfortunate complication of pancreatitis status post ercp, that his overall mortality would be unacceptably high. pentoxifylline was started initially to prevent the development of renal failure given his liver failure. however, this was later stopped due to the question of possible sepsis. the surgical service recommended no surgical intervention as an option at this time. they felt that the increase in the bilirubin, and the bowel wall thickening appeared to be related to his extensive liver failure. they felt no surgical intervention was indicated given his overall clinical picture. the patient was hemodynamically stable during his initial stay in the micu. he was transferred to the floor on . however, on the patient became increasingly confused and his temperature was noted to drop to 90. because of his confusion and severe hypothermia, he was returned to the micu service for further evaluation as he appeared to be rapidly deteriorating. also, the patient's blood pressure had again dropped to the 70 range. he received treatment with iv fluids, and antibiotics were continued for broad coverage of bowel flora. antibiotic regimen which had been started on initial admission to the micu included ampicillin, levofloxacin, and flagyl. his pentoxifylline was discontinued given the concern for the development of sepsis at this point. the patient's liver function tests showed a mixed picture of improvement vs deterioration. his total bilirubin gradually was decreasing after peaking in the 24 range. meanwhile his amylase and lipase had again returned to the 200 range after initial improvement. his abdominal distention was worsening and plain radiographs of the abdomen showed very distended loops of bowel. there was no overt evidence of obstruction. the patient was continuing to pass stool. the metronidazole was changed to an alternating dose between po and iv given the concern for c. diff colitis. there was no radiographic evidence of toxic megacolon. on the patient became hemodynamically unstable with blood pressures dropping to the 60's and 70's systolic range. he was emergently intubated for airway protection given his mental status, and he was started on pressors with dopamine initially. on the ventilator, the patient was hyperventilated to attempt to compensate for his severe metabolic acidosis. his serum ph ranged between 7.2 and 7.3 on the ventilator. on , the patient continued to deteriorate from a hemodynamic standpoint requiring the addition of two more pressor agents. he eventually was stabilized on a regimen of dopamine, norepinephrine, and vasopressin. the norepinephrine and vasopressin were maintained at maximum doses, while the dopamine was at the range of mcg/kg/minute. the patient's central venous pressure appeared to be low and he was continued to be aggressively hydrated with multiple iv fluid boluses. there was no obvious source of infection found at the time of this dictation, however, his white count did continue to trend upward into the 20 range. blood cultures have been sent again to seek a source of infection which may not be covered by his current antibiotic regimen. also, at this time we are considering repeating an ultrasound to look for any evidence of obstruction so that if his alkaline phosphatase continues to elevate despite the improvement in his total bilirubin and his other liver function tests. at the time of this dictation, the patient is still too unstable to have an mrcp performed nor would he potentially tolerate therapeutic ercp. extensive discussions have been held with the family to discuss his overall condition and poor prognosis. the patient's primary care physician, . , has also been involved in these discussions. at the time of this dictation, the patient's family has decided that he will remain a full code status. however, they wish that if he does have an arrest, that a prolonged code not be performed should he not be revivable in a quick manner. a discharge summary addendum will follow this discharge summary to summarize the remaining events during this hospital course. , 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 Insertion of endotracheal tube Percutaneous abdominal drainage Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Unspecified