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asked by dr. to evaluate infant for sepsis risk. infant is a ft, 3385 gram male newborn who was born by vaginal delivery to a 31 y.o. g1p0 mother. pregnancy uncomplicated. social/family history non-contributory. serologies: ab+, ab neg, hep neg, rpr nr, ri, gbs negative. sepsis risks: gbs - negative, fever tmax - 100.4, rom - < 24 hours, maternal abx - x 15 minutes ptd, nonsustained fetal tachycardia. vacuum-assisted vaginal delivery. apgars 8,9. on exam: comfortable. afsf. +molding. +caput. palate intact. lungs cta, =. cv rrr, no murmur, 2+fp. abd soft, +bs. nl phallus. testes down bilaterally. patent anus, no sacral anomalies. +plantar and palmar grasps, good suck, symmetric moro. a/p: well-appearing aga ft male newborn born to a mother with fever. no other concerning sepsis risks. will check cbc w/ diff and blood cx. hold abx unless labs abnormal or clinical course changes. to nbn once evaluation complete. Procedure: Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section

history of present illness: this is an 81 year-old male resident of the who presented to the emergency room after an episode of coffee ground emesis about 100 cc. the patient was unable to give a detailed history, but had been complaining of four days of epigastric pain at the nursing home, which he currently denied. vital signs were stable at the . he had a temperature 98.0, blood pressure 96/58, pulse 113 and was transferred to the . in the emergency room he had a small amount of melena in his colostomy bag. he has a history of uc status post colostomy. his hematocrit was 25.6, which was 25 at the nursing home earlier in the day and in was 36. his vital signs on arrival were heart rate of 136, blood pressure 96/60. he had transient drop in his blood pressure to 75/palp. he received 2 liters of intravenous fluids, 3 units of packed red blood cells and given his drop of heart rate into the 100s and systolic blood pressures in 110s to 130s range. an electrocardiogram with normal t waves in leads, 2, 3, avf, v5 and v6. 2 units of packed red blood cells were given and the patient had increasing amounts of melena in his colostomy bag. past medical history: 1. ulcerative colitis status post colostomy. 2. coronary artery disease status post coronary artery bypass graft in . 3. osteoporosis. 4. low back pain. 5. hypertension. 6. anemia. 7. depression. 8. benign prostatic hypertrophy. 9. chronic obstructive pulmonary disease. 10. gastroesophageal reflux disease. 11. dementia. medications on admission: 1. aspirin. 2. lipitor. 3. multivitamin. 4. protonix. 5. zoloft. 6. trazodone. 7. xanax. 8. accolate. 9. megace. 10. lipitor. 11. combivent. allergies: sulfas. social history: he lives at the . he is a retired rail road worker, previous 68 pack year smoking history, quit 40 years ago. physical examination on admission: temperature 99.2. pulse 102. blood pressure 121/59. respiratory rate 19. sats 100% on 4 liters. general, he is awake, alert and oriented times two, unable to give detailed history, pleasantly demented in the emergency department and in no acute distress. heent pupils are equal, round and reactive to light. extraocular movements intact. membranes were tachy. neck jvp was flat. cardiovascular regular, tachycardic. no murmurs. diffuse bilateral rhonchi. abdomen was melena in the ostomy bag, positive bowel sounds, nontender, nondistended. extremities no lower extremity edema. neurological examination was awake, alert and oriented times one. no gross defects answering yes and no questions . laboratories on admission: white blood cell count 10.3, hematocrit 25.6, platelets 194, inr 1.4. chemistries otherwise normal except bun of 52, creatinine of 1.0. liver function tests were normal. troponin t less then 0.01. total bilirubin 0.2. urinalysis was negative. chest x-ray with congestive heart failure with bilateral pleural effusions. kub no free air and no evidence of obstruction. electrocardiogram sinus at 106, normalized t waves in 2, 3, avf, v5 and v6, left anterior descending coronary artery with poor r wave progression. hospital course: this is an 81 year-old gentleman with a history of coronary artery disease, hypertension, ulcerative colitis status post colostomy, gastroesophageal reflux disease and dementia here with blood loss anemia and severe esophagitis and hiatal hernia. 1. blood loss anemia: the patient's baseline hematocrit around 36, 25 on admission and received a total of 3 units of packed red blood cells with good response in hematocrit. at the time of discharge hematocrit was 30 after receiving the 3 units of blood otherwise the patient had negative hemolysis workup, iron deficiency and anemia workup and was otherwise stable. the patient eventually went for an esophagogastroduodenoscopy to evaluate for source of bleeding. on esophagogastroduodenoscopy they found evidence of erythema, ulceration and friability in the lower third of the esophagus compatible with severe esophagitis consistent with severe reflux disease. he also had a large hiatal hernia, question whether there was periesophageal versus a sliding hernia. he will go for an upper gastrointestinal study to evaluate this for possible surgical intervention if desired by the patient after study. he also had a question of an angiectasia in the duodenal bulb, but no other active sites of bleeding. secondary to the severe esophagitis the patient was started on a b.i.d. ppi. also plans to start on b.i.d. sucralfate two hours after each ppi dose. also was put on gastroesophageal reflux disease precautions with plans to elevate the head of the bed greater then 20 degrees at all times when sleeping and otherwise was tolerating a regular diet without difficulty. 2. cough/shortness of breath: initially the patient came slightly hypoxic with persistent cough. plans were for the patient to continue a ten day course of levaquin for a presumed pneumonia. the patient's sputum grew out gram positive cocci in pairs and were waiting final sensitivities, however, likely just a community acquired pneumonia and will continue to treat with levaquin for ten days. 3. chronic obstructive pulmonary disease: the patient was stable and at baseline per his patient. was started back on his home regimen of combivent and zafirlukast and with nebulizers prn, but those were not required and the patient was not requiring oxygen at the time of discharge and otherwise breathing was stable. 4. coronary artery disease status post coronary artery bypass graft: he was ruled out by enzymes and overall doing well. likely had some changes on electrocardiogram related to demand ischemia that resolved after stabilization in the hematocrit. he did have initial complaints of some chest pain, but was either severe heartburn reflux disease versus demand ischemia. the pain resolved after admission and plans were to restart his aspirin ten days after discharge. the patient will continue on his metoprolol. 5. hypertension: the patient's blood pressure remained stable on his home dose of metoprolol. 6. hyperlipidemia: the patient's cholesterol was stable on his statin. 7. depression: the patient was stable on his zoloft and xanax. 8. code: the patient is dnr/dni, which was reconfirmed and his sister is his health care proxy. discharge condition: good. patient ambulating without difficulty, tolerating a regular diet, stable hematocrit. discharge status: discharged to . discharge diagnoses: 1. blood loss anemia. 2. severe esophagitis. 3. gastroesophageal reflux disease. 4. pneumonia. 5. chronic obstructive pulmonary disease. 6. coronary artery disease. 7. hypertension. 8. hyperlipidemia. 9. depression. discharge follow up: the patient is to follow up with his primary care physician in seven to ten days. dr., 11-402 dictated by: medquist36 Procedure: Other endoscopy of small intestine Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Esophageal reflux Congestive heart failure, unspecified Acute posthemorrhagic anemia Aortocoronary bypass status Osteoporosis, unspecified Ulcerative colitis, unspecified Esophageal hemorrhage Acute esophagitis

allergies: methadone attending: chief complaint: altered mental status major surgical or invasive procedure: femoral line placement on right in ed history of present illness: ms is a 54f with a pmhx significant for esrd on hd, narcotic abuse, hcv, iddm and recent right knee infection who presented after she was en route to a doctor's appointment when she became acutely altered. per ems she was incontinent of urine and stool. in the ed, initial vitals were t=, bp=167/74, hr=68, rr=10, o2sat=100% on nrb, finger stick 303. somnolent in ed but without complaints other than being unable to eat for the past few days, her somnolence precluded learning more about this. the team was able to rouse her only with painful stimuli and was concerned about her airway. she was given narcan, pt woke up quickly, but had become more as she waited in the ed. her cxr was questionable for atelectasis vs pna. her head ct was negative. access difficult, has right groin line. renal has been called. pt given vanc and zosyn out of concern for sepsis and right leg infection. ecg ok. had foley placed and was given 1l ns. admitted for monitoring and work up of mental status and likely narcotic overdose. . vs at the time of transfer were: 120/66 12 96% on ra hr 68 afebrile . on arrival to the floor the patient is somnolent and unable to fully complete exam questions. she denies any recent narcotic use. reports that she is tired because she hasn't been able to sleep for the past few days diarrhea. missed hd yesterday due to diarrheal illness. it is unclear when the diarrhea started. she reports going to the ed 5 days ago for leg pain and being give oxycodone, with the diarrhea possibly starting after this. she reports loose stool whenever she eats, more than every hour. no fevers. she is shivering and complaining of feeling very cold. denies taking any other pills or drugs. unable to complete ros as patient falls asleep during exam. . past medical history: esrd on hd (since )mwf at south suburban unit narcotic abuse/dependence depression pe (history questionable) hep c iddm history of sexual abuse htn hl esophagitis atrial flutter (resolved after d/c methadone and quetiapine) lymphedema right knee infection s/p washout (?) history of qt prolongation on methadone social history: disabled, lives at home in apartment in . has three children, daughter and son are primary supports. uses wheelchair due to right knee pain. widowed. -tobacco history: 6 cigarettes a day. -etoh: none -illicit drugs: history of cocaine and heroin abuse, last heroin in , last cocaine in . transitioned to methadone, tapered off in . conflicting reports from patient and omr regarding narcotic abuse. family history: brother died of mi at 56. father died of cva @ 85. mother has sle, htn, asthma. physical exam: vs: t=96.0, bp=118/64, hr=72, rr=16, o2 sat=94% ra general: middle aged african american female. somnlolent. arouses to voice. shivering heent: ncat. sclera anicteric. no conjunctival injection or icterus. disconjucate gaze corrects with effort. mmm. neck: supple. s/p punctures from central line placement attempt. no hematoma. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. mild anterior rhonchi/wheeze. hd tunneled line in place on left is c/d/i abdomen: soft, ntnd. no hsm or tenderness. negative sign. no abdominial bruits. extremities: asymmetric l>r edema. femoral line in place, bloody dressing. s/p right wrist surgery with some deformity. healed ulcer on left leg. skin: no stasis dermatitis, ulcers, scars, or xanthomas. on leaving ama: mental status alert and oriented x 3, vitals stable, systolic murmur at lusb pertinent results: admission labs : wbc-7.3 rbc-3.27* hgb-10.9* hct-33.4*# mcv-102* mch-33.2* mchc-32.5 rdw-16.4* plt ct-141* neuts-60.8 lymphs-28.1 monos-7.0 eos-3.7 baso-0.4 pt-12.3 ptt-34.9 inr(pt)-1.0 glucose-211* urean-70* creat-11.3*# na-142 k-5.5* cl-103 hco3-22 angap-23* alt-10 ast-12 ck(cpk)-53 alkphos-201* totbili-0.4 ck-mb-notdone ctropnt-0.31* calcium-7.7* phos-8.8*# mg-1.9 d-dimer-2758* blood asa-neg ethanol-neg acetmnp-17.3 bnzodzp-neg barbitr-neg tricycl-neg ama discharge labs : 07:50am blood wbc-7.7 rbc-2.93* hgb-9.1* hct-29.7* mcv-101* mch-31.2 mchc-30.8* rdw-16.2* plt ct-190 07:50am blood glucose-457* urean-38* creat-6.3*# na-136 k-4.3 cl-100 hco3-26 angap-14 07:50am blood calcium-8.7 phos-3.9 mg-1.6 microbiology: blood culture: blood culture, routine (final ): staph aureus coag +. final sensitivities. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. consultations with id are recommended for all blood cultures positive for staphylococcus aureus and species. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ 1 s urine culture (final ): yeast. 10,000-100,000 organisms/ml.. blood and stool cultures negative catheter tip culture wound culture (final ): (torulopsis) . >15 colonies. dr. requested speciation . dr. requested fluconazole sensitivity . sent to for susceptibility testing. refer to sendout system for results. blood/fungal culture (preliminary): no fungus isolated. blood/afb culture (preliminary): no mycobacteria isolated. imaging: ekg: sinus rhythm. consider right atrial abnormality. left ventricular hypertrophy by voltage. prolonged qtc interval is non-specific. correlation is suggested. since the previous tracing of sinus tachycardia is absent and the qtc interval appears longer. ct head: no acute intracranial process. cxr: cardiomegaly without evidence of failure. retrocardiac opacity may reflect atelectasis versus early pneumonia. if needed, a dedicated pa and lateral view may be obtained to better assess. leni: no evidence of dvt in the left lower extremity. transthoracic echo: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. left ventricular systolic function is hyperdynamic (ef>75%). the estimated cardiac index is high (>4.0l/min/m2). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. there are filamentous strands on the aortic leaflets consistent with lambl's excresences (normal variant). there is no valvular aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. there is moderate pulmonary artery systolic hypertension. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no vegetations or clinically-significant regurgitant valvular disease seen (good-quality study). hyperdynamic biventricular systolic function. compared with the prior study (images reviewed) of , right ventricular function now appears quite normal. the other findings are similar. cxr: in comparison with the study of , the lungs are essentially clear and there is no convincing evidence of vascular congestion or pleural effusion. dialysis catheter extends to the cavoatrial junction or into the upper portion of the right atrium. transesophageal echocardiogram: no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. no atrial septal defect is seen by 2d or color doppler. a catheter is identified in the superior vena cava and right atrium. the catheter tip is adjacent to the tricuspid valve. there is a small mass on the catheter that likely represents thrombus. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch and 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 there is no mitral valve prolapse. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. no definite vegetation/mass is seen on the valves. there is a very small (~2 mm) filamentous structure on the atrial surface of the anterior mitral valve leaflet in some views (see clips 61 and 14) which may represent a lambl's excrescence (an incidental finding) but a vegetation cannot be excluded. impression: small structure of unclear significance on the mitral valve as described above. no abscess seen. mild symmetric left ventricular hypertrophy with preserved biventricular systolic function. catheter in superior vena cava and right atrium with tip adjacent to tricuspid valve with a small mass on the side of the catheter that likely represents thrombus. suggest withdrawing the cathether by 2-3 cm to avoid contact of the tip with the tricuspid valve. simple atheroma in the aortic arch and descending thoracic aorta. brief hospital course: 54f with a history of narcotic abuse, esrd on hd, hcv and iddm presenting with acute altered mental status and found to have mrsa bacteremia and infection of prior tunneled hd line. # mrsa bacteremia- she had 1/4 bottles positive for mrsa on admission and was treated with vancomycin. she will require a total 6 week course given tee was unable to rule out endocarditis. patient will receive vancomycin dosed with hd to maintain trough between 15-20. she will be followed by the clinic. # on catheter tip- she was empirically treated with micafungin to complete a 14 day course but left against medical advice prior to completing course. # altered mental status- differential initially included narcotic overdose vs. infection, especially given positive ua from the ed and indwelling tunneled dialysis line. pt was still altered despite resolution of hypoglycemia. the patient was treated with supportive care initially with plan to obtain lp if mental status did not trend towards improvement. over the first 24 hrs, the pts mental status fortunately improved significantly. blood cultures grew gpcs from 1 of 4 bottles, at which time the presumed source was thought to be the hd catheter. ir was contact to remove the old tunneled line and place a new temporary line in the groin. mental status cleared with hd and antibiotics. # pt was initially hypotensive in the icu, thought secondary to possible septic component related to bacteremia/line infection. supported with peripheral levophed initially with gentle bolus ivf hydration to avoid overload given crf. levophed was titrated off and bps remained stable. anti-hypertensives where restarted as the bp recovered. # esrd on hd- missed last dialysis session prior to admission due to diarrheal illness. potassium trended upward over first several days of admission to the icu until pt was able to be dialyzed after the new temporary hd line was placed. her original tunneled line was removed and she received two temporary hd catheters throughout stay for dialysis. she had tunneled line placed the day prior to leaving against medical advice. # home situation: patient with complicated home situation. she reports that her daughter stole from her and left the hospital against medical advice in order to file a police report. she also has a 81 year-old mother who supports her but is not in great health. there was also the question whether if she can manage at home. pt saw the patient while inhouse and thought that the patient would likely benefit from rehab but the patient was not amendable. # dm- she was on an insulin sliding scale while in the hospital. patient left against medical advice. medications on admission: amlodipine 10mg daily nephrocaps daily calcium acetate tid gabapentin 300mg daily hydralazine 10mg tid (confirmed with pharmacy, written as 100mg tid in omr) iss levemir 17 units qhs omeprazole 20mg daily ondansetron 4mg prn acetaminophen prn simvastatin 5mg daily oxycodone 5-10mg q4-6 prn discharge medications: 1. vancomycin mg iv hd protocol 2. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 3. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 4. hydralazine 10 mg tablet sig: one (1) tablet po tid (3 times a day). 5. calcium acetate 667 mg capsule sig: two (2) capsule po tid w/meals (3 times a day with meals). 6. gabapentin 300 mg capsule sig: one (1) capsule po q48h (every 48 hours). 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 8. simvastatin 10 mg tablet sig: 0.5 tablet po daily (daily). 9. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever. 10. insulin please continue your home 17 units of levemir every evening. discharge disposition: home discharge diagnosis: primary: mrsa bacteremia with possible endocarditis fungemia altered mental status secondary: end stage renal disease on hemodialysis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital for altered mental status and were found to have an infection in your blood. you improved with antibiotics and changing your dialysis catheter as well as getting hemodialysis. you had an echocardiogram of your chest that showed a small spot on one of your heart valves concerning for infection, and you should have a total of 6 weeks of antibiotics. you also had yeast growing on your old hemodialysis line and are being treated with antifungals. please follow-up with your pcp and see psychiatrist to discuss your depression and medications. you should continue your regular hemodialysis sessions. the following changes were made to your medications: 1. started vancomycin, an antibiotic, to treat your blood stream infection. you should get this with every dialysis session until . 2. started fluconazole, an antifungal , to treat the yeast in your blood. 3. stopped your percocet as the narcotics may be causing more confusion. you should take tylenol for your pain. you left against medical advice despite being warned about the risks of leaving without complete results of your yeast blood cultures. you understood that leaving put you at risk for worsening infection, confusion and even death. weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: please follow up with pcp Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Hemodialysis Venous catheterization for renal dialysis Diagnoses: Thrombocytopenia, unspecified End stage renal disease Renal dialysis status Toxic encephalopathy Chronic hepatitis C without mention of hepatic coma Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Intestinal infection due to Clostridium difficile Other and unspecified infection due to central venous catheter Other and unspecified mycoses Endocarditis, valve unspecified, unspecified cause Methicillin resistant Staphylococcus aureus septicemia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: nausea major surgical or invasive procedure: ercp cardioversion history of present illness: 53 yo f patient of the good dr. with a past medical history significant for esrd, dm, hcv, htn, chf, now with one day of abd pain and emesis. patient reports she was at the store when she felt onset of intense nausea and suprapubic/epigastric pain. pt has had vomitting but unable to quantify how many times. denies constipation, diarrhea, fevers, chills, hematemesis. denies etoh ingestion or abuse of naroctic medications. also denies illicits. although pt has a history of missing hd appointments, she was at her last dialysis session on friday. . in the ed, patient vs significant for 97.1 88 171/85 16 99 on ra. ua looked positive. abdomen was noted to be soft, and patient was without cva tenderness. cbc without leukocytosis. nauasea responded to zofran 4mg ivx1 and gi cocktain, and abd pain responded to morphine 2mg ivx1. patient was given ns 500 cc. no abx were administered, though levaquin was ordered as a one time dose. ct a/p prelim read significant for small hiatal hernia, but no other noted abnormalities. patient was transferred to the dialysis unit prior to transfer to the medicine floor. at hd, pat had uf 1.3 l off. initially htn 200/94, but decreased to 138/79 with uf. noted to be somnolent at hd, but was not noted to be somnolent in the ed. . of note, patient was admitted with headache to to . she presented with ha that was felt to be consistent with migraines. headache improved with better bp control. patient high blood pressures likely due to missed hd appointment prior to admission. she as continued on home antihypertensive regimen. pt was originally treated with ctx for positive ua, and cx only grew mixed . . at the time of this assessment, patient lethargic but arousable. she is a poor historian secondary to lethargy and slow response. she is reporting vague suprapubic pain, pain at hd line, and ha consistent with her migraine. she is no long having nausea. she denies tongue biting and loss of bowel/bladder continence. . ros was otherwise essentially negative. the pt denied recent unintended weight loss, fevers, night sweats, chills, dizziness or vertigo, changes in hearing or vision, including amaurosis fugax, neck stiffness, lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia, odynophagia, diarrhea, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, shortness of breath, chest pain, palpitations, dyspnea on exertion, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. past medical history: -coag-neg staph (mrse) hd line infection, catheter changed over a wire on , on vancomycin -esrd on hd, on hd since . -dm2 -htn -hyperlipidemia -hep c -chronic diastolic chf (ef 75% in ) -lll segmental pe () -migraine -depression -narcotic dependence, on methadone -lymphedema -l heel pressure ulcer - ? h/o of seizure one year ago - not on ppx - fracture to her left leg and right wrist in at the social history: lives with mother . former employee of social services/dss. 2 sons, 1 daughter. 1 son was murdered (). smokes 1/2ppd x 20 years. rare etoh. last snorted heroin in . denies ivdu. family history: brother died of mi at 56. father died of cva @ 85. mother has sle, htn, asthma. physical exam: on admission vitals: t: 97.3 bp: 154/90 p: 88 r: 20 sao2: 98% ra fs: 140 general: lethargic but arousable. nad. somewhat slow verbal response. heent: ncat, perrl, eomi, no scleral icterus, mmm, no lesions noted in op neck: supple, no significant jvd or carotid bruits appreciated pulmonary: distant breath sounds, no wheezes, ronchi or rales cardiac: rr, nl s1 s2, no murmurs, rubs or gallops appreciated abdomen: soft, nt, nd, normoactive bowel sounds, no masses or organomegaly noted. neg. . extremities: 2+ le edema, 2+ radial, dp pulses b/l. no cva tenderness. right side wrist swelling, nontender. lymphatics: no cervical, supraclavicular, axillary or inguinal lymphadenopathy noted skin: no rashes or lesions noted. neurologic: alert, oriented x 3. noted difficulty relating history, marked mostly by slow response but answers are accurate and appropriate. cranial nerves ii-xii intact. 4/5 strength throughout. with lifting of arms, marked tremulousness, but no asterexis. no deficits to light touch throughout. pertinent results: ========= labs ========= 09:00am blood wbc-7.9 rbc-4.08* hgb-12.3 hct-38.7 mcv-95 mch-30.1 mchc-31.7 rdw-17.6* plt ct-173 01:51pm blood wbc-10.0 rbc-4.34 hgb-12.8 hct-40.2 mcv-93 mch-29.6 mchc-32.0 rdw-16.9* plt ct-203 08:00am blood wbc-9.8 rbc-4.46 hgb-13.4 hct-42.3 mcv-95 mch-30.1 mchc-31.8 rdw-16.7* plt ct-223 09:22am blood wbc-9.3 rbc-4.61 hgb-13.4 hct-43.7 mcv-95 mch-29.1 mchc-30.6* rdw-16.5* plt ct-250 05:15am blood wbc-9.1 rbc-4.18* hgb-12.6 hct-39.7 mcv-95 mch-30.2 mchc-31.8 rdw-16.2* plt ct-230 06:59am blood wbc-6.0 rbc-3.24* hgb-9.6* hct-30.4* mcv-94 mch-29.7 mchc-31.6 rdw-16.0* plt ct-180 05:18am blood wbc-5.2 rbc-3.18* hgb-9.6* hct-29.7* mcv-93 mch-30.1 mchc-32.3 rdw-15.6* plt ct-157 09:00am blood alt-46* ast-31 ld(ldh)-223 alkphos-295* totbili-0.2 01:51pm blood alt-36 ast-40 ck(cpk)-70 alkphos-256* amylase-179* totbili-0.4 08:00am blood alt-41* ast-61* ld(ldh)-248 ck(cpk)-64 alkphos-251* amylase-151* totbili-0.6 09:22am blood alt-45* ast-63* alkphos-223* amylase-148* 01:51pm blood lipase-239* 08:00am blood lipase-85* 09:22am blood lipase-109* 03:00pm blood ck-mb-7 ctropnt-0.19* 01:51pm blood ck-mb-notdone ctropnt-0.44* 08:00am blood ck-mb-5 ctropnt-0.36* 09:22am blood ck-mb-8 ctropnt-0.34* ========= radiology ========= ct abdomen/pelvis 1. moderate-sized hiatal hernia with distal esophageal wall thickening, new from prior study. findings likely reflect esophagitis, and can be evaluated with endoscopy and/or upper gi. 2. diverticulosis without diverticulitis. 3. fibroid uterus. 4. oblong hyodense lesion adjacent to the left wall of the bladder, measuring 3.2 cm, similar in size from . this appears separate from the ovary, and is of uncertain significance or origin. an mr is recommended for further evaluation . ct head there is no evidence of infarction or hemorrhage. -white matter differentiation is preserved. the ventricles and sulci are normal in size and configuration. the calvarium and soft tissues are normal. the visualized paranasal sinuses and mastoid air cells are clear. . cxr in comparison with study of , the cardiac silhouette is again at the upper limits of normal in size with no evidence of vascular congestion, pleural effusion, or acute pneumonia. ========= micro ========= urine culture (final ): mixed bacterial ( >= 3 colony types), consistent with skin and/or genital contamination. 06:59am blood wbc-4.3 rbc-3.23* hgb-9.7* hct-29.6* mcv-92 mch-29.9 mchc-32.6 rdw-15.6* plt ct-177 05:18am blood wbc-5.2 rbc-3.18* hgb-9.6* hct-29.7* mcv-93 mch-30.1 mchc-32.3 rdw-15.6* plt ct-157 02:45pm blood hct-29.5* 09:22am blood neuts-55.4 lymphs-34.4 monos-9.3 eos-0.2 baso-0.6 06:59am blood plt ct-177 05:18am blood plt ct-157 12:44am blood pt-14.2* ptt-41.9* inr(pt)-1.2* 06:59am blood glucose-104 urean-45* creat-6.9* na-138 k-3.4 cl-96 hco3-30 angap-15 05:18am blood glucose-74 urean-40* creat-6.0*# na-141 k-3.7 cl-100 hco3-31 angap-14 06:59am blood glucose-63* urean-31* creat-4.8*# na-141 k-3.1* cl-97 hco3-32 angap-15 06:59am blood alt-38 ast-64* alkphos-148* amylase-138* 05:18am blood alt-39 ast-72* amylase-48 06:59am blood alt-38 ast-68* alkphos-150* totbili-0.5 06:59am blood lipase-36 05:18am blood lipase-23 06:59am blood ggt-224* 09:22am blood lipase-109* 09:22am blood ck-mb-8 ctropnt-0.34* 06:59am blood calcium-8.7 phos-5.6* mg-1.7 05:18am blood calcium-8.4 phos-6.3* mg-1.8 06:59am blood totprot-5.7* albumin-3.3* globuln-2.4 calcium-8.4 phos-5.3*# mg-1.8 09:00am blood %hba1c-7.2* 06:59am blood angiotensin 1 - converting -pnd 05:46am blood lactate-1.5 _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ blood cx, central line: staphylococcus, coagulase negative. isolated from one set only. corynebacterium species (diphtheroids). brief hospital course: ## abdominal pain: patient initially reported suprapubic pain, and medical team felt this was secondary to possible cystitis. however, by hd #2 pain was mostly isolated to ruq and labs were concerning for pancreatitis. ua significant for > 50 wbc, moderate le and few bacteria, but cx only shows mixed , less likely uti or pyelonephritis. cardiac enzymes elevated, but likely at baseline given renal dysfunction and prior biomarkers in the setting of esrd. an ercp was pursued that showed ulcers in the lower third of the esophagus and erythema and congestion in the duodenal bulb compatible with duodenitis. hiatal hernia. normal biliary tree and complete pancreas divisum. otherwise normal ercp to the third part of the duodenum. patient was started on double dose ppi and will need repeat egd with biopsies after 8weeks of therapy. diet was gradually advanced to regular and abdominal pain much improved. . ## change in ms: improved markedly by hd #2. likely over medication at home with methadone, ativan and seroquel. given persistent nausea, there was some concern for benzo withdrawal. patient was placed on a ciwa but did not require any administration. . ## svt: on , patient was found on routine vitals check to have tachycardia to the 130s. ekg was consistent with atrial flutter. at the time, patient did not have iv access. the medical team attempted peripheral access without success at first. a trial of po betablockers was initiated but hr did not respond. iv access was finally obtained and with a single dose of iv lopressor patient dropped her sbp to the 90s. in this setting, patient was transferred to the ccu team for further care. in the ccu, the patient was found to be in new atrial flutter. poorly controlled pain and adrenergic surge from pancreatitis was considered as the cause of new onset atrial flutter. the patient was initially treated with diltiazem iv with some rate control. she underwent a tte to rule out presence of thrombus, anticoagulated with a heparin drip, then underwent dc cardioversion. she remained in nsr following. as her tte showed evidence of lvh, she was also started on standing metoprolol. patient remained in nsr after transfer back to the floor. . ## esrd on hd: mwf schedule. patient continued on hd schedule. renal followed patient while in house. . ## dmii: last a1c 9.3 in . a1c 7.2 implying reasonable control over last several months. fs below 300 in house. patient continued lantus and iss in house with good blood sugar control. . ## anemia: patient's hematocrit remained around 29-30 while in house. her baseline appears to be 30-40. patient did have guiac positive stool in house therefore heparin gtt held. patient had a work up in for occult gi bleed with normal colonoscopy and egd demonstrating erythema in antrum consistent with gastritis. . ## depression: patient continued on celexa. . ## chronic pain: patient continued on methadone and given po morphine for breakthrough pain secondary to pancreatitis. . ## oblong hypodense lesion in bladder noted incidentally on ct of abdomen and pelvis. patient will need mri follow up as outpatient. . ## elevated tsh: tsh elevated to 4.3 during admission. patient will need outpatient thyroid function tests to evaluate for possible hypothyroidism. . ##: blood culture: one set of blood culture from patient's central line grew coag neg staph and diphtheroids. line was pulled and patient demonstrated no signs of infection therefore this was thought to be contenement. medications on admission: aspirin 81 mg po daily methadone 20 mg po tid atorvastatin 20 mg po daily omeprazole 20 mg po daily senna 8.6 mg tablet po bid cholecalciferol (vitamin d3) 400 unit tablet po daily docusate sodium 100 mg po bid nephrocaps 1 tab po daily quetiapine 100 mg po qhs calcium acetate 1334 mg po tid citalopram 20 mg po daily nicotine 14 mg/24 hr patch amlodipine 5 mg po daily lantus 8 u qhs lisinopril 40 mg po daily discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*0* 2. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 5. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 7. calcium acetate 667 mg capsule sig: two (2) capsule po tid w/meals (3 times a day with meals). 8. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 9. methadone 10 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*0* 10. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* 11. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 12. 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* 13. quetiapine 25 mg tablet sig: one (1) tablet po once (once) for 1 doses. 14. oxycodone 5 mg capsule sig: one (1) capsule po every hours as needed for pain. disp:*25 capsule(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: pancreatitis gastritis atrial flutter discharge condition: stable discharge instructions: you were admitted for nausea, vomiting, and abdominal pain and developed atrial flutter. you were transferred to the intensive care unit where you were cardioverted and your heart rate returned to rate and rhythm. with regard to your abdominal pain, you underwent ercp which demonstrated severe severe esophagitis. you were given morphine for pain and started on a medication called protonix for your esophagitis. please avoid nsaids including ibuprofen, motrin, advil. . with regard to your medications, your lisinopril was decreased to 10mg daily and you were started on metoprolol 12.5mg 2xday. . on ct scan of your abdomen lesion was noted in your bladder. you will need a follow up mri as outpatient arranged by your pcp to further evaluate this. . your thyroid hormone (tsh) was elevated during this admission. you will need further thyroid tests as an outpatient to fully evaluate this. . please call you doctor if you have chest pain, shortness of breath, nausea, vomiting, increased abdominal pain, or any questions or concerns. please keep your follow up appointments as outlined below. followup instructions: , md phone: date/time: 3:00 (cardiology) , m.d. phone: date/time: 3:00 (nephrology) provider: , md phone: date/time: 9:00 (gastroenterology) 02:30p ,, md ctr, medical unit (primary provider) Procedure: Venous catheterization, not elsewhere classified Hemodialysis Atrial cardioversion Endoscopic retrograde cholangiopancreatography [ERCP] Diagnoses: End stage renal disease Anemia, unspecified Congestive heart failure, unspecified Chronic hepatitis C without mention of hepatic coma Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Depressive disorder, not elsewhere classified Atrial flutter Poisoning by benzodiazepine-based tranquilizers Accidental poisoning by benzodiazepine-based tranquilizers Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Poisoning by other antipsychotics, neuroleptics, and major tranquilizers Esophagitis, unspecified Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Unspecified gastritis and gastroduodenitis, without mention of hemorrhage Acute pancreatitis Chronic diastolic heart failure Unspecified disease of pancreas Poisoning by methadone Accidental poisoning by methadone Accidental poisoning by other specified tranquilizers

allergies: methadone attending: chief complaint: neck pain, feeling "awful" major surgical or invasive procedure: placement of triple lumen catheter in right ij history of present illness: 56 year old woman with dm, htn, esrd on hd, recent mva, who presents with neck pain and feeling "awful." she was involved in a mva two weeks ago when another car struck her car from the passenger side. she was in the passenger seat, wearing a seatbelt, did not strike her head but did experience a jerking motion of her neck. afterward she began to experience severe headaches and posterior neck pain. she was seen at on and diagnosed with whiplash. x-rays were ordered which she did not have done. she went to hospital yesterday for the pain and was given dilaudid and ativan and discharged home. she continued to feel unwell so came to the ed. in the ed she initially triggered for hypoxia of 82% on ra in triage, but on recheck was 100% on ra. other vs were 99.0, 47, 94/35, 16. she was a&ox3 but slightly lethargic with pain over her posterior c-spine. ekg with a junctional rhythm (old) and no ischemic changes. she dropped her sbp to the 80s so a rij was placed and she was given a dose of empiric zosyn and 2l ns. she did not required pressors. notable for hct 25 (baseline high 20s-low 30s), stool guiac neg. cxr with mild vascular congestion but no pneumonia or other acute process. vs prior to transfer were 98/50 (map 63), 46, satting in the high 90s on 4l. on arrival to the micu, the patient continues to experience severe posterior neck pain and headache. having chest pain in the center of her chest, gerd-like, feels like she needs to burp, worse with deep breaths, and then vomited twice (2nd time dark, guiac positive). her symptoms resolved with anti-emetics, and her hypotension and hypoxia resolved so she was transferred to the floor. on the floor, she continued to be rather lethargic but a rousable. she continued to complain of pain and anxiety, requesting dilaudid and ativan, consistent with reports from prior hospitalizations. she also complained of neck and back pain. her vital signs remained stable except for drops in her pressure to the 80s systolic during hemodialysis. past medical history: - diabetes - hypertension - hyperlipidemia - esrd on hd (m/w/f) - hepatitis c - anemia - h/o pe - migraines - depression - narcotic dependence - chronic lymphedema in right leg - atrial flutter s/p cardioversion - esophagitis - mrsa bacteremia and candidemia - junctional bradycardia social history: lives alone in an apartment in with a pca who comes in m-f. smokes ppd and has smoked since age 25 (previously smoked 1-1.5 ppd). denies etoh or illicit drug use. uses an private ambulance company for transport to and from the hospital. family history: mother had lupus. physical exam: admission exam: vitals: 97.9, 54, 119/39, 14, 99% on 4l general: appears uncomfortable, in pain, vomiting heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: posterior midline tenderness cv: bradycardic but regular, normal s1/s2, 3/6 systolic murmur at upper sternal border lungs: poor respiratory effort but overall clear, no wheezes or rales abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley rectal: stool guiac neg (in ed) ext: wwp, chronic lle swelling (unchanged per pt), 1+ dp/pt pulses, well-healing lle ulcer on lateral aspect of leg with granulation tissue, no drainage. neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, finger-to-nose intact, gait deferred discharge exam: vitals: 98.4, 101-133/41-63, 60-74, 18, 95% on ra gen: alert and oriented, no longer lethargic, however emotionally labile heent: ncat, mmm, op clear, eomi, perrl, sclera anicteric, conjunctiva pink neck: supple, right ij successfully removed, no posterior midline tenderness cv: rrr, normal s1 and s2, 3/6 systolic murmur heard best at lusb and additional systolic murmur heard at the apex of the heart resp: good aeration, ctab, no w/r/r abd: soft, nd, nt, normoactive bs, no organomegaly, no r/g ext: wwp, 1+ pitting edema of , well-healed and dressed lle ulcer on anterior tibia neuro: cn ii-xii grossly intact, 5/5 strength, grossly normal sensation, no focal deficits pertinent results: admission : 03:00pm blood wbc-6.0 rbc-2.73* hgb-8.1* hct-25.0* mcv-92# mch-29.5 mchc-32.2# rdw-15.7* plt ct-114* 03:00pm blood neuts-56.8 lymphs-34.2 monos-5.6 eos-3.1 baso-0.4 03:00pm blood glucose-155* urean-23* creat-6.0*# na-140 k-4.2 cl-99 hco3-27 angap-18 03:00pm blood ctropnt-0.21* 08:15pm blood ck-mb-2 ctropnt-0.23* 08:15pm blood ck(cpk)-79 03:00pm blood calcium-8.1* phos-9.1*# mg-1.8 discharge : 06:40am blood wbc-6.8 rbc-2.94* hgb-8.6* hct-26.7* mcv-91 mch-29.3 mchc-32.3 rdw-18.2* plt ct-81* 06:40am blood pt-11.2 ptt-28.3 inr(pt)-1.0 06:40am blood glucose-117* urean-37* creat-6.2*# na-136 k-3.8 cl-96 hco3-29 angap-15 06:40am blood calcium-8.9 phos-3.3 mg-2.2 06:40am blood vanco-17.4 relevant : 04:13am blood type-central ve po2-39* pco2-56* ph-7.32* caltco2-30 base xs-0 04:13am blood lactate-1.3 02:43am blood cortsol-19.3 05:46am blood hapto-50 03:53am blood ck-mb-2 ctropnt-0.23* 08:15pm blood ck-mb-2 ctropnt-0.23* 03:00pm blood ctropnt-0.21* micro: blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. unable to perform urine cx as pt does not produce urine. imaging: ecg study date of 2:37:52 pm probable junctional rhythm. prolonged q-t interval. poor r wave progression. non-specific st-t wave abnormalities. compared to the previous tracing of , junctional rhythm is present, voltage criteria for left ventricular hypertrophy are now absent. the qrs change in lead v4 could be due to variability in lead placement. rate pr qrs qt/qtc p qrs t 41 0 102 560/526 0 9 21 portable semi-upright ap view of the chest: there is moderate enlargement of the cardiac silhouette which is stable. the mediastinal contours are unchanged. the pulmonary vascularity is mildly engorged suggesting an element of elevated pulmonary venous pressure. no consolidation, pleural effusion or pneumothorax is identified, though the left costophrenic angle is excluded from the field of view. there are no acute osseous abnormalities. impression: mild pulmonary vascular congestion. cta chest 1. no evidence of acute pulmonary embolism or thoracic aortic pathology. 2. pulmonary arterial hypertension with moderate cardiomegaly, and findings suggesting mild right heart decompensation. 3. mild centrilobular emphysema cta head and neck impression: there is no evidence of acute intracranial hemorrhage or acute intracranial process. there is mild-to-moderate cerebral atrophy and mild vertebral and internal carotid artery vascular calcifications. the cta of the head demonstrates moderate calcifications in both carotid siphons and tortuous course of both cervical internal carotid arteries with no evidence of occlusions or severe stenosis. no aneurysms are identified. centrilobular emphysema is present. no cervical fractures are identified. multilevel degenerative changes are visualized, more significant at c5/c6. a preliminary report was provided by dr. and communicated to dr. at 11:45 p.m. on . us lue avf impression: patent left upper extremity av fistula without surrounding fluid collection. tte impression: mild symmetric left ventricular hypertrophy with normal regional and hyperdynamic global systolic function. pulmonary artery hypertension. dilated ascending aorta. compared with the prior study (images reviewed) of , the findings are similar. brief hospital course: primary reason for hospitalization: 56 year old woman with dm, htn, esrd on hd, recent mva, who presents with headache/neck pain/vomiting/hematemesis and found to be bradycardic, hypotensive, and hypoxic. active diagnoses: # neck pain/headache: mrs. came to the ed complaining of pain from a prior mva. pain continued throughout her hospital stay but lessened in severity each day. ct head and neck did not show any acute process. her c collar was removed, and she remained neurologically intact with full rom. her pain was treated with iv dilaudid and will likely improve with outpatient pt. # hypotension: pt initially came in with sbp in the 80s, which responded to 2l ns in the ed. home antihypertensives were held. her hypotension was thought to be due to either hypovolemia (overdialysis), sepsis, anemia, or adrenal suppression. she came in with a hct of 25, several points below her baseline. her stools were guaiac negative, but she had an episode of hematemesis while on the micu (see hematemesis below). her hematemesis resolved, and she had not other sources of active bleeding (see anemia below). her cortisol level was normal. looking back at previous hospitalizations, she has a history of mrsa bacteremia and fungemia. she did not become febrile, however her temperatures were higher than expected given she is a hd patient. there was adequate concern for septicemia, and sources of infection were investigated. she remained on empiric treatment with vanc and zosyn for 7 days, and no definitive source of infection was identified. after starting the abx, her hypotension resolved and she remained normotensive throughout her hospital stay (except during hd). she was instructed to continue vancomycin for 2 additional hd doses for a total 7 day course. post-discharge, it is still unclear whether or not she had a transient bloodstream infection. her blood cultures came back negative x 4. # bradycardia: the pt has a documented history of junctional rhythm on ekg. her home medications, amlodipine and carvedilol, were held, and her bradycardia resolved. the decision to restart should be based on a discussion with her pcp. # hypoxia: the patient received a cxr and cta which ruled out pe, pna, or other acute process. likely attributed to volume overload, as pt has esrd and receives hd mwf. her oxygenation improved in the micu and was normal on the floor on ra. # anemia: the pt has a longstanding hx of anemia, likely secondary to esrd. however, she presented with lower than normal hct and often complained of weakness/dizziness. she was transfused one unit of blood with dialysis, which improved her numbers. #thrombocytopenia: she has longstanding thrombocytopenia but numbers dipped below baseline by nearly 50% since admission. she received heparin products while hospitalized, including during dialysis. there was low suspicion for a consumptive process. we stopped all heparin products and considered getting hit ab titers, however the pt's platelets came back up, and suspicion for hit was low. no further workup was deemed necessary. # hematemesis: this occurred once while in the icu. although she has a hx of hepatitis c she has no hx of cirrhosis (ruq neg in 5/). h/o hematemesis and had egd in with gastritis but no active bleeding and no varicose. colonoscopy in also normal. patient on asa 81mg but no other nsaids. ultimately, the hematemesis resolved, so no further wok up was necessary. if she continues to experience hematemesis as an outpatient, she would likely benefit from a repeat egd. # elevated troponins: her tropnins were approx 0.2 x 3, but did not have st changes on ekg. looking back at previous hospitalizations, it appears that this is her baseline, presumably related to esrd. she was not symptomatic. #anxiety: the pt continued to complain of anxiety throughout her stay, requesting ativan daily. we ordered her home ativan dose, which she normally takes prior to hd. there appeared to be some level of dependence on ativan. she also takes wellbutrin at home. upon discharge she continued to complain of anxiety and will likely need outpatient follow up with pcp or psychiatry. chronic diagnoses: # esrd on hd: patient was dialyzed mwf per her home schedule, and we continued her nephrocaps. before d/c, we ensured she has adequate transportation to and from dialysis. # hypertension: home medications were held due to hypotension. # hyperlipidemia: continued home medication, simvastatin daily. # dm: she was placed on insulin sliding scale with fsbgs in acceptable range. # hepatitis c: she showed no signs of decompensation. no cirrhosis seen on ruq u/s in 5/. she is followed by a gastroenterologist, last seen in . # pituitary adenoma: pt has appointment for mri scheduled in with outpatient neurology follow up. this is not suspected to be related to her current condition. transitional issues: #she will need home pt for her mva injuries. #her coreg and amlodipine were held during hospitalization for hypotension/bradycardia but may need to be restarted given echo findings of lvh. her dose may need adjustment by her pcp. #pt appears to have anxiety issues which could not be managed appropriately in the hospital. she would likely benefit from outpatient counseling and adjustment of medications #mri of pituitary scheduled with neuro follow up. #she has follow up with nephrology #she has a follow up appt with hematology for her anemia medications on admission: amlodipine 10 mg tablet daily b complex-vitamin c-folic acid caps] 1 mg capsule) by mouth once a day benzonatate 100 mg 1 capsule(s) by mouth three times a day as needed for cough bupropion hcl 150 mg 1 tablet(s) by mouth monday/wednesday/friday only take after hemodialysis carvedilol 25 mg 1 tablet(s) by mouth twice a day gabapentin 300 mg capsule by mouth q48hr glucagon (human recombinant) 1 mg kit use as needed prn hydroxyzine hcl 25 mg 1 tablet(s) by mouth every six (6) hours as needed for pruritus insulin aspart 100 unit/ml insulin pen inject per sliding scale four times a day or as directed ; max 12u for bg >400 insulin aspart 100 unit/ml insulin pen per sl sc prn lorazepam 1 mg tablet by mouth three times weekly before dialysis as needed for anxiety omeprazole 20 mg capsule, delayed release(e.c.) 1 capsule(s) by mouth twice a day oxycodone 10 mg tablet by mouth up to tid as needed for severe pain simvastatin 5 mg tablet by mouth once a day (prescribed by other provider) acetaminophen 325 mg tablet 1 tablet(s) by mouth prn aspirin 81 mg tablet, delayed release (e.c.) by mouth daily bisacodyl 10 mg suppository 1 suppository(s) rectally as needed as needed for constipation loperamide 2 mg tablet by mouth every 12 hours as needed for diarrhea hydroxide 400 mg/5 ml suspension 30 ml by mouth as needed for constipation sodium phosphates 19 gram-7 gram/118 ml enema 1 enema(s) rectally as needed as needed for constipation discharge medications: 1. aspirin 81 mg po daily 2. bupropion (sustained release) 150 mg po mwf after hd 3. gabapentin 300 mg po q48h 4. lorazepam 1 mg po mwf:prn anxiety prior to dialysis 5. oxycodone (immediate release) 10 mg po q8h:prn pain 6. sevelamer carbonate 1600 mg po tid w/meals 7. simvastatin 5 mg po daily 8. vancomycin 1000 mg iv hd protocol duration: 2 doses take with dialysis for 2 more doses: friday and monday 9. nephrocaps 1 cap po daily 10. benzonatate 100 mg po tid:prn cough 11. glucagon 1 mg im q15min:prn hypoglycemia protocol 12. hydroxyzine 25 mg po q6h:prn pruritis 13. novolog *nf* (insulin aspart) inject per sliding scale subcutaneous as prior to admission 14. acetaminophen 325 mg po q6h:prn pain or fever 15. bisacodyl 10 mg pr hs:prn constipation 16. loperamide 2 mg po bid:prn diarrhea discharge disposition: home with service facility: vna discharge diagnosis: primary fever hypotension bradycardia hypoxia anemia thrombocytopenia secondary congestive heart failure end stage disease on hemodialysis diabetes mellitus discharge condition: level of consciousness: alert and interactive. activity status: uses wheelchair. mental status: clear and coherent. discharge instructions: dear ms. , it was a pleasure caring for you at . you originally came to the emergency department for pain in your neck and back from your recent car accident. in the emergency department, you were found to have a low blood pressure, fever, low oxygen levels, and slow heart rate. the doctors were concerned that you might have an infection, so they inserted a large iv into your neck for easier administration of fluids and antibiotics, and they sent you to the medical intensive care unit. you were started on antibiotics for a presumed infection. they stopped your normal medicines for high blood pressure (carvedilol and amlodipine). the following day, your vital signs improved, and you were transfered to the general medicine floor. on the medicine floor, we continued your iv antibiotics and investigated sources of possible infection because you had a fever. we did a chest ct which did not show any pneumonia. we did blood cultures which were pending at the time of your discharge. we also examined your av fistula site and chronic left shin ulcer as possible sources. *****on the last day of your stay, you received a transthoracic echocardiogram to make sure you did not have a bacterial clot on the heart valve but you decided to leave the hospital against the medical advice of your physicians before finding out the final result. the risks associated with this include overwhelming infection and death.***** although we did not find a source of infection, you improved on the strong antibiotics we gave you. your fevers and low blood pressure resolved. you are being discharged with plans to receive vancomycin at hd on friday and monday . note that when you were tranferred to our service you also had a slow heart beat. you have a history of a slow heart beat (junctional bradycardia) according to your records. this improved with treating your presumed infection. you also had nausea and vomiting, which resolved as well, without requiring intervention. while you were here, you became quite confused and anxious, requiring occasional doses of anti-anxiety medication. as your infection got better, this problem seemed to resolve. during your stay, your blood counts (hematocrit) were quite low despite receiving medication to raise them (epogen) during dialysis, requiring us to transfuse a unit of blood. we tested your stool to see if you were bleeding from your digestive tract, but those tests were negative. you did not show any active signs of bleeding. we presume that your low blood counts were related to your chronic kidney disease. please follow up with your nephrologist (at dialysis) and hematologist (appointment listed below) to discuss the proper long term treatment plan. your platelets were low during your stay as well. we looked in your previous records and found that this has been a problem in the past and was stable. therefore we did not transfuse platelets or perform any other investigations. throughout your stay, you received dialysis on monday/wednesday/friday as normally scheduled. no changes were made to the treatment of your kidney disease. we made the following changes to your medications: -start vancomycin 1000mg iv with hd for 2 more doses: on friday and monday (this will complete a 1 week course since being afebrile, last fever was early in the morning on ) -hold amlodipine until instructed to restart it -hold carvedilol until instructed to restart it followup instructions: primary care department: when: tuesday at 3:00 pm with: , md building: sc ctr campus: east best parking: garage hematology department: hematology/oncology when: thursday at 2:00 pm with: , md / building: sc ctr campus: east best parking: garage nephrology you will be followed by your nephrologist at hemodialysis. Procedure: Hemodialysis Diagnoses: Anemia in chronic kidney disease End stage renal disease Renal dialysis status Congestive heart failure, unspecified Unspecified viral hepatitis C without hepatic coma Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Ulcer of other part of foot Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Hypotension, unspecified Long-term (current) use of insulin Fever, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Metabolic encephalopathy Chronic diastolic heart failure

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status major surgical or invasive procedure: intubation extubation lumbar puncture history of present illness: 51 yo f with mmp presenting from nursing home found unresponsive. per report patient went out on "social" leave yesterday. upon returing she was somnolent and refusing drug screen. somnolence increased overnight. per pt report, fell and hit the right side of her head. . in the ed the patient was found to be febrile 101.8, and confused. hemodynamically stable. intubated for airway protection. tox screen pos only for methadone. became extremely aggitated with a single dose of narcan. found to have infiltrates on cxr consistent with aspirations pneumonitis/pna. suctioning from ett was copious and green. given vanc/flagyl/ctx. past medical history: 1. dm2 c/b neuropathy/proteinuria and r foot ulcer; reports being on methadone for neuropathy since last yr. 2. hep c with vl >700,000 3. anemia of chronic dz 4. hsv2 5. culture negative endocarditis 6. depression/anxiety 7. polysubstance abuse, including heroin 8. h/o hilar adenopathy 9. pulm embolism dxed during hospitalization in , not on coumadin secondary to failure to comply with coumadin clinic; ?supposed to be on lovenox but self-d/ced? 10. 2nd degree burns on left foot, hot water injury by pt's mother 11. h/o esophagitis 12. +h. pylori , given outpt triple tx social history: not employed; nh resident. smokes 7 cig/day (but heavier use, has been smoking >25 years). no etoh, former iv drug user (denies). family history: brother died of mi in his 40s; father died of natural causes. mother alive with lupus. physical exam: upon admission to the icu vs - 98.7 88 160/111 resp - ac 550/14/100%/5 sat 100% gen - intubated, sedated heent - pupils 2mm sluggish neck - in collar chest - diffuse ronchi cor - rrr no murmurs appreciated abd - s/non-distended, +bs rectal - guaic neg per ed ext - + edema bilat pertinent results: 02:13pm blood glucose-216* lactate-2.3* na-143 k-5.5* cl-108 calhco3-27 08:24pm blood lactate-1.9 02:00pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 10:00pm blood hiv ab-negative 06:10am blood pth-158* 06:05pm blood tsh-0.71 06:55am blood triglyc-186* hdl-pnd 03:42am blood %hba1c-7.6*# 07:33pm blood caltibc-183* ferritn-488* trf-141* 06:07am blood vitb12-962* folate-6.3 05:08am blood ck-mb-6 ctropnt-0.06* probnp-4371* 02:00pm blood ck(cpk)-1244* 06:07am blood ck(cpk)-106 05:25am blood alt-20 ast-23 alkphos-163* totbili-0.4 02:00pm blood urean-43* creat-2.1*# 01:15am blood glucose-120* urean-41* creat-3.3* na-134 k-4.1 cl-101 hco3-21* angap-16 06:07am blood glucose-159* urean-27* creat-1.7* na-140 k-5.9* cl-102 hco3-31 angap-13 06:25am blood glucose-119* urean-32* creat-1.6* na-139 k-4.5 cl-103 hco3-27 angap-14 04:00am blood neuts-61.6 bands-16.2* lymphs-16.2* monos-3.0 eos-3.0 baso-0 nrbc-1* 06:02am blood neuts-46.7* lymphs-33.8 monos-6.8 eos-12.3* baso-0.3 02:00pm blood wbc-9.2# rbc-3.82* hgb-11.6* hct-36.2 mcv-95# mch-30.3 mchc-32.0 rdw-14.4 plt ct-130* 01:15am blood wbc-18.1* rbc-2.76* hgb-8.4* hct-25.3* mcv-92 mch-30.4 mchc-33.1 rdw-14.5 plt ct-186 06:25am blood wbc-6.8 rbc-3.75*# hgb-11.6*# hct-34.5* mcv-92# mch-31.0 mchc-33.7 rdw-14.5 plt ct-316 06:07am urine hours-random creat-73 totprot-22 prot/cr-0.3* 02:00pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-pos 05:48pm cerebrospinal fluid (csf) wbc-1 rbc-1* polys-0 lymphs-92 monos-8 05:48pm cerebrospinal fluid (csf) totprot-38 glucose-136 04:15pm stool clostridium difficile toxin b assay-test . reports: ct head: impression: no intracranial hemorrhage. . admission cxr impression: 1. endotracheal tube in standard position. 2. pulmonary edema. additional basilar opacities may be due to a combination of dependent edema and atelectasis, but aspiration should also be considered. . echo ef >60% the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. regional left ventricular wall motion is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation (however, views are suboptimal). the mitral valve leaflets are structurally normal. no mitral regurgitation is seen (however, views are suboptimal). the tricuspid valve leaflets are mildly thickened. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. . renal u/s: impression: unremarkable renal ultrasound . chest xray : impression: chest clear, no overt failure. brief hospital course: f#altered mental status: the differential diagnosis for this was broad including medications, infection. pt was intubated and admitted to micu and treated for pneumonia as below. her mental status improved and after extubation was at baseline with no further unresponsiveness or evidence of seizure. head imaging did not show any acute process. lumbar puncture unremarkable. . #aspiration pneumonia: pt had copious secretions via ett. she was started on and complete a 10d course of broad spectrum antibiotics for pneumonia. once extubated, her respiratory status improved steadily. . #diastolic chf: pt diuresed with lasix with improvement. she was able to come off of oxygen. repeat cxr demonstrated clearance of chf and effusions. she was then maintained on a steady dose of po lasix and antihypertensives. intially on bb, hydralazine and imdur, but given diastolic dysfunction, lopressor titrated to 62.5 mg on discharge. this should be titrated prn to goal hr ~ 60 given diastolic dysfunction. . #acute renal failure: was likely from atn. this improved with diuresis. pt was then overdiuresed and cr climbed again to 2.0. lasix was held and then decreased and cr settled in mid 1s which is her baseline. lasix dose at discharge was 40 mg daily. would avoid ace-i for now as she has had problems with hyperkalemia (see below). . #hyperkalemia: likely multifactorial. seen by renal. felt to be hypoaldo state. improved with lasix, florinef and low k diet. given concurrent dchf, florinef held at discharge, but she should have her k levels monitored as an outpatient. she should become hyperkalemic again, florinef (.1 mg) should be restarted. . #sinusitis: completed course of augmenin. . #psych: another large componenet of this hospitalization. pt had been on ativan as outpt for anxiety. she was also on celexa which was continued. started on wellbutrin and in process of tapering off ativan slowly. she is also on methadone maintenance. dose was reduced to 60mg and pt is interested in coming off methadone. current dose of ativan is now .5 mg qhs. this may be decreased to .25 mg qhs for a few days and subsequently stopped. no signs of benzo w/d in house. of note, pt had a ppd placed which was negative. medications on admission: lasix 60mg qday atenolol 25mg qday citalopram 40mg qday cholestyramine 4g qday magnesium oxide 400mg qday mvi zocor 10mg qday methadone 70mg qday / 20mg qhs omeprazole 20mg qday lyrica 75mg prn (started ) insulin - humalog sliding scale oxycodone prn lorazapam 1mg q6h ntg sl prn tylenol prn discharge medications: 1. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 2. cholestyramine-sucrose 4 g packet sig: one (1) packet po daily (daily). 3. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 4. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 5. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 6. methadone 10 mg tablet sig: six (6) tablet po qam (once a day (in the morning)). 7. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 8. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime). 9. metoprolol tartrate 25 mg tablet sig: 2.5 tablets po bid (2 times a day). 10. quetiapine 25 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)) as needed for insomnia. 11. bupropion 100 mg tablet sustained release sig: one (1) tablet sustained release po bid (2 times a day). 12. fluticasone 50 mcg/actuation aerosol, spray sig: one (1) spray nasal (2 times a day). 13. insulin nph 32 u qam 12u qhs 14. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. discharge disposition: extended care facility: - discharge diagnosis: mental status changes, resolved acute renal failure, resolved diastolic congestive heart failure aspiration pna type 2 diabetes anxiety/depression hyperkalemic, resolved mental status changes, resolved acute renal failure, resolved diastolic congestive heart failure aspiration pna type 2 diabetes anxiety/depression hyperkalemic, resolved discharge condition: stable discharge instructions: please contact your primary care provider should you have any chest pain, shortness of breath, nausea, vomiting, or any other serious complaints. take all medications as prescribed. followup instructions: provider: , md phone: date/time: 1:10 please follow up with your primary care doctor within 2 weeks of discharge. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Spinal tap Incision of lung Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Hyperpotassemia Thrombocytopenia, unspecified Congestive heart failure, unspecified Unspecified essential hypertension Chronic hepatitis C without mention of hepatic coma Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Polyneuropathy in diabetes Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Diastolic heart failure, unspecified Unspecified sinusitis (chronic) Diabetes with neurological manifestations, type II or unspecified type, uncontrolled

