Datasets:

adalbertojunior

/

ICD_dataset

like 1

Admission Date: [**2111-2-10**] Discharge Date: [**2111-4-15**] Date of Birth: [**2046-3-27**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5755**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 64 [**Doctor First Name **] Scientist female w/ h/o untreated diabetes who presents from her living facility with change in mental status. She has been living at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist facility receiving supportive care for the past 2 months. She was ambulatory as recently as a few days ago, able to ambulate to a bedside commode, and she was noted to have urinary frequency. Over the past couple of days, her family noticed a change in mental status, as she became less verbal and less lucid. By this morning she was clearly delirious and agitated and was brought to [**Hospital1 18**] ED. . In the ED, her blood glucose level was found to be 1135. She was started on an insulin gtt and given aggressive IVF hydration. Her rectal temp on arrival was 99.8 and her abdomen was noted to be distended and firm. The patient was initially treated broadly with Vancomycin and Flagyl. A Foley catheter was placed and 2L of urine was drained. UA was positive and CT abdomen showed mod/severe bilateral hydronephrosis with pyelonephritis. The patient was given CTX. The patient was given a total of Haldol 5mg IV and Ativan 1mg IV for agitation. A CXR and 2 head CTs limited by motion were unremarkable. . On arrival to the [**Hospital Unit Name 153**], FS was critically high (>400). A 5U bolus of insulin was given and the rate of the gtt was increased to 10U/hr. Past Medical History: Diabetes Poor vision (?diabetic retinopathy vs. cataracts) Social History: Has 2 children (son and daughter), has been a practicing [**Doctor First Name **] Scientist for at least 30 years Family History: mother, sister w/ DM Physical Exam: VS: 97.2 (axillary), 113, 117/66, 19, 99% 2L NC Gen: drowsy, intermittently agitated, not responsive to commands HEENT: left pupil opaque, right pupil round and reactive to light, anicteric Neck: supple, no carotid bruits Lungs: limited by inability to follow commands, but CTAB CV: tachy, RR, nl S1S2, no m/r/g Abd: hypoactive bowel sounds, S/NT/ND, midline surgical scar from lower abdomen to pubic symphysis Rectal: guaiac neg per ED Ext: no c/c/e, DP/PT pulses 2+ b/l Neuro: drowsy, not oriented, unable to conduct full neuro exam due to mental status Pertinent Results: Imaging: CXR: No acute cardiopulmonary disease. No evidence of infiltrate or aspiration. . Head CT #1: Technically limited study secondary to patient motion artifact. No gross abnormality identified. The foramen magnum was not evaluated on this exam. . Head CT #2: Limited study with no evidence of acute intracranial hemorrhage. . CT Abd/pelvis [**2111-2-10**]: 1. Moderate/severe bilateral hydronephrosis with right sided pyelonephritis and evidence of early liquefaction. Follow-up CT is recommended following treatment to exclude an underlying lesion. 2. Dilated ureters extend into the pelvis to a circumferentially thick-walled, enhancing bladder - the appearance is concerning for infection. 3. Distended bladder despite foley catheter. Clinical correlation is requested. 4. Mild stranding in right inguinal region may be related to renal infection/inflammation. While the appendix is not clearly visualized, there is no abnormal enhancement in and around the cecum to suggest appendicitis. . CT ABD/PELVIS/CHEST [**2111-2-17**]: 1. Interval development of right perinephric abscess inferior to the lower pole of right kidney. 2. Interval resolution of left hydronephrosis and hydroureter. Partial resolution of the right hydronephrosis and hydroureter. Complete drainage of the enlarged bladder. 3. Prebronchial opacity in the right upper lobe most likely represents inflammatory change, please correlate clinically and evaluate for resolution. . [**2110-2-20**] CT-GUIDED DRAINAGE: Successful percutaneous CT fluoroscopy-guided aspiration of the perinephric abscess. . [**2111-4-7**] CT ABD/PELVIS: 1. No evidence of bowel obstruction or bowel wall thickening to explain the patient's persistent diarrhea. 2. Interval resolution of right perinephric abscess/infection inferior to the lower pole of the right kidney. 3. Decreased size of hypodense wedge-shaped areas of low attenuation within the lower pole of the right kidney, likely reflecting resolving pyelonephritis. 4. Mild to moderate bilateral hydronephrosis and hydroureter. No obstructing stone or mass identified. There is marked distention of the bladder. Findings may represent ureteral reflux secondary to bladder outlet obstrution or atony. Clinical correlation is recommended. . EKG: sinus tachy at 109, nl axis, nl intervals, no ST-T changes . [**2111-2-10**] URINE INSTRUMENTATION: NEGATIVE FOR MALIGNANT CELLS. Urothelial cells, squamous cells, histiocytes, neutrophils, and red blood cells. . [**2111-2-16**] RENAL U/S: Persistent hydronephrosis, moderate on the right and borderline mild on the left. Heterogeneous echogenicity with several echogenic areas in the right kidney likely pyelonephritis. . [**2111-3-9**] MR [**Name13 (STitle) 6452**]: No evidence of focal disc protrusion. Facet disease at 4-5 and [**5-26**]. Diffusely abnormal marrow signal attributable to fibrosis. No definite evidence of disc infection or epidural abscess. . [**2111-4-6**] ABD (SUPINE AND ERECT): No evidence of free air or obstruction. . [**2111-2-10**] 10:30AM PT-11.7 PTT-26.3 INR(PT)-1.0 [**2111-2-10**] 10:30AM WBC-13.5* RBC-4.43 HGB-12.4 HCT-38.4 MCV-87 MCH-28.1 MCHC-32.4 RDW-13.9 . [**2111-2-10**] 10:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2111-2-10**] 10:30AM cTropnT-<0.01 [**2111-2-10**] 10:30AM GLUCOSE-1135* UREA N-59* CREAT-1.5* SODIUM-131* POTASSIUM-6.0* CHLORIDE-89* TOTAL CO2-21* ANION GAP-27* [**2111-2-10**] 11:29AM GLUCOSE-748* K+-3.9 . URINE CULTURE (Final [**2111-4-4**]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. URINE CULTURE (Preliminary): CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML.. Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML.. FURTHER IDENTIFICATION TO FOLLOW. Brief Hospital Course: 64F w/ untreated diabetes presents with altered mental status, found to be in DKA. . ## DKA: Glucose was found to be 1135 on admission. She was started on insulin gtt in the ED and received IV hydration with NS originally. She did have ketones in her urine and her bicarb was 21. Her anion gap had closed upon transfer to ICU and her glucose had corrected to 400s. Her insulin drip was continued and her blood glucose continued to correct. With improved control of her glucose, insulin gtt was stopped and she was started on basal insulin and sliding scale with good control of her BS. This occurred in the setting of a UTI/pyelonephritis and longstanding uncontrolled diabetes. [**Last Name (un) **] followed throughout hospital course. Eventually patient transferred to NPH [**Hospital1 **] with outstanding control of blood sugars. . ## Transaminitis: Suspect secondary to antibiotics. Hepatititis A,B,C serologies negative. CK normal. CT showed a normal liver. Bilirubin remained normal and patient had no ruq pain. LFTs have since returned to the normal range. . ## Diarrhea: Suspect viral gastroenteritis. C diff negative x 3, including toxin B negative. Symptom free x 5 days. . ## Altered mental status: At baseline, son reports very functional w/o delirium nor dementia. Certainly multifactorial in the setting of gross hyperglycemia and metabolic insult, hypernatremia, and infection. Her mental status began to clear with correction of the above. With continued treatment of her pyelonephritis, her mental status returned to baseline. Folate, B12, TSH, and RPR unrevealing. Psychiatry was consulted later in the hospital course, who was concerned about an underlying dementia (see legal issues, below). . #Legal Issues: as noted above, the patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist. She was living in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist group home, and during the hospital course she expressed some remorse that her son had allowed her to come to the ED. She expressed doubts about modern medicine and remained adamant that prayer and healing would cure her diabetes. However, while in the hospital she did not refuse medical treatments and was quite agreeable to the medical team's recommendations for acute treatment. Psychiatry was consulted to help to determine whether the patient truly understood the basis of her disease and had the capacity to make her own decisions. Further history obtained from psychiatry was that the patient had several pscyh hospitalizations in the past, and that her [**Doctor First Name **] Scientist beliefs were not mainstream. Hence, legal gaurdianship was pursued and is currently pending. Her son was not intereseted in pursuing this role as he felt his mother still harbored resentment to his views of [**Doctor First Name **] Scientists. Please note, patient is not felt to be competent to refuse insulin treatment. . ## UTI/pyelonephritis: In the ED, her UA was positive, but urine culture revealed microflora. When foley was placed, 2L of urine returned. CT abdomen/pelvis revealed bilateral hydronephrosis and right pyelonephritis. She was started on vancomycin and ceftriaxone. In the [**Hospital Unit Name 153**], vanco was discontinued and antibiotics were changed to ciprofloxacin. However, while on cipro she again began to spike fevers so her antibiotics were changed to zosyn. She continued to have fevers and thus repeat CT was done which showed a small perinephric fluid collection. Given persistent fevers, this collection was drained to identify the underlying organism to rule out resistance. CT done for this procedure showed a resolving fluid collection. 2 cc of bloody fluid was obtained but culture was negative. Patient defervesced (following addition of azithro as well for ? RUL infiltrate). ID consulted to aid with possible po regimen. She completed a total of 3 weeks of antibiotics (eventually changed to PO Augmentin/Cipro. She is now back on cipro for a recurrent UTI (CITROBACTER FREUNDII COMPLEX and a 2nd gram negative rod). Sensitivities of the 2nd gram negative rod are still pending at the time of this dictation. . ## Urinary retention: Given untreated diabetes, may reflect neurogenic bladder w/ bilateral hydronephrosis resulting. A foley was placed and maintained while mental status remained depressed. Urology was consulted in house and do not recommend stenting at this time, given hydronephrosis improving. She subsequently failed multiple voiding trials. For a period of time she received intermittent straight cath but is requiring this at least 1-2 times per day to decompress her bladder. Given current UTI, foley placed to aid in clearance of UTI and to minimize risk of ascending infection. She will need outpatient urology follow-up for urodynamic testing. . ## ARF: Likely from dehydration and UTI/pyelo/obstruction. Her creatinine normalized rapidly with IV hydration, relief of obstruction, and antibiotic initiation. . ## Anemia: Unknown baseline. She was without evidence of active bleeding and hct drop was likely from aggressive fluid resuscitation. Hct remained stable following initial resuscitation. Anemia stuides c/w Anemia of Chronic Disease. . ##Toe Drop: the patient developed Left Toe drop while in house. Neuro consulted, who felt that likely etiology was peripheral neuropathy. MRI L spine negative. Improved sponatenously during hosptialization. Medications on Admission: None Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. 2. insulin 70/30 9 units SQ qam, 10 units SQ qpm 3. regular insulin sliding scale 1 injection sq qid Please follow insulin sliding scale provided Discharge Disposition: Extended Care Facility: [**Hospital1 10283**] Center - [**Location (un) **] Discharge Diagnosis: primary: pyelonephritis complicated by perinephric abscess diabetic ketoacidosis secondary: urinary tract infection viral gastroenteritis urinary retention - foley in place anemia of chronic disease Discharge Condition: good: afebrile, tolerating po, no diarrhea x 5 days Discharge Instructions: Please monitor for temperature > 101, lethargy, or other concerning symptoms. Followup Instructions: 1. Please follow-up with the [**Last Name (un) **] diabetes doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**], [**2111-4-21**] at 9:00 AM (This will be a 2 hour appointment). Phone: [**Telephone/Fax (1) 2384**] 2. Please follow-up with your new primary care doctor, Dr. [**First Name (STitle) **] [**Name (STitle) **] on Wednesday, [**2111-4-29**] at 1:30 PM. Phone: [**Telephone/Fax (1) 250**] 3. Please follow-up with the urologist, Dr. [**Last Name (STitle) **], on Monday, [**2111-4-20**] at 2:00 PM. Phone: ([**Telephone/Fax (1) 772**]

Admission Date: [**2116-2-5**] Discharge Date: [**2116-2-17**] Date of Birth: [**2048-4-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD Colonoscopy Capsule endoscopy History of Present Illness: 67M w/ h/o multiple myeloma since [**2111**], neuropathy, bed-bound, cared for by Dr [**Last Name (STitle) 284**] at [**Company 2860**], last seen at [**Hospital1 18**] in [**2112**], presented with GI bleed. Patient was at nursing home when maroon stools were noted by staff members. Patient himself unaware of rectal bleeding. He denies GI symptoms. He reports slight lightheadedness. He was transferred from NH to [**Hospital1 **] ED. In ED, he was tachy in 110s-120s, BP initially was 90/50. His hct came back at 17.6, and he had a thrombocytopenia of 45,000. NG lavage did not show blood. Patient was transfused 2U PRBC and 6U Plt. GI was consulted, felt there was no need for scope tonight. They recommended supportive therapy for now. If active bleeding, they would want angio / or tagged RBC scan. ROS: no fever/chills/nausea/vomiting/diarrhea/abdominal pain Past Medical History: Per OMR / patient Multiple myeloma. Diagnosed [**12-3**]. Depression Schizo-affective disorder 2nd/3rd degree burns to his legs [**2109**] Seen and being treated for myeloma at [**Company 2860**] by Dr [**Last Name (STitle) 284**]. Social History: former smoker (1 pack/wk x 30 years). Now quit. No EtoH use. Family History: NC Physical Exam: In ICU - VS: 98.7 BP 121/61 HR; 104 RR: 18 100% room air general: NAD AOx3 HEENT: PERLLA, EOMI, Anicteric, pale chest: CTA b/l heart: RR, no murmurs rubs/gallops abdomen: +b/s, soft, nt, nd extremities: no edema skin: multiple skin grafts, healing wounds rectal guiaic positive neuro: peripheral neuropathy Pertinent Results: [**2116-2-17**] 06:05AM BLOOD WBC-2.9* RBC-3.12* Hgb-9.3* Hct-28.3* MCV-91 MCH-29.8 MCHC-32.8 RDW-14.7 Plt Ct-52* [**2116-2-15**] 06:35AM BLOOD WBC-4.1# RBC-3.11* Hgb-9.5* Hct-28.4* MCV-91 MCH-30.4 MCHC-33.3 RDW-14.6 Plt Ct-18* [**2116-2-10**] 06:20AM BLOOD WBC-2.4* RBC-3.04* Hgb-9.2* Hct-26.8* MCV-88 MCH-30.2 MCHC-34.4 RDW-14.7 Plt Ct-39* [**2116-2-5**] 06:30PM BLOOD WBC-7.8# RBC-1.93*# Hgb-6.1*# Hct-17.6*# MCV-91# MCH-31.7 MCHC-34.9 RDW-15.3 Plt Ct-45*# [**2116-2-16**] 07:05AM BLOOD Neuts-67.1 Lymphs-29.1 Monos-1.2* Eos-2.6 Baso-0.1 [**2116-2-5**] 06:30PM BLOOD Neuts-82.1* Bands-0 Lymphs-16.6* Monos-0.4* Eos-0.4 Baso-0.4 [**2116-2-16**] 07:05AM BLOOD PT-15.0* PTT-33.2 INR(PT)-1.3* [**2116-2-17**] 06:05AM BLOOD Glucose-107* UreaN-8 Creat-0.8 Na-135 K-3.8 Cl-101 HCO3-24 AnGap-14 [**2116-2-5**] 06:30PM BLOOD Glucose-167* UreaN-37* Creat-1.1 Na-136 K-4.7 Cl-102 HCO3-22 AnGap-17 [**2116-2-5**] 06:30PM BLOOD ALT-53* AST-20 CK(CPK)-21* AlkPhos-281* TotBili-0.5 [**2116-2-17**] 06:05AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1 [**2116-2-14**] 06:15AM BLOOD Hapto-268* [**2116-2-5**] 06:38PM BLOOD Hgb-5.4* calcHCT-16 [**2116-2-12**] 11:23AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 [**2116-2-12**] 11:23AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG [**2116-2-12**] 11:23AM URINE RBC-4* WBC-37* Bacteri-MANY Yeast-NONE Epi-1 TransE-<1 [**2116-2-5**] 11:55PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.011 [**2116-2-5**] 11:55PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2116-2-5**] 11:55PM URINE RBC->50 WBC-21-50* Bacteri-MANY Yeast-NONE Epi-0-2 [**2116-2-12**] 11:23 am URINE Site: CLEAN CATCH Source: CVS. **FINAL REPORT [**2116-2-15**]** URINE CULTURE (Final [**2116-2-15**]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMIKACIN-------------- =>64 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Time Taken Not Noted Log-In Date/Time: [**2116-2-5**] 11:55 pm URINE Site: CATHETER **FINAL REPORT [**2116-2-10**]** URINE CULTURE (Final [**2116-2-9**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMIKACIN-------------- =>64 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Pathology Report INVESTIGATION OF TRANSFUSION REACTION Study Date of [**2116-2-11**] (ICD9 CODE: 999.8) INDICATION FOR CONSULT: INVESTIGATION OF TRANSFUSION REACTION INDICATIONS FOR CONSULT: Investigation of transfusion reaction CLINICAL/LAB DATA: Mr. [**Known lastname 14558**] is a 67 y/o man with PMH significant for multiple myeloma, DVT and schizophrenia admitted on [**2116-2-5**] for GI bleeding. Two weeks ago he was admitted to [**Hospital1 112**] for similar reasons, and he was transfused at that time. He has received multiple blood transfusions at [**Hospital1 18**] during this admission with no previously reported reactions. On [**2116-2-11**] at 2215, following premedication with tylenol, Mr. [**Known lastname 14558**] was transfused approximately 170 ml of compatible leukoreduced packed red blood cells. Pre-transfusion vitals were: T=99.8; HR=99; RR=20; BP=136/84. The transfusion was stopped at 2330, after his temperature rose to 101.2. He also developed chills/rigors, but had no other symptoms. There were no significant changes in BP, HR and RR during the transfusion. Of note, on admission, he had a urine culture positive for Klebsiella Pneumonia. A routine clerical check revealed no errors. Laboratory Data: Patient ABO/Rh: Group O, Rh positive Red Cell Product (21KQ[**Pager number 58759**]) ABO/Rh: Group O, Rh positve Post-transfusion serum: yellow, DAT negative Transfusion History: Previous non-reactive red cell transfusions: 7 Previous non-reactive platelet transfusions: 4 Transfusion restriction met: Yes DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [**Known lastname 14558**] experienced a mild temperature increase of 1.4 degrees F after receiving 170 ml of a leukoreduced compatible red cell. Laboratory workup revealed no evidence of hemolysis. The patient had a positive urine culture for Klebsiella Pneumonia upon admission. Given that leukoreduction significantly decreases the incidence of febrile non-hemolytic transfusion reactions, the patient's fever is likely secondary to his underlying illness. However, a febrile non-hemolytic transfusion reaction cannot be completely ruled out. No change in transfusion practice is recommended at this time in this patient. ORDERING/ATTENDING MD: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DIAGNOSED BY: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] CONSULTING PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] Cardiology Report ECG Study Date of [**2116-2-6**] 10:28:28 AM Sinus rhythm with borderline sinus tachycardia Normal ECG Since previous tracing of [**2113-1-12**], rate faster, QRS voltage less prominent and ST-T wave changes decreased Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W. EGD: Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Other Prominent papilla Impression: Prominent papilla Otherwise normal EGD to third part of the duodenum Recommendations: Follow HCT and transfuse as needed 4L Golytely for colonoscopy tomorrow. Additional notes: There was no fresh or old blood noted to the third part of the duodenum. Would proceed to colonoscopy followed by capsule study if colonoscopy is negative. We were unable to capture images due to a computer error. The procedure was done by the attending and GI Fellow. Colonoscopy - Findings: Excavated Lesions Multiple diverticula were seen in the sigmoid colon and descending colon.Diverticulosis appeared to be of moderate severity. Impression: Diverticulosis of the sigmoid colon and descending colon Additional notes: The efficiency of colonoscopy in detecting lesions was discussed in detail with the patient. It was explained that colon cancer and colon polyps may on rare occasions be missed during a colonscopy. The attending was present during the entire procedure Routine Post-Procedure orders No source of bleeding seen on this exam The patient??????s reconciled home medication list is appended to this report Capsule endoscopy read pending. Brief Hospital Course: 67 year old man with history of advanced multiple myeloma refractory to multiple treatments, pancytopenia, neuropathy secondary to Velcade, recurrent UTI's and obscure overt GI bleeding admitted with GI bleeding. Admit [**2116-2-5**] GI bleeding/Acute blood loss anemia: Anemia - baseline HCT 24 (as per oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**]). Recent EGD/[**Last Name (un) **] at [**Hospital6 **] for source of bleed. Admitted to ICU here. Given 4 units of blood with stabilization of hematocrit, resolution of melena. EGD negative for bleeding soruce. Transferred to floor on [**2-8**]. No further bleeding. Hematocrit drifted down again to 24 and given one more unit on [**2-11**]. Colonoscopy without discrete bleeding source. Capsule endoscopy [**2-13**], results pending at discharge. hematocrit stable at discharge. Multiple Myeloma/Pancytopenia: WBC supported by neupogen. Bactrim and acyclovir discontinued given drop in platelets to [**Numeric Identifier 7206**]. Transfused with effect on [**2-16**]. Plt to [**Numeric Identifier 58760**]. Crit as above, stable Admission discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**], oncologist at [**Hospital6 **]. Limited remaining options, patient at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on hospice care. Hematology consulted here for thrombocytopenia, recommended transfusions and consideration of steroids once patient treated for UTI. Patient to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] after discharge. repeat CBC recommended in [**2-2**] days of discharge. Overall has poor prognosis and may consider hospice follow up at facility. Recurrent UTI's: Found to have ESBL klebsiella on admit to MICU. Treatment deferred given possibility of chronic colinization and clinical stability. Patient had foley on admit, discontinued on [**2-12**] and urine culture re-sent, again growing >100,000 ESBL klebsiella. Started on meropenem on [**2-14**]. Needs 10 day course to complete [**2-24**]. After this, consideration of steroids for multiple myeloma as above. Neuropathy: thought secondary to velcade. Stable throguhout, patient bed bound. Pain from myeloma: MS Contin; IV morphine PRN breakthrough pain, morphine IR a ded. Psych/schizophrenia: Pt has refused all outpatient psych medications. Stable throughout without HI, SI, paranoia, delusions. Skin grafts/scars from previous burns/Wounds: wound care maintained. BPH: patient refuses alpha blocker. continued on finasteride. Foley initially, d/ced on [**2-12**] with successful voiding trial. Bactrim stopped as could contibute to pancytopenia and could be restarted at discretion of PCP/ oncologist. Case manager discussed with ex-wife [**Name (NI) 15406**] on day of duischarge re. patient's discharge to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Patient aware and was agreeable to transfer. Midline care recommended at [**Location (un) **] [**Doctor Last Name **] as well as follow up blood work as outlined in page 1. Medications on Admission: MS contin Unclear if taking Morphine IR neupogen bactrim MWF on decadron, off velcade, revlimid since [**2115-12-11**] prilosec Procrit Discharge Medications: 1. Filgrastim 300 mcg/mL Solution Sig: One (1) injection Injection MWF (Monday-Wednesday-Friday). 2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Meropenem 500 mg IV Q6H 4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). 5. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. Procrit 40,000 unit/mL Solution Sig: One (1) Injection once a week. 7. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 8. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 11. Midline care as needed Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Discharge Diagnosis: 1. Gastrointestinal bleeding 2. Acute blood loss anemia 3. ESBL klebsiella UTI 4. Multiple myeloma 5. Pancytopenia 6. Neuropathy 7. Schizophrenia 8. BPH 9. Neuropathy Discharge Condition: Stable, at baseline, afebrile. Discharge Instructions: Follow up as below. All medications as prescribed. We have discontinued your acyclovir and bactrim. Contact your doctor if you develop recurrent blood in your stool, abdominal pain, fevers, pain or any other new concerning symptoms. Intravenous antibiotics are recommended for treatment for urine infection. To be continued as recommended. A repeat blood work (CBC, LFT, BUN/creatinine) will be required in [**2-2**] days at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Followup Instructions: Follow up with your oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] [**Telephone/Fax (1) 58761**] at [**Hospital6 **] / [**Hospital3 328**] cancer institute - within one week of discharge from hospital. Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1355**] [**Telephone/Fax (1) 45347**] - follow up with your primary care doctor in 1 week.

Admission Date: [**2189-11-19**] Discharge Date: [**2189-12-4**] Date of Birth: [**2189-11-19**] Sex: M Service: NB Baby [**Name (NI) **] [**Known lastname **] is the 696 gram product of a 24 and [**2-21**] week twin gestation. Baby [**Name (NI) **] [**Known lastname **] is twin two. The infant was born to a 28 year old gravida III, para 0 mother. Mother's blood type O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B negative, group B strep status unknown. There was prenatal diagnosis that this twin had a neural tube defect. Mother had spontaneous rupture of membranes and preterm labor. The infant was born by cesarean section on [**2189-11-19**], due to transverse lie. He had no respirations, minimal heart rate at the time of delivery. He required resuscitation in the delivery room. Apgar scores were one at one minute, one at five minutes, five at ten minutes and seven at fifteen minutes. He was admitted to the Neonatal Intensive Care Unit from the delivery room on assisted ventilation. The following is the assessment at the time of admission - Examination was consistent with a 24 and [**2-21**] week gestation. Infant birth weight 696 grams with severe respiratory distress, obvious neural tube defect. Summary of infant's course from [**2189-11-19**], through [**2189-12-4**], is that he continued to have respiratory failure secondary to his immature lungs and severe neonatal lung disease. He also had hydrocephalus which is in conjunction with his neural tube defect. The progressive hydrocephalus may also have contributed to his cardiovascular respiratory failure. On the day of his death, his cardiovascular respiratory failure exacerbated despite being on increasing intervention with assisted ventilation at 100 percent oxygen, increasing pressures from the respirator, increasing ventilator rate. The baby required frequent bag mask ventilation as he would not recover on his own from severe bradycardia and desaturations. The infant had a continuous leak from his neural tube defect. Neurosurgeons would not be able to correct this particular defect given his other concerns until he was approximately ten weeks older than when he was born. Parents were well aware that lack of surgery with continued leaking of the neural tube defect would predispose the infant to infection. The infant was on antibiotics. The Neonatal Intensive Care Unit staff discussed with the parents multiple times during the course from the time the infant was born through the day of his death regarding his extremely critical status and for consideration of limiting or withdrawing support. The parents understood the major medical challenges that the infant faced. Due to the progression of bradycardia and desaturations on [**2189-12-4**], and what was apparent futility in continuing treatment, we discussed again with the family withdrawal of support. Because of his progressive deterioration, they were in agreement with withdrawal of support. The baby was extubated [**2189-12-4**], ten minutes after three pm. He was pronounced dead [**2189-12-4**], at 1550. Autopsy was requested of the parents by myself. The parents declined autopsy. At the time of this dictaion on [**2189-12-5**], the hospital staff is still awaiting information regarding what funeral home and funeral director will be responsible for taking the body from the hospital morgue. The family has not yet made a decision about funeral director or funeral home or the type of service for the baby. I called and spoke with the mother [**2189-12-4**] to inform her about the time of death. I also followed up with a telephone call to the mother on the morning of [**12-5**] to inquire how they were and to update the parents on the status of the surviving sibling, [**Last Name (un) **]. Overall assessment of [**Known lastname 19961**]: extremely preterm baby 24 and [**2-21**] week gestation twin who had additional major complications of neural tube defect (that was not reparable at this time) and hydrocephalus. Both the severe preterm lung disease and progressive hydrocephalus contributed to this infant's overall cardiorespiratory failure which I attribute to both the extreme immaturity and the hydrocephalus. [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**] Dictated By:[**Last Name (NamePattern1) 56577**] MEDQUIST36 D: [**2189-12-5**] 10:14:43 T: [**2189-12-5**] 11:28:03 Job#: [**Job Number 57240**]

Admission Date: [**2109-8-24**] Discharge Date: [**2109-8-26**] Date of Birth: [**2053-12-14**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 358**] Chief Complaint: CC:[**CC Contact Info **] Major Surgical or Invasive Procedure: Intubation History of Present Illness: The history was taken using the night-float notes and using the medicine resident as an interpreter. HPI: This patient is a 50 yo spanish speaking man with h/o EtOH abuse, no other known PMH, who initially presented on [**2109-8-24**] after being found down. The patient was found down in the hallway of an apartment building and does not remember falling down. Per report on the field, he was minimally/non-responsive, had had urinary incontinence, but was breathing spontaneously. He was brought to the ED. In the ED, the pt had HR 84, bp 150/p, RR 16-20, SaO2 98% on 2L, was intubated for airway protection. Labs notable for EtOH level of 627, mild transaminitis. Other w/u included head CT which was negative, C-spine showed rotation of C1 and C2 which was likely positional but patient was placed in a hard collar. FAST U/S was negative. He received 4L banana bag, versed 10mg IV x 1 and was admitted to MICU. Past Medical History: 1.) EtOH - Per pt's sister, has had numerous admissions to [**Hospital **] in past for EtOH intoxication and ?withdrawl. Unknown h/o withdrawl szs. Social History: SH: Pt lives with sister, who is "fed up" with his drinking. Long h/o EtOH abuse. No tobacco or illicits. Family History: FH: unknown Physical Exam: PE: Vitals: T 98.3, BP 140/80, HR 79, RR 20, O2 97% RA. Gen: Awake, alert, non-tremulous, NAD HEENT: anicteric sclerae, MMM Lungs: CTA b/l, no wheezes, no rhonchi, no rales. Card: regular rhythm, slightly tachycardic, Nl S1, S2, no murmurs appreciated Abd: normoactive BS, soft, NT/ND, no HSM, no ascites. Ext: no edema, DP 2+ b/l Skin: no telangiectasias or spider angiomas. 2 cm x 3 cm scab on R chest. Pertinent Results: [**2109-8-26**] 06:20AM BLOOD WBC-4.6 RBC-4.21* Hgb-13.6* Hct-39.3* MCV-93 MCH-32.4* MCHC-34.7 RDW-14.5 Plt Ct-98* [**2109-8-25**] 04:08AM BLOOD Neuts-75.4* Lymphs-20.0 Monos-3.4 Eos-1.0 Baso-0.3 [**2109-8-25**] 04:08AM BLOOD PT-12.3 PTT-28.9 INR(PT)-1.1 [**2109-8-24**] 01:30PM BLOOD Fibrino-256 [**2109-8-26**] 06:20AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-139 K-3.3 Cl-98 HCO3-30 AnGap-14 [**2109-8-26**] 06:20AM BLOOD ALT-40 AST-74* CK(CPK)-519* [**2109-8-25**] 04:08AM BLOOD Lipase-91* [**2109-8-25**] 11:59AM BLOOD CK-MB-20* MB Indx-3.5 cTropnT-0.01 [**2109-8-25**] 04:08AM BLOOD CK-MB-15* MB Indx-3.5 cTropnT-<0.01 [**2109-8-24**] 10:02PM BLOOD cTropnT-0.02* [**2109-8-26**] 06:20AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.0 [**2109-8-24**] 10:02PM BLOOD Triglyc-83 [**2109-8-24**] 01:30PM BLOOD ASA-NEG Ethanol-627* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2109-8-24**] 10:14PM BLOOD Type-ART Temp-37.2 pO2-220* pCO2-47* pH-7.41 calTCO2-31* Base XS-4 Intubat-INTUBATED [**2109-8-24**] 10:14PM BLOOD Lactate-2.3* . CT Spine ([**8-24**]): IMPRESSION: 1. No evidence of fracture. 2. Rotation of C1 on C2 which may be positional but must be clinically correlated. 3. Cystic structure lateral to the left massator muscle may represent a sebaceous cyst but it should be clinically correlated. . CT head ([**8-24**]): IMPRESSION: 1. No hemorrhage or mass effect. 2. Mild paranasal sinus mucosal disease. . Urine Culture: No growth . Blood Culture: pending Brief Hospital Course: Pt is a 50 yo man with h/o EtOH, found down with EtOH intoxication, initially intubated for airway protection and admitted to MICU. . # EtOH: Pt presented after being found down, presumably from EtOH intoxication as EtOH level was 627 on presentation. CT head showed to intracranial hemorrhage or mass effect. He was initially intubated for airway protection, and was sent to the MICU where he remained stable. He was then extubated, and continued to be awake and alert. He was monitored for alcohol withdrawal (he reports his last drink was on Thursday) and was maintained on a CIWA scale. His CIWA had gone up to 11 overnight in the MICU, and he only required [**12-29**] doses of diazepam for some tremulousness and mild tachycardia (HR low 100's). He was given 4 L of a banana bag in the ED, which was changed to MVI, thiamine and folic acid PO once the patient was transferred to the floor. Social Work was consulted for his EtOH abuse and family relations (sister is "fed up" with pt's EtOH use, and patient lives w/ his sister). The patient was referred to a [**Month/Day (3) 32231**] Partial Program at [**Hospital1 1680**]/[**Location (un) 538**] from Monday - Friday, which will start the day following his discharge. The patient reports he is willing to join AA. . # Elevated CK: Pt presented wtih elevated CK, but had flat MB and trop. CK initially trended up to 671, now at 519. This is likely secondary to him being found down, and was not in the range consistent with rhabdomyolysis. The patient did not need high rate IVF for this the elevated CKs. . # Transaminitis: Pt w/ mildly elevated LFTs on presentation which appear stable. The transaminitis is likely due to alcoholic liver disease. HepBsAG negative and HepBsAb negative. Otherwise, the patient had no other signs of synthetic dysfunction as his albumin and coags were within normal limits. . # Thrombocytopenia: Pt presented with mild thrombocytopenia (down to 98) on CBC. This is likely secondary to marrow suppression vs splenic sequestration from EtOH. . # Malrotation of C1-C2: Pt had C-spine film that demonstrated rotation of C1 and C2, which may be positional. It also showed a cystic structure lateral to the left massator muscle may represent a sebaceous cyst but it should be clinically correlated. The patient was placed in a hard C-collar. Neurosurgery cleared his neck and the hard collar was removed. The patient is scheduled for a repeat cervical CT scan in 6 weeks, and a follow up appointment with Dr. [**Last Name (STitle) 548**] in neurosurgery. Medications on Admission: ASA daily Multivitamin daily . NKDA Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Cap(s) 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY 1. Alcohol intoxication 2. Mild transaminitis, likely ETOH-related 3. Thrombocytopenia, likely alcohol-related SECONDARY 1. Alcohol Abuse Discharge Condition: afebrile, tolerating POs Discharge Instructions: 1. Take all medications as prescribed 2. Make all follow-up appointments 3. If you develop fevers, chills, nausea, vomiting or any other concerning symptoms, please contact your provider or report to the Emergency Department 4. Refrain from alcohol use Followup Instructions: We have contact[**Name (NI) **] your primary care provider [**Last Name (NamePattern4) **]. [**First Name (STitle) 17832**] [**Name (STitle) 16365**] at [**Hospital3 33953**] Community Health Center and they will be contacting you with an appointment. They are aware of your admission and your follow-up issues. If you do not hear from them, their number is [**Telephone/Fax (1) 17826**]. . Our social worker has set you up with the [**Name (NI) 32231**] Partial Program at [**Hospital1 1680**]/[**Location (un) 538**] from Monday - Friday. Please report to the location provided beginning tomorrow morning.

Admission Date: [**2124-10-9**] Discharge Date: [**2124-10-20**] Date of Birth: [**2043-8-8**] Sex: F Service: SURGERY Allergies: Bactrim / Cipro / Lactose Attending:[**First Name3 (LF) 668**] Chief Complaint: Right upper quadrant and epigastric pain without fever or nausea/vomiting Major Surgical or Invasive Procedure: [**2124-10-10**]: ERCP with common bile duct stent placement [**2124-10-13**]: ERCP with removal of common bile duct stent, removal of gallstones, and sphincterotomy History of Present Illness: The patient is an 81 year old female who was transferred from an outside hospital after presenting with complaint of persistent, dull, severe abdominal pain x10 hours. The pain was primarily loacalized to the right upper quadrant and epigastric region, and radiating to the back. The patient denied any nausea or vomiting, and denied fevers or chills. She was noted to have an elevated bilirubin at the OSH and with RUQ ultrasound demonstrating stones in the gallbaldder, a dilated common bile duct, and pericholecystic fluid. She was transfered to [**Hospital1 18**] for likely cholecystitis/choledocolithiasis and for further care. Past Medical History: Past medical history: End-stage renal disease on hemodialysis (T/Th/Sa) secondary to Good Pasture's Syndrome Hypothyroidism Coronary artery disease s/p stent placement x1 CHF Atrial fibrillation on Coumadin and with pacemaker in place HTN Hyperlipidemia Past surgical history: s/p bilateral knee surgeries Pacemaker placement Left thigh AV graft Social History: The patient lives with her husband. She denies any alcohol, cigarette, or recreational drug use Family History: Denies family history of cancer or hepatobiliary disease Physical Exam: GENERAL: No acute distress; alert and oriented; responsive and cooperative HEENT: Mucous membranes moist and pink; sclera anicteric; MMM, no ocular or nasal discharge NECK: No thyroid enlargement or masses; JVP not elevated; no carotid bruit CARDIAC: Regular rate and rhythm; normal S1 + S2; no murmurs, rubs, or gallops LUNGS: Clear to auscultation bilaterally; no wheezes, rales, or ronchi ABDOMEN: Soft, non-distended, non-tender; +bowel sounds; no rebound or guarding; liver and spleen not palpable EXTREMITIES: Warm and well perfused; 2+ dorsalis pedis pulses bilaterally; no swelling/edema bilaterally; left thigh AV graft with thrill and bruit Pertinent Results: ADMISSION LABS: [**2124-10-9**] 03:20AM PT-81.9* PTT-44.5* INR(PT)-9.5* [**2124-10-9**] 03:20AM WBC-16.3* RBC-4.14* HGB-12.4 HCT-37.5 MCV-91 MCH-29.9 MCHC-33.0 RDW-14.2 [**2124-10-9**] 03:20AM NEUTS-91.6* LYMPHS-5.7* MONOS-2.0 EOS-0.4 BASOS-0.2 [**2124-10-9**] 03:20AM PLT COUNT-155 [**2124-10-9**] 03:20AM DIGOXIN-3.1* [**2124-10-9**] 03:20AM ALT(SGPT)-36 AST(SGOT)-39 ALK PHOS-248* TOT BILI-5.0* DIR BILI-3.7* INDIR BIL-1.3 [**2124-10-9**] 03:20AM GLUCOSE-112* UREA N-23* CREAT-6.0* SODIUM-136 POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-30 ANION GAP-17 IMAGING/STUDIES: GALLBLADDER/LIVER ULTRASOUND [**2124-10-9**]: Impression: 1. Dilated CBD to 1 cm with multiple stones within it, consistent with choledocolithiasis. Mild intrahepatic biliary prominence. 2. Distended gallbladder with wall thickening, pericholecystic fluid and non-shadowing stones/sludge, concerning of cholecystitis. ERCP [**2124-10-10**]: Impression: The exam of major papilla was normal. A 5Fx5cm pancreatic stent was placed to facilitate the cannulation of CBD. Cannulation of the biliary duct was successful and deep. Given cholangitis, small amount of contrast was injected with opacification of CBD only. There were some filling defects at the distal CBD suggesting stones and sludge. CBD measured 7-8 mm. The proximal PD was normal. Given the elevated INR, sphincterotomy was deferred. A 7cm by 10FR Cotton [**Doctor Last Name **] pancreatic stent was placed successfully in the CBD. Some pus and sludge came out. The PD stent was removed with a snare. Otherwise normal ERCP to third part of the duodenum. ERCP [**2124-10-13**]: Impression: A plastic stent was noted in the biliary tree - This stent appeared to be blocked with stones/sludge. A guidewire was placed into the biliary duct through the stent. A snare was then passed to remove the stent while maintaining access. Sphincterotome was then advanced over the guidewire into the biliary tree and contrast medium was injected resulting in complete opacification. Several small stones and one 1 cm stone were seen at the common bile duct. The CBD measured 11 mm. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Two stones and debris were extracted successfully using a balloon. Final cholangiogram did not reveal any filling defects. Brief Hospital Course: The patient was admitted to the West-1 surgery service with suspected cholelithiasis and cholecystitis. Given her extensive medical history/co-morbidities which included end stage renal disease in conjunction with congestive heart failure, she was admitted to the SICU for close monitoring of her fluid status and further management of her biliary disease. She was begun on IV Vancomycin and Zosyn prophylactically - dosed for dialysis - and kept NPO. She was immediately transfused 2 units of FFP and given 5 of Vitamin K+ in an attempt to normalize her elevated INR (9.5 on admission). Her Coumadin was held, and she underwent a R. upper quadrant ultrasound which demonstrated findings consistent with both choledocolithiasis and cholecystitis. The patient was stabilized on antibiotics overnight, and was scheduled for ERCP the following morning. However at that time her INR remained elevated at 5.6 and she required another 4 units of FFP while on dialysis, in addition to 10 of Vitamin K+ in order to normalize her to an INR of 1.6. During the ERCP a pancreatic stent was required to facilitate access to the biliary system (removed at the end of the procedure), and a common bile duct stent was placed to allow drainage of the biliary obstruction caused by stones and sludge. However, due to the patient's elevated INR, no sphincterotomy or stone removal was performed. Frank pus was noted to be draining from the common bile duct, and post-ERCP it was recommended that the patient remain on IV Zosyn for at least a week. The Vancomycin was discontinued. Initially the patient did well post-procedure and the following morning was transferred out of the SICU to the floors - during which time she was tolerating PO and with improved abdominal pain. However, later in the afternoon her bilirubin levels were noted to be elevated (to 9.9 from 6.5 and the following morning this was further increased to 12.0 - leading to concern for obstruction of the biliary stent. As the patient was noted to be clinically stable, afebrile with a normal WBC count, pain-free, and in all other respects with a non-septic clinical picture, it was recommended by gastroenterology that the patient's LFTs/serum bilirubin be trended and the patient be observed for another day on antibiotics. On hospital day 4 (post-procedure day 3) the patient returned to ERCP for re-evaluation of her biliary stent as her LFTs and bilirubin continued an upward trend. On ERCP the previous biliary stent was noted to be acutely obstructed by biliary sludge and stones. As the patient's INR was normalized to 1.2, a sphincterotomy was safely performed, with removal of several biliary stones in addition to the common bile duct stent. At the conclusion of the procedure, retrograde cholangiogram was negative for filling defects. The patient again tolerated the procedure well, and without complications. However, post-procedure her serum bilirubin levels remained elevated for several days, with a slow down-trend despite negative hemolysis work-up, and no complaint of further abdomina pain, nausea, or vomiting. A R. upper quadrant ultrasound was obtained on hospital day 7 (post-procedure day 2 following second ERCP) to rule out liver abscess as a possible cause of persistently elevated bilirubin. This was negative for abscess and the gallbladder was noted to be non-distended although the gallbladder wall remained thickened. Hepatitis serologies were negative for infection. The ERCP team was again consulted, and did not believe a repeat procedure to be warranted as they believed the elevated bilirubin levels to be secondary to accumulation from prior biliary obstruction and slow clearance due to the patient's severe renal dysfunction. Additionally, beginning on hospital day 6 the patient had multiple bouts of diarrhea and stool samples returned positive for C. diff colitis. As WBC count was not elevated, the patient was initially treated with oral Flagyl alone. However following two days of increasing numbers of bowel movements despite antibiotics, treatment was upgraded to oral Vancomycin and IV Flagyl. The patient was stabilized on this regimen with a gradual down-trend in her serum bilirubin levels and a decrease in her diarrhea. By hospital day 12 it was deemed appropriate to discharge the patient home. At the time of discharge she was tolerating PO, had been afebrile since initial admission, was ambulating independently with a cane, had no pain issues, and was otherwise stable. The patient was discharged on PO Augmentin 500mg q24hrs (replaced IV Zosyn) to complete a total of 14 days antibiotics. As her diarrhea had demonstrated significant improvement and her WBC count remained within normal limits, IV Flagyl and PO Vancomycin were discontinued and she was discharged with PO Flagyl 500mg q8hrs. She will follow-up with her PCP for titration of her Coumadin which had been held for the entirety of her hospital stay. INR prior to discharge was 1.5 The patient will follow-up with Dr. [**Known lastname **] in clinic during the week following discharge and re-evaluation of liver enzymes and bilirubin levels. Medications on Admission: Coreg 3.12mg [**Hospital1 **] Synthroid 0.112mg daily Coumadin 2.5mg daily Lipitor 40mg daily Digoxin 0.125mg every other day Nephrocaps 40mg daily PhsLo Prilosec 20mg [**Hospital1 **] Cardizem 360mg daily Amiodarone 200mg daily Discharge Medications: 1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*4 Tablet(s)* Refills:*0* 9. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 11 days. Disp:*33 Tablet(s)* Refills:*0* 10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: INR monitored by your nephrologist. 11. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a day: with meals. 12. Cardizem CD 360 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: Cholangitis, Common Bile duct stones 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: Please Call Dr [**Known lastname 9411**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, worsening diarrhea, increased abdominal pain, inability to tolerate food, fluids or medications, increased yellowing of your skin or eyes, worsening itch or other concerning symptoms. Continue the antibiotics as ordered Return to Dr [**Known lastname 9411**] office on Monday [**10-23**] for labwork and to see Dr [**Known lastname **] Continue your outpatient dialysis regimen of Tues-Thurs-Sat, they are expecting you at your outpatient clinic on Saturday [**10-21**]. Dr [**Last Name (STitle) 5970**] will be seeing you and will be responsible for monitoring your coumadin dosing No heavy lifting greater than 10 pounds Followup Instructions: Outpatient Dialysis: Tues/Thurs/Sat. Start Saturday [**10-21**] [**First Name11 (Name Pattern1) **] [**Known lastname 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2124-10-23**] 10:40 [**Last Name (NamePattern1) **], [**Hospital Unit Name **] [**Location (un) **], [**Location (un) 86**], MA Completed by:[**2124-10-20**]

Admission Date: [**2158-4-9**] Discharge Date: [**2158-4-11**] Date of Birth: [**2119-9-1**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 38-year-old male with a past medical history significant for bipolar disorder as well as a previous suicide attempt by carbon monoxide poisoning, who was started on lithium one month prior to admission, who took 90 tablets of sustained lithium on the day of admission. The patient stated he had been feeling quite depressed concerning his wife and was concerned that she had been unfaithful to him. The patient states he took the lithium at about 7 a.m. on the morning of admission and was found by his father around 3 p.m. At that time, he was lethargic but arousable. He was then taken to [**Hospital3 **] Hospital at 4 p.m. where his lithium level was 5 mEq per liter. The patient vomited times three. There were pill fragments noted. He was given 2 liters of normal saline, 1 liter of GoLYTELY by nasogastric tube, and was then transferred to [**Hospital1 346**]. The patient was seen by both Toxicology and Renal who decided that emergent dialysis would be safest option. PAST MEDICAL HISTORY: 1. Bipolar disorder. 2. Attention deficit disorder. 3. Suicide attempt times one in the past. 4. Carbon monoxide poisoning attempt in the past. MEDICATIONS ON ADMISSION: Lithium 300 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a smoker. He lives with his father. FAMILY HISTORY: Depression in mother and father. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission to the Medical Intensive Care Unit revealed vital signs with a blood pressure of 105/48, heart rate was 89, oxygen saturation was 95%, respiratory rate was 18, and oral temperature was 98.1. Neurologic examination revealed alert and oriented times three. No sensory or motor deficits. Lethargic with 5/5 strength. No nystagmus. Deep tendon reflexes were 2+. Head, eyes, ears, nose, and throat examination revealed mucous membranes were moist. No jugular venous distention. Cardiovascular examination revealed tachycardic. Lungs were clear to auscultation bilaterally. The abdomen was benign. Extremity examination revealed no edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed white blood cell count was 9, hematocrit was 40.7, and platelets were 265. Differential with 86% neutrophils, 4% bands, 6% lymphocytes. Sodium was 139, potassium was 3.9, chloride was 106, bicarbonate was 25, blood urea nitrogen was 20, creatinine was 1.3, and blood glucose was 82. Lithium level was 5.5. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed sinus tachycardia. HOSPITAL COURSE: This is a 38-year-old gentleman with acute lithium intoxication secondary to a suicide attempt. The patient was admitted for close observation, placed on telemetry, and lithium levels were checked every two to three hours. On presentation, the patient received emergent hemodialysis with a resultant lithium level of 1.2. On a follow-up lithium check, it had elevated to approximately 1.5. Due to concern of a fluid shift, the patient received hemodialysis for a second time. The dialysis courses were approximately six hours a piece. The patient was also continued on half normal saline of approximately 4 liters to increase urine output. Goal urine output was 2 cc/kg per hour. The patient was also continued on GoLYTELY. There was concern for diabetes insipidus due to lithium. Osmolalities were checked. First was in the 400s and the second was in the 500s; thus, this concern was put to rest. A urine toxicology screen was also sent which was negative. Due to the suicide attempt, the patient was put on a one-to-one sitter while an inpatient. Due to a concern of Haldol interactions, this was not used. Since the patient did well status post dialysis with lithium levels returning to a therapeutic range, and symptoms of confusion and gastrointestinal toxicity had resolved, the patient was transferred to the floor where he continued to be monitored for another 24 hours. The patient continued to improve symptomatically. His lithium level continued to decrease at 0.7. Thus, the patient was medically cleared for discharge to a psychiatric facility for treatment of his bipolar disorder, depression, and suicide attempt. MEDICATIONS ON DISCHARGE: The patient was discharged on only docusate 100 mg p.o. b.i.d. and Protonix 40 mg p.o. q.d. CONDITION AT DISCHARGE: Condition on discharge was stable and improved. DISCHARGE STATUS: Discharge status was to inpatient psychiatry facility. DISCHARGE DIAGNOSES: 1. Lithium overdose. 2. Suicide attempt. 3. Depression. 4. Bipolar disorder. [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**MD Number(1) 28963**] Dictated By:[**Name8 (MD) 8876**] MEDQUIST36 D: [**2158-4-11**] 13:05 T: [**2158-4-11**] 13:46 JOB#: [**Job Number 48874**]

Admission Date: [**2176-2-6**] Discharge Date: [**2176-2-15**] Date of Birth: [**2095-1-2**] Sex: F Service: SURGERY Allergies: Norvasc / Clonidine / Pollen Extracts Attending:[**First Name3 (LF) 1234**] Chief Complaint: Cold left lower extremity Major Surgical or Invasive Procedure: [**2176-2-7**] s/p LLE thrombectomy [**2176-2-7**] hematoma evacuation History of Present Illness: 81F with CAD, CHF and Afib s/p AVR with bioprosthetic valve and hisotry of CEA in the past presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with pain loss of pulses in left lower extremity. Pt had a remote history of GI bleed on Coumadin in the past and is off coumadin now. Was heme neg at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and was bolused 4000U and run at 1000U an hour pt currently on Plavix. On seeing her in the [**Name (NI) **] pt was in pain on left lower extremity with dusky appearance and weak motor but sensation in tact. Pt walks with a walker at home at baseline and has no symptoms of rest pain at baseline. Prior to the onset of symptoms the leg was normal in color, painless and warm. Past Medical History: CAD CABG AS prothetic valve a fib CHF h/o of CVA with residual right sided weakness NIDDM Social History: N/C Family History: N/C Physical Exam: VSS: 98.1, 87, 110/56, 20, 97%RA General: NAD Cardiac: irregular Lungs: CTA Abd: soft,non tender Resolving LT groin hematoma, large bruising/echymsosis resolving B/L DP/PT dop Pertinent Results: [**2176-2-13**] 06:42AM BLOOD WBC-12.4* RBC-3.56* Hgb-11.3* Hct-32.2* MCV-91 MCH-31.9 MCHC-35.2* RDW-16.1* Plt Ct-240 [**2176-2-12**] 04:41PM BLOOD Hct-31.9* [**2176-2-13**] 06:42AM BLOOD Plt Ct-240 [**2176-2-13**] 06:42AM BLOOD Glucose-130* UreaN-18 Creat-1.2* Na-137 K-4.1 Cl-103 HCO3-26 AnGap-12 [**2176-2-13**] 06:42AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.2 [**2176-2-12**] 04:41PM BLOOD Hct-31.9* [**2176-2-12**] 03:00AM BLOOD WBC-12.3* RBC-3.53*# Hgb-11.0*# Hct-31.5* MCV-89 MCH-31.2 MCHC-34.9 RDW-15.7* Plt Ct-191 [**2176-2-11**] 01:22PM BLOOD Hct-33.9*# [**2176-2-11**] 04:00AM BLOOD WBC-13.0* RBC-2.81* Hgb-8.6* Hct-25.3* MCV-90 MCH-30.6 MCHC-34.0 RDW-15.5 Plt Ct-187 [**2176-2-10**] 04:41AM BLOOD WBC-12.8* RBC-3.33* Hgb-10.2* Hct-29.1* MCV-88 MCH-30.7 MCHC-35.1* RDW-15.6* Plt Ct-171 [**2176-2-9**] 05:47AM BLOOD Hct-31.2* [**2176-2-9**] 12:44AM BLOOD Hct-25.3* [**2176-2-8**] 12:18PM BLOOD Hct-25.1* [**2176-2-8**] 03:25AM BLOOD WBC-14.8* RBC-3.19* Hgb-9.7*# Hct-28.5* MCV-90 MCH-30.4 MCHC-34.0 RDW-15.3 Plt Ct-155 [**2176-2-7**] 11:04PM BLOOD Hct-29.7* [**2176-2-7**] 07:13PM BLOOD Hct-32.1* [**2176-2-7**] 03:13PM BLOOD Hct-30.1* [**2176-2-7**] 10:16AM BLOOD Hct-33.1* [**2176-2-7**] 05:45AM BLOOD WBC-16.2* RBC-4.17* Hgb-13.0 Hct-36.9 MCV-88 MCH-31.3 MCHC-35.3* RDW-14.6 Plt Ct-232 Brief Hospital Course: [**2176-2-6**]- ED consult for this 81F with CAD, CHF and Afib s/p AVR with bioprosthetic valve and history of CEA in the past presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with pain loss of pulses in left lower extremity at 2pm today. Pt had a remote history of GI bleed on Coumadin in the past and is off coumadin now. Was heme neg at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and was bolused 4000U and run at 1000U an hour pt currently on Plavix. On seeing her in the [**Name (NI) **] pt was in pain on left lower extremity with dusky appearance and weak motor but sensation in tact. Pt walks with a walker at home at baseline and has no symptoms of rest pain at baseline. Before 2pm this leg was normal in color, painless and warm. Sent to [**Hospital1 18**] for evaluation, admission and treatment [**2176-2-6**] Underwent Left femoral popliteal/tibial embolectomy [**2176-2-7**]. Overnight, she was monitored in ICU and was noticed to have a slowly developing hematoma in the left groin. Heparin was stopped, but her hematocrit fell and her hematoma continued to enlarge; so the decision was made to bring to the operating room and underwent Left groin hematoma evacuation. [**2-8**]- Remained in CVICU. VSS. Left groin ecchymosis. JP in place draining. HCT 25, patient transfused 1unit PRBCs. [**2-9**]- Transferred to [**Wardname **]. Tolerating diet. OOB with nursing staff and PT consulted. Lopressor IV given HR 130's. Also had 22 run VTACH. ECG-baseline afib. Electrolytes drawn, potassium repleted. [**2-10**]-No overnight events, VSS. Home medications resumed. [**Date range (1) 35350**]-Transfused 2u PRBCs for HCT 25.3. Coumadin resumed and then discontinued as pt developed bleeding from LE, lower portion of groin wound. Heparin and coumadin discontinued. ASA continued. [**Date range (1) 80542**] VSS. No events. HCT stable. Tolerating po. Ambulating with assist. LT groin hematoma softer. Voiding clear yellow urine. Physical therapy recommending rehab. PCP's office update on pt status and inability to continue Coumadin. Mile LLE pain, relived with tylenol. [**2-15**]- No overnight events. VSS. Plan discharge to rehab. Post op visit with Dr. [**Last Name (STitle) **] scheduled. Medications on Admission: Lopressor 50", Nifedical 60', detrol 2', amiodarone 200', plavix 75', hydralazine 20"", Lasix 20', acidophilus 1", colace 100" Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q 24 (). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Regular Insulin Sliding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-60 mg/dL [**11-24**] amp D50 61-159 mg/dL 0 Units 160-199 mg/dL 2 Units 200-239 mg/dL 4 Units 240-279 mg/dL 6 Units 280-319 mg/dL 8 Units 320-359 mg/dL 10 Units > 360 mg/dL 12 Units Discharge Disposition: Extended Care Facility: [**Location (un) **] Discharge Diagnosis: acute onset of cool left foot PMH: CAD AS a fib NIDDM Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity 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 [**12-26**] 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 Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2176-2-27**] 1:45 Completed by:[**2176-2-15**]

Admission Date: [**2142-11-5**] Discharge Date: Date of Birth: [**2066-5-2**] Sex: M Service: CCU CHIEF COMPLAINT: Status post ethanol ablation for hypertrophic obstructive cardiomyopathy. HISTORY OF PRESENT ILLNESS: The patient is a 76 year old white male with a history of a heart murmur since he was a child. In [**2142-9-29**] he felt chest pain during the night. He went to [**Hospital 11252**] Hospital in [**Location (un) 3844**] in the morning. Echocardiogram at that time revealed left ventricular hypertrophy, increased velocity across the left ventricle, aortic valve gradient of 45 mmHg, 92 mmHg with Valsalva and after exercise, 266 mmHg. The patient was discharged to Dr. [**Last Name (STitle) **] at [**Hospital1 188**] and discharged from [**Location (un) 11252**]. Since that time he has been asymptomatic. He is normally quite active, plays tennis. He reports lightheadedness after exertion every one to two months, dyspnea on exertion after climbing stairs and palpitations at rest occasionally. He denies chest pain, diaphoresis, PND, orthopnea or swelling of the extremities. At [**Hospital1 69**] during precatheterization he received hydration and his initial left ventricular outflow tract gradient was 30 to 40. It increased to 100 mm during the procedure and two septal arteries were injected and subsequent left ventricular outflow tract gradient was 0 mmHg. After the procedure he was admitted to the CCU. He had no complaints at that time. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Hypothyroidism. Peptic ulcer disease. Status post right herniorrhaphy. MEDICATIONS ON ADMISSION: Verapamil 180 mg every morning, Ecotrin 81 mg q.day, Zocor 40 mg q.day, Synthroid 0.075 mg q.day, cimetidine 400 mg q.day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No history of tobacco use. Drinks an occasional glass of wine. FAMILY HISTORY: Significant for father who died naturally, but who also had an "enlarged heart." PHYSICAL EXAMINATION: On admission blood pressure was 163/78, pulse 68, respirations 16, height 173 cm, weight 73 kg. Physical exam was remarkable for a healthy appearing 76 year old man. JVP 5 to 6 cm of water, no carotid bruits, normal S1, S2, 3/6 systolic ejection murmur at the apex and base without radiation to the carotids. Exam of the extremities was remarkable for a left catheterization site with slight blood, without hematoma or bruit, right catheterization site pressure bandage in place. Left dorsalis pedis pulse was [**2-1**], right obtainable only with Doppler. There was no clubbing or cyanosis of the extremities. Neurologically all cranial nerves were intact. Muscle strength was [**6-2**] bilateral upper and lower extremities. LABORATORY DATA: On admission hemoglobin was 14.8, hematocrit 44.2, white blood cell count 5, platelets 181. Chem-7 was sodium 138, potassium 4, chloride 104, bicarb 30, BUN 20, creatinine 1.5, glucose 94. INR was 1.0. Angiography at the time of the procedure revealed normal left main, left anterior descending and left circumflex, 30% ostial right coronary artery. EKG at the time of admission to the CCU showed normal sinus rhythm, possible right bundle branch morphology, left axis -40 degrees, inferior and lateral ST changes. Inferior myocardial infarction could not be ruled out. Creatine phosphokinase level was 33. On [**11-6**] creatine phosphokinase level was 833. HOSPITAL COURSE: On [**11-6**] at approximately 12:30 p.m. the patient noted some left groin pressure. A left hematoma was noted approximately 2 x 2 cm. Pressure was applied for 1 1/2 hours by the cardiology Fellow and nurse. The patient was sent to ultrasound where a pseudoaneurysm was not found in the left groin. The patient's hematocrit was stable at 35.2% the following day. On the afternoon of [**11-7**] his temporary pacemaker was removed and he was transferred to the floor, Fahr 3, at 2:00 a.m. in the morning. Creatine kinase on [**11-7**] was 363. On [**11-8**] the patient complained of mild nasal congestion. He had no events on telemetry. Creatine phosphokinase was 126. Hematocrit was 33.5%. After discussion with Dr. [**Last Name (STitle) **], the patient was deemed eligible for discharge. He was stable at discharge. DISCHARGE DIAGNOSES: 1. Hypertrophic obstructive cardiomyopathy status post ethanol ablation. 2. Hypothyroidism. 3. Hypertension. 4. Peptic ulcer disease. DISCHARGE MEDICATIONS: 1. Ranitidine 150 mg p.o. b.i.d. 2. Simvastatin 40 mg p.o. q.h.s. 3. Aspirin 81 mg p.o. q.d. 4. Synthroid 0.075 mg p.o. q.d. 5. Verapamil 240 mg p.o. q.a.m. 6. Tylenol 650 mg q.six hours p.r.n. for pain. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Last Name (NamePattern1) 15820**] MEDQUIST36 D: [**2142-11-9**] 15:44 T: [**2142-11-10**] 11:34 JOB#: [**Job Number 36155**]

Admission Date: [**2196-4-16**] Discharge Date: [**2196-4-17**] Date of Birth: [**2128-12-7**] Sex: M Service: MICU-ORANG HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 42101**] is a 67 year old male originally from [**Country 2045**] and French Creole speaking who has a past medical history significant for diabetes mellitus on oral hypoglycemics as well as prostate cancer, who presents with left hip pain. He was transferred to the [**Hospital1 346**] from [**Hospital3 17310**], where he presented complaining of left hip pain as well as generalized confusion and weakness. The patient was living in [**Country 2045**] until approximately two weeks prior to admission. Approximately one week prior to admission, he began experiencing left hip pain and went to [**Hospital 8**] Hospital. At that time, a CBC and Chem-7 was drawn and the Chem-7 was within the normal range for all of his electrolytes as well as his renal function. Results of the CBC are not known at the time of this dictation. At [**Hospital 8**] Hospital, he was advised to take NSAIDS and to rest the hip. No Microbiology data was obtained at [**Hospital 8**] Hospital. Two days prior to admission, the patient's daughter noted that the patient was becoming increasingly confused. On the morning of admission, the patient fell in his bathtub and was reportedly increasingly confused. He was sent to the [**Hospital1 **] [**Hospital1 **] where to concern for an abdominal aortic aneurysm was raised, which prompted the patient to be transferred to the [**Hospital1 190**]. The concerns for the abdominal aortic aneurysm stem from patient complaining of abdominal as well as back pain. When he arrived in the Emergency Department at the [**Hospital1 1444**], he was found to have a lactic acidosis, a right hip myositis as well as a right septic hip, as well as acute renal failure and hyperglycemia. In the Emergency Department, the hip was aspirated, the patient was intubated, a Swan-Ganz catheter was placed and the patient became hypotensive to a blood pressure of 80/60, therefore, Levophed was started. A more detailed summary of the patient's laboratory data prior to arrival to the [**Hospital1 1444**] is as follows: A [**Hospital1 **] [**Hospital1 **], the patient was noted to have a white blood cell count of 5.3, a hematocrit of 39.3, platelet count of 406. Differential on the white count was 82% polys, 15% lymphs, 4% monos. Chem-7 was sodium of 139, potassium 4.2, chloride 97, bicarbonate 7, BUN 61, creatinine 3.8, glucose 508, calcium 9.6, albumin 2.5, total protein 5.8, total bilirubin 0.8, alkaline phosphatase 202. ALT 55, AST 120, CK 4710. An arterial blood gas was 7.18, 26, 236. Urinalysis had greater than 1000 mg of glucose, trace ketones. Again, this is data that was obtained at the [**Hospital **] [**Hospital3 2063**]. As mentioned, the patient then arrived at the [**Hospital1 346**] where he had an aspiration of his hip. He also had a CT scan of his abdomen and pelvis which showed gas and fluid in the right hip, fat stranding around the right gluteus, diffuse edema around the right hip extending into the pelvis and leg muscle compartments. These findings were reported to be consistent with a right hip infection with surrounding myositis. Also, gas attenuation in the spinal canal was seen, which raised the question of an abscess. The patient, in the Emergency Department, had a CT scan of his head in the setting of increasing confusion to the point of being unresponsive. The CT scan of his head was normal. The fluid from the hip was sent to the Microbiology laboratory for Gram stain and culture. Meanwhile, as mentioned, the patient became hypotensive in the Emergency Department and was started on Levophed. He was also intubated and a Swan-Ganz catheter was placed, and a nasogastric tube was placed. The patient was originally then admitted to the Surgical Team and went to the Surgical Intensive Care Unit, however, after approximately one hour in the Surgical Intensive Care Unit it was determined that owing to the complexity of his medical condition, he warranted transfer to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Prostate cancer status post prostate resection three years ago. 3. Gunshot wound ten years ago with a bullet still indwelling at the level of S1. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Prilosec. 2. Glyburide. SOCIAL HISTORY: As mentioned, the patient is originally from [**Country 2045**]. He arrived in this country two weeks ago to visit his family. He does not speak English; he speaks French Creole. His daughter lives in [**Name (NI) **], [**State 350**]. FAMILY HISTORY: Not obtained. After the patient was transferred to the Medical Intensive Care Unit, it was noted that the patient was not responsive to painful stimuli, in fact, he was intubated on Levophed with the Propofol drip turned off and still remained unresponsive. His pupils were normal in size but not reactive to light. Details of his physical examination are as follows: PHYSICAL EXAMINATION: Temperature 99.1 F.; heart rate 89; blood pressure 94/34; in the Emergency Department he was 99.1 F., with a heart rate of 130 and a blood pressure of 90/100. In general, he was intubated and unresponsive. HEENT examination: Pupils were equal; they were not dilated; they were not reactive to light. There was a bluish opalescent haziness over both pupils, which raised the possibility of cataract disease bilaterally. There was a right Swan-Ganz catheter in place. Cardiac examination reveals that he was tachycardic, II/VI systolic ejection murmur which sounded like a flow murmur heard at the left upper sternal border. Respiratory examination: He was clear to auscultation bilaterally in the anterior fields. Abdomen was distended. Bowel sounds were not heard. The abdomen was soft. Extremities revealed a right thigh that was twice the size of the left thigh. The right thigh was tense, extending into the mid-pelvis as well as down to the knee. His right dorsalis pedis pulse was diminished. There was no left lower extremity edema. The skin was intact. Neurologic examination: He was, as mentioned, unresponsive, with the exception of occasional muscle twitching in the left lower extremity. LABORATORY: Data obtained in the Emergency Department at 06:00 p.m. on the day of his admission includes a white count of 3.1, hematocrit of 34.4, platelet count of 278. Sodium 143, potassium 3.7, chloride 108, bicarbonate 13, BUN 60, creatinine 3.3, glucose 270. Calcium 8.1, magnesium 2.7, phosphate 5.6. Differential on the white count included 46% polys, 28% bands, 2% lymphs and 16% monos. ALT 56, AST 137, total bilirubin 0.7, alkaline phosphatase 152, amylase 24, lipase 14, troponin less than 0.3. CK 5149 with MB index of 1.7, lactate 10.8. Arterial blood gas was 7.21, 30, 305. Serum tox screen was negative. Urinalysis was greater than 300 protein, 100 glucose, trace ketones, leukocyte esterase and nitrite negative, [**12-27**] red cells and [**1-26**] white cells. The patient, as mentioned, had 2 cc of turbid fluid aspirated from the right hip in the Emergency Department. The patient also received three units of fresh frozen plasma prior to the procedure and one unit fresh frozen plasma following the procedure. Of note, the patient also had an abdominal ultrasound done in the Emergency Department which showed no evidence of abdominal aortic aneurysm. A chest film done in the Emergency Department showed no evidence of pleural fusion, no pneumothorax and a right IJ line located in the right atrium. As mentioned, a head CT scan showed no hemorrhage and no midline shift, and as mentioned, a CT scan of the abdomen was in particular notable for fluid and gas in the right hip joint extending into the anterior compartment as well as into the pelvic tissues displacing the Foley catheter to the left. On arrival to the Intensive Care Unit, there was significant concern about the patient;s right lower extremity, given the fact that it was twice the size of the left lower extremity and that it was very tense; also, given the patient's clinical picture of florid sepsis. Therefore, the Orthopedic Team was consulted regarding testing for compartment syndrome. This was done at approximately 3 a.m. at which time the Orthopedic fellow was called in from home to the hospital to do compartment testing. The anterior and posterior compartments demonstrated normal pressures, however, the right gluteal compartment had a pressure of 42, which was felt to be consistent with a compartment syndrome. The patient was then taken to the Operating Room for a fasciotomy and for further investigation of a compartment syndrome as well as for obtaining tissue and fluid for analysis. HOSPITAL COURSE: At this time, I will continue to talk about the [**Hospital 228**] hospital course by issue: 1. Infectious Disease: As mentioned, the concern was for a compartment syndrome as evidenced by elevated compartment pressures in the right gluteal area. The patient was taken to the Operating Room where tissue and fluid were obtained. The patient initially received Flagyl, Ceftriaxone and Vancomycin in the Emergency Department. These were then switched to Clindamycin, Zosyn and Vancomycin when the patient was admitted to the Surgical Team. This antibiotic coverage was continued overnight while pending further Microbiology data. The tissue and joint fluid Gram stains came back with four plus Gram positive cocci as well as four plus polys. This Microbiology data is what prompted surgical intervention. The patient was then continued on the Clindamycin, Zosyn and Vancomycin until consultation with Infectious Disease occurred on the [**2196-4-17**]. At this time, the microbiology data revealed moderate growth of Group A strep from the joint fluid as well as from the tissue, prompting the change in antibiotics to penicillin 4,000,000 Units intravenously q. four hours, discontinuation of the Zosyn and continuation of the Clindamycin and Vancomycin. Overall, the patient then was being treated for both a septic right hip as well as for a necrotizing myositis including the right gluteal area and extending all the way down the patient's right thigh. The patient's original white count from the initial labs at this institution included a white count of 3.1 with 28% bands. Repeat labs showed a white count that fell to 1.2. Serial laboratory data included a white count that eventually did increase up to 5.9 at 9 p.m. on [**4-17**]. There is one outstanding Infectious Disease issue on this patient and that is his HIV status. The family was contact[**Name (NI) **] and gave consent for HIV testing. At the time to his dictation, HIV results are still pending. 2. Cardiovascular: The patient was noted to be, as mentioned, hypertensive in the Emergency Department and was started on Levophed. When he arrived in the Medical Intensive Care Unit, his blood pressure remained stable but low with systolic blood pressures in the low 90s. Throughout the day on the [**4-17**], the patient became more hypotensive and required addition of Vasopressin as well as increasing doses of Levophed. Towards the end of the day on [**2196-4-17**], Dopamine was added as a third pressor. The Dopamine was added in the setting of the patient going into a cardiac arrest. His hypotension requiring pressors was obviously a consequence of the patient being in florid sepsis. A Swan-Ganz catheter was in place for CVP monitoring. 3. Sepsis: As mentioned, the patient was in florid sepsis, requiring two pressors. The patient was felt to meet the inclusion criteria for activated protein-C and at 1 p.m. on [**2196-4-17**], the patient was started on activated protein-C. He was also treated with aggressive fluid resuscitation as well as with high dose steroids. 4. Neurologic: As mentioned, the patient was unresponsive in the setting of being intubated as well as on pressors. At the time that his compartment testing was done, the patient was on no sedation whatsoever and was not responsive at all to the procedure of testing his compartment. Similarly, when he was taken to the Operating Room for a fasciotomy in the gluteal area, he required only a small amount of morphine and was not given any other medication for sedation owing to his status of being essentially obtunded. There was a question of an epidural abscess that was raised based on the CT scan finding of gas seen in the spinal canal on the CT scan on [**4-16**]. A follow-up MRI was done on [**4-17**], at 7 a.m. The MRI of the head showed no abnormalities and no mass effect and no focal signal abnormality. MRI of the spine showed abnormal soft tissue posterior to L5 and S1, suspicious for epidural inflammation. There was also enhancement along the cord and cauda equina suggestive of inflammation. There were multi-level degenerative changes. There was no cord compression and there was no signal abnormality in the cord. Neurosurgery was consulted and was following the case with the Medical Intensive Care Unit team. They had initially planned to perform a laminectomy for the question of an epidural abscess, however, owing to the patient's significant comorbidities, it was their decision to hold off on the laminectomy and to just cover the patient with antibiotics. At the time of this dictation, it is not known whether or not the patient did definitively have an epidural abscess, however, as mentioned, given his significant comorbidities, it was felt that it was not in the patient's best interest to do an invasive procedure for treatment of a possible epidural abscess at this time. 5. Respiratory failure: The patient was intubated in the Emergency Department. He was put on the assist control mode of ventilation. He was initially put on 600 by 15 with an FIO2 of 40%. This was then increased to a total volume of 800 by 18 with FIO2 of 40%, and the total volume was continued to be increased as the patient's blood gases revealed continued significant acidosis with the inability to decrease his carbon dioxide accordingly. A summary of his arterial blood gas data will be included under the patient's acid status during his hospital course. 6. Hematologic: The patient received a significant number of blood products during his hospital stay, including packed red blood cells and fresh frozen plasma. The patient received a total of 5 units of packed red blood cells and a total of 14 bags of fresh frozen plasma. The fresh frozen plasma was given before and after any procedure that the patient had. It was given before and after the patient had his right knee tapped in the Emergency Department as well as prior to the fasciotomy prior to his right knee being tapped by Orthopedics on [**4-17**], and it was also given prior to planned placement for a catheter for dialysis, however, this last intervention actually never occurred and the patient never received hemodialysis. The patient was noted to be in rapidly progressing DIC. His initial platelet count in this institution was 278 at 6 p.m. on [**4-16**]. His platelet count then progressively decreased quite rapidly. At 1 a.m. on [**4-17**], his platelet count was 94, at 2 a.m. 86, at 11 a.m. on [**4-17**] it was 72, 2 p.m. it was 57, 5 p.m. 42 and at 9 p.m. his platelet count had dropped to 40. As well, his INR continued to climb from initially 1.9 to 2.1 and ultimately to 2.6 and then 2.8 at 9 p.m. on [**4-17**]. The patient did receive one dose of Vitamin K 5 mg but was otherwise supported with packed red blood cells, fresh frozen plasma as well as platelets. 7. Renal: The patient was noted to be in acute renal failure secondary to both sepsis as well as myoglobinuria. The patient was noted to have a urinalysis which was positive for blood, but negative for red cells. The patient was put on a sodium bicarbonate drip, 3 ampules in one liter of D5W and this was infused at a rate of 250 cc per hour. In addition, he was given additional doses of bicarbonate in the setting of severe acidosis. The bicarbonate was given in an effort to alkalinize his urine in the setting of myoglobinuria. The Renal Team was consulted at approximately 9 p.m. on [**4-17**], and there was a plan for the patient to have a catheter placed and for hemodialysis to begin, however, the patient went into a cardiac arrest and expired prior to receiving hemodialysis. 8. Fluids, Electrolytes and Nutrition: The patient was noted to have some profound metabolic abnormalities, in particular, hypocalcemia and hyperkalemia. The patient, as mentioned, was put on a bicarb drip. He was also repleted with calcium; 3 grams were given at 2 a.m. on [**4-17**] and then repeated later in the day on [**4-17**]. The patient was given insulin for his hyperkalemia. He was given a continuous infusion of insulin plus D50. In addition, the patient was given Kayexalate. All of these were done in an effort to bring his potassium down. His hyperkalemia was in the setting of acute renal failure. His hypocalcemia was in the setting of sepsis and muscle necrosis. It should be noted that his calcium levels were as follows: His calcium on [**4-16**] at 6 p.m. was 8.1; at 1 a.m. it had dropped to 5.9; at 2 a.m. on [**4-17**], ionized calcium was 0.92; at 11 a.m., his calcium was 5.6 with an ionized calcium of 0.99. At 2 p.m. his calcium was 6.8, at 5 p.m. his calcium was 6.1 with an ionized calcium of 0.91 and at 9 p.m. his calcium was 8.2. 9. Acid-Base: Finally, the last issue and most complex issue on this critically ill patient was his acid-base status during his hospital stay. As mentioned, the patient was originally admitted and noted to have a significant metabolic acidosis with an arterial blood gas of 7.21, 30 and 305; this was in the Emergency Department. At that time, an acetone level was checked and it was negative. This was felt to be a primarily metabolic acidosis. When he arrived in the Intensive Care Unit, an arterial blood gas was done which was 7.19, 29 and 287. The patient's metabolic acidosis persisted with pH ranging from 7.13 to 7.21. At 2 a.m. his arterial blood gas was 7.13, 34, and 383, at which time his ventilation settings were changed to give him a larger total volume with the aim of trying to decrease his CO2. Repeat arterial blood gas was 7.17, 22 and 158. The goal was to give the patient bicarbonate to try both to treat his renal failure caused by both sepsis and myoglobinuria, as well as to treat his lactic acidosis. In an effort to treat his acid-based abnormalities, the patient received continuos bicarbonate drip as well as several occasions on which bicarbonate was pushed with an effort to more rapidly correct his metabolic abnormalities. The patient had a total of six ampules of calcium gluconate pushed as well as a total of three ampules of sodium bicarbonate pushed, however, sodium bicarbonate was also pushed during the patient's cardiac arrest. At approximately 9 p.m., the patient went into cardiac arrest and a Code was called. Sinus rhythm was obtained on the patient, however, at 10:31 p.m. the patient went into cardiac arrest the second time and he was unable to be resuscitated. Time of death was therefore 10:31 p.m. on [**2196-4-17**]. The laboratory data available at that time closest to his death revealed a white count of 5.9, hematocrit of 18.2, platelet count of 40. Chem-7 including a sodium of 150, potassium of 6.4, chloride of 113, bicarbonate of 8, BUN of 5.2, creatinine of 2.8, glucose of 254. PT 20.1, PTT 140.9, INR of 2.8. CK of 6766, calcium 8.2, phosphate of 4.8, magnesium of 2.1. At the time of this dictation, additional data that is available includes joint fluid from his knee which had been aspirated on [**4-17**], by the Orthopedic surgeons. The joint fluid grew out Gram positive cocci in pairs and chains, which was found to be Group A strep. A tissue culture from [**4-17**], of the right gluteal area showed Group A Streptococcus as well as four plus Gram positive cocci. Fluid from his hip on [**4-17**], also showed heavy growth of Group A Streptococcus. His blood culture data has no growth so far and his urine culture was negative. To put this very complicated case together, then, in summary, it is a 67 year old male from [**Country 2045**], who presented approximately two weeks ago to an outside hospital complaining of left hip pain at which time he was treated with NSAIDS. The patient then, a week prior to admission, got progressively worse. On the day of admission to this hospital, was first seen at an outside hospital complaining of abdominal and back pain. A suspicion was raised of an abdominal aortic aneurysm and he was transferred to the [**Hospital1 1444**] Emergency Room at which time an abdominal ultrasound was negative for abdominal aortic aneurysm and it was found that the patient had both a septic right hip as well as a significant myositis including his right gluteal region and much of his right thigh, extending down towards his right knee. The patient was then intubated in the Emergency Department and started on Levophed. He was then transferred to the Surgery Team for a brief time, after which time he was transferred to the Medical Intensive Care Unit. In the evening of his admission to the Intensive Care Unit, he had compartment testing done which showed elevated pressures in the right gluteal compartment. He then had a fasciotomy done in the Operating Room. When he came back out of the Operating Room approximately two hours later, it was noted that his right lower extremity was continuing to swell significantly. He also developed whole body anasarca including significant scrotal and penile edema as well as rapidly increasing right lower extremity edema. A bedside incision was made by the Surgical Chief Resident with an aim of draining and relieving the pressure inside the right thigh. This wound was packed and left open for further drainage. The patient was then started on activated protein-C and his right knee was tapped by the Orthopedic surgeon. Meanwhile, the Neurosurgeons were following along with us for a question of an epidural abscess. No interventional procedure was done to further investigate the epidural abscess, given to how critically ill the patient was. The patient was increased on his Levophed and started on Vasopressin and throughout the day on the [**4-17**], he continued to get progressively worse. His antibiotic coverage was changed to penicillin in consultation with the Infectious Disease team and when preliminary culture data came back, he was also continued on Clindamycin and Vancomycin. Prior to that time, he had been on Clindamycin, Zosyn and Vancomycin. The patient, throughout the day, had profound electrolyte abnormalities most notably remained severely acidotic with a lactic acidosis as well as with significant hyperkalemia and hypocalcemia despite aggressive volume resuscitation as well as aggressive attempts at correcting his hypocalcemia and hyperkalemia. The patient went into cardiac arrest. After the first code was called, the patient was able to be resuscitated. However, shortly thereafter, a second code was called and the patient was unable to be resuscitated. The patient ultimately died on [**2196-4-17**], at 10:31 p.m. DISCHARGE STATUS: Expired. DISCHARGE DIAGNOSES: 1. Septic right hip. 2. Streptococcal pyrogens myositis in the right lower extremity. 3. Sepsis. 4. Lactic acidosis. 5. Hypotension. 6. Respiratory failure. 7. DIC. 8. Hypocalcemia. 9. Hyperkalemia. 10. Acute renal failure. 11. Question of an epidural abscess. DISPOSITION: The patient's family were made aware of the patient's grave condition from his initial admission to the hospital. They did come to the hospital and were informed of the patient's status and they were informed at the time of his death. The patient's family did consent to an autopsy. The results of that autopsy are pending at the time of this dictation. The attending covering for the attending physician during this patient's hospitalization was Dr. [**Last Name (STitle) 575**], who was made aware of the patient's death. DR.[**Last Name (STitle) **],[**First Name3 (LF) 1569**] 12-684 Dictated By:[**Last Name (NamePattern1) 29450**] MEDQUIST36 D: [**2196-4-19**] 15:26 T: [**2196-4-19**] 15:35 JOB#: [**Job Number 42102**]

Admission Date: [**2152-4-17**] Discharge Date: [**2152-5-29**] Date of Birth: [**2152-4-17**] Sex: M Service: Neonatology HISTORY: The patient triplet number two is the 1330-gram product of a 30-3/7 weeks triplet gestation born to a 30-year- old G2, P0 now three mother. PRENATAL SCREENS: B positive, antibody negative, RPR nonreactive, rubella immune, hepatitis surface antigen negative, GBS unknown. Pregnancy complicated by cervical funneling with admission at 21-4/7 weeks for bed rest. Terbutaline and indomethacin for uterine irritability. Had been on magnesium sulfate since [**2-23**]. Received a full course of betamethasone at approximately 24 weeks. Progressive labor with cervical change prompted C section delivery under combined spinal epidural anesthesia. Rupture of membranes at delivery. Infant was born with poor tone, decreased respiratory effort and heart rate less than 100, required stimulation, positive pressure ventilation, and suctioning. Apgars were 4 and 8. PHYSICAL EXAMINATION ON ADMISSION: Weight 1330 grams (50th percentile). Head circumference 28 cm (50th percentile). Length 40 cm (25th-50th percentile). Anterior fontanel is soft, flat, nondysmorphic, intact palate. Fair aeration, positive retractions. Soft murmur. Normal pulses. Soft abdomen. Three-vessel cord, no hepatosplenomegaly, normal male, testes in upper scrotum. Patent anus, no hip click, Mongolian spot on buttocks, normal tone. HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The patient was admitted to the Newborn Intensive Care Unit. He was noted to have increased work of breathing and decision was made to intubate infant. He received a total of one dose of Surfactant. He was weaned to CPAP and trialed off CPAP within the first 24 hours of life. He has remained in room air since day of life one. He never received methylxanthine treatment, but did have mild apnea and bradycardia of prematurity. Last documented apneic/bradycardic spell was on [**2152-5-8**]. Cardiovascular: Infant was noted to have a murmur. An echocardiogram was performed on [**4-20**], and it demonstrated a moderate patent ductus arteriosus. Infant received one course of indomethacin treatment. Repeat echocardiogram on [**4-24**] demonstrated no PDA, but had a PFO with left-to- right flow. Infant does have an audible murmur at this time thought to be consistent with flow murmur versus peripheral pulmonic stenosis (PPS). The murmur should be followed and a cardiology consult should be considered if there is a change in the quality of the murmur or in his clinical course. He has been otherwise cardiovascularly stable. Fluid and electrolytes: Birth weight was 1330 grams. Discharge weight is 2325 gms. Infant was initially started on 80 cc/kg/day of D10W. Parenteral nutrition was initiated within the first 24 hours of life. Infant started Enteral feedings on day of life number six, advanced to full enteral feedings by day of life number 10, and is currently ad lib feeding breast milk 24 calories concentrated with Enfamil powder taking in excess of 150 cc/kg/day. GI/GU: His peak bilirubin was on day of life number three of 13.3/0.3. He was treated with phototherapy for a total of five days. Phototherapy was discontinued and rebound bilirubin was 4.4/0.3 on [**2152-4-26**]. Infant was noted to have a right inguinal hernia on day of life number 29. Surgery was consulted and a herniorraphy with circumcision was performed on [**2152-5-26**] Hematology: Hematocrit on admission was 41.9. Infant did not require any blood transfusions during his hospital course, and is currently receiving supplemental Fer-In-[**Male First Name (un) **]. His most recent hematocrit was 31.6 on [**5-14**] with a reticulocyte count of 3.6. Infectious disease: CBC and blood culture obtained on admission. Antibiotics with ampicillin and gentamicin were provided for the first 48 hours of life at which time blood cultures remained negative, and the antibiotics were discontinued. He has had no further issues with sepsis during this hospital course. Sensory: Hearing screen was performed with automated auditory brain stem responses and the infant passed both ears. Ophthalmology screening: Immature Zone 3, follow-up in 3 weeks with Dr. [**Last Name (STitle) **]. Neurology: Infant had two HUS with the latest at approximately 1 month of age ([**2152-5-26**]). Both studies were normal. Psychosocial: A social worker has been involved with this family, and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 8717**]. DISCHARGE CONDITION: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 5279**] [**Last Name (NamePattern1) 43699**], M.D. Telephone number [**Telephone/Fax (1) 43701**]. FEEDS AT DISCHARGE: Continue ad lib enteral feedings of breast milk 24 calories concentrated with Enfamil powder. MEDICATIONS: Continue Fer-In-[**Male First Name (un) **] supplementation (25mg/ml concentration) at 0.4 cc po daily. Vi-Daylin 1 cc po daily. CAR SEAT POSITION SCREENING: Passed. STATE NEWBORN SCREENS: Have been sent per protocol with no abnormal results reported. IMMUNIZATIONS: Hepatitis B vaccine given [**2152-5-17**]. FOLLOW-UP APPOINTMENTS: 1. Dr. [**First Name8 (NamePattern2) 9464**] [**Last Name (NamePattern1) 43699**], [**2152-5-30**] at 2:00pm. 2. Dr. [**Last Name (STitle) **], Ophthalmology [**2152-6-13**], 11:00 am. 3. Dr. [**Last Name (STitle) 37080**], Surgery [**2152-6-13**] at 3:15 pm. 4. [**Hospital1 1474**] Early Childhood Intervention Program 5. [**Hospital1 1474**] VNA DISCHARGE DIAGNOSES: 1. Preterm triplet number two. 2. Mild respiratory distress. 3. Patent ductus arteriosus. 4. Hyperbilirubinemia. 5. Apnea and bradycardia of prematurity. 6. Rule out sepsis. 7. Herniorraphy and circumcision. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2152-5-26**] 01:20:22 T: [**2152-5-26**] 05:43:56 Job#: [**Job Number **]

Admission Date: [**2133-7-24**] Discharge Date: [**2133-7-30**] Date of Birth: [**2085-6-19**] Sex: M Service: HEPATOBILIARY SURGERY SERVICE DIAGNOSIS: Non-alcoholic steatohepatitis, cirrhosis, liver mass x 2, probable hepatocellular carcinoma. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male who during laparoscopy for planned gastric bypass was noted to have cirrhosis. A liver biopsy was taken. It demonstrated established cirrhosis and steatohepatitis. A mass lesion on the inferior margin of the liver was seen but not biopsied. Mass measures 3.5 x 4 cm. Also of note, elevated alpha fetoprotein of 135. CT of abdomen on [**6-16**] demonstrated a 4.3 x 2.9 exophytic mass within segment V of the liver which enhances slightly compared to the rest of the liver. Also within segment V and to the right of the gallbladder there is a patchy area of arterial-phase enhancement measuring approximately 2 cm x 1.9 cm. The patient underwent an MRI of the abdomen on [**2133-7-15**] demonstrating a large exophytic lesion, 2 lesions adjacent to the gallbladder, and a 4th lesion in the posterior right lobe of the liver. The other 3 lesions are indeterminate but do appear to be slightly hypervascular. The patient was seen by Dr. [**Last Name (STitle) **] for hepatic resection of the exophytic lesion. PAST MEDICAL HISTORY: History of morbid obesity; the current BMI is 43.9; history of hypertension; type 2 diabetes mellitus; sleep apnea. PAST SURGICAL HISTORY: Significant for left knee surgery. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Glipizide 5 mg daily, metformin 1000 mg daily, lisinopril 20 mg daily, hydrochlorothiazide 25 mg daily, nifedipine 30 mg daily, and Reglan 10 mg p.o. p.r.n. SOCIAL HISTORY: He has been married for 19 years; 2 children. He is a psychiatric social worker. [**Name (NI) **] history of alcohol use. No tobacco. No history of IV drug use, marijuana. No history of blood transfusions, tattoos, or piercing. PHYSICAL EXAMINATION: The patient is awake and alert, afebrile, vital signs stable, blood pressure of 136/86, pulse of 72, respirations of 20, a temperature of 99.6. His height is 6 feet 1 inch and weighs 323 pounds. Physical exam reveals he an obese male in no acute distress. HEENT reveals no scleral icterus. The lungs are clear to auscultation. The abdomen is obese. Normal bowel sounds. No hepatomegaly. No masses or tenderness. Extremities reveal no peripheral edema. RADIOLOGIC AND OTHER STUDIES: A preoperative EKG was performed demonstrating a sinus rhythm, rate of 84, normal EKG. A recent chest x-ray on [**2133-7-2**] demonstrated a slightly asymmetrical opacity at the left 1st costochondral junction level, likely due to asymmetric degenerative changes at the site. No pleural effusions. Another preoperative chest x-ray was obtained, an apical lordotic, demonstrating a dense nodular density in the left upper lobe which measured 2.3 x 2 cm in dimension. No evidence of pleural effusion. The heart is not enlarged. PREOPERATIVE LABORATORY DATA: Included a WBC of 5.50, a hematocrit of 38.8, a PT of 15.0, platelets of 122, PTT of 33.0, fibrinogen of 235. Sodium of 142, potassium of 4.5, chloride of 103, bicarbonate of 18, BUN of 11, creatinine of 0.8. ALT of 118, AST of 158, alkaline phosphatase of 59, amylase of 46, total bilirubin of 2.1, with a lipase of 25. HOSPITAL COURSE: On [**2133-7-24**] the patient was operated on by Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**Name5 (PTitle) **] assistant [**First Name8 (NamePattern2) 3825**] [**Last Name (NamePattern1) 3826**]. The patient had a laparoscopic cholecystectomy, laparoscopic intraoperative ultrasound, attempted laparoscopic segment V resection converted to open segment V mass resection adjacent to gallbladder. Please see the operative note for more details; described by Dr. [**First Name (STitle) **]. The patient was transferred to the ICU. While in the ICU the patient had intraoperative bleeding converted to open. Systolic blood pressures in the 50s. Placed on Neo- Synephrine. The patient had an acidosis trough. The patient had a lactate peak of 13.8. Estimated blood loss of 8500; received 13 units of packed red blood cells, 9 units of FFP, 3 units of platelets, 3 units of cryogen, 1 liter of crystalloid, with a urine output of 900 cc. The patient was intubated while in the ICU overnight. The patient was weaned off his vent and was extubated on [**2133-7-26**]. Labs on the 24th revealed a WBC of 11.4, hematocrit of 31.1, platelets of 70. PT of 14.6, PTT of 32.9, INR of 1.4. Sodium of 139, potassium of 4.2, chloride of 108, bicarbonate of 25, BUN of 11, creatinine of 2.6, with a glucose of 181. Also on [**2133-7-26**] ALT of 325, AST of 385, alkaline phosphatase of 79, amylase of 46, total bilirubin of 1.7. On [**2133-7-26**] the patient was transferred to the floor. On postoperative day 5, the patient's Foley was removed, IV was hep-locked, diet was advanced. On the back of his neck he did have a severe abrasion, believed due to positioning in the OR which had been treated with DuoDerm gel applied daily. Physical therapy and occupational therapy were consulted. The patient had a temperature on postoperative day 6 of 101.3; was cultured. Currently, all the blood cultures are pending. The patient had an IJ in place which was removed and sent for culture. The patient's pathology from the wedge resection demonstrated HCC with margins, which means that patient needs to have a liver transplant - which was discussed with him by Dr. [**Last Name (STitle) **]. On postoperative day 7, the patient was doing well. No events overnight, afebrile, vital signs stable. The patient's neck was still irritated but not putting pressure on the area. I's and O's good. Cultures are pending. Labs on the 28th are as follows. WBC of 10.5, hematocrit of 34.0, platelets of 113. Sodium of 133, potassium of 3.4 (which was replaced with 40 mEq of K), chloride of 99, bicarbonate of 27, BUN of 15, creatinine of 0.8, glucose of 106. ALT of 87, AST of 64, albumin of 2.4, AFP of 19.6. Since the patient is a pre transplant candidate, multiple pre transplant labs were sent; including HBsAg, HBsAb, HBcAb, HIV- AB IgM-HIV AFP which we know the results, which is 19.6, and HCV AB pending. HIV also pending. The patient is going to have a TTE this afternoon and then the patient can go home. Wound care nurse did see the patient for his wound and felt that the patient should have VNA and have DuoDerm gel applied daily with a dry gauze applied on top of that without any pressure to the neck. DISCHARGE DISPOSITION: The patient is going to go home today (on [**2133-7-30**]). MEDICATIONS ON DISCHARGE: Tylenol 325/650 p.o. q.4-6h. p.r.n.; glipizide 5 mg daily; hydrochlorothiazide 25 mg daily; Dilaudid 2 mg q.3h. p.r.n.; insulin sliding scale; lisinopril 20 mg daily; metformin 1000 mg daily; Reglan 10 mg q.6h. p.r.n.; nifedipine CR 30 mg daily; Protonix 40 mg q.24. DISCHARGE INSTRUCTIONS: The patient is to call the transplant team at ([**Telephone/Fax (1) 62221**] immediately if any fevers, chills, nausea, vomiting, increased jaundice, excessive dizziness, any changes in his abdominal incision (including redness/discharge); and the VNA nurse or staff should let transplant team know immediately if there is any change in color of the neck wound/any discharge from the neck wound immediately. The patient has a JP drain that the patient is going to be going home with that needs to be emptied every 3 to 4 hours. The record of the amount and color of drainage needs to be brought to his next appointment so that someone from the transplant team can see the record. DISCHARGE FOLLOWUP: The patient needs to follow up with Dr. [**Last Name (STitle) **]. Please call ([**Telephone/Fax (1) 3618**] for an appointment and also will probably need an appointment with one of the liver transplant coordinators. Also, they should be contacting you to make an appointment. The patient also needs to have an endoscopy and colonoscopy as an outpatient as part of the pre transplant workup. When the patient does come for a follow-up appointment, someone from the transplant team needs to see his neck wound to make sure that it is healing. FINAL DIAGNOSIS: Multiple liver masses; pathology demonstrates hepatocellular carcinoma with margins. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2133-7-30**] 14:47:13 T: [**2133-7-30**] 15:54:39 Job#: [**Job Number 62222**]

Admission Date: [**2163-3-11**] Discharge Date: [**2163-3-21**] Service: CARDIOTHORACIC Allergies: Procainamide / Flomax / Uroxatral Attending:[**First Name3 (LF) 165**] Chief Complaint: fatigue, dyspnea Major Surgical or Invasive Procedure: Cardiac Catheterization Coronary artery bypass graft times two and aortic valve replacement with a 27mm [**Company 1543**] Mosaic Porcine valve [**2163-3-16**] History of Present Illness: This 87 year old gentleman has a history significant for aortic stenosis, tachy-brady syndrome s/p pacemaker and paroxysmal atrial fibrillation. Recently, he has been experiencing shortness of breath with minimal exertion and also reports intermittent chest pressure that occurs unrelated to activity. He had a fall in his basement last week. He denies having syncope and states he tripped. He denies LOC. He denies any dizziness or lightheadedness at all. He has chronic right foot edema after knee replacement surgery. He denies any PND or orthopnea andstates he sleeps very well. He sleeps in a recliner due tochronic back pain. He denies any claudication symptoms. Hereports frequent skin tears and currently has one on his right lower leg and left forearm. Due to concern about these symptoms, the patient was seen by his PCP and an echo was done on [**2163-3-8**]. This report is not presently available, however it reportedly revealed worsening aortic stenosis. The patient was referred for catheterization to further evaluate need for AVR and possbly CABG. On [**2163-3-11**] patient [**Date Range 1834**] cardiac cath which revealed a tight stenosis in LCx and RCA. It was therefore decided that he would undergo both CABG for his CAD as well as AVR for his severe AS complicated by CHF. Past Medical History: Prostate cancer diagnosed 7 months ago, treated conservatively TURP 21 years ago for BPH Aortic stenosis Atrial fibrillation Pacemaker [**2162-4-29**] Chronic back pain s/p remote spinal fusion surgery [**2118**] Breast tumor removed at age 15 Bilateral hernia repairs Rectal surgery x 4 for fissures and hemorrhoids Total knee replacement- right Appendectomy age 13 Elbow surgery s/p cardiac catheterization approx 13 years ago with clean coronaries essential tremor of unknown origin hypothyroid Cardiac Risk Factors: Diabetes(-), Dyslipidemia(+), Hypertension(+) Pacemaker/ICD for AF/tachy-brady syndrome Social History: Social history is significant for the 3ppd X 20yrs quit 47 years ago. There is no history of alcohol abuse. Married, patient??????s wife and daughter will accompany pt to procedure and then return home. They would like to be called post procedure and can be reached at [**Telephone/Fax (1) 81183**] or cell # [**Telephone/Fax (1) 81184**] [**Doctor First Name 717**]. Family History: both parents died at age 76-mother died from a stroke, father died following a stroke from complications from carotid artery surgery. Father had an MI at age 60. Brother died from suicide. Another brother died from pancreatic cancer. Physical Exam: VS - T 96.6 HR 60s BPs 130s-160s/40s-60s RR18 O2sat 98RA Gen: WDWN elderly male in NAD. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink. MMM Neck: Supple with no JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [**2-4**] soft systolic murmur at RUSB radiating to carotids No thrills, lifts. No S3 or S4. Chest: CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Groin site without hematoma, dressing c/d/i. No bruit. Ext: Edema to ankles bilaterally R>L. Neg homans signs Skin: stasis dermatitis bilaterally, no ulcers. Pulses: Right: Femoral 2+ DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [**2163-3-11**] 09:15AM GLUCOSE-150* UREA N-27* CREAT-1.4* SODIUM-137 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13 [**2163-3-11**] 09:15AM ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-119* AMYLASE-54 TOT BILI-0.5 DIR BILI-0.1 INDIR BIL-0.4 [**2163-3-11**] 09:15AM ALBUMIN-3.8 [**2163-3-11**] 09:15AM %HbA1c-5.4 [**2163-3-11**] 09:15AM WBC-5.1 RBC-3.07* HGB-9.8* HCT-29.0* MCV-94 MCH-31.9 MCHC-33.8 RDW-14.6 [**2163-3-11**] 09:15AM NEUTS-78.5* LYMPHS-14.1* MONOS-4.4 EOS-2.7 BASOS-0.2 [**2163-3-11**] 09:15AM PLT COUNT-144* [**2163-3-11**] 08:56AM TYPE-ART PO2-114* PCO2-44 PH-7.44 TOTAL CO2-31* BASE XS-5 INTUBATED-NOT INTUBA [**2163-3-11**] 08:56AM HGB-12.2* calcHCT-37 O2 SAT-98 [**2163-3-11**] 08:00AM INR(PT)-0.9 [**2163-3-20**] 05:16AM BLOOD WBC-8.8 RBC-3.07* Hgb-9.8* Hct-27.8* MCV-91 MCH-32.0 MCHC-35.4* RDW-16.6* Plt Ct-91* [**2163-3-20**] 05:16AM BLOOD PT-15.5* INR(PT)-1.4* [**2163-3-20**] 05:16AM BLOOD Glucose-106* UreaN-26* Creat-1.0 Na-139 K-3.3 Cl-104 HCO3-28 AnGap-10 Brief Hospital Course: A cardiac catheterization was performed on [**2163-3-11**] which demonstrated two vessel coronary artery disease. On [**2163-3-11**] carotids were performed and revealed less than 40% stenosis on the right and 70-79% on the left. Dental clearance was obtained. He was seen by podiatry for right 2nd digit pain and an abscess was drained at bedside. He was seen by speech and swallow and found to have mild dysphagia. He was seen by wound care for a right lower leg ulcer which has been healing poorly. Adaptic was recommended to be placed on the wound. He was placed on Kefzol for thrombophlebitis on his right upper extremity. On [**2163-3-16**] Mr. [**Known lastname 43400**] [**Last Name (Titles) 1834**] a coronary artery bypass grafting times two and an aortic valve replacement with a 27mm [**Company 1543**] Mosaic Porcine valve. He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. Mr. [**Known lastname 43400**] was weaned from the ventilator and extubated without difficulty. His pacing wires were removed on POD#2 since he has his own internal pacer. He was transferred from the ICU to the floor on POD#2. He was started on coumadin for baseline atrial fibrillation which he was in prior to surgery and betablocker and diuretics. His platelet count was noted to be steadily declining. His medications were reviewed and zantac d/c'd. A HIT panel was negative. His chest tubes were removed on POD#3. Hematocrit and platelets are recovering. Mr. [**Known lastname 43400**] was evaluated by physical therapy and rehab was recomended. The patient was found stable for discharge to rehab on POD 5. Medications on Admission: Slow K 600mg 1 capsule [**Hospital1 **] Warfarin 5mg/7.5mg MWF, last dose Monday Amiodarone 200mg daily Amlodipine 5mg daily Primidone 50mg daily Lasix 20mg, 3 tablets daily Docusate sodium 100mg [**Hospital1 **] Erythromycin Ophthalmic ointment daily for dry eye Synthroid 0.125mg daily konsyl OTC for fiber 6 grams daily with juice aspirin 81mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed Release (E.C.)(s) 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic DAILY (Daily). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 5. Primidone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose will change daily for goal INR [**2-1**], Dx: A-fib. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for 2 days: through [**2163-3-22**]. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Furosemide 40 mg IV Q12H 17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: TBA Discharge Diagnosis: two vessel coronary artery disease severe aortic stenosis hypertension hypercholesterolemia prostate cancer tachy-brady syndrome atrial fibrillation chronic back pain essential tremor of unknown origin hypothyroidism s/p fall last week (no syncope) s/p rectal surgery for fissures s/p appendectomy s/p permanent pacemaker s/p right total knee replacement s/p transurethral resection of prostate s/p bilateral elbow surgery s/p spinal fusion in [**2118**] s/p breast tumor removed age 15 s/p hernia repairs s/p bilateral cataract surgery Discharge Condition: good Discharge Instructions: You were admitted to the hospital with fatigue and an abnormal valve in your heart. You had a catheterization to evaluate the valve and this showed some coronary artery disease as well. You were having trouble swallowing. You had some tests that show that the muscles that help you swallow are very tight which is causing your trouble swallowing. You were given instructions for how to swallow and should follow them at home. You should crush your medications to take them. You may at some point want to have surgery for this and your primary care doctor can help you arrange this. Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 1 week ([**Telephone/Fax (1) 81185**] please call for appointment Dr [**First Name8 (NamePattern2) 518**] [**Last Name (NamePattern1) 8579**] in [**2-1**] weeks ([**Telephone/Fax (1) 81186**] please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3071**]) [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2163-3-21**]

Admission Date: [**2149-12-6**] Discharge Date: [**2149-12-6**] Date of Birth: [**2070-12-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: None History of Present Illness: 78 yo M w/ h/o seizure disorder, Parkinson's, dementia, recent hospitalization for aspiration pneumonia and encephalopathy/delirium presents to the ED with altered mental status and hct drop from 28.4 upon discharge [**12-2**] to 21.7 (baseline appears to be 33-35). . He was recently dischared from [**Hospital1 18**] [**Date range (1) 52345**] hospitalization for aspiration pneumonia and encephalopathy/delirium and went to NH from there. At the NH this am, [**Name8 (MD) **] RN report had acute onset AMS and was found to be hypoxic with O2 sats in the mid 80s which responded to O2 via nasal cannula (nml. O2 sats high 90s on RA). His wife reports that 1 day PTA, she noted that at the NH, he had multiple large black stools; no bright red blood. Upon tx to the ED, medics found him to have "low blood sugar" although exact number is not known. He received D50 en route to the hospital. . In the ED, he was found to have the above mentioned hct drop and had melanotic stool. Gastric lavage was not performed in the ED. He received 2U prbcs. He was found to have diffuse pulmonary crackles and O2 requirement and CXR revealed e/o pulmonary edema and b/l pleural effusion c/w heart failure. BNP was 1193. Vitals on presentation revealed hypothermia, BP 94/65 RR 16 O2 sat was 100% (unclear in documentation on what settings). Bear hugger was applied and he was started on Bipap. Blood cultures were sent and he received vanco, ceftaz and flagyl x1. He received 3L IVF for persistent hypotension into 70s systolic to which his BP only transiently responded. Discussion was had with his family by the ED staff and although he is DNR/DNI, pressors are exceptable although they do not want central line placement. Thus, he was started on levophed and was transferred to the [**Hospital Unit Name 153**] for further management. . During his most recent hospitalization [**Date range (1) 52345**], He was treated with unasyn for aspiration pneumonia. He was discharged on augmentin to complete the course on [**12-9**]. Given his probable aspiration pneumonia, he was evaluated by speech and swallow at the bedside who recommended pureed solids and nectar thick liquids. He was also started on flagyl for C. diff colitis which he is to complete on [**12-16**]. Additionally, pt. had movements that were originally thought c/w seizure. Neurology evaluated him and thought movements were likely dyskinesis from Parkinson's. With the restarting of Parkinson's medication, he became more responsive. Past Medical History: 1. Parkinsons Dx [**2136**] in [**Country 651**] 2. ? H/O Stroke 3. GERD 4. BPH 5. ? Seizures 6. Fatigue 7. Atypical chest pain, noncardiac Social History: Lives at [**Location **]. Children and wife live locally. From [**Country 651**] originally, Cantonese speaking. Denies tobacco, ETOH, and drugs Family History: Non-contributory Physical Exam: Vitals: T 95.0 ax BP 121/61 HR 61 RR 14 100% on 2L NC Gen: Unresponsive, nonverbal, does not follow commands HEENT: PERRL, MMM, shallow wound on chin. Neck: supple, +JVD to angle of jaw CV: RRR, No mrg Resp: rhonchorus anteriorly with intermittent exp wheeze right anterior chest Abd: Decreased bowel sounds. Thin. No guarding. No organomegaly. Gastric lavage w/ sl. pink fluid Ext: B/L upper extremity decorticate posturing. Able to bend arms but w/ resistance. 2+ b/l LE edema to mid shins. When attempt to bend left arm at elbow, pt. moans. Neuro: 1+ patellar reflexes. Unable to get biceps reflexes [**12-26**] to stiffness and extensor posturing. Pertinent Results: [**2149-12-6**] EKG: NSR with rate 67. Nml axis. 1st degree AV delay. No acute ST-T wave changes appreciated. . [**2149-12-6**] CXR: 1. Bilateral pleural effusions, fluid overload with interstitial edema. More confluent suprahilar opacities may be due to dependent atelectasis component of edema or a superimposed process such as acute aspiration. 2. Likely left humeral fracture. Dedicated shoulder radiographs could be performed for further characterization. . [**2149-12-6**] Left shoulder x-ray: read pending . [**2149-12-6**] Head CT: No acute intracranial hemorrhage or mass effect . [**2149-11-25**] MRA BRAIN: 1. 5-mm low signal intensity in the white matter of the right frontal lobe consistent with hemosiderin and could represent a cavernoma or trauma. 2. Diffuse abnormal bone marrow signal in the cervical spine could represent anemia or other diffuse infiltrative process. 3. Normal circle of [**Location (un) 431**] MRA. . [**2149-11-21**] CT BRAIN: No intracranial hemorrhage or mass effect. Unchanged appearance from [**2148-7-4**]. . [**2149-11-21**] CT CSPINE: 1. No evidence of fracture or spondylolisthesis. 2. Multilevel degenerative change. . [**2150-11-21**] CXR: Left basal and right infrahilar opacity concerning for evolving pneumonia or aspiration. Brief Hospital Course: # GI bleed: Significant hct drop from 28.4 on [**2149-12-2**] to 21.7 in the ED on presentation, with elevated BUN where it was previously was normal. Unclear source. Lavage with minimal pinkish tinge p 200cc, but NGT at G-E junction. Family did not wish currently to pursue aggressive measures (EGD/[**Last Name (un) **]). He was transferred to the FIU as a DNI and after discussion with family, he was made DNR/DNI. . # Sepsis: Probable pulmonary source given recent hospitalization for aspiration pneumonia. Patient was hypothermic with WBC >12 (12.3) w/ probable aspiration pneumonia as source. He was not tachycardic nor tachypneic. He was hypotensive despite 3L fluid resuscitation and required pressors to maintain his BP. Currently on peripheral pressors started in the ED, but family requested no central line placement. He was continued on zosyn to cover anaerobes, vanco given recent hospitalization, and flagyl for known C. diff. Above, family discussion was had regarding their wishes and he was made DNR/DNI. Despite peripheral levophed, his BP continued to drop and he expired within hours of [**Hospital Unit Name 153**] transfer. Family was at bedside. . # Altered mental status: Likely toxic metabolic in the setting of sepsis and GIB. CT head was negative for acute intracranial process. . # Coagulopathy: Elevated INR to 1.9 and has not been on any anticoagulants. Fibrinogen was normal, other DIC labs not sent. Likely largely nutrtional. He was given vitamin K in setting of GIB and elevated INR. . # CHF: Has no previous h/o CAD nor CHF. Last echo in [**6-28**] with nml EF. BNP 1193 w/ clear e/o fluid overload on CXR, elevated JVD on exam nad peripheral edema. CEs were negative x1. . # Parkinson's disease: Plan was to continue sinemet, entacapone, pramipaxole, and trihexyphenidyl. . # BPH: Foley was placed, tamsulosin was held in setting of severe hypotension. Medications on Admission: 1. Acetaminophen 650 mg PO Q6H prn 2. Entacapone 200 mg q4h w/ sinemet 3. Carbidopa-Levodopa 25-250 mg 1 PO Q 3AM, 6AM, 9AM, NOON, 3PM, 6 PM 4. Carbidopa-Levodopa 50-200 mg 1 PO Q9PM 5. Pramipexole 0.25 mg Tablet 1 PO TID 6. Trihexyphenidyl 2 mg Tablet 1 PO BID 7. Tamsulosin 0.4 mg Capsule 1 PO QHS 8. Lactulose 10 g/15 mL Syrup 30ML PO Q8H prn 9. Albuterol Sulfate 0.083 % Solution 1 neb Q6H prn 10. Docusate Sodium 100 mg PO BID 11. Multivitamin,Tx-Minerals 1 PO daily 12. Aspirin 325 mg Tablet 1 PO daily 13. Pantoprazole 40 mg Tablet 1 PO qdaily 14. Calcium Carbonate 500 mg Tablet 1 PO TID 15. Cholecalciferol (Vitamin D3) 800 unit daily 16. Flagyl 500 mg Tablet 1 PO q8h (to complete on [**2149-12-16**]) 17. Augmentin 875-125 mg Tablet 1 PO bid (to complete [**2149-12-9**]) . Discharge Disposition: Expired Discharge Diagnosis: Sepsis GI bleed Discharge Condition: Expired Followup Instructions: None