protein-calorie malnutrition Percutaneous transluminal coronary angioplasty status Acute respiratory failure Other shock without mention of trauma Other and unspecified alcohol dependence, continuous Acute alcoholic hepatitis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest discomfort. major surgical or invasive procedure: cabgx4(lima->lad, svg->diag, pda, plv) history of present illness: this is a 77 yo male patient presented with complaints of week history chest discomfort with shortness of breath, nausea, and vomitting. he reports sub-sternal chest pain that awoke him from sleep on the morning of admission. in the emergency room he had some st depressions on ekg with + enzymes. in the cardiac cath lab he was found to have 3 vd with 80% lm, 80% lad, 50% lcx, and 90% rca. he was at that time referred for coronary artery bypass grafting. past medical history: diabetes type 2. hypertension. asthma. social history: patient lives in with his wife. is retired. drives. his activity is limited due to shortness of breath and he requiresthe use of both a cane and walker intermittently. he has a remote history of tobacco use, having quit 60 years ago. denies etoh use. family history: father deceased with mi at age 47. sister with cad -- unknown age. physical exam: on admission: height: 5'9" weight: 104 kg vs: 75 sr 140/61 96% on 1l nc general: seen sitting up in bed in nad. neuro: a+o x 3. appropriate. questionable historian denying documented pmh and stating "i just don't know!" neck: + carotid bruits bilaterally. resp: cta. cv: rrr -- distant heart sounds. gi: soft, obese, nt< nd, + bs. extremities: warm, well perfused. + pitting edema. - varicosities. right groin cath site without hematoma. pertinent results: 04:45am blood wbc-10.0 rbc-3.03* hgb-9.2* hct-28.8* mcv-95 mch-30.5 mchc-32.1 rdw-15.9* plt ct-486* 04:45am blood plt ct-486* 04:21am blood glucose-87 urean-43* creat-2.2* na-143 k-4.3 cl-102 hco3-33* angap-12 10:51pm blood calcium-8.1* phos-3.4 mg-1.8 brief hospital course: this is a 77 yo male patient presented with complaints of week history chest discomfort with shortness of breath, nausea, and vomitting. he reports sub-sternal chest pain that awoke him from sleep on the morning of admission. in the emergency room he had some st depressions on ekg with + enzymes. in the cardiac cath lab he was found to have 3 vd with 80% lm, 80% lad, 50% lcx, and 90% rca. he was at that time referred for coronary artery bypass grafting. on exam, this patient was found to have carotid bruits bilaterally with carotid ultrasound showing a 70-79% stenosis on the left side. a neurology consult was obtained stating, after thorough exam, that the patient was thought to be safe for surgery without further neurological examination. he proceeded to the operating room on with dr. . he underwent a cabg x 3 with lima to the lad, svg to the diag, and svg to the pda and plb. total cardio-pulmonary bypass time 78 minutes and cross clamp time 49 minutes. he proceeded to the csru in a nsr with rate 74, map 85, cvp 16, on neo and propofol drips. he failed to weane in the immediate post-operative period but was successfully weaned and extubated on the evening of post-op day one. he was initially confused with periods of lucidity. on pod 3 he experienced atrial fibrillation and was started on amiodarone. becasue of his history of copd adn asthma, lopressor was used cautiously and hydralazine was used for htn. on this same day, his mediastinal chest tubes were discontinued. on pod 4 amiodarone was changed to po, nph insulin was started for blood glucose control, and he was transferred to the inpatient floor for continued rehabilitation and recovery. on pod 5 his remaining chest tubes and epicardial wires were discontinued. he continued in atrial fibrillation with ongoing amiodarone and low-dose beta blockers. mr. was known to chronic renal insufficiency with a pre-op creat of 1.9. on pod 6, his creat was elevated to 2.6. he was also noted to be 10 kg up from his pre-op weight. his lasix was thus discontinued and natracor was initiated for diuresis. on this same day he converted to a nsr. on post-operative day 8, he lost his venous access and was sent for picc placement