allergies: morphine / codeine / chocolate flavor attending: chief complaint: fever, hypotension major surgical or invasive procedure: 1. debridement of the left foot 2. hemodialysis 3. central venous catheter history of present illness: this is a 78 yo m with a past medical history significant for esrd, dm2, pvd, cad s/p cabg who presents to the ed after having fevers to 105, 1 episode of nonbloody/nonbilious emesis, and tachycardia upon arriving to hd today but was able to complete dialysis for a total of -3.8l. he was given a dose of vanco there. when ems arrived, he was found also to be hypotensive to the 70's, but he was still mentating clearly. . in the ed, he was volume resuscitated with 3+l, had a right subclavian cvl placed, and after blood cx were drawn, received doses of levo/flagyl. a ua was sent which was unremarkable. a cxr was unremarkable for infiltrate, except for known left sided pleural effusion, which, if anything, looked improved, and some right sided basal atelectasis. because he did not really respond to ivf resuscitation, he was started on levophed. labs were notable for for a lactate of 1.9, a vbg of 7.43/50/59 and a leukocytosis to 17,000 with a left shift. after going for abdominal ct, he will be sent to the for further management of sepsis. . on arrival to the , the patient admitted that he has been feeling unwell for the past several weeks. he describes having vague abdominal discomfort as if "he was going to come down with something" but it never blossoms into anything. he notes that he has become more constipated in the last 2-3 weeks and his stool has become darker. he has also had a productive cough on a daily basis bringing up grey/yellow/white sputum. he denies fevers, nausea/vomiting until today. he denies sore throat, headache, ear pain, or dysuria. he also denies sick contacts or recent travel. he has a new ulcer on his right foot, and is s/p left 3rd toe amputation secondary to gangrene but was just at the podiatric surgeon the day pta and had both areas debrided. he has not noted any change in the area of his avf. past medical history: esrd type 2 diabetes mellitus (') pvd, s/p r -dp bpg neuropathy htn hypercholesterolemia chronic anemia hiatal hernia cad, s/p cabg lima-lad, svg rca, om lower back pain s/p surgery for ?disk herniation - admission for herpes encephalitis and zoster s/p av graft thrombectomy recent l 3rd toe amputation social history: the patient lives at manor. his wife is his primary caregiver and hcp. is an ex-smoker (approx 40yrs), quit 22 years ago. used to drink socially, no longer drinks. family history: the patient's mother died of mi at 89, father had dm, ?heart dz died at 79, paternal gm had dm. he reports other family members with heart disease. physical exam: vitals: t 100.1 p 92 bp 133/69 r 17 sat 100% nc 3l general: pale 78 yo m, appears fatigued, but nad heent: at/nc, eomi, perrl (reduced visual acuity in right eye), anicteric sclerae. mm dry, op clear. fair dentition. neck: no cervical, supraclavicular lad. supple. jvp at 7cm chest: rrr harsh iii/vi sem heard best at the lusb radiating to the neck as well as across the precordium. no rubs. lungs: decrease bs at the left base, minimal dry rales at the right base. otherwise, no rhonchi/wheezes. abd: soft, nt/nd +bs, no hsm ext: feet are wrapped in dressings s/p debridement yesterday, legs are warm until distal leg/proximal ankle, then slightly cooler. venous stasis changes present to mid-calf. trace to 1+ radial pulses. neuro: a&ox3. reduced visual acuity in r eye. reduced sensation to lt at ankles. cn iii-xii in tact. skin: warm, no jaundice, no unusual lesions or rashes. access: rsc, slightly tender to palpation. pertinent results: admission labs: 12:33pm wbc-17.3*# rbc-4.56* hgb-14.9 hct-45.4 mcv-100* mch-32.7* mchc-32.8 rdw-16.2* 12:33pm neuts-84* bands-0 lymphs-10* monos-6 eos-0 basos-0 atyps-0 metas-0 myelos-0 12:33pm glucose-128* urea n-17 creat-2.6*# sodium-137 potassium-4.9 chloride-91* total co2-34* anion gap-17 12:33pm calcium-9.7 phosphate-2.9# magnesium-2.1 03:10pm alt(sgpt)-9 ast(sgot)-17 ck(cpk)-20* alk phos-79 tot bili-0.4 03:10pm lipase-55 03:10pm pt-13.3* ptt-32.6 inr(pt)-1.2* 12:48pm lactate-1.9 03:10pm ck-mb-2 ctropnt-0.30* . imaging: ct abdomen w/contrast 3:31 pm 1. small simple (by hounsfield units) left pleural effusion with enhancing pleural rim is suggestive of empyema. would suggest diagnostic thoracentesis for evaluation. adjacent area of consolidation is most reflective of atelectasis, however there is not vivid enhancement, so early underlying pneumonia cannot be completely excluded. 2. cholelithiasis with a slightly distended gallbladder lumen measuring up to 4 cm. no inflammatory changes to suggest acute cholecystitis. please correlate with clinical exam. if indicated, further evaluation with hida scan recommended. 3. hypoattenuating splenic lesion, too small to definitively characterize but likely benign. 4. extensive atherosclerotic disease. 5. diverticulosis without evidence of acute diverticulitis. . chest (portable ap) 12:39 pm cardiac silhouette, mediastinal and hilar contours are unchanged. the patient is status post cabg. interval placement of a right-sided subclavian approach central venous line with its tip projecting at the mid svc. linear opacity in the right lung base likely represent disc-like atelectasis. mild interval improvement in the left pleural effusion. no pneumothorax. . ecg study date of 12:26:36 pm sinus tachycardia. left axis deviation with left anterior fascicular block. poor r wave progression - probably old anteroseptal myocardial infarction. compared to tracing of there is no significant diagnostic change. . echo study date of the left atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 5-10 mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is top normal/borderline dilated. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50-55%). there is no ventricular septal defect. the right ventricular cavity is mildly dilated. right ventricular systolic function is borderline normal. the aortic root is mildly dilated at the sinus level. the aortic arch is mildly dilated. 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 mild aortic valve stenosis (area 1.2-1.9cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. compared with the report of the prior study (images unavailable for review) of , mild as is now detected and the severity of mitral and tricuspid regurgitation has slightly increased. if clinically indicated a tee may better excluded a small valvular vegetation. . foot ap,lat & obl bilat port 9:01 pm prelim 1. focal area of lucency along the lateral aspect of the fifth proximal phalanx of the left foot, new compared with _____ previous study. in the correct clinical context, the possibility of osteomyelitis must be considered. 2. post-operative changes status post amputation of the left third digit. 3. chronic post-operative changes of the right foot. 4. neuropathic changes of the feet bilaterally. brief hospital course: a/p: 78 yo m with esrd, dm2, cad admittied from hd with fevers, leukocytosis, and hypotension 1. septic shock, resolved: with fevers, leukocytosis, hypotension and tachycardia and and the most likely source of infection being possible introduction of bacteria by recent debridement of foot ulcers and surgical site (pt has h/o mrsa and enterococcus from wound) v. parapneumonic effusion/empyema on ct, the patient had met criteria for septic. peak lactate was 1.9, now 0.6. he was given total of 4l ns (3.8 taken off at hd) and required levophed only overnight from day of admission. he now is maintaining sbps in 120s. blood cxs from grew coag + staph sensitive to vanc. pt is on vanc per hd protocol, day 4. podiatry evaluated the patient, took wound cultures of his feet bilaterally. x-rays of bilateral feet were taken; prelimin read suggests possible osteomyelitis along the lateral aspect of the fifth proximal phalanx of the left foot. podiatry (attending dr. is following. pt also had a thoracentesis that removed 60 cc of serosanguinous fluid. this has been a chronic effusion, seen on prior cxrs for months. pleural fluid analysis reveals exudative process with predominance of lymphs. this is currently not thought to be the source of infection given chronicity and initial fluid analysis. abdominal ct revealed no source of infection. he was subsequently transferred to the floor without further incidents. 2. mrsa bacteremia. an extensive evaluation by infectious diseases concluded that the most likely source of mrsa bacteremia was from the foot. it was recommended to continue the patient on vancomycin for a total of 6 weeks. 3. osteomyelitis. inconclusive evidence on plain film, and unable to obtain a mri given dialysis. supportive test of esr of 121 consistent with osteomyelitis. as in #2, id recommended 6 weeks of antibiotic therapy. 4. complex pleural effusion. pulmonary was consulted and this was thought to be from septic embolus. a ct scan was recommended in 3 months time to assess for resolution. 5. esrd: patient is being followed by renal and his usual dialysis days are tues, thurs, sat. his medications were dosed for his level of kidney function and he was maintained on vancomycin regimen with dialysis. 6. cardiac: the patient has a history of 3vd cad s/p cabg. he was maintained on his aspirin, metoprolol, and statin therapy. 7. type 2 diabetes mellitus. the patient was maintained on sliding scale insulin during hospitalization. on discharge, his glipizide was resumed. 8. hypercholesterolemia. due to the risks of combination therapy for dialysis patients, his gemfibrozil and niacin were held. he was maintained on his simvastatin and ezetimibe. a follow up fasting lipid panel is recommended in weeks. 9. peripheral artery disease / diabetic foot ulcer. podiatry and vascular surgery consults monitored the foot wounds and recommended close outpatient follow up on discharge. deep tissue cultures demonstrated pseudomonas and staph colonization vs. osteomyelitis.patient transfered to dr. service for left tma done on . pod#1 no overnight events. continued on vancomycin but cipro and flagyl discontinued. deit advanced. physical thearphy consulted for nonweight bearing left foot for toatal of four weeks.vanco will be continued for a total of 6 weeks which will becompleted on . cbc,elec and renal function should be monitered while recieving antibitocs. he will followup with dr. in clinic@ that time. (see appointments). /07 pod# continued to progress. d/c to home with services. medications on admission: 1.ezetimibe 10 mg qd, 2.glipizide 1.25 mg 3.gemfibrozil 600 mg 4.pantoprazole 40 mg qd, 5.simvastatin 40 mg qd 6.hep sc 5000mg 7.renagel 1600mg tid prior to meals, 8.colace 100mg qd, 9.flonase 0.05 each nose qd 10. niacin 500mg qd discharge medications: 1. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous hd protocol (hd protochol). disp:*qs * refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 4. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 5. fluticasone 50 mcg/actuation aerosol, spray sig: two (2) spray nasal daily (daily). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 8. collagenase 250 unit/g ointment sig: one (1) appl topical (2 times a day). disp:*1 tube* refills:*2* 9. docusate sodium 100 mg capsule sig: two (2) capsule 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). 11. sorbitol 70 % solution sig: 30-150 mls miscellaneous (2 times a day) as needed for constipation. 12. sevelamer 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). 13. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po bid (2 times a day). 14. vancomycin 1000 mg iv during dialysis on to be dosed during dialysis on 15. outpatient lab work cbc, bun/cr, electrolytes,weekly @ hd 16. outpatient lab work random vanco level 2x/week 17. insulin glargine 100 unit/ml solution sig: seven (7) units subcutaneous at bedtime. 18. humalog 100 unit/ml solution sig: as directed subcutaneous three times a day. discharge disposition: home with service facility: vna discharge diagnosis: 1. septic shock, resolved 2. mrsa bacteremia 3. osteomyelitis of the foot 4. esrd on hemodialysis 5. type 2 diabetes mellitus with complications 6. peripheral arterial disease history of right bypass 7. coronary artery disease history of cabg 8. hiatal hernia 9. hyperlipidemia discharge condition: improving, without fever or hypotension discharge instructions: 1. continue with hemodialysis as scheduled. you will receive a total of 6 weeks of vancomycin given during hemodialysis. 2. continue with wound care of your feet through home nursing visits. have cbc w diff and electrolytes and bun creatinine weekly while on antibiotics call resultts to clinic att:dr. followup instructions: 1. make an appointment with podiatry within 1 week 2. make an appointment with vascular surgery within 1 week 3. you have an appointment scheduled with infectious diseases, dr. , on 9:00a. Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Hemodialysis Thoracentesis Amputation through foot Excisional debridement of wound, infection, or burn Diagnoses: Anemia in chronic kidney disease End stage renal disease Pure hypercholesterolemia Unspecified pleural effusion Unspecified septicemia Severe sepsis Aortocoronary bypass status Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Ulcer of other part of foot Alkalosis Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Septic shock Pressure ulcer, heel Dehydration Disruption of external operation (surgical) wound Acute osteomyelitis, ankle and foot Other bone involvement in diseases classified elsewhere

allergies: morphine / codeine / chocolate flavor attending: chief complaint: altered mental status major surgical or invasive procedure: 1) heel wound debridement and late closure. 2) central venous line placement history of present illness: 78m w/esrd on hd, dm2, cad presenting to the ed w/mental status changes. his present illness began with an episode of postherpetic neuralgia which he was seen for @ on at which time he was started on neurontin. he was seen in fu @ at which time he was experiencing euphoria and unsteady gait, which were to the neurontin. neurontin was subsequently tapered from 600hs to 300hs. he was switched to tegretol. on the day of presentation, his daughter called to report severe pain and sx of delirium (talking to self, confused) and temp 99. emesis sat and today. . in the ed his temp was 101 and he was found to have pressures in the 80's. he received 2 liters of fluid with immediate response of his bp to the 100's. he was given ceftriaxone, vancomycin and acyclovir in the ed and an lp showed 27 wbc and 1 rbc. . family denies any travel. only pet in house is a dog. past medical history: esrd type 2 diabetes mellitus (') pvd, s/p r -dp bpg neuropathy htn hypercholesterolemia chronic anemia hiatal hernia cad, s/p cabg lima-lad, svg rca, om lower back pain s/p surgery for ?disk herniation social history: the patient lives in with his wife who is his primary caregiver. is an ex-smoker (approx 40yrs), quit 22 years ago. used to drink socially, no longer drinks. family history: the patient's mother died of mi at 89, father had dm, ?heart dz died at 79, paternal gm had dm. he reports other family members with heart disease. physical exam: gen: well developed, well nourished, in no acute distress, awake and alert heent: mmm, perrl, eomi, op clear, no lad, able to fully rom neck without pain, no meningismus cv: rrr nl s1 s2 no murmurs lungs: cta b no resp difficult, no increased resp effort abd; soft nt nd + bs no ruq ttp ext: 2+ radial pulses bilaterally, 1+ dp pulse on right foot, doppler pulse on left dp, decreased sensation in bilateral plantar surfaces of the feet with normal sensation above the ankle on the right and above mid calf on the left, 5/5 strength in rle and bue, in lle, large ulcer on left heel with necrotic base and no bone evident, venostasis color changes of left toes skin: dried red, crusted vesicles over the l3 dermatome of the left buttocks and left medial aspect of thigh/ knee, very painful/irritable to touch, open area of vesicle on left buttocks, stage 1 sacral decub ulcer in midline of sacrum. pertinent results: hematocrit: 34.2 on . low of 25.8 on , rose to 27.7 on . mcvs consistently high at 96-103. . electrolytes: patient was admitted with a ca/mg/phos of 8.6/2.0/7.7 on . his phosphate continued to rise to maximum of 9.3 on . his dose of renagel was increased to 1600 mg tid, and he was started on lanthanum, with some improvement. haptoglobin was 206, ldh was 282 on , ck was 293 on , alkphos was normal at 77 on , not suggestive of hemolysis, rhabdomyolysis or osteolysis. pthrp <2.0 (neg) on . spep showed igg elevation without monoclonal band. on discharge , he had a phosphate of 6.6. . esr: 108, 85. crp: 130.7, 60.3 . endocrine: tsh 1.3 on . pth 91 on on . cortisol 21.0 on .5 on . . anca negative and . . blood gas: art 7.43/82/49/34 art 7.46/57/49/36 csf: : 27 wbcs, 96% lymphs, 1 rbc : 12 wbcs, 97% lymphs, 41 rbcs . micro: blood cx: grew enterobacter cloacae. all cultures negative on , , , (mycolytic/fungal), , , , , . . csf culture/pcr: negative bacterial/fungal culture. negative bacterial/fungal/viral culture, negative cryptococcal antigen, virus pcr, anaplasma titer. and negative pcr for hsv, vzv, cmv. . heel ulcer swab: positive for mrsa and enterobacter cloacae. . sputum culture: positive for mrsa. . imaging: . eeg impression: mildly abnormal eeg mostly in the drowsy state due to a mildly slowed background in waking. this suggests a widespread encephalopathy. medications, metabolic disturbances, and infection are among the most common causes. there were no prominent focal abnormalities, and there were no epileptiform features. . cxr impression: stable appearance of the chest. no pneumonia appreciated. . mri head impression: severely limited study. the previously demonstrated subtle flair signal hyperintensity in the right mesial temporal lobe is no longer apparent on the current exam. . head mri impression: 1. subtle, asymmetric flair signal hyperintensity in the right mesial temporal lobe. while not specific for hsv encephalitis, this is a classic location for signal abnormality in the setting of this entity. 2. multiple probable areas of chronic infarction. . heel xr impression: increased size of ulcer along the plantar surface of the heel with subcutaneous air, but no radiographic evidence of bony involvement. if a more sensitive evaluation is needed, bone scan or mri could be helpful for further assessment. . ekg sinus rhythm probable left atrial abnormality intraventricular conduction delay with left axis deviation - in part left anterior fascicular block delayed r wave progression - could be in part left axis deviation/ intraventricular conduction delay or possible prior septal myocardial infarction since previous tracing of , low t wave amplitude improved . head ct: no intracranial hemorrhage or mass effect. small foci of air in the right frontal subcutaneous tissues of uncertain etiology. . cxr: increased left lower lobe opacity again seen, concerning for possible pneumonia. . brief hospital course: mr. is a 78 year old male with esrd on hd, cad, pvd presenting with delerium likely secondary to hsv or vzv encephalopathy in addition to gnr bacteremia. . # aseptic encephalitis: the patient presented with with personality changes over the past month and was delirious in the hospital, but improved during and after his icu stay. despite the long time course and negative pcr for hsv/vzv/cmv/ and crypto ag, erlichia, he could have had encephalitis, given his history of recent zoster outbreak and classical findings on mri. a repeat lp on showed findings similar to previous (99 prot, 54 glu, 17 wbc, 96% lymphs). eeg on was read as a diffuse encephalopathy, consistent with metabolic disturbance, medication effect, or infection. a repeat mri on shows no acute process. patient has finished his course of acyclovir. viral/fungal cultures are negative thus far, and vdrl is pending. - the patient was previously on tegretol and neurontin prior to his admission which caused changes in mental status. these medications should be avoided. as his zoster has improved, it is unlikely that he will need this in the future. - he is to follow up with dr. in weeks. . # enterobacter bacteremia: blood cultures were positive on ; all subsequent cultures were negative. a left heel ulcer is believed to be the source of bacteremia. he is on cipro/vanco for 6 weeks secondary to osteomyelitis. cipro should stop on . vancomycin will end on . - on ciprofloxacin and vancomycin for total six week course. vancomycin is to be dosed by levels (dose for level < 15) at dialysis. levels are to be drawn every other day starting tomorrow, . - echo was negative for vegetation. - surveillance cultures were negative. . # hypotension: the patient was hypotensive for several days. this seems to have resolved for now. he has been weaned from midodrine and is tolerating dialysis. he originally did not respond to fluid bolus, and for severl days he was running even for volume on dialysis,. he was ruled out for adrenal insufficiency. no clear etiology was ascertained. however, infection was possible but patient doing well on cipro/vanc. apparently, in the micu, blood pressures were 20 points higher on a line than with cuff. at the time of discharge, the patient's blood pressures were in the 100-120 range systolically. he was restarted on a low dose of his beta blocker, toprol xl at 25 mg daily. . #. ischemic optic neuropathy : pathology was negative for temporal arteritis. he is to be discharged on a prednisone taper x 9 more days. patient had covered his right eye with patch for discomfort. he was encouraged to take off the patch. he is now more comfortable but still minimal vision in right eye. - optho recs for ischemic optic neuropathy include continue asa daily, taper steroids, follow up with optho in next 6 months. he has an appointment with dr. in . - he was also encouraged to see his usual ophthalmology, dr. . . #.delirium: mental status currently at baseline and stable. . #. renal failure- the patient is to continue dialysis per renal recs (t,th,s) as an outpatient. he is on sevelamer for hyperphosphatemia. - he is set to be dialyzed tomorrow, . he was last dialyzed on . . #. left heel ulcer: the patient was followed by . the ulcer probed to bone on exam. intra-op cultures on debridement grew mrsa and enterobacter. x-rays performed which showed an ulcer along the plantar surface of the heel with subcutaneous gas, but no radiographic evidence of bony involvement. the ulcer is now status post closure. as above, he will stay on cipro/vanc for a total of six weeks. he will follow up with dr. from next week. . # hiatal hernia: he is to continue a ppi. he intermittently complains of sensation of food getting stuck and has the urge to vomit. he was followed by nutrition consult, who have suggested giving moist, soft food, with some improvement. at the time of discharge, he was tolerating a regular diet. he will attempt fully solid foods but may prefer soft solids/ground food. . # diabetes mellitus: his finger sticks have been running less than 110, but increased to as high as 275 with improved po intake. we restarted his home glyburide at discharge. . # chronic anemia: his hematocrit was stable but low, within baseline range. b12/folate were checked for macrocytosis and found to be wnl. . #access: central line was removed on the day of discharge without complication. as the patient's vancomycin will be dosed at dialysis, there was no need for more permanent access. . # high cholesterol: we continued his hyperlipidemia meds. . # cad and htn: his toprol was restarted prior to discharge. he was maintained on asa 81 mg daily. . # fen: he tolerated a renal diet. he tolerates ground foods without any difficulty. he can attempt to have a regular diet as his symptoms allow. . #ppx: he is to continue sq heparin until ambulatory, tolerating po diet on ppi. he should continue on an aggressive bowel regimen as necessary. . #full code d/w family . #comm: wife and son, patient medications on admission: asa 81mg qd calcitriol .75qd fluticasone 100ug qd furosemide 40mg qd gemfibrizol 600 glipizide 1.25 mg lipitor 80mg qd lomotil 2.5-.025mg niaspan 500mg qd percocet prn prilosec 20mg qod reglan 10mg q6h prn regranex .01%gel tegretol 200mg toprol 25 mg qd zetia 10mg qd discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). tablet, chewable(s) 2. calcitriol 0.25 mcg capsule sig: three (3) capsule po daily (daily). 3. gemfibrozil 600 mg tablet sig: one (1) tablet po bid (2 times a day). 4. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 5. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 6. fluticasone 50 mcg/actuation aerosol, spray sig: one (1) spray nasal daily (daily). 7. niacin 500 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 8. sevelamer 800 mg tablet sig: two (2) tablet po tid (3 times a day) as needed for hyperphosphatemia. 9. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 10. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 11. metoprolol succinate 25 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*0* 12. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 20 days. disp:*20 tablet(s)* refills:*0* 13. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) gram intravenous q48h (every 48 hours) for 25 days: dosed when level < 15 at dialysis. goal level 15-20. to end on . disp:*qs gram* refills:*0* 14. prednisone 5 mg tablet sig: as directed tablet po once a day for 9 days: start : take 20 mg x 3 days (, , ). take 10 mg x 3 days (, , ). take 5 mg x 3 days (, , ). then stop. 15. glyburide 2.5 mg tablet sig: one (1) tablet po once a day. 16. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 17. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day) as needed for constipation. 18. bisacodyl 10 mg suppository sig: one (1) suppository rectal (2 times a day) as needed for constipation. 19. heparin sig: 5000 (5000) u subcutaneous three times a day: while patient not ambulatory. 20. outpatient lab work please check patient's electrolytes (sodium, potassium, chloride, bicarbonate, bun, creatinine, glucose), hematocrit, and vancomycin level every other day, starting on thursday, . please fax results to (. discharge disposition: extended care facility: northeast- discharge diagnosis: primary diagnoses: 1) osteomyelitis (bone infection) of left heel 2) bacteremia (blood infection) 3) aseptic meningoencephalitis . secondary diagnoses: 1) type ii diabetes 2) ischemic optic neuropathy (right eye) 3) hypotension 4) end stage renal disease 5) chronic anemia 6) hyperlipidemia 7) hiatal hernia discharge condition: afebrile, normotensive, comfortable on room air. discharge instructions: please take your medications as prescribed. please call your doctor or return to the emergency room should you develop any of the following symptoms: confusion or decreased alertness, fever > 101, chills, nausea or vomiting with inability to keep down liquids or medications, diarrhea, chest pain, difficulty breathing, increased pain in your left heel, drainage from your heel wound, increased redness or swelling of your left heel wound or foot, or any other concerns. . you were evaluated for your confusion and low blood pressures. it is likely that your confusion is secondary to inflammation caused by your recent shingles infection. this seems to have resolved. your vision loss is likely due to low blood flow to the arteries in your eye. this may improve slightly over time. you should follow up with the neuroophthalmologist here at . you can also see your regular ophthalmologist. . you were found to have an infection in your blood and likely in the bone of your left foot. you need a total of 6 weeks of treatment with antibiotics. you will need to take one antibiotic by mouth and another will be dosed at your dialysis. you should not bear weight on your left leg for 4 more weeks. you will follow up with dr. from on . followup instructions: please return to see dr. on at 8:50 am. provider: , dpm phone: date/time: 8:50 . please call dr. office for an appointment within the next 1-2 weeks. phone number is . provider: , .d. phone: date/time: 1:50 please return to see dr. , the neuro-ophthalmologist, on . provider: , md phone: date/time: 10:30 md, Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Hemodialysis Local excision of lesion or tissue of bone, other bones Local excision of lesion or tissue of bone, other bones Biopsy of blood vessel Other incision of soft tissue Reconstruction of eyelid with tarsoconjunctival flap Radical excision of skin lesion Application or administration of an adhesion barrier substance Diagnoses: Other iatrogenic hypotension Anemia in chronic kidney disease Pure hypercholesterolemia Aortocoronary bypass status Personal history of tobacco use Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Disorders of phosphorus metabolism Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Atherosclerosis of native arteries of the extremities with ulceration Ulcer of heel and midfoot Septicemia due to gram-negative organism, unspecified Herpetic meningoencephalitis Unspecified osteomyelitis, ankle and foot Ischemic optic neuropathy

pt transferred from floor for hypotension. please see md admit note for complete history. pt recent admission for ms changes likely secondary to hsv or vzv encephalopathy in addition to gnr bacteremia. pmh: esrd on hd, cad, pvd,hyperlipidemai, cad, niddm. pt also has left foot wound vac. allergies: codeine, morphine, chocolate flavor neuro: pt disoriented upon arrival. he stated "i don't know" to all questions asked, including question asked if he had pain. currently, pt is receiving haldol for line placement. mri was ordered when pt was on floor for head. ? if pt still needs. resp: floor rn report, pt had had no o2 requirments 2 days ago. on floor she reported pt on 2 l nc and sating 100%. upon transfer to micu, pt's sats 86% and o2 increased to 5l n/c. ls decreased. cv: sbp's 80's upon arrival to micu. neosynephrine initiated and pt given 500cc fluid bolus. pt having rt eye visual changes. seen by opthamology who feels it is optic nerve ischemia due to hypotension. goal bps 110-'120's. gi: npo after midnoc for ? or in am. bs presnet gu: anuric on hd. id: tmax 99. pt has left heel vac dressing and per podiatry note, pt to have vac removed tomorrow on am rounds. ? pt going to or in am for ? procedure. social: wife and son in to visit. plan to call for update this evening. dispo: remain in micu. full code Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Hemodialysis Local excision of lesion or tissue of bone, other bones Local excision of lesion or tissue of bone, other bones Biopsy of blood vessel Other incision of soft tissue Reconstruction of eyelid with tarsoconjunctival flap Radical excision of skin lesion Application or administration of an adhesion barrier substance Diagnoses: Other iatrogenic hypotension Anemia in chronic kidney disease Pure hypercholesterolemia Aortocoronary bypass status Personal history of tobacco use Sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Disorders of phosphorus metabolism Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Atherosclerosis of native arteries of the extremities with ulceration Ulcer of heel and midfoot Septicemia due to gram-negative organism, unspecified Herpetic meningoencephalitis Unspecified osteomyelitis, ankle and foot Ischemic optic neuropathy

history of present illness: per the admission paperwork, mr. is a 72 year old gentleman with a history of diabetes, chronic renal insufficiency and a positive stress test in who presented with 2-3 months of increasing dyspnea on exertion, especially worse over the past 2-3 weeks. the patient reports feeling short of breath with chest constriction, walking up stairs or walking more than blocks. the chest constriction is mainly with exertion. he denies nausea, vomiting, light-headedness, dizziness or palpitations. the patient also reports one episode of bright red hemoptysis on the day of admission with some similar episodes over the past week. past medical history: significant for diabetes type ii complicated by neuropathy, nephropathy and peripheral vascular disease, chronic renal insufficiency with a baseline creatinine of 1.5 to 1.6, positive bowel study in 10/98 with a moderate reversible perfusion defect in the inferior lateral wall, normal wall motion, normal ejection fraction. cataracts bilaterally. hypercholesterolemia. allergies: codeine and morphine sulfate which cause nausea and vomiting. medications on admission: glyburide, lopid, zantac, lasix, metoprolol xl, lipitor, aspirin, motrin, tylenol and nitro stat. social history: significant for tobacco, quit 16 years ago, occasional alcohol family history: both parents had heart disease. laboratory: on admission are significant for a hematocrit of 29.9, k of 5.3, bun of 55, creatinine of 2.0. normal coags. ck of 110, ck mb of 5, troponin of 3.1. electrocardiogram showed sinus rhythm with left axis deviation, q's in v1 and v2, t-wave inversion avl but no cute changes. chest x-ray showed increased interstitial markings, question congestive heart failure. the patient was admitted to the medicine service where he underwent a rule out myocardial infarction protocol. cardiology consult was obtained. cardiology did recommend catheterization. the patient underwent catheterization on . catheterization showed few vessel coronary artery disease of the left anterior descending and left circumflex, elevated right and left filling pressures, moderate pulmonary hypertension. the patient also underwent an echocardiogram which revealed left ventricular enlargement with severe regional systolic dysfunction, moderate mitral regurgitation, pulmonary artery hypertension, mild aortic regurge. ejection fraction was not noted. the patient was then referred to cardiac surgery service. pulmonary consultation was also obtained due to the patient's history of hemoptysis. ct scan obtained showed no abnormalities aside from prominent subcarinal lymph node. these did meet criteria to be considered enlarged. pulmonary consult recommends follow-up ct scan in months and consideration of a bronch should the patient's symptoms recur. the patient did not have further evidence of hemoptysis while hospitalized. subsequent to the catheterization, the patient underwent coronary artery bypass graft on . he had a left internal mammary artery graft to the left anterior descending. he had vein grafts to the right coronary artery and to the obtuse marginal. consequently, the patient was taken to the cardiothoracic intensive care unit where he remained on neo for the first two postoperative days. he was extubated on postoperative day two and was transferred to the floor on postoperative day three. on the floor, he was slowly advanced in his diet and activity level. physical therapy worked with the patient and eventually it was decided that he was suitable for discharge to home. he was discharged to home on postoperative day number six. on final day, his incision was clean, dry and intact without a click. his bilateral lower extremities had ecchymosis but no erythema. condition on discharge: stable. discharge disposition: to home. discharge medications: 1. plavix 75 mg p.o. q.d. 2. lipitor 20 mg p.o. q. day. 3. glyburide 1.25 mg p.o. b.i.d. 4. percocet one to two tabs p.o. q.4-6h. p.r.n. 5. metoprolol 25 mg p.o. b.i.d. 6. lasix 20 mg p.o. t.i.d. 7. aspirin 81 mg p.o. q. day. 8. zantac 75 mg p.o. b.i.d. the patient is to follow-up with his primary care physician weeks. he is to follow-up with dr. in four weeks and will return to the floor for wound check in approximately one week's time. of note, it was included in the paperwork to the patient's primary care physician that he is to have a follow-up ct scan in months to further evaluate his hemoptysis. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass 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: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Primary pulmonary hypertension Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled Peripheral angiopathy in diseases classified elsewhere

service: neonatology history of present illness: is the former 1.97 kg product of a 33 week gestation pregnancy, born to a 37-year-old gvi pii-iii african-american woman. prenatal screens: blood type o negative, antibody positive for both anti-d and anti-c antibody, rubella immune, rpr positive with beta strep status unknown. pregnancy was complicated by rh isoimmunization. the fetus was followed with serial amniocenteses and medial cerebral artery doppler flow studies the mother received two doses of betamethasone and was beta complete on . there was also a past history of fully treated syphilis, with appropriate follow-up serology. this infant was initially scheduled for induction fetal heart rate decelerations and was taken to cesarean section. the infant emerged apneic and limp, required positive pressure ventilation and blow-by oxygen. apgars were 4 at one minute and 8 at five minutes. she was admitted to the neonatal intensive care unit for treatment of prematurity. physical examination: upon admission to the neonatal intensive care unit, weight 1.97 kg (50th percentile), length 42.5 cm (50th percentile), head circumference 30.5 cm (50th percentile). general: non-dysmorphic, pre-term female, in moderate respiratory distress. head, eyes, ears, nose and throat: anterior fontanel open and level, symmetric facial features, palate intact. neck without masses or swelling. chest: moderate retractions, fair air entry. cardiovascular: regular rate and rhythm, no murmur, femoral pulses +2. abdomen: soft, nontender, no masses. genitourinary: normal pre-term female genitalia. extremities: moving all, hips stable. neurologic: appropriate tone and reflexes. hospital course by system: 1. respiratory: required treatment for transitional respiratory distress with continuous positive airway pressure. she was able to be weaned to room air by day of life one, and she remained in room air throughout her subsequent neonatal intensive care unit admission. she did not have any episodes of apnea during the admission. 2. cardiovascular: maintained normal heart rates and blood pressures during the admission. no murmurs have been noted. 3. fluids, electrolytes and nutrition: was initially nothing by mouth and maintained on intravenous fluids. enteral feedings were started on day of life number six, and gradually advanced to full volume. she was on 24 calorie formula throughout her neonatal intensive care unit admission, and she is being discharged home on enfamil fortified to 24 calories/ounce. serum electrolytes were checked in the first ten days of life and were within normal limits. discharge weight is 2.675 kg, with a length of 46.5 cm and a head circumference of 33.5 cm. 4. hematology: initial cord bilirubin was 3.9 total/0.3 direct. initial hematocrit at birth was 27%. over the first four days of life, the hematocrit declined gradually to a low of 11%. underwent double volume exchange transfusion on to correct her hemolytic anemia due to the known rh isoimmunization. her most recent hematocrit was 36.9% on , which was up from 26.7% on . she is being discharged home on supplemental iron. her blood type is o positive, and she was direct antibody positive. 5. gastrointestinal: peak serum bilirubin occurred on day of life number five with a total of 10.1/0.3 direct. she was treated with intensive phototherapy from the date of birth through the first two weeks of life. her rebound bilirubin on was 5.7 total/0.2 direct. 6. infectious disease: due to her respiratory distress at birth, was evaluated for sepsis and treated presumptively with intravenous ampicillin and gentamicin. a blood culture obtained prior to starting antibiotics was no growth. she also received three doses of oxacillin around the time of her double volume exchange transfusion due to the use of her umbilical vein for the exchange transfusion. rpr and treponemal antibody tests were sent on the infant on . the rpr was nonreactive, and the treponemal antibody test results remain outstanding. 7. neurology: a head ultrasound was obtained on and showed a small right germinal matrix hemorrhage. a head ultrasound is being recommended at approximately one month of age to be done on an outpatient basis. 8. sensory: a hearing screening was performed with automated auditory brain stem responses. passed in both ears. condition at discharge: good discharge disposition: home with parents primary pediatric care: will be provided through the pediatric house associates clinic at . care recommendations: 1. feedings: by mouth ad lib 130 cc/kg/day minimum of enfamil fortified to 24 calories/ounce. 2. medications: fer-in- 25 mg/ml dilution, 0.2 cc by mouth once daily. 3. car seat position screening was performed prior to discharge, with adequate oximetry saturations. 4. state newborn screen was sent on day of life number three, with no report of abnormal results. 5. immunizations: initial hepatitis b vaccine was administered on . 6. 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 gestation; (2) born between 32 and 35 weeks, with plans for day care during respiratory syncytial virus season, with a smoker in the household, or with preschool siblings; or (3) with chronic lung disease. influenza immunization should be considered annually in the fall for pre-term 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. 7. follow-up appointments recommended with the primary pediatric provider within week of discharge. a repeat head ultrasound by two months of age. discharge diagnosis: 1. prematurity at 33 3/7 weeks gestation 2. transitional respiratory distress 3. rh isoimmunization 4. rule out sepsis 5. hemolytic anemia status post double volume exchange transfusion , m.d. dictated by: medquist36 d: 01:22 t: 01:56 job#: Procedure: Enteral infusion of concentrated nutritional substances Other phototherapy Prophylactic administration of vaccine against other diseases Exchange transfusion Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Neonatal jaundice associated with preterm delivery Other respiratory problems after birth Other preterm infants, 1,750-1,999 grams 33-34 completed weeks of gestation Hemolytic disease of fetus or newborn due to ABO isoimmunization

allergies: , , univasc, lipitor, unasyn. pmh/sh: etoh, tobacco, htn, polio, colitis, lipidemia. Procedure: Parenteral infusion of concentrated nutritional substances Drainage of pancreatic cyst by catheter Diagnoses: Unspecified essential hypertension Alcohol abuse, unspecified Alkalosis Chronic pancreatitis Cyst and pseudocyst of pancreas

history of present illness: the patient is an 83-year-old female who was transferred to on from for long-standing alcohol related pancreatitis. she was admitted to one month before with abdominal pain, fever and a ct scan that verified a pancreatic pseudocyst, which was drained percutaneously on with initial improvement. she had been on total parenteral nutrition at and had continued abdominal pain and intermittent fevers. a repeat ct scan at on showed a recurrent collection and cyst fluid that had grown staphylococcus non-aereus. she had been treated at with vancomycin, clindamycin and levofloxacin and had been put on a clear p.o. diet before transfer from . hospital course: the patient had a ct scan on that confirmed a pancreatic pseudocyst collection. during this ct scan, dr. of interventional radiology removed the patient's percutaneous pseudocyst drainage catheter. he attempted to put in a new drain, but was unsuccessful at that time. at that time, the patient was continued on vancomycin, levofloxacin and clindamycin. on , the patient had a repeat ct scan and at that time interventional radiology was, in fact, able to place a percutaneous drain. cultures from the percutaneous drain that was discontinued grew out 4+ gram-positive cocci on gram's stain. thus, the patient was again continued on vancomycin, levofloxacin and clindamycin. over the next few days, the patient began to do better. the patient pulled her nasogastric tube out on . her abdominal examination became much better over the next few days after the drain was placed. as of , the patient was started on a clear diet. it was also noted that her white blood cell count was steadily trending down from 19,100 on to 16,400 on and to 14,200 on . as of , which was hospital day #8, post percutaneous day #4, vancomycin day #7, levofloxacin day #8 and clindamycin day #8, it was decided, since the patient had been afebrile for a few days and she was now nontender on examination, that we would stop the patient's antibiotics and see if the patient had any temperature spikes. over the next few days, she did not have any temperature spikes and thus antibiotics were not restarted. the patient was advanced to a low fat diet on . her total parenteral nutrition was continued for additional nutrition support. she was placed back on her home blood pressure medications as well. condition on discharge: on the morning of , it was decided that the patient was stable for discharge to rehabilitation. she was afebrile on total parenteral nutrition, tolerating a decent amount of p.o. intake and making good urine output. she had been afebrile for several days. discharge medications: propanolol 80 mg p.o. t.i.d. diovan 80 mg p.o. q.d. chlorothiazide 500 mg p.o. q.d. protonix 40 mg p.o. q.d. total parenteral nutrition. follow up: the patient will follow up with dr. . disposition: the patient will be discharged to rehabilitation today. , m.d. dictated by: medquist36 Procedure: Parenteral infusion of concentrated nutritional substances Drainage of pancreatic cyst by catheter Diagnoses: Unspecified essential hypertension Alcohol abuse, unspecified Alkalosis Chronic pancreatitis Cyst and pseudocyst of pancreas

allergies: , , univasc, unasyn, demerol meds at home: inderal, lasix, diovan neuro: pt alert and oriented times three but is somnolent and her speech is slow but not slurred. her voice is quiet and what she says is sometimes difficult to understand. she mae. pupils are rec=active to light. she follows commands. cv: pt being ruled out by enzymes. her triponin is rising and pt is going to be seen by cardiology tonight and may need echo. she denies chest pain. i was able to wean off the dopamine as of 8pm. map is to be kept greater than 65. hr has been 70-90, nsr. she required calcium and mag repletion this afternoon. repeat labs ordered for 11pm tonight. a-line and central line placed and working well. cvp goal . last cvp at 8pm was 12. resp: pt becoming increasingly acidotic as the day progresses and abg at 8pm has ph down to 7.26. plan is for frequent abg's, labs and to give pt two amps bicarb now. she is currently on o2 35% face tent with good sats. lungs are clear with crackles at both bases. cxr has been done to confirm placement of central line. cxr shows pleural effusions. gi: ngt repositioned and is in good placement draining green bile. pt has had dry heaves at times today. kept npo. hct 29 after the one unit of prbc's. on protonix. gu: uo 30-60/hr via foley. Procedure: Parenteral infusion of concentrated nutritional substances Thoracentesis Arterial catheterization Diagnoses: Acidosis Mitral valve disorders Unspecified pleural effusion Congestive heart failure, unspecified Atrial fibrillation Methicillin susceptible pneumonia due to Staphylococcus aureus Chronic pancreatitis Diseases of tricuspid valve

history of present illness: an 85-year-old female with a history of , m.d. dictated by: medquist36 Procedure: Parenteral infusion of concentrated nutritional substances Thoracentesis Arterial catheterization Diagnoses: Acidosis Mitral valve disorders Unspecified pleural effusion Congestive heart failure, unspecified Atrial fibrillation Methicillin susceptible pneumonia due to Staphylococcus aureus Chronic pancreatitis Diseases of tricuspid valve

history of present illness: this is an 85 year old female with a history of chronic pancreatitis secondary to ethanol use and peptic ulcer disease, status post distal diskectomy, admitted to surgical intensive care unit from hospital where she presented with nausea, vomiting, diarrhea and epigastric pain. the patient presented to at 9:45 pm, with a history of weakness, nausea, vomiting and creamy diarrhea times one to two weeks with poor p.o. intake. the patient reports a one month history of diarrhea. no fever or chills. the patient reports epigastric pain, 6 out of 10, no radiation. past medical history: 1. chronic pancreatitis diagnosed in with pancreatic pseudocyst drained ; 2. peptic ulcer disease, status post partial distal diskectomy; 3. atrial fibrillation; 4. gout; 5. hyperlipidemia; 6. ethanol abuse. medications on admission: medications at home include - 1. lasix; 2. diovan; 3. propranolol. social history: positive tobacco history, none currently. positive heavy ethanol use in the past, unclear use now. the patient is married and lives with her husband. family history: non-contributory. physical examination: on admission temperature was 96.3, pulse 86, blood pressure 126/54, respirations 18, sating 100% on 100% face mask. the patient was on dopamine 7.5 mcg/min. general: frail elderly female in mild distress secondary to abdominal pain. head, eyes, ears, nose and throat: positive icterus, oral mucosa slightly dry. oropharynx clear. neck: supple, jugulovenous distension to jaw line at 45 degrees. no lymphadenopathy. cardiac: regular rhythm, no murmurs, rubs or gallops. lungs: decreased breathsounds with mild rhonchi. abdomen: old scar noted. normoactive bowel sounds. soft, moderate tenderness in the epigastrium, positive guarding. distention of abdomen, but soft without evidence of peritoneal signs or rebound. extremities, warm with no edema. rectal, poor tone, guaiac negative. laboratory data: laboratory studies on admission revealed white blood cell count 10.6, hematocrit 25.3, platelets 310, inr 1.1, ptt 25.5, sodium 138, potassium 4.1, chloride 115, bicarbonate 12, bun 51, creatinine 1.6, glucose 151. alt 43, ast 72, alkaline phosphatase 140, total bilirubin 1.2, amylase 27, lipase 52, calcium 7.6, magnesium 1.3, phosphorus 3.5. arterial blood gases, 7.29, 28, 68, lactate 1.3. computerized tomography scan: small amount of fluid in retroperitoneum. mildly thickened small bowel loop, bilateral pleural effusions, positive pleural plaques. ultrasound: no dilated common bile duct, cholelithiasis but no evidence of cholecystitis. hospital course: 1. abdominal pain - the patient's abdominal pain with nausea, vomiting and diarrhea was felt to be consistent with chronic pancreatitis flare versus gastroenteritis. there was no evidence of cholecystitis or common bile duct dilatation on right upper quadrant ultrasound and aside from a few loops of thickened bowel on abdominal computerized tomography scan, abdominal findings were unremarkable. the patient's initial acidosis were felt secondary to fluid losses from diarrhea and improved with volume resuscitation. the patient's abdominal examination steadily improved and her liver function tests remained unremarkable throughout the hospital stay. at the time of discharge the patient was without nausea, vomiting or diarrhea. 2. cardiology - the patient's cardiac enzymes were cycled with a troponin peak of 0.14. cardiology was consulted who recommended a transthoracic echocardiogram and persantine mibi with gentle diuresis for elevated jugulovenous pressure and initiation of lopressor. the patient's transesophageal echocardiogram on showed an ejection fraction of 60% with 1+ mitral regurgitation, 2+ tricuspid regurgitation, severe pulmonary artery and systolic hypertension. the patient's troponin leak is likely secondary to strain and further workup not pursued at this time. the patient will require a persantine mibi scheduled as an outpatient through her primary care physician. 3. respiratory - the patient developed a cough with increased respiratory rate into the 30s on . a chest x-ray at that time showed left upper lobe and lower lobe opacities consistent with congestive heart failure versus pneumonia as well as a bilateral pleural effusion. the patient was diuresed with lasix over 2.3 liters over the next 36 hours with no improvement in respiratory symptoms. follow up chest x-ray showed an increase in the size of the left pleural effusion and multifocal bilateral pulmonary infiltrates. the patient was begun empirically on levofloxacin and flagyl and was transferred to the medicine intensive care unit for further management of suspected nosocomial pneumonia. the patient had sputum culture taken on and which grew methicillin-resistant staphylococcus aureus and vancomycin was added upon transfer on to the medicine intensive care unit. the patient will continue ciprofloxacin, flagyl and vancomycin for a total of 14 day course for nosocomial pneumonia. the patient underwent a thoracentesis on which gram stain showed no polymorphonucleocytes and no microorganism. total protein 1.3, albumin less than 1, glucose 138, ldh 81, preliminary probe fluid culture was negative. based on these results pleural effusion was felt to be a transudate likely secondary to congestive heart failure and the patient was gently diuresed during the course of the hospital stay. the patient was noted to have copious secretions throughout length of stay in the medicine intensive care unit requiring frequent suctioning. she had a weak cough and was unable to bring up secretions on her own without chest physical therapy. 3. fluids, electrolytes and nutrition - the patient was noted to be hypernatremic with sodium 149 at time of transfer to the medicine intensive care unit. free water deficit was 1.6 liters. the patient was repleted with 1/2 normal saline. the sodium had stabilized at the time of discharge. sodium was 139. metabolic acidosis was noted on admission to surgery intensive care unit, resolved with closing anion gap and normalization of ph. the patient had speech and swallow evaluation on given concern of possible aspiration as a contributor to her current pneumonia. bedside swallowing evaluation showed that the patient appeared to aspirate water but refused to take more than one bite or one sip. her lack of cooperation, lack of desire to eat and drink and her waxing and level of alertness placed her at significant nutritional risk, even if she could swallow safely. therefore, the patient's dobbhoff tube was placed and tube feeds started. the patient will require further evaluation once strength increases to evaluate whether she is able to take p.o. once she is over her acute illness. 5. anemia - the patient was noted to have decreased hematocrit on transfer to the medicine intensive care unit, although this was within her baseline ranges of 25 to 35. the patient was guaiac negative. iron studies suggestive of anemia of chronic disease. we continued to monitor her hematocrit through her hospital course. it remained stable and at the time of discharge was 28.2. the patient will require further monitoring of her hematocrit as an outpatient to ensure that it remains stable. 6. delirium - the patient was noted to have waxing and mental status throughout the course of her hospital stay although it gradually improved as we avoided sedatives. the delirium was felt likely secondary to acute infection overlying the existing underlying dementia, possibly from prior heavy ethanol use. the patient's mental status stabilized. no further workup was performed at this time. 7. renal failure - the patient's elevated creatinine noted on admission to surgery intensive care unit gradually returned towards normal with a creatinine of 1.0 at the time of discharge. given the patient's creatinine clearance, less than 35, all medications were dosed renally. the patient will require further follow up of creatinine to ensure that it remains within normal limits. the patient's elevated creatinine on admission was likely secondary to prerenal although there may have been an acute tubular necrosis component. condition on discharge: fair discharge status: to be discharged to acute rehabilitation facility. discharge diagnosis: 1. chronic pancreatitis 2. nosocomial pneumonia 3. atrial fibrillation 4. gout 5. peptic ulcer disease 6. hyperlipidemia discharge medications: 1. colace 100 mg p.o. b.i.d. 2. metronidazole 500 mg intravenously q. 8 hours 3. regular insulin sliding scale 4. pantoprazole 40 mg p.o. q. 24 hours 5. ciprofloxacin 400 mg intravenously q. 24 hours 6. vancomycin 500 mg intravenously q. 24 hours , m.d. dictated by: medquist36 Procedure: Parenteral infusion of concentrated nutritional substances Thoracentesis Arterial catheterization Diagnoses: Acidosis Mitral valve disorders Unspecified pleural effusion Congestive heart failure, unspecified Atrial fibrillation Methicillin susceptible pneumonia due to Staphylococcus aureus Chronic pancreatitis Diseases of tricuspid valve

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: car vs tree major surgical or invasive procedure: : external fixator to left femur : cephaolmedullary nail to left femur : orif l knee pcl avulsion history of present illness: mr. is a 26 year old male who was involved in a motor vehicle crash.(car hit tree). no loc, long extracation (20 min), + airbag deploymemt. he was med flighted to . past medical history: asthma general anxiety disorder social history: nc family history: nc physical exam: upon admission: alert and oriented cardiac: regular rate rhythm chest: lungs clear to auscultation abdomen: soft non-tender non-distended extremities: left leg shortened, externally rotated, + edema, + sensation and movement, + pulses. pertinent results: 05:20pm blood hct-26.2* 06:34am blood wbc-10.0 rbc-3.33* hgb-9.8* hct-29.4* mcv-88 mch-29.5 mchc-33.5 rdw-15.1 plt ct-608* 08:45am blood wbc-12.5* rbc-3.34* hgb-10.2* hct-28.8* mcv-86 mch-30.5 mchc-35.4* rdw-14.8 plt ct-471*# 07:35am blood wbc-9.1 rbc-3.10* hgb-9.4* hct-26.6*# mcv-86 mch-30.4 mchc-35.5* rdw-13.3 plt ct-243 06:16am blood wbc-7.5 rbc-2.55* hgb-7.9* hct-21.2* mcv-83 mch-31.0 mchc-37.2* rdw-13.6 plt ct-193 11:15pm blood hct-22.6* 09:33am blood hct-23.0* 02:46am blood wbc-8.0 rbc-2.82* hgb-8.6* hct-24.1* mcv-85 mch-30.4 mchc-35.6* rdw-13.6 plt ct-145* 09:10pm blood hct-25.6* 03:04pm blood hct-22.3* 09:35am blood hct-24.6* 04:01am blood wbc-9.0 rbc-3.12* hgb-9.4* hct-26.5* mcv-85 mch-30.2 mchc-35.6* rdw-13.6 plt ct-202 10:59pm blood hct-26.9* 06:55pm blood wbc-9.7 rbc-3.16*# hgb-9.4*# hct-27.1*# mcv-86 mch-29.7 mchc-34.7 rdw-13.4 plt ct-181 09:50am blood wbc-14.6* rbc-4.39* hgb-13.2* hct-37.4* mcv-85 mch-30.2 mchc-35.4* rdw-13.4 plt ct-257 06:34am blood glucose-93 urean-14 creat-0.7 na-139 k-4.2 cl-102 hco3-30 angap-11 12:05pm blood glucose-141* urean-12 creat-0.9 na-138 k-3.9 cl-106 hco3-24 angap-12 brief hospital course: mr. was seen in the emergency room and admitted to the trauma service. he was found to have a closed left femur fracture. he was taken urgently to the operating room with the orthopedic service for fixation of his femur fracture. in the or upon prepping and draping the patient he became hypotensive. it was decided to temporarily stabilize his fracture with an external fixator. he tolerated this well. he was then taken to the tsicu for further monitoring. it was thought that the episode of hypovolemia was due to hypovolemia. he was appropriately fluid resuscitated. on he was brought back to the operating room for internal fixation of his femur fracture. he received 2 units of prbc's in the or. he tolerated the procedure well. he was brought back to the tsicu in stable condition. while in the t/sicu he remained tachycardiac and was started on propanolol. on he was extubated without incident. in the afternoon he was transferred to the floor to the orthopedic service. the patient was evaluated by physical therapy and progressed well. his pain was well controlled. on he was brought back to the operating room for fixation of his left pcl avulsion fracture. he tolerated the procedure well. he was extubated and brought to the recovery room in stable condition. once stable in the pacu he was transferred to the floor. on the floor he did well. he continued to progress with physical therapy. his hospital course was otherwise without incident. his pain was well controlled. his labs and vitals remained stable. he is being discharged today in stable condition. he was given instructions to follow up with his primary care physician for management of his tachycardia and propanolol. medications on admission: effexor ativan advair albuterol 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. enoxaparin 30 mg/0.3 ml syringe sig: one (1) 30mg syringe subcutaneous q12h (every 12 hours) for 4 weeks. disp:*56 30mg syringe* refills:*0* 3. hydromorphone 2 mg tablet sig: 1-2 tablets po q3-4h (every 3 to 4 hours) as needed for pain. disp:*90 tablet(s)* refills:*0* 4. propranolol 40 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: l femur fracture l pcl avulsion fracture post operative anemia discharge condition: stable discharge instructions: please continue with the touch down weight bearing on your left leg. keep the knee immobilizer on at all times. please do not bend your knee. please keep incision clean and dry. dry dressing daily as needed. if you notice any increased redness, swelling, drainage, temperature >101.4, or shortness of breathe please md or report to the emergency room. take all medications as prescribed. you need to take the lovenox shots for 4 weeks to prevent blood clots. you may resume any normal home medications. please follow up as below. call with any questions. followup instructions: you have scheduled appointments with dr. and dr. along with follow up x-rays. provider: xray (scc 2) phone: date/time: 12:40 provider: , md phone: date/time: 1:00 provider: , md phone: date/time: 1:45 please follow up with your primary care physician in the next 1-2 weeks, as you are on a medication for your heartrate. you have only been written for one month suppply of this medication, your primary care physician will follow you on this. md, Procedure: Open reduction of fracture with internal fixation, tibia and fibula Removal of external immobilization device Open reduction of fracture with internal fixation, femur Transfusion of packed cells Closed reduction of fracture without internal fixation, femur Application of external fixator device, femur Other repair of the cruciate ligaments Diagnoses: Other iatrogenic hypotension Iron deficiency anemia secondary to blood loss (chronic) Open wound of forehead, without mention of complication Anxiety state, unspecified Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle Closed fracture of upper end of tibia alone Closed fracture of sacrum and coccyx without mention of spinal cord injury Closed fracture of shaft of femur Closed fracture of unspecified part of neck of femur Contusion of shoulder region Contusion of ankle

discharge medications: 1. haldol 2 mg p.o.q.6.h. around the clock, wean as tolerated. 2. ativan 0.5 mg p.o.q.6h.p.r.n. agitation. 3. dilaudid 0.5 to 2 mg p.o.q.4h.p.r.n. 4. multivitamin, one p.o.q.d. 5. protonix 40 mg p.o.q.d. 6. heparin subcutaneously 5000 units b.i.d. diet: the patient will have a regular diet. discharge diagnoses: 1. bilateral pneumothoraces, resolved. 2. bilateral hemothoraces, resolved. 3. bilateral pulmonary contusions, resolved. 4. multiple rib fractures. 5. left clavicular fracture. 6. multiple left humerus fractures. 7. small intraventricular hemorrhage, all resolved. dr., 02-349 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 Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Arterial catheterization Open reduction of fracture with internal fixation, humerus Diagnoses: Traumatic pneumohemothorax without mention of open wound into thorax Other specified complications of procedures not elsewhere classified Traumatic subcutaneous emphysema Flail chest Closed fracture of multiple ribs, unspecified Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration Closed fracture of fifth cervical vertebra Closed fracture of surgical neck of humerus Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle

history of present illness: the patient is a 39 year old male who was an unrestrained driver involved in a rollover motor vehicle accident. he was partially ejected from the vehicle. he had a prolonged extrication time, approximately 30 minutes and was found unresponsive by paramedics at the scene and intubated. the patient was transferred to an outside medical facility where he had some left side crepitus noted. he had a left chest tube placed for relief of this pneumothorax. the patient, at that time, was noted to be hypotensive and had a diagnostic peritoneal lavage performed which was negative. the patient's chest x-ray at that time showed a pneumothorax on the opposite side, on the right side, for which another chest tube was placed. the patient was packaged and prepared for transfer through , however, upon wheeling the patient away from that facility, he was found to be hypotensive initially and then had an asystolic arrest. two additional bilateral chest tubes were placed with relief of bilateral tension hemopneumothoraces with return of perfusing cardiac rhythm. the patient was stabilized for transfer to . upon arrival in our trauma bay, the patient was intubated, sedated, and paralyzed. the patient had three chest tubes in place and was hemodynamically stable. hospital course: trauma work-up at our facility revealed bilateral pneumothoraces with minimal hemothoraces, adequately drained by his chest tubes. however, persistent air leaks were noted and it was identified that the patient'a proximal ports of his chest tubes were out of the chest. during the ct scan, he became hypotensive and these tubes had to be emergently advanced with good result. the patient's trauma series revealed multiple rib fractures and hemopneumothoraces as stated above. the patient had a head ct scan which was negative and a ct scan of the cervical spine which showed a tiny c5 avulsion fracture which was non-displaced. ct scan of his chest revealed bilateral pulmonary contusions, bilateral consolidation and a left clavicular fracture. ct scan of his abdomen and pelvis showed a minimal amount of free fluid consistent with his diagnostic left clavicular fracture. ct scan of his abdomen and pelvis showed a minimum amount of free fluid consistent with his diagnostic peritoneal lavage. the patient also noted to have multiple bilateral rib fractures. the patient's plain film also on a later read revealed question of a left iliac fracture which was non-displaced. the patient also was noted by a consultation by orthopedic surgeons to have a glenoid fracture in addition to a humerus fracture. the patient was transferred to the surgical intensive care unit where two fresh sterile chest tubes were placed and his three other chest tubes were removed. he required intermittent pressor support and aggressive fluid resuscitation. neurosurgery was consulted and determined that this c5 fracture was nondisplaced, not requiring any specific therapy, however, that the patient should be in a hard collar for six weeks. the patient developed pulmonary infiltrate and some fevers for which he was started on ceftriaxone for some gram negative rods growing in his sputum. on hospital day four, the patient was taken to the operating room by the orthopedic surgeons for open reduction and internal fixation of his humeral fractures; the patient tolerated this procedure well without any complications. postoperatively, he was transferred back to the surgical intensive care unit where he underwent a prolonged ventilatory wean. the patient was extubated but noted to be somewhat confused and initially combative. the patient was thought to be withdrawing from alcohol and was started on ativan drips to control this. he progressed very well. mental status improved. he was transferred to the floor. on the floor, he continued to do well with slowly improving mental status. psychiatry was consulted for care of this and recommended a slow ativan wean and slow haldol wean. the patient's antibiotic course was completed. follow-up chest x-ray revealed resolution of his consolidations and the patient's sputum became normal. he began working with physical therapy and advanced to a regular diet which he tolerated well and will be discharged to rehabilitation. dr., 02-349 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 Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Arterial catheterization Open reduction of fracture with internal fixation, humerus Diagnoses: Traumatic pneumohemothorax without mention of open wound into thorax Other specified complications of procedures not elsewhere classified Traumatic subcutaneous emphysema Flail chest Closed fracture of multiple ribs, unspecified Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration Closed fracture of fifth cervical vertebra Closed fracture of surgical neck of humerus Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle

history of present illness: this is an 82-year-old male with history of coronary artery disease status post a mi in , duodenal ulcer, b cell gi lymphoma status post sbo and resection presenting with black stool x1 day. patient states that he awoke the morning of admit with dizziness. he had three bouts of dark diarrhea and felt weak and fatigued. he saw his primary care physician in clinic, who sent him to the emergency room for evaluation. he does not have a history of aspirin, nsaids, or alcohol use, no abdominal pain, vomiting, hematuria, or hematemesis. no fever, chills, or nausea. the patient also gives a history of using sublingual nitroglycerins per day. he states that he has frequent chest pain with minimal exertion or exposure to cold. he states that his chest pain is a feeling of pressure substernally without radiation and resolves with one tablet of nitroglycerin at home. in the emergency room, patient was given iv protonix and 1 liter of normal saline. he complained of chest pain substernally and it was relieved with one sublingual nitroglycerin. ekg was significant for st depressions throughout the anterolateral leads. an attempt was made for nasogastric lavage, but when nasogastric tube was being placed, the patient complained of chest pain, which resolved with one sublingual nitroglycerin as well. nasogastric lavage was not able to be done. past medical history: 1. coronary artery disease status post mi in . 2. prostate cancer status post abdominal resection, turp in . 3. duodenal ulcer status post upper gi bleed in the distant past. 4. hypertension. 5. status post left inguinal hernia repair in . 6. status post back surgeries x2. 7. history of b-cell lymphoma status post small bowel obstruction and resection in . 8. history of atrial fibrillation with rapid ventricular response on coumadin. 9. history of chronic abdominal pain. 10. history of bladder calculi. allergies: no known drug allergies. medications: 1. isosorbide dinitrate 20 mg b.i.d. 2. coumadin 4 mg p.o. q.h.s. 3. atenolol 25 mg p.o. q.d. 4. sublingual nitroglycerin prn. social history: no alcohol or drugs. no smoking. retired. lives with , his partner and her son for the past 20 years. physical exam: on physical exam, the patient had a temperature of 98.6, heart rate 68, blood pressure 137/70, respiratory rate 16, and saturating 100% on 2 liters nasal cannula. in general, he is alert and oriented times three in no acute distress. heent: pupils are equal, round, and reactive to light. mucous membranes dry. cardiovascular: regular rate and rhythm with a 2/6 systolic murmur at the left lower sternal border. lungs are clear to auscultation bilaterally. abdomen is soft, nontender, and nondistended, positive bowel sounds, guaiac positive. extremities: no edema. pertinent laboratories on admit: patient had a white count of 9.2, hematocrit of 29.1, platelets of 228. inr was 3.3. potassium 5.3, bun 86, creatinine 1.3. first two sets of cardiac enzymes were within normal limits. liver function tests and lipase were within normal limits. ekg was normal sinus rhythm at 66 beats per minute with wide qrs, normal axis, qs in ii, iii, and avf, and st depressions in v1 through v6 with t-wave inversion consistent with interventricular conduction delay of right bundle branch morphology. repeat ekg had improved st depressions. hospital course by systems: 1. gastroenterology: the patient presented with three bouts of melena at home likely from a gi bleed of the upper gi tract. gi was consulted on admit and they decided not to do an urgent egd given his labile cardiac status. nasogastric lavage was not able to be done in the ed secondary to the patient's chest pain. he did not have any further melena while on the floor. the differential diagnosis includes an ulcer versus tumor versus gastritis versus avm. the patient was h. pylori negative in . he is followed by dr. with gastroenterology. he had two large bore ivs placed. he was placed on protonix 40 mg iv b.i.d. he was initially made npo and his diet was advanced as tolerated. he was given 3-4 units of packed red blood cells in total, and was reversed initially with 2 units of ffp and 10 mg of p.o. vitamin k for his supratherapeutic inr secondary to coumadin. after his transfusions, his hematocrit remained stable in the upper 30s. coumadin was not restarted secondary to the increased risk of bleed. 2. cardiology: on the night of admit, the patient developed substernal crushing chest pain. again ekg showed st depressions anteriorly and laterally. the patient was given four sublingual nitroglycerins without relief as well as 1 mg of iv morphine. he was transferred to the cardiac floor for nitroglycerin drip. the nitroglycerin drip was up to 200 mcg per hour and his chest pain resolved five hours later. cardiac enzymes were cycled peaked at a troponin of 2.0 with a ck of 427. the patient remained stable on the floor, but then complained of increasing chest pain and ekg showed st depressions anterolaterally, but then rapid afib with inferior st segment elevations thought to be secondary to demand ischemia. the patient refused catheterization at this time, but was sent to the coronary intensive care unit for better monitoring. echocardiogram on showed an ef of 20% with mild symmetric lvh, moderate as, 1+ ar, pulmonary artery systolic pressure of 34 with 1+ mr, + tr, and no effusion. the patient was loaded with amiodarone for his rapid afib and beta-blocker was titrated up. he was started on a daily aspirin, but no further anticoagulation was given secondary to his gi bleed. he is to continue on his beta-blocker, statin, and long-acting nitrate. his ace inhibitor was held secondary to acute renal failure during his hospitalization. patient's ekgs were followed. his qtc interval increased to 0.53. haldol and antipsychotics were held. it was thought that part of the qtc prolongation maybe secondary to his amiodarone. the patient will follow up with dr. , his cardiologist on discharge. 3. neurology: on admit, the patient was alert and oriented times three. after transfer to the intensive care unit, he became delirious with mental status changes, but no focal neurologic deficits. the patient became very disoriented not knowing place, time, or why he was in the hospital. he frequently became very agitated and combative, required zyprexa, soft restraints, as well as 24-hour sitters. he also developed hallucinations. neurology was consulted. the patient's b12, folate, rpr, and tsh were within normal limits. head ct did not show any acute process. the patient's sedating medications were held as there is a thought that they might be contributing to his confusion. the patient's delirium continued to improve throughout his hospital course. 4. renal: patient developed acute renal failure with a creatinine up to 2.0. his usual baseline is 1.2 to 1.4. this was likely hypovolemic and prerenal in the setting of a gi bleed as well as poor ejection fraction as well as poor p.o. intake. he was given mild iv hydration without signs of heart failure, and his creatinine improved. his ace inhibitor was discontinued secondary to his acute renal failure, but should be restarted in the future. 5. fen: the patient was maintained on a 2-gram sodium, low cholesterol/low fat diet. speech and swallow was consulted as the patient was found to be coughing during his meals. video swallow test was performed, which did not show any signs of silent aspiration and the patient was maintained on a regular diet with thin liquids. electrolytes were repleted as needed. he was encouraged to increase his p.o. intake. 6. full code: heathcare proxy, , his partner of 20 years. discharged to: rehab. discharge status: good. discharge medications: 1. lopressor 75 mg p.o. b.i.d. 2. imdur 30 mg p.o. q.d. 3. nitroglycerin sublingual 0.4 mg prn chest pain. 4. protonix 40 mg p.o. b.i.d. 5. atorvastatin 20 mg p.o. q.d. 6. heparin 5000 units subq b.i.d. 7. amiodarone 200 mg p.o. b.i.d. 8. calcium carbonate 10 cc p.o. q.i.d. 9. aspirin 325 mg p.o. q.d. follow-up instructions: the patient is to followup with his cardiologist, dr. two weeks after discharge. he is also to followup with dr. for an outpatient egd. , m.d. dictated by: medquist36 Procedure: Transfusion of packed cells Transfusion of other serum Diagnoses: Subendocardial infarction, initial episode of care Toxic encephalopathy Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Atrial fibrillation Pulmonary collapse Unspecified gastritis and gastroduodenitis, with hemorrhage Angiodysplasia of stomach and duodenum with hemorrhage Chronic or unspecified peptic ulcer of unspecified site with hemorrhage, without mention of obstruction

history of present illness: this 57 year old white male with a history of diabetes, hypercholesterolemia and asthma presented on with increased dyspnea on exertion, pnd, lower extremity edema, and orthopnea. he had a recent mibi which showed a moderate reversible defect of the apex and anterior septum with an ef of 34 percent. he was admitted in chf to the floor. past medical history: past medical history is significant for history of insulin dependent diabetes, hypercholesterolemia, status post retinal hemorrhage, history of asthma, history of cataracts status post cataract surgery and history of hypertension. allergies: he has no known allergies. admission medications: his medications on admission: 1. altace, 10 mg po q day. 2. lipitor, 20 mg po q day. 3. glipizide, 5 mg po q day. 4. lantus, 10 units at bedtime. 5. azithromycin for bronchitis. social history: he does not smoke cigarettes and drinks several drinks per week. family history: unremarkable. review of systems: as above. physical examination: he is a well developed, well nourished, white male in no apparent distress. vital signs stable. afebrile. heent: normocephalic and atraumatic. extraocular movements intact. oropharynx benign. neck was supple. full range of motion. no lymphadenopathy or thyromegaly. carotids were 2 plus and equal bilaterally without bruits. lungs had bibasilar rales. abdomen was soft and nontender with positive bowel sounds. no masses or hepatosplenomegaly. extremities had bilateral pedal edema with 1 plus pulses bilaterally throughout. neuro exam was nonfocal. hospital course: he was admitted and underwent cardiac cath on , which revealed an 80 percent ostial left main stenosis, 80 percent lad stenosis, 60 percent left circumflex stenosis, and mild ostial disease of the rca. an intra- aortic balloon pump was placed and the patient was transferred to the ccu. dr. was consulted and on the patient underwent a cabg times three with lima to the lad and reverse saphenous vein graft to om1 and om3, cross-clamp time was 52 minutes, total bypass time 68 minutes. he was transferred to the csicu on epinephrine, neo- synephrine and propofol in stable condition. he was extubated on the post-op night and his epi was weaned off. he was transfused one unit of blood. postop day one his intra-aortic balloon pump was discontinued. postop day two his drips were off and chest tubes were discontinued. postop day three he was transferred to the floor in stable condition. carvedilol was started. his epicardial pacing wires were discontinued on postop day number four and postop day five he was discharged to home in stable condition. laboratory data: his labs on discharge were hematocrit 32.4, white count 7600, platelets 283,000. sodium 136, potassium 4.3, chloride 100, co2 27, bun 32, creatinine 1.3 and glucose 94. discharge medications: his medications on discharge are: 1. aspirin, 81 mg po q day. 2. colace, 100 mg po bid. 3. lipitor, 20 mg po q day. 4. glipizide, 5 mg po q day. 5. carvedilol, 6.25 mg po bid. 6. dilaudid, one to two po q4-6 hours prn pain. 7. lantus, 12 units subcu q p.m. 8. lasix, 40 mg po bid for 7 days. 9. potassium, 20 meq po bid for 7 days. 10. altace, 10 mg po q day. discharge diagnoses: 1. coronary artery disease. 2. insulin dependent diabetes. 3. hypertension. 4. hypercholesterolemia. 5. congestive heart failure. disposition: he will be followed by dr. in one to two weeks and by dr. in four weeks. , m.d. 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 Implant of pulsation balloon Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled

history of present illness: this 57-year-old white male has a history of diabetes, hypercholesterolemia, and asthma and presented on with increased dyspnea on exertion, shortness of breath and lower extremity edema, paroxysmal nocturnal dyspnea and orthopnea. he had a recent mibi which showed moderate reversible defects in the apex and anterior septum and the ejection fraction at that time was 34 percent. he was admitted on with congestive heart failure. he underwent cardiac catheterization on which revealed an 80 percent left main stenosis, 80 percent lad stenosis, 60 percent distal left circumflex stenosis and mild osteal disease of the rca. he had an intra-aortic balloon placed and was transferred to the ccu in stable condition. dictation ended. , m.d. 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 Implant of pulsation balloon Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled

allergies: phenergan attending: chief complaint: confusion, rigors major surgical or invasive procedure: ercp history of present illness: 74yo m with h/o cad s/p cabg, dmii, htn and cri who underwent elective ercp today for intrahepatic duct stone seen on mri evaluation for renal cysts. ercp was complicated in that multiple attempts were made for gallstone extraction in the cbd and intrahepatic ducts. the patient went to recovery area where he did well for approx 2 hrs post procedure. he rec'd 25mg phenergan at 4pm for nausea. 45 minutes later, the patient was found in the bathroom, confused with peripheral iv pulled out. he was not oriented to place or time. he was also noted to be rigoring. his slightly hypotn, tachycardic and hypoxic at this time, sbp 80-90s, hr 90's, sao2 80s. he remained afebrile (98.3) despite rigors. he was given 25mg of demerol for rigors. he was placed on nrb, given add'l ns bolus x 1 l, and ekg obtained. labs, blood cx x 2, ua, ucx sent, patient given levofloxacin 500mg x 1 and flagyl 500mg x 1. sent to for further care. in the he has had a short stay; he was treated with unasyn and agressive iv fluids to maintain pressure, but he required no pressors. he returned quickly to baseline and is sent to the floor and accepted by us on the next day. past medical history: 1. cad, status post cabg in . 2. hypertension. 3. hypercholesterolemia. 4. gastroesophageal reflux disease. 5. benign prostatic hypertrophy. 6. cholelithiasis, status post ercp in . 7. cholelithiasis, status post laparoscopic to open cholecystectomy, cholangiogram, resection of hepatic rim on gallbladder on . 8. basal cell ca. social history: married, lives with wife, significant for moderate etoh, remote history of tobacco. the patient quit 15 years ago, about 35 pack year. family history: non contributory physical exam: physical examination (on admission to floor): vital signs: t 98 bp 123/53 hr 78 rr 16 100% nrb general: elderly man, confused, somnolent but arousable heent: perrl, anicteric, eomi, sl dry mm lungs: clear to auscultation bilaterally. cardiovascular: s1, s2. rrr, no mrg. abdomen: mildly obese, soft, nontender, nondistended, + bs. midline scar (cabg), oblique scar (cholecystectomy in the past) extremities: without edema, warm, + dps neuro: alert and oriented x 3 pertinent results: 05:15am blood wbc-10.3# rbc-3.67* hgb-11.6* hct-34.0* mcv-93 mch-31.7 mchc-34.2 rdw-13.2 plt ct-119* 05:15am blood neuts-85.8* bands-0 lymphs-8.7* monos-3.8 eos-1.2 baso-0.5 05:15am blood plt ct-119* 05:15am blood pt-13.3 ptt-27.0 inr(pt)-1.1 05:15am blood glucose-110* urean-16 creat-0.9 na-140 k-3.4 cl-112* hco3-20* angap-11 05:15am blood alt-33 ast-26 ld(ldh)-162 ck(cpk)-82 alkphos-43 amylase-63 totbili-0.9 12:26am blood ck(cpk)-75 05:15am blood lipase-29 05:15am blood ck-mb-2 ctropnt-<0.01 05:15am blood albumin-2.9* mg-1.4* brief hospital course: 74yo m with cad, dmii, htn, cri s/p ercp presented with hypoxia, hypotension, tachycardia and ms changes. he was admitted to the icu. 1. shock: likely related to bacteremia/sepsis from ercp and stone extraction. he was initially treated presumtively for bacteremia with unasyn for possible gi flora from translocation from ercp vs. cholangitis. blood and urine cultures were sent. his map was maintained >60 with ivf ns boluses. his o2 saturation was maintained >92% on 2l nc. the patient in a few hours became stable, afebrile, saturation 98% on room air. he is kept on levofloxacin and flagyl x 7-10 days. we will follow up on culture results. 2. choledolitiasis: the patient is discharged on ursodiol tid as per gi recs. 2. cad: h/o cabg, event post-procedure. there was no evidence of ischemia on ekg, cardiac enzymes negative. he is continued on asa and atorvastatin. his antihypertensive medications were held but he was given prescriptions to re-start his usual regimen upon discharge, as his bp was becoming elevated on no meds one hour prior to discharge. 3. dmii: blood sugars were monitored q4. he was on sliding scale insulin, and able to eat a normal diet. 4. cri: last creatinine 0.9. no edema. good urine output. 5. fen: diabetic diet 6. ppi: ppi, teds if needed. patient is ambulatory. 7. code: full medications on admission: medications: prilosec 20 once daily lipitor 40 once daily lopressor 100 b.i.d. enalapril 10 once daily, hydrochlorothiazide 25 once daily aspirin 325 once daily multivitamin one a day. discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. 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* 4. ursodiol 300 mg capsule sig: one (1) capsule po tid (3 times a day). 5. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours). 6. multi-vitamin oral 7. lopressor 100 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 8. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 9. enalapril maleate 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary diagnosis 1. choledocholithiasis 2. septic shock secondary diagnosis 1. coronary artery disease 2. hypertension 3. benign prostatic hyperplasia 4. gerd 5. dm type ii discharge condition: able to ambulate without assistancebreathes well on room aireats a normal diet without nausea or vomitingfeels very well discharge instructions: call your pcp or go to the ed for any concerning symptoms, such as fever, dizziness, abdominal pain, chest pain or shortness of breath take your medications as prescribed followup instructions: follow up with dr phone number within two to three weeks after discharge. you need to have an abdominal mri in months to follow up on your hepatic lesion and renal cyst. Procedure: Endoscopic removal of stone(s) from biliary tract Diagnoses: Esophageal reflux Pure hypercholesterolemia Other postoperative infection Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Aortocoronary bypass status Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Septic shock Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction Calculus of bile duct without mention of cholecystitis, without mention of obstruction

history of present illness: the patient is a 73-year-old male with history of coronary artery disease, hypertension, hypercholesterolemia who presented with a 12-hour history of left-sided chest pain radiating to the back and shoulder. the patient's pain was rated and the patient had concomitant nausea, but denied having shortness of breath or palpitations. the patient also noted similar pain on a admission which required two sublingual nitroglycerin to alleviate. the patient denies a history of bright red blood per rectum, melena, dysuria, diarrhea, fevers, chills, or cough. most recently the patient was admitted on with a stress mibi which lasted approximately nine minutes on modified protocol with achievement of 57% of maximum heart rate. the patient also was noted to have a new mild reversible defect in the inferolateral region although no ekg changes were noted and the patient's blood pressure decreased inappropriately to exercise. at this time the patient underwent a cardiac catheterization at which revealed 20% left main coronary artery disease, left anterior descending coronary artery with hazy eccentric 70% and 50% mid, left circumflex normal, right coronary artery completely occluded, and saphenous vein graft to right coronary artery with 60-70% mid disease. given these findings, cardiothoracic surgical evaluation was obtained. past medical history: 1. coronary artery disease status post saphenous vein graft to right coronary artery bypass in . catheterization showed patent graft, 50% left anterior descending coronary artery. stress, ejection fraction 68% with no free wall motion abnormality. 2. gallstones with common bile duct dilatation status post ercp and sphincterotomy. 3. gastroesophageal reflux disease. 4. hypertension. 5. hypercholesterolemia. allergies: the patient has no known drug allergies. medications: 1. aspirin 81 mg p.o. q.d. 2. mevacor 40 mg p.o. b.i.d. 3. nadolol 80 mg p.o. q.d. 4. vasotec 40 mg p.o. q.d. 5. hydrochlorothiazide 25 mg p.o. q.d. 6. ambien p.r.n. 7. melatonin. 8. multivitamins. social history: the patient currently lives with his wife, has a history of former ethanol abuse and quit tobacco in . family history: no history of coronary artery disease, no diabetes, no cerebrovascular accidents and a positive history in the mother for hypertension. physical examination: vital signs were temperature 99.4, pulse 66, sinus, blood pressure 113/50, respiratory rate 16 and 93% saturation on room air. the patient was a well-developed, well-nourished male in no apparent distress. heent: sclerae anicteric, cranial nerves ii-xii were intact. mucous membranes were moist, no evidence of oral ulcers. neck: no evidence of cervical lymphadenopathy noted. chest: sternotomy site without any drainage, no evidence of click and no evidence of erythema. clear to auscultation bilaterally. heart: regular rhythm and rate, no evidence of murmur. abdomen: soft, nondistended, nontender with positive bowel sounds. no hepatosplenomegaly and no evidence of inguinal lymphadenopathy. extremities: no evidence of rash and +1 lower extremity symmetric edema. laboratory data: laboratory studies as of showed a white blood cell count of 8.3, hematocrit 26.4, platelet count 148, sodium 138, potassium 4.3, chloride 104, bicarbonate 24, bun 16, creatinine 0.9, calcium 7.9, magnesium 2.0, phosphorous 3.0. hospital course: mr. is a 73-year-old male status post coronary artery bypass grafting in (svg to rca) who presents with cardiac catheterization which revealed occluded right coronary artery, saphenous vein graft to right coronary artery with 60-70% mid disease, left anterior descending coronary artery with hazy eccentric 70% disease and 50% mid disease. following the successful preoperative evaluation, the patient was taken to the operating room on and underwent an uncomplicated redo coronary artery bypass grafting x 2 (lima to lad, svg to pda). postoperatively the patient was taken to the cardiac surgery recovery unit for close observation. the patient was immediately extubated and was noted to have labile blood pressure which improved within several hours. during this time the patient maintained sinus rhythm with occasional premature ventricular contractions and was breathing spontaneously on four liters nasal cannula with good saturations at 97%. by postoperative day number two the patient was transferred to the floor in good condition and initiated on metoprolol while pacing wires were intact. no evidence of bradycardia occurred and pacing wires were removed on the following day. by postoperative day number three the patient cleared level five physical therapy requirement for discharge to home, however the decision was made to discharge the patient on the following day to further monitor the patient's improvement. condition on discharge: good. discharge status: to home. discharge diagnoses: status post redo coronary artery bypass grafting x 2. discharge medications: 1. aspirin 325 mg p.o. q.d. 2. lasix 20 mg p.o. b.i.d. 3. metoprolol 12.5 mg p.o. b.i.d. 4. atorvastatin. 5. potassium 20 mg p.o. b.i.d. the lasix and potassium are to be discontinued approximately two weeks after discharge. follow-up plans: 1. the patient was instructed to follow up with dr. in six weeks after discharge. 2. the patient was also instructed to follow up with dr. and dr. in seven to 10 days. , m.d. dictated by: medquist36 d: 09:29 t: 10:32 job#: Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter (Aorto)coronary bypass of one coronary artery Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Aortocoronary bypass status

history of present illness: mr. is an 80-year-old man with a past medical history of coronary artery disease, polymyalgia rheumatica who presents from outside hospital with episode of chest discomfort and shortness of breath. he was in his usual state of health until one week prior to admission when he began having worsening shortness of breath and dyspnea on exertion while on vacation at . he had worsening shortness of breath on the day prior to admission, an episode of chest pain and went to the emergency department at an outside hospital in . he had electrocardiogram changes which were nonspecific, possible st elevation on lead 1 and l, t-wave inversion in 3 and was ruled out for myocardial infarction with cks and troponin. originally started on aggrastat and heparin which was discontinued on . he was continued on beta blocker and aspirin, started on an ace inhibitor and plavix and received diuresis with intravenous lasix. he was transferred to and at presentation he was with shortness of breath which was improved. no chest pain, no fevers, chills, nausea or vomiting, however he did have a cough productive of brown sputum. past medical history: 1. coronary artery disease, status post cardiac catheterization many years prior notable for 80% right coronary artery stenosis treated medically. 2. prostate cancer three years prior to admission treated with radiation. 3. polymyalgia rheumatica, treated with prednisone from and 4. hcs 5. status post appendectomy 6. diverticulosis, status post resection 7. spinal stenosis 8. dysphasia admission medications: 1. nitroglycerin 2. zocor 3. baclofen 4. aspirin 5. hydrocodone 6. aspirin allergies: he has no known drug allergies. family history: negative social history: the patient works as a banker. he has a 15 pack year smoking history, but quit 40 years ago. admission physical exam: vital signs: temperature was 97.9??????, blood pressure 108/58, pulse 90, respirations 20. o2 saturation is 95% on 4 liters. general: he is a pleasant man in no acute distress. head, ears, eyes, nose and throat: anicteric. oropharynx is clear. jugular venous pressure is 3 cm. heart: regular rate and rhythm, s1 and s2. the patient also has an s3. no murmurs, rubs or gallops. chest: bibasilar wet crackles at the bases bilaterally one half up. abdomen: soft, nontender, nondistended, active bowel sounds. extremities: no edema, 2+ dorsalis pedis pulses bilaterally. warm extremities. neurologic: alert and oriented x3, mentating well. admission labs: notable for cks 45, 29 and 27, troponin less than 0.10 x2 and less than 0.15. white blood count was 13.1, hematocrit 35, platelets 378. chem-7 146, 4.3, 109, 20, 27, 1.1 and 168. his coagulation studies were normal. chest x-ray showed multiple patchy bilateral opacities in the mid and lower lobes, partially obscuring the mediastinal and hilar contours. no preliminary vascular engorgements. hospital course by systems: 1. pulmonary: mr. was aggressively diuresed with lasix, as it was felt that he had pulmonary edema. his oxygen saturation did not improve with his diuresis, in fact it gradually worsened prompting a chest ct scan on which revealed diffuse air space disease predominantly of the mid and lower lung zones consistent with infectious or inflammatory process that were groundless opacities bilaterally. he therefore had multiple serologies checked and a biopsy done through a vats procedure on . the serologies were notable for positive p-anca confirmed by myeloperoxidase and positive rheumatoid factor and an elevated esr, otherwise negative. he had had the biopsy which revealed acute and organizing pneumonitis with interalveolar fibrin deposition and type ii pneumocyte hyperplasia, fresh and organizing vascular thrombi, but no evidence of active vasculitis. stains were negative for evidence of infection. around this time on , he had been transferred to the medical intensive care unit because of worsening respiratory status and intubated. he was started on cytoxan and solu-medrol and improved respiratory wise over the next few weeks. he was extubated on and his sedation was gradually titrated. pulmonary wise, he remained stable, but still had an oxygen requirement on the date of discharge at approximately 2 to 3 liters nasal cannula. 2. cardiovascular: the patient presented and was ruled out for myocardial infarction. the initial feeling was that he had pulmonary edema from congestive heart failure, however his echocardiogram revealed a normal left ventricular ejection fraction. no significant valvular disease and no evidence of pericardial effusion or tamponade. therefore, the aggressive lasix diuresis was stopped and he was simply continued on aspirin, lasix 40 mg intravenous qd, amlodipine, metoprolol and isordil. his lipitor had been stopped because of elevated cks and his ace inhibitor had been stopped because of his renal function. he did not have any chest pain or new electrocardiogram changes during his hospital course and telemetry was discontinued when he left the medical intensive care unit. 3. renal: the patient developed renal insufficiency which was believed to be secondary to the aggressive diuresis he received upon admission and his bun increased into the 100s and his creatinine increased to a maximum of 3.7 on . it had improved back to 2.2. his urinalysis was noted for muddy brown casts. his fena was 5% and spap and upap were negative. his gbm was also negative. it was felt that he probably did not have vasculitis infecting his kidneys and that it was probably simply acute tubular necrosis. his renal function had improved by the time of discharge to a creatinine of 1.4. 4. musculoskeletal: when the patient had reversal of his sedation, it was noted that he was diffusely weak. this delayed his extubation for a few days. when he was finally extubated, he had difficulty talking. he had difficulty moving his head and difficulty moving his extremities. the neurology and rheumatology services were consulted for this weakness and after thorough investigation including emg nerve conduction studies and a muscle biopsy, the belief was that this was secondary to a steroid myelopathy or a critical illness myopathy believed to improve with time and weaning of his steroids. his strength gradually improved since transfer to the floor and currently he has 3+ strength in his fingers and hands, 3+ strength in his toes and feet and 1+ to 2+ strength in the rest of his extremities. he has 3+ strength in his neck muscles. his extraocular movements are intact. his ldh and ck had been followed for evidence of muscle injury and they had been increasing and now are decreasing. his ldh is currently 363 and his ck is 291 on the date of discharge. 5. heme: his hematocrit has remained relatively stable during this admission. he has no current active bleeding. 6. infectious disease: he is currently not on any antibiotics and has not shown any recent evidence of infection. 7. fluids, electrolytes and nutrition: the patient was having issues with hypernatremia and received d5 water various times during his admission and free water boluses through his tube. because of this and his sodium had improved to 148 on the day of admission, his feeding was done through his nasogastric tube initially and he had a g-tube placed through interventional radiology and the nasogastric tube was removed. his g-tube has been functioning well with low residuals and he has been getting ultracal tube feeds. discharge plan: the plan is to discharge on the following medications. discharge medications: 1. cyclophosphamide 120 mg per g-tube qd 2. heparin 5000 units subcutaneous 3. furosemide 40 mg intravenous qd 4. prednisone 80 mg per g-tube q od x2 weeks, then 70 mg po q od x2 weeks, then 60 mg po q od indefinitely. 5. bactrim double strength 1 tablet per g-tube 3x per week 6. amlodipine 10 mg per g-tube qd 7. metoprolol 75 mg per g-tube 8. isordil 40 mg per g-tube tid 9. lacrilube ointment 1 both eyes prn 10. colace 100 mg per g-tube 11. lansoprazole solution 30 mg per g-tube 12. calcium acetate 1 per g-tube tid with meals 13. aspirin 81 mg po qd 14. albuterol metered dose inhaler 1 to 2 puffs q6h prn 15. atrovent metered dose inhaler 2 puffs q6h prn discharge instructions: he will continue on ultracal tube feeds full strength at a rate of 70 cc per hour. residuals should be checked every four hours and tube feeds should be held for residuals greater than 100 cc. he should receive flushes of 120 cc of water q4h. he should have his cbc checked every week and if his white blood count decreases below 3.5 or his other blood counts remain dangerously low, the cytoxan dose should be decreased. his urine output goal is greater than 2 liters per day because of his cytoxan. he should have active physical therapy. it was notable that he had no functional impairments prior to admission except for increased endurance and early fatigue. final diagnoses: 1. interstitial lung disease 2. acute tubular necrosis 3. renal insufficiency 4. prostate cancer 5. critical illness myopathy 6. positive p-anca , m.d. dictated by: medquist36 d: 11:22 t: 11:34 job#: cc: , m.d. dictated by: medquist36 d: 11:22 t: 11:34 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Other gastroenterostomy without gastrectomy Open biopsy of lung Open biopsy of soft tissue Diagnoses: Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Acute respiratory failure Iatrogenic pneumothorax Postinflammatory pulmonary fibrosis Toxic myopathy Hyperosmolality and/or hypernatremia Drug-induced delirium

history of present illness: the patient was a 68-year-old gentleman with a history of stage iv colon cancer metastatic lung and liver who was transferred from a nursing home status post developing tachypnea, hypoxia 80% on room air, and a change in mental status. the patient was seen in the emergency department and was hypotensive with blood pressures of 80/47 and a respiratory rate in the 30s. the patient was in moderate respiratory distress, and chest x-ray showed a retrocardiac density. the patient was persistently hypotensive despite multiple fluid boluses. antibiotics were started. the patient was started on pressors and intubated with an arterial blood gas on room air of a ph of 7.21, a pco2 of 60, and a po2 of 86. the patient's oncologist (dr. from was contact in order gain more information on the patient's stage iv colon cancer. apparently, the patient refused any further treatment about six months ago and desired be do not resuscitate/do not intubate. the patient's course was also discussed with the family, and it was decided make the patient comfort measures only. the patient was subsequently extubated on . pressors were weaned off, and morphine drip was started. the patient remained comfortable and in no apparent distress and was transferred out of the intensive care unit the general medical floor. past medical history: 1. stage iv colon cancer widely metastatic lung and liver. a computerized axial tomography on showed a left pleural effusion, bilateral lung nodules, and liver enlargement with increasing new liver masses, left adrenal nodule, left moderate--severe hydronephrosis secondary retroperitoneal lymph nodes. the patient is status post gastrojejunostomy tube placement secondary dysphagia and failure thrive. 2. hypertension. 3. hypercholesterolemia. 4. right cerebrovascular accident. physical examination on presentation: on physical examination, the patient's temperature was 96.9 degrees fahrenheit, his blood pressure was 70s 80s/30s 40s, his heart rate was 60s 70s, and his oxygen saturation was 96% on room air. in general, the patient was not arousable. not responsive pain, but he appeared comfortable. head, eyes, ears, nose, and throat examination revealed nonreactive pupils but equal. the mucous membranes were dry. neck examination revealed no jugular venous distention. pulmonary examination revealed coarse rhonchi throughout the lung fields. cardiovascular examination revealed a regular rate and rhythm. normal first heart sounds and second heart sounds. no murmurs, rubs, or gallops. the abdomen was distended, notable bowel sounds, and jejunostomy tube in place. extremity examination revealed 3+ pitting edema the lower extremities. neurologic examination revealed pupils were nonreactive. positive corneal reflexes. negative doll's eyes. the patient did not withdraw pain. negative babinski. brief summary of hospital course: the patient was a 68-year-old gentleman with metastatic stage iv colon cancer admitted with respiratory distress, hypotension, hypoxia, acute renal failure, and unresponsiveness. the patient was made comfort measures only; per family's wishes. the patient was extubated. pressors were withdrawn. a morphine drip was started. the patient was comfortable and in no apparent distress. the patient expired on with the time of death being approximately 11:15 in the evening. the patient was examined by night float resident. the patient's family friend ) was notified of the patient's death. she helped interpret this information the patient's son who was only. the patient's attending was contact. the patient's family declined autopsy. the immediate cause of death was cardiopulmonary arrest secondary stage iv metastatic colon cancer. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Pure hypercholesterolemia Malignant neoplasm of liver, secondary Unspecified essential hypertension Acute kidney failure, unspecified Pneumonitis due to inhalation of food or vomitus Secondary malignant neoplasm of lung Unspecified late effects of cerebrovascular disease Gastrostomy status Other Staphylococcus pneumonia

history of present illness: ms. is an 88-year-old woman with a history of chronic obstructive pulmonary disease and congestive heart failure as well as paroxysmal atrial fibrillation who presented from her nursing home with acute respiratory distress. per nursing home report, the patient was in her usual state of health until the night prior to admission when she was noted to be short of breath and to be hypoxic with unknown room air saturation. she was also noted to be "congested" and placed on 3 liters of nasal cannula with an oxygen saturation of 92%. the following morning, a chest x-ray showed moderate congestive heart failure (per their report). as well, her oxygen saturation was 74% on room air with a heart rate of 118 and modeled extremities. the patient was sent to the emergency department for evaluation. she had a white count of 17 at the nursing home. she denied cough, fever, orthopnea, paroxysmal nocturnal dyspnea, or increased lower extremity edema. en route to the emergency department, the patient had an oxygen saturation was of 84% on room air and 100% on a nonrebreather. she was given 40 mg of intravenous lasix en route to the hospital, and her oxygen saturation improved to 96% on 100% nonrebreather. on arrival, the patient was lethargic but alert and oriented. her blood pressure was 154/88, her heart rate was 118 (in atrial fibrillation), her respiratory rate was 24, and her oxygen saturation was 94%. arterial blood gas at that time showed a ph of 7.47, a pco2 of 35, and a po2 of 83 on 100% nonrebreather. a chest x-ray showed mild pulmonary congestion and small bilateral effusions with a question of retrocardiac infiltrate. the patient received 1 gram of intravenous ceftriaxone, 500 mg of azithromycin, and 40 mg of intravenous lasix, as well as nebulizer treatment. she was also tried on a trial of -level positive airway pressure with improvement in her oxygen saturations and her ventilation. after a short trial, she was again placed on 100% nonrebreather and once again became tachypneic and hypoxic with an oxygen saturation of 88% to 93%. she was again placed on -level positive airway pressure with a decrease in her blood pressure to 60 to 80 systolic. she was started on levophed to maintain her blood pressure at that time. past medical history: 1. paroxysmal atrial fibrillation; not anticoagulated. 2. hypertension. 3. status post cerebrovascular accident with a left residual hemiparesis. 4. coronary artery disease; history unknown. 5. congestive heart failure. 6. chronic obstructive pulmonary disease. 7. type 2 diabetes mellitus. 8. history of right lower lobe pneumonia in . 9. chronic constipation. medications on admission: 1. aspirin 81 mg by mouth once per day. 2. lasix 20 mg in the morning. 3. glipizide 2.5 mg once per day. 4. lisinopril 10 mg once per day. 5. protonix 40 mg once per day. 6. effexor-xr 37.5 mg once per day. 7. albuterol and atrovent nebulizers as needed. 8. lipitor 10 mg at hour of sleep. 9. serevent 2 puff twice per day. 10. senna. 11. colace. 12. milk of magnesia. 13. compazine as needed. allergies: no known drug allergies. social history: the patient is a resident of nursing home. family history: family history was deferred. physical examination on presentation: temperature was 99.1 degrees fahrenheit, her blood pressure was 112/68, her heart rate was 118 (in atrial fibrillation), and her oxygen saturation was 92% on 100% nonrebreather, and her respiratory rate was 32. in general, alert and oriented times three. in moderate respiratory distress. head, eyes, ears, nose, and throat examination revealed arcus senilis. the pupils were equal, round, and reactive to light. the extraocular movements were intact. the sclerae were anicteric. the mucous membranes were dry. the neck was supple. there was no lymphadenopathy. pulmonary examination revealed decreased air movement throughout with scattered expiratory wheeze and bronchial breath sounds at the left base. decreased breath sounds at the right base. cardiovascular examination revealed an irregularly irregular. distant heart sounds. there were no murmurs. the abdomen was distended and tympanitic. the abdomen was soft and nontender with decreased bowel sounds. there was no hepatosplenomegaly. there was no guarding. rectal examination revealed no stool in the vault. there was no blood. extremity examination revealed 1+ lower extremity nonpitting edema. extremities were modeled. neurologic examination revealed the patient was alert and oriented to name, place, and year. she followed commands. motor was 5-/5 in the upper extremity and right lower extremity. there was minimal movement of the left upper extremity and left lower extremity. sensation was grossly intact. cranial nerves ii through xii were intact. pertinent laboratory values on presentation: admission laboratories were significant for a white blood cell count of 21.3 (with 90 neutrophils, 4 lymphocytes, and no bands), her hematocrit was 32.9, and her platelets were 127. her creatinine was 1.2. pertinent radiology/imaging: chest x-ray per history of present illness. an electrocardiogram showed atrial fibrillation at a rate of 106. no st-t wave changes acutely. t wave inversions in v3 to v6; unchanged from prior electrocardiogram. a kub showed multiple dilated loops of bowel. impression: initial impression revealed an 88-year-old woman with a history of congestive heart failure, chronic obstructive pulmonary disease, and paroxysmal atrial fibrillation who presented with hypoxic respiratory failure. brief summary of hospital course: the patient did well after transfer to the medical intensive care unit. pressors were able to be quickly weaned after some intravenous fluids were given back. she was again weaned from -level positive airway pressure and able to be maintained on nasal cannula and shovel mask for oxygenation. the initial impression was that her respiratory failure was due primarily to congestive heart failure, but on further review of her studies her right-sided effusion was noted to be potentially representative of a parapneumonic effusion. a thoracentesis was done on the third hospital day with the study consistent with exudate; thought to be due to a parapneumonic effusion. her antibiotic coverage was continued. in addition, she was started on diltiazem for rate control of her rapid atrial fibrillation. in addition, while in the medical intensive care unit, the patient decided to reverse her code status from do not resuscitate/do not intubate to full code. the patient was thought to be sufficiently competent to make this decision. she was called out to the floor on with plans to discharge back to the nursing home with continued oxygen therapy and intravenous antibiotics at the nursing home in the morning. discharge disposition: the patient to be discharged to nursing home. condition at discharge: condition on discharge was improved and stable. medications on discharge: 1. ceftriaxone 1 gram intravenously q.24h. (for a total of a 2-week course). 2. albuterol and atrovent nebulizers as needed. 3. colace 100 mg by mouth twice per day. 4. dulcolax 10 mg by mouth/per rectum once per day as needed. 5. senna. 6. lactulose as needed. 7. insulin sliding-scale. 8. diltiazem 30 mg by mouth once per day. 9. prednisone 60 mg by mouth once per day (with plan for a slow taper). 10. aspirin 325 mg by mouth once per day. discharge diagnoses: 1. pneumonia. 2. congestive heart failure. 3. chronic obstructive pulmonary disease. , m.d. dictated by: medquist36 Procedure: Thoracentesis Non-invasive mechanical ventilation Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Congestive heart failure, unspecified Atrial fibrillation Obstructive chronic bronchitis with (acute) exacerbation Acute respiratory failure Other shock without mention of trauma Diastolic heart failure, unspecified

history of present illness: this 72 year old male has had recent increased chest pain and dyspnea on exertion. his exercise tolerance test was stopped in secondary to fatigue and myoview revealed reversible deficit. the cardiac catheterization revealed a 60% left main lesion, subtotal left anterior descending, 90% left circumflex, 50% right coronary artery and an ejection fraction of 40%. he is now being admitted for coronary artery bypass graft. past medical history: significant for a history of sleep apnea, he uses cpap, history of hypercholesterolemia, status post cerebrovascular accident in with left leg weakness residual, status post myocardial infarction in , history of insulin dependent diabetes mellitus for 15 years, history of prostate carcinoma, status post radiation ten years prior to admission, status post hernia repair 30 years ago and status post remote mastoidectomy on the right. medications on admission: trazodone 50 mg p.o. q.d.; aspirin 81 mg p.o. q. day; hydrochlorothiazide 25 mg p.o. q. day; lisinopril 40 mg p.o. q. day; atenolol 50 mg p.o. q. day; avandia 8 mg p.o. q. day; zoloft 50 mg p.o. q. day; imdur 30 mg p.o. q. day; lipitor 20 mg p.o. q. day; amitriptyline 100 mg p.o. q. day. he was on 40 of humalog in the morning and at dinner and 60 of nph in the morning and at bedtime. allergies: no known drug allergies. review of systems: significant for question of slight left leg weakness, sleep apnea. physical examination: on physical examination he is a well developed, well nourished elderly white male in no apparent distress. vital signs, stable afebrile. head, eyes, ears, nose and throat examination, normocephalic, atraumatic, extraocular movements intact. oropharynx benign. neck supple, full range of motion, no lymphadenopathy or thyromegaly. carotids 2+ and equal bilaterally without bruits. lungs were clear to auscultation and percussion. cardiovascular examination, regular rate and rhythm, normal s1 and s2, with no murmurs, rubs or gallops. abdomen was soft, nontender, with positive bowel sounds, no masses or hepatosplenomegaly and obese. extremities were warm and well perfused with positive pulses, trace edema bilaterally and no varicosities. neurological examination, nonfocal. hospital course: on , the patient underwent a coronary artery bypass graft times four with left internal mammary artery to the left anterior descending, reverse saphenous vein graft to the diagonal, obtuse marginal and posterior descending artery. crossclamp time was 71 minutes, total bypass time 79 minutes. the patient was transferred to the cardiac surgery recovery unit in stable condition. he was extubated on his postoperative night. postoperative day #1 his chest pains were discontinued. he did go into atrial fibrillation on postoperative day #2. he was started on amiodarone and his lopressor was increased. he did convert to sinus rhythm. he did fail to void after having his foley catheter discontinued. urology was consulted. he was anticoagulated on heparin and coumadin. he was also followed by specialists and they advised on his insulin regimen. he remains in atrial fibrillation and converted to sinus on postoperative day #5. he was in stable condition and discharged to rehabilitation on postoperative day #6. laboratory data on discharge was hematocrit 31, white count 8,300, platelets 319, sodium 141, potassium 4.8, chloride 102, carbon dioxide 30, bun 23, creatinine 1.1, blood sugar 147. medications on discharge: lopressor 100 mg p.o. b.i.d.; lasix 40 mg p.o. b.i.d. times seven days; colace 100 mg p.o. b.i.d.; potassium 20 mg p.o. q. day times seven days; aspirin 81 mg p.o. q. day; coumadin 5 mg p.o. tonight with an inr goal of 2.5; trazodone 50 mg p.o. q.h.s. prn; zoloft 50 mg p.o. q. day; insulin nph 60 units q. am and 40 units at bedtime with humalog 40 units at breakfast and 40 units at dinner and a sliding scale; percocet 1 to 2 p.o. q. 4-6 hours prn pain; amitriptyline 100 mg p.o. q.h.s.; lipitor 20 mg p.o. q. day; avandia 8 mg p.o. q. day; amiodarone 400 mg p.o. b.i.d. times one week, then decrease to 400 mg p.o. q. day times one week, then decrease to 200 mg p.o. q. day times two weeks. discharge instructions: he also failed another voiding trial and will go to rehabilitation with a leg bag in place. he needs to see dr. of urology in one week and he needs to make an appointment with in one to two weeks and an appointment with dr. in four to six weeks, and dr. in 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 Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Cardiac complications, not elsewhere classified Atrial fibrillation Other and unspecified angina pectoris Unspecified sleep apnea Retention of urine, unspecified Urinary complications, not elsewhere classified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p fall; right chest and abdominal pain major surgical or invasive procedure: none history of present illness: 89 yo female s/p fall while going to the bathroom she lost her balance and fell against the bathtub hitting her right side. she denies any head trauma or loc. she went back to bed and awoke next morning with right chest and abdominal pain. she was taken to an area hospital where she was noted with liver laceration and rib fractures. she was subsequently transferred to for continued trauma care. past medical history: hypothyroid htn s/p left orif social history: denies etoh and tobacco lives with her daughter family history: noncontributory physical exam: a+ox3 perrl, eomi, tms clear or clear, trahcea midline no cspine ttp r chest ttp rrr ctab sft, nd, ruq ttp pertinent results: 09:47am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-0.2 ph-6.0 leuk-neg 09:47am pt-11.7 ptt-24.5 inr(pt)-1.0 09:47am plt count-235 09:47am wbc-9.5 rbc-3.31* hgb-10.7* hct-31.1* mcv-94 mch-32.3* mchc-34.4 rdw-12.8 09:47am urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 09:47am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 09:47am alt(sgpt)-287* ast(sgot)-325* alk phos-107 amylase-45 tot bili-0.3 09:47am urea n-33* creat-1.0 09:52am glucose-140* lactate-1.7 na+-137 k+-4.8 cl--99* tco2-28 chest (portable ap) 1:59 pm chest (portable ap) reason: eval for infection medical condition: 89 year old woman who spiked temp this am reason for this examination: eval for infection study: ap chest, . history: 89-year-old woman with fever. evaluate for infection. findings: comparison is made to the previous study from , . the right-sided ij catheter has been removed. there is persistent cardiomegaly. there is calcification throughout the aorta. there is linear plate-like atelectasis within the right mid lung field which is new. there are also linear densities at the left base. this likely represents atelectasis as well; however, early infiltrate would be difficult to exclude. femur (ap & lat) bilat 1:59 pm femur (ap & lat) bilat reason: eval for inflammatory process, fracture medical condition: 89 year old woman with swelling and pain reason for this examination: eval for inflammatory process, fracture study: three views of each femur, . history: 89-year-old woman with swelling and pain. evaluate for inflammatory process or fracture. findings: comparison is made to the prior films from , . two views of the left femur demonstrates a total hip prosthesis with a cemented femoral component. there is no evidence for hardware loosening. there is some heterotopic bone seen adjacent to the greater trochanter. there are vascular calcifications. there are degenerative changes seen of the left knee. chondrocalcinosis is identified. there is generalized osteopenia. no left knee joint effusion is seen. two views of the right femur demonstrates no signs of acute fracture or dislocations. chondrocalcinosis are seen about the right hip and the right knee. vascular calcifications are identified. there are severe degenerative changes of the right knee with marked loss of the lateral joint space and prominent osteophytosis. no knee joint effusion is seen. impression: no signs of acute bony injury on either side. degenerative changes as described above. sinus rhythm with marked first degree a-v block. marked left axis deviation. right bundle-branch block. compared to the previous tracing of no significant change. tracing #2 read by: , a. intervals axes rate pr qrs qt/qtc p qrs t 75 /488.57 31 -67 79 ct abdomen w/contrast 11:27 am ct pelvis w/contrast; ct 150cc nonionic contrast reason: interval change of liver laceration - iv and po contrast field of view: 41 contrast: optiray medical condition: 89 year old woman with liver laceration 3 days ago, now worse hypotension reason for this examination: interval change of liver laceration - iv and po contrast contraindications for iv contrast: none. indication: 89-year-old female with liver laceration three days ago, now with worsening hypotension. comparison: ct torso. technique: mdct acquired axial images of the abdomen and pelvis were performed with iv contrast. ct abdomen: there has been interval development of small bilateral pleural effusions right greater than left. both demonstrate fluid density consistent with effusion rather than hematoma. within the liver, again noted is a similar sized large laceration seen within segment vii and segment viii. now present are multiple areas of hyperdensity surrounding the laceration, likely representing active extravasation. arterial vs venous supply cannot be distinguished. the largest area is best seen on series 2, image 23 seen equal distant between middle and right hepatic veins. this area of hyperdensity measures 8 x 7 mm. the perihepatic and perisplenic hematomas are grossly unchanged in size. the gallbladder, pancreas, spleen, adrenal glands, kidneys are stable. multiple low attenuation lesions are again seen within the kidneys bilaterally that are too small to characterize. the small and large bowel are unremarkable. a small central fat containing hernia is again seen and unchanged. there is no free air. ct pelvis: free fluid is again noted in the pelvis likely representing hematoma and unchanged. a foley catheter is seen within the urinary bladder. the visualized portions of the uterus, rectum, sigmoid colon are unremarkable. optimal evaluation of the pelvis is limited by a left hip prosthesis. bone windows: minimally displaced fracture of 9th right rib again noted. multiple fractures within the left pelvis, likely old. left hip prosthesis. impression: 1) large liver laceration in segment 7 and 8 of the liver with focal areas of active extravasation seen. arterial vs. venous etiology cannot be determined. both laceration size as well as surrounding perihepatic and perisplenic hematoma unchanged in size. 2) bilateral new small pleural effusions, right greater than left. brief hospital course: patient admitted to the trauma service and after resuscitated in the trauma bay was transferred to the trauma icu. serial hematocrits were monitored; initially they dropped slightly. ct imaging of abdomen showed 20% liver laceration and repeat ct of abdomen showed active extravasation from liver laceration. it was discussed with patient to undergo hepatic angiogram and embolization procedure, but patient refused. her subsequent hematocrits remained stable x 24 hours and she was transferred from the trauma icu to the floor. her most recent hematocrit drawn today was 31.6 at 12:25pm; this is up from 29.4 at 6:50 a.m. earlier on the same day. during her hospitalization she was noted to have possible infiltrate on cxr and pan sensitive e. coli in blood, she was started on levofloxacin and aggressive pulmonary toilet. the levofloxacin will need to continue for 7 more days after discharge. physical and occupational therapy have evaluated patient and have recommended short term rehab stay. medications on admission: lopressor 12.5 levoxyl 112qd colace prilosec discharge disposition: extended care facility: & rehab center - discharge diagnosis: s/p fall urinary tract infection bacteremia liver laceration rib fractures discharge condition: stable discharge instructions: follow up in trauma clinic in 2 weeks. follow up with your primary doctor after you are discharged from rehab seek immediate medical care if you experience dizziness, fainting, fevers and severe abdominal pain followup instructions: call for an appointment in trauma clinic with dr. in 2 weeks. call to schedule an appointment with your primary doctor after your discharge from rehab. Procedure: Arterial catheterization Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Unspecified acquired hypothyroidism Unspecified fall Bacteremia Traumatic hemothorax without mention of open wound into thorax Injury to liver without mention of open wound into cavity laceration, unspecified Closed fracture of eight or more ribs Cellulitis and abscess of finger, unspecified

history of present illness: the patient is a 70-year-old female with a complex medical history who was admitted after a cardiac arrest on . she was initially taken to the ccu, thought to be in congestive heart failure. subsequently developed sepsis, acute ards, respiratory-cardiopulmonary failure. on , at 3:15 p.m., the patient was pronounced dead. family was at bedside. date of death . time of death 3:15 p.m. , Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Insertion of temporary transvenous pacemaker system Arterial catheterization Pulmonary artery wedge monitoring Transfusion of other serum Diagnoses: Thrombocytopenia, unspecified Congestive heart failure, unspecified Acute and subacute necrosis of liver Acute kidney failure, unspecified Unspecified septicemia Cardiac arrest Other shock without mention of trauma

history of present illness: the patient was a 73-year-old female admitted to the ccu on with hyperkalemia and bradycardia. the patient had a past medical history significant for hypertension, glaucoma, and breast cancer treated with lumpectomy, xrt in . she was in her usual state of health until when she began to note shortness of breath. she saw her pcp and performed chest x-ray, which revealed a right upper lobe density. this was followed up with a ct scan, which revealed a lobulated mass of 2.3 cm in the posterior segment of the right lower lobe and bilateral lobe interstitial fibrosis. follow-up pet scan was nondiagnostic. the patient had a mediastinoscopy, which showed no evidence of malignancy or lymph nodes. lung biopsy was performed, which revealed pulmonary fibrosis. subsequent spirometry revealed a mild restrictive defect. the entire picture was thought to represent uip. on , she presented to the with a complaint of nausea, vomiting, and diarrhea times several days. in the waiting room, she developed presyncope. she was urgently brought to the trauma bay, there her heart rate was in the 30s with the ekg revealing a junctional rhythm. her sbp was in the 80s. attempts made to place a temporary pacing wire but during the procedure the patient suffered respiratory arrest. she was intubated and resuscitated, and a line was successfully placed. subsequent labs revealed a potassium of 9.8. the patient was treated with calcium bicarb, insulin, and glucose and admitted to ccu. in the ccu, the patient was started on levophed and dopamine for hypotension. swan-ganz catheter was placed to evaluate her hypotension and revealed an svr of 2473 with a cardiac output of 2.2. two hours later, the cardiac output was 6.5 and svr was 898 after pressors were weaned down. urgent tte revealed normal systolic function, no pericardial effusion. potassium dropped to 4.3 after 1 day. the patient was empirically treated with vancomycin, levofloxacin, and flagyl for hypotension, which was thought possibly due to sepsis. by hospital day 3, she was off pressors, her white blood count was 16.1. she was successfully extubated, and her potassium remained normal. by hospital day 4, she continued to have mild respiratory distress despite being extubated. she was thought to be in mild chf. she was diuresed. levofloxacin and vancomycin were continued for possible pneumonia. by hospital day 5, she developed worsening respiratory distress, and the patient agreed to elective intubation. she was then transferred to the micu for further workup and care. past medical history: hypertension. glaucoma. breast cancer. uip. allergies: no known drug allergies. medications on admission: 1. verapamil. 2. propranolol. 3. tamoxifen. 4. xalatan eye drops. 5. betoptic eye drops. 6. calcium carbonate. 7. aspirin. 8. folate. 9. vitamin e. physical examination: on admission to the micu, temperature 98.9 degrees, blood pressure 126/61, and pulse 108. the patient was sedated and intubated. her lungs revealed diffuse crackles bilaterally. cardiac exam was within normal limits. abdomen was benign. lower extremity revealed no edema. pertinent laboratory data: on admission to the micu included a white count of 21.9, hematocrit of 29.3, and platelets of 85. chest x-ray on admission to micu revealed persistent bilateral upper lobe patchy opacities, may represent interstitial edema plus aspiration. continued patchy atelectasis within the left lower lobe and small left pleural effusion. concise summary of hospital course: the patient was admitted to the medical intensive care unit with presumed diagnosis of sepsis. subsequently, she developed a picture consistent with ards and required multiple pressors. after several days in the ccu, she was on 3 different pressors and was unable to maintain her blood pressure. she was requiring increasing ventilatory support. a discussion was held with the family who decided that the patient will be made dni/dnr due to the fact that cpr was likely to be unhelpful if the patient arrested. on at 03:15 p.m., the patient was pronounced dead. the family was at the bedside. condition on discharge: expired. discharge status: expired. discharge medications: none. follow up plan: none. discharge diagnoses: septic shock. respiratory failure. hyperkalemia causing cardiopulmonary arrest. dr., 12-746 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Insertion of temporary transvenous pacemaker system Arterial catheterization Pulmonary artery wedge monitoring Transfusion of other serum Diagnoses: Thrombocytopenia, unspecified Congestive heart failure, unspecified Acute and subacute necrosis of liver Acute kidney failure, unspecified Unspecified septicemia Cardiac arrest Other shock without mention of trauma

past medical history: htn; glaucoma; right breast ca treated with lumpectomy and radiation therapy in . allergies: nkda review of systems: pt was initially on pressors in the ccu but they were weaned off and now has a labile b/p. she was admitted to the micu with a b/p of 103/50, hr 114. she dropped her b/p tothe 70's which responded to 500cc fluid bolus, increasing her b/p to 114/56. however around 1845 she became tachypnic and restless so was given a bolus of propofol 50 mcg to which she dropped her b/p again to the low 70's. she again responded to 250cc ns bolus increasing her b/p to 116/64. her k+ in the ccu was 3.6 this am so was supplemented with 40 meq kcl. she has a swan ganz catheter showing a pa 41-46/21-22, cvp 11-12; unable to wedge; co in the ccu was 6.2, ci 3.3 with svr in the 800's. resp: pt arrived intubated vent settings a/c 600 x 18, peep 12, fio2 70% o2 sats 92-96%. she was suctioned for thick yellow secretions and minimal oral secretions. breath sounds coarse throughout. gi: pt with ogt in place receiving promote with fiber at 30cc/hr being increased to a goal of 55cc/hr. mushroom catheter in place draining dark brown liquid stool. she was receiving lactulose in the ccu but it has been d/c'ed. gu: foley draining dark amber urine in minimal amounts. in the last hour, even with the fluid boluses she has put out 10cc. bun 33/ creat 1.3. she may go for an abd ct with contrast tonight so was given one dose of mycomust in the ccu at 1130 today. neuro: pt is being maintained on propofolat 12.5 mcg/kg/min. she was opening her eyes and looked like she was gasping for breath so was given the bolus of propofol as stated above. she was mae with eye reactive brisklly to light. id: temp via swan is 100.4, her wbc's 21.9 (they were 30.2 earlier) and she is receiving levo, vanco and flagyl. social: she has 4 children with as the spokesperson. home # and the second daughter as second home . they both seem very involved. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Insertion of temporary transvenous pacemaker system Arterial catheterization Pulmonary artery wedge monitoring Transfusion of other serum Diagnoses: Thrombocytopenia, unspecified Congestive heart failure, unspecified Acute and subacute necrosis of liver Acute kidney failure, unspecified Unspecified septicemia Cardiac arrest Other shock without mention of trauma

allergies: bactrim / remeron attending: chief complaint: respiratory distress major surgical or invasive procedure: endotracheal intubation from /08 through tracheostomy on history of present illness: 85 y/o man with h/o chf, cad, pvd, and chronic atrial fibrillation on who is well known to with multiple admissions who presented to the ed from rehab with respiratory distress/dyspnea. cxr at rehab the day pta with b/l lower lobe pna. he was also noted to be hypotensive in the ed with sbps in the 70s. of note, he was recently admitted to for most of with ftt and dehydration. . ed course: vitals on presentation: t 97.9 hr 104 bp 132/68 rr 27 85% nrb improved to 95% ra then 100% nrb. in the ed, the patient was intubated for respiratory distress and increased work of breathing. he was also hypotension with systolics in the 70s which responded with ivf. he was given ceftriaxone, vanc, and azithromycin. from . he had been dnr/dni but code status was reversed in the ed. past medical history: diastolic chf, most recent ef 60-65%, on lasix at rehab pvd s/p right sfa to at bypass in cad, s/p mi in , s/p nstemi in setting of rapid afib (admission ) chronic atrial fibrillation, had been on in the past, stopped several months ago for unclear reasons, now on asa alone t2dm hypercholesterolemia hypothyroidism. he was diagnosed with hypothyroidism around . he had been taking 12.5mcg synthroid until his recent hospitalization this when his synthroid was increased to 25mcg once daily as his tsh was high at that time. the synthroid was again increased to 50mcg at rehab at unknown day as his tsh was high persistently, according to medical record which was faxed to us from dr. office. so his is taking 50mcg once daily now. recurrent c. diff colitis. post-polio weakness/contracture. he developed polio infection at age of 25 and has bilateral legs weakness and right upper arm weakness. chronic urinary retention to bph multiple prolonged recent hospitalizations: - /07 - admitted for right sfa to dp bypass for severe gangrene of right foot - - atrial fibrillation, c.diff, hypotension - /07 - hypotension, uti, afib with , diarrhea - /07 - pulmonary edema, pneumonia, afib with , placement, cpap, pulm edema requiring thoracentesis and bronchoscopy - /07 - rehab - - , dehydration, acute renal failure and was then transferred to for further management of renal failure, fluid overload. his clinical course was complicated by recurrent c. diff colitis, pseudogout in right wrist and uti. he was discharged to nursing home . - 15/08 - , ftt, hyperkalemia, esbl uti tx with im gent, chronic c.diff on po vanc, pseudogout of right wrist, subacute stroke on asa and plavix, discharged dnr/dni s/p placement concern for depression at recent geriatric visit on , refused to take any antidepressant, tried remeron in the past but didn't tolerate it because of hallucination, also refused megace . social history: sh: home: normally lives with wife at home but has been in rehab. denies tobacco, etoh, and drugs family history: n/c physical exam: ed vitals: t-96 hr 90 bp 137/63 rr 28 sats initially 85% on nrb general: appears malnourished, but in no acute distress. heent: no trauma. extraocular movement are intact. clear conjunctivae. neck: supple. no thyroid nodule palpable. no jvd, no lymphadenopathy. cardiovascular: irregularly irregular heart rate and rhythm. no heart murmur, no gallops. respiratory: distant lung sounds, limited airway movement, no wheezing, no crackle. abdomen: soft, nontender, nondistended. no hepatosplenomegaly. bowel sounds are present in all four quadrants. g- in place. the site of g- is clean and dry. penis retracted pouch in place. there is leakage of urine around the pouch. the skin on scrotum is not erythematous but wet. extremities: no edema, no clubbing, no cyanosis. the extremities are cold secondary to peripheral disease. neuro: alert, awake, and oriented to the place and person. his language is appropriate. speech intact. pertinent results: 07:25am wbc-5.1# rbc-3.29* hgb-9.2* hct-28.9* mcv-88 mch-28.0 mchc-31.8 rdw-14.9 07:25am plt count-482* 07:25am neuts-88.9* lymphs-6.8* monos-3.7 eos-0.5 basos-0.2 07:25am pt-21.5* ptt-41.1* inr(pt)-2.0* 07:25am calcium-8.6 phosphate-6.0*# magnesium-2.1 07:25am ck-mb-10 mb indx-9.9* probnp-* 07:25am ctropnt-0.20* 07:25am ck(cpk)-101 07:25am glucose-220* urea n-42* creat-1.1 sodium-134 potassium-5.6* chloride-101 total co2-17* anion gap-22* 07:34am lactate-4.4* k+-5.1 10:40am urine color-yellow appear-cloudy sp -1.012 10:40am urine blood-mod nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-mod 10:46am o2 sat-80 01:27pm cortisol-28.5* . **** micro **** respiratory viral screen positive for influenza b antigen sputum mrsa 2/19, blood cx pending legionella urinary antigen negative 2/19, urine cx yeast urethral fluid yeast afb smear (-) x3 . ekg atrial fibrillation, average ventricular rate about 100 per minute. borderline low limb lead voltage. complete right bundle-branch block. non-specific st-t wave changes. compared to the previous tracing of no diagnostic change. **** imaging **** cxr single supine view of the chest at 8:30 a.m.: there has been interval placement of an endotracheal , terminating approximately 4.5 cm from the carina. layering pleural effusions are seen bilaterally, left greater than right. increased opacity is seen throughout both lungs, likely due to a combination of mild pulmonary edema, pleural effusions, and basilar atalectasis. cardiomediastinal and hilar silhouettes are unchanged. impression: appropriate position of endotracheal . layering bilateral pleural effusions and mild pulmonary edema. tte the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is moderate to severe global left ventricular hypokinesis (lvef = 25-30 %). no masses or thrombi are seen in the left ventricle. right ventricular chamber size is normal with moderate global free wall hypokinesis. the aortic valve leaflets appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the prior study (images reviewed) of , there has been marked/diffuse biventricular systolic dysfunction c/w diffuse process (toxin, metabolic, cannot exclude multivessel cad but less likely as no focality to dysfunction). the left pleural effusion is now much larger. renal u/s 1. no evidence of hydronephrosis or mass within the urinary bladder. 2. a 1.9 cm angiomyolipoma of the right kidney. 3. moderate enlargement of the prostate consistent with bph. picc placed on impression: uncomplicated ultrasound and fluoroscopically guided 5 french double-lumen picc line placement via the right brachial venous approach. final internal length is 45 cm, with the tip positioned in svc. the line is ready to use. : ct sinus/mandible/maxillofacial without contrast: impression: air fluid levels in the sphenoid sinus and in the mastoid air cells. this could be consistent with sinusitis/mastoiditis. clinical correlation recommended. chest ct: impression: 1. probable right lower lobe pneumonia. 2. bilateral pleural effusions, longstanding, with associated compressive atelectasis. non contrast head ct: findings: evaluation is limited secondary to patient motion. allowing for these limitations, there is no evidence for intracranial hemorrhage or mass effect. the ventricles, cisterns, and sulci are prominent secondary to involutional changes. periventricular white matter hypodensities are the sequela of chronic small vessel infarction and area of encephalomalacia in the left occipital lobe indicates prior infarction. there is dense atherosclerotic disease of the cavernous carotid arteries. the visualized paranasal sinuses are clear. there is partial opacification of the mastoid air cells. impression: limited examination secondary to patient motion, there is no evidence of intracranial hemorrhage. mr is more sensitive for the evaluation of acute brain ischemia. brief hospital course: 85 y/o man admitted with respiratory failure and sepsis from influenza a complicated by a mrsa pneumonia. # respiratory failure: pt was dnr/dni prior to this presentation to the ed. upon arrival to the , pt was in mild respiratory distress with hypotension. code status was reversed, pt was intubated & aggressively volume resussitated. pt was found to have influenza a complicated by an mrsa pna, he was also noted to have some e/o demand ischemia. echo revealed a globally depressed ef of 20-30%, cxr revealed bilateral pulm effusions. pt was treated with 10 days of vancmcyin for an mrsa pna. pt was having difficulty weaning with rsbis>100 & low niffs. pt then developped recurrent low grade temps & elevated wbc count. sputum was +klebsiella and pt was started on zosyn for vap & switched to meropenem (for esbl producing klebsiella) to complete a 7 day course of abx. pt was intubated for 16 days with niffs ranging from -1 to -7. rsbis ranging from 80-120. pt has a known h/o post polio syndrome with presumed weak resp muscles and was thought not likely to tolerate extubation. pt had trach placement on , which he toleratd well. his volume status was optimized via lasix and diuresis, and his respiratory status improved. the ventilator was weaned to pressure support, and then tracheostomy collar with blow-by oxygen. upon transfer from the micu, he was tolerating humidified air with good oxygenation and ventilation. after transfer the state lab called, and it was noted that he had a positive afb culture on a negative smear specimen drawn ~1 month prior to admission. infection control was consulted, who felt that the patient could go home once he had ruled out for afbx3 smears, as far as his contagious risk. he had 3 smears which were negative prior to discharge, and cultures were consistent with mac. # bacteremia/fungemia: pt was noted to have low grade fevers & rising wbc count on . blood cultures from were + vre & fungus. pt was started on linezolid for 14 day course for bacteremia. urine culture was +yeast on & . foley was changed out & caspofungin was started for a 14day course treating fungemia & funguria. sputum from & was +klebsiella, pt was treated with a 8 day course of meropenem for presumed vap. patient completed a course of caspofungin and linezolid and subsequently remained afebrile and hemodynamically stable. # atrial fibrillation with labile bp: pt with h/o chronic a.fib was noted to have labile bps thought likely due to agitation & volume. acheived better rate and bp control with metoprolol 100mg tid. diltiazem was added for additional rate control, however, pt had an episode of bradycardia on and diltiazem was stopped. heart rates were generally stable in 80-100's on metoprolol 100mg tid, digoxin 0.125mg & low dose asa 81mg. anticoagulation was held due to hematocrit drop with ongoing bloody secretions from oropharynx, will defer to outpt cardiologist regarding plan for future anticoagulation, although in light of hospice services, it is unlikely to be significantly adjusted. # chronic diastolic and acute systolic heart failures: pt with h/o diastolic chf, found to have globally depressed ef of 25-30% on admission, possible related to viral myocarditis vs sepsis induced cardiomyopathy. echo showed no evidence of regional wall motion abnormality thought pt was noted to have evidence demand ischemia in setting of sirs on admission. lv function was thought likely to recover in 6-8wks, he will likely need follow up echo as outpt. pt was switched from captopril to lisinopril for afterload reduction and developped hyperkalemia despite otherwise normal renal function and the ace-i was discontinued. he was mantained on metoprolol. his lasix was converted to po and a stable daily regimen to maintain euvolemia was established at 120 mg po tid. # oropharyngeal bleed: pt was noted to have increased bloody secretions around ett while on a heparin drip for systemic anticoagulation (for afib). heparin was held & ent was consulted, felt this was likely due to skin breakdown & abrasions under ett after prolong intubation. pt received prbc tranfusions for mild hct drop & bleeding stopped after systemic anticoagulation was held. # delerium: pt was noted to be persistently non-responsive to stimuli after extubation. non con head ct was neg for acute intracran pathology (positive for small vessel dz), vit b12 was wnl & eeg showed slowed background and global encephalopathy. both ethics & the pain/palliative care were consulted, olanzapine 5mg was started for possible underlying delirium. upon clearing his infections, the patient made considerable improvement in his ms. a passy-muir valve was provided for the trach and the patient appropriately answered questions and followed commands. # uti - bacterial: urine cultures from were positive for yeast. pt completed 3 days of amphotericin cbi. repeat uas were +leukocytes & wbcs but no yeast. foley was changed out on & repeat urine cultures have been ngtd. # type 2 dm controlled: pt with a history of type ii dm was covered with humalog insulin sliding scale while receiving tf of nutren pulm at 45cc/hr. # c. diff colitis: pt with h/o relapsing/recurrent c.diff on a slow po vancomcyin taper as outpatient. pt was given treatment dose po vancomycin at 125mg q6hr while on broad spect abx. his outpatient taper was re-started on the last day of systemic antibiotics, . # left shoulder dislocation: this was noted incidentally on early admission cxr, per ortho, they deferred management until medically stable to tolerate mri. repeat shoulder films unable to confirm dislocation, pain was managed with po morphine. #afb (+) cultures cultures at state lab were positive from prior admission. as such he was ruled out with 3xafb smears which were all negative, and on day of discharge the state lab's cultures were read out at mac rather than mtb. medications on admission: levothyroxine 100 mcg po daily diltiazem hcl 30 mg po qid aspirin 81 mg po daily miconazole nitrate 2 % powder : one (1) appl topical tid (3 times a day) as needed. albuterol sulfate 2.5 mg/3 ml solution for nebulization : one (1) inhalation q6h (every 6 hours) as needed. simvastatin 5 mg po mwf clopidogrel 75 mg tablet : 0.5 tablet po daily (daily). prilosec 20 mg po daily calcium carbonate 500 mg tablet, chewable : one (1) tablet, chewable po bid (2 times a day). cholecalciferol (vitamin d3) 400 unit tablet : two (2) tablet po daily (daily). 12. insulin insulin per sliding scale qid. acetaminophen 325 mg tablet : two (2) tablet po every six (6) hours. vancomycin 125 mg capsule : one (1) capsule po every other day: last day . metoprolol tartrate 25 mg po tid 16. gentamycin gentamycin 50mg intramuscular q12 hours. six doses, first dose given on at 4pm. megace 200 mg po bid levaquin 250 mg po x 7 days, started on ciprofloxacin 500 mg po bid x 7 days, started on milk of mag bisacodyl lantus mvi colace (per family, not on transfer records) discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. levothyroxine 100 mcg tablet : one (1) tablet po daily (daily). 3. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 4. simvastatin 10 mg tablet : 0.5 tablet po qmowefr (monday -wednesday-friday). 5. albuterol 90 mcg/actuation aerosol : 6-10 puffs inhalation q4h (every 4 hours) as needed for sob. 6. ipratropium bromide 17 mcg/actuation aerosol : 4-6 puffs inhalation q4h (every 4 hours) as needed for sob. 7. calcium carbonate 500 mg tablet, chewable : one (1) tablet, chewable po tid (3 times a day). 8. cholecalciferol (vitamin d3) 400 unit tablet : one (1) tablet po daily (daily). 9. chlorhexidine gluconate 0.12 % mouthwash : one (1) ml mucous membrane (2 times a day). 10. miconazole nitrate 2 % powder : one (1) appl topical tid (3 times a day) as needed. 11. digoxin 125 mcg tablet : one (1) tablet po daily (daily). 12. olanzapine 5 mg tablet : one (1) tablet po bid (2 times a day). 13. metoprolol tartrate 50 mg tablet : two (2) tablet po tid (3 times a day). 14. docusate sodium oral 15. morphine 10 mg/5 ml solution : one (1) po q4 hours (). 16. morphine 10 mg/5 ml solution : one (1) po q3h (every 3 hours) as needed for respiratory distress or discomfort. 17. acetaminophen 325 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for fever. 20. vancomycin 125 mg capsule : one (1) capsule po q8h (every 8 hours) for 14 days, then decrease to 125mg q12hrs for 14 days, then decrease to 125mg once a day for 2weeks then decrease to 125mg every other day for 2weeks then stop. discharge disposition: home with service facility: hospice of the good discharge diagnosis: respiratory failure s/p prolonged intubation & tracheostomy mrsa pna klebsiella vap atrial fibrillation candidal uti ms changes discharge condition: stable discharge instructions: you were admitted with sepsis due to influenza, this was complicated by an mrsa pneumonia. you were also treated for a ventilator assoc pneumonia. you have had a prolonged icu course including intubation & tracheostomy placement. you will need to continue with vent weaning at the . followup instructions: pls call his pcp . at for follow up appointments. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Temporary tracheostomy Diagnoses: Pure hypercholesterolemia Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Severe sepsis Unspecified acquired hypothyroidism Candidiasis of other urogenital sites Atrial fibrillation Infection with microorganisms resistant to penicillins Acute respiratory failure Septic shock Intestinal infection due to Clostridium difficile Methicillin susceptible pneumonia due to Staphylococcus aureus Unspecified accident Other and unspecified complications of medical care, not elsewhere classified Pneumonia due to Klebsiella pneumoniae Influenza with pneumonia Acute on chronic combined systolic and diastolic heart failure Closed dislocation of shoulder, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: right foot gangrene major surgical or invasive procedure: right superficial femoral artery-anterior tibialis bypass with insitu gsv history of present illness: 84 m well known to service presents with new gangrene of the 1st and 5th toes of the right foot. patient has fevers but denies chills. patient denies odor, purulent discharge, erythema around wound. past medical history: cad htn hypercholesterolemia dm2 mi' peripheral arterial disease post-polio contractures social history: no tobacco, occiasional etoh married, lives with wife family history: non-contributory physical exam: t=98 hr=50 bp=196/76 rr=20 o2 sat 100%ra gen: aaox3, nad neck: supple, from, no lymphadenopathy, no carotid bruits chest: cta b/l heart: rrr 1/6 sem abd: soft, nt, nd, +bs ext: b/l palp fem., non palp. distal pulses, gangrene of 1st and 5th toe pertinent results: 02:15pm pt-11.7 ptt-27.0 inr(pt)-1.0 02:15pm plt count-435 02:15pm neuts-85.0* lymphs-10.0* monos-4.2 eos-0.5 basos-0.2 02:15pm wbc-10.9 rbc-4.50*# hgb-14.2# hct-40.5 mcv-90# mch-31.5# mchc-35.0 rdw-14.0 02:15pm glucose-122* urea n-20 creat-0.7 sodium-136 potassium-4.2 chloride-98 total co2-25 anion gap-17 05:38pm urine rbc-0 wbc-0 bacteria-none yeast-none epi-0 05:38pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 05:38pm urine color-ltamb appear-clear sp -1.025 right foot xray: no radiographic evidence of osteomyelitis le angiography: patent infrarenal abdominal aorta, bilateral renal arteries, bilateral common, internal and external iliac arteries. we see heavily calcified, moderate stenotic plaques within both proximal common iliac arteries. the right lower extremity runoff revealed a patent common profunda and superficial femoral arteries. this continued down into the distal above-the-knee popliteal but the below- the-knee popliteal is occluded just at the knee joint, and we see reconstitution of the tibioperoneal trunk at the takeoff of the anterior tibialis with a patent peroneal which gives the main runoff down to the foot. the posterior tibialis and anterior tibialis are both occluded. however, the distal anterior tibialis is reconstituted from peroneal collaterals into a widely patent dorsalis pedis. we performed successful balloon angioplasty of an occluded below-the-knee popliteal artery into the proximal peroneal. there was some evidence of distal embolization which we were able to manage by angioplasty, as well as aspiration of the embolus. completion arteriography demonstrated a patent peroneal with an improved flow via collaterals into the anterior tibial which is preserved into a widely patent dorsalis pedis. non-invasive arterial and venous studies: there is a widely patent right greater saphenous vein and a patent left greater saphenous vein from the saphenofemoral junction to the mid calf. the right cephalic and basilic veins are patent from the antecubital fossa proximally and the left cephalic and basilic veins are patent from the antecubital fossa proximally. however, there is a small clot identified in the left cephalic vein at the antecubital fossa. pulsed volume recordings were obtained bilaterally at the metatarsal level. on the right side, there is much artifact and the metatarsal deflection is difficult to determine, although it appears to be less than 6 mm. on the left side, there is approximately an 8-9 mm deflection. pmibi: interpretation: the image quality is adequate. left ventricular cavity size is normal. rest and stress perfusion images reveal a moderate, partially reversible defect in the lateral wall. this lateral wall defect appeared completely reversible on the prior study from . gated images reveal normal wall motion. the calculated left ventricular ejection fraction is approximately 60%, which is increased since the prior study when it was 52%. impression: partially reversible lateral wall defect. ef is approximately 60%. wound swab: staph aureus coag + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin------------- 0.5 s penicillin------------ =>0.5 r trimethoprim/sulfa---- s brief hospital course: patient was admitted to dr. service on . vanco/levo/flagyl were started, patient was made npo and hco3 was started for angiography. right foot xray was negative for osteomyelitis. angiography on hd2 revealed an occluded right below-the-knee popliteal artery. angioplasy of the peroneal artery corrected the patient's rest pain, but not enough for treatment of the gangrene. patient was pre-oped for bypass surgery. cardiology was consulted and performed a pmibi stress test. pmibi was consistent with a partially reversible lateral wall defect and an ef approximately 60%. cardiology cleared patient for surgery. on hd7, patient was brought to the or for r sfa-at bypass with insitu gsv. postoperatively, patient had a palpable graft pulse and right dp. patient was transferred to the vicu with an uncomplicated post-operative course. patient continued with asa, beta-blockade, and antibiotics. podiatry was consulted for serial debridements of his right toe gangrene. patient also suffers from urinary retention. foley catheter has been placed pre-operatively and the patient failed a post-operative voiding trial. patient will continue with foley leg bag and follow up with urology as an outpatient. patient was followed by pt and was recommended that he be discharged to a rehab facility. a post-operative wound swab was found to be positive for staph aureus coag+, sensitive to levofloxacin and bactrim. patient was then started on levofloxacin. on hd11, a rehab bed was made available. on hd 12, pod5, patient remained afebrile, maintained palpable graft and dp pulses, and has active healing of his right toe wounds. patient will be discharged to rehab facility on pod5. medications on admission: plavix 37.5 qd metoprolol 50 lisinopril 20 qd glyburide ?dose prilosec zocor 5mg 3x/wk discharge medications: 1. simvastatin 10 mg tablet sig: 0.5 tablet po qmowefr (monday -wednesday-friday). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. glyburide 5 mg tablet sig: 0.5 tablet po daily (daily). 4. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours): please continue for 10 more days. disp:*10 tablet(s)* refills:*0* 5. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). disp:*30 capsule, sust. release 24 hr(s)* refills:*1* 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. lisinopril 10 mg tablet sig: three (3) tablet po daily (daily). 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 9. hydromorphone 2 mg tablet sig: one (1) tablet po every hours as needed for pain: please take colace while taking dilaudid to prevent constipation. disp:*30 tablet(s)* refills:*0* 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): please take colace while taking percocet to prevent constipation. disp:*60 capsule(s)* refills:*2* 11. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. disp:*60 tablet(s)* refills:*2* discharge disposition: extended care facility: center discharge diagnosis: right lower extremity arterial insufficiency discharge condition: good discharge instructions: division of and endovascular surgery lower extremity bypass surgery discharge instructions what to expect when you go home: 1. it is normal to feel tired, this will last for 4-6 weeks ?????? you should get up out of bed every day and gradually increase your activity each day ?????? unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? increase your activities as you can tolerate- do not do too much right away! 2. it is normal to have swelling of the leg you were operated on: ?????? elevate your leg above the level of your heart (use pillows or a recliner) every 2-3 hours throughout the day and at night ?????? avoid prolonged periods of standing or sitting without your legs elevated 3. it is normal to have a decreased appetite, your appetite will return with time ?????? you will probably lose your taste for food and lose some weight ?????? eat small frequent meals ?????? it is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? to avoid constipation: eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do: ?????? no driving until post-op visit and you are no longer taking pain medications ?????? unless you were told not to bear any weight on operative foot: ?????? you should get up every day, get dressed and walk ?????? you should gradually increase your activity ?????? you may up and down stairs, go outside and/or ride in a car ?????? increase your activities as you can tolerate- do not do too much right away! ?????? no heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? you may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? take all the medications you were taking before surgery, unless otherwise directed ?????? take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? call and schedule an appointment to be seen in 2 weeks for staple/suture removal what to report to office: ?????? redness that extends away from your incision ?????? a sudden increase in pain that is not controlled with pain medication ?????? a sudden change in the ability to move or use your leg or the ability to feel your leg ?????? temperature greater than 100.5f for 24 hours ?????? bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions continue levofloxacin 500mg once a day for 10 more days continue with the foley catheter until urology follow up followup instructions: provider: , surgery (nhb) date/time: 2:45 please follow up with your pcp weeks dr. (podiatry) wks for further care of your feet, call at ( for an appointment please follow up with urology, please call at ( for a follow up appointment Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Other (peripheral) vascular shunt or bypass Excisional debridement of wound, infection, or burn Aortography Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Ulcer of other part of foot Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Old myocardial infarction Arterial embolism and thrombosis of lower extremity Gangrene Cellulitis and abscess of foot, except toes Late effects of acute poliomyelitis Other specified retention of urine Contracture of joint, ankle and foot