Admission Date: [**2153-12-25**] Discharge Date: [**2154-1-2**] Date of Birth: [**2086-9-27**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Heparin Agents Attending:[**First Name3 (LF) 1283**] Chief Complaint: chest pain/ODE/fatigue Major Surgical or Invasive Procedure: [**12-25**] redo [**Doctor Last Name **] AVR (mech) CABG x1 (SVG>PDA) History of Present Illness: 67 yo M with h/o CAD, followed by echo, now with severe AS.Repeat cath also showed occluded OM and RCA vein graft. Past Medical History: Hypertension Elevated triglycerides CAD s/p CABG [**2141**] (LIMA -> LAD, SVG ->RCA, SVG->D1->OM2->OM3) MI- age 35 Ischemic cardiomyopathy with an EF 25% on TTE [**6-4**] s/p ICD [**2150**] for a cardiac arrest (DDDR [**Company 1543**]) Aortic stenosis, valve area 0.88cm2 CRI BPH Right knee replacement GERD/Hiatal hernia Thrombocytopenia of unclear etiology Social History: - Denies current tobacco use. - Denies history of alcohol abuse. - Family history: mother with prior MI??????s. died in her 80??????s from heart disease. - Two brothers w/ CABG in their late 50??????s or 60??????s; sister had CABG in her 60??????s. Family History: - Two brothers w/ CABG in their late 50??????s or 60??????s; sister had CABG in her 60??????s. Physical Exam: NAD HR 62 RR 12 BP 104/60 well healed sternotomy/R ACW PPM site, L GSV harvest from ankle to groin Chest CTAB Heart RRR 3/6 SEM Abdomen benign Extrem warm, trace LE edema Pertinent Results: [**2154-1-1**] 08:10AM BLOOD WBC-6.1 RBC-3.37* Hgb-9.3* Hct-28.7* MCV-85 MCH-27.7 MCHC-32.5 RDW-17.1* Plt Ct-134* [**2154-1-2**] 07:25AM BLOOD PT-29.4* INR(PT)-3.0* [**2154-1-1**] 10:42AM BLOOD PT-37.9* INR(PT)-4.1* [**2154-1-1**] 08:10AM BLOOD PT-41.5* PTT-46.3* INR(PT)-4.6* [**2153-12-31**] 07:25AM BLOOD PT-33.7* PTT-51.4* INR(PT)-3.5* [**2154-1-2**] 07:25AM BLOOD Glucose-124* UreaN-20 Creat-1.4* Na-140 K-4.5 Cl-103 HCO3-28 AnGap-14 [**2154-1-1**] 08:10AM BLOOD Glucose-98 UreaN-25* Creat-1.5* Na-141 K-4.0 Cl-105 HCO3-26 AnGap-14 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 33123**]Portable TTE (Complete) Done [**2154-1-1**] at 3:30:00 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2086-9-27**] Age (years): 67 M Hgt (in): 66 BP (mm Hg): 142/54 Wgt (lb): 192 HR (bpm): 73 BSA (m2): 1.97 m2 Indication: Right ventricular function. Aortic valve replacement ([**Street Address(2) 11688**]. [**Male First Name (un) 923**]). CABG. ICD-9 Codes: 402.90, V43.3, 414.8, 424.0, 424.2 Test Information Date/Time: [**2154-1-1**] at 15:30 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**], RDCS Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Suboptimal Tape #: 2007W043-1:20 Machine: Vivid [**8-5**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: *7.2 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.7 m/s Left Atrium - Peak Pulm Vein D: 0.3 m/s Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s Right Atrium - Four Chamber Length: *6.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 20% to 25% >= 55% Left Ventricle - Stroke Volume: 53 ml/beat Left Ventricle - Cardiac Output: 3.90 L/min Left Ventricle - Cardiac Index: *1.98 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *18 < 15 Aorta - Sinus Level: 2.6 cm <= 3.6 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aortic Valve - Peak Velocity: *2.7 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *34 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 15 mm Hg Aortic Valve - LVOT VTI: 17 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 1.6 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A ratio: 2.00 Mitral Valve - E Wave deceleration time: *119 ms 140-250 ms TR Gradient (+ RA = PASP): *37 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 1.2 m/sec <= 1.5 m/sec Findings This study was compared to the prior study of [**2153-8-14**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Severely depressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. Transmitral Doppler and TVI c/w Grade III/IV (severe) LV diastolic dysfunction. No resting LVOT gradient. RIGHT VENTRICLE: Dilated RV cavity. RV function depressed. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Normal AVR gradient. Trace AR. [The amount of AR is normal for this AVR.] MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. Mild (1+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed but images of the RV are limited. The ascending aorta is mildly dilated. A bileaflet aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2153-8-14**], overall left ventricular systolic function has declined further. An AVR is now present with normal transvalvular gradients and trivial aortic regurgitation. The severity of mitral and tricuspid regurgitation has decreased. The other findings are similar. CHEST (PORTABLE AP) [**2153-12-29**] 3:10 PM CHEST (PORTABLE AP) Reason: r/o effusion [**Hospital 93**] MEDICAL CONDITION: 67 year old man with hypoxia REASON FOR THIS EXAMINATION: r/o effusion PORTABLE CHEST, [**2153-12-29**] AT 15:26 COMPARISON STUDY: [**2153-12-27**]. CLINICAL INFORMATION: Question effusion, history of hypoxia. FINDINGS: The heart is markedly enlarged. Patient is status post median sternotomy. Right AICD/pacer is present with three leads in the right atrium and right ventricle. Since the prior study, there has been interval clearing of right lower lobe opacity seen on the prior study. Both lungs are relatively clear. IMPRESSION: Marked cardiomegaly. Interval clearing of right lower lobe opacity. Brief Hospital Course: He was taken to the operating room on [**12-25**] where he underwent a redo sternotomy/AVR and CABG x 1. He was transferred to the ICU in critical but stable condition on epi, milrinone, levophed and propofol. He was extubated on POD #1. He was weaned from his vasoactive drips by POD #3. He was transfused for HCT of 23. He was started on coumadin for his mechanical valve. He awaited a therapeutic INR and was ready for discharge home on POD #8. Medications on Admission: Amiodarone 200 [**Last Name (LF) 4962**], [**First Name3 (LF) **] 325', Atorvastatin 40 QPM, CoReg 40', Lasix 80", Plavix 75', ImDur 60", Prilosec 20', Altace 10', Terazosin 5' Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for for stent. Disp:*30 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Coumadin 2 mg Tablet Sig: 1.5 Tablets PO at bedtime for 2 doses: 3 mg [**1-2**] and [**1-3**], check INR [**1-4**] with results to Dr. [**Last Name (STitle) 9751**] for further dosing. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Aortic stenosis now s/p AVR CAD (MI in [**2117**], [**2150**], s/p CABG in [**2141**], PCI/stenting [**2152**],[**2153**]) VFIB arrest in [**2150**] s/p ICD [**2150**], upgrade to BiV [**2153**] chronic systolic heart failure HTN high cholesterol thrombocytopenia CRI BPH GERD Right TKR x 2 Discharge Condition: Good. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Take medications as prescribed on discharge. Coumadin for mechanical aortic valve. Goal INR 2.5-3.0. Have INR checked [**1-4**] with results called to Dr [**Last Name (STitle) 9751**] at ([**Telephone/Fax (1) 33124**]. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (STitle) 9751**] 1-2 weeks Dr. [**Last Name (STitle) 33125**] 2 weeks Dr. [**Last Name (Prefixes) **] 4 weeks Completed by:[**2154-1-2**]

Admission Date: [**2118-8-31**] Discharge Date: [**2118-9-6**] Date of Birth: [**2042-9-29**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2118-9-2**] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to LAD, and vein grafts to Ramus and PDA. History of Present Illness: Mr. [**Known lastname 6339**] is a 75 year old male with known coronary disease. During evaluation for myelodysplastic anemia, he noted significant shortness of breath and worsening fatiuge. He subsequently underwent cardiac cathterization which revealed 50% left main lesion and severe three vessel coronary artery disease. He was urgently transferred to the [**Hospital1 18**] for further evaluation and treatment. Past Medical History: Coronary Artery Disease, s/p PCI with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] [**2114**] History of Myocardial Infarction Type II Diabetes Mellitus COPD, Pulmonary Hypertension Chronic Renal Insufficiency Anemia, Myelodysplastic Disease History of Atrial Fibrillation/Flutter Sick Sinus Syndrome, s/p Pacemaker Implantation Osteoarthritis History of Renal Calculi - s/p Lithotripsy History of Skin Cancer - s/p removal Bladder Cancer - s/p Prostatectomy, TURP Prior Knee Surgery Social History: Retired engineer. 75 pack year history of tobacco. Admits to [**12-8**] glasses of wine per day. Family History: Father, MI at age 61. Sister with atrial fibrillation. Physical Exam: Admit PE: vitals - bp 138-149/70-74, hr 64 general - elderly male in no acute distress skin - multiple nevi heent - oropharynx benign, PERRL, sclera anicteric neck - supple, no JVD, no carotid bruits chest - lungs clear bilaterally heart - regular rate and rhythm, normal s1s2, no murmur abd - benign ext - warm, no edema neuro - nonfocal pulses - 2+ distally bilaterally Pertinent Results: [**2118-9-1**] TTE: The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with distal septal hypokinesis. The remaining segments contract normally (LVEF = 50%). Right ventricular chamber size and free wall motion are normal. There is a minimally increased gradient consistent with minimal aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2118-9-1**] Carotid: Mild calcified plaques in the common and internal carotid arteries bilaterally with less than 40% stenosis on both sides. [**2118-9-2**] Intraop TEE: PREBYPASS 1. The left atrium is moderately dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No thrombus is seen in the left atrial appendage. No atrial septal defect of PFO is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis seen in inferioseptal and septal walls. 3. The aortic arch is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 4. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). 5. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-8**]+) mitral regurgitation is seen. POSTBYPASS 1. Patient is on phenylephrine and epinephrine infusions 2. Left ventricular function is improved. EF 55%. Inferioseptal and septal walls are improved but patient is on inotropes. 3. Right ventricular functions is improved, although on inotrope infusion. 4. Aortic contour is smooth after decannulation. CAROTID U/S IMPRESSION: Mild calcified plaques in the common and internal carotid arteries bilaterally with less than 40% stenosis on both sides. This is a baseline examination at the [**Hospital1 18**]. [**2118-9-5**] 05:27AM BLOOD WBC-9.6 RBC-2.62* Hgb-8.9* Hct-25.9* MCV-99* MCH-33.9* MCHC-34.2 RDW-15.8* Plt Ct-183 [**2118-9-6**] 05:45AM BLOOD PT-13.9* INR(PT)-1.2* [**2118-9-5**] 05:27AM BLOOD Plt Ct-183 [**2118-8-31**] 05:17PM BLOOD WBC-7.6 RBC-3.47* Hgb-11.5* Hct-34.5* MCV-100*# MCH-33.0* MCHC-33.2 RDW-15.3 Plt Ct-239 [**2118-8-31**] 05:17PM BLOOD Plt Ct-239 [**2118-8-31**] 05:17PM BLOOD PT-15.8* PTT-26.3 INR(PT)-1.4* [**2118-9-5**] 05:27AM BLOOD Glucose-137* UreaN-33* Creat-1.2 Na-135 K-3.6 Cl-101 HCO3-25 AnGap-13 [**2118-8-31**] 05:17PM BLOOD Glucose-156* UreaN-33* Creat-1.1 Na-139 K-4.0 Cl-97 HCO3-33* AnGap-13 [**2118-8-31**] 05:17PM BLOOD ALT-18 AST-24 CK(CPK)-24* AlkPhos-81 Amylase-51 TotBili-0.5 [**2118-8-31**] 05:17PM BLOOD Lipase-25 [**2118-9-5**] 05:27AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.1 [**2118-8-31**] 05:17PM BLOOD %HbA1c-5.9 Brief Hospital Course: Mr. [**Known lastname 6339**] was admitted to the cardiac surgical service and underwent routine preoperative testing which included carotid ultrasound, and echocardiogram - see result section. He remained stable on intravenous Heparin. Workup was unremarkable and he was cleared for surgery. On [**9-2**], Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting surgery. For surgical details, please see operative report. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. Low dose beta blockade, lasix, Plavix and Warfarin were resumed. He maintained stable hemodynamics and transferred to the SDU on postoperative day one. Physical therapy worked with him on strength and mobility. He was ready for discharge home with VNA and physical therapy post operative day 4. Medications on Admission: Warfarin - stopped [**8-27**], Digoxin 0.25 qd, Plavix - stopped [**8-30**], Atenolol 75 [**Hospital1 **], Avalide 150/12.5 qd, Mg Oxide 400 [**Hospital1 **], Allopurinol 300 qd, Lupron injection, Lipitor 10 qd, Lasix 40 MWF and 20 TuThSat, KCL 20 MWF, Aspirin 81 qd, Spiriva daily, Folate 1 qd, Nitro patch, Zithromax Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. [**Hospital1 **]:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. [**Hospital1 **]:*60 Tablet(s)* Refills:*0* 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Warfarin 2.5 mg Tablet Sig: INR goal 2.0-2.5 Tablets PO once a day: 2.5mg wednesday with lab draw [**9-8**] results to MWHC coumadin clinic for further dosing. [**Month/Day (2) **]:*90 Tablet(s)* Refills:*0* 8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. [**Month/Day (2) **]:*30 Tablet(s)* Refills:*0* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): if increased edema or weight please contact physician. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0* 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0* 11. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO once a day. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0* 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). [**Name Initial (NameIs) **]:*qs Cap(s)* Refills:*0* 13. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). [**Name Initial (NameIs) **]:*90 Tablet(s)* Refills:*0* 14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. [**Name Initial (NameIs) **]:*50 Tablet(s)* Refills:*0* 15. MagOx 400 mg Tablet Sig: One (1) Tablet PO once a day. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: Coronary Artery Disease - s/p CABG Type II Diabetes Mellitus Aortic stenosis COPD, Pulmonary Hypertension Chronic Renal Insufficiency Renal Calculi Osteoarthritis Neuropathy Anemia, Myelodysplastic Disease Atrial Fibrillation/Flutter Sick Sinus Syndrome, s/p Pacemaker Implantation Discharge Condition: Good Discharge Instructions: 1)Please shower daily. Wash incisions with soap and water. Do not apply creams, lotions or ointments to surgical incisions. 2)No driving for at least one month. 3)No lifting more than 10 lbs for at least 10 weeks from surgical date. 4)Please contact cardiac [**Name2 (NI) 5059**] if you develop fevers and/or any signs of wound infection (redness, drainage), [**Telephone/Fax (1) 170**]. Followup Instructions: Please call to schedule appointments Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 59121**] in 1 week Dr. [**Last Name (STitle) 1655**] or Young in [**1-9**] weeks Wound check - please schedule with RN [**Telephone/Fax (1) 3071**] PT/INR for atrial fibrillation goal INR 2.0-2.5 - results to coumadin clinic at [**Hospital1 **] heart center [**Telephone/Fax (2) **] First draw thrusday [**9-8**] Completed by:[**2118-9-6**]

Admission Date: [**2117-3-12**] Discharge Date: [**2117-3-22**] Date of Birth: [**2041-3-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Progressive dyspnea on exertion Major Surgical or Invasive Procedure: [**2117-3-15**] Aortic Valve Replacement(25mm [**Company 1543**] Mosaic Porcine) and Three Vessel Coronary Artery Bypass Grafting(left internal mammary artery to left anterior descending artery, vein grafts to obtuse marginal and PDA) History of Present Illness: Mr. [**Known lastname **] is a 76 year old male with known severe aortic stenosis. Over the past few months, he has complained of progressive dyspnea on exertion. He subsequently underwent cardiac catheterization which revealed severe three vessel coronary artery disease including a 75% distal left main lesion. Given the above findings, he was transferred to the [**Hospital1 18**] for cardiac surgical intervention. Past Medical History: Hypertension Peptic Ulcer Disease - History of Upper GI Bleed Chronic Obstructive Pulmonary Disease Spinal Stenosis s/p Laminectomy s/p Appendectomy Social History: Over 50 pack year history of tobacco, quit [**2116-6-23**]. Admits to 1-3 beers per day. Denies history of ETOH abuse. Retired, lives with his wife. Family History: No premature coronary artery disease. Physical Exam: Admission: Vitals: 159/88, 74, 18 General: elderly male in no acute distress Skin: macular rash noted across lower back HEENT: oropharynx benign Neck: supple, no jvd Chest: distant breath sounds throughout Heart: regular rate and rhythm, s1s2, 3/6 systolic ejection murmur heard throughout the precordium and carotids Abdomen: benign Extremities: warm, no edema Neuro: grossly intact Pulses: 2+ distally Pertinent Results: [**2117-3-12**] 07:10PM BLOOD WBC-8.1 RBC-4.58* Hgb-14.7 Hct-42.4 MCV-93 MCH-32.1* MCHC-34.6 RDW-14.6 Plt Ct-282 [**2117-3-12**] 07:10PM BLOOD PT-15.2* PTT-32.1 INR(PT)-1.3* [**2117-3-12**] 07:10PM BLOOD Glucose-105 UreaN-10 Creat-0.7 Na-134 K-3.9 Cl-98 HCO3-27 AnGap-13 [**2117-3-12**] 07:10PM BLOOD ALT-13 AST-24 LD(LDH)-218 AlkPhos-143* TotBili-0.7 [**2117-3-12**] 07:10PM BLOOD %HbA1c-5.3 [**2117-3-12**] 07:10PM BLOOD Albumin-4.5 [**2117-3-13**] Echocardiogram: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are complex (>4mm, non-mobile) atheroma in the ascending aorta beginning at 4cm above the aortic valve (clip #[**Clip Number (Radiology) **]). The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-25**]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [**2117-3-14**] Chest CT Scan: 1. Diffuse atherosclerotic calcifications as above. 2. Patchy bilateral predominantly peribronchiolar nodules likely represent chronic bronchiolitis from infection such as MAC or hypersensitivity pneumonitis with likely reactive lymphadenopathy. Imaging in three months can be obtained after therapy as clinically indicated. 3. Compression fractures at L1 and L2 are of indeterminate age. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the cardiac surgical service and underwent routine preoperative evaluation. Given his critical anatomy, intravenous Heparin was initiated. Workup included an echocardiogram which confirmed severe aortic stenosis, and also showed mild to moderate mitral regurgitation and normal left ventricular function. Echocardiogram was also notable for a dilated ascending aorta with plaque for which chest CT scan was obtained. The CT scan showed that the aorta was normal in course and caliber. There were moderate atherosclerotic calcifications throughout the aorta without evidence of dissection or penetrating ulcer. Preoperative course was otherwise uneventful. He remained pain free on intravenous therapy and was cleared for surgery. Given his inpatient stay was greater than 24 hours prior to surgery, Vancomycin was utilized for perioperative antibiotic coverage. On [**3-15**] rd, Dr. [**Last Name (STitle) 914**] performed an aortic valve replacement and coronary artery bypass grafting. For surgical details, please see operative note. Following the operation, he was brought to the CV ICU for invasive monitoring. Initially hypotensive and anemic, he required inotropic support with Levophed and vasopressin. Several units of packed red blood cells were transfused. Over the next 24 hours, hemodynamics improved and hematocrit stabilized. Pressors were weaned, he remained stable, was weaned from the ventilator and was extubated. He was transferred to the floor on POD3. Beta blockers were resumed, diuresis was continued along with aggressive pulmonary care and bronchodilators. PT worked with him for strength and mobility. He has baseline mobility issues, using a walker due to instability from his spinal stenosis. There was some erythema of the sternal wound and Keflex was given empirically. Diuretics were changed to oral formulations at discharge. His CXR demonstrated some intravascular fullness, but was essentially clear. He denies SOB, despite his wheezing. He developed atrial fibrillation for which Amiodarone was begun and Lopressor was adjusted with rate control.. Anticoagulation was begun with Coumadin for this as well. He progressed satisfactorily and was ready for rehabilitation. Diuretics were continued after transfer and will continue until he reaches his preoperative weight, about 72 kg. The Atrovent was changed to a more selective preparation given the severity of his pulmonary disease. Discharge precautions, medications and follow up instructions were noted in the transfer paperwork and summary. Medications on Admission: Metoprolol 100 mg daily Discharge Medications: 1. Influen Tr-Split [**2115**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One (1) ML Intramuscular ASDIR (AS DIRECTED). 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): for 7 days then reduce to one tablet twice daily(200mg [**Hospital1 **]). 13. Lopressor 50 mg Tablet Sig: 1 [**12-25**] Tablet PO three times a day. 14. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q4h (). 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily): hold K>4.5. 16. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for sternal erythema for 5 days. 17. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. 18. Warfarin 2.5 mg Tablet Sig: as ordered Tablet PO once a day: INR [**1-26**]. Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: Aortic Stenosis - s/p Aortic Valve Replacement Coronary Artery Disease - s/p Coronary Artery Bypass Grafting Chronic Obstructive Pulmonary Disease Hypertension Spinal Stenosis Peptic Ulcer Disease, History of Upper GI Bleed Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) 914**] in [**3-28**] weeks, [**Telephone/Fax (1) 170**] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-26**] weeks Dr. [**Last Name (STitle) **] in [**1-26**] weeks, [**Telephone/Fax (1) 10381**] please call for appointments Completed by:[**2117-3-22**]

Admission Date: [**2122-5-25**] Discharge Date: [**2122-5-28**] Date of Birth: [**2037-11-9**] Sex: F Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 443**] Chief Complaint: left shoulder pain Major Surgical or Invasive Procedure: Cardiac Catheterization [**2122-5-25**] with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] History of Present Illness: Patient reports that she first experienced pain in her left shoulder and radiating down her left arm yesterday morning. She was not exerting herself, not eating, she was playing cards which she usually does most mornings before breakfast. The pain was very difficult to describe, not sharp or dull per se, she thought it was her arthritis. Lasted about 10 minutes and spontaneously resolved without interventions. Then this morning she had another episode of similar left shoulder pain this am, lasting a little longer, maybe about 1-2 hours. She denies having shortness of breath, nausea, or diaphoresis with these episodes. With the pain this am she had a second of lightheadedness and that is why she decided to come in to the hospital for it. In the ED, initial vitals were 97.2 88 122/62 16 99% 2L NC. Labs and imaging significant for troponin of 0.25 with normal renal function and EKG with ST elevations in aVR and lead III > II as well as depressions in I, II, V4-V6. Otherwise NA/NI, rate 80s, + LVH and LAE. Patient given heparin gtt, morphine, and NTG in the ED then taken immediately by cardiology to the cath lab. In the lab, she had totally occluded RCA, which was old from [**2111**] and previous stent to LAD was patent. Occluded OM off a tortuous circ. DES to circ to obstuse marginal. Angioplasty to native circumflex. Perclose. . On arrival to the floor, patient is feeling well, no more pain in the left shoulder. She does not have any complaints. She does report history of caludication symptoms in the past and some chronic shortness of breath, not exertional. Denies PND. . REVIEW OF SYSTEMS On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She reports exertional calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Past Medical History: . CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: occluded RCA and s/p DES to LAD -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD [**2111**] -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: peripheral vascular disease s/p right fem-[**Doctor Last Name **] bypass [**2111**] s/p L CEA [**2111**] arthritis bladder incontinence--? overflow incontinence Social History: Retired economist. Originally from [**Location (un) 6079**], [**Country 532**]. Has lived in [**Location 86**] for 19 years with her husband. She is the caretaker and they both attend daycare during the week. -Tobacco history: none -ETOH: one drink per 6 months -Illicit drugs: denies Family History: NC, 84 yo Physical Exam: ADMISSION PHYSICAL EXAM: VS: T98.6, BP 137/74, HR 77, RR 18, O2 sat=97% RA GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 5 cm. CARDIAC: 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 in left groin, dressing c/d/i. SKIN: + stasis dermatitis, no ulcers, scars, or xanthomas. NEURO; 5/5 strength b/l in dermatomes C5-T1 and L4-S1 and sensation intact to the same dermatomes. CN 2-12 intact PULSES: Right: radial 2+ DP 2+ PT 1+ Left: radial 2+ DP 2+ PT 1+ DISCHARGE PHYSICAL EXAM VS afebrile, BP 100-120s/80s, HR 70-80s, saturations > 97% RA exam unchanged Pertinent Results: ADMISSION LABS: [**2122-5-25**] 11:55AM BLOOD WBC-8.4 RBC-4.16* Hgb-12.3 Hct-37.5 MCV-90 MCH-29.7 MCHC-32.9 RDW-14.3 Plt Ct-291 [**2122-5-25**] 11:55AM BLOOD Neuts-81.5* Lymphs-14.3* Monos-2.2 Eos-1.4 Baso-0.5 [**2122-5-25**] 11:55AM BLOOD PT-11.0 PTT-31.5 INR(PT)-1.0 [**2122-5-25**] 11:55AM BLOOD Glucose-140* UreaN-26* Creat-0.9 Na-140 K-4.0 Cl-103 HCO3-31 AnGap-10 [**2122-5-25**] 11:55AM BLOOD CK(CPK)-188 [**2122-5-25**] 11:55AM BLOOD CK-MB-17* MB Indx-9.0* [**2122-5-25**] 11:55AM BLOOD cTropnT-0.25* [**2122-5-25**] 11:55AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0 . IMAGING: [**2122-5-25**] CARDIAC CATH: 1) Selective angiography of this right-dominant system demonstrated significant three-vessel coronary artery disease. The LMCA was free of angiographically-apparent flow-limiting stenoses. The LAD had a patent proximal stent, with a long 60-70% mid-vessel eccentric calcified stenosis. The LCx system had a 100% stenosis of a major OM branch; there was also a 90% mid-vessel stenosis. The RCA was known to have a 100% mid-vessel stenosis and filled via left-to-right collaterals. 2) Limited resting hemodynamics revealed systemic arterial normotension, with a central aortic pressure of 132/67 mmHg. 3) Successful PTCA of the LCx with a 2.5 mm balloon (see PTCA comments). 4) Successful PTCA and stenting of the LCx into a major obtuse marginal branch with a 3.0 x 30 mm Resolute [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] to 3.25 mm (see PTCA comments). 5) Successful RFA Perclose (see PTCA comments). FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful PTCA of the LCx with a 2.5 mm balloon. 3. Successful PCI of the LCx into a large obtuse marginal branch with a 3.0 x 30 mm Resolute [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] to 3.25 mm. 4. Successful RFA Perclose. [**5-26**] tte: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Moderately depressed LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV free wall thickness. Normal RV chamber size. RV function depressed. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild (1+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Mild [1+] TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PS. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - body habitus. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) secondary to severe hypokinesis of the inferior, posterior, and lateral walls. The right ventricular free wall thickness is normal. Right ventricular chamber size is normal. with depressed free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Ms. [**Known lastname 11154**] is a 84 year old female with known coronary artery disease (CAD) who presented with left shoulder pain, found to have ST elevations in aVR and ST depressions diffusely, with troponin elevations. She was admitted to the CCU after placement of drug eluding stent (DES) to left circumflex (LCx). . # CAD: Has 3 vessel disease (3VD) on cath this admission, with DES placed to Lcx on [**2122-5-25**]. Also known 100% occlusion of RCA, LAD with 60-70% mid-vessel disease but patent proximal DES (from [**2111**]). Post-cath her EKG showed resolution of her ST changes and her CKMB peaked at 153. Her echo showed new EF 35% with inferior hypokinesis. She was continued on valsartan 80 mg daily and her atenolol was changed to metoprolol succinate 100 mg daily. She was also dicharged on aspirin 81 mg daily and clopidogrel 75 mg daily. Physical therapy saw her and recommended home with home PT. . # New systolic heart failure: Had decreased EF to 35% after her MI and crackles on exam. Responded well to furosemide 20 mg daily, continued metoprolol succinate 100 mg daily. She should be set up with heart failure clinic. Should have another echo checked at follow-up and if remains in low EF then consider for ICD placement. . # Arthritis: Was given tylenol for pain, continued vytorin gel at home. . # Bladder incontinence: chronic, sounding like overflow incontinence. [**Month (only) 116**] also have a contribution from chronic constipation. Was given senna, docusate, and miralax as an inpatient and her stools improved. . CODE: confirmed full EMERGENCY CONTACT: daughter [**Name (NI) 335**], [**Telephone/Fax (1) 11155**] . TRANSITIONAL ISSUES: - Should have another echo checked at follow-up and if remains in low EF then consider for ICD placement and also spironolactone. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Pharmacy. 1. Lipitor 20 mg PO DAILY 2. Valsartan 160 mg PO DAILY 3. Levothyroxine Sodium 25 mcg PO DAILY 4. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg one Tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 2. Levothyroxine Sodium 25 mcg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Valsartan 80 mg PO DAILY Please hold for SBP < 100 RX *Diovan 80 mg one Tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 5. Aspirin 325 mg PO DAILY RX *aspirin 325 mg one Tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 6. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg one Tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 7. Furosemide 20 mg PO DAILY Please hold for SBP < 100 RX *furosemide 20 mg one Tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 8. Metoprolol Succinate XL 50 mg PO DAILY Hold for SBP<100 or HR<60 RX *metoprolol succinate 50 mg ONE Tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: ST elevation acute myocardial infarction Dyslipidemia 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: Dear Ms. [**Known lastname 11154**], You were admitted to the hospital because you had a heart attack. You were taken to the cath lab where they saw a blockage in one of the vessels supplying the heart muscle with blood and had a drug eluting stent to open up this blood vessel. You tolerated this procedure well and were monitored in the CCU for an evening. Your heart is weak after the heart attack, it will probably get stronger over the next month but you have been started on new medicines to help the heart recover. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2122-6-1**] at 12:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: THURSDAY [**2122-6-4**] at 11:00 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: VASCULAR SURGERY When: WEDNESDAY [**2122-7-8**] at 10:45 AM With: VASCULAR LMOB (NHB) [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Last Name (LF) **],[**First Name3 (LF) **] L. Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**] Phone: [**Telephone/Fax (1) 4606**] Appointment: Thursday [**2122-6-4**] 1:45pm

Admission Date: [**2128-7-9**] Discharge Date: [**2128-7-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1436**] Chief Complaint: Presented to [**Hospital3 3583**] with Chest Pain. Transfered to [**Hospital1 18**] from [**Hospital3 3583**] with respiratory arrest, CHF, & NSTEMI. Major Surgical or Invasive Procedure: Intubation Cardiac cath with stent placmenent & Valvulopasty Chest tube placement History of Present Illness: [**Age over 90 **]yo F with PMH significant for HTN, colon CA, hyperlipidemia, and CAD who presented to [**Hospital3 **] on the evening of [**7-8**] with sudden onset CP. On arrival to [**Hospital3 3583**], her SaO2 was found to 79% on room air, and she was intubated. A chest CT-angiogram was done, which was reportedly negative for pulmonary embolus. Initial ECG demonstrated a junctional rhythm with new 2-3mm inferior and anterolateral ST depressions and ST elevations in AVR and V1. She was given ASA, loaded with plavix, and started on heparin and integrillin gtt prior to transfer. In the [**Hospital1 **] ED, her VS were T 95.8F (rectal) to 99.8F, HR 63-80, BP 100-127/40-50. ECG demonstrated junctional rhythm with HR 60 with persistent lateral ST depressions, but resolving ST depressions in inferior leads and resolving ST elevations in AVR and V1. Initial CEs were CK 185(17), tropT 0.63, drawn 6 hours after onset of symptoms. Other initial labs were significant for BUN/Cr of 28/1.9, K 2.8, and BNP of [**Numeric Identifier 961**]. CXR demonstrated hyperinflation with hilar congestion and possible R-sided consolidation--question of PNA. She received levofloxacin 500mg IV and blood cultures were sent. She was admitted to CCU for further management of NSTEMI, CHF and respiratory distress. Past Medical History: HTN Hyperlipidemia ?CAD - note made of h/o angina h/o Colon CA s/p resection s/p hip fracture with THR Vit B12 deficiency Social History: Lives in senior housing where meals are prepared for her. Walks with a cane. Daughter comes to visit daily. Family states she has never smoked and does not drink. No h/o lung problems or use of home O2. Family History: non-contributory. Physical Exam: T: 98.8F (rectal), BP: 108/46, HR 62 (junctional), RR: 11 Current settings: AC 450x12/5/60%. Gen: Intubated and sedated. NAD HEENT: PERRL, MMM CV: RRR, II/VI harsh SEM radiating to carotids, II/IV diastolic murmur Chest: Coarse BS diffusely, no rales. BS equal. Abd: Soft, NT/ND, +BS, no HSM Extr: 1+ LE edema bilaterally, 2+ DPs bilaterally Neuro: Intubated, sedated. No focal deficits. Pertinent Results: [**2128-7-24**] INR = 4.4 (off coumadin for 2days) [**2128-7-8**] 11:45PM GLUCOSE-180* UREA N-28* CREAT-1.9* SODIUM-133 POTASSIUM-2.8* CHLORIDE-98 TOTAL CO2-21* ANION GAP-17 [**2128-7-8**] 11:45PM WBC-22.5* RBC-4.21 HGB-12.0 HCT-34.0* MCV-81* MCH-28.5 [**2128-7-8**] 11:45PM calTIBC-222* FERRITIN-226* TRF-171*, RET AUT-1.8 [**2128-7-8**] 11:45PM cTropnT-0.63*, CK(CPK)-185* [**2128-7-9**] 10:59AM TYPE-ART PO2-76* PCO2-33* PH-7.41 TOTAL CO2-22 BASE XS-2 Echo [**2128-7-9**]: Ejection Fraction: 45% to 50% 1. The left atrium is moderately dilated. 2.Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include anterior hypokinesis with distal septal akinesis. 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis. Trace aortic regurgitation is seen. 5.The mitral valve leaflets are moderately thickened. There is minimal to mild mitral stenosis. Mild (1+) mitral regurgitation is seen. 6.There is no pericardial effusion. Brief Hospital Course: #Cardiovascular- STEMI: Pt found to have NSTEMI with troponin peaking 1.232. Trigger for MI may have been plaque rupture or, also, demand-supply mismatch in the setting of possible PNA & respiratory failure. Cardiac catheterization on [**2128-7-12**] revealed normal LMCA, 70-80% calcified stenosis of LAD, small LCx, and RCA with 90% mid-occlusion. The RCA was stented with Sirolimus-eluting stents. Pt recovered uneventfully from the cath. NSTEMI & post-cath therapy included ASA, Plavix, and heparin gtt. . CHF: Pulmonary edema on admission thought to be due to CHF. Echo on [**7-9**] revealed moderate to severe AS (tx'd at cath) and an EF of 45 to 55%. It appears that pt may have mild CHF. After admission, she showed few if any signs of heart failure. . A-fib: Pt monitored on telemetry. Went into rapid a. fib during admission. Underwent D/C cardioversion, which failed to convert her to NSR. Multiple meds were equired to slow rate (amiodarone, metoprolol, and diltiazem). Her rapid afib seemed to respond best to the diltiazem & amiodarone. On these three medications, she eventually converted into sinus rhythm, which she has been in for 3 days now. Since converting into sinus rhythm, her HR has dropped into the 50's. Because of this slow rate, her beta-blocker was d/c'd and her calcium-channel blocker was continued at lower dose--short acting diltiazem 30mg, three times a day. The patient was also started on coumadin for the afib. However, there was debate over whether the patient should be on coumadin (given her age, risk factors for a fall, and the fact that she is already on aspirin & plavix for her cardiac issues). After extensive discussion, it was determined to proceed with coumadin therapy during hospitalizaiton and to discuss the issue with the patients PCP before discharge; however, we were unable to contact PCP prior to this discharge. While on coumadin, the pt had two bouts of uncomplicated, supratherapeutic INRs. Becuase of this we eventually, decided that it would be safer for her to be off coumadin, and tx'd only with aspirin & plavix. . # Aortic Stenosis: Found to have moderate to sever AS on echo. During cath, the pt underwent balloon valvuloplasty for AS (valve area 0.7cm2-->0.9cm2), reducing the gradient by 50%. . #Respiratory failure: Hypoxic respiratory failure. Intubated on [**7-9**]. Failed extubation on [**7-12**], after developing worsening pulmonary edema. Successful extubation on [**7-13**], post-cath. . #? RLL PNA/infx: afebrile on admission, though CXR suspicious for PNA. Pt tx'd with azithromycin, ceftriaxone & levofloxacin, which were d/c'd after concern of pt developing ATN w/ azithro & CTX and of further prolonging QTc interval. Pan-cultured, yielding no evidence of infection. . #Pneumothorax: caused during placement of central line. Resolved with chest tube. . #Elevated WBC w/ monocytosis: Noted upon arrival at [**Hospital1 18**]. Unclear what baseline white count or differential is. While WBC has declined somewhat, it is still elevated, The differential has shown persistent monocytosis (>4,000 u/L) along with promyelocytes and metamyelocytes on peripheral smear. (No blasts seen on smear.) Pt seen & elavuated by Hematology/Oncology, who believes pt likely has a myeloproliferative disorder. They have recommended a number of blood tests (including a complete anemia evaluation and cytogenetic testing). They will help develop plan for follow-up care, and are in the process of contacting the pt's PCP. . #Anemia: Pt required multiple transfusions during hospitalization. She reportedly has h/o B12 defic, requiring B12 injections. Iron studies revealed a nml iron level (88) and an elevated ferritin (226). If the pt does have a myeloproliferative d/o, her anemia may be related to that. . #Renal Failure: baseline Creatinine is unknown, though her crt has settled at 0.9. It peaked at 2.4, and improved since then. Exact cause of her ARF is unclear. It may have been due in part to a pre-renal state given that she was showing some signs of CHF. Medications renally dosed. . #Coagulation issues: after pt was started on coumadin for afib, she developed a supratherapeutic INR. Coumadin d/c'd because of pt's risk for fall. . #FEN: pt started on tube feeds via NGT while intubated. She continued on tube feeds s/p extubation after failing two swallowing evaluations. Her NGT was removed. She underwent a third swallowing evaluation with video imaging, which revealed that she could safely take ground solids and nectar thick liquids. She needs assistance with feeding herself. . #Psych/Neuro: Some confusion during hospitalization. Required wrist restraints & a sitter for short period. Oriented to place (hospital) and people. . #[**Name (NI) **] pt seen and evaluated by PT, who recommends therapy * assist for poor balance. Medications on Admission: Diltiazem 360mg PO qD Imdur 60mg PO qD Norvasc 5mg PO qHS Lipitor 10mg PO qD Aciphex 20mg PO qD B12 inj qmonth MV Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 7. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Ipratropium Bromide 0.02 % Solution Sig: [**1-19**] Inhalation Q6H (every 6 hours) as needed. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: Life Care Center - [**Location (un) 3320**] Discharge Diagnosis: 1.Hypoxic respiratory failure 2.Non-ST elevation MI s/p percutaneous transluminal coronary angiography with Sirolimus-eluting stents 3.CHF (diastolic) 4.Atrial fibrillation (rate & rhythm controlled) 5.Anemia 6.?Myeloproliferative disorder 7.Dysphagia requiring ground & nectar thick liquids 8.Hard of hearing Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . Please continue to take all your medications as prescribed and follow up with your appointments as below. . Please do not stop your aspirin and plavix until you speak with your cardiologist. . If you have chestpain, shortness of breath or fevers or chills please contact your PCP or return to the emergency room. Followup Instructions: 1. An appointment with Mrs.[**Doctor Last Name 29172**] PCP [**Name9 (PRE) **] [**Name9 (PRE) 67752**] (phone #[**Telephone/Fax (1) 60784**]) should be scheduled within 1 week of discharge from [**Hospital1 18**]. 2. Pt's PCP should review whether or not pt a candidate for coumadin tx for afib. 3. Heme-onc follow-up to be arrange with PCP via [**Hospital1 18**] [**Name9 (PRE) **] team.

Admission Date: [**2174-2-1**] Discharge Date: [**2174-2-7**] Date of Birth: [**2113-3-14**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain/lightheadedness/SOB/worsening fatigue Major Surgical or Invasive Procedure: Cardiac catheterization [**2174-2-1**] Aortic valve replacement (mechanical) [**2174-2-1**] History of Present Illness: 60 yo with known bicuspid aortic valve with aortic stenosis and regurgitation s/p Ascending Aortic repair in [**2168**] in [**State 12000**]. She reports exertional chest pain, orthopnea, and PND in the past month and was referred for nuclear stress test and [**State 461**]. Nuclear stress test was normal, however echo revealed severe aortic stenosis with [**Location (un) 109**] 0.6cm2. She is referred to Dr. [**First Name (STitle) **] for evaluation for Redo sternotomy/Aortic valve replacement Past Medical History: Hypertension Hyperlipidemia Bicuspid Aortic Valve Osteoarthritis of hands and knees Osteoporosis Scoliosis colon polyps s/p Ascending Aortic Aneurysm repair [**2168**] at the [**Hospital 104612**] Hospital s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 931**] Rod for scoliosis [**2145**] s/p Hysterectomy for fibroid uterus Social History: Lives with:divorced, lives with sister and 15 year old adopted son; has 3 adult biological children Occupation:Unemployed on disability Tobacco:denies ETOH:denies Family History: Family History:NC Physical Exam: Physical Exam Pulse:48 Resp:16 O2 sat: 99% RA B/P Right: 122/73 Left: `126/75 Height: 5'4" Weight:172 # General:SOB and very fatigued Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera; OP unremarkable; dentures in place Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x]; well-healed sternotomy Heart: RRR [x] Irregular [] 5/6 SEM radiates throughout precordium to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: Grossly intact; MAE 4.5 /5 strengths; nonfocal exam Pulses: Femoral Right: 2+ Left:2+ DP Right: 1+ Left:1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit :murmur radiates loudly to bil. carotids Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 104613**] (Complete) Done [**2174-2-2**] at 11:15:53 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Right ventricular chamber size and free wall motion are normal. The appearance of the ascending aorta is consistent with a normal tube graft. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. There is critical aortic valve stenosis (valve area <0.8cm2). The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Aortic valve replaced with 23mm mechanical valve; new valve is well seated with trace aortic regurgitation within struts, peak gradient 8mmHg. There is no aortic dissection seen. Trace mitral regurgitation, no [**Male First Name (un) **] seen. Preserved biventricular systolic function. These results were communicated to the surgical team at the time of exam. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**] TWO-VIEW CHEST [**2174-2-6**] COMPARISON: Radiograph of one day earlier. INDICATION: Pneumothorax. FINDINGS: Small left apical pneumothorax is slightly decreased in size and there has been slight improvement in aeration at the lung bases. There is otherwise no substantial change since the recent radiograph. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: SUN [**2174-2-6**] 12:06 PM [**2174-2-6**] 07:45AM BLOOD WBC-7.1 RBC-3.64* Hgb-9.7* Hct-29.6* MCV-81* MCH-26.6* MCHC-32.8 RDW-15.8* Plt Ct-162 [**2174-2-6**] 07:45AM BLOOD PT-25.8* INR(PT)-2.5* [**2174-2-5**] 05:00PM BLOOD PT-28.1* INR(PT)-2.8* [**2174-2-4**] 06:10AM BLOOD PT-14.9* PTT-32.4 INR(PT)-1.3* [**2174-2-6**] 07:45AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-141 K-3.8 Cl-107 HCO3-24 AnGap-14 [**2174-2-7**] 07:40AM BLOOD PT-29.6* INR(PT)-2.9* Brief Hospital Course: Admitted after cardiac catheterization for preoperative evaluation. On [**2174-2-1**] Ms. [**Known lastname **] was brought to the operating room and underwent aortic valve replacement. See operative note for details. She was brought from the operating room to the ICU intubated. She weaned from ventilator and was extubated without difficulty on POD#1. She had recieved IV morphine for pain and became confused. Her narcotics were discontinued and her mental status cleared over the next 24hrs. Her pain was well controlled on tylenol and motrin. She was started on betablockers and diuretics and couamdin for her mechanical aortic valve. Crestor was resumed. She was transferred to the step down unit on POD#2. Chest tubes and temporary pacing wires were removed per protocol. She was evaluated and treated by physical therpay and cleared for discharge to home on POD#5. Medications on Admission: Crestor 20mg po daily [**Last Name (un) 28031**] (Norvasc/Olmesartan) 10/40mg po daily Bystolic 10mg po daily Alendronate 70 mg q Sunday Discharge Medications: 1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). Disp:*4 Tablet(s)* Refills:*0* 2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed Release (E.C.)(s) 4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*0* 6. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 1 weeks. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dose will change daily for goal INR [**3-16**]. Dr. [**First Name (STitle) **]/ [**Hospital 3052**] to manage. Disp:*30 Tablet(s)* Refills:*2* 9. Outpatient Lab Work serial PT/INR dx: mechanical aortic valve ([**2174-2-2**]) goal INR [**3-16**] Results to [**Hospital 104614**] [**Hospital3 **] fax [**Telephone/Fax (1) 3534**] (managed by Dr. [**First Name (STitle) 9466**] [**Name (STitle) **]) 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Aortic stenosis s/p Aortic valve replacement ( 23 St. [**Male First Name (un) 923**] mechanical) HTN, Hyperlipidemia, Bicuspid AV, Osteo Arthritis hands and knees, Osteoporosis, Scoliosis, colon polyps, s/p Ascending Aortic Aneurysm repair [**2168**], s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 931**] Rod for scoliosis [**2145**], s/p Hysterectomy for fibroid uterus Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with tylenol and motrin prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 303**] (for Dr. [**First Name (STitle) 9466**] [**Name (STitle) **]) [**2174-2-21**] 2:45pm [**Telephone/Fax (1) 250**] Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Your INR will be checked on [**2174-2-8**] and results faxed to [**Telephone/Fax (1) 3534**] [**Hospital3 **] (for Dr. [**First Name (STitle) **] for coumadin dosing. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-3-2**] 1:00 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-3-2**] 11:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2174-2-7**]

Admission Date: [**2148-9-30**] Discharge Date: [**2148-10-2**] Date of Birth: [**2078-1-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 45**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Coronary catheterization with stenting of large OM1 History of Present Illness: 70 yo M with DM2, HTN, hyperchol., who experienced CP 4 days ago, lasted ~2 days. Patient admitted to [**Hospital3 **] hosiptal where an EKG was negative, "ruled out" overnight. Patient had + exercise stress test in hospital, 1 AM on [**9-30**] experienced nausea, vomiting, and diarrhea. Fingerstick BS was 19, and glucose given. The patient had substernal "chest discomfort," and EKG demonstrated 1mm STE in leads 2,3,F. He was transferred to [**Hospital1 18**] for urgent catheterization. Cath: LMCA distal taper 30% occl. LAD - prox calcification without critical lesions LCX - 60% lesion, modest calcification. Occ mid OM1 at prev stent location RCA - Dominant vessel 90% lesion at origin, TIMI 3 flow, stent patent. - LCx stent with 3x23 cypher -> 0% Past Medical History: DM2 Hypertension, hypercholesterolemia CAD s/p RCA and LCx stent History of subdural hemorrhage after MVA Social History: Nonsmoker. Single. Ran golf course business, previously very active walking. No tobacco use during lifetime. ~3 drinks per day. Family History: Non Contributory Physical Exam: VS: Afebrile, BP 140/73, P71 R16 SpO2=97% Gen: Alert, oriented, no distress. Pleasant and conversant. CV: S1 S2 with no MRG. Regular with rare ectopy / VPB. Lungs: Clear anterior Abd: NT/ND Groin - R catheteriztion site with no hematoma Ext - 1+ pitting edema bilateral ankle Pertinent Results: Admission Labs: . [**2148-9-30**] 04:55AM BLOOD WBC-11.1* RBC-4.14* Hgb-12.6* Hct-37.2* MCV-90 MCH-30.4 MCHC-33.9 RDW-13.2 Plt Ct-204 [**2148-9-30**] 04:55AM BLOOD PT-15.3* PTT-125.7* INR(PT)-1.6 [**2148-9-30**] 04:55AM BLOOD Glucose-298* UreaN-17 Creat-0.8 Na-134 K-4.3 Cl-102 HCO3-21* AnGap-15 [**2148-9-30**] 04:55AM BLOOD CK(CPK)-353* [**2148-9-30**] 04:55AM BLOOD CK-MB-39* MB Indx-11.0* cTropnT-0.66* [**2148-9-30**] 01:49PM BLOOD Mg-1.6 [**2148-9-30**] 04:55AM BLOOD %HbA1c-7.9* [Hgb]-DONE [A1c]-DONE [**2148-9-30**] 06:18AM BLOOD O2 Sat-69 . [**Hospital3 **]: . [**2148-9-30**] 04:55AM BLOOD CK(CPK)-353* [**2148-9-30**] 01:49PM BLOOD CK(CPK)-1168* [**2148-9-30**] 09:05PM BLOOD CK(CPK)-921* [**2148-10-1**] 06:03AM BLOOD CK(CPK)-555* [**2148-9-30**] 04:55AM BLOOD CK-MB-39* MB Indx-11.0* cTropnT-0.66* [**2148-9-30**] 01:49PM BLOOD CK-MB-143* MB Indx-12.2* [**2148-9-30**] 09:05PM BLOOD CK-MB-80* MB Indx-8.7* . Discharge Labs: . [**2148-10-2**] 07:00AM BLOOD WBC-7.4 RBC-4.34* Hgb-13.1* Hct-37.1* MCV-86 MCH-30.3 MCHC-35.4* RDW-13.4 Plt Ct-202 [**2148-10-2**] 07:00AM BLOOD Plt Ct-202 [**2148-10-2**] 07:00AM BLOOD Glucose-173* UreaN-18 Creat-1.0 Na-138 K-4.0 Cl-102 HCO3-25 AnGap-15 [**2148-10-2**] 07:00AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9 . CXR [**9-30**]: Marked engorgement of the superior mediastinal veins may be due in part to supine positioning, alternatively right heart dysfunction and/or pericardial effusion. Leftward displacement of the trachea at the thoracic inlet is probably due to an enlarged thyroid gland or other mass. Lungs are low in volume but clear, free of pulmonary edema and there is no appreciable pleural effusion. . EKG's: EKG: OSH [**1-1**] 1:15 AM - NSB 50 bpm, 2 mm [**Apartment Address(1) **],3,F. No Q waves. Axis 0 EKG 2 AM - SB 47 bpm, submm STE lead 2, TWI AvL and AvR. No STE. . Stress at OSH: MIBI [**9-28**]: 5 [**First Name8 (NamePattern2) **] [**Doctor First Name **] protocol with suboptimal HR response and stopped due to fatigue. No angina. <1mm ST depressions laterally. Small fixed defect in inf. and inflat wall c/w prior infarct. Mild lateral ischemia. WMA with infbasal hypokinesiws, LVEF 51%. . Cardiac Cath: 1. Selective coronary angiography of this right dominant system revealed two vessel coronary artery disease. The left main coronary artery was mildly calcified and there was distal tapering of the vessel to 30%. The left anterior descending artery had no angiographic evidence of coronary artery disease. There was proximal calcification of the LAD. The left circumflex artery had a 60% stenosis at the ostium of the vessel. The AV groove circumflex artery was a small vessel. The OM1 was a large vessel with occlusion in the mid-segment. The RCA was a dominant vessel with a 90% lesion at the origin of the vessel. A mid-RCA stent was visuallized and was widely patent. 2. Right heart catheterization revealed elevated right sided pressures. Mean PCWP = 23 mmhg. 3. Left heart catheterization revealed systemic hypertension. Fick calculated cardiac output and index were normal at 6.2 and 2.6 respectively. 4. Successful predilation using a 2.0 X 15 Maverick balloon, stenting using a 3.0 X 23 Cypher stent and post dilation using a 3.5 X 15 Maverick balloon of the acutely occluded mid Cx with lesion reduction from 100 % to 0%. The final angiogram showed TIMI III flow with no dissection or embolisation. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Systemic hypertension. 3. Elevated PCWP. 4. Preserved cardiac output. 5. Successful acute MI angioplasty of the mid Cx . ECHO post cath: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded (inferior wall and apex were not well visualized). Overall left ventricular systolic function is normal (LVEF>55%). The aortic root is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. . Brief Hospital Course: Mr. [**Known lastname 2412**] is a 70 year old man with a history of type II diabetes, hypertension, and hypercholesterolemia., who had been stented in the past. He r/o'd for MI at OSH and had a positive stress then developed chest pain and was found to have ST elevations in leads II, III, and aVF on EKG. He was transferred to [**Hospital1 18**] for emergent cath for his inferior STEMI on a heparin drip, integrillin drip, and nitro drip. In cath, he was found to have a LMCA with a distal taper to a 30% occlusion, LAD without critical lesions, a very small LCx with a 60% lesion. A very large OM1 had a total occlusion in the mid section in the area of a previous stent. This was opened with a 3x23 cypher stent to 0% occlusion. The dominant RCA was found to have an ostial lesion of unknown clinical significance estimated to be 90% but with TIMI 3 flow and a patent stent in the RCA. Mr. [**Known lastname 2412**] recovered well after his catheterization. He was placed on plavix and high dose lipitor. He was continued on aspirin and lisinopril. His toprol XL was increased to 75mg QD from 50mg QD. He was observed in the CCU for monitoring and had no evidence of hematoma or vascular compromise at the femoral artery. Nor did he exhibit further symptoms, EKG changes, or arrhythmias. Enzymes peaked and trended down. His HTN was well controlled throughout his hospital course. Echo showed a preserved EF after catheterization. He was transferred to the floor prior to planned discharge after a PT evaluation. Of note, he continued to receive heparin SQ prophylaxis throughout his hospital stay. In addition, his diabetes was managed with RISS throughout his stay with moderate control of his blood glucose. His metformin was d/c'd prior to transfer to [**Hospital1 18**], as was his avandia. The patient was restarted on these medications after discharge home (72 hours after dye load). There are a few outstanding issues: 1. Mr. [**Known lastname 2412**] will need to be enrolled in cardiac rehabilitation. 2. Prior to cardiac rehab, he would likely benefit from a stress test to evaluate the physiologic significance of the ostial lesion in the RCA 3. The ostial lesion was not stented at this hospitalization as it was thought to have played no part in the patient??????s STEMI and therefore could be re-evaluated in the future. To this end, I have established a follow-up appointment for the patient with his cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital3 **] on [**2148-10-21**]. I have also faxed a letter to this effect to Dr.[**Name (NI) 62997**] office describing the patient's presentation and hospital course. His primary physician is [**Last Name (NamePattern4) **]. [**First Name (STitle) **], with whom he has also been instructed to follow-up. The patient was discharged to home in good condition. Medications on Admission: Lipitor 40 mg po qd Lisinopril 20 mg po qd ASA 325 mg po qd Toprol 50 mg po qd Avandia 4 mg po qd Metformin 500 mg po bid Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Fluocinonide 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*qs for one month's supply * Refills:*0* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day: Take as before hospitalization. . 9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as needed as needed for pain: Take one tablet if chest pain occurs, wait 5 minutes and repeat up to 3 times or until the pain disappears. Disp:*20 tabs* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: ST Elevation MI now s/p stenting DM2 controlled CAD HTN Discharge Condition: Good. Discharge Instructions: You were admitted to the hospital for an MI or "heart attack." You had a coronary catheterization and received a stent. It is VERY IMPORTANT that you take the plavix we prescribe for you EVERY DAY. You have a follow-up appointment with Dr. [**Last Name (STitle) **] at [**Hospital3 **] on [**10-21**] at 10:15am. It is very important that you see him for this visit. - he will enroll you in cardiac rehabilitation classes after you have an exercise stress test to evaluate the function of your heart. - you continue to have some narrowing on the right side of your heart that did not cause your current MI. Dr. [**Last Name (STitle) **] knows of this and will follow your care for this issue. You should make a follow-up appointment with Dr. [**First Name (STitle) **] within the next 2-4 weeks to follow up after this hospitalization. You should avoid strenuous exercise for the next two weeks. Do not lift more than [**9-21**] pounds at a time. If you develop pain in your groin, bleeding or swelling in your groin, lightheadedness, new chest pain, severe new back pain, or other worrisome symptoms, please seek immediate medical attention. Followup Instructions: Dr. [**Last Name (STitle) **] (cardiology) at [**Hospital6 33**] on [**2148-10-21**] at 10:15am Dr. [**First Name (STitle) **] (Primary Care) within 2-4 weeks. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**] Completed by:[**2148-10-2**]

Admission Date: [**2121-10-23**] Discharge Date: [**2121-10-28**] Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 7333**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with two bare metal stents placed to the RCA History of Present Illness: [**Age over 90 **]F with HTN, macular degenration, without known CAD with new RCA STEMI s/p BMS x2. . Mrs [**Known lastname 46690**] first felt unwell at about 9:30 this morning. She later developed [**2120-4-6**] chest pressure that radiated to her L arm as well as nausea. She waited 15 minutes then her nephew brought her to [**Hospital1 18**] where an EKG showed STE in II III AVF, with neg troponin, a code STEMI was called and she was taken to the cath lab. There she was found to have a tight stenosis of the proximal RCA and complete occlusion of the distal RCA. These lesions were angioplastied and two BMS were placed. She was also noted to have 80-90% proximal LAD and 60-70% Circ stenoses. Her CP completely resolved. Her groin was closed with a closure device though she still had some oozing from the site. . Of note she has been having chest pressure associated with exertion for approximately 1 year. She denies orthopnea or PND. By report she does take some pill for lower extremity edema but denies CHF history. There is a question of a possible CVA or TIA in the past year. She also has someone stay with her 24 hours a day because of forgetfulness. . On review of systems, she denies deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. However because of her mental status this history may not be entirely accurate. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Carotid stenosis ?pAF (not on coumadin) -Macular degeneration - Melanoma of L thigh B/L hip replacement Social History: Lives with 24 hour caretaker in [**Name (NI) **]. Has nephew and neice who are very involved in her care. Has mild forgetfulness at baseline. Limited ambulation at home but can cook and do small chores. - Tobacco history: None - ETOH: Minimal - Illicit drugs: None Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: VS: T= 97 BP= 110/71 HR=84 RR=23 O2 sat= 99 3L GENERAL: NAD. A&Ox2-3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP not appreciated 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. Anterior exam CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. GROIN: small oozing from femoral line, no hematoma or bruit EXTREMITIES: No c/c/e. No femoral bruits. DP pulses dopplerable b/l SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . Discharge exam: VS: Tmax/Tcurrent: 97.5/97.1 HR: 68-104, RR 20, BP: 134-155/84-85. O2 sat 99% RA. In/Out: Last 24H: 680/inc Last 12H: 0/inc Weight: 48.9 kg (49.6 kg) . Tele: SR, rate 80-107 . GENERAL: well-appearing elderly female sitting up in the bed. NAD. Oriented to person only. Alert and conversant. HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with no JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. LUNGS: Severe kyphosis. Resp were unlabored, no accessory muscle use. LS clear throughout. ABDOMEN: Soft, NTND. No HSM or tenderness. GROIN: Right groin with mild ecchymosis, no bleeding/ hematoma or bruit noted. DP/PT per doppler SKIN: intact Pertinent Results: ADMISSION LABS: [**2121-10-23**] 12:12PM GLUCOSE-176* UREA N-19 CREAT-0.5 SODIUM-141 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-29 ANION GAP-15 [**2121-10-23**] 12:12PM estGFR-Using this [**2121-10-23**] 12:12PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-1.7 [**2121-10-23**] 12:12PM WBC-6.5 RBC-4.41 HGB-13.2 HCT-40.3 MCV-91 MCH-29.9 MCHC-32.7 RDW-12.1 [**2121-10-23**] 12:12PM NEUTS-71.3* LYMPHS-21.4 MONOS-4.5 EOS-2.5 BASOS-0.3 [**2121-10-23**] 12:12PM PLT COUNT-289 [**2121-10-23**] 12:12PM PT-13.8* PTT-150* INR(PT)-1.2* . PERTINENT LABS: [**2121-10-23**] 12:12PM BLOOD cTropnT-<0.01 [**2121-10-23**] 07:03PM BLOOD CK-MB-107* MB Indx-19.2* cTropnT-3.26* [**2121-10-24**] 04:18AM BLOOD CK-MB-68* MB Indx-16.1* cTropnT-2.47* [**2121-10-25**] 11:10AM BLOOD CK-MB-8 cTropnT-0.78* [**2121-10-25**] 05:28PM BLOOD CK-MB-7 cTropnT-0.82* [**2121-10-23**] 07:03PM BLOOD ALT-17 AST-67* CK(CPK)-558* AlkPhos-125* TotBili-0.3 [**2121-10-25**] 06:10AM BLOOD ALT-14 AST-34 AlkPhos-97 TotBili-0.3 [**2121-10-23**] 07:03PM BLOOD Triglyc-85 HDL-85 CHOL/HD-2.2 LDLcalc-88 . DISCHARGE LABS: [**2121-10-28**] 07:40AM BLOOD WBC-6.2 RBC-4.53 Hgb-13.5 Hct-41.0 MCV-91 MCH-29.9 MCHC-33.0 RDW-12.5 Plt Ct-247 [**2121-10-28**] 07:40AM BLOOD Glucose-81 UreaN-15 Creat-0.4 Na-140 K-3.6 Cl-100 HCO3-29 AnGap-15 . EKG [**10-23**] Baseline artifact at the end of the tracing. ST segment elevation in leads II, III, aVF and V6 with ST segment depression in the lateral and the anterior precordial leads suggestive of acute injury, probable myocardial infarction. Poor R wave progression across the precordium - cannot rule out prior anterior myocardial infarction. No previous tracing available for comparison. . CATH [**10-23**] COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated 3 vessel coronary artery disease. The LMCA had mild plaquing, and a 20% ostial lesion. The proximal LAD was noted to have an 80-90% stenosis. It was notable for a cuff adequate for endovascular treatment of this lesion without necessarily involving the LMCA. It was noted to be very heavily calcified, and would thus consider rotablation. The LCx had a proximal 60-70% lesion. The RCA had a thrombotic occlusion of the distal RCA. There was also a tight calcific lesion noted in the proximal RCA. 2. Limited resting hemodynamics revealed systemic arterial normotension with a central aortic pressure of 128/68, mean 94 mmHg. 3. Successful PCI to the dRCA lesion with a 3.5x18mm Vision BMS and the pRCA with a 3.5x15mm Vision BMS. 4. Perclose to the Right CFA. 5. No complications. FINAL DIAGNOSIS: 1. Thrombotic lesion in the distal RCA with notable disease in the LAD and LCx as well. 2. Systemic arterial normotension. 3. Successful PCI to the dRCA and pRCA with two Vision BMS. 4. No complications of the procedure. 5. Patient is to remain on aspirin indefinitely and clopidogrel for at least 9-12 months given the setting of an acute MI. . EKG [**10-24**] Baseline artifact. Sinus rhythm. Q waves in leads III and aVF with deep T wave inversion in the inferior and lateral precordial leads, consistent with an evolving inferior myocardial infarction. Poor R wave progression in leads V1-V3 suggestive of a prior anteroseptal myocardial infarction. Compared to the previous tracing of [**2121-10-23**] the diffuse T wave inversions are new, as are the inferior Q waves, consistent with evolution of the previously seen inferior myocardial infarction pattern. ECHO: [**10-24**] The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) secondary to inferior, posterior, and lateral hypokinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall thickness is normal. Right ventricular chamber size is normal. with depressed free wall contractility. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . CXR [**10-24**] FINDINGS: Evaluation is slightly limited due to severe levoscoliosis of the thoracic spine. Within those limitations, the cardiomediastinal silhouette and hila are normal. There is no pleural effusion and no pneumothorax. IMPRESSION: Severe thoracic levoscoliosis, no acute cardiothoracic process. . Brief Hospital Course: [**Age over 90 **]F with HTN, macular degeneration, without known CAD with new RCA STEMI s/p BMS x2. . # CAD/RCA STEMI: Presented with RCA STEMI. SHe was treated with aspirin plavix and taken to the cath lab with succesful PTCA and BMSx2 placement with resolution of CP. Post catheterization EKG demonstrated resolution of the STE but new Q waves in II and AVF. Echo the following day demonstrated LVEF 35% and depressed RV function. She was placed on atorvastatin 80mg, metoprolol, lisinopril and imdur. Her cardiac cath also showed significant CAD of the LAD and circumflex artetries but no intervention was performed. These lesions will be treated medically for now. . #HTN: Had HTN prior to admission treated with diltiazem. After her MI she was started on metoprolol, lisinopril, and imdur, and her diltiazem was discontinued. Blood pressure was well controlled at discharge. #Acute Systolic Dysfunction: Has been on lasix 40 mg for lower extremity edema. Her LVEF is 35% on recent echo thought to be depressed from baseline. She looked mildly hypervolemic but was not actively diuresed as she is likely preload dependent in setting of her RV infarct. Her home lasix was retarted prior to discharge. . #Hyperlipidemia: had history of HLD and was on pravastatin 20 mg daily. This was changed to atorvastatin 80mg after her MI . #Macular degeneration: Stable . #Urinary tract infection: Multiple episodes of urinary incontinance in past 24h since foley removed. Pt denies incontinence at home. U/A positive, started on ceftriaxone empirically and culture grew klebsiella in urine, sensitive to ciprofloxacin. She will finish a 7 day course of antibiotics with cipro for 4 days. . # Dementia. Baseline at present, possible additional component of delirium. Pt much clearer today, A+Ox3, following commands, conversant, pleasant. . Transitional issues: 1. consider repeating u/a once antibiotics are finished 2. consider stress test in the future to assess for ischemia given known occlusions 3. Chem-7 to be drawn in 3 days at rehabilitation as pt is newly on lisinopril 4. BP and HR monitoring on new medicines 5. Repeat ECHO in 6 weeks to assess EF. Medications on Admission: Diltiazem 240 daily lasix 40 daily pravastatin 20 daily detrol LA 2mg daily KCL 10MEQ 2 pills daily Ca 600 vit D 400 daily omeprazole 20 daily symbicort 80/4.5 2 puffs [**Hospital1 **] Cortisporin eye drops 4 drops [**Hospital1 **] Flonase 50mg daily senna PRN (confirmed with niece [**2121-10-28**]) Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 9. Detrol LA 2 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 10. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 11. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 13. Cortisporin 3.5-400-10,000 mg-unit/g-1% Ointment Sig: Four (4) drops Ophthalmic twice a day. 14. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) Nasal once a day. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 16. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Senior Healthcare - [**Location (un) 1887**] Discharge Diagnosis: Coronary artery disease Hypertension ? CVA [**2119**] Dyslipidemia Atrial fibrillation Macular degeneration Carotid stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hopital on [**2121-10-23**] with a heart attack. You had a heart catheterization the same day and 2 bare metal stents placed in your right coronary artery. You had blockages in your left anterior descending artery and left circumflex artery which are being treated with medication. You should take Aspirin 325mg daily indefinitely and Plavix 75mg daily for a minimum of [**8-11**] months. Do not stop either of these medications unless instructed to do so by Dr. [**Last Name (STitle) 91316**]. Stopping either of these medications early COULD result in a blockage inside your stents and cause another heart attack. You were also treated for a urinary tract infection while you were in the hospital. You should continue Ciprofloxacin (antibiotic) 500mg for 4 more days. You should take Lisinopril 5mg daily (for your heart failure and high blood pressure). You will need labs repeated in 3 days. The heart attack made your heart weak and you may retain extra fluid. You are on medicines to help your heart pump better but you need to watch for any swelling in your legs. Please weigh yourself every morning, call Dr. [**Last Name (STitle) 91316**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Medication Changes: Stop Pravastatin 20mg and start Lipitor 80mg daily (for cholesterol) Stop Diltiazem Stop Prilosec and start Ranitidine (Zantac) 300mg daily (safer medication for heartburn while you are on Plavix) Start ASA and Plavix as above Start Toprol 50mg daily (to take some work load away from your heart) Start Ciprofloxacin 500mg [**Hospital1 **] for 4 more days (urine infection) Start IMDUR 15mg daily (to help with chest pain for blockages in your heart) Start Lisinopril (for weak heart and blood pressure) Followup Instructions: Cardiology: Dr. [**First Name (STitle) **] [**Name (STitle) 91316**]([**Hospital6 4620**]) [**Telephone/Fax (1) 18278**] Tuesday [**2121-11-11**]:30am -green building #562

Admission Date: [**2125-6-19**] Discharge Date: [**2125-6-22**] Date of Birth: [**2041-5-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Strawberry / Dicloxacillin Attending:[**First Name3 (LF) 5129**] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: None History of Present Illness: 84 year-old woman with a history of CVA was found unresponsive and reported to be pulseless at her nursing home. CPR was initiated briefly until her DNR/DNI status was discovered. Patient states that she was aware of the chest compressions. En route to ED she had 4 episodes of non-bloody, non-bilious emesis. In ED patient, was on a non-rebreather. Labs notable for positive urinalysis with WBC 57 and positive leukocyte esterase and nitrates. Lactate 1.9, CXR without pneumonia. CT ABDOMEN/PELVIS initially concerning for intermittent cecal volvulus, but on review with radiologist there is contrast past cecum so unlikely to have obstruction. Ceftriaxone given for UTI and 3 liters of IV fluids given. Patient had transient decrease in SBP to 75, but spontaneously increased to > 100 upon awakening. Admitted to ICU for monitoring. ICU course: Patient did not have any hypotension in the ICU. Review of Systems: (+) Per HPI and has urinary incontinence at basline and has paranoid delusions. Denies dysuria, fever, chills, chest pain, syncope, headache, vision changes, shortness of breath, palpitations, neck stiffness, abdominal pain, diarrhea, or constipation. (-) Denies night sweats, weight change, visual changes, oral ulcers, bleeding nose or gums, orthopnea, PND, lower extremity edema, cough, hemoptysis, melena, BRBPR, dysuria, hematuria, easy bruising, skin rash, myalgias, joint pain, back pain, numbness, weakness, dizziness, vertigo, headache, confusion, or depression. All other review of systems negative. Past Medical History: - GERD - Post herpetic neuralgia - Chronic pain began in [**11/2118**] following an episode of herpes zoster. - Polymyositis diagnosed in [**2113**]. - Hypothyroidism status post thyroidectomy 12 years ago for goiter. - Stress fracture, left thigh (femur). - Spinal stenosis. - Basal cell carcinoma. - Recurrent falls. - Paranoid schizophrenia, last hospitalization two years ago. - Depression. - Cholecystectomy - 3 episodes of sepsis in [**2119**] requring MICU stay and intubation. Last in [**4-20**]. Methortrexate stopped after last MICU stay. Social History: Living in [**Hospital 100**] Rehab currently. No history of smoking, alcohol, or recreational drug use. Walks with a walker. Independent in some activities of daily living, like toileting, feeding, walking, using telephone, etc. Needs assistance or is dependent on rest. Has 3 involved daughters. Family History: Mother with asthma. Father died of old age. Physical Exam: ADMISSION EXAM: Vitals: T: 99.4 BP: 111/41 P: 74 R: 14 O2: 94% on 4L General: Alert, oriented x 3, no acute distress HEENT: Sclera anicteric, moist mucous membrane, oropharynx clear, no thrush Neck: supple, JVP not elevated, no LAD Lungs: trace crackle at right lung base, otherwise CTAB with no wheeze or rhonchi. CV: Regular rate and rhythm, normal S1 + S2, 1/6 systolic murmur at LUSB, no rub or gallops Abdomen: soft, non-tender, +BS, minimal distension, no HSM, no rebound or gaurding, tympanic to percussion over epigastric area. GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: alert, oriented to year, place and person. CN II-XII grossly intact. spontaneously moves all 4 extremities. sensation intact throughout. Skin: no rashes noted. TRANSFER TO FLOOR EXAM [**2125-6-20**]: VS: 98.9, 130/80, 78, 20, 97% on room air Pain: None GEN: NAD HEENT: EOMI, MMM, no oral lesions NECK: Supple, JVP flat CHEST: Right basilar mild rales CV: RRR, normal S1 and S2 ABD: Soft, nontender, nondistended, bowel sounds present EXT: No lower extremity edema SKIN: No rash GU: Foley in place NEURO: Alert, oriented x3, CN 2-12 intact, sensory intact throughout, strength 5/5 BUE/BLE, fluent speech, normal coordination PSYCH: Calm Pertinent Results: [**2125-6-20**] 04:07AM BLOOD WBC-5.7 RBC-3.01* Hgb-9.6* Hct-29.0* MCV-96 MCH-32.0 MCHC-33.3 RDW-12.6 Plt Ct-183 [**2125-6-18**] 11:10PM BLOOD WBC-4.5 RBC-3.87* Hgb-11.9* Hct-36.4 MCV-94 MCH-30.7 MCHC-32.7 RDW-13.1 Plt Ct-211 [**2125-6-20**] 04:07AM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-140 K-4.0 Cl-106 HCO3-29 AnGap-9 [**2125-6-18**] 11:10PM BLOOD Glucose-137* UreaN-22* Creat-0.7 Na-138 K-4.2 Cl-101 HCO3-29 AnGap-12 ECG [**2125-6-18**]: Sinus tachy, rate 116, normal axis, 1st degree AV conduction delay, incomplete RBBB, poor R-wave progression ECG [**2125-6-19**]: Sinus rhythm, rate 71, normal axis, 1st degree AV conduction delay, incomplete RBBB, poor R-wave progression Microbiology: Urine culture [**2125-6-19**]: E. coli >100,000 URINE CULTURE (Final [**2125-6-21**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Feces negative for C.difficile toxin A & B by EIA Blood culture [**2125-6-18**] and [**2125-6-19**]: No growth to date Radiology: CXR [**2125-6-18**]: Mild cardiomegaly, but no acute cardiopulmonary process. CXR [**2125-6-19**]: Findings concerning for early heart failure. CT ABDOMEN AND PELVIS [**2125-6-19**]: 1. Findings compatible with cecal bascule. 2. Mild intra- and moderate extra-hepatic biliary dilatation. While these findings might be seen in post-cholecystectomy patients of this age, ultrasound may be considered to assess for an obstructing stone or lesion. Brief Hospital Course: 84 year-old woman with history of CVA found to be unresponsive at nursing home likely [**1-17**] urinary tract infection. Patient had transient hypotension for which he was observed in the ICU. This may have due to a sepsis syndrome or due to hypovolemia from several days of diarrhea reporteddly before admission. Problem [**Name (NI) **]: # E. Coli UTI: Initially received three days of IV Ceftriaxone. When the sensitivities of the E.Coli in the urine came back, she was switched to oral Cipro x 5 more days (total of 8 days of Abx) # Hypotension - Monitored in ICU without further hypotension. Responded to fluids and antibiotics. See above. Did not recur. # Schizophernia: Chronic. Pt with active paranoid delusions both with family and staff. Geriatrics, in the ICU, recommended holding QHS doses and using zyprexa only PRN if agitated for now to see if she continues with apnea/hypotension at night. Restarting home risperidone slowly to make sure blood pressure tolerates. Started on risperidone 1mg [**Hospital1 **] (normally 1mg Qam, 2mg Qpm). On this regimen, she did well from a psychiatric point of view for the few days she was here. # Hypothyroidism s/p thyroidectomy: Continue Levothyroxine # Post-Herpetic Neuralgia: Continue Gabapentin and Oxycodone prn # DVT prophylaxis: Subcutaneous heparin # Communication: Patient/HCP [**Name (NI) **],[**First Name3 (LF) **] (DAUGHTER) Phone: [**Telephone/Fax (1) 61842**] Other Phone: [**Telephone/Fax (1) 61843**] # Code: DNR/DNI, pressors okay if not primary pulmonary issue(discussed with HCP) Medications on Admission: Oxycodone 2.5mg [**Hospital1 **] Oxycodone 2.5 mg q4h prn breakthrough pain Seroquel 100 mg qpm Vitamin D2 5000 unit Risperidone 1 mg qam Risperidone 2 mg q1900 Levothyroxine 50 mcg daily Magnesium Hydroxide (Milk of Magnesia) 30 mL daily Gabapentin 100 mg q1200, 200 mg q1600 Tylenol 650 mg q6h prn fever/pain Senna 1 tab qhs Cadexomer apply daily to affected area Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 6. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 9. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation. 10. risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Discharge Disposition: Extended Care Facility: [**Hospital1 100**] Senior Life - [**Location (un) 2312**]; [**Location (un) 550**] versus Long-Term Care Discharge Diagnosis: Sepsis syndrome Urinary tract infection Fecal impaction Hypovolemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for low blood pressure and difficulty awakening felt to be due to dehydration from diarrhea and urinary tract infection. You improved with antibiotics and IV fluids. Other than severe constipation no significant other abnormalities were identified. Followup Instructions: Your primary care physician and your psychiatrist will see you at the [**Hospital1 100**] Senir Life Rehabilitation and Long Term Care Center upon your arrival there.

Admission Date: [**2118-1-31**] Discharge Date: [**2118-2-5**] Date of Birth: [**2118-1-31**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 66504**] is the 2.985 kg product of a 34 week gestation born to a 30-year-old G3, P0, now 1 mother. Prenatal screens - A positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, GBS unknown. PAST OBSTETRICAL HISTORY: Remarkable for an intrauterine fetal demise at 30 weeks gestation. This pregnancy complicated by hydramnios also. The baby's autopsy was reported to be normal. Dates are by first trimester ultrasound. Pregnancy was complicated by severe polyhydramnios with an AFI of 45 just prior to delivery. Mother has had multiple ultrasounds and fetal surveys at 17 and 21 weeks that had been unremarkable. Mother was transferred to the [**Country 3867**] from [**Hospital **] Hospital in the middle of [**Month (only) 404**] with increasing polyhydramnios and preterm labor. She received a full course of betamethasone on [**1-14**] and was treated with magnesium sulfate until [**1-29**]. She was given 1 dose of nifedipine 2 days ago as a tocolytic without effect. Delivery by cesarean section was prompted by ongoing labor. Preterm labor with new onset of late decelerations and breech presentation. Nuchal cord was noted at delivery. The infant cried after bulb suctioning and stimulation. Apgars were 8 and 8. PHYSICAL EXAMINATION: Weight 2.985 kg, 95th percentile; length 48 cm, 85th percentile; head circumference 35 cm, greater than 95th percentile. Anterior fontanel soft and flat. Head shape normal with mildly flattened on top consistent with breech positioning in utero. Facies nondysmorphic, palate intact. Mild intermittent grunting noted with mild subcostal retractions. Good air entry bilaterally. S1 and S2 normal intensity. No murmur noted. Perfusion good. Abdomen soft with no masses. Three vessel cord. Normal male with testes palpable bilaterally. Tone initially low normal but improved within normal limits on admission. Hips increased lax knee but no obvious dislocation. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname **] has been admitted to the newborn intensive care unit and has been stable in room air since admission. CARDIOVASCULAR: Infant has an audible murmur. Cardiology consult of the infant on [**2-4**]. Echocardiogram results were within normal limits revealing a PPS murmur. FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was 2.985 kg. Discharge weight .. The infant was initially started on 60 cc per kg per day of D10W. Enteral feedings were initiated on day of life No.1. The infant is currently on a 120 cc per kg per day of premature Enfamil 20 calorie or breast milk, tolerating feeds well. Electrolytes on day of life 1 showed a sodium of 142, potassium of 5.1, chloride of 108, and total CO2 of 23. GASTROINTESTINAL: Bilirubin on [**2-3**] was 8.2/0.3. Surgery was consulted to rule out a TE fistula as the infant had an incidental pass of a gavage tube into his right bronchus. TEF was primarily ruled out as [**Last Name (un) 37079**] was passed easily to stomach and x-ray revealed good position. HEMATOLOGY: Hematocrit on admission was 38.2. The infant has not required any blood transfusions. INFECTIOUS DISEASE: CBC and blood cultures were obtained on admission. CBC was benign and blood cultures remained negative at 48 hours at which time ampicillin and gentamicin were discontinued. Initial CBC had a white count of 16, platelet count of 204, 53 polys and 0 bands. NEUROLOGY: Appropriate for gestational age. MUSCULOSKELETAL: Of note incidental finding on x-ray, the infant has a hemivertebra at T11. AUDIOLOGY: Hearing screen has not been done but should be done prior to discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To [**Hospital **] Hospital. NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 56727**]. Telephone No. [**Telephone/Fax (1) 65821**]. CARE RECOMMENDATIONS: 1. Continue advancing fluid volume to support infant's weight gain needs. 2. Medications: Not applicable. 3. Car Seat Position Screening has not been performed. 4. State Newborn Screen was sent on day of life 3. 5. Immunizations received: The infant has not received any immunizations at this time. DISCHARGE DIAGNOSES: Premature infant born at 34 weeks. Rule out sepsis with antibiotics. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 37305**], M.D. [**MD Number(2) 59540**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2118-2-4**] 21:56:45 T: [**2118-2-4**] 22:38:39 Job#: [**Job Number 66505**]

Admission Date: [**2126-5-7**] Discharge Date: [**2126-6-18**] Date of Birth: [**2126-5-7**] Sex: F Service: NB HISTORY: This is twin #1, born at 27 and 2/7 weeks gestation to a 36 year-old, G6, P1 mother with [**First Name8 (NamePattern2) **] [**Name (NI) **] of [**2126-8-4**]. Prenatal screens: Blood type A positive, antibody negative, HBSAG negative. RPR nonreactive. Rubella immune. GBS unknown. PAST OBSTETRIC HISTORY: Significant for 3 ectopic pregnancies as well as still born twins at 21 and 5/7 weeks gestation and a full term infant born in [**2124**] who is now 16 months of age. Also history of cervical incompetence, requiring a cerclage in this pregnancy at 13 weeks gestation. On [**2126-4-25**], mother was admitted to [**Name (NI) **] Hospital with cervical shortening. At that time, she was transferred to [**Hospital1 18**] on [**2126-4-26**] at 25 and 4/7 weeks gestation for monitoring of preterm labor. She was betamethasone complete on [**2126-4-26**]. On [**2126-5-7**], mother had spontaneous, persistent preterm labor which led to a Cesarean section. This infant emerged with a weak but spontaneous cry and then became apneic, received bagged mask ventilation and was intubated at 5 minutes of age. Had Apgars of 5, 5 and 8 at 1, 5 and 10 minutes. Infant was transferred to the NICU for further care. PHYSICAL EXAMINATION: On admission, physical examination showed appropriate for gestational age infant. Active with spontaneous movements. Pink and well perfused. HEENT: Normal head. Anterior fontanel soft and flat. Bilateral red reflexes. Nares and nose normal. Intact palate. Supple neck. No masses. Chest: Appropriate and normal with mild retractions. Clear and equal breath sounds. CV: Normal heart sounds, no murmur. Normal rate and rhythm. Pulse is normal, well perfused. Abdomen soft, nontender. No hepatosplenomegaly. No masses. Three vessel cord. Genitourinary: Normal preterm female. Back normal and appropriate. Extremities: Normal. Neuro: Active, normal tone and appropriate for gestational age. Weight 1090 grams which is 50th percentile. Length 35.5 cm which is 25th to 50th percentile. Head circumference 26.5 cm which is 50th to 75th percentile. HOSPITAL COURSE BY SYSTEMS: Respiratory: The infant had respiratory distress syndrome on admission to the NICU and received 2 doses of Surfactant therapy while on conventional ventilation. At 24 hours of age, she extubated to CPAP after initiation of caffeine citrate for prophylactic methylxanthine therapy. She remained on CPAP until [**2126-5-20**], day of life 13, at which time she transitioned to nasal cannula where she remains at this time. She does occasionally have apneic and bradycardiac episodes but are rare. She has had none in the past 3 days. She remains on caffeine citrate. Nasal cannula is at 200 cc flow, 28 to 30% FI02. Cardiovascular: She had an intermittent murmur audible shortly after birth. The murmur became more persistent on day of life 3 at which time she had an echocardiogram done which was on [**2126-5-10**], showing a large PDA and a small VSD. She received an initial course of indomethacin therapy at that time. She had a second course of indomethacin given for persistent murmur on [**2126-5-12**]. She had a follow-up echocardiogram done after the second course of Indocin on [**2126-5-13**]. At that time, she had a 2 mm PDA with a left to right flow. She had a follow-up echocardiogram on [**2126-5-15**] which showed a 1.5 mm PDA with high velocity continuous left to right flow. She had a persistent intermittent murmur and continues to do so at this time. She had another echocardiogram done on [**2126-6-7**] which showed a 3 mm PDA with left to right flow but it was felt to be restrictive without clinical compromise, so no further management has been done. Otherwise, she has maintained a normal blood pressures and heart rates. Fluids, electrolytes and nutrition: Double lumen UVC was placed on admission to the NICU and the infant was started on IV fluids and parenteral nutrition on the first day. She remained N.P.O. due to patent ductus arteriosus and received initial enteral feedings on [**2126-5-16**], day of life 9. Feedings were slowly advanced and she received full enteral feedings on [**2126-5-24**], day of life 17. At that point, her calories were further concentrated to maximum caloric density of breast milk with 30 cals per ounce and BeneProtein. She is presently on BM26 with Beneprotein at 150 ml/kg/day given via gavage over 90 minutes. She has had adequate weight gain. Her most recent weight is 1875 grams (25-50%). Her most recent head circumference is 29 cm (10-25%), and her most recent length is 41cm (10-25%). Ferrous sulfate and Vitamin E were initiated on [**2126-5-26**]. Hematology: Her hematocrit at birth was 41.5 with a platelet count of 208. She has required 2 blood product transfusions, first one on [**2126-5-20**] and the most recent one on [**2126-6-11**] and that was given for hematocrit of 23.9 with a retic count of 4.6 and symptomatology of increased apnea and bradycardia. There have been no further hematocrits measured. She remains on iron at this time. Gastrointestinal: The infant developed hyperbilirubinemia with a peak bilirubin level of 5.9 over 0.5. She received a total of 10 days of phototherapy. Her hyperbilirubinemia has resolved. Infectious disease: A CBC and blood culture were screened on admission to the NICU due to maternal preterm labor. The CBC was benign. Ampicillin and gentamycin were initiated and discontinued after 48 hours of negative blood culture. There have been no further issues with sepsis. Neurology: The infant has had 2 head ultrasounds done. The initial one was on [**2126-5-14**] followed up by a head ultrasound on [**2126-6-5**], both within normal limits. It is recommended to repeat the head ultrasound at a postmenstrual age of 36 weeks' gestation. Sensory: Audiology: A hearing screen has not been performed to date. The infant will need a hearing screen prior to discharge from the hospital. Ophthalmology: An initial eye examination was done on [**2126-6-10**] showing immature retina to zone 2, needs follow-up at 2 weeks from that exam. Psychosocial: A [**Hospital1 18**] social worker has been in contact with the family. There are no active issues at this time but if there are any concerns, she can be reached at [**Telephone/Fax (1) 8717**]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Transfer to [**Hospital **] Hospital, level 2 nursery. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45949**], [**Hospital1 1774**]-[**Location (un) **] CARE RECOMMENDATIONS: Feedings: PG feeds at 150 ml/kg/day of 26 calorie breast milk with BeneProtein given 90 minute period of time, q 4 hours. MEDICATIONS: 1. Ferrous sulfate (concentration 25 mg/mL) dose of 0.14 ml per day which is approximately 2 mg/kg per day. Iron and vitamin D supplementation: Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive Vitamin D supplementation at 200 i.u. (may be provided as a multi-vitamin preparation) daily until 12 months corrected age. 2. Vitamin E 5 units pg daily. 3. Caffeine citrate 13 mg pg daily which is approximately 7 mg per kg per dose. Car seat position screening is recommended prior to discharge home. State newborn screen was sent on [**2126-5-10**] which showed elevated amino acids. A repeat state screen was sent on [**2126-5-20**] and showed a thyroxine level of 5 which is borderline low. Repeat specimen was sent on [**2126-5-28**] which was within normal limits. IMMUNIZATIONS RECEIVED: The infant received hepatitis B vaccine on [**2126-6-16**]. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following four criteria: (1) Born at less than 32 weeks; (2) Born between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease or (4) hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. This infant has not received ROTA virus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least 6 weeks but fewer than 12 weeks of age. DISCHARGE DIAGNOSES: 1. Prematurity born at 27 and 2/7 weeks gestation, now 33 and 1/7 weeks gestation. 2. Respiratory distress syndrome, resolved. 3. Chronic lung disease, ongoing. 4. Apnea of prematurity, ongoing. 5. Sepsis ruled out. 6. Patent ductus arteriosus, ongoing. 7. Small ventriculoseptal septal defect, ongoing. 8. Anemia of prematurity, ongoing. 9. Hyperbilirubinemia, resolved. 10. Immature vascularization of the retina, ongoing. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**] Dictated By:[**Name8 (MD) 62299**] MEDQUIST36 D: [**2126-6-16**] 21:48:03 T: [**2126-6-17**] 05:10:07 Job#: [**Job Number 74246**]

Admission Date: [**2117-8-2**] Discharge Date: Service: This is an 83-year-old male who presents from an outside hospital with multiple episodes of chest pain. He was found to have an elevated troponin. He underwent cardiac catheterization which showed three-vessel disease with an ejection fraction of 25% and was transferred to [**Hospital1 **] for planned CABG. Of note during his stay at the outside hospital, he was found to have a [**12-25**] A-V block and needed ventricular pacing. His Lopressor was stopped and he also had hematuria, which Urology was consulted. His past medical history is significant with chronic anemia, history of PE with an IVC filter in place, chronic venous stasis ulcers and disease, colon cancer status post colectomy in the 70s. MEDICATIONS: He was on aspirin. He was on a Heparin drip. He was on Imdur 30 mg q day, hydroxyzine, and lisinopril. He had no known drug allergies. His lungs were clear to auscultation bilaterally. His heart was regular rate, but bradycardic. His abdomen was soft, nontender, nondistended. Bowel sounds are present. He had a positive colectomy. He had good pulses. He was taken to the operating room on [**2117-8-3**] where a CABG x2 was performed. The patient had a LIMA to left anterior descending artery, a [**Doctor Last Name 4726**]-Tex graft to the right RDA and a left radial to OM. The patient was transferred to the SICU postoperatively. He was slowly weaned from his ventilator and was extubated. He was also started on Plavix for his radiograph as well as for his [**Doctor Last Name 4726**]-Tex graft. He continued to do well. The patient's monitor was slowly turned off, and he was found to be significantly bradycardic and Electrophysiology was consulted. Electrophysiology saw the patient and found that he has had bradycardic heart rate. It was decided at that time for a pacemaker to be placed, and it is scheduled to be done after discharge at a cardiac rehab facility. Physical therapy was also consulted to assess ambulation, and he did well. However, physical therapy agreed with Electrophysiology in requesting patient go to rehabilitation for potential increased physical therapy and range of motion. Patient was transferred to the floor postoperatively and he continued to improve. Foley was removed. He was unable to urinate, therefore Foley was replaced. Patient was not started on beta blockade because for his sinus bradycardia and for antinodal blockade. The patient was continued on the pacemaker at that time and continued on Imdur and Plavix for his graft. His pacer was set for DDI at 60. He continued to improve at that time. On [**2117-8-9**] postoperative day #7, the patient was discharged to rehab facility in stable condition with plan to have a pacer placement at that time. The patient was discharged. Discharge medications include Imdur 30 mg po q day, Plavix 75 mg po q day, captopril 12.5 mg po tid, Percocet 1-2 tablets po q4 hours prn, aspirin 325 mg po q day, Zantac 150 mg po bid, Colace 100 mg po bid, Lasix 20 mg po bid, and [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq po bid. Patient is discharged to rehabilitation in stable condition instructed to followup with primary care physician [**Last Name (NamePattern4) **] [**11-25**] weeks. Also follow up with Cardiology after his pacer as needed and follow up with Dr. [**Last Name (STitle) **] in four weeks. The patient was discharged to rehab in stable condition. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**First Name (STitle) **] MEDQUIST36 D: [**2117-8-9**] 06:27 T: [**2117-8-9**] 06:36 JOB#: [**Job Number **]

Admission Date: [**2166-2-6**] Discharge Date: [**2166-2-8**] Date of Birth: [**2090-6-19**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12**] Chief Complaint: Weakness, fatigue Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: 75 yo woman with polycythemia [**Doctor First Name **], melanoma, prior DVT here with progressive weakness and fatigue, no other focal complaints . Pt was seen in ED [**1-13**] for abdominal pain where RUQ u/s showed gallstones without evidence of cholecystitis. Surgery evaluated pt who recommended HIDA scan, which also did not show cholecystitis. INR at that time was 4.1. . Since that time, she has had progressive weakness and fatigue and has undergone extensive outpatient workup including labs, echo, ct of chest, abd, pelvis to assess the concerns of recurrent melenoma. Labs have demonstrated a decline of hct from 41 on [**1-13**] to 34 on [**1-28**], to 28 today. Patient reports weakness has been progressing slowly, but is now at a point where she can no longer walk without assistance of her husband. She reports decreased PO intake over the past week, no POs today as she has "no appetite", feeling "dry", and having a nosebleed this morning. She feels slightly short of breath. She has not noticed any blood in her bowel movements, denies any f/c/n/v, cp, palpitations, falls, cough, visual changes, mental status changes, confusion, headache, dysuria. She has noted increasing bilateral edema over the past week. Abdominal pain largely resolved unless abdomen is palpated. Past Medical History: PmHx: (1) Thromboembolism. (2) She has a previous h/o polyp [**2160**]. Repeat screening colonoscopy [**2165-8-21**] showed a hyperplastic polyp. (3) Polycythemia [**Doctor First Name **]. Before starting 6-MP, had been on hydroxyurea (complicated by erratic platelet counts, necessitating a change in antimetabolite therapy in 11/00). not required therapeutic phlebotomy for control of polycythemia since [**2165-8-14**] (4)[**2162**], ALTs to 75-100, with normal ASTs and alk phos levels.presumably relates to 6-MP. (5) s/p wide excision of in-situ melanoma associated with her invasive stage IIB melanoma of the left leg. The latter was widely excised on [**2164-2-16**] with sentinel lymph node biopsy. (stage IIB). declined interferon-alfa (IFA) for adjuvant therapy of her melanoma (6) DVT in the past. 3+ times,no history of arterial thrombosis. (7). Hypertension. (8). Glaucoma. (9). Status post total abdominal hysterectomy for fibroids. (10). Status post appendectomy . Social History: Soc: Married. She is independent. They have no children. She has needed husband to assist with walking for the past week. No EtOH, no Tob. Family History: FAMILY HISTORY: Remarkable for her mother with diabetes. She does not know her paternal family history. Physical Exam: T 97, HR 100, BP 151/57, RR 24 93% on RA, 97% on 2L Gen: elderly, weak appearing, speaking in soft voice, pleasant, appears mildly short of breath HEENT: dried blood noted around nares, conjunctiva pale, no scleral icterus, OP DRY, no OP erythema, PRRL, EOMI, no LAD CV: tachy, regular, no murmers noted, carotids without bruit Pulm: CTA, but decreased BS at bases Abd; abdominal scars noted. NABS, slight pain to palp RUQ, no r/g, no peritoneal signs, non-distended, Guiac: per ED Negative brown stool Ext: 2+ edema bilaterally to shins, feet cool to touch, no skin breakdown Neuro: CN intact, grip and dorsi/plantar felxion [**5-22**], patient having some trouble lifting legs of bed with resistence. 2+ plantar reflexes . Pertinent Results: [**2166-2-5**] 12:20PM RET AUT-0.4* [**2166-2-5**] 12:20PM PT-70.3* PTT-44.6* INR(PT)-31.1 [**2166-2-5**] 12:20PM PLT SMR-LOW PLT COUNT-98* [**2166-2-5**] 12:20PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-2+ SCHISTOCY-1+ TEARDROP-1+ [**2166-2-5**] 12:20PM NEUTS-62 BANDS-15* LYMPHS-10* MONOS-7 EOS-0 BASOS-0 ATYPS-2* METAS-1* MYELOS-1* PROMYELO-1* NUC RBCS-2* OTHER-1* [**2166-2-5**] 12:20PM WBC-7.9# RBC-3.60* HGB-9.5* HCT-28.3* MCV-79* MCH-26.4* MCHC-33.5 RDW-18.2* [**2166-2-5**] 12:20PM ASA-NEG [**2166-2-5**] 12:20PM ACETONE-NEG [**2166-2-5**] 12:20PM ALBUMIN-3.2* CALCIUM-8.4 PHOSPHATE-3.6 MAGNESIUM-2.0 [**2166-2-5**] 12:20PM ALT(SGPT)-27 AST(SGOT)-72* LD(LDH)-4486* ALK PHOS-242* AMYLASE-25 TOT BILI-1.8* DIR BILI-0.9* INDIR BIL-0.9 [**2166-2-5**] 12:20PM GLUCOSE-206* UREA N-71* CREAT-1.4* SODIUM-132* POTASSIUM-5.2* CHLORIDE-93* TOTAL CO2-16* ANION GAP-28* [**2166-2-5**] 08:40PM HAPTOGLOB-338* [**2166-2-5**] 08:40PM URIC ACID-1.9* [**2166-2-5**] 08:45PM LACTATE-4.8* [**2166-2-6**] 04:56AM VIT B12-159* [**2166-2-6**] 01:15PM PLT COUNT-50*. . . EKG: NSR, 100,nl axis, PR prolonged 250ms (unchanged from prior in [**2164**]), no st changes. . [**2-5**]: RUQ US: Cholelithiasis without evidence of acute cholecystitis. Small right pleural effusion. . [**2166-1-28**] CT chest, abd, pelvis: At least three tiny noncalcified pulmonary nodules within the right middle lobe. Given the patient's history of melanoma, a three-month follow-up examination is recommended to insure stability.; Dense coronary artery calcifications; Small bilateral pleural effusions; Splenomegaly; ) Cholelithiasis without cholecystitis; Small amount of free fluid within the pelvis. . [**2-5**]: Pelvic CT wet read:no discrete retroperitoneal hemorrhage. increased free fluid in abd. and pelvis, and bilat pleural effusions and subcutaneous tissue.. . [**2166-1-31**]: Echo:The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF> 55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Brief Hospital Course: 1. Anemia: Unclear cause. Hct had been trending down over the past few weeks prior to admission. There was great concern for bleed with elevated INR, but CT showed no evidence of RP bleed. Throughout hospital course, all guaiacs negative. Pt seen by hematology oncology. Lab tests did not show any indication of mircoangiopatic hemolytic anemia on peripheral smear, nor was there any evidence of DIC. Hematocrit remained fairly stable, however, the elavated LDH and concurrent lactic acidosis was thought to be secondary to the rapid cell turnover. Bone marrow biopsy showed 2+ PMNs on the gram stain, but no orgs. Pt was given Fe supplementation during hosptial stay. 2. Thrombocytopenia/left shift: Platelet count low with concerning etiology of infection vs. malignancy. Peripheral smear "toxic" appearing but left shift resolving. Platelet counts followed closely with low threshold to transfuse. 3. INR elevation: Baselin INR 4. INR peaked in the hospital at 41. No evidence of bleed on CT. Guiac negative in ED. Fall precautions. Received 2 U FFP, and SC and IV vitamin K in ED. 4. Acidosis: gap: Multiple possible etiologies. Patient has had elevated glucose since [**Month (only) 1096**], elevated now with decreased PO intake, however serum acetone was negative. Urine ketones, serum acitone negative. Serum ASA negative. Appeared to be lactic acidosis and probable renal failure contributing. Hypoalbumin may have masked size of anion gap. IN the MICU, pt continued to have high Lactate, with noted consolidation on CXR. Pt was started on broad spectrum antibiotics, with strict glycemic control. 4.5. Respiratory failure secondary to hypoxia. Increased A-a gradient. The differential diagnosis was broad upon admission to the MICU, including worsening PNA, viral or bacterial with special consideration of influenza, as the leading causes, not excluding TRALI. Given patient's hx and likely immunosuppression, pt remained on broad spectrum antibiotics. Pt became rapidly tachypnic and dyspnic on the floor, and was intubated secondary to respiratory failure. 5. [**Doctor First Name 48**]: Normal cr is 0.6-0.9. Acute process most likely secondary to intravascular volume depletion in the setting of volume overload. . 6. Tachypnea: likely from anemia and a respiratory compensation to metabolic acidosis. . 7. Edema/anasarca: Bilat leg edema worsening over hospital course was not likely consistent with bilat DVT, but given hx may consider LENIs. CT showed increase size in pleural effusions, subcutaneous edema, free abdominal fluid and a new pericardial effusion that was not seen on [**1-31**]. Albumen was low. 30 protein in the UA. There was Concern for malignancy though no mass noted on CT scans. . 8. Elevated LFTs: AST/ALT at baseline, has had elevated AST presumably realted to 6-MG since [**2162**]. LDH abnormally high in the 4000s. Unclear if this was related to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2043**] process, hemolysis, cancer. Will recheck today . 9. Elevated blood glucose. QID FS, RISS . 10. Hypertension: changed long acting antihypertensives to metoprolol [**Hospital1 **] and Dilt QID dosing. . Medications on Admission: Coumadin 7 mg daily except Fridays and Mondays when she takes 8 mg. 6-MP 75 mg daily. ASA 81 mg daily; Atenolol 50 mg daily; cardiazem 240 mg daily; Xalatan eye drops for glaucoma. She does not use herbal or other supplements Discharge Medications: pt expired Discharge Disposition: Expired Facility: [**Hospital1 18**] Discharge Diagnosis: pt expired Discharge Condition: pt expired Discharge Instructions: pt expired Followup Instructions: pt expired