for continued natracor therapy. on pod 9 a renal consult was obtained. they recommended continued natracor with lasix for increased diuresis. (creatinine 2.6.) continued to diuresis with both lasix and natracor for 4 days with discontinuation of natracor on pod 12. (creatinine 2.8.) on pod 13, renal signed-off as they felt situation was stable. he continued to diurese with lasix; with creatinine stable at 2.7-2.9, and weight decreasing. he had a burst of strial fibrillation on pod 15 and converted to nsr following an iv amiodarone bolus and ongoing po amiodarone. he was followed by the physical therapy team throughout his hospitalization and was thought not to be safe for home. he was recommended for rehabilitation placement. on the day of dichharge, mr. was stable with his creatinine dropping (2.2) and his edema and weight lessening. medications on admission: lasix 80mg daily. unknown doses of: hctz allopurinol, protonix advair insulin discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. atorvastatin calcium 20 mg tablet sig: one (1) tablet po daily (daily). 5. allopurinol 100 mg tablet sig: 1.5 tablets po daily (daily). 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. amiodarone hcl 200 mg tablet sig: two (2) tablet po daily (daily) for 7 days: then decrease dose to 200 mg daily. 8. hydrocodone-acetaminophen 5-500 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 9. furosemide 80 mg tablet sig: one (1) tablet po daily (daily). 10. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). discharge disposition: extended care facility: hospital - discharge diagnosis: coronary artery disease. iddm htn asthma atrial fibrillation discharge condition: good. discharge instructions: follow medications on discharge instructions. you should not drive for 4 weeks. you should not lift more than 10 lbs. for 3 months. you should shower, let water flow over wounds, pat dry with a towel. followup instructions: make an appointment with dr. for 1-2 weeks. make an appointment with dr. for 6 weeks. Procedure: 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 Coronary arteriography using two catheters Transfusion of packed cells Injection or infusion of nesiritide Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Atrial fibrillation Unspecified disorder of kidney and ureter Chronic obstructive asthma, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: motor vehicle accident major surgical or invasive procedure: exploratory laparotomy, gastrostomy, jejunostomy, ivc filter placement history of present illness: 63yo m who was in a motor vehicle collision who was treated at an outside hospital, had a left chest tube placed and was intubated and was brought to for further treatment and care. the patient was an unrestrained driver who hit a bridge wall. at the scene, he was awake, c/o cp/sob. by report, he had seizure activity in transit. upon arrival to trauma and undergoing resuscitation the patient was found to be hypotensive and had ended up having a positive dtl. he went into pea and had chest tube placed without blood back, had cpr, epi/atropine x 1 and was successfully resuscitated. he was deemed too unstable for the ct scanner and was brought emergently to the or. he underwent ex-lap, which revealed pelvic hematoma. he also had a bolt placed, with opening pressure 80. maximum gcs here was 3. pupils were unreactive on exam, no response to painful stimuli in any extremities. past medical history: copd, esophageal strictures s/p multiple dilatations, pvd, carotid stenosis, h/o arrhythmia, 70+ppy tobacco physical exam: p/e v/s 130s 80/40s gen intubated cv rrr pulm course bs b/l abd distended, poor bs, +dpl ext no gross deformity, 2+ pulses . neuro ms unresponsive to noxious stimuli cn r pupil unable to open, l pupil 2mm unreactive. +gag reflex and cough motor no response to noxious stimuli . pertinent results: 08:17am blood wbc-15.6*# rbc-3.64* hgb-10.9* hct-33.6* mcv-92 mch-29.9 mchc-32.3 rdw-17.3* plt ct-71* 02:10am blood wbc-6.2# rbc-2.97* hgb-9.0* hct-28.2* mcv-95 mch-30.4 mchc-32.1 rdw-17.2* plt ct-81* 07:36pm blood wbc-1.8*# rbc-3.21* hgb-9.6* hct-29.7* mcv-93 mch-29.9 mchc-32.3 rdw-17.0* plt ct-105* 02:28am blood wbc-4.6 rbc-3.11* hgb-9.9* hct-28.1* mcv-90 