history of present illness: the patient is an 84-year-old man well known to dr. service, who presents to dr. clinic with right foot gangrene in addition to right lower extremity weakness with new onset of first and fifth toe gangrene of right foot. the patient denies odor, purulent discharge or edema around the wound. the patient has positive fevers, but no chills. the patient denies chest pressure, chest pain or left arm pain. the patient denies slurred speech, extremity weakness or amaurosis fugax. the patient denies dysuria, no urinary frequency and no hesitancy. the patient denies constipation, diarrhea. the patient presents for further care for his right foot gangrene. past medical history: mi in , coronary artery disease, diabetes type 2, and hypercholesterolemia. allergies: nkda. medications: at home, plavix 37.5 mg daily, lopressor 50 mg twice a day, lisinopril 20 daily, zocor 5 mg 3 times a week, glyburide 2.5 mg, prilosec 20 mg. social history: occasional alcohol, no tobacco. he is married. family history: noncontributory. physical examination: temperature 98, heart rate 50, blood pressure 196/76, respiratory rate 20, and 100% o2 in room air. general: awake, alert and oriented x3 in no apparent distress. neck supple, full range of motion, negative lymphadenopathy, negative supraclavicular nodes. chest clear to auscultation bilaterally. heart: regular rate and rhythm, 1/6 systolic ejection murmur. abdomen: soft, nontender, nondistended, positive bowel sounds. exam: no carotid bruits. femoral pulses palpable bilaterally. distal pulses nonpalpable except for left dp. right first and fifth toe gangrene. hospital course: the patient was admitted to dr. service, was put on vancomycin, levofloxacin and flagyl. the patient was preopped for angiogram for the morning. he was npo at midnight getting bicarbonate at 80 cc/hour after midnight. cultures taken of his wounds. urine culture, chest x-ray and labs were drawn. the patient was continued on his current medications. on admission, the patient had an x-ray of his right foot which showed no radiographic evidence of osteomyelitis. admission ecg showed sinus rhythm, borderline first degree av delay, left atrial abnormality, right bundle branch block. this is new finding since his previous tracing in . on hospital day 2, the patient had angiography with special intervention. during angioplasty, he was found to have occluded below the knee popliteal artery and the proximal peroneal artery. there was some evidence of distal embolization which we were able to manage by angioplasty as well as aspiration of the embolus. although the patient received peroneal angioplasty that relieved his rest pain, it was not enough to heal his gangrene. the patient was then preopped for surgical intervention. the patient was followed by cardiology and received a p-mibi scan and stress test which showed moderate lateral inferior wall myocardial perfusion defect at the level of exercise. imaging showed a partially reversible lateral wall defect, ejection fraction was approximately 60%. the patient's preoperative workup, the patient had vein mapping and pvr. vein mapping showed right greater saphenous vein with a diameter of 0.2 to 0.4, left greater saphenous vein of 0.15 to 0.37. in addition pvrs showed right metatarsal at 6 mm and left metatarsal at 9 mm, was consistent with peripheral disease. hospital day 7, the patient was brought to the or for right proximal superficial femoral artery to distal anterior tibial artery bypass graft with in situ saphenous vein. the patient had an uneventful operative course. the patient was transferred to the vicu for further observation with a right at graft palpable. during the patient's admission, podiatric surgery was consulted for examination of the patient's right foot gangrenous ulcers and performed multiple bedside debridements during the patient's admission. the patient was eventually transferred to floor status and was followed by physical therapy due to patient's post coil contractures. the patient will require rehabilitation for further postoperative care. the patient continued no vancomycin, levofloxacin and flagyl during his hospital admission. the patient had cultures taken of the right foot ulcer. wound was positive for staph aureus coagulase positive susceptible to levofloxacin and bactrim. the patient's vancomycin, levofloxacin and flagyl were discontinued and the patient was started on levofloxacin. on hospital day 11, postoperative day 4, a rehabilitation bed was available for the patient. the patient remained afebrile with palpable right graft pulses and palpable dp pulses on the right side. the patient continued to work with physical therapy. on hospital day 12, postoperative day 5, the patient to be discharged to rehabilitation. the patient will need to follow up with dr. in 2 weeks for postoperative check. the patient will also follow up with dr. , podiatry, within 1-2 weeks from discharge. in addition, the patient has continued with a foley catheter due to urinary retention during his hospital stay and will need to follow up with urology as an outpatient. , m.d. Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Other (peripheral) vascular shunt or bypass Excisional debridement of wound, infection, or burn Aortography Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Ulcer of other part of foot Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Old myocardial infarction Arterial embolism and thrombosis of lower extremity Gangrene Cellulitis and abscess of foot, except toes Late effects of acute poliomyelitis Other specified retention of urine Contracture of joint, ankle and foot

history of present illness: this is an 84-year-old man well known to dr. service who presented to his office with right foot gangrene for admission in addition to right lower extremity weakness. he had had problems walking and new episodes of shortness of breath. dictation ended , m.d. Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Other (peripheral) vascular shunt or bypass Excisional debridement of wound, infection, or burn Aortography Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Ulcer of other part of foot Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Old myocardial infarction Arterial embolism and thrombosis of lower extremity Gangrene Cellulitis and abscess of foot, except toes Late effects of acute poliomyelitis Other specified retention of urine Contracture of joint, ankle and foot

*allergies: bactrim (rash), ? remeron *access: l picc (not central, does not draw blood), 20g r piv ** please see admit note/fhp for admit info and hx. neuro: a&o x3, follows commands, assists w/ turns, soreness w/ rom of extremeties, otherwise no c/o pain. did not sleep well last few nights, asked team for something to assist w/ sleep before he becomes confused, team agreed but nothing ordered yet, ? ambien. cardiac: a.fib w/occasional pvc's, hr 82-97, sbp 99-116, lopressor po tid. hct stable @ 29.3. needs a picc that draw blood, ordered for single lumen to be placed in ir tomorrow am. current double lumen is not central (could not pass wire all the way @ bedside) and does not draw blood. resp: currenly on 80% hi-flow neb, was down to 50% this afternoon but had to increase when came back from ct. had ct for ?pe, initially noted that pt has lg pl. eff on l side (almost completely white out) w/ atelectisis and also on r. at this time plan not in order, but team trying to determine ? tap (may need to be done in ir) and/or bronch which would require pt to be intubated. this shift, o2sat 92-99, rr 14-26, ls coarse upper/diminshed lower. cough @ times, productive, swallows or sxns on own. gi/gu: thickened liquid diet, tolerating meds well (sit pt up to his comfortable level), pudding, apple juice, and ice cream for dinner, observe feedings for aspiration precautions. +bs, no stool this shift, abd soft/non-tender. urine out foley, started brownish, now more yellow/ clear, 15-60cc/hr, treatment @ this time for decreased urine output. received contrast w/ ct, has bicarb 150meq running @ 100cc/hr for 1l. fsbg 97-118, no coverage per riss. id: temp 96.5-97.6 axillary, wbc 10.0. vanco, levofloxacin and flagyl for uti, ?pna, ?c.diff, no grownth to date on cx's. iv sites wnl, edema to bilat ue's. psychosocial: wife visited this afternoon, updated by this nurse and the attending md. son called from and updated by mother. pt seen by geriatric team who is communicating w/ his nursing home ( rehab). Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Diagnoses: Pure hypercholesterolemia 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 Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Atrial fibrillation Infection with microorganisms resistant to penicillins Acute on chronic diastolic heart failure Acute respiratory failure Intestinal infection due to Clostridium difficile Methicillin susceptible pneumonia due to Staphylococcus aureus Hyperosmolality and/or hypernatremia Other and unspecified infection due to central venous catheter Atherosclerosis of native arteries of the extremities, unspecified

allergies: bactrim / remeron attending: chief complaint: dyspnea, tachypnea major surgical or invasive procedure: peg placement history of present illness: mr. is an 84 y/o man with pmh notable for cad s/p mi (), type 2 dm, hypertension, pvd, and chronic atrial fibrillation on who presents to the ed from rehab after being discharged from less than 24hr prior to representation. on he was admitted with hypotension (bp80s/50s) attributed to a combination of dehydration, urosepsis, and partial sbo. he was initially treated broadly with vancomycin and zosyn. this was tapered to bactrim to which he developed a drug rash and was finally changed to cipro for uti (to be completed on ). in terms of his sbo, he was seen by surgery who recommended medical treatment with ngt and npo as diet. his bowel was decompressed and he began to have bms prior to d/c. stool was positive for c. diff and he was sent home on flagyl to be continued until after completion of other antibiotics. he presents today with a chief complaint of worsening dyspnea. at rehab he was noted to have increased wob, rr 22-24 with o2 sat 70%. he was initially taken to osh where he reportedly complained of chest pain and shortness of breath. he was given lasix 10mg po. he was then transferred to for further care. en route was hypoxic to 74% on ra to 80s on nrb. ems gave 40mg iv lasix and sl ntg. after nitro bp dropped to 80s systolic. at ed, vs were t100, hr 99, bp 80/49, r31, o2sat 95% nrb. bp improved to 92/57, hr 99. he was started on cpap and given levofloxacin/flagyl for possible uti/pna. he was also given an aspirin. past medical history: peripheral arterial disease s/p right sfa to at bypass in prior nstemi in setting of rapid afib (admission ) chronic atrial fibrillation on dm2 hypercholesterolemia hypothyroidism post-polio weakness/contractures social history: prior to hospitalization in , patient was living at home with wife. recently at rehab. prior smoker. drinks 1 glass wine/nightly prior to recent hospitalization and rehab stay. has two sons. previously worked at dept. of public health. family history: non-contributory physical exam: t:95.3 bp: 135/73 hr: 98/ rr: 23/ o2 100% on nrb gen: elderly male in nad. using accessory muscles. heent: no conjunctival pallor. perrl. eomi. tongue dry. neck: supple, jvd 10 cm. no thyromegaly or palpable lymphadenopathy. cv: irregularly irregular with nl s1, s2. no m/r/g. lungs: rales bilaterally, r>>l. abd: slightly distended, nontender to palpation. ext: 2+ edema in b/l le as well as ue. dp pulses 2+ bilaterally. bandage covering r great toe. skin: erythematous rash over lle neuro: a&ox3. cn 2-12 grossly intact. gait not assessed. pertinent results: labs: 05:55am blood wbc-12.2* rbc-3.52* hgb-10.6* hct-30.8* mcv-87 mch-30.2 mchc-34.5 rdw-16.4* plt ct-356 02:45pm blood neuts-89* bands-2 lymphs-5* monos-4 eos-0 baso-0 atyps-0 metas-0 myelos-0 05:55am blood pt-25.1* ptt-35.2* inr(pt)-2.5* 05:55am blood plt ct-356 05:55am blood glucose-90 urean-6 creat-0.6 na-134 k-4.1 cl-104 hco3-22 angap-12 06:04am blood ck(cpk)-70 02:54am blood lipase-19 06:04am blood ck-mb-notdone probnp-5528* 05:55am blood albumin-2.3* calcium-7.6* phos-3.3 mg-1.8 04:41am blood caltibc-134* vitb12-1077* folate-11.9 ferritn-370 trf-103* 02:15pm blood type-art temp-37.0 fio2-95 o2 flow-15 po2-113* pco2-34* ph-7.58* caltco2-33* base xs-10 aado2-556 req o2-89 intubat-not intuba 06:12am blood lactate-2.1* 08:46pm blood o2 sat-89 04:18pm blood freeca-1.11* sputum cx - mrsa blood cx - coag negative staph blood cx - coag negative staph brief hospital course: mr. is an 84 y/o man with history of cad s/p mi, htn, hypercholesterolemia and recent admission for uti, hypotension, partial sbo admitted with shortness of breath likely due to pulmonary edema +/- pneumonia in setting of ivf overload. course complicated by difficulty weaning oxygen. ct chest showed collapsed l lobe with large bilateral effusions. # hypoxemia/respiratory distress: likely due to pulmonary edema +/- pneumonia (possibly aspiration) in the setting of neuromuscular weakness from multiple recent hospitalizations, nutritional deficiency, and post-polio. last echocardiogram done in with normal ef 60%, no evidence of diastolic dysfunction, repeat done on showed new moderate pulmonary hypertension and +tr, otherwise unchanged. negative 6-7l since admission. ct chest showed large regions of atelectasis within the lower lobes mucus within the segmental and subsegmental airways and bilateral pleural effusions. patient underwent ir guided thoracentesis on , removal of 2l. he was electively intubated on for peg procedure and bronchoscopy was done with copious removal of mucus. he was extubated the following day and was maintained on intermittent cpap. he completed a 10 day course of iv vnacomycin for mrsa pna. hypoxia initially improved although patient had recurrent mucus plugging and frequent desaturations during his icu course secondary to lll collapse. eventually, when his bp tolerated, he was diuresed successfully with iv lasix drip. one day prior to discharge, patient was transitioned from lasix drip to iv lasix boluses of 40mg iv lasix with goal of 500cc-1l negative daily. he was followed daily with electrolytes in the setting of aggressive diuresis. upon discharge, patient's respiratory status improved significantly and was requiring between 2-4l oxygen by nasal canula. # cardiac: the patient has a h/o nstemi attributed to af with rvr. he was maintained on aspirin. his was held given his acute illness and the planned peg placement on . he was started on a heparin drip for anticoagulation but was eventually stopped because of bloody secretions, a 7 point hematocrit drop, and guiac positive stools. regarding future anticoagulation, patient should have a repeat colonoscopy as an outpatient and readdress anticoagulation as an outpatient. given his guiac positive stools and discussion with pcp, was discontinued. regarding his heart rate control, he was maintained on metoprolol when his bp tolerated. for much of his icu course this was held but was restarted as his bp tolerated. he was restarted on metoprolol 12.5mg po bid several days prior to discharge. this may be titrated up as his blood pressure tolerates. # anemia: over the course of his admission, pt's hematocrit slowly trended downward to a nadir of 21.4. he was transfused one unit of prbcs with a 1 point increase in his hematocrit. patient is recommended to have a repeat colonoscopy as an outpatient. he should have cbc's checked every other day for the next week and transfused for hct <24. if transfusion needed, it should be given with a dose of iv lasix. # c. diff: loose stool on admission. presented with elevated wbc count to 25, now down to 13. had been treated for c. diff last admission, positive on culture from . c. diff negative x2. no diarrhea currently. the patient was continued on po vancomycin (concern for resistant c. diff), po flagyl. the plan was for both po flagyl and po vanco to be continued 1 week after other antibiotics are stopped. c diff toxin b was positive and patient was recommended to continue po vancomycin and flagyl through , 2 weeks after completing his antibiotic course. he was also started on cholestyramine for symptom relief. # uti: positive ua on admission. history of uti sensitive to cipro. it was felt that hypotension last admission was related to urosepsis. he initially completed a course of levofloxacin. subsequently, a ua was again positive on and the patient was started on a 7 day course of ceftriaxone. cultures were negative. # dm: bg have been well controlled. he was maintained on an insulin sliding scale. # hypothyroidism - the patient was continued on synthroid. medications on admission: levothyroxine 25mcg tablet daily metoprolol tartrate 25mg tablet clopidigrel 37.5mg daily lisinopril 20mg daily flagyl 500mg tid zolpidem 5mg hs riss protonix 40mg tylenol prn ciprofloxacin 250mg q12h (for 3 days) warfarin 1mg daily simvastatin 5mg qmwf lactobacillus 2 capsules po tid x 7 days discharge medications: 1. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed. 2. acetaminophen 325 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed. 3. simvastatin 10 mg tablet : 0.5 tablet po qmwf (). 4. clopidogrel 75 mg tablet : 0.5 tablet po daily (daily). 5. levothyroxine 25 mcg tablet : 0.5 tablet po daily (daily). 6. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 7. lidocaine hcl 2 % solution : one (1) ml mucous membrane tid (3 times a day) as needed. 8. zinc oxide-cod liver oil 40 % ointment : one (1) appl topical prn (as needed). 9. sucralfate 1 g tablet : one (1) tablet po q6h (every 6 hours) as needed. 10. loperamide 2 mg capsule : one (1) capsule po tid (3 times a day) as needed. 11. ipratropium bromide 0.02 % solution : one (1) inhalation q6h (every 6 hours) as needed. 12. albuterol sulfate 0.083 % (0.83 mg/ml) solution : one (1) inhalation q4h (every 4 hours) as needed. 13. cholestyramine-sucrose 4 g packet : one (1) packet po bid (2 times a day). 14. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 15. metronidazole 500 mg tablet : one (1) tablet po tid (3 times a day) for 13 days: last day should be . 16. vancomycin 250 mg capsule : one (1) capsule po q6h () for 13 days: last day should be . 17. metoprolol tartrate 25 mg tablet : 0.5 tablet po bid (2 times a day). 18. furosemide 10 mg/ml solution : one (1) injection (2 times a day). 19. insulin regular human 100 unit/ml solution : 1-20 units injection asdir (as directed): please follow provided insulin sliding scale. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary diagnosis: 1. pulmonary edema 2. pneumonia 3. atrial fibrillation 4. clostridium difficile 5. type 2 diabetes mellitus secondary diagnoses: 1. peripheral arterial disease s/p right sfa to at bypass in 2. prior nstemi in setting of rapid afib (admission ) 3. chronic atrial fibrillation on 4. dm2 5. hypercholesterolemia 6. hypothyroidism 7. post-polio weakness/contractures discharge condition: stable - patient is tolerating discharge instructions: while you were in the hospital, you were diagnosed with significant shortness of breath and respiratory distress. this was thought most likely secondary to fluid in your lungs, pneumonia, and significant neuromuscular weakness. we treated your pneumonia with antibiotics, we removed significant amounts of fluid from your lungs with lasix, and we tried to improve your strength with physical therapy and nutrition. upon leaving the hospital, you were requiring just 2-4 liters of oxygen by nasal canula alone. when you leave the hospital, it will be very important for you to continue your water medications to remove more fluid from your lungs. it will also be important for you to participate in physical therapy and rehabilitation to improve your strength. if you have persistent or worsening shortness of breath, please seek medical attention. followup instructions: please follow-up with your appointments with the lab on 2:30 and your surgeon dr. on 3:15. if you need to cancel or reschedule, please call dr. office at . when you go to rehab, you will still require diuresis to remove fluid from your lungs. you are currently on 40mg iv lasix . please continue this regimen for at least 2-3 days upon rehab with daily electrolytes. after this, you may re-assess your fluid status to decide about a further regimen. please also follow-up with your primary care physician . upon your discharge from rehab. his phone number is . Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Diagnoses: Pure hypercholesterolemia 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 Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Atrial fibrillation Infection with microorganisms resistant to penicillins Acute on chronic diastolic heart failure Acute respiratory failure Intestinal infection due to Clostridium difficile Methicillin susceptible pneumonia due to Staphylococcus aureus Hyperosmolality and/or hypernatremia Other and unspecified infection due to central venous catheter Atherosclerosis of native arteries of the extremities, unspecified

allergies: bactrim, remeron precautions: mrsa neuro: pt alert and opening eyes spontaneously most of the shift, dozed intermittently. orientation status waxes and wanes between . able to weakly mea x4 - lifts bue, moves ble on bed. denies discomfort. afebrile. resp: lung sounds clear in bilateral upper lobes and diminished at the bases. cough productive for thick white/blood tinged secretions - pt is able to mobilize secretions to be suctioned with yankauer. nts x1 by rt with small amt of thick brown/blood tinged secretions. denies sob, however pt does appear to breathe with accessory muscle use at times. rr 20's-30's, spo2 94-100%. received pt on hi flow mask with 40% fio2, switched to face tent for comfort-pt tolerating well. cv: hr 80's-120's afib with occasional pvc's. sbp 90's-120's with maps 60's-80's. denies cp. palpable radial/dp pulses. pt's hct noted to be 22.2 this am - goal is >25. team aware, however will wait to transfuse with prbc's until fluid status is more negative - thought to be at high risk for flash pulmonary edema. pt has patent #18 piv in left wrist. gi/gu: abdomen soft, bowel sounds present x4. tf via peg at goal rate of 50ml/hour. pt had 2 loose blackish green bm's this shift - guiac positive, dr. made aware. indwelling foley catheter patently draining 35-130 ml/hour cloudy yellow urine. lasix gtt titrated to maintain goal uop of >50 ml/hour. integ: skin peeling on extremities. buttocks red and raw, cream applied. noted to have area on coccyx that appears to be blanching-skin unbroken. duoderm applied. pt at times refusing to turn despite being informed of risk of breakdown. social: son and wife in to visit, all questions answered appropriately. plan: continue to diurese with goal fluid balance of 1 liter negative/24 hours. titrate lasix gtt to maintain upo >50ml/hour. once pt's fluid balance is more negative, prbc's. monitor sbp, metoprolol dose to be increased for hr once able to tolerate. monitor electrolytes while on lasix gtt, replete prn. last set of electrolytes drawn at 1545 - result pending. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Diagnoses: Pure hypercholesterolemia 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 Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Atrial fibrillation Infection with microorganisms resistant to penicillins Acute on chronic diastolic heart failure Acute respiratory failure Intestinal infection due to Clostridium difficile Methicillin susceptible pneumonia due to Staphylococcus aureus Hyperosmolality and/or hypernatremia Other and unspecified infection due to central venous catheter Atherosclerosis of native arteries of the extremities, unspecified

allergies: bactrim-rash, remeron. access: midline (dual lumen) admit from rehab less than 24 hrs after discharge from for tx of hypotension, uti. presented to ed productive congested cough, increasing sob, wob, crackles, sat 70%, cp. given sl ntg, lasix, flagyl, levoquin, pr asa, placed on cpap. cxr showed pleural effusions, infiltrates. troponin=0.11, bnp=5500. thick yellow sputum, +mrsa. neuro: alert, oriented to place, self, month, year. lethargic this morning. muscle weakness s/p adult polio infection. oob to recliner via x2hrs. impaired gag, very weak/absent cough effort. speech/swallow eval states pt. is high risk for aspiration. nectar thick liquids recommended. cv: a-fib. coumadin held last night and tonight for procedure in am. received 2 units ffp, po vit k, iv vit k to reverse inr. rate 80-100's. sbp 90- lopressor held for sbp=90. pulses by doppler. +ai, tr per echo. resp: desat this am to 84%, fingertip cyanosis on 80% venti mask. placed on 100% nrb with sat increase to 96-100%. abg showed good o2 level, not retaining co2. chest pt q2hrs this shift. little to no cough effort. cxr shows bilateral pleural effusions, l worse than r. severe atelectasis with poor volumes. patient very resistant to cpap. plan ir guided thoracentesis tomorrow morning, possible elective intubation with bronch afterwards. gi: abdomen soft, +bs present. smears of stool only. +c diff. very poor/absent nutritional intake. 3 bites ensure pudding today. sips thickened juice, ice chips. takes po meds whole in applesauce. needs to sit up, chin to chest to swallow or else he chokes. plan for peg placement on monday. gu: foley cath draining small amount amber urine. lasix 20mg iv x1 this shift. +2 edema bilat arms. id: afebrile. iv levofloxacin, vancomycin for tx of pneumonia. po flagyl, vancomycin for tx of c-diff. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Diagnoses: Pure hypercholesterolemia 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 Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Atrial fibrillation Infection with microorganisms resistant to penicillins Acute on chronic diastolic heart failure Acute respiratory failure Intestinal infection due to Clostridium difficile Methicillin susceptible pneumonia due to Staphylococcus aureus Hyperosmolality and/or hypernatremia Other and unspecified infection due to central venous catheter Atherosclerosis of native arteries of the extremities, unspecified

code: dni/contact precautions: mrsa sputum, c-diff/ allergies: bactrim=rash, remeron. neuro: initially lethargic, had received morphine last night. narcan ivp with improvement, narcan gtt. oriented x2-3, waxing and this shift, follow commands. cv: a-fib rate 80-110. sbp 105-110. scheduled lopressor partial dose given to control rate (25mg) so as not to bottom out bp. 250cc ns bolus given @ 0700, again @ 1830 for low uop, low bp. dopplerable pedal pulses. ptt>150, heparin gtt held @ , then d/ md. resp: this am on hi-flow 80% mask, tolerated cpap x1 hr. epsiode @ 1500 where pt. orally suctioned for large amounts blood, large clot. desat to 55%, became lethargic, agonal breathing with slowing rr. fellow called to bedside, witnessed long resp pause. turned on side, chest pt, oral sx back of throat for more blood with improved sat 86%, placed on cpap with sat improved to 96-100%, became alert again. cxr taken. second episode @ 1830 desat 66% on 100% , nts for large amount thick bloody secretions, patient able to cough. placed on cpap with sat improving to 100%. gi: nutren pulmonary at goal rate 50cc/hr via peg, low residual. 600cc liquid stool plus incontinent x2 prior to mushroom cath insert. gu: foley draining scant cloudy amber urine. uc + for new uti. new abx ceftriaxone. bun=29, creat=1.3 id: oral vanco/flagyl for c-dif (now testing neg for c-dif alpha. c-diff beta test sent. ua/c&s, bcx2, sputum also sent. afebrile. wbc=18.7 skin: excoriated perineum due to loose stool. barrier cream/lidocaine slurry/carafate "magic ointment" to perineum qid prn for comfort and skin protection. social: family meeting with attending/fellow/resident/social services/ rn/ spouse/ son (son not present). patient is dni. ethics consult dr. met patient today. challenging family with difficulty coping. be realising patient's tenuous status as they witnesses near resp arrest today. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Diagnoses: Pure hypercholesterolemia 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 Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Atrial fibrillation Infection with microorganisms resistant to penicillins Acute on chronic diastolic heart failure Acute respiratory failure Intestinal infection due to Clostridium difficile Methicillin susceptible pneumonia due to Staphylococcus aureus Hyperosmolality and/or hypernatremia Other and unspecified infection due to central venous catheter Atherosclerosis of native arteries of the extremities, unspecified

dispo: full code allergies: bactrim - rash access: lt midline nuero: pt. dozing intermittenly t/o shift. a&o x3, mentating, able to answer/ask questions appropriately. moves upper extremities, following commands. cv: hr 85s-100s, afib with rare pvcs. bp 100-115s/50s-60s. lopressor given. diff. to palpate pulses. resp: ls coarse to diminished bilaterally, with ls becoming more diminished t/o during shift. cxr showing complete white out on left lobe. recieved pt on 60% hi flow neb, able to wean to 4l nc, then sats dropped to 80s. switched to 100% , pt refusing nts. poor cough, unable to clear secretions. pt continued to poor sats, pt then agreed with nts, with little to no white thick secretions. pt's upper airway very coarse, with shallow breathing. pt. cont. to refuse nts. resp. administering cough device intermittenly with minimal effects. when asked about intubation, pt clearly states his wishes to not be intubated to this rn. rr 20-25, with sats 80-100%. pt remains on 95% cool neb. gi/gu: abd soft, non-distended, non-tender to palpation. + bs x 4 quadrants, no stool this shift. npo ? of elective intubation for bronch. decided to hold on procedure at this time ? pt's wishes regarding goal of care. pt with aspiration risk impaired cough/swallow polio disorder. pt refusing peg tube placement. repeatedly asked pt about peg tube placement and the implications of not receiving nutrition, pt aware and continuing to refuse. foley catheter secure and patent, draining minimal amounts of dark amber urine. rec'd 20 mg lasix ivp for low u/o. id: afebrile this shift. remains on vanco/flagyl for c. diff. remains on levaquin/vanco for uti/mrsa pna. skin: pt with red rash medication. dry and peeling, no open areas noted. +1 non pitting edema noted on upper extremities bilaterally. midline appears to have fluid accumulation below site. arm elevated and warm pack applied. social: pt reportedly refusing nts overnight (repeatedly). pt refusing nts today. pt also refusing peg tube placement. pt mentating and able to make needs known. discussed wishes with pt about direction of care. pt stated wanting to "fade away." when asked if pt wanted to be intubated, pt stated no. pt stated understanding the implications of refusing care. family in to visit. heard son speaking with pt, "do you want to leave your wife a widow?" "cooperate." family meeting to be held this afternoon. social work in to meet with family and patient seperately. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Diagnoses: Pure hypercholesterolemia 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 Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Atrial fibrillation Infection with microorganisms resistant to penicillins Acute on chronic diastolic heart failure Acute respiratory failure Intestinal infection due to Clostridium difficile Methicillin susceptible pneumonia due to Staphylococcus aureus Hyperosmolality and/or hypernatremia Other and unspecified infection due to central venous catheter Atherosclerosis of native arteries of the extremities, unspecified

dnr/dni contact precautions: mrsa sputum, c-diff stool allergies: bactrim: rash, remeron pmh: afib on coumadin at home, cad, chf, dm, htn, mi, pvd s/p rle bypass , polio, frequent uti, chronic foley cath, hyperlipidemia, c-diff, sm. bowel obstruction. access: l ac midline neuro: alert, oriented x2 to self, place. speech difficult to understand. weakly moves extremites to command. perl. post-polio syndrome muscle weakness. unable to cough effectively. tylenol 650mg x1 per peg for generalized discomfort with good relief. cv: afib. diltiazem gtt off this morning due to bradycardic episodes to 20-40's. rate now 70-80's. sbp 90's-120's. extremites were very cyanotic and cold this morning, unable to register temp. rectal temp<96, bair hugger blanket placed on. cyanosis improved, but bp has decreased as patient warmed. weak palp pedal pulses this shift. resp: nt sx. for muccous plug x1 desat 84%. increased work of breathing, difficulty speaking due to dyspnea. bronchial lung sounds, exp wheezes. cxr showed worsening pulmonary edema. lasix 10mg ivp, placed on cpap as tolerated, with breaks to hi-flow neb mask 95% o2. gi: nutren pulmonary @ goal rate 50cc/hr via peg. residuals 0-5cc. abdomen soft, +bs present. mushroom cath draining loose brown/green stool. gu: foley cath draining cloudy yellow urine. good response to lasix. bun=42, creat=1.1. skin: coccyx/perineum red, some excoriation that appears to be healing. desitin/barrier cream/lidocaine/carafate mixture to area for comfort with good response. rash from allergy healing, continues to be dry/peeling. lotion applied several times. id: latest c-diff cultures all negative; continue to treat with vanco/flagyl per peg as other antibiotics continue. ceftriaxone iv for uti, vanco iv for mrsa pneumonia. wbc=14.2. lactate=1.9. hypothermia. plan: patient is dnr/dni, no central lines, no pressors confirmed with patient in presence of family by icu team at family meeting yesterday. patient has been very consistent in this despite great pressure from son who is opposed to this. chest pt, cpap as tolerated, nt suction as needed for plugs/desat. frequent oral care for dry muccosa. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Diagnoses: Pure hypercholesterolemia 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 Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Atrial fibrillation Infection with microorganisms resistant to penicillins Acute on chronic diastolic heart failure Acute respiratory failure Intestinal infection due to Clostridium difficile Methicillin susceptible pneumonia due to Staphylococcus aureus Hyperosmolality and/or hypernatremia Other and unspecified infection due to central venous catheter Atherosclerosis of native arteries of the extremities, unspecified

pt. has allergies to remeron, and bactrim. pt. remains a/a/o and denies any pain or discomfort throughout this shift. pt. has not slept over the past three days, until tonight. pt. received 10mg po ambien with desired effects reached. pt. has followed all commands, remains afebrile. pt. remains afib in a controlled rate of 80-109, with rare pvc's. b/p has been stable ranging 114-130's/50-60's. pulses are weak but palplable. lung's are coarse and diminished. pt. resp rate is controlled and sats are >93% while remaining on 80% high flow neub. pt. is scheduled for a possible thoracentesis in ir today. ct scan yesterday exhibited moderate effusions bilat. pt. was r/o for p.e. m.d. pt. remains on aspiration precautions, and tolerates his thickened liquids. bowel sounds are easily audible and no bm noted this shift. blood sugars have ranged 120-160's. foley catheter remains secured and continues to drain small but adequate amt's of clear yellow urine, >30cc/hr. skin remains intact with coccyx remaining red, but intact. pt. turned frequently. left picc which is not central no longer pulls back blood. pt. is scheduled this am for new picc to be placed i.r. plan is for possible thoracentesis and picc line insertion. wean o2 when able to. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Diagnoses: Pure hypercholesterolemia 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 Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Atrial fibrillation Infection with microorganisms resistant to penicillins Acute on chronic diastolic heart failure Acute respiratory failure Intestinal infection due to Clostridium difficile Methicillin susceptible pneumonia due to Staphylococcus aureus Hyperosmolality and/or hypernatremia Other and unspecified infection due to central venous catheter Atherosclerosis of native arteries of the extremities, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: cardiac cath x 2 with stenting history of present illness: 85y/o m w/ h/o cad s/p cabg, htn, hypercholesterolemia, remote tobacco history who was in usoh pta. he had been hospitalized for a pneumonia ~6 weeks ago, treated and sent home on 2l oxygen. one month ago he was able to walk up a flight of stairs (12 steps) without any dificulty or doe. up until one week ago he started noticing that he could not walk up the full flight of stairs, he would stop at 6 steps sob and abdominal pressure/tightness. 2.5 days ago he could only go up 4 stairs prior to symptoms starting, he also noticed that he developed a pressure around his waist that waxed and waned in intensity. this morning, he quickly became sob with minimal exertion lasting 30min before recovering his breath. he dressed himself, washed and shaved and was readily out of breath, developed pressure around his waist that was worse than before non radiating, no lh/dizziness/n/v. he gave himself oxygen which helped ease both the abdominal tightness and sob. he called ems who found him to have a p: 84, bp: 170/80, r: 24, o2 84% on 2l then switched to nrb iwth o2 95%, they gave him lasix 40mg and 2 baby asa and was taken to hospital. there he was noted to be in florid heart failure, given ntg, morpine 2mg+2mg, lasix 40mg, started on ntg drip, 2 baby asa, lovenox 80mg sc, mucomyst 600mg iv, lopressor 2.5mg, and started on tirofiban. hct was 46.4, wbc 13.2, bun 46, cr 2.3, ck 67, tropi 0.5. he was subsequently transferred to for cardiac catherization. upon arrival to floor patients face was dark red/almost purple, c/o severe abdominal pressure, non radiating, acutely sob, no lh/dizziness, no n/v. he was tachypneic on nrb with sats in the high 80's/low 90's, jvd ~14cm, heart rrr, lungs with crackles from bases to of lung field. he was given 80mg iv lasix, 2mg of morphine, started on heparin iv, then given additional 100mg of iv lasix. cxr with pulmonary congestion/edema, sats improved to the low 90's and no longer was desating with conversation. abg's showed 7.39/34/48-> 7.34/39/63-->7.37/39/76. he diuresed 2l total after 180mg of lasix and was no longer in distress, abdominal pain resolved after 10min on floor. patient still on nrb. ros: no cough, no pnd, no orthopnea, no edema, no n/v/f/ch, no pleuritic chest pain, past medical history: pmh: 1. parkinsons 2. cad s/p cabg, chf diastolic dysfunction ef 60-65% 3. ppm afib 4. htn 5. hypercholesterolemia 6. peripheral neuropathy 7. cardiomegaly on cxr and effusion 8. pulm nodules on ct: 2, 2mm in the lul social history: soh: remote tobacco: used to smoke 1ppd with 1-2 cigars, then switched to pipe. quit 21yrs ago, no etoh. married lives with wife no ivdu family history: fmh: had one brother that died from mi at age 35, two other brothers that died at ages 66 and 80 from mi. brother that died at 80 died after shovelling snow, immediate death. physical exam: gen: moderate distress upon arrival, face dark red, c/o sob and abdominal pressure, tachypneic heent: eomi, perrl, mmdry, o/p clear, neck: jvd ~14cm, supple, ?bruit in the left carotid cv: rrr, paced, no m/r/g, surgical scar appreciated pulm: crackles lung field b/l, mild exp wheezes in the lower bases, no rhonchi, good inspiratory and expiratory efforts abd: soft, round, nabs, nt/nd, no hepatic tenderness, no hm, no hjr, no massess, no pulsatile masses appreciated. groin: bruits appreciated in both groins, pulses palpable ext: 1+ edema to bk b/l, no c/c, dp/pt both palpable, ext warm and perfused neuro: grossly intact, cn ii-xii grossly intact pertinent results: 05:42pm type-art temp-36.3 rates-/24 o2-100 po2-76* pco2-39 ph-7.37 total co2-23 base xs--2 aado2-615 req o2-98 intubated-not intuba comments-non-rebrea 05:42pm o2 sat-96 03:10pm type-art po2-63* pco2-39 ph-7.34* total co2-22 base xs--4 intubated-not intuba 03:10pm hgb-14.4 calchct-43 o2 sat-92 carboxyhb-0.5 met hgb-0.8 02:59pm glucose-124* urea n-48* creat-2.3* sodium-141 potassium-5.2* total co2-20* 02:59pm alt(sgpt)-14 ast(sgot)-19 ck(cpk)-58 alk phos-85 tot bili-1.0 02:59pm ck-mb-notdone ctropnt-0.07* 02:59pm albumin-4.2 calcium-8.9 phosphate-3.8 magnesium-2.1 02:59pm wbc-12.2* rbc-4.70 hgb-14.7 hct-43.2 mcv-92 mch-31.2 mchc-34.0 rdw-14.2 02:59pm plt count-201 02:59pm pt-15.0* ptt-139* inr(pt)-1.4 02:47pm type-art temp-35.0 o2-100 po2-48* pco2-34* ph-7.39 total co2-21 base xs--3 aado2-648 req o2-100 intubated-not intuba 02:47pm hgb-14.4 calchct-43 o2 sat-89 carboxyhb-0.3 met hgb-0.9 echo 1. the left atrium is mildly dilated. 2. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 3. the aortic valve leaflets (3) are mildly thickened. 4. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. 5. there is moderate pulmonary artery systolic hypertension. stress mibi 1) moderate, reversible inferior and inferolateral wall perfusion defect. 2) slight hypokinesis of the lateral wall with calculated ejection fraction of 46%. cath 1. selective coronary angiograpy of this right dominant system revealed multi-vessel disease. the lmca contained mild, diffuse disease. the lad was occluded mid vessel and filled via svg-d. the lcx was occluded proximally. the rca had diffuse disease up to as much as 80% stenosed. 2. vein graft imaging revealed patent lima-lad without significant disease. the svg-rpl was totally occluded. the svg-d1 had 70-80% lesions proximally. 3. resting hemodynamics revealed a severely elevated mean pcpw of 22mmhg. the cardiac index by the fick method was 2.3 l/min/m2. 4. successful stenting of the svg to rpl with distal to proximal overlapping cypher dess (3.0x33, 3.0x33, and 3.5x23) (see ptca comments). cath 1. selective angiography of the recently stented svg to the rpl revealed widely patent stents. the svg to the lad had a 80% proximal stenosis. 2. successful stenting of the proximal segment of the svg to the lad with a 3.5x18mm cypher with a 4.5x12mm quantum maverick at 20 atms using filterwire ez rx for distal protection (see ptca comments). brief hospital course: 85y/o m with cad s/p cabg, diastolic heart failure, htn, hypercholesterolemia, p/w 2 day history of usa and acute pulmonary edema. 1. cv: history c/w ua progressing to acs. cad: patient arrived on tirofiban his arf and ntg gtt. we started patient on heparin, asprin full dose, metoprolol, holding acei, started lipitor. ntg gtt titrated to relieve pain. once initially stabalized the pt had no chest pain for the entire admission. once resp status stabalize pt sent for a stress mibi which demonsrated a reversible inf/inf-lat perfusion defecit with hk of the lat wall. he was sent to cath where the pt was found to have multi vessel disease. the svg-rpl was stented with overlapping stents. he was brought back for repeat cath and stenting of the svg-lad. with both caths the pt was prehyd with na bicarb and mucomyst. his groin cath sites did not have evidence of eccymoses or bleeding. he had a small hematoma on the r which was stable. he also has been hemodynamically stable throughout the admission. the pt will be sent out on asa, plavix, acei, lipitor, and b blocker. pump: supposed ef of 60-65% with diastolic heart failure, patient presently in acute heart failure and hypoxic. nitro gtt was given for afterload reduction and lasix for diuresis. given morphine here, one dose for pain releif and pulm vasculature dilation. the patient was oxygenating well but requiring a non-rebreathing mask at 100%. when the mask was taken off the pt would desat to the 80's immediately. he was diuresed with lasix requiring 100mg iv mult time to put out about 2 liters. he was started on natrecor and sent to the ccu for further diuresis with close supervision. the diuresis was successful at relieving the patient's respiratory distress but his cr. did rise. the pt was then free from shortness of breath from the remainder of the hospitalization. rhythm: on telemetry, paced. medications on admission: 1. adalat 60mg once a day (nifedipine) 2. atenolol 50mg twice a day 3. avapro 150mg once a day (ibesartan) 4. proscar .05mg once a day 5. finesteride 20mg once a day 6. furosemide 20mg once a day 7. stalebo 100mg qid (parkinsons) 8. neurontin 300mg qid discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). disp:*30 tablet sustained release(s)* refills:*2* 4. metoprolol succinate 100 mg tablet sustained release 24hr sig: two (2) tablet sustained release 24hr po daily (daily). disp:*60 tablet sustained release 24hr(s)* refills:*2* 5. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tab sublingual as needed as needed for chest pain: please take for chest pain. if not releived by 3 tabs then go to emergency room. disp:*30 tabs* refills:*0* 8. neurontin 300 mg capsule sig: one (1) capsule po four times a day. 9. proscar 5 mg tablet sig: one (1) tablet po once a day. 10. lasix 20 mg tablet sig: one (1) tablet po once a day. 11. stalevo 100 25-100-200 mg tablet sig: one (1) tablet po four times a day. discharge disposition: home with service facility: vna discharge diagnosis: unstable angina diastolic chf cad parkinson's disease htn chronic renal failure discharge condition: stable discharge instructions: please take all medications as instructed on discharge paperwork. you will be given sublingual nitroglycerin tabs. if pain does not resolve after 3 tabs then call you primary doctor or go to the emergency room. i you have shortness of breath, dizziness, fainting, palpitations, chest pain at rest or chest pain that does not immediately respond to the nitro please call you doctor or go to the emergency room. followup instructions: please follow up with dr () with in 2 weeks. md 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 Injection or infusion of thrombolytic agent Injection or infusion of nesiritide Insertion of drug-eluting coronary artery stent(s) Insertion of drug-eluting coronary artery stent(s) Injection of anticoagulant Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Coronary atherosclerosis of autologous vein bypass graft Paralysis agitans Unspecified disorder of kidney and ureter Diastolic heart failure, unspecified

history of present illness: baby girl , twin i, was a 36-week, 2795-gram product of a 30-year-old gravida 4, para 0 to 2 mother with serologies o positive, antibody negative, rubella immune, rapid plasma reagin nonreactive, hepatitis b not detected, group b strep status negative. delivery was by cesarean section secondary to spontaneous rupture of this twin and breech positioning. there were no septic risk factors. baby girl was in the newborn nursery when she was noted to have a dusky episode associated with apnea for which she was admitted to the neonatal intensive care unit. physical examination on presentation: weight was 2795 grams (50 percentile), length was 19 inches, 48 centimeters (50-75 percentile), and head circumference was 32.5 cm (50 percentile). this was a well-developed given gestational age. her anterior fontanel was soft and flat. her face was symmetric. her nares appeared patent. her oropharynx was moist and pink with palate intact. her tinea were well formed. her neck was supple without pits or masses. her heart was in a regular rate and rhythm without murmurs. her lungs were clear to auscultation bilaterally. her abdomen was soft, nontender, and nondistended. she had no hepatosplenomegaly. this was . the anus was patent. she had no hair or sacral dimple on her back. all extremities were intact. she had equal movement. tone was appropriate for gestational age. summary of hospital course by issue/system: 1. respiratory issues: baby girl remained on room air throughout her hospital stay. she had dusky episodes, primarily associated with feedings. she would choke and desaturate as low as the 40s, and her heart rate dipped as low as 59 beats per minute. throughout her hospital course as her feeding coordination improved, these episodes became less frequent. her last bout was on . she has subsequently done well without any noted apnea or bradycardia. she is taking oral intake well without notable color changes during feedings. the parents are comfortable with her feeding. 2. cardiovascular issues: baby girl has been cardiovascularly stable with the exception of bradycardias associated with feedings per above. 3. fluids/electrolytes/nutrition issues: baby girl has been maintained breast milk 20 and enfamil 20 throughout her hospital course. she is currently feeding by mouth ad lib, exceeding 120 cc/kg per day. weight on discharge was 3325 grams, length 54 centimeters, head circumference 35 centimeters. 4. gastrointestinal issues: baby girl was treated with phototherapy for hyperbilirubinemia. she reached a peak bilirubin of 15.8 and a direct bilirubin of 0.2 on . she was treated with phototherapy for two days. her last bilirubin on was 9.2/0.4. 5. hematologic issues: baby girl initial complete blood count was notable for a white blood cell count of 9.4, with a differential of 0 bands and 44 segmented neutrophils. her initial hematocrit was 49, and her platelets were 393. she received no transfusions during her admission, and her most recent hematocrit was 33.8 on . 6. infectious disease issues: an initial blood culture was sent on admission on which was negative. she was treated with ampicillin and gentamicin for 48 hours which was discontinued after the cultures were negative. she showed no further signs of infection. 7. neurologic issues: given the apnea and dusky episodes, she had an initial head ultrasound which showed bilateral choroid plexus blood. a repeat head ultrasound done on was normal. otherwise, she has been neurologically stable throughout her hospitalization. 8. sensory/audiology issues: hearing screening was performed with automated auditory brain stem responses, and she passed on . 9. ophthalmologic issues: eye examination was not necessary due to her gestational age. 10. psychosocial issues: social work was involved with the family. the contact social worker is , and she can be reached at telephone number . condition at discharge: stable. discharge disposition: to home. primary pediatrician: dr. with pediatrics (office telephone number ; fax number ). care and recommendations: 1. feedings at discharge: breast milk/enfamil 20 by mouth ad lib. 2. medications at discharge: tri-vi- 1 cc by mouth once per day and desitin to diaper area as needed. 3. car seat position screening. 4. newborn state screens were sent; most recent on and were normal. 5. hepatitis b vaccination was given 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 gestation; (2) born between 32 and 35 weeks gestation with 2/3 of the following: plans for day care during respiratory syncytial virus season, with a smoker in the household, neuromuscular disease, airway abnormalities, or with school-age siblings; and/or (3) with chronic lung disease. influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers to protect the infant. discharge instructions/followup: 1. dr. on . 2. care group to visit the home on (contact telephone number ). discharge diagnoses: 1. apnea of prematurity. 2. feeding immaturity. , m.d. dictated by: medquist36 Procedure: 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 Primary apnea of newborn Neonatal bradycardia 35-36 completed weeks of gestation Other preterm infants, 2,500 grams and over

allergies: compazine / codeine / benzodiazepines attending: chief complaint: n/v and weakness major surgical or invasive procedure: l femoral cvl placement history of present illness: pt is a 43 yo woman who presented to clinic to return equipment associated with her capsule endoscopy. she c/o n/v and weakness. fsbs checked there revealed bs>400. she was referred to ed for evaluation. she had been given golytely bowel prep several days before for cleaning the bowel in prep for capsul endoscopy as eval for anemia past medical history: 1. type 1 diabetes -- 2 failed pancreatic transplants, most recent in , at 2. gerd, now s/p nissen in . 3. constipation. 4. history adenomatous polyps, negative colonoscopy in . 5. ocd 6. status post wrist and knee surgeries for tendon repairs. 7. possible seizure disorder, primary neurologist, dr. ,at . the patient has never been seen in the hospital to have true seizure disorder; however, she has described seizures consistent with tonic clonic seizures at home and, therefore, is on depakote for seizure prophylaxis. she is also noted to have psychogenic seizures, per dr. , which are characteristically episodes of unresponsiveness or shaking that is not consistent with organic brain seizures. she has had several psychogenic seizures and has been admitted at other hospitals for these episodes, usually they pass over a number of hours and the only thing that has been shown to help is constant reassurance from the staff that the patient is doing well. 8. hypercholesterolemia. 9. history of schizo-affective disorder. 10. history of catatonic depression. 11. question of bipolar disorder. 12. adhd 13. hypothyroid 14. allergic to tegretol, codeine (rash) social history: - tob, - etoh, - drugs family history: nc physical exam: physical examination on admission: vital signs: temperature 97.8, blood pressure 104/68, heart rate 70 , respiratory rate 16/min, saturating 97% in room air. general: nad heent: perlla, oropharynx clear neck: supple, no jvd heart: rrr, nl s1+s2, no m/r/g lungs: ctab, nl effort abdomen: soft, non tender, nl bs extremities: no o/c/c neurologic: a&o x 3 pertinent results: 10:10am blood wbc-3.0* rbc-3.40* hgb-10.9* hct-31.8* mcv-93 mch-32.1* mchc-34.4 rdw-15.6* plt ct-189 10:10am blood glucose-112* urean-13 creat-0.8 na-142 k-3.6 cl-105 hco3-30 angap-11 10:54am blood alt-8 ast-21 ld(ldh)-169 ck(cpk)-109 alkphos-51 amylase-45 totbili-0.1 10:54am blood lipase-11 10:54am blood ck-mb-4 ctropnt-<0.01 05:10am blood calcium-8.8 phos-4.3 mg-2.5 10:54am blood hapto-44 10:54am blood ammonia-15 12:22pm blood valproa-96 11:18am blood type-art po2-247* pco2-49* ph-7.42 caltco2-33* base xs-6 intubat-not intuba 05:47pm blood glucose-217* lactate-2.7* na-140 k-4.5 cl-101 calhco3-29 11:06am blood freeca-1.18 lue ultrasound: findings: -scale, color, and pulse wave doppler son were performed of the left internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins. normal flow, compressibility, waveforms, and augmentation is demonstrated. no intraluminal thrombus is identified. no discrete fluid collection is identified to suggest abscess. impression: no evidence of dvt or abscess in the left upper extremity. portable ap chest radiograph compared to . the heart size is normal. mediastinal contours, position, and width are unremarkable. the lung volumes are generally low. crowdedness of the lung vessels in both bases is demonstrated accompanied by small patchy areas of consolidation, especially in the left retrocardiac space which may represent atypical bacterial or viral infection. the possibility of the upper lung redisrtribution of the blood flow cannot be excluded, and might reflect minimal volume overload. no pleural effusions or pneumothorax are demonstrated. impression: focal areas of small patchy opacities, most likely due to atypical bacterial infection or viral pneumonia. volume overload cannot be excluded. brief hospital course: pt was given fluids in ed and admitted to 11 medical floor. her fingerstick blood sugars were followed and she was given insulin. dr. of consult team was consulted to evaluate the cause of her hyperglycemia. on the morning of , she was found rapidly unresponsive with a fingerstick of 60. her insulin pump was removed and a code blue was called, and the patient had no central or peripheral access. oral glucose was given and a small peripheral iv was placed during attempt at r femoral cvl. femoral cvl wire could not be advanced in the vessle. the patient had notable skin bleeding. direct pressure for 5 minutes held. through the left arm pvl 1xamp d50 was pushed with return to consciousness of the patient. while waiting for transfer to the micu, several minutes later the patient was noted to be twitching, and the lue pvl dislodged. at this time a second fs was 60, and she again was unresponsive, so a second code-blue was called. a left femoral cvl was placed, with some resistance to advancement of the wire, but the catheter was placed succesfully. 2 amps of d50 were given. she then was placed on a d5 drip and transferred to the micu. after line placement she was noted with petechia over her body, and it was not known if they were there before. hemolysis labs, coagulation profile and platelets were checked which were normal. in the micu she was given additional dextrose, with close followup by , was stabilized on a new regimen. it is unclear what caused the hypoglycemia, but it is through to be dose stacking with the pump. she was observed for 48h with stable blood sugars. 1. type 1 dm uncontrolled - consultation, with close f/u with dr. this week - continue pump 2. lue thrombophlebitis - d50 infiltration during code - no dvt on us - warm packs 3. hypothyroidism - synthroid 4. hyperlipidemia - lipitor 5. adhd - adderal 6. epilepsy - depakote medications on admission: medications - confirmed with pt all doses in ed at : 1. insulin pump with humalog. 2. protonix 40 mg p.o. b.i.d. 3. neurontin 900 mg q.a.m., 900 mg q. lunch, 1,200 mg q.h.s. 4. depakote er 1,500 mg q.d. 5. lipitor 10 mg q.d. 6. levoxyl 75 mg p.o. q.d. 7. hctz 12.5 mg po qd 8. lisinopril 40 mg po qd 9. adderal 20 mg po qd 10. luvox 250 mg po qd 11. asa 81 mg po qd discharge medications: 1. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 2. gabapentin 300 mg capsule sig: three (3) capsule po q8h (every 8 hours). 3. divalproex 500 mg tablet sustained release 24 hr sig: three (3) tablet sustained release 24 hr po daily (daily). 4. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 6. hydrochlorothiazide 25 mg tablet sig: 0.5 tablet po daily (daily). 7. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 8. dextrose (diabetic use) 300 mg tablet sig: one (1) tablet po prn (as needed). 9. adderall 10 mg tablet sig: one (1) tablet po once a day. 10. insulin take your insulin as previously directed by clinic discharge disposition: home discharge diagnosis: type 1 dm uncontrolled with complications lue thrombophlebitis hypothyroidism hyperlipidemia adhd epilepsy discharge condition: good discharge instructions: closely monitor your blood sugars, and if they become lower than 80, immediately consume sugar containing foods. closely monitor your insulin pump as instructed by your diabetes doctors followup instructions: dr. at clinic (please contact dr. for an appointment next week) dr. in , ma dr. at clinic provider: , md phone: date/time: 11:00 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Anemia, unspecified Esophageal reflux Unspecified acquired hypothyroidism Polyneuropathy in diabetes Other constipation Epilepsy, unspecified, without mention of intractable epilepsy Dehydration Other vascular complications of medical care, not elsewhere classified Phlebitis and thrombophlebitis of superficial veins of upper extremities Attention deficit disorder with hyperactivity Diabetes with neurological manifestations, type I [juvenile type], uncontrolled Schizoaffective disorder, unspecified Poisoning by insulins and antidiabetic agents Accidental poisoning by hormones and synthetic substitutes Obsessive-compulsive disorders

allergies: compazine, codeine, benzo's pt was admitted on for n/v/inability to eat after having the capsule study done in gi suite. admitted for observation and has had multiple complaints since admission of gas, abdominal distension, right flank pain. overnight she had been given mophine sq (she lost iv access and was not able to get iv in place) and then complained of itching all over. she was then given benadryl for the itchiness. her glucose this am was 275 before breakfast and she gave herself 3.1units reg insulin via her pump. she was alert at 9am and took all her am meds. at 10am she was seen by medical team and was unresponsive. bp 150/70, good sat fingerstick was 62. access was obtained and pt given d50w then d5w was hung. pt was seen twitching ?seizure and ?breathing. code was called and iv found to be infiltrated and femoral line was placed. pt woke somewhat and transported to micu for further care. left arm infiltrate elevated and cold compress applied but pt felf it to be too heavy. pharmacy called and treatment for d50 infiltrate initiated. elevate extremitiy. cold or warm compress as tolerated and medical team instilled hyaluronidase around infiltrate site. neuro: pt awake and alert with many complaints which make it difficult to tell which ones are more serious than the other. mae and follows commands. she has spastic movements with episodes of calling out at times but is able to stop and have a conversation and is able to stop them to eat. cooperative with care and pleasant. oriented times three but says she is confused. she thought it was the middle of the night once but oriented easily. still has complaints of right flank pain but has not needed any meds for it yet. cv: bp 100-140/60. hr 70's nsr. has left groin femoral line in place.ekg normal. resp: came to us on 100% nrb but quickly weaned to 2l n/c and the off. lungs clear with decreased sounds at bases. o2 sat 99% on ra. gi: abdomen is distended and non tender passing flatus easily. last bm restarted diabetic diet at 1430. only took small amts since she felt she might choke. gu: voiding well on bedpan. endocrine/diabetic: titrating insulin drip according to blood glucose. initially blood sugar was 379 and pt started on 1u/hr after 4 unit bolus. pt's glucose dropped quickly and pt started on iv dextrose in ivf at 2pm. will continue to check glucose q1hr and titrate drip as needed with plans for to come by this afternoon and restart pt on her insulin pump. id: given one dose of cefazolin because she was given groin line in code situation. pt is afebrile. wbc 4.0. two blood cultures sent as ordered. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Anemia, unspecified Esophageal reflux Unspecified acquired hypothyroidism Polyneuropathy in diabetes Other constipation Epilepsy, unspecified, without mention of intractable epilepsy Dehydration Other vascular complications of medical care, not elsewhere classified Phlebitis and thrombophlebitis of superficial veins of upper extremities Attention deficit disorder with hyperactivity Diabetes with neurological manifestations, type I [juvenile type], uncontrolled Schizoaffective disorder, unspecified Poisoning by insulins and antidiabetic agents Accidental poisoning by hormones and synthetic substitutes Obsessive-compulsive disorders