Admission Date: [**2120-12-11**] Discharge Date: [**2120-12-18**] Service: MICU HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old woman with a history of bronchogenic adenocarcinoma, status post left lower lobe resection in [**2120-7-7**] complicated by pneumonia and failure to wean from the ventilator. She is transferred from [**Hospital1 **] Rehabilitation Center at The patient's course status post her left lower lobe adenocarcinoma resection was notable for multiple episodes of respiratory failure which required re-intubation. She also had multiple episodes of pneumonia. She had a tracheostomy and jejunostomy tube placed in [**2120-7-7**]. From that point, the patient has had a prolonged course in which she Her course at [**Hospital1 **] Rehabilitation Center is notable for decreased hematocrit and guaiac positive stools. Her Coumadin had been stopped, an esophagogastroduodenoscopy was unsuccessful and the barium swallow was deferred secondary to high aspiration risk. The patient was on Coumadin for atrial fibrillation which had developed postoperatively but resolved after initiation of Amiodarone. The patient also had a right sided thoracentesis for a large (greater than 2 liters) pleural effusion. She had rapid re- accumulation of this effusion which was by report a transudate. The patient did have sputum which grew Methicillin resistant Staphylococcus aureus. The patient also had stool that was positive for C. difficile. The patient also had recurrent urinary tract infection most recently with Klebsiella which was treated with a 5 day course of Zosyn just prior to admission here. Family reports that at baseline the patient is deaf but is able to communicate through writing and lip [**Location (un) 1131**]. They have noted no recent changes in her mental status. They have become frustrated that she has not been able to progress off the ventilator and are requesting further evaluation at [**Hospital1 1444**]. PAST MEDICAL HISTORY: 1. Paroxysmal atrial fibrillation complicated by hypotension during recent hospitalization to [**Hospital1 69328**]. 2. Left lower lobe adenocarcinoma of the lung, status post resection surgically by Dr. [**Last Name (STitle) 175**] at [**Hospital1 29402**] in [**2120-7-7**]. 3. Triple A repair in [**2110**]. 4. Hypertension. 5. Osteoporosis. 6. Open reduction and internal fixation of the right hip. 7. C. difficile stool infection. 8. Methicillin resistant Staphylococcus aureus in sputum. 9. Recurrent urinary tract infections. 10. Right sided pleural effusions. MEDICATIONS ON TRANSFER: 1. Combivent MDI two puffs q.i.d. 2. Albuterol nebs q two hours p.r.n. 3. Premarin 0.625 mg p.o. G-tube q day. 4. Multivitamin one q day. 5. Omeprazole 40 mg per G-tube q day. 6. Flovent 225 mg two puffs b.i.d. 7. Neurontin 100 mg per G-tube q 8 hours. 8. Celexa 40 mg per G-tube q day. 9. Potassium 20 mEq q day. 10. Iron Sulfate 5 cc's per G-tube q day. 11. Lasix 40 mg per G-tube q day. 12. Zosyn 3.375 mg intravenous q 6 hours, completed on [**2120-12-10**]. PHYSICAL EXAMINATION: Heart rate 60, normal sinus rhythm, blood pressure 110/60. Afebrile. Vent settings IMV with a rate of 14, tidal volume 450, pressure support 10, PEEP 5, FIO2 0.45. General: The patient closes eyes tightly in response to tactile fremitus. Chest: Coarse breath sounds anteriorly without rales or signs of consolidation. Tracheostomy is in place. Cardiovascular: JVP obscured by trach collar, regular S1 and S2. Coarse 2/6 systolic murmur at the left lower sternal border towards the apex. Abdomen: Rare bowel sounds, soft, nontender, nondistended. G-tube is in place. Well healed midline surgical scar. Pulses: 2+ radial, femoral, dorsalis pedis, posterior tibial pulses bilaterally. Lower extremities: No edema, bruising distal to the knee. No skin breakdown obvious. Neurologic: In response to tactile stimulation the patient closes her eyes tightly. There is a tremor with intention of the extremities and head. She has diffuse rigidity with sustained ankle clonus bilaterally. She is diffusely hyperreflexic. LABORATORY FINDINGS: White blood count 8.6, hematocrit 28.6, platelets 276, sodium 135, potassium 3.3, chloride 94, bicarbonate 35, BUN 30, creatinine 0.5. Glucose 105, ALT 20, AST 22, alk phos 135. Total bilirubin 0.3, albumin 2.5, calcium 8.6, phosphate 2.1. Urinalysis 1.014 specific gravity, trace protein, 2 white cells, occasional bacteria, no yeast, one epithelial. Sputum with greater than 25 polys and less than 10 epithelial cells with 1+ gram negative rods, 4+ gram positive rods. Chest x-ray: Shows slight cardiomegaly, bilateral pleural effusions, mild to moderate pulmonary edema. HOSPITAL COURSE: 1. Pulmonary: The patient was initially diuresed with an extra dose of Lasix the day of her admission. She was then sent for a CT scan of her chest on [**2120-12-13**] and this showed the following. Question of a left lingular bronchus partially obstructing lesion. Ground glass opacity changes mostly in the upper lobes, predominantly the right upper lobe. Generally aside from the right upper lobe findings, the parenchyma is much improved compared to a CT scan from [**2120-8-7**]. There is question of overinflation of the cuff of her tracheostomy. There is interval increase in the right sided pleural effusion with interval decrease in her left sided pleural effusion. The patient underwent bronchoscopy on [**2120-12-16**], which revealed a somewhat concerning appearance to a heaped up type lesion at the left lower lobe stump. This lesion was biopsied times three given its somewhat concerning appearance. The tissue at this lesion was not friable nor did it bleed in an abnormal way. The biopsies are pending at the time of dictation. The patient was put on trials of trach mask. The patient surprisingly tolerated these trials on trach mask quite well. She was generally rested over night on SIMV, however, during the day she was able to tolerate trach mask for several hours during the day. We will continue to put her on trials of trach mask off the ventilator as tolerated while she is still at [**Hospital1 69**]. On the day of discharge from the [**Hospital1 18**], she tolerated trach collar >24 hours (including overnight). It is possible that some component of pulmonary edema from congestive heart failure may be impeding her ability to wean. Bronchoscopy otherwise revealed areas of thick mucous plugs which were clear in appearance and not purulent. Also, the Pulmonary Interventional Service will evaluate the patient on [**2120-12-17**] to change her trach collar to a different size so that there is no leak as a leak had been noted around the trach collar, however, the CT scan suggested her cuff is overinflated. They suggested the size of the trach is actually somewhat small for her airway. 2. Cardiovascular: There were no acute cardiovascular issues during this admission. As noted we did try some mild extra diuresis and changed her Lasix to twice a day dose while here. She generally maintained a negative fluid balance over 24 hour period. There was no recurrence of atrial fibrillation during this admission. The patient had a transthoracic echo, which otherwise unchanged from previous echocardiograms at this institution as well as [**Hospital1 **], revealed question of a left atrial mass. It was not entirely clear from the views on the TTE as to the nature of this mass, however, upon review with cardiology attending, the mass did not appear to be displaying paradoxical motion within the atrium. A transesophageal echocardiogram was scheduled, however, the patient did not tolerate sedation required for the procedure as she dropped her blood pressure precipitously. This blood pressure drop responded to a brief bolus of pressors. She had no further hemodynamic instability following the procedure. The procedure was aborted and is not being rescheduled at this time. It is felt that the mass that was seen on the TTE is likely within the wall of the atrium rather than an attached thrombus or myxoma. This will not e further pursued during this admission. 3. Infectious Disease: The patient was still spiking temperatures above 101.0. She was cultured multiple times, with sputum showing greater than 25 polys and 1+ gram negative rods. At the time of this dictation those gram negative rods are being speciated and sensitivities to the antibiotics are pending. We suspect the 4+ gram positive rods are likely colonizer, especially upon review of prior sputum samples this has turned out to be corynebacterium. The CT scan did raise some question of whether there is an atypical pneumonia with deep ground glass opacity findings in her right upper lobe. Given the spike temperature and her multiple courses of antibiotics, we elected to start Ceftazidime. This was started empirically to cover gram negative rods in her sputum as well as apparently gram negative rods in her urine which were growing. There is some concern whether a five day course of Zosyn may have been somewhat short for the purulent strain that she had grown. Other data at the time of this dictation is pending with regards to her cultures. She will be discharged on Ceftazidime 1 gram q 12 hours intravenous, started on [**2120-12-16**]. 4. Renal. The patient maintained a good urine output during this admission with a good response to Lasix and Hemodynamic stability. There were no active issues otherwise. 5. Gastrointestinal. The patient tolerated tube feeds throughout this admission. They were changed to a different tube feed formulation in an effort to reduce CO2. This is changed to Respalor. The patient tolerated tube feeds well and no further changes were necessary. 6. Access. The patient was had a peripheral intravenous during this admission, no central access was necessary. 7. Prophylaxis: The patient was on Protonics, pneumoboots, and subcutaneously Heparin. 8. Code Status: "Do Not Resuscitate", confirmed with the patient's proxy, [**Name (NI) **] [**Name (NI) 36924**]. DISCHARGE MEDICATIONS: 1. Ceftazidime 1 gram intravenous q 12 times 10 days. Started on [**2120-12-16**]. 2. Albuterol nebs q 2 hours p.r.n. 3. Prevacid suspension 30 mg nasogastric tube q day. 4. Lasix 40 mg nasogastric tube b.i.d. 5. Heparin 5000 units subcutaneously b.i.d. 6. Premarin .625 mg per G-tube q day. 7. Multivitamins one per G-tube q day. 8. Potassium chloride 20 mEq per G-tube q day. 9. Celexa 40 mg per G-tube q day. 10. Neurontin 100 mg per G-tube three times a day. 11. Flovent MDI 220 mcs b.i.d. 12. Combivent MDI two puffs b.i.d. 13. Iron sulfate 5 cc's per G-tube q day. DISCHARGE DIAGNOSIS: 1. Prolonged mechanical ventilation dependence. 2. Mild pulmonary edema. 3. Question lesion at left lower lobe stump site. Status post biopsy, biopsy results pending. 4. Question gram negative rods in sputum and urine. 5. Question left atrial mass, however, further identification aborted due to inability to tolerate TTE. 6. History of paroxysmal atrial fibrillation. 7. Left lower lobe adenocarcinoma, status post resection [**2120-7-7**]. 8. Status post tracheostomy, mechanical ventilation dependent. 9. Hypertension. 10. Osteoporosis. 11. Open reduction and internal fixation right hip. 12. C. diff colitis. 13. History of Methicillin resistant Staphylococcus aureus in sputum. 14. Recurrent urinary tract infection. 15. Right sided pleural effusion, transudate. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**] Dictated By:[**Name8 (MD) 16017**] MEDQUIST36 D: [**2120-12-16**] 18:12 T: [**2120-12-16**] 18:13 JOB#: [**Job Number 92814**]

Admission Date: [**2141-10-11**] Discharge Date: [**2141-10-23**] Date of Birth: [**2120-2-4**] Sex: F Service: MEDICINE Allergies: Prochlorperazine Attending:[**First Name3 (LF) 1257**] Chief Complaint: Tachycardia/Hypertension/Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 21 y/o F, nursing student, with h/o head trauma in [**2133**] with minor bleed, tonic clonic seizure, now off dilantin, IBD; constipation predominant, and episodes of tachycardia, hypertension, chest pain and palpitations, concerning for autonomic dysfunction. Pt was in her USOH until 12 days ago. She was on her clinicals as a 3rd year nursing student on the Ob/Gyn [**Hospital1 **] when she abruptly felt light-headed and as if she was about to faint. Denies syncope or LOC, headache, vision changes. weakness, numbness/paresthesias. Pt does note that she had a URI a day or two prior to that day. She also notes that her OCP was changed to a generic about 1 month ago. . The pt was initially admitted to [**Hospital6 28728**] Center after presenting with diaphoresis and vision changes. CTA Chest/Abdomen were unremarkable. CT Head was also unremarkable. Patient was transferred to [**Hospital1 18**] for further management of these episodes. . Patient reports that episodes are induced when she sits up, but can occur at any position: lying or sitting. Her BP during these episodes have been noted to be as high as 200/130 with HR 150's. Dyspnea, chest tightness and palpitations typically accompany these episodes. She denies ever having LOC, or numbness/weakness. She underwent cardiac and pulmonary workups which are negative to date including ROMI and negative CTA. TTE with bubble study was normal. [**Doctor First Name **], ANCA, RF, alpha 1 antitrypsin, urine catecholamines, metanephrines, VMA, 5-HIAA, cortisol pending at time of transfer. CT adomen had per prelim report showed normal adrenal glands. . Past Medical History: Traumatic Head Injury related to ice skating accident in [**2133**]. She had a generalized tonic-clonic seizure and was on Dilantin for 2 months. No seizures since this event Knee Surgery ? IBS - pt reports several year history of constipation alternating with diarrhea. Underwent EGD this summer showing gastritis. Social History: Nursing student, single with boyfriend, no tobacco/EtOH/illicit drug use Family History: Mother - Breast Ca Physical Exam: General: Awake and alert, NAD HEENT mucous membranes, no lesions Neck Supple, no thyromegaly, no LAD, no bruits Chest CTAB CV nl s1/s2 mrg ABD Soft, NT/ND, NABS EXT no C/C/E, distal pulses full, warm and well perfused Neuro: AA&Ox3, appropriate, normal affect Speech Fluent CN II-XII intact, R pupil>L but both brisk and reactive, EOMI no nystagmus, Motor: Normal bulk and tone, no tremor, rigidity Strength: [**5-22**] throughout, Finger to nose and heel to shin intact . Orthostatics: The patient was sat up in bed - BP subsequently dropped from 116/72 to 75/48 with HR change of 85 to 169. Pt had convulsions with episode of hypotension but was alert and communicative throughout episode. ALL subsequent exams and episodes of tachycardia were associated with Hypertension, not hypotension. The paroxysmal episodes are consistent, typically begin with chest discomfort or sometimes HA, followed by worsening chest pain, tachycardia, back-arching/shaking, and hypertension. Episodes resolve after several minutes or quickly after administration of 0.5-1mg Morphine, and 0.5-1mg ativan. Pain and tachycardia are the predominant features. Pt denies any anxiety before or during episodes. Episodes occur whenever pt is elevated to sitting position, but also occur when supine. They have only occured during the day or evening, never at night when the pt is sleeping. Pt is awake and alert during episodes, is able to speak and mentate normally. She is able to request medication. She is aware enough of her surrounds to look at the monitor to see her own vital signs. During episodes, EKGs show only reguarl sinus tachycardia. BPs observed as high as 170s/110s, but generally decrease quickly to 140s before normalizing. Pessures are equal bilaterally. She appears somewhat fatigued afterwards, but does not demonstrate post-ictal symptoms of MS depression. Her neurologic exam is the same before and after episodes. Pertinent Results: [**2141-10-11**] 06:11PM BLOOD WBC-6.7 RBC-4.14* Hgb-12.3 Hct-33.8* MCV-82 MCH-29.7 MCHC-36.4* RDW-12.7 Plt Ct-302 [**2141-10-19**] 05:00AM BLOOD WBC-5.5 RBC-4.23 Hgb-13.0 Hct-34.6* MCV-82 MCH-30.6 MCHC-37.5* RDW-13.1 Plt Ct-266 [**2141-10-11**] 08:16PM BLOOD Neuts-52.4 Lymphs-38.6 Monos-6.0 Eos-2.6 Baso-0.4 [**2141-10-11**] 06:11PM BLOOD PT-13.2 PTT-26.9 INR(PT)-1.1 [**2141-10-13**] 04:45AM BLOOD D-Dimer-169 [**2141-10-11**] 06:11PM BLOOD Glucose-111* UreaN-7 Creat-0.8 Na-139 K-4.2 Cl-107 HCO3-25 AnGap-11 [**2141-10-19**] 05:00AM BLOOD Glucose-85 UreaN-9 Creat-0.8 Na-138 K-4.2 Cl-103 HCO3-26 AnGap-13 [**2141-10-11**] 06:11PM BLOOD ALT-21 AST-22 LD(LDH)-111 CK(CPK)-44 AlkPhos-51 TotBili-0.2 [**2141-10-11**] 06:11PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2141-10-12**] 12:08PM BLOOD Lipase-42 [**2141-10-11**] 06:11PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.8 Mg-2.1 [**2141-10-19**] 05:00AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.0 [**2141-10-14**] 06:21AM BLOOD calTIBC-394 Ferritn-29 TRF-303 [**2141-10-12**] 12:08PM BLOOD Prolact-11 TSH-2.1 [**2141-10-12**] 08:04AM BLOOD Cortsol-33.6* [**2141-10-12**] 12:08PM BLOOD HCG-<5 [**2141-10-12**] 12:08PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG EKG [**2141-10-11**]: Sinus tachycardia Otherwise probably normal ECG, although unstable baseline makes assessment difficult. No previous tracing available for comparison ECG09/30/08 Sinus tachycardia Normal ECG except for rate Since previous tracing of [**2141-10-15**], no significant change CT-HEAD: [**2141-10-11**] NON-CONTRAST HEAD CT: There is no evidence of infarction, hemorrhage, edema, shift of normally midline structures or hydrocephalus. The density values of the brain parenchyma are within normal limits. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Imaged paranasal sinuses and mastoid air cells are pneumatized and well aerated. Surrounding soft tissues and osseous structures are unremarkable. IMPRESSION: Normal head CT. MRI-HEAD [**2141-10-13**]: IMPRESSION: Two areas of cystic appearance are visualized on the right temporal region, possibly consistent with arachnoid cysts, there is no evidence of abnormal enhancement in this area or mass effect. Normal flow void signal is identified in the major vascular structures. No other abnormalities were detected intracranially. MRA-NECK: [**2141-10-13**] MRA OF THE NECK. There is evidence of vascular flow in both common carotids, the carotid bifurcations appear unremarkable, the vertebrobasilar system is also normal. The takeoff and appearance of the supraaortic branches is normal. IMPRESSION: Normal MRA of the neck. OCTREOTIDE([**2141-10-16**]); HISTORY: Question pheochromocytoma. INTERPRETATION: Whole body images obtained at 6 hours and 24 hours SPECT images of the abdomen and pelvis obtained at 24 demonstrate no octreotide avid tissue. IMPRESSION: No octreotide avid tumor localized. BARRIUM SWALLOW IMPRESSION ([**2141-10-16**]): Normal barium swallow, without evidence of esophageal dysmotility. Brief Hospital Course: 21 year old female nursing student with hx traumatic brain injury ([**2133**]) presenting with paroxysmal tachycardia and hypertension and CP of unclear etiology. The patient was initially admitted to the general medicine floor, though was quickly transferred to the MICU after triggering for episodes of hypertension, tachycardia and chest pain. Throughout her course in the MICU the patient appeared to be a well-appearing, healthy young woman, in no distress and with completely stable vital signs between her paroxsymal episodes of CP, Tachycardia, and HTN. Her course generally consisted of daily exams, consultations and tests. Cardiology, Neurology (Autonomics), and Psychiatry were all consulted and contributed to the evaluation of the pt. Her initial presenting complaint was orthostatic tachycardia and HTN. Since admission the pt has had multiple episodes of CP, tachycardia, and HTN, both when supine, and with elevation. While the events can be precipitated by postural changes, they do not require them. The episodes have a significant component of chest pain, substernal, [**8-27**], nonradiating, that will slowly decrease after episodes has resolved. Some episodes also are preceeding by headache. Pt has been observed to develop signs of pain before hemodynamic changes, though the two events happen close in time. The differential includes Pheochromocytoma, POTS, carcinoid, GBS w/ autonomic dysreflexia, psuedopheochromocytoma, panic disorder and cardiac ischemia, PE, esophageal spasm, pain from foreign body. -PE: Pt had negative D-dimers both at [**Location (un) 1121**] and at [**Hospital1 18**]. She had a CT-PA negative for PE at [**Location (un) **]. -Pheochromocytoma was initially the leading diagnosis in this patient, though as tests returned negative, it was felt that this was unlikey the etiology of this patient's symptoms. Her serum was negative for metanephrines at [**Hospital 1121**] Hospital, where she was hospitalized prior to her transfer. Serum metanephrines are the test with the highest specificity for pheochromocytoma (approx 97%), 24h Urine metanephrines and catecholamines have greater specificity, and were also normal from [**Location (un) 1121**]. The 24H urine metanephrines and catecholamines were repeated here and were again negative. Additional serum fractionated metanephrines were also repeated here and again returned negative. Additionally a CT-Abd at the [**Location (un) 1121**], showed normal kidneys and adrenals and no other masses or abnormalities. -Carcinoid was considered in this patient, though felt to be unlikely with a negative Octreotide scan at [**Hospital1 18**] and a reassuring CT-abd at [**Location (un) 1121**], that showed normal peri-appendiceal regions. There was a small density in the appendix that was likely a fecolith. 24h Urine 5-HIAA was negative. -[**Last Name (un) 4584**] [**Location (un) **] syndrome was also considered, but the patient was noted to have a normal EMG at the OSH and she had no further evidence of ascending weakness or paralysis and remained neurologically intact throughout her hospitalization. -Intracranial process: This was ruled out as the patient had negative Head CT x 2. MRI/MRA of head/neck was also normal (two cystic structures, read as likely chronic arachnoid cysts) CT neck and chest were unremarkable though an incidental single [**3-21**] mm perifissural right middle lobe nodule, which was likely an intrapulmonary lymph node was identified, and was determined to be clinically insignificant with no further work up warranted. -PE/Dissection/pulmonary/pleuritic process: negative CT-[**MD Number(3) 80047**], normal CXRs, normal sats, negative D-dimer x 2. - CAD unlikely w/ stable CEs at multiple points, Normal EKGs, and regular sinus tachycardia on EKGs during episodes. - Cardiac structural/vascular mass: ECHO was normal. - Seizure, unlikely, with normal LOC during episdoes, ability to speak and mentate noramlly and response to morphine and no typical post-ictal symptoms. Neurology was following this case and was also in agreement that the patient's symptoms were unlikely to be related to seizure activity. - Lyme serologies - negative - Psych consulted for consideration of psychiatric related diagnoses after all testing is completed (e.g. panic disorder, paroxysmal hypertension/pseudopheochromocytoma. Initial impressions were that episodes were not panic disorders. The patient refused formal evaluation by psychiatry, though did agree that she would be amenable to seek counseling on an outpatient basis. - Autonomic dysfunction: Evaluated by neurology to have no evidence of autonomic or baroreceptor dysfunction. -Esophageal spasm, stricure, or foreign body. No evidence of esophageal dysmotility or abnormalities were seen on barrium swallow. -Renal artery stenosis was evaluated for with a renal ultrasound with dopplers, which was a normal study. Given this patient's extensive work up with no identifiable organic cause of her paroxysms of hypertension associated with chest pain and tachycardia, the diagnosis of pseudopheochromocytoma was considered and the patient was started on beta blocker therapy and an SSRI for her symptoms. The patient's blood pressure in between episodes would not tolerate the addition of an alpha blocker. After starting therapy with propranalol, the patient had marked improvement in her symptoms, and had rare minor episodes of chest pain that were not incapacitating. She was monitored over 48 hours with no evidence or documentation of further episodes, and was noted to be up and ambulating without difficulty or recurrences of her episodes. Given the improvement in her symptoms, she was advised to continue taking nadolol as an outpatient, given the ease of once a day dosing, as well as citalopram. She was also advised to continue ativan as an outpatient, but to slowly taper it in the future if she continued to do well, without symptoms. She was also instructed to follow up with her primary care physican after discharge to monitor her symptoms. Medications on Admission: OCP daily Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety, chest pain. Disp:*30 Tablet(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Ocella 3-0.03 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Pseudopheochromocytoma Secondary: IBS Discharge Condition: Stable and improved. Discharge Instructions: You were admitted to the hospital with episodes of chest discomfort, high blood pressure, and tachycardia. Blood work and urine were sent for evaluation and you were diagnosed with pseudopheochromocytoma. You were started on a beta blocker and an SSRI and your symptoms improved. You have been cleared medically for discharge home. Medication changes (added): - nadalol 20mg once per day - citalopram 20mg - tylenol 350-650mg - ativan 0.5mg 1 tab as needed three times a day for breakthrough pain/anxiety Please return to the ED if your symptoms return and significantly worsen, or you have a fever > 101. Followup Instructions: Please monitor your blood pressure at home. If your systolic blood pressure is less than 90, avoid taking your next dose of ativan or atenolol. If your heart rate is less than 50 beats/minute, please hold your next dose of atenolol. If you experience any fainting, please contact your doctor. Follow up with your primary care physician [**Last Name (NamePattern4) **] 3 wks. Dr. [**Last Name (STitle) 73250**], on Thursday [**2141-11-9**] at 3:00pm ([**Telephone/Fax (1) 54195**]) Please keep all your previously scheduled appointments. Completed by:[**2141-10-24**]

Admission Date: [**2199-10-17**] Discharge Date: [**2199-10-31**] Date of Birth: [**2149-3-13**] Sex: M Service: SURGERY Allergies: Bactrim Attending:[**First Name3 (LF) 668**] Chief Complaint: liver/kidney transplantation Major Surgical or Invasive Procedure: [**2199-10-17**]: Exploratory laparotomy, orthotopic liver transplant, renal transplant. [**2199-10-18**]: Exploratory laparotomy, removal of intra-abdominal packing, liver biopsy, and hepaticojejunostomy. History of Present Illness: 50M with ESLD due to hepatitis C cirrhosis and ESRD thought to be multifactorial from HTN, DM and hepatorenal syndrome, recently started on dialysis, presents today for liver-kidney transplantation. His ELSD has been characterized by ascites (requiring multiple taps), encephalopathy (treated with lactulose/rifaximin) and grade 1 varices (no history of GI bleed). He was recently admitted from [**Date range (1) 30596**] for these issues; he was tapped twice, treated with lactulose for asterixis, and started on dialysis for worsening renal failure. He was tapped again yesterday at [**State 792**]Hospital. He feels well today. No complaints. Denies recent fever, chill, nausea or vomiting or pain anywhere. Past Medical History: PMH: hepatitis C ([**2184**]) c/b cirrhosis, salmonella gastroenteritis with acute renal failure, chronic kidney disease with renal stones s/p lithotripsy ([**2192**]), DM (dx [**2188**], off medications, diet-controlled), HTN ([**2196**], well-controlled, off medications), ITP s/p splenectomy ([**2173**]), asthma PSH: splenectomy [**2173**], lithotripsy [**2192**] Social History: SH: Lives with fiancee, has two children. Prior heroin user, sober for two years, on methadone program. Family History: FH: His family history is significant for an aunt and uncle with diabetes. Physical Exam: Discharge Physical VS: T 98.4 P 95 BP 137/96 RR 18 O2sat 99RA NAD, AAOx3 no murmurs ctab abd soft, apropriately tender over incision, incision closed with staples c/d/i, minimal surrounding ecchymosis, no discharge from incisions. two JP sites closed with nylon suture. no LE edema Pertinent Results: [**2199-10-20**] LIVER U/S: 1. No evidence of biliary dilation. Patent hepatic vasculature. 2. Stable appearance of a postoperative right perihepatic fluid collection adjacent to the right hepatic dome. A left subhepatic collection is newly apparent, though this may be secondary to differences in imaging technique, and is likely post-operative in nature. 3. Moderate left pleural effusion. 4. Diffusely increased echogenicity of the liver most compatible with fatty infiltration, with focal areas of sparing, concerning for a substantial parenchymal abnormality. 5. Geographic and nodular hypoechoic areas in the liver, which may be associated with focal fatty sparing. A 6 mm lesion in the right lobe is not specific; follow-up ultrasound surveillance or consideration of MR evaluation is recommended if clinically indicated. PATH: Pt's liver: Liver, native hepatectomy (A-M): Established cirrhosis, confirmed by trichrome stain. Moderate septal and mild periseptal and lobular mononuclear inflammation (Grade 2 inflammation), consistent with chronic viral hepatitis C. Several microscopic foci of small cell dysplasia; reticulin stain evaluated. Gallbladder with chronic cholecystitis and cholelithiasis. Negative vascular and biliary margin. Iron stain shows mild iron deposition in hepatocytes. [**10-18**]/:11 Donor Liver, allograft, needle core biopsy: 1. Moderate mixed macro- and microvesicular steatosis and focally prominent neutrophils. 2. Mild portal mononuclear inflammation, non-specific. 3. No necrosis or features of acute cellular rejection are seen. 4. Trichrome and iron stains will be reported in an addendum. LABS: [**2199-10-30**] 05:18AM BLOOD WBC-18.4* RBC-3.90* Hgb-12.3* Hct-37.3* MCV-96 MCH-31.6 MCHC-33.0 RDW-15.7* Plt Ct-173 [**2199-10-23**] 02:13AM BLOOD PT-14.3* PTT-21.4* INR(PT)-1.2* [**2199-10-30**] 05:18AM BLOOD Plt Ct-173 [**2199-10-31**] 05:20AM BLOOD Glucose-125* UreaN-33* Creat-1.2 Na-135 K-4.1 Cl-102 HCO3-24 AnGap-13 [**2199-10-31**] 05:20AM BLOOD ALT-18 AST-16 AlkPhos-141* TotBili-1.4 [**2199-10-31**] 05:20AM BLOOD Albumin-2.8* Calcium-7.6* Phos-2.3* Mg-1.4* Brief Hospital Course: Pt was admitted to hospital for combined liver/kidney transplant. Pt was brought to OR, after informed consent was obtained, including explaining to the patient the risks associated with the donor liver including steatosis and increased risk of delayed graft function and failure. Intraop significant hemorrhage with no surgical bleeding but a massive amount of just diffuse ooze was encountered. Activated factor VII was given and shortly after the patient began making clot and drying up. It was not thought to be safe to close primarily packed the right upper quadrant and the iliac fossa with sponges and placed a temporary abdominal closure with anticipation of returning the patient to the operating room in 24 hours for washout and definitive closure. Introp received 16 of packed cells, 6 of CRYO, 15 of FFP, 5 of platelets and 1 dose of factor VII. See operative dictation for full details. Transferred to SICU intubated. Overnight, continued transfusions to goal hct >30, plt >100, INR <1.5, receiving 7 units pRBCs, 3 plts. Morning POD#1 returned to OR for Exploratory laparotomy, removal of intra-abdominal packing, liver biopsy, and hepaticojejunostomy. See operative dictation for full details. Transferred back to SICU intubated. [**2199-10-18**] U/S showed all vessels are patent. Over next two days hct remained stable ~30 with 4 units pRBCs, 3 units plts. No other transfusions during hospital course. Extubated on [**2199-10-19**]. Following day had increasing oxygen requirement secondary to pulm edema as mobilized fluid. Was diuresed in SICU and transferred to floor on [**2199-10-23**]. Course on floor was uneventful, except for pain control. Methadone and dilaudid doses were adjusted apropriately. Was ultimately continued on home methadone dose 35 mg, and pain well controlled with intermittent dilaudid po 5 mg q6 prn. Lateral JP d/c'ed [**10-25**], medial removed [**10-30**]. No evidence ascites leak through JP sites or incision. Immunosuppression was administered and titrated per pathway. Ppx was given per pathway. Pt tolerated regular diet, pain controlled with oral pain medications, voiding without difficulty, and ambulating. PT felt safe for pt to be d/c'ed home. On day of discharge pt and staff felt it safe for pt to be discharged home with VNA. Medications on Admission: nephrocaps 1', clotrimazole 10 troche''''', lasix 80'', lactulose 30''', propanolol 20'', rifaximin 550'', renleva 800''', spironolactone 50', venlafaxine 37.5', MVI,methadone 35'(methadone clinic, Codac in RI [**Telephone/Fax (1) 89015**], fax [**Telephone/Fax (1) 89016**]) Discharge Medications: 1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): follow taper schedule. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. methadone 5 mg Tablet Sig: Seven (7) Tablet PO DAILY (Daily): For Pain . Disp:*49 Tablet(s)* Refills:*0* 7. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 10. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous once a day: AM. Disp:*1 bottle* Refills:*2* 11. Humalog 100 unit/mL Solution Sig: follow sliding scale units Subcutaneous four times a day: see printed scale. 12. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day. 13. Kayexalate Powder Sig: Four (4) tsp PO prn: 4 tsp Powder(s) by mouth once a day as needed for for high potassium level Transplant . 14. pentamidine 300 mg Recon Soln Sig: One (1) inh Inhalation once a month: last dose [**2199-10-24**]. 15. One Touch UltraSoft Lancets Misc Sig: One (1) Miscellaneous four times a day. Disp:*1 box* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of Greater [**Location (un) 511**] Discharge Diagnosis: Hep C Cirrhosis/ESRD now s/p combined liver/kidney transplant DM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: VNA of Greater [**Location (un) 511**] [**State 792**]Hospital for labs every Monday and Thursday Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fevers, chills, nausea, vomiting, diarrhea, constipation, increased redness, drainage or bleeding from the incision, increased abdominal pain, yellowing of the skin or eyes, inability to tolerate food, fluids or medications. No heavy lifting You may shower, no tub baths or swimming Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-11-7**] 2:20 [**2199-11-14**] at 9:00 Dr. [**Last Name (STitle) 9835**] at [**Hospital **] Clinic [**Telephone/Fax (1) 2384**], [**Last Name (un) 3911**], [**Location (un) 551**] [**2199-11-14**] at 10:00, [**Last Name (un) **] Nurse educator [**Telephone/Fax (1) 2384**] at [**Last Name (un) 3911**], [**Location (un) 551**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-11-14**] 2:40 Completed by:[**2199-11-1**]

Admission Date: [**2166-11-29**] Discharge Date: [**2166-12-3**] Date of Birth: [**2099-5-14**] Sex: M Service: NEUROLOGY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Doxycycline Attending:[**First Name3 (LF) 618**] Chief Complaint: weakness, fall Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 67 yo RH man with PMH of HTN, prostate CA was transfered from OSH for evaluation of ICH. This am, He tried to get up from bed around 11 am,. As soon as he got up from bed and tried to walk, he fell down. He felt that both his legs are weak, but left was much more weak than right side. He felt weakness in LUE as well. He was on the floor and was crawling around the house. He was awake the entire period , alert and knew that he had weakness and heavy feeling on the left side, both upper and lower extremities. at around 12 noon, he crwaled over, somehoe managed to get hold of his medicines and he took a tablet of aspirin and atenonol. He thinks that weakness and heavy feeling was same all over this period. It did not increase or fluctuate and was maximum at the onset. he didnt call 911 and thought that it will go away. When his wife returned from work around 6 pm, she noted that he is lying in the floor.He was awake , able to answer all questions. he was taken to OSH for evaluation. At [**Hospital **] hospital, His blood pressure was very high 190/110, he was noted be having "sensory deficits on left side and some weakness on left side" basic lab work was done, WBC 10, Hb 15.4, Plt 224, Trop less than 0.03, INR 1, CPK 568. CT head showed a large IPH in the right basal ganglia with intraventricular spread and shift. He denies any vision changes, sensory changes, clumsiness. He does endorse a mild headache for the last few hours. Past Medical History: HTN, prostate CA. thyroid cyst appendectomy Multiple orthopedic procedures prostate surgery Social History: Retired, most recently worked as a printer.Exd smoker left 34 years ago, 10 pack years. 1 glass of wine per week Family History: Prostate ca in father, CAD in father Physical Exam: O: T: 98.0 BP: 191/120 HR: 80 R 14 O2Sats 100 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: perrl [**2-20**] Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Attentive with months of the year backwards Language: Speech fluent with good comprehension and repetition. he is able to read all the sentences on the stroke card. he is able to name all the obejcts over the stroke card and describe the picture. No dysarthria or paraphasic errors. no apraxia, shows how to brush teeth. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields full but with occasional left field neglect sometimes he is able to tell the obejcts in both fields but sometimes he misses on the objects on the left side. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Significant promator drift on left. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 4- 5 4- 4- 5 3 4 4 5 4 5 5 4 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, pain , vibration and position. throughout but with significant left hemibody sensory neglect to double simultaneous stimulation. Reflexes: B T Br Pa Ac Right 1 1 1 2 2 Left 1 1 1 2 2 Toes up bilaterally Coordination: intact throughout right but ataxic left on FNF and Heel shin testing. rapid tapping clumsy on left side as well. Pertinent Results: [**2166-11-28**] 11:48PM PT-12.6 PTT-24.8 INR(PT)-1.1 [**2166-11-28**] 11:48PM PLT COUNT-191 [**2166-11-28**] 11:48PM WBC-9.0 RBC-5.55 HGB-15.0 HCT-45.3 MCV-82 MCH-27.0 MCHC-33.1 RDW-13.1 [**2166-11-28**] 11:48PM CK-MB-11* MB INDX-2.1 [**2166-11-28**] 11:48PM cTropnT-<0.01 [**2166-11-28**] 11:48PM CK(CPK)-512* [**2166-11-28**] 11:48PM GLUCOSE-122* UREA N-15 CREAT-0.9 SODIUM-138 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-18 [**2166-11-29**] 10:00AM URINE RBC-0-2 WBC-[**1-23**] BACTERIA-OCC YEAST-NONE EPI-0-2 [**2166-11-29**] 10:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-SM [**2166-11-29**] 10:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2166-11-29**] 10:36AM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-1.9 [**2166-11-29**] 10:36AM CK-MB-8 cTropnT-<0.01 [**2166-11-29**] 10:36AM CK(CPK)-469* [**2166-11-29**] 10:36AM GLUCOSE-134* UREA N-20 CREAT-1.2 SODIUM-139 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16 [**2166-11-29**] 06:24PM CK-MB-8 [**2166-11-29**] 06:24PM CK(CPK)-450* CT head [**2166-11-29**] COMPARISON: Outside hospital head CT performed at [**Hospital **] Hospital at 8:58 p.m. on [**2166-11-28**]. FINDINGS: There is a hyperdense acute 5.3 x 2.3 cm hemorrhage centered in the region of the right thalamus extending into the caudate. There is hemorrhage in the the third ventricle (2:15) and occipital horns of both lateral ventricles and denser appearanc eof the choroid plexux in the body of the right lateral ventrcile.(2:14). There is diffuse subarachnoid hemorrhage, in the region of the right sylvian fissure (2:19) and along the posterior parietal sulci on both sdies, more prominent from prior (2:19). The frontal [**Doctor Last Name 534**] of the right lateral ventricle is compressed by the mass effect from this hemorrhage. There is very minimal shift of midline structures to left. The size and configuration of the ventricles is stable compared to the earlier examination, with slight prominence of the temporal horns of the lateral ventricles. There are no new foci of hemorrhage. [**Doctor Last Name **]-white matter differentiation appears well preserved without evidence for acute infarct. There is expansion of the left frontal bone with heterogeneous appearance, including lucent areas within- (series 105b/im 28-33) The differential diagnosis includes fibrous dysplasia, hemangioma, etc and further evaluation with MR can be helpful to further characterize. A samllr etention cyst is noted in the left maxillary sinus. IMPRESSION: 1. Multicompartmental acute intracranial hemorrhage as above with involvement of the right thalamus, caudate and 3rd and lateral ventricles and SAH as above. Mass effect on the right lateral ventricle, unchanged. Associated vascular cause cannot be excluded based on this exam, though this is likely to be seen with HTN- correlate with hisotry and consider further work up for the same. 2. Subarachnoid hemorrhage and intraventricular hemorrhage, more apparent than on the prior examination. 3. Expansion of the left frontal bone with heterogeneous appearance, as described above- DDx includes fibrous dysplasia, hemangioma less likely, etc. Further evaluation with MR can be helpful to assess nature and extent, if there is no contra-indication. CXR [**2166-11-29**] IMPRESSION: Mild cardiomegaly, but no consolidations. Elbow x-ray [**2166-11-29**] FINDINGS: An IV catheter is seen in the antecubital fossa with a kink in the IV line. A bony spur seen at the olecranon. Other than mild degenerative changes, the elbow appears normal. CT head [**2166-11-30**] IMPRESSION: 1. Parenchymal hemorrhage centered in the right basal ganglia, corona radiata and thalamus, extending into the ventricles and, to a lesser extent, subarachnoid spaces. The overall appearance suggests primary hypertensive hemorrhage. 2. Overall, the total volume of hemorrhage appears similar to the comparison study, and there is no evidence of interval hemorrhage or definite development of hydrocephalus. CXR [**2166-12-2**] A single bedside radiograph of the chest excludes the lung apices from the field of view. Within that constraint the lungs appear unchanged, with no focal consolidation, pleural effusion or pneumothorax. Cardiac, mediastinal and hilar contours are also unchanged. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Mr. [**Known lastname 84196**] is a 67 yo RHM with HTN who presented with acute onset weakness and heaviness over left side. Exam at the time of admission showed left hemiparesis (arm more than leg), left hemisensory neglect more prominent to tactile stimuli than visual fields, and BL upgoing toes. The CT scan shows large R BG bleed with IV extension. The most likely etiology is hypertension, given his uncontrolled blood pressure and typical location of bleed. He had been seen by neurosurgery who have suggested no acute intervention. He was initially admitted to the neurology ICU and started on a nicardipine drip for blood pressure control. A repeat CT head showed a stable size of his hemorrhage and he was titrated off the nicardipine drip and transferred to the floor. Initially he had some difficulties with blood pressure control and his home atenolol was increased to 100 mg [**Hospital1 **] with good response. His other home medications including his [**Last Name (un) **] and Inspira were continued. His outpatient cardiologist, Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] regarding his medical regimen and it was determined that he has had a number of intolerance/adverse reaction to multiple other antihypertensives including ace-inhibitors and calcium channel blockers. Dr. [**Last Name (STitle) **] commented that he was planning to start Mr. [**Known lastname 84196**] on Tektura 150 mg daily. This may be considered if his blood pressure requires additional treatment. ID- On [**2166-12-1**] the patient spiked a temperature of 102. He was pancultured which have been unrevealing. Final blood cultures are still pending at the time of discharge. MSK- Patient did have some occasional lower back pain during the hospital course. A plain film x-ray did not reveal any identifiable cause. It was thought this may have been musculoskeletal and has been controlled with tylenol and occasional oxycodone for breakthrough pain Medications on Admission: Tenormin 37.5, 12.5 am and 25 pm Avapro 300mg daily, Inspira 100mg daily, centrum magnesium ca / vit D ASA 325 on the morning of presentation Discharge Medications: 1. Eplerenone 50 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 2. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO Q 12H (Every 12 Hours). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO Q4H (every 4 hours) as needed for pain. 7. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Right basal ganglia hemorrhage Discharge Condition: MS; A&Ox3, speech fluent. Naming, repetition, and comprehension intact. CN; Mild L neglect on visual fields. EOMI, L facial droop Motor; 4/5 strength LUE, LLE limited by back pain but appears at least [**2-23**]. [**3-25**] on RUE, RLE Sensory; extinction to DSS on left Discharge Instructions: You were admitted after an episode of weakness. You were found to have a large bleed in a part of your brain called the basal ganglia which was likely caused by high blood pressure. Your bleed has been stable on repeat imaging studies and you will be transferred to a rehabilitation facility for further care. Followup Instructions: Appointment with PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 48633**], on Tuesday [**2166-12-16**] at 2:30PM. The office is located at [**Hospital1 84197**], [**Location (un) 47**] [**Numeric Identifier 7398**]. Please call Dr.[**Name (NI) 84198**] office at [**Telephone/Fax (1) 35142**] if you need to reschedule this appointment. Appointment with Neurology Stroke attending, Dr. [**Last Name (STitle) **], on Tuesday [**2167-1-6**], at 1:30PM. The office is located in the [**Hospital Ward Name 23**] building [**Location (un) **] at [**Hospital1 18**]. Please call Dr. [**Name (NI) 59895**] office at [**Telephone/Fax (1) 2574**] if you need to reschedule this appointment. When you are discharged from rehab, please call your cardiologist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5068**]) for a follow-up appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Admission Date: [**2185-9-21**] Discharge Date: 08/23-24/[**2185**] (pending rehab placement) Service: HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old female with known coronary artery disease documented in [**2182**] with an ejection fraction of approximately 30-35%, who had been managed medically and was living an active lifestyle. She had been experiencing some chest pain and worsening shortness of breath and orthopnea. On the night prior to admission, the patient had worsening chest pain and presented to the emergency room for evaluation. Upon arrival, she complained of chest pain and the electrocardiogram showed new lateral ST depressions concerning for acute ischemia. Her cardiac enzymes were positive for a CK leak with a troponin of 43. Her chest x-ray was consistent with congestive heart failure. The patient was given sublingual nitroglycerin, morphine, beta blockers and aspirin and was started on a heparin drip. The cardiology service was consulted and the patient was taken for a cardiac catheterization. PAST MEDICAL HISTORY: The past medical history was significant for coronary artery disease with previous echocardiograms documenting an ejection fraction of 30-35%, hypertension, colon cancer status post partial colectomy, partial deafness and right eye blindness secondary to eyeball rupture. MEDICATIONS ON ADMISSION: Her medications at home included aspirin, Lipitor, Zestril, Lopressor, Fosamax, nortriptyline and Imdur. ALLERGIES: The patient had no known drug allergies. SOCIAL HISTORY: The patient lived at home with her husband, who was also very active per her primary care physician. PHYSICAL EXAMINATION: On examination, the patient was afebrile with vital signs stable. The heart rate was 84 and the blood pressure was in the 150s/70s. The oxygen saturation was 90-98% on a nonrebreather mask. The heart had a regular rate and rhythm with no murmurs, rubs or gallops. The lungs had crackles bilaterally. The abdomen was soft, nontender and nondistended. The extremities revealed no clubbing, cyanosis or edema with palpable dorsalis pedis pulses. HOSPITAL COURSE: The patient was taken to the cardiac catheterization laboratory and catheterization revealed diffuse disease of the left anterior descending artery, a 40% ostial lesion of the left main coronary artery, a 90% proximal lesion of the left circumflex coronary artery and a 100% mid lesion of the right coronary artery. An intra-aortic balloon pump was placed, the patient was transferred to the unit and the cardiac surgery service was consulted. On the following day, the intra-aortic balloon pump was removed and the patient was managed medically and stabilized. On [**2185-9-26**], the patient underwent coronary artery bypass grafting times four. She received a left internal mammary artery graft to the left anterior descending artery and saphenous vein grafts to the first obtuse marginal artery and right posterolateral vein as a sequential graft as well as another saphenous vein graft to the diagonal artery. The patient tolerated the procedure well and was transferred to the unit in stable condition. The patient was maintained on milrinone drip at 0.5 mg overnight, which was weaned on the following day. The patient was also extubated without any problems and she was transferred to the floor on postoperative day #1. On postoperative day #2, the patient was noted to be extremely stable as she remained afebrile with stable vital signs. She had mild hypertension and thus her Lopressor was increased from 25 to 50 mg p.o. b.i.d. Her Zestril was also increased from 5 to 10 mg p.o. q.d. Her chest tubes were removed and the physical therapy service was consulted. Upon the physical therapy consultant's recommendation, it was deemed that the patient would benefit best from a rehabilitation stay. On postoperative day #3, the patient remains afebrile with stable vital signs. Her blood pressure is well controlled with a heart rate of 75 and a blood pressure of 100/50. All of her chest tubes and pacing wires have been removed. The patient is currently awaiting rehabilitation placement. She will discharged to rehabilitation, as soon as a rehabilitation bed is available. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: Coronary artery disease, status post acute myocardial infarction, status post coronary artery bypass grafting times four. DISCHARGE MEDICATIONS: Lopressor 50 mg p.o. b.i.d. Zestril 10 mg p.o. q.d. Lasix 20 mg p.o. b.i.d. times five days. K-Dur 20 mEq p.o. b.i.d. times five days. Colace 100 mg p.o. b.i.d. Percocet one to two tablets p.o. every four to six hours p.r.n. Aspirin 81 mg p.o. q.d. Lipitor 10 mg p.o. q.d. Fosamax 10 mg p.o. q.d. DISCHARGE INSTRUCTIONS: The patient will follow up in rehabilitation. She should follow up with Dr. [**Last Name (STitle) 70**] in approximately three weeks. She should also follow up with her primary care physician in approximately two weeks. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Name8 (MD) 3181**] MEDQUIST36 D: [**2185-9-29**] 08:20 T: [**2185-9-29**] 09:32 JOB#: [**Job Number 100042**]

Admission Date: [**2153-1-2**] Discharge Date: [**2153-1-26**] Date of Birth: [**2089-12-12**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 58850**] is a 63-year-old male with a known history of coronary artery disease, status post a silent myocardial infarction in [**2143**], who presented to [**Hospital3 1280**] Hospital Emergency Department this morning with 8/10 chest pain, epigastric distress, nausea, and shortness of breath. He had ST depressions laterally and ST elevations in V1. These resolved with intravenous nitroglycerin and Lopressor in the Emergency Department. He was taken for cardiac catheterization which revealed 3 plus calcified LAD with a 95 percent proximal occlusion, a 70 to 80 percent proximal circumflex lesion, and 100 percent occluded RCA with collaterals. Echocardiogram revealed 1 to 2 plus mitral regurgitation, trace tricuspid regurgitation, and an left ventricular ejection fraction of 30 percent. He was placed on intravenous Integrilin and transferred to [**Hospital1 1444**] for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Myocardial infarction. 3. Hypertension. 4. Hypercholesterolemia. 5. Sleep apnea (with BiPAP). 6. Status post abdominal aortic aneurysm repair with two endovascular stents followed by surgical repair with a questionable open bypass of the left femoral artery in [**2152-2-28**] at [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] Hospital. 7. Status post carpal tunnel repair in [**2152-10-30**] with a brief period of postoperative atrial fibrillation. The patient admits to not taking his medications at that time. He was treated with Coumadin for one month without further atrial fibrillation. SOCIAL HISTORY: The patient quit smoking nine years ago. He had an 80-pack-year history. He admitted for four to six beers a day for significant alcohol abuse. He is married and lives with his wife and works as a plant manager. MEDICATIONS AT HOME: Atenolol 100 mg p.o. once daily, Lipitor 40 mg p.o. once daily, aspirin 325 mg p.o. once daily, vitamin D, and fifth medicine is unclear. MEDICATIONS ON TRANSFER: At [**Hospital3 1280**] Hospital he was started on intravenous Integrilin, Lopressor, aspirin, heparin, intravenous nitroglycerin, and antacids. ALLERGIES: He has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Neurologically, he was grossly intact without any carotid bruits. His lungs had a few bibasilar crackles. His heart was regular in rate and rhythm with S1 and S2. No murmurs noted. His abdomen was slightly firm, distended, and nontender. His extremities were warm without any edema with positive peripheral pulses. SU[**Last Name (STitle) 42242**]OF HOSPITAL COURSE: The patient was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] on intravenous Integrilin, nitroglycerin, and heparin. He had epigastric discomfort since his admission which was increasing. Intravenous nitroglycerin was also increased. This was discussed with Dr. [**Last Name (Prefixes) **] and an emergent Cardiology consultation was ordered, but the patient continued to have chest pain. He was seen by a cardiologist. He continued to have chest pain. It was determined the patient was unable to have an intraaortic balloon pump placed for his continuing chest pain due to his three endovascular stents. The patient was seen by Dr. [**Last Name (STitle) 16646**] of Cardiology when he was admitted. Preoperative laboratories were as follows. Sodium was 137, potassium was 3.5, chloride was 99, bicarbonate was 30, blood urea nitrogen was 11, creatinine was 0.7, with a blood sugar of 165. White count was 12.3, hematocrit was 42.9, and platelet count was 204,000. CK's went from 125 to 284 to 725 with troponin's from less than 0.04 to 1.75 to 3.38; ruling the patient in for a significant myocardial infarction. Th[**Last Name (STitle) 1050**] was taken to the Operating Room emergently that evening and underwent emergent coronary artery bypass grafting times three with a LIMA to the LAD, a vein graft to the PDA, and a vein graft to the OM by Dr. [**Last Name (Prefixes) **]. He was taken to the Cardiothoracic Intensive Care Unit in critical condition on an epinephrine drip at 0.05 mcg/kg/min, a nitroglycerin drip at 0.5 mcg/kg/min, a titrated propofol drip, and a Neo-Synephrine drip at 1 mcg/kg/min. In the immediate postoperative period the patient developed several problems. The first was atrial fibrillation which was treated with an amiodarone bolus and started on an intravenous drip. He ultimately required cardioversion by anesthesia and then later repeat cardioversion by Electrophysiology. The second significant incident was the patient's liver function tests rose dramatically given his significant alcohol abuse. A Critical Care consultation was also called. The patient was clearly undergoing alcohol withdrawal and developed delirium tremens. He was continued on amiodarone. Within a day or two he was also seen by the Clinical Nutrition team as the Critical Care team was evaluating his nutritional status and liver function. He remained in the Cardiothoracic Intensive Care Unit all that week. On [**1-12**], he continued with an inability to wean from the respirator. He developed atelectasis which was apparent on his chest x-ray and significant copious secretions. He was awake and was on CPAP with pressure support but continued to require significant pulmonary toilet and was unable to wean from the ventilator. Given these secretions, blood cultures were also sent in addition to sputum cultures. An evaluation by Dr. [**First Name (STitle) **] [**Name (STitle) **] of the Critical Care Pulmonary Service was obtained. The patient's blood cultures grew out gram-positive cocci and sputum secretions grew out coagulase- positive Staphylococcus. The patient was started empirically the next day on vancomycin, Levaquin, and fluconazole. An Infectious Disease consultation was called. The patient was seen by Infectious Disease on [**1-13**]. Please refer to their official consultation note. In addition, the patient remained on amiodarone, digoxin, and was started on carvedilol for beta blockade and management of his atrial fibrillation which continued to be an issue. Clearly, given his respiratory failure, there was great concern about the process going on in his lungs. When the cultures came back, the sensitivities showed a sensitivity to oxacillin. The bronchoscopy secretion and alveolar lavage which was done by Dr. [**Last Name (STitle) **] showed methicillin-resistant Staphylococcus aureus. Blood cultures showed methicillin-sensitive Staphylococcus aureus that came back on [**1-13**]. The patient was changed over. His vancomycin, levofloxacin, and fluconazole were stopped given the lack of sensitivities to his bacteria, and he was switched to intravenous oxacillin. The patient was also initially evaluated by Physical Therapy. He had again failed an extubation wean; again failed in his ability to attempt to wean for extubation on [**1-12**] prior to his bronchoscopy which necessitated a Pulmonary consultation. Given the fact that the patient had very little mobility at that time, heparin was also started for anticoagulation in preparation for Coumadin starting for anticoagulation for his atrial fibrillation. Additional blood cultures and sensitivities came back, and the patient was switched back to vancomycin approximately on [**1-20**]. On [**1-21**], he continued to markedly improve on the CPAP and was ultimately extubated. The patient continued to have mental status issues with confusion and disorientation - from which he would rapidly reorient but then become significantly confused again. The patient had some doses of Haldol to help with this and continued to be dosed with Coumadin once daily in an effort to get him anticoagulated. Finally, on [**1-23**], the patient was transferred to [**Hospital Ward Name 121**] Two. The patient had been treated all along for his delirium tremens and alcohol withdrawal under the direction of the Critical Care team and was on an Ativan drip. On [**1-21**], his white count increased from 12.2 to 12.5. His hematocrit remained stable at 34.6 with a normal platelet count. His creatinine was 0.8. A transesophageal echocardiogram was ordered to rule out endocarditis, and this was done by Cardiology. This was performed on [**1-25**] prior to his discharge and showed no vegetations, a mildly thickened aortic valve, a mildly thickened mitral valve, with mild 1 plus mitral regurgitation, and no evidence of endocarditis. The patient continued to be evaluated and worked on by Physical Therapy and the nurses for significant pulmonary toilet as well as physical therapy while he was out on the floor. He remained on a heparin drip as he became therapeutic with his Coumadin. He was receiving albuterol as needed, and Combivent, and Flovent to assist with his pulmonary toilet. He also remained on carvedilol. Lisinopril had been started at 5 mg also. The patient continued to rapidly improve on postoperative day 22. He was encouraged to ambulate and to increase his oral intake. If the patient ruled out for endocarditis - which he did - he was to be switched over from intravenous vancomycin to oral linezolid and then planned for discharge to home. On postoperative day 23 - the day prior to his discharge - his laboratories were as follows. White count was 10.9, the hematocrit was 31.3, and the platelet count was 407,000. The PT was 17.2, PTT was 64.3, and INR was 1.9 on both heparin and Coumadin. Sodium was 137, potassium was 5.2, chloride was 96, bicarbonate was 30, blood urea nitrogen was 19, creatinine was 1.1, with a blood sugar of 109. The patient's weight was 71.6 (down from his preoperative weight of 81 kilograms). He was saturating 94 percent on room air and was hemodynamically stable and doing very well with a blood pressure of 110/66. The respiratory rate was 18. In a sinus rhythm at 68. He was alert and oriented and nonfocal. His lungs were clear bilaterally. His sternum was stable with no drainage or erythema. He had bowel sounds. No peripheral edema. His left leg incision saphenous vein graft site was healing well. His central venous line had been removed. The pacing wires had been removed. No chest tubes were in place as these had been removed days before. He was switched over to linezolid 600 mg p.o. twice daily. Heparin was discontinued. The patient received Coumadin 3-mg dose that evening in preparation for increasing his INR. His heparin was discontinued that night. He was gain evaluated by Case Management so he could be discharged to home with VNA services. DISCHARGE DISPOSITION: On postoperative day [**1-22**] - the patient was discharged to home with VNA services. He was in a sinus rhythm at 73. The blood pressure was 97/51 and was saturating 97 percent on room air with an unremarkable and much improved physical examination. DISCHARGE DIAGNOSES: 1. Status post emergent coronary artery bypass grafting times three. 2. Coronary artery disease. 3. Ethanol abuse and status post withdrawal. 4. Myocardial infarction. 5. Hypertension. 6. Hypercholesterolemia. 7. Sleep apnea (with BiPAP). 8. Status post abdominal aortic aneurysm with three endovascular stents. 9. Status post left femoral open bypass. 10. Status post carpal tunnel repair on the right. 11. Atrial fibrillation. 12. Pneumonia with bacteremia. 13. Respiratory failure status post surgery. DISCHARGE STATUS: The patient was discharged to home on [**2153-1-26**]. CONDITION ON DISCHARGE: Stable. DISCHARGE FOLLOWUP: 1. The patient was instructed to come to the [**Hospital1 20311**] [**Hospital 409**] Clinic approximately two weeks post discharge. 2. The patient was instructed to see his cardiologist - Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 3659**] - in approximately two to three weeks post discharge. 3. The patient was instructed to see Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in the office in four weeks for his postoperative surgical visit. MEDICATIONS ON ADMISSION: 1. Carvedilol 3.125 mg p.o. twice daily. 2. Lisinopril p.o. once daily. 3. Amiodarone 400 mg p.o. twice daily for one week; then 400 mg p.o. once daily for one week; then 200 mg p.o. once daily. 4. Digoxin 0.125 mg p.o. once daily. 5. Fluticasone propionate 110-mcg actuation aerosol 2 puffs inhaled twice daily. 6. Albuterol ipratropium 103/18 mcg actuation aerosol 1 to 2 puffs inhaled q.6h. 7. Multivitamin capsules one capsule p.o. once daily. 8. Enteric coated aspirin 81 mg p.o. once daily 9. Colace 100 mg p.o. twice daily. 10. Percocet 5/325 one to two tablets p.o. q.6h. as needed (for pain). 11. Coumadin 1 mg p.o. once daily (for [**1-26**], [**1-27**], and [**1-28**]); then the patient was instructed to check with Dr. [**Last Name (STitle) 3659**] - his cardiologist - for continued dosing beyond [**1-28**] and blood draws to evaluate his INR therapeutic level. 12. Linezolid 600 mg p.o. twice daily (for 18 days with the last dose scheduled for [**2153-2-13**]). [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2153-2-22**] 12:01:54 T: [**2153-2-22**] 13:28:20 Job#: [**Job Number 58851**]

Admission Date: [**2143-4-13**] Discharge Date: [**2143-4-29**] Date of Birth: [**2077-4-10**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5547**] Chief Complaint: Severe gallstone pancreatitis Major Surgical or Invasive Procedure: Tracheostomy History of Present Illness: This is a 66 year old male, transferred from [**Hospital3 7569**] with pancreatitis, respiratory failure, ?pna, and NSVT. Pt initially presented to [**Hospital3 7569**] on [**4-7**]; by report, he had sudden onset of bdominal/epigastric pain with associated nausea (no vomiting). He was initially afebrile, hypertensive, tachycardic; amylase was 1851, lipase was >6000. Past Medical History: PNA, Schizophrenia, Syncope Pertinent Results: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2143-4-13**] 11:00 PM LIVER OR GALLBLADDER US (SINGL Reason: evaluate gallbladder, duct; please measure CBD [**Hospital 93**] MEDICAL CONDITION: 66 year old man with gallstone pancreatitis, fevers, ?dilation of CBD REASON FOR THIS EXAMINATION: evaluate gallbladder, duct; please measure CBD INDICATION: 66-year-old male with gallstone pancreatitis and concern for common bile duct dilatation. RIGHT UPPER QUADRANT ULTRASOUND: The liver demonstrates a 1.8 x 1.6 x 1.5 cm well circumscribed echogenic focus of the posterior right hepatic lobe compatible with a hemangioma. The gallbladder is contracted and contains sludge and a few small stones. There is no pericholecystic fluid. The contracted state of the gallbladder causes apparent wall thickening. There is no intra- or extrahepatic biliary ductal dilatation. The common bile duct measures 3-4 mm. There is no ascites. Incompletely visualized is a right pleural effusion. The pancreas is not well seen due to overlying bowel gas. There is appropriate hepatopetal portal venous flow. The right kidney is unremarkable. IMPRESSION: 1. Contracted gallbladder with small stones and sludge. 2. No intra- or extrahepatic biliary ductal dilatation, with the common duct measuring 3-4 mm. 3. 1.8 cm well circumscribed echogenic focus of the posterior right hepatic lobe is consistent with an hemangioma. 4. Limited evaluation of the pancreas due to overlying bowel gas. Cardiology Report ECHO Study Date of [**2143-4-15**] PATIENT/TEST INFORMATION: Indication: Atrial/ventricular ectopy. Left ventricular function. Height: (in) 69 Weight (lb): 165 BSA (m2): 1.91 m2 BP (mm Hg): 96/51 HR (bpm): 115 Status: Inpatient Date/Time: [**2143-4-15**] at 11:00 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W022-0:20 Test Location: West MICU Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.5 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 3.6 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: >= 60% (nl >=55%) Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm) Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A Ratio: 0.88 Mitral Valve - E Wave Deceleration Time: 183 msec TR Gradient (+ RA = PASP): *32 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy of the interatrial septum. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic root. AORTIC VALVE: Normal aortic valve leaflets. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA systolic hypertension. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - ventilator. Based on [**2133**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). 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 root is mildly dilated. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Preserved global biventricular systolic function. Mild pulmonary artery systolic hypertension. Based on [**2133**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. CHEST (PORTABLE AP) [**2143-4-19**] 6:00 AM CHEST (PORTABLE AP) Reason: interval changes in lung volumes, infiltrate [**Hospital 93**] MEDICAL CONDITION: 66 year old man new transfer from OSH with pancreatitis, Elevated Peak Pressures, abd distention REASON FOR THIS EXAMINATION: interval changes in lung volumes, infiltrate AP CHEST, 6:07 A.M., [**2143-4-19**]. HISTORY: Pancreatitis. IMPRESSION: AP chest compared to [**4-14**] and 24. Left lower lobe collapse has not improved. Lung volumes are low normal. Small bilateral pleural effusions unchanged. No pneumothorax. Heart size normal and mediastinum midline. ET tube and left subclavian line, and nasogastric tube are in standard placements respectively. CT HEAD W/O CONTRAST [**2143-4-22**] 9:49 AM CT HEAD W/O CONTRAST Reason: Intracranial process causing sedation and coma [**Hospital 93**] MEDICAL CONDITION: 66 year old man with pancreatitis, Off all sedation but not responding neurologically REASON FOR THIS EXAMINATION: Intracranial process causing sedation and coma CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 66-year-old male with history of pancreatitis. The patient is now off all sedation but not responding. COMPARISONS: No comparisons are available. TECHNIQUE: CT of the head without IV contrast. FINDINGS: There are very severe periventricular hypodensities. These are more severe in the bilateral frontal lobes where there is loss of the [**Doctor Last Name 352**]- white matter differentiation at some point. There is also encephalomalacia and atrophy involving predominantly the right temporal lobe. There is a lacunar infarct within the left thalamus. The ventricles are prominent. The above findings are most likely secondary to chronic ischemic changes and chronic infarcts. There are calcifications in the falx. There is no evidence of herniation. There is no evidence of hemorrhage, shift of normally midline structures. No evidence of mass effect. There is mild opacification of the bilateral maxillary sinus, ethmoid sinuses, and sphenoid sinuses. There is severe septal deviation to the right side. The NG tube is coiled in the nasopharynx. There is mild opacification of the external auditory canal bilaterally (left greater than right), correlate with physical examination. There is mild opacification of the bilateral mastoid air cells. IMPRESSION: 1. No evidence of hemorrhage. 2. Chronic encephalomalacic changes likely representing chronic infarcts and chronic ischemia. 3. Mild opacification of the paranasal sinus, and mastoid air cells as was described above. The feeding tube is coiled within the nasopharynx. If indicated, MRI could be performed for further evaluation. OBJECT: PANCREATITIS. R/O SEIZURE. REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] FINDINGS: ABNORMALITY #1: Brief polymorphic bursts of moderate to, at times, moderately high voltage mixed frequency slower theta were seen bifrontally, without clear laterality at times in a somewhat bursting character. No associated sharp or spike activity was seen. BACKGROUND: Well-formed and moderately well-sustained moderate voltage 10 Hz activity was seen biposteriorly present without significant asymmetry. The anterior-posterior voltage gradient was preserved. HYPERVENTILATION: Not performed. INTERMITTENT PHOTIC STIMULATION: Not performed. CARDIAC MONITOR: No arrhythmias noted. IMPRESSION: Normal EEG due to some bifrontal slow bursts. Whether this represents increased cortical hyperreactivity related to subcortical or deeper midline structures increased irritability is uncertain. No definitive spike discharges were seen. No persistent slowing suggestive of a destructive or structural process could be seen. CHEST (PORTABLE AP) [**2143-4-27**] 12:08 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN Reason: dobhoff placement? [**Hospital 93**] MEDICAL CONDITION: 66 year old pancreatitis w/ new Dobhoff placement. REASON FOR THIS EXAMINATION: dobhoff placement? AP CHEST, 1:12 P.M. ON [**4-27**]. HISTORY: Pancreatitis. New Dobbhoff tube placement. IMPRESSION: AP chest compared to 11:21 a.m.: New feeding tube, with wire stylet in place passes through the distal stomach and out of view. Nasogastric tube ends in the upper stomach. ET tube and right subclavian line in standard placements. Moderate left pleural effusion has increased. Left lower lobe atelectasis is stable. Atelectasis at the medial aspect of the right lung is worsening. Mediastinal venous engorgement and upper lobe vascular dilatation have worsened indicating cardiac decompensation or volume overload although heart size remains normal. No pneumothorax. CHEST (PORTABLE AP) [**2143-4-29**] 4:42 AM CHEST (PORTABLE AP) Reason: ETT placement [**Hospital 93**] MEDICAL CONDITION: 66 year old pancreatitis w/ new Dobhoff placement. REASON FOR THIS EXAMINATION: ETT placement The findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1924**] at 11 a.m., [**2143-4-29**]. REASON FOR EXAMINATION: Evaluation of the ET tube placement and Dobbhoff placement. Portable AP chest radiograph compared to [**2143-4-27**]. The ET tube is low at the level of the carina. There is no Dobbhoff tube inserted demonstrated on the current film. The right subclavian line tip is in mid portion of superior vena cava. The heart size is markedly decreased as well as there is prominent improvement of bilateral pulmonary edema with decreased bilateral, mostly on the left, pleural effusion. IMPRESSION: 1. Low position of the ET tube. 2. Marked improvement with almost complete resolution of pulmonary edema and decrease in left pleural effusion. Brief Hospital Course: 1. Pancreatitis: Amylase and lipase were very elevated on admission to [**Location (un) **] (AST and ALT mildly elevated). US and CT were suspicious for gallstones in cystic duct with dilation of CBD. Persistent fevers are concerning for necrotic pancreas, and most recent CT had findings suspicious for phlegmon. He was started on meropenem, and vancomycin was added when he continued to have fevers. Cultures have been negative, but he is growing klebsiella from sputum. - will continue meropenem (d6)/vanco (d2) - continue IVF with goal CVP>12, MAP>65 - will review OSH radiology (CT scans) - ERCP consult given concern for stones in duct - repeat cultures - TPN for now given ileus - insulin gtt for tight control - protonix daily . 2. ?PNA: CXR concerning for pna at left base, with klebsiella in sputum - continue meropenem/ vanco - repeat sputum culture - repeat CXR (?tappable effusion) . 3. Respiratory failure: hypercarbic, ?in setting of sepsis - will ck ABG, wean vent as tolerated - treat PNA, may need to tap effusion - fentanyl and versed for sedation - [**4-25**] trach'ed . 4. Ileus: will repeat KUB, NGT to suction if necessary, NPO with TPN . 5. NSVT: will continue amio gtt, is currently hemodynamically stable, will shock if unstable rhythm - t/c cards input if ectopy persists - replete lytes as needed . 6. Hypotension: now stable, was requiring pressors, will give IVF, keep MAP>65, A-line in place . 7. PPX: SQ hep, PPI, bowel meds . 8. FEN: NPO for now, IVF, replete lytes as above . 9. Code: Full, confirmed with power of attorney . 10. Access: R IJ (will need to resite), R A-line ([**4-13**]) . 11. Contact: power of attorney: [**Name (NI) 8513**] [**Name (NI) 67329**] ([**Telephone/Fax (1) 67330**], [**Telephone/Fax (1) 67331**]) . 12. Dispo: ICU care. . MICRO: [**4-25**] cath tip: no growth; [**4-21**] CDiff +; [**4-20**] sputum: yeast [**4-20**] urine - [**4-20**] blood:P [**4-15**] Sputum: 3+ yeast, Cx Mod yeast, OP flora; blood:NGTD; Urine:Neg; C.Diff:Neg; [**4-14**] blood:NGTD; Cath tip:Neg; [**4-13**] sputum:Cx=yeast, Klebsiella (pan-[**Last Name (un) 36**]); blood:NGTD; Urine: Neg [**4-12**] Sputum from outside hosp Klebsiella resist to Amp(otherwise sensitive) RADS: [**4-23**] EEG nonspecific; [**4-23**] CXR: no change; [**4-22**] CT head: chronic ischemic changes [**4-17**] CXR: improved LLL consolidation, borderline pulm edema; [**4-14**] CXR: L effusion, mild CHF; CXR [**4-13**]: Left effusion, [**4-13**] US: no intra/extra hepatic dilatation, some gallstones/sludge Mr. [**First Name (Titles) 25408**] [**Last Name (Titles) **] on [**2143-4-29**]. Medications on Admission: Wellbutrin, Buspar, Neurontin . Discharge Disposition: [**Date Range **] Discharge Diagnosis: severe gallstone pancreatitis Discharge Condition: deceased Completed by:[**2143-7-18**]

Admission Date: [**2178-2-25**] Discharge Date: [**2178-4-15**] Date of Birth: [**2122-9-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: s/p arrest Major Surgical or Invasive Procedure: Intubation Central venous line insertion History of Present Illness: 54 yo M without any known PMH was brought in by EMS for respiratory distress after being notified by neighbor. History was consistent with having been down for a considerable time before being seen by EMS. He was brought in on BiPAP ventilation, sats in low 90s and unresponsive. He had a narrow complex tachycardia in the 140s. He had a difficult intubation with 3 attempts complicated by vomiting and witnessed aspiration. After intubation, O2 sat noted to be 90%, pt developed PEA arrest. He had several rounds of epi/atropine, CPR with subsequent wide complex tachycardia treated with DCCV and amiodarone bolus. He was started on amiodarone drip, levophed drip, received 3L NS for hypotension. He had a R femoral TLC placed. He was started on cooling protocol. Head CT unremarkable, CXR performed. Received ceftriaxone, clindamycin. . On arrival, he was in normal sinus rhythm at 78 bpm, BP 113/68, pt unresponsive, with the team unable to obtain any further direct or supporting information. Past Medical History: IDDM CAD s/p MI [**8-16**] s/p DES to D1 and prox LAD Hypertension Hyperlipidemia Schizophrenia Social History: Previous smoking history, unclear how long Family History: non-contributory, was not able to be obtained Physical Exam: Initial exam: VS: T 35 C on cooling, BP 113/68, HR 78, RR 26, TV 500 on 100% FIO2, PEEP 5. Gen: middle aged male intubated, unresponsive with ocassional myoclonic movements. HEENT: pupils 3mm b/l, unresponsive. Neck: Supple, JVP not visualized in flat position CV: RRR nl s1, s2, no murmur, heart sounds obscured by respirator sounds. Chest: breath sound b/l with loud wet upper airway sounds, frothy sputum in respirator tube. Abd: Obese, soft, no HSM Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: tr DP pulses b/l, cool skin. Pertinent Results: [**2178-2-25**] 06:35AM BLOOD WBC-16.3* RBC-5.56 Hgb-16.8 Hct-50.9 MCV-92 MCH-30.2 MCHC-32.9 RDW-13.0 Plt Ct-541* [**2178-2-28**] 05:01AM BLOOD WBC-11.2* RBC-3.10* Hgb-9.5* Hct-27.8* MCV-90 MCH-30.6 MCHC-34.1 RDW-14.0 Plt Ct-243 [**2178-2-25**] 06:35AM BLOOD PT-12.0 PTT-26.4 INR(PT)-1.0 [**2178-2-26**] 05:42AM BLOOD PT-14.4* PTT-39.1* INR(PT)-1.3* [**2178-2-25**] 06:35AM BLOOD Glucose-322* UreaN-23* Creat-1.5* Na-138 K-5.4* Cl-101 HCO3-13* AnGap-29* [**2178-2-25**] 09:33PM BLOOD Glucose-222* UreaN-24* Creat-0.7 Na-137 K-4.1 Cl-108 HCO3-18* AnGap-15 [**2178-2-28**] 05:01AM BLOOD Glucose-166* UreaN-32* Creat-0.9 Na-141 K-4.0 Cl-109* HCO3-24 AnGap-12 [**2178-2-25**] 06:35AM BLOOD ALT-84* AST-84* LD(LDH)-574* CK(CPK)-442* AlkPhos-189* Amylase-39 TotBili-1.0 [**2178-2-25**] 01:23PM BLOOD CK(CPK)-644* [**2178-2-26**] 05:42AM BLOOD ALT-63* AST-49* LD(LDH)-255* CK(CPK)-452* AlkPhos-94 Amylase-38 TotBili-1.6* [**2178-2-25**] 06:35AM BLOOD CK-MB-5 cTropnT-<0.01 proBNP-1627* [**2178-2-25**] 01:23PM BLOOD CK-MB-18* MB Indx-2.8 cTropnT-0.14* [**2178-2-26**] 05:42AM BLOOD CK-MB-20* MB Indx-4.4 cTropnT-0.08* [**2178-2-26**] 05:42AM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.2 Mg-2.0 Cholest-85 [**2178-2-26**] 05:42AM BLOOD Triglyc-45 HDL-54 CHOL/HD-1.6 LDLcalc-22 LDLmeas-<50 [**2178-2-26**] 05:42AM BLOOD %HbA1c-7.8* [**2178-2-28**] 05:01AM BLOOD Valproa-74 [**2178-2-25**] 06:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2178-2-25**] 06:40AM BLOOD Glucose-280* Lactate-4.4* Na-138 K-3.8 Cl-100 calHCO3-20* [**2178-2-28**] 08:50AM BLOOD Lactate-1.0 CT Head: 1. No acute intracranial hemorrhage. 2. Mild sinomucosal disease in the ethmoid sinus. 3. Opacification of some of the left mastoid air cells; correlate clinically. CXR: Heart size is mildly enlarged given technique and mediastinal and hilar contours are normal. There is diffuse airspace opacification. An ET tube is in place with its tip located 4 cm from the carina. An NG tube is seen with its tip projecting over the gastric bubble; the side-hole port is not clearly identified. There is no significant pleural effusion, pneumothorax, or obvious osseous abnormality. IMPRESSION: 1. Standard position of ET tube and likely of the NG tube, although side-hole port is not clearly demonstrated below the diaphragm. 2. Diffuse airspace opacification likely represents pulmonary edema, in this clinical context. EEG: This telemetry showed a continued burst suppression record. There were frequent truncal myoclonic jerks evident on video. These correlated with movement artifact on EEG. Although there were sharp waves as part of the bursts during the burst suppression record, sharp activity was not particularly rhythmic nor suggestive of ongoing electrographic seizures or status epilepticus. Overall, the recording is most suggestive of anoxic myoclonus and an extremely severe encephalopathy. Brief Hospital Course: # s/p PEA arrest: The patient was successfully revived after his PEA arrest. The causative [**Doctor Last Name 360**] for his arrest was thought to be hypoxia in the setting of fluid overload. His hemodynamics improved with diuresis and positive pressure ventilation. . # Post anoxic myoclonus/ Status epilepticus: The patient underwent arctic sun cooling protocol. EEG consistent with seizure activity. Patient was loaded with valproate and phenytoin which were adjusted based on level. Repeat EEG showed disorganized function. Given his anoxic brain injury and non-convulsive status, his prognosis for meaningful recovery was very poor. He was appointed a guardian by the court. Prior to this the team was prepared to place PEG and trach, but delayed this given that the team was recommending to the guardian, once she could be appointed, that the patient should be made CMO. Ultimately, a PEG was not placed. He did not show any signs of responsiveness or meaningful indepedent motor or verbal activity during any part of the admission. . # Coronary Artery Disease: The patient was maintained on a regimen of aspirin 325, clopidogrel 75, lisinopril 10, atorvastatin 80, and metoprolol throughout his stay until he was CMO. . # Fevers: The patient had an observed aspiration in the context of his emergent intubation. He was initially treated with ten days of azithromycin, ceftriaxone, and clindamycin. He continued to have fevers. BCx showed GPC and he was started on vancomycin, which was discontinued when cultures failed to grow organisms. Sputum culture grew pseudomonas and enterococcus. He was given zosyn and cipro for VAP per with defervescence lasting > 10 days. However, he became febrile again. Repeat culture showed GNR by gram stain, thought likely to be a colonizer. CT of his sinuses showed miltifocal opacities possibly demonstrating acute sinusitis. Antibiotics were continued. He had significant eosinophilia later in the admission suggesting the possibility of a drug reaction but ultimately as this was not clearly creating clinical consequences antibiotics and other medications were continued until he was made CMO. . # Red eye: developed red eye on [**3-15**], began having serosanguinous drainage on [**3-16**]. optho saw patient and believe is chemosis. Recommended non-antibiotic ointment. This improved with diuresis. . # Pump: Earlier in the admission he became total body fluid overloaded and was diuresed with improvement. He was kept euvolemic for the remainder of his stay. . # DM: During much of his stay he was strikingly insulin resistant. He was managed with ISS and glargine. . # Proph: PPI, bowel regimen, pneumoboots. dc'd sc heparin for elevated PTT and oozing from injection sites. . # Goals of care and code status: Patient was initially full code. After guardian was appointed, it was ultimately made comfort measures only after a court order to appoint a guardian and allow DNR/CMO late in the day on the [**10-14**]. On the 6th of [**Month (only) 116**], after consultation with the guardian, he was extubated, most medications were discontinued and he was kept on a morphine drip for respiratory comfort. He was breathing without apparent distress and ultimately died while remaining apparently comfortable; at 10:55 AM on [**4-15**] he was pronounced. Prior to this a chaplain was called to administer last rites in keeping with what appeared to have been the religious beliefs of the patient. . # Disposition: Patient died on [**2178-4-15**]. Medications on Admission: aspirin 325mg daily clopidogrel 75mg daily atenolol 10mg daily ezetemibe 10mg daily glyburide 5mg daily atorvastatin 80mg daily Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: PEA arrest anoxic brain injury status epilepticus ventilator associated pneumonia chemosis of left eye Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a

Admission Date: [**2125-7-30**] Discharge Date: [**2125-8-4**] Date of Birth: [**2101-12-9**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: This is a 21 year old female who fell down a flight of stairs and was found at the bottom with possible head trauma. Witnesses did not recall any seizure-like activity. On later questioning the patient reported having lost 25 pounds over the past month while taking Brazilian diet pills, with accompanying orthostasis, polydypsia, polyuria and dry mouth. She said she fell down the stairs in the context of presyncope and she believes she lost consciousness. She had no other syptoms prior to admission; no URI symptoms, UTI symptoms, shortness of breath, palpitations, chest pain, history of siezures, or focal neurologic complaints. Past Medical History: None Social History: occassional EtOH No tob/drugs Family History: CVA (father) no h/o seizure/sudden death Physical Exam: VS T98.6 P80 BP104/70R20 98%RA Gen: well-appearing, asking to go home Chest: Clear bilaterally CV: Regular rate and rhythm Abd: Soft, nontender, nondistended Ext: Well perfused Pertinent Results: CT head: right putamen bleed vs calcification MRI: head: small calcification in putamen, inflammation vs infection MRA, MRV: negative CT abd/pelvis: 1.6cm fatty lesion in liver CT C-spine: negative ECG: normal (24 hour tele) Carotid US: normal Serum/urine tox: normal Brief Hospital Course: Upon arrival the patient was responsive only to painful stimuli and was intubated for a GCS of 10 and respiratory difficulty. There were no obvious signs of trauma on evaluation and no fractures or internal injuries were identified. There was no evidence of bowel or bladder incontIn the ED she had some episodes of activity not entirely consistent with but concerning for seizure. Neurology and Neurosurgery were consulted and evaluated the patient in the ED. The patient was admitted to the Trauma ICU and self-extubated later that day, remaining stable afterwards. On the following day she had some episodes of tachypnea and/or apnea with return of flickering eye movements, and she was re-intubated. The patient was extubated without problems and monitored on telemetry in the ICU for another day with no events. She was transferred to the floor on telemetry and again had no return of apneic or hypoxic events. Her electrolytes remained within normal limits and she had no other complaints. She was evaluated by Medicine as well as Neurology and Neurosurgery, with no clear etiology found and a normal EEG. The most likely explanation at the time of discharge was drug-induced orthostasis combined with anxiety-associated hyperventilation. The patient was encouraged to follow up with her physician or the Trauma Surgery clinic and to return to an ER if any symptoms returned. She was also encouraged to avoid diet pills and have adequate food and liquid intake, along with taking slow deep breaths when anxious. Medications on Admission: Diet pill Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Syncopal event, likely in setting of drug-induced orthostatic hypotension Apneic episode Discharge Condition: Good Discharge Instructions: You should call a physician or come to ER if you have loss of consciousness, fevers, chills, nausea, vomiting, shortness of breath, chest pain, tingling, numbness, seizures, weakness, or any other questions or concerns. Do not take diet pills. Take slow deep breaths if you start to feel anxious. Otherwise you may resume all your normal activities. Followup Instructions: Call your primary care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment in 1 week. You will need a repeat head CT at that time. If you do not have a primary care physician you may call the Trauma Surgery clinic ([**Telephone/Fax (1) 2359**]) for a follow up appointment.

Admission Date: [**2188-12-5**] Discharge Date: [**2188-12-18**] Date of Birth: [**2124-9-28**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / moxifloxacin / metronidazole / cefazolin / Iodine / morphine / piperacillin / trimethoprim / Avelox Attending:[**First Name3 (LF) 5790**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2188-12-5**] Tracheoplasty with mesh right mainstem bronchus and bronchus intermedius, bronchoplasty with mesh left mainstem bronchus, bronchoplasty with mesh, bronchoscopy with bronchoalveolar lavage. History of Present Illness: Mrs. [**Known lastname 91270**] is a 64F with tracheomalacia s/p tracheal y-stent with subsequent stent removal [**2188-10-27**] for chronic infections. She has done well since her stent removal but continues to have a persistent cough and breathlessness with speaking. She presents now for right thoracotomy and tracheoplasty and bronchoplasty. Past Medical History: tracheomalacia s/p tracheal y-stent on [**2188-3-27**] s/p PFO closure [**2183**], [**Hospital1 3278**] Factor V Leiden deficiency with h/o DVT and CVA migraine fibrmyalgia asthma COPD, bronchiectasis glaucoma c-diff ([**2178**]) PSH: hemicolectomy (diverticulitis) nissen ([**2177**]) with chronic complications including gastroparesis and bilateral lower extremity neuropathy cholecystectomy appendectomy Social History: Retired social worker. Lives in [**Location 20291**] with husband. Alcoholism, quit 27 years ago. Tobacco use, quit [**2175**]. Family History: Father (d) depression, COPD Mother alcoholism Physical Exam: Temp 97.8, BP 107/68, HR 74, O2 sat 97% on RA General: Standing in exam room in no apparent distress. Cardiac: S1, S2, no r/m/g appreciated. Resp: RLL late expiratory crackles otherwise clear GI: Abdomen round. Skin: Warm, dry, no cyanosis. Neuro: A&O x3. Speech fluent and appropriate. Pertinent Results: [**2188-12-5**] 06:50PM WBC-14.4*# RBC-4.47 HGB-14.1 HCT-44.0 MCV-98 MCH-31.4 MCHC-32.0 RDW-14.4 [**2188-12-5**] 06:50PM PLT COUNT-272 [**2188-12-5**] 06:50PM PT-12.4 PTT-22.9 INR(PT)-1.0 [**2188-12-5**] 06:50PM CALCIUM-8.0* PHOSPHATE-2.4* MAGNESIUM-2.0 [**2188-12-5**] 06:50PM GLUCOSE-314* UREA N-23* CREAT-0.7 SODIUM-137 POTASSIUM-4.8 CHLORIDE-108 TOTAL CO2-21* ANION GAP-13 [**2188-12-8**] CXR : 1. No pneumothorax visualized in the right apex. 2. Stable appearance to the chest with low lung volumes bilaterally and right hemidiaphragm elevation. Stable post-surgical changes to the right posterior rib. 3. Dilated esophagus due to esophagus dysmotility. [**2188-12-11**] Ba swallow : Dilated proximal esophagus with narrowing distally at the site of the prior Nissen. This likely reflects worsening stenosis in the Nissen fundoplication. [**2188-12-15**] EGD : The esophagus appeared tortuous and dilated with solid food retained within. The lower esophagael sphincter was open without pathological narrowing - the scope easily passed through. These findings are suggestive of an esophagael motility disorder rather than a mechanical obstruction. Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Mrs. [**Last Name (STitle) **] was admitted to the hospital and taken to the Operating Room where she underwent a right thoracotomy with tracheoplasty and bronchoplasty (see formal Op note for further details). She tolerated the procedure well and returned to the SICU in stable condition. She was extubated and placed on a non rebreather with adequate saturations. Her pain was controlled via an epidural catheter with Bupivacaine and a Dilaudid PCA. She maintained stable hemodynamics and stayed in the SICU for 48 hours for pulmonary toilet. Her chest tube was removed on [**2188-12-7**] and her post pull film showed a small right pneumothorax and low lung volumes. Following transfer to the Surgical floor she continued to make slow progress. She was maintained on bronchodilators, Chest PT and used her incentive spirometer though not always effectively. Her right thoracotomy incision was healing well without erythema or drainage. She complained of some dysphagia and was evaluated by the speech and swallow therapist who felt that all of her symptoms were related to her pre op GERD as opposed to a swallowing problem. She was placed on her pre op motility agents and PPI but continued to complain of epigastric pain and nausea with all foods/liquids. A barium swallow was done which revealed a dilated proximal esophagus with some narrowing distally, possibly at the site of her prior Nissen. She then underwent an EGD and the scope passed easily without obstruction. The esophagus showed evidence of reflux. In the interim she was placed on TPN to help maintain her caloric needs. After no new pathology was identified a diet was reinstituted and she was able to take small frequent meals. The psychiatric service was also consulted as she appeared depressed, discouraged and difficult to engage in her care. They felt that her symptoms were magnified by her anxiety and recommended continuing Ativan and increasing her Gabapentin. As her oral intake improved though modestly, her TPN was discontinued on [**2188-12-17**]. Her blood sugars were in good control and she was encouraged to eat upright at all times, take small frequent portions of soft, mushy foods and avoid bread. Due to her history of Factor 5 Leiden deficiency the hematologist recommended that she be maintained on 4 weeks of anticoagulation post op. She is on Lovenox which should continue through [**2189-1-2**] and she is able to administer it to herself. After a lengthy stay she was discharged on 11/1011 to home with VNA services including Physical Therapy and she will follow up in the Thoracic Clinic in 2 weeks. Medications on Admission: ASA', Celebrex 400', Celexa 60', Flexeril 10 QHS Advair 500/50", folate', SSI, loratadine 10', motilin 10 qachs, MVI, omeprazole 40'', simvastatin 20', Spiriva 18', mucinex 1200", metformin 500", Fioricet 20-325 prn headache, Zantac 300 qhs Discharge Medications: 1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to right shoulder. Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2* 4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day) as needed for glaucoma. 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours). 6. meloxicam 7.5 mg Tablet Sig: One (1) Tablet PO once a day. 7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. citalopram 20 mg Tablet Sig: Three (3) Tablet PO once a day. 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 10. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO twice a day. 11. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 12. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 14. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Flexeril 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Cosopt 2-0.5 % Drops Sig: One (1) drop Ophthalmic twice a day: Both eyes. 17. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 18. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily): thru [**2189-1-2**]. Disp:*16 mg* Refills:*0* 19. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 20. nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:*100 Capsule(s)* Refills:*2* 21. ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2* 22. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. Disp:*60 Tablet(s)* Refills:*2* 23. other medication Domperidome 1 tab QID before meals and at bedtime Discharge Disposition: Home With Service Facility: [**Location (un) **] VNA Discharge Diagnosis: Tracheobronchomalacia GERD 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 surgery to repair your trachea and main airway so that your breathing will be a bit easier. The operation was done through an incision in the right chest which is healing. * Your appetite has been poor due to your reflux but the endoscopy showed that everything is widely patent which is reassuring. * Make sure that you remain upright for an hour after meals. Elevate your head, neck and chest when in bed with a wedge pillow or place the headboard on blocks to help prevent reflux. * Stick with soft foods and things that appeal to you while you get your appetite back. * Use your incentive spirometer and continue to cough and deep breath to exercise your lungs and keep from developing pneumonia. * Take adequate pain medication so that you'll be comfortable with minimal incisional pain. These drugs can be constipating so take a stool softener or gentle laxative to stay regular. * Due to your history of blood clots, the hematologist recommended that you stay on a blood thinner for 4 weeks post op which goes through [**2189-1-2**]. * If you develop any increased work of breathing, chest pain, leg swelling or any other symptoms that concern you, please call your doctor or return to the Emergency Room. Followup Instructions: Call Dr. [**Last Name (STitle) 9035**] for a follow up appointment in [**3-13**] weeks to review your medications. Call Dr. [**Last Name (STitle) 19688**] for a follow up appointment in [**2-10**] weeks. Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2189-1-6**] at 2:30 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You will need a chest xray prior to your appointment so please report to Radiology on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical Center 30 minutes before your appointment. Completed by:[**2188-12-18**]

Admission Date: [**2173-9-16**] Discharge Date: [**2173-9-21**] Date of Birth: [**2098-1-26**] Sex: M Service: MEDICINE Allergies: A.C.E Inhibitors / Lidocaine / Hydrocodone/Acetaminophen / Codeine Attending:[**First Name3 (LF) 7651**] Chief Complaint: Acute on chronic systolic heart failure Shortness of breath [**First Name3 (LF) **] bleed Major Surgical or Invasive Procedure: Nasal packing by ENT History of Present Illness: 75M with CAD s/p CABGx2 and multiple caths, EF 35%, moderate AS, PPM DM2, who presents with a history of shortness of breath due to acute on chronic systolic heart failure. Cath [**2173-3-12**] at [**Hospital1 1774**] showed LMCA had a distal 40% stenosis. The LAD, ramus, and RCA were proximally occluded. LCX had a patent stent. The LIMA-LAD and SVG-ramus were patent, and the SVG- RCA had a proximal 30%-40%. He presented to the ED yesterday with [**Hospital1 **] bleeding. He denies any chest pain or SOB. . In ED, nasopharynx was [**Hospital1 37883**]. Pt was hemodynamically stable. Past Medical History: -CAD S/P CABG and stent placements in LMCA and LCX -CABG [**2146**], [**2159**] -Type 2 Diabetes mellitus -bilateral ten toe amputation following cholesterol emboli after CABG -Hypertension -Hypercholesterolemia -Paroxysmal atrial fibrillation/flutter -Aortic stenosis (valve area 0.8) -History of multiple strokes s/p bilateral carotid stents -Peripheral arterial disease -Gout -Chronic kidney disease (baseline Cr 1.4-1.9) -Mild dementia -Status post pacer implantation in [**2172-5-30**] for AV conduction delay (2:1 conduction with ventricular rate of approximately 30) -Chronic myositis with elevated CK -Remote syncope with no inducible arrhythmias at EP Study Social History: Social history is significant for the absence of current tobacco use, but smoked a pipe in past, quit 50 yrs ago. There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. Married. Wife has [**Name2 (NI) 11964**]. Patient is primary caregiver. Lives in [**Location **] in [**Hospital3 **] center. Retired pilot and thermodynamics specialist. Father died in 90's of unknown causes. Mother died in 80's of liver cancer. Family History: Father died in 90's of unknown causes. Mother died in 80's of liver cancer. Physical Exam: VS: T 98.5, 108/54, 85, 19, 92-98% 30% face tent Gen: WDWN middle aged male in NAD, resp or otherwise. mildly sleepy but awake, alert, conversational and appropriate HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with no JVD to angle of jaw CV: RR, normal S1, S2. systolic murmur LUSB radiating to carotids. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crackles at bases Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: trace LE edema. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP MEDICAL DECISION MAKING Pertinent Results: [**2173-9-16**] 10:44PM CK(CPK)-119 [**2173-9-16**] 10:44PM CK-MB-10 MB INDX-8.4* cTropnT-0.03* [**2173-9-16**] 10:44PM HCT-33.4* [**2173-9-16**] 03:05PM GLUCOSE-190* UREA N-30* CREAT-2.0* SODIUM-138 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17 [**2173-9-16**] 03:05PM estGFR-Using this [**2173-9-16**] 03:05PM CK(CPK)-86 [**2173-9-16**] 03:05PM CK-MB-5 cTropnT-0.03* [**2173-9-16**] 03:05PM WBC-10.1 RBC-3.54* HGB-10.8* HCT-32.8* MCV-92 MCH-30.5 MCHC-32.9 RDW-14.2 [**2173-9-16**] 03:05PM NEUTS-74.5* LYMPHS-16.4* MONOS-5.3 EOS-2.9 BASOS-0.8 [**2173-9-16**] 03:05PM PLT COUNT-542*# [**2173-9-16**] 03:05PM PT-25.0* PTT-32.8 INR(PT)-2.5* . . . [**2173-9-20**] 08:40AM BLOOD WBC-8.9 RBC-3.28* Hgb-10.1* Hct-30.1* MCV-92 MCH-30.7 MCHC-33.5 RDW-14.1 Plt Ct-488* [**2173-9-16**] 03:05PM BLOOD Neuts-74.5* Lymphs-16.4* Monos-5.3 Eos-2.9 Baso-0.8 [**2173-9-20**] 08:40AM BLOOD Plt Ct-488* [**2173-9-20**] 08:40AM BLOOD PT-14.3* PTT-26.2 INR(PT)-1.3* [**2173-9-20**] 08:40AM BLOOD Glucose-109* UreaN-15 Creat-1.6* Na-140 K-4.1 Cl-106 HCO3-25 AnGap-13 [**2173-9-18**] 07:40AM BLOOD CK(CPK)-158 [**2173-9-17**] 02:10PM BLOOD CK(CPK)-172 [**2173-9-17**] 04:11AM BLOOD ALT-23 AST-29 CK(CPK)-173 AlkPhos-80 TotBili-0.5 [**2173-9-18**] 07:40AM BLOOD CK-MB-8 cTropnT-0.25* [**2173-9-17**] 02:10PM BLOOD CK-MB-19* MB Indx-11.0* cTropnT-0.34* proBNP-5805* [**2173-9-17**] 04:11AM BLOOD CK-MB-18* MB Indx-10.4* cTropnT-0.15* [**2173-9-16**] 10:44PM BLOOD CK-MB-10 MB Indx-8.4* cTropnT-0.03* [**2173-9-16**] 03:05PM BLOOD CK-MB-5 cTropnT-0.03* [**2173-9-20**] 08:40AM BLOOD Mg-2.3 [**2173-9-17**] 04:11AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0 . . pCXR [**2173-9-17**]: IMPRESSION: Small left pleural effusion. Brief Hospital Course: 75M with CAD s/p CABGx2 and multiple caths, EF 35%, moderate AS, PPM DM2, who now presents with shortness of breath and tachycardia. Diagnosed with acute on chronic systolic heart failure exacerbation with troponin leak. . 1. Cardiac: a. Coronaries: The patient had no chest pain symptoms, though was found to have elevated troponins in the setting of CHF. The peak troponin was up to 0.35, peak CK 173, MB 18. These were noted to be trending dow. The mild enzyme elevation was likely attributable to CHF vs demand ischemia. There is a history of CAD s/p cabg x2. Cath [**3-6**] at [**Hospital1 1774**] revealed patent grafts. The patient was continued on aspirin, plavix, lipitor 80, Beta blocker. . b. Pump: The patient presented intially with CHF and he was diuresed to euvolemic. There is a history of CHF with EF 35%. He was continued on beta blocker and ACE. . c. Rhythm: There is a history of paroxysmal afib on coumadin. Pacemaker was for for 2:1 AV block [**6-4**]. In the ED, the patient was noted to have a complex rhythm which showed pacer spikes. This was consistent with an SVT with pacer tracking. There was initially concern in the ED for possible ventricular tachycardia though review of the ECG strip by cardiology confirmed that this was not the case. The ECG showed a sinus tachycardia with ventricular pacing. . d. Valves: There is a history of aortic stenosis, [**Location (un) 109**] 1.1 mean gradient 32 by cath at [**Hospital1 1774**] [**2173-3-12**]. The plan is for non-operative management per Dr. [**Last Name (STitle) **] since pt is a poor surgical candidate and has complex aortic atheroma . 2. Epistaxis: There was heavy bleeding on presentation, enough to fill a cup or two per the patient. This was controlled with the nasal packing by ENT. The packing was left in place until the day prior to discharge. Coumadin was held initially. The plan for anticoagulation and antiplatelet therapy was discussed with the patient's outpatient cardiologist, Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] recommended continuing dual anti-platelet therapy given the concern for stent thrombosis, which the patient was assessed as high risk for this given his coronary anatomy. He had taxus stent in [**12-6**]. The plan was to pursue a lower INR target for anticoagulation from 1.8 - 2.5, though this would be recalibrated to 2.0 - 3.0 as an outpatient if there was no further bleeding. . DM2: The patient was continued on insulin and sliding scale. . Access: PIV Proph: anticoagulated, PPI Medications on Admission: Protonix 40 daily ASA 325 daily Lasix 20 daily Humulog 25U QAC Isordil 60 daily Lantus 60U Qhs Lidex [**Hospital1 **] Plavix 75 daily Nitroglycerin 0.3 prn Valsartan 80 daily Lipitor 80 daily Metoprolol 25 daily Coumadin 10 daily Senna Colace Prednisone Clobetasol Mupirocin 2% Cream Hydrocortisone 1% Ointment Calcipotriene 0.005% Cream Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical DAILY (Daily). 7. Hydrocortisone 1 % Ointment Sig: One (1) Appl Topical DAILY (Daily). 8. Calcipotriene 0.005 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Insulin Glargine 100 unit/mL Solution Sig: Seventy (70) Units [**Hospital1 37882**] qHS. 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Coumadin 2.5 mg Tablet Sig: Four (4) Tablet PO once a day: please take a directed by coumadin clinic. New target INR per patient's cardiologist is 1.8 - 2.5. 14. Outpatient Lab Work INR check Thursday [**9-23**] or Friday [**9-24**] Discharge Disposition: Home With Service Facility: Care Tenders Discharge Diagnosis: Primary Diagnosis: epistaxis Acute on chronic systolic CHF exacerbation Secondary Diagnosis: Coronary artery disease Paroxysmal atrial fibrillation Discharge Condition: stable Discharge Instructions: You came to the hospital because you had a significant nosebleed. Otolaryngology doctors [**Name5 (PTitle) 37883**] the [**Name5 (PTitle) **] to stop the bleedingl. We stopped your coumadin medicine while you were in the hospital, although we are restarting this medicine now that you are being discharged. You should hold the valsartan for now because your blood pressure was running lower. This should be restarted by Dr. [**First Name (STitle) **] when he sees you in clinic on [**9-24**] if your blood pressure is improved. We recommend increasing the lantus dose from 60 units daily to 70 units daily. You should resume all of your other medications as previously including the coumadin. If you have further episodes of bleeding, if you have chest pain, shortness of breath, or any other concerning symptoms, please call your doctor or go to the emergency room. Followup Instructions: You have an appointment scheduled to see you primary care physician. [**Name10 (NameIs) 2169**] [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 12637**], M.D. Date/Time:[**2173-9-24**] 10:00 Please have an INR check on Thursday or Friday that should be followed up by the [**Hospital3 **] You have an appointment scheduled to see your cardiologist. Provider [**Name9 (PRE) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2173-10-28**] 10:20 Provider [**First Name11 (Name Pattern1) 2747**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**] Date/Time:[**2173-12-1**] 11:15

Admission Date: [**2142-6-16**] Discharge Date: [**2142-7-1**] Service: GENERAL SURGERY/BLUE HISTORY OF PRESENT ILLNESS: The patient is a 79 year old lady with diabetes mellitus, coronary artery disease, dementia and colonic polyp which was removed during colonoscopy, who presented with bright red blood per rectum starting the day prior to presentation. The patient had similar episode in [**2142-1-27**], and was found to have numerous colonic polyps. The day prior to presentation she started complaining about lower abdominal crampy pain after having massive bright red blood per rectum with clots. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. Coronary artery disease. 3. Congestive heart failure. Echocardiogram [**1-28**], showed an ejection fraction of 30%, 2+ mitral regurgitation, 3+ tricuspid regurgitation. 4. Hypercholesterolemia. 5. Chronic atrial fibrillation. 6. Migraines. 7. Nasal polyp. 8. Venous stasis and chronic edema. 9. Chronic renal insufficiency. 10. Depression. 11. Degenerative joint disease. 12. Colonic polyps, status post gastrointestinal bleed in [**1-29**]. 13. Peripheral vascular disease, status post lower extremity bypass. PAST SURGICAL HISTORY: 1. Status post left lower extremity bypass. 2. Status post appendectomy. 3. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy from menorrhagia at age of 33. MEDICATIONS ON ADMISSION: 1. Cozaar 25 mg p.o. once daily. 2. Celexa 20 mg once daily. 3. Zaroxolyn 2.5 mg once daily. 4. Calcitriol 6.25 once daily. 5. NPH 30 units once daily. ALLERGIES: Sulfa/rash. Keflex/diarrhea. SOCIAL HISTORY: The patient lives alone in assisted facility. The patient denies tobacco and alcohol use. PHYSICAL EXAMINATION: The patient is pleasant and cooperative in no acute distress. Temperature is 98.7, pulse 84, blood pressure 124/64, heart rate 18, oxygen saturation 100% in room air. Mucous membranes are moist. Lungs are clear to auscultation bilaterally, decreased breath sounds inferiorly. Heart irregular rhythm, regular rate, II/VI systolic ejection murmur. The abdomen is obese, soft, nontender. Extremities - 2+ edema, warm. LABORATORY DATA: White blood cell count was 8.6, hematocrit 31.2, platelet count 150,000. Sodium 142, potassium 4.0, chloride 103, bicarbonate 25, blood urea nitrogen 100, creatinine 2.7, glucose 115. Prothrombin time 14.9, partial thromboplastin time 33.6, INR 1.5. Urinalysis negative. HOSPITAL COURSE: The patient was admitted to Medicine service and placed in the Intensive Care Unit. Surgery was consulted. Nasogastric tube was placed. The patient was typed and crossed and transfused to keep her hematocrit above 30.0. Red blood cell scan was performed. The patient's coagulopathy was reversed with Vitamin K and fresh frozen plasma. On hospital day number two, the patient is afebrile and vital signs are stable. The patient continued to have some bright red blood per rectum, transfused to keep hematocrit above 30.0. Bleeding scan localized bleeding into the area of the cecum. Gastroenterology was also consulted who at that time recommended correcting coagulopathy and conservative management. The patient remained in the Intensive Care Unit for observation. Her bleeding has stopped by itself. She was transferred to the floor on [**2142-6-22**]. The patient again started bleeding with bright red blood per rectum and hematocrit dropped (anemia). The patient was again typed and crossed and transfused to keep hematocrit above 30.0. Surgery was reconsulted. At that time, the patient's bleeding stopped by itself. Surgery requested cardiology consultation. The patient had a Swan-Ganz catheter placed for cardiac monitoring. She was also started on Lopressor for cardiac prophylaxis. However, overnight, the patient started bleeding again. She was then taken to the operating room on [**2142-6-24**], for right hemicolectomy. Please see operative note for details. The patient tolerated the procedure well and was transferred back to Intensive Care Unit in stable condition. Postoperative day number one, the patient is afebrile and vital signs are stable. She is diuresing well and unable to wean off ventilator due to edema. She was started on TPN for failure to thrive. She was also placed on Vancomycin, Levofloxacin and Flagyl (Vancomycin for Staphylococcus aureus urinary tract infection). She also was started on Lasix, however, she did not really respond well to it and it was stopped. The patient continued diuresis. The patient had a couple episodes of bradycardia down to high 30s, low 40s. Her Lopressor was stopped which improved her bradycardia (heart rate in high 50s and low 60s). The patient self extubated on postoperative day number three. Nasogastric tube was removed. She was started on sips and advanced to clears which she was tolerating well. She continued on TPN. She started with physical therapy. She continued on Vancomycin for urinary tract infection until second urine culture came back positive. On postoperative day number four, the patient is afebrile and vital signs are stable. She was started on p.o. medications. She was also restarted on Cozaar for blood pressure control. Second culture came back as MSSA. The patient was switched to Oxacillin. The patient was transferred to regular floor. Her Foley was removed. At renal service suggestion, she was started on Epogen and Zaroxolyn. Her diet was advanced to regular diabetic diet which she was tolerating well. She was walking with physical therapy. On postoperative day five and six, the patient is afebrile and vital signs are stable. She is ambulating a few steps and moving from bed to chair with physical therapy. The wound is clean, dry and intact. She is confused at times, however, this is the patient's baseline. Otherwise, she is stable with no concerns, no active issues at this time. CONDITION ON DISCHARGE: Good. DISPOSITION: The patient is discharged to rehabilitation with physical therapy on diabetic diet. The patient should remain on Epogen until she is followed up with primary care physician to determine length of treatment. MEDICATIONS ON DISCHARGE: 1. Tylenol one to two tablets p.o. q4-6hours p.r.n. pain. 2. Celexa 20 mg p.o. once daily. 3. Triamcinolone Ointment applied to affected areas twice a day. 4. Sarna Lotion twice a day. 5. Compazine 10 mg q6hours p.r.n. 6. Benadryl 25 mg p.o. q.h.s. p.r.n. 7. Calcium Carbonate 500 mg p.o. three times a day with meals. 8. Calcitriol 0.25 mcg once daily. 9. Regular insulin sliding scale - please see sliding scale for details. 10. Metolazone 2.5 mg once daily. 11. Losartan 25 mg p.o. once daily. 12. Epoetin 5000 units two tablets a week. 13. Lasix 40 mg p.o. once daily. 14. Protonix 40 mg p.o. once daily. DISCHARGE DIAGNOSES: 1. Lower gastrointestinal bleed, status post right hemicolectomy. 2. Hypovolemia requiring blood and fluid rescucitation 3. Urinary Tract Infection on this admission 4. Diabetes mellitus. 5. Coronary artery disease. 6. Congestive heart failure. 7. Hypercholesterolemia. 8. Chronic atrial fibrillation. 9. Migraines. 10. Venous stasis and chronic edema. 11. Chronic renal insufficiency. 12. Depression. 13. Degenerative joint disease. 14. Peripheral vascular disease. 15. Postoperative anemia. 16. Failure to thrive. 17. Episodic Bradycardia. 18. Malnutrition requiring parenteral nutrition [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19318**] Dictated By:[**Last Name (STitle) 7487**] MEDQUIST36 D: [**2142-6-30**] 14:18 T: [**2142-6-30**] 14:57 JOB#: [**Job Number 105183**]

Admission Date: [**2141-9-26**] Discharge Date: [**2141-10-4**] Service: This is a [**Age over 90 **]-year-old female admitted to the Vascular service on [**2141-9-19**] and discharged [**2141-10-4**]. CHIEF COMPLAINT: Right foot cellulitis and gangrenous ischemic toes. HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female hospitalized in [**Month (only) 216**] of this year for right foot ischemia, who underwent a diagnostic arteriogram with Perclose groin closure and right leg runoff for HIT induced thrombocytopenia with right foot embolus. The study demonstrated right SFA popliteal disease with single-vessel runoff via the peroneal artery. The patient was seen in Dr.[**Name (NI) 1392**] clinic on [**2141-9-19**] for right foot cellulitis. Since discharge, last dialysis was on [**Month (only) **] __________. The right foot and blood toes remained the same but in the last 48 hours there is increasing erythema, edema and drainage from the wound. The patient denies any constitutional symptoms. She is now admitted for IV antibiotics and consideration for revascularization of the right lower extremity. ALLERGIES: Penicillin, manifestations not known; heparin, HIT antibody positive. MEDICATIONS: Include levothyroxine 75 mcg daily, Lopressor XL 75 mg daily, __________ 10 mg daily, calcium 1000 mg t.i.d., multivitamin capsule daily, Coumadin 2 mg Monday, Wednesday, Friday, and 1 mg Tuesday, Tuesday, Saturday, Sunday, aspirin 81 mg daily, Protonix 40 mg daily, senna tablets 8.6 mg twice a day, Colace 100 mg b.i.d., oxycodone 2.5 mg q.8h. p.r.n. pain. ILLNESSES: Include endstage renal disease, stage V, on dialysis Tuesdays, Thursdays and Saturdays; status post right IJ PermCath in [**2141-8-9**]; history of coronary artery disease with a non-ST elevated MI; history of peripheral vascular disease; history of hypertension; history of anemia of renal disease; history of osteodystrophy; history of hypothyroidism; history of gastroesophageal reflux disease. SOCIAL HISTORY: The patient denies tobacco or alcohol use. The patient is dialyzed at [**Location (un) **] Hemodialysis Center. Their number is [**Telephone/Fax (1) 26161**]. Her nephrologist is Dr. [**Last Name (STitle) **]. [**Doctor Last Name 118**], his number is [**Telephone/Fax (1) 435**]. Cardiologist is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], office number [**Telephone/Fax (1) 1989**]. PHYSICAL EXAMINATION: Vital signs: 95.3 axillary, 104, 18, blood pressure 111/85, O2 sats 97% on room air. HEENT exam: There is no JVD or carotid bruits. Pulses are palpable 2+ bilaterally. Lungs are clear to auscultation bilaterally. Heart is of regular rate and rhythm without murmur, gallop or rub. Abdomen is mildly distended, nontender, with bowel sounds x4. There are no abdominal bruits or masses. Extremity exam shows left foot is pale, cool, without lesions. The right foot is with 2 to 3+ edema, white toes with erythema at the toes extending to the ankle. The foot is cool. Pulse exam shows 2+ femoral pulses with 1+ popliteal, BP, and PT bilaterally. Neurological exam: Oriented x person and place, nonfocal. HOSPITAL COURSE: The patient was admitted to the Vascular service. Wound cultures were obtained and she was begun on triple antibiotic therapy of vancomycin, ciprofloxacin, and Flagyl. Wound culture Gram stain showed no polys or microorganisms. The wound culture was finalized as no growth. Renal was consulted for hemodialysis and the patient was continued on her preadmission schedule for Tuesdays, Thursdays and Saturdays. The patient's INR on admission was 2.9. Epo was started at 22,000 units at dialysis. A long discussion was held with the family, amputation versus bypass, given the patient had poor outflow and questionable graft patency, was presented to the family. They were adamantly against amputation. The patient proceeded to surgery after being evaluated by Cardiology who felt that patient was at moderate risk for a perioperative event. Her medications were adjusted to improve her blood pressure and heart rate for a goal of systolic pressure of 120-140 and a pulse rate of 60 or less. The cellulitis improved and edema improved with antibiotics and bedrest. The patient underwent on [**2141-9-26**], a right fem-DP bypass graft in situ saphenous vein angioscopy. The patient tolerated the procedure well and was extubated and transferred to the PACU in stable condition. On arrival to the PACU, the foot was cold, there was no signal in the graft. The patient returned to the OR and underwent a thrombectomy of the right femoral DP bypass x2. The patient was extubated and returned to the PACU. The graft pulse was marginal after the second surgery and decision was made if the graft failed that no further surgical intervention would be attempted. The patient remained intubated overnight and in the PACU. Postoperative day 1 there were no overnight events. The patient was weaned off Neo-Synephrine for systolic blood pressure control. The patient was weaned off __________. She underwent hemodialysis and then was attempted at extubation. Postoperative day 2 there were no overnight events. The patient was afebrile. The patient was extubated the day prior and was transferred to the VICU for continued monitoring of care. She was continued on triple antibiotics with vanco, Cipro, and Flagyl. We will continue to follow the patient for her hemodialysis needs. She was transfused 1 unit of packed red blood cells for a hematocrit of 26. Postoperative day 3 overnight events: The patient experienced chest pain with ST depressions. She was given aspirin and nitroglycerin with relief of her symptoms. The patient continued to do well from a cardiac standpoint. Arterial studies were done on [**2141-10-2**] which showed on the right foot 3 mm pressure wave tracings and on the left 2 mm. Post transfusion hematocrit was 29.3. The patient remained on argatroban for her history of heparin allergy. __________ was restarted on [**2141-10-1**] for regained Doppler signals in the left foot that had been initially lost. Physical therapy was requested through the patient for evaluation for discharge planning. Case management was consulted to assist in discharge planning needs. The patient will be discharged when medically stable per PT's evaluation. DISCHARGE MEDICATIONS: Include levothyroxine 75 mg daily, __________ 10 mg daily, calcium carbonate 1000 mg t.i.d., Niferex capsule 1 daily, aspirin 81 mg daily, Colace 100 mg b.i.d., oxycodone/acetaminophen 5/325 solution [**5-18**] mL q.4h. p.r.n. for pain, Protonix 40 mg daily, senna tablets 8.6 mg b.i.d., metoprolol 75 mg t.i.d., warfarin 2 mg Monday, Wednesday and Friday, and 1 mg Sunday, Tuesday, Thursday and Saturday, lisinopril was started for her systolic hypertension at 5 mg daily. DISCHARGE INSTRUCTIONS: She may ambulate essential distances. She should wear an Ace from foot to knee on the right side when ambulating. She should keep the right foot and leg elevated in a chair. She should continue her Coumadin for history of thrombus and heparin allergy and take as directed. The goal INR is 2.0-3.0. She should follow up with her primary care physician for monitoring of her INR and adjustment of her Coumadin dosing as required. We have made arrangements for her to see hematologist because of her history of clotting problems, please keep that appointment. Please call Dr.[**Name (NI) 1392**] office for the following reasons: If you develop fever greater than 101.5, if the with wound changes, becomes red, swollen or drainage, or there is any increasing blue discoloration of the right toe or increasing right foot pain. You may shower but no tub baths. Please continue to take the stool softener, Colace, as directed while you are taking pain medication since pain meds can cause constipation. DISCHARGE DIAGNOSES: 1. Right foot cellulitis with ischemic toes. 2. History of endstage renal disease, stage V, on dialysis Tuesday, Thursday and Saturday. 3. History of hypertension, uncontrolled. 4. History of peripheral vascular disease. 5. History of anemia of renal disease. 6. History of renal osteodystrophy. 7. History of hypothyroidism. 8. History of gastric reflux. 9. History of coronary artery disease status post non-ST myocardial infarction. 10.History of heparin-induced thrombocytopenia, postoperative blood loss anemia, transfused. MAJOR SURGICAL PROCEDURES: Right femoral-dorsalis pedis bypass in situ saphenous vein with thrombectomy of the right femoral-dorsalis pedis graft x2 on [**9-26**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2141-10-2**] 15:54:51 T: [**2141-10-2**] 23:17:22 Job#: [**Job Number 68452**]