mch-32.0 mchc-35.4* rdw-16.6* plt ct-117* 08:17am blood plt smr-very low plt ct-71* 02:10am blood plt smr-low plt ct-81* 02:10am blood pt-19.7* ptt-48.1* inr(pt)-1.9* 07:36pm blood plt smr-low plt ct-105* 12:33pm blood fibrino-388 04:33pm blood fibrino-435* 09:20pm blood fibrino-390 08:17am blood urean-29* creat-1.1 na-143 k-5.7* cl-110* hco3-20* angap-19 02:10am blood glucose-54* urean-26* creat-0.9 na-143 k-5.5* cl-109* hco3-24 angap-16 07:36pm blood glucose-78 urean-21* creat-0.7 na-145 k-4.6 cl-110* hco3-28 angap-12 08:17am blood alt-15 ast-66* ld(ldh)-406* alkphos-35* amylase-40 totbili-2.9* 04:22am blood alt-18 ast-49* alkphos-40 amylase-39 totbili-0.7 04:22am blood lipase-21 12:39pm blood ck-mb-4 ctropnt-<0.01 08:17am blood albumin-1.7* calcium-7.5* phos-6.7* mg-2.1 02:10am blood calcium-8.0* phos-6.3*# mg-2.1 11:54am blood osmolal-295 01:50pm blood cortsol-26.7* 01:59am blood phenyto-3.0* 10:30am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 01:14pm blood type-art temp-38.3 rates-22/ peep-10 fio2-60 po2-116* pco2-45 ph-7.28* caltco2-22 base xs--5 intubat-intubated vent-controlled 10:28am blood type-art temp-37.9 peep-10 fio2-60 po2-107* pco2-44 ph-7.29* caltco2-22 base xs--4 intubat-intubated 09:28am blood type-art temp-37.7 po2-171* pco2-45 ph-7.29* caltco2-23 base xs--4 intubat-intubated 08:27am blood type-art temp-37.7 po2-341* pco2-47* ph-7.27* caltco2-23 base xs--5 04:40am blood type-art temp-38.3 po2-65* pco2-64* ph-7.17* caltco2-25 base xs--6 intubat-intubated 01:14pm blood glucose-90 lactate-8.0* 10:28am blood glucose-98 lactate-7.0* 09:28am blood glucose-126* 08:27am blood freeca-1.14 10:44pm blood freeca-1.08* 10:36pm blood heparin dependent antibodies- 10:13pm urine blood-mod nitrite-neg protein-neg glucose-neg ketone-15 bilirub-neg urobiln-1 ph-5.0 leuks-neg 10:30am urine blood-mod nitrite-neg protein-30 glucose-250 ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg 10:13pm urine rbc-* wbc-0-2 bacteri-rare yeast-none epi-0 10:30am urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg . . 10:13 pm blood culture site: central line **final report ** aerobic bottle (final ): no growth. anaerobic bottle (final ): no growth. . . chest (portable ap); -76 by same physician ap view of the chest (two radiographs): in the interval, there has been placement of a second tube in the left hemithorax with tip in the apex. large left pneumothorax is unchanged. interval improvement of right upper lobe collapse with increase in aeration. otherwise, there are no changes. . . ct abdomen w/contrast 2:23 pm ct chest, abdomen, and pelvis with intravenous contrast impression: 1. multiple injuries, including rib fracture, scapular fracture, pneumothorax, pleural effusions (hemothorax could not be excluded due to limitation by extensive streaky artifact), pulmonary embolus, right upper lobe consolidation, subcutaneous emphysema, large fluid collection with air in the mid abdomen, large hematoma in the pelvis, pelvic fractures. spleen laceration cannot be excluded. . . bilat lower ext veins port bilateral lower extremity doppler ultrasound: grayscale, color, and doppler son of the right and left superficial femoral and popliteal, as well as right common femoral veins was performed. evaluation of the left common femoral vein was limited by overlying bandages. there is normal compression, color flow, augmentation, and waveforms. there is no evidence of deep vein thrombosis. impression: no deep vein thrombosis in the right or left superficial femoral and popliteal veins, or the right common femoral vein. this is a limited examination. . . abdomen (supine only) 8:55 pm findings: supine abdominal radiograph was reviewed. immediately prior to acquisition of the radiograph, contrast was injected via the g- and j-tubes. there is contrast within the stomach without evidence for extravasation. contrast is present in the jejunum without gross extravasation. impression: no gross extravasation. . . chest (portable ap) portable ap chest. comparison: . there is no definitive pneumothorax on the left. note that the left costophrenic sulcus is not included in the film. the chest tubes, the et tube, and right subclavian catheter are in good position. bilateral lung opacities