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: angina major surgical or invasive procedure: three vessel coronary artery bypass grafting utilizing left internal mammary to left anterior descending, and vein grafts to the pda and obtuse marginal. history of present illness: mr. is a 70 year old male with known coronary artery disease. he has been treated with medical therapy but has recently started to note exertional anginal symptoms. he underwent stress testing which was notable for ischemia. subsequent cardiac catheterization in revealed a right dominant system, severe three vessel disease including left main, and normal lv function(60%). angiography showed a 70% ostial left main stenosis, 80% mid lad lesion, ostial occlusion of the rca, and moderate disease in the circumflex. based on the above results, he was referred for surgical revascularization. past medical history: coronary artery disease, hypertension, hypercholesterolemia, diabetes mellitus type 2, ibs, history of syndrome, carotid disease s/p right and left carotid stenting in and social history: retired firefighter. lives alone. admits to 60 pack year history of tobacco, quit approximately 8 years ago. denies excessive etoh. family history: father with several mi's. brother died of mi in his 60's. physical exam: vitals: bp 168/62, hr 66, rr 16 general: well developed male in no acute distress heent: oropharynx benign, neck: supple, no jvd, heart: regular rate, normal s1s2, no murmur or rub lungs: clear bilaterally abdomen: soft, nontender, normoactive bowel sounds ext: warm, no edema, mild le varicosities noted pulses: 2+ distally neuro: nonfocal pertinent results: 06:37am blood wbc-11.6* rbc-3.37* hgb-10.5* hct-29.5* mcv-88 mch-31.2 mchc-35.6* rdw-14.5 plt ct-272 06:37am blood urean-13 creat-0.6 k-4.3 05:57am blood glucose-148* urean-18 creat-0.7 na-132* k-3.7 cl-93* hco3-28 angap-15 brief hospital course: on , mr. was admitted and underwent three vessel coronary artery bypass grafting by dr. . for surgical details, please see seperately dictated op note. following the operation, he was brought to the csru for invasive monitoring. within 24 hours, he awoke neurologically intact and was extubated without incident. he maintained stable hemodynamics as he weaned from inotropic support. low dose beta blockade was resumed and diuretics were initiated. all chest tubes and epicardial wires were eventually removed without complication. his csru course was uneventful and he transferred to the sdu for telemetry and further recovery. over several days, medical therapy was optimized. he made steady progress with physical therapy and continued to make clinical improvements. the rest of his hospital course was uncomplicated and he was medically cleared for discharge on postoperative day six. at discharge his bp was 120/56, with a heart rate in the 70's and oxygen saturation of 97% on room air. all wounds were clean, dry and intact without evidence of infection. medications on admission: aspirin 325 qd, metformin 500 qam, metformin 1000 at lunch and dinner, glyburide 10 , avandia 8 qd, lipitor 80 qd, zetia 10 qd, zestril 40 qd, norvasc 10 qd, plavix 75 qd, multivitamin discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*100 tablet, delayed release (e.c.)(s)* refills:*2* 3. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 6-8 hours as needed for pain. disp:*60 tablet(s)* refills:*0* 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 6. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. rosiglitazone 8 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* 9. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 10. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 5 days. disp:*10 tablet(s)* refills:*0* 11. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po q12h (every 12 hours) for 5 days. disp:*10 tab sust.rel. particle/crystal(s)* refills:*0* 12. metformin 500 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 13. metformin 500 mg tablet sig: two (2) tablet po qlunch and dinner (). 14. glyburide 5 mg tablet sig: two (2) tablet po bid (2 times a day). discharge disposition: home with service facility: discharge diagnosis: coronary artery disease - s/p cabg, hypertension, carotid disease - prior carotid stenting, diabetes mellitus type ii, history of syndrome, ibs discharge condition: good discharge instructions: patient may shower, no baths. no creams, lotions or ointments to incisions. no driving for at least one month. no lifting more than 10 lbs for at least 10 weeks from the date of surgery. monitor wounds for signs of infection. please call with any concerns or questions. followup instructions: cardiac surgeon, dr. in weeks. local pcp, . in weeks. local cardiologist, dr. in weeks. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Occlusion and stenosis of carotid artery without mention of cerebral infarction Other and unspecified angina pectoris Irritable bowel syndrome

allergies: patient recorded as having no known allergies to drugs attending: addendum: mrs. will be sent to rehabilitation on amiodarone 200 mg daily, ongoing. discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 6. amiodarone hcl 200 mg tablet sig: one (1) tablet po once a day. 7. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po daily (daily) for 7 days. capsule, sustained release(s) 8. zolpidem tartrate 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. discharge disposition: extended care facility: - md 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 Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Atrial fibrillation Rheumatoid arthritis

allergies: patient recorded as having no known allergies to drugs attending: addendum: pt. was to go to rehab but had intermittent afib. she was anticoagulated with heparin and coumadin and was loaded with amiodorone. she is now in sinus rhythm and her inr is 2.0 discharge disposition: extended care facility: - md 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 Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Atrial fibrillation Rheumatoid arthritis

allergies: patient recorded as having no known allergies to drugs attending: addendum: see previous addendum major surgical or invasive procedure: cabg x 4 on . discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 5. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). 6. amiodarone hcl 200 mg tablet sig: one (1) tablet po once a day. 7. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po daily (daily) for 7 days. capsule, sustained release(s) 8. zolpidem tartrate 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 9. lipitor 10 mg tablet sig: one (1) tablet po once a day. 10. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 11. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 12. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 13. lorazepam 0.5 mg tablet sig: one (1) tablet po q12h (every 12 hours) as needed. 14. warfarin sodium 5 mg tablet sig: one (1) tablet po once a day: inr goal 2-2.5. discharge disposition: extended care facility: - md 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 Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Atrial fibrillation Rheumatoid arthritis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: mild angina. major surgical or invasive procedure: cabg x 4 on . history of present illness: this is a 77 yo female patient without known history of cad. she had a stress test pre-op for total knee replacement that showed some lateral wall hk. she had proceeded with her knee surgery and had an elective cath at osh that showed a lcx occlusion. she was transferred here to the on for cath and planned pci. cath here revealed lad 80%, lcx 95%, and rca occlusion of 50%. she was then referred for cabg. past medical history: atrial fibrillation. hypertension. hyperlipidemia. osteoarthritsi. rheumatoid arthritis. macular degeneration. bilateral total knee replacements. social history: patient lives alone in , however she's been staying with her daughter in recently. she is retired. she continues to drive and be active. she has a 20 pack year smoking history but quit 37 years ago. family history: father with angina in his 60s. brother s/p cabg at age 70. physical exam: on discharge: vs: t 98.0 hr 78 sr bp 131/71 rr 18, o2 sat on ra 94%. weight: pre-op 75.5 kg, now 76 kg. neuro: alert, oriented, non-focal. pulmonary: lungs with crackles at bilat bases. cardiac: rrr. abdomen: soft, non-tender, non-distended, + bs. extremities: warm, 1+ edema. sternal incision without drainage pr erythema. left leg incision clean and dry. pertinent results: 06:10am blood wbc-9.2 rbc-2.68* hgb-8.4* hct-25.8* mcv-97 mch-31.3 mchc-32.4 rdw-14.9 plt ct-252# 06:10am blood plt ct-252# 06:10am blood glucose-96 urean-22* creat-0.7 na-131* k-5.2* cl-95* hco3-27 angap-14 06:05am blood calcium-8.3* phos-2.9 mg-2.2 brief hospital course: as per hpi. patient proceeded to the operating room with dr. on . she underwent a coronary artery bypass graft x 4 with the lima to the lad, svg to the rca, svg to the diag, and svg to the om. her total cardiopulmonary bypass time was 83 minutes, and her cross-clamp time was 65 minutes. she proceeded to the crdiac surgery recovery unit a-paced at a rate of 86 on neo and propofol drips. she was successfully extubated on the evening of her operative day. on post-operative day one she was transfused with one unit of packed red blood cells for a hct of 26.2. she was also transferred to the inpatient floor. on post-opertative day two her cardiac pacing wires and chest tubes were discontinued. she also experienced bursts of atrial fibrillation treated with po and iv beta blockade, magnesium, and amiodarone bolus. she converted to a nsr on the morning of pod three and was continued on po amiodarone and lopressor. over the course of pods four, five, and six mrs. activity level was increased and she was followed by the physical therapy team. she was also diuresed with iv lasix for le edema adn treated with anzemet for nausea. she was followed by physical therapy throughout her stay and was found to be progressing slowly -- she was therefore recommended for rehabilitation. medications on admission: atenolol 100 mg daily. cartia 240 mg daily. feso4 325 daily. lipitor 10 daily. aspirin 81 mg daily. bactrim ds 1 tab po bid x 5 days (last ). celebrex and humira d/c'd 10 weeks prior to surgery. discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 6. amiodarone hcl 200 mg tablet sig: two (2) tablet po bid (2 times a day) for 7 days. 7. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po daily (daily) for 7 days. capsule, sustained release(s) 8. zolpidem tartrate 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. discharge disposition: extended care facility: - discharge diagnosis: coronary artery disease, s/p cabg x 4. atrial fibrillation. osteo-arthritis. rheumatoid arthritis. discharge condition: stable. discharge instructions: no heavy lifting, greater than 10 pounds. no swimming or tub bathing. shower and wash incisions daily with mild soap. do not apply any creams, lotions, ointments, or powders. followup instructions: follow-up with dr. in weeks. follow-up with dr. in 4 weeks. follow-up with primary care physician weeks. 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 Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Atrial fibrillation Rheumatoid arthritis

history of present illness: this is a 65 year old pedestrian who was struck by a car was found asystolic and unresponsive in the field, full acls code was run and he was intubated and brought to after return of pulse. at computerized tomography scan of the head, chest x-ray and pelvis films were done with severe head injury noted, positive subarachnoid hemorrhage, epidural parenchymal bleed reported by head computerized tomography scan. he was given mannitol and transferred to with stable vital signs throughout his transit. he was given no sedation or paralytic at or in transit. past medical history: his only known past medical history is end stage renal disease on hemodialysis. medications/allergies: his medications and allergies are unknown. physical examination: his vital signs on arrival to showed a heartrate of 78, blood pressure of 220/palpable, respiratory rate 15 by ambu bag and oxygen saturation of 100%. on examination he had coma scale of 4t with decerebrate posturing. he was intubated and noted to have some emesis in the oral cavity around his endotracheal tube. his pupils were equal at approximately 2 mm. both tympanic membranes were obscured by wax without any blood noted. his left pinna had a degloving fresh extensive laceration injury in the posterior aspect of his head, a lot of soft tissue swelling and lacerations and obvious depressed skull fracture. he had abrasions of bilateral temples, though his facies was stable. his trachea was midline. his lungs were clear. his heart was regular in rate and rhythm. his abdomen was soft. his pelvis was stable. he had normal rectal tone and was guaiac negative with a normal prostate. he had a foley catheter in place with clear yellow urine draining from it. he has ecchymosis and abrasions noted in the right knee as well as abrasions in his right foot and left hand. on examination of his back, his spine had no stepoff. laboratory data: laboratory data returned with a white count of 26.3, plus hematocrit of 29.5 and platelets of 203. his bun and creatinine were 45 and 7.2. pt was 14.2 and ptt 33.7, inr 1.3. he had a negative toxicology screen and amylase of 196, fibrinogen 166. urinalysis was negative with the exception of 21 to 50 red blood cells, and an arterial blood gases that was 7.36/36/350/21/-4. studies ordered included a head computerized tomography scan, repeated from the study, the one done here shows bilateral subdural hemorrhages with midline shift toward the left side, herniation and infarcted brain, a left frontal contusion, depressed skull fractures and a left subarachnoid hemorrhage. computerized tomography scan of the neck revealed a c1 fracture with cord compression. computerized tomography scan of the chest and abdomen were negative for injury. hospital course: neurosurgery evaluated the patient in the computerized tomography scanner and in the trauma bay and determined that his head injury was so extensive as to not be operable. this was discussed with the patient's family at length while he was brought up to the trauma surgery intensive care unit. the family understood the severity of injury and the fact that it was nonsurvivable and shared with us that the patient would not have wanted to be kept alive in this state. therefore, all care was withdrawn and his endotracheal tube was removed. he expired shortly thereafter at 10:57 pm on . , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Compression of brain Cerebral artery occlusion, unspecified with cerebral infarction Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with prolonged [more than 24 hours] loss of consciousness, without return to pre-existing conscious level

history of present illness: this is an 83 year old male with a past medical history of migraine headaches, hypercholesterolemia, and gastroesophageal reflux disease who presented to the emergency room as a transfer from hospital with complaints of left-sided weakness. the patient was found to have a large right parietal occipital inter-parenchymal hemorrhage. he was found on the floor by his family, unable to get up prior to his presentation at hospital. he had been prior independent, alert, and communicating clearly. neurologically, the patient was alert and oriented times three. pupils were equal and reactive. extraocular movements were full. his face was symmetrical. hospital course: the patient did exhibit left hemiparesis and left-sided hemineglect. the patient was placed on a nipride drip in the emergency room for blood pressure of 200 systolic. the patient was started on dilantin and was given 1 unit of fresh frozen plasma for inr of 1.5. the patient was placed on fluid restriction, 1 liter once daily and placed on a nipride drip to keep the systolic blood pressure less than 140. the patient received 50 grams of mannitol times one dose in the emergency room and was eventually placed on mannitol 15 mg q6 hours. the patient was placed on levaquin for pneumonia and eventually received 4 units of fresh frozen plasma total. on , left external ventricular drain was placed at 7 cm without complications for increased intracranial pressure of 20. repeat head ct on at 10:00 p.m. revealed no change. on , the patient's creatinine began to rise to 3.9. the patient was started on gentle hydration and mannitol was held. the patient neurologically opened eyes and moved right side briskly, but did not follow any commands on . two feeds were started at . intracranial pressures remained 16 to 18 on . the patient was started on labetalol drip to keep blood pressure less than 140. the patient was placed back on a fluid restriction of 1.5 liters once daily on . creatinine dropped backed to 2. subsequent head ct's revealed persistent inter-parenchymal hemorrhage with some subarachnoid hemorrhage, subdural hemorrhage, and interventricular extensions. the patient's prognosis was discussed with family and the patient was made "do not resuscitate" and "do not intubate" by son who is the healthcare proxy. the patient spiked a temperature on and was pan cultured. cerebrospinal fluid was sent which was negative for organisms. the patient was started on a morphine drip on . on , the patient's family decided the patient should have comfort measures only. on , at 5:10 p.m. team was called to evaluate the patient for respiratory arrest. the patient is a "do not resuscitate" and "do not intubate" and had been on a morphine drip for comfort measures since . the patient had no pulse, no respiratory effort, no corneal reflexes, and was unresponsive to noxious stimuli. at that time, he was pronounced dead at 17:10 on . the patient's family was notified. , m.d. dictated by: medquist36 Procedure: Intravascular imaging of intrathoracic vessels Arterial catheterization Diagnoses: Pneumonia, organism unspecified Acute kidney failure, unspecified Subarachnoid hemorrhage

allergies: zosyn attending: chief complaint: hypoxia, seizure major surgical or invasive procedure: intubation and mechanical ventilation history of present illness: 51 y/o f with h/o hep c, copd, and sz disorder presents from home w/ hypoxia and ?seizure. recent micu admit with respiratory failure requiring intubation and subsequent tracheostomy attributed to ards (suspected viral etiology). she was treated w/ broad spectrum antibiotics and steroids. course c/b vap due to klebsiella and serratia ( meropenem; res cephalosporins), coag (-) staph line infection (s/p vanco x 14 days). pt was discharged to rehab ; trach removed and pt d/c home . she initially went to in-laws with husband for 4-5 hours, the three of whom were recently diagnosed with bronchitis. she then went to stay with her sister and mother for 1 week were she received vna services. on , she went to her home with her husband, who she had not been exposed to in 1 week. on , she c/o being tired. on day of admission, . per family, pt awoke feeling "" and short of breath. because she felt like she was going to have a seizure, she presented to osh, where she was noted to be hypoxic 84% ra -> 90s on 100% nrb. an x-ray shwed bilateral infiltrates, and she received levofloxacin 500 mg iv x 1 and was transferred to for further management. in pt 96% 100% nrb, sbp 80s-90s. she was initially conversant, however then she had episodes where her eyes rolled up in her head, and she began posturing her upper extremities. each episode lasted 10-15 seconds, occurring every 1-2 minutes for a total of 20 minutes. she received 2 mg iv ativan for suspected seizure, after which she was somnolent. neuro was consulted, who was concerned for status epilepticus and pt received 20 mg/kg iv fosphenytoin. further history/ros could not be obtained patient's mental status. . she had a course in the micu which was complicated by failed extubation on and . and had bronchoscopy which on microbiology but not pathology showed viral cytopathic changes, possibly c/w cmv pneumoitis, but no immunostains had been done. she has had a history in the past of klebsiella and serratia vap (pan-sensitive) and one klebs blood cx which was esbl, but on this admission has not had any positive cultures for blood, sputum, bal, csf, urine, c diff tox, flu, or legionella. tte has shown diastolic dysfunction with ef 60% and 1+ mr and mild-mod pulmonary artery htn. bb have been controlling her rate well. . she has been on moerately high doses of benzodiazepines for sedation. and on prednisone for stress dosing, and has been weaning off of both. she also recently had her ngt removed and with a (+) gag reflex was started on a nectar thick diet until video swallow assessment could be made. in the meantime, her glargine has been held due to low oral intake. . her subclavian and arterial lines have been removed and she is maintained by peripheral iv's. past medical history: 1) copd 2) hepatitis c 3) seizure disorder 4) depression 5) recent admission w/ ards c/b vap and line infection (see above) 6) percutaneous tracheostomy () 7) egd with peg placement () social history: + tob, 1.5 ppy x many years, no etoh, lives with husband though recently stayed with mother and sister after rehab, has a 25yo son physical exam: admission physical exam: pe: tc 99.7 (rectal), pc 94, bpc 91/53, resp 16, 100% nrb gen: middle-aged female, initially somnelent, not responsive to sternal rub, then opens eyes and answers simple questions (oriented only to self), follows simple commands heent: perrl, eomi, anicteric, pale conjunctiva, omm slightly dry, op clear, neck supple, no lad, no jvd cardiac: rrr, ii/vi sm at rusb, no r/g pulm: crackles at bases bilaterally. occasional upper-airway ronchi abd: nabs, soft, nt/nd, no masses ext: 1+ pedal edema neuro: perrl, eomi, face symmetrical, (+) gag, moves all 4 extremities in response to painful stimuli. 2+ dtr bilaterally, 3+ dtr le bilaterally. pertinent results: 12:55pm pt-14.6* ptt-33.2 inr(pt)-1.3 12:55pm plt count-175 12:55pm hypochrom-3+ poikilocy-1+ 12:55pm neuts-82.1* lymphs-13.8* monos-3.8 eos-0.2 basos-0.2 12:55pm wbc-25.9*# rbc-3.59* hgb-9.6* hct-31.4* mcv-88 mch-26.8*# mchc-30.6* rdw-14.0 12:55pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 12:55pm tsh-0.75 12:55pm vit b12-780 folate-7.0 12:55pm albumin-3.4 calcium-8.4 phosphate-3.5 magnesium-1.6 12:55pm ck-mb-9 ctropnt-0.05* probnp-585* 12:55pm lipase-11 12:55pm alt(sgpt)-50* ast(sgot)-77* ck(cpk)-225* alk phos-100 amylase-21 tot bili-0.3 12:55pm glucose-127* urea n-11 creat-0.4 sodium-142 potassium-3.7 chloride-106 total co2-32* anion gap-8 01:02pm lactate-1.4 01:27pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 01:27pm urine color-yellow appear-clear sp -1.016 01:27pm urine gr hold-hold 01:27pm urine hours-random 02:40pm type-art po2-139* pco2-76* ph-7.24* total co2-34* base xs-2 02:10pm ammonia-83* 04:10pm po2-80* pco2-80* ph-7.22* total co2-34* base xs-1 04:10pm lactate-1.0 04:10pm %hba1c-6.0* -done -done 04:30pm phenytoin-24.1* 09:05pm type-art temp-37.2 po2-172* pco2-60* ph-7.29* total co2-30 base xs-1 intubated-intubated 10:00pm cortisol-13.2 10:00pm calcium-8.1* phosphate-2.3* magnesium-1.4* 10:00pm ck-mb-6 ctropnt-0.04* 10:00pm glucose-115* urea n-10 creat-0.3* sodium-142 potassium-3.0* chloride-107 total co2-31* anion gap-7* 10:35pm cortisol-16.1 11:05pm cortisol-16.5 brief hospital course: note: the patient was discharged against medical advice. please see the section "disposition" for the relevant details. the hospital course up to this point is summarized first: a/p: 51 yof w/ h/o copd, seizure disorder recent admit w/ ards presents w/ leukocytosis, hypoxia, and episodes concerning for seizure. intubated with ards of unclear etiology, failed extubation x2 ( and ) with hypoxic resp failure of unclear etiology. * 1) hypoxic/hypercarbic respiratory failure and ards: unclear cause. all cultures were negative, including blood, sputum, bal, csf, urine, c dif, flu, legionella. intubated in ed with abg of 7.26/76/139. on nebs, flovent. pt was covered for 1 week with meropenum, azithro, vanco until (pt has h/o klebsiella/serretia vap and esbl klebs bacteremia). second attempt at extubation was attempted , and the patient did well initially, but then acutely desaturated and was reintubated. aspiration vs. flash pulm edema were considered as factors complicating extubation. . pt was beta-blocked and a swan-ganz catheter was in place before the third extubation attempt on in order to diagnose and manage acute manifestations of heart failure upon extubation. bal microbiology but not pathology showed cytopathic changes but viral and bacterial cultures as well as cmv immunology were negative. . 2) seizure: pt has a h/o seizure disorder, the precipitant of which may be proximate to inadequate treatment on a single (dilantin) in the setting of fever and hypoxia. head ct and urine tox were neg. an eeg showed diffuse encephalopathy without status epilepticus. additional history obtained from outpt neurologist dr. showed that the pt presented to regional with generalized tonic-clonic seizure on with dilantin level of 22, started on zonegran because she failed a single , and was discharged on hd#2 with normal mental status. at the , she required successive reloading of dilantin -20, before the patient left against medical advice. despite leaving against medical advise before a therapeutic serum level of dilantin could be achieved, the patient was nevertheless scheduled with her primary care physician for dilantin dose adjustment. she was also scheduled in seizure clinic at the for follow-up of her seizure disorder. zonegran was increased to 300mg qd (on ) after 2 weeks of 200mg. * 3) leukocytosis and fever: pulmonary source was initially suspected (ddx: hap, aspiration pneumonia/pneumonitis) given the patient's hypoxia and bilateral infiltrates. u/a negative, bcx ngtd, csf neg, bal and sputum neg. c dif neg x 4. empiric oral vanco d/c'd . covered w/ meropenem/azithro empirically to cover hap/aspiration pneumonia x 1 week until . spiked on to 101 and re-cultured without any growth in culture. * 4) sepsis/hypotension/adrenal insufficiency: pt was initially on levophed, weaned off after fluid resusitation. minor troponin leak to 0.05. ef by echo 60% with 1+mr. pt was on steroids for ards during last recent admission, and was started on hydrocortixone for a positive cortisol stim test, which showed adrenal insufficiency with a maximal cortisol of 16-17. her hypotension did resolve with stress-dose steroids in a few days. she has been on a prednisone taper, receiving 7.5 mg on , and due to receive 5 mg on . because of the adrenal insufficiency documented by absolute value as well as a relative value, the patient was scheduled for follow-up in endocrinology clinic within 1 month from discharge. she was discharged on prednisone 10mg until this appointment. * 5) pulm edema: ef 60%. pt with pulm edema on after extubation resulting in reintubation. have been due to post-negative pressure pulm edema or flashing due to possible diastolic dysfunction. diuresed but again showed signs of chf after fluid resusitation. swan placed with mixed picture before diuresis. decreased svr and high ci supported a septic physiology, but a high cvp supportive of chf. pt developed upper and lower extremity edema that started to resolve with gradual diruesis. she has been euvolemic on exam for over 4 days preceding discharge. * 5) anemia of chronic disease: the paient's baseline 26-28 from prior admission. vit b12 and folate wnl. transfused 2 units but otherwise has not required any blood products. hct remained stable and >28 without additional transfusions. . 6) thrombocytopenia: hit negative, lfts unchanged. platelets improved with improvement of acute illness. * 7) borderline type ii dm: hba1c = 6.0. pt was temporarily on an insulin drip while on tpn and hydrocortisone, transitioned to insulin glargine with sliding scale, but since the patient had poor oral intake, she had glargine held x 5 days and did not require dosing in the hospital. the patient was instructed to hold any additional insulin and covered with riss until 1 day prior to admission when the patient's glood sugar. she began taking better oral intake before discharge. * 8) nsvt: documented on evening of . multiple 3-4 beat runs over a minute with sinus beats in between. likely due to concurrent medical illness, resolveing the etiology was not clear. electrolytes were normal. pt was asymptomatic without further events. * 9) diastolic dysfunction: ef 60% with 1+ mr, mild-mod pulmonary artery htn. bb has been controlling her rate well. * 10)hepatitis c: mild transaminitis, not significantly changed from prior admission * 11)depression: will restart prozac . 12)f/e/n: tube feeds by nasogastric tube started . -once the ng tube was removed, the pt was noted to have a (+) gag reflex and was advanced to nectar thickened diet until video swallowing study could confirm that she could safely swallow. the patient was seen on the video study to have aspiration with thin liquids. she nevertheless refused to maintain a diet of thickened liquids, despite numerous conversations informing her that this diet may only be for a limited time until her swallow improved and informing her of the risks of swallowing thin liquids such as recurrent aspiration, pneumonia, intubation, or death. - electrolytes monitored and repleted as needed * 13)ppx: heparin sq, pneumoboots, iv lansoprazole. * 14)access: left subclavian and right a-line d/c'd after patient transferred to the medical floor from the icu. afterwards, the patient was maintained with pivs. * 15)code: full code, confirmed by sister. * 16)comm: (home), (his mother's home where he is staying), sister (home), (work). . 17)dispo: the patient was seen by pt who, along with the medical and nursing staff, felt that the patient was not safe for independent discharge because of weakness, imbalance, and because of low dilantin level which would require further loading with dilantin. the patient refused discharge to rehabilitation, stating that she had spent too much time already in the hospital and rehabilitation hospital. multiple conversations informed her of the risks of aspiration, seizure, fall, head injury, and death, but the patient nevertheless demanded to sign out of the hospital against medical advice and left in this manner despite recruiting the patient's husband and daughter to convince the patient. mrs. was discharge against medical advice on , and refused to wait until services could be set up for the patient, noting that she would set them up herself. medications on admission: prozac 20 oxybutynin patch monday and thursday protonix 40 qd dilantin 450 qd combivent two puffs qid albuterol 1 prn tylenol prn an anti-epileptic started recently starting with "z", ?zonergan discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). disp:*1 inhaler* refills:*2* 2. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q2h prn (). disp:*1 inhaler* refills:*2* 3. fluticasone propionate 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). disp:*1 inhaler* refills:*2* 4. albuterol sulfate 0.083 % solution sig: one (1) nebulizer treatment inhalation q6h (every 6 hours) as needed. disp:*25 nebulizer treatment* refills:*0* 5. ipratropium bromide 0.02 % solution sig: one (1) nebulizer treatment inhalation q6h (every 6 hours). disp:*50 nebulizer treatment* refills:*2* 6. zonisamide 100 mg capsule sig: two (2) capsule po daily (daily). disp:*60 capsule(s)* refills:*2* 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 8. multivitamin capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 9. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for headache. disp:*50 tablet(s)* refills:*0* 10. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po tid (3 times a day): because you left the hospital ama, you are not yet at the correct blood level of this medication. you should be mointored on it. disp:*90 capsule(s)* refills:*2* 11. 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* 12. prednisone 10 mg tablet sig: one (1) tablet po once a day: you should not stop this medication until you are tested in the endocrine clinic. disp:*30 tablet(s)* refills:*2* 13. fluoxetine hcl 20 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 14. diphenoxylate-atropine 2.5-0.025 mg tablet sig: one (1) tablet po q6h (every 6 hours). disp:*120 tablet(s)* refills:*2* 15. lorazepam 1 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: 1. recurrent respiratory failure. 2. seizure. 3. hospital acquired pneumonia. 4. diastolic heart failure. 5. adrenal insufficiency. 6. non-sustained ventricular tachycardia. 7. non-immune mediated thrombocytopenia. 8. diarrhea nos. 9. aspiration with thin liquids secondary/past medical history: 1. copd. 2. hepatitis c. 3. seizure disorder. 4. adult respiratory distress syndrome. 5. ventilator associated pneumonia. 6. coagulase negative line sepsis. 7. diabetes mellitis type ii. 8. percutaneous gastrostomy tube. discharge condition: fair. discharge instructions: patient is leaving against medical advice. we have explained to her in detail our recommendations for inpatient rehabilitation, but she refuses. we have also made clear that she is at increased risk for morbidity, rehospitalization, or mortality. she was lucid and understood the implications of her decision. instructions to patient: continue taking prednisone for adrenal insufficiency until instructed otherwise by your physician. loperamide for diarrhea. follow-up on friday (the next available appointment) with dr. for adjustment of your seizure medicine--because you left the hospital early against medical advice, you have not reach the correct blood levels of the medicine and are at risk for seizure because you cannot be appropriately monitored and have your medications appropriately adjusted. followup instructions: you must see your physician . on friday at 12:45pm, the next available appointment, to have your dilantin level checked. it is low and you are at risk of seizure by leaving the hospital with a low level despite increasing the dose. additionally, you have been made a follow-up in neurology clinic on friday at 9am for an appointment with dr. of the neurology department seizure division. you need to call to give your registration information. provider: , md where: neurology phone: date/time: 9:00 finally, please follow-up in endocrine clinic to determine whether you have adrenal insufficiency. do not stop taking prednisone until you are instructed otherwise. provider: . where: medical specialties phone: date/time: 10:00 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Insertion of endotracheal tube Arterial catheterization Closed [endoscopic] biopsy of bronchus Pulmonary artery wedge monitoring Transfusion of packed cells Electroencephalogram Diagnoses: Acidosis Thrombocytopenia, unspecified Anemia of other chronic disease Anemia, unspecified Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Unspecified viral hepatitis C without hepatic coma Other chronic pulmonary heart diseases Other convulsions Sepsis Paroxysmal ventricular tachycardia Acute respiratory failure Pneumonia due to Pseudomonas Pneumonitis due to inhalation of food or vomitus Personal history of noncompliance with medical treatment, presenting hazards to health Chronic obstructive asthma, unspecified Diastolic heart failure, unspecified Cytomegaloviral disease Alcohol abuse, continuous Pneumonia in cytomegalic inclusion disease

allergies: zosyn attending: chief complaint: respiratory distress/?ards major surgical or invasive procedure: percutaneous tracheostomy () egd with peg placement () history of present illness: 51f with pmh sig for copd, hep c, depression, sz d/o who presented to osh p 4 days of progressive sob and subjective fevers at home. 2 days pta, pt seen by pcp with /o cough prod of yellow sputum and was started on levoquin for question of pna. pt presented to osh after hallucinating at home and increasing sob. pt awoke the night of admission at home and insisted to husband that there was someone in the house when there was not. at osh cxr showed bilateral infiltrates and was found to be hypoxic with o2 sat of 76% on ra. at that time, she was thought to have worsening pna +/- chf. her bnp was elevated in the 800's. she was started on bipap and transferred to the icu. she was given ceftaz and clinda as well as steroids for presumed copd flare. she was diuresed with lasix. her oxygenation did not improve and she was combative with bipap, so was intubated . she had a cta that was negative for pe, but showed patchy ground glass infiltrates with septal thickening consistent with "crazy paving". radiology ddx included ards, pcp pna, alveolar proteinosis, among others. vancomycin and bactrim were added. during the course at the osh, the pt had elevated cks to 2400 with negative mb fraction and negative troponin i. her ekg shows small 1mm st depressions in the lateral leads from . she had a negative ua, negative influenza dfa, sputum cx that grew , no pcp x 2. tox screen was + for opiates on admission. pt was started on zydis for hallucinations before intubation. on arrival to , pt was intubated and sedated, unable to answer questions. no family available for further history. past medical history: copd hepatitis c seizure disorder depression social history: + tob, 1.5 ppy x many years no etoh physical exam: admission physical exam: 98.4, bp 98/56, hr 82 rr 12 90% on ac 400 x 24 fio2 100% peep 12 pplat 22 gen: intubated, sedated skin: spider angioma on chest heent: perrl neck: intubated chest: good air movement, scattered rales at bases cv: rrr, no mrg abd: soft, nd + bs ext: no edema, + r groin line * physical exam on transfer: t 98.4, tc 98.2, bp 102-115/58-61, hr 80-92, rr 20, 95-98% on trach 40% fio2 (12 l/min) gen- chronically ill appearing, c/o pain in buttocks heent- eomi. pupils 5->3 b/l. non-icteric, non-injected sclera neck- trach collar in place pulm- coarse bs b/l. no focal ronchi or rales cv- rrr. normal s1/s2. no m/r/g abd- peg tube in place w/ minimal erythema. no pus or bleeding from site. nt/nd. nabs ext- 3+ b/l le edema. globally weak. ue strength b/l(able to resist some against gravity); weak grip. poor rom of le's secondary to edema. sensation intact b/l ue's/le's. neuro- oriented to person, place, not time. language raspy but appropriate medications on admission: famotidine methylprednisolone 125 q4 phenytoin 300 qd fluoxetine 40 ceftaz 1 vanc 1 heparin sc clindamycin 600 tid olanzapine prn mso4 prn cisatracurium gtt ativan gtt albuterol nebs prn atrovent nebs prn bactrim dopamine gtt discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. fluoxetine hcl 20 mg/5 ml solution sig: one (1) po bid (2 times a day). 3. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 4. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed). 5. artificial tear ointment 0.1-0.1 % ointment sig: one (1) appl ophthalmic prn (as needed). 6. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 7. sodium chloride 0.65 % aerosol, spray sig: two (2) spray nasal qid (4 times a day). 8. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 9. phenytoin 100 mg/4 ml suspension sig: one (1) po qd at 1200 (). 10. phenytoin 100 mg/4 ml suspension sig: one (1) po bid at 0400 and (). 11. lorazepam 1 mg tablet sig: one (1) tablet po every eight (8) hours: 1mg q8 1mg q12 1mg q6prn continuous. 12. haloperidol lactate 2 mg/ml concentrate sig: one (1) po bid (2 times a day) as needed for agitation. 13. albuterol 90 mcg/actuation aerosol sig: eight (8) puff inhalation q2-4h (every 2 to 4 hours) as needed. 14. ipratropium bromide 18 mcg/actuation aerosol sig: six (6) puff inhalation q4-6h (every 4 to 6 hours) as needed. 15. acetaminophen-caff-butalbital mg tablet sig: tablets po q4-6h (every 4 to 6 hours) as needed for headache/migraine. 16. insulin nph human recomb 100 unit/ml suspension sig: fifteen (15) units subcutaneous twice a day. 17. insulin regular human 300 unit/3 ml syringe sig: sliding scale units subcutaneous qachs: per sliding scale table. discharge disposition: extended care facility: - discharge diagnosis: acute respiratory distress syndrome ventilator associated pneumonia seizure disorder chronic hepatitis c depression discharge condition: stable discharge instructions: please follow up with your primary care doctor once completed rehab followup instructions: please follow up with your primary care doctor 1-2 weeks after leaving rehab facility Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Transfusion of packed cells Infusion of vasopressor agent Diagnoses: Pneumonia due to other gram-negative bacteria Congestive heart failure, unspecified Chronic hepatitis C without mention of hepatic coma Acquired coagulation factor deficiency Chronic airway obstruction, not elsewhere classified Other convulsions Hypopotassemia Acute and chronic respiratory failure Hypotension, unspecified Pneumonitis due to inhalation of food or vomitus Bacteremia Infection and inflammatory reaction due to other vascular device, implant, and graft Acute diastolic heart failure Opioid abuse, unspecified Pneumonia due to Klebsiella pneumoniae Viral pneumonia, unspecified

history of present illness: the patient is a 39-year-old male who developed sudden onset of severe headache approximately three to four weeks ago. the patient describes having constant headache without a history of head trauma. there is a positive family history of aneurysm. the patient was admitted for diagnostic angio. physical examination: notably, his neuro exam was essentially nonfocal. hospital course: a diagnostic angio was performed. the patient's cerebral vasculature, it was noted that there was a left internal carotid artery aneurysm. the patient received endovascular placement of stent and coil. the patient did extremely well postoperatively. the sheath was removed on postop day #1 without any evidence of hematoma formation. the patient was continued on heparin until the day prior to discharge when it was dc'd. however, he was continued on aspirin and plavix. the patient was discharged in stable condition. he was ambulating, voiding and defecating without difficulty. his neurologic exam remained stable throughout. discharge condition: stable. discharge status: to home. discharge diagnosis: aneurysm, status post aneurysmal clipping, coiling and stenting. discharge medications: 1) plavix 75 mg qd, 2) aspirin 325 mg po qd, 3) colace 100 mg po bid, 4) percocet 1-2 tabs q 4-6 h prn. follow-up: scheduled with dr. in one week. the patient was instructed to call to schedule this appointment. , m.d. dictated by: medquist36 Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Accidental puncture or laceration during a procedure, not elsewhere classified Cerebral aneurysm, nonruptured Backache, unspecified

allergies: pcn, sulfa meds: tenormin, asa, maxide ros: neuro: (a&o in ew). arrived in sicu v belligerent and unable to cooperate. she mae and will grasp hands bilat but will not follow any other commands or answer questions. c collar on and remains on logroll precautions. dilantin load given. no sz activity. cv: initially htn and started labetalol gtt after one dose of 10mg labetalol. now bp 88-100/50 and labetalol off. hr 70's nsr w/ frequent apc's. renal: adequate u/o via foley. k=2.9. ivf w/ 60 kcl. pt will need central line. ca low. gi: dry heaves on arrival. zofran for nausea, resolved. abd soft distended. heme: hct 26.8 down from 31. no evidence of active bleeding. id: afebrile, wbc 22.8. clinda given in or. skin: echymosis all over body w/ lge contusions on l ankle and r knee. pink area on coccyx. a: altered neuro status. hypotensive w/ apc's. Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Incision of abdominal wall Suture of artery Diagnoses: Closed fracture of second cervical vertebra Traumatic hemothorax without mention of open wound into thorax Closed fracture of scapula, unspecified part Accidental fall from or out of building or other structure Closed fracture of clavicle, unspecified part Closed fracture of three ribs Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Dissection of aorta, unspecified site

history of present illness: the patient is an 80 year-old woman that fell fourteen feet from her porch onto her left side with questionable loss of consciousness. the patient was worked up at an outside hospital and transferred to for further management of multiple trauma. her multiple trauma included a subarachnoid hemorrhage with intraparenchymal blood. a c2 transverse foramina fracture, left 5th, 6th and 7th rib fractures, aortic laceration versus dissection. the patient had ct angiogram, which confirmed aortic dissection without extravasation. portion of a right tibial plateau fracture, which is old versus new. the patient had negative right knee film and negative right tibia fibula films. the patient has left clavicle fracture. left ankle negative for fracture and the patient has a left scapular fracture. on , the patient required 3 units of packed red blood cells. she had a repeat ct of the chest, which showed blood in the chest and with aortic disruption and intraparenchymal bleed in the spleen. the patient had a chest tube placed on for hemothorax. on arrival to the cicu the patient was belligerent and uncooperative. she moved all extremities. bilateral grasp strong and unable to follow commands or answer questions. she had a c collar in place and remained on log rolling precautions. she was loaded with dilantin. she had no evidence of seizure activity. the patient had an arteriogram to delineate the aortic dissection. during the procedure the catheter broke off in her artery. she was taken emergently for a cut down to have that removed. that was done successfully and there were no complications from that. the patient was extubated on . she was awake, alert and oriented times three and moving all extremities strongly. she had periods of confusion on and off with periods of agitation. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Incision of abdominal wall Suture of artery Diagnoses: Closed fracture of second cervical vertebra Traumatic hemothorax without mention of open wound into thorax Closed fracture of scapula, unspecified part Accidental fall from or out of building or other structure Closed fracture of clavicle, unspecified part Closed fracture of three ribs Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Dissection of aorta, unspecified site

service: neurosurgery history of present illness: the patient is an 80 year-old woman that fell fourteen feet from her porch onto her left side with a question of loss of consciousness. the patient was worked up at an outside hospital and transferred to for management of multiple hemorrhage with intraparenchymal blood, c2 transverse fracture, left 5th, 6th and 7th rib fracture, aortic dissection without extravasation, grade 2 spleen laceration, left scapular fracture and left clavicle fracture. the patient was taken emergently to the angiogram suite where an angiogram was performed to evaluate the aortic dissection. a partial cerebral angiogram was then performed but could not be completed because of the patient's dilated thoracic aorta and calcified arch despite attempts with mutiple catheter types. during the procedure the catheter became twisted and could not be retrieved throught the vascular sheath. the patient was taken urgently to the operating room to have a cut down and extraction of the angiocatheter. the procedure was done without complications. postoperatively, the patient was monitored in the surgical intensive care unit. she was awake and oriented times two with some periods of agitation and moving all extremities strongly. she was breathing spontaneously. she required three units of packed red blood cells on . ct of the chest revealed aortic dissection with blood in the chest with aortic disruption. ct surgery was called and the patient had a chest tube placed for hemopneumothorax. the patient required no surgical intervention for any of her fractures. she was monitored iwth strict blood pressure control for her aortic dissection, which required no surgical intervention. the patient had mra/mri of the head and neck to rule out vertebral and a carotid dissections, which was negative. the patient was transferred to the floor on . she was seen by physical therapy and occupational therapy and was found to require rehab prior to discharge to home. her chest tube remained in placed until when it was discontinued. chest x-ray post chest tube removal showed no evidence of pneumothorax. the patient's vital signs remained stable. she remained afebrile throughout her hospital stay. medications on discharge: percocet one to two tabs po q 4 hours prn, tylenol 650 po pr q 4 hours prn, zantac 150 mg po b.i.d., dilantin 100 mg po t.i.d., labetalol 200 mg po t.i.d., levaquin 500 mg po q day. the patient did have an increase in her respiratory rate with fever spike on . chest x-ray showed left retrocardiac pneumonia. the patient was started on levaquin 500 mg po q day times ten days. the patient is currently on room air. sats are in the high 90s. her respiratory rate is in the 20s. her other vital signs were stable. neurologically, she is awake, alert and oriented times three, moving all extremities strongly with no drift and no extremity weakness. the patient will be transferred to rehab with follow up with dr. in one month's time with repeat ap and lateral c spine films and head ct at that time. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Incision of abdominal wall Suture of artery Diagnoses: Closed fracture of second cervical vertebra Traumatic hemothorax without mention of open wound into thorax Closed fracture of scapula, unspecified part Accidental fall from or out of building or other structure Closed fracture of clavicle, unspecified part Closed fracture of three ribs Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Dissection of aorta, unspecified site

history of present illness: this is a 50-year-old male with poorly controlled hypertension and hyperlipidemia with atrial fibrillation refractory to cardioversion. the patient has been cardioverted every few months since , but unfortunately remains in normal sinus rhythm for a few weeks after cardioversion. a radiofrequency ablation was attempted in but was aborted due to an episode of hypotension in the catheterization laboratory. he was admitted on and underwent an elective radiofrequency ablation which was complicated by septal perforation and cardiac tamponade with hypotension. a pericardial drain was placed and drained for a few hours. it was pulled after a repeat echocardiogram demonstrated no re-accumulation of fluid. he was then discharged home on and was without complaints until three days prior to the current admission when he noticed increased shortness of breath, chest pain, and presyncopal symptoms. he followed up with his primary care physician who sent him in for a transthoracic echocardiogram which showed re-accumulation of pericardial fluid. he was brought to the catheterization laboratory at where he was found to have equalization of pressures (right atrial was 17, right ventricular was 40/25, pulmonary capillary wedge pressure was 22, pulmonary artery pressure was 42/25). a pericardicentesis was performed in which 350 cc of bloody fluid was withdrawn. he was then admitted to the coronary care unit for hemodynamic monitoring and treatment with the pericardial drain in place. past medical history: 1. hypertension. 2. asthma. 3. hyperlipidemia. 4. gout. 5. atrial fibrillation. 6. spinal cord injury, status post motor vehicle accident. 7. peptic ulcer disease without symptoms for the last 20 years. medications on admission: outpatient medications included lipitor 10 mg p.o. q.d., losartan 100 mg p.o. q.d., atenolol 50 mg p.o. q.d., rythmol 225 mg b.i.d., probenecid 500 mg p.o. b.i.d., aspirin 81 mg p.o. q.d. allergies: zestoretic causes gastrointestinal upset. penicillin (allergic reaction during childhood). allopurinol causes facial swelling. past surgical history: 1. neck surgery secondary to motor vehicle accident. 2. laryngeal polyps which were removed as a teenager. social history: he denies any tobacco use, occasional alcohol use. physical examination on presentation: physical examination on admission to the coronary care unit revealed a temperature of 100.1, blood pressure was 134/89, heart rate was 79 in normal sinus rhythm, respiratory rate was 25, oxygen saturation was 97% on room air. swan numbers were pulmonary artery pressure of 19/13, a cpp of 8. in general, the patient was in no apparent distress. he was mildly obese and was in moderate pain. head, eyes, ears, nose, and throat revealed the oropharynx was clear. mucous membranes were moist. there were no carotid bruits, and he had anicteric sclerae. his chest was clear to auscultation bilaterally. the pericardial drain was in place without any hematoma. cardiovascular examination revealed he was a regular rate. he had a normal first heart sound and second heart sound. there were murmurs, rubs or gallops. abdominal examination revealed his abdomen on examination was soft, nontender, and nondistended. normal active bowel sounds. there was no hepatosplenomegaly. his extremities demonstrated no cyanosis, clubbing or edema. his right femoral sheath was in place; there was no hematoma or bruit. there were 2+ dorsalis pedis pulses and posterior tibialis pulse bilaterally. his skin was warm and dry. pertinent laboratory data on presentation: laboratory data revealed a white blood cell count of 12.5, hemoglobin was 12.3, hematocrit was 35.9, platelets were 410. chemistry revealed sodium was 135, potassium was 3.8, chloride was 103, bicarbonate was 22, blood urea nitrogen was 16, creatinine was 0.9, blood glucose was 102. pt was 13.9, inr was 1.4. pericardial fluid revealed total protein of 5.3, ldh was 585, glucose was 101, amylase was 38, albumin was 3.2. impression: this is a 49-year-old male with recurrent atrial fibrillation refractory to medications and cardioversion. radiofrequency ablation performed earlier this month was complicated by septal perforation and tamponade. he returns now with re-accumulation of fluid and cardiac tamponage physiology, status post pericardiocentesis. hospital course: the patient was admitted to the coronary care unit with a pericardial drain in place which had previously drained 350 cc in the catheterization laboratory. about 50 cc were drained overnight, and a repeat echocardiogram was done in the morning which showed a trivial effusion. therefore, the drain was pulled on without complications. the patient was started on his outpatient drug regimen and started on a prednisone taper in order to decrease pericardial inflammation. he was transferred to the floor on the evening of in stable and improved condition. a follow-up echocardiogram was done on the day of discharge which showed a normal ejection fraction, a decrease in size of the effusion, with a thickened pericardium demonstrating early constrictive physiology. the patient was asymptomatic throughout his hospital course, denying any shortness of breath or syncopal symptoms while out of bed. given his history of atrial fibrillation, he was monitored closely on telemetry and demonstrated no arrhythmias. condition at discharge: condition on discharge was stable and improved. discharge diagnoses: 1. atrial fibrillation, status post radiofrequency ablation. 2. cardiac tamponade. 3. hypertension. 4. hyperlipidemia. 5. gout. 6. asthma. 7. remote history of peptic ulcer disease. medications on discharge: 1. atenolol 50 mg p.o. q.d. 2. lipitor 10 mg p.o. q.d. 3. probenecid 500 mg p.o. b.i.d. 4. rythmol 225 mg p.o. b.i.d. 5. protonix 40 mg p.o. q.d. 6. prednisone taper 50/50, 40/40, 30/30, 20/20, , . the patient was to discontinue losartan until follow-up appointment. the patient was to discontinue aspirin for the next 30 days. discharge followup: 1. the patient was scheduled for a transthoracic echocardiogram on at 11 a.m. 2. the patient was to schedule a follow-up appointment with dr. in two to four weeks after discharge. , m.d. dictated by: medquist36 Procedure: Pericardiocentesis Right heart cardiac catheterization Diagnoses: Unspecified essential hypertension Atrial fibrillation Asthma, unspecified type, unspecified Unspecified disease of pericardium

history of present illness: this is a 49-year-old male with poorly controlled hypertension and hyperlipidemia with refractive atrial fibrillation who has been cardioverted every few months since , but only remains in normal sinus rhythm a few weeks after cardioversion. an rf ablation was attempted in , but was aborted due to vagal episodes and systolic blood pressures in the 50s. he was admitted for an elective rf ablation. during the procedure, contrast was noted in the pericardium which was thought due to a possible septal perforation. transesophageal echocardiogram was done which showed a moderate sized effusion and patient began hypotensive. tamponade was suspected and pericardial drain was placed from which approximately 300 cc was removed with another 60 cc being removed over the following hour. a repeat echocardiogram was then performed which showed that the drain was still in place and there was no residual effusion. while in the post anesthesia care unit, the patient complained of chest pain refractory to most medications and 1% lidocaine was administered through the drain with excellent relief of symptoms. he was admitted to the coronary care unit for close hemodynamic monitoring, as well as telemetry. past medical history: 1. hypertension. 2. peptic ulcer disease. 3. asthma. 4. gout. 5. hyperlipidemia. 6. atrial fibrillation. 7. status post spinal cord injury from a motor vehicle accident in . past surgical history: 1. neck surgery secondary to motor vehicle accident. 2. laryngeal polyps removed as a teenager. social history: patient denies any tobacco use. occasional alcohol use. he is married. outpatient medications: 1. hyzaar 100/25 mg. 2. norvasc 5 mg. 3. atenolol 25 mg. 4. probenecid 500 mg b.i.d. 5. aspirin 81 mg q.d. allergies: zestoretic causing gastrointestinal upset. penicillin, allopurinol causing facial swelling. physical examination on admission to the coronary care unit: temperature 99.9. blood pressure 131/74. heart rate 86 in normal sinus rhythm. respiratory rate 20. oxygen saturation 95% on three liters nasal cannula. patient is in no apparent distress, winces mildly in pain. oropharynx is clear. mucous membranes were moist. there was no carotid bruits present. his lungs were clear to auscultation anteriorly (patient was lying flat due to pericardial drain). his heart was regular rate with a normal s1, s2. the drain was in place with no oozing or hematoma. on abdominal exam, the patient was nontender, nondistended, normal active bowel sounds were present. there was no hepatosplenomegaly. there was no cyanosis, clubbing or edema. the femoral sheath was in place on the left side. there was no hematoma or signs of infection. 2+ dorsalis pedis and posterior tibial pulses were felt bilaterally. skin was warm and dry. he was alert and oriented, mildly sedated, but answered questions appropriately. laboratory data on admission: white blood cell count 18.1, hemoglobin 15.3, hematocrit 42.9, platelet count 233,000. pt 13.1, ptt 28.0. sodium 142, potassium 3.9, chloride 104, bicarbonate 27, bun 19, creatinine 1.1, glucose of 136. admission electrocardiogram: showed normal sinus rhythm with a heart rate of 95, normal axis and intervals, no acute st or t wave changes when compared to previous electrocardiograms. impression: this is a 49-year-old man with refractory atrial fibrillation, here for a second rf ablation, complicated by perforation and tamponade, treated with pericardial drain and resolution of effusion by transesophageal echocardiogram. hospital course: 1. cardiac: the patient was transferred to the coronary care unit with a pericardial drain in place, very sedated. he developed atrial fibrillation around 11 a.m. the following day and was cardioverted times two with 2 mg intravenous ibutilide administered with reversion back to normal sinus rhythm. pericardial drain was pulled a few hours later. a transesophageal echocardiogram was performed which showed no pericardial effusion and no pulmonary vein stenosis. a small asd which was previously known was also noted. following conversion to normal sinus rhythm, the patient was started on propafenone 225 b.i.d. he was also restarted on his losartan 100 and atenolol 50 q.d. which he takes as an outpatient. no other events were noted on telemetry and patient remained in normal sinus rhythm for remainder of hospital course. 2. pulmonary: patient with no signs of heart failure. oxygen saturations were in the high 90s on two liters nasal cannula. 3. hematology: of note, hematocrit dropped from 43 to 35 which was assumed mostly dilutional due to large volume of intravenous fluids administered. he was stable around 35 on discharge. 4. rheumatology: the patient was treated with probenecid for gout prophylaxis. he had no symptoms of acute gout during the hospital course. condition at discharge: stable and improved. discharge diagnoses: 1. atrial fibrillation, status post rf ablation. 2. hypertension. 3. hyperlipidemia. 4. gout. 5. peptic ulcer disease. 6. asthma. discharge medications: 1. lipitor 10 q.d. 2. colace 200 b.i.d. 3. prednisone taper for pericardial irritation. 4. atenolol 50 q.d. 5. propafenone 225 b.i.d. 6. losartan 100 q.d. 7. percocet 1-2 tablets q. 4-6 hours prn pain #30 pills. 8. aspirin 325 mg. follow-up: 1. patient to schedule an appointment with dr. in one month. 2. two week course of of heart's. patient was scheduled to have of heart's set up before discharge, however, patient refused to wait for the of heart's to be placed and, therefore, arrangements were made for patient to go to holter laboratory for of heart's to be set up and patient was instructed to stop by the holter laboratory immediately after discharge. 3. repeat cardiac mri to be scheduled one month as an outpatient by electrophysiology. , m.d. dictated by: medquist36 Procedure: Diagnostic ultrasound of heart Other esophagoscopy Pericardiocentesis Catheter based invasive electrophysiologic testing Excision or destruction of other lesion or tissue of heart, endovascular approach Atrial cardioversion Cardiac mapping Diagnoses: Unspecified essential hypertension Atrial fibrillation Asthma, unspecified type, unspecified Accidental puncture or laceration during a procedure, not elsewhere classified Other and unspecified hyperlipidemia Acute pericarditis, unspecified Personal history of peptic ulcer disease

history of present illness: this is a 77-year-old female with a past medical history of coronary artery disease, status post myocardial infarction, chronic obstructive pulmonary disease (on home oxygen) who presented to the emergency room on with a chief complaint of increased cough, decreased oral intake, and weakness for several days. her home had noted a decreased blood pressure this same period as well as weakness, and inability to ambulate, and decreased functional ability. she was brought to the emergency room for evaluation of this. past medical history: (past medical history is notable for) 1. congestive heart failure (with an ejection fraction of 25% to 30%). 2. coronary artery disease; status post coronary artery bypass graft. 3. chronic obstructive pulmonary disease (on home oxygen). 4. hiatal hernia. 5. osteoarthritis. allergies: allergies include erythromycin and codeine. medications on admission: flovent 110 2 puffs b.i.d., isosorbide ointment, lopressor 50 mg p.o. b.i.d., nifedipine-xl 30 mg p.o. q.d., valsartan 80 mg p.o. q.d., valium 5 mg p.o. q.h.s. as needed, lasix 40 mg p.o. q.d., k-dur 10 meq p.o. q.d. social history: she lives at home with her husband with . family history: family history was noncontributory. physical examination on presentation: physical examination in the emergency room revealed vital signs with a temperature of 98.9, blood pressure was 110/70, heart rate was 86, respiratory was 20, oxygen saturation was 90% on 2 liters. in general, she was in no acute distress. examination of the head and neck revealed mucous membranes were dry. no teeth. no increased jugular venous pressure. cardiovascular examination revealed a regular rate and rhythm. no murmurs, rubs or gallops. normal first heart sound and second heart sound. a murmur in the left lower sternal border. lungs revealed diffuse rhonchi, crackles at the bases (left greater than right). the abdomen was soft, nontender, and nondistended. no hepatosplenomegaly. positive bowel sounds. extremities revealed no clubbing, cyanosis or edema. neurologically, awake and oriented times three. cranial nerves ii through xii were intact. motor was grossly nonfocal. pertinent laboratory data on presentation: laboratory examination revealed white blood cell count was 11, hematocrit was 37, platelets were 391. pt was 13.2, inr was 1.2, ptt was 30.9. chemistry-7 revealed sodium was 144, potassium was 4.5, chloride was 101, bicarbonate was 28, blood urea nitrogen was 12, creatinine was 0.8, and blood glucose was 120. urinalysis was negative. radiology/imaging: a chest x-ray showed bibasilar infiltrates and a large hiatal hernia. electrocardiogram showed a normal sinus rhythm with a rate of 96; no change from prior baseline. hospital course: the patient was admitted to the hospital for treatment of bibasilar pneumonia. she was treated with levofloxacin initially. the patient initially did well on antibiotic therapy; however, several days into her course she had an episode of respiratory failure for which she was intubated and transferred to the intensive care unit. antibiotic coverage was broadened at that time. a further evaluation over the next several days included a ct scan which revealed a right middle lobe mass, and a bronchoscopy which diagnosed cancer by cytology. the patient failed to improve despite maximal medical therapy including mechanical ventilation, broad spectrum antibiotics, and circulatory support. the family was informed of the grave prognosis. on life support was withdrawn, and the patient passed. the date of death was . the cause of death was pneumonia and respiratory failure. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Thoracentesis Closed endoscopic biopsy of lung Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Aortocoronary bypass status Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Methicillin susceptible pneumonia due to Staphylococcus aureus Chronic obstructive asthma, unspecified

technique: ct chest with iv contrast. 100 cc optiray was administered intravenously for patient's history of allergies. ct chest with iv contrast: soft tissue windows reveal mediastinal and hilar lymphadenopathy, the largest one measuring approximately 1.8 cm in size in short axis in the pretracheal region. there is small bilateral pleural effusions. the patient is s/p cabg, pacemaker placements and et tube placement. the heart size is enlarged. there is no pericardial effusion. the et tube cuff is over-extended. retained secretion is demonstrated above the et tube cuff. lung windows reveal peripheral reticular pattern. there is patchy air space opacification in the right upper lobe and bilateral lower lobes. there is demonstrated in the right lower lobe consolidation posteriorly, raising the question of necrotizing pneumonia. note is also made of termination of right middle lobe bronchus, there is post-obstructive right middle lobe collapse/consolidation. in the proximal right middle lobe there is an area of homogeneous soft tissue density, which could represent a large obstructing lesion, measuring approximately 3.7 x 3.8 cm in size. within the right middle lobe, multiple hypoattenuation areas are present, which could represent post- obstructive necrosis. there is associated volume loss of the right lung. a large complex hernia is demonstrated at the thoraco-abdominal junction, probable periesphageal, containing both stomach and bowel loops. a small amount of ascites is demonstrated. a focal hypoattenuation area is demonstrated in the medial segment of the left hepatic lobe adjacent to the falciform ligament, most likely representing focal fat infiltration. bone windows reveal degenerative changes and a healed left lower rib fracture. impression: 1) findings concerning for centrally obstructing neoplastic mass, with post- obstructive right middle lobe collapse/pneumonitis with areas of necrosis. recommend correlation with bronchoscopy. (over) 3:57 pm ct chest w/contrast; ct 100cc non ionic contrast clip # reason: evaluate persistent / recurrent lower lobe infiltrates for p field of view: 30 contrast: optiray amt: 100 ______________________________________________________________________________ final report (cont) 2) bilateral lower lobe consolidations, raising the question of aspiration pneumonia associated with patient's large hernia. pockets of air demonstrated in the right lower lobe consolidative region raise the question of necrotizing pneumonia,. 3) large complex probable periesophageal hernia containing both stomach and bowel. 4) the et tube cuff is over-distended. 5) bilateral small pleural effusions and mediastinal and hilar lymphadenopathy. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Thoracentesis Closed endoscopic biopsy of lung Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Aortocoronary bypass status Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Methicillin susceptible pneumonia due to Staphylococcus aureus Chronic obstructive asthma, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transfer for evaluation of tamponade major surgical or invasive procedure: pericardial drain placement, icd lead revision history of present illness: 76 yo f with s/p ddd pacer/icd placement (? for av block) on , presented to today w/ complain of sob and chest pain for the past 2-3 days, as welll as lh amd weakness, worse w/ exertion. had a bedside echo which showed pericardial effusion with ra and rv diatolic collapse suggestive of tamponade. pt was sent to for pericardial drain. at cath, found to have ra and pericardial pressure of 10 mmhg--> 200 cc of loculated effusion drained with decompession of pericardium (pressure of 2). during cath pt had an episode of a flutter. also, suspected intramyocardial v-lead during procedure--> ep consulted for evaluation of possible rv perforation; plan to go to ep lab in am for lead revision. on ros: no fevers/chills; + dyspnea, lh, chest pressure before cath; some chest dyscomfort (reprodusible on exam) after cath; denies lifting heavy weights or doing maneuvers that could have dislodged v lead. she had a nl colonoscopy last year and nl mammogram (up to date on cancer screening) past medical history: htn arthritis 2:1 avb social history: no etoh/tobacco family history: cad, pvd in mother; pud father; no cancers physical exam: afebrile 60-90 123/56 rr12 96% 2l nc gen: nad neck: jvd 7 cm pulm: cta b cvs: rrr; s1/2; holosystolic murmur at l mid sternal border without radiation; pericardail drain in place; no icd pocket hematoma abd: + bs; soft; nt/nd ext: non pitting edema pertinent results: labs: cr 1.1; inr 1.0; ast 83; alt 78 trop <0.04 tte w/ large pericardial effusion; no valvular dz brief hospital course: 76 yo f with 2:1 avb; s/p icd placement 10 days ago, p/w low pressure tamponade; s/p drainage and pericardial drain placement. 1. tamponade: pt was watched in ccu for hd stability post percardial drain placement. ? rv perf as found to have intramyocardial v lead during the case. mrs. was given iv hydration o/n and antihypertensives were held. per ep, no rv perf. percocet for pain post procedure but most prominent pain is actually her chronic sciatic and l shoulder pain exacerbated by icd placement. drain was successfully d/ced with no evidence of reaccumulation on tte. follow up fluid micro/cytology and cell counts. percocet for pain post procedure (limit to 2 g tylenol/ day as unclear etiology of transaminitis). 2. ? intramyocardial v lead: ep consulted. lead revision was without complications. 3. rhythm: episode of aflutter during drain placement. ddd interrogated: underlying 2:1 avb. cont tele. no anticoagulation at this time given recent pericardial effusion. pt will follow up with dr. in one week and will rediscuss anticoagulation at that time. 4. transaminitis: unclear etiology. check hepatitis panel. consider ruq u/s. repeat lfts in am. outpt workup. 5. lines: groin swan (in ivc) was d/ced after ep procedure tomorrow. piv 6. fen: gentle hydration was administered and serial crits were followed. 7. proph: po diet; sq heparin was used 8. full code throughout hospital stay medications on admission: meds: evista; asa 81; hyzaar 100-25 discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*20 tablet(s)* refills:*2* 2. sotalol hcl 80 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*90 tablet(s)* refills:*2* 3. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2 times a day) as needed for constipation. 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. discharge disposition: home with service facility: nursing services discharge diagnosis: primary diagnosis: 1. cardiac tamponade s/p pericardial drain 2. paroxysmal atrial fibrillation secondary diagnosis: 1.htn 2.2:1 av block 3. arthritis discharge condition: good discharge instructions: please call your pcp or return to the emergency department if you develop chest pain, shortness of breath, weakness, dizziness, or other worrisome symptom. followup instructions: please call neurology at to adresse your memory problems. provider: , his office will call you to schedule a follow-up appointment within 1 week at his office. at that time, he should discuss with you the possibility of starting anticoagulation for your atrial fibrillation. provider: , md where: cardiac services phone: date/time: 4:30 Procedure: Pericardiocentesis Pulmonary artery wedge monitoring Revision of lead [electrode] Monitoring of cardiac output by other technique Right heart cardiac catheterization Artificial pacemaker rate check Artificial pacemaker rate check Artificial pacemaker rate check Diagnoses: Unspecified essential hypertension Atrial fibrillation Atrial flutter Constipation, unspecified Unspecified disease of pericardium Osteoarthrosis, unspecified whether generalized or localized, site unspecified Other complications due to other cardiac device, implant, and graft Pain in joint, shoulder region Mobitz (type) II atrioventricular block Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH]