Admission Date: [**2178-4-23**] Discharge Date: [**2178-5-10**] Date of Birth: [**2129-5-19**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: Miss [**Known lastname **] is a 48 year old woman with a past medical history of hypothyroidism carrying the diagnosis of systemic lupus erythematosus who presents from [**Hospital3 35813**] Center in [**Doctor Last Name 792**]with Group A beta hemolytic Strep sepsis, rash, anopsia, myalgia, arthralgia and hypoxia, and respiratory failure requiring intubation. She initially presented to [**Hospital3 35813**] Center on the evening of [**4-19**], complaining of upper extremity pain and fever to 102.0 F. The pain was most severe in her left axilla and shoulder. Four weeks prior to admission, she began having upper extremity swelling and stiffness particularly in her hands. She was prescribed Vioxx for her symptoms. On the 1st, she was referred to a rheumatologist who prescribed Prednisone 20 mg q. day and then she presented to the outside hospital on the 4th complaining of fever, diarrhea, stiff joints and puffiness in her hands. She decided to go the Emergency Department particularly because her left arm and shoulder had increased in pain. She had an outside hospital course notable for increased erythematous rash on the left arm, neck, and chest, increased white blood cell count to 22.0 with bandemia approximately 10 to 12%, positive blood cultures, four out of four bottles drawn on the 4th for Group A beta hemolytic strep. She initially was started on Rocephin which was changed to penicillin and clindamycin. On [**5-22**], she developed wheezing, hypoxia and shortness of breath. She was transferred to the Medical Intensive Care Unit. She was intubated on the 7th. Chest x-rays showed evidence of pulmonary edema but she had a normal transthoracic echocardiogram, normal ejection fraction and no evidence of vegetations at the outside hospital. She had a chest CT scan that showed significant lymphadenopathy in the mediastinum, axillae, retroperitoneum and supraclavicular regions with some question of mediastinal fluid. The patient has a distant history of a malar rash especially related to photosensitivity, sun exposure. Her [**Doctor First Name **] was positive 1 to 320 at the outside rheumatologist's office on the first. The CRP and ESR were also elevated, CRP to 144 and the ESR to 74. There was some concern at the outside hospital, but at [**Hospital1 1444**] her platelets were normal. Her INR was normal. Her fibrinogen was 653. On the date of transfer to [**Hospital1 69**], the patient was given one dose of intravenous IG at 36 grams times one. On transfer she was hemodynamically stable without need for pressors. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Systemic lupus erythematosus. No coronary artery disease, diabetes mellitus, pulmonary or renal disease. MEDICATIONS ON TRANSFER: 1. Synthroid 50 micrograms intravenous q. day. 2. Zantac intravenously q. 12. 3. Heparin subcutaneously. 4. Clindamycin 900 mg intravenous q. eight. 5. Intravenous IG 36 grams times one. 6. Ativan 2 to 4 grams intravenously. 7. Morphine sulfate 2 to 4 gram intravenous p.r.n. 8. At home the patient was taking Vioxx and Synthroid 100 micrograms q. day. ALLERGIES: The patient denies any allergies, however, the patient did have a rash to Dilaudid at the outside hospital. LABORATORY: Microbiological data drawn on the [**5-20**], the patient had four out of four bottles of Group A beta hemolytic strep at the outside hospital. EKG sinus tachycardia, normal axis, normal intervals. The patient had ultrasound of the left upper extremity which revealed no deep venous thrombosis; this was on the [**5-20**] at the outside hospital. The patient had a chest x-ray at the outside hospital on [**4-23**] with parenchymal changes consistent with low grade edema, vascular engorgement, congestive heart failure. The patient had a CT scan of the chest as noted on the 5th, adenopathy in mediastinum, retroperitoneal, axilla, supraclavicular regions with small pericardial effusion. Possible question of mediastinal fluid/mediastinitis. Pertinent laboratory data at transfer: Lyme serology negative. Hepatitis B, Hepatitis C negative. Parvovirus B19 negative. Antistreptolysin 46, P-ANCA negative. Rheumatoid factor 19. [**Doctor First Name **] positive 1:320, homogenous, anticentromere antibody negative. CRP 1 in 44; ESR 74; antismooth antibody negative. Ferritin 759. Hemoglobin 9.1, hematocrit 27.4, white count 14.6 with 7 bands, 82 PMNs, one meta. INR 1.2, platelets 196. Sodium 131, potassium 4.3, chloride 99, bicarbonate 21, anion gap 11, BUN 26, creatinine 1.0, glucose 96. Albumin 2, total bilirubin 1.0, SGOT 62, down from 200; SGPT 40, down from 131. CBC from the outside hospital on the 4th: her white blood cell count was 22 with 11 bands. This decreased to 15.6 on the day prior to transfer to 14.6 on the day of transfer. Platelets on presentation were 219 the day prior to transfer, 196 on the day of transfer. TSH was 12.8, T4 was 6.6. Ventilation settings at the time of transfer was AC-550 by 14, 50%, PEEP of 5 with an arterial blood gas of 7.33, 44, 151. She was on 15 of Propofol for sedation. PHYSICAL EXAMINATION: Pulse 78; blood pressure 120/70; 97% on the above stated ventilator settings. Her intakes and outputs were roughly on presentation the first 12 hours one liter in and one liter out. Temperature at presentation was 99.8 F.; temperature maximum of 100.4 F.; she was sedated and intubated. She had erythema in her right neck supraclavicular region as well as her left breast and left medial aspect of her arm. There is petechiae in her right ankle. There was swelling and warmth in her shoulder, deltoid and axilla region on the left hand side. Upon palpation of these areas the patient would grimace, bite down the ETT tube and become hypertension and tachycardic implying pain in the region. HEENT: Pupils equally round and reactive to light and accommodation. Neck with no jugular venous distention. No bruit. Lungs were clear to auscultation anteriorly however, there were scattered wheezes bilaterally. Regular rate and rhythm. S1, S2. There is a I to II systolic ejection murmur at the apex to axilla. Abdomen was soft, normoactive bowel sounds, no hepatosplenomegaly. Abdomen was mildly distended. Plus two upper extremity edema in hands as well as plus one in the feet. As stated earlier, the patient was sedated. Ventilator settings at [**Hospital1 69**] on presentation were AC40%, 550 by 16, volume approximately 8.8, PEEP of 8. ASSESSMENT: This is a 48 year old woman with Group alpha beta hemolytic strep sepsis transferred from the outside hospital. She was hemodynamically stable, not on pressors, with report of toxic shock syndrome but with normal renal and end-organ function with the exception of Pulmonary status at presentation, with left arm axilla pain at presentation. HOSPITAL COURSE: 1. BETA HEMOLYTIC STREP SEPSIS: Unclear at the entry for the source of the Group A beta hemolytic strep. The patient denies symptoms of pharyngitis, however, there were reports later on after discussion with the patient of excoriations and possibly a dermatological portal of entry. The infectious disease service was consulted, and the patient was continued on penicillin and Clindamycin until the [**2178-5-3**], at which time penicillin was discontinued. The patient's white count decreased to 6.4 on the 18th with no bands and 76 PMNs. Given the patient's pain and significant adenopathy and CT scan from the outside hospital, it was felt that the left shoulder was indeed the portal source for the bacteremia. The patient had an MRI on the [**4-25**] which showed edema and enhancement about the left shoulder girdle, prominent tracking along the subclavian and axillary vessels and in the subacromial and subdeltoid bursa, fat and along the superficial surface of the deltoid and within the anterior fibers of the deltoid. These findings are consistent with inflammation making this highly suspicious for soft tissue infection including focal myositis of the deltoid. Both the Surgical and Orthopedic Teams felt that given the patient's improvement clinically in terms of a white count and examination of the left shoulder, that there was no indication to have a surgical intervention. There was no focal collection of fluid and although the patient seemed to have evidence of mild myositis, there was no evidence of necrotizing fasciitis on clinical examination. The patient will require a total of three weeks of Clindamycin, at which time the patient should get a repeat MRI to evaluate the left shoulder, and then follow-up at Infectious Disease clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. 2. FEVER: The patient's fever curve generally improved. Although her baseline temperature was low grade 99 to 100.0 F., she had spike to 102.0 F. Multiple blood cultures were drawn. The patient has blood cultures from the 19th, two sets; 15th two sets; 12th two sets; 11th one set; 10th two sets; 9th two sets. Only positive cultures were coagulase negative Staphylococcus on the [**2178-4-30**]. The patient had had a PICC line on the [**2178-4-27**]. This PICC line was associated with hypotension and ventricular tachycardia. The PICC line was placed at the bedside. The patient had runs of ventricular tachycardia with blood pressure into the 80s. The patient was bolused intravenous fluids. The line was pulled back 8 cm with resolution of the abnormal heart rhythm. Further x-ray was done which showed the tip of the catheter PICC line still in the right ventricle. This was pulled back an additional 4 cm. Due to the prolonged exposure of the PICC line to the environment, when patient spiked on the 15th, the PICC line was promptly removed. However, the patient continued to have fevers even after this line was discontinued. Despite a general improvement in her swelling of her left arm and left soft tissues, continued maintenance of a white count in the 6.0 range as well as good urine output and no focal symptoms, one possibility was the Clostridium difficile infection, the patient did not have diarrhea and had two negative cultures for Clostridium difficile on the 12th. However, given the treatment with clindamycin, this placed the patient at a high risk for Clostridium difficile and it is noted that the patient should be monitored for Clostridium difficile infections. If she has any continued fevers, high white counts or diarrheal symptoms, that Clostridium difficile toxin should be sent and empiric coverage with Flagyl should be considered. A possible source of the patient's fever was a reaction to beta lactate antibiotics, particular penicillin. The patient had a maculopapular rash on her left arm as well as on her flanks associated with fever spikes in the context of taking penicillin with her clindamycin. The patient had a urine culture on the [**4-24**] which showed extended spectrum beta lactamase E. coli. Unclear whether this was a colonizer or a pathogen but the patient had a Foley catheter in place. The patient was treated with Ciprofloxacin for five days and repeat urine cultures thereafter were negative. 3. HYPOXEMIC RESPIRATORY FAILURE: The patient was intubated at the outside hospital. Shortly after being transferred to [**Hospital1 1444**], she was switched from AC to pressure support and did well. The patient eventually did well on the spontaneous breathing trial. The cuff was taken down and the patient did not have a cuff leak around the balloon, suggesting airway edema. The patient also had expiratory wheezes. Given the patient's chest x-ray it was hypothesized the wheezes might be secondary to volume overload as the patient did not have any asthma history or reactive airway history. The patient was given empiric treatment with intravenous Lasix, but this did not improve the cuff leak around the ET tube. However, it should be noted that the patient's pulmonary edema/infiltrates that were reported at the outside hospital improved as her infection improved after treatment course progressed, most likely suggesting some degree of capillary leak at the outside hospital. The patient was brought to the Operating Room for extubation. She had no supplemental oxygen requirement after four additional days. 4. SYSTEMIC LUPUS ERYTHEMATOSUS: The patient has a past medical history consistent with possible systemic lupus erythematosus. Please see the next discharge summary for further details regarding the patient's continued care. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 1659**] MEDQUIST36 D: [**2178-5-5**] 14:50 T: [**2178-5-5**] 16:50 JOB#: [**Job Number 48209**]

Admission Date: [**2181-8-23**] Discharge Date: [**2181-8-30**] Date of Birth: [**2102-3-8**] Sex: M Service: MEDICINE Allergies: Bacitracin Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 79yo M with PMH of PE on coumadin, sytolic HF (EF 35%), AS, Prostate CA, ETOH use who presented to OSH with SOB and increased swelling of right leg with known DVT. + Cough and ? low grade temps. AT [**Location (un) 620**], VS: T99.6, 107, [**11/2156**], 20, 93% 4L. LENI noted extension of DVT and patient was given lovenox 100mg x 1. Also noted to have elevated troponin 0.33 and BNP 10,190. Given lasix 10mg IV x 1. Also 1" nitropaste. Patient then transfered to [**Hospital1 18**] for further management. . In the ED, VS: T 99.6 HR 107 BP 111/87 RR 20 93% on 4L. Patient underwent CTA that showed interval improvement in previously noted PEs with no new thrombi. Patient was given dose of ceftriaxone, azithro for concern of pneumonia. . On review of systems, he denies any prior history of stroke, TIA, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope. . Of note, patient triggered on the floor at time of evaluation. He developed acute shortness of breath, tachycardia with sats of 85% on 5L (though patient was mouthbreathing). Lung exam was notable for poor air movement and diffuse wheezes. He improved with ipratropium, levalbuterol, 10 IV lasix. Past Medical History: # Dyslipidemia # Hypertension # Systolic heart failure- EF 35% # Aortic stenosis- moderate to severe # PE: junction right upper and right middle lob artery; also PE of RML, RLL, LLL distal vessels # Extensive mural thrombus of aortic arch and descending abdominal aorta # RLE DVT # Prostate CA s/p radiation # Hypercholesterolemia # COPD # Hx of ETOH abuse Social History: Positive for alcohol and tobacco use: 6beers and 2 shots/day, 60pack year hx. Lives with his son. Family History: FAMILY HISTORY: No family history of early MI, otherwise non-contributory. Physical Exam: VS: T 98.2 BP 115/48 HR 65 RR 24 97%5L GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm at 60 degrees 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 labored with poor air movement, diffuse wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: R leg 3+ pitting edema to knee; SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2181-8-23**] 07:05PM cTropnT-0.55* [**2181-8-23**] 07:05PM CK(CPK)-224* [**2181-8-23**] 07:05PM WBC-8.7 RBC-3.75* HGB-11.5* HCT-35.1* MCV-94 MCH-30.7 MCHC-32.8 RDW-13.7 NEUTS-70.9* LYMPHS-17.1* MONOS-5.8 EOS-5.9* BASOS-0.3 PLT COUNT-272 PT-19.3* PTT-39.2* INR(PT)-1.8* GLUCOSE-113* UREA N-16 CREAT-1.1 SODIUM-135 POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-30 ANION GAP-15 [**2181-8-23**] 07:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG RBC-0-2 WBC-0 BACTERIA-FEW YEAST-NONE EPI-0-2 URINE HYALINE-0-2 CTA [**2181-8-23**]: 1. No new pulmonary emboli. Small resolving pulmonary emboli in the lower lobes bilaterally, right middle lobe, and left upper lobe, smaller than the prior CTA of the chest [**2181-7-12**]. 2. Increasing mediastinal and hilar lymphadenopathy of unclear etiology. Attention should be paid on followup exams to ensure resolution. 3. Two small pulmonary nodules measuring 3 and 6 mm in the right lung, the larger of which is likely related to atelectasis and unchanged from recent prior exam. Followup CT in six months is recommended to ensure stability. [**2181-8-24**] 03:30AM BLOOD CK-MB-12* MB Indx-7.0* cTropnT-0.66* [**2181-8-25**] 05:41AM BLOOD CK-MB-NotDone cTropnT-0.26* [**8-26**] LENI: 1. Right lower extremity nonocclusive DVT involving the right external iliac, common femoral, superficial femoral, and popliteal veins. Questionable extension into the IVC. This can be better evaluated at time of dedicated venogram during IVC filter placement. 2. No left-sided deep venous thrombosis. Brief Hospital Course: A+P [**8-29**]: 79y/o with PE, [**Month/Year (2) 7792**], COPD exacerbation, transfered back to floor from CCU after breathing improved with diuresis, steroid, and NIPPV. . #. [**Month/Year (2) 7792**]: Pt ruled in with [**Month/Year (2) 7792**] with troponin peak of 0.66. Pt denies having Chest pain at all, however he is not a could historian and is unclear of his presenting symptoms. Talked with family, was SOB, and consfused upon admission. There are no EKG changes, although it is hard to evaluate it in setting of LBBB. Medically manage [**Name (NI) 7792**], pt did not get cath on admission because to unstable on presentation. No cath at this time since the ischemic event is complete. Unable to do stress test at this time, can not exercise (fall risk), reluctant to do dobutamine in setting of ACS, Persantine contraindicated in COPD exacerbation. Will need chemical stress when COPD treatment complete likely after pt d/c to rehab. Was on heparin gtt, stoped [**8-29**] after INR was 2.0 x 3. Also on ASA 81mg daily, simvastatin 80mg, Metoprolol 12.5mg [**Hospital1 **], lisinopril 5mg, Plavix 75 daily, will continue for 9 months in setting of [**Hospital1 7792**] . #. Resp failure: Patient triggered for desaturation which caused transer to CCU. Multifactorial, including systolic CHF (EF 30-35%), PE, COPD exacerbation. Pt significantly improved with nebs, steroids, levofloxacin, and diuresis. Pt denies any meds as outpt, however family confirms on ipatropium. CHF management, as below. For COPD exacerbation, finished steroid taper 8/21(2nd day 20mg), nebs, levofloxacin [**6-16**] day course. Pt aslso has PE, improving as per CTA this admission, s/p IVC filter this admission. Pt responding inappropriately on questioning [**8-29**]. ABG 7.48/48/62/37, lactate 2.4. Metabolic alk with compensatory resp acidosis. Bordreline O2 on RA. F/u with VBG 7.39/56/41/35, lactate 2.1. Lactate improving with hydration. Started on Oxygen to improve PO2. Pt clinically improved since out of CCU, breathing unlabored, lungs with decreased crackles . # PUMP/ acute on chronic systolic CHF: [**7-16**] echo moderate regional left ventricular systolic dysfunction with sveere hypokinesis of the basal to mid septum and anterior wall, EF 30-35%. severe aortic valve stenosis (area 0.8-1.0cm2). Mild to moderate ([**1-10**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. BNP over 10,000 at admission. Depressed EF likely [**2-10**] CAD given focal abnormailites. Hessitant to aggressively overdiurese given severe AS. Records state on 20mg PO lasix at home. Had incrased lasix to 60 PO daily with one additional 10IV lasix dose in setting of increased crackles. This caused a Cr increase to 1.7 and pt was orthostatic with PT on [**8-28**]. Lasix stoped for 2 days now, had bolus IVF, with improved BP and Cr and crackles on lung exam has also diminished. [**Month (only) 116**] need to restart maintance dose of 20 PO lasix in future. Continue lisinopril 5mg, BB. . #HTN - On BB, ACE, prn lasix. Pt was orthostatic [**8-28**] with SBP to 80, improved BP with boluses . #PE: PE discovered on previous admission in [**Month (only) 205**]. Resolving according to CTA on this admission. Recent for DVT and PE unclear. Distant h/o Prostate CA. The pt will need hypercoagulable / CA workup as outpt. There was concern that the PE lead to the [**Month (only) 7792**] and SOB/COPD flare. Repeat LENIs showed extension of R DVT, possibly to IVC. Therefore pt had IVC filter placed [**8-27**]. Pt was on heparin gtt until [**8-29**], as Warfarin became theraputic. INR now 2.0 on 4 straight measurements. On Warfarin 5mg daily plus 2.5mg [**8-29**]. Continue to monitor INR . # Metabolic alkalosis: ABG gotten [**8-29**] because of high HCO3 and inapropriate question answering [**8-29**]. ABG 7.48/48/62, lactate 2.4. Met alk with compensatory resp acidosis, likely contraction alk [**2-10**] diuresis. No GI losses noted. Repeated VBG after small bolus, was 7.39/56/41/35, lactate 2.1, improving with hydration. Continue to hold lasix and hydration if needs. KCL as needed. HCO3 downtrending from 37 to 32 with this regimen. Etiology of lactate elevation unclear, likely [**2-10**] recent MI or DVT/PE. No evidence of infection. . #Eosinophilia - present for 2 months, now downtrending since starting steroids. Dx includes Neoplasm (as above, needs screening), undiagnosed asthma?, adrenal insufficiency (no e/o hypotension or hypoglycemia, but has evidence of adrenal disease on ct scan with normocytic anemia), connective tissue disease, sacrdoidosis, parasites (do not know travel history). CTA did show Increasing mediastinal and hilar lymphadenopathy of unclear etiology which needs 6 month f/u. [**Month (only) 116**] work up for connective tissue disorders as an outpt. #Etoh abuse: Pt states drinkes 5-6 beers and 2 shots of vodka a day, however family states has not had etoh since [**Month (only) 205**] admission. Was on CIWA with valium, but not requiring doses. Continue folic acid, thiamine. LFTs normal except elevated LDH . #change in MS: Pt is poor historian, unclear of what events occured prior to or while in hospital, although he is oriented x3. Family claims is at baseline. Ddx includes steroid or unit induceed delirium, or Wernickes considering significant Etoh history. Pt has waxing and [**Doctor Last Name 688**] orientation. Pt angry [**8-29**] about not going home. family is concern he will try to leave hospital. Told them we would get psych to determine decision making capacity if necessary . # ARF: Cr trending down from 1.7 to 1.4 (.9 to 1.0 baseline). Felt to be prerenal since downtrending with decreased diuresis and hydration. . # GERD - PPI . #FEN: cardiac diet, repleat lytes prn . #Prophylaxis: Theraputic on coumadin, PPI, ISS while on steroids (now may stop since done steroids) . #Code: DNR/DNI, confirmed with pt and family . #Dispo: plan for Rehab. PT wants agreeable with rehab on [**8-30**], . # Comm: Health care proxy #1 [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **], #[**6-11**] [**Last Name (NamePattern1) 79102**]. They are also co-durable power of attorny. Will bring it paperwork to have on chart. Medications on Admission: ASA 325mg daily Coumadin Lasix 20 daily Lisinopril 2.5 daily Simvastatin 10mg daily Pantoprazole 40 PO daily Ipatropium Albuterol Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Continue through [**8-31**]. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Non ST elevation MI ([**Location (un) 7792**]) systolic congestive heart failure acute renal failure aortic stenosis - moderate to severe mulitiple Pulmonary Embolism - R-upper/R-middle lobe artery, ext mural thrombus aortic arch and descending abdominal aorta RLE Deep Vein Thrombosis Prostate CA s/p radiation Hypercholesterolemia COPD - unknown pfts, on albuterol med list at-home Hx ETOH abuse GERD Discharge Condition: stable: [**Location (un) 7792**] medically managed, needs stress test once COPD exacerbation controled. PE resolving, s/p IVC filter. CHF controled but needs further management of lasix dose. Waxing and [**Doctor Last Name 688**] MS. Discharge Instructions: You were admitted to the hospital because you were short of breath and were confused at home. You were found to have a heart attack ([**Doctor Last Name 7792**]) and be in heart failure (CHF) which contributed to your shortness of breath. We are treating your heart attack and heart failure with medicines. However your fluid level continues to need adjustment and your lasix dose with continue to be changed at the rehab facility. You will need further testing (a stress test) of your heart after you are finished being treated for your COPD exacerbation. You should discuss this when you go for your cardiology appointment. You also had an exacerbation of your COPD (breathing problem) and are being treated with steroids, an antibiotic (Levofloxacin), and breathing treatments. You were found to have a blood clot in your right leg (DVT) as well as your lungs (pulmonary embolus) on your previous admission to the hospital. The imaging of your lungs during this admission (CTA) showed that the clot in your lung is resolving. However imaging of your leg showed that the clot is getting bigger. Therefore you got a IVC filter placed in your vein to prevent future clots in your lungs. You are also on blood thinners to treat the clot The CTA (chest imaging) also showed enlarged lymph nodes "increasing mediastinal and hilar lymphadenopathy" of unclear etiology which needs follow up imaging in 6 months. You should discuss this with your doctor. In is important that you continue your efforts to stop drinking when you return home. You are at increased risk for seriously bleeding becuase of blood thinner if you fall. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases > 3 lbs. Adhere to 2 gm sodium diet . Please stop smoking. Information was given to you on admission regarding smoking cessation. If you became acutely short of breath or develop chest pain you should return to the Emergency room. Followup Instructions: PCP: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Location (un) **], MA ([**Telephone/Fax (1) 79103**]). You need to call for a appointment within the next two weeks. You should discuss the need for further imaging of your chest in six months to follow up 'increasing mediastinal and hilar lymphadenopathy' of unclear etiology. Also showed discuss your eosinophia. Cardiology: You have an appoint with [**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2181-9-18**] 2:20. The clinic is located at [**Location (un) **], [**Location (un) 86**], [**Numeric Identifier 718**]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 23**] CLinical Center [**Location (un) 436**]. You should discuss the need for a stress test to evaluate your heart disease at that time. Completed by:[**2181-8-30**]

Admission Date: [**2110-11-4**] Discharge Date: [**2110-11-12**] Date of Birth: [**2061-11-11**] Sex: M Service: MEDICINE Allergies: Erythromycin Estolate / Penicillins Attending:[**First Name3 (LF) 425**] Chief Complaint: Transfer for EP study/VT ablation Major Surgical or Invasive Procedure: EP study s/p mapping/ablation History of Present Illness: 48 yo M with hx of CAD, MI x2, CABG x4 [**1-13**], EF 15-20%, hx of VT s/p ICD, multiple ICD shocks and noted slow VT, admitted to [**Hospital3 17921**] Center in NH on [**2110-11-1**] after having his ICD fire 10 times followed by few seconds of syncope despite being on amiodarone and quinidine. He has been having recurrent VT which was treated with amiodarone dose, quinidine, and increased Beta-blocker. He reports that he could feel the PVC's and slow VT's and could tell the threshold before having the syncopal episode. He was recently cathed on [**9-12**] to rule out ischemic component of dysrrhythmia which showed patent grafts. Since he was discharged, he has had several ICD shocks and was treated with increasing dose of B-blocker. On the day of admission to [**Hospital3 17921**] Center, he had 10 ICD firings, one of which was associtated with loss of consciousness for few seconds. At [**Hospital3 17921**], pt was started on amiodarone and lidocaine drips. ICD interrogation revealed a slow VT which was terminated with pacing. He was also found to have another fast VT. Now with AV (atrial/biventricular) pacing after device reprogramming. Pt was transferred to [**Hospital1 18**] for VT ablation. In the EP lab here, aggressive attempts were made to induce the sustained VT but only short runs of short VT were induced. Mapping and ablation of multiple foci of slow VT were done. Fast monomorphic VT w/ LBBB/L axis occurred (not induced) which were not pace terminable requiring shock 360 J x3 and then converted to sinus rhythm. EP History: History of VT '[**08**] s/p ICD placement, hx of multiple recurrent ICD shock between [**2108**]-[**2109**], hx of slow monophasic VT (580-590 msec) noted in 4/'[**09**], which was pace terminated and ICD reprogrammed, upgrade to biventricular ICD [**2110-7-30**], VT ablation [**2110-8-5**]. EP study on [**2110-9-10**] after having ICD firing after rapid VT 320-360 msec which failed to terminate with pacing. Study showed 4 episodes of sustained monomorphic VT (320-340 msec), series of ATP algorithms tested but no successful termination + was ultimatley terminated with shock. Past Medical History: -CAD-remote IMI, anterior MI [**1-13**], s/p CABG [**1-13**]: LIMA-LAD, SVG-ramus+PDA, SVG-OM. -Cath [**2110-9-12**]: 100% LAD; 100% LCx; 100% RCA; LIMA-LAD patent; AO-OM patent; AO-ramus-PDA patent. -CHF: Echo [**7-19**] w/ EF 15-20% regional wall motion abnl c/w ischemic dz, mod biatrial enlargement, mild MR, LVH. RVH w/ hypokinesis -HTN -Hypothyroidism -CRI (baseline 1.6-1.8 in [**2-16**]) -Obstructive sleep apnea -Obesity -Hypercholesterolemia -COPD -Paroxismal a-fib Social History: Pt lives in [**Location 5450**], NH with his wife, has 7 kids (2 step kids, 2 adopted kids, and 3 biological kids), 35 yr of smoking 1 pack/day and quit 1 yr ago, occasional EtOH, no recreational drug Family History: Pt was adopted, and does not know about his biological paterents. Physical Exam: VS: T 99.6 BP 110/61 HR 60 RR 18 O2sat 93% RA GEN: Obese, cheerful male lying in bed post-cath in NAD HEENT: NC/AT, PERRL, EOMI, MMM, no visible JVP COR: RRR, distant S1, S2, no audible murmurs or rubs LUNGS: CTA on anterior exam ABD: +BS, obese, soft, NTND EXT: R groin with no hematoma or eccymosis, no femoral bruits, 2+DP bilaterally, no edema NEURO: A+Ox3, CN intact, nonfocal. Pertinent Results: [**2110-11-4**] WBC-11.9* RBC-3.58* Hgb-9.9* Hct-31.2* MCV-87 MCH-27.7 MCHC-31.8 RDW-17.3* Plt Ct-216 [**2110-11-7**] WBC-14.0* RBC-3.35* Hgb-9.5* Hct-29.1* MCV-87 MCH-28.4 MCHC-32.8 RDW-17.5* Plt Ct-205 [**2110-11-8**] WBC-11.9* RBC-3.32* Hgb-9.6* Hct-28.8* MCV-87 MCH-28.8 MCHC-33.2 RDW-17.4* Plt Ct-245 [**2110-11-9**] WBC-9.7 RBC-3.53* Hgb-9.9* Hct-31.5* MCV-89 MCH-27.9 MCHC-31.3 RDW-16.9* Plt Ct-250 [**2110-11-12**] WBC-13.2* RBC-3.84* Hgb-10.6* Hct-34.0* MCV-89 MCH-27.5 MCHC-31.1 RDW-16.6* Plt Ct-391 [**2110-11-6**] Neuts-85* Bands-9* Lymphs-2* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2110-11-9**] Neuts-89.7* Lymphs-4.9* Monos-3.6 Eos-1.7 Baso-0.1 [**2110-11-4**] PT-18.6* PTT-54.7* INR(PT)-2.2 [**2110-11-8**] PT-16.5* PTT-36.7* INR(PT)-1.7 [**2110-11-12**] PT-22.9* PTT-73.4* INR(PT)-3.3 [**2110-11-4**] Glucose-108* UreaN-32* Creat-1.9* Na-138 K-4.4 Cl-101 HCO3-25 [**2110-11-6**] UreaN-45* Creat-2.9* Na-135 K-4.8 Cl-99 [**2110-11-6**] Glucose-89 UreaN-52* Creat-3.9* Na-137 K-4.9 Cl-99 HCO3-26 [**2110-11-8**] Glucose-101 UreaN-49* Creat-2.2* Na-140 K-4.7 Cl-104 HCO3-25 [**2110-11-10**] Glucose-84 UreaN-29* Creat-1.7* Na-140 K-4.3 Cl-104 HCO3-27 [**2110-11-12**] Glucose-104 UreaN-15 Creat-1.3* Na-138 K-4.4 Cl-103 HCO3-22 [**2110-11-6**] ALT-25 AST-24 AlkPhos-64 Amylase-28 TotBili-0.9 [**2110-11-4**] CK(CPK)-218* CK-MB-16* MB Indx-7.3* cTropnT-2.06* [**2110-11-7**] Calcium-8.9 Phos-4.8*# Mg-2.2 [**2110-11-12**] Calcium-9.3 Phos-3.9 Mg-2.0 [**2110-11-4**] Calcium-8.2* Phos-3.0 Mg-1.9 [**2110-11-8**] VitB12-203* Folate-7.3 [**2110-11-7**] Iron-26* calTIBC-281 Hapto-447* Ferritn-459* TRF-216 AEROBIC BOTTLE (Final [**2110-11-11**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2110-11-11**]): NO GROWTH. URINE CULTURE (Final [**2110-11-6**]): <10,000 organisms/ml. FECAL CULTURE (Final [**2110-11-8**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2110-11-8**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2110-11-6**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. CXR [**11-5**]: There is moderate cardiomegaly in a patient with dual lead pacemaker insertion. The pacemaker chips overlie the right atrium and ventricle. Patient has undergone prior CABG. There is bilateral moderate pulmonary vascular redistribution and perihilar haziness. The osseous structures are unremarkable. CXR [**11-6**]: Stable moderate-to-severe cardiomegaly in a patient status post CABG. The dual-lead pacemaker tips overlie the right atrium and ventricle. There is a slightly improved pulmonary vascular redistribution and interstitial edema. The osseous structures are unremarkable. IMPRESSION: Slight interval improvement in CHF. [**11-6**]: CT OF THE ABDOMEN WITHOUT CONTRAST: Patchy opacity is present within the right lung base which could represent atelectasis. The liver, spleen, pancreas, gallbladder, adrenal glands, kidneys, and small bowel are normal in appearance. No pathologically enlarged retroperitoneal or mesenteric lymph nodes are seen. CT OF THE PELVIS WITH CONTRAST: There is focal fat stranding within the pelvic fat surrounding the sigmoid colon. There are multiple diverticula. There is extraluminal gas adjacent to this area of fat stranding. There is no drainable fluid collection. Oral contrast reaches the transverse colon indicating no evidence of obstruction. Bone windows show no suspicious lytic or sclerotic lesions. REFORMATTED IMAGING: Images reformatted in the coronal and sagittal plane were essential in evaluating the patient's abdomen and pelvis and show fat stranding within the deep pelvis adjacent to the sigmoid colon, indicating diverticulitis. IMPRESSION: Sigmoid diverticulitis with a suggestion of microperforation. No drainable fluid collection present. AXR [**11-6**]: Left upper chest pacemaker device, sternal wires and mediastinal clips are noted. The heart appears enlarged. There is no free air. Images of the abdomen are of poor technical quality. A nonspecific bowel gas pattern is noted. AXR [**11-8**]: Gaseous distention of stomach and moderate gaseous distention of multiple loops of small bowel with retained contrast in the rectosigmoid colon. Findings could be related to ileus in the presence of intra-abdominal inflammatory process but correlate clinically. The gaseous distention of the stomach could be re- evaluated after passage of NG tube if clinically indicated. Brief Hospital Course: 1)Rhythm: As stated in HPI, pt underwent EP study with multiple ablation of slow VT foci, but unable to map and ablate the focus of fast VT. Mapping and ablation of multiple foci of slow VT were done. Fast monomorphic VT w/ LBBB/L axis occurred (not induced) which were not pace terminable requiring shock 360 J x3 and then converted to sinus rhythm. VT occurred during the study which was not induced, not terminable with pacing, and had to be shocked with 360 J x3. Pt was transferred to the CCU and to the floor with no significant event. Pt remained AV paced at a rate of 60 BPM, increased to 80 bpm subsequently. Pt was initially scheduled to return to NIPS and DFT. However, pt developed fever and abdominal pain, and therefore NIPS and DFT were canceled. The EP team felt that NIPS were not urgent, and they have spoken with his cardiologist Dr. [**Last Name (STitle) 23246**] who will follow up with him in 4 weeks to do the NIPS. He was continued on amiodarone 400 mg po qd but quinidine was discontinued. Due to hypotention, Coreg was reduced to 12.5 mg [**Hospital1 **] from 50 mg [**Hospital1 **]. Pt was continued on coumadin for his paroxysmal a-fib - he will need frequent INR checks while on antibiotics for diverticulitis (see below). 2)Pump: Recent Echo 15-20%. As above, pt will be discharged with reduced dose of Coreg, and will be continued on his home meds of lisinopril, torsemide, and spironolactone. Pt appeared euvolemic/hypovolemic clinically with hypotension to SBP 80's but the CXR showed moderate CHF with increased interstitial markings and vascular redistribution. Pt got one dose of Lasix which increased the creatinine from 1.9 to 2.9. Pt later received IVF which lowered the creatinine. Additionally, his torsemide was held during the hospitalization, as well as spironolactone and lisinopril secondary to hypotension, and rising creatinine. He was started on digoxin 3 days before discharge and had improvement in his blood pressure enough to tolerate the lisinopril and spironolactone. Additionally, his creatinine had normalized, also allowing reintroduction of these meds. His creatinine had been stable at 1.3 for two days prior to discharge, with SBP around 120. 3)CAD: Hx of prior inferior and anterior MI. Patient was continued on ASA, Zocor, Coreg, and lisinopril. 4)Diverticulitis: On the second day of admission, pt developed fever of 102, abdominal pain, loose stools, and leukocytosis. Patient had tender lower quadrant abdominal pain to palpation but with no peritoneal signs. Pt underwent CT abdomen which showed sigmoid diverticulitis with possible microperforation. An AXR did not demonstrate any free air. He was made NPO, and started on levaquin and flagyl. His abdominal pain improved significantly, and had completely resolved, with only residual mild tenderness to palpation on discharge. Reglan was started when an AXR revealed gaseous distention of his stomach and intestine. His diet was slowly able to be advanced to low residue, which he was tolerating prior to discharge. His wbc count rose on the day of discharge, however the patient remained afebrile and was clinically improved; additionally, the hct and platelets also rose, making it most likely secondary to dehydration after restarting his diuretics. The patient was instructed to increase his fluid intake slightly over the next couple of days while he isn't taking in a full diet. He should remain on a low residue, heart healthy diet until he sees a gastroenterologist, at which time they may want to place him on a high fiber diet. 5)HTN: Pt was continued on Coreg, lisinopril, Torsemide + spironolactone. 6)Hypercholesterolemia: Pt was continued on Zocor. 7)COPD: initially, albuterol was held since it could potentially trigger VT. Pt was continued on Flovent and Atrovent, but continued to have diffuse wheezing. Pt was discharged with his home meds of Comvient and Flovent. 8)Sleep apnea: Pt was continued on BIPAP 15 cm. Overnight, pt showed episodes of apnea and desaturation to the 70's and 80's. 7)Hypothyroid: Patient was continued on Synthroid. 8)CRI: Baseline Cr 1.6-1.8. Creatinine on admission was 1.9 but Creatinine increased to 2.9 after patient was NPO for planned NIPS. Pt also appeared intravscularly dry especially after getting a dose of IV Lasix. Pt got IVF bolus but creatinine continued to be elevated. His lisinopril and aldactone were held, and as his diverticulitis resolved his creatinine returned to baseline. His renal insult may have been a combination from his VT with hypoperfusion, as well as dehydration. His creatinine was 1.3 for two days prior to discharge. Medications on Admission: Meds on Transfer: Amiodarone 400 mg po qd Spironolactone 25 mg po bid Synthroid 100 mcg po qd Flovent 110 mcg 2 puffs [**Hospital1 **] Combivent 3 puffs prn Zocor 40 mg po qhs ASA 325 mg po qd Coreg 12.5 mg po bid Toresmide 50 mg po qd Amiodarone drip 0.5 mg/hr Lidocaine drip 1 mg/min Home Meds: Amiodarone 400 mg po qd QuinoGlute 324 mg po bid Coreg 50 mg po bid Lisinopril 10 mg po qd Torsemide 50 mg po bid Spironolactone 25 mg po bid Lexapro 10 mg po qd Combivent 14.7g 3 puffs PRN Flovent 110 mcg 2 puffs [**Hospital1 **] ASA 325 mg po qd Warfarin 2.5 mh po qd Zocor 40 mg po qd Synthroid 100 mcg po qd Discharge Medications: 1. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Combivent 103-18 mcg/Actuation Aerosol Sig: Three (3) Inhalation Q4H:PRN. 10. Torsemide 20 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Digoxin 250 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 9 days. Disp:*9 Tablet(s)* Refills:*0* 14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 9 days. Disp:*27 Tablet(s)* Refills:*0* 15. Warfarin Sodium 1 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily): 2.5 mg, except for Tues, Thurs, Sat. 1.5 mg, and as dictated by your INR checks. Tablet(s) 16. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: VT s/p EP study Diverticulitis CAD Congestive heart failure COPD Hypertension Hypothyroidism Discharge Condition: Hemodynamcially stable, improved, having bowel movements, urinating on his own. Discharge Instructions: Take all of your medications as directed - we have resumed all of your previous medications - except for the QUINIDINE. We have decreased your dose of carvedilol to 12.5 mg twice a day (instead of 50). We have started two new medications: 1) digoxin - this is for your heart. 2) Cyanocobalamin (Vitamin B12) - this is for your anemia. You will also be on two antibiotics called levaquin and flagyl for the next 9 days. Seek medical attention (PCP, [**Last Name (NamePattern4) **]) if you develop worsening abdominal pain, nausea/vomiting, fever, chills, chest pain, palpitation, ICD firing, SOB, or any other concerning symptoms. You will need to follow up with your cardiologist Dr. [**First Name4 (NamePattern1) 30512**] [**Last Name (NamePattern1) 23246**] in 4 weeks. If she has any questions, she can reach Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 285**]. You will also need to see Dr. [**Last Name (STitle) 519**] (surgery), or another gastroenterologist in a couple of weeks to follow how your diverticulitis is doing. They will schedule you for a colonoscopy in the next 2-3 months. Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) **] number is [**Telephone/Fax (1) 6554**]. You will need to have your INR checked on Friday, and every 3 days while you are on the antibiotics. You will need to stay on a low residue diet until you see Dr. [**Last Name (STitle) 519**] or another surgeon, at which time they should place you on a high fiber diet which you should stay on to help avoid future episodes of diverticulitis. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) **]. Please make an appointment with her in the next 2 weeks. Please have your PCP make an appointment for you with a gastroenterologist in your area. If they have any questions, or you would like to see a doctor here for your diverticulitis, call Dr. [**Last Name (STitle) 519**] at [**Telephone/Fax (1) 6554**]. You will need a colonoscopy in [**12-17**] months, which they can set you up with. Please see your primary care doctor in the next week or two - he should check your blood pressure, among other things, and consider going back to your usual carvedilol dosage.

Admission Date: [**2200-3-14**] Discharge Date: [**2200-4-2**] Date of Birth: [**2116-6-4**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: Pneumonia Major Surgical or Invasive Procedure: Intubation for mechanical ventilation History of Present Illness: 83M with esophageal CA, recent admission for FTT, pneumonia. The patient was sent from nursing home, reportedly ill-appearing. We do not yet have any history from his facility, [**Hospital3 537**]. I have left a message with the nurse on duty. The patient's sister reports that he had been treated for pneumonia two weeks ago at [**Hospital3 **]. (Our records suggest the patient was discharged on [**2200-3-3**], but not treated for pneumonia at that time.) The patient did have a prescription for levaquin in his records from [**Date range (1) 105283**], so he probably was diagnosed with pneumonia recently. His sister spoke to him the day before this hospitalization and says he sounded fine. He was able to go to lunch and dinner that evening. The patient's sister also reports that his usual nuring support could not reach him due to the inclement weather this week. . In the ED, the patient was tachycardic, hypoxic on RA on arrival. He was brought in looking unwell, hypoxic, and with altered mental status. In addition, the patient was exteremly cachectic. The patient's CXR showed PNA and he received vancomycin, levaquin, zosyn (recently admitted with Pseudomonas). The patient had terrible IV access and so was underresuscitated. A Right IJ triple lumen was placed. The patient was progressively tachypneic to low 40s, and his lactate was 4.9. After failureo f NRB, the ED felt the need to intubate, with sedation via fentanyl and Versed. Though his SBP was 115 before intubation, afterward he had transient periods of SBP around 60-90. Phenylephrine was then started. Though altered, pt wished to be full code. (His sister was unaware of her brother's exact wishes but felt he would probably want to be full code and would agree to all of the items on the ICU consent form.) Past Medical History: Esoph Ca s/p esophagectomy with ? gastric pullup at [**Hospital1 2025**] ~ 10 years ago Prostate Ca Nephrolithiasis Social History: Immigrated from [**Country 4754**] in 62. Worked for Sears-[**Last Name (un) 40191**]. Smoked until his esophagectomy ~ 10 years ago. No recent EtOH. Lives independently at [**Hospital3 537**], takes his own medications, sporadic nursing checks. Family History: Non-contributory Physical Exam: Admission physical exam: VS: Temp: 97.3 BP: 108/65 HR: 63 (RR: 22 O2sat 96%) GEN: intubated, sedated, cachectic HEENT: PERRL, secretion in mouth, oropharynx with some erythema, likely secondary to intubation. RESP: Quiet breath sounds with wheeze CV: S1, S2, no murmurs auscultated ABD: Non-distended, quiet bowel sounds, no guarding, liver felt below costal margin. EXT: Clubbing of nails, dusky fingernails with > 2 seconds capillary refill, no edema. SKIN: Many seborrheic keratoses NEURO: Sedated, small pupils, but responsive to light. 2+ biceps reflexes bilaterally. 2+ patellar reflexes bilaterally. Babinski downgoing in left foot, equivocal in right. Pertinent Results: Admission labs: [**2200-3-14**] 02:00PM WBC-16.4* RBC-3.95* HGB-10.3* HCT-34.9* MCV-88 MCH-26.0* MCHC-29.4* RDW-15.1 [**2200-3-14**] 02:00PM NEUTS-77* BANDS-11* LYMPHS-4* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-0 [**2200-3-14**] 02:00PM GLUCOSE-75 UREA N-25* CREAT-0.8 SODIUM-145 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-23* [**2200-3-14**] 02:00PM CALCIUM-8.9 PHOSPHATE-5.1* MAGNESIUM-2.1 [**2200-3-14**] 02:00PM cTropnT-<0.01 [**2200-3-14**] 03:38PM LACTATE-4.9* . CT torso [**2200-3-18**]: IMPRESSION: 1. Multifocal pneumonia and signs of atypical infection including tree-in-[**Male First Name (un) 239**] opacities (which can be seen with endobronchial PNA or tuberculosis) as well as centrilobular ground-glass nodules (which can be seen with atypical pneumonia such as mycoplasma or viral pneumonia). Secretions within the right main stem bronchus and trachea are likely due to extensive infection as the patient is intubated and aspiration is less likely. 2. Extremely limited evaluation of the abdomen, however, possible right hydronephrosis. If clinically indicated, a renal ultrasound could be performed for further evaluation. 3. Small-to-moderate axial hiatal hernia. . ECHO [**2200-3-19**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. 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. There is moderate thickening of the mitral valve chordae. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Moderate pulmonary hypertension. Moderate tricuspid regurgitation. Very small pericardial effusion. . [**2200-3-19**] Renal ultrasound: IMPRESSION: 1. Echogenic kidneys compatible with medical renal disease, although without atrophy. Indeed the parenchyma seems mildly swollen. No evidence of hydronephrosis or abscess. 2. Extensive ascites. . [**2200-3-26**] CXR: FINDINGS: As compared to the previous radiograph, there is no relevant change. Minimally increase in opacities at the left lung base, the other opacities in both the left and the right lung are constant. Unchanged high position of the endotracheal tube, the tube could be advanced by 1 to 2 cm. No newly appeared focal parenchymal opacities. Unchanged bilateral symmetrical apical thickening. Brief Hospital Course: The patient had a complicated hospital course including a MICU stay where he was on pressors for quite a while as well as refractory respiratory failure. He was treated with multiple courses of antibiotics for HCAP but failed to improve. Given his failure to improve and the severity of his illness, a goals of care conversation was conducted by the MICU team. The patient's sister did not feel that pursuing a tracheostomy, a PEG tube and prolonged intubation were consistent with his wishes. As such, the patient was made DNR/DNI and was extubated on [**3-30**]. He actually did well initially. As such, a code conversation was had with the sister and he was made [**Name (NI) 3225**]. He was transferred out of the unit on [**3-31**]. He initially did well and was able to communicate with his sister and with myself. However, his respiratory status deteriorated. He was given morphine for pain and for respiratory distress. He ultimately passed away on [**4-2**] at 1:40 PM. His family was at his bedside at the time of his death. Medications on Admission: nexium 40 mg qd florinef 0.1mg qd Zoloft 25 mg qd bethanecol 25 qd Carafate 1g QID Discharge Disposition: Expired Discharge Diagnosis: Sepsis, respiratory failure Discharge Condition: Deceased Discharge Instructions: Expired Followup Instructions: Expired

Admission Date: [**2130-9-14**] Discharge Date: [**2130-9-19**] Date of Birth: [**2057-2-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: Coronary Artery Bypass grafts x 3(LIMA-LAD, SVG-OM,SVG-PDA) [**2130-9-15**] History of Present Illness: This 73 year old white male was at his primary care physician's office when he developed acute dyspnea and palpitations. He was found to be in supraventricular tachycardia in the ED and was treated with oral lopressor and IV adenosine with conversion to sinus rhythm. Enzymes were equivocal for myocardial injury and a cardiac catheterization was performed. Catheterization revealed triple vessel disease and LVEF of 47%. He was transferred to [**Hospital1 18**] for surgical evaluation. Past Medical History: Insulin dependent diabetes hypertension dyslipidemia obesity s/p appendectomy Social History: Works as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3456**]. Nonsmoker Lives with his wife. Family History: noncontributory Physical Exam: awake, oriented and alert Cor- NSR at 72. Crisp heart sounds Lungs- sl. decreased BS at bases extremeties- 1+ edema wounds- healing well. Sternum stable. Pertinent Results: [**2130-9-14**] 04:49PM TRIGLYCER-236* HDL CHOL-32 CHOL/HDL-5.4 LDL(CALC)-93 [**2130-9-18**] 05:35AM BLOOD WBC-11.3* RBC-3.43* Hgb-10.2* Hct-28.8* MCV-84 MCH-29.9 MCHC-35.5* RDW-13.6 Plt Ct-171 [**2130-9-18**] 05:35AM BLOOD Glucose-160* UreaN-23* Creat-1.2 Na-130* K-4.3 Cl-97 HCO3-29 AnGap-8 [**2130-9-17**] 03:05AM BLOOD ALT-33 AST-103* LD(LDH)-493* AlkPhos-49 Amylase-22 TotBili-1.0 [**2130-9-14**] 04:49PM BLOOD %HbA1c-9.0* Brief Hospital Course: Following transfer the patient remained stable. Carotid ultrasound demonstrated a 60-69% right narrowing of the internal carotid and <40% on the left. On [**9-15**] he was taken to the operating room where revascularization was undertaken. Grafts to the LAD, obtuse marginal and PDA were done. he weaned from bypass om phenylephrine, insulin and propofol. He was transferred to the CVICU in stable condition. He required pressor support for the first 24 hours and he weaned from the ventilator on the first postoperative day, awakening agitated the first two attempts. He had transient SVT and when pressor were off, beta blockade was resumed and he was loaded with and begun on Amiodarone. He was transferred to the floor on the second postoperative day. His CTs were removed. Pacing wires were removed on the third day and he was in sinus rhythm. Diuretic doses were increased to facilitate diuresis to preoperative weight given his significant peripheral edema. PT worked with him for ambulation. He was stable for discharge home with a walker. His glucoses were contro;lled with insulin and he was on his preoperative regimen at discharge. He was instructed to follow up with his primary care physician for further glucose treatment. he was sent home on oral Lasix to continue diuresis and for blood pressure control. Discharge medications and instructions were discussed with him prior to discharge. Medications on Admission: lopressor 25mg [**Hospital1 **], ASA 325mg/D, Lantus 35units@ HS, Novolg15units /breakfast Discharge Medications: 1. Influen Tr-Split [**2129**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One (1) ML Intramuscular ASDIR (AS DIRECTED). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 weeks. Disp:*56 Tablet(s)* Refills:*0* 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Ibuprofen 200 mg Tablet Sig: Four (4) Tablet PO three times a day for 2 weeks: with food. 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 11. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Continue insulin as preoperatively:35units Lantus at bedtime, 15 units Novolg with breakfast and as directed by your primary care doctor. Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Coronary artery disease insulin dependent diabetes mellitus obesity paroxysmal atrial fibrillation hypertension dyslipidemia Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions report any drainage from, or redness of incisions report any temperature greater than 100.5 no driving for 4 weeks and off all narcotics no lifting more than 10 pound for 10 weeks take all medications as directed report any weight gain greater than 2 pounds a day or 5 pounds a week Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**11-30**] weeks Dr. [**Last Name (STitle) 8579**] in 2 weeks please call for appointments Completed by:[**2130-9-19**]

Admission Date: [**2134-4-24**] Discharge Date: [**2134-4-28**] Date of Birth: [**2056-10-31**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Penicillins / Sulfa (Sulfonamides) / Shellfish / Adhesive Tape Attending:[**First Name3 (LF) 134**] Chief Complaint: STEMI, pneumonia Major Surgical or Invasive Procedure: cardiac catheterization with stent placed in the LAD History of Present Illness: Pt is a 77 yo woman with PMH of diet controlled DM2, HTN, breast ca s/p surgical resection and XRT who was transferred to [**Hospital1 18**] from [**Hospital3 4107**] for STEMI. Patient was in her USOH until 1 week prior to presentation at [**Hospital3 **] when she began having cough productive of yellow-colored sputum tinged with specks of blood, also noted fevers/chills, some SOB with exertion. The patient was started on Levaquin as an outpatient 3 days prior to presentation which did not alleviate her sxs. She denies any SOB w/ exertion prior to onset of cough and fevers, orthopnea, PND, chest pain/pressure, palpitations. Does have some LE edema which she attributes to knee surgery. Patient presented to [**Hospital3 **] on [**2134-4-19**] with above complaints, and was found to have pneumonia with CXR findings demonstrated RUL, RML, RLL pneumonia. She was also found to be hypokalemic with K=2.9 on admission. Patient was treated with potassium repletion, abx included IV azithromycin and cefotaxime that was changed to levaquin and cefazolin. Influenza swab and legionella titers were negative. Pt had some clinical improvement, although remained w/ cough and SOB w/ exertion throughout her hospital course. On [**2134-4-23**], pt developed SSCP on and off throughout the day, received morphine and NTG, EKG demonstrated ST elevation of anterior leads on top of underlying J point elevation, with some reciprical changes seen in inferior leads - these EKG findings were noted in retrospect. Patient then developed VFib arrest and was successfully defibrillated. She was started on integrilin gtt, heparin gtt, plavix 300mg x 1, ASA 325mg x 1, lopressor 5mg IV x ?[**4-4**], then transferred to [**Hospital1 18**] for emergent cath. Unknown time of transit b/w onset of chest pain and arrival in cath lab (un-documented per OSH when chest pain occurred). Patient was complaining of [**4-9**] CP on arrival to cath lab. She received pre-medication with benadryl, solumedrol, pepcid due to her dye allergy. Cath demonstrated 50% PDA and PL lesions, 90-99% LAD lesion (right after take-off of D1). She had stent placed to LAD lesion. [**Name (NI) 2076**] pt was CP free. Cardiac cath c/b low stick (likely in SFA) and R thigh hematoma, patient remained hemodynamically stable. Currently pt feels well, chest pain free, no SOB at rest, but has not tried moving around. No other complaints. . ROS: Also + for syncopal episodes x past couple years on occasion, denies prodrome of N/V, diaphoresis, does have some dizziness prior to episodes at times, at time no prodrome at all. Has LOC for seconds to minutes, denies loss of bowel or bladder fxn, denies post-ictal state. Past Medical History: DM2 - diet controlled HTN Breast cancer s/p resection and XRT DJD Hx DVT post-op - not currently on anticoagulation s/p CCY s/p Appy s/p TAH s/p b/l total knee replacement ?gout Social History: No tobacco, EtOH, drug use, has 4 children Family History: Non-contributory Physical Exam: Vitals - T 99, HR 67, BP 114/67, RR 20, O2 95% 5L NC General - awake, alert, pleasant, lying supine, NAD HEENT - PERRL, EOMI, MMM Neck - no carotid bruit b/l, JVP @ 10cm CVS - RRR, nl S1,S2, no M/R/G Lungs - could not assess posterior lung fields as pt lying supine, anteriorly rhonci on R, b/l lower lung crackles Abd - soft, NT/ND, +BS Groin - R groin site covered in bandage, + eccymoses, + hematoma extending to anterior thigh (drawn perimeter around site), mildly tender to palpation, no bruit ascultated. Ext - trace LE edema b/l, 1+ DP pulses b/l Pertinent Results: [**2134-4-24**] 06:30AM WBC-4.6 RBC-3.51* HGB-11.4* HCT-32.7* MCV-93 MCH-32.6* MCHC-35.0 RDW-14.1 [**2134-4-24**] 06:30AM NEUTS-86.2* LYMPHS-9.0* MONOS-3.4 EOS-0.6 BASOS-0.7 [**2134-4-24**] 06:30AM PLT COUNT-202 [**2134-4-24**] 10:35AM GLUCOSE-167* UREA N-13 CREAT-0.8 SODIUM-137 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15 [**2134-4-24**] 10:35AM CK(CPK)-1479* [**2134-4-24**] 10:35AM CK-MB-214* MB INDX-14.5* cTropnT-6.54* [**2134-4-24**] 10:35AM CALCIUM-8.5 PHOSPHATE-3.8 MAGNESIUM-1.8 CHOLEST-133 [**2134-4-24**] 10:35AM TRIGLYCER-138 HDL CHOL-36 CHOL/HDL-3.7 LDL(CALC)-69 [**2134-4-24**] 12:20PM %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE [**2134-4-24**] 03:43PM CK(CPK)-1000* [**2134-4-24**] 03:43PM CK-MB-129* MB INDX-12.9* cTropnT-4.06* . Cardiac cath ([**4-24**]): 1. One vessel coronary artery disease. 2. Acute anterior myocardial infarction, managed by acute ptca. PTCA of vessel. 3. PCI of the mid LAD. 4. Right groin hematoma . TTE ([**4-24**]): The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is severe regional left ventricular systolic dysfunction. No masses or thrombi are seen in the left ventricle. Resting regional wall motion abnormalities include akinesis of the antero-septum, anterior wall distal LV/apex. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve is not well seen. There is no aortic valve stenosis. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . CXR ([**4-24**]): Multifocal consolidation in right lung, in keeping with the provided history of pneumonia. Followup radiographs are suggested to confirm resolution. . Brief Hospital Course: . # Cardiac: A. Ischemia: Pt had STEMI in anterior leads on presentation, underwent cardiac cath [**2134-4-24**] with stent placed in lesion in LAD (right after D1). Initially maintained on integrilin, but it was discontinued postcath in setting of a groin hematoma. Cardiac enzymes trended down, peak CK 1479 on admission. The patient was chest pain free for the remainder of her stay. Her hematoma and Hct were stable and no bruit was auscultated. She was discharged on ASA, Plavix, Toprol XL, lisinopril, and high-dose Lipitor. . B. Rhythm: Pt had VFib arrest at OSH, successfully cardioverted, likely secondary to ischemia. At baseline, has borderline long QTc at 468. Also concern for arrythmia given syncope hx (see below). As VF arrest was in the setting of acute STEMI, she was not felt to meet criteria for ICD from that standpoint. QT prolonging medications were avoided. EP consult for syncope workup as below. . C. Pump: Unknown EF. Pt clinically appeared volume overloaded on admission, with elevated JVD, and crackles in lungs. ECHO [**4-24**] demonstrated EF=25%, anterior WMA consistent with an LAD lesion, and apical akinesis. She was diuresed with prn IV Lasix. She was started on IV heparin for apical akinesis. EP evaluated her and recommended repeat TTE in 1 month, with ETT-T wave alternans and signal average ECG-EP study to determine if she qualifies for ICD per MADIT II criteria. She was discharged on Toprol XL, lisinopril, and Coumadin with a Lovenox bridge, with an INR check later that week. . # Syncope: Pt reports long history of syncope, generally without prodrome, and with significant injuries with fall (i.e. hitting head, breaking ankle, etc.). The story was felt to be concerning for arrythmia. MRI/A showed no significant vertebrobasilar stenosis. EP was consulted, but flet her history was more consistent with vasovagal vs. hypoglycemic episodes. She was discharged to continue further workup as per PCP. . # ID/Respiratory: Patient presented to the outside hospital with evidence of R sided pneumonia. Repeat CXR here was consistent with RML vs RUL pneumonia. She was transferred on levaquin and Cefazolin, but was found to have a borderline prolonged QTc. Therefore, she was switched to Ceftriaxone and azithromycin. As azithromycin can also prolong QT, it was discontinued as well. She wa safebrile with a normal WBC count, and was weaned off O2. Cultures were negative. She was discharged on cefpodoxime for 5 more days, to complete a 14-day course of antibiotics. . # HTN: On atenolol, hydralazine, enalapril, HCTZ, and amlodipine for BP control at home. She was changed to metoprolol and captopril for easier titration. Her other antihypertensives were held in an effort to pursue titration of her beta blocker and ACE-i. She was discharged on Toprol XL and lisinopril. . # DJD pain: Continue on outpatient [**Last Name (LF) 23314**], [**First Name3 (LF) **] patient only thing that controls her pain. . # Code status: Full . Medications on Admission: Medications as outpatient: Atenolol 25mg QD Hydralazine 25mg TID Vasotec (enalapril) 20mg QD HCTZ 25mg QD Norvasc 5mg QD Symvalta 60mg QD Allopurinol 300mg QD Darvocet PRN Lasix PRN . Medication on transfer: Atenolol 25mg QD HCTZ 25mg QD Norvasc 5mg Qd Symvalta 60mg QD Allopurinol 300mg QD ASA 325mg QD Xopenex q8hr Albuterol neb PRN Aldactone 25mg [**Hospital1 **] Darvocet PRN Levaquin 500mg QD Lisinopril 10mg QD Cefazolin Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*20 Tablet(s)* Refills:*0* 10. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous [**Hospital1 **] (2 times a day) for 10 days: Please follow up with Dr. [**Last Name (STitle) 1637**] regarding when to stop this medication. Disp:*1400 mg* Refills:*0* 11. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 12. Outpatient Lab Work INR check Monday, Wednesdays, Fridays Please fax to Dr. [**Last Name (STitle) 1637**] at [**Telephone/Fax (1) 66123**], tel:([**Telephone/Fax (1) 66124**] Discharge Disposition: Home With Service Facility: [**Location (un) 38640**] VNA Discharge Diagnosis: Primary: Anterior ST elevation MI Congestive heart failure, EF 25% Apical akinesis Secondary: Type 2 diabetes mellitus Hypertension s/p VF arrest at [**Hospital3 **] Discharge Condition: good, on Lovenox bridge to Coumadin for apical akinesis Discharge Instructions: Please take all of your medications as prescribed. Please have your INR checked by Dr. [**Last Name (STitle) 1637**] on Friday at your appointment. If you experience chest pain, shortness of breath, loss of consciousness, or other concerning symptoms, please call your doctor or go to the ER. Followup Instructions: 1) Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**], [**2134-4-30**] at 11:30am, ([**Telephone/Fax (1) 66124**]. 2) Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31438**] ([**Telephone/Fax (1) 66125**], to schedule a follow up appointment within the next 7 to 10 days. 3)Electrophysiology provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2134-5-26**] 2:30 4)Provider: [**Name10 (NameIs) 10081**] TESTING Phone:[**Telephone/Fax (1) 1566**] Date/Time:[**2134-5-18**] 1:15 for T wave alternans study and Signal Averaging EKG study. Completed by:[**2134-7-29**]

Admission Date: [**2104-1-30**] Discharge Date: [**2104-2-13**] Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 425**] Chief Complaint: Hypoxia. Major Surgical or Invasive Procedure: Status post pacemaker lead removal. Temporary wire placement. History of Present Illness: 87 year-old male with CAD s/p CABG, CHF (EF 30% with BiV ICD), AF (on coumadin), diet-controlled DM, s/p recent admission for sepsis, who now presents s/p fall with hypoxia and hypotension. The patient fell x2 the night prior to admission at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] stating he felt "weak". He denies dizzines, lightheadedness, LOC, or head trauma. He was subsequently dyspneic, found to have an oxygen saturation in mid 70's, and noted to be cyanotic. EMS was then called. . Review of systems positive for increased SOB over past several days. The patient denies chest pain. He also denies fevers, chills, nausea, vomiting, abdominal pain, or diarrhea. He has had some minor dysuria recently with increased frequency. . In the ED, patient had SBP in 70's and lactate 4.0. A CVL was placed, and he was given 1L NS, vancomycin 1g IV, levofloxacin 500mg IV, and flagyl 500mg IV. BP improved to 80/44. CVP noted to be 24 and levophed was started instead of further fluid bolus. Oxygen saturations were 95-98% on 100% NRB. He had oral temperature of 99.5. He was then transferred to the MICU for further treatment. Past Medical History: 1. Coronary artery disease status post CABG in [**2089**] 2. Congestive heart failure, EF 30% 3. Atrial fibrillation 4. Status post pacemaker/AICD placement 5. History of idiopathic intrinsic lung disease, on 3L O2 at home 6. Diabetes mellitus type II, diet-controlled 7. Benign prostatic hyperplasia 8. Gastrointestinal bleeding without clear etiology and resulting anemia 9. Hypothyroidism 10. Right ear melanoma status post excision Social History: Used to deliver milk for job. Lives by himself but son is in same house, widower, retired. Denies tobacco past or present, previous moderate EtOH use, no IVDU. Family History: Father>>Tb Physical Exam: Vitals: T 98 BP 133/72 HR 104 RR 24 O2 97% on 100% NRB Gen: Mild respiratory distress, but able to speak a [**2-28**] word sentences comfortably. Lying flat. HEENT: OP dry. Circular area of hypopigmentation medial to right ear (s/p melanoma surgery). Neck: R IJ in place. Cardio: RRR, nl S1S2, [**1-29**] sys murmur at LUSB. Resp: Crackles [**1-27**] way up on left, crackles [**11-27**] way up on right. Abd: Soft, mildly distended, +BS (somewhat hypoactive), non-tender Ext: 2+ pitting edema BL LE Neuro: A&Ox3. Pertinent Results: CT Head on [**2104-1-30**]: IMPRESSION: 1. No evidence of intracranial hemorrhage. 2. Dilated superior ophthalmic veins (right greater than left). This may be related to differences in section location on current study v. the prior examination. It is likely not clinically significant but suggest correlation for bruits on auscultation. . CHEST (PORTABLE AP) [**2104-1-30**] FINDINGS: Compared with [**2103-12-28**], the left lower lobe is now clear. There is now bilateral perihilar and right lower lobe edema consistent with CHF/fluid overload. No obvious consolidating pulmonary infiltrates. . Echocardiogram on [**2104-1-31**]: IMPRESSION: No valvular vegetations seen. Dilated and hypertrophied left ventricle with moderate global systolic dysfunction. Dilated right ventricle with moderate systolic dysfunction. Moderate to severe tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2103-12-24**], the left ventricle appears slightly more dilated. The other findings are similar. . Chest Ultrasound [**2104-2-1**]: IMPRESSION: No abscess identified around the pacemaker pocket. . ECG Study Date of [**2104-2-6**] 8:09:30 AM Atrial fibrillation and ventricular paced rhythm with capture. Occasional ventricular ectopy. Compared to the previous tracing of [**2104-2-5**] there is occasional ventricular ectopy. Otherwise, no diagnostic interim change. . [**Numeric Identifier **] PICC W/O PORT [**2104-2-6**] IMPRESSION: Successful placement of PICC line via the left basilic vein, terminating in the superior vena cava. Ready for use. . Labwork on admission: [**2104-1-30**] 06:50AM WBC-30.0*# RBC-3.58* HGB-10.0* HCT-31.5* MCV-88 MCH-28.0 MCHC-31.8 RDW-16.9* [**2104-1-30**] 06:50AM PLT COUNT-285 [**2104-1-30**] 06:50AM NEUTS-94.5* LYMPHS-2.6* MONOS-2.7 EOS-0.1 BASOS-0.1 [**2104-1-30**] 06:50AM PT-20.8* PTT-32.5 INR(PT)-2.0* [**2104-1-30**] 06:50AM GLUCOSE-94 UREA N-36* CREAT-2.3*# SODIUM-138 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-23 ANION GAP-21* [**2104-1-30**] 06:50AM CK(CPK)-48 [**2104-1-30**] 06:50AM CK-MB-NotDone proBNP-[**Numeric Identifier 43211**]* [**2104-1-30**] 06:50AM cTropnT-0.08* [**2104-1-30**] 07:03AM LACTATE-4.0* K+-4.6 . Labwork on discharge: [**2104-2-13**] 06:50AM BLOOD WBC-7.3 RBC-3.45* Hgb-9.6* Hct-30.4* MCV-88 MCH-27.9 MCHC-31.6 RDW-17.5* Plt Ct-307 [**2104-2-13**] 06:50AM BLOOD PT-20.3* PTT-38.3* INR(PT)-2.0* [**2104-2-13**] 06:50AM BLOOD Glucose-90 UreaN-29* Creat-1.5* Na-138 K-3.6 Cl-94* HCO3-35* AnGap-13 Brief Hospital Course: 87 year-old male with coronary artery disease s/p CABG, congestive heart failure, atrial fibrillation, diabetes mellitus, with recent admission for sepsis, who now presents status post fall with hypoxia and hypotension secondary to sepsis. . 1. Sepsis: The patient had a recent admission for sepsis and was found to have MRSA bacteremia and Pseudomonas UTI at that time. The patient's recurrent sepsis on this admission was thought to be secondary to infected ICD leads and the patient went to the operating [**2104-2-3**] for lead removal and temporary lead placement. The differential initially included endocarditis, recurrent UTI, pneumonia, and C. difficile infection. These diagnoses were excluded as there were no vegetations noted on intraoperative TEE, the patient's urinalysis was negative, chest X-ray negative for pneumonia, and C. difficile cultures negative. The patient was followed by Infectious Disease during admission. The patient was started on vancomycin [**2104-1-30**] and will continue to complete a four-week course from [**2104-2-3**], the date of pacer lead removal. The patient will have a permanent pacemaker placed once the antibiotic course is completed. The patient was transiently on cefepime and metronidazole empirically but these were discontinued. The patient initially required levophed but this was weaned the second day of admission. Lactate 4.0 on presentation but subsequently normalized. . 2. Hypoxia: The patient has a history of lung disease of unclear etiology (restrictive and diffusion defects by last pulmonary function testing). The patient has a history of amiodarone use, but CT chest in [**2101**] did not show definitive signs of amiodarone toxicity. The patient has a baseline oxygen requirement 2-3L. The patient's increased oxygen requirement on admission was believed secondary to hypoxia secondary to sepsis and/or CHF. The patient's BNP was elevated on admission. There were no signs of pneumonia on imaging or sputum culture. The patient's oxygen requirement decreased during admission with diuresis and treatment of sepsis. On discharge, the patient was saturating 93% on 3L at rest, but required higher levels of oxygen on ambulation from severe deconditioning. The patient should be given nebulizers and increased oxygen prior to exertion. The patient also intermittently desaturated during sleep, likely secondary to intermittent hypoventilation. The patient responds to brief use of increased oxygen or non-rebreather mask as needed. . 3. Acute renal failure: The patient had creatinine 2.3 on admission, from baseline 0.9. This was likely pre-renal in setting of sepsis and congestive heart failure. The patient's creatinine improved with diuresis and treatment of sepsis. The patient's renal failure subsequently remained stable 1.4-1.5 and this may represent a new baseline. . 4. Status post fall: The patient suffered a fall prior to admission likely secondary to hypotension and/or hypoxia in the setting of sepsis. No obvious syncope or trauma. Head CT negative for acute intracranial pathology. . 5. Atrial fibrillation: There is no need for rate control. The patient is on coumadin as an outpatient and was therapeutic on admission. Anticoagulation was held prior to the pacemaker removal but restarted prior to discharge. The patient was started on low-dose amiodarone for rhythm control. The patient's pacemaker was removed with temporary pacemaker placement. The patient will have a permanent pacemaker placed once his course of antibiotics is complete. . 6. Congestive heart failure: LVEF 30%, 1+ MR, 3+ TR from last echocardiogram. The patient had a BiV ICD/pacer on admission which was removed as above and replaced with a temporary screw-in pacemaker. A permanent pacemaker will be placed once the patient has completed a course of antibiotics. The patient had an elevated BNP on admission and crackles on exam consistent with a CHF exacerbation. The patient responded to diuresis with improved oxygenation. The patient's beta-blocker and ACE-inhibitor were initially held secondary to hypotension. The patient was started on carvedilol prior to discharge. ACE-inhibitors were held secondary to relative hypotension and persistently elevated creatinine. An ACE-inhibitor can be restarted as an outpatient if blood pressures remain stable and the patient's creatinine is believed to be at a new baseline. The patient's digoxin was held for supratherapeutic levels with renal failure and initiation of digoxin. The patient's digoxin can be restarted as an outpatient for symptoms. . 7. Coronary artery disease: No signs or symptoms of active ischemia. Status post CABG in [**2089**] (LIMA -- D1, SVG-- LAD, SVG -- Ramus; SVG -- OM; SVG-- PDA). CK/troponins negative on admission. The patient was continued on beta-blocker and atorvastatin. The patient has an allergy to aspirin. . 8. Diabetes mellitus, type II: Diet-controlled as an outpatient. The patient was maintained on sliding scale insulin. . 9. Anemia: History of B12 deficiency and gastrointestinal losses. Recent baseline hematocrit 27-29. The patient was continued on B12 supplementation. . 10. Benign prostatic hypertrophy: No active issues. The patient was continued on finasteride. . 11. Code: Full. . 12. MACU for IV antibiotics, telemetry monitoring until permanent pacemaker placement. Medications on Admission: Doxycycline 100mg [**Hospital1 **] Atorvastatin 10 mg qd Levothyroxine 25 mcg qd MVI qd Prilosec 20mg qd Carvedilol 6.25 mg [**Hospital1 **] Finasteride 5 mg qd Cyanocobalamin 1000 mcg qd Albuterol/atrovent nebs q6h Warfarin 5 mg qhs Lisinopril 10mg qd Furosemide 40 mg [**Hospital1 **] NaCl nasal spray [**Hospital1 **] prn Digoxin 125 mcg qd Advair 250/50 1 puff [**Hospital1 **] Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection DAILY (Daily). 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-27**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed. 11. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 16. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Outpatient Lab Work Please monitor weekly CBC with differential, BUN/creatinine, vancomycin trough, and liver function tests and fax results to [**Hospital **] clinic at [**Telephone/Fax (1) 1419**]. 19. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Please follow insulin sliding scale as provided. 20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 21. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day: Titrate to goal even fluid balance. 22. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q 24H (Every 24 Hours): 750 mg QD started [**2104-2-3**] for four-week course . 23. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: 1. MRSA bacteremia 2. Hypoxemia, back to baseline oxygen requirement 2-3L NC 3. Acute renal failure, new baseline creatinine 1.5 . Secondary: 1. Coronary artery disease status post CABG in [**2089**] 2. Congestive heart failure, EF 30% 3. Atrial fibrillation 4. Status post pacemaker/AICD placement 5. History of idiopathic intrinsic lung disease, on 3L O2 at home 6. Diabetes mellitus type II, diet-controlled 7. Benign prostatic hyperplasia 8. Gastrointestinal bleeding without clear etiology and resulting anemia 9. Hypothyroidism 10. Right ear melanoma status post excision Discharge Condition: Afebrile, vital signs stable. Satting 96% on 3L at rest (requires much higher levels of oxygen with ambulation). Creatinine 1.5. INR 2.0. Discharge Instructions: You were hospitalized with bacteria in your blood, likely from an infected pacemaker wire. You are on antibiotics for infection. Your pacemaker was removed and you now have a temporary pacemaker wire. You will have a permenant pacemaker placed once you have finished your antibiotics. . You have a history of congestive heart failure. Please follow the below instructions regarding your heart: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1 liter . Please take your medications as prescribed. - You were started on amiodarone to help control your heart rhythm. You will likely need to take this for one month and can reassess the need for this medication with Dr. [**Last Name (STitle) **]. - Your digoxin was discontinued for levels that were too high with kidney failure. Please discuss future use of this medication with your primary care physician or cardiologist. - Your lisinopril was discontinued for acute kidney failure. Please discuss future use of this medication with your primary care physician or cardiologist. . Please keep your follow-up appointments as below. Followup Instructions: Follow-up in Electrophysiology Device Clinic for pacemaker interrogation and left pacer lead dressing change: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2104-2-18**] 10:30 . Follow-up in Cardiac Surgery clinic regarding your chest wound: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2104-2-20**] 02:00p . The office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] will contact you regarding a follow-up appointment in four weeks for permenant pacemaker placement. Please call the office at [**Telephone/Fax (1) 285**] if you do not hear from a representative by Friday, [**2-15**]. . Please contact the office of your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 608**] to schedule a follow-up appointment within two weeks of discharge from the rehab facility. You should discuss restarting digoxin and lisinopril with your primary care physician or cardiologist. . Follow-up in Infectious Disease clinic: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2104-3-11**] 11:30a . Previously scheduled appointments: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/CUT. ONC. DERM Date/Time:[**2104-2-13**] 10:45a . Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 19848**] CUTANEOUS ONCOLOGY Date/Time:[**2104-2-13**] 11:00a

Admission Date: [**2150-12-21**] Discharge Date: [**2150-12-29**] Date of Birth: [**2086-7-25**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2150-12-24**]: Coronary artery bypass x2 with blood with left internal thoracic artery to left anterior descending and a reverse saphenous vein graft to the obtuse marginal branch. History of Present Illness: 64 year old male who presented to OSH for exertional chest pain on/off since [**Month (only) 359**]. His chest pain is squeezing in nature, located in the xiphoid area, and radiates to the left chest and arm, brought on by exertion. It is occasionally associated with shortness of breath, and has worsened such that it now occurs with fairly minimal activity. He presented to [**Hospital3 **] on [**12-21**] as these episodes were becoming more frequent. Cardiology was consulted at OSH and thought this was consistant with unstable angina, and recommended transfer to [**Hospital1 18**] for cardiac catheterization. He was found to have left main disease and is now being referred to cardiac surgery for revascularization. Cardiac Catheterization: Date:[**2150-12-22**] Place:[**Hospital1 18**] LMCA: 80% LCX: minimal luminal irregularities LAD: minimal luminal irregularities RCA: dominant but no single PDA Past Medical History: Dyslipidemia ? Hypertension (undiagnosed, but was hypertensive at OSH) Current smoker Perpherial vascular disease s/p stenting in Left leg 8 years ago BPH s/p TURP Past Surgical History: Perpherial vascular disease s/p stenting in left leg 8 years ago Social History: Race:Caucasian Last Dental Exam:1 month ago Lives with: wife Contact:[**Name (NI) 19313**] Phone #H [**Telephone/Fax (1) 92395**], C [**Telephone/Fax (1) 92396**] Occupation:retired. Used to work in maintenance Cigarettes: Smoked no [] yes [x] last cigarette [**12-21**] Hx:1 pack per day x45 years Other Tobacco use:denies ETOH: < 1 drink/week [] [**2-2**] drinks/week [x] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- Mother died of a heart attack at age 81. His brother died suddenly at age 58, unknown circumstances Physical Exam: Pulse:61 resp:13 O2 sat:99/RA B/P Right:138/79 Left:140/72 Height:5'5" Weight:175 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2 Left:2 DP Right: 1 Left:1 PT [**Name (NI) 167**]: 2 Left:1 Radial Right: 2 Left:2 Discharge Exam: VS: T: 98.1 HR: 88-92 SR BP: 117/68 Sats: 94% RA WT: 81.8 Kg General: 64 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 no murmur Resp: clear breath sounds through out. No wheezes or crackles GI: benign Extr: warm no edema Incision: sternal mild erythema superiorly no discharge, sternum stable no click Neuro: awake, alert oriented, MAE Pertinent Results: [**2150-12-29**] WBC-7.5 RBC-3.06* Hgb-9.6* Hct-28.1* MCV-92 MCH-31.3 MCHC-34.0 RDW-13.2 Plt Ct-297 [**2150-12-28**] Hct-27.7* [**2150-12-27**] WBC-12.7* RBC-3.13* Hgb-9.8* Hct-28.8* MCV-92 MCH-31.3 MCHC-34.0 RDW-13.2 Plt Ct-205 [**2150-12-26**] WBC-13.7* RBC-3.03* Hgb-9.5* Hct-27.7* MCV-91 MCH-31.5 MCHC-34.5 RDW-13.0 Plt Ct-181 [**2150-12-25**] WBC-15.4* RBC-3.28* Hgb-10.3* Hct-30.1* MCV-92 MCH-31.4 MCHC-34.2 RDW-13.0 Plt Ct-194 [**2150-12-24**] WBC-16.9* RBC-4.03*# Hgb-12.6*# Hct-36.5*# MCV-91 MCH-31.4 MCHC-34.6 RDW-12.9 Plt Ct-186 [**2150-12-29**] Glucose-130* UreaN-15 Creat-0.8 Na-137 K-4.1 Cl-100 HCO3-28 [**2150-12-28**] UreaN-16 Creat-0.8 Na-137 K-4.4 Cl-98 HCO3-30 AnGap-13 [**2150-12-27**] Glucose-138* UreaN-16 Creat-0.7 Na-138 K-3.8 Cl-101 HCO3-29 [**2150-12-26**] Glucose-118* UreaN-17 Creat-0.9 Na-140 K-3.8 Cl-104 HCO3-31 TTE [**2150-12-24**] LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. Moderately depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Focal calcifications in ascending aorta. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Filamentous strands on the aortic leaflets c/with Lambl's excresences (normal variant). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. Conclusions PRE BYPASS 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. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is moderately, globally depressed (LVEF= 35-40 %). The right ventricle displays mild global free wall hypokinesis. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POST BYPASS There is normal right ventricular systolic function. Global left ventricular systolic function is improved - now mild global hypokinesis with an ejection fraction of 45%. The mitral regurgitation may be slightly worsened and borders on being mild to moderate. The thoracic aorta is intact after decannulation. CXR: [**2149-12-27**]: The lungs are hyperinflated, suggesting background COPD. The patient is status post sternotomy, with mild-to-moderate cardiomegaly, unchanged compared with [**2150-12-26**] at 11:33 a.m. There is mild relatively diffuse prominence of the interstitial markings, however, CHF findings are considerably improved compared with the earlier film. There is patchy opacity in the retrocardiac region, also somewhat improved. Minimal blunting of the posterior costophrenic angles is seen, but no gross effusion identified. Brief Hospital Course: The patient was brought to the operating room on [**2150-12-24**] where the patient underwent Coronary artery bypass x2 with blood with left internal thoracic artery to left anterior descending and a reverse saphenous vein graft to the obtuse marginal branch. CARDIOPULMONARY BYPASS: 57 minutes. CROSS-CLAMP TIME: 43 minutes. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. His Foley was removed and he failed a voiding trial. He was given Flomax and Foley was removed again and he voided initially 120 cc. He subsequently was bladder scanned for 1 Liter. Foley was reinserted and patient was discharged home with a leg bag and follow up appointment with outpatient urologist was arranged. Preop Plavix was restarted for PVD. He was started on Kefzol for upper sternal pole erythema and tenderness - sternum was without drainage and stable. He was afebrile and WBC was 7.5. He was continued on a 7 day course of Kefzol at the time of discharge for sternal erythema. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD5 the patient was ambulating freely, the wound was healing, he was 92% on Room air and pain was controlled with oral analgesics. He was given a nicotine patch and smoking cessesation teaching. The patient was discharged in good condition with appropriate follow up instructions. Medications on Admission: HOME MEDS - Atorvastatin 40mg PO daily - Plavix 75mg PO daily - Aspirin 81mg PO daily . MEDS ON TRANSFER - plavix 75mg PO daily - ASA 81mg PO daily - ASA 325mg PO once - lipitor 80 - lovenox 60 today 10:30am - Magnesium hydroxide 10mL daily PRN constipation - Nitroglycerin 0.4mg SL Q5M PRN chest pain Discharge Medications: 1. nicotine (polacrilex) 2 mg Gum Sig: One (1) gum Buccal every 1-2 hours as needed for nicotine cravings. Disp:*100 * Refills:*2* 2. nicotine 21-14-7 mg/24 hr Patch, TD Daily, Sequential Sig: One (1) patch Transdermal once a day: 6 week total course. Disp:*42 * Refills:*2* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 8. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-28**] Puffs Inhalation Q6H (every 6 hours). Disp:*1 inhaler* Refills:*2* 9. cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a day for 7 days. Disp:*28 Tablet(s)* Refills:*0* 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while taking narcotics. 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) scoop PO DAILY (Daily). 12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 13. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day for 5 days. Disp:*5 Capsule, Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease Dyslipidemia Hypertension (undiagnosed, but was hypertensive at OSH) Current smoker Peripherial vascular disease s/p stenting in Left leg 8 years ago BPH s/p TURP Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] Date/Time:[**2151-1-5**] 10:00 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on Date/Time:[**2151-2-3**] 1:15 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] PCP Dr [**Last Name (STitle) 29247**] - office to arrange appt [**Telephone/Fax (1) 29248**] Urologist: Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] on Tues [**1-5**] at 1:45 PM Needs cardiologist referral from PCP **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2150-12-29**]

Admission Date: [**2161-6-23**] Discharge Date: [**2161-7-2**] Date of Birth: [**2111-6-30**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Headache Major Surgical or Invasive Procedure: [**2161-6-24**]: Cerebral Angiogram with coiling of left PComm Artery Aneurysm History of Present Illness: 49F was at home, had had a couple beers when developed severe sudden onset headache. Went to OSH where CT showed CT with SAH. Neuro intact. Transferred [**Hospital1 18**] ED for further management. Past Medical History: depression, inc cholesterol Social History: Etoh Family History: n/a Physical Exam: PHYSICAL EXAM: O: T:98.4 BP: 138/76 HR:86 O2Sats 97 2l Gen: WD/WN, NAD but eyes closed with cold cloth on head. HEENT: Pupils: [**4-7**] EOMs full Neck: Supple.minimal pain with flex/ex Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 5 to 4 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-8**] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal PHYSICAL EXAM UPON DISCHARGE ******* Pertinent Results: ADMISSION LABS: [**2161-6-22**] 11:00PM WBC-16.6*# RBC-4.46 HGB-13.5 HCT-40.2 MCV-90 MCH-30.4 MCHC-33.7 RDW-14.1 [**2161-6-22**] 11:00PM PT-12.3 PTT-27.5 INR(PT)-1.0 [**2161-6-22**] 11:00PM GLUCOSE-167* UREA N-22* CREAT-0.7 SODIUM-139 POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-18* ANION GAP-15 [**2161-6-23**] 03:42AM PHENYTOIN-14.8 IMAGING: CTA Neck [**6-23**]: extensive SAH centered at the left aspect of the suprasellar cistern. 7mm x 7 mm lobulated aneurysm at the junction of the left MCA and carotid artery. [**2161-6-26**] Head CT: IMPRESSION: 1. New area of hypoattenuation in the left parietal lobe s/p aneurysm coiling, suspicious for acute infarction. 2. Small amount of residual subarachnoid hemorrhage. [**2161-6-30**] Head CTA: IMPRESSION: 1. No significant change in the hypodense area in the left parietal lobe at the vertex compared to the recent study of [**6-26**], though it is new compared to [**6-24**] and may represent a focus of infarction. 2. Short segment areas of stenosis, in the left posterior cerebral artery -P2 segment, may be real/related to adjacent artifacts from the coils. Short segment narrowing of the distal Basilar artery is likely related o artifacts. Atherosclerotic calcified and non-calcified plaques in the cavernous segments on both sides with some degree of stenosis. Otherwise, no flow-limiting stenosis or occlusion of the major arteries noted. [**Date range (1) 59214**] EEG: IMPRESSION: This is a normal video EEG telemetry in the awake and drowsy states. There was no organized epileptiform activity or electrographic seizures. Brief Hospital Course: The patient was admitted to the Surgical ICU for Q1 neuro checks and tight blood pressure control. She was placed on nimodipine for vasospasm prophylaxis, and dilantin for seizures. A repeat CTA was performed, which demonstrated a 7x7mm lobular aneurysm at the junction of the L carotid/MCA. She was taken to the angio suite on [**6-23**] and underwent coiling of the P Comm Artery aneurysm. Procedure was without complication but due to a small coil protrusion in the parent artery, she was left on a heparin drip overnight. Patient returned to the ICU for close neurological monitoring. The following morning the heparin was discontinued and EEG monitoring was initiated per protocol. She was also started on a prednisone taper for additional pain control. On [**6-25**] dilantin level was reloaded. On [**6-26**] a CT was performed at the discretion of the ICU team for continued headaches. This revealed a small left parietal infarction. The patient remained neurologically stable and asymptomatic, but hypertension and hypervolemia were initiated. From [**6-27**] through [**6-30**] the patient remained neurologically intact in the ICU. Pain medications were changed frequently in attempt to reach an acceptable comfort level. On [**6-30**] the patient was cleared for discharge to the floor. Her IVF was halfed to 100ml/hr. EEG monitoring was discontinued and she was encouraged to be out of bed. On [**7-1**] A CTA was obtained to assess for vasospasm and was negative. IVF was discontinued. On [**7-2**] the patient was ambulating independently and tolerating a PO diet. H/A was stable and current pain regimen is tolerable. Pt was cleared for discharge home at this time. Medications on Admission: toprimate 100hs, sertraline 150 qday, ranitidine 150 qday, valium 10 prn, gabapentin 100 [**Hospital1 **], cipro 500 [**Hospital1 **], seroquel 200 qhs Discharge Medications: 1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 13 days. Disp:*156 Capsule(s)* Refills:*0* 2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Tablet(s) 3. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-6**] Tablets PO Q4H (every 4 hours) as needed for pain: Alternate with Florinal to decrease tylenol intake. Disp:*60 Tablet(s)* Refills:*0* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Butalbital-Aspirin-Caffeine 50-325-40 mg Capsule Sig: [**12-6**] Caps PO Q4H (every 4 hours) as needed for h/a: Alternate with Florinal to decrease tylenol intake. Disp:*60 Cap(s)* Refills:*0* 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Aneurysmal Subarachnoid Hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications Followup Instructions: You need to follow up with Dr. [**First Name (STitle) **] in 1 month. You will need an MRI/MRA of your head before this appointment. Please call Takesia at [**Telephone/Fax (1) 1669**] to schedule this. Completed by:[**2161-7-2**]

Admission Date: [**2158-10-8**] Discharge Date: [**2158-10-14**] Date of Birth: [**2082-5-3**] Sex: M Service: MEDICINE Allergies: Penicillins / Vancomycin Attending:[**First Name3 (LF) 4963**] Chief Complaint: abdominal pain, dizziness, nausea, malaise x4 days Major Surgical or Invasive Procedure: EGD [**10-12**] History of Present Illness: HPI: Patient is a 76 y/o m hx of CAD s/p CABG w/ a four day hx of dizziness, nausea and constipation, w/ gen malaise, poor po intake over the past few weeks. Recent episoded of diarrhea followed by constipation over the past week. Poor PO intake, because angina worse with eating, has led to avoidance of food. Patient has severe angina that is refractory to maximal medical management per recent notes in OMR, 2-3 episodes per day per patient. Denies syncope or claudication. Pt states angina is not becoming more frequent or severe. Angina is relieved by SlNTG . Originally presented to [**Hospital **] Hospital [**10-8**] w/ c/o lightheadedness, CP x2 episodes similar to angina, which was relieved by NTG. At OSH SBP in 80s then drop to 60s. Responded to SBP in 100s after given NTG. Noted to be guaic positive. patient hypotensive there but responed to nitro and fluids. Transferred to [**Hospital1 18**] for further management. Patient was hypotensive to 60s responded to several fluid boluses, w/ BP responding to SBP 137, then having CP, [**6-25**] that was relieved w/ NTG sublingual. Transferred to MICU given hypotension . MICU Course: Patient remained stable in MICU. No episodes of hypotension. No use of pressors. cardiac enzymes negative x3. No ischemic changes on ECG. TTE showed worsening AS, now severe. Past Medical History: CAD s/p CABG [**2148**] DM Bradycardia s/p dual chamber [**Year (4 digits) 4448**] BPH Total knee replacement Arthritis Social History: SH: lives alone, has 2 daughters in the area. retired fine arts teacher, current theater clinic. quit tob 45 yers abo no etoh Family History: FH: [**Last Name (un) **] DM 75 died' Mom MI [**26**] Dad MI [**14**] Pertinent Results: p-MIBI: Mild, fixed perfusion defect involving the basilar portion of the inferior wall, unchanged from prior study. 2. Mild left ventricular enlargement with calculated EF of 67%. . [**10-9**] TTE: Conclusions: The left atrium is mildly dilated. The estimated right atrial pressure is [**5-25**] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area 0.7cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. An eccentric, anteriorly directed jet of mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [**10-9**] EKG: Sinus bradycardia Ventricular pacer spikes in pattern of pseudofusion complexes suggested First degree A-V delay Intraventricular conduction delay - probably left bundle branch block Since previous tracing of [**2158-10-8**], probably no significant change . [**10-12**] CTA: Abdomen to evaluate for ? mesenteric ischemia Impression: Altherosclerotic disease involving aorta and vessels of major tributaries. However there is no focal stenosis or post-stenotic dilatation of any of the vessels, all vessels are patent. No secondary signs to suggest mesenteric ischemia. . [**10-12**] EGD: Gastric and duodenal erosions. Gastric ulcer. Biopsy taken. Brief Hospital Course: Briefly this is a 76M with CAD s/p 4vCABG [**2148**] presenting with poor po intake, 30 lb weight loss, abdominal discomfort and angina found to be hypotensive, admitted initiallo to MICU for monitoring and resucsitation. . 1. Hypotension: BP improved with fluids. TTE showed severe AS, which in a volume depleted person who is pre-load dependent was thought to be the likely etiology of pt's hypotension. On date of discharge pt's BP is stable and he has tolerated re-initiation of home antihypertensives. . 2. CAD: with chronic stable angina that is refractory to maximal medical therapy per outpatient cardiology notes. Ruled out with CEs, EKG. Likely etiology for angina is severe AS. . 3. AS. Pt was seen by cardiothoracic surgery who recommended a full pre-operative work-up in anticipation of AVR with possible CABG: including cardiac catheterization, and GI consult. Pt received part of work up in house including GI consult and b/l carotid ultrasounds. Pt will return in ~2 weeks for elective outpatient catheterization and will be in touch with CT surgery regarding bypass surgery scheduling and expectations. . 4. Abdominal discomfort:Pt presented with symptoms of abdominal pain and angina with eating. He also was guaiac positive and anemic. Of note pt had recently been incompletely treated for an assumed h. pylori infection. He had received 2 weeks of a three week course of antibiotics before self discontinuing the medications due to diarrhea. Pt had a history of a recent colonoscopy in [**2157**] which was significant only for grade 2 internal hemorrhoids. Pt underwent an EGD on [**10-12**] which showed gastric and duodenal erosions and a gastric ulcer. Pt continued on PPI. Biopsy taken, will return in a week, if remains H. Pylori positive, pt's PCP will contact the pt re: starting prevpac. Pt also underwent a CTA of the abdomen to evaluate for mesenteric ischemia in light of his symptoms of post-prandial pain, this study showed no evidence for any occluded bowel vessels. . 5. Diabetes: RISS and metformin continued, metformin held for 48 hours after administration of CTA dye load. . 6. BPH: Pt initially experienced urinary retention requiring foley which was shortly thereafter discontinued, on the day prior to discharge pt again experirenced an episode of retention requiring foley replacement, this was again weaned prior to leaving the hospital. Pt continued on proscar and doxazosin. Plan to follow up with outpatient urology if retention remains an active issue. Pt initally emperically treated for UTI with cipro, whis was d/c'd when culture results returned negative. Pt will contact his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58**] for a follow up appointment within a week after discharge. He will also be following up with cardiothoracic surger regarding completion of pre-op workup including outpatient cardial catheterization, dental clearance, and potential vein mapping. Will need repeat EGD prior to OR given risk of bleeding with surgery/anticoagulation. Pt/PCP to follow up EGD biopsy results in 1 week post discharge for result of h. pylor test, if postive to complete prevpac treatment. Pt to return to Dr. [**First Name (STitle) 679**] for repeat EGD in [**6-27**] weeks. Medications on Admission: Home MEDS: Medications: Atenolol 50mg daily Lasix 20mg dialy lisinopril 10mg daily proscar 5mg daily lipitor 10mg daily metformin 500mg po bid mvi fosamax 70mg daily glucosamine . Transfer MEDS: Lisinopril 5 mg PO DAILY Aspirin 81 mg PO DAILY MetFORMIN (Glucophage) 500 mg PO BID Atorvastatin 10 mg PO DAILY Metoprolol 12.5 mg PO BID Doxazosin 1 mg PO HS Multivitamins 1 CAP PO DAILY Finasteride 5 mg PO DAILY Nitroglycerin SL 0.3 mg SL PRN Heparin 5000 UNIT SC TID Pantoprazole 40 mg PO Q24H Insulin SC Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP <100. Disp:*30 Tablet(s)* Refills:*3* 2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*3* 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID PRN as needed for constipation. Disp:*60 Capsule(s)* Refills:*3* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed for constipation. Disp:*60 Tablet(s)* Refills:*3* 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for HR<55, SBP <100. Disp:*30 Tablet(s)* Refills:*3* 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**1-17**] Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain. Disp:*30 Tablet, Sublingual(s)* Refills:*3* 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day: Start next dose on [**10-15**]. Disp:*60 Tablet(s)* Refills:*3* 10. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*3* 11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*3* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Moderate to Severe Aortic Stenosis Gastric ulcer BPH related urinary retention Discharge Condition: Fair Discharge Instructions: Please take all medications as prescribed. Please attend all scheduled follow up appointments. Call your doctor or return to the emergency room if you experience chest pain not responsive to nitroglycerin, increasing shortness of breath, abdominal pain, loss of consciousness, intractable abdominal pain, nausea,vomiting, blood in stool/vomit or black stool. Followup Instructions: You have the following scheduled appointments in the [**Hospital1 18**] system. Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2158-11-7**] 10:15 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2159-2-6**] 2:30 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2159-4-12**] 2:00 Please call your primary care physician for [**Name Initial (PRE) **] follow up appointment within 1 week of discharge: Dr. [**Last Name (STitle) 58**] [**Telephone/Fax (1) 3329**]

Admission Date: [**2199-11-12**] Discharge Date: [**2199-11-21**] Date of Birth: [**2122-4-28**] Sex: M Service: NEUROLOGY Allergies: Hydrochlorothiazide Attending:[**First Name3 (LF) 2090**] Chief Complaint: Intracerebral hemorrhage, Headache, change in mental status. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known lastname 105462**] is a 77yo LH man with a PMHx significant for metastatic melanoma (mets to liver and lymph nodes), afib on coumadin, placement of a pacemaker and lumbar spinal stenosis who was originally admitted to neurosurg on [**11-12**] and transferred to OMed on [**11-15**]. He is being transferred to the Neuro ICU because of concern for altered mental status this AM. To briefly recount his history: he had been in his USOH until the day of admission, when he developed a sudden left temporal headache. He was having difficulty walking and eventually was unable to stand up. He was found down with decreased movement of his left side next to his bed. Concerned, his wife activated EMS and he was brought to an OSH for evaluation. There, a NCHCT showed a right temporal IPH with intraventricular extension. His INR at that point was noted to be "supratherapeutic". He was intubated and then transferred to [**Hospital1 18**] for further management (INR on arrival was 2.3). Upon arrival, he was admitted to the Neurosurgery service for further management. He was observed and his anticoagulation was reversed while on that service. He was also started on PHT on admission for seizure ppx. A head CT with contrast on [**11-13**] was concerning for an intracerebral hemorrhage, On the AM of [**11-15**], he was found to have decreased responsiveness -- he barely responsive to name, would have difficulty opening his eyes and and difficult to arouse. He also had a fever to 100.4 with perseveration and [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing. Concerned, neuroonc was consulted and it was recommended that he be transferred to the NeuroICU for further management for concern for worsening of his bleed. He was started on decadron and nimodipine. He also received an extra dose of phenytoin (200mg) He also received a NCHCT prior to transfer, that was unchanged from the one the day prior. Past Medical History: PAST MEDICAL HISTORY: 1. Metastatic melanoma, diagnosed in [**3-/2199**] (lesion on vertex of head) with mets to LNs of neck and LLL of lung. 2. Atrial fibrillation, status post pacemaker placement in [**2196**]. 3. Hypertension. 4. History of TIA. 5. Lumbar spinal stenosis with resultant severe symm. peripheral neuropathy -- followed by Dr. [**Last Name (STitle) **] in clinic for many years 6. Basal cell carcinoma. 7. Remote history of seizure. PAST SURGICAL HISTORY: 1. Status post partial thyroidectomy 15 years ago. 2. Status post total laminectomy of L4-L5, partial laminectomy of L3, fusion of L4-L5 in [**2187**]. Social History: Married lives with his wife. Retired police officer. Does not smoke or drink Family History: His father died at age 72 from complications of lupus. His mother died at age [**Age over 90 **] from congestive heart failure. His sister, age 79, is healthy. His 2 daughters and a son are healthy. Physical Exam: Neurosurgery Exam on Admission: PHYSICAL EXAM: O: T: afebril BP: 130's/80's HR:62 R 10 vented / not over breathing the vent O2Sats Gen: WD/WN, comfortable, NAD. HEENT: No hemotymapnum / no battles / no raccoon / NC/AT / no csf rhinorrhea otorrhea / Pupils: 2 trace rxn bilaterally gaze conjugate Neck: in collar Neuro: GCS E=1 M=5 V=1T / =7T No eye opening to stimulation or voice, perrl trace reaction at 2mm b/l / gaze conjugate wihtout nystagmus / no facial assymetry noted / localizes with RUE to sternal rub / weak w/d of LUE / trace withdrawal of b/l LE / no clonus / toes down going. Neurology Exam on Transfer to Neurology Service: Genl: Awake, alert, friendly, NAD HEENT: Sclerae anicteric, no conjunctival injection, oropharynx clear CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: CTA bilaterally, no wheezes, rhonchi, rales Abd: NABS, soft, NTND abdomen Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**] backwards easily. Dysarthric speech, but fluent with normal comprehension and repetition; able to make jokes. No right-left confusion. No evidence of apraxia. $1.75 = 7 quarters. Has dense left sided neglect (only able to ID half of people in the room). Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Difficult to assess visual fields with neglect. Extraocular movements intact bilaterally without nystagmus. Sensation intact V1-V3. left sided facial droop. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Tongue midline, movements intact. Motor: Increased tone in left leg. No observed myoclonus, asterixis, or tremor. Unable to keep left arm up to do pronator drift. [**Doctor First Name **] Tri [**Hospital1 **] WE IP H Q DF PF R 5 5 5 5 5 5 5 5 5 L 5- 5- 5- 5 4 4 4 4 4 Sensation: Decreased distally to all modalities in LE. Intact to light touch. + Extinction to DSS. Reflexes: 2+ on UE bilaterally, unable to obtain in LE b/l. Toes mute bilaterally. Coordination: Weakness with finger-nose-finger, finger-to-nose, L>R. Gait: Deferred. At time of discharge, Mr. [**Known lastname 105462**] had a waxing and [**Doctor Last Name 688**] mental status and his orientation could be good on one day and patchy on another, with an otherwise similar exam. Pertinent Results: ADMISSION LABS: [**2199-11-12**] 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2199-11-12**] 05:30PM PT-24.3* PTT-33.4 INR(PT)-2.3* [**2199-11-12**] 05:30PM NEUTS-87.6* LYMPHS-8.4* MONOS-2.9 EOS-0.9 BASOS-0.3 [**2199-11-12**] 05:30PM WBC-9.6 RBC-4.38* HGB-12.7* HCT-38.5* MCV-88 MCH-28.9 MCHC-32.9 RDW-14.4 [**2199-11-12**] 05:30PM GLUCOSE-107* UREA N-15 CREAT-0.9 SODIUM-138 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13 CT Head [**11-13**]: Large right temporal intraparenchymal hemorrhage with intraventricular and subarachnoid extension. Given history of melanoma, underlying mass lesion is a possibility and may be evaluated with MRI (not possible given pacer). Follow-up CT's stable on [**11-15**]/10-->done for altered mental status. EEG reveals encephalopathy (generalized slowing) with come assymetry (possibly attributable to hemorrhage). Portable chest films revealed cephalization and edema, resolving during the admission. No frank consolidation. EKG's revealed atrial fibrillation with atrial pacing and some periods of AF with RVR earlier in admission. Telemetry with rate control later in admission. DISCHARGE LABS: [**2199-11-21**] 05:45AM BLOOD WBC-9.6 RBC-4.51* Hgb-13.7* Hct-38.3* MCV-85 MCH-30.3 MCHC-35.7* RDW-14.2 Plt Ct-132* [**2199-11-21**] 05:45AM BLOOD PT-13.2 INR(PT)-1.1 [**2199-11-21**] 05:45AM BLOOD Glucose-126* UreaN-25* Creat-1.0 Na-136 K-3.1* Cl-101 HCO3-25 AnGap-13 [**2199-11-18**] 07:25AM BLOOD ALT-13 AST-17 LD(LDH)-276* AlkPhos-71 TotBili-1.2 [**2199-11-21**] 05:45AM BLOOD Calcium-8.8 Phos-2.6* [**2199-11-20**] 06:15AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0 [**2199-11-21**] 05:55AM BLOOD Vanco-12.2 [**2199-11-21**] 12:51AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025 [**2199-11-21**] 12:51AM URINE Blood-LG Nitrite-NEG Protein-25 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2199-11-21**] 12:51AM URINE RBC-[**10-26**]* WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 [**2199-11-16**] 09:20AM URINE Mucous-RARE Brief Hospital Course: Initial Hospital Course with Neurosurgical Team The patient was admitted to the SICU for further evaluation. He was loaded with Dilantin, and his INR was immediately reversed with FFP and Vit K for a goal INR < 1.4. He was extubated in the morning, and on his exam he was following commands and MAE. A Head CT with contrast on [**11-13**] demonstrated a right temporal hamorrhage and was read as having no underlying mass. On further inspection of the scan it was felt that there was an underlying mass consistent with metastatic melanoma. On [**11-14**] he was deemed fit to be trasnferred out of the ICU and the family was thoroughly updated by Dr. [**Last Name (STitle) **]. He was medially stable overnight on the floor however was agitated and required Posey restraint and Geodon. What stable, he was transferred to the care of Neurology and their floor service. Intracerebral Hemorrhage Contributors: Likely cerebral metastases of melanoma (difficult to further evaluate in this context and given MRI could not be performed owing to pacer), coumadin, striking of head (possibly occurred after bleed - unclear). [**Name2 (NI) **] should remain on Lovenox prophylaxis given lesser risk of more bleeding, but likely hypercoagulable state at present. Please do not restart coumadin at this time. Dr. [**Last Name (STitle) 724**] will re-address these questions in clinic. He also is likely to have had a seizure, hence starting of Dilantin. His mental status worsened slightly with Dilantin, so we have started zonisamide and started tapering Dliantin (was at 150 mg TID) - see instructino in med list below. Gabapentin has likely been anticonvulsant and was mistakenly continued at 300 mg TID rather than 600 mg TID, but this is now continued at the lower dose given stability at present and some sedation. This should be revised after Dilantin is stopped and with continued evaluation of mental status. Given underlying melanoma, dexamethasone was started, with dosing revised by Dr. [**Last Name (STitle) 724**] at NeuroOnc follow-up. Given steroid treatment, IV H2 blocker (now PPI on DC as per home regimen), insulin were started. Vitamin D and calcium given. Dr. [**Last Name (STitle) 724**] plans whole brain radiation and chemotherapy is also possible. This is another reason why we preferred zonisamide (mostly renal clearance) to Dilantin (non-linear/saturatable and inducing, hepatic). Melanoma Scalp lesion presently not active. Metastatic disease. Was seen by oncology in house. Present issue is likely cerebral metastases. Fluid Overload Patient with significant pulmonary edema on transfer to neurology. Self-resolving but also treated with small Lasix doses (20 mg). Likely primary reason for increased respiratory rate and hypoxia. Pneumonia Patient likely aspirated and given overall fragile state, treated. Vancomycin and Zosyn chosen given less likely to provoke seziures than other regimens. Treatment to finish on [**2199-11-28**]. PICC line was placed and is in the correct location for use. [**Last Name (un) 6055**]-[**Doctor Last Name **] Respiration Echo not performed, but may contributors likely low-output cardiac state or due to hemorrhage or even metastases. Given stability and attribution of increased work of breathing to edema, was not further worked-up. Atrial Fibrillation Metoprolol continued through the admission with good rate control. Patient typically takes metoprolol succinate 25 mg QAM with additional 25 mg of tartrate if needed. Pacer interrogation appointment on [**2199-11-25**] (same day as NeuroOnc appointment). He was seen by the electrophysiology service while an inpatient. Pacer working well but will be interrogated in clinic. SSRI Citalopram dose held at 20 mg. Can be increased when patient stabilized to 40 mg if indicated, as intended by Dr. [**Last Name (STitle) **]. Hypothyroidism Would recommend outpatient TSH check given interaction of levothyroxine with calcium. Hyperlipidemia Continued atorvastatin at 10 mg. Hematuria and Urinary Management Trace in context of Lovenox treatment and Foley in place. Foley removed prior to DC. Please repeat UA to see that blood does not increase. CODE STATUS: DNR/DNI Medications on Admission: MEDICATIONS: ATORVASTATIN [LIPITOR] - 10 mg Tablet - one Tablet(s) by mouth once a day CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth once a day CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth Daily start after finishing 20mg tablets GABAPENTIN - 300 mg Capsule - 2 Capsule(s) by mouth three times a day LEVOTHYROXINE [LEVOXYL] - 125 mcg Tablet - 1 Tablet(s) by mouth qam LORAZEPAM - 0.5 mg Tablet - 1 Tablet by mouth Take 2 hours prior to the MRI You may take an additional dose if there is no effect in one hour METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth twice a day PRN as needed as instructed OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day OXYCODONE-ACETAMINOPHEN [ENDOCET] - 5 mg-325 mg Tablet - [**12-8**] Tablet(s) by mouth Q4-6H as needed for pain please do not drive or operate machinery while taking pain medications QUINIDINE GLUCONATE - 324 mg Tablet Sustained Release - 1 Tablet(s) by mouth three times a day WARFARIN - 2 mg Tablet - 3 Tablet(s) by mouth daily as directed Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Was to be increased to 40 mg daily - we leave this to discretion of PCP after acute illness. . 3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): . 4. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush: PICC line flush. 5. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours): Last day [**2199-11-28**]. 6. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): Last day [**2199-11-28**]. Level suggested 15-20. Please check level and adjust dose accordingly. 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain or fever. 10. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day): With meals. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. insulin regular human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED): While receiving dexamethasone. . 13. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 14. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): Please give 100 mg TID for two days, then 50 mg TID for two days, then 25 mg TID for two days, then stop. 16. zonisamide 100 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)). 17. dexamethasone sodium phosphate 4 mg/mL Solution Sig: One (1) Injection Q8H (every 8 hours): Continue - Dr. [**Last Name (STitle) 724**] will determine whether change needed in clinic. 18. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Primary Intracerebral hemorrhage Seizure Metastatic Melanoma, with likely cerebral metastases Pneumonia Secondary Atrial fibrillation, status post pacemaker placement in [**2196**]. Hypertension. Lumbar spinal stenosis. Discharge Condition: Mr. [**Known lastname 105462**] is typically alert, but inattentive, oriented to self, and variably to place, time, context. A typical response might be correct month, confusion with exact day or date, "[**9-15**]" instead of [**2198**] and hospital. His mental status tends to vary through the day from drowsy to alert. He often gives full sentence, but inappropriate answers to questions. He is typically quite cheerful and interactive. He needs assistance to chair and will benefit from continued physical therapy. Discharge Instructions: You were admitted to the hospital after bleeding in your brain, in the context of falling out of bed and likely metastases of melanoma to your brain. This has also been associated with seizures. We started Dilantin (an anti-seizure medication) and changed this to Zonegran given some sedation. Your brain bleed is now stable. You were seen by Cardiac Electrophysiology and Oncology while an inpatient and will follow-up with both in clinic. It is now safe for you to go to rehabilitation where you will complete a course of antibiotics and undergo physical therapy. Please take your medications as directed and attend follow-up appointments. your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? Please do not restart warfarin at this time. CALL YOUR NEUROSURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Please attend the following appointments (we have shifted them to the same day to minimize transportation): 1. Neurooncology: Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2199-11-25**] 10:30 2. Cardiology: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2199-11-25**] 1:30 Also: ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **] , to be seen in [**3-12**] weeks. ?????? You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2199-12-12**] 10:30 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]