may be consistent with resolving contusions. essentially no change from the lung findings from prior radiograph. brief hospital course: this patient was admitted to on after sustaining a motor vehicle crash while driving as an unrestrained passenger and hitting a bridge (brick wall/pylon). he was brought to as a transfer patient and there was seizure activity while in transit. he was also intubated before being brought to and a left chest tube was placed for a left sided pneumothorax. at , his injuries were noted as the following: mutiple scalp / facial lacerations with bleeding, persistent pneumothorax on left, no obvious pelvic fx. there was a witness arrest in trauma bay and the acls protocol initiated by housestaff ?????? the patient regained vitals and bilateral chest tubes were placed. despite all efforts, he remained hypotensive. a dpl was performed in the trauma bay which was positive, and hence the patient was taken to the or for an exploratory lapartomy. he did not receive any furthur imaging while in the emergency department of . in the or, there was ontinued aggressive resuscitation with prbc, ffp, platelets, and cryoprecipitate. an exploratory laparotomy revealed no intraperitoneal bleeding source; however, a pelvic hematoma was seen that was non-expanding. the abdomen was left oven and the patient transfered to the recovery room, followed by the trauma icu. an icp monitor was placed which showed a severely elevated opening pressure. he settled out around 40-50 over the course of the next few hours. in the icu, there was continued resuscitation with fluids and pressors. he was sedated and paralyzed, under pressure control ventilation to help his respiratory status. his injuries at this time: - no intracranial hemorrhage - multiple facial fractures - left sided flail chest - left superior / inferior pubic rami fx / sacral fx the patient's family was hesitant to continue with care, as they were sure that the patient was insistent that he only wanted to live in a fully functional state. on postoperative day four, the patient was clinically stabilizing and was requiring decreased ventilator support and minimal pressor support ?????? eventually weaned off. he was then taken back to the or for an abdominal wall closure ?????? this was done with retention sutures; a gastrostomy tube and a jejunostomy tube were placed. the patient then developed culture positive pneumonia with gram negative bacteria (acenitobacter / enterobacter) which was treated with antibiotics.on postoperative days 6 and 2, the patient displayed septic physiology: he was hypotensive, tachycardic, required increasing ventilation support, was sedated / paralyzed and on maximal pressor support.a chest x-ray and tube study was done to rule out recurrent pneumothorax (required multiple chest tubes to drain) and to rule out enteral leakage around feeding tubes. at this point, a family meeting was conducted, who decided they did not want to pursue further care and hence the patient was made cmo the following morning and he expired shortly after. discharge medications: n/a discharge disposition: expired discharge diagnosis: n/a discharge condition: n/a discharge instructions: n/a followup instructions: n/a Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for 96 consecutive hours or more Other enterostomy Interruption of the vena cava Enteral infusion of concentrated nutritional substances Other bronchoscopy Other bronchoscopy Exploratory laparotomy Arterial catheterization Pulmonary artery wedge monitoring Closure of skin and subcutaneous tissue of other sites Transfusion of packed cells Cardiopulmonary resuscitation, not otherwise specified Other gastrostomy Transfusion of other serum Other diagnostic procedures on brain and cerebral meninges Transfusion of platelets Other suture of abdominal wall Transfusion of coagulation factors Suture of laceration of external ear Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Tobacco use disorder Congestive heart failure, unspecified Acute posthemorrhagic anemia Unspecified septicemia Chronic airway obstruction, not elsewhere classified Other convulsions Open wound of forehead, without mention of complication Defibrination syndrome Traumatic