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sternal drainage major surgical or invasive procedure: s/p sternal rewiring history of present illness: 83 y/o male s/p coronray artery bypass graft x 4 on without post-op complications who present to ed with sternal drainage after coughing spell. upom exam, pt was found to have an unstable sternum and cxr revealed displacement and rotation of sternotomy wires, consistent with sternal dehiscence. past medical history: coronary artery disease s/p coronray artery bypass graft x 4 on hyperlipidemia s/p appendectomy in social history: he lives in with his wife. retired 1 year ago from sales. he drives. he uses no assistive devices. he is very active. he quit smoking in . he has a 40-pack-year history. he has 3 alcoholic drinks per year. family history: his father died of a mi at the age of 87. pertinent results: cxr : interval increase in moderate left pleural effusion. displacement and rotation of sternotomy wires, consistent with sternal dehiscence. 06:07am blood wbc-12.3* rbc-3.74* hgb-10.8* hct-32.9* mcv-88 mch-28.8 mchc-32.7 rdw-14.4 plt ct-371# 05:55am blood wbc-10.9 rbc-3.03* hgb-8.7* hct-26.8* mcv-88 mch-28.7 mchc-32.5 rdw-14.1 plt ct-433 08:15am blood pt-13.3 ptt-26.4 inr(pt)-1.1 06:07am blood glucose-93 urean-26* creat-1.1 na-139 k-4.4 cl-102 hco3-27 angap-14 05:35am blood glucose-107* urean-32* creat-1.3* na-134 k-4.0 cl-98 hco3-26 angap-14 05:55am blood urean-29* creat-1.2 k-4.8 06:07am blood calcium-7.7* phos-3.8 mg-2.1 05:35am blood calcium-7.9* phos-3.5 mg-2.1 12:13pm urine color-straw appear-clear sp -1.006 12:13pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg brief hospital course: pt. was admitted on with sternal dehiscence. iv abx were started and pt was kept npo for preparation to or the next day. on hd #2 he was brought to the operating room and underwent sternal rewiring. please see op note. pt. tolerated the procedure well, was extubated in the or and was transferred to the csru in stable condition. pod #1 pt was recovering well after rewiring. he was not receiving any gtts and pre-op meds were started. pt. cont. to need aggressive chest pt, nebs and o2 to remain adequate o2 stats. he therefore remained in the csru until pod #2. on this day he was transferred to the telemetry floor. his chest tubes were removed and abx were cont. his pre-op culture (urine) was negative and the chest swab performed in the or was negative as well. from pod # pt slowly improved. he cont. to need o2 via nc which was slowly weaned with aggressive pt, is and nebs. vanco was continued until day of discharge where it was stopped. exam on pod #5 was unremarkable. chest was stable, without clicks or drainage. pt was discharged home with the appropriate follow-up. discharge disposition: home with service facility: discharge diagnosis: sterile sternal dehiscence after cabg coronary artery disease s/p coronray artery bypass graft x 4 on hyperlipidemia s/p appendectomy in 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 6 weeks. Procedure: Other repair of chest wall Local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] Diagnoses: Unspecified pleural effusion Disruption of internal operation (surgical) wound Aortocoronary bypass status

history of present illness: the patient is an 83-year-old male without a history of coronary artery disease who reports dyspnea on exertion and shoulder discomfort with exertion, and these symptoms resolve with rest. he had a stress echocardiogram on which revealed ekg changes and hypokinesis and akinesis in the inferior wall. his cath on showed severe 3-vessel disease. his lad was 90% occluded, d1 was 80%, left circumflex was 90%, and rca was 90% occluded. he was therefore referred for coronary artery bypass surgery. past medical history: hyperlipidemia. past surgical history: appendectomy in . allergies: he has no known drug allergies. medications at home: lipitor 10 mg daily, aspirin 81 mg daily, calcium, and a multivitamin daily. social history: he lives in with his wife. retired 1 year ago from sales. he drives. he uses no assistive devices. he is very active. he quit smoking in . he has a 40-pack-year history. he has 3 alcoholic drinks per year. family history: his father died of a mi at the age of 87. review of systems: negative except for the symptoms stated in the hpi. physical examination on admission: height is 5 feet 7 inches. weight is 177.5 pounds. vital signs reveal a heart rate of 78, sinus rhythm, bp of 143/72, respirations of 15. in general, he was lying flat in bed in no acute distress. neurologically, he was alert and oriented x 3, appropriate, nonfocal. cranial nerves ii through xii were intact. his lungs were clear to auscultation bilaterally. his heart rate was regular in rate and rhythm. positive s1 and s2. no clicks, rubs, murmurs, or gallops. his abdomen was soft, nontender, and nondistended. round with positive bowel sounds. his extremities were warm and well perfused. negative edema or varicosities. his pulses were 2+ throughout, and he had no carotid bruits. preoperative laboratory data: white blood count was 9.4, hematocrit was 37.7, and platelets were 252. sodium was 138, potassium was 3.7, chloride was 105, bicarbonate was 24, bun was 26, creatinine was 0.9, and blood glucose was 164. pt of 13.3, ptt of 28.3, and inr of 1.1. alt of 17, ast of 25, amylase of 72, total bilirubin of 0.6, albumin of 3.8, alkaline phosphatase of 122. discharge status: he was discharged to home with vna services. discharge diagnoses: 1. coronary artery disease. 2. status post coronary artery bypass grafting x 4 on , . 3. hypercholesterolemia. medications on discharge: potassium chloride 10-meq capsules 2 capsules b.i.d., colace 100 mg p.o. b.i.d., aspirin 81 mg p.o. daily, atorvastatin 50 mg p.o. daily, lasix 20 mg p.o. b.i.d., lopressor 50 mg p.o. b.i.d., ibuprofen 600 mg p.o. q.6h. p.r.n. (for pain), albuterol inhaler 2 puffs q.i.d. p.r.n. (for shortness of breath or wheezing). discharge followup: the patient was recommended to follow up with dr. in 4 to 6 weeks, and with dr. in 1 to 2 weeks, and with dr. in 1 to 2 weeks. , Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Left heart cardiac catheterization Coronary arteriography using a single catheter Angiocardiography of right heart structures Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Other and unspecified hyperlipidemia

history of present illness: the patient is an 83-year-old male without a history of coronary artery disease who reports dyspnea on exertion and shoulder discomfort with exertion, and these symptoms resolve with rest. he had a stress echocardiogram on which revealed ekg changes and hypokinesis and akinesis in the inferior wall. his cath on showed severe 3-vessel disease. his lad was 90% occluded, d1 was 80%, left circumflex was 90%, and rca was 90% occluded. he was therefore referred for coronary artery bypass surgery. past medical history: hyperlipidemia. past surgical history: appendectomy in . allergies: he has no known drug allergies. medications at home: lipitor 10 mg daily, aspirin 81 mg daily, calcium, and a multivitamin daily. social history: he lives in with his wife. retired 1 year ago from sales. he drives. he uses no assistive devices. he is very active. he quit smoking in . he has a 40-pack-year history. he has 3 alcoholic drinks per year. family history: his father died of a mi at the age of 87. review of systems: negative except for the symptoms stated in the hpi. physical examination on admission: height is 5 feet 7 inches. weight is 177.5 pounds. vital signs reveal a heart rate of 78, sinus rhythm, bp of 143/72, respirations of 15. in general, he was lying flat in bed in no acute distress. neurologically, he was alert and oriented x 3, appropriate, nonfocal. cranial nerves ii through xii were intact. his lungs were clear to auscultation bilaterally. his heart rate was regular in rate and rhythm. positive s1 and s2. no clicks, rubs, murmurs, or gallops. his abdomen was soft, nontender, and nondistended. round with positive bowel sounds. his extremities were warm and well perfused. negative edema or varicosities. his pulses were 2+ throughout, and he had no carotid bruits. preoperative laboratory data: white blood count was 9.4, hematocrit was 37.7, and platelets were 252. sodium was 138, potassium was 3.7, chloride was 105, bicarbonate was 24, bun was 26, creatinine was 0.9, and blood glucose was 164. pt of 13.3, ptt of 28.3, and inr of 1.1. alt of 17, ast of 25, amylase of 72, total bilirubin of 0.6, albumin of 3.8, alkaline phosphatase of 122. discharge status: he was discharged to home with vna services. discharge diagnoses: 1. coronary artery disease. 2. status post coronary artery bypass grafting x 4 on , . 3. hypercholesterolemia. medications on discharge: potassium chloride 10-meq capsules 2 capsules b.i.d., colace 100 mg p.o. b.i.d., aspirin 81 mg p.o. daily, atorvastatin 50 mg p.o. daily, lasix 20 mg p.o. b.i.d., lopressor 50 mg p.o. b.i.d., ibuprofen 600 mg p.o. q.6h. p.r.n. (for pain), albuterol inhaler 2 puffs q.i.d. p.r.n. (for shortness of breath or wheezing). discharge followup: the patient was recommended to follow up with dr. in 4 to 6 weeks, and with dr. in 1 to 2 weeks, and with dr. in 1 to 2 weeks. , dictated by: medquist36 d: 14:11:34 t: 16:23:45 job#: Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Left heart cardiac catheterization Coronary arteriography using a single catheter Angiocardiography of right heart structures Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Other and unspecified hyperlipidemia

history of present illness: the patient is a 63 year-old woman with a complicated history who was well until until elective repair of a symptomatic 6.4 cm abdominal aortic aneurysm at . postoperative course was complicated by deep venous thrombosis, pulmonary embolism, status post ivc filter placement and large retroperitoneal bleed, pancreatic cyst with growth of staph and serratia, small bowel obstruction, diarrhea and ischemic colitis documented by sigmoidoscopy with severe malnutrition requiring total parenteral nutrition. she was discharged from the on after hospital course for enterococcal and serratia bacteremia, multiple deep venous thromboses, severe malnutrition, improving pancreatic pseudocyst, ongoing ischemic colitis, paroxysmal atrial fibrillation, and depression. the patient was transferred to sanai on at which time she continued to undergo total parenteral nutrition and had fair po intake. she remained afebrile while on ampicillin for her bacteremia. over the course of her rehabilitation stay she was noted to have increasing abdominal distention, lower quadrant pain bilaterally and kub demonstrating persistent ileus. on the day of admission she was noted to be tachycardic in the 120s and irregularly irregular with a systolic blood pressure in the 110s, hematocrit was noted to be 22.9. she received intravenous fluids, protonix, vitamin k for an inr of 2.6 and was transferred back to the for further evaluation. in the emergency department she was afebrile at 99, 100/56, 126, 97%, guaiac positive stool. nasogastric lavage was positive for small amount of dried blood, received vancomycin, levaquin and flagyl and was transferred to the intensive care unit for further care. physical examination: vital signs 99, 110, 108/60, 20, 97% on room air. general, she was awake, alert and oriented times three. heent pupils are equal, round and reactive to light and accommodation. extraocular movements intact. anicteric. oral mucosa dry. neck supple. no lymphadenopathy. lungs clear to auscultation bilaterally. cor tachycardic, but regular. normal s1 and s2. abdomen soft, mildly distended, nontender, positive bowel sounds. stool guaiac negative in the emergency department. extremities 2+, anasarca, warm, 2+ dorsalis pedis pulses and radial pulses bilaterally. neurological cranial nerves ii through xii are intact, 4 out of 5 muscle strength in all four extremities. laboratory: white blood cell count 18.1, hematocrit 25, platelets 377, 74 neutrophils, 4 bands, 14 lymphocytes, inr 2.0, arterial blood gas 7.52/39/95 with a lactate of 1.1. chest x-ray with low lung volumes and no signs of congestive heart failure or pneumonia. kub with air filled loops of bowel consistent with an ileus. hospital course: in the emergency department the patient received a cta to rule out pulmonary embolism or aortic enteric fistula or ischemic colitis. the results of this was negative. the patient was admitted to the intensive care unit for further management. she received blood transfusions for her anemia and continued to receive vitamin k for her elevated inr. she was maintained on vancomycin, levaquin and flagyl and infectious disease was consulted. the patient then went into rapid atrial fibrillation with a heart rate in the 150s, blood pressure 110/50. she was started on an esmolol drip due to her recent hypotension. during this her blood pressure decreased to 47 systolic and the drip was discontinued. heart rate was maintained in the 90s. she tolerated the low blood pressure well. while in the intensive care unit her picc line was discontinued and a central line was placed. blood cultures were performed. gi was consulted for ongoing bleeding and the patient had gastroscopy demonstrating only a hiatal hernia that was reduced with a scope. sigmoidoscopy to 30 cm revealed the luminary with a possible stricture from old ischemic colitis versus a large diverticulum, status post surgical change. on hospital day number three the patient again went into rapid atrial fibrillation with a blood pressure decreased to 87/44 that responded with normal saline boluses. also had a short run of supraventricular tachycardia. right groin ultrasound and right upper extremity ultrasound revealed no evidence of deep venous thrombosis. the patient's blood cultures grew gram positive and gram negative organisms. later that day the patient went to radiology for gastric graph to better characterize the nature of her stricture. the procedure was complicated by bradycardia to 37 likely a vasa vagal event. the patient then went into supraventricular tachycardia in the 160s, which lasted for less then one minute and spontaneously resolved. on hospital day number four the patient continued to have melanotic stools. she remained tachycardic in the 110s. she also grew out vre in her blood cultures and was started on linezolid. a transthoracic echocardiogram was performed on hospital day number five, which demonstrated a large vegetation on the posterior mitral leaflet, normal ejection fraction, 1+ mitral regurgitation. this was highly consistent with endocarditis likely vre endocarditis given her positive blood cultures. the patient then proceeded to go back into atrial flutter with heart rate in the 160s, blood pressure again decreased to the 80s. the patient complained of a sore chest for several minutes, which resolved after she was treated with diltiazem. a long discussion with the patient and her family resulted in the patient expressing that she did not wish to have any intensive treatment, but for her to have ventilation, but does not want ventilation or cpr performed if she became worse. also she did not wish to have a painful procedures performed and would prefer leaning toward comfort care. this was a reasonable decision as the patient continued to have ongoing gastrointestinal bleeding, rapid atrial fibrillation that was difficult to control as well as new enterococcal endocarditis. the patient was transferred to the floor for additional management. on the floor she became minimally responsive. discussions with the family was then readdressed and the patient's family wished to make the patient cmo. they felt this best represented her wishes. she was made comfort care only. palliative care was consulted. the patient then passed on hospital day number eight. condition on discharge: expired. discharge diagnoses: 1. enterococcal endocarditis. 2. enterococcal and serratia bacteremia. 3. atrial fibrillation/atrial flutter. 4. supraventricular tachycardia. 5. gastrointestinal bleed. 6. microischemic colitis. 7. right femoral hematoma. 8. malnutrition. 9. hypotension. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Rigid proctosigmoidoscopy Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Anemia, unspecified Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Atrial fibrillation Atrial flutter Diaphragmatic hernia without mention of obstruction or gangrene Bacteremia Acute and subacute bacterial endocarditis Hemorrhage of gastrointestinal tract, unspecified

history of present illness: is the former 3.31 kilogram product of a term gestation pregnancy, born to a 40 year old, gravida i, para 0 to i woman. estimated date of confinement was . prenatal screens revealed blood type 0 negative, antibody negative, hepatitis b surface antigen negative, rpr nonreactive, rubella immune. group beta strep negative. pregnancy was uncomplicated. conception was achieved by intrauterine insemination. labor and delivery were uncomplicated until the time of delivery when the occiput posterior position was noted. fetal heart rate tracing was noted to be unremarkable prior to delivery. the infant was born by spontaneous vaginal delivery. he was limp and cyanotic with a heart rate of less than 100 at birth. he was immediately treated with positive pressure bag and mask ventilation with improvement of heart rate and some improvement of color and development of some respiratory effort. apgars were two at one minute, four at five minutes and five at ten minutes. the baby's tone remained poor. his respiratory effort continued to improve, though his breath sounds remained very coarse bilaterally. he was transferred to the neonatal intensive care unit for further treatment. physical examination: upon admission to the neonatal intensive care unit, weight was 3.31 kilograms; length 53 cm; head circumference 34 cm, appropriate for gestational age. general: markedly reduced tone. some spontaneous movements of arms and legs, beginning at 30 minutes of life. head, eyes, ears, nose and throat: anterior fontanel large, soft and flat. sutures mobile. prominent molding and large amount of edema, bogginess and erythema of the left occipital parietal lesion. palate intact. normal facies. pupils equal and reactive to light. positive red reflex bilaterally. chest: breath sounds extremely coarse with rhonchi bilaterally. minimal air entry. ineffective respiratory effort. cardiovascular: normal s1 and s2 without murmur. perfusion initially decreased with prolonged capillary refill. pulses were normal. abdomen: soft with no distention or masses. genitourinary: normal male, testes descended bilaterally. neurologic: symmetrical habitus. decreased tone. hospital course: hospital course by systems, including pertinent laboratory data: 1. respiratory: was intubated shortly after admission to the neonatal intensive care unit for ineffective respiratory effort. his peak ventilator settings were a peak inspiratory pressure of 30 over a positive end expiratory pressure of 6 and intermittent mandatory ventilatory rate of 30 and 100% oxygen. his initial blood gas had a ph of 7.05, a pc02 of 45, p02 of 93. he was treated with 20 cc/kg of volume and sodium bicarbonate with a repeat gas of ph of 7.41, pc02 of 36, p02 of 93. he gradually weaned to room air and on his ventilation rate, he was extubated on day of life one to room air. chest x-ray was consistent with retained fetal lung fluid and was otherwise normal. at the time of discharge, he is breathing comfortably in room air with respiratory rates in the 30's to 40's. 2. cardiovascular: no murmurs were noted. maintained normal heart rate and blood pressure. he had an umbilical venous catheter placed for administration of fluid and ventral access. her received 20 cc per kg of a normal saline bolus shortly after admission. 3. fluids, electrolytes and nutrition: initial glucose was 171 mg/dl. intravenous fluids of d-10-w were started. enteral feeds were started on day of life one, after extubation and were well tolerated. at the time of discharge, he is exclusively breast feeding or p.o. feeding expressed mother's milk. weight on the date of discharge is 3.31 kg. serum electrolytes were sent three times during admission and were within normal limits. 4. infectious disease: due to the unknown etiology of the birth apnea and perinatal depression, was evaluated for sepsis. a white blood cell count was 22,600 with a differential of 64% polymorphonuclear cells and 0% band neutrophils. a blood culture was obtained. was treated with intravenous ampicillin and cefotaxime. the blood culture was negative at 48 hours and the antibiotics were discontinued. 5. hematology: is blood type 0 negative, coombs negative. hematocrit at birth was 56%. he has not transfused any transfusions of blood products. 6. gastrointestinal: liver function tests were sent on day of life #2 and were mildly elevated with an alt of 42 and an ast of 93; alkaline phosphatase of 63. peak serum bilirubin occurred on day of life 4 with a total of 8.3. 7. neurologic: a head ultrasound was performed on day of life number one and was normal with bilateral evolving cephalohematomas. a magnetic resonance scan was performed on and was within normal limits. with rapid improvement after delivery and the consistent normal examination and imaging studies, his long term prognosis at this juncture appears excellent. 8. sensory: hearing screening was performed with automated auditory brain stem responses. passed in both ears. condition at discharge: good. discharge disposition: home with the parents. primary pediatrician: dr. , pediatric associates, ., , . phone number . care and recommendations: 1. feeding: ad lib breast feeding. 2. no medications. 3. state newborn screen was sent on with no notification of abnormal results to date. 4. no immunizations administered. the parents declined the hepatitis b vaccine. 5. immunizations recommended: synagis-rsv prophylaxis should be considered from through for infants who meet any of the following three criteria: 1.) born at less than 32 weeks. 2.) born between 32 and 35 weeks with two of three of the following: day care during the rsv season, a smoker in the household, neuromuscular disease, airway abnormalities, school age siblings. 3.) with chronic lung disease. influenza immunization is recommended annually in the fall for all infants once they reach six months of age. before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. follow-up appointment: appointment with dr. within three days of discharge. early intervention and vna referrals have also been made. discharge diagnoses: 1. term male. 2. perinatal depression. 3. suspicion for sepsis, ruled out. 4. bilateral cephalohematomas. dr., 50-569 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Umbilical vein catheterization Diagnoses: Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Primary apnea of newborn Other injuries to scalp

allergies: gemfibrozil attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization history of present illness: ms. is a 78 year-old woman with h/o htn, hyperchol, chf, esrd (not yet on hd) who was transfered from for management of nstemi. . the patient describes 2 types of pain. the first pain is a r sternal pain that occurs while eating and is usually relieved with physical massage. she reports having this pain for years. . the second type of pain started 2 days ago, but has not recurred now for more than 24 hours. she reports having epigastric chest pain 2 days prior to admission that lasted for a whole day. she also noted pain in her r arm at the same time. denies associated n/v, diaphoresis, or sob. no recent change in weight, le swelling, or pnd. patient did have some mild cough with yellow productive sputum, but no f/c. she also c/o chronic lightheadedness that she attributes to her medication along with some intermittent vertigo. patient otherwise denies any myalgias/arthralgias. she continues to urinate, no dysuria/hematuria, intermittent constipation. she also has chronic insominia. her exercise capacity consists of a block, limited by fatigue. patient told her daughter about the pain, who then contact patient's pcp, . . pcp referred the patient to ed for evaluation. . upon arrival to the osh ed, labs revealed cr 2.7; ck 301; ckmb 59; trop t 1.46; ekg was unchanged. elevated cardiac enzymes were confirmed with ck of 317, troponin 1.68 with no prior baseline. she was started on a heparin gtt, asa 325, lopressor 5 mg iv x 1. patient was then transferred to for further managment. . currently, patient feels well, denies cp/sob. past medical history: cva (; mri showing left internal capsular defect, little residual effect) esrd still not on hd - cr 3.0 (1.7-6.0) - followed by dr. congestive heart failure (echo , technically limited showed mild concentric lvh with ef at 60%, ?pericardial effusion (size unspecified) s/p right renal artery stent () by dr. hypertension hypercholesterolemia, hypothyroidism depression degenerative joint disease tah-bso/repair of umbilical hernia for benign ovarian mass (path=fibroma ) social history: former light smoker (ages 25-73); quit 4 yrs ago. no history of etoh or other drugs. formerly worked as a paralegal. now living in public senior housing in . mother of two--one daughter lives nearby. family history: notable for diabetes and renal failure in a brother. physical exam: vs: 97.8 - 130/59 - 60 - 16 - 98% 2l gen: elderly female in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple; jvp flat. cv: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abd: soft, nt, nd. ext: no c/c/e. no femoral bruits. pulses: 2+ femoral, 2+ dp/pt pulses . pertinent results: labs on admission: 09:30pm blood wbc-8.3 rbc-4.00* hgb-13.0 hct-36.3 mcv-91 mch-32.5* mchc-35.8* rdw-13.8 plt ct-186 09:30pm blood neuts-64.2 lymphs-21.7 monos-6.2 eos-7.4* baso-0.5 09:30pm blood pt-13.1 ptt-127.1* inr(pt)-1.1 09:30pm blood plt ct-186 09:30pm blood glucose-87 urean-30* creat-2.5* na-142 k-3.4 cl-109* hco3-21* angap-15 09:30pm blood alt-18 ast-49* ck(cpk)-317* 09:30pm blood ck-mb-54* mb indx-17.0* ctropnt-1.68* 06:42am blood alt-13 ast-40 ck(cpk)-239* 06:42am blood ck-mb-38* mb indx-15.9* ctropnt-1.88* 05:05am blood ck(cpk)-518* 05:05am blood ck-mb-58* mb indx-11.2* ctropnt-3.53* 07:15am blood ck(cpk)-351* 05:25am blood ck(cpk)-152* 09:30pm blood calcium-9.9 phos-2.4* mg-2.5 02:45pm blood %hba1c-5.6 . cardiac catheterization (preliminary report) 1. selective coronary angiography revealed two vessel coronary artery disease. the left main coronary artery was short with no angiographically apparent flow limiting stenoses. the lad had moderate diffuse disease with a 70% stenosis in the mid vessel and a 70% stenosis at the origin of the first diagonal. the lcx had an om1 upper pole with a 99% stenosis and slow flow. the lcx had a 70% stenosis in the mid vessel. the rca was small in caliber and had no angiographically apparent flow limiting stenoses. 2. limited resting hemodynamics were performed upon entry. systemic arterial pressure was moderately elevated (aortic pressure was 160/73mmhg). final diagnosis: 1. two vessel coronary artery disease. . ct abdomen (preliminary report) 1. small hemorrhagic pericardial effusion. 2. small bilateral pleural effusion. 3. no evidence of reteroperitoneal bleed. 4. diffuse atherosclerotic disease. 5. atrophic kidneys. not significantly changed form ct from , . . echo the left ventricular cavity size is normal. lv systolic function appears depressed with lateral hypokinesis (regional wall motion not fully assessed). right ventricular chamber size is normal. right ventricular systolic function is normal. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. . cxr : (preliminary report) 2 views of the chest compared to a single view done 4 days earlier. there are no focal infiltrates or definite effusions. mediastinum and bony structures are unchanged including findings consistent with rotator cuff disease involving the right shoulder. there is also marked aortic tortuosity and prominence, this is also unchanged. over the cervical prevertebral area, there is a superimposed air which likely represents the trachea as well as the piriform sinuses. please correlate clinically in this patient with fever. . ct chest (non-contrast): 1. extensive aortic and coronary atherosclerosis with suspected descending thoracic aorta dissection and intraluminal thrombus, stable. this study is not dedicated to evaluation of the vascular system and additional examination might be considered. 2. right lower lobe atelectasis and small pleural effusions. brief hospital course: mrs. is a 78 year-old woman with a history of hypertension, hypercholesterolemia, congestive heart failure, end stage renal disease (not yet on hemodialysis) who was transfered from for management of nstemi. . # nstemi: the patient was diagnosed with a non-st elevation mi at the outside hospital. she underwent cardiac catheterization on showing 2 vessel disease(lad 70%, d1 70%; lcx 70%, om1 99%). during cath, the cardiologists were unable to cross the lcx/om1 lesion with the wire. ct surgery was called for evaluation of possible surgical revascularization given the inability to perform pci. plavix was held given this consideration of surgical revascularization in the future. she was continued on aspirin and statin. the patient was not on a betablocker as an outpatient; however, this was not started initially after cath due to hypotension (see below). her hypotension resolved, and a beta blocker was started. because of ongoing fevers and clinical pneumonia, cabg was deferred and the pt was discharged home with instructions to follow-up with ct surgery for cabg in several weeks. . # hypotension: approximately 2 hours after catheterization, the patient was noted to have an asymptomatic low blood pressure of 74/47. iv fluid bolus was started immediately with some response and her sbp rose to the mid-80's. the cardiology team, including the interventional cardiology attending, and the attending of record were present to evaluate the patient. a stat bedside echo was done given concern for dissection/perforation since there was difficulty attempting to cross lcx/om lesion during cath. this echo revealed a small amount of fluid in pericardial space; however, there was no evidence of tamponade. the patient was given atropine given due to concern for vagal response since she still had a femoral sheath in place. she responded to this medication with good response in her blood pressure (sbp rose from the 80's to 100's); however, this was only a transient response. a stat hematocrit was sent given concern for retroperitoneal bleeding. this value was stable was stable. she was given a total 1.5l bolus of normal saline. the patient was then transferred to the ccu for further management. . on arrival to the ccu, her bp continued to fall, and more atropine was given (total 1.2mg) along with a dopamine infusion for augmentation of blood pressure. a triple lumen catheter was placed in her right femoral vein, and 2 units of prbcs were transfused. she was taken for an emergent ct abdomen once her map was consistently above 65 while on dopamine drip. neosynephrine was added for a short period en route to ct, but was titrated off during the scan. this ct scan of the abdomen and pelvis was negative for a retroperitoneal bleed. on return to the ccu, an arterial line was placed. the pt. became somewhat delerious and agitated and was given haldol 1mg x2 and 0.25 mg lorazepam x2 for sedation. . she did well overnight with improvement in her blood pressure. dopamine was titrated off at 12am (total duration approximately 4 hours). after weaning dopamine, the patient maintained her blood pressure well in the range of 104-143/50-76. . the etiology of her hypotension was thought to be secondary to a vagal response due to her femoral sheath. once her blood pressure stabilized, she was started on a low dose betablocker. she remained with normal blood pressure throughout the remainder of her stay. . # fever: the patient spiked temperature overnight on . she denied all infectious symptoms. her wbc count was normal. ua was negative, blood cultures show no growth to date. cxr did not show evidence of pneumonia, however pt had adventitious lung sounds on exam. she continued to spike fevers for several days, and then became mildly hypoxic, so she was started on levofloxacin for presumed pneumonia. . # end stage renal disease: the patient is not yet on hemodialysis. during this admission, her creatinine bumped slightly from 2.4 to 2.8. her fena was less than 1%. she was likely prerenal with a component of contrast nephropathy from the catheterization. her creatinine promptly improved from 2.8 back to her baseline of 2.4. . # hyperlipidemia: she was placed on lipitor 80mg daily given her nstemi. . # htn: she is on norvasc as an outpatient. this was held initially due to her hypotension. she was later started on a low dose of metoprolol given her nstemi, and her norvasc was discontinued. her acei was also held both during the admission and upon discharge due to her renal dysfunction and upcoming cabg. . # depression: she was continued on zoloft. . # hypothyroidism: she was continued on her outpatient dose of levothyroxine. . # code: she was originally dnr/dni, however after further discussion with the pt, she decided to be full code. . medications on admission: aspirin 325 daily plavix 75 daily, levothyroxine 88 mcg daily norvasc 5 mg daily zoloft 50 mg daily simvastatin 10 mg daily aranesp 25 mcg every month benazepril 10 mg daily phoslo 667 mg t.i.d. vitamin c and vitamin e daily. zantac prn calcitriol 25 mcg qmwf discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 3. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 4. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. aranesp 25 mcg/ml solution sig: twenty five (25) mcg injection once a month. 6. calcium acetate 667 mg capsule sig: one (1) capsule po tid w/meals (3 times a day with meals). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 8. calcitriol 0.25 mcg capsule sig: one (1) capsule po every other day (every other day). 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). disp:*45 tablet(s)* refills:*2* 10. levofloxacin 250 mg tablet sig: one (1) tablet po q48h (every 48 hours) for 10 days. disp:*5 tablet(s)* refills:*0* discharge disposition: home with service facility: community vna discharge diagnosis: primary diagnosis: non-st elevation myocardial infarction secondary diagnoses: hypotension end stage renal disease stable small aortic dissection discharge condition: stable. no chest pain. discharge instructions: please call your doctor or return to the emergency room if you experience chest pain, difficulty breathing, palpitations, dizziness, weight gain, leg swelling, or any other concern. . take your medications as prescribed. the following changes were made to your medications: you should stop taking plavix, you should take lipitor instead of simvastatin, you should stop taking your benazepril, and you were started on metoprolol. you should complete a 10 day course of levofloxacin for pneumonia. . please attend all follow-up appointments. followup instructions: you have an appointment with dr. (cardiac surgery) on wednesday @ 2:30. medical office building . please also follow-up with your pcp in the next 7 days, as some of your medications may need to be adjusted. you also have the following appointments scheduled: provider: , .d. phone: date/time: 11:15 provider: , rn phone: date/time: 11:30 provider: , m.d. phone: date/time: 11:30 Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Left heart cardiac catheterization Arterial catheterization Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Other iatrogenic hypotension End stage renal disease Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified acquired hypothyroidism Atherosclerosis of aorta Personal history of tobacco use Depressive disorder, not elsewhere classified Systolic heart failure, unspecified Pulmonary collapse Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Unspecified disease of pericardium Other late effects of cerebrovascular disease Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Surgical or other procedure not carried out because of contraindication Syncope and collapse Dissection of aorta, thoracic Other complications due to renal dialysis device, implant, and graft

allergies: gemfibrozil attending: chief complaint: angina,nstemi major surgical or invasive procedure: cabg x4 (lima to lad, svg to diag, svg to om 1 and om 2) history of present illness: 78 yo female with mutiple cardiac risk factors. recently admiutted for angina and ruled in for nstemi. cath revealed lad 70%, diag 70%, om1 99% cx 70%, and small rca without lesions. pci was unsuccessful at cath and now referred for cabg. past medical history: nstemi cva (; mri showing left internal capsular defect, little residual effect) esrd still not on hd - cr 3.0 (1.7-6.0) - followed by dr. congestive heart failure (echo , technically limited showed mild concentric lvh with ef at 60%, ?pericardial effusion (size unspecified) s/p right renal artery stent () by dr. hypertension hypercholesterolemia, hypothyroidism depression degenerative joint disease tah-bso/repair of umbilical hernia for benign ovarian mass (path=fibroma ) social history: former light smoker (ages 25-73); quit 4 yrs ago. no history of etoh or other drugs. formerly worked as a paralegal. now living in public senior housing in . mother of two--one daughter lives nearby. family history: notable for diabetes and renal failure in a brother. physical exam: 55.9 kg 58" elderly female in nad mild erythema on abd. neck supple with full rom, no carotid bruits ctab rrr, no murmur soft, nt, nd, +bs warm, well-perfused, no edema or varicosities neuro grossly intact fems bil. 2+ dp/pt/radials 1+ bil. pertinent results: 07:15am blood wbc-10.3 rbc-4.05* hgb-13.2 hct-38.3 mcv-94 mch-32.5* mchc-34.4 rdw-15.0 plt ct-111* 07:15am blood plt ct-111* 06:20am blood pt-14.9* ptt-28.1 inr(pt)-1.3* 07:15am blood urean-44* creat-2.7* k-3.8 cardiology report echo study date of patient/test information: indication: intraoperative tee for cabg procedure height: (in) 58 weight (lb): 123 bsa (m2): 1.48 m2 bp (mm hg): 187/67 hr (bpm): 56 status: inpatient date/time: at 10:51 test: tee (complete) doppler: limited doppler and color doppler contrast: none tape number: 2007aw1-: test location: anesthesia west or cardiac technical quality: suboptimal referring doctor: dr. measurements: left ventricle - septal wall thickness: *1.3 cm (nl 0.6 - 1.1 cm) left ventricle - ejection fraction: >= 55% (nl >=55%) aorta - ascending: 3.4 cm (nl <= 3.4 cm) aortic valve - peak velocity: 1.2 m/sec (nl <= 2.0 m/sec) aortic valve - peak gradient: 6 mm hg mitral valve - e wave: 0.8 m/sec mitral valve - a wave: 0.8 m/sec mitral valve - e/a ratio: 1.00 mitral valve - e wave deceleration time: 311 msec pericardium - effusion size: 0.6 cm interpretation: findings: right atrium/interatrial septum: a catheter or pacing wire is seen in the ra and extending into the rv. no asd by 2d or color doppler. left ventricle: mild symmetric lvh. normal regional lv systolic function. overall normal lvef (>55%). no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. simple atheroma in ascending aorta. normal aortic arch diameter. complex (>4mm) atheroma in the aortic arch. normal descending aorta diameter. complex (>4mm) atheroma in the descending thoracic aorta. aortic valve: three aortic valve leaflets. filamentous strands on the aortic leaflets c/with lambl's excresences (normal variant). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. no ms. mild (1+) mr. tricuspid valve: mild tr. pericardium: small pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. no tee related complications. the patient was under general anesthesia throughout the procedure. the patient appears to be in sinus rhythm. results were personally conclusions: prebypass 1.no atrial septal defect is seen by 2d or color doppler. 2.there is mild symmetric left ventricular hypertrophy. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). 3. right ventricular chamber size and free wall motion are normal. 4.there are simple atheroma in the ascending aorta. there are complex (>4mm) atheroma in the aortic arch. there are complex (>4mm) atheroma in the descending thoracic aorta. 5.there are three aortic valve leaflets. there are filamentous strands on the aortic leaflets consistent with lambl's excresences (normal variant). there is no aortic valve stenosis. no aortic regurgitation is seen. 6. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. 7.there is a small pericardial effusion. postbypass 1. patient is being av paced and receiving an infusion of phenylephrine. 2. biventricular systolic function is unchanged. 3. mild mitral regurgitation persists. 4. aorta is intact post decannulation. electronically signed by , md on 16:29. physician: () brief hospital course: admitted and underwent cabg x4 with dr. . transferred to the csru in stable condition on titrated propofol, phenylephrine and nitroglycerin drips. extubated that evening and remained in the csru for 2 days requiring titrated antihypertensives as well as an insulin drip.transferred to the floor on pod #2. hit screen sent for decreasing platelets, but results were negative. chest tubes removed without incident on pod #3. pacing wires removed on pod #5 and plavix restarted. cleared for discharge to rehab on pod #5. pt. is to make all follow-up appts. as per discharge instructions. medications on admission: asa 325 mg daily levothyroxine 88 mcg daily sertraline 50 mg daily lipitor 80 mg daily calcium acetate 667mg tid protonix 40 mg daily calcitriol 0.25 mg every other day metoprolol 12.5 mg tid vits. c/e discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 10 days. 2. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 10 days. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 6. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 7. calcitriol 0.25 mcg capsule sig: one (1) capsule po every other day (every other day). 8. calcium acetate 667 mg capsule sig: one (1) capsule po tid w/meals (3 times a day with meals). 9. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 10. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 11. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 12. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 13. sertraline 50 mg daily. discharge disposition: extended care facility: - discharge diagnosis: s/p cabg x4 cad nstemi crf with esrd cva renal artery stent chf htn discharge condition: stable discharge instructions: no driving for one month no lotions, creams, or powders on any incision no lifting greater than 10 pounds for 10 weeks may shower over incisions and pat dry call for fever greater than 100.5, redness or drainage followup instructions: see dr. in weeks see dr. in weeks see dr. in 4 weeks Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of four or more coronary arteries Diagnoses: End stage renal disease Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified acquired hypothyroidism Depressive disorder, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Personal history of other diseases of circulatory system Osteoarthrosis, unspecified whether generalized or localized, other specified sites

allergies: cephalexin attending: chief complaint: pain in left 3rd toe and foot major surgical or invasive procedure: placement of dialysis cathether in right subclavian vein. - diagnostic abdominal aortogram and pelvic arteriogram with unilateral lower extremity runoff, contralateral third order catheterization, primary balloon angioplasty of the anterior tibialis x 3. infusion for thrombolysis of the distal at. cpt codes , , , - open third ray amputation left foot - exploration of right groin and repair of bleeding, right common femoral artery. , . - operation: 1. open ray amputation left fourth toe. 2. debridement of skin and subcutaneous tissue, muscle, and bone. history of present illness: ms. is a 66 yo f with a 6-month history of ulcer on her left 3rd toe. she has been followed by dr. of podiatry in . she reports that she last saw him three weeks ago and he thought her toe was improving. two weeks ago, she began to have increasing pain in her toe and instep, and noticed that her toe appeared darker. her cousin, with whom she lives, noticed her rubbing her toe frequently and encouraged her to see a doctor, but she did not. one week ago, she noticed redness on the dorsal aspect of her foot. she finally saw her podiatrist and he sent her to the ed. she describes her pain as , in her 3rd toe and instep of her left foot. additionally, she complains of a stinging pain in her great toes bilaterally secondary to gouty arthritis. she has remained afebrile. she denies prior foot ulcers or injury, as well as numbness or tingling in her feet. she notes that she normally moves freely about her home, and climbs stairs several times a day to do laundry. she has had recent falls without injury after tripping over the cord for an electrical blanket. on review of systems, she has had recent nosebleed and asthmatic symptoms. she denies ha, dizziness, cp, sob, fevers/chills, abdominal discomfort, dysuria, urgency, or muscular weakness. she has had some recent intentional weight loss. past medical history: 1) chronic renal insufficiency: fsgs, s/p nephrectomy, baseline cr >3.0 . 2) type ii diabetes, controlled by diet, hba1c has always been less than 6.4% . 3) endometrial cancer, stage ii/iii, s/p tah/bso and radiation . 4) complete heart block, apparently related to nephrectomy, with implanted 18 months after surgery . 5) colonic adenomas in , . 6) skull fracture at age 6, truck , has mild mr . 7) hypercholesterolemia, total chol 206, ldl 105 . 8) gout, primarily in big toes bl . 9) stress incontinence . 10) asthma, no prior hospitalizations, no oral steroids. . 11) osteopenia, height loss of 3 inches . 12) allergic rhinitis . 13) atrial fibrillation/flutter, on warfarin . 14) anemia, renal failure, on procrit . 15) hypertension, controlled on lisinopril, nifedipine . 16) s/p cholecystectomy social history: lives with cousin ). on medicare. has a dog. past smoking history but quit in . occasional etoh. family history: father-ca and at age 61, grandmother-breast ca and diabetes, mother-diabetes, stroke, cad. physical exam: hgt 4'9" wgt 52.4 kg (max 102 kg 18 years ago) t 98.1 p 69 bp 130/72 rr 18 99% ra gen: appears older than stated age. nad. aaox3. thin hair. heent: right fronto-temporal scar, convexity. sclera anicteric. no conjunctival pallor. mmm. clear oropharynx. no thyromegaly or nodules. cv: ir / ir, nl s1, s2. no m/r/g. lungs: ctab, clear breath sounds in all fields. abd: flat, soft, nt, nd. no organomegaly or mass. ext: palpable fems b/l, palp r dp, dopp r pt, l dp/pt wounds: site: right groin type: surgical dressing: gauze - dry site: left foot amp description: draining sm amount sang drng. care: on vac @ 125mm/hg / change dressing every two days site: right groin thrombectomy site description: staples intact/eccymotic area,hard to touch/old dsg. with sang drng sm amount site: coccyx description: stage iii pertinent results: admission labs: 01:35pm blood wbc-16.2*# rbc-3.86* hgb-11.1* hct-33.0* mcv-86 mch-28.9 mchc-33.8 rdw-16.7* plt ct-280 01:35pm blood neuts-92.6* bands-0 lymphs-5.1* monos-1.9* eos-0.3 baso-0 01:35pm blood hypochr-normal anisocy-1+ poiklo-normal macrocy-normal microcy-1+ polychr-normal 01:35pm blood plt smr-normal plt ct-280 06:20pm blood pt-31.1* ptt-38.0* inr(pt)-3.3* 01:35pm blood esr-120* 01:35pm blood glucose-141* urean-82* creat-3.9* na-138 k-4.1 cl-97 hco3-27 angap-18 01:35pm blood calcium-9.8 phos-3.3 mg-2.3 03:15pm blood lactate-1.8 . microbiology: blood cultures x 2 () no growth wound swab: mssa, group b strep (levo resistant), and diptheroids urine cultures: () no growth () <10,000 organisms/ml. () yeast. >100,000 organisms/ml. dfa for varicella () negative. . studies: xr left foot: impression: 1. indistinct cortical contour of terminal tuft of the left third distal phalanx, concerning for osteomyelitis, related to an adjacent ulcer. 2. cystic change in the first metatarsal head is likely degenerative, related to the hallux valgus deformity, although the less likely possibility of gout could be considered in the appropriate clinical setting. 3. calcifications. . lower extremity arterial doppler: impression: significant bilateral popliteal/tibial artery occlusive disease with severe flow deficit to both forefeet. . venous dup extext bil: findings: the greater and lesser saphenous veins are patent bilaterally. please see digitized image on pacs for formal sequential vein measurements. . stress p-mibi: impression: no anginal symptoms with an uninterpretable ekg for ischemia. normal pharmacologic myocardial perfusion study with normal left ventricular wall motion and cavity size. compared with the study of , no significant change. . dialysis catheter placement: impression: successful placement of right internal jugular tunneled hemodialysis catheter with tip in the right atrium. the catheter is now ready for use. . pre-op cxr impression: 1. small bilateral pleural effusions with no evidence of parenchymal consolidation. mild symettric promince suggests possible fluid overload related to underlying renal condition. . pre-op ekg regular ventricular pacing; atrial flutter; since previous tracing, atrial flutter more apparent. . other pertinent results: 07:05am blood glucose-133* urean-123* creat-5.5* na-136 k-4.0 cl-97 hco3-23 angap-20 07:30am blood hapto-434* 09:30am blood triglyc-294* hdl-19 chol/hd-8.8 ldlcalc-89 06:50am blood pth-100* 01:15pm blood hbsag-negative hbcab-negative 05:55am blood vanco-20.4* 01:15pm blood hcv ab-negative 07:38am blood ph-7.41 07:38am blood freeca-1.08* . discharge labs: 07:45am blood wbc-9.3 rbc-2.94* hgb-8.8* hct-25.8* mcv-88 mch-30.0 mchc-34.2 rdw-16.3* plt ct-278 04:56am blood pt-17.3* inr(pt)-1.6* 07:45am blood plt ct-278 07:45am blood glucose-143* urean-34* creat-2.2* na-136 k-3.6 cl-97 hco3-30 angap-13 07:45am blood calcium-8.3* phos-3.0 mg-1.6 uricacd-4.6 11:47 am swab source: left 4th toe ulcer - deep. final report 02/28/0 gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram positive cocci, in pairs and clusters. 1+ (<1 per 1000x field): gram positive rod(s). smear reviewed; results confirmed. wound culture (final ): staph aureus coag +. heavy growth. penicillin sensitivity available on request. staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin-------------<=0.25 s trimethoprim/sulfa---- s anaerobic culture (final ): prevotella species. moderate growth. beta lactamase positive. brief hospital course: in the ed, she was seen by podiatry, who probed her wound to bone, obtained wound and blood cultures, and ordered chem 10, cbc, coags, lactate, esr, and foot xray. she was started on unasyn empirically. . 1) toe ulcer: ms. presented with an ulcer that had been present for six months with fluctuating course, and was found to be osteomyelitis after being probed to bone, with possible cellulitis spreading in foot. she was started on vancomycin, levofloxacin, and flagyl. a culture of the wound grew levo-resistant group b strep, mssa, and diptheroids. levofloxacin was discontinued. insufficiency was confirmed by doppler of lower extremities and abis which showed significant bilateral popliteal/tibial artery occlusive disease with severe flow deficit to both forefeet. additionally, she was found to have poor proprioception in her toes on admission. on , a new pungent odor from toe was appreciated. although her white count was intermittently elevated, the erythema was stable, as was her temperature. surgery was then consulted: procedures: - diagnostic abdominal aortogram and pelvic arteriogram with unilateral lower extremity runoff, contralateral third order catheterization, primary balloon angioplasty of the anterior tibialis x 3. infusion for thrombolysis of the distal at. cpt codes , , , - open third ray amputation left foot - exploration of right groin and repair of bleeding, right common femoral artery. , . - operation: 1. open ray amputation left fourth toe. 2. debridement of skin and subcutaneous tissue, muscle, and bone. . 2) acute on chronic renal failure: ms. had had a prior nephrectomy for secondary fsgs and a perinephric abscess. on admission, her baseline creatinine was around 3.0-3.5. she was admitted with a creatinine of 3.9, which rose to 5.5. lasix was d/c'ed as there was no evidence of volume overload. all medications were redosed for inrenal function as needed. she had had a previous failed attempt at av fistula formation due to poor vessel quality, so she then received a central venous dialysis catheter. renal team followed her and she was dialyzed twice while on the medicine service with procrit, iron, and calcitriol given at dialysis as needed. the etiology of the acute renal process was never definitively determined, although it was thought that there may have been contribution from medications, volume depletion, or an intrinsic process. there were signs suggestive of an intrinsic renal process, including albumin:cr of 176 (serum albumin low at 2.8, lfts normal) and granular casts were noted on urinary sediment, suggestive of atn. she was continued on an ace inhibitor to minimize albumin loss. she was not a regular hd schedule. this will be determined by renal. she did get hd . on - this was renals recommendations: access - tunneled line no issues, working well at hd . renal function - esrd . na, bp volume - cont lopressor, lisinopril . potassium - low k diet, 3.5 k bath . acid base - 35 bicarb bath at hd . anemia - epo 10,000 units at hd . ca, phos - zemplar 1 mcg at hd . renal replacement - hd today 3 1/2 hrs 350 qb goal 1 kg uf . 3) orthopnea- ms. developed positional dyspnea on , which was though to be likely due to volume overload, as she had received approximately 1 liter of iv fluids in the preceding day as renal protection for scheduled angiography. her oxygen saturation fell to 92% on room air on , and she was put on 2l oxygen by nasal cannula with improvement to 99%. a cxr was c/w volume overload. by the afternoon of , her oxygen saturation was adequate on room air, and she denied further symptoms. . 4) dermatomal vesicular rash- first noted by the patient on on chest midline t4, tender to light touch. this was felt to be concerning for vzv. acyclovir was started empirically and she was put on contact precautions. a dfa came back negative for vzv on , and acyclovir was discontinued. much improved on dc. . 5) type ii diabetes: ms has longstanding dm that she says is controlled by diet alone and her hba1c has always been less than or equal to 6.4%, which implies reasonable control. she says that she is followed by an ophthalmologist at and that she does not have any ocular disease. she strongly denies neuropathy, although her position sense in her toes did not appear to be fully intact. her finger sticks were monitored , and then changed to qid for tighter control on an insulin sliding scale. . 6) 5 point hematocrit drop- from to , patient's hematocrit dropped from 29.8 to 24.0. there was no record of significant blood loss during ir procedure. she had no sign of hematoma at procedure site. a haptoglobin, ldh, and tbili were not consistent with a hemolytic process. all stools were guaiac negative. 2 units prbcs were given with an appropriate response, and she experienced no further drop in hematocrit. to note pt did have an angiogram on . on it was thought that the pt developed a psueedo anuerysm post cath. pt experienced extreme thigh pain / dropped her pressure. pt was taken to the the or emrgently for hematoma evacuation and repair odf her femoral arery. pt did recieve prbc. on dc hct is stable . 7) asthma: ms. has had no prior hospitalizations or oral steroid use for her asthma. she had an exacerbation on at night, but responded to albuterol inhaler with no further exacerbations. she was given albuterol and fluticasone inhalers daily for control of symptoms. . 8) atrial fibrillation/flutter: ms has a history of paroxysmal a-fib. she is on warfarin, and was admitted with a supratherapeutic inr at 3.9 that rose to 4.5. lfts were normal. warfarin was held. she was given vitamin k and 2 units of fresh frozen plasma with correction of her inr to 1.3. im heparin was given for dvt prophylaxis at this point. when her vascualr issues were completed. pt restarted on her coumadin on dc her inr is 1.6 . 9) social/financial: patient expressed concerns regarding insurance coverage of dialysis and that she has been trying to get on medicare. she is on disability and has few financial resources. social work was consulted and will follow with recommendations for outpatient dialysis placement. . 10) ms. hypertension was controlled on lisinopril, nifedipine. . 11) hypertriglyceridemia: a lipid panel was ordered which showed trigglycerides 294, cholesterol 167, and ldl 89. before hospital discharge, her pcp should be consulted regarding whether she would advise adding gemfibrozil. medications on admission: albuterol 17 gm, 2 puffs qid prn cough allopurinol 200 mg qday atenolol 50 mg qday azmacort 100 mcg, 3-4 puffs furosemide 40 mg qday lisinopril 5 mg qday loratidine 10 mg qday mva qday nasonex 50 mcg, 2 sprays each nostril qday prn nifedical xl 30 mg qday nortryptiline 20 mg qhs procrit 10,000 units sq qweek tums 750 mg tid with food tylenol 1,000 mg prn tylenol-codeine#3 300/30 mg, 1-2 tabs qhs prn pain warfarin 2.5-5.0 mg qday discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 2. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 3. fexofenadine 60 mg tablet sig: one (1) tablet po bid (2 times a day). 4. fluticasone 50 mcg/actuation aerosol, spray sig: one (1) spray nasal daily (daily). 5. nortriptyline 10 mg capsule sig: two (2) capsule po hs (at bedtime). 6. acetaminophen-codeine 300-30 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. allopurinol 100 mg tablet sig: one (1) tablet po qtuthsa (tu,th,sa). 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed. 11. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 12. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed. 13. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. 14. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for abd discomfort. 15. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 16. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 17. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 18. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for skin breakdown in abd. skin folds. 19. warfarin 2.5 mg tablet sig: one (1) tablet po hs (at bedtime). 20. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 21. insulin insulin sc sliding scale breakfast lunch dinner bedtime humalog glucose insulin dose 0-70 mg/dl 4 oz. juice and 15 gm crackers 4 oz. juice 71-150 mg/dl 0 units 0 units 0 units 0 units 151-200 mg/dl 1 units 1 units 1 units 1 units 201-250 mg/dl 2 units 2 units 2 units 2 units 251-300 mg/dl 3 units 3 units 3 units 3 units 301-350 mg/dl 4 units 4 units 4 units 4 units 351-400 mg/dl 5 units 5 units 5 units 5 units > 400 mg/dl notify m.d. discharge disposition: extended care facility: - - discharge diagnosis: l 4th toe open ulceration / cellulitis right groin hematoma post angiogram dm(ii)diet controlled a. flutter cri(3.0) htn pressure ulcer coccyyx discharge condition: stable discharge instructions: vac dressing discharge instructions introduction: this will provide helpful information in caring for your wound. if you have any questions or concerns please talk with your doctor or nurse. you have an open wound, as opposed to a closed (sutured or stapled) wound. the skin over the wound is left open so the deep tissues may heal before the skin is allowed to heal. premature closure or healing of the skin can result in infection. your wound was left open to allow new tissue growth within the wound itself. the wound is covered with a vac dressing. this will be changed every two days. the vac: _ helps keep the wound tissue clean _ absorbs drainage _ prevents premature healing of skin - promotes healing when to call the doctor: watch for the following signs and symptoms and notify your doctor if these occur: temperature over 101.5 f or chills foul-smelling drainage or fluid from the wound increased redness or swelling of the wound or skin around it increasing tenderness or pain in or around the wound followup instructions: provider: , surgery (nhb) date/time: 2:30 provider: call phone: date/time: 9:30 provider: clinic phone: date/time: 9:00 Procedure: Hemodialysis Angioplasty of other non-coronary vessel(s) Injection or infusion of thrombolytic agent Arteriography of femoral and other lower extremity arteries Venous catheterization for renal dialysis Amputation of toe Amputation of toe Excisional debridement of wound, infection, or burn Transfusion of packed cells Control of hemorrhage following vascular surgery Transfusion of other serum Other partial ostectomy, tarsals and metatarsals Procedure on single vessel Diagnoses: Anemia in chronic kidney disease End stage renal disease Abnormal coagulation profile Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Gout, unspecified Atrial fibrillation Infection with microorganisms resistant to penicillins Personal history of malignant neoplasm of other parts of uterus Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Ulcer of other part of foot Hemorrhage complicating a procedure Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Peripheral vascular complications, not elsewhere classified Pressure ulcer, lower back Cardiac pacemaker in situ Atherosclerosis of native arteries of the extremities with gangrene Acquired absence of kidney Personal history of irradiation, presenting hazards to health Arterial embolism and thrombosis of lower extremity Epistaxis Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, unspecified Cellulitis and abscess of foot, except toes Asthma, unspecified type, with (acute) exacerbation Acute osteomyelitis, ankle and foot Aneurysm of artery of lower extremity Mild intellectual disabilities Other specified disorders of skin Chronic glomerulonephritis with lesion of membranous glomerulonephritis

allergies: pcn--anaphylaxis. neuro: alert and oriented x 3. mae w/ equal strength. seems a bit sleepy this am after receiving 2 percocet but easily awakens to voice. cv: a pacing turned down to aai with rate at 56 this am with intrinsic hr 80's nsr and adequate co/ci. bp 104-130/60-70. cont's on 25 mg captopril tid. hct stable. swan d/c'd without difficulty. 20 meq po kcl given for k+ 3.4. ct's w/ mod amt serousang dng, 100cc with oob to chair activity this am. to remain in place until later today. +2 left ankle edema. resp: bs diminished throughout, rales at left base. using is up to 1250 w/ encouragement. cough strong, non productive. o2 sats 98% or greater on 2l np. gi/gu: tolerating po's without difficulty. abd soft, nd, + bs. u/o drifting down to 30's over last hour. will continue to monitor. lasix given at 0300. id: temp max of 101.3 this am. down to 98 po at 0800. endo: stable. skin: intact. leg incision w/ steristrips, no dng, ace wrap intact. sternal incision w/ steristrips, ota. comfort: percocet prn. tolerated 1 percocet without sleepiness yesterday. toradol cont's. good pain control. activity: oob to chair this am-tol well. a: hemodynamically stable. ? sleepy from 2 percocets. Procedure: Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Other and unspecified coronary arteriography Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Mitral valve disorders Unspecified essential hypertension

history of present illness: mr. is an 82-year-old male with a past medical history for benign prostatic hypertrophy, hypertension, hypercholesterolemia, with recent onset of dyspnea on exertion but denied any evidence of chest pain. this brought him to be evaluated by his primary care physician, ultimately led to a positive stress test showing 2 mm st segment depressions in the inferior and lateral leads, relieved by rest but ultimately asymptomatic. he was admitted on to and was therefore transferred to , where he underwent cardiac catheterization. cardiac catheterization revealed a left ventricular end diastolic pressure of 22. there was some mild mitral regurgitation seen. left ventricular ejection fraction was reported as "normal," with no mitral regurgitation. left main coronary artery was calcified with diffuse tubular stenosis of approximately 80%. the left anterior descending had 70 to 80% mid-left anterior descending lesion after the diagonal. the left circumflex was very small, with marginals. there was a ramus that was also present with major lateral wall vessel, 70% mid and 90% small upper pole branch. the right coronary artery with diffuse mild disease, 50% origin, very short posterior descending artery, distal disease in the short plv. the left internal mammary artery filled late on left ventriculogram. no angina was seen. as a consequence, the patient was diagnosed with significant left main disease as well as three vessel coronary artery disease. he was admitted to the c-med service and cardiothoracic surgical consultation was obtained with dr. and dr. . the patient agreed to have elective surgery and ultimately went to the operating room on , where he underwent a coronary artery bypass graft x 2, including saphenous vein graft to the left anterior descending, and saphenous vein graft to the ramus. this was done because of the late filling and poor quality of the left internal mammary artery. the patient's pericardium was left open. he had a right radial a-line, right internal jugular swan-ganz catheter, one ventricular and one atrial pacing wires present. he had mediastinal and right pleural tube, as well as mean arterial pressure of 68 and a right atrial pressure of 10. pulmonary artery diastolic pressure was 12, with a mean of 18. he was a-paced at 68. he was on a propofol drip at 20 mcg/kg/minute, and nitroglycerin at 1 mcg/kg/minute. he was transferred to the cardiac surgical recovery unit, where by postoperative day number one, he was extubated, alert and oriented. he was 80, with a-paced. his rhythm was 30, 129/48 blood pressure. he was 98% on nasal cannula with a blood gas of 7.38/39/82/24/-1. his postoperative hematocrit was 25, his bun and creatinine were 18 and 1.0. preoperative hematocrit was 39, and preoperative creatinine was 1.0. neurologically, he was intact. cardiovascularly, lopressor and aspirin and captopril were started. chest tubes were kept in. he was started on a cardiac diet, and was ultimately transferred to the floor. on the floor, the patient did well. he had no issues. his chest tubes were subsequently removed. he was continued to have lopressor held due to the fact that he still required a-pacing and was being paced -max was 101.3 going into postoperative day number two. this was felt to be due to poor pulmonary toilet. he was therefore worked on aggressively with chest physical therapy and incentive spirometry, as well as coughing and deep breathing drills. he was 95% on nasal cannula. no blood gas was available. hematocrit was 25 on postoperative day number two, and bun and creatinine were 21 and 1.2. on the floor, physical therapy worked with the patient. he was ambulating at a level iii by postoperative day number three. he had no complaints overall. ep consultation was called for a seven beat run of nonsustained ventricular tachycardia but, given his normal ejection fraction and the fact that his beta blocker was being held, they just recommended repleting his electrolytes as needed, starting a beta blocker when it would be tolerated when he was no longer being paced, and no further intervention was required. his chest tubes were ultimately removed on postoperative day number two. on postoperative day number three, he was ambulating, still at a level iii. his lungs were clear. oxygen saturation was 96%. blood pressure was 118/47, with a heart rate of 73 and sinus. no further ventricular ectopy or nonsustained ventricular tachycardia was seen. hematocrit was 24, bun and creatinine were 25 and .3. at the time of discharge, the patient's sternum was stable, no drainage or erythema, open to air. the heart was regular, with no murmur, rub or gallop. the lungs were clear, decreased at the bases. the extremities were warm and well perfused, with palpable dorsalis pedis and posterior tibial pulses bilaterally. his hematocrit was 24, his bun and creatinine were 25 and 1.3. his white blood cell count was 11,000. he was ambulating at a level iv. his lopressor was titrated accordingly. his wires were ultimately removed. the patient was deemed an appropriate rehabilitation candidate due to the fact that he only reached level iv one time and was otherwise persistently ambulating at a level iii. he was requesting the rehabilitation facility, which was ultimately what we tried to achieve for him. discharge medications: lasix 20 mg by mouth once daily for seven days, k-dur 20 meq by mouth once daily for seven days, colace 100 mg by mouth twice a day, protonix 40 mg by mouth once daily, captopril 25 mg by mouth three times a day, lipitor 10 mg by mouth once daily, percocet 5/325 one to two tablets by mouth every four to six hours as needed, lopressor 75 mg by mouth twice a day, aspirin 325 mg by mouth once daily. follow up instructions include to be seen by dr. in one month, see his primary care physician or cardiologist in two to three weeks from the time of discharge. he will be at rehabilitation, where they can do his wound check. discharge status: to rehabilitation. discharge diagnosis: 1. coronary artery disease, coronary artery bypass graft x 2, saphenous vein graft to left anterior descending and saphenous vein graft to ramus , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Other and unspecified coronary arteriography Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Mitral valve disorders Unspecified essential hypertension

discharge condition: stable. discharge status: home. discharge diagnoses: acute myocardial infarction, congestive heart failure, ejection fraction 30%, status post ventricular tachycardic arrest, status post aicd placement, gastrointestinal bleeding, left arm phlebitis. discharge medications: aspirin 325 q day, lisinopril 5 q day, furosemide 40 , lipitor 10 mg q day, sublingual nitroglycerin prn, colace 100 prn, ambien 5 mg q hs prn, protonix 40 mg , keflex 500 mg qid for seven days. discharge followup: she will be followed up by her private cardiologist, dr. . she will also be followed up by her primary care physician, will have colonoscopy and esophagogastroduodenoscopy arranged through her primary care physician. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Left heart cardiac catheterization Catheter based invasive electrophysiologic testing Insertion of temporary transvenous pacemaker system Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Diagnoses: Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Hyposmolality and/or hyponatremia Paroxysmal ventricular tachycardia Peripheral vascular complications, not elsewhere classified Hemorrhage of gastrointestinal tract, unspecified Acute myocardial infarction of inferoposterior wall, initial episode of care Diseases of tricuspid valve

final discharge medications: 1. vancomycin 1 gram iv q12 hours, last dose on (for a total of 14-day course). 2. zestril 5 mg po q day. 3. atenolol 12.5 mg po q day. 4. lipitor 10 mg po q day. 5. aspirin 325 mg po q day. 6. lasix 40 mg po bid. 7. colace 100 mg po bid prn. 8. ambien 5 mg po q hs prn insomnia. 9. sublingual nitroglycerin 0.5 mg tablets sublingual q5 minutes prn chest pain. dr.,josseph 12-255 dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Left heart cardiac catheterization Catheter based invasive electrophysiologic testing Insertion of temporary transvenous pacemaker system Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Diagnoses: Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Hyposmolality and/or hyponatremia Paroxysmal ventricular tachycardia Peripheral vascular complications, not elsewhere classified Hemorrhage of gastrointestinal tract, unspecified Acute myocardial infarction of inferoposterior wall, initial episode of care Diseases of tricuspid valve

history of present illness: this is a 63-year-old woman with no known coronary artery disease who was in her usual state of health until the saturday night prior to admission when she started to experience chest pain. the pain was sharp located substernal and left chest region radiating to the back to the right chest and to the left arm. she also had some diaphoresis, nausea, and vomiting, but no shortness of breath. she thought her symptoms were due to flu-like symptoms. she had persistent symptoms, but did not seek any medical advice. she presented to the emergency room on monday (two days after her initial presentation) as a walk-in patient. she complained of chest pain. her initial electrocardiogram showed q waves, st elevation, and t-wave inversions in leads ii, iii, and avf. she was treated with aspirin, morphine, and nitroglycerin. her chest pain subsided to . she remained hemodynamically stable in the emergency room. she was later transferred to for percutaneous transluminal angiography. however, the percutaneous transluminal angiography was unsuccessful due to the difficulty of her achieving greater than timi flow. the patient also experienced some transient bradycardia intraoperatively, and required a temporary pacer placement. she was transferred to ccu in stable condition for further medical management. medications: none. allergies: no known drug allergies. past medical history: status post cholecystectomy years ago, status post five normal vaginal deliveries, regular annual examinations. social history: smoker, quit six months ago, 22, 30-pack year history. occasional alcohol. no other drug abuse. family history: heart disease. examination on admission: temperature 99.5, blood pressure is 127/77, heart rate 99, and o2 sat is 96% on room air. general: looks comfortable in bed in no acute distress. head and neck examination: normocephalic, atraumatic. pupils are equal, round, and reactive to light. extraocular movements are intact. cardiovascular: normal s1, s2, faint heart sounds. lungs are clear to auscultation bilaterally anteriorly. abdomen is soft, nondistended, and nontender. extremities: no edema. neurologic is nonfocal. laboratories at : white count 17.3. differential is 88% neutrophils, 8% lymphocytes, 2% monocytes. hematocrit is 40.9, platelets 243. chem-7 within normal limits. ck mb is 102. troponin is 54. electrocardiogram showed q waves in leads iii and avf. st elevation in ii, iii, and avf. t-wave inversions in ii, iii, and avf. st depression . st depression v2 and poor r-wave progression. laboratories on admission at : complete blood count is 20.4, hematocrit is 35.7, platelets 190. pt is 13.5, ptt is 39.8, inr is 1.3. chem-7 within normal limits with bun and creatinine of 20/0.6. ck is 2048. electrocardiogram i: second degree a-v block, q waves in iii and avf, v1, st elevation and t-wave inversions in leads ii, iii, and avf. st depression in v1 to v3. right sided electrocardiogram showed sinus tachycardia, q waves in iii, avf, v2 to v3, st elevation, t-wave inversions in leads ii, iii, and avf, st depression in , elevation in v4-v6. catheterization: two vessel disease. mid right coronary artery 100% occlusion, proximal left anterior descending artery 60%, mid left anterior descending artery 50%, diagonal i 80%, diagonal ii 30%, acute inferior myocardial infarction. hospital course: the hospital stay was essentially uncomplicated. she had episodes of chest discomfort initially which had no associated electrocardiogram changes and unrelieved with sublingual nitroglycerin and morphine. her ck peaked at 2048 on admission, and continued to trend down to 147 on discharge. she had an echocardiogram done on hospital day two, which showed ejection fraction of 30% with inferior-posterior infarction. a temporary pacer wire was pulled on hospital day three, and she had no significant events on telemetry. she had episodes of hyponatremia which serum sodium down to 128 secondary to congestive heart failure, which was successfully managed with aggressive diuresis. on discharge, her serum sodium went back to 136. her urine culture went back positive for e. coli. she was also treated for a seven-day course of bactrim for uncomplicated urinary tract infection. patient's hip culture also came back positive for corynebacterium, but it was very likely contaminant, so the decision was not to treat, but to draw a set of blood cultures, given the patient was doing well clinically without fever and increasing white blood cell count. she also developed guaiac-positive stools while inhouse with hematocrits slowly changing down from 36 to 30. hematocrit was stabilized around 30 with protonix tid. decision was made to have outpatient and esophagogastroduodenoscopy workup. she tolerated medical management with aspirin, beta blocker, ace inhibitor, statin, and diuretics very well. the patient was evaluated by physical therapist before discharge and deemed stable enough to go home without further physical therapy. she will be followed by her primary care doctor, dr. and her cardiologist, dr. as an outpatient. discharge condition: stable. discharge status: home. discharge diagnoses: acute inferior-posterior myocardial infarction. discharge medications: lipitor 10 mg po q day, aspirin 325 q day, atenolol 25 mg q day, lisinopril 10 mg q day, sublingual nitroglycerin prn, protonix 40 mg , ambien 5 mg q hs prn, lasix 40 mg po bid, colace 100 mg prn. follow-up arrangements: dr. , cardiologist. aicd evaluation given ejection fraction of 30%. stress test in weeks. dr. , primary care physician, and esophagogastroduodenoscopy arrangements for guaiac-positive stools. the patient will see her primary care physician and cardiologist in a week after discharge. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Left heart cardiac catheterization Catheter based invasive electrophysiologic testing Insertion of temporary transvenous pacemaker system Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Diagnoses: Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Hyposmolality and/or hyponatremia Paroxysmal ventricular tachycardia Peripheral vascular complications, not elsewhere classified Hemorrhage of gastrointestinal tract, unspecified Acute myocardial infarction of inferoposterior wall, initial episode of care Diseases of tricuspid valve