Admission Date: [**2156-8-21**] Discharge Date: [**2156-8-27**] Service: [**Doctor Last Name 1181**]-ME HISTORY OF PRESENT ILLNESS: The patient is an 86 year old man with multiple co-morbidities who presented after being found unresponsive at the nursing home with a temperature of 100.3 F.; blood pressure of 150/70; oxygen saturation 79% to room air. The patient was found to be more lethargic and more congested on examination and the patient was then sent to the Emergency Room at [**Hospital1 69**] and first admitted to the Medical Intensive Care Unit. HOSPITAL COURSE: While in the Intensive Care Unit, the patient received frequent suctioning, however, was not intubated during this initial part of the stay. The patient was made "Do Not Resuscitate" and "Do Not Intubate" after the status was confirmed with the [**Hospital 228**] health care proxy, who is the patient's niece. The chest x-ray performed right after admission also showed possible bilateral patchy opacities consistent with pneumonia. The patient was started on Levofloxacin and Flagyl. After the patient was stabilized and no longer required q. one hour suctioning, the patient was transferred to the medical floor, where the patient's course remained stable. The patient required throughout the hospitalization, frequent suctioning every two to three hours. This frequency later on subsided to every three to four hours. The patient's cultures grew back Methicillin resistant Staphylococcus aureus pneumonia and the patient was also started on Vancomycin. During his hospitalization, the patient slowly became more responsive, however, he remained alert and oriented times one to his name only throughout his hospitalization. His oxygen saturation remained stable throughout the hospital stay at 94 to 96% on 50% of face mask. The patient also was initially admitted with a high sodium of 150; this subsequently decreased to a level of 140 to 143 after the first day of hospitalization. The patient's Metformin was held and an insulin sliding scale was started for the patient and the patient's glucose levels remained stable throughout his hospital stay. In addition, the patient's blood pressure medications were held as well and his blood pressure readings remained stable throughout his hospital stay. CONDITION ON DISCHARGE: The patient's condition on discharge is stable. DISCHARGE STATUS: His discharge status is stable. DISCHARGE DIAGNOSES: 1. Methicillin resistant Staphylococcus aureus pneumonia. DISCHARGE MEDICATIONS: 1. Vancomycin one gram q. 12 hours. 2. Aspirin 81 mg q. day. 3. Multivitamins. 4. Acetaminophen 650 mg q. four to six hours p.r.n. 5. Erythromycin 0.5% Ophthalmologic Ointment 0.5 three times a day. 6. Levofloxacin 500 mg q. 24 hours intravenously. 7. Metronidazole 500 mg q. eight hours intravenously. 8. Docusate sodium 100 mg twice a day. 9. Brimonidine tartrate 0.15% Ophthalmologic solution, one drop q. eight hours. DISPOSITION: The patient is to be discharged to a nursing home. DISCHARGE INSTRUCTIONS: 1. The patient is also to be discharged on tube feeds, which were started on day three of hospitalization at a rate of 40 to 60 cc per hour. 2. The patient is being discharged to a nursing home. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AEW Dictated By:[**Name8 (MD) 749**] MEDQUIST36 D: [**2156-8-27**] 16:13 T: [**2156-8-27**] 18:12 JOB#: [**Job Number 51274**]

Admission Date: [**2174-12-30**] Discharge Date: [**2175-1-6**] Date of Birth: [**2107-9-15**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 67 year old woman with dilated cardiomyopathy and depressed left ventricular ejection fraction to less than 25% by last echocardiogram in [**2172-12-30**], who has resided at a rehabilitation facility for most of the interval prior since her discharge from [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] in [**2174-7-31**] for dehydration and congestive heart failure. The patient now presents from rehabilitation with a complaint of one month of an increased size of abdomen, weight gain and lightheadedness, and orthostatic symptoms. She also reports some shakiness and tremor for the last few days. On admission, the patient denied any fever or chills prior to admission, and denied any chest pain or shortness of breath. PAST MEDICAL HISTORY: 1. Hypertension. 2. Congestive heart failure (echocardiogram [**2172-12-30**] revealed mild aortic stenosis, mild mitral regurgitation, left ventricular dilatation, left ventricular ejection fraction less than 25%, diffuse hypokinesis, decreased right ventricular ejection fraction). 3. Status post cholecystectomy. 4. Coronary artery disease. MEDICATIONS ON ADMISSION: Digoxin 0.25 mg p.o.q. Tuesday, Thursday, Saturday and Sunday and 0.125 mg p.o.q.d. Monday, Wednesday, Friday, lisinopril 5 mg p.o.b.i.d., and Protonix. ALLERGIES: Zomax, codeine, sulfa and carvedilol. FAMILY HISTORY: Family history is significant for congestive heart failure and coronary artery disease on the patient's mother's and father's side. SOCIAL HISTORY: The patient is a widow. She denies smoking or alcohol abuse. PHYSICAL EXAMINATION: On physical examination on admission, the patient had a temperature of 99.2, heart rate 70, blood pressure 123/70 and oxygen saturation 98% in room air. General: Patient in no acute distress, speech slurred, patient inattentive with bilateral asterixis and stigmata of liver disease. Head, eyes, ears, nose and throat: Anicteric sclerae, moist mucous membranes. Neck: Positive jugular venous distention, no bruits. Cardiovascular: S1 and S2, III/VI holosystolic, old. Lungs: Bibasilar crackles. Abdomen: Distended with ascites, mild right upper quadrant tenderness. Rectal: Guaiac negative. Extremities: 2+ pitting edema. Neurologic examination: Patient very inattentive, oriented to month only and place, positive asterixis but no focal deficit. HOSPITAL COURSE: The patient had been admitted for weight gain and shakiness and dizziness. She had been found to have ascites in the Emergency Room and, since she appeared encephalopathic, a diagnostic paracentesis was done in the Emergency Room to rule out spontaneous bacterial peritonitis, which did not confirm spontaneous bacterial peritonitis. 1. Gastrointestinal: The patient was admitted and found to have worsening ascites. This had been noted in the past but her weight gain over the period of three weeks had been about 30 pounds. She also noted enlargement of her abdomen. A CT scan of the abdomen was performed to rule out venous thrombosis, which was negative. Her liver appeared cirrhotic on CT scan, with ascitic fluid, which was increased in the amount in comparison with previous CT scan of the abdomen several months ago. The patient received a prophylactic dose of ciprofloxacin after admission for spontaneous bacterial peritonitis but, since she remained without signs of infection, this was discontinued. She was worked up for etiology of liver cirrhosis. She denied alcohol use, which would be the most common cause. She had previously had hepatitis C and B serologies were negative. These were repeated during this hospital course and also turned out to be negative. The patient was seen by the liver service, who recommended workup for cirrhosis, including her hepatitis serologies, which were negative. The majority of the tests for her cirrhosis were still pending at the time of dictation. A liver biopsy and esophagogastroduodenoscopy were not indicated at this time. She was started on Aldactone and her dose of Lasix had been increased to help with the ascites. The patient had a therapeutic paracentesis with removal of three liters of fluid, with improvement of her weight. On [**2175-1-8**], the day of tentative discharge, the patient developed abdominal discomfort and her weight increased by several pounds. Clinically, there was worsening of the size of the ascites and the decision was made to retap her abdomen. On Monday, [**2175-1-9**], the patient had a repeat paracentesis with 3,800 cc of peritoneal fluid was taken off with subsequent receiving of albumin. She was doing very well after the tap and had no abdominal discomfort. The liver service recommended increasing the dose of diuretics, Aldactone 200 mg daily and Lasix 40 mg daily. It was felt that the patient will need a repeat paracentesis in the future and a follow-up appointment was scheduled for mid-[**Month (only) 404**] by the liver service. In the meantime, her electrolytes should be checked on a regular basis, at least once a week. 2. Cardiovascular: The patient has known dilated cardiomyopathy. She ruled out for a myocardial infarction. A repeat echocardiogram was performed, which was unchanged from the previous study. It was felt that her ascites is mainly related to liver cirrhosis rather than congestive heart failure. The patient was diuresis but, on hospital day number four, after increasing her diuretic doses and after a therapeutic paracentesis, she became hypotensive and required an overnight Medical Intensive Care Unit stay. During the hypotension, she was lethargic and felt lightheaded. It was felt that the reason for her hypotension is most likely due to fluid shift, and she responded well to fluid boluses and did not require any pressors. Since then, she remained with a low systolic blood pressure in the range of 70 to 110/palpable to 50. She, however remained very stable and was not symptomatic. Her diuretic doses were decreased and the patient had been doing well. 3. Encephalopathy: Initially, the patient was admitted with encephalopathy, but improved after starting lactulose. 4. Laboratory data: White blood cell count 6.2, hematocrit 33, hemoglobin 10.9, platelet count 119,000, glucose 79, sodium 133, potassium 4.5, chloride 102, bicarbonate 27, BUN 24, creatinine 0.7, calcium 7.7, phosphorous 3.7, INR 1.3, alkaline phosphatase 171, amylase 20, lipase 9, ALT 29, AST 50, total bilirubin 0.5 and ammonia 68. DISCHARGE DIAGNOSES: Liver cirrhosis of unclear etiology, status post paracentesis times two. Dilated cardiomyopathy. Congestive heart failure. DISCHARGE MEDICATIONS: Lasix 40 mg p.o.q.d. Aldactone 100 mg p.o.q.d. Trazodone 50 mg p.o.q.d.p.r.n. Lactulose 30 cc p.o.b.i.d. Digoxin 0.125 mg p.o.q. Tuesday, Thursday, Saturday and Sunday and 0.25 mg p.o.q.d. Monday, Wednesday, Friday. Protonix 40 mg p.o.q.d. Darvocet N-100 one p.r.n. pain. DISCHARGE STATUS: The patient will be discharged to a rehabilitation facility in stable condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 6063**] MEDQUIST36 D: [**2175-1-12**] 13:04 T: [**2175-1-14**] 12:29 JOB#: [**Job Number 7889**]

Admission Date: [**2131-2-8**] Discharge Date: [**2131-2-12**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 15247**] Chief Complaint: Decreased hematocrit and generalized fatigue Major Surgical or Invasive Procedure: -EGD on [**2131-2-9**]. -Colonoscopy on [**2131-2-12**]. History of Present Illness: Patient is an 84 year old woman with a past medical history significant for HTN, DMT2, atrial fibrillation on warfarin and normocytic anemia who presented with a hematocrit drop from the mid 30's to 17 at her PCP's office, noted on [**2131-2-8**]. Daughter is present to interpret for this Russian speaking woman. . Patient states that she was in her usual state of health until last Saturday when she states that during a visit to her daughter in [**Name2 (NI) **], she woke up from sleep after sensing someone smoking in the house. The smoke made her vomit once, clear fluid, non-bloody, non-bilious. After that, she states that she felt "weak" all over especially in her legs. She denies any lightheadedness, dizzyness, shortness of breath, chest pain, abdominal pain, or any discomfort. She does have heartburn once a week, but takes no medications. She is chronically constipated requiring enemas. She denies ever looking at her stools, so does not know if her stools have ever been black or red. She denies any history of hemorrhoids. She had a normal sigmoidoscopy in [**2125**], but has never had a colonoscopy. . Per her daughter, patient has been looking more pale and fatigued since last Saturday. In addition to her fatigue, patient has noted high BS for the past few days. Usually BS ranged from 140-190. For past few days, FS 140-290. On the morning of admission, FS 290 and daughter took her to [**Name (NI) 6435**] office. . At PCP's office, BS 349 2 hours postprandial, BP 120/70, pulse 84, temp 98.1. HCT 17. She was guaiac positive, so she was sent to ED. . IN ED, T 96 BP 181/61 69 24 100% RA. INR 2.7, given Vit K SQ 10 mg. NG lavage negative after 100 cc flush. Given Protonix, transfused 2U PRBC, FFP ordered but not given, 1.5 L NS. . . Review of symptoms: No CP, SOB, PND, orthopnea, +ankle swelling as demonstated by not being able to zip up ankle boots. Denies any dysuria or hematuria but notes urinary frequency. No recent changes in meds or diet. No recent infections requiring Abx. She denies any cough or f/c. Past Medical History: 1. Anemia: normocytic, followed by Dr. [**Last Name (STitle) 2148**], receiving aranesp injections, B12 repletion 2. Atrial fibrillation. Continued on chronic anticoagulation with warfarin. Rate is in good range. Has had epistaxis. Usually INR is less than 3 per daughter. 3. Hypertension 4. Hyperlipidemia 5. DM type II: on oral hypoglycemics 6. Decreased hearing 7. Anxiety 8. The patient had declined mammogram 9. Hx of left leg lesion concerning for malignancy-declined derm Social History: She is Russian speaking only and lives completely independently, althought daughter lives close by and is very closely involved. She emigrated in [**2116**] from the [**Location (un) 3156**]. Retired high school chemistry teacher. Widowed 26 years ago. Has 2 children and 3 grandchildren, all of whom are living in the USA. Has never smoked and drinks one glass of alcohol per year. Family History: Mother who died at the age of 75 of causes not known to the patient. Her father died at the age of 73 of a heart attack. No history of bleeding or clotting disorders. Physical Exam: (on transfer to floor): Vitals: BP 177/78, HR 115, RR 19, O2sat: 98% on 2L Gen: Pleasant, well appearing. Laying in bed. HEENT: Slight conjunctival pallor. No icterus. Slightly dry mucous membranes. Oropharynx clear. NECK: Supple. No cervical or supraclavicular lymphadenopathy. JVD estimated at 7cm. No thyromegaly. CV: Irregularly irregular. Normal S1 and S2. No murmurs, rubs or [**Last Name (un) 549**] appreciated. LUNGS: Decreased breath sounds in lower lung fields, bilaterally. Crackles, bilaterally, in lower and middle lung fields. No wheezes or rhonci appreciated. ABD: Normal active bowel sounds in all four quadrants. Soft. Nontender and nondistended. No guarding or rebound. Liver edge not palpated. No splenomegaly appreciated. EXT: Warm and well perfused. No clubbing or cyanosis. 1+ pitting edema bilaterally, in lower extremities. 2+ dorsalis pedis and radial pulses, bilaterally. Pertinent Results: Images: Colonoscopy ([**2131-2-12**]): Diverticulosis of the sigmoid colon. Lipoma in the cecum (biopsy). Will need biopsy follow up. . EGD ([**2131-2-9**]): The ulcer has no stigmata of bleeding. Repeat EGD in 8 weeks for follow up. . EKG ([**2131-2-8**]): Irregularly irregular. Rate at 120. Normal axis. Could not appreciated any ST changes. . Chest Xray ([**2131-2-9**]): Comparison is made to earlier on the same day. Cardiac and mediastinal contours are unchanged. Diffuse interstitial abnormality is not significantly changed. There is right basilar atelectasis and a probable effusion, probably unchanged, allowing for differences in technique. There is no evidence of free air. IMPRESSION: No evidence of free air. Stable appearance of the chest. . Labs: [**2131-2-12**] 07:30AM BLOOD WBC-9.7 RBC-3.21* Hgb-9.4* Hct-28.3* MCV-88 MCH-29.1 MCHC-33.0 RDW-15.4 Plt Ct-464* [**2131-2-12**] 07:30AM BLOOD PT-11.6 PTT-28.1 INR(PT)-1.0 [**2131-2-12**] 07:30AM BLOOD Plt Ct-464* [**2131-2-12**] 07:30AM BLOOD Glucose-162* UreaN-18 Creat-1.5* Na-137 K-4.3 Cl-101 HCO3-19* AnGap-21* [**2131-2-12**] 07:30AM BLOOD Calcium-10.5* Phos-3.3 Mg-2.0 [**2131-2-10**] 05:50AM BLOOD WBC-8.2 RBC-3.22* Hgb-9.3* Hct-27.5* MCV-85 MCH-28.9 MCHC-33.9 RDW-15.4 Plt Ct-427 [**2131-2-9**] 06:08AM BLOOD WBC-7.9 RBC-3.04* Hgb-8.8* Hct-25.8* MCV-85 MCH-28.9 MCHC-34.1 RDW-15.9* Plt Ct-390 [**2131-2-8**] 02:20PM BLOOD WBC-8.0 RBC-2.26* Hgb-6.3* Hct-20.1* MCV-89 MCH-27.6 MCHC-31.1 RDW-16.4* Plt Ct-432 [**2131-2-8**] 11:50AM BLOOD WBC-7.5 RBC-2.07*# Hgb-5.9*# Hct-17.8*# MCV-86 MCH-28.3 MCHC-32.9 RDW-16.7* Plt Ct-424 [**2131-2-8**] 02:20PM BLOOD Neuts-64.5 Lymphs-25.6 Monos-5.3 Eos-3.9 Baso-0.6 [**2131-2-10**] 05:50AM BLOOD Plt Ct-427 [**2131-2-9**] 06:08AM BLOOD Plt Ct-390 [**2131-2-9**] 06:08AM BLOOD PT-18.5* PTT-29.4 INR(PT)-1.7* [**2131-2-8**] 11:50AM BLOOD Plt Ct-424 [**2131-2-8**] 11:50AM BLOOD PT-26.6* INR(PT)-2.7* [**2131-2-10**] 05:50AM BLOOD Glucose-160* UreaN-14 Creat-1.1 Na-140 K-4.1 Cl-103 HCO3-22 AnGap-19 [**2131-2-8**] 11:50AM BLOOD UreaN-29* Creat-1.2* Na-130* K-4.3 Cl-99 HCO3-22 AnGap-13 [**2131-2-9**] 12:53PM BLOOD CK(CPK)-73 [**2131-2-8**] 09:55PM BLOOD ALT-13 AST-13 AlkPhos-74 Amylase-75 TotBili-0.7 [**2131-2-8**] 11:50AM BLOOD LD(LDH)-155 [**2131-2-8**] 02:00PM BLOOD ALT-13 AST-22 CK(CPK)-96 AlkPhos-85 Amylase-66 TotBili-0.2 [**2131-2-8**] 02:00PM BLOOD Lipase-82* [**2131-2-9**] 12:53PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2131-2-10**] 05:50AM BLOOD Calcium-10.2 Phos-2.9 Mg-1.9 [**2131-2-8**] 11:50AM BLOOD calTIBC-399 VitB12-979* Folate-5.9 Hapto-144 Ferritn-24 TRF-307 [**2131-2-8**] 10:03PM BLOOD %HbA1c-9.1* [Hgb]-DONE [A1c]-DONE [**2131-2-9**] 12:53PM BLOOD PTH-155* [**2131-2-9**] 12:53PM BLOOD PEP-PND . MICRO: Urine culture ([**2131-2-8**]): <10,000. . H. pylori Ab ([**2131-2-9**]): Positive. . Legionella ([**2131-2-11**]): Pending. Brief Hospital Course: Hospital Course/Assessment and Plan: Patient is an 84 year old female with a history of atrial fibrillation, normocytic anemia, diabetes and hypertension who presented with weakness and a hematocrit drop from the mid 30's to 17. Patient's INR elevated, guaiac postive, but EGD negative. Received two units of packed red cells and FFP and guaiac positive. . . 1) GI bleed: Patient initially found to be guaiac positive. INR 2.7 NG lavage negative. Patient received one unit of FFP and 2 units of packed red blood cells and hematocrit demonstrated appropriate increase. Initially monitored in the MICU. EGD on [**2-9**] did not demonstrate any active bleeds. Biopsy performed of gastric ulcers. Pathology results pending. Colonoscopy did not reveal any active bleeding lesions. Biopsy results pending. -Hematocrit stable at 28.3. On admission, hematocrit 17. -H. pylori positive. Placed on omeprazole 20 [**Hospital1 **], amoxicillin 500mg [**Hospital1 **], clarithromycin 500bid for ten days. After ten days, will switch to omeprazole 20mg qd. -Restarted coumadin upon discharge, with goal INR between 2 and 3. Will instruct patient to have INR and hematocrit levels to be measured by VNA. -GI recommends capsule endoscopy as outpatient in the week after discharge. Provided phone number for patient's family to arrange. Follow up EGD and potential colonoscopy in eight weeks. To be arranged by PCP. . 2) Anemia: Patient has history of normocytic anemia. Believed to be component of iron deficiency as well as B12 deficiency and is followed by Dr. [**Last Name (STitle) 2148**]. Haptoglobin 144, ferritin 24, TRF 307, TIBC 399. Folate 5.9 and B12 971. Continued on iron replacement and B12 replacement. -Scheduled for aranesp injection with Dr. [**Last Name (STitle) 2148**] on [**2131-2-15**]. Follow up appointments with Dr. [**Last Name (STitle) 2148**] on [**2131-2-28**]. . 3) Diabetes Type II: Patient's hemoglobin A1c 9.1. Blood sugar levels have been slightly elevated lately, with some glucosuria on UA. - Continued on insulin sliding scale. Restart home oral hypoglycemics. Consider increasing dose as outpatient if blood glucose levels elevated. . 4) Atrial fibrillation: Initially, well rate controlled in the 80s. Held diltiazem as concern that patient couldn't mount an adequate compensatory response if decreased volume from GI bleed. Held coumadin dose, initially, due to concern for GI bleed. Patient's rate on transfer in the low 100's. Received 10 mg IV and 60mg PO diltiazem. [**Hospital **] transfer to floor, elevated heart rate to 140's. Discharged home on home diltiazem dose of 360qd. . 5) Crackles on examination: No evidence of consolidation. Slight pulmonary edema. Will cautiously try to diurese fluid, now that perceived to be hemodynamically stable. Restarted lasix on home dose of 20qAM. . 6) Questionable Hyperparathyroidism: Patient with elevated PTH (155), in setting of elevated calcium. UPep, SPep, and vitD 1,25 levels sent. Pending. Consider outpatient follow-up. 7) Hypertension: Initially, blood pressure medications held, in setting of GI bleed. Restarted and tolerated well. . 8) Prophylaxis: Placed on PPI, [**Hospital1 **]. On discharge, omeprazole, amoxicillin, and clarithromycin for ten days. -Will hold fosamax until appointment with PCP [**Last Name (NamePattern4) **] [**2131-2-19**]. Discontinued Foley on [**2131-2-10**]. . 9) CODE: FULL. Confirmed with patient and daughter. Medications on Admission: Cardizem CD 360 QD Clonidine 0.2 mg [**Hospital1 **] cyanocobalmin SQ QWk Fosamax 70 Qwk Furosemide 20 QAM Glyburide 5 QAM, 10 QPM Lipitor 10 QD Lisinopril 40 QD Lorazepam 0.5 QD Metformin 850 QAM, 1000 QPM MVT SLNTG B12 1000 mcg QD Coumadin 2.5 QD Discharge Medications: 1. Cardizem CD 360 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 2. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection once a week. 4. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week: HOLD UNTIL YOUR NEXT APPOINTMENT WITH DR. [**First Name (STitle) **]. 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 7. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Metformin 850 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 12. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 13. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 15. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Outpatient Lab Work Draw hematocrit and INR levels. Please fax to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) **]. 17. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days. Disp:*20 Capsule(s)* Refills:*0* 18. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* 19. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day for 10 days: Take twice a day for ten days. After ten days, take one pill once a day. Disp:*20 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 20. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family Services Discharge Diagnosis: Primary: -GI bleed -Atrial fibrillation . Secondary: -Anemia: normocytic, followed by Dr. [**Last Name (STitle) 2148**], receiving aranesp injections, B12 repletion -Hypertension -Hyperlipidemia -DM type II: on oral hypoglycemics -Decreased hearing -Anxiety Discharge Condition: Stable. Discharge Instructions: -You were admitted for generalized weakness. In your PCP's office, you were noted to have a decreased hematocrit. In the hospital, you had an EGD and colonoscopy that were negative for an acute bleed. -You received several units of blood and your blood levels have remained stable. -You have an appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) **]), on Monday, [**2131-2-19**] at 11:50AM. You will need Dr. [**First Name (STitle) **] to schedule a repeat EGD and colonoscopy in 8 weeks. -In addition, you need to call [**Telephone/Fax (1) 94127**] in the next two days to schedule a capsule endoscopy study. -You are to continue on all medications prescribed upon discharge. Several new medications, omeprazole, amoxicillin, and clarithromycin, have been started. Prescriptions have been provided. You will NOT take the fosamax until you see Dr. [**First Name (STitle) **]. -In addition, you have an appointment with Dr. [**Last Name (STitle) 2148**] on Thursday, [**2131-2-15**] at 10AM for an injection of aranesp. Another appointment with DR. [**Last Name (STitle) 2148**] will occur on Wednesday, [**2131-2-28**] at 4:30PM. -You need to continue to have your coumadin levels measured. -If you experience any bloody stools, vomiting, weakness, lightheadedness, or any other concerning symptoms, please call your PCP or go to the ED immediately. Followup Instructions: -You have an appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) **]), on Monday, [**2131-2-19**] at 11:50AM. You will need Dr. [**First Name (STitle) **] to schedule a repeat EGD and colonoscopy in 8 weeks. -You need to continue to have your coumadin levels monitored. Have the results faxed to Dr.[**Name (NI) 17003**] office ([**Telephone/Fax (1) **]). -You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2148**] on Thursday, [**2131-2-15**] at 10AM and Wednesday, [**2131-2-28**] at 4:30PM. His office is located at [**Last Name (NamePattern1) 439**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 15248**]

Admission Date: [**2106-8-9**] Discharge Date: [**2106-8-23**] Date of Birth: [**2047-9-9**] Sex: M Service: MEDICINE Allergies: Compazine / Codeine / Atenolol Attending:[**First Name3 (LF) 2932**] Chief Complaint: CC:[**CC Contact Info 10965**] Major Surgical or Invasive Procedure: Lumbar Puncture History of Present Illness: This is a 58 YOM with PMHx significant for HTN, PE/DVT (s/p IVC filter), IVDA,and Hep B/C who presents with N/V, headache, blurry vision, sob, and chest pain. He normally takes clonidine 0.2mg po tid, lisinopril 40 mg po qd, and hydralazine 25 mg po tid but has not taken his medications in 3 days. In the ED his initital BP was 183/114 with HR 92. He stated his usually SBP is around 180. He was symtomatic with this pressure so his home meds were restarted and he was also started on a nitropruside drip. BP then controled to range SBP 160s with resolution of symptoms. Past Medical History: normal P-MIBI [**6-28**], normal EF on echo [**3-29**] - PE: s/p IVC filter, recent CTA [**2106-5-2**] negative for PE - Heroin abuse: methadone maintenance clinic Habit Management; per pt, quit 20 yrs ago - Hepatitis B previous infection, now sAg negative - Hepatitis C, undetectable HCV RNA [**3-29**] - Malignant Hypertension - COPD - Gastroesophageal reflux disease - Post traumatic stress disorder - Anxiety / Depression - antisocial personality disorder with several psychiatric hospitalizations - Microcytic Anemia baseline 27 - Vit B12 deficiency Social History: He lives in [**Location 4288**] with his wife. [**Name (NI) **] WAS enrolled in the methadone clinic at Habit Management ([**Telephone/Fax (1) 10948**] and denies ongoing IV opioid abuse. Was making "fentanyl tea" up until recently (ie, taking fentanyl patches he got on the street, squeezing the liquid, and putting in water). Was also using methadone he got on the street. Also claims that he has not had alcohol 30+ years. Admits to tobacco use ([**1-25**] ppd). No children. Family History: NC Physical Exam: Vitals: T:98.7 P:95 BP: 180/97R: 12 SaO2:98% on 2LNC General: Awake, alert. Lying with eyes closed. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP. Poor dentition. Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally Cardiac: Tachy. RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: No deficits to light touch throughout. Pertinent Results: Laboratory studies on admission: [**2106-8-9**] 12:00PM WBC-5.2 RBC-4.45* HGB-11.5* HCT-33.3* MCV-75* MCH-25.9* MCHC-34.6 RDW-15.2 [**2106-8-9**] 12:00PM NEUTS-74.8* LYMPHS-20.8 MONOS-2.0 EOS-1.4 BASOS-0.9 [**2106-8-9**] 12:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2106-8-9**] 12:00PM CALCIUM-10.2 PHOSPHATE-3.6 MAGNESIUM-1.8 [**2106-8-9**] 12:00PM GLUCOSE-103 UREA N-17 CREAT-1.2 SODIUM-144 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-23 ANION GAP-18 [**2106-8-9**] 12:00PM ALT(SGPT)-9 AST(SGOT)-20 LD(LDH)-208 ALK PHOS-97 TOT BILI-0.4 [**2106-8-9**] 12:00PM CK(CPK)-97 [**2106-8-9**] 12:00PM cTropnT-<0.01 [**2106-8-15**] 04:54PM CEREBROSPINAL FLUID (CSF) TotProt-51* Glucose-68 [**2106-8-15**] 04:54PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0 Lymphs-78 Monos-22 CSF GRAM STAIN (Final [**2106-8-15**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2106-8-18**]): NO GROWTH. . CT Head IMPRESSION: No intracranial hemorrhage or mass effect is identified. This study cannot exclude an acute ischemic process, especially in the posterior fossa, and if there is clinical concern for this issue, further evaluation with an MRI/MRA with diffusion- weighted imaging should be obtained. . MRI/A Abdomen IMPRESSION: Normal renal MRA. Simple cysts in right kidney, no focal lesions. No change in high signal in posterior segment of right liver, which at that time was thought to represent post-biopsy change. . MRI Head: F Fidings: There is miminal periventricular hyperintensity of the white matter adjacent to the right frontal [**Doctor Last Name 534**]. There is opacification of the right frontal sinus. Otherwise the study is normal. There is no evidence of hemorrhage, edema, masses, mass effect, or infarction. However, no diffusion images were performed. If there is a concern of venous ischemia, a repeat MR should be performed to obtain diffusion images. The MRV demonstrates a normal appearance of the dural sinuses. The inferior sagittal sinus is not seen, but this may be a normal observation on MRV. . MRI C-spine: IMPRESSION: No abnormally enhancing lesions of the cervical spine. Mild degenerative changes of the cervical spine as described above. . Brief Hospital Course: 1) Hypertension: In the ED, he was started on a Nitroprusside drip with resolution of his symptoms. He had no ECG changes and ruled out for MI. Initially he was restarted on his home dose of Lisinopril 40; Clonidine .3 mg patches (2 qwk) along with HCTZ and Norvasc were also started. On the floor, the patient expressed a strong desire to get off the patches and back on to Clonidine pills--despite excellent BP control. He stated, "I'll forget to change the patch but I won't forget my pills". During his admission, Clonidine patches were slowly weaned off and his pills restarted. The patient had problems with intermittent hypotension secondary to starting of methadone while in house (see below). On the day of discharge, his blood pressure was stable on clonidine 0.1 mg PO TID. He will follow-up with his PCP as an outpatient Regarding secondary causes for his hypertension, MRI of Kidneys were negative for RAS. His TSH was normal. He did not have any stigmata of Cushings Disease and random AM cortisol normal. His primary care doctor can consider further workup of Pheochromacytoma or Hyperaldosteronism as an outpatient. 2) Headache: Thought to be a combination of clonidine/narcotic withdrawl, along with hypertensive emergency. Had numerous studies to evaluate the headache including: Head CT (negative for bleed), head MRI (negative for stroke, mass), LP (CSF not c/w meningitis), MRI C-spine (negative), CRP wnl (making temporal arteritis unlikely. His headache had resolved at the time of discharge, and he was advised to follow-up with neurology as an outpatient. 3) Opioid Abuse: The patient stated he was using methadone he got on the streets. He was also making "fetanyl tea" as described in the social history. He was started on methadone as there was concern of ?opioid withdrawl contributing to his headaches. He was seen by the addiction service and will follow-up with a methadone clinic as an outpatient. At the time of discharge, he was on methadone 30 mg PO qAM and 40 mg PO qPM. 4) Gait disorder: Despite being "ataxic" while being walked by PT, he had several completely normal neuro exams. He was slightly orthostatic, which was felt to be due to his methadone. Of note, several nurses documented that patient being completely independant to the kitchen and bathroom. 5) Microcytic Anemia: indicies normal, including B12, Fe studies. Given h/o microcytic anemia, Hemoglobin electrophoresis was sent, which is currently pending at time of discharge. Medications on Admission: 1. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Methadone 10 mg/mL Concentrate Sig: One (1) PO QAM (once a day (in the morning)). 8. Methadone 10 mg/mL Concentrate Sig: One (1) PO QPM (once a day (in the evening)). 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO four times a day. 10. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day) for 2 days. Disp:*1 bottle* Refills:*0* 11. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* Discharge Medications: 1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*42 Tablet(s)* Refills:*0* 6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Methadone 10 mg Tablet Sig: Three (3) Tablet PO qAM: and 40 mg qhs. 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Hypertensive Urgency/Emergency: likely [**2-25**] Clonidine withdrawl 2. Headache due to above 3. Microcytic Anemia 4. Opioid dependance Secondary Diagnoses: 1. h/o Hepatitis C 2. h/o Pulmonary Embolism s/p IVC filter 3. GERD 4. Anxiety/Depression 5. h/o COPD Discharge Condition: stable Discharge Instructions: Please contact your primary care provider should you have any worsening headache, fevers, chills, sweats, dizziness while standing, difficulty walking, or any other serious complaints. Followup Instructions: Please see Dr. [**Last Name (STitle) 3357**] ([**Telephone/Fax (1) 4606**]) within the next 1-2 weeks on [**9-2**] 3:45 p.m.. You should speak to him about obtaining blood tests to rule out a 'pheochromacytoma' and 'hyperaldosteronism' as well as having a colonoscopy. In addition, to follow up on your headache, please call to make an appointment with Neurology. The number is ([**Telephone/Fax (1) 2528**]. Please follow-up with the methadone clinic as scheduled. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**] Completed by:[**2106-8-23**]

Admission Date: [**2102-7-9**] Discharge Date: [**2102-7-14**] Date of Birth: [**2026-3-27**] Sex: M Service: MEDICINE Allergies: Keflex Attending:[**First Name3 (LF) 2751**] Chief Complaint: petechiae Major Surgical or Invasive Procedure: None History of Present Illness: 76 yo man with DM, HTN, PVD s/p left toe amputation and L iliac stent in [**4-/2102**] c/b large RP bleed, prostate cancer s/p prostatectomy, hx of prior DVT ([**3-/2102**] [**Name8 (MD) **] MD report) on coumadin and chronic left foot wound who presented to [**Hospital1 18**] with petechia/bruising x 1 day in setting of starting keflex at rehab and was found to have profound TP and anemia. . He was admitted to the floor o/n, with normal BPs and HR in 100s, and was found to have continuing dropping HCT 29 on admission -> 23 -> 1UPRBC -> 19.9 in setting of severe thrombocytopenia. Initial evaluation in the ED for DIC was negative (see hematology note) and he was felt to have either drug induced TP, ITP or HIT (no evidence of thromboses). He was started on Prednisone 50mg given 4U FFP and 5mg Vit K to reverse the INR (3.7->2.0). This morning, HCT continued to drop as above despite PRBC transfusions, he is thus being transferred to MICU for further care. Of note, he has had guaiac positive stools but no melena or hematochezia. Per discussion with patient and Admission notes, he was in USOH at rehab until AM of admission, when he noticed small red dots all over his legs, which proliferated through the day. He also noted slight bleeding from his mouth/lips. He was initially taken [**Hospital 8125**] Hospital, then transferred to [**Hospital1 18**] for further evaluation. . "Recent medication changes include recent initiation of Keflex (for leg ulcer) which was started on [**7-7**]. Further, heparin was DCd on [**6-23**]. Otherwise he denies any recent sick contacts. [**Name (NI) **] exposure to ticks or recent bug bites." . At time of MICU resident evaluation, he had no complaints, other than wanting to go home. Denied pain, blood stools, hemoptysis, abodminal distension. He did not feel he was confused, but could not perform calculations or attention tasks. He has no HA, vision changes, numbness, but states that Right leg has had different sensation over the past few weeks. Per ROS on admission: refer to admission note. . "In the ED initial vitals, Temp: Not recorded, 91 120/74 18 94. Heme/Onc and vascular consults were obtained. Vascular was asked to evalute the lower extremity ulcer for possible osteomyeleitis and intervention - found pulses palpable with doppler, recommended non invasive lower extremity studies and antibiotics (Vanc, Cipro, Flagyl). Heme reviewed peripheral smear which did not reveal schistocytes and thought this to be secondary to drug reaction or ITP and advised to wait on transfusing plt, reverse INR, and start prednisone 50mg Daily." Past Medical History: -DM: diet-controlled, not insulin-dependent -chronic L foot ulcer (per OSH records, cx'ed Pseudomonas and MRSA on [**6-30**]: PA sensitive to cefepime and amikacin; MRSA sensitive to Bactrim, gent, vanc, rifampin) -HTN -CAD: [**3-/2102**] MIBI from OSH showed 53% EF, small inferior scar w/ minimal peri-infarct ischemia -PVD sp left toe ([**1-3**]) amputation ([**2102-4-29**] - [**Hospital3 **]), s/p L -iliac stent c/b RP bleed while on AC. -Prostate cancer sp prostatectomy ([**2056**]) - ? Hx of prior DVT, ? on coumadin for this though no documentation of DVT at OSH records. -Chronic Left Foot Wound -AAA < 3cm, intra-abdominal -ischemic colitis [**2095**] -HL -carries a diagnosis of mild dementia (per son no dementia, since starting dilaudid has seen the changes). Social History: Was at rehab. Used to work as a photographer. Widowed last [**Month (only) **]. - Tobacco: 10 cigs/day - Alcohol: denies. - Illicits: denies. Family History: NC. Physical Exam: General: Alert, oriented, inattentive. HEENT: Sclera anicteric, dMM, palatal petechiae, tobacco stain on mustache Neck: supple, no JVD. no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RR, normal S1 + S2, [**2-4**] SM at 2RICS. Abdomen: soft, non-tender, non-distended, bowel sounds present, no splenomegaly Ext: warm, dry, well perfused on R. Left foot dressed. Petechiae throughout, predominantly in LEs, but also on abdomen, chest arms and face. Pertinent Results: Admission lab results: [**2102-7-9**] 08:20PM RET AUT-1.4 [**2102-7-9**] 08:20PM FIBRINOGE-481* [**2102-7-9**] 08:20PM PT-35.6* PTT-31.5 INR(PT)-3.7* [**2102-7-9**] 08:20PM PLT SMR-RARE PLT COUNT-<5* [**2102-7-9**] 08:20PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BITE-OCCASIONAL [**2102-7-9**] 08:20PM NEUTS-76.1* LYMPHS-16.7* MONOS-4.9 EOS-1.6 BASOS-0.6 [**2102-7-9**] 08:20PM WBC-13.1* RBC-3.22* HGB-9.9* HCT-28.9* MCV-90 MCH-30.9 MCHC-34.4 RDW-14.2 [**2102-7-9**] 08:20PM HAPTOGLOB-214* [**2102-7-9**] 10:54PM D-DIMER-550* Platelet levels: [**2102-7-9**] 08:20PM BLOOD Plt Smr-RARE Plt Ct-<5* [**2102-7-10**] 11:21AM BLOOD Plt Smr-RARE Plt Ct-5* [**2102-7-10**] 01:35PM BLOOD Plt Ct-99*# [**2102-7-10**] 03:19PM BLOOD Plt Ct-78* [**2102-7-10**] 08:28PM BLOOD Plt Ct-81* [**2102-7-11**] 01:27AM BLOOD Plt Ct-62* [**2102-7-11**] 09:30PM BLOOD Plt Ct-49* [**2102-7-12**] 12:16AM BLOOD Plt Ct-90*# [**2102-7-12**] 08:27AM BLOOD Plt Ct-110* [**2102-7-12**] 10:25PM BLOOD Plt Ct-86* [**2102-7-13**] 06:04AM BLOOD Plt Ct-97* [**2102-7-14**] 01:15AM BLOOD Plt Ct-159# [**2102-7-14**] 05:43AM BLOOD Plt Ct-223 Lab results at discharge: [**2102-7-14**] 05:43AM BLOOD WBC-13.9* RBC-3.61* Hgb-10.8* Hct-31.6* MCV-88 MCH-29.8 MCHC-34.0 RDW-16.1* Plt Ct-223 [**2102-7-14**] 05:43AM BLOOD Glucose-107* UreaN-22* Creat-0.8 Na-142 K-3.9 Cl-107 HCO3-30 AnGap-9 [**2102-7-14**] 05:43AM BLOOD Calcium-9.6 Phos-3.0 Mg-2.1 CT Abdomen and Pelvis from [**2102-7-9**]: IMPRESSION 1. Moderate sized retroperitoneal hematoma involving the right psoas and iliopsoas muscle. An additional fluid collection within the retroperitoneum abutting the transversalis muscle on the right also likely represents a separate site of hematoma given the clinical history. 2. 3-cm infrarenal abdominal aortic aneurysm. No evidence of active bleeding. 3. Small right pleural effusion. Scattered centrilobular nodules, tree-in-[**Male First Name (un) 239**] opacities, and mild bronchial wall thickening all suggestive of underlying infectious bronchiolitis, possibly aspiration related. Given size and appearance a followup CT in three to six months can be obtained to document resolution after appropriate treatment. 4. Prominent pancreatic duct and common bile duct with no obstructive mass lesions seen. While this may reflect underlying ampullary stenosis, differential diagnostic considerations for the dilated pancreatic duct includes main branch IPMT. If alteration in care will occur, can consider correlation with MRCP or ERCP. 5. Left adrenal adenoma. Moderate-to-severe sigmoid diverticulosis with no findings of acute diverticulitis. 6. Probable Paget's disease of left iliac [**Doctor First Name 362**]. [**2102-7-14**] 05:43AM BLOOD WBC-13.9* RBC-3.61* Hgb-10.8* Hct-31.6* MCV-88 MCH-29.8 MCHC-34.0 RDW-16.1* Plt Ct-223 [**2102-7-14**] 01:15AM BLOOD WBC-15.2* RBC-3.56* Hgb-10.9* Hct-30.7* MCV-86 MCH-30.7 MCHC-35.6* RDW-16.1* Plt Ct-159# [**2102-7-13**] 06:04AM BLOOD WBC-13.5* RBC-3.41* Hgb-10.5* Hct-29.5* MCV-86 MCH-30.8 MCHC-35.6* RDW-15.9* Plt Ct-97* [**2102-7-14**] 05:43AM BLOOD Glucose-107* UreaN-22* Creat-0.8 Na-142 K-3.9 Cl-107 HCO3-30 AnGap-9 Brief Hospital Course: # RETROPERITONEAL BLEED (RP BLEED), SPONTANEOUS The patient came in with a low hematocrit around 30, from a previous level of 41. Upon admission to the floor, the patient's Hct dropped from 28.9 to 23.3 on [**2102-7-10**]. The patient was noted to have a severe, normocytic anemia. There was no evidence of hemolysis: per Heme, no sign of hemolysis on smear, labs not suggestive of hemolysis. Aspirin and coumadin were held and the patient was given vitamin K and fresh frozen plasma. A CT scan on [**2102-7-10**] showed a large fluid collection in the right transversalis muscle measuring 6.9 cm (AP) x 3.4 cm (transverse) x 13.1 cm (CC), most consistent with a retroperitoneal hematoma. He was seen by vascular surgery, who given his hemodynamic stability, felt that he should be managed conservatively. His retic was 1.4, an inappropriately low response in setting of a severe anemia, implicating involvement of the BM. The patient was transfused 2 units of pRBC on [**2102-7-11**] with an appropriate bump in Hct to 28.2. The patient's Hct remained stable subsequently without need for further transfusion. # THROMBOCYTOPENIA, ACUTE: The patient arrived with severe thrombocytopenia, with a plt count less than 5K. There was no evidence of DIC. The differential included ITP and drug-induced thrombocytopenia. The patient was started on prednisone 100 MG daily. A Coomb's test was negative. The HIT Ab came out as being mildly positive (patient had Hx of hep on [**6-27**] at rehab), but the likelihood of having HIT was deemdd low. Per consult with hematology, the picture was inconsistent with HIT, as platelet levels hardly ever go below 20-30K. The patient was transfused with a goal plt count of > 50. He received one unit of platelets on [**7-11**] with a bump in platelet levels to 91K. His platelet response afterwards was robust, with his platelets increasing to 226K on discharge. It is unclear whether he had ITP or drug-induced thrombocytopenia. He should avoid Keflex, other cephalosporins and, likely, other beta-lactams unless he is in a highly supervised setting, in case this is a drug reaction. He should taper off prednisone slowly under the care of a hematologist (being set-up at this time), with 60mg of prednisone daily for 2 weeks and decreasing slowly afterwards, in case this is ITP. He recevied the pneumovax and meningococcal vaccines. An HIV test was negative. # Coagulopathy: The patient was found to have an elevated INR to 3.7 upon admission. Per history from an outside surgeon, the patient was on coumadin for a presumed, acute occlusion of the left foot that led to ulcerations. The coumadin was held in the ED, and the patient was given 4 units of FFP and was reversed with vitamin K (5MG). The INR drifted downwards during admission, and eventually reached 1.1 by the time he was called out to the floor. Per discussion with outside surgeon, the coumadin was to be held until further evaluation for the need of anticoagulation. This discussion should be re-evaluated by his primary care doctor or his surgeons at [**Hospital6 33**]. # PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA remity Ulcer: S/p amputation of toes [**1-3**]. Pulses dopplerable as noted by Vascular. Vascular surgery saw patient and said there was no operative management necessary. There was no evidence of osteo on XR. Clinically does not appear to have osteo. Foot ulcer grew Pseudomonas and MRSA on [**6-30**]. Podiatry also followed the patient and started the patient on wet to dry dressings. Pain was the most pressing issue regarding his condition, and was addressed with fentanyl patch, gabapentin, and prn dilaudid. The patient's fentanyl was increased from 50 mcg Q72 hours to 75 mcg. Dilaudid prn was also required for dressing changes (PO 4mg Q4hrs PRN). Coumadin was discontinued. Aspirin was restarted prior to discharge. # CAD/HTN. The patient has been normotensive throughout hospital stay. EF 50-55% at OSH ~ 2mo ago. Has hypokinesis of basal inferolateral flow on echo in [**Month (only) 547**]. Betablockade and aspirin are continued. Zocor was continued. #. DM: at home, diet-controlled and on Metformin. Holding Metformin while in the unit. Fingersticks from 100-200. On a diabetic diet. Metformin restarted on discharge. Medications on Admission: Liquid Antacid 30ml PO q4H PRN Dyspepsia Bisacodyl 10mg Suppository PR PRN constipation Milk of Magnesia 30ml PO daily PRN Constipation Dilaudid 8 mg PO Q3H PRN pain Imodium 2mg PO Q6H PRN loose stool Miralax 17 grams mixed with 8 ounces fluid PO dialy Fentanyl Patch (50 mcg) apply one patch Q 72hours Alprazolam PO four times daily Acetaminophen 325 2 tabs PO prn pain or increased temperature Keflex 500mg 4 times daily - started [**7-7**] Heparin 5000U TID - stopped [**6-24**] Metformin 500 mg PO daily Lasix 40mg Daily Omeprazole 20mg Daily Zocor 20mg one tab daily at bedtime ASA 81mg Daily Multivitamin one tab daily Neurontin 300mg TID Atenolol 50mg Daily Coumadin 5mg Daily Discharge Medications: 1. Liquid Antacid 200-200-20 mg/5 mL Suspension Sig: Thirty (30) mL PO every four (4) hours as needed for heartburn. 2. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 3. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO once a day as needed for constipation. 4. Dilaudid 8 mg Tablet Sig: One (1) Tablet PO q3 as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 5. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for loose stool. 6. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day. 7. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. Disp:*10 patches* Refills:*0* 8. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety: Dosage unclear on transfer to [**Hospital1 18**]. Not given in hospital. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO PRN as needed for fever or pain. 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 15. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 16. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 17. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 18. Prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 31006**] of [**Location (un) **] Discharge Diagnosis: Primary: Thrombocytopenia, retroperitoneal bleed, anemia, left foot wound Secondary: Diabetes mellitus, hypertension, peripheral vascular disease 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: Dear Mr. [**Known lastname **], It was a pleasure taking care of you during your hospitalizaton. You were admitted with very low platelets and a low blood count. It was determined that you were bleeding into your back. You were transferred to the Medical Intensive Care Unit and treated by getting blood and platelet transfusions. Your blood count stabilized and your platelet count returned to a normal level, and you were transferred back to the regular floor. It was thought that the low platelets were related either to an antibiotic you received, Keflex, or to a condition called ITP, where the immune system attacks its own platelets. We stopped the Keflex and you were started on steroids, which can help treat ITP. We discharged you on a steroid taper. It is very important that you follow up with your doctors at rehab and the Hematologist as you need to have your blood counts followed. You were also found to have blood in your stool, so you should have a colonoscopy as an outpatient. You should follow up with your primary care doctor regarding this. We stopped on of your blood thinners, Coumadin, because you had a large bleed. Please talk to your surgeon and primary care doctor about whether you should restart the Coumadin. Followup Instructions: You will be seen by the doctors at rehab Department: Hematology Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58397**] Time: Friday, [**7-21**] at 8:30am Location: [**Hospital3 328**], [**Location (un) 936**], MA Phone: [**Telephone/Fax (1) 85183**] Completed by:[**2102-7-16**]

Admission Date: [**2167-8-27**] Discharge Date: [**2167-9-2**] Date of Birth: [**2092-2-10**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 75 year-old female who was initially admitted to the Coronary Care Unit and then transferred to the [**Hospital Unit Name 196**] Service. She has a history of chronic atrial fibrillation, congestive heart failure, mitral regurgitation, hypertension, BOOP and status post recent left hip fracture repair. The patient presented with persistent worsening of shortness of breath. In the Emergency Department the patient was noted to be in rapid atrial fibrillation and congestive heart failure. After a CTA to rule out PE was done the patient at that time developed worsening hypoxia and was transiently on BiPAP and went to the Coronary Care Unit. After she was appropriately rate controlled and diuresed the patient was transferred to the floor for further management of her atrial fibrillation. PAST MEDICAL HISTORY: 1. Congestive heart failure EF of 40 to 50% 2. Moderate to severe mitral regurgitation. 3. Hypertension. 4. Chronic atrial fibrillation. 5. BOOP treated with steroids complicated by steroid psychosis. 6. Glaucoma. 7. OSA. 8. History of falls. 9. History of angiopathy. 10. Status post cerebrovascular accident times three. 11. Left hip fracture. ALLERGIES: Prednisone causes psychosis. Tape and Bacitracin MEDICATIONS AS AN OUTPATIENT: 1. Lasix 20. 2. Diltiazem 120 once a day. 3. Lipitor 10 once a day. 4. Coumadin 3 mg alternating with 1.5 mg every other day. 5. Synthroid. 6. Advair. 7. Albuterol. 8. Methazolamide. PHYSICAL EXAMINATION: The patient was afebrile 97.8. Blood pressure 140/70. Heart rate 100. Sating 96% on 2 liters nasal cannula. In general, the patient was calm and in no acute distress. Head and neck examination JVD noted 10 to 11 cm. Heart irregular irregular, rapid heart with a systolic murmur radiating to the apex. Lungs crackles at bases bilaterally. Abdomen soft and nontender. Extremities show 1+ edema bilaterally. LABORATORY: The patient had a hematocrit of 35.2, platelets 385, sodium 140, potassium 3.1, which went to 4.0 with repletion, chloride 101, bicarb 28, BUN 15, creatinine .8, glucose 84. Negative cardiac enzymes. TSH 3.2. Chest x-ray slight improvement in pulmonary edema. More confluent area of opacity in the right upper lobe zone. CTA showed no pulmonary embolism and patchy areas of ground glass opacities. Electrocardiogram on admission showed atrial fibrillation with rapid ventricular response at 151, left axis deviation. HOSPITAL COURSE: The patient was appropriately rate controlled with Diltiazem and Lopressor. The patient was anticoagulated on heparin and sent for AV nodal ablation and pacer placement. The patient tolerated the procedure well and had no further drop in hematocrit and was placed on a three day course of antibiotics with follow up in the device clinic. Shortness of breath, the patient responded well with diuresis with good O2 saturations and saturated well on room air. She is discharged on outpatient Lasix. Urinary tract infection, the patient was found to have a urinary tract infection on admission. Will follow up with course of Levofloxacin. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: Home with services. PRIMARY DIAGNOSIS: Atrial fibrillation status post AV nodal ablation and pacer placement. SECONDARY DIAGNOSIS: 1. Mitral regurgitation. 2. Hypertension. 3. BOOP. 4. Glaucoma. 5. Falls. 6. Angiopathy. 7. Cerebrovascular accident. 8. Left hip fracture. 9. Saphenous vein thrombosis. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg once a day. 2. Levofloxacin 88 micrograms alternating with 100 micrograms once a day. 3. Ipratropium meter dose inhaler. 4. Methazolamide 25 mg twice a day. 5. Bromanantine drops twice a day. 6. Prednisolone drops once a day and twice a day. 7. Coumadin 3 mg once a day, please follow up at PT/[**Hospital 263**] clinic in one week. 8. Promethazine 25 mg q 6 hours as needed for nausea and vomiting. 9. Lisinopril 20 mg once a day. 10. Levofloxacin 500 mg once a day times three days. 11. Protonix 40 mg once a day. 12. Docusate 100 mg twice a day as needed for constipation. 13. Aspirin enteric coated 325 mg once a day. FOLLOW UP PLANS: The patient will follow up with her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 120**], call to schedule an appointment within one week for check for PT/INR. The patient will also follow up at the vice clinic. The patient will have home services, which included skilled nursing, medical social work and physical therapy. The patient was told that if she had any shortness of breath, recurrent nausea, vomiting, chest pain, or other concerning symptoms that she should call her primary care physician or return to the Emergency Department. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Last Name (NamePattern1) 5815**] MEDQUIST36 D: [**2167-9-2**] 04:20 T: [**2167-9-4**] 12:39 JOB#: [**Job Number 5816**]

Admission Date: [**2138-3-31**] Discharge Date: [**2138-4-7**] Date of Birth: [**2072-8-11**] Sex: F Service: NEUROSURGERY Allergies: Cephalosporins / Dulcolax / Advil / Ciprofloxacin / Aromasin / Tape / Xeloda / Doxorubicin / Dexamethasone / Acyclovir / Arimidex / Neurontin Attending:[**First Name3 (LF) 2724**] Chief Complaint: NECK PAIN Major Surgical or Invasive Procedure: PROCEDURES: 1. Posterior segmental instrumentation C2 to C7. 2. Posterior arthrodesis C2 to C7. 3. Local autograft. 4. Tumor resection left C3 lateral mass. 5. Foraminotomy on the left at C4-C5 for weakness of the deltoid. BLOOD TRANSFUSIONS ECHOCARDIOGRAM History of Present Illness: This 65-year-old woman had a history of metastatic breast CA now with intractable neck pain. MRI and CT scan demonstrated complete destruction of the C3 lateral mass on the left side. There was disease at C4 as well. Past Medical History: #. Metastatic Left Breast Cancer - diagnosed in [**6-/2134**] - infiltrating with ductal and lobular features - ER/PR positive, LVI negative, HER-2/neu indeterminate - [**12-29**] lymph nodes positive - known metastases to the L3 vertebral region and the sacrum - treated with radiation in the past - failed multiple chemo agents due to intolerance of side effects - taking Faslodex with quarter-annual Zometa infusions - peripheral neuropathy since chemo #. Osteopenia - last BMD -2.46 in [**1-26**] - currently on Zometa for bone mets #. Paroxysmal atrial fibrillation - s/p ablation at [**Hospital1 2025**] ~[**2129**] - also had cardiac cath at that time, negative per patient - large LLE hematoma on Warfarin - unwilling to continue this med despite Cardiology recs - refuses further cardiology followup #. Obstructive sleep apnea - CPAP about 7 hours a night #. Asthma #. Ocular migraines #. Rheumatoid arthritis in the hands #. Benign Familial Microscopic Hematuria - worked up and felt to be benign - worrisome causes were ruled out #. Gyn History - G3, P3 - Paps always negative prior to hysterectomy #. Past Surgeries - hysterectomy for fibroids - Laparoscopic salpingectomy [**8-24**] #. Childhood Illnesses - Ruptured appendix at age five - Rheumatic heart disease at age seven - Herpes zoster age eleven #. OTHER - Right knee meniscal tear as noted by MRI [**12-1**] - Hx of colonic adenomas, found [**4-26**], colonoscopy [**8-31**] negative - Diverticulosis incidentally found on CT [**3-27**] - Gallstones discovered incidentally during surgery, ~[**2122**] - Loss of hearing left ear due to car accident - Left lower extremity cellulitis ~[**2132**], Resistant bug requiring long term IV infusion pump, Salmonella UTI around the same time Social History: Widowed since [**77**], no romantic involvement since. Teaches at [**University/College 34597**] and the [**Location (un) 1468**] Police Academy. Formerly smoked ~70pack years, quit at age 30. Mother of three, youngest daughter currently applying to med school. Family History: Father with MI at age 47, subsequently had 8 MI's before passing away in his 60's. Brother also had MI in his 60's. Physical Exam: On admission pt was A&Ox3, HT: rrr, lungs: CTA, Cranial Nerves II-XII intact, decreased ROM of RUE however 5/5 strength through out except right deltoid [**3-30**] Upon Discharge: Cranial nerves II-XII intact, motor she is 5/5 strength throughout except for her R deltoid is [**3-30**] (per pt has previous weakness and decreased ROM). She did not have clonus or [**Doctor Last Name 937**] sign. HR irregular irregular. LS CTA bilat. GI/GU no issues. Pertinent Results: [**2138-3-31**] 02:05PM BLOOD WBC-7.2# RBC-3.27* Hgb-10.0* Hct-27.5* MCV-84 MCH-30.6 MCHC-36.3* RDW-15.0 Plt Ct-148* [**2138-4-1**] 02:25AM BLOOD WBC-6.7 RBC-3.02* Hgb-9.4* Hct-24.9* MCV-83 MCH-31.1 MCHC-37.6* RDW-15.1 Plt Ct-106* [**2138-4-2**] 01:50AM BLOOD WBC-6.3 RBC-2.31* Hgb-7.2* Hct-19.6*# MCV-85 MCH-31.0 MCHC-36.6* RDW-15.1 Plt Ct-105* [**2138-4-4**] 02:31AM BLOOD WBC-6.2 RBC-3.02* Hgb-9.0* Hct-26.3* MCV-87 MCH-29.8 MCHC-34.1 RDW-14.7 Plt Ct-161 [**2138-3-31**] 02:05PM BLOOD PT-14.7* PTT-25.7 INR(PT)-1.3* [**2138-4-2**] 03:50PM BLOOD PT-14.0* PTT-25.2 INR(PT)-1.2* [**2138-4-3**] 01:56AM BLOOD PT-13.0 PTT-23.0 INR(PT)-1.1 [**2138-3-31**] 02:05PM BLOOD Glucose-176* UreaN-16 Creat-0.6 Na-138 K-4.3 Cl-110* HCO3-21* AnGap-11 [**2138-4-2**] 05:53PM BLOOD Glucose-112* UreaN-9 Creat-0.6 Na-137 K-3.7 Cl-103 HCO3-28 AnGap-10 [**2138-4-4**] 02:31AM BLOOD Glucose-126* UreaN-11 Creat-0.7 Na-135 K-3.9 Cl-100 HCO3-28 AnGap-11 [**2138-3-31**] 02:05PM BLOOD Calcium-7.3* Phos-3.9 Mg-1.6 [**2138-4-2**] 01:50AM BLOOD Calcium-7.9* Phos-1.8* Mg-1.9 [**2138-4-3**] 01:56AM BLOOD Calcium-8.1* Phos-2.0* Mg-2.3 [**2138-4-4**] 02:31AM BLOOD Calcium-8.5 Phos-1.7* Mg-2.2 [**4-3**] FRONTAL & LATERAL VIEWS OF THE CERVICAL SPINE: C1 through C7 are seen on the lateral view. Posterior fusion devices are noted in C2 through C7. Normal cervical lordosis is maintained. There are no fractures or subluxations. There is mild loss of disc height most prominent at C5-6 and C6-7. Vertebral body heights are maintained. Anterior osteophyte formation is noted in the lower cervical spine. A central venous catheter ends at the lower SVC/right atrium. Skin staples are noted over the posterior neck. Brief Hospital Course: Pt was admitted to the hospital electively and was taken to the OR where under general anesthesia she underwent posterior cervical instrumented fusion under general anesthesia. She did have an episode of hypotension intra-op at end of surgery and pt was kept intubated post-op and transferred to PACU. She was monitored closely and received massive fluid resuscitation. She was lightened from sedation and was moving all 4 extremities well. She did not have cuff-leak so remained intubated and was transferred to TICU. She had known history of atrial fibrillation and required diltiazem drip for rate control. Cardiology followed pt and made recommendations. She was able to be extubated POD#1. Her hematocrit was followed post-op and she required several PRBC transfusuions. Pain management was done with consultation of Pain Service who has followed pt in past. She had JP drain in surgical site that was removed POD#2. Right deltoid remained slightly weak as pre-op. Diet and activity were advanced. PT evaluated pt and recommended discharge to home with outpatient PT. Incision was clean and dry with staples. Medications on Admission: albuterol prozac propranolol Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. 3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Diltiazem HCl 360 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 8. Outpatient Physical Therapy 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: metastatic breast cancer to cervical spine atrial fibrillation POST-OP HYPTOTENSION/HYPOVOLEMIA Discharge Condition: neurologicaly stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/take daily showers ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE RETURN TO THE SPINE CENTER -[**Hospital Ward Name **] 2- ON TUESDAY, [**4-15**] AT 11:15 AM DAYS FOR REMOVAL OF YOUR STAPLES PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED AP/Lat C-SPINE XRAYS PRIOR TO YOUR APPOINTMENT FOLLOW UP WITH YOUR PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] FOLLOW UP WITH CARDIOLOGY DR [**Last Name (STitle) **].PLEASE CALL [**Telephone/Fax (1) 62**] FOR APPT. Provider: [**Name10 (NameIs) **] PSYCHOLOGY Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2138-4-15**] 8:00 Provider: [**Name10 (NameIs) 1089**] [**Name11 (NameIs) 1090**], MD Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2138-4-15**] 9:30 Completed by:[**2138-4-7**]

Admission Date: [**2177-8-7**] Discharge Date: [**2177-8-18**] Date of Birth: [**2103-11-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dizziness and weakness Major Surgical or Invasive Procedure: [**2177-8-12**] Urgent Four Vessel Coronary Artery Bypass Grafting(left internal mammary artery to left anterior descending artery, with vein grafts to ramus, obtuse marginal and posterior descending artery) History of Present Illness: This is a 73 year old male who has a history of multiple strokes in the past, last in '[**75**] with minor defecit of left leg weakness, DMII, hypercholesterolemia, and hypertension presents to outside hospital reporting generalized weakness, inability to ambulate with his cane due to fatigue, and a near syncopal episode.He ruled in for NSTEMI and radiographic evidence of heart failure. He was found to have acute anemia and transfused packed red blood cells. He was admitted to the OSH ICU and later was cathed. Cardiac cath revealed 3 vessel disease. He was transferred to [**Hospital1 18**] for cardiac surgical evaluation of coronary artery revascularization. Past Medical History: - History of CVA x 3 - last '[**75**] with (L)LE weakness - Type II Diabetes Mellitus - Hypertension - Dyslipidemia Social History: Lives with: wife, has 5 children. Occupation: Construction company owner Tobacco: denies ETOH: denies Family History: Father died at 57yo of heart failure. Mother died at 86 yo-"old age". He has two brothers, both living - 1 with history of MI, the other has high blood pressure. Physical Exam: Preop Exam: BP Right:128/75 Pulse:80 Resp:18 O2 sat: 99% on RA General: Elderly male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur 2/6 SEM Abd: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema - trace Varicosities: None None[x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: none Left:none Pertinent Results: [**2177-8-7**] WBC-11.6* RBC-3.67* Hgb-11.6* Hct-33.9* Plt Ct-252 [**2177-8-7**] PT-12.9 PTT-23.4 INR(PT)-1.1 [**2177-8-7**] Glucose-289* UreaN-48* Creat-1.8* Na-138 K-3.9 Cl-98 HCO3-27 [**2177-8-7**] ALT-24 AST-54* LD(LDH)-432* AlkPhos-109 Amylase-89 TotBili-1.0 [**2177-8-7**] %HbA1c-6.8* eAG-148* [**2177-8-8**] Echocardiogram: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with near akinesis of the distal half of the anterior septum and anterior walls, distal inferior wall, and apex. The remaining segments contract normally (LVEF = 35 %).There is an apical left ventricular aneurysm. Mild spontaneous echo contrast but no masses or thrombi are seen in the left ventricular apex. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-8**]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [**2177-8-8**] Head CT Scan: There is no evidence of acute major vascular territorial infarct. There is no intra- or extra-axial hemorrhage, obvious masses, mass effect, or shift of normally midline structures. Moderate atrophy is seen causing prominence of ventricles and sulci. Osseous and soft tissue structures are unremarkable. IMPRESSION: 1. No acute intracranial pathology. 2. Left parieto-occipital hypoattenuation likely from old infarct. 3. Chronic small vessel ischemic disease, and moderately severe atrophy. Brief Hospital Course: Mr. [**Known lastname **] was admitted with NSTEMI and congestive heart failure. Given recent Plavix, surgery was delayed and he underwent extensive preoperative evaluation. He remained pain free on intravenous Heparin. Preoperative antibiotics were given for a positive urinalysis. Head CT scan showed no acute pathology. Neurology evaluation was consistent with dementia, most likely multiple infarct dementia. He was cleared for surgery by the Neurology service but remained high risk for stroke based on his risk factors and previous history of strokes. After extensive evaluation, his family agreed and gave surgical consent to proceed with surgical revascularization. The remainder of his preoperative course was uneventful. On [**8-12**], Dr. [**Last Name (STitle) **] performed urgent coronary artery bypass grafting surgery. See operative note for details. Following surgery, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. Given dementia, narcotics were avoided. He otherwise maintained stable hemodynamics and transferred to the SDU on postopertive day one. Blood glucoses were initially elevated, but came under better control on resuming home doses of metformin and glipizide, in addition to Lantus and sliding scale insulin. Lantus was discontinued upon discharge. BUN and Creatinine rose and were monitored closely. creatinine peaked at 1.9 with baseline of 1.5. Foley was maintained to closely monitor urine output. When the foley was removed, he failed a void trial, despite a bladder scan for 800cc, foley was replaced and Flomax was started. he will need a repaet voding trial at rehab. The patient was evaluated by the physical therapy service for assistance with strength and mobility and rehab was recommended prior to return to home. By the time of discharge on POD #6 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital **] rehab in [**Location (un) 701**] in good condition with appropriate follow up instructions. Medications on Admission: Aggrenox 25/200(2), Metformin 1000(2), HCTZ 25(1), Quinipril 40(1), Glipizide 5(2), Clorazepate 7.5(1), Lipitor 20(1), Atenolol 50(1) Discharge Medications: 1. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days: or until at pre-op weight 169#'s. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/temp. 11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 10 days: while on lasix. Discharge Disposition: Extended Care Facility: [**Location (un) **] of [**Location (un) **] Discharge Diagnosis: Coronary Artery Disease, s/p CABG NSTEMI Congestive Heart Failure Cerebrovascular Disease Dementia Hypertension Dyslipidemia Type II Diabetes Mellitus Preoperative Urinary Tract Infection Atrial Fibrillation Discharge Condition: Alert and oriented x1-2 nonfocal Ambulating with assistance Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg /Left - healing well, no erythema or drainage. Edema -trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Repeat voiding trial in next one or two days. Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Dr. [**Last Name (STitle) **] on [**2177-9-18**] @ 1PM PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 85044**] in [**2-8**] weeks, call for appt Cardiologist: Dr. [**Last Name (STitle) **] in [**2-8**] weeks, call for appt Completed by:[**2177-8-22**]

Admission Date: [**2132-9-26**] Discharge Date: [**2132-9-29**] Date of Birth: [**2048-8-10**] Sex: F Service: MEDICINE Allergies: Bactrim Ds / Neurontin / Codeine / Lyrica / Sulfa (Sulfonamide Antibiotics) / Trimethoprim / Lactose Attending:[**First Name3 (LF) 898**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 84 yo presenting with AFIB, HTN, CHF who presented with SOB since yesterday. Pt resides at [**Doctor First Name 391**] Bay NH, and on morning pill administration (0530) pt was found to have room air oxygen sats in 70s, as well as SOB and congestion. Facemask 5L O2 was placed at NH and sats improved to 93%. BP at NH was 148/82. . In the ED, initial vs were: T 98 P 87 BP 195/76 RR 40 O2sat 93% on NRB. The pt did not require bipap, and was found to have crackles and edema on exam. Pt had UA concerning for UTI, lactate was 2.2, WBC 20, Creatinine was 1.4, which may be baseline or slightly elevated from baseline. Troponin was 0.02, and on recent admission in [**8-31**] Trop was 0.03. Patient was given nitro gtt, lasix 40 IV x1, zosyn and tylenol. Vanco was written for, but pt did not receive it before transfer to the ICU. Reason for ICU admission was that pt still requiring nitro gtt. Transfer vitals 70 164/90 26 99% NRB. Pt is DNR [**Name (NI) 835**], transfered from NH with signed order. . On the floor, the pt appears comfortable on NRB, with lips becoming cyanotic on 6L NC O2. Pt endorses new shortness of breath since last night, mild dysuria for several days, stable two pillow orthopnea, no PND, increased lower extremity edema and increased urination. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Denied arthralgias or myalgias. Past Medical History: 1. DM c/b L femoral neuropathy, prior hypoglycemic episodes. Was instructed to cut her metformin dose, but hasn't. 2. HTN with orthostatic changes 3. Spinal stenosis s/p laminectomy 4. Recurrent falls - suspected [**2-25**] numbers 1,2,3 above, as well as poor center of gravity from kyphoscoliosis 5. Depression 6. Hyperlipidemia 7. Chronic anemia - negative EGD [**7-30**]. Colon polyp removed [**10-29**]. 8. CRF 9. OA 10. CCY 23 y ago 11. s/p C-section 12. Stress incontinence 13. Bilateral carpal tunnel syndrome 14. R cataract removal 15. Lactose intolerance 16. h/o H pylori gastritis [**10-29**] - treated. Social History: Lives in [**Location **]. Uses wheelchair, can ambulate with [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 15935**] steps in PT at NH. Denies t/e/d. Family History: DM in many family members Physical Exam: Vitals: T: 97.8 BP: 177/68 P: 73 R: 22 18 O2: 96% on NRB, 90% on 6L NC O2 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, lips cyanotic on NC O2 Neck: supple, +JVD ~10, no LAD Lungs: Bilateral crackles, R>L half way up, no wheezes, no dullness to percussion CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: +foley, no suprapubic ttp, no CVA ttp Ext: warm, well perfused, 1+ pulses, 2+ pitting edema bilat LE, L>R Neuro: A+Ox3, hard of hearing, speech fluent, answers questions appropriately CN II-XII intact Motor: 5/5 strength UE and LE bilat Coordination: No dysmetria, gait assessment deferred Pertinent Results: [**2132-9-26**] 06:50a . 140 108 37 AGap=18 ------------- 228 4.7 19 1.4 . estGFR: 36/43 (click for details) . CK: 46 MB: Notdone Trop-T: 0.02 proBNP: 3288 . Ca: 9.8 Mg: 1.7 P: 4.9 . 9.4 20.0 ------- 430 29.9 N:83.4 L:11.0 M:2.6 E:2.6 Bas:0.3 . PT: 12.3 PTT: 27.4 INR: 1.0 . Echo. [**2132-9-26**]. The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2131-9-25**], pulmonary pressures are lower. The other findings are similar. . CXR. [**2132-9-26**]. IMPRESSION: Findings consistent with interval development of pulmonary edema and mild congestive heart failure. Brief Hospital Course: 84 year old woman with history of DM, HL, diastolic CHF, admitted with respiratory distress and likely flash pulmonary edema [**2-25**] hypertensive urgency, perhaps provoked by underlying UTI. . # Acute Pulmonary Edema - Initially was treated in MICU with lasix IV and nitro gtt. SOB improved. CXR consistent with pulmonary edema. Thought to have flashed in setting of elevated BP with hx of diastolic HF. Oxygen requirements decreased with diuresis. Echo ruled out systolic dysfunction with EF>55%. On the floor, continued diuresis with IV Lasix with significant improvement of her breathing. . # Acute on chronic diastolic CHF: Echo with unchanged from prior with EF>55%. Tx with lasix for fluid overload. Continued ACE-I and atenolol. Initiated salt restriction and 2L fluid restriction. She was discharged on her home doses of the atenolol and lisinopril. . # Urinary tract infection: Pt reports urinary frequency leading up to her admission. Received zosyn x 1 in Ed, cefepime x 1 in MICU. Was then changed to cipro. Initial UA positive for UTI and culture showed GNR. She was treated with Cirpo IV and discharged on a 14 day po course, as pt had a foley throughout her hospitalization. . # Hypertension: BP initially controlled with nitro gtt initially. Pt continued on amlodpine, atenolol and lisinopril throughout her stay to manage high BP with adequate control. . # Chronic renal insufficiency: At baseline Cr 1.4 with slight increase to Cr 1.8 in the setting of Lasix diuresis. . # Anemia: Pt is at recent baseline hct (29). Pt was seen in [**Month (only) **] by hematology, and was diagnosed with anemia of chronic disease secondary to chronic renal failure. Medications on Admission: Tylenol 1000 tid Alendronate 70 weekly Omeprazole 20mg daily MVI daily Vit B12 1000mcg daily Vit D 800u daily Aspirin 1 tab daily Glipizide 10mg daily Lisinopril 20mg daily Oxybutynin ER 10mg daily Sertraline 25 mg 3 tabs daily Atenolol 50 daily Amlodipine 10 daily Levothy 75 daily Calcarb 600 [**Hospital1 **] Cranberry tabs [**Hospital1 **] Simvastatin 80 daily Ipratrop-Alb q6 prn Loperamide 2mg prn diarrhea Milk of Mag 30 prn constip Compazine 1 tab q8 prn nausea Tramadol 50 q8 prn pain Tums prn Insulin humalog 3 u pre-breakfast, 2 u pre-dinner Insulin lispro ss Insulin glargine 11u qam Bengay Bilat hand splints Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheeze. 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Sertraline 25 mg Tablet Sig: Three (3) Tablet PO once a day: Total dose of 75mg daily. 16. Oxybutynin Chloride 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 17. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 18. Cranberry 405 mg Capsule Sig: One (1) Capsule PO twice a day. 19. Loperamide 2 mg Tablet Sig: One (1) Tablet PO as needed as needed for diarrhea. 20. Milk of Magnesia 400 mg/5 mL Suspension Sig: [**1-25**] PO as needed as needed for constipation. 21. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. 22. Humalog 100 unit/mL Cartridge Sig: Three (3) units Subcutaneous before breakfast daily: As directed per sliding scale. 23. Humalog 100 unit/mL Cartridge Sig: Two (2) units Subcutaneous before dinner daily: As directed per sliding scale. . 24. Insulin Glargine 100 unit/mL Solution Sig: Eleven (11) units Subcutaneous qAM: As directed. 25. BenGay Arthritis Formula Cream Topical 26. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous per sliding scale. 27. Tramadol 50 mg Tablet Sig: One (1) Tablet PO q8h prn as needed for pain. 28. Compazine 10 mg Tablet Sig: One (1) Tablet PO q8h prn as needed for nausea. 29. [**Male First Name (un) **]-Tussin Original 13-4-83-25 mg/5 mL Solution Sig: Thirty (30) ml PO every twelve (12) hours as needed for cough. 30. Calcarb 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 31. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 12 days. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay - [**Hospital1 392**] Discharge Diagnosis: Primary diagnosis: 1. Pulmonary Edema 2. Urinary Tract Infection Secondary diagnosis: 1. Congestive Heart Failure 2. Hypertension Discharge Condition: stable Discharge Instructions: You were seen at [**Hospital1 18**] for an episode of shortness of breath. You had your heart function checked with an Echocardiogram, which showed no change from your previous study echocardiogram. You also had a chest x-ray that showed fluid in your lungs and you were given medication to help you get rid of this fluid. You were also found to have a urinary tract infection and you were treated with antibiotics to resolve this problem. Medication changes: - Ciprofloxacin 500mg daily was added to be taken for 12 additional days (for a full course of 14 days). If you experience fever, shortness of breath, chest pain, or other concerning symptoms, please return to the hospital. Followup Instructions: Please follow up with your primary care provider at the nursing home within 1 week of being discharged.

Admission Date: [**2141-8-20**] Discharge Date: [**2141-8-24**] Date of Birth: [**2060-9-29**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: "confusion, headache, imbalance" Major Surgical or Invasive Procedure: Bilateral burr hole craniotomies History of Present Illness: This is a 80 year old right handed man who is full code who lives at home with his sister. [**Name (NI) **] initially presented on [**2141-7-23**] when he stuck the back of his head on a table when picking an item up off the floor. The Head CT taken at [**Hospital1 **] was consistent with bilateral hygromas and he was sent here for further evaluation by neurosurgery. Today, he presents again with increased mental confusion, imbalance, gait disturbance, and increased headache. He stood up from bed this morning and tripped but did not hit his head. The patient denies syncopy or palpitations at the times of his fall this morning. He denies loss of consiuousness, nausea, vomiting, weakness, numbness, or tingling sensation. He denies taking anticoagulant medication other than daily aspirin 325 mg. The patient has basline difficulty with hearing, a right knee that is fused/imobile although he ambulates without cane or walker, and decreased motion of both shoulders for the past 10 + years Past Medical History: HTN Hyperlipidemia palpitations - on/off x years right knee surgery right shoulder surgery Social History: Lives with his sister. [**Name (NI) 1403**] as a tailor. No tobacco, EtOH, or illicit drug use. Family History: Family history of diabetes mellitus Physical Exam: PHYSICAL EXAM: On admission O: T:99.3 BP: 174/73 HR:61 R: 16 O2Sats: 98 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 4-3mm bilaterally EOMs: intact Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing decreased at baseline left worse than right IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-5**] throughout except pt unable to bend right knee due to prior surgery and fusion in [**2083**]. Also limited ROM of bilateral shoulders at basline with prior right shoulder surgery [**40**] years ago. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements. CT:[**2141-8-20**]: NCHCT- large left SDH subacute, smaller right sided SDH. EKG: possible new T wave inversions V 4-V6 Labs:platlets 129, PT12.7, PTT23.1, INR 1.1, K 3.3, NA 143 On Discharge :neurologically intact. Pertinent Results: [**2141-8-20**] 12:45PM PLT COUNT-136* [**2141-8-20**] 12:45PM NEUTS-74.8* LYMPHS-19.6 MONOS-4.1 EOS-0.6 BASOS-0.8 [**2141-8-20**] 12:45PM WBC-7.9 RBC-4.33* HGB-13.7* HCT-39.6* MCV-91 MCH-31.6 MCHC-34.6 RDW-14.1 [**2141-8-20**] 12:45PM GLUCOSE-123* UREA N-19 CREAT-0.8 SODIUM-145 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-29 ANION GAP-14 [**2141-8-20**] 01:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG CT head [**8-20**] There are bilateral subdural fluid collections containing areas of acute hemorrhage larger on the left. The left collection along the frontoparietal convexity measures up to 2.1 cm in maximal thickness. On the right the collection is smaller measuring up to 1 cm. There is some compression of the cerebrum greater on the left. Shift of midline structures measure up to 2 mm (2:14). No evidence of downward herniation is seen. There is some compression of the left lateral ventricle. However no evidence of entrapment is seen. No concerning osseous lesion is seen. The visualized paranasal sinuses are clear. CT head [**8-21**] Patient is status post bifrontal subdural evacuation with burr holes in the bilateral occiput of the vertex. There has been near-complete evacuation of the subdural hematoma with small residual iso- to slightly hyperdense material near the vertex (2:24). There is bifrontal pneumocephalus, larger on the left causing mass effect upon the left frontal lobe. There is no midline shift. No evidence for herniation. There is no acute hemorrhage. The size and configuration of the ventricles appears normal. The visualized paranasal sinuses, mastoid and ethmoid air cells are clear. [**8-23**] CT head 1. Status post bifrontal subdural hematoma evacuation with resulting pneumocephalus, now resolving. 2. Apparent prompt recurrence of bilateral subdural hygromas, seen previously on [**2141-7-23**], raising the possibility of CSF leak through persistent tears in the [**Doctor First Name **]-arachnoid membrane, bilaterally. Brief Hospital Course: [**8-20**] Pt admitted to neurosurgery service at taken to the OR urgently for bilateral burr hole craniotomies and evacuation of chronic subdural hematomas. Pt tolerated this procedure very well with no complications. Post operatively he was transferred to the ICU for further care including q1 neurochecks and strict blood pressure control less than 140 systolic. Upon post op exam he is doing well. He is awake and alert and following commands. He was moving all extremities with full strength. His pain was well controlled and his surgical site was clean and dry. A post op head ct showed good resolution of subdural hematomas. [**8-21**] Pt seen on morning rounds and doing well. His exam remained unchanged and he remained in the ICU on this day for continued care and blood pressure control. [**8-22**] Pt transferred to the floor in stable condition. On [**8-23**], patient was observed to have tachycardia to the 140s in the morning, IVF were started as well as a bolus. Upon examination, patient reported palpitations, but denied chest pain or SOB. EKG was also ordered which rapid a-fib. Medicine was re consulted for assistance in management for untreated a-fib, they increased his beta blocker. Patient also fell in room, denied hitting his head, but complained of headache. Head CT was ordered and showed no new hemorrhage. He was neurologically intact. On [**8-24**] he was medically cleared for DC. Medicine changed his metoprolol to Toprol XL for convenience. PT was recommended for home. He was discharged on [**2141-8-24**] Medications on Admission: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Amlodipine-Benazepril 5-10 mg Capsule Sig: One (1) Capsule PO twice a day. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Dilantin Kapseal 100 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): over the counter . 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. Amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Benazepril 10 mg Tablet Sig: One (1) Tablet PO bid (). Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Bilateral SDH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your [**Location (un) 2729**] are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. MEDICATIONS ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: o Narcotic pain medication such as Dilaudid (hydromorphone). o An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? You may use Aspirin on [**2141-8-25**]. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ACTIVITY The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**6-10**] days (from your date of surgery) for removal of your [**Date Range 2729**] and a wound check. Although we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**] or staples. Be sure to point out any incisions, which may be covered by clothing at the time of suture/staple removal. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 2731**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4_weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2141-8-24**]

Admission Date: [**2192-8-31**] Discharge Date: [**2192-9-7**] Date of Birth: [**2138-4-5**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 297**] Chief Complaint: Altered MS Major Surgical or Invasive Procedure: Left IJ Arterial line History of Present Illness: The patient is a 54 yo M with a PMH significant for C4 paraplegia in [**2166**] [**3-15**] to a MVA found on the floor with altered mental status 4ft from his bed today. He was last seen 2 Days PTA noted to be AAOx3. Patient unable to provide further details. . In the ED he was found to be completely disoriented and hypotensive to the SBP's 80-90s and tachycardic to the 120s. He received 3L IVF and his pressure increased to the 90-100s. The patient then received 5mg haldol and 2mg of ativan prior to a head CT, he became hypotensive to the 80s rr 9 and did not respond to a 4th liter of fluid so a code sepsis was initiated and a central line was placed. He spontaneously normalized his pressures to the 120s, with concordant increase in rr to 12. He received a total of 5L IVF in the ED. His lactate went from 3.1 --> 1.5 with hydration in the ED. . He was noted to have a 3x4 cm ecchymosis on right knee and found by x-ray to have a comminuted tibal plateau fracture of right knee. Orhto consulted but had yet to see the patient at the time of transfer to the MICU. His urine looks dirty (mod LE, many bacteria, [**4-15**] WBC) and he was noted to have a stage 3-4 decub on left lateral malleolus. A CXR was WNL. He was given a dose of vanco/levo/flagyl in the ED. Of note, his urine tox was positive for cocaine/opiates/benzos. Past Medical History: Paraplegia and SCI [**3-15**] MVA [**2166**] R buttock decubitus ulcer since [**2186-7-2**] Right bimalleolar ankle fracture [**2-12**] Left distal third tib fib fracture [**3-14**] Anemia secondary to iron deficiency. Hepatitis C. Vitamin D deficiency. Social History: The patient lives at home. He used to smoke one pack per day, now a few cigarettes per day. He uses alcohol occasionally, approximately four beers per month. He also reports occasional marijuana. On previous admission he denies intravenous drug abuse, cocaine and heroin (although today tox screen positive for cocaine). Family History: NC Physical Exam: VS - afebrile, HR 92, BP 119/49, O2 100%, RR 8 Gen - minimally responsive, grimaces and moves slightly to name HEENT pupils pinpoint, minimally responsive to light CV - RRR, no murmur appreciated Chest - course breath sounds Abd - soft, NT/ND Ext - large 3x4cm stage 4 decub on left lateral malleolous; right leg in brace Neuro - reponds to name, not following commands Genitals - swollen scrotum Brief Hospital Course: Brief MICU course: # Septic shock - +WBC/hypotensive/tacycardia with multiple possible sources of infection, including stage 4 lateral malleolus decubitis ulcer or urine. CXR unremarkable although aspiration possible given that he was found unresponsive. Difficult to assess for abdominal tenderness. Pt was given aggressive fluid resusitation per sepsis protocol to maintain MAP >60 and CVP 8-12. Patient was briefly on pressors (2 hours) and was taken off when a-line inserted showed normal BPs. Responded well to supportive treatment. Patient was started on vanco/levo/flagyl initially and then tailored to zosyn when urine/blood cx grew out GNR. Blood cultures ultimately revealed serratia and E.coli and Urine had >100K E.coli as well as >100K Klebsiella. CXR initially showed almost complete collapse of left lung on admission. Repeat CXR showed good reexpansion after chest PT. WBC trended down and patient remained afebrile. On [**2192-9-5**], the pt. had one more episode of hypotension and fever to 102.2. As a result, he was kept on broad spectrum Abx. (Vanco/Zosyn/Levo) After pt. stable and afebrile for several days, stopped double coverage for GNR and went to just Zosyn and Vanco # Urethral tear/scrotal rupture - A foley was placed due to evolving penile skin ulcerations from the condom catheter. This was initially in good position as confirmed by a bladder scan. The patient subsequently underwent a CT abdomen/pelvis ordered to r/o pancreatitis in setting of elevated amylase/lipase which showed the foley balloon inflated in penile urethra with large collections of fluid in the scrotum, perineum, and left thigh. Felt to be urethral tear present with leakage of urine into scrotum and other tissues. Due to tense fluid collection and skin breakdown, on [**9-6**], a small hole developed in the scrotum and fluid (urine and purulent fluid) drained out. Urology has been following the patient and feels no intervention needed at this time as the pateint has spontaneously drained well. Likely will develop fistula. Does need to f/u with GU. Cx and gramstain sent of fluid in scrotum. Will need to be checked and should probably get ID f/u given this infxn in setting of numerous abx given. . # Altered mental status - etiology may be hepatic encephalopathy. Markedly improved with lactulose, continues to improve. No focal neuro sx. -- CT Head unremarkable -- monitor mental status, symptoms improved -- SW eval after MS improves for substance abuse (pt. had tox screen + for benzo/cocaine on arrival). # Elevated Transaminases/[**Name (NI) **] - unclear source. likely from hypotension. if trend up will get RUQ U/S. CT Abd/Pelvis negative for hepatobiliary or pancreatic dz. All LFT's have trended down and normalized except amylase. echeck amylase. . . # Leg Fracture - ortho consulted. --Non-operative -- ortho following -- xray of foot and pelvis showed no fx # ARF- Likely prerenal given elevated BUN/Cr ratio and FeNa <1%; Cr trended back to baseline after IVF. Good UOP >50cc/hr. # Elevated Cardiac Enzymes - Pt found down, cycling enzymes, initial set, MB fraction increase. likely [**3-15**] to being down. -- cycle enzymes . # Paraplegia - ; likely osteopenic given condition. probably contributed to leg fracture. Pt started back on baclofen but other home meds held. . # PPX - PPI, heparin SQ, bowel regimen . # FEN - replete lytes PRN. S&S to evaluate on monday. NPO for now. Pt. has decreased gag. . # ACCESS - left foot IV, right EJ; central line (RIJ) . # CODE - Assumed Full . # DISP - Stable to go to floor . # [**Name (NI) **] - Friend [**Name (NI) **] [**Name (NI) 5700**] [**Telephone/Fax (3) 108251**] Medications on Admission: * Baclofen 20mg qid * motrin 800mg tid prn * Soma 350mg [**Hospital1 **] prn * Vicodin 7.5/750 1 tab tid prn (last filled [**8-2**]) * Valium 5mg tid (last filled [**8-2**]) * Valium 2mg (last filled [**8-2**]) * Darvocet 65mg (last filled on [**7-31**]) * Lomotil (filled on [**8-26**]) * Lactulose Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary - E.coli + Serratia bacteremia, E.coli/Klebsiella bacteremia scrotal fluid collection [**3-15**] foley trauma Secondary - Paraplegia and SCI [**3-15**] MVA [**2166**] R buttock decubitus ulcer since [**2186-7-2**] Right bimalleolar ankle fracture [**2-12**] Left distal third tib fib fracture [**3-14**] Anemia secondary to iron deficiency. Hepatitis C. Vitamin D deficiency. Discharge Condition: Stable Discharge Instructions: -continue with medications as prescribed -f/u with urology -physical therapy as needed to improve strength and conditioning -continue tube feeds until patient has a repeat speech/swallow eval to r/o aspiration (may need video swallow eval) -continue antibiotics for a remaining one week course Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **] [**2-13**] weeks after discharge from rehab. follow up with urology Completed by:[**2192-9-7**]

Admission Date: [**2140-11-25**] Discharge Date: [**2140-12-9**] Date of Birth: [**2072-11-9**] Sex: M Service: [**Company 191**] The patient was admitted to the [**Company 191**] Service overnight. The patient did well. No complaints of chest pain, shortness of breath or abdominal pain. DISPOSITION: Patient to be discharged home today. Patient underwent evaluation by PT and OT and they deemed him safe to good home. Patient will have VNA, OT and PT at home. He will follow up with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 29041**] on [**12-19**] at 10:15 AM. Dr.[**Name (NI) 45529**] phone # is [**Telephone/Fax (1) 3183**]. DISCHARGE MEDICATIONS: 1. Captopril 100 mg p.o. t.i.d. 2. [**Doctor First Name **] 60 mg p.o. q.d. 3. Lansoprazole 30 mg p.o. q.d. 4. Glyburide 1.2 mg p.o. q.d. 5. Spironolactone 25 mg p.o. q.d. 6. Lopressor 50 mg p.o. t.i.d. 7. Lasix 40 mg p.o. b.i.d. 8. Miconazole powder 2% applied t.i.d. p.r.n. 9. Aspirin 325 mg p.o. q.d. 10. Lactulose 15 cc q. eight hours p.r.n. Note patient's Zocor 40 mg p.o. q.d. was not restarted due to his recent LFT abnormalities. Patient's PCP should restart the Statin as an outpatient. Also notes that the Glyburide was started due to patient's recently diagnosed type 2 diabetes mellitus. The Glyburide should be titrated up on an outpatient. FOLLOW UP: As mentioned above, patient to follow up with Dr. [**Last Name (STitle) 29041**] on [**12-19**] at 10:15 AM. As recommended by the GI Service, patient is to undergo an outpatient MRCP. MRCP should be set up by Dr. [**Last Name (STitle) 29041**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) 1730**] 12-290 Dictated By:[**Last Name (NamePattern1) 5092**] MEDQUIST36 D: [**2140-12-9**] 13:08 T: [**2140-12-9**] 13:22 JOB#: [**Job Number 45530**] cc:[**Telephone/Fax (1) 45531**]

Admission Date: [**2136-4-25**] Discharge Date: [**2136-4-26**] Date of Birth: [**2075-3-15**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 338**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Rigid bronchoscopy Right bronchial/PA embolization History of Present Illness: Mr. [**Known lastname **] is a 61 yo M with SCLC s/p chemo and XRT who presents from OSH after episode of hemoptysis. The history is obtained per report, but over the last few days the patient has had URI symptoms (possible sinus congestion). However, at 10PM he experienced an episode of hemoptysis with "frank blood.". Of note, he received his last dose of chemotherapy last friday. . He presented to [**Hospital **] med center where initial VS T 102.7, RR 22, BP 116/67, 98%RA. For his fever he was given vanco 1g, Levoflox 750mg x1, Flagyl 500mg x1, tylenol, and zofran. He also received 2L NS. However, the patient subsequently experienced 1 episode of hemoptysis with 300ml frank blood. He was transferred here for further care. . In the [**Hospital1 18**] ED, T 99, HR 109, BP 102/59, RR 15, 96%RA. Hct 27. The patient underwent CTA demonstrating Right lobe infiltrating of the tumor with narrowing and multifocal consolidation. IP was urgently consulted and patient was taken for rigid bronch, showing eroded bronchial wall with non-bleeding vessel protruding. . On arrival to the floor, patient is intubated. . ROS: Unable given patient is intubated. Past Medical History: NSCLC, dx [**11-13**], s/p XRT and chemo, Finished radiation 2 wks ago, last chemotherapy cycle ([**10-17**]) last Friday. Receives chemo at [**Hospital 3075**] [**Hospital **] hospital. Oncologist Dr. [**Last Name (STitle) **] Social History: Divorced, has son. 30 pack year smoking history, quit >1yr ago. Denies alcohol or recreational drug use otherwise Family History: Non-contributory Physical Exam: VS: T 97.1, HR 92, BP 93/62, RR 12, 100% AC, 100% Fi02, PEEP 0, Tv 600, RR 12 Gen: intubated, sedation, cachectic appearing HEENT: PERRL, anicteric sclera, ETT in place Neck: supple Heart: RRR no m/r/g Lung: Coarse BS bilat with exp wheeze, symmetric Abd: thin, soft NT + BS Ext: warm, well perfused, 2+ DP pulses Neuro: sedated Pertinent Results: [**2136-4-25**] 08:41PM TYPE-ART TEMP-39.4 PO2-151* PCO2-56* PH-7.31* TOTAL CO2-30 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2136-4-25**] 07:47PM HCT-31.8* [**2136-4-25**] 06:25PM TYPE-ART PO2-320* PCO2-51* PH-7.32* TOTAL CO2-27 BASE XS-0 [**2136-4-25**] 06:11PM GLUCOSE-101 UREA N-8 CREAT-0.5 SODIUM-137 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11 [**2136-4-25**] 06:11PM CALCIUM-8.2* PHOSPHATE-4.2 MAGNESIUM-1.6 [**2136-4-25**] 06:11PM WBC-7.9 RBC-3.74* HGB-10.5* HCT-31.9* MCV-85 MCH-28.1 MCHC-32.9 RDW-20.0* [**2136-4-25**] 06:11PM PLT COUNT-437 [**2136-4-25**] 06:11PM PT-13.8* PTT-29.7 INR(PT)-1.2* [**2136-4-25**] 04:24PM WBC-10.2# RBC-3.92*# HGB-11.1* HCT-36.6*# MCV-90 MCH-28.4 MCHC-31.7 RDW-19.5* [**2136-4-25**] 04:24PM PLT COUNT-540* [**2136-4-25**] 11:02AM HCT-24.5* [**2136-4-25**] 06:44AM GLUCOSE-109* UREA N-10 CREAT-0.6 SODIUM-136 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-23 ANION GAP-12 [**2136-4-25**] 06:44AM CALCIUM-8.2* PHOSPHATE-3.2 MAGNESIUM-1.7 [**2136-4-25**] 06:44AM WBC-5.3 RBC-3.13* HGB-8.9* HCT-27.4* MCV-88 MCH-28.4 MCHC-32.4 RDW-20.4* [**2136-4-25**] 06:44AM PLT COUNT-460* [**2136-4-25**] 06:44AM PT-14.5* PTT-30.5 INR(PT)-1.3* [**2136-4-25**] 12:20AM URINE HOURS-RANDOM [**2136-4-25**] 12:20AM URINE HOURS-RANDOM [**2136-4-25**] 12:20AM URINE GR HOLD-HOLD [**2136-4-25**] 12:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2136-4-25**] 12:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2136-4-24**] 11:40PM GLUCOSE-112* UREA N-12 CREAT-0.6 SODIUM-138 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13 [**2136-4-24**] 11:40PM PLT COUNT-511* [**2136-4-24**] 11:40PM PT-14.5* PTT-29.6 INR(PT)-1.3* [**2136-4-24**] 11:38PM LACTATE-1.2 . CTA Chest: IMPRESSIONS: 1. Right hilar mass with extension into mediastinum and with lymphangitic carcinomatosis in RLL and RML, consistent with reported history of RLL small cell carcinoma. 2. Bronchoceles in the RLL with wall thickening and containing debris and fluid are consistent with necrotizing bronchiectasis; if the patient has not had radiation therapy, infectious cause would be most suspect. Patchy peripheral opacities likely representing infection from aspirated fluid/debris from bronchoceles. 3. Right hilar mass causes narrowing of arteries and bronchi, and amputates the right pulmonary vein. No pulmonary embolism seen. Brief Hospital Course: A/P: 61 yo M with NSCLC s/p XRT and recent chemo, presenting with episodes of hemoptysis. His hospital course is as follows: . . Hemoptysis: Likely was related to his lung cancer. His Hct was initially stable at 27. However, he underwent rigid bronchoscopy which showed blood in the bronchial tree, as well as a large vessel protruding from an area of his eroded bronchial wall. He was intubated with a double lumen ETT. IR was consulted. The patient underwent intercostals and R inferior PA. However, returning to the MICU he re-bled, requiring single lung ventilation. With discussion with the family given his dire prognosis, he was made DNR. He passed away later in the evening. . Fever: T was 102.7. His source was likely related to the lung infection. He was treated empirically with vanco/levo/flagyl. However, the patient later passed away. No obvious infectious source was identified. Medications on Admission: None Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Non Small Cell Lung Cancer Right pulmonary and bronchial artery hemorrhage with hemoptysis Cardiovascular collapse Respiratory failure Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

Admission Date: [**2143-7-3**] Discharge Date: [**2143-7-7**] Date of Birth: [**2067-10-14**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4949**] is a 75 year old male with a history of hypertrophic obstructive cardiomyopathy, who reports that he has had chest pain for approximately the past 40 years. Over the past two years, this has gotten progressively worse. The pain is provoked by exertion, such as walking 25 to 30 feet, taking out the garbage or climbing one flight of stairs. He does not experience pain at rest. He has occasional lightheadedness but denies syncope, denies claudication, orthopnea, edema or paroxysmal nocturnal dyspnea. A recent dobutamine echocardiogram was done on [**2143-6-13**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Baseline echocardiogram showed left ventricular hypertrophy with prominence of the basal septum. There was moderate mitral regurgitation, borderline systolic aortic motion and then outflow gradient less than 60 mm of mercury; after dobutamine, the gradient increased to greater than 100 mm of mercury, for a diagnosis of hypertrophic obstructive cardiomyopathy. The patient was taken to the catheterization laboratory on the day of admission for alcohol ablation to be performed on the septal artery which, unfortunately, led to complete heart block without ventricular escape, and full cardiac arrest. Cardiopulmonary resuscitation was performed on the patient for 15 minutes, at which point electrophysiology screwed in a sequential A-V pacer which started a perfusing rhythm. The patient was then transferred to the Coronary Care Unit in stable condition. PAST MEDICAL HISTORY: 1. Hiatal hernia. 2. Acid reflux. 3. Hypothyroidism. 4. Chronic osteoarthritis. 5. Undescended testicle. 6. Hypertrophic obstructive cardiomyopathy. PHYSICAL EXAMINATION: On physical examination on admission, the patient was an intubated and sedated obese male, responsive to voice but unable to follow instructions initially. Head, eyes, ears, nose and throat: Pupils equal, round, and reactive to light and accommodation, sluggish pupillary response, pupils slightly dilated at 4 mm but were responsive to 2 mm with light reflex, oropharynx clear, moist mucous membranes, no thyromegaly. Neck: No jugular venous pressure, no carotid bruits. Cardiovascular: Regular rate, II/VI systolic ejection murmur at the apex, no rubs or gallops. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly, no guarding. Extremities: 2+ dorsalis pedis and posterior tibialis pulses, no lower extremity edema, bilateral groin catheterization sites free of bleeding or hematoma, no bruits over catheterization sites. LABORATORY DATA: Admission CK was 1,289, CK/MB 179 and MB index 13.9. Arterial blood gases: pH 7.37, pCO2 32, pO2 144, total CO2 19, intubated. Potassium was 4.1, hemoglobin 12.4 and hematocrit 37. Electrocardiogram showed sinus rhythm with a first A-V block, conduction defect of right bundle branch block type which was new since the prior tracing prior to the septal ablation. HOSPITAL COURSE: 1. Complete heart block: The patient was initially put on an extracutaneous synchronous A-V pacemaker, which maintained a perfusing rhythm throughout his hospitalization. Interrogation of the pacemaker throughout the hospitalization showed occasional A-V conduction initially, which then disappeared, therefore leaving the patient completely relying on the A-V synchronous pacer for a perfusing rhythm. Due to the continual complete heart block, the patient was taken to the electrophysiology laboratory on [**2143-7-5**] for a permanent pacemaker placement, which was done successfully and without complication. A chest x-ray following the procedure confirmed proper placement of the leads in the atrium and ventricle. The patient was observed overnight and had no complications and continued to maintain a perfusing rhythm with adequate hemodynamic function. The patient's pacemaker was interrogated prior to discharge and was functioning properly. The patient was instructed to follow up at the Device Clinic on either Wednesday, [**2143-7-10**] or Friday, [**2143-7-12**] to have his pacemaker interrogated again. The patient was also instructed that Dr. [**Last Name (STitle) **] will be contacting him early in the week to arrange outpatient cardiology follow-up with her. 2. Hypertrophic obstructive cardiomyopathy: The patient's alcohol septal ablation was complicated by the complete heart block but not necessarily unsuccessful in terms of ablating the septum that had been obstructing his outflow tract. An echocardiogram following the procedure, done on [**2143-7-5**], showed a markedly dilated left atrium, moderately dilated right atrium, severe symmetric left ventricular hypertrophy with normal ventricular cavity size, mild regional left ventricular systolic dysfunction, mild resting left ventricular outflow tract obstruction with a peak left ventricular outflow tract gradient of 37 mm of mercury, which was slightly higher compared with the prior study of [**2143-7-3**], prior to the ablation. INCOMPLETE DICTATION; CUT OFF. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Last Name (NamePattern1) 7942**] MEDQUIST36 D: [**2143-7-8**] 14:45 T: [**2143-7-9**] 13:54 JOB#: [**Job Number **]