pneumohemothorax without mention of open wound into thorax Cardiac arrest Septic shock Pressure ulcer, other site Traumatic subcutaneous emphysema Other pulmonary embolism and infarction Contusion of lung without mention of open wound into thorax Traumatic shock Gangrene Closed fracture of sacrum and coccyx without mention of spinal cord injury Closed fracture of scapula, unspecified part Other motor vehicle nontraffic accident involving collision with stationary object injuring driver of motor vehicle other than motorcycle Intracranial injury of other and unspecified nature without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level Injury to other intra-abdominal organs without mention of open wound into cavity, peritoneum Closed fracture of pubis Closed fracture of five ribs Open wound of external ear, unspecified site, without mention of complication

pmh: reported as copd/emphysema and 'forgetfullness". wife also reports 'unsteady gait over past few months that has not been worked-up. pt has previous admission for pneumonia(). ...quit smoking 2 years ago ...no allergies meds: advair q am adl's: wife reports pt is independent. icu course: ongoing bleeding of unclear source; significant blood loss from left ct initially. jp drains active for > 1000cc s/s fluid. multiple blood products to manage bleeding and coagulopathy: pc's, ffp, plts, cryoprecipitate, and factor 7 administered..see i&o flowsheet. neosynephrine @ .5 to 2mcg/kg/min to maintain bp. bolt was placed with opening icp in 70 range..now in mid 20's with cpp maintianed >60 with transient dips into 50's; (initial cpp notable in 40's). unable to assess neuro staus at this time d/t neuro-hemodynamic instability. rsc cco swan was placed with elevated filling pressures noted. svo2 62>58 with co/ci 3.4/1.7 with improvement to ci >2 with ongoing volume infusing. u/o adequate second left ct placed for pneumothorax per cxr; persistent pntx per cxr but improved. initial cxr revealed rul collapse which has improved following ett repositioning. resp- multiple vent changes made to improve gas exchange; pt on pcv with 100% and 14cm peep. see careview for latest abg's. mod amt bloody secretions suctioned. **right ct removed since no pathology found on right and ct not positioned fully in pleural space. ..pt required paralytic bolus and sedation for ett obstruction d/t biting. Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for 96 consecutive hours or more Other enterostomy Interruption of the vena cava Enteral infusion of concentrated nutritional substances Other bronchoscopy Other bronchoscopy Exploratory laparotomy Arterial catheterization Pulmonary artery wedge monitoring Closure of skin and subcutaneous tissue of other sites Transfusion of packed cells Cardiopulmonary resuscitation, not otherwise specified Other gastrostomy Transfusion of other serum Other diagnostic procedures on brain and cerebral meninges Transfusion of platelets Other suture of abdominal wall Transfusion of coagulation factors Suture of laceration of external ear Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Tobacco use disorder Congestive heart failure, unspecified Acute posthemorrhagic anemia Unspecified septicemia Chronic airway obstruction, not elsewhere classified Other convulsions Open wound of forehead, without mention of complication Defibrination syndrome Traumatic pneumohemothorax without mention of open wound into thorax Cardiac arrest Septic shock Pressure ulcer, other site Traumatic subcutaneous emphysema Other pulmonary embolism and infarction Contusion of lung without mention of open wound into thorax Traumatic shock Gangrene Closed fracture of sacrum and coccyx without mention of spinal cord injury Closed fracture of scapula, unspecified part Other motor vehicle nontraffic accident involving collision with stationary object injuring driver of motor vehicle other than motorcycle Intracranial injury of other and unspecified nature without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level Injury to other intra-abdominal organs without mention of open wound into cavity, peritoneum Closed fracture of pubis Closed fracture of five ribs Open wound of external ear, unspecified site, without mention of complication