allergies: latex / lisinopril attending: chief complaint: left femur fracture major surgical or invasive procedure: left distal femur orif history of present illness: 60 yo female with history of paf, hl, hypothyroidism, htn and metastatic renal cell carcinoma s/p chemo/xrt, r nephrectomy , adrenalextomy , t11-l1 lami/tumor resection/t9-l2 fusion who presented with new l distal femur fracture upon standing up and is now s/p orif on . patient was noted to be in afib with rvr in the or and was started on neo gtt. she remained in the pacu for >24 hr and subsequently spontaneously converted to nsr and was able to be weaned off the neo gtt. she was then transferred to the floor but after arriving on the floor the she went back in afib with rvr and had hypotension down to sbp 80s. she was given lopressor 5 mg x 1 without good effect and a cards consult was obtained. cardiology recommended resuming home bb when able, pain control and digoxin if bp could tolerate. she was dig loaded but continued to be hemodynamically unstable and was transferred to sicu. . in the sicu, she was treated with metoprolol, her dig was discontinued and she converted to nsr. she has had issues with pain control and has been noted to be delirious at times but mostly aox3. . review of sytems: (+) 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 nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: metastatic renal cell carcinoma (s/p surgery/xrt/chemo) paroxysmal af htn hypothyroidism dyslipidemia right nephretomy adrenalectomy left knee surgery tonsillectomy and adenoidectomy polypectomies social history: -tobacco history: none -etoh: none -illicit drugs: none family history: noncontributory physical exam: vs: t= 98.1, bp=118/70, hr=95, rr=22, o2 sat=100% 3l nc general: oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of *** cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. . pertinent results: imaging . femur film impression: distal femur diaphyseal fracture. . chest xray impression: unchanged bilateral pulmonary metastases. no acute process identified. . left femoral reamings 1. fragments of bone and bone marrow with maturing trilineage hematopiesis, no evidence of malignancy; multiple levels are examined, see note. 2. fibroadipose tissue and skeletal muscle. . intraop films 28 spot fluoroscopic images were obtained intraoperatively without the presence of a radiologist. flouro time recorded as 533.1 s on the electronic requisition. views demonstrate steps related to fixation of a distal femoral shaft fracture. fcorrelaiton with real-time findings and,when appropriate, conventional radiographs is recommended for full assessment. . cta chest impression: 1. no evidence of pulmonary embolism. 2. interval progression of metastatic disease since with increase in the size and number of metastatic foci. 3. interval development of pulmonary edema and small bilateral pleural effusion. . femur right the film is listed as two views of the femur. however, the study consists of a single view of the femur and a single view of the right lower extremity. the right hip and proximal femoral neck are not well evaluated on this scan. no acute fracture is detected on this limited exam. no suspicious lytic or sclerotic lesions are detected. some non-aggressive periosteal new bone seen in the proximal tibial diaphysis medially likely relates to a muscle insertion site. however, if this corresponds to the site of symptoms, then conventional ap and lateral views of the right lower extremity or alternatively an mri scan would be recommended for further assessment. there are degenerative changes of the right knee. . bilateral lenis: there is nonocclusive thrombus of some age in one of the left posterior tibial veins. the other deep veins of the lower extremities show no ultrasound evidence of deep venous thrombosis. brief hospital course: ms. is a 60 year old woman with metastatic renal cell carcinoma. she underwent an orif on . her post-operative course was complicated by atrial fibrillation with rvr and hypotension. . # dvt: patient was found on leni to have left posterior tibial vein deep vein thrombosis. it was unclear how long the blood clot had been there (chronic or new). patient was started on lovenox (therapeutic dosing) and given her hemoptysis, closely monitored. patient did not have any issues with increased bleeding on lovenox. - continue lovenox 110mcg q12 daily . # hemoptysis: on and ms. had an episode of hemoptysis. each episode was approximately 1 teaspoon. pulmonary was consulted who felt this was likely related to known pulmonary metastatic disease in the presence of lovenox for dvt prophylaxis. patient did benefit from 2l nasal cannula at night, more for osa. ultimately, patient's lovenox had to be increased to therapeutic doses given her left lower extremity dvt. she did not have any hemoptysis for >48 hours, however, prior to discharge - with close supervision. - continue 2l nasal cannula at night, room air during the day - continue lovenox at dvt treatment dosing . #. s/p left orif: she underwent a orif. she was started on enoxaparin post-operatively. she worked with physical therapy. - patient has follow-up appointment in orthopedic surgery clinic on at 10:40am (for xrays on 2nd fl) and 11am (w/ , np) - please encourage patient to continue working with physical therapy. she should get extra pain medications as needed prior/during work with physical therapy. . # pain control: the pain service was consulted to help manage ms. pain. she was started on nortriptyline and increased morphine. nortriptyline was eventually stopped given some concerns for tremor and weakness in her upper extremities. patient was started on gabapentin, ms contin (titrated up to 90mg tid) and lidocaine patches with control of her pain. - continue morphine sulfate ir 15-30mg every 4 hours for breakthrough pain - continue ms contin 90mg tid for ongoing pain (can decrease to 90/60/90mg if overly sedated) - continue gabapentin and lidocaine patches - the latter has been particularly helpful in controlling patient's pain . #. atrial fibrillation: her post-operative course was complicated by atrial fibrillation with rvr and hypotension. she required care in the sicu. cardiology was consulted. she was loaded with digoxin and converted into a regular rate. she maintained a regular rate throughout the rest of the hospitalization. she was placed on metoprolol tid. - continue current metoprolol tid dose . #. delirium: post-op course complicated by delirium. this resolved outside of the icu. - continue lorazepam prn for anxiety and before bed to help with sleep . #. metastatic renal cell: ms. is s/p nephrectomy/adrenalectomy, spinal tumor resection/t9-l2 fusion, and left orif on . a family meeting was held on which discussed her treatement plans. she will restart her sutent after allowing a couple of weeks for her fracture to heal. patient does also have a number of metastasis to her skin (left flank purplish nodules), confirmed by biopsy pathology reports. . # hypothyroidism: continue home dose of levothyroxine. . # skin nodules: per review of path reports, she has nodules on her back which were consistent with known metastatic disease. . # oxygen saturation: desaturates slightly when sleeping. likely due to obstructive sleep apnea. - continue 2l nasal cannula when sleeping - continue incentive spirometry, mobilization, and avoid increasing sedating meds. . code: ms. is full code. medications on admission: lopressor 25 qam/50 qpm asa 325 qd gabapentin 800 mg tid levothyroxine 200 mcg qd lorazepam 2mg qhs ms contin 60 mg q12 ms ir 15-30 mg q4 nystation cream omeprazole 20 mg prochlorperazine 10 mg q8 prn nausea extra strength tylenol q6 prn pain fish oil ibuprofen 400 mg methylsulfonylmethane 1 gram qd miralax pyridoxine 100 mg qd discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. gabapentin 400 mg capsule sig: two (2) capsule po tid (3 times a day). 4. levothyroxine 100 mcg tablet sig: two (2) tablet po daily (daily). 5. pyridoxine 50 mg tablet sig: two (2) tablet po daily (daily). 6. polyethylene glycol 3350 17 gram/dose powder sig: one (1) dose po daily (daily). 7. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours) for 5 days. 8. lorazepam 1 mg tablet sig: two (2) tablet po hs (at bedtime). 9. morphine 15 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain: please use for increased pain with movement. be sparing during the evenings. hold for sedation, rr<12. 10. multivitamin tablet sig: one (1) cap po daily (daily). 11. famotidine 20 mg tablet sig: one (1) tablet po daily (daily). 12. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed for rash on bilateral thighs and groin. 13. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 14. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 15. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for anxiety. 16. ondansetron hcl (pf) 4 mg/2 ml solution sig: one (1) injection q8h (every 8 hours) as needed for nausea/vomiting. 17. ms contin 30 mg tablet sustained release sig: three (3) tablet sustained release po three times a day. 18. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: three (3) adhesive patch, medicated topical daily (daily): please keep on 12 hours, off 12 hours. one for sacrum, one for hip, one for knee. 19. lidocaine-diphenhyd--mag- 200-25-400-40 mg/30 ml mouthwash sig: 15-30 ml mucous membrane four times a day as needed for oral pain: swish and spit. 20. lovenox 80 mg/0.8 ml syringe sig: one y (160) mg subcutaneous once a day. discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: metastatic renal cell cancer left distal femur fracture. hemoptysis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: thank you for allowing us to take part in your care. you were admitted to the hospital after a fracture of your left femur. you had a surgery to repair the fracture. your post-operative course was complicated by an irregular rhythm which has now resolved. your post-operative pain is also being controlled with a specific medication regimen. you were also found to have a blood clot in your left leg, so you were started on blood thinners. you were discharged to a rehab facility. . we made several changes to your medications. the important ones are as follows: we started lovenox injections for the blood clot we started morphine intermediate release as needed for breakthrough pain and ms contin for ongoing pain we started lidocaine patches for pain control we stopped nortriptyline because of tremors/weakness. we stopped ibuprofen. we stopped fish oil. we stopped methylsulfonylmethane. we changed acetaminophen. we changed your dosing of metoprolol to better control your irregular heart rate. followup instructions: please follow up with the orthopedics department. you have an appointment with , np on thursday, at 11am. you are to get x-rays prior to the appointment at 10:40. provider: xray (scc 2) phone: date/time: 10:40 provider: , : date/time: 11:00 . please follow up with dr. once you are discharged from rehab. if you are in rehab longer than two weeks, please call his office for an appointment. his office will also check-in with the rehab facility weekly on your discharge progress. you can reach dr. office at (. md, Procedure: Arterial catheterization Open reduction of fracture with internal fixation, femur Diagnoses: Other iatrogenic hypotension Obstructive sleep apnea (adult)(pediatric) Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Other and unspecified hyperlipidemia Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Secondary malignant neoplasm of skin Secondary malignant neoplasm of lung Personal history of malignant neoplasm of kidney Acquired absence of kidney Delirium due to conditions classified elsewhere Secondary malignant neoplasm of bone and bone marrow Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Neoplasm related pain (acute) (chronic) Arthrodesis status Pathologic fracture of other specified part of femur Chronic venous embolism and thrombosis of deep vessels of distal lower extremity

allergies: latex attending: chief complaint: left lower extremity weakness major surgical or invasive procedure: t11-l1 decompressive laminectomy, tumor resection, t9-l2 instrumented fusion with neuromonitoring history of present illness: this is a 58-year-old female who is known to dr. . she was diagnosed previously with a long history of renal cell carcinoma and has recently presented with progressive metastases to her lumbar spine. she has a large lesion in the post. elements overlying t12-l1 with infiltration of both lamina, the facet joint as well as the epidural space. there was noted to be sig. spinal cord compression. the patient is symptomatic. it is felt that she is not a candidate for radiation therefore wished to undergo surgical decompression of the lesion. past medical history: renal cell carcinoma adrenal recurrence rt. nephrectomy adrenalectomy left knee surgery t&a polypectomies social history: non-smoker/non-drinker family history: unknown physical exam: on discharge: neurologically intact with the exception of left lower extremity weakness() in the quadracep. sensorium is reported to be intact. surgical incision is slightly erythemic, but intact. there is a small blister noted adjacent to the right of midline incision. pertinent results: wbc-9.1 rbc-2.87* hgb-8.0* hct-24.9* mcv-87 mch-28.0 mchc-32.3 rdw-15.3 plt ct-332 plt ct-332 glucose-112* urean-8 creat-0.6 na-136 k-4.3 cl-103 hco3-30 angap-7* ct-t-spine: post-operative thoracolumbar spine, with posterior fusion from t10-l3 with pedicle screws in t10, t11, t12, l2, and l3. satisfactory position of pedicle screws. laminectomy from t11-l1 with resection of metastases. sacral soft tissue mass causing bone destruction, and measuring almost 5 cm. mri t spine: final report pending at discharge. intraoperative pathology: final report pending at discharge brief hospital course: to o.r. as planned. immediately following surgergy on post op day one and two the pt recieved a total of 4 units of packed red blood cells for symptomatic low urine output, hypotension and decreasing hematocrit. the pt tolerated the transfusions well, with no signs of volume overload or cardiac dysfunction. subsequent hematocrits have been stable, and symptoms of hypovolemia resolved. this is likely attributed to intraoperative volume losses. lower extremity motor strength is noted to be improving daily and the patient reports her preoperative pain is also improved. pt has been consulted to work with the pt daily and evaluate for any post discharge needs. she was found to be an appropriate rehab candidate, and was discharged to an appropriate facility on with appropriate follow up instructions. medications on admission: amlodipine, hctz, levothyroxine, lorazepam, nystatin,omprazole, oxycodone, valsartan, zometa discharge disposition: extended care facility: health center discharge diagnosis: thoracic tumor discharge condition: stable discharge instructions: ?????? do not smoke. ?????? keep your wound(s) clean and dry / no tub baths or pool swimming for two weeks from your date of surgery. ?????? no pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? limit your use of stairs to 2-3 times per day. ?????? have a friend or family member check your incision daily for signs of infection. ?????? take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? do not take any anti-inflammatory medications such as motrin, advil, aspirin, and ibuprofen etc. unless directed by your doctor. ?????? increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. we recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. call your surgeon immediately if you experience any of the following: ?????? 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, and drainage. ?????? fever greater than or equal to 101?????? f. ?????? any change in your bowel or bladder habits (such as loss of bowl or urine control). followup instructions: *you will need to have your staples and stitch removed in days from your date of surgery. this may be done at the rehab facility. ??????please call ( to schedule an appointment with dr. to be seen in 4 weeks. ??????you will not need x-rays prior to your appointment, as this was done during your acute hospialization. Procedure: Imageless computer assisted surgery Excision or destruction of lesion of spinal cord or spinal meninges Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Dorsal and dorsolumbar fusion of the posterior column, posterior technique Fusion or refusion of 4-8 vertebrae Diagnoses: Acute posthemorrhagic anemia Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Personal history of venous thrombosis and embolism Hypovolemia Personal history of malignant neoplasm of kidney Acquired absence of kidney Secondary malignant neoplasm of bone and bone marrow Myelopathy in other diseases classified elsewhere

allergies: latex / morphine / codeine attending: chief complaint: sepsis major surgical or invasive procedure: 1. intubation 2. central line placement 3. lumbar puncture 4. paracentesis history of present illness: 35 yo woman transferred from osh with sepsis. per report, pt presented to the osh with altered mental status, headache (possibly her typical migraine), myalgias, n/v, and slurred speech; these symptoms had reportedly been present for 2 days. at the osh she was initially afebrile (100.7 orally) but soon spiked a temperature to 102; she was initially tachycardic but was otherwise hemodynamically stable throughout her time there. her physical examination was reportedly noteworthy for mild lethargy, slightly dry mucous membranes, and no meningeal signs; her exam was reportedly otherwise unremarkable. her labs were noteworthy for a wbc of 16.6 (75 pmn, 20 bands, 3 monos, 2 eos), hct 36.1 (baseline high 20's), plt 31 (baseline low 40's); na 130, no anion gap, albumin 2.7, inr 1.9, ast 80, alt 81, alk phos 146, bili 2.6 (direct 0.85). u/a hazy, 3+ blood, 15-25 rbc, no wbc/bacteria. lp not done due to thrombocytopenia and coagulopathy. two units ffp were given prior to a diagnostic paracentesis that reportedly demonstrated ~2300 wbc with 87% pmn. a head ct was reportedly normal. she received vancomycin 1 gram iv, ampicillin 1 gram iv, zosyn, ceftriaxone 2 grams iv, and hydrocortisone 100 mg iv at the osh. a rij central line was placed there. osh blood cxs were already growing gram negative rods by time of arrival here. she is transferred here for further management since her hepatologist, dr. , is based here. past medical history: 1. primary sclerosing cholangitis vs. stricture in the cbd 2. crohn's disease s/p ex-lap with cecectomy and ileectomy 3. autoimmune hepatitis c/b cirrhosis with portal htn, splenomegaly, and varices, listed for liver 4. diffusely thickened gallbladder wall with increased enhancement on mrcp (suggesting chronic cholecystitis vs. inflammation due to psc vs. diffuse neoplastic process) 5. possible early proliferative phase of myelofibrosis vs. hypercellularity of autoimmune disease 6. r adrenal adenoma 7. moderate l pleural effusion 8. r nephrolithiasis 9. depression 10. anxiety 11. raynaud's phenomenon 13. fibromyalgia 14. dermatitis herpetaformis 15. appendectomy social history: the patient is unemployed and currently living with her mother and step-father. she has never been married and has no children; she had a long-term partner with whom she lived until . she denies any history of heavy alcohol abuse and no longer drinks any alcohol at all. she does not smoke cigarettes and has never used illicit drugs. family history: father has ankylosing spondylitis. one half-sister has hypothyroidism and rheumatoid arthritis. mother is alive and well. physical exam: temp 98.9 orally, bp 139/49, hr 145, rr 36, spo2 96% on 35% humidified face mask gen: confused, not answering questions appropriately, tachypneic but not using accessory muscles of respiration, thin, mild distress due to tachypnea heent: ncat, no sinus tenderness, perrl, conjunctivae edematous, dry oral mucosae with dried blood on the lips and teeth, op otherwise clear neck: soft, supple, no cervical adenopathy, r ij triple lumen catheter in place cv: tachycardic, regular, normal s1 and s2, s3 present, no murmurs or rubs appreciated pulm: r > l basilar crackles, otherwise cta bilaterally abd: soft, diffusely tender, non-distended, active bowel sounds, no rebound or guarding, sign present (exam limited by pt's confusion and inability to cooperate), liver span 5-6 cm on scratch testing, no splenomegaly noted back: no cva or paraspinal tenderness ext: 2+ dp and pt pulses, no edema skin: scattered ecchymoses at sites of attempted iv placement, no rashes or lesions otherwise, no petechiae neuro: unable to name place or date, confused and answering questions inappropriately ("my darvon" was her response when asked whether or not she were having any pain), mild neck pain on passive rotation of her head to the left but no pain on flexion or passive rotation to the right, complaint of back pain on extension of the l knee, no eye closing on assessment of pupil reactivity to light but complaint of photophobia pertinent results: osh labs: wbc 16.6 (75 pmn, 20 bands, 3 monos, 2 eos), hct 36.1, plt 31 pt 21.0, ptt 35.7, inr 1.9 na 130, k 4.3, cl 96, bicarb 22, bun 28, cr 1.1, gluc 58, calcium 10.2 alt 81, ast 80, alk phos 146, bili 2.6 (direct 0.85), albumin 2.7 u/a hazy, 3+ blood, 15-25 rbc, no wbc/bacteria urine tox with benzos, otherwise negative ascites: ~2300 wbc (87% pmn), gluc 63, alb 0.4, tp <1, bili 0.43, 25, ldh 39 abg: 7.47/28/91 cxr: mild bibasilar patchy opacities (l > r) consistent with mild pulmonary edema, r ij catheter in good position, no frank infiltrates head ct: "negative" per report labs here: wbc-19.6 hct-28.3 mcv-89 plt count-19 neuts-88 bands-6 lymphs-1 monos-4 eos-0 basos-0 atyps-1 metas-0 myelos-0 pt-19.3 ptt-40.1 inr(pt)-2.3 fibrinogen-325 d-dimer-5973 fdp-10-40 sodium-138 potassium-3.3 chloride-106 total co2-18 bun-26 cr-0.9 gluc-141 calcium-8.7 magnesium-1.3 phosphate-2.4 uric acid-3.1 alt-63 ast-112 ldh-215 alk phos-92 tot bili-1.9 amylase-47 lipase-24 albumin-2.5 abg 7.47/27/66 on 35% face mask, lactate 5.0, ionized calcium 1.19 cxr: progressive, bibasilar patchy opacities (l > r) consistent with worsening pulmonary edema, no clear infiltrate, r ij catheter in good position brief hospital course: 35 yo woman with autoimmune hepatitis leading to cirrhosis currently undergoing evaluation for liver transplantation, crohn's disease, primary sclerosing cholangitis, pancytopenia, who was transferred from osh with sepsis most likely due to spontaneous bacterial peritonitis complicated by bacteremia. she was in the micu from - . then she was transferred to the floor. 1. sepsis: the pt was initially empirically treated with ceftriaxone for a presumed sbp, along with vancomycin and flagyl to cover possible secondary sbp and/or cholangitis. an lp was preformed revealing no wbc's. blood and urine cx's did not grow out anything. blood cultures from the osh however, grew out klebsiella x2, sensitive to levofloxacin, but only intermediately sensitive to cefoxitin, so her ceftriaxone was switched to levofloxacin. a repeat paracentesis was preformed on hd2 which revealed ~1100 wbcs, down from 2300 at prior to admission. because the wbc decline was not as substantial as anticipated on levofloxcin, flagyl and vancomycin were continued. she was given a course of sepsis dose hydrocortisone and fludrocortisone for 7 days. she did not require pressors. she becamse hemodynamically stable and was transferred to the floor. the patient did not have a repeat paracentesis because her white count continued to decline. flagyl was stopped on . levofloxacin will be continued for a total of 14 days from the start and she will be placed on cipro 500 qd for sbp ppx. 2. altered mental status: altered ms to toxic-metabolic encephalopathy secondary to overwhelming sepsis. other etiololgies for altered mental status were investigated: an lp was preformed to rule out meningitis. head ct was preformed and was negative. ammonia levels were checked given her history of cirrhosis, and returned only mildly elevated at 49. serum and urine tox screens were negative. once extubated, pt was alert and oriented with baseline ms. 3. respiratory distress: on admission patient had a primary respiratory alkalosis secondary to persistent tachypnea, likely induced by her septic state. in addition she had a lactic acidosis. her rr had been greater than 30 for nearly 12hours on admission, hence she was intubated to ensure an adequate airway. on hd1, after aggressive fluid ressucitation and receiving blood products, she became increasingly hypoxic secondary to pulmonary edema, and required increased peep's to 10 for adequate oxygenation. she was gently diuresed, and her respiratory status improved. on hd3 she was requiring minimal pressure support and peep, and was successfully extubated. she had no ongoing respirtoy issues. 4. arf: developed a cr increase from 1.0 to 1.5 post-diuresis. arf thought to be secondary to intravascular depletion secondary to over-diuresis. lasix was held pts arf resolved, with cr returning to 1.0 and brisk uop daily. 5. cirrhosis: the patient has decompensated liver failure with decreased synthetic function and portal hypertension. the gi service followed the patient throughout her icu and floor stay. her admission inr of 2.3 improved daily back to her baseline of 1.5 with hydration. her dic labs were followed daily and were within normal range. she received an albumin infusion on hd 1 and 3 per sbp protocol to prevent hepatorenal syndrome sequelae. as she was a candidate for liver , she was followed by the service as well. on her last day of icu stay, her inr rose to 2.0. given that she was npo for several days, this was thought to be secondary to malnutrition, and she was given vit k. however, the patient had repeated doses of vitamin k over a few days and her inr failed to respond. this will need to be followed as an outpatient. for her extravascular volume overload, her aldactone was restarted and she was discharged on her home dose of lasix - 40 po qd. 5. anemia: pt's admission hct was roughly at baseline of 28. hct decreased progressively to 19 on hd2 with guaiac + stools and ng lavage with blood clots. pt was transfused with prbc's and hct stabilized at ~30, with ng lavage back to bilious aspirates. gi considered an egd, however once hct stabilized this was held off. no evidence of hemolysis on lab data. protonix continuous infusion was started for gi protection. this was switched to po when she was sent to the floor. the patient will continue her lansoprazole as an outpatient. 6. thrombocytopenia: pt has known baseline thrombocytopenia due to myelofibrosis and/or end stage liver disease of ~40. plt levels continued to drop during hospital course, with no evidence of obvious bleed or hemolysis. the likely cause is splenic sequestration. pt was transfused to keep plts >50 prior to invasive procedure, otherwise >10k unless suspicion for active bleed. her platlets were 24 on day of discharge and this will need to be followed closely as an outpatient. 7. transaminitis: most likely due to mild tissue hypoperfusion in the setting of sepsis, although liver enzymes may be elevated due to cholangitis as noted above. liver enzymes gradually declined throughout stay with adequate hydration. 8. crohn's disease: pts sulfasalizine was continued. stress dose steroids were started in setting of sepsis in place of budesonide for total of 7 days. the patient was tapered to 10mg of prednisone and will continue on this. budesemide was no restarted and dr. will follow this up as an outpatient with the patient's gastroenterogist. 10. allergies/pruritis: cetirizine, hydroxyzine as needed 11. subconjunctival hemorrhage: pt developed a subconj hemorrhage post-extubation. her vision was unaffected, and her platelets were kept > 50 to prevent further bleeding. this was stable for several days on day of discharge. 13. htn: post-extubation pts bp rose gradually from sbp 130's to 170's. she was started on lopressor 25 po tid with good response. this was stopped on discharge because the patient's blood pressure was slightly low and she has no documented history of varices. 14. abd pain: post extubation, pt experienced mild diffuse abd discomfort. this was accompanied by an amylase of 133 and lipase of 228. given that she had no other sx's of pancreatitis, and no obvious cause, she was continued on clear sips and monitored closely for resolution. in the subsequent days of admission, she had no abdominal pain. 15. f/e/n: initial exam and labs were consistent with intravascular volume depletion. after receiving aggressive fluids, albumin, blood and platelets, she became volume overloaded with pulmonary congestion and subsequent hypoxemia. she was gently diuresed until her lungs and respiratory status stabilized, and kept even from then on. she was advanced to a full diet and tolerated this for many days withougt nausea or vomiting. 16. access: r ij triple lumen catheter (with ability to measure svo2) placed and removed with out incident on . 17. communication: mother and step-father 18. code: full (confirmed with mother and step-father) medications on admission: 1. spironolactone 200 mg once daily 2. furosemide 40 mg once daily 3. prednisone 20 mg once daily 4. budesonide 9 mg once daily 5. sulfasalazine 1500 mg twice daily 6. lansoprazole 30 mg once daily 7. propoxyphene 65 mg twice daily 8. sertraline 100 mg once daily 9. hydroxyzine 25-50 mg as needed for pruritis 10. cetirizine 10 mg once or twice daily 11. alprazolam 1 mg at bedtime discharge medications: 1. sulfasalazine 500 mg tablet sig: two (2) tablet po bid (2 times a day). 2. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 6 days. disp:*10 tablet(s)* refills:*0* 3. ursodiol 300 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 4. spironolactone 100 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 5. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day). disp:*2700 ml(s)* refills:*2* 6. ciprofloxacin 500 mg tablet sig: one (1) tablet po at bedtime: begin this after you finish the levofloxacin (). disp:*30 tablet(s)* refills:*2* 7. prednisone 10 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 8. walker 9. lasix 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 10. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 11. darvon 65 mg capsule sig: one (1) capsule po twice a day as needed for pain. 12. sertraline hcl 100 mg tablet sig: one (1) tablet po once a day. 13. hydroxyzine hcl 25 mg tablet sig: 1-2 tablets po once a day as needed for itching. 14. zyrtec 10 mg tablet sig: one (1) tablet po once a day as needed for allergy symptoms. discharge disposition: home with service facility: discharge diagnosis: spontaneous bacterial peritonititis complicated by sepsis respiratory failure requiring intubation acute renal failure delirium cirrhosis crohn's disease primary sclerosing cholangitis depression discharge condition: stable, afebrile, no abdominal pain, ascites discharge instructions: take all medications as prescribed. do not take more than 2grams /day of tylenol. call your hepatologist or go to the ed if you have fevers, chills, abdominal pain, or blood in your stool or vomit. followup instructions: provider: , center (nhb) where: lm clinic phone: date/time: 2:50 provider: , md where: lm phone: date/time: 9:10 provider: , where: social work date/time: 10:30 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Spinal tap Incision of lung Insertion of endotracheal tube Percutaneous abdominal drainage Transfusion of packed cells Other irrigation of (naso-)gastric tube Transfusion of other serum Transfusion of platelets Transfusion of other substance Diagnoses: Acidosis Anemia, unspecified Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Severe sepsis Portal hypertension Depressive disorder, not elsewhere classified Acute respiratory failure Other septicemia due to gram-negative organisms Other encephalopathy Other chronic hepatitis Hemorrhage of gastrointestinal tract, unspecified Hyperosmolality and/or hypernatremia Cholangitis Regional enteritis of small intestine with large intestine

discharge medications: 1. aspirin 325 mg p.o. q.d. 2. plavix 75 mg p.o. q.d. 3. levofloxacin 500 mg p.o. q.d. times seven more days to finish a ten day course. 4. pantoprazole 40 mg b.i.d. 5. thiamine 100 mg p.o. q.d. 6. folic acid 1 mg p.o. q.d. 7. multivitamin one a day. 8. lisinopril 10 mg p.o. q.d. 9. atorvostatin 10 mg p.o. q.d. 10. toprol xl 150 mg p.o. q.d. follow-up: the patient has a follow-up appointment to be made early next week with cardiologist, dr. , at . the cardiologist already discussed with patient. both aware. the patient will call for an appointment for the next week. also, the patient is to call pcp for . the patient is aware and the patient agreed. also, the patient has care at the house with support from brother , 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 Angiocardiography of left heart structures Implant of pulsation balloon Nonoperative removal of heart assist system Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Tobacco use disorder Cardiac complications, not elsewhere classified Pulmonary collapse Cardiac arrest Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute myocardial infarction of inferolateral wall, initial episode of care Other specified hypotension

history of present illness: the patient is a 61 year-old male intubated and sedated upon arrival. history was taken from medical records only. the patient without history of coronary artery disease presented to outside hospital with complaints of chest pain. the patient noted that he felt lightheaded and called ems to be transported to outside hospital. initial laboratories there showed a troponin i of less then 0.04. electrocardiogram with bradycardia, left axis deviation and st elevations in 2, 3 and avf, v3-v5 and st depressions in avl, v2, v1 also with a right bundle branch block. he was given aspirin, morphine and fluids in the field and then the emergency department gave him atropine, started a dopamine and heparin drip. at that point he went into a wide complex tachycardia, which was read as v fibrillation and was shocked with 200 jewels with conversion to junctional rhythm of 100 beats per minute and the patient at that point was hemodynamically stable. the patient was given a half a dose of retavase for lytic therapy and was transferred to for further evaluation and catheterization. the patient was intubated prior to arrival to . in the the patient was sinus tachy, normal axis, normal intervals, 2 to elevation in inferior leads and anterior leads. he was taken to the catheterization laboratory. catheterization wet read showed a three vessel disease with left anterior descending coronary artery totally occluded, left circumflex was 40% lesion and right coronary artery with a 95% mid vessel lesion thought to be the culprit lesion. he had an angiojet and his right coronary artery was stented at that point at which point he was transferred to the coronary care unit for further observation and management. past medical history: no past medical history was recorded. allergies: no known drug allergies. medications: the only medication was recorded was benadryl prn. social history: recorded as two packs per day. family history: father with myocardial infarction and mother with myocardial infarction and brother with myocardial infarction at the age of 59. physical examination: vital signs upon arrival to the emergency department, pulse of 71 and blood pressure of 106/palp and afebrile. generally he was a frail appearing male intubated and sedated. heent pupils are equal, round, and reactive to light and accommodation. no lymphadenopathy. no jvd. cardiovascular regular rate and rhythm. no murmurs, rubs or gallops appreciated. pulmonary was not examined. abdomen soft, nontender, nondistended. positive bowel sounds. extremities no clubbing, cyanosis or edema. laboratories on admission: sodium 139, potassium 3.6, chloride 105, bicarb 27, bun 10, creatinine 1.1, glucose 108, white blood cell 9.2, hematocrit 42.8, platelet 440, mcv 101. inr .91 and ptt of 28.2. the troponin i of less then 0.04. chest x-ray showed ep tube in right main, opacity in retrocardiac, possible atelectasis versus pneumonia and on arrival his electrocardiogram was pending. his catheterization showed an ra of 23/24/22, rv of 33/23, pa 33/22, wedge of 22/24, , lv of 90/22, svr 1082 and pvr of 25. his ef was 39% with hypokinetic anterolateral apical and inferior walls. hospital course: the patient was status post stent mid right coronary artery. for his coronary artery disease three vessel disease. he was continued on aspirin and plavix and did well. his beta blockers were initially held secondary to bradycardia and negative inotropic effects. at that point later on he was switched over two days later to beta blockers. on discharge date his beta blockers were switched over from metoprolol 75 b.i.d. to toprol xl 150 q.d. his lipids were checked and liver function tests were checked. he had an elevated ast, slightly elevated alt at which point lipitor was not started, but the day of discharge lipitor was started given that his ast rise was most likely secondary to his myocardial infarction insult. he may need future percutaneous intervention on left anterior descending coronary artery and d1. his cks were followed post intervention and the goal was to keep the cvp around 18 to 20. he did well after transfer to the emergency department and was extubated the next day and weaned off of his o2 and transferred to the floor. for his pump status he was later on started on captopril and on the day of discharge his captopril t.i.d. was switched to lisinopril q.d. for after load reduction. rhythm, his electrolytes were checked regularly. the goal was to keep his k over 4 and his magnesium over 2. initially he was continued on the lidocaine drip until the morning after admission to the coronary care unit at which point he was discontinued off the lidocaine. he had an atropine at bedside for possible bradycardia and secondary hypotension secondary to bradycardia, which was not used and his beta blockers as we noted earlier was held on the first day and later on started as he tolerated it. the day after admission he was started on levaquin for presumed right lower lobe consolidation secondary to community acquired pneumonia. the patient did well and has been afebrile and white blood cell count decreasing daily since transfer to the floor. for him to continue a ten day course of levaquin. he is now on day three of ten and will continue the next seven days when discharged to home or to rehab. gastrointestinal, no issues. tolerating his medications and his diet well. the patient was sent to rehab center for further evaluation and further treatment. final diagnosis: inferior myocardial infarction status post right coronary artery stent. recommended follow up: the patient is to follow up with his primary care physician and also with cardiologist in the next week or two for post discharge care. call for an appointment. major surgical invasive procedures done: status post right coronary artery stent and catheterization. discharge condition: stable. discharge medications: 1. aspirin 325 mg po q.d. 2. plavix 75 mg po q..d 3. levofloxacin 500 mg po q.d. for the next seven days, that will be a ten day regimen. 4. protonix 40 mg po q.d. 5. thiamine 100 mg po q.d. 6. folic acid 1 mg po q.d. 7. multivitamins one per day. 8. lisinopril 10 mg po q day. 9. atorvastatin 10 mg po q.d. 10. toprol xl 150 mg po q.d. diet: cardiac diet as tolerated. the patient received physical therapy and medical teaching about his medications. activities: as tolerated, out of bed with assist initially. follow up: as discussed above. , 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 Angiocardiography of left heart structures Implant of pulsation balloon Nonoperative removal of heart assist system Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Tobacco use disorder Cardiac complications, not elsewhere classified Pulmonary collapse Cardiac arrest Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute myocardial infarction of inferolateral wall, initial episode of care Other specified hypotension

history of present illness: this is a 60 year old woman with a history of stage 3a nonsmall cell lung cancer, status post right pneumonectomy whose medical course was further complicated by bronchopleural fistula and development of empyema in the pneumonectomy cavity. she was also status post rib resection and tube drainage. she has also had stenosis of her left main stem bronchus for which she had stent placed. she has had multiple episodes of pneumonia/bronchitis with methicillin-resistant staphylococcus aureus in the past and most recently with pseudomonas. her course has also been complicated by bronchopleural fistula. over the past three days the patient has experienced increasing shortness of breath and secretions. she denies fevers, chills or chest pains. she was admitted to computerized tomography scan on for rigid bronchoscopy. following the bronchoscopy in the post anesthesia care unit she was complaining of increased shortness of breath. she was treated with nebulizers. she continued to experience increased secretions and respiratory distress over night and was taken for an urgent rebronchoscopy, both flexible and rigid. she was found to have a patent left main stem with moderate secretions. the stent was removed and a biopsy was done around the site to rule out recurrent cancer. there was also noticed to be a 2 mm right posterior fistula consistent with her bronchopleural fistula. this was sealed with fibrin glue. following the procedure she continued to have large amount of secretions and respiratory distress and was ultimately intubated. physical examination: on initial examination prior to transfer to the medicine intensive care unit she was sedated but reactive in no acute distress. she was intubated. her vital signs revealed temperature of 98.9??????, heartrate of 108, respiratory rate of 12, and blood pressure 92/61 with an oxygen saturation of 98%. her neck was supple without lymphadenopathy. her chest had loud upper respiratory sounds but was clear at the left base. heart was regular rate and rhythm without murmur, rub or gallop and slightly tachycardiac. abdomen was soft, nontender, nondistended with normoactive bowel sounds. extremities revealed no cyanosis, clubbing or edema. laboratory data: significant laboratory data reveals an admission white blood cell count of 11.9, hematocrit 30.9, and platelets 522. chem-7 revealed a sodium of 143, potassium 4.2, chloride 106, bicarbonate 26, bun 20, creatinine 0.8. her arterial blood gases immediately prior to intubation was 7.23/66/64. bronchial washings from her initial rigid bronchoscopy showed 3+ polymorphonucleocytes and 4+ gram positive cocci in pairs and clusters with heavy growth of staphylococcus aureus. hospital course: she was admitted to the medicine intensive care unit where she was watched carefully and sources for her respiratory distress were investigated. she had a good oxygenation, adequate ventilation and minimal secretions throughout her stay. it was felt that her failure to wean off of the ventilator may have been related to anxiety. for this she was given ativan and roxicodone as needed as she takes similar medicines at home. she underwent bronchoscopy on at least a couple of occasions to verify that secretions were adequate and there was no mucous plugging or other explanation for why she might be failing extubation, weaning. these studies revealed no clear reason for why she should be having difficulty weaning from the ventilator. she was also started on ceftazidime and vancomycin given the presence of both methicillin-resistant staphylococcus aureus and pseudomonas in her sputum. while it is quite likely that these are both colonizers given the heavy secretions, it was thought to treat empirically on the chance that a tracheobronchitis may be contributing to difficulty in weaning her from the ventilator. from a cardiovascular perspective her cardiac enzymes were cycled to rule out the possibility of myocardial infarction. she remained with a lowgrade tachycardia throughout her hospital course. evidently she tends to be tachycardiac at baseline, even at home. nevertheless, chest computerized tomography scan was obtained with angiography to rule out pulmonary embolus. the study was also negative. on , the patient was tolerating minimal ventilatory support and was extubated. however, after two hours she was clearly in a significant amount of distress, becoming red in the face, very uncomfortable and not moving air well. she was reintubated. on , the patient self-extubated and immediately began having difficulties with breathing. nebulizers were tried at this time. ativan was also tried. racemic epinephrine was also tried. nevertheless, she had significant respiratory distress and began desaturating into the 80s, 70s and even 60s. anesthesia was called and the patient was reintubated. in addition to her pulmonary difficulties during this admission the patient also experienced an upper gastrointestinal bleed on . esophagogastroduodenoscopy revealed esophagitis with superficial ulcerations which were thought to be consistent with nasogastric tube trauma. however, the hematocrit was low and the patient was transfused 3 units of packed red blood cells. it should be noted that the patient was a very difficult cross-match and it took nearly 36 hours to locate compatible blood for transfusion. fortunately she experienced no further bleeding episodes and remained stable from a cardiovascular standpoint throughout her admission. from an oncological perspective biopsies done at the time of her bronchoscopy ultimately showed poorly differentiated nonsmall cell carcinoma. numerous discussions were held with the patient and her health care proxy and other family members. it became clear that the patient's pulmonary status is not such much an acute decompensation as it is representation of a continuing decline in her pulmonary status over the past several months. it is unlikely that she would be able to support her ventilation without the assistance of a , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closure of other fistula of thorax Diagnoses: Dysthymic disorder Acute respiratory failure Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Osteoporosis, unspecified Other emphysema Acute bronchitis Hemorrhage of gastrointestinal tract, unspecified Empyema with fistula Malignant neoplasm of main bronchus

history of present illness: this is a 60 year-old female with history of non-small cell carcinoma status post right pneumonectomy whose course has been complicated by bronchopleural fistula and empyema. she also had stenosis of the left main stem bronchus requiring stenting. she has had multiple episodes of bronchitis / pneumonia with mrsa and most recently pseudomonas. over the past few days the patient noticed productive cough and worsening shortness of breath. she was admitted for rigid bronchoscopy on . the stent was patent and secretions were noted to be moderate. over night she experienced persistent shortness of breath and increased secretions. she was taken urgently for repeat bronchoscopy which showed the stent to remain patent with persistent moderate secretions. the stent was removed and the 2 mm right bronchopleural fistula was covered with fibrin glue. following the procedure she continued with secretions and shortness of breath and was ultimately intubated and transferred to the micu on . past medical history: 1. stage iii non-small cell carcinoma. status post chemotherapy, status post radiation therapy, status post right pneumonectomy five to six years ago. 2. left main stem stent for bronchopleural fistula and stenosis in . 3. copd / emphysema. 4. osteoporosis. 5. anxiety / depression. 6. status post appendectomy. 7. status post right oophorectomy. allergies: no known drug allergies. medications: on admission: 1. tobramycin. 2. oxycontin. 3. flovent. 4. albuterol. 5. prozac. 6. trazodone. 7. percocet prn. social history: she quit tobacco five years ago. her daughter, , is her health care proxy. physical examination: she is afebrile with a temperature of 98.9 f, heart rate 108, blood pressure 92/61. her neck is supple without lymphadenopathy. her chest is with loud upper airway noises but clear at the left base. her heart is regular without murmur. her abdomen is soft, nontender, nondistended with normoactive bowel sounds. her extremities are without cyanosis or edema. laboratory data: white count 11.9, hematocrit 30.1, platelet count 522,000. bun 20, creatinine 0.8. bronchial washings on showed 3+ polymorphum nuclear lymphocytes and 4+ gram positive coccyx later identified to be methicillin resistant staph aereus. hospital course: the patient was admitted to the micu service where investigation for respiratory status was undertaken. cardiac enzymes were cycled to rule out mi. ceftazidine and vancomycin were started to treat a questionable pneumonia / bronchitis. given the increased secretions and foreign body despite remaining afebrile with a stable white blood cell count. bronchoscopy was performed on two separate occasions to ascertain the extent of secretions, presence of mucus plugging or other explanation for respiratory difficulty. ct scan angiogram of the chest was obtained to rule out pe. biopsies of the trachea revealed recurrent non-small cell carcinoma, poorly differentiated. she maintained adequate oxygenation and ventilation throughout her hospital course. nevertheless it was not possible to successfully wean her off the ventilator. she would become hypertensive, tachypneic and red in the face when her pressure support was weaned off. eventually she tolerated 5+0 and was extubated. within two hours she was in clear respiratory distress and was re-intubated. on the patient self extubated during an apparent confused episode and became immediately stridorous, anxious and dropped her oxygen saturation to the 80, 70 and 60s despite ativan, nebulizers and racemic epinephrine. she was re-intubated. given the clear inability to extubate mrs. despite medical authorization attention was focused on disposition. on further discussion with the family it was apparent that her respiratory distress was not likely an acute problem, but rather more likely representing a progressive worsening of her baseline shortness of breath. mrs. made it clear that she did not wish to be re-intubated, but was not ready to be extubated knowing it may represent rapid onset of her death. she contemplated an extubation trial in the setting of a do not intubate order versus tracheostomy and long term care facility placement possibly a hospice setting. on she elected to proceed with tracheostomy placement. on the days following procedure she remained anxious requesting ativan regularly to keep herself comfortable. on she and her family decided on dnr code status. ultimately on with her breathing still uncomfortable and worsening secondary to increase need for sedating medications she was moved to comfort measures only status. she was started on morphine drip for comfort and the ventilator withdrawn. off ventilator despite supplemental oxygen her o2 saturations rapidly dropped to the 60s. she was pronounced dead at 2 a.m. on . a post mortem examination was offered to the family. of note her hospital course was further complicated by an episode of coffee-grounds in her ng aspirated on . she dropped her hematocrit to the low 20s and was transfused 3 units of packed red blood cells. egu was performed which showed esophagitis and linear ulcerations in the stomach consistent with ng tube trauma. there were no further episodes of bleeding and her hematocrit remained stable. of note it was difficult getting cross match for mrs. taking 36 plus hours to locate compatible blood. during this period she was at no time hemodynamically compromised. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closure of other fistula of thorax Diagnoses: Dysthymic disorder Acute respiratory failure Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Osteoporosis, unspecified Other emphysema Acute bronchitis Hemorrhage of gastrointestinal tract, unspecified Empyema with fistula Malignant neoplasm of main bronchus

discharge medications: 1. enteric coated aspirin 325 mg p.o. q. day. 2. lipitor 10 mg p.o. q. day. 3. hydralazine 100 mg p.o. q. six hours; hold for a systolic blood pressure less than 90. 4. metoprolol 50 mg p.o. twice a day; hold for systolic blood pressure less than 100; heart rate less than 55. 5. imdur 60 mg p.o. three times a day; hold for systolic blood pressure less than 100. 6. norvasc 5 mg p.o. q. day. hold for systolic blood pressure less than 90. 7. lasix 100 mg p.o. q. day. 8. protonix 40 mg p.o. q. day. 9. nph 40 units a.m. and 16 units p.m. 10. insulin coverage with sliding scale. 11. iron sulfate 325 mg p.o. q. day. 12. epogen 4000 units subcutaneously two times per week. 13. colace 100 mg p.o. twice a day. 14. percocet one to two tablets p.o. q. four to six hours p.r.n. for pain. 15. levothyroxine 100 micrograms p.o. q. day. 16. zolpidem 5 mg p.o. h.s. p.r.n. for sleep. 17. calcium carbonate 500 mg p.o. three times a day with meals. 18. flagyl 500 mg p.o. three times a day times five days. , m.d. dictated by: medquist36 Procedure: Hemodialysis Venous catheterization for renal dialysis Diagnoses: Pneumonia, organism unspecified Acidosis Mitral valve disorders Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage of gastrointestinal tract, unspecified Acute myocardial infarction of unspecified site, initial episode of care

history of present illness: this is a 75 year old female with past medical history significant for diabetes mellitus, cad status post cabg, peripheral vascular disease and hypercholesterolemia, who presents to hospital on with shortness of breath. of note, on she was admitted to vascular surgery at for femoral popliteal bypass surgery. at that time preadmission creatinine was 1.5 and after bypass surgery she was in acute renal failure with her dye load and creatinine that had risen to 4. this was recovered to 2.0 during that admission. on she was readmitted with chf and at that time diuresed. an echo revealed an ejection fraction of 50% with mr tr. since that admission she has had progressive fatigue, malaise and decreased appetite with some dyspnea on exertion, pnd and increased peripheral edema in the setting of decreased urine output. she was admitted to hospital where she was found to have crackles and increased jvd with acute renal failure, bun 80, creatinine 4.7. she also had anion gap acidosis with a question of pneumonia on chest x-ray. at , therefore, she was given iv lasix in increasing doses with 500 mg of diuril for potentiation. she was started on a furosemide drip at 20 mg per hour. she was given iv nitroglycerin without effect. on the day of transfer to she had received 500 cc of fluids over two hours with worsened respiratory status and some lateral st segment depressions with elevated troponin. it is in this setting that the patient was transferred to . past medical history: hypertension. diabetes mellitus with resultant retinopathy and neuropathy. hypercholesterolemia. peripheral vascular disease. cad status post cabg in with lima to lad, svg to d1, om1 and pda. hypothyroidism. chf. gout. allergies: sulfa causes an unknown reaction. ace inhibitors result in hyperkalemia. medications: at hospital lasix 20 mg continuous drip, hydralazine 20 mg iv q.six, diuril 500 mg iv b.i.d., lopressor 12.5 mg p.o. t.i.d., simvastatin 20 mg p.o. q.h.s., iv nitroglycerin at 200 mcg per minute. at home lopressor 75 mg p.o. t.i.d., isordil 20 mg p.o. t.i.d., zocor 10 mg p.o. q.d., aspirin 325 mg p.o. q.d., levoxyl 100 mcg p.o. q.d., albuterol and atrovent p.r.n., hydralazine 50 mg p.o. t.i.d. social history: no history of tobacco or ethanol use. patient lives at home with her husband and son and is usually able to perform adls. contact information for her includes her daughter, home phone number , cell phone . physical examination: vitals temperature 97.3, blood pressure 132/44, heart rate 88, respiratory rate 19, o2 saturation 97% on cpap. in general, mild respiratory distress. heent perrl, surgical pupils bilaterally, eomi, anicteric, mucous membranes moist. cardiovascular regular rhythm, normal rate, no murmurs. elevated jvd. pulmonary crackles of the way up on the left and possibly on the right. abdomen positive bowel sounds, obese, soft, nondistended, nontender. extremities 3+ edema. dermatology left mid-abdominal healing injection site. neuro cn ii-xii intact. laboratory data: white count 15.7, differential 89 polys, 0 bands, 6 lymphs, 4 monos, hematocrit 27.0, mcv 91, platelets 309. pt 14, ptt 63, inr 1.4. electrolytes sodium 120, potassium 4.5, chloride 85, bicarb 13, bun 92, creatinine 5.3, glucose 236. ck 87. anion gap negative 22. calcium 8.5, phosphorus 7.5, magnesium 2.3. urine no evidence of dysmorphic red blood cells or casts. ekg from outside hospital revealed sinus rhythm at 81 beats per minute, normal axis and intervals, st segment depressions in avl, 1, . chest x-ray bilateral effusion with cephalization and curly b lines. hospital course: the following is as noted by , m.d., phd. on arrival to the coronary care unit patient was found to be in acute respiratory distress and feeling nauseous with some bright red blood per rectum in the setting of a heparin drip given her elevated troponin at hospital. heparin was discontinued at this time with resolution of her gi bleed. she was started on protonix 40 mg p.o. b.i.d. the nephrology service was consulted for urgent hemodialysis and renal fellow, dr. , saw the patient and after obtaining central venous access, he started hemodialysis with resultant removal of 4 liters of fluid. subsequently patient was managed in the ccu with initially intermittent bolus dose of furosemide. however, this was with minimal effect and, therefore, she was converted to a furosemide drip titrated to urine output of greater than 100 cc an hour. furosemide drip was increased to 40 mg an hour for one day with improvement in her urinary output and her overall volume status improved. however, given the possibility of increased ototoxicity at these doses, nephrology recommended decreasing the rate and starting nitrocor bolus and drip, which was done. over the next one to two days the patient's furosemide drip was decreased to 20 mg an hour with nitrocor drip accompanying. she was also started on metolazone 5 mg p.o. b.i.d. to augment her renal response to furosemide. patient had markedly good response to this regimen and over the next several hospitalization days diuresed a total of 10 liters at the time of this dictation. she had symptomatic relief with decreased shortness of breath and decreased oxygen requirement. on the day of this dictation nitrocor and furosemide drips were discontinued and the patient maintained on iv furosemide at 100 mg b.i.d. with 5 mg of metolazone scheduled b.i.d. 30 minutes before furosemide. this regimen thus far has been adequate in maintaining a negative fluid balance. in addition, the patient was also started and titrated up on hydralazine for afterload reduction and oral nitrates for her preload. the patient's renal function continued to improve throughout the hospitalization and at the time of this dictation her creatinine had improved steadily to 2.9. the patient also had an episode of chest pain and shortness of breath with ekg consistent with ischemia, but no evidence of st segment elevation. cardiac enzymes revealed relatively normal ck with peak at 265 and mb index of 11, however, with troponin which peaked at greater than 50, which is the laboratory maximum. given the patient's underlying medical conditions and after discussion with patient and family, it was decided to medically manage this non-st segment elevation mi as to avoid catheterization at least in the setting of acute renal failure in an attempt to preserve renal function and avoid hemodialysis. hematology. as noted, patient developed lower gi bleed in the setting of heparinization for a troponin leak as noted at hospital. heparin was discontinued on arrival to and patient was started on protonix 40 mg b.i.d. and transfused one unit of blood with appropriate rise in hematocrit. at the time of this dictation, patient's hematocrit was steadily improving and was up to 38. infectious disease. patient was started on a course of levofloxacin at hospital for pneumonia. therefore, we opted to continue a full course of seven days. she did well throughout the hospitalization without a temperature. she had no signs or symptoms of pneumonia. however, one day after discontinuation of levofloxacin, patient developed diarrhea and elevated white count to 21. therefore, this is concerning for the possibility of pseudomembranous colitis. therefore stool was sent for c.difficile and patient started on an empiric course of metronidazole 500 mg p.o. t.i.d. overall, the patient's clinical condition is markedly improved as compared with her admission. her acute renal failure is improving steadily as well as her chf. she has had no recurrent episodes of chest pain concerning for ischemia in the past three to four days. she is making steady clinical improvement and we anticipate that she will be able to transfer to the medical floor the following day. dr. will take over the care of the patient effective and he will complete the rest of this dictation. we anticipate, however, given the patient's clinical course, she will benefit from a cardiac regimen to include aspirin, beta blocker, ace inhibitor once her creatinine function improves. she will further benefit from both preload and afterload reduction. of course, she will need a diuretic regimen to maintain her fluid balance once she has achieved her dry weight. this will likely include metolazone and furosemide in some combination. we further anticipate that patient will benefit from a short course of rehabilitation. thank you very much for the opportunity to participate in the care of this very pleasant patient. , m.d. dictated by: medquist36 Procedure: Hemodialysis Venous catheterization for renal dialysis Diagnoses: Pneumonia, organism unspecified Acidosis Mitral valve disorders Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage of gastrointestinal tract, unspecified Acute myocardial infarction of unspecified site, initial episode of care

history of present illness: the patient is a 31-year-old man with history of diabetes for about six years, who presented with nausea and vomiting. the patient states that he was in his usual state of health until the morning prior to admission when he woke up and had nausea and vomiting. he continued to have extensive vomiting throughout the rest of the day stating he vomited approximately 20 times. he had mild improvement by the evening prior to admission, however, upon awaking on the day of admission, he again had severe nausea and vomiting. he is unable to take any p.o. foods or liquids. he also stated that his vomitus had coffee ground-like material in it. he denies any bright red blood in the vomitus. the patient denies any use of drugs or alcohol several days prior to these symptoms. he denies any unusual foods. he denies any recent travel. he also denies any abdominal pain or diarrhea. patient states that since he started vomiting, he has had a very bad sore throat. he denies any cough or shortness of breath. he states that he has been taking his insulin regularly. he states that he only checks his fingersticks every other day or so, and has not checked it since the nausea and vomiting began. the patient states that he does not regularly see a doctor nor he does he have regular followup for his diabetes. he denies any complications of diabetes except for erectile dysfunction. he denies any numbness or tingling in the extremities. he denies any visual changes. past medical history: 1. diabetes mellitus type 1 (diagnosed approximately six years ago). patient is on stable insulin regimen as below. he has no known complications, although he does complain of erectile dysfunction currently. 2. lyme's disease: diagnosed six years ago and treated. patient presented with arthritis symptoms. 3. attention-deficit disorder. 4. history of oral herpes ulcers. medications on admission: 1. insulin: 8 units of nph and 8 units of regular before breakfast and before dinner. 2. ritalin 20 mg q.d. allergies: no known drug allergies. social history: the patient works as a fisherman and lives in . he smokes approximately cigarettes per week and has been doing so for five years. he drinks alcohol only occasionally on the weekends. he has occasional marijuana use. the patient is heterosexual and is in a monogamous relationship. he does have a history of unprotected sexual intercourse. family history: noncontributory. physical exam on admission: vital signs: temperature 100.1, blood pressure 121/54, pulse 112, respiratory rate 24, and o2 saturation is 100% on room air. in general, the patient is a middle-age man in no apparent distress. is well appearing. heent exam is significant for erythema in the oropharynx with dry mucous membranes. pupils are equal, round, and reactive to light. sclerae are anicteric and noninjected. tympanic membrane examination: cerumen was noted in the left ear canal with clear right ear canal. lung exam was clear to auscultation bilaterally. heart exam showed tachycardia with a regular rate, normal s1, s2 and no murmurs. abdomen was benign. the patient had emesis, which was gastroccult positive. extremities showed no edema with good distal pulses. neurologic exam was intact. rectal exam showed no stool in the vault with normal prostate and normal rectal tone. laboratories on admission: cbc showed a white count of 36 with a differential of 81% neutrophils, 2% bands, and 12% lymphocytes, hematocrit was 47.9, platelets 561. chem-7 notable for a sodium of 141, potassium 5.8, chloride of 93, bicarbonate of 9, bun of 23, and creatinine of 1.6 with a glucose of 730. the anion gap was 39. arterial blood gas was 7.09/19/158. coagulation studies were within normal limits. lactate was 4.6. free calcium was 1.2. chest x-ray did not show any acute processes. ekg showed normal sinus rhythm at 111 beats per minute with normal axis and normal intervals with no st-t wave changes. summary of hospital course by issue: 1. diabetic ketoacidosis: the patient was admitted with a diagnosis of diabetic ketoacidosis. he was admitted to the icu. he was given extensive iv fluid hydration with normal saline. he was also started on insulin drip with q.1h. fingersticks. once his blood glucose went below 200, insulin drip and hydration, patient's iv fluids were changed to d5 normal saline to prevent hypoglycemia as he was continued on insulin drip. the exact etiology of the patient's diabetic ketoacidosis was unclear. has no severe infection. however, he did have question of gastroenteritis, and as stated below, he has possibility of candidal esophagitis, although this would not be expected to cause him to go into diabetic ketoacidosis. cultures did not show any evidence of infection. patient received his insulin drip for approximately 24 hours. at that point, his anion gap was closed. after he began to eat, the insulin drip was shut off, and the patient was placed on a standing regimen of insulin. the initial regimen was nph in the morning and evening with the sliding scale of regular insulin. this was suggested after the patient was called out of the icu and put on the regular floor. initially the patient had elevated blood sugars in the 200s. however, his insulin regimen was increased giving him 34 units of nph in the morning with 10 units of regular and 15 units of nph with 8 units of regular before dinner. on this regimen, the patient's blood sugars were well controlled in the low 100's even after he resumed a somewhat normal diet. the patient's anion gap remained closed during the rest of the hospitalization. in terms of general diabetes management, the patient was consulted by nutrition for diabetic diet teaching. he was also counseled by his physicians on the importance of tight blood sugar control and close followup with his outpatient primary care provider. 2. upper gi bleed: the patient had evidence of upper gi bleed given coffee-ground emesis and gastroccult-positive emesis. gi was consulted, and an egd was performed. the egd showed erosive esophagitis with possibility of candidal esophagitis. there was also evidence of gastritis in the fundus and stomach body. the patient's hematocrit remained stable during the hospital admission. his candidal esophagitis was treated with three days of fluconazole and nystatin swish and swallow. he continued to have significant pharyngeal pain upon swallowing either liquids or solids. this was thought to be due to a combination of erosive esophagitis from extensive emesis that he had several days prior to admission and the candidal esophagitis. the patient received minimal relief with viscus lidocaine or nystatin. he was therefore put on iv morphine so that he could eat, and his blood sugars could be better stabilized. prior to discharge, he was transitioned over to p.o. morphine and tolerated this well. he was discharged with p.o. narcotics with continued pain management so that he can eat regularly. it was expected that his symptoms of pain would resolve on its own as his esophagitis resolves. 3. acute renal failure: patient's acute renal failure was thought to be due to hypovolemia from his diabetic ketoacidosis. once he was volume repleted with iv fluids, his creatinine returned to baseline. 4. nutrition: as stated above, the patient had a nutrition consult for diabetic diet teaching. because of his odynophagia, he was placed on a diet of puree solids and diabetic shakes. he tolerated this well reasonably well when he was taking pain medication. 5. candidal esophagitis: the patient was treated for candidal esophagitis as stated above with fluconazole and nystatin swish and swallow. though it was possible that patient's candidal esophagitis was secondary to poorly controlled diabetes, there is also concern for hiv especially the potential etiology for the diabetic ketoacidosis. patient also wished to have hiv testing even though he was low risk. hiv antibody was sent and was negative. patient was given post-test counseling, and advised that if he feels that he is at risk, then he should be tested. 6. code status: patient was full code on admission and at discharge. discharge status: the patient was discharged to home. discharge condition: patient is in good condition. he is afebrile, stable and tolerating p.o. discharge diagnoses: 1. diabetic ketoacidosis. 2. diabetes mellitus type 1. 3. candidal esophagitis. 4. acute renal failure. discharge medications: 1. nystatin swish and swallow 5 ml p.o. t.i.d. for three more days after discharge. 2. protonix 40 mg p.o. q.d. 3. insulin nph 34 units in the morning and 15 units in the p.m. before breakfast and dinner. 4. insulin regular 10 units before breakfast and 8 units before dinner. 5. vicodin 5-500 mg tablet one tablet one p.o. q.4-6h. as needed for pain for seven days. 6. insulin syringe. 7. lancets. 8. test strips. discharge instructions and follow-up plans: patient was instructed to adhere to a strict diabetic diet. is recommended that he continue to take soft puree solids until his odynophagia improves. he was instructed to call his doctor or return to the hospital if he is unable to eat and take fluids. with regards to his insulin regimen, the patient was instructed to check his blood sugars by fingerstick at least 4x a day before meals and at bedtime, occasionally after meals. he was told to do this vigorously for approximately two weeks and then his diabetic control could be reassessed when he visits his pcp. patient was aware of symptoms he gets before becoming hypoglycemic and is aware that he needs to take juice if he does have these symptoms. the patient will follow up with his new primary care provider, . at . he is instructed to call to make an appointment at the first available date. he will be referred to the diabetes center by his pcp. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Diagnoses: Tobacco use disorder Acute kidney failure, unspecified Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled Hemorrhage of gastrointestinal tract, unspecified Candidal esophagitis Lyme Disease Arthropathy associated with other infectious and parasitic diseases, site unspecified Attention deficit disorder without mention of hyperactivity

service: neonatology history of present illness: baby girl was transferred to the neonatal intensive care unit on day of life 2 for evaluation of hypothermia and hyperbilirubinemia and episodes of desaturation . she was born at 36 weeks gestation by spontaneous vaginal delivery to a 40-year-old gravida 3, para 0 now 1 woman whose prenatal screens were blood type o negative, antibody negative, rubella immune, rpr nonreactive, hepatitis surface antigen negative and group b strep negative. this pregnancy was uncomplicated. the infant emerged, requiring 30 seconds of positive pressure and then blow-by oxygen. apgars were 7 at 1 minute and 8 at 5 minutes. the rupture of membranes occurred 20 hours prior to delivery. there was no interpartum fever and no other sepsis risk factors. the the birth head circumference was 34.5 cm. the infant had been breast feeding well in the newborn nursery and was noted to have some hypothermia and persistent hyperbilirubinemia. the admission physical exam to the newborn intensive care unit revealed an infant who was sleepy, pale but pink, jaundice, non dysmorphic. mucous membranes dry. palate intact. breath sounds clear. respirations unlabored. normal s1, s2, heart sound, no murmur. abdomen soft and nontender, no hepatosplenomegaly. cord drying. spine straight without a dimple and was also noted to have some shallow breathing with desaturations to the 70s. neonatal intensive care unit course by system: respiratory status: the infant did have a few more episodes of desaturation and then completed five days without any apnea or bradycardia before discharge. the apnea was felt to be immaturity of the breathing. she also remained in room air and at the time of discharge, her respirations were comfortable, lung sounds clear and equal. cardiovascular status: she remained normotensive throughout her neonatal intensive care unit stay on all cardiovascular issues. fluids, electrolytes and nutrition status: she was noted to be 10% below her birth weight on day of life 2. on day of life 2, mother also began supplementing with formula. at the time of discharge, she was breast feeding well with some supplementation formula. her weight at the time of discharge was 2470 gm. she was taking approximately 160 to 260 cc per kg per day. gastrointestinal status: she was treated with phototherapy for hyperbilirubinemia. her peak bilirubin on day of life 4 was 14.2, direct 0.5. her last rebound bilirubin on day of life 7 was total 7.4, direct 0.5. hematological status: her hematocrit at the time of admission was 57.8 with platelets of 231,000. she never received any blood products during her neonatal intensive care unit stay. infectious disease status: she did have a blood culture drawn at the time of admission and was started on ampicillin and gentamicin. they were discontinued after 48 hours and the infant was clinically well and the blood cultures remained negative. discharge condition: good. the infant was discharged home with her parents. primary pediatric care will be provided by dr. of pediatrics. telephone number . feedings at discharge: the infant is breast feeding with supplementary formula with a plan to wean from supplementation as appropriate. discharge medications: the infant is discharged on no medications. the infant passed the car seat positioning test on . state newborn screen was sent on the day of discharge, . infant received her hepatitis b vaccine on . discharge diagnoses: 1. prematurity at 36 weeks gestation 2. resolved apnea of prematurity 3. sepsis ruled out 4. status post physiologic hyperbilirubinemia , m.d. dictated by: medquist36 d: 06:45 t: 07:36 job#: Procedure: Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Other preterm infants, 2,500 grams and over Unspecified fetal and neonatal jaundice Other hypothermia of newborn