Admission Date: [**2147-12-8**] Discharge Date: [**2147-12-11**] Date of Birth: [**2091-9-13**] Sex: F Service: MEDICINE Allergies: Amoxicillin Attending:[**First Name3 (LF) 1253**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: 56F with PMH of DM2, CHF with multiple admissions for CHF exacerbation and recently discharged [**2147-11-21**] for atypical chest pain thought to be secondary to viral syndrome presents with tacycardia. She went to her endocrinology appointment today and her heart rate was in the 130s, so she was send to the ED for evaluation. She endorses approcximately 1 week of weakness and previously had a sore throat, which has resolved. She also notes she bumped her leg 3-4 days ago and has developed a scab with surrounding erythema. Per the patient, she has been busy running to various appointments over the past week or so. She has not been eating quite as much and feels dehyrated. Of note, she mentions her Lasix dose was recently ([**12-5**]) increased from 80mg daily to 80mg [**Hospital1 **]. On arrival to the ED, she denied any chest pain, palpitations, SOB, or DOE. . In the ED, initial vs were T 99.1, BP 175/9, RR 15, sat 100% on 2LNC, and she triggered for HR of 142. On exam had very dry mucous membranes. Labs notable for HCT 33 (baseline), lactate 3.0, U/A negative. EKG showed sinus tach at 132, non-path Q III which was old, STD with TWF V4-V6 that are ?rate related or similar to prior. Patient was also given Cefazolin IV for 4cm area cellulitis around the site of her scab. Given her CHF she was gently rehydrated with 1L IVF bolus, following which her HR decreased to the 120s, but rales were reported in the lung bases. ABG at 10pm was 7.44/51/62/36. Given hypoxia and hypercarbia on ABG and need for careful fluid balance, she is being admitted to the ICU. Vitals at the time of transfer HR 123, BP 116/72, RR 11, and sat 97% on 2L. . On arrival to the ICU, she complians of feeling dehydrated. Her ROS was + for headache and otherwise unremarkable. Per the pt, her leg swelling is at baseline. Past Medical History: - dCHF (echo in [**7-1**] EF 50-55%) - hypertension - diabetes melitus type II - migraines - gastritis - seasonal allergies - OSA, managed with 2L NC at night - atypical CP (stress last admission reproduced pain without any ST changes) Social History: Hx heroin, cocaine, EtOH abuse x 20 years: clean since [**2137-12-26**]. The patient has two children who live in [**Location (un) **]. She smokes [**3-27**] cigarettes/day and is not compliant with diet and medications per her husband. Lives with her disabled husband and [**Name2 (NI) 1685**] son in [**Name (NI) **] Corner. Has missed doses of her diuretics and admits that she does not take care of herself as she is always caring for others. Goes to Bay Cove and receives methadone from Dr. [**First Name (STitle) 116**] for hx of polysubstance abuse. Drinks glass of wine 3x/week. Retired. Was prescribed wellbutrin for smoking cessation, but was never filled, per patient. Family History: There is no family history of premature coronary artery disease or sudden death. Parents and siblings w/ diabetes. Also htn, colon ca. Physical Exam: Admission: VS: Temp: 98.6, BP:132/78, HR: 116, RR: 14, 96% on RA GEN: pleasant, comfortable, NAD HEENT: pupils equil, anicteric, dry mucous membranes RESP: CTA b/l with good air movement throughout, no crackles or rales appreciated CV: tachycardic but RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt EXT: warm, no edema, B/L ankles and distal calves with violaceous chronic changes, warm and tender to touch, symmetric NEURO: alert and oriented, appropriate. No focal deficit . Discharge: VS: afebrile 129/81 88 18 98RA CV: RRR. No mrg. No JVD. RESP: CTA B. No WRR. Ext: no peripheral edema. Pertinent Results: [**2147-12-9**] 03:13AM BLOOD WBC-8.4 RBC-3.74* Hgb-10.4* Hct-30.3* MCV-81* MCH-27.7 MCHC-34.2 RDW-14.5 Plt Ct-375 [**2147-12-10**] 05:30AM BLOOD Glucose-147* UreaN-9 Creat-1.0 Na-138 K-4.2 Cl-99 HCO3-32 AnGap-11 [**2147-12-9**] 03:13AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.8 [**2147-12-8**] 09:54PM BLOOD Type-ART pO2-62* pCO2-51* pH-7.44 calTCO2-36* Base XS-8 UA Negative [**2147-12-9**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2147-12-8**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] [**2147-12-8**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2147-12-8**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**12-8**] EKG Sinus tachycardia. Possible left atrial abnormality. Baseline artifact. Non-diagnostic Q waves in leads III, aVF and leads V5-V6. Poor R wave progression. Non-specific ST-T wave changes. Compared to the previous tracing of [**2147-11-21**] sinus tachycardia is new and T wave changes are more pronounced which could be rate-relatead. . CHEST (PA & LAT)IMPRESSION: No acute intrathoracic process. Brief Hospital Course: 56yo F with multiple admissions for dCHF exascerbation who presents with tachycardia in the setting of a viral syndrome and mild cellulitis admitted for close management of fluid status. 1. Tachyacrdia: Given lactate of 3.0 on admission, exam on initial presentation, recent viral illness, and recent uptitration lasix, patient was hypovolemic on exam. Her tachycardia and volume status improved with gentle hydration. Patient received antibiotics in the ED, which were held on arrival to the ICU, as it did not appear that she had ongoing cellulitis. 2. Hypercarbia, hypoxia: Pt does not have known primary lung disease, but is a current smoker and has OSA. She had no prior ABG in our system, but her bicarb since [**6-/2147**] has been persiatntly in the 30s, indicating that she has a chronic respiratory acidosis (i.e. CO2 retention). Given HCO3 that appears to be between 32-36 at baseline, her expected PCO2 would ~60. ABG in the ED demonstrated a PCO2 of 51. 3. Chronic dCHF/hypertension, benign: Home diuretics and antihypertensives were held on initial arrival to the ICU. Held home Lasix and lisinopril given normotension and initial hypovolemia. She was continued to be monitored on the medical floor on metoprolol while her lasix, amlodipine, and lisinopril were held. She continued to be normotensive, without evidence of CHF despite holding these medications. We were unable to resume her diuretics or other antihypertensives as an inpatient, as it did not appear that her BP or volume status would tolerate. Pt is scheduled to see her cardiologist, Dr. [**Last Name (STitle) **], on [**12-13**] for follow up, at which time she should be reevaluated for resuming medications. Given the fact that she remained normotensive off of multiple cardiac medications for several days while inpatient, I suspect she has a significant dietary component of her dCHF and hypertension. She was counselled on the importance of maintaining sodium restriction and [**Location (un) 1131**] food labels. 4. Type II DM: Held orals while inpatient, covered with HISS. Resumed metformin at the time of discharge. 5. Hx of opiate abuse: Continued home methodone dose. 6. Hyperlipidemia: Continued Simvastatin 20 mg PO/NG DAILY. Medications on Admission: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day FLUTICASONE - 50 mcg Spray, Suspension - 1 spray nasally daily FUROSEMIDE - recently increased from 80mg daily to 80mg [**Hospital1 **] HYDROXYZINE HCL - 25 mg Tablet - 1 Tablet(s) by mouth every [**5-30**] hours as needed as needed for for pruritis LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day METHADONE - (Prescribed by Other Provider; Dose adjustment - no new Rx; 85 mg daily) - Dosage uncertain METOPROLOL SUCCINATE - 100 mg Tablet Sustained Release 24 hr - 3 Tablet(s) by mouth DAILY (Daily) PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice daily SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth daily SUMATRIPTAN SUCCINATE - 50 mg Tablet - 1 Tablet(s) by mouth daily as needed for migraine headache ASPIRIN [ENTERIC COATED ASPIRIN] - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth DAILY (Daily) Discharge Medications: 1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal once a day. 2. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every [**5-30**] hours as needed for itching. 3. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 4. methadone 10 mg/mL Concentrate Sig: Eighty Five (85) mg PO DAILY (Daily). 5. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: # Dehydration/hypovolemia/Tachycardia # Hx dCHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You were admitted with dehydration, due to your lasix. You were rehydrated, and monitored off of your lasix and some of your blood pressure medications. We were unable to restart some of these medications, because your blood pressure was normal off of these medications. You will need to follow up closely with your PCP and cardiologist to decide when to resume these medications, which you will likely need again in the near future. For now, please do not take until you are instructed to do so: Lasix Amlodipine Lisinopril Followup Instructions: It is very important that you keep your appointment with Cardiology on [**12-13**]. . Department: CARDIAC SERVICES When: WEDNESDAY [**2147-12-13**] at 11:20 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: TUESDAY [**2147-12-26**] at 2:35 PM With: [**Doctor Last Name **],[**Doctor Last Name **] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2148-1-10**] at 8:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2124-12-6**] Discharge Date: [**2124-12-7**] Date of Birth: [**2061-11-20**] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base Attending:[**First Name3 (LF) 1515**] Chief Complaint: post-cardiac catheterization right femoral access site groin hematoma Major Surgical or Invasive Procedure: [**2124-12-6**] - Cardiac catheterization History of Present Illness: 63 y/o F with bicuspid aortic valve (recent echo showed valve area 0.8) who is undergoing workup for planned upcomming AVR as well as aortic root replacement for 4.5cm aneurysm who presented to [**Hospital1 18**] cath lab today for elective pre-op cath. Cath revealed clean coronaries but post-cath course complicated with right groin hematoma after pulling sheath as well as 20 min vaso-vagal episode requiring 0.5mg atropine and dopamine drip. . [**Hospital1 18**] cath lab: Initialy tried radial approach and gave heparin. Unsuccessful so switched to right femoral. Cath revealed clean coronaries. Post cath, sheath was pulled and hematoma developed in R groin. Pt also vaso-vagaled post cath and BP 50s, HR 40s, given atropine 0.5mg x1, 1 L IVF, dopamine. Plan is to admit to CCU for monitoring overnight. . On arrival to the floor, patient denied any active complaints. She reports chronic mild chest pressure and shortness of breath with exertion. No orthopnea or PND. No heart palpitations. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough. She denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes (diet-controlled), +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: NONE - PERCUTANEOUS CORONARY INTERVENTIONS: NONE - PACING/ICD: NONE 3. OTHER PAST MEDICAL HISTORY: - Aortic stenosis - rheumatic fever (age 7) - scarlet fever (age 7) - Hypertension - hypercholesterolemia - hypothyroidism - rt foot fracture (s/p ORIF) - s/p appendectomy - s/p ovarian cyst removal - osteoporosis - arthritis rt hand Social History: She is a widow, living alone. Looking for part-time work. She used to manage medical records for [**Hospital1 1501**]. Does not exercise. She is a widow, living alone. Sister lives nearby. Tobacco: quit [**2097**] ETOH: [**2-25**] wine/wk. Family History: Both parents died early of alcohol abuse. Brother died of esophageal cancer. She has two sisters living. Paternal uncle with sudden cardiac death in his 40's. Physical Exam: PHYSICAL EXAMINATION (on admission): VS: T=96.5 BP=95/49 HR=93 RR=17 O2 sat=98%2LNC GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD noted. CARDIAC: Harsh crescendo-decrescendo 2/6 systolic murmur heard throughout. 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. No abdominial bruits. EXTREMITIES: No c/c/e. Femoral cath site intact with no evidence of active bleeding. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 1+ Left: DP 1+ Pertinent Results: [**2124-12-6**] 10:30AM BLOOD WBC-4.9 RBC-3.67* Hgb-11.5* Hct-33.4* MCV-91 MCH-31.4 MCHC-34.5 RDW-12.2 Plt Ct-232 . [**2124-12-6**] 10:30AM BLOOD PT-10.8 PTT-32.4 INR(PT)-1.0 . [**2124-12-6**] 05:15PM BLOOD WBC-6.7 RBC-3.66* Hgb-11.2* Hct-34.2* MCV-93 MCH- 30.6 MCHC-32.8 RDW-12.1 Plt Ct-222 . [**2124-12-6**] 09:21PM BLOOD WBC-9.1 RBC-3.43* Hgb-10.9* Hct-31.3* MCV-91 MCH-31.7 MCHC-34.7 RDW-12.1 Plt Ct-240 . [**2124-12-6**] 10:30AM BLOOD Ret Aut-1.1* . [**2124-12-6**] 10:30AM BLOOD Glucose-128* UreaN-25* Creat-0.5 Na-139 K-4.0 Cl-106 HCO3-25 AnGap-12 . [**2124-12-6**] 10:30AM BLOOD ALT-32 AST-28 AlkPhos-48 Amylase-77 TotBili-0.3 . [**2124-12-6**] 03:08PM BLOOD Cholest-133 . [**2124-12-6**] 10:30AM BLOOD %HbA1c-5.8 eAG-120 . [**2124-12-6**] 03:08PM BLOOD Triglyc-43 HDL-56 CHOL/HD-2.4 LDLcalc-68 . MICROBIOLOGIC DATA: [**2124-12-6**] Urine culture - negative [**2124-12-6**] Staph aureus screening - pending . IMAGING STUDIES: [**2124-12-6**] CARDIAC CATH - Selective coronary angiography of this right-dominant system demonstrated no angiographically apparent flow-limiting disease. The LMCA, LAD, LCx and RCA had no significant stenoses. The RCA had the catheter deeply engaged with pleating but no fixed stenoses, it could not be selectively engaged without deep seating and damping. Limited resting hemodynamics revealed normal systemic arterial pressures. ortography revealed a dilated thoracic aorta. No angiographically apparent flow-limiting coronary artery disease. Normal systemic arterial pressures. Dilated thoracic aorta. . [**2124-12-7**] VASCULAR ULTRASOUND OF RIGHT GROIN - Color Doppler and spectral analysis of the vasculature of the right groin was performed. Normal arterial and venous waveforms were seen in the CFA and CFV, wihtout evidence of pseudoaneurysm. The common femoral and greater saphenous veins were compressible, and no filling defect was noted by Grey scale imaging. No focal fluid collection in the region of visible hematoma was observed. . [**2124-12-7**] CXR (PA AND LATERAL) - pending final read per radiology. Brief Hospital Course: 63F with a PMH significant for acute rheumatic fever in childhood, with known severe bicuspid aortic valve stenosis ([**Location (un) 109**] of 0.7 cm2) and aortic root dilation, now pre-op for AVR-Bental procedure on [**2125-1-2**], who came to [**Hospital1 18**] today for an elective pre-op left heart catheterization. The procedure was attempted radially but was technically not possible, so right femoral access was obtained. The patient was heparinized during the case due to this initial radial attempt. The femoral sheath was pulled and an appropriate ACT with good hemostasis was noted, but then the patient felt a popping sensation and developed hypotension and a new groin hematoma. She appeared to be having a vagal response, and was given Atropine and IVF with improvement. She was started on Dopamine gtt for hypotension, but this could not be completely weaned off. The patient was then transferred to the CCU for close monitoring. . # HYPOTENSION - Patient likely developed a vasovagal episode in the settiong of groin hematoma and compression at the time of her cardiac catheterization procedure. She received Atropine and IVF resuscitation with some repsonse, but then required initiation of Dopamine gtt which was subsequently weaned the morning following her procedure. Her anti-hypertensive medications were held in this setting. Her hematocrit was stable on serial evaluation (range 31-34%) without evidence of further bleeding on exam. We continued to monitor her hemodynamics serially and provided low-dose fluid boluses as needed. Her blood pressure was still mildly low in the 90-100 mmHg systolic range following Dopamine discontinuation and we held her Lisinopril and HCTZ at discharge. . # BICUSPID AORTIC VALVE, AORTIC ROOT DILATATION, AORTIC STENOSIS - Patient presents with valve area of 0.7 cm2. She denies dyspnea, syncope, lightheadedness, or pedal edema on this admission. Of note, her aortic aneurysm was found to be 4.5-cm. She is scheduled for upcoming AVR and aortic root replacement (Bentall procedure) with Cardiac Surgery in [**2124-12-24**]. She will continue her pre-op surgical evaluation prior to her procedure with Dr. [**Last Name (STitle) 914**] in [**Month (only) 404**]. . # GROIN HEMATOMA - In the cardiac catheterization lab, patient was noted to develop right femoral access site groin hematoma following sheath pull with subsequent vagal episode. Her hematoma was clinically monitored and appeared stable overnight. She had a stable hematocrit with no further evidence of bleeding. We maintained an active type and screen with peripheral IV access at all times. . # HYPOTHYROIDISM - We continued her home dosing of Levothyroxine 112 mcg PO daily. . # HYPERLIPIDEMIA - We continued her home dosing of Ezetimibe 10 mg PO daily and Simvastatin 40 mg PO daily. . TRANSITION OF CARE ISSUES: 1. Stopped Lisinopril and HCTZ at discharge because of low blood pressure. She will check BP the day after discharge and call Dr. [**Last Name (STitle) **] with the results. 2. Scheduled follow-up with Dr. [**Last Name (STitle) **] (her primary care physician) after discharge. 3. At the time of discharge, a chest X-ray and Staph aureus swab screening were pending. Medications on Admission: EZETIMIBE-SIMVASTATIN [VYTORIN 10-40] 10 mg/40 mg Tablet daily GENTAMICIN - 0.1 % Cream - apply twice daily HYDROCHLOROTHIAZIDE 25 mg daily KETOCONAZOLE - 2 % Cream - apply to rash daily LEVOTHYROXINE 112 mcg daily LISINOPRIL 40 mg daily TRIAMCINOLONE ACETONIDE 0.1 % Cream - apply to ears and neck daily for 7 to 10 days TYLENOL EXTRA STRENGTH 1000 mg [**Hospital1 **] CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE + D] Dosage uncertain. Discharge Medications: 1. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. 2. gentamicin 0.1 % Cream Sig: One (1) application Topical twice a day. 3. ketoconazole 2 % Cream Sig: One (1) application Topical once a day as needed for rash. 4. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for pain. 6. calcium citrate-vitamin D3 Oral Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Post-cardiac catheterization right femoral access site groin hematoma . Secondary Diagnoses: 1. Hypertension 2. Hyperlipidemia 3. Diabetes mellitus, type 2 4. Severe aortic stenosis 5. Bicuspid aortic valve 6. History of acute rheumatic fever 7. Aortic root dilatation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], . It was a pleasure taking care of you during yuor admission. You were admitted to the Coronary Care Unit (CCU) at [**Hospital1 771**] after you underwent elective cardiac catheterization prior to your planned valve surgery in [**Month (only) 404**] of [**2124**]. Following the procedure, you developed a small right groin hematoma (evidence of bleeding) and were closely monitored overnight in the CCU. You briefly required IV medication to support your low blood pressure. This medication was stopped and your blood pressure was stable but still slightly low. Your bleeding remained stable and your hematocrit (blooc count) was stable prior to discharge. Because your blood pressure was low, we have stopped your home antihypertensives, lisinopril and hydrochlorothiazide. As was discussed prior to discharge, please measure your blood pressure at any local pharmacy and call Dr. [**Last Name (STitle) **] with the results. Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. . CHANGES IN YOUR MEDICATIONS: . * Upon admission, we ADDED: NONE . * The following medications were DISCONTINUED on admission and you should NOT resume: -Lisinopril 40mg daily -Hydrochlorothiazide (HCTZ) 25mg daily . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: Department: [**Hospital **] MEDICAL GROUP When: THURSDAY [**2124-12-14**] at 9:00 AM With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2400**] [**Telephone/Fax (1) 133**] Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**] Campus: OFF CAMPUS Best Parking: On Street Parking Please call Dr. [**Last Name (STitle) **] tomorrow, [**2124-12-8**], with your blood pressure as he had discussed with you.

Admission Date: [**2111-10-16**] Discharge Date: [**2111-10-21**] Date of Birth: [**2055-11-20**] Sex: M Service: MEDICINE Allergies: Penicillins / Aspirin / Ibuprofen / Ciprofloxacin Attending:[**First Name3 (LF) 4393**] Chief Complaint: hypoxia and feeding tube replacement Major Surgical or Invasive Procedure: intubation on [**10-17**] Bronchoscopy History of Present Illness: 55-year-old male who is s/p orthotropic liver [**Month/Year (2) **] in [**Month (only) 205**] [**2108**] for alcoholic cirrhosis, history of colon cancer s/p colectomy, on rapamune who was discharged from the ICU on [**2111-9-22**] after an admission for sepsis, pneumonia, and severe malnutrition. He required intubation during that admission and sats were still low. He was bronched and suctioned for large mucus plugs. Given his mucus plugging he was ultimately trached. He then had an NG tube placed for his poor nutrition. The decision was made not to place a feeding tube due to the liver team's concerns of infection. . Per report from his nurse at rehab he weaned off the ventilator well. He was decanulated last week and tolerated it well. His NG tube had remained in place until earlier this week when it came out. 2 days ago there was an attempt to place a dubhoff but it could not be passed beyond the nasopharynx into the oropharynx. The catheter would repeatedly enter the trachea. He was supposed to have it placed under guidance yesterday but no anesthesiologist was available so he was sent back to Spauling without the dubhoff placed. He has received no TF or po medications since [**10-13**] with the exception of sirolimus which he has been allowed to take po. He's had no witnessed aspiration events. He's been on D5 1/2 NS at 80cc/hr. . Yesterday evening when he became very anxious about not getting the dubhoff placed and said that he felt like he would die. He dropped his sats to the 70s and was placed on a NRB and it took almost an hour for his sats to normalize. His o2 sats increased when he finally fell asleep. He was maintained on the NRB overnight. He was weaned to NC of 2L this Am but his sats dropped to 70s when at the side of the bed working with PT. Earlier this week he was satting fine on 0-2L. . His most recent set of vitals at rehab were afebrile, BP 148/104 (generally 130-low 140s), HR 85, RR24 and 97% on 2L NC. He has been taking ice chips. He has been getting ativan 0.5mg IV q 6hrs and morphine 2mg q3hrs. HCT was approx 29 on the 14th and 15th. Then on [**10-14**] and [**10-15**] HCT was 22. He received 2 units of blood and his HCT increased to 37.5. He was A & O x3 prior to transfer. . On arrival to the ICU, vital signs were 97.9 99 151/89 RR22 93% on 100% high flow face mask. He reports pain at the head of his penis and pain with urination. He also reports that over the last few days he has experienced spurts of SOB that occur suddenly. He then begins to feel anxious like he is going to die. This occurs on and off. He was decanulated last week and says that his cough has improved over this time. His cough is productive of bloody mucusy sputum but only after traumatic dubhoff placement. He denies fevers or chills. . Review of systems: (+) Per HPI , + for nausea, + for diarrhea less now that he has not taken po x several days. Last week had between [**1-30**] BMs a day. + for coughing up some blood since the attempts to place dubhoff. (-) Denies fever, chills. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, constipation, abdominal pain, no blood in stool, no black stool. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: #. Alcoholic cirrhosis, s/p Liver [**Month/Day (1) **] [**2109-6-6**], [**2109-6-23**] exploration for hematoma and fluid collection, last liver biopsy [**2110-3-14**] no acute cellular rejection, but [**Month/Day/Year 65**] for increased iron deposition. -H/o malnutrition -Prior ESLD c/b ascites, hepatorenal syndrome, grade II esophageal varices and portal gastropathy, candidal and bacterial (SBP) peritonitis Post-[**Month/Day/Year **] course has been complicated by diarrhea and malnutrition s/p extensive workup that has not found a cause. This diarrhea is controlled with cholestyramine, Imodium, tincture of opium, and he has [**12-31**] bowel movements a day. #. Recurrent UTIs: Most recent cultures ([**2110-5-7**]) grew pan sensitive kleb pnemonia and corynebacterium, but in the past has grown out resistant strains of pseudomonas sensitive only to meropenem ([**3-6**]), to amikacin ([**2-3**]). #. History of Torsades while on ciprofloxacin. - Of note: recent hospitalization [**4-5**] w/ multiple episodes of VT/torsades s/p magnesium & cardioversion x2. At that time thought [**12-30**] to meds (Reglan, celexa, lyrica and Bactrim) and contribution from congenital long QTc. QTc was 499-536 despite holding meds and given daily magnesium and potassium. - Cardiology evaluated him ad thought not a candidate at that time for implantable device given recent infections. Followed as outpatient by cardiology thought pt stress cardiomyopathy, recommended avoiding zofran. #. Anemia with baseline Hct 27-30 #. Hydroureteroephrosis/Urinary retention: Seen by [**Month/Day (2) **] as outpatient. Most recent OMR note: secondary to recurrent infections and that intermittent catheterization led to hydronephrosis. Managed w/ indwelling foley. #. Colorectal cancer (stage unknown) s/p colectomy in [**11/2108**] #. Cervical stenosis #. History of C Diff colitis #. History of depression #. BPH #. Chronic pancytopenia . PSH: s/p colectomy in [**11/2108**] s/p OLT [**2109-6-6**], s/p exlap for hematoma and fluid collection [**2109-6-23**] s/p exlap/LOA [**8-5**] s/p exlap/LOA/washout, temp closure [**8-5**] s/p exlap/abd closure, cmpt separation [**8-5**] s/p trach [**8-5**] s/p R hip fx [**2110-1-23**] Social History: Lives with daughter. Wife died 4 weeks ago. Has not had any ETOH use in "years." Smoking history: 1/2ppd for 20 yrs, quit over 5 years ago. No illicit drug use. Family History: Non-contributory Physical Exam: Admission PE: VS: Temp: afebrile, BP 148/104 (generally 130-low 140s), HR 85, RR24 and 97% on 2L NC GEN: Emaciated, chronically ill appearing man, alert and interactive HEENT: PERRL, EOMI grossly, anicteric, MMM, op without lesions. Trach site well healed. RESP: diffuse rhonci L lung> R CV: RR, S1 and S2 wnl, no m/r/g ABD: severly cachectic, decreased b/s, soft, nt, no masses or hepatosplenomegaly, + suprapubic tenderness EXT: mildly cold, thin extremities, DP and radial pulses intact, no edema or clubbing SKIN: no rashes/no jaundice/no splinters NEURO: A & O x3, UE and LE strength 5/5 Pertinent Results: [**2111-10-16**] 09:21PM BLOOD WBC-7.7# RBC-4.00*# Hgb-12.4*# Hct-36.0*# MCV-90 MCH-30.8 MCHC-34.3 RDW-15.2 Plt Ct-151 [**2111-10-17**] 02:36AM BLOOD WBC-8.2 RBC-4.03* Hgb-12.6* Hct-36.2* MCV-90 MCH-31.4 MCHC-35.0 RDW-15.3 Plt Ct-157 [**2111-10-18**] 04:08AM BLOOD WBC-4.4 RBC-3.06* Hgb-9.4*# Hct-27.0*# MCV-88 MCH-30.6 MCHC-34.7 RDW-15.0 Plt Ct-123* [**2111-10-19**] 05:11AM BLOOD WBC-3.0* RBC-3.10* Hgb-9.7* Hct-28.0* MCV-90 MCH-31.3 MCHC-34.6 RDW-15.1 Plt Ct-105* [**2111-10-20**] 04:18AM BLOOD WBC-3.7* RBC-3.24* Hgb-10.0* Hct-28.7* MCV-89 MCH-30.7 MCHC-34.7 RDW-14.9 Plt Ct-105* . [**2111-10-16**] 09:21PM BLOOD Neuts-79.8* Lymphs-14.2* Monos-3.4 Eos-2.1 Baso-0.5 [**2111-10-18**] 04:08AM BLOOD Neuts-70.6* Lymphs-18.7 Monos-4.0 Eos-6.4* Baso-0.3 . [**2111-10-16**] 09:21PM BLOOD PT-14.5* PTT-37.5* INR(PT)-1.3* [**2111-10-18**] 04:08AM BLOOD PT-14.5* PTT-37.0* INR(PT)-1.3* [**2111-10-19**] 05:11AM BLOOD PT-14.3* PTT-41.7* INR(PT)-1.2* [**2111-10-20**] 04:18AM BLOOD PT-13.8* PTT-37.8* INR(PT)-1.2* . [**2111-10-16**] 09:21PM BLOOD Glucose-72 UreaN-47* Creat-1.2 Na-140 K-5.2* Cl-108 HCO3-23 AnGap-14 [**2111-10-17**] 02:36AM BLOOD Glucose-79 UreaN-52* Creat-1.3* Na-139 K-5.4* Cl-107 HCO3-20* AnGap-17 [**2111-10-17**] 12:51PM BLOOD Glucose-122* UreaN-46* Creat-1.2 Na-134 K-5.4* Cl-103 HCO3-21* AnGap-15 [**2111-10-19**] 05:11AM BLOOD Glucose-81 UreaN-30* Creat-1.1 Na-133 K-3.7 Cl-105 HCO3-22 AnGap-10 [**2111-10-20**] 04:18AM BLOOD Glucose-102* UreaN-26* Creat-1.1 Na-137 K-3.7 Cl-106 HCO3-23 AnGap-12 . [**2111-10-16**] 09:21PM BLOOD ALT-46* AST-41* LD(LDH)-174 AlkPhos-147* TotBili-0.5 [**2111-10-17**] 02:36AM BLOOD ALT-45* AST-47* LD(LDH)-211 AlkPhos-147* TotBili-0.6 [**2111-10-18**] 04:08AM BLOOD ALT-32 AST-30 LD(LDH)-153 AlkPhos-121 TotBili-0.4 . [**2111-10-16**] 09:21PM BLOOD Albumin-3.1* Calcium-9.1 Phos-3.5 Mg-1.9 [**2111-10-18**] 04:08AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.7 [**2111-10-20**] 04:18AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.6 . [**2111-10-18**] 04:08AM BLOOD rapmycn-17.6* [**2111-10-19**] 05:11AM BLOOD rapmycn-7.8 . [**2111-10-18**] 04:55AM BLOOD Type-[**Last Name (un) **] Temp-36.4 pO2-43* pCO2-47* pH-7.33* calTCO2-26 Base XS--1 Intubat-INTUBATED [**2111-10-18**] 10:45AM BLOOD Type-[**Last Name (un) **] Temp-36.0 Rates-/20 Tidal V-450 FiO2-40 pO2-34* pCO2-47* pH-7.34* calTCO2-26 Base XS-0 Intubat-INTUBATED [**2111-10-18**] 12:37PM BLOOD Type-[**Last Name (un) **] Rates-/22 pO2-34* pCO2-45 pH-7.34* calTCO2-25 Base XS--1 Intubat-NOT INTUBA Comment-50% OPEN F . [**2111-10-17**] 01:50AM URINE RBC-21-50* WBC->50 Bacteri-FEW Yeast-NONE Epi-0 [**2111-10-17**] 01:50AM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [**2111-10-17**] 01:50AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.025 . [**2111-10-17**] 03:53PM BAL Polys-91* Lymphs-4* Monos-0 Eos-1* Macro-4* . [**2111-10-17**] 1:50 am URINE Source: Catheter. **FINAL REPORT [**2111-10-19**]** URINE CULTURE (Final [**2111-10-19**]): GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. GRAM NEGATIVE ROD(S). ~4000/ML. . [**2111-10-17**] 5:54 am SPUTUM Source: Expectorated. **FINAL REPORT [**2111-10-17**]** GRAM STAIN (Final [**2111-10-17**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. . [**2111-10-17**] 3:53 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2111-10-17**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2111-10-20**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. ~7000/ML. OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES PERFORMED ON CULTURE # 310-5543S [**2111-10-17**]. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2111-10-17**]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies is strongly suspected, contact the Microbiology Laboratory (7-2306). if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2111-10-18**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2111-10-19**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): . Cardiology Report ECG Study Date of [**2111-10-16**] 11:16:10 PM Normal sinus rhythm. Moderate baseline artifact. Low voltage in the limb leads. Poor R wave progression. Diffuse T wave flattening. Compared to the previous tracing of [**2111-9-12**] there was moderate baseline artifact in that tracing as well. There is probably no diagnostic interval change. Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M. Intervals Axes Rate PR QRS QT/QTc P QRS T 88 152 76 370/419 72 45 78 . Chest xray portable [**10-16**] IMPRESSION: AP chest compared to [**9-21**]: Large scale consolidation in the right lung has worsened appreciably since [**9-21**], while less pronounced consolidation in the left mid lung has improved. Left lung is markedly emphysematous. Small right pleural effusion has increased. No nasogastric tube is in place, but I cannot assess the caliber of the stomach. Patient has had tracheostomy in the past. These recurrent severe pneumonias suggest either free reflux or tracheoesophageal fistula. Heart size normal. No pneumothorax. . Brief Hospital Course: 55-year-old male who is s/p orthotropic liver [**Month (only) **] in [**Month (only) 205**] [**2108**] for alcoholic cirrhosis, history of colon cancer s/p colectomy, on sirolimus who presents with need for placement of Dobhoff tube and with hypoxia of 90% on 100% face mask. . #. Hypoxia: Infiltrates in his right lung on CXR are concerning for PNA. On admission, he required non-rebreather to maintain his sats. It was decided to electively intubate the patient for placement of his NJ tube endoscopically. A bronch was also performed which revealed RLL mucous plugging that was easily suctioned. His sputum was sent for culture from the BAL. He was started on vanco/meropenem for HAP coverage given his past respiratory isolates of pseudomonas sensitive only to meropenem. He was given aggressive chest PT and suctioning for thick secretions. After bronchoscopy, secretion burden lessened and he was easily extubated. He was transferred to the general liver wards for further management. Abx were continued for presumed HAP. He was mid 90s on RA and occasionally wearing NC O2 for comfort. Cough productive of yellow/white sputum reported per pt. No longer on O2 supplement at time of discharge. Plan to monitor vanco troughs daily and dose per level w goal 15-20 for total of 14 days, started on [**10-16**]. Dose needs to be adjusted to his renal function despite normal serum cr, pt is cachectic and has likely renal failure unaccounted for in normal labs. Cont meropenem as well. . #. Malnutrition: Pt without any po access at time of admission. Lost NG tube earlier this week and pt came to [**Hospital1 **] 2 days ago and they were unable to place dubhoff as it was coming out through trach site. Unfortunately pt returned to [**Hospital1 **] for guided placement of dobhoff but no anesthesiologist was available so pt unfortunately did not get it placed. NJ tube was placed in the ICU under endoscopic guidance. He was started on tube feeds per nutrition recs on [**10-19**]. Phos levels monitored for refeeding syndrome and repleted as needed. Plan for LTAC to monitor levels daily and replete as needed in acute refeeding period. . #. Normocytic Anemia: Baseline HCt per old notes 26-28. Likely anemia of chronic disease [**12-30**] liver failure. B12 and folate have been normal/high in the past also. [**First Name8 (NamePattern2) **] [**Hospital1 **] signout HCT was approx 29 on the 14th and 15th. Then on [**10-14**] and [**10-15**] HCT was 22. He received 2 units of blood and his HCT increased to 37.5 at rehab. HCT here 36. Unclear whether low HCT could have been secondary to traumatic placement of dubhoff. Increased HCT likely secondary to hemoconcentration in the setting of NPO although his platelets are not hemoconcentrated. Hct had been stable on the general wards and at his baseline. He did not require transfusion of any blood products during his stay. . #. Alcoholic cirrhosis s/p liver [**Month/Year (2) **] in [**2108**]: AST/ALT/Alk ph all elevated from baseline. Post-[**Year (4 digits) **] course has been complicated by diarrhea and malnutrition s/p extensive workup with no obvious cause. This diarrhea in the past was controlled with cholestyramine, Immodium, tincture of opium. Sirolimus was restarted when PO access became available. He was restarted on 2mg daily w drug levels followed. Dosing based on labs. . #. Irritation at urethral meatus/pain with urination: Lidocaine was used for comfort. Pt with long h/o UTIs. Urine culture did not suggest acute UTI - inconclusive results. Pt afebrile w resolved leukocytosis on vanco and meropenem for HAP. . #. Depression/anxiety: Home antidepressants were held until dobhoff in place. Psychiatry to follow at [**Name (NI) **] - pt would benefit from therapy and acute grief counseling. Would consider adding antidepressant if clinically appropriate. uptitrated remeron for incr'd appetite. . #. Chronic pancytopenia: Relative leukocytosis w left shift WBC 7.7 on admission, likely indicating infection. This fell with treatment of pneumonia. Cell counts at baseline at time of discharge. . #. Pain control: Lidocaine patch, fentanyl patch, po oxycodone and IV morphine were continued. . #. Comm: [**Name (NI) 4489**] [**Name (NI) 102989**] (mother) [**Telephone/Fax (1) 103052**]; [**Doctor Last Name **] (daughter) [**Telephone/Fax (1) 103053**] Medications on Admission: --amitriptyline 50 mg po qhs --mirtazapine 15 mg PO HS --sirolimus 3 mg PO DAILY (1mg/ml oral solution) --ferrous sulfate 300mg/5ml TID --calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet 1 tab twice a day. --multivitamin PO DAILY --thiamine HCl 100 mg po daily --albuterol 90mcg inhaler 4 puffs q4hrs --fentanyl patch 12mcg/hr q72hrs (last changed on [**10-15**]) --fondaparinux 2.5mg/0.5ml 2.5mg sq daily --guaifenesin 600mg [**Hospital1 **] --omeprazole 20mg daily --protein supplement- beneprotein resource instant protein 2 scoops [**Hospital1 **] --trazodone 12.5mg qhs --xenaderm ointment TP TID --ativan 0.5mg IV q6hrs prn anxiety --morphine 2mg IV every 3 hrs --compazine 10mg q6hrs prn nausea --oxycodone 7.5mg q3hrs prn pain Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) injection Injection TID (3 times a day): for dvt prophylaxis to be continued while bedbound and at rehab. 2. lidocaine HCl 2 % Gel [**Hospital1 **]: One (1) Appl Mucous membrane PRN (as needed) as needed for pain at urethral meatus . 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 4. fentanyl 12 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): last change [**10-18**]. 5. therapeutic multivitamin Liquid [**Month/Year (2) **]: Five (5) ML PO DAILY (Daily). 6. amitriptyline 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at bedtime). 7. mirtazapine 15 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO HS (at bedtime). 8. sirolimus 1 mg/mL Solution [**Month/Year (2) **]: Two (2) ml PO DAILY (Daily). 9. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Month/Year (2) **]: Five (5) ml PO TID (3 times a day). 10. oxycodone 5 mg/5 mL Solution [**Month/Year (2) **]: 7.5 ml PO Q4H (every 4 hours) as needed for pain: hold for sedation. 11. thiamine HCl 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 12. guaifenesin 100 mg/5 mL Syrup [**Month/Year (2) **]: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Year (2) **]: Four (4) Puff Inhalation Q4H (every 4 hours) as needed for SOB, wheezing. 14. heparin, porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 15. lorazepam 0.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 16. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable PO BID (2 times a day). 17. prochlorperazine Edisylate 5 mg/mL Solution [**Month/Year (2) **]: Ten (10) mg Injection Q6H (every 6 hours) as needed for nausea. 18. morphine 100 mg/4 mL Solution [**Month/Year (2) **]: Two (2) mg Intravenous q3h as needed for pain: hold for sedation or RR<12. 19. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 20. meropenem 1 gram Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln Intravenous every twelve (12) hours for 9 days. 21. potassium & sodium phosphates 280-160-250 mg Powder in Packet [**Last Name (STitle) **]: Two (2) Packet PO once a day: consider dc at follow up at hepatology [**10-28**]. 22. vancomycin 1,000 mg Recon Soln [**Month/Day (4) **]: dose by level Intravenous dose by level for 9 days: goal trough 15-20. please follow daily levels, dose by level. . Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Hospital acquired pneumonia Malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital from rehab for low oxygen and pneumonia. You were started on antibiotics that must be continued through your PICC line. You also required replacement of your feeding tube. You required intubation for your breathing and for stability while your tube was replaced. Tubefeeds were restarted on [**10-19**]. You were restarted on your home medications as well. . The following changes were made to your medications: STARTED Vancomycin IV antibiotic for 2 week course (day 1 [**10-16**]) STARTED Meropenem IV antibiotic for 2 week course (day 1 [**10-16**]) RESTARTED tubefeeds STARTED Phosphate supplement during initial restart of tubefeeds to prevent refeeding syndrome/hypophosphatemia INCREASED Remeron for better appetite . We recommend that you continue to see psychiatry at [**Hospital1 **] to see if you require an antidepressant or additional therapy. Continued on sirolimus, vitamin supplements, home anti-depressants . Please follow up with your physicians as stated below. Followup Instructions: Department: [**Hospital1 **] When: WEDNESDAY [**2111-10-28**] at 8:40 AM With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital Ward Name **] When: WEDNESDAY [**2111-11-4**] at 1:20 PM With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]

Admission Date: [**2145-6-30**] Discharge Date: [**2145-7-6**] Date of Birth: [**2074-10-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: 70yo Chinese speaking man with history of previous IMI [**2134**], hypertension, and borderline diabetes, recent admission for dyspnea found to have CAD with 3VD, EF of 20% and 3+MR and 2+AR with plan for medical management of CAD/CHF. He presented with SOB. In ED initially felt to be in CHF and siuresed. THen found to have several subsegmental PE's. He required a NRB for a time. He was transferred to the CCU with hypotension. Given his poor cardiac function, it was felt he was hemodynamically unstable and would benefit from lysis of PE. TPA and heparin administered. Afterwards, he developed a hematoma on L groin site in area of prior catheterization. This responded to pressure. He remained hemodynamically stable with several small IVF boluses. Past Medical History: CAD s/p inferior MI [**2134**], 3 vessel CAD 3+ MR Hypertension Borderline diabetes mellitus; untreated Social History: Patient lives in [**Country 651**], visiting son in the US. Denies tob, EtOH, illicit drug use. Poor English with need for interpreter. Family History: Brother MI 75yrs, Mother MI 80s Physical Exam: Afebrile, 100-120, 90/60, 24, 90% initially on 4 L (went down to 65% in ED->NRB improved to 90%) GENL: mild respiratory distress HEENT: OP clear, PERL, CV: RRR, +systolic murmur LUNGS: crackles 3/4 up Abd: soft, nt, nd, +bs Ext: trace pedal edema Pertinent Results: [**2145-6-30**] 07:40PM HCT-32.8* [**2145-6-30**] 07:40PM PTT-91.2* [**2145-6-30**] 04:15PM FIBRINOGE-242 [**2145-6-30**] 03:46PM WBC-15.0* RBC-4.15* HGB-12.1* HCT-35.6* MCV-86 MCH-29.1 MCHC-34.0 RDW-13.6 [**2145-6-30**] 03:46PM PLT COUNT-237 [**2145-6-30**] 08:54AM TYPE-ART RATES-/30 PO2-171* PCO2-45 PH-7.44 TOTAL CO2-32* BASE XS-6 INTUBATED-NOT INTUBA VENT-SPONTANEOU COMMENTS-NON-REBREA [**2145-6-30**] 08:00AM GLUCOSE-170* UREA N-18 CREAT-1.2 SODIUM-139 POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17 [**2145-6-30**] 08:00AM CK(CPK)-38 [**2145-6-30**] 08:00AM cTropnT-0.06* [**2145-6-30**] 08:00AM CK-MB-NotDone [**2145-6-30**] 03:54AM CK(CPK)-35* [**2145-6-30**] 03:54AM cTropnT-0.10* [**2145-6-29**] 07:56PM LACTATE-2.2* [**2145-6-29**] 07:30PM CK-MB-NotDone cTropnT-0.13* [**2145-6-29**] 07:30PM ALBUMIN-4.4 [**2145-7-6**] INR 2.6 PTT 19.8 [**2145-6-29**] ABD CT INDICATION: Right upper quadrant pain IMPRESSION: Technically limited exam with no gallstones identified. There is apparent mild/moderate bilateral hydronephrosis, right greater than left and likley due to high post-void residual. EKG: Baseline artifact. Sinus tachycardia. Left axis deviation. Non-specific intraventricular conduction delay. Left atrial abnormality. Q waves in the inferior leads with possible ST segment elevation. Non-specific lateral ST-T wave changes. Compared to the previous tracing of [**2145-6-26**] possible inferior ST segment elevation is new. If ischemia is a clinical concern, a repeat tracing is recommended. [**2145-6-29**] CXR: IMPRESSION: 1. Persistent CHF. 2. Stable left lower lobe opacity, probably representing atelectasis. 6/22/05CT reconstruction IMPRESSION: 1. Bilateral pulmonary emboli as described above. 2. Multiple right-sided lung nodules. In the absence of known malignancy, followup CT scan in 12 months may be performed. In the presence of primary malignancy, followup scan in 3 months may be performed. 3. Multiple likely bilateral renal cysts. 4. Small hypodense lesion in the inferior portion of the spleen, too small to characterize, that may represent a small hemangioma. 5. Aneyrusmal dilatation of the common iliac arteries [**2145-7-4**] EKGSinus rhythm. Left axis deviation. Non-specific intraventricular conduction delay. Left atrial abnormality. Q waves in the inferior leads consistent with prior inferior myocardial infarction. Non-specific anterior and lateral ST-T wave changes. Compared to the previous tracing of [**2145-6-30**] ST-T wave changes are more extensive. Brief Hospital Course: 1) Pulmonary Emboli - As stated in the HPI, the patient presented with SOB and some right epigastric vs. pleuritic chest pain. A CTA was done with showed multiple bilateral pulmonary emboli, and due to the patients SOB and hypotension in the setting of severe ischemic cardiomyopathy, the patient given lysis treatment with tPA. He was started on Heparin for anticoagulation and transitioned to coumadin by discharge. His symptoms of SOB improved daily and his breathing was baseline at discharge. 2) CHF - The patient has known ischemic cardiomyopathy with NYHA Class III CHF. Initially many of his medications were held due to hypotension, but as the patient's BP stabalized and he clinically improved, he was placed back on all of the medications from prior hospitalization, including lasix, sprinolactone, lisinopril, and carvedilol, and imdur. 3) CAD - known 2 VD, not surgical candidate, s/p failure of PTCA attempt. EKG c/w pulmonary emboli with no evidence of acute or ongoing ischemia during hospitalization. Continued to optimize medical management of patient with ASA, plavix, atrovastatin, carvedilol, lisinopril, imdur, SL nitro PRN, and above medications. 4) Hyperglycemia - the patient showed evidence of glucose intolerance. A converstaion was had regarding the need to treat, and it was decided that while the patient was inhospital with sickness that could elevate blood sugars, treatment was not felt to be necessary. However, this decision was made with the idea that the patient would have the issued addressed more fully as an outpt. 5) FEN - SBP remained 90-100's. Ate a cardiac/heart healthy diet. Received daily potassium. 6) PPX - heparin to prevent DVT's and PPI to prevent stress ulcer 7) Dispo - discharged home to son's place in [**Location (un) **], wife accompanying. F/U scheduled with Dr. [**Last Name (STitle) **] on Friday [**7-9**] at 2:30 pm at [**Hospital6 733**] in [**Hospital Ward Name 23**] 6. Additional f/u on [**7-19**] with Dr. [**Last Name (STitle) **] of cardiology and [**7-26**] with Dr. [**First Name (STitle) 3037**] in [**Hospital 191**] clinic. VNA will follow patient's INR in meantime and call Dr. [**First Name (STitle) 3037**] to make decision regarding coumadin dosing. Medications on Admission: Meds (from recent d/c summary) Aspirin 325 mg Tablet QD Atorvastatin Calcium 80 mg QD Clopidogrel 75 mg QD Docusate Sodium 100 mg [**Hospital1 **] Senna 8.6 mg PRN Nitroglycerin 0.3 mg PRN chest pain Lisinopril 30 mg QD Isosorbide Mononitrate 30 mg QD Furosemide 40 mg QD Spironolactone 25 mg QD Toprol XL 50 mg QD Discharge Medications: 1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). Disp:*30 Tablet, Sublingual(s)* Refills:*2* 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 8. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 12. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. Disp:*40 Capsule(s)* Refills:*0* 15. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: CHF PE CAD T2DM Discharge Condition: Stable. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 liters. Please return to the emergency room if you have severe shortness of breath, chest pain, palpitations or any other symptom that bothers you. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] on Friday [**7-9**] at 2:30 pm at [**Hospital6 733**] in [**Hospital Ward Name 23**] 6. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3037**] on [**7-26**] at 1:30 pm at [**Hospital6 733**] in [**Hospital Ward Name 23**] 6. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**7-19**] at 3:15pm at [**Hospital Ward Name 23**] [**Location (un) 436**].

Admission Date: [**2161-8-6**] Discharge Date: [**2161-8-13**] Date of Birth: [**2077-7-15**] Sex: M Service: MEDICINE Allergies: Aspirin / Hydrochlorothiazide Attending:[**First Name3 (LF) 689**] Chief Complaint: hyponatremia, fatigue Major Surgical or Invasive Procedure: None. History of Present Illness: 84 year old male with history recent kidney stone, recent travel to [**Country 14635**], presents with increased lethargy, constipation, back pain, and decreased appetite. He was admitted in [**Month (only) 205**] with kidney stone and pyelonephritis. He was treated with antibiotics, he passed the stone and he felt much improved. He went on a trip to [**Country 14635**] and was very active and feeling well. He had been told to hold his Hyzaar until he returned from his trip and to drink plenty of fluids (2L daily). He noted that he had new peripheral edema, for which he reduced his sodium intake. He has a oral intake of about 2L of fluid daily, he is certain it is not more than than, and tried to meet that goal daily. He returned from his trip on [**7-14**] feeling well. He resumed his Hyzaar on [**7-16**] and noted that his low back pain had started once again. He thought it was another kidney stone. Around [**7-24**] he noticed that he was lethargic. He was less active, tired, and moving more slowly. He became progressively more lethargic. He was unable to do chores, driving due to sleepiness, or extensive walking, but maintaining ADLs. He noted a new tremor in his right hand over the last week and half prior to admission. He was urinating 4-5 times daily due to increased fluid intake. He urinated small to moderate quantities. He was unsure if he voided completely. He denies urgency. He also complained of low back pain at the level of the CVA, and felt the pain is similar to when he had kidney stones. He also complained of abdominal pain, band like. He had been constipated for 1 week. No flatus but burping. He had no nausea vomiting. He complained of reduced appetite. Wt loss 20 lbs over 5 years intentionally. He noticed worsening vision, d/x of glaucoma in right eye, however, he noticed this prior to symptoms of weakness. He went to see his PCP on the day of admission who checked his sodium which was 126 and he was sent to the ED. CXR unremarkable, lots of bowel loops. He received 1000 cc NS, morphine. In the ED, initial VS: 97.7 80 158/73 18 100. Normal mental status. Vitals prior to medicine admit: 76 182/72 20 98/RA. ROS: Denied fever, chills, night sweats, headache, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1.) Diabetes Type II: on Metformin, HgbA1c in [**2-9**]: 6.1 2.) Coronary artery disease status post CABG 20yrs ago Normal stress test [**6-10**]; Echo [**9-10**]: EF 50% 3.) Hypertension-stable, well-controlled 4.) Hyperlipidemia: [**12-12**]: Tchol 126, TG 76, HDL 52, LDL 59 5.) Abdominal aortic aneurysm; infrarenal, 3.6 cm, stable by abd u/s [**8-11**] 6.) Right Common Iliac aneurysm, 2.3 cm, stable by u/s [**8-11**] 7.) Bilateral internal carotid artery stenosis, <40% by doppler [**8-11**] 8.) Stroke, h/o TIA - in [**2156-2-2**] 9.) Mitral regurgitation- mild-moderate, stable 10.) Transaminitis with normal synthetic function, stable, followed in GI 11.) TURP 20 years ago for obstruction [**1-5**] BPH after CABG [**63**].) Nephrolithiasis, 1st episode [**6-11**], 4mm distal uric acid stone passed w conservative tx; currently on flomax per urology recs. Social History: The patient lives in [**Location 3320**] with his wife. [**Name (NI) **] has four healthy children. He does not drink alcohol, smoke, or use drugs with no history of the above. He is currently not working, having retired from accounting 25 years ago. He was injured in his left leg by an explosive during WWII. He was the first person in his division to be awarded a Purple Heart. He has been an active man previous to this most recent state. Family History: elder son with DM. no history of cancer. Physical Exam: ADMISSION: Vitals - T:97 BP:150/82 HR:87 RR:22 02 sat:97RA GENERAL: elderly gentleman, appears stated age, appears fatigued HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNG: Poor inspiratory effort. No rales, wheezes, rhonchi. ABDOMEN: soft, non distended, non tender. EXT: no clubbing or cyanosis. has 1+ pitting edema up to mid calf.2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&OX3. Appropriate. CN2-12 intact. Preserved sensation throughout. [**4-7**] strenth in upper extremities and lower extremties, but has difficulty pushing without falling backwards. Sensation is generally intact. Rectal exam - good tone, no blood. DERM: Small scattered bruises noted on upper extremities. PSYCH: Listens and responds to questions appropriately, pleasant DISCHARGE: Vitals: T: 97.6 HR: 78 BP: 102/89 RR: 18 O2sat: 97%RA Orthostatic BP measurements wnl. GENERAL: elderly gentleman, appears stated age, A+Ox3, NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. Some redness and watery exudate from L eye. MMM. OP clear. Left TM without erythema or edema, no vesicles or evidence of infection. NECK: Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNG: CTAB. No rales, wheezes, rhonchi. ABDOMEN: soft, non distended, slightly ttp in LLQ. EXT: no clubbing or cyanosis. has 1+ pitting edema up to mid calf.2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&OX3. Appropriate. CN2-12 intact except baseline R lid lag, and new L sided facial droop, inability to fully close L eye, L sided nasolabial flattening, decreased ability to raise L eyebrow, and asymetric smile. Preserved sensation throughout-patient has baseline loss of sensation in LLE from trauma. 5/5 strength in upper extremities and lower extremties. PSYCH: Listens and responds to questions appropriately, pleasant, alert and oriented * [**1-6**] ( sometimes misses date) Pertinent Results: ADMISSION LABS: [**2161-8-6**] 09:40AM BLOOD WBC-12.2* RBC-4.18* Hgb-13.1* Hct-37.8* MCV-90 MCH-31.4 MCHC-34.7 RDW-13.1 Plt Ct-176 [**2161-8-6**] 09:40AM BLOOD Neuts-74.0* Lymphs-19.4 Monos-5.5 Eos-0.7 Baso-0.3 [**2161-8-6**] 09:40AM BLOOD Plt Ct-176 [**2161-8-6**] 09:40AM BLOOD Glucose-148* UreaN-24* Creat-1.0 Na-122* K-3.4 Cl-83* HCO3-27 AnGap-15 [**2161-8-6**] 09:40AM BLOOD ALT-28 AST-28 CK(CPK)-181* AlkPhos-107 TotBili-1.1 [**2161-8-6**] 09:40AM BLOOD CK-MB-9 [**2161-8-6**] 09:40AM BLOOD cTropnT-<0.01 [**2161-8-6**] 09:40AM BLOOD Calcium-9.7 Phos-2.6* Mg-1.6 NADIR SODIUM: [**2161-8-7**] 03:00PM BLOOD Na-120* UOsms: [**2161-8-7**] 02:58AM URINE Osmolal-527 [**2161-8-7**] 02:15PM URINE Osmolal-572 [**2161-8-8**] 01:46AM URINE Osmolal-481 [**2161-8-8**] 06:34PM URINE Osmolal-653 [**2161-8-10**] 02:50PM URINE Osmolal-702 [**2161-8-11**] 07:34PM URINE Osmolal-697 DISCHARGE LABS: [**2161-8-11**] 06:35AM BLOOD WBC-9.2 RBC-4.11* Hgb-12.9* Hct-38.3* MCV-93 MCH-31.3 MCHC-33.5 RDW-13.5 Plt Ct-175 [**2161-8-12**] 07:10AM BLOOD Glucose-153* UreaN-23* Creat-0.8 Na-136 K-4.0 Cl-98 HCO3-26 AnGap-16 [**2161-8-10**] 03:44AM BLOOD cTropnT-<0.01 [**2161-8-9**] 10:55PM BLOOD cTropnT-<0.01 [**2161-8-9**] 07:50PM BLOOD cTropnT-<0.01 [**2161-8-12**] 07:10AM BLOOD Calcium-9.4 Phos-2.4* Mg-1.7 [**2161-8-6**] 07:35PM BLOOD TSH-0.59 [**2161-8-7**] 07:20AM BLOOD Cortsol-20.4* Lyme and HSV serologies PENDING. IMAGING: CT/CTA Head [**2161-8-9**]: IMPRESSION: 1. Similar multifocal lucencies within the bihemispheric supratentorial white matter, much of which likely relates to chronic microvascular disease, though the presence of an acute infarct cannot be excluded and could be further evaluated with dedicated MRI as indicated clinically. 2. Intracranial vascular variant as detailed above, with multifocal ectasia with a 2 mm aneurysm at the left A3 origin as detailed. 3. Multifocal atherosclerotic disease with a focal irregularity within the high cervical segment of the right internal carotid artery which may be artifactual, though it is concerning for the possibility of a focal dissection versus ulcerative plaque. Further imaging with dedicated MRA with the T1 fat saturated sequence is recommended in further evaluation of this finding. 4. Extensive atherosclerotic disease of the right vertebral artery with near complete occlusion proximally. 5. Extensive multilevel degenerative changes of the cervical spine, which could be further evaluated with dedicated cervical spine MRI as indicated clinically. 6. Heterogeneous thyroid gland, which may represent an underlying multinodular goiter and should be correlated with patient's clinical course and son[**Name (NI) 493**] findings. CAROTID U/S [**2161-8-11**]: IMPRESSION: Less than 40% stenosis of the bilateral internal carotid arteries. No flow detected in the right vertebral artery (likely occlusion). CARDIAC ECHO [**2161-8-11**]: LVEF: 60% No cardiac source of embolus identified (cannot definitively exclude). Compared with the prior study (images reviewed) of [**2160-9-9**], left ventricular systolic function is probably similar although images are technically suboptimal for comparison. Mitral regurgitation is now less prominent and estimated pulmonary artery systolic pressure is now lower. MRI/MRA Head and Neck with T1 dissection protocol [**2161-8-12**] Wet Read: No evidence of R ICA dissection. No evidence of acute ischemia or bleed. Extensive white matter changes consistent with chronic microvascular infarcts. Brief Hospital Course: MICU COURSE. Patient was admitted to MICU for hypertonic saline for sodiumd of 120 on [**2161-8-6**] (his nadir). He was started on hypertonic saline at 30ml/hr. Goal was to correct by 10 mEq/L over first 24 hours, and with correction not to exceed 0.5 mEq/L per hour. He was also placed on fluid restriction 750 ml per day and HCTZ-Losartan was held. Upon transfer to the floors, sodium had increased to 129. The patient also had a transient hypokalemia of 3.2 on [**2161-8-7**]. His potassium was repleted and was found to be normal throughout the remainder of this admission. FLOOR COURSE: On [**2161-8-9**], the patient was transferred to medicine. On the floor, the patient appeared in NAD with improved lethargy, and was alert and oriented to person, place, and time. A serum cortisol was slightly elevated at 20.4 and a TSH was normal. The etiology of his hyponatremia was deemed to be due to his high fluid intake over the past few months and his decreased sodium intake, in addition to his HCTZ use. He was continued on a 750 mL fluid restriction, high sodium diet, and was kept off of HCTZ. His serum sodium trended towards normal and was 133 by [**2161-8-11**]; on this date he was increased to a 1L daily fluid allowance, per nephrology recommendations. His serum creatinine remained normal throughout admission. On the day prior to discharge, he had a serum sodium of 136. Urine osmolarities showed upward trend on fluid restriction. Patient was discharged on 1- 1.5L fluid restriction. On [**2161-8-10**], the patient was noted to have a new left sided facial droop. He was triggered for stroke and neurology evaluated the patient. CT/CTA of head/brain showed no acute infarct or bleed but there was a question of artifact vs. focal dissection in the right ICA. An MRI/MRA of brain/neck on [**2161-8-11**] confirmed no acute infarct or bleed and showed no evidence of focal R ICA dissection. The patient was ruled out for stroke, and 3 sets of troponins were done and found to be normal. Carotid u/s on [**2161-8-11**] showed stable 40% ICA stenosis bilaterally and cardiac echo showed no evidence of thrombus formation and LVEF of 60%. His neuro exam over the next 48 hours progressed to include the upper part of the left face, and the patient was diagnosed with Bell's Palsy. Ear and skin examination showed no evidence of herpes zoster or other infection. HSV and Lyme titers were drawn and pending at the time of discharge per neurology recommendations. The patient was started on a one week course of 60 mg po prednisone daily for his Bells Palsy on [**2161-8-12**] with no taper. He was also started on a nightly eye patch and artificial tear lubricant to prevent corneal dryness. In addition, since Lyme serologies are pending, we are empirically treating patient with po doxycycline x 21 days and recommend follow-up of labs by patient's PCP and rehab facility (results should be back by Tuesday, [**2161-8-18**]). During this hospitalization, the patient also had complained of upper back pain (initially [**9-12**], radiating down arms bilaterally). Xrays of the total spine were completed and showed only degenerative changes. The patient's pain improved on Tylenol and was deemed to be musculoskeletal in origin. The patient was continued on his home medications for CAD and HTN during admission, with the exception of HCTZ which was discontinued. His blood pressures were noted to trend up during his hospital course to systolic BPs in the 150s-160s. Once acute cerebral infarct/ischemia was ruled out by imaging, the patient's atenolol was increased from 37.5 mg daily to 50 mg daily for better blood pressure control ([**2161-8-12**]). He continued on Losartan 100 mg po daily. His vital signs were stable throughout admission. The patient was deemed medically stable for discharge on [**2161-8-12**]. He was evaluated by physical therapy who determined that the patient would benefit from discharge to a rehabilitation facility. He has been informed to have close follow-up with his primary care physician within two weeks of discharge from rehab. A follow-up appointment has been made for the patient with urology, as he will likely require a different prevention approach regarding his nephrolithiasis. The patient was FULL CODE during this admission Medications on Admission: Atenolol 25 mg once a day Tamsulosin 0.4 mg capsule SR, once a day Clopidogrel [Plavix] 75 mg Tablet once a day Dorzolamide-Timolol [Cosopt] 0.5 %-2 % Drops twice a day Lumigan 1 drop nightly right eye Losartan-Hydrochlorothiazide [Hyzaar] 100 mg-25 mg by mouth twice a day Metformin 500 mg Sust Rel by mouth once a day Simvastatin 40 mg by mouth once a day Multivitamin by mouth daily Omega-3 Fatty Acids-Vitamin E by mouth once a day Vitamin D Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for back pain. 9. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) ML Rectal PRN (as needed) as needed for constipation. 13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO twice a day as needed for constipation: hold for diarrhea. 15. Erythromycin 5 mg/g Ointment Sig: One (1) thin ribbon Ophthalmic twice a day as needed for eye redness for 5 days: apply to bottom inner eyelid of left eye. 16. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) as needed for Bells Palsy for 6 days. 17. Lumigan 0.03 % Drops Sig: One (1) drop Ophthalmic at bedtime: one drop nightly in right eye. 18. Metformin 500 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 19. Doxycycline Monohydrate 100 mg Capsule Sig: One (1) Capsule PO twice a day for 21 days: PLEASE FOLLOW-UP LYME SEROLOGIES AT [**Hospital1 18**] on [**2161-8-18**], IF LYME NEGATIVE, DISCONTINUE THIS MEDICATION. Thank you. 20. Polyvinyl Alcohol 1.4 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day) as needed for eye dryness, Bells Palsy. 21. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 23. Insulin Lispro 100 unit/mL Solution Sig: as directed units Subcutaneous QIDAC: per sliding scale attached. 24. Tears Again Ointment Sig: One (1) thin ribbon Ophthalmic at bedtime: hold while on erythromycin, apply to help prevent eye dryness at night with bell's palsy. Discharge Disposition: Extended Care Facility: [**Hospital1 11057**] Nursing & Rehabilitation Center - [**Location (un) 3320**] Discharge Diagnosis: Hyponatremia Bells Palsy Musculoskeletal Back Pain Discharge Condition: Stable, Na 136. Discharge Instructions: Mr. [**Known lastname 93960**], you were admitted to the hospital because of hyponatremia, or low blood sodium level. This caused you to have confusion and lethargy prior to presenting to the hospital. You were originally treated with intravenous hypertonic saline in the medical intensive care unit. You were shortly after transferred to the medicine floor for further management. We initially restricted your daily fluid intake, and closely monitored your serum sodium levels. Your sodium levels improved to normal during your stay. We think that you had low sodium levels because you were drinking large amounts of water (2 liters/day) to prevent kidney stones, and because your medication, Hyzaar, contained hydrochlorothiazide, which is known to potentially cause low blood sodium. At home please watch what you drink and only drink 1 liter per day. A follow up appointment has been made for you with urology so that they can determine the appropriate kidney stone prevention plan. While you are in rehab, your sodium level should be checked once daily for the first week to ensure that your sodium level remains normal. You were also found to have a new left lower facial droop while in the hospital, which began on [**2161-8-9**] and progressed to involve the upper part of your left face as well. You were evaluated by neurology, and CT and MRI scans of your brain and neck showed no evidence of stroke. Carotid artery ultrasound and cardiac echocardiogram were normal and without change. Given your symptoms and the negative head imaging, you were diagnosed with Bells Palsy. Bells Palsy is a self-limited condition that is often due to an unclear reason but can be due to viral or bacterial infection. It is estimated that 85% of people show signs of recovery within three weeks and 71% of people have complete recovery. We tested your blood for herpes simplex virus and Lyme disease to see if perhaps these infections caused your symptoms. These tests were pending at the time of discharge, and may be followed-up by your primary care provider as an outpatient. As we await the results of these tests, we will empirically treat you with Doxycycline antibiotic for presumed Lyme infection. If the Lyme test returns negative, you may stop this medication. This lab result should be resulted by Tuesday [**2161-8-18**], and your physician at the rehabilitation facility or your primary care provider should follow this up for you. You were started on a one week course of prednisone for the Bells Palsy. Once you are out of rehab, you should see your primary care provider within two weeks so that he may assess you and manage your condition further if needed. In addition, you had complained of back pain during this admission. X-rays done of your complete spine showed only bony arthritic changes that are expected findings as people age. Your pain was likely related to a musculoskeletal strain, and improved over the time you were admitted in the hospital on Tylenol and a Lidocaine patch as needed. As you also complained of constipation, we placed you on a bowel medication regimen as outlined below in the medication section. Lastly, you were found to have elevated blood pressure once we stopped your Hyzaar. We continued you on Losartan, and increased your atenolol from 37.5 mg daily to 50 mg daily. You were deemed medically stable for discharge to a rehabilitation facility on [**2161-8-12**]. Physical therapy evaluated you and felt that a rehab facility would help you increase your strength prior to going home. Should you have any worsening or new lethargy, neurological symptoms, pain, or any other concerning symptom you should be seen by a medical provider [**Name Initial (PRE) 2227**]. The following changes have been made to your medications: STOPPED: HYZAAR CHANGED MEDICATIONS: Atenolol 25 mg po once daily --->to Atenolol 50 mg po once daily NEW MEDICATIONS: *Losartan 100 mg po once daily for high blood pressure *Prednisone 60 mg po once daily for 7 days then stop (no taper needed) for Bells Palsy *Docusate Sodium 100 mg capsule take one twice per day for constipation. *Senna 8.6 mg tablet, take one twice per day for constipation. *Bisacodyl 5 mg tablet, 2 tabs once daily for constipation, hold for diarrhea. *Lactulose syrup 30 mL, take once every 6 hours as needed for constipation. *Fleet enema, as needed for constipation *Acetaminophen 500 mg tablet, take 1-2 tabs every 6 hours as needed for pain. *Lidocaine 5% patch one patch daily as needed for back pain. *Erythromycin 5mg/g ointment, apply one thin ribbon to bottom L inner eyelid twice daily for eye redness. *Tears Again 1.4% drops, 1-2 drops into the left eye three times per day for left eye dryness until Bells Palsy resolves. *Doxycycline 100 mg twice daily x 21 days for infection. Followup Instructions: You have the following appointments: Vascular Surgery Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Location: [**Location (un) **], [**Hospital **] Medical Building, [**Location (un) 442**] Phone: [**Telephone/Fax (1) 1237**] Date: [**2161-8-31**] Time: 10:30 AM Urology Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Location: [**Location (un) **], [**Location (un) 86**], [**Last Name (LF) **], [**First Name3 (LF) **] 440 Phone:[**Telephone/Fax (1) 5727**] Date: [**2161-8-31**] Time: 3:00 PM You should also make an appointment with your primary care provider within two weeks of discharge from rehab: Name: [**First Name8 (NamePattern2) 2946**] [**Last Name (NamePattern1) **], MD Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 2205**] Completed by:[**2161-8-16**]

Admission Date: [**2165-7-26**] Discharge Date: Date of Birth: [**2097-1-31**] Sex: M Service: C-MEDICINE CHIEF COMPLAINT: Transferred for cardiac catheterization. HISTORY OF PRESENT ILLNESS: This is a 68 year old man with coronary artery disease, status post coronary artery bypass graft, hypertension, hyperlipidemia, diabetes mellitus, who presented to [**Hospital3 36606**] Hospital for sharp [**11-15**] back pain between scapulae. No radiation of pain or shortness of breath or palpitations associated. He had a similar episode of back pain prior to his coronary artery bypass graft approximately twenty years ago. He has not had a recurrence of the back pain until approximately one to two months ago when he started developing back pain with exertion. This pain was relieved with rest. It has never been associated with shortness of breath, palpitations, diaphoresis, nausea or vomiting. On the day of admission, he had one episode of the [**11-15**] back pain which occurred while at rest. At the outside hospital, a CT angiogram was performed which was negative for dissection. He was found to have evolving Electrocardiographic changes with T wave inversions initially in V1 through V3 which then developed within ten hours to include V1 through V6 as well as I and aVL. He was started on Nitroglycerin, Lovenox and given one dose of Lasix and sent to [**Hospital1 69**] for catheterization. On presentation to [**Hospital1 69**], he was pain free for the last few hours. He had one episode of [**2-15**] back pain which occurred during transient which was relieved with one sublingual Nitroglycerin. He currently is pain free. REVIEW OF SYSTEMS: He does complain of bilateral lower extremity edema over the last weeks to months. He has had no recent change in weight. No change in bowel or bladder function. No bright red blood per rectum or melena. No fever, chills, nausea, vomiting, no recent cough or trauma to the back. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft approximately twenty years ago. Anatomy is unknown. Report of exercise treadmill test in [**2162**], showing ischemic electrocardiographic changes lateral apex and posterior wall, however, this could not be confirmed with a report. 2. Diabetes mellitus. 3. Hypertension. 4. Gastroesophageal reflux disease. 5. Status post cholecystectomy. 6. Hyperlipidemia. 7. Status post left rotator cuff repair. 8. Carotid ultrasound [**2165-1-6**], showing no hemodynamic limiting stenoses. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: (On transfer and home medications): 1. Diltiazem XT 360 mg p.o. once daily. 2. Dipyridamole 50 mg p.o. three times a day. 3. Zestril 60 mg p.o. once daily. 4. Hydralazine 50 mg p.o. three times a day. 5. Aspirin 325 mg p.o. once daily. 6. Atenolol 100 mg p.o. once daily. 7. Protonix 40 mg p.o. once daily. 8. Hydrochlorothiazide 25 mg p.o. once daily which is new since [**2164**], and held at outside hospital. 9. Lipitor 20 mg p.o. once daily. 10. NPH 24 units q.a.m. and 27 units q.h.s. 11. Humalog 5 units q.a.m. and 6 units q.p.m. 12. Glucophage 1000 mg p.o. twice a day on hold. SOCIAL HISTORY: The patient denies any significant tobacco use although did smoke occasional cigar multiple years ago. No alcohol use. He did have a son die suddenly at age 39 years. He has multiple children in the area and they are very supportive family. PHYSICAL EXAMINATION: On presentation, vital signs revealed temperature 98.6, blood pressure 112/47, heart rate 47, oxygen saturation 94% in room air, respiratory rate 18. In general, the patient is in no apparent distress. He is comfortable, breathing in room air, well developed, well nourished. On head, eyes, ears, nose and throat examination, mucous membranes are moist. The oropharynx is clear. The patient is normocephalic and atraumatic. Sclera were anicteric. Neck was supple without lymphadenopathy. Jugular venous distention approximately eight centimeters above sternal notch. Chest - The lungs were clear to auscultation bilaterally. Cardiovascular - regular rate, II/VI systolic murmur present at the left sternal border. No S3 or S4 were noted. The abdomen was obese, soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly was noted. The extremities demonstrated 1 to 2+ bilateral lower extremity pitting edema. Back examination demonstrated no costovertebral angle or paraspinal tenderness to palpation. No reproducible back pain. On neurologic examination, he is alert and oriented times three, grossly intact. LABORATORY DATA: On admission, white blood cell count was 10.0, hemoglobin 12.7, hematocrit 38.4, platelet count 238,000, MCV 88. INR 1.1. Sodium 137, potassium 4.4, chloride 102, bicarbonate 24, blood urea nitrogen 28, creatinine 1.1, glucose 218,000. Electrocardiogram on admission to [**Hospital1 190**] showed normal sinus rhythm with a rate of 46 beats per minute, T wave inversion in V1 through V6, I and aVL consistent with electrocardiogram performed at outside hospital approximately 19 hours before. Right bundle branch block was noted which on reviewing previous notes has been present in the past. IMPRESSION: This is a 68 year old man with coronary artery disease, status post coronary artery bypass graft approximately twenty years ago, diabetes mellitus, hypertension, hyperlipidemia, who presents with anginal equivalent of back pain, starting approximately one to two months ago associated with exertion. Now with one episode of back pain at rest and electrocardiographic changes consistent with unstable angina. HOSPITAL COURSE: 1. Cardiovascular disease - coronary artery disease - The patient was transferred from outside hospital for unstable angina with anterolateral electrocardiographic changes. On arrival, he was pain free with his anginal equivalent being back pain. He was continued on his intravenous Heparin and Nitroglycerin without incident. Cardiac enzymes were continued to be cycled and he was noted to have an increase in his CK from 89 at outside hospital to as high as 145. His troponin, however, bumped from less than 0.4 initially to 13.3 on arrival at [**Hospital1 69**]. This, however, trended down. He had one episode of back pain [**4-15**] in intensity on hospital day number two which was relieved after approximately five minutes with an increase in his Nitroglycerin. Although he states that the pain is in a similar location, it was felt that it was most likely musculoskeletal in origin given that it was not as intense, relieved with very little intervention, and no electrocardiographic changes were present simultaneously. Nevertheless, cardiac enzymes continued to be cycled and were pending at the time of this dictation. Given that he remained relatively pain free throughout the first two hospital days, it was planned for a cardiac catheterization on Monday, [**2165-7-29**]. Should he become unstable in the interim, an emergent cardiac catheterization and/or addition of Integrilin to his medication regimen will be considered. He was continued on Aspirin and Lipitor, however, his Dipyridamole was held secondary to possible inducible ischemia from the medication. As well, his Diltiazem was held given his acute coronary syndrome. Lopressor was administered infrequently given his relative bradycardia with heart rate in the 40s. Congestive heart failure - He was diuresed at outside hospital prior to transfer for mild congestive heart failure with lower extremity edema and mild decrease in oxygen saturation. Chest x-ray was performed which showed no evidence of cardiomegaly without any evidence of acute congestive heart failure. He was continued on Zestril, Hydralazine and Hydrochlorothiazide. Of note, his oxygen saturation remained in the mid 90s during the first two days of hospitalization. Cardiac rhythm - He did have sinus bradycardia which appears to be chronic per his OMR notes. He was relatively bradycardic even from his baseline with heart rate in the 40s on presentation. This improved slightly and his Lopressor was given as tolerated for heart rate greater than 55. 2. Endocrinology - His Glucophage was held secondary to planned cardiac catheterization. He was continued on home insulin regimen and Humalog insulin sliding scale. 3. Renal - His creatinine was 1.1, however, given his unknown baseline, he will be given two doses of Mucomyst prior to cardiac catheterization as well as prehydrated. The remainder of hospital course including cardiac catheterization results will be dictated in discharge summary addendum which will include discharge diagnoses and medications. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. [**MD Number(1) 4062**] Dictated By:[**Last Name (NamePattern1) 6240**] MEDQUIST36 D: [**2165-7-27**] 14:38 T: [**2165-7-27**] 14:58 JOB#: [**Job Number 72066**]

Admission Date: [**2172-4-14**] Discharge Date: [**2172-4-15**] Date of Birth: [**2090-7-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p trauma Major Surgical or Invasive Procedure: none History of Present Illness: 81yM on ASA shopping downtown when he was running across the street in the rain was struck by a slow moving vehicle in the back of the head and knocked to the ground. He describes a + LOC, and is amnesic to events immediately following the trauma. He was taken to [**Hospital3 26616**] hospital for eval and was reported to have a small R intraparanchymal vs intraventricular hematoma. By report his C-spine and torso scans were negative. He was transferred to [**Hospital1 18**] for neursurgical and trauma consultation. In the ED he complains of occipital pain and discomfort from the foley but otherwise feels well. He denies any vision changes, numbness or tingling in the arms or legs. He denies feeling weak. Past Medical History: HLD, hypothyroid, HTN, s/p 3 vessel CABG [**2160**] with ? porcine valve (had short trial of coumadin but was switched to ASA) Social History: Denies any etoh, tobacco Lives with daughter but is independent and drives on his own. Worked for a long time in concrete manufacturing Family History: non-contributory Physical Exam: T:97.2 BP:110/68 HR:58 R20 O2Sats 98 on 3L O2 Gen: Elderly gentleman on logroll precautions in C-collar WD/WN, comfortable, NAD. HEENT: Pupils: 3-2mm brisk b/l EOMs intact Neck: in c-collar, no posterior bony tenderness Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-18**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Pertinent Results: CT Head [**4-14**] IMPRESSION: 1. Small left temporal subdural hemorrhage, without mass effect. 2. 4 x11 mm ovoid hyperdensity in the corpus callosal genu on the right is not typical in location for contusion. In the setting of trauma, diffuse axonal injury typically occur within the corpus callosum. However, given history of a conscious patient with reported GCS of 15, this is unlikely. This lesion is far remote from the site of impact, and therefore less likely to represent contusion. Additional less likely differential considerations include focal hemorrhage from a pre-existing vascular malformation or metastatic lesion from a primary hyperattenuated malignancy such as melanoma. Comparison to more remote prior exam when available would be helpful. Ultimately, MRI may be usefult to further characterize. 3. Large right parietooccipital subgaleal hematoma with laceration as well as left temporal small subdural hemorrhage, consistent with coup and contrecoup injury. . CT head [**4-15**]: IMPRESSION: Unchanged Brief Hospital Course: Patient was brought in as a trauma. He remained stable with no neuro changes. A repeat Head CT was done with no changes. He was able to eat and drink and ambulate. PT worked with him and he was cleared to go home. Neurosurgery said he was fine to restart his ASA and go home with follow up in 4 weeks with repeat Head CT. Medications on Admission: ASA 325', lasix 20', enalapril 20', simvastatin 20', spironolactome 25', toprol xl 50', levoxyl 0.15mcg' Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: s/p trauma R parietoocciptal subgaleal hematoma right gluteal hematoma scalp laceration left temporal small SDH Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were involved in a trauma and had a small amount of bleeding inside of your head, and some bleeding outside of the head as well. This bleeding was stable and you had no neurologic changes. . You should avoid driving for 1 week or performing any strenuous activity. If you notice new headache, changes in vision, weakness or any other concerning symptoms such as nausea, vomiting, chest pain, lightheadedness please call or return to the ER as soon as possible. Followup Instructions: please call the [**Hospital 4695**] clinic to schedule a follow up appt for 4 weeks from now with Dr. [**First Name (STitle) **]. You will need a repeat CT scan of your head at that time. Call [**Telephone/Fax (1) 1669**] to schedule and arrange

Admission Date: [**2159-7-27**] Discharge Date: [**2159-8-2**] Date of Birth: [**2091-9-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 348**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right internal jugular central line placement History of Present Illness: 67M history of gout, CVA, DM, ? cardiac disease who has had one week of right hip pain. He presented to [**Hospital3 **] because of intense hip pain with inability to walk. He was found to be hypotensive with BP 80/50. At [**Hospital1 **], he also had RLQ pain. CT abd/pelvis was negative for acute pathology. He received 2L NS but was still hypotensive to SBP 70s, was started on levophed, and then received 2.5 L NS. Labs were significant for acute renal failure with Cr 4. He became fluid overloaded with difficulty breathing with resultant pOx in low 90s during IVF infusion. He was placed on BiPap, which helped with work of breathing. He was given zosyn for ? sepsis and transferred to [**Hospital1 18**]. [**Hospital1 **] labs were significant Trop-I < 0.06, Cr 4, HCO3 10 [**Hospital1 **] imaging showed CT Abd showing normal appendix with no free air, bowel obstruction, or gross intestinal inflammation. In the ED, initial VS were: 01:24 (unable) 98.6 90 98/56 24 99% 15L on NRB. He was audibly wheezing and working to breath. He was placed on BiPap which helped his work of breathing, and he calmed down. On physical exam, he had tenderness to palpation in RLQ, right hip, and groin/scrotum. There was concern for [**Last Name (un) 12653**] gangrene, so surgery consult was obtained. CT Pelvis was obtained that did not suggest the diagnosis. He was also noted to have a "slight pericardial effusion" on US, but no tamponade and pulsus only of 6. He received 1 L NS with placement of RIJ CVC. Levophed was started at 0.8 mcg/min with resultant BP 120/80, HR 95, RR 17, pOx 100 % on biPap. He received flagyl for anaerobic coverage and vancomycin in addition to zosyn given at [**Hospital1 **]. Labs were performed: - WBC 4.6 Hgb 10.5 Hct 31.8 Plt 89 Diff A 2 - Na 143 K 5.8 Cl 122 HCO3 10 BUN 79 Cr 3.7 Glc 107 - ALT 34 AST 25 ALP 88 Tbili 0.5 Albumin 2.9 - CRP 251.1 - Serial ABG 7.13/31/83/11 --> pH 7.17/27/61/10 - Lactate 0.8 --> 0.8 - UA was bland - Blood culture pending Diagnostic testing was performed: - CXR: Borderline cardiomegaly, widening of mediastium, increased interstitial edema with pulmonary overload pattern. - CT Pelvis: Comminuted fracture of the right femoral head with associated cortical breakthrough and step off of the right acetabulum. BiPap settings were stable throughout ER course (NIV FiO2:30 PS: 5 PEEP: 5) On arrival to the MICU, the patient remained stable on continuous dose of levophed. He was taken off biPap with adequate respiratory status. He was AAOx3. His son [**First Name8 (NamePattern2) **] [**Name (NI) **]) was at bedside and provided translation. Past Medical History: - gout - CVA - DM - prior stress test in [**2141**] consistent with inferolateral and posterior myocardial -Possible incomplete medical history, as unable to obtain records from his PCP Social History: He lives with his daughter. Remote smoking history, denies alcohol use. Denies illicits. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: General: on biPAP, responds to verbal stimuli, unable to assess full mental status HEENT: Sclera anicteric, MMM, EOMI, PERRL Neck: supple, unable to assess JVP, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly. GU: foley. Scrotum has thickened skin, redness. Rectal exam with no abscess, + gross blood Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact DISCHARGE PHYSICAL EXAM: VS 98.7; 70-76; 114-126/74-81; 18; 95RA General: NAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: breathing well on room air. Clear to auscultation bilaterally, mild wheezing, rales, ronchi Ext: warm, well perfused, 2+ pulses, bilateral 3rd digit PIP swelling Exam otherwise unchanged Pertinent Results: [**2159-7-27**] 02:25AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 [**2159-7-27**] 02:25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2159-7-27**] 02:35AM PT-12.1 PTT-33.9 INR(PT)-1.1 [**2159-7-27**] 02:35AM SED RATE-45* [**2159-7-27**] 02:35AM NEUTS-65 BANDS-3 LYMPHS-19 MONOS-7 EOS-3 BASOS-1 ATYPS-2* METAS-0 MYELOS-0 [**2159-7-27**] 02:35AM WBC-4.6 RBC-3.61*# HGB-10.5*# HCT-31.8*# MCV-88 MCH-29.0 MCHC-32.9 RDW-16.3* [**2159-7-27**] 02:35AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2159-7-27**] 02:35AM CRP-251.1* [**2159-7-27**] 02:35AM cTropnT-0.03* [**2159-7-27**] 02:35AM CK-MB-4 [**2159-7-27**] 02:35AM ALBUMIN-2.9* [**2159-7-27**] 02:35AM ALT(SGPT)-34 AST(SGOT)-25 CK(CPK)-77 ALK PHOS-88 TOT BILI-0.5 [**2159-7-27**] 10:01AM CK-MB-6 cTropnT-0.04* [**2159-7-27**] 10:01AM CK(CPK)-94 [**2159-7-27**] 10:20AM LACTATE-0.7 [**2159-7-27**] 05:00PM HCT-30.0* [**2159-7-27**] 05:00PM CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-1.9 [**2159-7-27**] 05:00PM GLUCOSE-131* UREA N-62* CREAT-2.6* SODIUM-142 POTASSIUM-5.3* CHLORIDE-124* TOTAL CO2-12* ANION GAP-11 [**2159-7-27**] 05:21PM TYPE-ART TEMP-38.6 RATES-/16 O2 FLOW-2 PO2-127* PCO2-26* PH-7.27* TOTAL CO2-12* BASE XS--13 INTUBATED-NOT INTUBA [**2159-7-27**] 11:10PM CALCIUM-8.1* PHOSPHATE-3.1 MAGNESIUM-1.6 [**2159-7-27**] 11:10PM GLUCOSE-82 UREA N-54* CREAT-2.2* SODIUM-144 POTASSIUM-4.8 CHLORIDE-125* TOTAL CO2-11* ANION GAP-13 IMAGING: ECG [**7-27**]: Sinus rhythm with slowing of the rate as compared to the previous tracing of [**2159-7-27**]. There is variation in the precordial lead placement. More precordial lead voltage is recorded. There is low limb lead voltage. Cannot exclude prior inferior wall myocardial infarction. Compared to the previous tracing of [**2159-7-27**] no diagnostic interim change. ECHO [**7-27**]: The left atrium is elongated. The right atrium is moderately dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. CT PELVIS W/O CONTRAST [**7-27**]: 1. Comminuted fracture of the right femoral head with associated cortical breakthrough and step off of the right acetabulum . 2. Minimal thickening of bilateral scrotal skin and skin along the medial thighs (corresponding to area of redness clinically; ? cellulitis) with no focal fluid collections or gas locules to sugggest fourniers/abscess. CHEST (PA & LAT) [**7-30**]: There is no significant lung nodule in this exam. MICRO: Blood culture, urine culture [**7-27**] no growth Discharge labs: [**2159-8-2**] 07:00AM BLOOD WBC-6.0 RBC-3.63* Hgb-10.4* Hct-30.7* MCV-85 MCH-28.7 MCHC-33.9 RDW-16.3* Plt Ct-149* [**2159-8-2**] 07:00AM BLOOD PT-40.8* PTT-44.8* INR(PT)-4.0* [**2159-8-1**] 05:55AM BLOOD PT-14.5* PTT-40.9* INR(PT)-1.4* [**2159-8-2**] 07:00AM BLOOD Glucose-60* UreaN-20 Creat-1.1 Na-136 K-3.9 Cl-105 HCO3-21* AnGap-14 [**2159-8-2**] 07:00AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.7 Brief Hospital Course: 67-year-old Vietnamese male history of gout, CVA, DM2, ? cardiac disease presenting with one week history of right hip pain and transferred to [**Hospital1 18**] for hypotension of uncertain etiology and right hip fracture. Initially admitted to MICU for stabilization due to his hypotension and hypoxemic respiratory failure requiring BiPAP, then transferred to the floor. ACUTE ISSUES # Shock, undifferentiated Patient presented with hip fracture and hypotension. Initially thought to be sepsis; however, no obvious source in scrotum, pelvis/abdomen, urine, chest or other source. Cardiogenic shock appears to be unlikely. Hypovolemic shock may be possibility although no clear history of dehydration, and BP did appear to respond to IVF (currently 5.5 L NS total received on admission) with CVP 15. Distributive shock from hip fracture or even fat emboli may also explain picture. Secondary causes of hypotension such as pericardial effusion or systemic condition such as adrenal insufficiency were investigated and ruled out. His blood pressures stabilized while in the MICU, he was taken off of pressors and transferred to the floor. There, his blood pressures remained stable throughout the remainder of his hospital course. # Acute hypoxemic respiratory failure Etiology is likely secondary to flash pulmonary edema during fluid resuscitation and also respiratory compensation for severe metabolic acidosis although did have superimposed respiratory acidosis from likely from tiring out before biPAP. Patient was placed on BiPAP in ED and for a period of time while in the MICU. His respiratory status stabilized and after being transferred to the floor he maintained good oxygen saturation levels while on room air for the remainder of his hospital course. # Acute renal failure Admission Cr 3.7 (from 4) with K 5.8 HCO3 10 consistent with primary non-gap metabolic acidosis with normal anion gap and superimposed respiratory acidosis. Baseline Cr [**2159-6-22**] was 1.79. Renal failure likely pre-renal +/- some element of intrinsic disease +/- drug side effect from numerous NSAIDs on medication list. No evidence of obstruction on CT Abd. Patient's Cr was monitored during admission and was noted to have down trend in Cr following IV hydration. The patients creatinine continued to improve after being transferred to the floor, 1.1 on discharge. # Right Hip Avascular Necrosis: Patient received CT Pelvis to evaluate for Fournier's gangrene in setting of scrotal skin changes, was negative for Fournier's, but concerning Right hip changes were noted. Final read per radiology showed "Right femoral head avascular necrosis with subchondral collapse and subchondral fracture. Cystic area within the anterior femoral head presumably secondary to subchondral cystic change." Ortho was consulted for further evaluation and management. They suggested that given his acute medical instability that the patient follow up as [**Known firstname **] outpatient for operative management. Until follow up with Ortho, patient is non-weight bearing on the RLE. #New Onset Atrial Fibrillation with Rapid Ventricular Response While in the MICU, the patient had two brief episodes of AFib with RVR; once requiring a dose of IV metoprolol, and once self-converting into sinus rhythm. During his hospital course on the floor, however, the patient again began to enter a rhythm consistent with AFib, often times with a ventricular rate into the 140s. His metoprolol was increased gradually, but because of persistent episodes of AFib the decision was made to convert the patient from short acting to Metop XL 100mg [**Hospital1 **]. On this regimen the patient remained in sinus rhythm for the remainder of his hospital course. Given his new diagnosis of AFib and his history of diabetes, CAD and prior CVA, the decision was made to initiate anticoagulation with coumadin. Given 5mg on [**7-31**], 5mg on [**8-1**], INR was 4.0 on [**8-2**], so coumadin stopped. Please check daily INR at rehab, and restart at 2mg daily once INR between [**1-5**]. # Gout - On the day prior to discharge, patient had swelling of his PIP joints in bilateral middle fingers. Restarted on indomethicin and stopped allopurinol in the acute setting. Plan to restart allopurinol once acute flare is treated. # Abdominal pain/scrotum issue Patient's scrotum appears to be without acute infection. There is no acute abdomen to explain abdominal pain on admission. At the time od discharge, his abdomen is pain free. # Normocytic, normocytic Anemia Unknown baseline Hgb. He had positive gross blood on rectal exam. There is no evidence of blood loss into hip fracture at this time with neurovascular structures intact. # Thrombocytopenia Patient has platelets of 89 on admission with normal coags. Likely from marrow suppresion given acute illness with no stigmata of chronic liver disease. CHRONIC ISSUES # Diabetes - The patient was maintained on [**Known firstname **] insulin sliding scale during his hospital course. TRANSITIONAL ISSUES The patient will need to follow up with our [**Hospital 9696**] Clinic in order to plan possible operative intervention for his right hip avascular necrosis once he is more medically stable. The patient will need close follow up to monitor his INR given the initiation of anticoagulation therapy during his hospital course. Will need to restart allopurinol after acute flare. Medications on Admission: Unable to obtain information regarding preadmission medication at this time. Information was obtained from [**Hospital1 **] records. 1. CeleBREX *NF* (celecoxib) 200 mg Oral daily:prn gout flare 2. Allopurinol 300 mg PO DAILY 3. Indomethacin 50 mg PO TID:PRN gout flare 4. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 5. Clopidogrel 75 mg PO DAILY 6. Niaspan Extended-Release *NF* (niacin) 500 mg Oral daily 7. lisinopril-hydrochlorothiazide *NF* 20-12.5 mg Oral daily 8. Colchicine 0.6 mg PO Q 12H gout flare 9. HydrOXYzine 25 mg PO DAILY 10. Vitamin D 400 UNIT PO DAILY 11. GlipiZIDE 10 mg PO BID 12. Omeprazole 20 mg PO DAILY 13. Docusate Sodium 100 mg PO BID 14. Simvastatin 20 mg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Indomethacin 50 mg PO TID:PRN gout flare 4. Simvastatin 20 mg PO DAILY 5. Acetaminophen 650 mg PO Q6H 6. Aspirin 81 mg PO DAILY 7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB 8. Metoprolol Succinate XL 100 mg PO BID 9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain hold for sedation or RR<10 RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 10. Senna 1 TAB PO BID:PRN constipation hold for loose stool 11. Colchicine 0.6 mg PO Q 12H gout flare 12. GlipiZIDE 10 mg PO BID 13. Niaspan Extended-Release *NF* (niacin) 500 mg Oral daily 14. Omeprazole 20 mg PO DAILY 15. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 16. Vitamin D 400 UNIT PO DAILY 17. Lisinopril 5 mg PO DAILY Discharge Disposition: Extended Care Facility: Tower [**Doctor Last Name **] Discharge Diagnosis: AVN of the Right femoral head Atrial fibrillation Acute kidney injury Hypotension Acute hypoxemic respiratory failure Anemia Thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure to take care of you during your recent hospitalization at [**Hospital1 69**]. As you know, you were hospitalized with right hip pain that was complicated by low blood pressure and difficulty breathing. You were admitted to the ICU and given IV fluids which helped your blood pressure. Unfortunately this caused your lungs to build up fluid which made it difficult for you to breath. You were placed on BiPAP and your oxygen status improved. We then gave you medication to remove the fluid from your lungs, and your breathing improved even further. Your hip pain is the result of a type of fracture known as avascular necrosis. It is unclear at this time why you had such a fracture without any trauma. Our orthopaedic surgeons believe that you should follow up with them as [**Known firstname **] outpatient to plan possible operative fixation in the future once you are doing better from a medical standpoint. During your hospital stay you developed [**Known firstname **] irregular heart beat known as atrial fibrillation. We gave you medication in order to control your heart rate and keep it regular, and you should continue this medication as [**Known firstname **] outpatient. Because people who have atrial fibrillation are at a higher risk of developing strokes, we began treating you with a blood thinner known as coumadin, which can help decrease this risk. We have made the following changes to your medications: START Coumadin Metoprolol RESTARTED Indomethicin STOPPED allopurinol (during the acute gout flare. please restart after acute flare is done) DECREASED Lisinopril STOPPED Hydrochlorothiazide Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2159-8-16**] at 3:30 PM With: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *Please call your primary care doctor to request [**Known firstname **] insurance referral for this visit. Dr. [**Last Name (STitle) 12654**] [**Name (STitle) **] number which you will need to give to you PCP office is [**Numeric Identifier 12655**].

Admission Date: [**2197-8-28**] Discharge Date: [**2197-9-11**] Date of Birth: [**2126-10-12**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [**2197-8-28**] Exploratory Lap [**2197-8-29**] Closure of Abdominal wound History of Present Illness: 70 year old female involved in a motor vehicle crash; intubated at scene because of mental status changes; also was found to be in shock with a distended abdomen. She had both a positive FAST and DPL and was taken to the operating room directly from the trauma bay for exploratory. Past Medical History: Hypertension GERD Bilateral knee replacements with post-op GI bleed Family History: Nonconttibutory Physical Exam: Tm/c: 100.2/100.2 HR: 97 BP: 160/80 RR: 18 O2sat: 97%RA Gen: AAOx3, NAD, TLSO on HEENT: Left eye: EOMI, PERRL; Right eye: ptosis, CN IV and VI intact With TLSO off and patient lying flat in bed: CV: RRR, no murmurs Lungs: CTAB Abd: NA BS present, soft, NT, ND, steri-strips intact, distal wound opened, packed, bandaged - clean and intact Extr: venodynes, no C/C/E Pertinent Results: IMAGING . CT PELVIS W/CONTRAST [**2197-8-28**] 6:16 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST IMPRESSION: 1. Free air within the anterior mediastinum, and air anterior to the epicardium, of indeterminate etiology. 2. Edema within the lungs. 3. Small right pleural effusion. 4. Post-surgical changes of the abdomen, with an open abdominal wound and stomach, small and large bowel protruding through the wound defect. Free air and free fluid in the abdomen. Per the operative note, there was a tear at the root of the mesentery with vascular injury. 5. Multiple fractures, including the T11 vertebral body with retropulsion of fragments into the central spinal canal. The acuity of this finding is uncertain, as there are no priors for comparison. There is a fracture of some transverse processes of the lumbar spine, and a fracture of the right posterior eleventh rib. 6. Enhancement of the small bowel mucosa suggesting shock. . . CT C-SPINE W/O CONTRAST [**2197-8-28**] 6:16 PM CT C-SPINE W/O CONTRAST IMPRESSION: 1. No evidence of cervical spine fracture. 2. Grade I anterolisthesis of C3 on C4. 3. Edema at the lung apices. . . CT HEAD W/O CONTRAST [**2197-8-28**] 6:15 PM INDICATION: Status post MVC. Intubated. There are no prior studies for comparison. NONCONTRAST HEAD CT SCAN: There is a very small amount of subdural blood along the falx cerebri on the left side near the vertex (series 2 images 22 through 27). No other definite areas of hemorrhage are appreciated. The ventricles and cisterns are normal. The density values of the brain parenchyma are normal, with preservation of the [**Doctor Last Name 352**]-white matter differentiation. There are widened bifrontal extra-axial spaces, which may be related to involutional change. There is a small amount of fluid layering posteriorly within each maxillary sinus. There is partial opacification of the ethmoid air cells. The mastoid air cells are clear. Osseous and soft tissue structures are unremarkable. IMPRESSION: Small subdural hematoma along the left side of the falx cerebri. No shift of the normally midline structures. The finding was discussed with Dr. [**Last Name (STitle) 69770**] at the conclusion of the exam. . . TRAUMA #2 (AP CXR & PELVIS PORT) [**2197-8-28**] 6:08 PM INDICATION: Trauma. CHEST: Trauma supine chest and pelvis reviewed. There is diffuse opacification of both lungs. The left diaphragmatic border is obscured. The pleura are grossly clear without large effusions or pneumothoraces. No displaced rib fractures are identified. The patient is intubated with the ET tube located 1.5 cm above the carina. NG tube is present in the stomach. The heart and mediastinal contours are within normal limits given the supine projection. IMPRESSION: Diffuse opacification of both lungs likely secondary to pulmonary edema versus contusion. ET tube 1.5 cm above the carina, some withdrawal may provide more optimal position is possible. PELVIS: No displaced pelvic fractures are identified. Evaluation of the proximal femur is limited secondary to rotation. There is lumbar scoliosis with convexity to the left with associated osteophytes and degenerative changes. Bowel gas is unremarkable. IMPRESSION: No gross injury. . . CT HEAD W/O CONTRAST [**2197-8-29**] 10:57 AM INDICATION: Evaluation for interval change in a 70-year-old lady, status post motor vehicle accident. Assessment for intracranial hemorrhage. TECHNIQUE: Axial images of CT of the head. COMPARISON: [**2197-8-28**]. FINDINGS: There is left subdural hematoma on the free edge of falx that is unchanged in comparison to prior study. There is no new acute extra- or intraaxial hemorrhage. There is no major or minor territorial infarct. There is no mass effect or shift of normal midline structures. There is no fracture line or soft tissue density abnormality identified. There is normal soft tissue density of the brain parenchyma. There are widened stable bifrontal extra-axial spaces which are related to atrophic changes . There are air fluid levels within the maxillary sinuses and sphenoid sinuses that are unchanged in comparison to prior study. Mastoid air cells are clear. IMPRESSION: Unchanged small left subdural hematoma along the falx. No new change. . . CHEST (PORTABLE AP) [**2197-8-30**] 4:54 AM INDICATION: Status post MVC and exploratory laparotomy. Evaluate for interval change. FINDINGS: Compared with [**2197-8-28**], lines and tubes are unchanged in position. There has been considerable partial interval clearing of the diffuse patchy pulmonary densities, with mild residual atelectasis at the left base. . . CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2197-8-31**] 9:16 AM INDICATION: Trauma, evaluate for facial fractures. COMPARISON: Head CT, [**2197-8-29**]. TECHNIQUE: MDCT-acquired contiguous axial images of the facial bones were obtained without intravenous contrast. Three-dimensional reconstructed images were obtained. CT OF THE FACIAL BONES WITHOUT INTRAVENOUS CONTRAST: No facial fracture is identified. Mild-to-moderate mucosal thickening is seen involving all of the paranasal sinuses, with air-fluid levels demonstrated in the maxillary, sphenoid, and ethmoid sinuses. All of these findings are likely secondary to patient's intubated state. Tiny hyperdensity within a right sphenoid sinus air cell likely represents a minute osteoma. Visualized portions of the mastoid air cells are clear. Surrounding soft tissue structures appear unremarkable. There is extensive atherosclerotic calcification of the cavernous portion of both internal carotid arteries. At C2-3 and C3-4, facet degenerative changes are present, more pronounced on the right leading to mild-to-moderate neural foraminal narrowing. An endotracheal tube and nasogastric tube are partially imaged within the airway and esophagus respectively. IMPRESSION: 1. No facial fracture identified. 2. Air-fluid levels within the paranasal sinuses consistent with the patient's intubated state. . . CHEST (PORTABLE AP) [**2197-9-1**] 9:19 PM CLINICAL INDICATION: Evaluate lung integrity. TECHNIQUE: AP semierect portable examination is compared with prior examination dated [**2197-8-30**]. FINDINGS: A left-sided chest tube is visualized with side port projecting over the subcutaneous soft tissues outside of the hemithorax. Recommend advancement. Left-sided subclavian line terminates in the proximal SVC. NG tube projects over the body of the stomach. Cardiomediastinal silhouette is within normal limits. There is increased left lower lung hazy opacity. Right-sided pleural effusion again seen. Small left apical pneumothorax again appreciated. New surgical staples seen over the upper abdomen. IMPRESSION: 1. Recommend advancement of left-sided chest tube with side port seen projecting outside of the left hemithorax. 2. Interval increase in left lower lung hazy opacification. . . CHEST (PORTABLE AP); CHEST, SINGLE VIEW ON [**9-2**] at 2100. REASON FOR THIS EXAMINATION: s/p removal chest tube HISTORY: Left chest tube to waterseal, status post removal of chest tube. FINDINGS: There has been interval removal of the left chest tube. There is a small left pneumothorax that is similar in size to that seen on the film from the prior day. There continue to be bibasilar opacities and patchy areas of volume loss. . . CHEST (PORTABLE AP) [**2197-9-2**] 5:16 AM REASON FOR THIS EXAMINATION: eval for interval change CLINICAL INDICATION: 50-year-old woman status post MVC, evaluate for chest tube placement. IMPRESSION: Interval advancement of left-sided chest tube, small residual left apical pneumothorax. Interval increase in bibasilar opacities. . . CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS [**2197-9-6**] 6:19 PM REASON FOR THIS EXAMINATION: ? aneurysm in carotid system in setting of CNIII palsy CLINICAL INFORMATION: Cranial nerve III palsy, question carotid aneurysm. NON-CONTRAST HEAD CT Exam shows near complete resolution of the left parafalcine subdural hematoma posteriorly seen on prior study of [**2197-8-29**]. The low-density extra-axial fluid collections over the frontal aspects of both hemispheres are again noted and unchanged. Ventricular dimension is unchanged. IMPRESSION: Some resorption of the left parafalcine subdural hematoma. No other new findings. CT ANGIOGRAM OF THE CERVICAL VESSELS WITH MULTIPLANAR REFORMATTED IMAGES AND 3-DIMENSIONAL RECONSTRUCTED IMAGES IMPRESSION: No evidence of significant internal carotid artery stenosis. See above comment regarding the appearance of C4-5 on the left. CT ANGIOGRAM OF THE INTRACRANIAL CIRCULATION There is no evidence of aneurysm or flow abnormality. The cavernous portions are always difficult to assess on CT angiography for technical reasons. If there remains a clinical question regarding a small aneurysm in either cavernous portion, formal catheter angiography may be considered for further evaluation. IMPRESSION: No definite evidence of aneurysm. See above comment regarding the appearance of the cavernous portions of the internal carotid arteries. . . ABDOMEN (SUPINE ONLY) [**2197-9-6**] 3:18 PM REASON FOR THIS EXAMINATION: r/o obstruction or other processes INDICATION: 70-year-old woman status post motor vehicle accident, status post exploratory laparotomy, now with increasing nausea and vomiting. Rule out obstruction. COMPARISON: Abdominal radiograph [**2197-8-29**]. FINDINGS: There is unremarkable bowel gas pattern. There is air in the rectum. Multiple surgical clips are projecting over the midline. Interval removal of the nasogastric tube. Fractures of 11th posterior, ninth lateral ribs. Levoconvex scoliosis, centered at L3-L4. IMPRESSION: No evidence of obstruction. . . PROCEDURES . OPERATIVE REPORT [**Last Name (LF) **],[**First Name3 (LF) **] J. Name: [**Known lastname **],[**Known firstname **] T Unit No: [**Numeric Identifier 69771**] Service: MED Date: [**2197-8-28**] Date of Birth: [**2139-12-26**] Sex: F Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], MD 2211 INDICATIONS: This woman has been in a motor vehicle accident. She was found to be in shock and her abdomen was distended. I should mention that 1 of her pupils was also wide. PROCEDURE: She was taken to the operating room and placed in a supine position, given a general anesthetic. The abdomen was prepped and draped using Betadine. A vertical incision was made taking it down to the level of the fascia. The fascia was opened. The abdomen was opened and the following findings were noted. Considerable bleeding was noted within the abdomen. There was a large rent in the mesentery of the small bowel that extended into the right lower quadrant. There was bleeding from vessels at the root of the mesentery and we managed to control the bleeding with several sutures of 3-0 silk and 2-0 silk up through the mesentery. The patient, at this point, was extremely hypothermic and we needed to get control of this and we had transected the bowel both on the ileum and also on the ascending colon. We removed the intestine by clamping with [**Doctor Last Name 1356**] clamps and then ligating with 2-0 silk sutures. Once this was done, we carried out a very fast anastomosis using the linear cutting stapler and a TA stapler across the remaining part. The anastomotic line was inverted using interrupted 3-0 silk sutures. At this point, after making sure that we controlled the blood vessel in the mesentery with the silk sutures, we decided to leave the mesenteric defect open. I should mention that we carried out a look at the spleen. The spleen was not bleeding. There was an adhesion to the lower end of the spleen which was divided. The liver was similarly not bleeding. We did not open the lesser sac. We placed a [**Location (un) 5701**] bag in place and then used warm saline to irrigate. We then closed the abdomen using 0 Prolene suture in continuous fashion to the skin and thus the abdomen was left open, the [**Location (un) 5701**] bag being used to hold the abdominal contents in place. Two [**Location (un) 1661**]-[**Location (un) 1662**] drains were left in place and a superficial dressing was placed. There were 2 liters of blood within the abdomen. This was suctioned out with the autotransfusor and got the bloodback from the cell [**Doctor Last Name 10105**]. ESTIMATED BLOOD LOSS: 500 cc. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**] . . OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Motor vehicle crash resulting in open abdomen mesenteric vein avulsion. POSTOPERATIVE DIAGNOSIS: Motor vehicle crash resulting in open abdomen mesenteric vein avulsion. PROCEDURE: 1. Closure of mesenteric defect. 2. Closure of abdomen. INDICATIONS FOR SURGERY: The patient is a 70-year-old female who sustained a motor vehicle crash that required an exploratory laparotomy the day prior. She was noted to have a mesenteric avulsion with profuse bleeding from the venous system. These were suture ligated, and hemostasis was achieved; however, the abdomen was left open due to the necessity for a second look to assess the viability of the bowel, thus the patient was taken back to the operating room for closure. PROCEDURE IN DETAIL: The patient was brought to the operating room in stable condition. She was already intubated in the intensive care unit prior to presentation to the operating room. The abdomen was prepped and draped with sterile Betadine. The previously-placed [**Location (un) 5701**] bag was removed from the circumferential surrounding skin, and the abdomen was explored. There was noted to be adequate hemostasis at the mesenteric rent. The bowel seemed adequately viable. Four laparotomy pads were removed from the abdomen which had been placed as packing the day before. The mesenteric defect was then closed with interrupted 3-0 silk sutures at the previously performed ileocolostomy anastomosis. An NG tube was placed with adequate positioning in the stomach. The wound was then closed with looped #1 PDS sutures. It was noted to come together nicely without undue tension. The peak inspiratory pressures on the ventilator did not increase substantially at all during this procedure. The subcutaneous tissue was then copiously irrigated, and the skin was closed with skin staples. The patient was transferred back to the ICU in stable condition. All sponge and needle counts were correct at the end of the case x 2. The patient did undergo an abdominal x-ray, as the previous sponge count had not been counted. There was no evidence of any retained instruments or sponge counts in the abdomen. Dr. [**Last Name (STitle) **] was present and scrubbed during the entire procedure. [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 67332**] . . URINE [**2197-9-8**] URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML - FURTHER IDENTIFICATION TO FOLLOW LABS: [**2197-8-28**] 06:17PM FIBRINOGEN-146* [**2197-8-28**] 06:17PM PT-14.2* PTT-31.8 INR(PT)-1.3* [**2197-8-28**] 06:17PM PLT COUNT-143* [**2197-8-28**] 06:17PM WBC-12.9* RBC-2.88* HGB-9.8* HCT-27.0* MCV-94 MCH-34.1* MCHC-36.3* RDW-12.9 [**2197-8-28**] 06:17PM UREA N-18 CREAT-1.1 [**2197-8-28**] 06:24PM freeCa-0.99* [**2197-8-28**] 06:17PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2197-8-28**] 06:24PM HGB-10.3* calcHCT-31 O2 SAT-82 CARBOXYHB-1.6 MET HGB-0.1 [**2197-8-28**] 06:24PM GLUCOSE-173* LACTATE-3.2* NA+-132* K+-3.3* CL--105 TCO2-23 [**2197-8-28**] 07:32PM HGB-8.6* calcHCT-26 [**2197-8-28**] 09:11PM OSMOLAL-286 [**2197-8-28**] 09:11PM CALCIUM-6.4* PHOSPHATE-3.5 MAGNESIUM-1.2* [**2197-8-28**] 09:11PM CK-MB-45* MB INDX-3.1 cTropnT-0.20* [**2197-8-28**] 09:11PM ALT(SGPT)-25 AST(SGOT)-49* CK(CPK)-1455* ALK PHOS-29* TOT BILI-0.4 [**2197-8-28**] 09:11PM GLUCOSE-209* UREA N-15 CREAT-0.7 SODIUM-133 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-20* ANION GAP-12 [**2197-8-29**]: Glucose 205*, Urea Nitrogen 15, Creatinine 0.8, Sodium 133, Potassium 3.1*, Chloride 105, Bicarbonate 21*, Anion Gap 10, Creatine Kinase (CK)3864*, Creatine Kinase, MB Isoenzyme 118*, CK-MB Index 3.1 % 0 - 6 Calcium, Total 6.8* Phosphate 2.5* Magnesium 2.2 Creatine Kinase (CK) 4314* Creatine Kinase, MB Isoenzyme 99 CK-MB Index 2.3 % [**2197-9-1**]: Phenytoin 9.4* ug/mL [**2197-9-5**]: White Blood Cells 10.8 Red Blood Cells 3.29* Hemoglobin 10.3* Hematocrit 30.4* % MCV 92 fL 82 - 98 MCH 31.4 pg 27 - 32 MCHC 34.0 % 31 - 35 RDW 15.0 % 10.5 - 15.5 Platelet Count 172 K/uL 150 - 440 [**2197-9-8**]: Glucose 119* Urea Nitrogen 13 Creatinine 0.6 Sodium 133 Potassium 3.4 Chloride 100 Bicarbonate 25 Anion Gap 11 Calcium, Total 7.9* Phosphate 3.2 Magnesium 1.9 Hemoglobin A1c 6.1* % Urine Color Yellow, Urine Appearance Clear Specific Gravity 1.005 DIPSTICK URINALYSIS Blood SM, Nitrite NEG, Protein NEG, Glucose NEG, Ketone NEG, Bilirubin NEG, Urobilinogen NEG, pH 7.0, Leukocytes SM MICROSCOPIC URINE EXAMINATION RBC [**2-26**]*, WBC [**11-13**]*, Bacteria MANY, Yeast NONE, Epithelial Cells <1, Transitional Epithelial Cells 0-2 Brief Hospital Course: She was admitted to the trauma service; because of a positive DPL and FAST exams she was immediately taken to the operating room for exploratory laparotomy (see Pertinent results). . Neurosurgery was consulted because of the subdural hematoma; this injury was nonoperative; serial head CT scans were performed and were stable; neurologically she has remained intact. She was fitted for a TLSO brace because of her L1 transverse process fracture. This will need to be worn at all times while out of bed; while in bed if not worn she will need to be log rolled. She will follow up with Dr. [**Last Name (STitle) 548**] in 6 weeks for repeat imaging. . Ophthalmology was consulted for ptosis of her right eye following the crash; ?post traumatic CN III palsy; this was nonoperative. She underwent CTA of her head and neck, no acute processes were identified (see Pertinent results). . Her finger sticks were somewhat elevated throughout her hospital stay 200's; she was placed on a sliding scale. There was no documented history of Diabetes. She also experienced vertigo during this admission; she was started on Meclizine which improved the dizziness that she was experiencing. Physical therapy worked with patient to assess for BPPV; the vertigo was not reproducible with maneuvers. . She also experienced 2 days of nausea and vomiting; KUB did not reveal any obstruction. She was placed on Reglan which was eventually stopped; the Meclizine seemed to improve these symptoms. It was later discovered that she had a UTI and that she has had frequent UTI's in the past and was planning on having bladder suspension surgery in the future prior to her admission. This could be the reason for her elevated finger sticks. Ciprofloxacin for 10 days was started. . She tolerated a regular diet and her staples were removed and steri-strips with benzoin were applied prior to her discharge to her rehabilitation facility. Medications on Admission: HCTZ 25' Toprol XL 100' Accupril 20' Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal twice a day as needed for constipation. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection four times a day as needed for based on fingersticks per sliding scale. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP <110. 6. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP <110. 7. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic [**Hospital1 **] (2 times a day): Apply OD. 8. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for UTI for 10 days. 12. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily) for 5 days. 13. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily): hold for HR <60 and/or SBP <110. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: s/p Motor vehicle crash Left subdural hematoma Right 11th rib fracture L1 transverse body fracture Post traumatic CN III palsy Discharge Condition: Stable Discharge Instructions: Please take your medications as directed. Please always have your brace on unless you are lying flat in bed. Please ask for assistance in putting on your brace. Please call for your follow-up appointments as detailed. Please call/return to [**Hospital1 18**] if you have persistent pain, fever, nausea/vomit, bleeding/drainage from your wound, dizziness and/or difficulty breathing. Followup Instructions: Follow-up with plastic surgery clinic the Friday after discharge. Call [**Telephone/Fax (1) 5343**] to schedule the appointment. Follow up with Opthamology Resident Clinic in 1 week, call [**Telephone/Fax (1) 253**] for an appointment. Follow-up with Dr. [**Last Name (STitle) 548**], Neurosurgery in 5 weeks; call [**Telephone/Fax (1) 1669**] to schedule the appointment. Inform the office that you will also need A/P & Lateral Thoracic/Lumbar spine films for this appointment. Please follow-up with Trauma clinic, please call [**Telephone/Fax (1) 6429**] Completed by:[**2197-9-11**]

Admission Date: [**2142-9-22**] Discharge Date: [**2142-9-25**] Date of Birth: [**2062-2-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy. History of Present Illness: 80M with a h/o COPD and HTN, prostate ca, s/p XRT 10yrs ago, presents to the ED after 2 days of BRPBPR. Reportedly woke up on [**2142-9-20**] with sheets soaked with BRB. Got up, showered, denied N/V/Dizzy/Lightheadedness, denied CP, SOB, went back to bed. Woke up with less amount of BRBPR, worried, called PCP. [**Name10 (NameIs) **] pt, PCP [**Name Initial (PRE) 12533**]: last [**Month (only) **] ([**2142**]) clean c-scope, so nothing to worry about. Pt went golfing, completed 2 holes, then noted pants soaked in blood. Went to the ED. Hct 37 reportedly on admission. In ED, reportedly, [**2-5**] tablespoons every 10-20mins, incontinent of stool. Still blood with no stool. No hematemesis or hematochezia. No chest pain, no SOB. no syncope or pre-syncope. Hct was as low as 29, and pt reportedly given 4units of PRBCs. Enzymes were checked, and he had a + MB fraction, but no EKG changes, Trop 0.03 thought to be an NSTEMI due to demand--pt was asymptomatic. He was continued on his betablocker, aspirin was held due to ongoing bleeding. Transferred to OSH ICU, underwent a c-scope: showed bleed in sigmoid colon and left colon with no definite source that could be identified. Hct 30.2 on [**9-22**] at OSH. Hct 37 on [**9-20**]. At least 1 episode of hypoT (BP 89/60) at OSH, given fluids and 2u PRBCs-->hypoT quickly resolved to Bp 120/80. Notes mention possible need for [**Female First Name (un) 899**] angiography of the [**Female First Name (un) 899**] to localize the source of the bleeding; therefore pt was transferred to [**Hospital1 18**] for further workup/management. . Upon arrival to [**Hospital1 18**], pt denies CP, SOB, dizziness, LH. He was tachycardic to 120s, other vital signs were stable. No frank rectal bleeding, but bright red blood in the rectal vault. Past Medical History: COPD (FEV 0.7, on home O2-2LNC) EF 55-60% HTN hyperlipidemia prostate ca s/p XRT->10yrs ago. diverticulosis of sigmoid colon h/o GI bleed 6-7yrs ago ([**3-8**] radiation proctatitis) Social History: h/o tobacco 3ppd for many yrs, quit 20yrs ago. No illicits, occ EtOH. Lives with his wife. retired, formerly was small business owner. Enjoys golf. Family History: noncontributory. Physical Exam: ADMISSION EXAM VS: Temp: 97.6 BP: 123-151/73-91; HR: 113-119 RR: 19 O2sat: 96% GEN: pleasant, comfortable, NAD, very hard of hearing HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: barrel chested. diffuse wheezing. good air movement. no crackles CV: RR, S1 and S2 wnl, hyperdynamic, 2/6 SEM at apex increases with inspiration. ABD: soft, distended, + BS. non-tender. no clear organomegaly identified. EXT: no c/c/e. cool. faint, but palpable pulses. SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps RECTAL: bright red blood in rectal vault. Pertinent Results: [**2142-9-22**] 05:53PM GLUCOSE-118* UREA N-17 CREAT-0.9 SODIUM-139 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11 [**2142-9-22**] 05:53PM ALT(SGPT)-16 AST(SGOT)-22 LD(LDH)-152 CK(CPK)-116 ALK PHOS-60 TOT BILI-0.5 [**2142-9-22**] 05:53PM CK-MB-9 cTropnT-<0.01 [**2142-9-22**] 05:53PM CALCIUM-8.3* PHOSPHATE-2.3* MAGNESIUM-2.0 [**2142-9-22**] 05:53PM WBC-12.9* RBC-3.40* HGB-10.3* HCT-28.8* MCV-85 MCH-30.1 MCHC-35.6* RDW-14.9 [**2142-9-22**] 05:53PM PLT COUNT-174 [**2142-9-22**] 05:53PM PT-13.2* PTT-27.7 INR(PT)-1.2* Brief Hospital Course: PCP: [**Name10 (NameIs) 69359**] [**Name11 (NameIs) 69360**] . Outside hospital Lab results: Fe 81 TIBC: 292 Transferrin: 208.8 . Creat: 1.4 at time of discharge ([**Last Name (un) 5487**] baseline) . Ck 194-->211 CkMB 6.4-->12.1 TnT: 0.03 . INR 1.0 . WBC: 11.7 HCT 37.0 on discharge: 31.0 pre-transfusion(on admisson): down to 29.8 on the day of xfer s/p 4 units PRBC's. Plt: 268 . TSH 1.29 EKG: [**2142-9-21**]. NSR 100. nml axis. occ PVCs. No ischemic changes. at [**Hospital1 18**]: sinus tach 110, normal axis. normal intervals 0.[**Street Address(2) 1755**] depressions V3, V4, V5 . Imaging: CXR at OSH showed L basilar density, unknown if new or old. R Foot XRAY: No acute fracture or dislocation is seen. There is an apparent lucency noted in the first distal phalanx. This lucency extends to the articular surface of the interphalangeal joint and has well circumscribed but nonsclerotic margins. This is best evaluated on the frontal and oblique radiographs and is not well seen on the lateral radiograph. No additional lytic or sclerotic lesions are seen. There is enthesopathy at the insertion of the Achilles tendon and a small plantar calcaneal spur. There is also trace vascular calcification. The soft tissues are unremarkable. IMPRESSION: 1. Apparent well circumscribed lucency in the first distal phalanx. Further evaluation with cross-sectional imaging is advised. 2. No acute fracture or dislocation. . Colonoscopy at OSH: bleeding from sigmoid and L colon area. no bleeding in terminal ileum, R colon, xverse colon. multiple diverticuli in sigmoid colon. couldn't locate the source of bleeed. . Echo at OSH: EF 70% LV hyperdynamic LVOT flow acceleration at rest, increased with valsalva RV normal trace MR [**First Name (Titles) **] [**Last Name (Titles) **]. no focal WMAs ******************** 80M with 2d of BRBPR likely due to diverticular bleed, s/p c-scope unable to localize source of bleeding, transferred to [**Hospital1 18**] for further workup and managment of the bleeding. The bleeding had slowed dramatically by transfer. Colonoscopy at [**Hospital1 **] revealed extensive diverticular disease of the sigmoid colon without active bleeding. The patient's Hct stabilized at ~25 for 24 hours, and on [**9-25**] the patient left against medical advice. He and his wife stated that they understood that the medical team wanted to continue to monitor his Hct, to obtain a PT consult as the patient had been bedbound for 5 days. The patient and his wife also stated their understanding that the patient was at risk to rebleed acutely, which could have devastating results. . #GI: BRBPR- Unlikely upper GI source per colonoscopy, original bleeding form the sigmoid, left colon per OSH. At admission the pt had bright red blood in the rectal vault. He was admitted to the MICU for close observation initially. He remained remained hemodynamically stable; Hct remained ~25 x 24 hours; therefore he was transferred to the floor on [**9-24**]. A repeat colonoscopy on [**9-24**] revealed sigmoid diverticular disease but no active bleeding. 1 unit PRBC's transfused [**9-25**] to maintain Hct >25. Per GI, the patient should see surgery in outpatient follow up for consideration of a partial colectomy given his extensive sigmoid diverticular disease and high risk of re bleeding. #CV: Ischemia: CKMB elevation at outside hospital; diagnosed with NSTEMI. This is likely due to demand ischemia in the setting of acute blood loss/anemia. There was no troponin elevation, no EKG changes, and the patient was asymptomatic throughout. The patient was started on a statin and continued on a betablocker. Aspirin was held given GI bleed. A repeat EKG at [**Hospital1 **] was unchanged from OSH. We continued the Betablocker and statin. The patient will follow up with his PCP for discussion of initiation of ASA therapy. Pump: HTN, TTE ot OSH revealed: EF of 70%, hyperdynamic, with no wall motion abnormalities. Betablocker was continued; ACE-I was restarted on [**9-25**] (after stabilization of blood pressure). Rhythm: The patient had intermittant sinus tachycardia to the 120s, thought to be due to hypovolemia and + increased catechols. This resolved overnight [**9-24**] with IVF hydration. Risk factors: HTN, hyperlipidemia: On Beta-blocker, ACE-I, Statin. . #Pulmonary: Pt has a history of COPD, on home O2. He was chronically wheezy on exam and was found to have a ?Left lower lobe infiltrate on CXR at OSH. He was maintained on albuterol/atrovent nebs, his advair was continued. He maintained O2 sats of 92-96% on 2LNC. . #Renal: The patient's creatinine was 1.4 on admission (baseline unknown). This was likely due to hypovolemia from his GIB, and resolved with IVF hydration (0.8 on [**9-25**]). . #heme: anemia: [**3-8**] GIB, but also has a h/o iron deficiency anemia, on iron supplementation at home. The patient reportedly required 4 units PRBC at the OSH and did require one unit PRBC transfusion at [**Hospital1 **] to maintain Hct >25. Iron supplements were continued. . #R Foot pain: The patient reported acute onset foot pain [**9-24**] over R 5th MTP joint. He denied h/o trauma; has no preceding h/o gout. He was found to be tender on exam w/ overlying edema, no erythema. Foot XRAY revealed no acute process, but did reveal a well circumscribed lucency in the first distal phalanx. We recommend an outpatient MRI as follow up. The patient's foot pain markedly improved spontaneously by [**9-25**]. #Prophylaxis: The patient was put on pneumoboots as PE prophylaxis. Full CODE #Comm: Wife: [**Name (NI) **] [**Name (NI) 1968**]: [**Telephone/Fax (1) 69361**]. Medications on Admission: Lopressor (? dose) Lisinopril HCTZ FeSO4 Advair 250/50 nexium 40 lipitor 40 qd Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 (65) mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Outpatient Lab Work Please check Complete blood count [**2142-9-25**] Discharge Disposition: Home Discharge Diagnosis: Diverticulosis. GI bleed. NSTEMI. Discharge Condition: Stable. Discharge Instructions: **PATIENT IS LEAVING AGAINST MEDICAL ADVICE** During this admission you have been treated for a GI bleed due to diverticulosis. You also had a small heart attack (which is called a NSTEMI) while at [**Hospital 5871**] [**Hospital 12018**] Hospital. Please continue to take all medications as prescribed. If you notice any recurrent bleeding from your rectum, or if you feel lightheaded, dizzy, experience chest pain or shortness of breath, or any other symptom that is concerning to you, please seek immediate medical care. In addition, the X-ray of your right foot showed a small abnormality in your 1st toe (a lucency of the distal phalanx); we recommend obtaining an MRI to further evaluate this finding. Followup Instructions: Have your hematocrit checked tomorrow and follow up with your PCP [**Name Initial (PRE) 503**]. You should have your BUN and Cr (kidney finction) checked in [**2-5**] weeks. Follow up with a surgeon in the next [**2-5**] weeks. Obtain an elective MRI of R foot.

Admission Date: [**2132-8-4**] Discharge Date: [**2132-8-7**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1666**] Chief Complaint: Chest tightness Major Surgical or Invasive Procedure: [**2132-8-4**]: Flexible cystodcopy, wire & catheter placed by Urology (now out) History of Present Illness: This is a 89 year-old male [**Location 7972**] male with a history of asthma who presents with chest tightness and difficulty taking a deep breath since 9 PM on the evening prior to admission. Patient denies any fevers, chills or cough. He denies any nausea, diaphoresis, vomitting or abdominal pain. The chest tightness improved in a span of [**1-27**] hours, after patient received treatment in ED. However, the patient did have some tachypnea in the ED, and was admitted to MICU for further observation of respiratory status. Otherwise, patient was currently without any complaints, and denies current shortness of breath. Denies any sick contacts. . In the ED, initial vitals were T:98, HR:96, BP:154/96, RR:34, O2Sat: 100% on RA. He received albuterol and ipratropium nebulizers and 125mg IV methylprednisolone, with improvement of his symptoms. Given leukocytosis and possible infiltrate on chest x-ray, he was also started on cefriaxone and azithromycin for pneumonia. Past Medical History: #. Asthma #. Hypertension #. Mild AS #. Chronic renal insufficiency, baseline creatinine ~1.5 #. Benign prostatic hyperplasia #. h/o Urinary obstruction #. Urinary retention, severe urethral stricture #. h/o Bladder stones #. Bilateral small renal cysts (Renal U.S., [**2132-8-5**]) #. DM2, controlled on oral hypoglycemics #. GERD with small axial hiatal hernia, per barium esophagram ([**2132-7-7**]) #. h/o Esophageal spasm #. Esophageal dysmotility, characterized by tertiary contractions per barium esophagram & anterior cervical vertebral body osteophytes giving a minor impression on the cervical esophagus ([**2132-7-7**]) #. HOH, [**Month/Day/Year 1192**] sensorineural hearing loss in both ears #. Osteoarthritis, bilat knees . PSHx: [**2127-7-14**] s/p Suprapubic prostatectomy, cystoscopy flexible [**2127-6-4**] s/p Complex cystometrogram, complex uroflowmetry [**2126-9-4**] s/p Cystometrogram [**2126-1-22**] s/p Cystoscopy, Electrohydraulic litholapaxy, Placement of suprapubic tube [**2126-1-9**] s/p Complex cystometrogram, Intra-abdominal voiding pressure studies with attempted complex uroflowmetry & flexible cystourethroscopy Social History: The patient is a Portuguese speaking man from [**Country 3587**]. He lives at home with his wife. His daughters live nearby. He drinks only occasionally. Previously snuffed tobacco. Denied any recreational drug use. Family History: No history of heart disease or clotting disorders. Physical Exam: DISCHARGE PE: ============ VS: 96.4, 90, 20, 162/80, o2 sat 95% RA GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear, poor dentation NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, S1 S2, 3/6 systolic murmur best @ 2ICS/RSB & apex PULM: [**Month (only) **] BS widely w/ inc AP-Lat diam. Bibasilar/posterior scant fine crackles which clear with DB&C, no wheezes. ABD: Obese/distended, soft, positive bowel sounds EXT: CSM intact, no edema or palpable cords NEURO: alert, oriented to person, place, and time. Face symmetrical at rest & with movement, tongue midline. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: ADMISSION LABS: ============== [**2132-8-4**] 06:29AM CK(CPK)-58 [**2132-8-4**] 06:29AM CK-MB-3 cTropnT-<0.01 [**2132-8-4**] 06:29AM WBC-14.3* RBC-4.41* HGB-12.9* HCT-38.3* MCV-87 MCH-29.3 MCHC-33.6 RDW-13.3 [**2132-8-4**] 06:29AM GLUCOSE-224* UREA N-32* CREAT-1.5* SODIUM-140 POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-21* ANION GAP-18 [**2132-8-4**] 03:15AM LACTATE-1.3 [**2132-8-4**] 03:15AM TYPE-[**Last Name (un) **] PO2-83* PCO2-38 PH-7.37 TOTAL CO2-23 BASE XS--2 [**2132-8-4**] 12:13AM CK(CPK)-75 [**2132-8-4**] 12:13AM cTropnT-<0.01 [**2132-8-4**] 12:13AM CK-MB-NotDone proBNP-434 . IMAGING: ======= [**2132-8-6**] Cardiac Echo (TTE) - The left atrium is elongated. The left atrial volume is increased. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is [**Year (4 digits) 1192**] pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2130-5-15**], the findings are similar. The prior echo assessed aortic valve area as 1.2cm2, however, this should have been 1.8-1.9cm2. . [**2132-8-5**] RENAL U.S. - FINDINGS: The right kidney measures 13.5 cm and the left 12.0 cm. The renal parenchymal thickness and echogenicity are normal without evidence of calculi or hydronephrosis. The right kidney demonstrates a small cyst in the upper pole measuring 1.5 x 1.5 x 1.3 cm. Within the interpolar region of the left kidney, there is a 1.1 x 0.9 x 1.1 cm cyst. The bladder is not fully distended. IMPRESSION: 1. No evidence of hydronephrosis, renal calculi, or solid masses; 2. Bilateral small renal cysts. . [**2132-8-4**] CHEST (PA & LAT) - FINDINGS: There is elevation of the left hemidiaphragm with left pleural thickening. There has been interval decrease in pulmonary interstitial markings when compared to prior exam. However, more confluent opacities in the right perihilar region are noted, which may represent atelectasis. A more nodular density measuring approximately 1 cm is noted in the right lung base which was not seen on prior exam and may represent the nipple. IMPRESSION: Interval decrease in interstitial pulmonary markings. Interval development of right basilar atelectasis. Right lung nodular opacity may represent nipple. Repeat study is recommended with nipple markers. . EKG: === [**2132-8-4**] - Sinus rhythm with atrial premature complexes; Consider left atrial abnormality; Modest nonspecific ST-T wave changes; Since previous tracing of [**2132-8-3**], no significant change. QT/QTc 380/430. . D/C LABS: ======== [**2132-8-7**] 06:11AM BLOOD WBC-12.2* RBC-4.83 Hgb-14.0 Hct-41.9 MCV-87 MCH-29.0 MCHC-33.4 RDW-13.2 Plt Ct-254 [**2132-8-7**] 06:11AM BLOOD Glucose-105 UreaN-36* Creat-1.3* Na-141 K-4.3 Cl-106 HCO3-26 AnGap-13 [**2132-8-7**] 06:11AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2 Brief Hospital Course: # Chest tightness/SOB: Given his leukocytosis (14.3), and ? of LLL infiltrate on CXR, the patient was initially treated as asthma exacerbation precipitated by pneumonia. He was given Prednisone, cefpodoxime and azithromycin. On HD2 the patient was clinically improved, denied SOB and was weaned off O2. During his stay the patient remained without wheezes on exam and it was noted that LLL opacity was unchanged from prior x-ray several years ago. He denied taking advair at home and denied history of asthma. He was also ruled out for MI w/EKGs and cardiac enzymes. He was discovered to have a history of esophageal spasm and this was felt to be a more likely explanation for the chest tightness. GI was consulted and recommended evaluation as an outpatient. His antibiotics were D/C'd on hospital day 2. THe patient received 4 days of steroids (Solumedrol 125 mg IV x's 1 on [**8-4**] in ED; Prednisone 60 mg PO x's 1 on [**8-5**] in ICU; Prednisone 40 mg PO QD x's 2 on floor. He NOT discharged on Prednisone. He was also started on a baby aspirin. Outpatient PFTs have been scheduled for the patient. Omeprazole 20 mg Capsule, Delayed Release was started for GERD/Hiatal hernia/Asthma. . # Urethral Stricture: Patient with h/o BPH s/p multpile urological procedures, including s/p Suprapubic prostatectomy. He was noted to have low urine output and bladder scan showed 360cc residual. It was impossible for staff to pass a foley. Urology was consulted, performed a flexible cystoscopy in the ICU and found severe urethral stricture. They were able to pass small cathether through and left in place. The patient leaked around the catheter, the catheter eventually came out but he continued to have good urine output and post-void bladder scans were performed q4h to ensure he did not have high residual volume. Urology suggested that when patient is stable he will have to be taken to the OR to have the stricture surgically fixed. . # Chronic renal insufficiency: Creatinine 1.3-1.6 baseline and up to 1.8 at presentation. Initially, nephrotoxic agents (lisinopril and glipizide) were held. A Renal U/S, to evaluate for hydronephrosis, was unremarkable. Creataninine at d/c was 1.3. . # Hypertension: The patient was continued on his home dose of nifedipine and was changed from metoprolol succinate to tartrate on admission and his BP was well controlled initially. At discharge, his BP was seen to be creeping back up (162/80) and his home dose of lisinopril was restarted, as his creatinine was back to the reported baseline. Additionally the patient was changed back to his home dose of Toprol XL 50 mg Tablet Sustained Release PO QD. . # Diabetes mellitus - On admission the home Glipizide but this was discontinued and blood sugars covered with SSI and a diabetic diet was prescribed. The patient was discharged on his home Glipizide. . # Sleep Disorder: The patient was on Quetiapine 25mg qHS on admission for "problems sleeping". This was stopped & Trazodone 25 mg PO prn was started. The patient stated he was sleeping well in the hospital, on discharge. Medications on Admission: Advair (states was not taking) Glipizide 10mg daily Lisinopril 20mg daily Nifedipine SR 20mg daily Quetiapine 25mg qHS Metoprolol succinate 50mg Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Inhalation* Refills:*2* 2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*15 Tablet(s)* Refills:*0* 3. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 6. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: ================= Asthma flare . Secondary Diagnosis: =================== #. Hypertension #. Mild symmetric LVH, per echo, LVEF>55% ([**2132-8-6**]) #. Mild AS, Mild to [**Month/Day/Year 1192**] [[**12-26**]+] TR, trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **] systolic hypertension (per Echo [**2132-8-6**]) #. Chronic renal insufficiency, baseline creatinine ~1.5 #. Benign prostatic hyperplasia #. h/o Urinary obstruction #. Urinary retention, severe urethral stricture (per Cysto on [**2132-8-5**]) #. h/o Bladder stones #. Bilateral small renal cysts (Renal U.S., [**2132-8-5**]) #. DM2, controlled #. GERD with small axial hiatal hernia, per barium esophagram ([**2132-7-7**]) #. Esophageal dysmotility, characterized by tertiary contractions per barium esophagram & anterior cervical vertebral body osteophytes giving a minor impression on the cervical esophagus ([**2132-7-7**]) #. HOH, [**Month/Day/Year 1192**] sensorineural hearing loss in both ears #. Osteoarthritis, bilat knees . PSHx: [**2132-8-4**] s/p Flexible cystoscopy [**2127-7-14**] s/p Suprapubic prostatectomy, cystoscopy flexible [**2127-6-4**] s/p Complex cystometrogram, complex uroflowmetry [**2126-9-4**] s/p Cystometrogram [**2126-1-22**] s/p Cystoscopy, Electrohydraulic litholapaxy, Placement of suprapubic tube [**2126-1-9**] s/p Complex cystometrogram, Intra-abdominal voiding pressure studies with attempted complex uroflowmetry & flexible cystourethroscopy Discharge Condition: Stable: no wheezing & o2 sat stable on RA. Discharge Instructions: You were admitted to the hospital chest tightness, some difficulty breathing and a fast heart rate. You were sent to the ICU for observation. Testing showed that you did NOT have a heart attack. Urology was consulted while you were in the ICU and found that your urethra (the tube coming from your bladder that carries urine out of your body through your penis) is very narrowed. They recommend that you come back to the hospital as an outpatient and have a procedure under anesthia to stretch it and make it larger. Please arrange for this with Dr [**Last Name (STitle) 8499**]. We have also scheduled you to have some breathing tests to more closely diagnosis the periodic breathing problems that you experience. . Please call your Primary Care Provider [**Name Initial (PRE) **]/or come back to the Emergency Room if you experience any of the following: trouble breathing that does not go away with the use of your inhalers, temperature > 101.6, shaking chills, chest pain or pressure, pain that is not relieved with medicines, inability to pass your urine, changes in mental status, uncontrolled nausea/vomitting, finger sticks at home that are over 400 mg/dl, blood in your stool or any other health related concerns. . One of your medicines that you were taking when admitted has been stopped: Seroquel. Please do NOT take any more Seroquel. You were started on another medicine to help you sleep at night: Trazodone. Take Trazodone as needed at bedtime if you have trouble sleeping. We have also started you on a baby Aspirin [**Name2 (NI) 24073**] to help prevent heart attacks and a medicine called Omeprazole to help prevent acid reflux. Followup Instructions: PCP: [**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2132-8-22**] 3:00 . PFTs: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB, [**Hospital Ward Name 2104**] 7, Phone:[**Telephone/Fax (1) 609**], Tuesday Date/Time:[**2132-9-2**] 11:00 . Urology: recommends out-patient dilatation under GA for pin-hole bladder neck; please talk with your Primary Care Provider (Dr. [**Last Name (STitle) 8499**] about this. . GI: recommends an evaluation as an outpatient for your esphogeal spasm; please talk with your Primary Care Provider (Dr. [**Last Name (STitle) 8499**] about this. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**] Completed by:[**2132-8-8**]

Admission Date: [**2165-1-27**] Discharge Date: [**2165-3-2**] Date of Birth: [**2165-1-27**] Sex: M Service: NB HISTORY: Baby [**Name (NI) **] [**Known lastname 911**] was a 30-5/7 weeks gestational age, baby boy twin #2 [**Name2 (NI) **] to a 27 year-old G3P2-4 mom with [**Name2 (NI) **] type A positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis B negative, hepatitis C negative, CMV negative, GBS positive mom who has a past medical history of passing kidney stones during the pregnancy. Mom was admitted to [**Hospital6 1597**] early on the day of birth secondary to contractions. She was treated with betamethasone and intrapartum antibiotics. She was then transferred to [**Hospital1 69**] on the day of admission secondary to concern over the preterm labor despite increasing mag sulfate given. The labor progressed and delivery was done via C-section secondary to a vertex/breech presentation. In the delivery room the OB had slight difficulty delivering twin #2 secondary to a transverse lie. Upon delivery the infant had spontaneous respirations. He required facial CPAP and oxygen with Apgars 6 and 8. Birth weight was 1635 grams. He was transferred to the Neonatal Intensive Care Unit. PHYSICAL EXAMINATION ON ADMISSION: Weight 1635 grams, head circumference 30.5 cm, length 43 cm, temperature 97.6, pulse 124, respiratory rate 30, [**Hospital1 **] pressure 68/34 (45), oxygen saturation 88 to 94%. General: Baby AGA for a 30-5/7 week gestational age child. No dysmorphic features. HEENT: Normocephalic, anterior fontanelle soft and flat. Eyes appear within normal limits. Externally ears, nose and mouth within normal limits to examination. Neck: No masses, no adenopathy. Chest: Breath sounds poor with poor aeration. CV: No murmur. Heart sounds and rhythm are within normal limits. Pulses and perfusion present. Abdomen soft, nontender, nondistended. Umbilicus within normal limits. GU: Patient is male. Anus patent. Back and extremities appear within normal limits. Skin: Left inguinal bruise. Neuro: Normal tone and movement, posture and strength for a 30-5/7 week gestational age baby. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Baby was quickly intubated and given Survanta x1. Baby extubated on day of life 1 to room air and has been on room air since that time without any problems. [**Known lastname **] did have some apnea of prematurity and desaturations with bottling which has since resolved. Cardiovascular: Baby has had good heart rates and [**Known lastname **] pressures throughout his stay in the Neonatal Intensive Care Unit and he has a mild soft intermittent murmur that we have not been concerned with. GI: Baby had some hyperbilirubinemia with a peak bilirubin of 8.2 on day of life 3. He had phototherapy on day of life 3 and day of life 4 and was discharged and he has had no further bilirubin issues. His last bilirubin level was on [**2-10**], day of life 14 which was 1.5 total bilirubin and .4 direct. Hematology: The baby had an initial CBC which demonstrated a white count of 5.6 with 23 neutrophils, 0 bands, 70 lymphs, a hematocrit of 52 and platelets of 230. Baby was started on iron on day of life 10 on which he continues. He has had no further issues or further need for CBC or laboratory work. Infectious disease: At birth baby had a [**Month (only) **] culture which was negative and was treated with ampicillin and gentamicin for 2 days and has had no further infectious disease issues. Neurology: Baby had a head ultrasound on the [**2-5**] which was day of life 7 and repeat on DOL #33 which was normal as well. No further issues. Sensory: Audiology: Hearing screen was performed with an automated auditory brain stem response which the baby passed on [**2-28**]. Ophthalmology - Baby was examined on [**2-25**] which demonstrated immature zone 3 bilaterally and need to repeat check in 3 weeks from the previous exam with Dr. [**Last Name (STitle) **]. CONDITION AT DISCHARGE: Excellent. DISCHARGE DISPOSITION: Home. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] in [**Hospital1 8**], MA. CARE RECOMMENDATIONS: Feeds at discharge: Baby is on all PO feeds of Special Care 24 and his most current weight is 2410 grams. Medications: Iron 0.3 cc p.o. q day. Immunizations received: Baby received hepatitis B vaccination on [**2-24**] and has received Synagis vaccination on [**2-27**]. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 3 criteria: 1) [**Month (only) **] at less than 32 weeks. 2) [**Month (only) **] between 32 and 35 weeks with 2 of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOW UP APPOINTMENT SCHEDULE RECOMMENDED: 1. Baby will see Dr. [**First Name (STitle) **] on [**Last Name (LF) 766**], [**3-3**] at 2:45 PM. 2. Follow up ophthalmology appointment will be made by parents. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Respiratory distress, resolved. 3. Rule out sepsis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**] Dictated By:[**Last Name (NamePattern1) 69933**] MEDQUIST36 D: [**2165-2-27**] 10:59:31 T: [**2165-2-27**] 11:30:33 Job#: [**Job Number 70363**]

Admission Date: [**2184-4-3**] Discharge Date: [**2184-4-8**] Date of Birth: [**2132-12-25**] Sex: F Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 613**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 51 y/o F w/COPD (FEV1 31%, multiple intubations in past), Hep C, hx IVDA, who presented to the ED tonight with SOB x several days. On [**2184-3-13**], she called her [**Date Range 19039**] c/o sinus congestion and rhinorrhea and was told she likely had a viral URI. This improved with symptomatic treatment with Advil Cold & Sinus. She called back on [**2184-3-22**] with a persistent cough and increased sputum production (yellow). At that point she was given a z-pack and a one-week course of prednisone (40 mg daily). She finished the prednisone yesterday. Since then, she has had continued productive cough and worsening SOB. Of note, her nebulizer prescription was changed from four times per day to once daily, so she has not been using her nebs as often. * In the ED, she was initially saturating 86% on RA. After an albuterol nebulizer, she improved to 94%. She was also given prednisone 60 mg and azithromycin. She was admitted to medicine for further management. Past Medical History: 1. COPD, followed in Pulmonary by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Most recent spirometry [**11-11**] revealed FEV1 of 1.13 (45% pred), FVC 2.58 (79% pred), and FEV1/FVC ratio of 0.44. Improved from prior in [**4-11**]. Full PFTs from [**10-12**] also showed diffusion capacity 45% pred. Exercise oximetry showed O2 sat 88%RA at rest, which decreased to 80% w/ambulation. ABG at that time 7.34/56/52 on RA. 2. Hep C, being monitored 3. Hx IVDA, on methadone maintenance 4. Hx seizure d/o Social History: lives with her common law husband in [**Name (NI) 3786**]; smokes 30 pack-years, currently [**2-9**] ppd; drinks occasional cocktail; h/o heroine addiction, quit 2 years ago, now on methadone maintenance; has 2 children. Family History: aunt w/CVA. mother had endometrial ca. father had lung ca. Physical Exam: T: 97.5 P: 73 BP: 156/83 R: 18 86% on RA/then 100% on 1L NC after neb Gen: alert and oriented pleasant female in NAD, speaking in full sentences, no accessory muscle use HEENT: pupils constricted and minimally reactive, anicteric, MM moist. Neck: supple, no cervical LAD, neck veins flat Lungs: rhonchorous throughout, worst at bases. decent air movement. no wheezes or crackles. CV: RRR, II/VI systolic murmur heard best at RUSB Abd: soft, nontender, nondistended. +bs. Ext: no edema. warm and dry. Pertinent Results: CXR: hyperinflated. no pna. . CTA: IMPRESSION: 1. No evidence of pulmonary embolism or dissection. 2. Mild emphysematous changes in the lungs, with mild scarring and basilar mild atelectasis. 3. Hiatal hernia. . CT head: FINDINGS: There is no evidence of mass effect or hemorrhage. There is no displacement of normally midline structures. There is no evidence of a focal extra-axial lesion or fluid collection. Ventricles and sulci are not remarkable. [**Doctor Last Name **] and white matter are not unusual. The visualized paranasal sinuses are clear. . Echo: Conclusions: 1. The left atrium is mildly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] 6.There is mild pulmonary artery systolic hypertension. 7.There is no pericardial effusion. . Compared with the findings of the prior report (images unavailable for review) of [**2182-10-15**], mitral regurgitation is now present. . Labs: [**2184-4-8**] 06:45AM BLOOD WBC-9.8 RBC-3.96* Hgb-12.8 Hct-37.3 MCV-94 MCH-32.3* MCHC-34.3 RDW-13.6 Plt Ct-175 [**2184-4-7**] 04:01AM BLOOD WBC-7.8 RBC-3.77* Hgb-12.1 Hct-35.1* MCV-93 MCH-32.0 MCHC-34.4 RDW-13.6 Plt Ct-164 [**2184-4-3**] 05:16AM BLOOD WBC-10.2 RBC-4.15* Hgb-13.6 Hct-39.2 MCV-94 MCH-32.8* MCHC-34.8 RDW-13.6 Plt Ct-196 [**2184-4-8**] 06:45AM BLOOD Glucose-72 UreaN-12 Creat-0.8 Na-141 K-3.4 Cl-105 HCO3-30 AnGap-9 [**2184-4-6**] 12:59PM BLOOD ALT-14 AST-26 LD(LDH)-215 AlkPhos-50 TotBili-0.3 [**2184-4-6**] 04:24AM BLOOD CK(CPK)-35 [**2184-4-5**] 06:00PM BLOOD CK(CPK)-27 [**2184-4-6**] 04:24AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2184-4-5**] 06:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2184-4-6**] 12:59PM BLOOD Ammonia-34 [**2184-4-6**] 12:59PM BLOOD TSH-1.3 [**2184-4-6**] 12:59PM BLOOD Free T4-0.8* [**2184-4-5**] 06:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: A/P: 51 y/o F w/hx COPD who presents with increased sputum production and SOB, c/w her usual COPD exacerbations. * ## COPD exacerbation: This was likely triggered by a viral URI and in the setting of under-using her nebulizer. She was started on prednisone 60 mg daily with plans to use a longer taper as she got worse so quickly after stopping the last time. Azithromycin was continued for a five-day course. Neb treatments were given prn. She remained stable on room air and intermittent 1L O2 with goal O2 sats 88-92%. She was able to maintain these levels most of the time, with some desaturation to 85% on ambulation. On [**4-5**] patient became somnolent and combative repeat ABG showed increased CO2 retention. Patient was subsequently transferred to MICU for closer observation. Patient was started on CPAP @ night with great improvement in her mental status. Patient did not require other antibiotics as her WBC remained normal while on steroids and she was never febrile with clear CXR. Patient slowly improved and was maintaining sats >91-92% with ambulation upon discharge. Patient is to continue using her BIPAP @ [**9-10**] @ home. She is to continue her prednisone taper and will follow up with her [**Month/Day (4) 19039**] * ## Confusion - patient became suddenly somnolent on [**4-5**]. The sudden onset of her symptoms was concerning for overmedication however patient had not received anything for 8 hours prior except Tylenol. UTox and serum tox were negative. ABG showed increasing CO2 retention. Patient was very angry when asked about potential drug abuse and she was upset that this assumption recurs as patient often mistaken her hypercarbia for intoxication. Her mental status quickly improved with initiation of BIPAP @ night with improvement in her CO2 levels. . ## MR - patient was found to have 2+ MR. The etiology of her MR remains unclear as she had no evidence of overwhelming LVH and no evidence of ischemia. Patient was counseled to take antibiotic prophylaxis when undergoing dental work or other invasive procedures. . ## urinary frequency: She reports increasing urinary frequency and also symptoms that may be consistent with an element of urinary retention. She was on a medication prescribed by her PCP ~8 months ago that may have been Detrol. Her UA was unremarkable, and her UCx grew <10,000 organisms. * ## Hep C: Genotype 2, stage I fibrosis on biopsy. No interferon per hepatology [**3-11**] pulmonary disease. * ## IVDA: She was continued on her methadone maintenance. She reports she has had her dose increased from 60 mg to 70 mg recently; however, no records in the OMR confirm this so she was continued on 60mg. * ## Seizure d/o: Keppra was continued. . Patient will follow up with her [**Month/Day (2) 19039**]. Medications on Admission: Keppra 1000 mg [**Hospital1 **] Advair 500/50 1 puff [**Hospital1 **] Albuterol prn Fioricet prn Flonase 2 puffs daily Spiriva 1 puff [**Hospital1 **] Methadone 70 mg daily Discharge Medications: 1. Medical supplies BIPAP machine with it's associated supplies; With settings of 8 on inspiratory phase and 5 on expiratory phase ([**9-11**]). 2. Methadone 10 mg Tablet Sig: Seven (7) Tablet PO DAILY (Daily): Patient received 70 mg of methadone daily while in the hospital. 3. 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* 4. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*30 Patch 24HR(s)* Refills:*3* 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-9**] Puffs Inhalation Q4H (every 4 hours) as needed. Disp:*1 inhaler* Refills:*5* 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) click/inhallation Inhalation [**Hospital1 **] (2 times a day). Disp:*1 disk* Refills:*5* 8. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*3* 9. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day: x 7 days, followed by 40 mg (4x10) for next 7 days and then decrease by 10 mg (1 tablet) each week. Disp:*150 Tablet(s)* Refills:*3* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. COPD exacerbation 2. hypercarbic respiratory failure 3. Seizure Disorder 4. mitral regurgitation Discharge Condition: Stable. Patient sating 91% on ambulation on discharge. Afebrile. Good po intake. Discharge Instructions: Please take all your medications as instructed, especially your prednisone. Please continue your prednisone at 40 mg for next 7 days and then decrease it by 10 mg next week and another 10 the week after that. If you have increasing shortness of breath, lightheadedness, confusion, lethargy, or episodes of loss of consciousness, call your doctor or seek medical attention immediately. . Please make sure you keep your appointment with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] as scheduled above. . Please use your BIPAP machine as instructed at night. Followup Instructions: Follow up with your PCP (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 250**]) within 1-2 weeks after discharge. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 16717**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2184-4-22**] 2:00 . [**5-24**] @ 3:30 pm with Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **]. Please arrive in time for pulmonary tests. Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2184-5-24**] 3:40 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2184-5-24**] 4:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2184-4-20**]

Admission Date: [**2122-2-13**] Discharge Date: [**2122-3-3**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy History of Present Illness: Mr [**Known lastname 65533**] is a [**Age over 90 **] year old man s/p right nephrectomy, s/p left ureterostomy ileal conduit who was transferred from [**Hospital1 18**] [**Location (un) 620**] for sharp and worsening abdominal pain. The patient denied any bowel movement in the 2-3 days prior to presentation but had some flatus in the previous hour. A CT scan performed at [**Location (un) 620**] was concerning for large bowel obstruction/cecal volvulus. Past Medical History: PMH: CAD, MI, HTN, DJD, renal CA, a-fib PSH: CCY, R nephrectomy, cystectomy/ileal conduit, AAA, pacemaker, PTCA Social History: No tobacco, occasional wine. Family History: Non-contributory Physical Exam: Temp 97.2 72 170/76 24 Gen: sitting up Chest: CTAB CVS: RRR Abd: firm, mild-severe tenderness, severely distended, no rebound, no guarding, no local masses Rectal: no masses, guiaic neg Ext: warm Pertinent Results: CT Abdomen [**Location (un) 620**] 2//906 Complete large bowel obstruction, possible cecal volvulus, possibly associated with ileal conduit Brief Hospital Course: Mr [**Known lastname 65533**] is a [**Age over 90 **] year old man s/p right nephrectomy, s/p left ureterostomy ileal conduit who presented with complete large bowel obstruction/cecal volvulus and who underwent ex lap, R colectomy, revision ileal conduit w/ Urology on [**2122-2-13**]. In the OR, the patient was found to have necrotic gut and underwent R colectomy and ileal conduit revision. Please see operative report for full details of the procedure. In the OR, the patient also underwent TEE that revealed an EF of 45%. . Post-operatively, the patient was transferred to the Trauma SICU. The patient was initially thought to be coagulopathic, but this was eventually found to be secondary to 'propofol syndrome' and with suspension of the propofol on post-operative day #1, his lab values improved. Otherwise, he remained on pressors until POD #4, was extubated on POD #7, completed a 7 day course of IV abx (Levo/flagyl) and transferred to the floor on POD #9. On that same day, the patient was found obtunded with worsening O2 sats to the 80s. This did not improve with lasix or nebs. ABG revealed paO2 of 39. Pt was also found to be hypoglycemic (23) due to poor oral intake and NPH administration. The patient was intubated and readmitted to the Trauma SICU. He was started on Levofloxacin prophylacticailly. On post-operative day #11, the patient was successfully extubated. On that day, a feeding tube was placed under fluoroscopy which was later pulled out by the patient. The patient was evaluated by speech and swallow who recommended that the patient reattempt oral feeds with pureed foods under supervision. Given this, the patient was transferred to the floor. . On the floor, the patient recovered well. He was evaluated by Nutrition who recommended supplementation to improve his nutritional status. He was seen by Cardiology after one episode of asymptomatic Vtach (18 beats) who recommended tight blood pressure control and resumption of anti-coagulation for Afib. He was started on warfarin on [**2122-2-27**] with Lovenox until INR is therapeutic at 2.0-2.5. At this point, Lovenox should be discontinued. The patient was discharged to extended care facility for rehab on [**2122-3-3**]. Medications on Admission: [**Last Name (un) 1724**]: prednisone 7.5, Coumadin 5/2.5, digoxin, Lipitor, lisinopril, Ativan, Lopressor, Tramadol Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*QS Tablet(s)* Refills:*0* 2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. Disp:*250 ML(s)* Refills:*0* 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day): please discontinue when INR therapeutic. Disp:*QS * Refills:*0* 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (once): please adjust to reach therapeutic INR level of 2.0-2.5. Disp:*QS Tablet(s)* Refills:*0* 9. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day: Except wednesday. Disp:*30 Tablet(s)* Refills:*0* 10. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: Ventral hernia Discharge Condition: stable Discharge Instructions: Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting, inability to eat, wound redness/warmth/swelling/foul smelling drainage, abdominal pain not controlled by pain medications or any other concerns. Please resume taking all medications as taken prior to this surgery and pain medications as prescribed. Please follow-up as directed. No heavy lifting for 4-6 weeks or until directed otherwise. Wound Care: [**Month (only) 116**] shower (no bath or swimming) if no drainage from wound, if clear drainage cover with dry dressing Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2122-3-13**] 1:45, [**Hospital Ward Name 23**] 3 Clinical Specialities Completed by:[**2122-3-3**]

Admission Date: [**2160-5-15**] Discharge Date: [**2160-5-24**] Date of Birth: [**2106-10-2**] Sex: F Service: MEDICINE Allergies: Actonel Attending:[**First Name3 (LF) 7281**] Chief Complaint: LBP/BLE pain Major Surgical or Invasive Procedure: [**2160-5-15**]: L4-S1 posterior decompression and fusion w/ bone marrow aspirate History of Present Illness: She is s/p a left-sided L4-L5 and L5-S1 microlumbar discectomy on [**12-26**]. She initially did well with her left lower extremity radiculopathy. Unfortunately,she has gone on to develop progressive symptoms. For that reason, she underwent followup MRI. She describes pain that radiates down the left leg and into the little toe. She has some right lower extremity weakness from prior surgery. Her bowel and bladder function is normal. Past Medical History: * DM1 - complicated by neuropathy, retinopathy autonomic dysfunction, gastropathy * HTN * Asthma * S/P Renal/Pancreas Transplant ([**2139**]) * Numular Eczema * H/O Rectal Bleeding ([**2152**]) * Psuedoaneurysm of left External Iliac Artery s/p stent ([**2154**]) * H/O Deep Venous Thrombophlebitis ([**2155**]) * Chronic Lower Back Pain * Left First Toe Osteomyelitis * Retinopathy of Right Eye Social History: Patient denies tobacco or illicit drug use. She infrequently consumes alcohol. She was living with her daughter but recently moved out. She currently lives alone. She has a very close relationship with her daughter. Family History: nc Physical Exam: On examination, her strength was [**5-28**] in hip flexion, extension,quadriceps, hamstrings, and plantarflexion bilaterally. Dorsiflexion was graded at 4/5 on the left and was normal on the right. Extensor hallucis longus could not be assessed on the left due to previous toe surgery and was normal on the right. Her sensory examination revealed a decreased appreciation of light touch in both the medial and lateral aspect of her left foot. ON DISCHARGE: Bialteral IP's [**4-28**], quad, ham, gastroc, AT, and Right [**Last Name (un) 938**] 5-/5, left [**Last Name (un) 938**] [**4-28**](secondary to toe surgery), incision clean dry intact with steri strips, sensation decreased to light touch on right lateral thigh and left lateral foot, ambulates with walker. Pertinent Results: An MRI of the lumbosacral spine obtained on [**2160-3-3**],demonstrates prior surgery both L4-L5 and L5-S1. There is a grade 1 spondylolisthesis at L4-L5. There is lateral recess stenosis bilaterally at L4-L5. There is a recurrent residual disc herniation at L5-S1 on the right side. Flexion and extension x-rays were obtained which demonstrate a grade 1 spondylolisthesis at L4-L5 and no abnormal movement when flexion and extension views were compared. [**2160-5-15**] 02:10PM BLOOD WBC-4.3 RBC-3.45* Hgb-10.2* Hct-30.8* MCV-90 MCH-29.7 MCHC-33.2 RDW-14.9 Plt Ct-216 [**2160-5-24**] 07:35AM BLOOD WBC-4.6 RBC-3.10* Hgb-9.1* Hct-27.6* MCV-89 MCH-29.3 MCHC-33.0 RDW-15.0 Plt Ct-429 [**2160-5-20**] 07:25AM BLOOD PT-11.1 PTT-23.6 INR(PT)-0.9 [**2160-5-20**] 07:25AM BLOOD Ret Aut-1.3 [**2160-5-15**] 02:10PM BLOOD Glucose-213* UreaN-23* Creat-1.2* Na-143 K-4.8 Cl-114* HCO3-24 AnGap-10 [**2160-5-24**] 07:35AM BLOOD Glucose-113* UreaN-25* Creat-1.5* Na-142 K-3.8 Cl-103 HCO3-31 AnGap-12 [**2160-5-16**] 01:13AM BLOOD CK(CPK)-235* [**2160-5-16**] 11:00AM BLOOD CK(CPK)-222* [**2160-5-16**] 07:30PM BLOOD CK(CPK)-236* [**2160-5-20**] 07:25AM BLOOD LD(LDH)-180 [**2160-5-16**] 01:13AM BLOOD cTropnT-<0.01 [**2160-5-16**] 11:00AM BLOOD CK-MB-8 cTropnT-<0.01 [**2160-5-16**] 07:30PM BLOOD CK-MB-6 cTropnT-<0.01 [**2160-5-15**] 02:10PM BLOOD Calcium-7.9* Phos-2.7 Mg-1.5* [**2160-5-24**] 07:35AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7 [**2160-5-20**] 07:25AM BLOOD calTIBC-147* Hapto-214* Ferritn-186* TRF-113* [**2160-5-17**] 07:05AM BLOOD Cyclspr-58* [**2160-5-22**] 08:00AM BLOOD Cyclspr-60* [**2160-5-23**] 07:40AM BLOOD Cyclspr-204 [**2160-5-24**] 07:35AM BLOOD Cyclspr-PND [**2160-5-20**] 01:15AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008 [**2160-5-20**] 01:15AM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-300 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2160-5-16**] 01:12AM URINE Hours-RANDOM Creat-136 Na-LESS THAN [**2160-5-17**] 05:51AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 [**2160-5-17**] 05:51AM URINE Blood-TR Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2160-5-17**] 05:51AM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0 [**2160-5-20**] URINE URINE CULTURE-FINAL INPATIENT [**2160-5-19**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2160-5-19**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2160-5-17**] URINE URINE CULTURE-FINAL INPATIENT Radiology Report L-SPINE (AP & LAT) Study Date of [**2160-5-17**] 2:27 PM FINDINGS: A frontal view is provided. The PLIF is in situ. Unremarkable appearance. Radiology Report CHEST (PA & LAT) Study Date of [**2160-5-19**] 6:04 PM There are no findings to suggest pneumonia. Heart size is normal. There is no pleural abnormality. Pulmonary vasculature is unremarkable. No free subdiaphragmatic gas. Brief Hospital Course: 1. Lumbar fusion: Pt was admitted on [**2160-5-15**] and underwent above procedure. Postoperativley she was continued on her home meds. She remained overnight in PACU and required multiple fluid boluses for low urine output. She was seen in consult by renal and [**Last Name (un) **] who followed her throughout her hospital course. She had JP that was removed late in the POD#1. She was out of bed with PT. She was managed on PO pain medications. On [**5-17**] her foley was removed and a UA was negative. She had a chest X-ray which showed small bilateral pleural effusions. On [**5-18**] her hematocrit was 26 and was being followed for potential need for transfusion. On [**5-19**] her hematocrit was 25.4 and did not require trasnfusion. She was screened for rehab, however due to postoperative complications of labile blood pressure, difficult to control blood glucose, anemia and low grade fevers, discharge was delayed (see below for discussion of postoperative complications). 2. Fevers: Post-operative fevers as high as 101.2 without focal symptoms of infection. Blood and urine cultures were drawn and patient had CXR on [**5-19**]. Started empirically on ciprofloxacin for presumed cystitis with positive U/A. When urine culture returned negative on [**2160-6-2**], ciprofloxacin was discontinued. Patient defervesced with no evidence of infectious etiology. 3. labile BP: patient has history of autonomic instability from underlying diabetes mellitus compounded by hypovolemia in setting of low grade fevers and anemia. Low salt diet was discontinued and midodrine was titrated up to 5mg TID in an effort to decrease orthostatic hypotension. Medications with anticholinergic side effects were also discontinued/ decreased to alleviate orthostatic symptoms. Although B-blocker was likely contributing to orthostatic hypotension by blocking compensatory response in heart rate, carvedilol was continued given marked supine hypertension. Patient continued to have labile blood pressure, but her symptoms had improved significantly and she was able to perform ADLs without significant difficulty. 4. acute on chronic anemia: Hct on admission 30.8, drifted down to 25 following spinal surgery. Likely etiology from multiple chronic medical problems i.e. renal insufficiency and blood loss from surgery. Iron studies are indicative of some mild iron -deficiency with serum iron of 21 and a borderline low transferrin saturation (14%). Ferritin is elevated in setting of illness. No signs of hemolysis. Patient continued on iron supplementation with Hct remaining stable through remainder of hospital stay. Hct on discharge was 27.6 5. s/p renal tranplant: during course of hospitalization, creatinine trended up to 1.6 from recent baseline of 1.1- 1.3. Etiology of renal damage unclear, may be indicative of brief period post op hypotension. Continued cyclosporine/ prednisone/ azathiodine at current dose. Continued bactrim SS for PCP [**Name Initial (PRE) **] 6. type 1 DM: hx of brittle diabetes with multiple medical cxs. Continued on home dose of lantus and humalog per sliding scale. [**Last Name (un) **] followed patient while in house, uring patient to consider insulin pump for tighter glycemic control 7. CAD s/p multiple PCI (baloon angioplasty): stable with no signs of ischemia Medications on Admission: Albuterol ASA Azathioprine Bactrim Captopril Clobetasol Cyanocobalamin Cyclosporine Cymbalta Flovent Folate Insulin Lyrica Metoprolol Midodrine Nitroglycerine Pravachol Prednisone Serevent Singulair Vicodin Vitamin D Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Unit Injection ac+hs: Dose as per PCP. 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 3. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cyclosporine 25 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Inhalation Q12H (every 12 hours). 9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual PRN (as needed) as needed for chest pain. 10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 12. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 13. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 16. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Pregabalin 150 mg Capsule Sig: One (1) Capsule PO twice a day. 18. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 19. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Home With Service Facility: Greater [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: Lumbar stenosis labile blood pressure post op anemia of blood loss Discharge Condition: Stable Discharge Instructions: ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up / take daily showers including incision ?????? You have steri-strips in place. Do not pull them off. They will fall off on their own or be taken off in the office ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT Please arrange follow up with Dr. [**Last Name (STitle) 14591**] at [**Telephone/Fax (1) 2384**] from [**Last Name (un) **]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 7284**]

Admission Date: [**2136-7-26**] Discharge Date: [**2136-8-1**] Date of Birth: [**2105-2-16**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: Diagnostic Cerebral Angiogram History of Present Illness: 31 yo M with hx of HTN and HLD, and hx of quesitonable aneurysm vs AVM follow by Dr. [**Last Name (STitle) 1128**] at [**Hospital1 2025**], experienced a first-time seizure around midnight last night in prison. He states that he has been experiencing some sensitivity to light and noise preceding the event, but no frank aura. He proceded to lose consciousness, and when he regained consciousness, he complained of some mild confusion, but knew where he was. He denies tongue biting or loss of bowel/bladder continence. He did complain of a HA afterward that was [**Hospital1 **]-frontal, and increased in intensity to a [**2138-6-5**] over hours, but has since died down to a current [**2-6**]. He also endorses some current stiffness in the back of the neck, but denies any other neurological problem including any vision changes, N/V, any focal weakness, or any change in sensation. He was initially taken to [**Hospital 8**] Hospital where a NCHCT was completed and showed a right frontal intraparchenymal hemorrhage and he was subsequently transferred to [**Hospital1 18**]. He was loaded with Dilantin, and no subsequent seizures. Past Medical History: HLD HTN Depression/anxiety EtOH abuse ? aneuryms vs AVM, followed at [**Hospital1 2025**] (Dr. [**Last Name (STitle) 1128**] Social History: usually lives in [**Location 246**] with girlfriend, [**Name (NI) 8298**]'t worked recently, supported by parents and girlfriend. Recently violated parole after being arrested for disorderly conduct following intoxication. Smokes [**11-30**] ppd x 10 yrs, admits to drinking [**5-6**] drinks 3x/week, but says it has been heavier in past, smokes occassional MJA, no other drugs. Family History: Unknown Physical Exam: O: T: BP: 138-155/108-109 HR: 69 R 15 O2Sats 97%RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 5-->3 mm B/L; fundi normal B/L w/ sharp disc amrgins EOMs: full Neck: c/o some tenderness and flexion mildly limited Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**1-30**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 5 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-2**] throughout. No pronator drift Sensation: Intact to light touch, temperature and vibration bilaterally. Reflexes: B T Br Pa Ac Right 0 0 0 0 0 Left 0 0 0 0 0 Toes mute bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin (HKS not tested on L, secondary to ankle cuff to bed) Pertinent Results: [**2136-8-1**] 10:50AM BLOOD WBC-10.7 RBC-4.78 Hgb-15.9 Hct-44.3 MCV-93 MCH-33.3* MCHC-35.9* RDW-12.8 Plt Ct-361 [**2136-7-26**] 01:17PM BLOOD Neuts-82.8* Lymphs-12.4* Monos-4.0 Eos-0.5 Baso-0.3 [**2136-8-1**] 10:50AM BLOOD Plt Ct-361 Brief Hospital Course: Mr [**Known lastname 79355**] was admitted to the ICU for close observation and neuro checks. He underwent a CTA on admission which showed a 2.3 x 1.3 cm intraparenchymal hematoma in the right frontal lobe with a small punctate focus of calcification normal caliber enhancing vessels are noted on the medial aspect An MRI showed no enhancing mass lesion or midline shift seen. Neurologically he remained in intact and underwent a cerebral angiogram which show right frontal cavernous hemangioma. This is the patients second bleed he was given the option of having this hemangioma resected via craniotomy. He has chosen to do so and the surgery is scheduled for [**8-10**]. We are attempting to get outside films from [**Hospital3 2576**] sent here for planning purpose. He will return on [**8-10**] and obtain a WAND study. On discharge his Dilantin level was 4.3 he was given a bolus of 600mg and he will continue at 200mg [**Hospital1 **] and should have a level checked in 2 days to keep level greater than 10. Medications on Admission: Celexa 40 mg PO Qday Klonopin 2 mg QAM and 1 mg QHS Visteral 100 mg TID PRN Simvastatin (dose unknown, but thinks 40 mg Qday) Lopressor 50 mg PO BID Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Hydroxyzine HCl 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day) as needed for anxiety. 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Thiamine HCl 100 mg 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. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Discharge Diagnosis: Cavernous Hemangioma Discharge Condition: Neurologically stable Discharge Instructions: ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room Followup Instructions: You are scheduled for surgery on Friday [**2136-8-10**]. You need to be at MRI ([**Hospital Ward Name 517**] Basment) mostly likely early am of the 12th. Dr[**Name (NI) 935**] assistant will call with the information Nothing to eat or drink after midnight on Thursday Completed by:[**2136-8-1**]

Admission Date: [**2153-10-8**] Discharge Date: [**2153-10-11**] Service: PAIN MED This is a [**Age over 90 **]-year-old female with past medical history of hypertension who presented to an outside hospital after several days of shortness of breath and dyspnea on exertion with minimal activity. She also has noted some left arm pain, but denied chest pain, nausea, vomiting. On the morning of admission, she was noted to be more restless and short of breath while lying in bed. She was taken to the outside hospital, where she was noticed to have congestive heart failure with electrocardiogram notable for an anterior ST elevation myocardial infarction. She was Med flighted to [**Hospital1 69**] for cardiac catheterization. This is where she was found to have a proximal left anterior descending artery stenosis of 99% for which she had percutaneous transluminal coronary angioplasty stent. PAST MEDICAL HISTORY: 1. Hypertension. 2. Breast cancer status post mastectomy at age 61 years old. 3. Hypothyroidism. 4. Dementia. HOME MEDICATIONS: Atenolol 50 mg q day, Synthroid 50 mcg q day. PHYSICAL EXAMINATION: On physical exam, patient was resting comfortably. Vital signs: Pulse 77, blood pressure 117/48. Head and neck unremarkable. No jugular venous distention. Lungs: Crackles at bases bilaterally. Cardiovascular: Regular, rate, and rhythm, normal S1, S2. Abdomen is soft and nontender. Extremities: Trace edema. Electrocardiogram on admission was normal sinus rhythm, T-wave inversions in I, aVL, and V6. Repeat showed continued T-wave inversions in aVL, [**Street Address(2) 2051**] elevations in V2, [**Street Address(2) 1755**] elevation V3 and V4, and [**Street Address(2) 2051**] elevation V5. LABORATORIES: Hematocrit 39.0, platelets 304. Sodium 142, potassium 4.1, chloride 105, bicarb 20, BUN 28, creatinine 0.9, glucose 167. Initial CK were 206, CK MB originally 52 and troponin 1.26. HOSPITAL COURSE: The patient was sent immediately to catheterization where a proximal left anterior descending that was stenosed 99% was stented with a 2.5 by 13 mm stent. The patient recovered well from procedure and throughout the course increased to a maximum CK 548, but trended down to 291. CK MB maximum of 52 trending down to 9, and troponin reached greater than 50. The patient was started on aspirin, Lipitor, beta blocker, ACE was held secondary to decreased urine output during the CCU stay. Repeat electrocardiogram on [**10-9**] showed some normal sinus rhythm at 70 beats per minute, Q waves in V1-V3, T-wave inversions V4 through V6, T-wave flattening/slight inversion in II, III, and aVF. Patient had a postcatheterization echocardiogram which showed an ejection fraction of 35% as well as severe valvular disease including 3+ MR, 3+ TR, 1+ AI. Patient's urine output improved once transferred to the floor. ACE was restarted. Beta blocker increased as well as the statin. Patient's blood pressure is stable in the 120s/60s, pulse 70s. Course was complicated by a brief period of hypoxia. When chest x-ray was taken revealing congestive heart failure with interstitial edema, she was diuresed and her oxygen requirement returned to baseline which was none ultimately to a saturation of being 97% on room air. Creatinine was entirely normal throughout the hospital stay, and hematocrit remained stable about 35 before and after procedure. Discharged patient to home with physical therapy and visiting nurse. She stays with her daughter and son-in-law who helps to take care of her. The patient was not put on Coumadin. Anticoagulation was not an option secondary to risks outweighed the benefits, such as risk of fall. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post anterior wall ST elevation myocardial infarction. 2. Congestive heart failure with ejection fraction of 35%. 3. Hypertension. 4. Status post breast cancer. 5. Hypothyroidism. 6. Dementia. DISCHARGE MEDICATIONS: 1. Plavix 75 mg q day x26 days. 2. Aspirin 325 mg po q day. 3. Levothyroxine 15 mcg q day. 4. Metoprolol 25 mg [**Hospital1 **]. 5. Atorvastatin 20 mg q day. 6. Colace 100 mg [**Hospital1 **]. 7. Multivitamin one tablet q day. The patient is to follow up with Dr. [**Last Name (STitle) **] in [**1-17**] weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2153-10-10**] 14:42 T: [**2153-10-16**] 06:43 JOB#: [**Job Number 45285**]

Admission Date: [**2192-2-16**] Discharge Date: [**2192-2-22**] Date of Birth: [**2138-2-25**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This 53-year-old male has had a known history of coronary artery disease and is status post coronary artery bypass grafting x 2 in [**2184**]. He had recurrent chest pain and shortness of breath on exertion and at rest since last [**Month (only) **] and underwent an exercise Myoview in [**12/2191**] which showed an anterior apical myocardial infarction with lateral ischemia. He then underwent a cardiac catheterization which revealed severe three-vessel disease with occluded bypass grafts. He was subsequently referred for redo coronary artery bypass grafting surgery. His cardiac catheterization on [**2-9**] revealed 100% occlusion of the native left anterior descending coronary artery, 100% occlusion of the left circumflex, 100% occlusion of the right coronary artery, the left anterior descending coronary artery graft was occluded, the right coronary artery and posterior descending coronary artery grafts were patent with multiple severe stenoses, and the left internal mammary artery was patent without significant disease. His ejection fraction was mildly decreased. He is now admitted for redo coronary artery bypass grafting surgery. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass grafting x 2 in [**2180**]. 2. History of hypertension. 3. History of hypercholesterolemia status post myocardial infarction in [**2180**]. 4. History of gastroesophageal reflux disease. 5. Hepatitis B positive, hepatitis C positive treated with interferon in [**2184**]. 6. Status post pneumonia in [**2190**]. 7. Status post bowel resection in [**2158**] for a gunshot wound to the abdomen. MEDICATIONS ON ADMISSION: 1. Lisinopril 10 mg p.o. q.d. 2. Verapamil 120 mg p.o. b.i.d. 3. Lipitor 10 mg p.o. b.i.d. 4. Prilosec 20 mg p.o. q.d. 5. Zetia 10 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. 7. Folate and vitamin B12. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Significant for coronary artery disease. SOCIAL HISTORY: He smokes 1?????? packs a day and has done so for the past 25-30 years and continues to smoke. He drinks alcohol very rarely. REVIEW OF SYSTEMS: Significant for shortness of breath, chest pain at rest and on exertion, gastroesophageal reflux disease and headaches. PHYSICAL EXAMINATION: He is a well-developed, well-nourished white male in no apparent distress. Vital signs were stable, afebrile. HEENT: Normocephalic, atraumatic, extraocular movements intact. Oropharynx benign. Neck: Supple with full range of motion, no lymphadenopathy or thyromegaly. Carotids were 2+ and equal bilaterally without bruits. Lungs: Clear to auscultation and percussion. Cardiovascular: Regular rate and rhythm, normal S1 and S2 with no murmurs, gallops, or rubs. Abdomen: Soft, nontender with positive bowel sounds; no masses or hepatosplenomegaly. He had a well-healed midline incision. Extremities: Without cyanosis, clubbing or edema. He had a well-healed left saphenectomy incision. He had no varicosities. Neurologic: Nonfocal, his pulses were 2+ and equal bilaterally throughout with the exception of his PTs which were 1+ bilaterally. The patient is right handed. HOSPITAL COURSE: On [**2192-2-16**] he underwent redo coronary artery bypass grafting x 4 with TMR. He had a left internal mammary artery to the left anterior descending coronary artery, reversed saphenous vein graft to the diagonal, RPL and left radial to the PDA. Cross-clamp time was 117 minutes. Bypass time was 81 minutes. He was transferred to the CSRU in stable condition. He was extubated on postoperative day number one as he was a very difficult intubation. He continued to require diuresis and aggressive respiratory therapy and was transferred to the floor on postoperative day number four, when he began to have some sternal drainage, which was mostly serous. He was then started on clindamycin and the following day he was discharged to home in stable condition as the drainage was decreased. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg p.o. b.i.d. 2. Lasix 20 mg p.o. b.i.d. x 7 days. 3. Colace 100 mg p.o. b.i.d. 4. Percocet [**12-1**] p.o. q. 4-6 hours p.r.n. pain. 5. Ecotrin 325 mg p.o. q. day. 6. Imdur 60 mg p.o. q. day. 7. Lipitor 10 mg p.o. q. day. 8. Plavix 75 mg p.o. q. day. 9. Wellbutrin 100 mg p.o. q. day. 10. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. x seven days. 11. Prilosec 20 mg p.o. q. day. 12. Clindamycin 450 mg p.o. t.i.d. x seven days. LABORATORY STUDIES ON DISCHARGE: Hematocrit 30.8, white count 7,200, platelet count 313, sodium 139, potassium 4, chloride 102, CO2 27, BUN 20, creatinine 0.9, blood sugar 93. FOLLOW UP: He will be followed by Dr. [**Last Name (STitle) **] in one to two weeks, Dr. [**Last Name (STitle) 2912**] in two to three weeks, and Dr. [**Last Name (STitle) **] in four weeks. He is going to have the VNA follow his wound every day and follow up for a wound check on Wednesday, [**2-29**], which is in one week. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 6516**] MEDQUIST36 D: [**2192-2-22**] 09:01 T: [**2192-2-22**] 09:16 JOB#: [**Job Number 39591**]

Admission Date: [**2166-10-9**] Discharge Date: [**2166-10-17**] Date of Birth: [**2092-2-6**] Sex: M Service: SURGERY Allergies: ciprofloxacin / latex Attending:[**First Name3 (LF) 473**] Chief Complaint: Adenocarcinoma of the head of pancreas Major Surgical or Invasive Procedure: Whipple procedure with SMV reconstruction History of Present Illness: Born in [**2091**], Mr. [**Known lastname **] is a strong and healthy gentleman who suffered a recent episode of acute pancreatitis in [**Month (only) **] of this summer of [**2166**]. He was identified as having a pancreatic head mass on CT imaging amidst the pancreatitis. This has been followed up further with subsequent MRI and MRCP imaging in [**Month (only) 205**]. He lost some weight, suffered through some anorexia that is slowly improving, and was ultimately discharged from the hospital and has continued to improve. He is moving his bowels, making good urine, and has no diarrhea. He has never developed obstructive jaundice. The only recent symptom otherwise was just a general feeling of dizziness about three to four months ago. He has no real prior surgical history. There was a question of coronary artery disease, but he did well according to his result with the stress test three to four years ago. I asked him to determine from you if he has had any sort of carotid imaging in light of the dizziness feeling and question of a vision loss that occurred three to four months ago. He had prostate cancer for which he received external beam radiation therapy and he has known Barrett's esophagus. He also underwent an endoscopic ultrasound by Dr. [**Last Name (STitle) **]. This clearly sees the pancreatic head lesion, which does not involve any of the vasculature. Quite surprisingly, in my judgment, the cytology report is negative for malignancy. He has no other symptoms of chest pains or palpitations; no pneumonia, shortness of breath, and he has not got diabetes. Other than the recent weight loss around this acute illness, he has been well. There is no family history of pancreatic cancer. He is not anticoagulated, but does take aspirin 325 mg a day. Past Medical History: Barrett's esophagus RETINAL VASCULAR OCCLUSION - BRANCH CANCER, PROSTATE s/p radiation beam therapy in [**2159**] CORONARY ARTERY DISEASE HEADACHE - MIGRAINE HYPERCHOLESTEROLEMIA PRESBYOPIA HEARING LOSS, SENSORINEURAL GLAUCOMA Social History: Retired. Software developer (worked on the first computer system at the [**Hospital1 **]), then product development consultant. Now composes computer music. Two children from previous marriage. Lives with wife. [**Name (NI) **]: [**Name2 (NI) **] cigars in 20s. EtOH/illicits: never. Family History: No first degree relatives with cancer. Physical Exam: Pre-Op Exam On physical exam, he is well appearing, not jaundiced, and quite intelligent. He understands the uncertainties of his case. His neck is supple with midline trachea and no jugular venous distention. His chest is clear. His cardiac rate and rhythm is normal. His abdomen is entirely benign today with no masses or tenderness. His extremities show no peripheral edema and full range of motion with a normal gait and grossly normal neurologic and vascular exams. Discharge Exam 98.2 97.6 67 122/62 18 99%RA Gen: NAD, A&Ox3 CV: RRR Pulm: CTAB Abd: Soft, non-distended, non-tender, well healing incision dressed with steri-strips; dressed prior JP site Pertinent Results: [**2166-10-13**] 11:00AM BLOOD WBC-8.5 RBC-4.32* Hgb-11.6* Hct-35.9* MCV-83 MCH-26.8* MCHC-32.2 RDW-14.3 Plt Ct-218 [**2166-10-11**] 02:00AM BLOOD WBC-15.5* RBC-4.15* Hgb-11.3* Hct-34.1* MCV-82 MCH-27.2 MCHC-33.1 RDW-14.7 Plt Ct-175 [**2166-10-10**] 03:25AM BLOOD WBC-21.9* RBC-4.40* Hgb-11.7* Hct-36.1* MCV-82 MCH-26.6* MCHC-32.4 RDW-14.8 Plt Ct-192 [**2166-10-9**] 06:08PM BLOOD WBC-24.5*# RBC-4.50* Hgb-12.1* Hct-37.2* MCV-83 MCH-26.9* MCHC-32.5 RDW-14.6 Plt Ct-191 [**2166-10-13**] 11:00AM BLOOD Plt Ct-218 [**2166-10-11**] 02:00AM BLOOD Plt Ct-175 [**2166-10-10**] 03:25AM BLOOD Plt Ct-192 [**2166-10-10**] 03:25AM BLOOD PT-14.2* INR(PT)-1.3* [**2166-10-9**] 06:08PM BLOOD Plt Ct-191 [**2166-10-9**] 06:08PM BLOOD PT-14.1* INR(PT)-1.3* [**2166-10-13**] 11:00AM BLOOD [**2166-10-11**] 02:00AM BLOOD [**2166-10-10**] 03:25AM BLOOD [**2166-10-9**] 06:08PM BLOOD [**2166-10-13**] 11:00AM BLOOD Glucose-123* UreaN-11 Creat-0.7 Na-139 K-4.2 Cl-104 HCO3-30 AnGap-9 [**2166-10-11**] 02:00AM BLOOD Glucose-129* UreaN-13 Creat-0.7 Na-139 K-4.2 Cl-105 HCO3-29 AnGap-9 [**2166-10-10**] 03:25AM BLOOD Glucose-148* UreaN-15 Creat-0.8 Na-137 K-4.3 Cl-104 HCO3-24 AnGap-13 [**2166-10-9**] 06:08PM BLOOD Glucose-147* UreaN-16 Creat-0.8 Na-137 K-4.5 Cl-106 HCO3-20* AnGap-16 [**2166-10-13**] 11:00AM BLOOD ALT-62* AST-52* AlkPhos-44 TotBili-0.3 [**2166-10-11**] 02:00AM BLOOD ALT-63* AST-48* AlkPhos-32* TotBili-0.5 [**2166-10-10**] 03:25AM BLOOD ALT-97* AST-72* AlkPhos-33* TotBili-0.5 [**2166-10-9**] 06:08PM BLOOD ALT-136* AST-104* AlkPhos-35* TotBili-0.7 [**2166-10-13**] 11:00AM BLOOD Albumin-3.3* Calcium-8.1* Phos-2.4* Mg-2.0 [**2166-10-11**] 02:00AM BLOOD Calcium-8.0* Phos-1.7* Mg-2.1 [**2166-10-10**] 03:25AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.3 [**2166-10-9**] 06:08PM BLOOD Calcium-7.9* Phos-4.3# Mg-1.7 [**2166-10-9**] 06:39PM BLOOD Type-ART pO2-86 pCO2-41 pH-7.32* calTCO2-22 Base XS--4 [**2166-10-9**] 04:30PM BLOOD Type-ART Temp-36.8 Rates-10/ Tidal V-560 FiO2-100 pO2-120* pCO2-46* pH-7.32* calTCO2-25 Base XS--2 AADO2-549 REQ O2-91 Intubat-INTUBATED Vent-CONTROLLED [**2166-10-9**] 02:09PM BLOOD Type-ART pO2-160* pCO2-44 pH-7.33* calTCO2-24 Base XS--2 [**2166-10-9**] 12:40PM BLOOD Type-ART pO2-194* pCO2-42 pH-7.39 calTCO2-26 Base XS-0 [**2166-10-9**] 04:30PM BLOOD Glucose-155* Lactate-4.0* Na-136 K-4.6 Cl-106 [**2166-10-9**] 02:09PM BLOOD Lactate-2.6* [**2166-10-9**] 12:40PM BLOOD Glucose-130* Lactate-1.7 Na-137 K-4.5 Cl-107 [**2166-10-9**] 04:30PM BLOOD Hgb-13.8* calcHCT-41 [**2166-10-9**] 02:09PM BLOOD Hgb-13.8* calcHCT-41 [**2166-10-9**] 12:40PM BLOOD Hgb-13.8* calcHCT-41 [**2166-10-9**] 04:30PM BLOOD freeCa-1.06* [**2166-10-9**] 12:40PM BLOOD freeCa-1.11* [**2166-10-17**] 11:01AM BLOOD CA [**73**]-9 -PND Brief Hospital Course: The patient was admitted to the Hepatopancreaticobiliary Surgery on [**2166-10-9**] for treatment of a presumed pancreatic adenocarcinoma with suspected invasion of superior mesenteric vein. On [**2166-10-9**], the patient underwent pylorus preserving pancreaticoduodenectomy with en bloc resection of superior mesenteric vein, superior mesenteric vein primary venorrhaphy (end-to-end), and CyberKnife fiducial placements, which went well without complication (reader referred to the Operative Note for details). Of note, a Left subclavian line was placed with a post-placement CXR that showed a Large left sided Pneumothorax. A pigtail catheter chest tube was placed and eventually, the lung fully expanded. The chest tube was then removed with post-removal CXR showing continued expansion of the lung. After a brief, uneventful stay in the PACU, the patient was transfered to the ICU for increased monitoring given his vascular repair. After being stabilized in the unit for a couple days, the patient arrived on the floor NPO on IV fluids, with a foley catheter and a JP drain in place, and an epidural for pain control. The patient was hemodynamically stable. The [**Hospital 228**] hospital course was uneventful except for the need for a chest tube placement (see above) and followed the Whipple Clinical Pathway without deviation. Post-operative pain was initially well controlled with an epidural, which was converted to oral pain medication when tolerating clear liquids. The NG tube was discontinued on POD#3, and the foley catheter discontinued at midnight of POD#4. The patient subsequently voided without problem. The patient was started on sips of clears on POD#4, which was progressively advanced as tolerated to a regular diet by POD#7. JP amylase was sent in the evening of POD#6; the JP was discontinued on POD#7 as the output and amylase level were low. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. At the time of discharge on [**2166-10-17**], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Staples were removed, and steri-strips placed. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. atorvastatin 20mg daily Discharge Medications: 1. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*5 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE [**Hospital1 **] 3. Diltiazem Extended-Release 120 mg PO DAILY 4. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]:PRN congestion 5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain RX *hydromorphone 2 mg [**2-10**] tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 6. Senna 1 TAB PO BID 7. Ranitidine 150 mg PO HS 8. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*5 9. Metoclopramide 10 mg PO Q6H RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth daily Disp #*56 Tablet Refills:*0 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 11. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home with Service Discharge Diagnosis: adenocarcinoma of the head of the pancreas Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a Whipple procedure for adenocarcinoma of the head of your pancreas with reconstruction of your superior mesentery vein. Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-19**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2166-10-27**] 9:30am

Admission Date: [**2183-4-16**] Discharge Date: [**2183-5-13**] Date of Birth: [**2115-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right IJ CVL placement Intubation Bronchoscopy Lung biopsy via repeat bronchoscopy History of Present Illness: Mr. [**Known lastname 12795**] is a 68 year-old male with CAD s/p CABG [**2169**], COPD on home O2, prior lung cancer (s/p RUL lobectomy), VT s/p ICD, hyperlipidemia, type II diabetes mellitus, and atrial fibrillation who was transferred from outside hospital for management of hypotension. Patient presented to [**Hospital3 18201**] on the afternoon of his admission on [**4-16**] with sytolic blood pressures in the 70's. He was intubated, given IVF, started on levophed and dopamine, given broad spectrum antibiotics, decadron and nebulizers. He was then sent to [**Hospital1 18**] ED for further evaluation. . Per the patient's wife he was recently admitted to [**Name (NI) 29710**] [**Date range (1) 29711**] for a COPD exacerbation requiring ICU admission but he had not needed intubation. He was discharged on a lengthy prednisone taper. Following discharge he remained short of breath, wheezy, and continued to have a productive cough at home. He also developed neck pain and shoulder pain over day prior to this presentation. On [**4-16**] he became febrile to 101.1F. He saw his pulmonologist in clinic [**4-16**] and was prescribed another course of antibiotics. Then, on the way home from this appointment he was complaining of feeling worse weakness. When patient and wife arrived at home he was too weak to even stand up and fell to the ground exiting the car. His wife activated 911. . When patient arrived to [**Hospital1 18**] ED, his pressors had been tapered to solely levophed and systolics were in the 80's. He was started back on neosynephrine, bolused a total of 5 liters, and started on heparin gtt given concern for pulmonary embolism. He was also given a dose of Cefepime and Tamiflu along with solumedrol 125mg IV x 1. He had atrial fibrillation with RVR to the 170's and BP again dropped to 70's. At this point levophed was weaned down. Notably ECG showed ST depressions in V1-V4 which appeared similar to prior tracings. He was seen by the cardiology fellow who suggested amiodarone if atrial tachycardia recurs. Patient transferred to MICU for further management. . Please see hospital course details below for ICU course summary. Past Medical History: -Type II Diabetes -Coronary Artery Disease: CABG done in [**2169**], LIMA to LAD, SVG to RAMUS, SVG to RCA. Additional PCI [**2177**]: DES placed LMCA --> LCx, required. Required AIBP at the time. Ventricular Tachycardia: ICD placed in [**2177**] for primary prevention ([**Company 1543**] [**Last Name (un) 24119**] DR, a 6949 right ventricular lead. Has PPM in place) -Lung cancer, s/p RUL lobectomy [**2172**] chemo/rads -COPD, on home oxygen -Gout -Hypertension -Hyperlipidemia -Atrial Fibrillation Social History: Patient is a retired engineer, lives with wife [**Name (NI) **] in [**Location (un) **] MA. Prior to this admission the patient was needing more supervision as he easily gets confused and was often disoriented. He smoked 1PPD for nearly 45 years and quit in [**2172**]. Rare ETOH use and no prior illicit drug use. Family History: Father had CABG in 60s, died at 81, mother with fatal MI at 71. Physical Exam: ADMISSION PHYSICAL EXAM: General: intubated, sedated HEENT: NC/AT, PERRL, OP clear Neck: supple, no LAD Lungs: anterior lung fields clear to auscultation bilaterally, no wheezes or crackles Heart: tachycardic, s1/s2 present, no murmurs Abd: +BS, soft, non-tender, non-distended Ext: no lower extremity edema, warm, well perfused Skin: right wrist erythema with raised circular lesion . No Discharge Exam: Patient was pronounced dead on [**2183-5-13**] at 4:20pm. Pertinent Results: ADMISSIONS LABS: . [**2183-4-16**] 08:44PM URINE RBC-[**7-3**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2183-4-16**] 08:44PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2183-4-16**] 08:44PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2183-4-16**] 08:44PM PLT SMR-LOW PLT COUNT-140* [**2183-4-16**] 08:44PM PT-13.2 PTT-27.9 INR(PT)-1.1 [**2183-4-16**] 08:44PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [**2183-4-16**] 08:44PM NEUTS-92* BANDS-5 LYMPHS-0 MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2183-4-16**] 08:44PM WBC-21.0* RBC-3.67* HGB-11.0* HCT-32.9* MCV-90 MCH-29.9 MCHC-33.4 RDW-15.7* [**2183-4-16**] 08:44PM CALCIUM-7.4* [**2183-4-16**] 08:44PM cTropnT-0.06* [**2183-4-16**] 08:44PM CK-MB-5 proBNP-4087* [**2183-4-16**] 08:44PM ALT(SGPT)-19 AST(SGOT)-26 CK(CPK)-179 ALK PHOS-50 TOT BILI-0.9 [**2183-4-16**] 08:51PM GLUCOSE-167* LACTATE-1.0 NA+-130* K+-4.4 CL--95* TCO2-25 [**2183-4-16**] 08:51PM COMMENTS-GREEN TOP [**2183-4-16**] 10:39PM TYPE-ART RATES-16/4 TIDAL VOL-450 O2-100 PO2-366* PCO2-56* PH-7.24* TOTAL CO2-25 BASE XS--4 AADO2-306 REQ O2-56 INTUBATED-INTUBATED VENT-CONTROLLED [**2183-4-16**] 11:30PM TYPE-ART PO2-108* PCO2-52* PH-7.25* TOTAL CO2-24 BASE XS--4 . . . MICROBIOLOGY STUDIES: [**2183-4-17**] 6:35 pm CATHETER TIP-IV Source: Femoral line. WOUND CULTURE (Final [**2183-4-19**]): No significant growth . Blood Culture, Routine (Final [**2183-4-20**]): 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. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- 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 . [**2183-4-17**] 10:04 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2183-4-20**]** GRAM STAIN (Final [**2183-4-17**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2183-4-20**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. 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. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- 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 [**2183-4-30**] 4:51 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2183-4-30**]** GRAM STAIN (Final [**2183-4-30**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2183-4-30**]): TEST CANCELLED, PATIENT CREDITED. . [**2183-5-1**] 2:40 pm BRONCHOALVEOLAR LAVAGE / **FINAL REPORT [**2183-5-4**]** GRAM STAIN (Final [**2183-5-1**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2183-5-4**]): ~[**2173**]/ML Commensal Respiratory Flora. . URINE CULTURE (Final [**2183-5-1**]): NO GROWTH. URINE CULTURE (Final [**2183-4-25**]): NO GROWTH. URINE CULTURE (Final [**2183-4-21**]): NO GROWTH. . Blood Culture, Routine (Final [**2183-5-7**]): NO GROWTH. Blood Culture, Routine (Final [**2183-5-7**]): NO GROWTH. Blood Culture, Routine (Final [**2183-5-6**]): NO GROWTH. Blood Culture, Routine (Final [**2183-5-6**]): NO GROWTH. Blood Culture, Routine (Final [**2183-4-30**]): NO GROWTH. Blood Culture, Routine (Final [**2183-4-30**]): NO GROWTH. Blood Culture, Routine (Final [**2183-4-25**]): NO GROWTH. Blood Culture, Routine (Final [**2183-4-24**]): NO GROWTH. ============================================== IMAGING: TTE [**2183-4-17**]: The left atrium is elongated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with thinned inferolateral and inferior wall akinesis/dyskinesis and anterolateral hypokinesis. Overall left ventricular systolic function is severely depressed (LVEF= 25 %). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Mild to moderate ([**1-25**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. An eccentric, posteriorly directed jet of Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild to moderate pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a promient fat pad. Compared with the prior study (images reviewed) of [**2181-10-17**], the severity of mitral and aortic regurgitation has increased. Regional left ventricular systolic function may be slightly worse. No vegetations identified. If clinically indicated, a transesophageal echocardiographic examination is recommended to evaluate for endocarditis. ------ TEE [**2183-4-18**]: No valvular or lead vegetations seen. Mild to moderate aortic regurgitation. Moderate mitral regurgitation. Complex (>4 mm, non-mobile) atheroma in the descending aorta and aortic arch. Depressed biventricular systolic function. . [**2183-4-16**] CXR: Markedly abnormal radiograph with no comparison available. Endotracheal tube is slightly high. Consider advancement by 2.5 cm for optimal placement. There is a right upper chest thoracoplasty which results in significant distortion of the normal anatomy. Patchy foci of opacity, particularly in the lateral left lung may represent foci of pneumonia or aspiration. . [**2183-4-18**] CXR: Bibasilar atelectasis and bronchiectasis persist, left greater than right. Small layering left pleural effusion is unchanged. There is no pulmonary edema. Right upper thoracoplasty changes are noted. Monitoring and support devices are stable in course and position. There is no pneumothorax. Multiple calcified gallstones are seen in the right upper quadrant. . [**2183-4-23**] CXR : Changes of right upper lobectomy and thoracoplasty are present. There is persistent bibasilar atelectasis, left greater than right. A small left pleural effusion is unchanged. Mild cardiomegaly is stable. Mediastinal clips and median sternotomy wires are well aligned. A right PICC terminates at the cavoatrial junction. A left chest wall pacemaker has leads in the right atrium and ventricle. A Dobbhoff tube courses into the abdomen and beyond the film. There is no pneumothorax. Calcified gallstones are again noted in the right upper quadrant. . [**2183-4-29**] CXR: Changes of right upper lobectomy and thoracoplasty are again seen. There is persistent bibasilar atelectasis, left greater than right. No focal consolidation is appreciated. Probable small bilateral layering effusions are present. The cardiomediastinal and hilar contours are normal. Monitoring support devices are unchanged in course and position. A right PICC is indistinctly seen at the level of the clavicle. There is no pneumothorax. Calcified gallstones are noted in the right upper quadrant. . [**2183-5-6**] CXR: In comparison with the study of [**5-5**], there is little change. Monitoring and support devices remain in place. Continued increased sharpness of the left hemidiaphragm, consistent with improved aeration at the left base.Nevertheless, there are continued low lung volumes and bibasilar atelectatic changes. . [**2183-5-9**] CXR: As compared to the previous radiograph, there is no relevant change. The minimal further improvement of ventilation in the region of the pre-existing retrocardiac and left basal opacity. Otherwise, unchanged appearance of the lung parenchyma, the cardiac silhouette and the chest wall. . [**2183-5-12**] CXR: Pulmonary edema previously, it is gone now. Multiple foci of atelectasis in the left lung are stable. Heart is borderline enlarged. New feeding tube with the wire stylet in place ends in the stomach. Gallstones noted in the right upper quadrant. Transvenous right atrial pacer and right ventricular pacer leads follow their expected courses. No pneumothorax. Small left pleural effusion or pleural thickening is longstanding. . [**2183-5-6**] LUNG PATHOLOGY FROM FNA / BIOPSY WITH BRONCHOSCOPY LUL : Lung (left upper lobe), fine needle aspirate: POSITIVE FOR MALIGNANT CELLS, consistent with squamous cell carcinoma. . [**4-17**] ADMISSION CT IMAGING: CHEST/ABD/PELVIS REPORT CT OF THE CHEST WITHOUT CONTRAST: There is a small left-sided pleural effusion. The patient is status post right upper and right middle lobectomies. There is a small right-sided pleural effusion and small areas of loculated fluid near the apex. There is bibasilar atelectasis. Right chest wall deformity is present from prior thoracotomy. There are prominent coronary artery calcifications. A small linear area of fat density is noted along the left ventricle, consistent with fatty deposition. The patient has a pacemaker with leads in right atrium and ventricle. There is a left subclavian stent. The endotracheal tube ends approximately 4.0 cm above the carina. Patient is status post sternotomy and CABG. CT OF THE ABDOMEN WITHOUT CONTRAST: The non-contrast appearance of the spleen, adrenal glands, stomach, and intra-abdominal loops of bowel are within normal limits. The liver demonstrates a small area of pneumobilia in the left lobe of the liver. There are multiple, calcified gallstones within the gallbladder. The common bile duct and pancreas are within normal limits. The kidneys are slightly small bilaterally. There are prominent renal vascular calcifications. There is no retroperitoneal or mesenteric lymphadenopathy. There is no free air or free fluid. There is a small fat-containing umbilical hernia. An NG tube ends within the stomach. . CT OF THE PELVIS WITHOUT CONTRAST: The rectum, prostate, and intrapelvic loops of bowel are within normal limits. A Foley catheter is noted within a decompressed bladder. There is no free air or free fluid. There is no pelvic or inguinal lymphadenopathy. The patient is status post placement of right femoral venous line, which ends in the right iliac vein just prior to the bifurcation. Areas of stranding and small foci of air within the right groin are likely due to recent line placement. There is dense calcification of the abdominal and pelvic arterial vasculature. BONE WINDOWS: No concerning osseous lesions are identified. Mild degenerative changes are noted most prominently in the lumbar spine. IMPRESSION: 1. No acute intrathoracic or intraabdominal process. 2. Status post right upper and right middle lobectomies with corresponding chest wall deformity. Small areas of loculated fluid noted at the right lung apex. Small left-sided pleural effusion. 3. Cholelithiasis. . ========================================== EKGs: [**2183-5-10**] - rate 105, Sinus tachycardia with ventricular premature beat versus aberrant conduction. [**2183-5-8**] -rate 80, Atrial paced rhythm. Right bundle-branch block. Infero-posterolateral myocardial infarction of indeterminate age but may be old. Diffuse ST-T wave abnormalities are non-specific but clinical correlation is suggested. [**2183-4-16**] - rate 108, sinus tachycardia with RBBB, evidence of prior MI in lateral and inferoposterior distribution, similar to EKGs from 2/[**2182**]. . ========================================== LAST SET OF LABS [**2183-5-13**] : [**2183-5-13**] 05:20AM BLOOD WBC-9.3 RBC-3.16* Hgb-9.8* Hct-30.7* MCV-97 MCH-30.9 MCHC-31.8 RDW-17.8* Plt Ct-319 [**2183-5-13**] 05:20AM BLOOD Glucose-253* UreaN-41* Creat-1.7* Na-146* K-4.4 Cl-101 HCO3-36* AnGap-13 [**2183-5-13**] 05:20AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.5 . THYROID STUDIES: [**2183-4-24**] 04:00AM BLOOD TSH-4.7* . DRUG MONITORING: [**2183-5-11**] 04:11AM BLOOD Vanco-20.9* [**2183-4-25**] 04:11AM BLOOD Digoxin-0.2* Brief Hospital Course: HYPOTENSION: Patient was transferred from OSH after presentation for weakness and pre-syncopal episode in his driveway witnessed by his wife. [**Name (NI) **] had notable systolic blood pressured in the 70s in ED at OSH prior to transfer and he needed to be placed on both levophed and neosynephrine initially. Hypotension likely due to his later established MRSA bacteremia and sepsis. CT done and no overt pulmonary emboli revealed to explain his marked hypotension. He was also ruled out for acute coronary syndrome given his prominent cardiac history and multiple risk factors. He also had rapid atrial fibrillation on day of admission which also contributed to poor cardiac output in setting of his already poor cardiac function with baseline EF of 35%. During his ICU course he was weaned down to Levophed alone and then slowly taken off pressor support completely with gentle fluid boluses for occasional low blood pressures which were predominantly limited to the setting of him requiring amiodarone boluses or IV metoprolol pushes when his atrial fibrillation episodes occurred throughout his ICU stay. Otherwise, blood pressures improved overall after patient had been adequately treated with IV Vancomycin for his MRSA bacteremia and MRSA pneumonia. MRSA BACTEREMIA: Blood cultures from admission grew out MRSA. Initially felt that his right hand cellulitis from recent IV placement may have been possible source. However, a sputum culture grew out MRSA within days of admission and his CXR had an area of patchy opacity in the lateral left lung on admission with was felt to represent foci of pneumonia vs. aspiration. During his hospital course he had immediate follow-up TTE and TEEs which were both negative for vegetations. He was given a prolonged course of IV Vancomycin starting on [**4-17**] or MRSA bacteremia and MRSA pneumonia. He was followed by the ID consult service. . RESPIRATORY FAILURE: Patient intubated at OSH before transfer. He was extubated to BIPAP and required intermittent BIPAP for about 24 hrs following extubation. He continued to struggle with hypoxemia and shortness of breath and required re-intubation after additional hypercarbia developed on [**2183-4-30**]. Treated with additional Zosyn antibiotics for concern for additional aspiration PNA which may have triggered need for his second intubation. He was given multiple IV Lasix PRN doses and even a Lasix drip at times to help accomplish diuresis for his ongoing pulmonary edema which was also another factor felt to be contributing to his poor respiratory status. On [**2183-5-1**] had a bronchoscopy that showed area of small collapse in LUL with question of recurrent lung cancer so interventional pulmonology team consulted and after holding Plavix dose for about a week he had lung biopsy and repeat bronchoscopy which was consistent with malignant mass and pathology revealed squamous cell lung cancer. A formal oncology consult was deferred in setting of his very tenuous status in ICU as team was waiting for patient to stabilize for formal consult and possible attempts for palliative radiation/medications but patient continued to clinically decline in ICU. There were brief discussions for PEG/tracheostomy placement but patient was able to be extubated successfully [**2183-5-7**]. He slowly declined again to the point of needing high flow face mask to maintain adequate oxygenation. Patient and family changed code status to DNR/DNI on [**2183-5-9**] and palliative care consult was called. Overall, patient's persistent decline and respiratory failure felt to be combination of his underlying poor reserve with COPD /prior lobectomy, recent PNAs, recurrent lung cancer and pulmonary edema which lingered as well. He was made CMO on [**2183-5-13**] and passed away later that night. . COPD EXACERBATION: Initially treated more aggressively with steroids and standing nebulizers. COPD flare up was attributed to persistent pneumonia. As above, respiratory failure required two intubations and multiple use of BIPAP and facemask at high flow to maintain oxygen saturations >88%. He continued to decline after second extubation and family and patient opted to be DNR/DNI, then changed to CMO. . ICU DELIRIUM: Multifactorial and felt to be related to infection, steroids, and being in ICU. Patient was also noted to have recurrent lung cancer and brain metastasis is also possible although patient was never stable enough to pursue any additional MRI or further workup for oncologic staging/management. Notably, wife reported sun downing at home and issues with confusion for several months prior to admission. He was treated initially with olanzapine and then switched to standing Haldol with good effect initially but he seemed to get more agitated so QHS Zydis was combined with standing and PRN haldol dosing. EKGs were monitored for QT changes. Psychiatry was consulted and agreed with Haldol therapy. Unfortunately, his delerium worsened over the last few days of his ICU course and he required soft restraints and additional doses of Haldol with frequent re-orientation by staff. . RAPID ATRIAL FIBRILLATION: Patient had known atrial fibrillation in the past. During his ICU course he had atrial flutter and fibrillation multiple times. Likely triggers were sepsis, pressor use, and hypoxia. Cardiology was consulted for additional guidance during his ICU stay. Patient's home regimen of quinidine stopped and he was loaded with IV amiodarone given his hemodynamic instability with rapid rhythm. Patient followed by electrophysiology service. He was re-bolused with Amiodarone for ongoing SVT and later in hospital course metoprolol IV was added on a standing basis for additional control and worked well. . SWALLOWING: Failed speech and swallow. Dobhoff placed for nutritional feedings. Started on TF regimen. PEG considered briefly but after goals of care discussion with family after recurrent lung cancer diagnosis and worse respiratory failure and progressive altered mental status the family wished to only keep patient comfortable and did not want any more surgeries. He was given Dobhoff feedings up until day he expired. . [**Female First Name (un) **] ESOPHAGITIS: Thrush on admission with throat pain. Treated with 7 day course of IV fluconazole for presumed [**Female First Name (un) **] esophagitis. Resolved with therapy. . Medications on Admission: ASA 325mg daily flucinolide 250mcg 2 puffs [**Hospital1 **] crestor 40mg daily plavix 75mg daily digoxin 125 mcg daily MWF floridil 12 mcg 1 [**Hospital1 29707**] [**Hospital1 **] lasix 40mg [**Hospital1 **] gabapentin 100mg [**Hospital1 **] levothyroxine 75mcg daily lisinopril 2.5mg daily proventil prednisone 10mg daily quinidine 324 mg QID spiriva 18 mcg daily spirinolactone 50mg daily Discharge Medications: No discharge medications to list . Patient deceased, died on [**2183-5-13**]. Discharge Disposition: Expired Discharge Diagnosis: patient deceased, passed away on [**2183-5-13**] Discharge Condition: patient deceased, passed away on [**2183-5-13**] Discharge Instructions: patient deceased, passed away on [**2183-5-13**] Followup Instructions: patient deceased, passed away on [**2183-5-13**] Completed by:[**2183-5-20**]

Admission Date: [**2104-3-6**] Discharge Date: [**2104-3-13**] Date of Birth: [**2049-12-6**] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is a 53-year-old gentleman being evaluated for a left total knee replacement. Underwent preoperative cardiac evaluation. Had a positive exercise treadmill test on [**2-20**] and was referred to [**Hospital1 **] for cardiac catheterization. Patient denies any history of coronary disease or angina. Cardiac catheterization showed an ejection fraction of 41%, a LVEDP of 20, 80% distal RCA lesion, 60% proximal LAD lesion, 80% mid LAD lesion, 90% first diagonal lesion, and 100% mid circumflex lesion. PAST MEDICAL HISTORY: 1. Hypertension. 2. Osteoarthritis of the left knee. 3. Status post multiple left knee arthroscopies. 4. Degenerative joint disease with chronic lower back pain and sciatica. 5. Status post lumbar laminectomy x5. 6. History of sleep apnea with BiPAP use at home. 7. Gout. 8. History of syncope with permanent pacemaker placement [**2103-9-29**] for symptomatic bradycardia. ALLERGIES: NKDA. PREOPERATIVE MEDICATIONS: 1. Hydrochlorothiazide 50 mg p.o. q.d. 2. Lisinopril 40 mg p.o. q.d. 3. Metoprolol 25 mg p.o. b.i.d. 4. Valium 10 mg p.o. prn. 5. OxyContin 40 mg p.o. t.i.d. 6. Percocet 5/325 prn. 7. Colchicine prn. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**3-6**], and was taken to the operating room with Dr. [**Last Name (STitle) **] for a CABG x4: LIMA to LAD, saphenous vein graft to PDA, SVG to OM, and SVG to diagonal. Total cardiopulmonary bypass time was 75 minutes, cross-clamp time 66 minutes. Please see operative note for further details. Patient was transported to the Intensive Care Unit in stable condition. Patient was weaned and extubated from mechanical ventilation on his first postoperative night. For the patient's history of chronic narcotic use, the Chronic Pain service was consulted with recommendations of restarting the patient on his oral regime as soon as possible. Patient was restarted on his nocturnal CPAP. Patient's pulmonary artery catheter was removed. Patient was started on Lopressor and Lasix, which he tolerated well. Patient's chest tubes were removed without incident. On postoperative day #2, patient began ambulating with Physical Therapy and was able to ambulate 500 feet without difficulty. On postoperative day #3, the patient was transferred from the Intensive Care Unit to the regular part of the hospital, where he continued to work with Physical Therapy. On postoperative day #4, his pacing wires were removed without incident, and the Electrophysiology service was consulted to interrogate his permanent pacer and it was determined that his pacing and sensing threshold remained appropriate. Discussions was had with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] regarding patient's chronic narcotic use, and plan for discharging the patient with appropriate narcotics was made. Per Dr. [**Last Name (STitle) **], the patient will be discharged to home with a week of OxyContin and oxycodone, and patient will receive his routine narcotic scripts from Dr. [**Last Name (STitle) **] as well. By postoperative day #5, patient was cleared for discharge to home. CONDITION ON DISCHARGE: T max 100.4, pulse 89 sinus rhythm, blood pressure 122/68, respiratory rate 16, on room air oxygen saturation 96%. Patient's weight on [**3-11**] was 113.5 kg. Preoperatively, the patient weighed 114 kg. LABORATORY DATA: White blood cell count 5.9, hematocrit 31.7, platelet count 172. Sodium 138, potassium 4.1, chloride 101, bicarb ......, BUN 10, creatinine 0.9, glucose 94. Neurologically, the patient is awake, alert, and oriented times three. Nonfocal neurologic examination. Heart regular rate and rhythm without murmur. Respiratory: Breath sounds are clear bilaterally. Abdomen: Positive bowel sounds, soft, nontender, and nondistended. Sternal incision: The staples are intact. There is no erythema and no drainage. Right lower extremity vein harvest site is clean, dry, and intact. There is no erythema or drainage. Patient has trace pitting edema in his left leg, [**11-30**]+ in his right leg. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass graft. 3. Chronic knee and lower back pain. 4. Chronic narcotic use. 5. Status post permanent pacer insertion. 6. Obstructive-sleep apnea with nocturnal CPAP use. DISCHARGE MEDICATIONS: 1. Enteric-coated aspirin 325 mg p.o. q.d. 2. Zantac 150 mg p.o. b.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Lopressor 50 mg p.o. b.i.d. 5. Lasix 20 mg p.o. q.d. x7 days. 6. Potassium chloride 20 mEq p.o. q.d. x7 days. 7. Oxycodone 5 mg tablets 1-2 tablets p.o. q.4h. prn. Patient will be given a prescription for 50 tablets. 8. OxyContin 40 mg tablets one p.o. b.i.d. prn, patient will be given a prescription for 40 tablets. CONDITION ON DISCHARGE: The patient is to be discharged to home in stable condition. FOLLOW-UP PLANS: The patient should follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**11-30**] weeks. Patient should follow up with Dr. [**Last Name (STitle) **] in [**11-30**] weeks. Patient should follow up with Dr. [**Last Name (STitle) **] in [**1-31**] weeks. Patient is being scheduled for wound check appointment approximately two weeks after the day of his surgery and return to [**Hospital Ward Name 121**] 2 to have his staples removed. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2104-3-11**] 08:52 T: [**2104-3-11**] 08:54 JOB#: [**Job Number 53199**]