history of present illness: mr. is a 76 year-old male who was admitted to the service originally on with complaint of progressively worse dyspnea on exertion over a period of years. he also had worsening lower extremity edema and orthopnea. he had a cardiac catheterization in , which showed diffuse disease, which was medically managed. he had an echocardiogram recently before admission showing small asd and moderate as with an ef of 35% with posterior basal akinesis. he was referred to for cardiac catheterization, which he had on showing nonsignificant asd, severe as with a peak gradient of approximately 40 and a valve area of 0.6, 70% lesion in his left anterior descending coronary artery, 80% ramus lesion and other more diffuse disease. his wedge at the time of catheterization was 26. he was admitted to the service for further management and evaluation for aortic valve replacement versus valvuloplasty. past medical history: 1. multinodular goiter. 2. atrial fibrillation. social history: the patient is surrounded by a very supportive family. he denies any history of tobacco, alcohol or drug use. family history: there is no history of coronary artery disease, diabetes, hypertension, or malignancy. allergies: penicillin with an unknown drug reaction. medications on admission: 1. bisoprolol 2.5 mg q.d. 2. coumadin 3 mg q.d. 3. lasix 40 mg b.i.d. 4. potassium chloride 10 mg b.i.d. physical examination: vital signs on admission revealed a temperature of 96.1, heart rate of 72, respiratory rate 20, blood pressure 110/61, oxygen saturation of 100% on 4 liters. in general, he is alert, oriented times three, pleasant and in no acute distress. neck revealed elevated jvd to the earlobe. lung examination revealed crackles approximately of the way up bilaterally. his abdomen was scaphoid, soft, nontender, nondistended. his heart was irregular and he had a 2 out of 6 systolic ejection murmur at the left upper sternal border, also audible at the apex. his extremities were warm and he had 2+ dorsalis pedis pulses and posterior tibial pulses bilaterally. hospital course: cardiovascular: mr. is admitted with progressively worsening dyspnea on exertion, edema, and orthopnea with cardiac catheterization at the time of admission showing severe as with a peak gradient of 40 and a valve area of 0.6. there was also evidence of coronary artery disease in his left anterior descending coronary artery and ramus. he was initially evaluated by cardiac surgery for aortic valve replacement, however, originally underwent aortic valvuloplasty instead with minimal results. he was then further reevaluated by cardiac surgery for aortic valve replacement. prior to him going to surgery he had a fall in his platelets and was found to be hit antibody positive. at this time it was felt it was unsafe to take him to surgery. it was conveyed by the surgeon that it may be possible at a later date to take him to surgery in approximately 60 days if he was retested and was hit antibody positive. throughout all of this time his congestive heart failure was worsening and he was attempted to be medically managed on the floor with lasix for diuresis. this had minimal results, and on he was transferred back to the coronary care unit for possible swan placement and swan guided hemodynamic therapy. a swan could not immediately be placed due to an elevated inr and ptt. while awaiting for these numbers to normalize the patient expressed wishes not to have anything else done and stated he was tired and did not want any more interventions at this time. he was managed well in the coronary care unit without a swan with peripheral dobutamine with an increase in urine output. he symptomatically did not improve, however. on a family meeting was held separate from and then a second family meeting with mr. in which the options were conveyed to him and his family, being either pursue aggressive medical management with placement of a swan and hemodynamic therapy with goals of optimizing him with a goal of getting to a possible aortic valve replacement date in several months or the option of going home with hospice and with mostly comfort care only. after much discussion these options were presented to mr. and he stated "i just want to go home." at this time it was felt after much discussion that it was best for him to go home with hospice services. mr. other cardiac issues including coronary artery disease, episodes of nonsustained ventricular tachycardia, atrial fibrillation, and a nonhemodynamically significant asd. all of these were managed throughout admission. he will be sent home on cardiac medications as he tolerates, however, he will not be sent home on anticoagulation for his atrial fibrillation. he will be discharged home with hospice services. discharge condition: at the time of discharge mr. was very cachectic and ill appearing. he was frequently in much discomfort and sleeping throughout most of the day. he was taking in minimal po and was on 2 liters of oxygen by nasal cannula. discharge medications: 1. fentanyl patch. 2. ms contin. 3. oxytrol patch. 4. ativan 0.5 mg q 4 to 6 hours prn. discharge diagnoses: 1. congestive heart failure. 2. atrial fibrillation. 3. nonsustained ventricular tachycardia. 4. severe aortic stenosis. 5. heparin induced thrombocytopenia. 6. acute renal failure. discharge status: on the day of planned discharge with hospice home services mr. passed away. , m.d. dictated by: medquist36 d: 08:46 t: 08:53 job#: 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 Percutaneous balloon valvuloplasty Injection or infusion of nesiritide Diagnoses: Coronary atherosclerosis of native coronary artery Acute kidney failure, unspecified Atrial fibrillation Paroxysmal ventricular tachycardia Rheumatic heart failure (congestive) Mitral valve insufficiency and aortic valve stenosis

history of present illness: mr. is a 77 year old male with a history of severe aortic stenosis, congestive heart failure, atrial fibrillation, and hypertension who originally presented to with a several month history of progressive dyspnea on exertion, shortness of breath, orthopnea, and increased lower extremity edema. he underwent an aortic valvuloplasty on . there was minimal improvement in aortic gradient and aortic valve area, and no change in cardiac index. he had minimal diuresis and was started with lasix and natrecor. he was then, subsequently, on the cardiac care unit service for medical management while awaiting aortic valve replacement. while on the cardiac care unit service, his platelets began to fall, and he was found to be heparin-induced thrombocytopenia antibody positive. at this point, it was decided by ct surgery that he would not currently be a candidate for a valve replacement due to the need to use heparin during the operation. it was felt that he could be re-tested in 60 days for possible resolution of his antibody, and at that time, may be a candidate for surgery. while awaiting surgery, and after discovery of the heparin-induced thrombocytopenia antibody, mr. continued to deteriorate on the floor with an inability to diurese very well due to renal insufficiency and hypertension. he was then transferred to the cardiac care unit for closer monitoring and possible swan placement and hemodynamic guided therapy. a line originally could not be placed due to coagulopathy, and while awaiting his coags to return to baseline, mr. expressed wishes for no more procedures or interventions. he expressed that he was fed up and tired and did not want anything else done. at this time, he was started on peripheral dobutamine through an iv that had previously been placed. he had an improvement in urine output at this point, and maintenance of heart rate and blood pressure, however, no symptomatic improvement. despite explanation of the risks and benefits of central line and pa catheter placement, mr. insisted that he did not want anything else done and that he was tired and just wanted to go home. on the evening of , a family meeting was held with of the ethics service, dr. , the attending, the family, and dr. , a member of the health staff, to discuss options and possible goals and plans of therapy. these options included doing everything possible medically with a goal of getting mr. to the possibility of an aortic valve replacement. the other option included comfort measures only with him going home with hospice. it was felt that he was competent to make this decision. these options were presented to him and he decided that he would rather go home with hospice care. on the morning of , at approximately 10:15 a.m., he became bradycardic with respiratory distress and hypotension. he subsequently passed away at 10:35 a.m. his son, , was at his bedside, and the team was also present in the cardiac care unit. no autopsy was desired. dr., 12-749 dictated by: medquist36 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 Percutaneous balloon valvuloplasty Injection or infusion of nesiritide Diagnoses: Coronary atherosclerosis of native coronary artery Acute kidney failure, unspecified Atrial fibrillation Paroxysmal ventricular tachycardia Rheumatic heart failure (congestive) Mitral valve insufficiency and aortic valve stenosis

service: ccu history of present illness: this is an 82 year old man status post three vessel cabg in (svg to lad, svg to om2, svg to pda) who presented to hospital on with one week history of exertional chest pressure which occurred only at night, nonradiating. chest pressure nausea, vomiting. it was unlike symptoms of prior mi. chest pressure was relieved with sublingual nitroglycerin. patient initially did not want to go for further workup, but was urged by wife and granddaughter to go to the hospital. at he was ruled out with negative cardiac enzymes (peak ck 96, troponin less than 0.3). at he attempted an exercise treadmill test, however, patient was unable to walk refused, therefore, he was taken to cardiac catheterization on . the catheterization showed 90% left main lad which was totally occluded, left circumflex which was totally occluded, rca which had a 90% mid-lesion, svg to lad graft was 90% occluded, svg to om2 was totally occluded, svg to pda was also totally occluded. he was then sent to for percutaneous intervention. cath here showed rca with 70% proximal, 80% mid and distal occlusion, elevated filling pressures (cardiac index 4.1, pulmonary capillary wedge pressure 16, ra 12). rca was stented in two locations with 0% residual. cardiac catheterization, however, was complicated by microperforation which was treated with perfusion balloon inflation. effective hemostasis was achieved in the cath lab and a tte was done which showed only a small pericardial effusion. he was then sent to the ccu for hemodynamic monitoring. past medical history: coronary artery disease. bph. atrial flutter. tia. glaucoma (legally blind). imi (). pacemaker. past surgical history: three vessel cabg (). appendectomy. hernia repair. social history: tobacco 50 pack years, but quit 25 years ago. alcohol one to two glasses of wine per week. he lives at home with his wife. is active around the house. he works frequently in his garden without any dyspnea. family history: noncontributory. outpatient medications: aspirin 81 mg q.d., atenolol 50 mg q.d., bumex 1 mg p.o. t.i.d., zocor 20 mg q.d., coumadin 3.5 mg q.d., prevacid 30 mg q.d., alphagan eyedrops, k-dur 10 meq q.d., colchicine 0.6 mg p.r.n. q.one to two hours, flomax 0.4 mg q.d., nitrocaps. physical examination: physical exam on admission to ccu showed vital signs temperature of 97.8, blood pressure 106/68, heart rate 94 which was v-paced with occasional pvcs, respiratory rate 18, sao2 95% on nasal cannula. in general, patient was in no apparent distress, laying flat comfortably in bed. oropharynx was clear. mucous membranes were slightly dry. jvp was approximately 10 to 12 cm. neck was supple. he had anicteric sclerae. chest was clear to auscultation anteriorly (patient was laying flat due to femoral catheter). cardiovascular exam showed an irregularly irregular rate, distant heart sounds, but no murmurs, gallops or rubs appreciated. abdomen was soft, nondistended, nontender, normoactive bowel sounds with no hepatosplenomegaly. on extremity exam the right groin site was without oozing. there was a 2 x 4 cm stable hematoma. no bruit was present. he had 1+ dorsalis pedis and posterior tibial pulses bilaterally. skin was warm and dry. on neuro exam pupils were equal, round, and reactive to light. there was no tracking secondary to patient's blindness. extraocular muscles were intact by command. he was alert and oriented times three. there were no gross motor or sensory deficits. laboratory data: on admission white count 8.1, hemoglobin 10.3, hematocrit 28.9, platelets 151. chemistry panel sodium 142, potassium 4.4, chloride 113, bicarb 17, bun 12, creatinine 0.6, glucose 173. pt 15.5, ptt 45.2, inr 1.7. ekg done post catheterization showed native beats and right bundle branch morphology with first degree av block which was interspersed with multifocal pvcs and infusion with paced beats. transthoracic echocardiogram on showed ef less than 20%, severe regional left systolic dysfunction with akinesis of anterior septum, anterior and inferior walls, remaining walls hypokinetic. moderate 2+ mr. hypokinesis without pericardial effusion. impression: this is an 82 year old with unstable angina status post three vessel cabg in with stenosis of all graft vessels. cardiac catheterization times two, once at and once at on with stents placed times two to native rca which was complicated by microperforation. hospital course: 1. coronary artery disease. cardiac catheterization showed stenosis of all bypass grafts. therefore, intervention was aimed at reperfusion of native vessels. rca was initially stented on the 22nd with good reflow, however, it was complicated by microperforation. serial echocardiograms ruled out significant pericardial effusion which was shown to have resolved on the day of discharge. on the 23rd patient was taken back to the cath lab at which time svg to lad was stented which showed 0% residual stenosis. serial cycling of cardiac enzymes showed peak ck at 1139 on the 23rd in the evening with peak ckmb of 156 and an index of 21.3. due to the magnitude of the ck and ckmb increase, it was thought that the patient had a fairly large mi. he was continued on aspirin and plavix was added for 30 days post cath to prevent stent thrombosis. 2. chf. prior to current hospital admission patient had a stress mibi done in at an outside hospital which showed an ef of 46%. however, during current admission serial echocardiograms were done which showed a severely depressed ef of 20%. it was thought that the extensive mi was responsible for the rapid decline in patient's cardiac function. patient was effectively diuresed with lasix which showed marked improvement in lung exam as well as decrease in jugular venous pulsation. he was started on lisinopril 2.5 q.d. for afterload reduction. patient tolerated the start of the ace inhibitor fairly well without dramatic decrease in blood pressure. patient's baseline systolic blood pressure runs around 90. 3. cardiac arrhythmia. patient with known as status post pacemaker placement. throughout hospital course patient was monitored on telemetry which showed a combination of paced beats as well as underlying native beats and fusion rhythm. he was restarted on coumadin, however, at a lower dose than outpatient dose due to start of plavix. it was recommended for his coumadin dose to be adjusted to an inr of 1.8 to 2.0 while he continues plavix. 4. hematology. patient on presentation had hematocrit of 28.9 which fell to 26 after the second catheterization while in-house. patient reports some baseline chronic anemia. however, it was thought that the etiology of acute drop in hematocrit was due to right groin hematoma which was present after first catheterization. hematoma resolved spontaneously and patient's hematocrit stabilized at 30 with transfusion of three units of packed red blood cells total during hospital admission. of note, he was guaiac negative. 5. disposition. patient was evaluated by physical therapy while in-house who achieved all in-house p.t. goals. upon discharge it was recommended for him to follow up with at-home physical therapy for cardiac rehabilitation three to four times a week. condition on discharge: stable and improved. discharge diagnoses: 1. myocardial infarction. 2. status post ptca times two, stents times three. 3. congestive heart failure. 4. hyperlipidemia. 5. coronary artery disease. 6. atrial fibrillation. 7. bph. 8. glaucoma. 9. status post pacemaker placement. discharge medications: 1. enteric coated aspirin 325 mg q.d. 2. atenolol 50 mg q.d. 3. zocor 20 mg q.d. 4. prevacid 30 mg q.d. 5. alphagan eyedrops. 6. k-dur 10 meq q.d. 7. colchicine 0.6 mg p.r.n. q.one to two hours. 8. flomax 0.4 q.d. 9. sublingual nitroglycerin p.r.n. 10. plavix 75 q.d. 11. lisinopril 2.5 mg q.d. 12. coumadin 2 mg q.d. 13. lasix 20 mg p.o. q.d. followup: patient is to follow up with dr. in one week. inr check to be scheduled on monday, , at with an inr goal of 1.8 to 2.0. home physical therapy for cardiac rehab as per arranged by case manager. , m.d. dictated by: medquist36 d: 19:32 t: 19:59 job#: Procedure: Insertion of non-drug-eluting coronary artery stent(s) Insertion of non-drug-eluting coronary artery stent(s) 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 Other and unspecified coronary arteriography Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute posthemorrhagic anemia Coronary atherosclerosis of autologous vein bypass graft Cardiac complications, not elsewhere classified Hematoma complicating a procedure Atrial flutter Accidental puncture or laceration during a procedure, not elsewhere classified

history of present illness: the patient is a 56-year-old male with history of type 1 diabetes, status post cadaveric renal transplant 1?????? years prior to admission, who presented to his primary care physician with fevers for the past week. he had a low grade fever approximately one week prior to admission and felt some chills. these symptoms subsequently improved but returned on the day of admission and his temperature was 101.5 at home. he was admitted directly to medical service. past medical history: type 1 diabetes diagnosed at 14 years of age, neuropathy. he uses leg braces and walker, retinopathy. he is status post laser surgery three years ago. chronic end stage renal disease on dialysis from to . history of peritonitis while on dialysis. he is status post cadaveric renal transplant . he has a history of acute rejection in treated with okt3, history of hip fracture in status post hip arthroplasty at that time, history of hypertension, history of hypercholesterolemia, chronic hiccups, coronary artery disease, gerd. medications: on admission, insulin nph 25 units q a.m., 6 units q p.m., regular insulin sliding scale, rapamycin 2 mg po q d, prednisone 10 mg po q d, lipitor 10 mg po q d, lasix 20 mg po q d, prograf 4 mg po bid, reglan 10 mg po bid, prilosec 20 mg po bid, calcium 1500 mg po q d. allergies: penicillin causes nausea. hospital course: the patient was admitted to medical service. his temperature on admission was 101.3, blood pressure 140/70, heart rate 80 saturating 100% on room air. his white count was 34, hematocrit 36.2, platelet count 291,000, sodium 137, potassium 5.1, chloride 101, co2 20, bun 43, creatinine 2 and blood sugar 346. his alt was 75, ast 96, alkaline phosphatase 180, bilirubin 0.5. he underwent chest x-ray which showed no signs of infiltrate. his abdomen was nontender and non distended with no signs of peritoneal irritation. the patient was placed on zosyn empirically and his white count started to come down. he underwent ultrasound which showed stones and sludge in the gallbladder and common bile duct and signs of cholecystitis. ercp consult was called and he underwent ercp for diagnosis of cholecystitis and cholangitis. sphincterotomy was done during ercp and multiple stones and sludge were extracted successfully. there were no remaining stones in the common bile duct at the end of procedure. the patient was maintained on zosyn and he underwent interval cholecystectomy on . an attempt to remove gallbladder laparoscopically was made but the gallbladder was very inflamed and the procedure had to be converted to open cholecystectomy. he tolerated the procedure well without complications. he did well initially postoperatively but then he noticed to have an increased scleral icterus. his lfts were checked and his alkaline phosphatase was 671 with bilirubin going up to 6.4. his amylase and lipase were normal. his creatinine was also rising up to 2.2. he underwent another ercp which showed dilatation of cvd and multiple blood clots in common bile duct along with one yellow stone. the sphincterotomy site was bicapped for possibility of bleeding from the sphincterotomy site and double pigtail stent was placed into common bile duct for drainage. after this ercp bilirubin peaked at 7.4 with alkaline phosphatase at 1100 and then started to slowly decrease. white count at the time was ranging between 12 and 17. he was afebrile. his blood sugars were under good control. he was tolerating regular diet. on post ercp day #4, the patient was noticed to be passing several stools with blood clots. he became lightheaded and his hematocrit dropped from 29 to 24 and urgent ercp was done which showed oozing from the sphincterotomy site with pulsating vessel on the bottom and stent eroding injury in sphincterotomy. due to close proximity of the sphincterotomy site to pancreatic duct, bicap could not be applied anymore but the vessel was injected with epinephrine several times and seemed to stop. the patient was admitted to surgical icu for close observation and serial hematocrits. he was transfused several units of packed red blood cells around the ercp but then his hematocrits were stable. he was eventually transferred back from the surgical icu to regular floor and his diet was slowly advanced. he tolerated this well. he was discharged home on postoperative day #14. at the time of discharge he was afebrile, stable, with heart rate of 73, blood pressure 140/60, blood sugars were well controlled. on the day of discharge his white count was 16.7, hematocrit 26.3 which was stable, platelet count 308,000, sodium 141, potassium 4.1, chloride 104, co2 26, bun 20 and creatinine 1.3, glucose in the morning was 94. his fk levels were 16.3 on discharge. discharge medications: included prednisone 5 mg po q d, prograf 4 mg po bid, rapamycin 5 mg po q d, norvasc 5 mg po q d, lopressor 50 mg po bid, flomax 0.4 mg po q d, calcium 1500 mg po q d, prilosec, lipitor, nph insulin 25 units subcu q a.m. and 6 units subcu q p.m. and iron supplements. he is also taking reglan and colace. follow-up: he will follow-up with dr. on monday following discharge and with dr. from ercp in two months for removal of his stent. , md dictated by: medquist36 Procedure: Endoscopic removal of stone(s) from biliary tract Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Endoscopic dilation of ampulla and biliary duct Cholecystectomy Endoscopic control of gastric or duodenal bleeding Endoscopic insertion of stent (tube) into bile duct Other irrigation of (naso-)gastric tube Diagnoses: Acute posthemorrhagic anemia Acute kidney failure, unspecified Hemorrhage complicating a procedure Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Other specified disorders of biliary tract Cholangitis Kidney replaced by transplant Calculus of gallbladder and bile duct with acute cholecystitis, without mention of obstruction

allergies: sulfamethoxazole/trimethoprim / aspirin attending: chief complaint: transfer to for peg placement major surgical or invasive procedure: placement of left subclavian central line (removed), and right internal jugular central line (removed) right sided thoracentesis for pleural effusions history of present illness: 61 year-old male with longstanding dm type 1 with triopathy, status post crt (baseline creat 2.9-3.0 in ), recurrent utis with mdr organisms, history of mrsa sepsis/osteo, initially transferred on from for peg placement. * he was originally admitted to on with mental status changes. his w/u was remarkable for vre uti (only 1000 colonies) and a lll pneumonia. he was initially started on cefepime, changed to imipenem and flagyl. a repeat urine culture grew burkholderia cepacia sensitive to zosyn, and zosyn therapy was initiated on . blood cx negative. a follow-up cxr showed resolution of his lll pneumonia. a tagged wbc scan was also performed and negative for infection. he remained disoriented despite treatment of his infection, and he was felt to be continually scratching his left biceps and having facial twitching. neurology was consulted. head ct showed mild atrophy but was otherwise negative. mri showed marked atrophy, as well as subtle changes in the posterior limb of the internal capsule that could possibly represent small subacute punctate infarcts. eeg was requested, but deferred "scheduling difficulties". per neurology, mr. was loaded with dilantin for possible seizure activity, with some subsequent improvement in his mental status. * still at the osh, his hct on admission was noted to be 25, and he was transfused 2 units of prbcs. he failed a bedside swallow evaluation, and a barium swallow showed evidence of penetration and aspiration. an ngt was placed. the patient reportedly did not want a peg tube, but was deemed incompetent to make decisions by psychiatry. while in the hospital, he was begun on risperdal and celexa was increased. * on the day of transfer (), his lab work was remarkable for a hco3 drop 20-->15, with development of an anion gap acidosis. he was started on ivf with dextrose, and given 1 amp of sodium bicarbonate. on arrival to , he was hemodynamically stable. however, his initial lab work was remarkable for an anion gap of 22, with hco3 of 9, glucose of 362. abg done 7.23/22/50 (?arterial). u/a positive for ketones. of note, standing insulin had been held at outside hospital. he was given insulin sc x few doses, then started on insulin drip on the floor on , along with ivf, with eventual closure of his gap. coincident with the metabolic derangements, however, he was noted to have declining mental status (responsive only to pain at time of transfer), and he was transferred to the micu for further care. * in the micu, he was continued on the insulin drip overnight, discontinued on at 1000 after overlap with nph. ag closed. consulted, with recommendation to start lantus. regarding his mental status, neurology was consulted. lp was performed with op 9, wbc 4, rbc 0, tp 93, gluc 145, gram stain negative, cryptococcal antigen negative, cultures pending. he was loaded with dilantin on at night pending eeg on . preliminary report negative for seizure activity. per neurology, dilantin was tapered off. past medical history: 1. dm type 1 with triopathy 2. status post cadaveric renal transplant in 3. chronic renal insufficiency with baseline creatinine 2.9-3.0 in 4. peripheral neuropathy 6. hypertension 7. cad, lvef >55% in 8. gerd 9. hypercholesterolemia 10. history of mrsa osteomyelitis/sepsis 11. history of recurrent utis with mdr organisms * other past surgical history: status post right thr status post left bka status post open chlecystectomy social history: widowed, ex-meat cutter, no tob, no etoh, no ivdu family history: mother with dm and pm and father with pm physical exam: vitals: tm 99.2, tc 98.9, hr 60s-70s, bp 120-170/50-60s, rr high teens to low 20s, sat 98-100% on ra. i/o: + 450 last 24 hours, then + 1700 cc today gen: caucasian male, in nad. answers questions, recognizes his name, not oriented to place or time. makes eye contact. : pupils sluggish, reactive. dry mm. neck: no cervical ln. resp: limited examination, clear anteriorly. cvs: rrr. normal s1, s2. gi: bs +. soft, non-tender. ext: 2+ pedal edema rle. left bka. neuro: moves all 4 extremities. pertinent results: micro: blood culture x2 negative csf spinal fluid gs negative, cultures negative csf cryptococcal antigen negative blood culture x 4 bottles negative * labs: trop 0.14 trop 0.16 ck-mb 2 trop 0.16 trop 0.20 relevant imaging studies: osh: cxr with lll pneumonia, resolved on cxr tagged wbc scan negative ct head: atrophy, no focal disease mri head: marked atrophic changes, possible subacute punctate infarcts. * : cxr: probable bibasilar pneumonia renal transplant u/s: normal ct head: no intracranial hemorrhage. no major vascular territorial infarction. eeg: bursts of generalized slowing consistent with encephalopathy. . mri with gadolinium, stroke protocol: mild-to-moderate brain atrophy and a chronic lacune in the posterior limb of the left internal capsule unchanged from the previous mri of . there are no mri signs of posterior encephalopathy seen. no mass effect or hydrocephalus noted. no acute infarcts are seen. egd: gastric antrum, mucosal biopsy - negative for h. pylori ct sinuses: no air-fluid levels to suggest acute sinusitis. mild mucosal thickening in the paranasal sinuses, as described. v/q scan: indeterminate lung scan. there are bilateral areas of decreased perfusion within the lung bases, asymmetrically with a larger defect on the right. although the pattern of this perfusion could be explained by bilateral pleural effusion, in the face of these abnormalities, it is difficult to exclude a pulmonary embolism. ct chest without contrast: 1. large bilateral pleural effusions with associated compressive atelectasis that are little changed when compared to . otherwise, clear lungs. 2. slightly dilated esophagus 3. dilatation of the extrahepatic biliary system with a probable calcified filling defect in the distal common duct. clinical correlation is advised. brief hospital course: assessment and plan: 61 yo male with longstanding dm type 1 with triopathy, s/p crt in on immunosuppression, transferred from osh with uti, change in mental status, in dka. dka resolved. also being anticoagulated for left dvt, likely pe. moderate to large pleural effusions bilaterally s/p right thoracentesis. pt has had chronic complaints of chest pain x >1 month, with negative work-ups, pain likely due to combination of costochondritis plus possible pe. pt also with ugib, esophagitis, duodenitis, duodenal ulcer not actively bleeding, and hct stable on anticoagulation. treated for uti with zosyn, however, pt found to have new uti during admission with fever, which was treated w/ meropenem. * 1) pe/dvt/chest pain: - pt complaining of chest pain which he reports to have had for greater than 1 month, pleuritic or with exertion. ekgs showed no changes from baseline, no ischemic changes. he had elevated cardiac enzymes, which were felt to be secondary to his poor renal clearance in addition to possible demand ischemia as they were drawn during a period of anemia/ugib. he had lower extremity dopplers which were positive for dvt in left superficial femoral vein, extending to beginning of popliteal. a v/q scan was performed as the pt was unable to have a cta due to his renal status; however, the study was suboptimal, unable to perform ventilation portion of study - on perfusion scan, unable to visualize bases bilateral pleural effusions, therefore unable to r/o pe's. the pt was started on heparin; coumadin was started at 3 mg, then increased to 5 mg to reach therapeutic inr of 1.7. - the patient also had bilateral pleural effusions which were present on chest ct's from a year ago. on , an ultrasound guided thoracentesis of right pleural effusion was performed, 1.2l was removed. pleural fluid showed no pmn's or organisms, ldh ratio indicative of transudative process, pleural cx's negative bacteria, fungus, afb smear, and cytology negative for malignancy. - pt also had reproducible cp on palpation over sternum, possible costochondritis. rib xray negative for fracture. * 2) id: the patient completed 2 week course of zosyn for uti as described above on . however, the pt subsequently became febrile accompanied by change in mental status, increased wbc - now has been afebrile with much improved mental status and decreasing wbc. broad spectrum abx started , with vancomycin renally dosed (discontinued) and zosyn; however, urine cx results + for non-fermenter not pseudomonas, intermediate sensitivity to zosyn, sensitive to meropenem. ruled out for pna, sinusitis, c. diff, line infection. zosyn was therefore discontinued, and pt was treated with meropenem 500 iv x7 days, completed . the patient also had yeast on ua/ucx, and was started on fluconazole x ~10 day course. the pt was subsequently afebrile with normal wbc, stable mental status. . id work-up: - central line d/c'd , placed ; new rij placed . - c.diff negative - diarrhea, likely from gi blood. - blood cultures 11/22, 23 negative - kub: no free air or obstruction - cxr: small bilateral pleural effusions - ct sinuses: no acute sinusitis; some paranasal sinus thickening - catheter tip: no significant growth - , 30 blood cultures no growth * 3) gi: upper gi bleed coffee ground emesis , and again on , requiring transfusions of prbc's, total 4 units. egd was performed , and showed esophagitis, duodenitis, duodenal ulcer, no active bleeding. an ngt was placed for gastric decompression, d/c'd . hct stable on anticoagulation. egd biopsy negative for h. pylori, protonix po bid, sucralfate qid. - the pt also developed fleeting ruq pain. incidental finding on chest ct , showed dilatation of the extrahepatic biliary system with a calcific density in the expected location of the distal common duct. ruq resolved, lft's and bilirubin normal except for increased alk phos ( 208, 439, 452). the pt may have some common bile duct stone/obstruction, given ct finding, however, he has declined ercp despite discussing possibility for progression to infection. * 4) dm type 1/dka: - dka resolved. basal insulin had been held at osh (transferred only on riss). pt's blood sugar was quite labile, fluctuating depending upon po status, infectious states, and had period of both low fsg's to 30's necessitating d50, as well as hyperglycemia to 477. he had fsg's checked qachs, and at 3am. his current regimen includes glargine 18 u at noon daily, as well as sliding scale included. * 5) delta ms: - the pt had an extensive work-up for initial changes in mental status, including an eeg which showed no epileptiform activity, lp with elevated protein and glucose, no evidence of infection, normal op, negative cultures, negative for cmv, virus, vzv. mri showed mild-to-moderate brain atrophy and a chronic lacune in the posterior limb of the left internal capsule unchanged from the previous mri of , no mri signs of posterior encephalopathy seen, no mass effect or hydrocephalus noted, no acute infarcts. - the pt's mental status changes were attributed to combination of acute infection as well as hyperglycemia/dka. he demonstrates mental status deterioration when febrile or infected, and when blood sugars are either elevated or low. the pt now at his new baseline, is awake and alert, speaking fluently, and cooperative with exam. * 6) s/p renal transplant: - the pt's immunosuppresion regimen was adjusted several times during course of admission. regimen on discharge includes: ** tacrolimus 1.5 mg ** sirolimus 2 mg mwf, 1 mg tthsasun ** prednisone 4 mg qd - the pt's cr slightly increased during admission to peak of 2.9. this may have been in the context of taking sublingual tacrolimus while npo, which per pharmacy causes greater bioavailability of drug and possible renal effect. cr subsequently decreased to 2.6. medications were adjusted for crcl <30. * 7) heme/anemia: upper gi bleed, plus anemia of chronic disease. hct decreased acutely in context of coffee ground emesis, with hct down to low of 20; received 1 unit prbc's after initial gib, and an additional 3 units . pt was on epogen, decreased steadily from 8000 units 3x/week to units 3x/week. hct remained stable for the last several weeks of admission, even while therapeutic on anticoagulation. last hct prior to discharge was 36.2 * 8) fen: - pt was initially npo while he had initial mental status changes. however, after treatment for dka/hyperglycemia and infections, he passed a bedside speech and swallow with no aspiration, was allowed to commence po diet. * 9) cv: patient with htn, cad. -pt had elevated blood pressures during last few weeks of admission. hydralazine had been d/c'd and amlodipine decreased to 5 qd in context of gi bleed and anemia. however, amlodipine was increased back to 10 as pt subsequently hypertensive. lasix 20 mg qd was also started secondary to htn * 10) derm: the pt was seen by dermatology for a scaling plaque, possible squamous cell ca on left temple. will need to schedule excisional biopsy as outpatient in derm clinic . * 11) psych: pt seen by psych consult for possible depression, no active suicidal ideation, but expressed desire to not pursue major interventions to prolong life; he is not denying any specific procedures at this time. per psychiatry, pt does not appear to be suicidal, and his wishes to limit invasive procedures is reasonable. celexa increased to 30 mg qd. * 12) pt/ot: evaluated by pt/ot during admission, rehab recommmended for ambulation and mobilization given left bka, deconditioning. medications on admission: meds on admission to osh (presumed) feosol 325 mg daily, colace 100 mg daily, senokot 1 tab qhs, flomax 0.4 mg qhd, reglan 10 mg po bid, lopressor 75 mg twice daily, norvasc 10 mg daily, plavix 75 mg daily, nexium 40 mg daily, celexa 10 mg daily, lasix 20 mg iv daily, hydralazine 10 mg po q6hours, cefepime 1 gm iv daily, prednisone 5 mg daily, mvi daily, tacrolimus 0.5 mg , heparin 5000 units sc bid humulin n 10 units qam, 5 units qhs * meds at time of transfer: rapamune 3 tabs 1 mg po daily protonix 40 mg iv daily tacrolimmus 0.5 mg po bid dilantin 300 mg po qhs norvasc 10 mg po qd zosyn 2.25 gm iv q6 hours (day 6 on transfer) lopressor 125 mg po bid celexa 20 mg daily risperidone 0.5 mg po bid riss * current meds in micu: metoprolol 75 mg po bid pantoprazole 40 mg iv q24h amlodipine 10 mg po daily citalopram hydrobromide 20 mg po daily phenytoin 100 mg iv q12h for 2 days, then 100 mg iv daily for 2 days daptomycin 300 mg iv q48h day 2 piperacillin-tazobactam na 2.25 gm iv q6h docusate sodium (liquid) 100 mg po bid epoetin alfa 4000 unit sc qmowefr start: hs senna 2 tab po bid:prn folic acid 1 mg iv daily sirolimus 3 mg po daily heparin 5000 unit sc tid tacrolimus 1 mg po bid renal transplant thiamine hcl 100 mg iv daily insulin sc glargine 10 units qhs (to receive first dose tonight) * discharge medications: 1. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day). 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. therapeutic multivitamin liquid sig: one (1) cap po daily (daily). 5. tamsulosin 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po hs (at bedtime). 6. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for 1 weeks. 7. sucralfate 1 g tablet sig: one (1) tablet po qid (4 times a day). 8. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 9. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily): hold for sbp <110. 10. codeine sulfate 30 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed: please give 1/2 hr prior to pt. 11. citalopram 20 mg tablet sig: 1.5 tablets po daily (daily). 12. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 13. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. 14. clotrimazole 1 % cream sig: one (1) appl topical (2 times a day) for 1 weeks: perianal area. 15. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). 16. sirolimus 1 mg tablet sig: two (2) tablet po qmowefr (monday -wednesday-friday). 17. sirolimus 1 mg tablet sig: one (1) tablet po qtuthsa (,tu,th,sa). 18. tacrolimus 0.5 mg capsule sig: three (3) capsule po bid (2 times a day). 19. mupirocin calcium 2 % cream sig: one (1) appl topical (2 times a day) as needed. 20. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 1 weeks. 21. insulin glargine 100 unit/ml solution sig: one (1) subcutaneous once a day: 18 units glargine at noon daily. 22. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 23. loperamide 2 mg capsule sig: one (1) capsule po tid (3 times a day) as needed. 24. outpatient lab work please check tacrolimus and sirolimus levels q3 days, please send results to transplant center at or . 25. outpatient lab work please check coags/inr twice weekly, and adjust coumadin level accordingly. 26. epoetin alfa 2,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday): u mwf. discharge disposition: extended care facility: rehabilitation & nursing center - discharge diagnosis: type i diabetes, cadaveric renal transplant, left dvt/?pe on anticoagulation, pleural effusions, upper gi bleeds (resolved) from esophagitis/duodenitis/duodenal ulcer, uti and yeast in urine discharge condition: stable discharge instructions: please continue taking your medications as written. please call your physician if you have any worsened chest pain, shortness of breath, palpitations, cough, fever, urinary symptoms, vomiting blood/"coffee ground" material, lightheadedness/dizziness, confusion, other worrisome symptoms followup instructions: please call dr. for follow-up appointment once discharged from wedgemere . you will need your blood levels of tacrolimus and rapamycin drawn every 3rd day, and results sent to tranplant center - please call for an appointment to be seen in clinic after discharge from wedgemere, for biopsy of lesion on left temple, md Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Thoracentesis Insertion of other (naso-)gastric tube Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Pneumonia, organism unspecified Unspecified pleural effusion Urinary tract infection, site not specified Unspecified essential hypertension Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled Unspecified disorder of skin and subcutaneous tissue Hematemesis Hyperosmolality and/or hypernatremia Complications of transplanted kidney Below knee amputation status Unspecified infectious and parasitic diseases Hip joint replacement

discharge medications: 1. prednisone 5 mg tabs, one tab p.o. q.d. 2. miconazole powder one application q.i.d. 3. hydralazine 25 mg tabs, one tab p.o. q.six hours. 4. lopressor 50 mg tabs, one tab p.o. b.i.d. 5. lansoprazole 30 mg capsule, one capsule delayed release p.o. b.i.d. 6. tylenol 325 mg tabs, one to two tabs sig. p.o. q.four to six hours p.r.n.. 7. clonidine 0.1 mg per 24 hour patch, one patch weekly transdermal q.saturday. 8. amlodipine 5 mg tabs, two tabs p.o. q.day. 9. albuterol nebs. 10. hydromorphone 4 mg tabs, one tab p.o. q.four to six hours p.r.n. 11. citalopram 20 mg tabs, 0.5 tab p.o. q.day. 12. tacrolimus 0.5 mg capsule, one capsule p.o. b.i.d. 13. sirolimus 1 mg per ml solution, sig. 0.5 ml p.o. q.day. 14. fluconazole 200 mg per 100 ml piggyback, sig. 100 ml iv q.24. 15. furosemide 10 mg per ml solution, 4 ml injection b.i.d. 16. vanco 10 gm recon solution, sig. 1 gm recon solution iv for a dose less than 15 of vanco level. the patient will follow up with dr. at 1:00 p.m. on in clinic. discharge diagnoses: sepsis. infected orthopaedic hardware status post removal. status post crt. mrsa bacteremia. hypertension. cad. gerd. hypercholesterolemia. herpes zoster. iddm. , Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Thoracentesis Endoscopic removal of stone(s) from biliary tract Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Arthrocentesis Diagnoses: Unspecified pleural effusion Methicillin susceptible Staphylococcus aureus septicemia Disseminated candidiasis Infection and inflammatory reaction due to other vascular device, implant, and graft Complications of transplanted kidney Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft Pyogenic arthritis, pelvic region and thigh

allergies: shellfish attending: chief complaint: acute stroke, s/p iv t-pa major surgical or invasive procedure: iv tpa history of present illness: 74 year old man with hx of cad (s/p mi, s/p cabg), htn, right carotid stenosis (s/p carotid stent ), and arthritis who presented to the ed on complaining of left sided weakness. a code stroke was called and the stroke fellow assessed the patient immediately (please see dr. note for details of initial assessment). he was initially found to have an nihss of 9. ct/cta was done and was negative for early signs of infarction, but did show a paucity of vessels in the right mca territory. iv tpa was administered by dr. at 8:53am. i arrived at 9:00am and obtained the following history. pt was feeling well when he went to bed last night, . he awoke in his usoh on the morning of admission at 5am, watched the news, then started to read a book. at that time, he was able to use both hands to hold the book and had no difficulty turning the pages. around 6-6:30am, he got out of bed to go to the bathroom. his left leg "gave out" and he slid to the floor. he thought that there might be something wrong with his heart so he reached for his nitroglycerine tablets. he noticed that he was unable to grip the bottle with his left hand. he crawled back into bed and called ems. he was brought to the ed where he arrived shortly after 8am. he was noted to have a left visual field cut, dysarthria, left sided inattention, left facial droop, left hemiplegia (arm>leg) and left hemisensory deficit. he was given iv-tpa. nihss=8 (see exam below). he denies fever/chills, cp, sob, palpitations, nausea/vomiting, or dysuria. he denies having similar symptoms in the past. past medical history: 1. cad- s/p mi and cabg yrs ago with subsequent coronary stenting 2. copd 3. htn 4. high cholesterol 5. pvd-s/p right leg stenting 6. osteoarthritis social history: divorced, lives alone. used to work appraising properties for the government. 60 pk yr smoking hx, quit 2 yrs ago. drinks once per week. no drugs. family history: brother - stroke parents had heart disease in their 60s. physical exam: t-96.6 bp-155/103 hr-72 rr-20 o2sat-100 gen: lying in bed, nad heent: nc/at, facial rubor, moist oral mucosa neck: no tenderness to palpation, normal rom, no carotid bruits cv: rrr, nl s1 and s2, hsm lung: decreased breath sounds throughout abd: +bs soft, nontender ext: no edema neurologic examination: mental status: awake and alert, cooperative with exam, normal affect. oriented to person, place, and date. he is attentive, says backwards. speech is fluent with normal comprehension and repetition; naming intact. moderate dysarthria. intact. registers , recalls in 5 minutes. no right left confusion. he has left sided inattention, but does look at examiner on the left. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 4 to 2 mm bilaterally. no visual field cut, +extinction to visual dss iii, iv, vi: right gaze preference, but extraocular movements full bilaterally, no nystagmus. v: sensation decreased to lt and pin on left v1-v3 vii: left lower facial palsy, also some weakness of orbicularis occuli on the left-though forehead moves symmetrically. viii: hearing intact to finger rub bilaterally ix, x: palate elevation symmetrical : sternocleidomastoid normal bilaterally. xii: tongue midline (when facial droop corrected), movements intact motor: normal bulk bilaterally. tone normal. no observed myoclonus or tremor left drift tri wf we fe ff ip h q df pf te tf r 5 5 5 5 5 5 5 5 5 5 5 5 5 4+ l 5- 5 5 3 2 1 2 5- 5 5 5 5 5 4+ sensation: intact to light touch, pinprick on right, decreased by (?50%) on left. vibration and proprioception diminished to shin/ankle bilaterally. decreased proprioception in left fingers (intact on right). +agraphesthesia on left. + extinction to dss on left. reflexes: +2 and symmetric throughout. toes upgoing bilaterally coordination: finger-nose-finger normal on left-ataxia in proportion to weakness on left, heel to shin normal, unable to do rams on left. gait/romberg: unable to assess pertinent results: 7.1>37.8<197 73n 17l 5e na 143 k 4.0 cl 106 co2 25 bun 20 cr 1.1 glu 112 ca 9.4 mg 1.7 ph 3.6 lip 43 pt 12.8 ptt 23.3 inr 1.1 a1c 5.2 chol 155 tg 110 hdl 69 ldl 64 u/a neg head ct - abrupt cut-off of the anterior division of the right middle cerebral artery (m3), consistent with acute occlusive thrombus or embolus. no intracranial hemorrhage or mass effect. head ct and - stable head ct with evidence of evolving right middle cerebral artery territory infarct, without definite hemorrhage. mri head - large area of restricted diffusion in the right middle cerebral artery territory in the right frontal and temporal lobes, consistent with acute infarct. mr s significantly decreased flow in the right mid cerebral artery branches transthoracic echocardiogram - due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). carotid ultrasound - minimal plaque on the right with a less than 40% carotid stenosis. on the left, there is moderate plaque with a 40-59% stenosis. neck mra - patent right internal carotid artery stent but with apparent slow flow. signal irregularity and apparent diminutive flow through the stent could be secondary to magnetic susceptibility from the stent, intimal hyperplasia, or a small amount of thrombus. preliminarily transesophageal echocardiogram: simple atheroma in descending aorta brief hospital course: 74 year old man with hx of cad, htn, high cholesterol, smoking, s/p recent right carotid stent, and family hx of stroke who presents with acute onset of left sided weakness. he is s/p iv tpa 2.5hrs after symptom onset. initial exam notable for left sided inattention, dysarthria, left facial, left sided weakness (primarily in arm with cortical hand), left sided sensory deficit to all modalities, left sided cortical sensory loss. deficits localize to the right fronto-parietal region. he was admitted to the neuro icu after receiving tpa; mri/a showed m2 or m3 occlusion, no recannulization. neuro - stroke was most likely related to embolism from stent thrombus. serial head cts stable, but more dense weakness beginning on hd#2. pt was continued on aspirin and plavix for stent. patient was started on low dose coumadin 2.5 mg a day with no load given that he is already on two antiplatelets. the target is for low inr around 2. plan for coumadin for 3 months, re-image stent, if patent, discontinue coumadin. exam remains most notable for dysarthria, l hemiplegia and l extinction to double simultaneous stimulation. cv - ruled out for mi upon admission. blood pressure was initially allowed to autoregulate. htn now controlled on metoprolol. no events on telemetry. tee performed on prelim read: simple atheroma in descending aorta, moderately thick aortic valve, no asd or pfo (final report pending). should follow up with his outpatient cardiologist, dr. , after discharge from rehab. should continue plavix for at least 6 months after stent placement; duration of therapy to be guided directly by pt's cardiologist. fen/gi - pt failed initial swallow evaluations, requiring tube feeds through . cleared by video swallow evaluation for soft solids and thin liquids on . heme - should start coumadin 2.5mg qhs on , goal inr ~2 (low therapeutic goal as pt will also be on aspirin and plavix and would be at high risk for bleeding with higher inr). check inr twice weekly. id - being treated with nitrofurantoin for uti, course to be complete on . tox - for significant alcohol history, pt was started on thiamine, folate. discharged to rehab on in stable condition. medications on admission: plavix asa 325 lipitor ntg fluticasone atneolol lisinopril folate elavil pletal folate temazepam discharge disposition: extended care facility: for the aged - discharge diagnosis: right mca stroke discharge condition: stable discharge instructions: please do not load with coumadin, just start coumadin gently and allow inr to trend slowing to goal inr of 2. seek medical attention for worsened weakness, numbness, difficulty speaking, sudden change in vision/hearing, severe headache, seizure, or for other concerns. take all medications (including new ones) as prescribed. followup instructions: 1. if you do not receive a call from dr. office (neurology) in weeks, please call her office at for an appointment 2. follow up with your primary care physician after discharge from rehab. Procedure: Diagnostic ultrasound of heart Injection or infusion of thrombolytic agent Diagnoses: Mitral valve disorders Urinary tract infection, site not specified Unspecified essential hypertension Aortocoronary bypass status Peripheral vascular disease, unspecified Old myocardial infarction Cerebral embolism with cerebral infarction Chronic obstructive asthma, unspecified

chief complaint and history of present illness: asked by dr. to see this 77 year old man with a history of aortic stenosis. the patient is morbidly obese with long standing hypertension and a history of only mild dyspnea on exertion without chest pain. no rest symptoms. the patient with severe bilateral venous stasis currently on diuretics. no history of congestive heart failure per the patient. recently, he stopped his diuretics. serial echocardiograms have shown increasing severity of aortic stenosis. he was admitted to in for a cardiac catheterization. past medical history: 1. hypertension. 2. aortic stenosis. 3. morbid obesity. 4. tobacco use. 5. venous stasis ulcers. past surgical history: 1. status post left cataract surgery. 2. status post tonsillectomy. 3. status post varicocele surgery. medications: 1. lisinopril 40 mg q. day. 2. spironolactone 25 mg q. day versus twice a day. allergies: norvasc, which causes increasing lower extremity edema. social history: tobacco use is remote; discontinued 40 years ago. positive etoh use; decreased per report by wife over the last four years. physical examination: height is 5'"; weight 310 pounds. heart rate 68 and in sinus rhythm; blood pressure 146/60; respiratory rate 20; o2 saturation 99% on room air. in general, an obese man with severely draining venous stasis ulcers in no acute distress. heent: anicteric, noninjected. extraocular movements intact. neck is supple with no jugular venous distention, no lymphadenopathy and no bruits. oropharynx is clear. cardiovascular is regular rate and rhythm with a iii/vi perisystolic murmur at the left sternal border. lungs clear to auscultation bilaterally. abdomen is soft, obese, nontender. bilateral tinea of the groins. extremities with bilateral venous stasis changes to just below the knees. ulcers with clear to green drainage on the lateral right and medial left. pulses: carotids two plus bilaterally, radial two plus bilaterally, femoral - left is the catheterization site; the right is two plus. popliteal two plus bilaterally dorsalis pedis and posterior tibial, both two plus bilaterally. neurological: motor and sensory is grossly intact. cranial nerves ii through xii grossly intact. laboratory: data is white blood cell count 9.3, hematocrit 33.9, platelets 288. sodium 136, potassium 4.7, chloride 100, carbon dioxide 30, bun 23, creatinine 1.1. inr was 1.3. ekg was sinus rhythm with left ventricular hypertrophy, nonspecific st-t wave changes in leads 5 and 6. echocardiogram with concentric left ventricular hypertrophy, severely dilated left atrium with an ejection fraction of 75%. mild resting lvot obstruction. catheterization showed 50% left main, 20% ostial right coronary artery, 40% diagonal, aortic valve area 1.3 centimeters squared. the patient was discharged to home following his catheterization for further treatment of his venous stasis ulcers and an appointment with vascular surgery for follow-up regarding lower extremity ulcers. hospital course: he returned on where he was admitted directly to the operating room. at that time, he underwent an aortic valve replacement with a #23 tissue valve and coronary artery bypass graft times one with the left internal mammary artery to the left anterior descending. please see the operating room report for full details. the patient tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient had a heart rate of 91. he was a-paced with a mean arterial pressure of 65 and a central venous pressure of 10. he had levophed at 0.12 mics per kg per minute and propofol at 20 mics per kg per minute. in the immediate postoperative period, the patient experienced a labile blood pressure. a transesophageal echocardiogram was performed at the bedside which showed some systolic anterior motion. his levophed and neo-synephrine were weaned to off and he was given volume. the patient did well hemodynamically following these maneuvers. then, his anesthesia was reversed. he was weaned from the ventilator and successfully extubated. he remained hemodynamically stable throughout the night of his surgery and on postoperative day one dictation ends , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Aortic valve disorders Pulmonary collapse Morbid obesity Varicose veins of lower extremities with ulcer and inflammation

history of present illness: the patient is a 77-year-old gentleman with a history of aortic stenosis. the patient is morbidly obese with a longstanding history of hypertension. he complained only of mild dyspnea on exertion with no chest pain and rest symptoms. serial echocardiograms showed an increasing severity of his aortic stenosis. therefore, the patient was admitted in for cardiac catheterization. past medical history: his past medical history at that time was significant for hypertension, aortic stenosis, morbid obesity, remote tobacco history, and venous stasis ulcerations. past surgical history: surgical history was significant for left cataract surgery, tonsillectomy, variceal surgery. allergies: he stated an allergy to norvasc (which increased lower extremity edema). medications on admission: (his medications at that time included) 1. lisinopril 40 mg by mouth once per day. 2. spironolactone 25 mg by mouth once per day versus twice per day (depending on lower extremity edema). social history: remote tobacco use. he quit times four years. social alcohol use; decreased over the last four years. physical examination on presentation: the patient's height was 5 feet 10 inches, his weight was 310 pounds, his heart rate was 68 (sinus rhythm), his blood pressure was 146/60, his respiratory rate was 20, and his oxygen saturation was 99% on room air. in general, a well-developed obese gentleman with severely draining venous stasis ulcerations. he was in no acute distress. head, eyes, ears, nose, and throat examination revealed the sclerae were anicteric. not injected. the extraocular movements were intact. the neck was supple. there was no jugular venous distention. no bruits. there was no lymphadenopathy. the oropharynx was clear. cardiovascular examination revealed a regular rate and rhythm. there was a harsh 3/6 systolic perisystolic murmur. the lungs were clear to auscultation bilaterally. the abdomen was obese, soft, and nontender. bilateral groin tenia. extremity examination revealed bilateral venous stasis changes to just below the knees. positive ulcerations draining clear to green fluid on the right lateral leg and medial left leg. pulse examination revealed carotid pulses were 2+ bilaterally, radial pulses were 2+ bilaterally, femoral pulses on the catheterization site on the right were 2+, and popliteal pulses were 2+ bilaterally. neurologically, motor and sensory examinations were grossly intact. cranial nerves ii through xii were grossly intact. pertinent laboratory values on presentation: white blood cell count was 9.3, his hematocrit was 33.9, and his platelets were 288. sodium was 136, potassium was 4.7, chloride was 100, bicarbonate was 30, blood urea nitrogen was 23, and his creatinine was 1.1. his inr was 1.3. pertinent radiology/imaging: an electrocardiogram revealed a sinus rhythm with left ventricular hypertrophy and nonspecific st-t wave changes in v4 through v6. echocardiogram showed concentric left ventricular hypertrophy with severely dilated left atrium, and an ejection fraction of 75%, and a mild resting left ventricular obstruction. cardiac catheterization showed 50% left main, 30% left anterior descending artery, 40% diagonal, 20% right coronary artery, and an aortic valve area of 1.3 cm2. concise summary of hospital course: as stated previously, the patient was a direct admission to the operating room. on , the patient underwent an aortic valve replacement with a #23 pericardial tissue valve and a coronary artery bypass graft times one with a left internal mammary artery to the left anterior descending artery. please see the operative report for full details. the patient tolerated the procedure well and was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient's heart rate was a paced at 91 beats per minute. he had a mean arterial pressure of 65 and a central venous pressure of 10. he had levophed at 0.1 mcg/kg per minute and propofol at 30 mcg/kg per minute. in the immediate postoperative period, the patient had a labile blood pressure. a bedside transesophageal echocardiogram done at that time showed some degree of systolic anterior motion. his levophed and neo-synephrine drips were weaned off, and he was treated with volume. following that, he was hemodynamically stable. his anesthesia was reversed, he was weaned the ventilator, and was successfully extubated. he remained hemodynamically stable throughout the postoperative day and on postoperative day one. on postoperative day two, the patient had a labile blood pressure requiring low-dose neo-synephrine to maintain an adequate blood pressure. he was also noted to have a white blood cell count of 21. he was pan-cultured and had a chest x-ray at that time. the chest x-ray revealed bibasilar atelectasis, but no evidence of failure, pneumothorax, or infiltrate. additionally, the patient's swan-ganz catheter was discontinued. once per day three, the patient was weaned from all cardioactive intravenous medications. his chest tubes were discontinued and diuresis was begun. once per day four, the patient continued to be hemodynamically stable. he remained in the cardiothoracic intensive care unit for vigorous pulmonary toilet. by postoperative day five, the patient continued to progress slowly. he was hemodynamically stable. his pulmonary status seemed to be slowly improving, and he was transferred from the intensive care unit to the two for continued postoperative care and cardiac rehabilitation. over the next several days, the patient had an uneventful hospital course. with the assistance of the physical therapy staff and the nursing staff, the patient's activity level was gradually advanced. on postoperative day six, his temporary pacing wires were discontinued. he continued to make slow progression in his activity level. on postoperative day seven, it was decided that the following day the patient would be stable and ready to be transferred to rehabilitation for continued postoperative care. at the time of discharge, the patient's physical examination was as follows. vital signs revealed his temperature was 97.2 degrees fahrenheit, his heart rate was 66 (sinus rhythm), his blood pressure was 118/60, his respiratory rate was 20, and his oxygen saturation was 93% on room air. his weight preoperatively was 291 kilograms. at discharge, his weight was 305 kilograms. laboratory data revealed his white blood cell count was 10.8, his hematocrit was 27.7, and his platelets were 262. sodium was 138, potassium was 4.4, chloride was 101, bicarbonate was 26, blood urea nitrogen was 32, creatinine was 1, and blood glucose was 142. physical examination revealed the patient was alert and oriented times three. he moved all extremities. he followed commands. respiratory examination revealed scattered wheezes throughout. cardiovascular examination revealed a regular rate and rhythm. normal first heart sounds and second heart sounds. no murmurs. the sternum was stable. the incision with steri-strips opened to air. clean and dry. the abdomen was soft and nontender. there were positive bowel sounds. extremities with venous stasis ulcerations bilaterally up to his knees. no open sores. pedal edema of 3+ bilaterally. medications on discharge: 1. metoprolol 25 mg by mouth twice per day. 2. lasix 40 mg by mouth twice per day (times two weeks) and then 40 mg by mouth once per day. 3. potassium chloride 20 meq by mouth twice per day (times weeks) and then 20 meq by mouth once per day. 4. colace 100 mg by mouth twice per day. 5. zantac 150 mg by mouth once per day. 6. enteric-coated aspirin 325 mg by mouth every day. 7. heparin 5000 units subcutaneously three times per day. 8. percocet 5/325-mg tablets one to two tablets by mouth q.4h. as needed. discharge diagnoses: 1. aortic stenosis; status post aortic valve replacement with #23 pericardial tissue valve. 2. coronary artery disease; status post coronary artery bypass grafting with a left internal mammary artery to the left anterior descending artery. 3. hypertension. 4. morbid obesity. 5. venous stasis ulcerations. condition at discharge: the patient's condition on discharge was good. discharge disposition: the patient was to be discharged to rehabilitation. discharge instructions/followup: 1. the patient was instructed to follow up with dr. in two to three weeks. 2. the patient was instructed to follow up with dr. in two to three weeks. 3. the patient was instructed to follow up with dr. in six weeks. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Aortic valve disorders Pulmonary collapse Morbid obesity Varicose veins of lower extremities with ulcer and inflammation

history of present illness: the patient is a 66 year old gentleman with a history of obesity, peripheral vascular disease, hypertension and heavy tobacco use was admitted initially to on complaining of chest pressure, dizziness, weakness, diaphoresis and hypotension. he was in his usual state of health until 11:00 p.m. that night when he took a double dose of zestril and suffered an episode of nausea, vomiting, diaphoresis and chest pressure without relief which lasted about three hours until he came to the emergency department. in the e.d. patient's blood pressure was 90/58, heart rate 82. within an hour patient's systolic blood pressure dropped to 45, heart rate dropped to 32 and patient was found in 2:1 heart block. patient received 0.5 mg of atropine and 1 mg of epi after which patient went into svt at a rate of 180. patient was cardioverted out of this rhythm with 50 joules after which patient's systolic blood pressure dropped to the mid-60s and patient was started on dopamine 10 mcg per kg per hour. patient was transferred to the ccu at . his ekg showed sinus tachycardia with frequent ectopy. per notes from the outside hospital, his ekg was suspicious for right sided mi especially in the context of receiving aggressive fluid replacement, close to 4 liters, and remaining persistently hypotensive. patient was started on acute coronary syndrome protocol, aspirin, heparin drip, integrilin drip. beta blocker was held secondary to bradycardia. dopamine drip was weaned off and neo drip was started. the next morning patient had an echocardiogram which showed ejection fraction of 40% and inferior/right ventricular hypokinesis. patient's ck peaked at 1293. patient was transferred to for cardiac catheterization. on arrival to , patient was chest pain free. he was on neo-synephrine drip with blood pressure of 140/100, pulse 75. past medical history: hypertension. peripheral vascular disease, status post right carotid endarterectomy in . history of tia. history of anxiety disorder. history of obesity. history of heavy tobacco use. medications: zestril, paxil 5 mg p.o. q.d., xanax 0.25 mg p.o. q.i.d., aspirin. medications on transfer: aspirin, heparin, integrilin, neo-synephrine 20 mcg per minute, protonix 40 p.o. q.d., paxil 10 p.o. q.d., xanax, levaquin 500 p.o. q.d. allergies: no known drug allergies. family history: coronary artery disease. father died of myocardial infarction at the age of 79. diabetes in patient's mother. hepatocellular carcinoma in patient's father. social history: more than 50 pack year smoking history. alcohol use one to two drinks per day. patient is retired. he has four children. physical examination: on transfer to the cardiac intensive care unit, the patient's temperature was 98.2, pulse 82, blood pressure 112/66, respirations 22, 95% on 3 liters, pulsus paradoxus 3 to 5 mm. patient was on neo-synephrine 0.2 mcg per minute. in general, patient demonstrated labored breathing, was speaking in short sentences, was lying in bed in mild respiratory distress. heent patient had very mild right eyelid droop. pupils were equal, round, and reactive to light and accommodation. there was poor dentition, but normal oropharyngeal mucosa. neck no carotid bruits. there was 3 to 4 cm jugular venous distention above the clavicle. pulmonary there was poor air movement, extensive audible wheezing in all fields, difficult to appreciate crackles. cardiovascular distant heart sounds with no murmurs, gallops or rubs noted. abdomen positive bowel sounds, distended and tight, but no fluid wave, no hepatosplenomegaly. extremities no cyanosis, clubbing or edema. normal peripheral pulses. neurologic was intact. laboratory data: peak ck 1500. white count 16.5, hematocrit 39.3, platelets 183. sodium 138, potassium 4.4, chloride 104, bicarb 28, bun 17, creatinine 1.0, glucose 122. normal lfts. ua showed small blood, positive nitrite, positive leukocyte esterase, more than 100 wbc, 20 to 30 rbc. ekg showed normal sinus rhythm, t wave inversions in leads 2, 3 and avf and development of progressive q waves in leads 2, 3 and avf. hospital course: the patient underwent cardiac catheterization which showed right atrial pressure of 19, pulmonary artery pressure of 51/30, pulmonary capillary wedge pressure (pcwp) of 27, cardiac output of 4.6, cardiac index of 2.0. patient showed left dominant system and one vessel disease with totally occluded mid-circumflex just after large obtuse marginal. patient's left sided pda filled via left to left collaterals. ptca and stenting were done with no residual stenosis and timi 3 flow. lv-gram was not performed due to reported creatinine of 1.6 at the outside hospital. patient had a chest x-ray which showed bilateral opacities consistent with pulmonary edema, no hyperinflation. 1. cardiovascular. the patient is status post ptca and stenting of mid-circumflex, status post inferior posterior mi hours prior to presentation complicated by hypotension and bradycardia, still requiring pressors during cardiac catheterization. upon transfer from the cardiac catheterization lab, aspirin, plavix and integrilin were continued. patient was started on lipitor. cardiac enzymes were cycled q.eight hours and were followed to the peak. it was postulated that patient's persistent hypotension was due to heightened vagal tone since there was no evidence of right sided mi by cardiac catheterization. patient was subsequently weaned off neo-synephrine and was started on ace inhibitor which he tolerated well. initially beta blockers were held due to presumed copd exacerbation, although patient does not have an official diagnosis of copd. patient was given lasix 20 mg p.o. once and showed good urinary output response to that, since patient did appear in mild pulmonary edema. however, most of patient's wheezing and shortness of breath were secondary to pulmonary etiology. patient has done very well in the intensive care unit and was subsequently transferred to the general medical floor. patient was started on a low dose beta blocker and tolerated that well. patient is to have cardiology followup. it was suggested that patient could follow up with a physician at , however, patient preferred to have followup set up by his primary care physician in his community. 2. pulmonary. the patient does not have a documented history of copd, however, given his extensive history of smoking and extensive wheezing and good response to bronchodilators, patient most likely does have copd. patient was given continuous neb treatments which we were able to change to metered dose inhalers. patient did receive appropriate education about their use. patient would greatly benefit from outpatient pulmonary function tests for proper diagnosis of copd. patient received excessive education on the necessity of quitting smoking. that was done repeatedly during daily conversations with the patient. 3. gi. the patient was treated with protonix for prophylaxis. 4. renal. the patient received mucomyst pre-cath and post-cath. patient's creatinine and electrolytes remained stable throughout the hospitalization. 5. id. the patient had e.coli uti per records from the outside hospital. patient was started on levaquin at the outside hospital. here the antibiotic was changed to bactrim which patient is to take for the few consecutive days during his hospitalization. 6. anxiety. the patient was continued on xanax and paxil. 7. nutrition. the patient is to follow a cardiac, low sodium diet. the patient received extensive education about the importance of adhering to this diet regimen. condition on discharge: good. discharge status: to home. discharge diagnosis: status post myocardial infarction. discharge medications: 1. aspirin. 2. plavix. 3. toprol xl 12.5 mg p.o. b.i.d. 4. lipitor 20 mg p.o. b.i.d. 5. lisinopril 10 mg p.o. b.i.d. 6. serevent mdi two puffs p.o. b.i.d. 7. albuterol mdi two puffs q.four to six hours p.r.n. followup: the patient is to follow up with his primary care physician, . , on at 3:45 p.m., phone number . patient's primary care physician is to schedule outpatient cardiology followup for patient about two weeks after discharge. patient will also need an echocardiogram four weeks after discharge. , m.d. dictated by: medquist36 d: 23:07 t: 09:50 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 Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Urinary tract infection, site not specified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atrioventricular block, complete Acute myocardial infarction of other inferior wall, initial episode of care