Admission Date: [**2106-9-3**] Discharge Date: [**2106-9-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 13541**] Chief Complaint: Syncope/fall with Subdural hematoma Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 84 yo f w/ PMHx afib on Coumadin, HTN, CHF, who presented to ED following fall in apt with questionable LOC. Positive head strike. Pt was evaluated at OSH and found to have subdural hematoma and transfered to [**Hospital1 18**] for treatment. In ED she was evaluated by Orthopedics and no it was determined that no surgical interventions needed at this time. Pt started on Dilantin x10d and had repeat CT head [**9-4**] which showed stable SDH. In [**Name (NI) **] pt was found to have PT 20 and was given vit K and FFP for coumadin reversal. Rec'd vit K and FFP in the ED. During FFP transfusion pt began complaining of pruritis. She was given benadryl, completed the transfusion and reported RIGHT shoulder rash and lip swelling. she was sent to SICU for observation. Once stable she was transfered to Medicine for syncope work-up. Past Medical History: 1)anemia, 2)CHF, 3)afib on coumadin, 4) hyponatremia, 5)HTN, 6)Mod severe MR [**First Name (Titles) **] [**Last Name (Titles) **], 7)CRI stage III, 8)sick sinus sp pacemaker [**3-29**]: [**Company 1543**] Sigma 200 SR, model SSR203B 9)TIA [**9-28**], [**8-/2098**], [**11-30**], 10)COPD, 11)Hemangioma of bowel sp resection Social History: Pt lives alone in assissted living apt. Pt drinks ETOH socially and occassionaly at home. She denies tobacco usage. Pt utilzes walker at home and has aides to help with ADL weekly. Family History: FH: Grandfather had MI, Father w/ [**Name2 (NI) **] CA Physical Exam: Vitals: 96.4 122/80 65 20 97%RA Gen: A+Ox3, in NAD HEENT: NC, MMM, PERRL, Large eccymosis post head, neck and L shoulder. Neck: Supple, no LAD, No JVD CV: pacemaker. RRR, Norm s1,s2. No murmur noted Pulm: CTA BL no w/r/r Abd: +BS, Soft, NT, ND Ext: Eccymosis R forearm. Palp DP pulses, No edema. Pertinent Results: Blood work on admission: CBC: [**2106-9-3**] 04:00AM WBC-6.1 RBC-3.13* HGB-9.9* HCT-30.0* MCV-96 MCH-31.6 MCHC-33.0 RDW-17.5* Coag: [**2106-9-3**] 04:00AM PT-20.8* PTT-32.7 INR(PT)-2.0* Chemistry: [**2106-9-3**] 04:00AM GLUCOSE-92 UREA N-40* CREAT-1.2* SODIUM-131* POTASSIUM-5.5* CHLORIDE-94* TOTAL CO2-25 ANION GAP-18 [**2106-9-3**] 04:00AM CALCIUM-9.6 PHOSPHATE-4.1 MAGNESIUM-1.3* Cardiac enzymes: [**2106-9-3**] 06:07PM CK(CPK)-68 [**2106-9-3**] 06:07PM CK-MB-NotDone [**2106-9-3**] 10:50AM CK(CPK)-80 [**2106-9-3**] 10:50AM CK-MB-10 MB INDX-12.5* cTropnT-0.02* [**2106-9-3**] 04:00AM CK(CPK)-143* [**2106-9-3**] 04:00AM cTropnT-0.02* [**2106-9-3**] 04:00AM CK-MB-14* MB INDX-9.8* [**2106-9-3**] 10:50AM DIGOXIN-0.3* U/A: [**2106-9-3**] 05:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2106-9-3**] 05:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2106-9-3**] 05:20AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 Relevant imaging studies: [**2106-9-4**] CT HEAD W/O CONTRAST: IMPRESSION: Interval decrease in the extent of small left parietal subdural hematoma with a dominant portion of the hematoma measuring unchanged, approximately 4 mm. [**2106-9-6**]: CAROTID SERIES, COMPLETE: IMPRESSION: No evidence of internal carotid artery stenosis on either side. Brief Hospital Course: 84 yo f w/ PMHx afib on Coumadin, HTN, CHF, who presented to ED following fall in with questionable LOC and confirmed subdural hematoma. 1) Fall: Syncope vs. mechanical fall. She recalled the events leading to the fall, but could not recall the actual fall except for the part where she hit her head, suggesting a probable syncopal event. This was unwitnessed, however, and corroboration could not be obtained. She was initially evaluated at an outside hospital, where a CT scan of the head showed a small left parietal subdural hematoma. She was transferred to [**Hospital1 18**] for further care. At [**Hospital1 18**], a repeat CT scan of the head without contrast confirmed a 4 mm left parietal subdural hematoma, without midline shift. Her warfarin-induced coagulopathy was reversed with vitamin K and FFP in the ED, and she was admitted to the trauma-ICU for close observation. A follow-up CT scan the following morning demonstrated interval decrease in the extent of the small left parietal SDH. She was transferred to the floor for furhter work-up of her apparent syncopal event. Per neurosurgery, she is to hold her anticoagulation for 1 month. 2) Syncope: Serial cardiac biomarkers showed a slightly elevated CK-MBI, with normal CK and flat troponins X 3. She was observed on telemetry, without arrhythmic events. The EP service additionally interrogated her pacer, without evidence of a recent event. Carotid series were finally obtained, and demonstrated no evidence of ICA disease. A basic infectious work-up was negative. The possibility of vasovagal syncope or orthostasis remains, but could not be confirmed. Orthostatic vitals obtained at the time of transfer to the floor were within normal limits. A repeat TTE was not obtained given our low overall suspicion of a cardiac ischemic event or severe stenotic valvular disease, but could certainly be considered in the out-patient setting. She was evaluated by physical therapy on the day of discharge, and deemed safe for discharge home with services, including physical therapy. Medications on Admission: Trazodone qHS, Atentolol 12.5 x1 Pantoprazole 40x1 Calcitriol Lorazepam 0.5 prn Lasix Digoxin 0.125 [**1-27**] x1 Lisinopril 10x1 Coumadin MVI Vit B12 Injection Fosamax 35 qwk Aranescp 200 qMonth Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 6. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 7 days. Disp:*21 Capsule(s)* Refills:*0* 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary: Syncope NOS Subdural hematoma Secondary diagnoses: Chronic atrial fibrillation, rate controlled Chronic systolic congestive heart failure Sick sinus syndrome status post pacemaker placement Discharge Condition: Vital signs stable. Good condition Discharge Instructions: You were admitted to [**Hospital1 18**] after falling and hitting your head. It is unclear whether or not you lost consciousness. You were taken to a different hospital and found to have a subdural hematoma (a small bleed in your head), at which time you were transferred to [**Hospital1 18**]. A repeat scan of your head showed the small bleed to be stable and not increasing in size or volume. An xray of your shoulder was taken and showed no fractures or dislocations. You were started on Dilantin while in the hospital. Please take dilantin for 7 more days after going home. Also, while in the hospital, your digoxin level was low and your dosage was increased to 0.125mg daily. Please take all of your medications as directed. Please go to all of your follow-up appointments. If you experience fever, chill, nausea, vomiting, headache, change in vision, loss of consciousness, or any other concerning symptom, please report to the emergency room immediately. Followup Instructions: Please follow up with PCP: [**Name10 (NameIs) 79226**],[**Name11 (NameIs) 79227**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10508**] within 2 weeks, and inform them of your stay with us and treatment rendered. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**] Completed by:[**2106-9-7**]

Admission Date: [**2163-6-23**] Discharge Date: [**2163-8-9**] Date of Birth: [**2163-6-23**] Sex: F Service: NB HISTORY: Baby girl [**Known lastname 73568**] is a 30-week twin A girl admitted to the NICU for issues of prematurity at 30 weeks of gestation on [**2163-6-23**]. She was born to a 38-year-old G1P0 mother. Prenatal screens, blood type O negative, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative. EDC [**2163-8-31**], based on IVF. The pregnancy was notable for di-di twin conception via IVF, complete placenta previa. Mother O negative blood type, status post RhoGAM at 28 weeks of gestation. Normal fetal surveys with recent weight 2 weeks ago twin A 80%, twin B 95%, normal nuchal translucency. Mother presented with vaginal bleeding on [**2163-6-20**] and required PRBC transfusion. Continued to have bleeding, milder and on the day of admission due to persistent bleeding the patient decided to deliver the twins. Mother is status post betamethasone complete with first dose on [**2163-6-20**] at 2130. No preterm contraction and no rupture of membranes. FAMILY HISTORY: Father is 1 of healthy triplets. He was born at 29 weeks of gestation in [**2128**]. Maternal family history: noncontributory. Girl [**Known lastname 73568**] was born [**2163-6-23**] at 1342 by C- section due to placenta previa. Apgar's of 7 at 1 minute and 8 at 5 minutes. She emerged with good respiratory effort and central cyanosis was noted, required blow by oxygen initially and transferred to the NICU in room air with mild respiratory distress. Unknown maternal GBS status, no maternal fever, ROM at delivery. She was transported to NICU. She developed respiratory distress. Rx with CPAP. PHYSICAL EXAMINATION AT ADMISSION: Weight 1465 grams, head circumference 27.5 cm, length 42 cm. Pale infant in mild respiratory distress with poor aeration bilaterally prior to CPAP. Anterior fontanel open and flat. Palate intact, normal S1-S2, no murmur. Bowel sounds present. ABDOMEN: Slightly distended, soft, nontender, well-perfused, tone appropriate for gestational age. Skin: no rash. Initial glucose stick was 36. The patient was AGA infant at 30 weeks with hypoglycemia, possible sepsis. The minimal risk factors and maternal indications for delivery and mild hyaline membrane disease. PHYSICAL EXAMINATION AT DISCHARGE: Weight 2595 grams, length 46 cm, head circumference 32.5 cm. She is pale, pink, mild retractions. HEENT: Anterior fontanel is open and flat. Pupils equal and reactive to light. Red reflex is present bilaterally. NECK: Supple. Nares patent and oral mucosa is mild. Respiratory system, she has mild intercostal and subcostal retractions noted while crying, comfortable. CHEST: Clear to auscultation bilaterally with good aeration bilaterally. CVS: Rate, rhythm regular, normal S1-S2. There is a short, soft, systolic murmur of 1 x 6 at the left upper sternal border with no radiation. Femoral pulses equal, brachial pulses. Cap refill less than 2 seconds. ABDOMEN: Soft, nontender, nondistended. No visceromegaly, bowel sounds present. GENITALIA: Normal female external genitalia, mild diaper rash is noted. NEUROLOGIC EXAMINATION: Tone appropriate for gestational age. Positive suck, Moro and grasp reflexes. EXTREMITIES: Active motion of all 4 extremities. Hips stable. SKIN: Pale and pink. HOSPITAL COURSE BY SYSTEM: RESPIRATORY SYSTEM: She was initially Rx nasal CPAP 6cm (DOL 0). CPAP continued until day of life 5. Her oxygen requirements ranged from 30% to 40%. On day of life 5, she was transitioned to room air successfully and continued on room air until the day of discharge. Onset of mild apnea and bradycardia episodes DOL [**1-8**]. Rx with caffeine. She continued to have occasional apnea and bradycardia episodes throughout her hospital course and her last bradycardia episode was noted on day of life #41 with the heart rate dropped to 72 and required mild stimulation. Caffeine discontinued with resolution of apnea, bradycardia, and desaturation episodes. No further apneic or bradycardic episodes after that episode. Initial chest x-ray at admission was significant for mild RDS. CARDIOVASCULAR SYSTEM: She remained hemodynamically stable. A soft, intermittent systolic murmur was noted on day of life 24 and remained stable at 1x6 with no radiation. FEN: Initially NPO, IV fluids via double lumen umbilical venous catheter. She received parenteral nutrition from DOL [**1-15**]. Gavage feedings initiated on day of life [**1-8**] with breast milk and Premature Enfamil slowly advanced. On DOL 11, she reached full feeds (150 cc/kg/day), all gavage. Umbilical venous catheter was discontinued. DOL 14, milk calories increased to 24 cal/oz, and DOL 16, calories increased to 26 cal/oz. Due to good wt gain, milk calories were decreased to 24 cal/oz and beneprotein was added on day of life 35. Iron and multivitamins were added on day of life 19. She continued to be gavage fed and the p.o. feeding was initially started on day of life 30 and was gradually advanced to reach full po feeds day of life 40. At present, she is taking breast milk and formula 24 kilocalories per ounce p.o. ad lib with minimum of 130 kilocalories. GI: Her bilirubin on day of life 2 was 5.2/0.2. She was started on phototherapy and she continued until DOL 5. The bilirubin on day of life 6 was 4.8 and 0.3. Her last bilirubin on day of life 11 was 7.2 and 0.3. Her last labs (DOL 29): calcium= 10.3, phosphate 6.3, alkaline phosphatase to 80. DOL 42, last serum electrolytes were performed on day of life 42: sodium 140, potassium 4.6, chloride 107 and bicarb 24. HEMATOLOGY: On day of delivery, WBC=7.9K, hematocrit 42.4%, and platelets 328K.(32 p, 0 bands). Her last CBC was performed on [**2163-7-19**] on day of life 26, white count 9.4K, hematocrit 26%, platelets 584, she has 33 neutrophils, 2 bands and 3 eosinophils. INFECTIOUS DISEASE: She was initially started on ampicillin, gentamicin. She continued for 48 hours, but discontinued due to negative culture. NEUROLOGY: Her head ultrasound was performed on day of life 3 on [**2163-6-26**] and day of life 33 [**2163-7-19**] and both were normal. SENSORY/AUDIOLOGY: Hearing screen was performed with automatic auditory brain stem response and she passed hearing in both ears. OPHTHALMOLOGY: Eyes examined mostly centrally on [**2163-8-3**] on day of life 41 revealing immaturity of the retinal vessels, but no ROP as of yet. She is classified as on 3 bilaterally and a followup is recommended in 3 weeks. She had a followup appointment with Dr. [**Last Name (STitle) **] on [**2163-8-23**] for her examination of the eye. PSYCHO/SOCIAL: Social Worker was involved with the family, but there were no concerns regarding the family. The contact social worker was provided and can be reached at [**Telephone/Fax (1) **]. Followup visit is provided if indicated. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. PRIMARY CARE PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 62869**], [**Hospital1 2436**]. CARE AND RECOMMENDATION: She's discharged. At discharge, she is taking breast milk or Enfamil 24 kilocalories per ounce, p.o. feeding ad lib on demand. MEDICATIONS: 1. Nystatin cream topical in the diaper area with each diaper change. 2. Multivitamin 1 mL p.o. daily. 3. Ferrous sulfate 0.4 mL p.o. daily. CAR SEAT POSITION SCREENING: Passed state newborn screen status. Her last day of newborn screen was performed on [**7-14**] and it was reported as normal. IMMUNIZATIONS RECEIVED: She received hepatitis B vaccine on [**8-23**]. IMMUNIZATIONS RECOMMENDED: Synagis, RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following for criteria: 1. Born at less than 32 weeks. 2. Born between 32 and 35 weeks. With 2 of the following: 1. Daycare during RSV season. 2. Smoker in the household. 3. Neuromuscular disease. 4.Cardiovascular abnormalities. 5. School aged siblings. 6. Chronic lung disease. 7. Hemodynamically significant congenital heart disease. 8. Influenza immunization is recommended annually in the autumn for all infants once they are 6 months of age. Before this age and for the first 24 months of the child's life, influenza immunization is recommended for household contacts and out of home caregiver. 9. This infant has not received Rotavirus vaccine AAP recommends initial vaccination of premature infants at or following discharge from hospital if they are clinically stable and at least 6 weeks of age, but fewer than 12 weeks of age. FOLLOWUP APPOINTMENT: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73569**], [**Hospital1 2436**], MA DISCHARGE DIAGNOSES: 1. Prematurity at 30 weeks of gestation. 2. Mild RDS. 3. Rule out sepsis, resolved. 4. Hypoglycemia, resolved. [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**] Dictated By:[**Name8 (MD) 67568**] MEDQUIST36 D: [**2163-8-9**] 09:38:11 T: [**2163-8-9**] 10:58:29 Job#: [**Job Number 73570**]

Admission Date: [**2160-6-19**] Discharge Date: [**2160-6-26**] Date of Birth: [**2086-6-5**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 74 year old male with a history of coronary artery bypass graft times three, most recently [**7-16**], and coronary stents, who complains of shortness of breath with chest pain times one day. He described a nonproductive cough for the past two months, but has had worsened cough overnight. He also complains of fevers and chills on the day of admission. The patient presented to his primary care physician's office on the morning of admission and was noted to be tachycardic to 120s and shaky. He also vomited times one. On evaluation in the Emergency Department, the patient's vital signs were temperature of 103.8, heart rate 120, blood pressure 90/50, respiratory rate 16, oxygen saturation 94% in room air. He received Aspirin, Tylenol, had two sets of blood cultures drawn and received 1.5 liters of normal saline in addition to Levofloxacin and Ceftriaxone. While in the Emergency Department, the patient had episodes of hypotension with systolic pressure in the 60s, though he mentated and did not feel lightheaded at any time. He was admitted to the CCU for further management. Significant cardiac history includes a transthoracic echocardiogram in [**8-16**], which demonstrated moderately dilated left ventricle with ejection fraction of 50%, anterior, anteroseptal, and inferior akinesis and hypokinesis, and depressed right ventricular function with 2+ mitral regurgitation. Cardiac catheterization [**2159-9-16**], resulted in stenting of the saphenous vein graft to OM1 and OM2. Prior coronary artery bypass graft redo in [**2159-7-16**], included left internal mammary artery to left anterior descending, radial artery to posterior descending artery, saphenous vein graft to D1, saphenous vein graft to D2, saphenous vein graft to OM1 and saphenous vein graft to OM2. Exercise stress test on [**2160-4-28**], resulted in a rate pressure product of 11,900, modified [**Doctor First Name **] protocol. The patient exercised for nine minutes and stopped due to fatigue with no anginal equivalents and an uninterpretable electrocardiogram. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction. 2. Coronary artery bypass graft times three. 3. Congestive heart failure with ejection fraction 50%. 4. History of ventricular fibrillation arrest. 5. Hypertension. 6. Elevated cholesterol. 7. Hepatitis B positive. 8. Back pain. ALLERGIES: 1. Penicillin causes a rash. 2. Morphine causes hypotension. 3. Sulfa. 4. Iodine. 5. Codeine. 6. Benadryl. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. once daily. 2. Carvedilol 3.125 mg p.o. twice a day. 3. Lisinopril 5 mg p.o. once daily. 4. Digoxin 0.125 mg p.o. once daily. 5. Lasix 40 mg p.o. twice a day. 6. Aldactone 25 mg p.o. once daily. 7. Protonix 40 mg p.o. once daily. 8. Remeron p.r.n. SOCIAL HISTORY: The patient has a distant tobacco history, discontinued almost forty years ago. He lives at home by himself. PHYSICAL EXAMINATION: On physical examination, the patient has a temperature of 100.9, heart rate 100, blood pressure 67/40, respiratory rate 22, oxygen saturation 95% on two liters by nasal cannula. In general, the patient was a pleasant elderly male in no apparent distress. Head and neck examination revealed moist mucous membranes, anicteric sclera, normal jugular venous distention. Lungs had crackles at the bases bilaterally with decreased breath sounds at the right lower lobe. Cardiovascular examination revealed tachycardia with normal S1 and S2 and a II/VI systolic murmur best heard at the apex. Abdomen was benign with no tenderness. Extremities had no edema. LABORATORY DATA: White blood cell count was 8.6, hematocrit 30.4, and platelet count 195,000. There was a left shift with 86% neutrophils and 9% lymphocytes. Coagulation studies demonstrated a prothrombin time of 14.5, INR 1.4. Panel seven was significant for a blood urea nitrogen of 32 and creatinine of 1.0. Two sets of cardiac enzymes revealed sequential CKs of 54 and 62 with MB of 1.0 and 0.9, respectively. Urinalysis showed no nitrites and no leukocyte esterase. Chest x-ray demonstrated prominent pulmonary vasculature with small left pleural effusion and retrocardiac haziness read as atelectasis versus consolidation. Electrocardiogram demonstrated sinus tachycardia of 120 beats per minute, with normal axis, left bundle branch block, unchanged from prior electrocardiogram in [**2159-11-16**]. HOSPITAL COURSE: 1. Hypotension - The patient was thought to be septic and thus received fluid resuscitation in the Emergency Department. A right internal jugular central venous catheter was placed and initial CVPs were measured at 3.0 to 4.0 of water. The patient's diuretics and antihypertensive medications were held, and he was started on Neo-Synephrine to maintain his blood pressure. The suspected source of infection was a pneumonia, although an abdominal process could not be ruled out given recent hospitalization at the [**Hospital3 2358**] six months prior with abdominal pain. Therefore, the patient was started on Levofloxacin and Flagyl. On the second day of hospitalization, the patient's white blood cell count peaked at 20.2 with a continued left shift. he had a temperature spike of 101.6, and subsequent blood cultures, urine cultures, and sputum cultures were all negative. His white blood cell count subsequently normalized within two days and he remained afebrile thereafter through the rest of his hospitalization. In addition, the Neo-Synephrine was quickly weaned off within 48 hours of admission and he required no further pressor support. The patient will complete a ten day course of Levofloxacin and Flagyl for sepsis with suspected pneumonia as the source. 2. Congestive heart failure - Following his fluid resuscitation, the patient appeared to be in mild congestive failure with tachypnea and hypoxia. He was diuresed with Lasix and then switched over to his outpatient regimen. He continued to diurese for several days, after which he felt at his baseline respiratory status. Electrophysiology was consulted, and they recommend biventricular pacing as possible aid to his congestive heart failure. This will be addressed on a return visit as an outpatient. 3. Coronary artery disease - The patient ruled out for myocardial infarction, and had no further episodes of chest pain. He was continued on his Aspirin and had no evidence of ischemia during his hospitalization. 4. Arrhythmias - During his first night of hospitalization, the patient had a twenty beat run of nonsustained ventricular tachycardia. He had additional episodes of nonsustained ventricular tachycardia on ablators and should thus have an AICD placed. Due to his recent sepsis, the patient should complete his antibiotic course and return as an outpatient for placement of his AICD as well as biventricular pacer. He was started on Amiodarone for his arrhythmias, and should continue this until follow-up with Electrophysiology. CONDITION ON DISCHARGE: The patient was discharged in stable condition to home. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Sepsis. 3. Congestive heart failure. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. once daily. 2. Levofloxacin 500 mg p.o. once daily times three days. 3. Metronidazole 500 mg p.o. three times a day times three days. 4. Digoxin 125 mcg p.o. once daily. 5. Furosemide 40 mg p.o. twice a day. 6. Spironolactone 25 mg p.o. once daily. 7. Klonopin 0.5 mg p.o. q.h.s. and 0.25 mg p.o. twice a day. 8. Amiodarone 200 mg p.o. three times a day times three weeks. 9. Carvedilol 3.125 mg p.o. twice a day. DISCHARGE PLAN: 1. The patient should follow-up with his primary care physician within two weeks. 2. At this time, the patient's ace inhibitor may be restarted. 3. The patient will follow-up with Electrophysiology in two weeks for placement of AICD as well as biventricular pacer. 4. The patient should continue taking Klonopin which was prescribed by his outpatient psychiatrist for anxiety and depression symptoms. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**] Dictated By:[**Last Name (NamePattern1) 6916**] MEDQUIST36 D: [**2160-6-26**] 12:13 T: [**2160-6-30**] 20:10 JOB#: [**Job Number 105769**]

Admission Date: [**2140-9-14**] Discharge Date: [**2140-9-19**] Date of Birth: [**2087-4-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2140-9-14**] Four Vessel CABG(left internal mammary artery to left anterior descending artery, vein grafts to diagonal, obtuse marginal, and posterior descending artery) History of Present Illness: Mr. [**Known lastname **] is a 53 year old male with newly diagnosed diabetes mellitus who presented with exertional shortness of breath and lightheadedness with minimal exertion. Stress testing was positive for ischemia and subsequent cardiac catheterization revealed severe three vessel coronary artery disease. Based upon the above, he was referred for cardiac surgical intervention. Past Medical History: Coronary Artery Disease Hypertension Hyperlipidemia Type II Diabetes Mellitus Morbid Obesity Social History: Denies tobacco and ETOH. Employed as a bus driver. Married, lives with his wife. Family History: Father died of MI at age 46 Physical Exam: Vitals: 150-170/60-74, HR 60's, Resp 18 Weight 360 lbs, Height 76 inches General: WDWN obese male in NAD HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD, no carotid bruits Lungs: CTA bilaterally Heart: Regular rate and rhythm, normal s1s2, no murmur or rub Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent coronary artery bypass grafting surgery by Dr. [**Last Name (STitle) **] on [**9-14**]. For surgical details, please see separate dictated operative 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. Beta blockade and diuretics were initiated. Given his recent history of new onset diabetes, [**Last Name (un) **] was consulted to assist with postoperative and discharge medical management. His CSRU course was otherwise uneventful, and he transferred to the SDU on postoperative day one. Pacing wires and chest tubes removed without incident. He continued to make good progress and was cleared for discharge to home with VNA services on POD #7. Pt. is to make all followup appts. as per discharge instructions. Medications on Admission: Lotensin 40 [**Hospital1 **], Norvasc 10 qd, Aspirin 325 qd, Levitra prn, Zocor 40 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. 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* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Lancets Misc Sig: As dir Miscellaneous four times a day. Disp:*QS 1 month* Refills:*0* 9. Test strips Glucometer test strips As dir QS 1 month 10. Aquacel Aquacel dressing 4x4" As dir QS 1 month 11. Allevyn Allevyn Foam adhesive 7x7" As Dir QS 1 month 12. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 3765**] Hospice Program Discharge Diagnosis: Coronary Artery Disease - s/p CABG Hypertension Hyperlipidemia Type II Diabetes Mellitus morbid obesity Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) **] in [**4-28**] weeks, call for appt [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 32668**] in [**2-27**] weeks, call for appt Completed by:[**2140-9-19**]

Admission Date: [**2103-2-22**] Discharge Date: [**2103-3-2**] Date of Birth: [**2079-4-1**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 896**] Chief Complaint: Fever, cough, dehydration. Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 23 yo male with history of type 1 DM, reports 10days of dry cough and fevers. He notes the initial onset of a fever 10 days ago, which was self limited. He felt better for approximately two days, but then developed a SOB, dry cough, congestion, and a stomach ache. He notes decreased appetite and decreased PO intake. He has not been checking his finger sticks but was self titrating his insulin to lower doses of only 15 units of Humalog tid instead of 21-23. He also notes intermittent dizziness with bilateral pleuritic chest pain, worse with deep breaths. He had nausea without vomiting, abdominal pain, diarrhea, or constipation. Denies problems with urination. He notes that his fevers, cough, and dehydration. were the most prominent symptoms, occuring every day. He has tried Dayquil and Mucinex without relief. Today, he noted increased dizziness, palpitations and difficulty breathing and decided to go to the ED. He denies any sick contacts. [**Name (NI) **] has not had a flu shot this year. He last travel was to the UAE in [**Month (only) 216**]. He has been in the US for 5 years for school. Of note, patient's friend reports outside of patient's room that he drinks alcohol every day, all day long and does not take much po otherwise. In the ED, he initially triggered for SVT to the 170's. Labs were drawn and were consistent with DKA. He received 3L of NS. He was started on insulin 5 units IV x1, then started on a drip at 5 units hour. Urine and blood cultures sent. CXR consistent with multifocal pneumonia so he was given a dose of ceftriaxone and azithromycin. Repeat EKG showed sinus tachycardia. Vitals prior to discharge wer 99.1 170 140/94 24. On the floor, he notes prominent cough and shortness of breath limiting his ability to take deep breaths. He feels better after his ED treatment, although notes that he feels dehydrated still. Past Medical History: Type 1 Diabetes, diagnosed age 5, no prior complications or hospitalizations, treating his own insulin that he gets from [**Country 6607**], last doctor seen was 3 years ago. Social History: He is a senior at [**University/College 5130**] majoring in Economics. He lives with his brother who is at [**Name (NI) 7709**]. He moved to the US for college, but is from UAE and plans to return after school. He reportedly drinks large volumes daily, but notes [**5-1**] vodka drinks with two shots a piece when he drinks which he says is not every day. He notes occaisional marijuana use. Sexually history notable for 4 female partners in the past year and uses condoms 100% of the time. Family History: Mother with HTN Father with Type 1 Diabetes [**Name (NI) **] Brother is healthy. No family history of pulmonary disease or TB. Physical Exam: Upon admission: VS: Temp: 101.5 BP: 154/84 HR: 124 RR: 34 O2sat 97% on RA FS 214, 160 GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, Neck: no supraclavicular or cervical lymphadenopathy, no jvd, no thyromegaly or thyroid nodules RESP: CTA b/l with decreased BS throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: +BS, soft, NT, ND, no masses or hepatosplenomegaly EXT: no c/c/e, wwp, DP 2+ bilaterally SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. Pertinent Results: Labs on admission: [**2103-2-22**] 03:32PM WBC-26.8* RBC-5.23 Hgb-15.4 Hct-47.5 MCV-91 MCH-29.4 MCHC-32.4 RDW-14.5 Plt Ct-461* Neuts-69 Bands-14* Lymphs-3* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-5* Myelos-0 Promyel-1* PT-13.6* PTT-26.2 INR(PT)-1.2* Glucose-310* UreaN-11 Creat-1.1 Na-134 K-4.2 Cl-96 HCO3-7* AnGap-35* ALT-14 AST-12 AlkPhos-146* TotBili-0.5 HIV: negative HgA1c: 9.4 MICRO: [**2103-2-22**] BLOOD CULTURE - MSSA CXR: Multifocal pneumonia, with relative sparing of the right lower lung. Brief Hospital Course: 1. DKA: Patient with history of Type 1 Insulin Dependant Diabetes since age 5. Had not seen a doctor in years. Obtaining insulin in [**Country 6607**] and self dosing based on "how he felt" On Admission, initial BS was 310, and he was started on an insulin drip in the ED. FS were monitored q1h and pH and lytes were checked q4h. He was maintained on an insulin drip until his AG closed and transitioned to SQ insulin. [**Last Name (un) **] consulted and aided in insulin regimen with higher dose of evening Lantus and an aggressive sliding scale; they will follow-up with patient within one week of discharge. 2. Community acquired multifocal pneumonia: Patient with reported 10 days of URI symptoms. CXR on admission consistent with multifocal pneumonia. There was some suspicion that this was a post-influenza bacterial pneumonia, with sputum Gram stain showing 3+ GPC in clusters, consistent with his MSSA bacteremia. Patient started on ceftiaxone/azithromycin on [**2-22**], which was later transitioned to Levofloxacin for a 5-day course. With continued fevers on this regimen, further cultures and imaging (CT chest) were obtained that showed know multifocal pneumonia with very small pleural effusions, and no evidence of abscess/loculation. On CXR upon transfer, there is a radiolucency that may be indicative of cavitation, which will need follow-up imaging. 3. MSSA bacteremia: Pulmonary source, with 3+ GPCs in clusters on gram stain. Gram positive cocci in clusters grew from cultures on [**2-22**], with surveillance cultures negative to date. Patient started on vancomycin on [**2-23**] which was transitioned to Nafcillin on [**2-24**] after grew out to be MSSA. Given the risk of endocarditis with Staph aureus, TTE was done and did not show any vegetations. A PICC line was placed once he was afebrile and culture-negative for >48 hours and he will be continued on Nafcillin for a 21-day course. 4. Tachycardia: Patient profoundly tachycardic on admission with heart rates in 170s. EKG demonstrated sinus tachycardia. Patient was aggressively hydrated, but the tachycardia persisted. Etiology deemed secondary to infection, pleuritic chest pain secondary to pneumonia, also possible withdrawal given negative serum EtOH or nicotine withdrawal. TSH was within normal limits. He required IVF boluses to manage his tachycardia on exertion that persisted despite being afebrile and improving clinically. 5. Alcohol abuse: Per report patient drinks [**5-1**] vodka drinks/day. Written for CIWA scale on night of admission. Received 5mg IV valium on night of admission due to persistent tachycardia into 170s and hypertension with SBP~150s. Heart and blood pressure improved. Since he did not score the CIWA scale, there was no need for further valium in house. Social work consulted to address alcohol use especially in setting of diabetes. Medications on Admission: Lantus 36 units at home Humalog R 21-23 units tid, has been taking 15 tid, self titrating Discharge Medications: 1. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) as needed for MSSA PNA for 16 days: Final day [**2103-3-17**]. Disp:*qs grams* Refills:*0* 2. Lantus 100 unit/mL Solution Sig: Sixty Seven (67) Subcutaneous once a day. 3. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: Please see attached sliding scale. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: 1. Community acquired pneumonia, bacterial 2. Bacteremia, staph aureus 3. Diabetic ketoacidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 90364**], You were admitted with pneumonia which resulted in a blood stream infection. In addition, this led to diabetic Followup Instructions: Department: INFECTIOUS DISEASE When: WEDNESDAY [**2103-3-14**] at 9:30 AM With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: WEDNESDAY [**2103-4-11**] at 9:30 AM With: [**Name6 (MD) 9462**] FLASH, MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Last Name (LF) 20556**], [**First Name7 (NamePattern1) 553**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Apartment Address(1) 20557**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2490**] Appointment: Tuesday [**3-6**] at 9AM Name: [**Last Name (LF) 20556**], [**First Name7 (NamePattern1) 553**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Apartment Address(1) 20557**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2490**] Appointment: Tuesday [**3-6**] at 9AM

Admission Date: [**2155-7-10**] Discharge Date: [**2155-7-16**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Falls Major Surgical or Invasive Procedure: PPM placement [**7-11**] History of Present Illness: 89 YO M with recent ETOH abuse, HTN, likely vascular dementia and episodes of arm and leg shaking with decreased responsiveness over the past 1.5 years presenting after several similar episodes within the past several days. Per his family, he had 3 episodes on [**7-5**] and 6th and 1-2 episodes of the 7th. He has had no episodes since that time. The patient's daughter and wife describe his past episodes as: eyes are dilated, he flails his arms out and he taps either foot, he is intermittently responsive throughout the episode. At other times he will cling to his chair, with his eyes dilated, and when his wife or daughter asks him what the matter is, he says "nothing." His family also notes that he is getting increasingly confused, falling about 3 times within the past month (without fractures). He denies any symptoms during the episodes and actually does not remember them at all. He does endorse one fall. . Upon presentation to the ED, his VS were initially notable for bradycardia to the 50s which dropped down to 30s with a stable BP and without symptoms. His labs were notable for hyponatremia to 129 and a negative trop. Multiple EKGs reportedly looked like AFLUT with variable slow conduction. EP and cards were called due to c/f complete HB. Per the ED resident's report, EP and cards did not think the EKGs were c/f CHB. Exam was otherwise notable for confusion, orientation times [**2-1**] which his family reported was at his baseline. His neuro exam was reportedly non-focal. Given his mental status and episodes of syncope, neurology was also called and felt these episodes were unlikely to be seizures. A CT head was done and showed small vessel disease which neurology felt was c/w with his poor mental status. Since the patient is on atenolol at home, he was given Ca gluconate although without effect. He was also given aspirin. Atropine was pulled but not given. Per report, his Bps remained stable. Vs prior to tx : 97.3 50 152/82 16 100% on 2L. . Upon arrival to the floor, he reports feeling well. He states that he stopped drinking 5-6 months ago because his wife stopped buying alcohol and not because he wasn't feeling well. He reports feeling himself and has no complaints. . Review of sytems: Unable to reliably provide but specifically denies chest pain, shortness of breath, palpitations. Past Medical History: Severe arthritis particularly involving his feet. He has had bilateral bunionectomies, has hammertoes, has had a total knee replacement on his right and he had a previous hip fracture. HTN Alcohol dependence BPH with urinary obstructive symptoms Elevated PSA Hearing loss Falls largely associated with alcohol use Dementia Chronic constipation snores at night ?OSA(not formally diagnosed) b/l cataract surgeries Social History: Both [**Doctor Last Name **] (patient's wife) and the patient are originally from [**Country 4754**]. They have 4 adult children. He is a non-smoker. He has drunk 7 beers and several shots of whisky all of his adult life, apart from the past 10 days. He worked as a custodian in a school. He does not use recreational drugs Family History: Not known, his mother lived until she was aged 106, and the patient's wife stated that she had her "marbles" until she died. Physical Exam: Vitals: 97.7 165/79 60 20 100RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: alert and oriented to self, hospital, and year. poor memory. On discharge: Pacemaker in place, slightly bruised and tender, but no drainage, edema. Pertinent Results: [**2155-7-10**] 09:30AM BLOOD WBC-8.6 RBC-4.79 Hgb-14.5 Hct-42.1 MCV-88 MCH-30.2 MCHC-34.4 RDW-13.1 Plt Ct-373 [**2155-7-10**] 09:30AM BLOOD Neuts-65.4 Lymphs-23.5 Monos-5.4 Eos-5.3* Baso-0.5 [**2155-7-10**] 09:30AM BLOOD PT-12.3 PTT-24.8 INR(PT)-1.0 [**2155-7-10**] 09:30AM BLOOD Glucose-107* UreaN-9 Creat-0.9 Na-129* K-4.0 Cl-93* HCO3-30 AnGap-10 [**2155-7-10**] 09:30AM BLOOD ALT-13 AST-20 AlkPhos-68 TotBili-0.5 [**2155-7-10**] 09:30AM BLOOD cTropnT-<0.01 [**2155-7-10**] 09:30AM BLOOD Albumin-3.9 Calcium-8.4 Phos-3.5 Mg-2.1 [**2155-7-10**] 09:30AM BLOOD VitB12-466 Folate-9.1 [**2155-7-11**] 03:12AM BLOOD Osmolal-265* [**2155-7-10**] 05:58PM BLOOD Ammonia-30 [**2155-7-10**] 09:30AM BLOOD TSH-1.9 [**2155-7-14**] 06:25AM BLOOD CRP-30.5* [**2155-7-14**] 06:25AM BLOOD Vanco-20.3* [**2155-7-16**] 06:20AM BLOOD WBC-7.4 RBC-3.63* Hgb-11.2* Hct-32.4* MCV-89 MCH-30.8 MCHC-34.5 RDW-13.8 Plt Ct-308 [**2155-7-16**] 06:20AM BLOOD Glucose-157* UreaN-14 Creat-1.1 Na-133 K-4.3 Cl-95* HCO3-26 AnGap-16 [**2155-7-16**] 06:20AM BLOOD Calcium-7.9* Phos-4.2 Mg-2.1 CT head: 1. No acute intracranial hemorrhage. 2. Small vessel ischemic disease and bilateral basal ganglia lacunes. 3. Ethmoid sinus disease and fluid in the bilateral mastoid air cells, with extension of fluid in the left middle ear cavity. Findings may represent an ongoing inflammatory process, but clinical correlation is recommended. 4. Gas in the cavernous sinus and the subcutaneous tissues, likely venous and secondary to injection/IV placement. 5. Enlarged ventricles disproportionate to the degree of sulcal atrophy, possibly due to central atrophy, but NPH is not excluded. CXR: Trace right pleural effusion. CXR: Pacemaker tip in right ventricle TEE attempted and unsuccessful. Panorex - read pending Brief Hospital Course: 89 year old man with a history of high alcohol intake until 10 days prior, HTN, and several months of episodes of altered mental status and falls now presenting s/p fall with bradycardia and pauses. # Bradycardia with history of atrial fibrillation and 5 second pauses. Patient was thought to be asymptomatic, but on observation in the ICU he was more confused during these episodes. EP was consulted and pacemaker was placed on [**2155-7-11**]. He was also started on ASA 325mg of atrial fibrillation. Coumadin was not started due to recent falls and ETOH abuse. Several hours after pacemaker was placed blood cultures drawn on admission returned positive. Blood cultures were obtained to complete workup for altered mental status though infection was not the leading diagnosis. Pt was started on vancomycin on [**2155-7-11**] after cultures returned positive. ID team was consulted who recommended TEE to rule out endocarditis. TEE was attempted but unsuccessful. He had a panorex on [**7-16**] and was evaluated by dentistry who did not feel he had an acute infection. At time of discharge plan was to continue nafcillin for 4 weeks, and 2 weeks of levoquin and rifampin orally. Midline should be pulled upon completion of nafcillin course. Weekly CBC/diff/electrolytes and LFTs should be checked and faxed to [**Hospital **] clinic. Pt has follow up with device clinic and [**Hospital **] clinic as noted below. . # Altered mental status. Likely [**3-4**] vascular dementia with possible contribution of hyponatremia and alcohol dependence. At risk for Wernicke's. He was given thiamine, MVI, folic acid. He did not score on CIWA during hospital stay. Blood cultures drawn to complete infectious workup and after 48 hrs grew three bottles of coag negative staphylococcus. Neurology consulted and B12, folate, and TSH, along with cardiac enzymes, CBC, chem 7, LFTs, ammonia returned within normal limits. #During his hospitalization pt was noted to have poor dentition. He will require follow up with the [**Hospital 9786**] clinic at rehab for complete exam, cleaning and plan to extract mobile teeth which include 1,16, 32, and fractured 9. # Hyponatremia. Urine lytes suggested SIADH possibly secondary to multiple strokes, history of ETOH abuse, or reset osmostat. Sodium corrected with fluid restriction. Pt should maintain on a 1500cc fluid restriction. # Shaking episodes at home. The etiology of this remains unclear. It may be related to pauses or episodes of profound bradycardia vs seizures. neuro did not feel EEG would be high yield. After pacer was placed, he had no further episodes during his hospitalization. # Falls. [**Month (only) 116**] be related to posterior column demyelinization vs ETOH abuse vs bradycardia. Pt was evaluated by PT who felt he was incredibly unsteady on his feet and would not be able to use a walker without placing excess weight on his left arm (pacemaker site). He was discharged to rehab. # Code: Full (discussed with wife) Rehab to do: [ ] Continue antibiotics as directed [ ] Pull midline upon completion of Nafcillin course [ ] f/u with device clinic and ID [ ] daily physical therapy [ ] evaluation by [**Hospital 9786**] clinic for tooth extraction once stable [ ] 1500 cc fluid restriction Medications on Admission: Ketoconazole 2 % Topical Cream use at least once a day between buttocks once a day Atenolol 50 mg Tab 1 Tablet(s) by mouth once a day Colace 100 mg Cap 2 Capsule(s) by mouth once a day Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day): for constipation . 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): to prevent stroke caused by irregular heart rate. 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily): (vitamin). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): (vitamin). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q6H (every 6 hours): day 1= [**7-11**], last day [**8-9**]. 4 week course. 9. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours): First day [**8-10**]. Last day is [**8-24**]. Two [**Doctor Last Name **] course following completion of 4 week course of nafcillin. . 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): First day [**8-10**]. Last day is [**8-24**]. Two [**Doctor Last Name **] course following completion of 4 week course of nafcillin. . 11. Outpatient Lab Work Please draw weekly CBC with differential, Basic Metabolic Panel including BUN and Cr, and liver function tests. Please fax to [**Telephone/Fax (1) 1419**] to the Infectious disease nurses. All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to on [**Name8 (MD) 138**] MD in when clinic is closed. 12. Pull midline Please pull midline upon completion of Nafcillin course. 13. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: primary: symptomatic bradycardia coagulase negative staph infection hypertension atrial fibrillation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [**Known lastname 5395**] - you were admitted for recent falls. You were found to have a very slow heart rate requiring a pacemaker. Pacemaker was placed. It was later discovered that you have had a blood stream infection that requires aggressive treatment. We tried to figure out where the infection came from but this was unclear. . Also during your hospitalization a dentist evaluated your teeth. You should be evaluated at [**Hospital 100**] Rehab by the dentist and likely will need extraction of several teeth. . You have a number of new medications. Please stop taking Atenolol. A number of medications were started. Please see attached list. Followup Instructions: Please make the following appointment: Department: CARDIAC SERVICES When: FRIDAY [**2155-7-18**] at 10:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2155-8-5**] at 10:50 AM [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage You may follow up with Dr. [**Last Name (STitle) 11616**] when you finish your rehab stay. Completed by:[**2155-7-17**]

Admission Date: [**2198-5-4**] Discharge Date: [**2198-5-8**] Date of Birth: [**2151-11-20**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8739**] Chief Complaint: headaches x5 days, clumsiness in his L-arm Major Surgical or Invasive Procedure: [**2198-5-4**]: R parietal craniotomy for metastic lesion History of Present Illness: The patient is a 46 yo R-handed man with a history of HTN who presents to the ED with a 5 day history of headaches, clumsiness in his L-arm and walking into objects on the L. The Pt was in his USOH until last Saturday ([**4-28**]), when he noted that when he tried to grasp his T-shirt with his L-arm, this arm "wasn't doing it properly". He says he could feel well and that the arm didn't feel weak, but that his arm didn't exactly do what he wanted it to do. He continued to drop items, especially small ones, during the rest of the week. No numbness or tingling. At the time he first noted the clumsiness, he also felt lightheaded. A few after the first event, he noted a headache, bifrontal, squeezing. The headache is not affected by position, light makes it worse. It has been associated with nausea, but no vomiting. No nightly awakenings. Typically, during the rest of the week, the headaches would last about 30 min. At baseline he never has any headaches like these; no migraines. In addition, he has noted that he has been walking into doorposts/objects at the left side only. He has not noted any problems with his vision. He attributed this to problems in his leg. Finally, he has been getting more forgetful, which is unusual for him. He contact[**Name (NI) **] his PCP with the above story, who refered him to the ED. He is accompanied by a good friend. ROS: denies any fever, chills,visual changes, hearing changes, neckpain/backpain, vomiting, dysphagia, weakness, tingling, numbness, bowel-bladder dysfunction, chest pain, shortness of breath, abdominal pain, dysuria, hematuria, or bright red blood per rectum. Weightloss 5pounds over the last months, no intention. Past Medical History: -hypertension since [**2-16**] yrs -L-inguinal hernia, s/p surgery Social History: Occupation: works as a DJ as well as in a digital photolab Smoking: no, but has been exposed to second hand smoke (as a DJ); EthOH: 6pack on Fridays; drug abuse: no. Single, takes care of mom; has had one unsafe sexual relationship Family History: -positive for DM and HTN; sister has seizures since childhood; no cancers; no migraines Physical Exam: VITALS: T99.4 HR108 BP173/74 RR16 sO2 100% GEN: NAD HEENT: mmm, anicteric NECK: no LAD; no carotid bruits; full range neck movements LUNGS: Clear to auscultation bilaterally HEART: Regular rate and rhythm, normal S1 and S2, II/VI murmur, gallops and rubs. ABDOMEN: normal bowel sounds, soft, nontender, nondistended EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema MENTAL STATUS: Awake and alert, cooperative with exam, normal affect. Oriented to place, month, day, and date (although it takes him a while to come up with [**2198**], first says [**2188**]), person. Attention: MOYbw: gets into trouble [**Month (only) 547**]-[**Month (only) 116**] (keeps reversing), finally makes it to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14489**]: Registration: [**3-16**] items; Recall [**3-16**] at 5 min. Language: fluent; repetition: intact; Naming intact, including colors; Comprehension intact; no dysarthria, no paraphasic errors. Writing: intact. [**Location (un) **]: intact; Prosody: normal. Fund of knowledge normal; No Apraxia. No Neglect. CRANIAL NERVES: II: Visual acquity intact. Visual fields: L-upperquadrantanopia, pupils equally round and reactive to light both directly and consensually, 2-->1 mm bilaterally. Disc margins sharp, no pappilledema. III, IV, VI: Extraocular movements intact without nystagmus. Fixation and saccades are normal. No ptosis. V: Facial sensation intact to light touch and pinprick. VII: Facial movement symmetrical; no facial droop. VIII: Hearing intact to finger rub bilaterally. IX: Palate elevates in midline. XII: Tongue protrudes in midline, no fasciculations. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. MOTOR SYSTEM: Normal bulk and tone bilaterally. No adventitious movements, no tremor, no asterixis. Strength is full. No pronator drift, but a clear parietal drift on the L. No rebound. SENSORY SYSTEM: Sensation intact to light touch, pin prick, temperature (cold), vibration, and proprioception in all extremities. agraphestesia in both hands; proposagnosia on the L-arm REFLEXES: B T Br Pa Pl Right 2 2 2 2 2 Left 3 3 3 3 3 (few beats clonus in ankle; crossed adductor) Toes: mute bilaterally. COORDINATION: Normal [**Last Name (LF) 11140**], [**First Name3 (LF) **], HTS. No dysmetria or pastpointing. GAIT: narrow based, normal arm swing, normal initiation. Romberg: negative. Able to do tandem gait, walk on toes, walk on heels. Pertinent Results: [**2198-5-4**] 01:00AM BLOOD WBC-7.3 RBC-4.30* Hgb-9.4* Hct-29.4* MCV-68* MCH-21.8* MCHC-31.8 RDW-15.4 Plt Ct-436 [**2198-5-4**] 01:00AM BLOOD Neuts-75.5* Lymphs-18.3 Monos-4.9 Eos-0.6 Baso-0.7 [**2198-5-8**] 07:10AM BLOOD WBC-6.2 RBC-4.88 Hgb-11.4* Hct-35.5* MCV-73* MCH-23.3* MCHC-32.0 RDW-16.5* Plt Ct-302 [**2198-5-4**] 01:00AM BLOOD PT-13.9* PTT-26.5 INR(PT)-1.2* [**2198-5-4**] 01:00AM BLOOD Glucose-122* UreaN-15 Creat-1.4* Na-138 K-5.1 Cl-97 HCO3-26 AnGap-20 [**2198-5-8**] 07:10AM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-145 K-3.5 Cl-102 HCO3-30 AnGap-17 [**2198-5-4**] 10:35AM BLOOD ALT-34 AST-27 LD(LDH)-244 AlkPhos-92 Amylase-50 TotBili-0.3 [**2198-5-4**] 10:35AM BLOOD Lipase-24 [**2198-5-4**] 10:35AM BLOOD Albumin-3.7 Calcium-9.5 Phos-4.4 Mg-1.9 [**2198-5-5**] 09:20AM BLOOD Phenyto-10.6 ----- Head CT [**5-3**]:IMPRESSION: 1.4-cm round mass lesion with peripheral hemorrhage and surrounding extensive vasogenic edema. There is minimal subfalcine herniation without evidence of transtentorial or uncal herniation. ----- Head CT [**5-4**]:IMPRESSION: Post-operative appearance to the brain without evidence of transtentorial or uncal herniation, and with minimal leftward subfalcine herniation, that was also present on the prior study. ----- Head MR 4/21:1. 1.8-cm enhancing mass in the right frontoparietal lesion with hemorrhagic component, with edema that partially enters into right side of the splenium of corpus callosum, corresponding to the finding on CT scan. The finding is most likely representing metastatic disease; however, other differential diagnoses include lymphoma and PNET. 2. Normal MR angiography. ----- Brain pathology: METASTATIC CLEAR CELL CARCINOMA most consistent with METASTATIC RENAL CELL CARCINOMA. ----- MRI post-op:IMPRESSION: Status post resection of right parietal enhancing lesion. Blood products are seen at the surgical site with a small area of residual enhancement suspected at the anterior margin of the surgical cavity. Surrounding edema is again noted, unchanged. No interval new abnormalities are seen. ----- CT torso:Large, heterogeneously-enhancing, necrotic left renal neoplasm, likely renal cell carcinoma. Pulmonary metastases as well as a single probable hepatic metastasis are seen. Filling defect within the left renal vein may represent non- occlusive bland or tumor thrombus. Brief Hospital Course: 46 yo R-handed man with a history of HTN who presented to the ED with a 5 day history of headaches, clumsiness in his L-arm, and walking into objects on the left. These symptoms had been fluctuating since onset. On exam, he was very mildly inattentive, had a L-upper quadrantanopia, a L-parietal drift, and agraphesthesia in the L-arm. CT head in the ED showed a round mass in the R-parietal region ([**Doctor Last Name 352**]/white junction) with extensive edema. In addition, he had anemia. An MRI with contrast was ordered which showed the mass in more detail. It was radiographically consistent with a metastasis. He was started on Decadron 4 mg q6h due to the edema. He was then taken to surgery for tumor resection. This went well without complication. His exam remained essentially unchanged afterwards. His decadron was slowly weaned after surgery. The preliminary path was renal cell carcinoma. He then had a torso CT which showed a large 11.1 x 18.3 x 13.1 cm renal mass on the left. This did not compress any major vessels. It also showed evidence of bilateral lung metastases and probable liver metastases. The oncology service was consulted and saw him here. They arranged for him to follow-up quickly as an outpatient. He will also follow-up in brain tumor clinic. The treatment course is not fully clear at this time and will be determined at his outpatient oncology appointments. He was seen by social work here for assistance with coping and his new cancer diagnosis. He is clearly upset, but does accept the diagnosis. For seizure prophylaxis, he was started on Keppra 500 mg [**Hospital1 **]. He will continue this and may need to increase it as an outpatient. He will see multiple neurologists in the near future and this can be managed as well. His dexamethasone will continue at 2 mg [**Hospital1 **] for now. Again, this may be decreased in the future depending on how he does as an outpatient. CV: Continued atenolol, but his creatinine was initially [**Last Name (LF) 14490**], [**First Name3 (LF) **] we stopped his HCTZ. He will follow-up in brain tumor clinic and with oncology. Medications on Admission: 1. Atenolol 37.5 mg p.o. daily. 2. Hydrochlorothiazide 25 mg p.o. daily. Discharge Medications: 1. Atenolol 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*2* 3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Metastatic renal cell carcinoma s/p resection of brain met Discharge Condition: neurologically stable Discharge Instructions: Please continue to work with physical therapy to improve your mobility and attend all out patient appointments. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 1729**] heme/oncologist in 1 week from discharge. Please call ([**2198**] to schedule an appointment. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] referred you to his office. Also follow-up with Dr. [**Last Name (STitle) 724**] on [**5-21**] at 3pm, call [**Telephone/Fax (1) 1844**] for directions to the Brain [**Hospital 341**] Clinic. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2198-5-21**] 4:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4406**] MD, [**MD Number(3) 8740**]

Admission Date: [**2178-12-14**] Discharge Date: [**2178-12-19**] Service: CARDIOTHORACIC Allergies: Latex / Codeine / Oxycodone / Percocet / Sulfa (Sulfonamide Antibiotics) / Vicodin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2178-12-14**] Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] tissue) History of Present Illness: 85 year old female with known aortic stenosis complaining of progressively woserning dyspnea on exertion. Echocardiograms have also shown worsening aortic valve area. Most recent 0.5cm2. Referred for aortic valve surgery. Past Medical History: Aortic Stenosis, Hypertension, Hypothyroidism, s/p Left knee meniscus repair, s/p bilateral eyelid surgery Social History: Lives with husband and son Quit smoking 30 years ago. Admits to glass of wine with dinner 2x/wk. Family History: Mother with myocardial infarction. Sister with coronary artery disease and valve surgery. Father with heart disease. Physical Exam: Admission VS: HR 85 RR 16 BP 145/80 HT 5'1" Wt 125# Skin: Unremarkable HEENT: Unremarkable Neck: Supple, Full range of motion Chest: Clear to auscultation bilaterally Heart: Regular rate and rhythm with 3/6 systolic ejection murmur radiation to neck Abd: Soft, non-tender, non-distended, +bowel sounds Ext: Warm, well-perfused, -edema Neuro: Grossly intact Discharge VS: HR 58 BP 123/77 RR 20 O2sat 96 RA WT 61 kgs Skin:MSI incision C/D/I, sternum stable Chest: Clear to auscultation bilaterally Heart: RRR Abd:soft, non-tender, non-distended, +bowel sounds Ext: warm, well-perfused, +1 edema lower extremity Neuro: grossly intact Pertinent Results: [**2178-12-14**] 12:26PM GLUCOSE-138* NA+-133* K+-4.3 [**2178-12-14**] 12:18PM UREA N-9 CREAT-0.7 CHLORIDE-111* TOTAL CO2-22 [**2178-12-14**] 12:18PM WBC-9.1 RBC-3.51*# HGB-10.8*# HCT-30.4*# MCV-87 MCH-30.7 MCHC-35.5* RDW-12.8 [**2178-12-14**] 12:18PM PLT COUNT-193 [**2178-12-14**] 12:18PM PT-14.8* PTT-62.9* INR(PT)-1.3* ECG Study Date of [**2178-12-14**] 12:43:20 PM Normal sinus rhythm. Possible anteroseptal myocardial infarction of unknown age but with ST segment elevation in leads V1-V3. Non-specific ST segment depression in leads II, III, aVF and V5-V6. Compared to the previous tracing of [**2178-12-8**] the changes are similar. Clinical correlation is suggested. Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 150 92 404/425 78 -20 85 [**2178-12-19**] 07:00AM BLOOD WBC-8.4 RBC-3.29* Hgb-10.0* Hct-29.0* MCV-88 MCH-30.4 MCHC-34.5 RDW-14.1 Plt Ct-290# [**2178-12-19**] 07:00AM BLOOD Plt Ct-290# [**2178-12-19**] 07:00AM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-138 K-5.0 Cl-105 HCO3-27 AnGap-11 Brief Hospital Course: Mrs. [**Known lastname 6955**] was a same day admit, and on [**12-14**] she was brought to the operating room where he underwent an aortic valve replacement. Please see operative note for surgical details. In summary she had an Aortic valve replacement with a 21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue valve. Her bypass time was 72 minutes with a crossclamp time of 50 minutes. She tolerated the surgery well and following surgery he was transferred to the CVICU for invasive monitoring in stable condition. She remained hemodynamically stable in the immedicate post-op period and was extubated on the day of surgery. On post-op day one she was started on beta blockers and diuretics and gently diuresed towards her pre-op weight. Later on this day she was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. In the evening of post-op day 2 she went into rapid atrial fibrillation. She was given an Amiodarone bolus, IV Lopressor and started on PO Amiodarone. She remained in atrial fibrillation requiring increasing doses of Metoprolol to control her rate. She was started on Coumadin on POD 3 for more than 24 hours of continuous atrial fibrillation. She gradually improved while working with physical therapy for strength and mobility. On post-op day five she was discharged to home with the appropriate follow-up appointments. Medications on Admission: Synthroid, Morvasc, Aspirin, Alprazolam, Estradiol/Progeterone Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for chest pain. Disp:*30 Tablet(s)* Refills:*0* 5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): take 400 mg (2 tablets) for 7 days, then taper down to 200 mg (1 tablet) daily. Disp:*60 Tablet(s)* Refills:*0* 7. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day: take 40 mg (2 tablets) for 5 days and then taper down to 20 mg (1 tablet) for 5 days. Disp:*30 Tablet(s)* Refills:*0* 9. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: do not take any coumadin [**12-19**] and then resume on [**12-20**] with 1 mg (1 tablet). Adjust further doses per the office of Dr. [**Last Name (STitle) 8051**]. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement PMH: Hypertension, Hypothyroidism, s/p Left knee meniscus repair, s/p bilateral eyelid surgery Discharge Condition: Good Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimming no lotions, creams or powders to incisions report any drainage from, or redness of incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Wound check and post-op visit with: Dr. [**Last Name (STitle) **] at [**Hospital3 1280**] in [**2-22**] weeks. Call ([**Telephone/Fax (1) 26917**] for appt Dr. [**Last Name (STitle) 8051**] in [**2-22**] weeks. Please call to schedule appt. INR checked on [**12-21**] with results sent to the office of Dr. [**Last Name (STitle) 8051**] ([**Telephone/Fax (1) 80078**]. Completed by:[**2178-12-19**]

Admission Date: [**2180-6-29**] Discharge Date: [**2180-8-21**] Date of Birth: [**2180-6-29**] Sex: M Service: NB HISTORY: Baby [**Name (NI) **] [**Known lastname 52546**] is the 995 gram product of a 28 [**12-31**] week gestation born to a 41 year-old primigravida. Fetal screens: A negative, antibody negative, RPR nonreactive, Rubella immune, hepatitis surface antigen negative, GBS positive. Mother complicated by preterm labor since [**00**] weeks treated with magnesium sulfate, beta complete on day of delivery, presented with unstoppable rapid cervical dilatation and therefore the decision made to deliver by cesarean section. Abdominal ruptured membranes at delivery. This twin emerged with spontaneous cry, heart rate approximately 80, rose to greater than 100 with positive pressure ventilation. Apgars were 6 and 7. PHYSICAL EXAMINATION: Weight 995 grams, length 36.5 cm, head circumference 25 cm. Overall appearance: Nondysmorphic and consistent with known gestational age. Anterior fontanelle soft, open and flat. Palate intact. Deep substernal retractions with decreased breath sounds bilaterally. Regular rate and rhythm without murmur, 2+ femoral pulses. Abdomen benign without hepatosplenomegaly, no masses. Three vessel cord. Normal male genitalia for gestational age with testes palpable in canal bilaterally. Back normal and extremities with stable hips. Skin bruised over left parietal region. Appropriate tone and overall reactivity. HISTORY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname 1692**] was intubated on admission to the Newborn Intensive Care Unit for management of respiratory distress syndrome. He received a total of 2 doses of surfactant and weaned to CPAP by day of life #2. His maximum respiratory support was 20/5, a rate of 25. He remained on CPAP for a total of [**3-24**]/2 weeks. On [**7-25**] he was transitioned to nasal cannula on O2 and continues on nasal cannula O2 25 to 50 cc on 100%. He was treated with caffeine citrate which was discontinued on [**2180-8-14**]. He has had no further issues with apnea of bradycardia of prematurity. CARDIOVASCULAR: [**Known lastname 1692**] has had a stable cardiovascular course, is currently on examination with an intermittent audible heart murmur consistent with PPS. Otherwise has been cardiovascularly stable. FLUID AND ELECTROLYTES: Birth weight was 995 grams. Discharge weight is 2100 gms. Initially started on 100 cc per kilo per day of D5W PN and enteral feedings were initiated on day of life #4. Infant advanced to full enteral feedings by day of life #11. Maximum enteral intake was 150 cc per kilo per day of breast milk or PE 40 calorie with ProMod. On [**7-23**] infant presented with grossly bloody stool, was made n.p.o. at that time. X-rays were nonspecific. Infant resolved bloody stool within 12 hours and clinical condition was consistent with milk allergy, was restarted on Nutramigen, got to full feeding and then had bilious aspirate and more concerning x- rays. At that time decision was made to treat for medical NEC. He remained n.p.o. for a total of 14 days, restarted enteral feedings on [**2180-8-10**]. He is currently on 140 cc per kilo per day of breast milk 26 calories, tolerating feeds but has frequent desaturation episodes during the feeds. GASTROINTESTINAL: Peak bilirubin was on day of life #5 of 4.8/0.3, was treated with phototherapy and this issue has since resolved. HEMATOLOGY: Hematocrit on admission was 44.7. Lasat Hct 27.5 ([**8-12**]) with retic count 5.4%. He has received 1 packed red blood cell transfusion on [**2180-7-18**]. His blood type is A positive. Direct Coombs negative. INFECTIOUS DISEASE: CBC and blood culture were obtained on admission. CBC was benign at 48 hours at which time antibiotics were discontinued. Infant was restarted on ampicillin, gentamicin and clindamycin with onset of grossly bloody stools. Blood culture grew back staph coag negative. Repeat blood culture on [**7-24**] also staph coag negative. Infant was treated with Vancomycin and gentamicin for a total of 18 days. He has been off all antibiotics since [**2180-8-8**]. NEUROLOGY: Head ultrasound on [**7-6**] and [**8-1**] were within normal limits. His examinations have been appropriate for gestational age. AUDIOLOGY: Hearing screen should be done prior to discharge. OPHTHALMOLOGY: Was most recently examined on [**8-7**] demonstrating immature retina to zone 2. Recommended follow up in 2 weeks. PSYCHOSOCIAL: This is a single mother with an in [**Last Name (un) 5153**] fertilization conception. She has been invested and involved in the infant's care. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Is to [**Hospital3 **]. Name of primary pediatrician is [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 63423**], M.D., telephone #[**Telephone/Fax (1) 63424**]. FEEDS AT DISCHARGE: Continue 140 cc per kilo per day of breast milk 26 calorie, adjusting calories as needed to support weight gain. MEDICATIONS: Continue Ferusal supplementation. CAR SEAT POSITION SCREENING: Should be done prior to discharge. STATE NEWBORN SCREENS: Have been sent and have been within normal limits. IMMUNIZATIONS: Infant has not received any immunizations as of yet but is due for immunization. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria: 1) born at less than 32 weeks, 2) born between 32 and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings, or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life against immunization is recommended for household contacts and out of home care-givers. DISCHARGE DIAGNOSES: Premature twin #1 born at 28-1/7 weeks. Respiratory distress syndrome treated with surfactant. Rule out sepsis with antibiotics. Necrotizing enterocolitis. Medical NEC. Hyperbilirubinemia. Apnea and bradycardia of prematurity. Anemia of prematurity. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2180-8-20**] 20:05:05 T: [**2180-8-20**] 20:53:18 Job#: [**Job Number 63425**]

Admission Date: [**2139-10-13**] Discharge Date: [**2139-10-18**] Date of Birth: [**2071-6-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: [**2139-10-13**] Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending; vein grafts to the obtuse marginal, ramus intermedius, and right coronary artery. History of Present Illness: Mr. [**Known lastname 66162**] is an 68 year old male with hypertension and elevated cholesterol. The night before his annual physical, he experienced an episode of palpitations. He was subsequently referred for stress test which was positive for ischemia. Cardiac catheterization in [**2139-8-22**] revealed severe three vessel disease, 1+ AI, 1+ MR and an LVEF of 45%. Angiography showed a 40% left main lesion, 60% mid LAD stenosis, total occlusion of the circumflex and 99% lesion in the right coronary artery. Based on the above results, he was referred for surgical revascularization. Past Medical History: Coronary artery disease; Hypertension; Hypercholesterolemia; Varicose Veins - s/p stripping; s/p Hernia repair; s/p Tonsillectomy Social History: Quit tobacco over 40 years ago. Occasional ETOH. He lives alone. Family History: Father died of "heart condition" at age 64 Physical Exam: Vitals: BP 150/80, HR 80, RR 14, 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, no varicosities in right leg Pulses: 2+ distally Neuro: nonfocal Brief Hospital Course: Mr. [**Known lastname 66162**] was admitted and underwent four vessel coronary artery bypass grafting. The operation was uneventful and he was transferred to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. He maintained stable hemodynamics as he weaned from inotropic support. On postoperative day one, he transferred to the SDU. He went on to experience paroxsymal atrial fibrillation which was treated with Amiodarone. He successfully converted back to a normal sinus rhythm. No further episodes of atrial fibrllation were noted, last episode coming on postoperative day 4. On post op day 4 the patient was discharged home with services in the care of his son. [**Name (NI) **] will be discharged on oral amiodarone and must have follow up with a local PCP in order to review his medications and labs. The patient is also being discharged on 10 days of oral keflex because of a left upper extremity superficial cellulitis on the medial aspect of the left arm. The patient has been informed along with the visiting nurse that this area needs to be closely watched. If he manifest and systemic symptoms or the area is worse, he must return the hospital for intravenous antibiotics. Medications on Admission: Lipitor 40 [**Last Name (LF) **], [**First Name3 (LF) **] 81 qd, Lisinopril 20 qd, Imdur 30 qd, Toprol XL 25 qd, MVI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**First Name3 (LF) **]:*60 Tablet(s)* Refills:*2* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). [**First Name3 (LF) **]:*20 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**First Name3 (LF) **]:*60 Capsule(s)* Refills:*2* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**First Name3 (LF) **]:*60 Tablet(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [**First Name3 (LF) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. [**First Name3 (LF) **]:*30 Tablet(s)* Refills:*0* 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**First Name3 (LF) **]:*30 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 1 week supply, please follow up with PCP . [**Name Initial (NameIs) **]:*20 Tablet(s)* Refills:*0* 9. Keflex 500 mg Tablet Sig: One (1) Tablet PO four times a day. [**Name Initial (NameIs) **]:*40 Tablet(s)* Refills:*0* 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). [**Name Initial (NameIs) **]:*44 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNS of New Port Bristal County Discharge Diagnosis: Coronary artery disease - s/p CABG; Postop Atrial Fibrillation; Hypertension; Hypercholesterolemia; Varicose Veins - s/p stripping; s/p Hernia repair; s/p Tonsillectomy 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. [**Last Name (STitle) 1290**] in [**2-24**] weeks. Local PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66163**] in [**12-25**] weeks. [**Telephone/Fax (1) 66164**] Local cardiologist Dr. [**First Name (STitle) **] in [**12-25**] weeks. [**Telephone/Fax (1) 170**]

Admission Date: [**2195-8-19**] Discharge Date: [**2195-8-24**] Date of Birth: [**2156-6-30**] Sex: F Service: MEDICINE Allergies: Reglan Attending:[**First Name3 (LF) 2817**] Chief Complaint: Metatstatic osteogenic sarcoma; SVC syndrome Major Surgical or Invasive Procedure: None History of Present Illness: ONCOLOGIC HISTORY. T cell lymphoblastic leukemia/lymphoma over 20 years ago, treated and cured with radiation and chemotherapy. Radiation included mediastinum and chest. Diagnosed with primary MFH (malignant fibrous histocytoma) of the bone (left tibia) in [**2193-6-24**]. Received neoadjuvant chemotherapy with cisplatin/adriamycin (AP), and had definitive resection in [**2193-11-24**]. Operative specimen showed suboptimal necrosis (only 5% necrosis) and her postoperative chemotherapy was switched to AP alternating with IE (ifosfamide/etoposide). Finished chemotherapy in [**2194-2-22**]. She was treated by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**]. Her chemotherapy course was complicated by profound myelosuppression and mucositis/esophagitis. HPI. Presents with worsening dyspnea (particularly on exertion), fatigue, and upper body/facial edema over the last several days. The patient was followed in Buffalo, NY, since she finished chemotherapy. She apparently was noted to have small lung nodule or nodules in early [**2194**] by imaging. This was followed by observation and in [**2195-5-24**] one of the nodules became very large (over 10 cm) and began to cause symptoms. She had a telephone discussion with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and she decided to pursue options including possible surgery in Buffalo [**Location (un) 63519**] Institute. However, the symptoms got quickly worse, and one of the lesions, apparently mediastinal in location, began to cause SVC type symptoms. She was treated with palliative XRT to the mediastinal mass to 18 [**Doctor Last Name **], finished on or around [**8-3**]. She was also started on gemcitabine/docetaxel as 3rd line sarcoma therapy. Due to extensive prior chemotherapy for her hematologic malignancy and osteosarcoma and previous serious myelosuppression with AP and IE, she was started on a 50% dose of gemcitabine and did NOT receive docetaxel for her 1st cycle. She receive day 1 of her 2nd cycle last Saturday ([**8-15**]) and was scheduled to receive day 8 (gemcitabine and docetaxel) next Saturday in Buffalo. She has received neulasta even with gemcitabine out of fear for myelosuppression. She decided to transfer her care back to [**Hospital1 18**]. She feels that her shortness of breath, particularly when she tries to ambulate is worse, and that her face and left arm have begun to swell up over the last 2 days. She is reasonably comfortable at rest, but uses oxygen 6-8 hours every day for the last few days. Seen in clinic today and was admitted to the hospital for aggressive palliative treatment of her progressive symptoms. Upon arrival to the floor, the patient states that she also has some increased chest pain in the midsternal area over the past 2 days. Not pleuritic in nature. Does not describe any acute worsening of her respiratory status, though is tachypneic at rest. She additionally describes worsening fatigue, with more difficulty with movement. Past Medical History: --T cell lymphoblastic lymphoma 20 years ago treated with chemo and mediastinal irradiation --Osteosarcoma of the proximal left tibia s/p 2 cycles of Adriamycin and Cisplatin in [**9-28**] and [**10-28**], complicated by febrile neutropenia, espophagitis, s/p radical resection on [**2193-12-23**] --Cecal volvulus s/p right partial colectomy --Thyroidectomy [**12-26**] thyroid nodules ([**12-26**] mediastinal radiation) --ARF, pre-renal, resolved --UE DVT [**12-26**] PICC Social History: Works as rad tech. Now not working. Lives in [**Hospital1 **] with a friend. [**Name (NI) **] tobacco, alcohol or drugs. Married, but her husband is living in [**Name (NI) 531**] (her state of residence.) Mother is local, and very involved in her care. Family History: Significant for HTN. No coagulopathy. Hx of cancer in two maternal aunts of unknown type. No sarcomas. Physical Exam: Vitals BP107/68 Pulse 124 Temp afebrile RR 23 O2 no pulsus sats 99% on 2L. Facial edema. No jaundice, no skin rash. Tongue coated with some green/whie exudate. No lymphadenopathy. Lungs, clear,with reduced breath sounds on right Heart regular, but tachycardic. no m/r/g Abdomen, soft non tender. Extremeties: Left upper: edema from the elbow down. No leg edema, well healed surgical scar in left tibia. Pertinent Results: ON ADMISSION: [**2195-8-19**] 06:35PM WBC-5.7 RBC-3.18* HGB-9.1* HCT-27.9* MCV-88# MCH-28.5 MCHC-32.6 RDW-19.7* [**2195-8-19**] 06:35PM PLT COUNT-165 [**2195-8-19**] 10:30PM BLOOD PT-14.1* PTT-22.1 INR(PT)-1.3* [**2195-8-19**] 06:35PM BLOOD Gran Ct-5070 [**2195-8-19**] 10:30PM BLOOD Glucose-111* UreaN-12 Creat-0.9 Na-132* K-4.9 Cl-97 HCO3-22 AnGap-18 [**2195-8-19**] 10:30PM BLOOD ALT-74* AST-69* LD(LDH)-521* CK(CPK)-47 AlkPhos-126* TotBili-0.9 [**2195-8-19**] 10:30PM BLOOD Albumin-2.5* Calcium-7.4* Phos-2.6* Mg-2.1 . STUDIES: CT CHEST with CONTRAST IMPRESSION [**8-20**]: 1) 16 x 15 x 10cm, new prevascular mediastinal mass occluding a long segment of the superior vena cava, severely compromising the right bronchial tree and right lung pulmonary circulation invading the pericardium, accompanied by new and/or enlarging right lung nodules and bilateral pleural effusions. 2) Well-developed collateral venous circulation reflecting superior vena cava syndrome. 3) Segmental pulmonary embolus, left lower lobe. . ECHO [**8-20**]:The left and right atria appear compressed by an extrinsic mass. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF>75%). The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. Mitral regurgitation is present but cannot be quantified. There is a trivial/physiologic pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2193-12-20**], the atria now appear compressed by an extrinsic mass. . INTERVENTIONAL RADIOLOGY VISUALIZATION OF VEINS IMPRESSION [**8-21**]: 1) Recent thrombosis of the left and right subclavian and brachiocephalic veins, due to severe encasement of the SVC. 2)A 12 mm x 8 cm stent was placed in the SVC and extended with a 10 mm x 6 cm stent into the left brachiocephalic vein with good angiographic results. . [**8-20**] Bilateral LENIs: negative . CXR [**8-23**]: Markedly increased bilateral basal consolidations are seen accompanied by bilateral increase in pleural effusion. This consolidations might be either due to bibasilar atelectasis or massive aspiration. Mild pulmonary edema is seen. There is no change in the position of the right central venous line. Unchanged position of the central venous stent. . HOSPITAL LABS: [**2195-8-23**] 09:45AM BLOOD WBC-10.4 RBC-3.60* Hgb-10.5* Hct-31.3* MCV-87 MCH-29.0 MCHC-33.4 RDW-19.5* Plt Ct-82* [**2195-8-20**] 12:15PM BLOOD Neuts-89.3* Bands-0 Lymphs-7.7* Monos-1.2* Eos-1.7 Baso-0.1 [**2195-8-23**] 09:45AM BLOOD PT-13.3* PTT-21.8* INR(PT)-1.2* [**2195-8-23**] 09:45AM BLOOD Glucose-152* UreaN-12 Creat-0.7 Na-134 K-4.5 Cl-102 HCO3-21* AnGap-16 [**2195-8-21**] 06:14AM BLOOD ALT-74* AST-37 LD(LDH)-276* AlkPhos-125* TotBili-1.2 [**2195-8-23**] 09:45AM BLOOD Calcium-7.3* Phos-3.0 Mg-2.1 [**2195-8-22**] 12:33PM BLOOD Type-ART Temp-38.0 pO2-127* pCO2-25* pH-7.42 calTCO2-17* Base XS--5 Intubat-NOT INTUBA [**2195-8-21**] 07:21PM BLOOD Glucose-118* Lactate-1.5 Na-131* K-3.7 Cl-105 Brief Hospital Course: 39 year old female with NHL at age 19 treated with chemo/XRT later developed tibia osteosarcoma with metastasis to the lung/mediastinum admitted to OMED for progressive shortness of breath, fatigue, found to have SVC syndrome, subsegmental pulmonary embolism and right and left atrial compression. . 1) Mediastinal Mass/SVC syndrome: Patient has developed a large medistinal mass compressing right upper lobe bronchus, shifting mediastinum to left and compressing right and left atria seen on CT scan. ECHO done confirming left and right atrial compression, but only physiologic effusion. Thoracic surgery consulted for surgical consideration, however, given extensive vascular invasion of mass, felt to not be a surgical candidate. Not a candidate for XRT per Rad-Onc given already has received maximal doses. . She was admitted to Oncology service on [**8-19**] as patient was considering chemotherapy options, although disease has progressed despite chemo/XRT. She is currently on 3rd line therapy, so prognosis is poor. Patient aware of prognisos. After CT scan was ordered showing SVC syndrome, right upper lobe lung compression, subsegmental PE, possible pericardial invasion and compression of right and left atria on Echo, she was transferred to the [**Hospital Unit Name 153**] on [**8-20**] for closer monitoring. . She was monitored overnight in the [**Hospital Unit Name 153**] without any overnight events. She remained tachycardic 120-130's (although has been for 1 month) and bp stayed 95-110 systolic (also stable for a month). Pulmonary performed thoracentesis of L pleural effusion. Sent for cell count/diff, LDH, total protein, cultures and cytology. Given the plan for IR SVC stent and possible Interventional Pulmonary stent, she was transferred to MICU West for plan to monitor for 24-48 hours. Oncology was notified prior to transfer. . On the [**Hospital Ward Name 517**] MICU [**Location (un) 2452**]. [**6-20**] Bronchoscopy left airways patent. Right Main Stem narrowed secondary to external compression. Bronchus intermedius collapsed. Balloon dilatation of right main stem, and bronchus intermedius. Covered stent placed in the bronchus intermedius, and Y stent placed (trachea-LMS-RMS). Returned from Interventional Pulmonary intubated, sedated, hypotensive on neo. Changed to fentanyl/versed. Pt was seen by IR, stent was placed with femoral line and sheath in arm for access. Pt was given 4 liters of fluid and 1 unit PRBC for procedure. Fluid overloaded by report and sedated; therefore pt was not extubated overnight. Pt alert and transfered to [**Hospital Unit Name 153**] [**8-22**] for extubation. For [**8-22**] patient was extubated, with improved aeration of right lung. Over the day, night patient developed increased sputum production and increasing opacity in left lower lobe. . On [**2195-8-23**] started on Acapella therapy, maximum ventilation via shovel mask/O2 via NC; still with dyspnea and poor saturation. Patient requiested code status change to DNR/DNI. Started on morphine IV for comfort/decreased dyspnea ---> changed to morphine gtt on [**2195-8-24**]. Added scopolamine for secretion management [**8-24**] and ativan prn for agitation. . Patient's respiratory status continued to decline. One the afternoon of [**8-24**] the patient began to take agonal breaths and PEA was noted on the cardiac monitor. Physician exam revealed patient had died. Time of Death 1553 on [**2195-8-24**]. Family was by patient's bedside. . 2) Tachycardia - Likely secondary to atrial irritation/compression with intermittent hypoxia. Taking poor po intake, additionally hypovolemic. Patient heart rhythm alternated tachy-brady until PEA. . 3) Thrombocytopenia- Improved, still low. Consider heavy heparin products and HIT especially in light of rapid drop. No further lab draws as of [**8-24**] given comfort measures status. . 4) PE- subsegmental, diagnosed on Chest CT. Not likely causing her symptomatology. Anticoagulation contraindicated given bleeding risk and invasion into pericardium. No further intervention given comfort measures status. . 5) LLL opacity- concerning for pneumonia. Possible evolving infarct from PE or new thrombus. No further intervention/CXR given comfort measures status. . 6) Non anion gap acidosis- consistent with persistent hyperventilation. No diarrhea or ATN noted. Continue to monitor. No further lab draws given comfort measures status. . 7) Anemia- patient has myelosupression secondary to chemotherapy. No further lab draws given comfort measures status. . 8) Hypothyroid - No further lab draws given comfort measures status. . 9)FEN: No further lab draws given comfort measures status. . 10)Contact: [**Name (NI) 21206**] [**Name2 (NI) 52711**] [**Telephone/Fax (1) 63520**]. She is currently at the bedside. . 11)IV access: Port . 12)DNR/DNI: discussed with patient & family . 13)Dispo: To Morgue and then Funeral Home as family wishes Medications on Admission: levothyroxine colace/senna Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Osteosarcoma Cardiac Arrest Discharge Condition: Death Discharge Instructions: N/A Followup Instructions: N/A

Admission Date: [**2179-4-3**] Discharge Date: [**2179-4-14**] Date of Birth: [**2114-10-14**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Percocet Attending:[**First Name3 (LF) 5790**] Chief Complaint: Bronchotrachealmalcia Major Surgical or Invasive Procedure: [**2179-4-8**] - Flexible bronchoscopy and right thoracotomy with intrathoracic tracheoplasty with mesh, right mainstem and bronchus intermedius bronchoplasty with mesh, and left mainstem bronchoplasty with mesh. [**2179-4-6**] Flexible and rigid bronchoscopy with foreign body (stent) removal. History of Present Illness: Ms. [**Known lastname 174**] is a 64 year-old woman who has had progressive DOE, cough, and recurrent respiratory infections over the past 3 years. She notes that her oxygen saturation has worsened over the past 1 year and she has required supplemental O2. She has had [**5-15**] repiratory infections requiring antibiotics over the past few years. Her coughing episodes were quite bothersome and occurred about 3-6 times per day. She denies orthopnea or tussive syncope, though she does sleep on 2 pillows and uses CPAP at night. She does not report having to have been intubated for respiratory failure. She has been on and off of prednisone over the past 2 years, and she carries a diagnosis of hypersensitivity penumonitis, having recently undergone a VATS R lung biopsy. She was found to have severe, diffuse tracheobronchomalacia. She underwent tracheobronchial silicone Y-stent placement on [**2179-3-11**]. She notes that she has had some difficulty clearing phlegm and annoying cough over the past few days, though her initial freedom from coughing over the first several days post-stenting was remarkable. She quotes her overall improvement in dyspnea at 9 out of 10. She notes that she has even gone up to 5 hours at a stretch without supplemental O2. Past Medical History: OSA hypersensitivity penumonitis, s/p R VATS lung biopsy TBM open chole tonsillectomy appendectomy benign skin lesions removed from neck HTN TBI, residual memory loss Social History: Jehovah's witness non smoker, no EtOH smoke exposure as a child Family History: lung cancer Physical Exam: General: 64 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple, no lymphadenopathy Card: RRR, normal S1,S2 no murmur/gallop or rub Resp: breath sounds clear, bilaterally GI: bowel sounds positive, abodmen soft non-tender/non-distended Extr: warm no edema Incision: Right thoracotomy site clean/dry/intact Neuro: non-focal Pertinent Results: [**2179-4-11**] WBC-9.5 RBC-3.87* Hgb-10.7* Hct-33.2 Plt Ct-245 [**2179-4-2**] WBC-13.6* RBC-4.55 Hgb-12.3 Hct-37.7 Plt Ct-515* [**2179-4-13**] Glucose-76 UreaN-26* Creat-0.8 Na-141 K-4.1 Cl-100 HCO3-32 [**2179-4-2**] Glucose-106* UreaN-25* Creat-1.0 Na-144 K-4.2 Cl-105 HCO3-27 [**2179-4-8**] TISSUE LOWER RIGHT LOBE WEDGE. GRAM STAIN (Final [**2179-4-8**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2179-4-11**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2179-4-9**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2179-4-9**]): NO FUNGAL ELEMENTS SEEN. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Pathology # SPECIMEN SUBMITTED: FS right lower lobe wedge. Wedge biopsy of lung (right lower lobe): Patchy organizing pneumonitis with features of bronchiolitis obliterans-organizing pneumonia/cryptogenic organizing pneumonia (BOOP/COP). No malignancy identified. Gross: The specimen is received fresh labeled with the patient's name "[**Known firstname 1894**] [**Known lastname 174**]" The medical record number and "frozen section right lower lobe wedge." It measures 5.2 x 4.1 x 1.4 cm and the surface is inked black. The wedge is serially sectioned to reveal a small pale nodule measuring 0.3 x 0.3 x 0.3 cm located 1.4 cm from the stapled margin. A representative sections is frozen for frozen section diagnosis. Frozen section diagnosis by Dr. [**Last Name (STitle) **] is "right lower lobe wedge biopsy; focal organizing pneumonitis, final diagnosis pending permanent section." The frozen section remnant is submitted in A. The remainder of the wedge biopsy is submitted in B-F with remaining nodule in B. [**2180-4-12**] CHEST (PA & LAT) FINDINGS: In comparison with the study of [**3-12**], there is little interval change. Again, there are low lung volumes with elevation of the right hemidiaphragm and atelectatic changes at both bases. No evidence of acute pneumonia. Brief Hospital Course: The patient was admitted on [**2179-4-3**] after presenting to the ED with worsening dyspnea and thick sputum production. She was resumed on bronchodilators, NS nebulizers, Mucomyst, mucinex, CPAP. On [**2179-4-5**] she had pulmonary function test with a 6 min walk prior to removal of Y stent. On [**2179-4-8**] she underwent successful Flexible bronchoscopy and right thoracotomy with intrathoracic tracheoplasty with mesh, right mainstem and bronchus intermedius bronchoplasty with mesh, and left mainstem bronchoplasty with mesh. She was transferred to the SICU for close monitoring, right chest tube to suction. Post operative steroid taper initiated. Perioperative Ancef started. Epidural for pain control, Dilaudid PCA continued. The patient required two boluses for a total of 500 ml, for low blood pressure associated with the epidural. The epidural was split, and a PCA was initiated. On POD #1 she was started on a clear liquid diet, steroid taper, chest tube continued to suction, wound care consult for burn from hot pack. Wound was treated with dry gauze and kerlix wrap then Adaptic following blister rupture. On POD #2 the right chest-tube was removed and her diet was advanced to a full liquid and advanced as she tolerated. On POD #4 the epidural was converted to PO pain medication, the foley was removed and she voided without difficulty. She was seen by physical therapy who deemed her safe for home. She continued to improve, her oxygenation requirements improved with 97% RA saturation at rest and 93-95% with activity. She was discharged to home on POD #6 on RA with home oxygen 1L via nasal cannula as needed. She will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: prednisone verapamil lisinopril lexapro neurontin mirtazapine Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 7. Verapamil 80 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Gabapentin 800 mg Tablet Sig: Two (2) Tablet PO at bedtime. 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**4-11**] hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 10. Albuterol Sulfate 1.25 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Discharge Disposition: Home Discharge Diagnosis: Tracheobroncho malacia s/p Tracheoplasty Hypersensitive pneumonitis, HTN/HLD, OSA, Hepatitis, B12 deficiency MVC '[**70**] closed head injury residual short-term memory loss Discharge Condition: Good Discharge Instructions: Please call the office of Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 1504**] if you have a fever greater than 101.5, chills, shortness of breath, chest pain, nausea, vomiting, redness or swelling around your wound site, excessive or purulent drainage from your wound, or any other symptom that should concern you. -Complete Prednisone course -Home Oxygen 1L as needed Goal Saturations > 93% -Narcotics: take stool softners while taking narcotics Followup Instructions: Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2179-4-22**] 3:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]. Report to the [**Location (un) **] Radiology Department for a Chest X-Ray 45 minutes before your appointment Completed by:[**2179-4-14**]

Admission Date: [**2200-7-13**] Discharge Date: [**2200-8-5**] Date of Birth: [**2146-8-12**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: diaphoresis and palpitations Major Surgical or Invasive Procedure: [**2200-7-18**] Coronary bypass grafting x4: Left internal mammary artery to left anterior descending artery; and reverse saphenous vein graft to the distal right coronary artery, obtuse marginal artery and first diagonal artery. History of Present Illness: 53 year old lady, with history significant for insulin dependent diabetes for 30 yrs, and multiple medicle issues who presented on [**2200-7-7**] to [**Hospital3 3583**] with substernal chest pain and shortness of breath, with onset at rest. On arrival to [**Hospital1 3325**] the Troponin was slightly elevated to 0.3 and the EKG had ST-T abnormalities (ST depressions in V4-V6, T wave inversions in aVL). A nuclear stress test was positive. She underwent cardiac catheterization showing multivessel disease and revascularization was recommended, for which the patient was trasnferred here on family request. Of note the [**Hospital3 3583**] course also complicated by hypertensive urgency, acute on chronic renal failure and cellulitis at the site of a right antecubital intravenous, for which she is being treated with doxycycline. Past Medical History: noninsulin dependent diabetes mellitus Dyslipidemia Hypertension obesity Chronic renal insufficiency (cr 1.9 in [**Month (only) 547**]) cerebrovascular accident 10 years ago hypothyroidism anxiety Charcot foot s/p hysterectomy s/p tubal ligation s/p tonsillectomy Social History: Lives with husband and son homemaker ETOH 1-2 times a year Tobacco quit 30 yrs ago - 3.5 pack year history Family History: Both parents had coronary artery disease, her mother had DM. Both died in their 30s. Physical Exam: Admission physical exam: 67" 250 # VS: T: 98.1 [Tm 98.5], BP: 183/94 R, 183/82 L [160-183/81-94] HR: 58, RR: 18, SpO2: 91% RA GEN: A+Ox3, NAD, appropriate and pleasant HEENT: NCAT. EOMI. MMM. No LAD. No JVD. Neck supple. No carotid bruits. CV: RRR, soft systolic murmur at LUSB without radiation to apex or carotids. Normal S1/S2. No S3 or S4. LUNG: CTAB, minimal crackles at left lung base ABD: Obese, soft, NT/ND. No fluid wave. EXT: WWP, right antecubital site of previous PIV with 1.5-cm diameter erythematous intduration with no bleeding or pus drainage, left leg with trace edema, left ankle/foot deformity NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. sensation intact to LT. 1+ patellar and brachioradialis reflexes. PULSES: Right: 2+ DP , Left: 2+ DP Pertinent Results: [**2200-7-14**] CXR (portable AP): FINDINGS: No previous images. Cardiac silhouette is mildly enlarged but there is no vascular congestion, pleural effusion, or acute focal pneumonia. [**2200-7-14**] Carotid Ultrasound: 1. 60-69% right internal carotid artery stenosis and less than 40% stenosis on the left internal carotid artery. 2. Atherosclerotic plaques in the internal carotid arteries bilaterally. Echo 1. Left atrium - No spontaneous echo contrast is seen in the body of the left atrium. Mild spontaneous echo contrast is present in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricle - There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). 3. Right ventricle - Right ventricular chamber size and free wall motion are normal. 4. Aorta - There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. Aortic valve - The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. Mitral valve - The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. Pericardium - There is a very small pericardial effusion. 8. Pleural effusion - A left pleural effusion is seen. POST-BYPASS: On phenylephrine infusion, a pacing. Improved biventricular systolic function. LVEF is now 55%. MR is trace. Aortic contour is normal post decannulation. CXR [**8-4**] FINDINGS: In comparison with the study of [**8-1**], allowing for obliquity of the patient, there is probably little overall change. Enlargement of the cardiac silhouette persists with extensive sternal metallic devices after surgery. No definite vascular congestion or pleural effusion. [**2200-8-4**] 05:35AM BLOOD WBC-10.4 RBC-3.10* Hgb-9.5* Hct-27.5* MCV-89 MCH-30.7 MCHC-34.5 RDW-13.1 Plt Ct-401 [**2200-7-14**] 02:00AM BLOOD WBC-8.7 RBC-3.89* Hgb-11.6* Hct-34.3* MCV-88 MCH-29.9 MCHC-33.9 RDW-13.7 Plt Ct-329 [**2200-7-21**] 02:22AM BLOOD Neuts-91.1* Lymphs-5.6* Monos-2.9 Eos-0.1 Baso-0.3 [**2200-8-4**] 05:35AM BLOOD Plt Ct-401 [**2200-7-22**] 02:18AM BLOOD PT-11.4 PTT-23.1 INR(PT)-0.9 [**2200-7-14**] 02:00AM BLOOD Plt Ct-329 [**2200-7-14**] 02:00AM BLOOD PT-12.1 PTT-21.6* INR(PT)-1.0 [**2200-7-18**] 12:51PM BLOOD Fibrino-277 [**2200-8-4**] 05:35AM BLOOD Glucose-200* UreaN-32* Creat-2.8* Na-132* K-3.9 Cl-96 HCO3-28 AnGap-12 [**2200-8-3**] 09:00AM BLOOD UreaN-35* Creat-3.0* Na-136 K-4.0 Cl-98 [**2200-7-14**] 02:00AM BLOOD Glucose-127* UreaN-45* Creat-2.0* Na-137 K-4.5 Cl-103 HCO3-29 AnGap-10 [**2200-7-15**] 07:40AM BLOOD Glucose-80 UreaN-41* Creat-1.7* Na-142 K-3.9 Cl-106 HCO3-31 AnGap-9 [**2200-8-2**] 12:49AM BLOOD UreaN-40* Creat-3.5* Na-138 K-4.8 Cl-98 [**2200-7-31**] 05:20AM BLOOD ALT-18 AST-17 AlkPhos-78 Amylase-15 TotBili-0.6 [**2200-7-31**] 05:20AM BLOOD Lipase-9 [**2200-7-21**] 02:22AM BLOOD Lipase-6 [**2200-7-14**] 02:00AM BLOOD CK-MB-3 cTropnT-<0.01 [**2200-8-4**] 05:35AM BLOOD Mg-2.2 [**2200-7-14**] 02:00AM BLOOD %HbA1c-11.9* eAG-295* [**2200-7-31**] 05:20AM BLOOD Ammonia-13 [**2200-7-25**] 05:07AM BLOOD TSH-1.4 [**2200-7-25**] 05:07AM BLOOD Free T4-1.6 [**2200-7-16**] 04:10PM BLOOD PTH-67* [**2200-7-26**] 01:36AM BLOOD Cortsol-11.9 [**2200-7-20**] 10:02AM BLOOD Vanco-39.0* [**2200-7-25**] 05:07AM BLOOD Metanephrines (Plasma)-Test Name [**2200-7-16**] 04:10PM BLOOD VITAMIN D [**12-31**] DIHYDROXY-Test [**7-28**] renal u/s The right and left kidneys measure 10.8 and 10.4 cm respectively. Both kidneys are normal in appearance, without hydronephrosis, stones or renal masses. Doppler analysis of the main and segmental renal arteries were performed in both kidneys. There is normal symmetric arterial waveforms in both kidneys, with resistive indices ranging from 0.72 x 0.87 on the right and 0.70 to 0.81 on the left. Normal flow is seen in both renal veins. IMPRESSION: Limited study demonstrating symmetric renal arterial waveforms in both kidneys, without evidence for renal artery stenosis. Brief Hospital Course: She was transferred in for surgical evaluation, of note the LV gram indicated EF 35% with mild peripheral edema and was treated with ACE inhibitor and betablocker preop op, repeat echocardiogram preoperatively revealed EF 60%. Additionally she was taken off aggrenox for wash out prior surgery. Her renal function was monitored with creatinine 2 on admission that was her baseline. Additionally she had been treated for right arm cellulitis at outside hospital and was on doxycycline at the time of transfer, and was resolved prior to surgery. In relation to neuro it was noted that she had been progressingly having issues with short term memory and was drastically worse since admission at outside hospital but there was no focal deficits. There was a question of NSTEMI but based on information the troponin 0.03 with elevated creatinine and CK 61, this is not definitive for NSTEMI and enzymes were normal on transfer. Also she was significantly hypertensive and antihypertensives were adjusted for management. On [**2200-7-18**] she was brought to the operating room for coronary artery bypass graft surgery, see operative report for further details. She was transferred to the CVICU in stable condition on propofol drip. The next day she was extubated but remained somulant with right sided weakness. On post operative day two she had CT scan and neurology was consulted. The CT scan revealed a hypodensity in the left occipital lobe that was considered chronic but there was no previous scan to compare to. She did not undergo MRI due to inability to lay still and risk of aspiration with sedation. Due to her somnulence a dobhoff was placed and she was started on tube feeds until she was cleared by speech and swallow. Additonally she was placed on lasix drip for diuresis with good response, and then transitioned to bolus dosing for continued diuresis. She continued to slowly improve and was transferred to the floor on post operative day five. She progressively became more hypertensive and was transferred back to the intensive care unit for intravenous medication for hypertension. Nephrology was consulted and further testing ruled out renal artery stenosis and pheochromocytoma. Her medications were changed and titrated for blood pressure management. She was transferred back to the floor on post operative day eleven for the remainder of her stay. She continued with slow responses and difficulty remembering, and MRI was not able to be obtained due to her inability to lay still. Physical therapy and occupational therapy worked with her and she is making slow progress. She was started on flomax for urinary retention. Her blood pressure medications were again adjusted with acute kidney injury with creatinine peak to 3.5 which has trended down off lasix and lisinopril. Of note this is the reason she is not discharged on ace inhibitor and diuretic, with plan for follow up labs at rehab. She was cleared for discharge on post operative day eighteen to acute rehab at [**Location (un) **] rehab for continued therapy. Medications on Admission: HOME MEDICATIONS: Unknown by pt and husband; confirmed with pharmacy ([**Last Name (un) **] supermarket in [**Location (un) 13360**] MA. [**Telephone/Fax (1) 89639**]) Aggrenox 1 tab PO BID Celexa 60 mg PO Q day trazodone 150 mg HS Ditropan XL 10 mg PO Q am HCTZ 25 mg PO daily Humalog with sliding scale per mealtime fingersticks Lantus 40 units SQ QHS Lopressor 50 mg PO Q 12 Lisinopril 5 mg PO Q day Zocor 80 mg PO QHS Synthroid 350 mcg daily . TRANSFER MEDICATIONS: Aggrenox 1 tab PO BID Clonidine 0.1 mg PO BID Celexa 60 mg PO Q day trazodone 150 mg HS Ditropan XL 10 mg PO Q am heparin 5000 units SQ TID Imdur 60 mg PO BID Lantus 30 units SQ QHS Lopressor 50 mg PO Q 12 Lisinopril 5 mg PO Q day Zocor 80 mg PO QHS Procardia XL 60 mg Q12 Synthroid 350 mcg daily (confirmed by OSH) doxycycline 100 mg [**Hospital1 **] colace 100 mg [**Hospital1 **] nitrostat 0.4 mg SL Q 5 min PRN senekot 2 tabs PO Q day PRN Tylenol 50 mg PO Q3 PRN Zantac 150 mg PO BID PRN Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Coronary Artery Disease s/p coronary artery bypass graft x4 Acute systolic heart failure Acute kidney injury Diabetic nephropathy Hypertension Hyperlipidemia Diabetes Mellitus type 2 Obesity Cerebral Vascular Accident Carotid stenosis Hypothyroidism Diabetic neuropathy Anxiety Charcot Foot Depression Insomnia Urinary Incontinence Discharge Condition: Alert, oriented to person reorients easliy to place and time Needs to continue with PT/OT currently being lifted in and out of bed by nursing staff Incisional pain managed with tylenol as needed Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon:Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2200-8-21**] at 1:15pm [**Hospital Ward Name **] [**Hospital Unit Name **] Cardiologist:Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**] on [**2200-8-8**] at 2:00 pm Wound check scheduled for [**8-12**] at 10:30Am at the [**Last Name (un) 2577**] building, [**Hospital Unit Name **].#[**Telephone/Fax (1) 170**] Please call to schedule appointments with: Primary Care Dr. [**First Name (STitle) **] [**Last Name (NamePattern4) 89640**] ([**Telephone/Fax (1) 17465**]in [**3-11**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2200-8-5**]

Admission Date: [**2143-2-13**] Discharge Date: [**2143-2-26**] Date of Birth: [**2060-2-12**] Sex: F Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 783**] Chief Complaint: Intramural [**First Name3 (LF) 8813**] hematoma. Major Surgical or Invasive Procedure: None. History of Present Illness: 83-year-old female was transferred from [**Hospital1 **] with a diagnosis of intramural [**Hospital1 8813**] hematoma, as seen on CT scan performed for initial complaints of abdominal pain. Yesterday morning she noted that the room was spinning. She had associated vomiting. Had been feeling unwell and unsteady fot a couple of days prior to this. Has had similar episodes in the past and diagnosed with Meniere's disease. Later that day, she complained of epigastric pain radiating to the back at 10/10 severity, no chest pain, no diaphoresis and no shortness of breath. On arrival at [**Hospital1 18**], she c/o dull aching abdominal pain. Otherwise asymptomatic. No fever. Past Medical History: Hyperlipidemia, Hypertension, GERD, Renal Insufficiency, Hypothyroidism, Degenerative Joint Disease, Anxiety/Depression, Meniere's disease PSH: Detached Left Retina, h/o colon perforation with colonoscopy, s/p R ear stapedectomy, Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to OM, SVG to RCA) [**2138**], Mitral Valve Replacement (27mm pericardial tissue valve), [**Year (4 digits) **] Valve Replacement (23mm pericaridial tissue valve), Ascending Aorta Replacement (28m gelweave graft), [**2139-6-10**] Mediastinal exploration with evacuation Social History: Artist. Denies tobacco. Rare wine. Family History: Mother with RHD. Physical Exam: Neuro/Psych: Oriented x3, Affect Normal. Neck: No right carotid bruit, No left carotid bruit. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear. Gastrointestinal: Non distended, No masses. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) LUE Radial: P.; Femorals palpable bilateral, Popliteals palp bilaterally; PT/DP dopplerable bilaterally. Pertinent Results: [**2143-2-13**] 02:25AM PT-21.2* PTT-32.8 INR(PT)-2.0* [**2143-2-13**] 02:25AM WBC-12.5* RBC-6.85*# HGB-15.7# HCT-47.5# MCV-69*# MCH-22.9*# MCHC-33.0 RDW-15.3 [**2143-2-13**] 02:25AM PLT COUNT-197 [**2143-2-13**] 02:25AM CK-MB-NotDone cTropnT-<0.01 [**2143-2-13**] 02:25AM ALT(SGPT)-19 AST(SGOT)-31 CK(CPK)-88 ALK PHOS-96 TOT BILI-1.2 [**2143-2-13**] 02:25AM LIPASE-22 [**2143-2-13**] 02:25AM GLUCOSE-139* UREA N-17 CREAT-0.9 SODIUM-135 POTASSIUM-3.1* CHLORIDE-97 TOTAL CO2-24 ANION GAP-17 [**2143-2-13**] 09:44AM CK-MB-3 cTropnT-<0.01 [**2143-2-13**] TTE showed: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. A bioprosthetic [**Month/Day/Year 8813**] valve prosthesis is present. The transaortic gradient is normal for this prosthesis. Trace [**Month/Day/Year 8813**] regurgitation is seen. The mitral valve leaflets are mildly thickened. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Patient is an 83 y/o female who initially presented with dizziness, found to have an [**Month/Day/Year 8813**] hematoma whose course has been complicated hyponatremia and a UTI. . #) [**Month/Day/Year **] Hematoma: Patient was initially admitted with abdominal pain and dizziness, found to have an [**Month/Day/Year 8813**] hematoma. She was initially admitted to the CVICU for strict blood pressure control, managed on a nitroglycerin gtt with a goal SBP of 90 to 120. A TTE was done that showed that her cardiac function was intact, when she was found to be hemodynamically stable, she was transferred to the CICU on [**2-15**]. Her coumadin was held due to concern for possible progression of her hematoma, and in case she needed future operative management. Her blood pressure regimen was adjusted to keep her goal BP under 120/80 if possible, at the time of discharge her blood pressure was mainly in the 120's systolic on her regimen of metoprolol 100mg TID, amlodipine 10mg daily and valsartan 160mg daily. A repeat CTA was done that showed her hematoma was stable, and vascular felt that she was safe for discharge with outpatient follow up with Dr. [**Last Name (STitle) **]. If her blood pressure is not at goal during her rehab stay, would avoid hydralazine and start low dose lisinopril to help with better BP management. She had also previously been on HCTZ 25mg daily, which would be another option as long as her sodium is stable. . #) Hyponatremia: on [**2-17**] patient was first noted to be hyponatremic with a serum Na of 128, she was initially treated with lasix and fluid restriction. Over the next few days her serum sodium did not improve and she was transferred to the medicine service for further management. Her serum sodium improved with normal saline over the next few days as she was hypovolemic, hyponatremic. . #) Urinary Tract Infection: on [**2-17**] patient complained of dysuria, a urinalysis was done that was suggestive of infection and she was initially started on cipro, a culture was done that grew pan-sensitive enterococcus and she was treated with a 4 day course of augmentin. . #) Altered Mental Status: on [**2-21**] patient was noted to be more somnolent, a CT of her head was done that showed a question of an old infarct, so neurology was consulted. After their evaluation, an MRI was recommended but due to prior stapedectomy she was unable to undergo the MRI, it was decided that since the lesion seen on the CT was old, she did not need an MRI. Her mental status improved over the next few days, and it was thought that her dehydration and hyponatremia were likely contributing her altered mental status. She will follow up with neurology as an outpatient. . #) Atrial Fibrillation: restarted home warfarin at 5mg daily, uptitrated metoprolol for blood pressure control . #) Hypothyroidism: continued home synthroid . #) GERD: continued home omeprazole Medications on Admission: asa 81mg celebrex 200mg claritin 10mg coumadin 5mg detrol 2mg qhs diovan/HCTZ 160/25 ergocalciferol 5000 qweek nasonex omeprazole 20mg synthroid 100mcg toprol 50mg simvastatin 10mg cymbalta 60mg Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation . 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: The Blare House Discharge Diagnosis: Intramural hematoma in aorta Hyponatremia Altered Mental Status Hypertension Discharge Condition: Vital Signs Stable Mental status: Alert/Oriented x 3, NAD Ambulating without assistance Discharge Instructions: Ms. [**Last Name (Titles) **], it was a pleasure taking care of you at [**Hospital1 18**]. You were admitted with a clot in the wall of your aorta. It is important that your blood pressure is controlled adequately. During your stay we also found that you sodium level was low, which was due to dehydration, your sodium level improved with IV fluids. You were also treated for an urinary tract infection during your staty. After you leave the hospital you will need close follow up with both your primary care provider and Dr. [**Last Name (STitle) **] the vascular surgeon who was helping care for you in the hospital. . We made some changes to your medications while in the hospital, 1. INCREASED Metoprolol to 100mg three times per day 2. ADDED Amlodipine 10mg daily 3. STOPPED HCTZ 25mg daily Please continue to take all other medications as previously prescribed Followup Instructions: Follow up with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**0-0-**] for blood pressure control, please call the office to make an appointment in the next week. You will also need to follow up with Dr. [**Last Name (STitle) **] after you leave the hospital, we made an appointment for you, you will get a CT scan to look at the blood clot in your aorta prior to seeing Dr. [**Last Name (STitle) **]. Department: RADIOLOGY When: TUESDAY [**2143-3-26**] at 1:30 PM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: VASCULAR SURGERY When: TUESDAY [**2143-3-26**] at 2:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: NEUROLOGY When: [**2143-4-9**] at 11:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**] Building: [**Hospital 830**] Campus: East [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

Admission Date: [**2170-11-14**] Discharge Date: [**2170-11-27**] Date of Birth: [**2095-1-20**] Sex: M Service: MEDICINE Allergies: Bactrim / Vancomycin / Ambien / Augmentin / Cephalexin / IV Dye, Iodine Containing Attending:[**First Name3 (LF) 5129**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: PICC placement History of Present Illness: 75yo male with complicated medical history including hypertension, hyperlipidemia, afib, and systolic CHF (EF of 15%) who is being re-admitted with dyspnea. The patient has had 2 recent hospitalization in [**2170-10-28**]. He was admitted from [**Date range (1) 98263**] with acute on chronic sytolic CHF and multifocal pneumonia and sepsis. During that admission, he was intubated and on pressors. He had received large volumes of fluid for hypotension and then was dramatically diuresed to improve his respiratory status. By discharge, the patient was euvolemic and his home diuretics were restarted. At his re presentation on [**2172-11-6**], the patient appeared more fluid overloaded with LE edema. He was diuresed with lasix over 2 days. He was discharged on 60mg po lasix. Of note, he has a recent history of MDR Klebsiella Pneumonia. He was put on meropenem during his hospital stay, and discharged on ertapenem. He will complete his abx course on [**2170-11-16**]. Patient was found this morning at rehab with O2 sats in 60s. At baseline he is on 2-4L of oxygen. EMS put a NRB on him and he was 100% O2 sat. In the ED, initial VS:BP 141/64 HR 70 RR 16 100% on 15L NRB. Labs notable for an INR of 4.4 and BNP of [**Numeric Identifier 98264**]. CXR was concerning for worsening multifocal infiltrates. The patient was placed on BiPap with some relief of respiratory distress and sent to the MICU. Past Medical History: -Hypertension -Hyperlipidemia -Chronic Systolic CHF (dry weight 196 lbs) secondary to dilated cardiomyopathy. EF 15% per TEE [**10/2169**] -Atrial fibrillation s/p DCCV x 2 w/ reccurence and ablation [**2169-10-13**] -h/o Pulmonary embolism -Rectal adenocarcinoma s/p transanal excision [**2166**] -s/p umbilical hernia repair with mesh -LLE insufficiency s/p ablation of L greater saphenous vein, c/b ulcer formation. -Osteoarthritis s/p knee surgery -Spinal stenosis s/p back surgery -Allergic rhinitis -s/p nasal surgery -rosacea -actinic keratosis -h/o psychogenic polydipsia and SIADH -Subclavian artery stenosis causing chronic low L-arm BPs - history of adrenal insufficiency Social History: Home: usually lives at [**Hospital1 1501**], recently discharged to rehab after complicated admission Tobacco: 40 PPY smoking history but quit 34 years ago EtOH: 2-3 beers, [**1-30**] x per week Drugs: Denies Occupation: retired firefighter Family History: Brother deceased in 70's. No family history of early cardiac disease. Physical Exam: Initial physical exam: Vitals - T: 99.1 BP: 146/40 HR:80 RR:16 02 sat: 99% on Bipap FiO2 of 40% GENERAL: BiPAP in place. Patient nods to questions, but has difficulty answering questions [**1-29**] mask. HEENT: NCAT. Unable to assess further given BIPAP mask. No LAD. Neck supple. Unable to assess JVP given Bipap mask. CARDIAC: RRR. No murmurs. LUNG: Coarse rhonchi bilaterally on anterior exam. Intermittent wheezes. No crackles. ABDOMEN: Soft, NT, ND. No masses. No rebound or guarding. EXT: WWP. No LE edema. NEURO: A+Ox3. Moving all extremities. Non focal. DERM: Multiple ecchymoses. Pertinent Results: Labs on admission: [**2170-11-14**] 05:12AM BLOOD WBC-11.3* RBC-3.38* Hgb-8.9* Hct-28.1* MCV-83 MCH-26.3* MCHC-31.7 RDW-16.6* Plt Ct-221 [**2170-11-14**] 05:12AM BLOOD Neuts-82.2* Lymphs-11.1* Monos-4.3 Eos-2.3 Baso-0.2 [**2170-11-14**] 05:12AM BLOOD PT-41.6* PTT-55.1* INR(PT)-4.4* [**2170-11-14**] 05:12AM BLOOD Glucose-90 UreaN-23* Creat-1.2 Na-135 K-4.1 Cl-92* HCO3-36* AnGap-11 [**2170-11-14**] 05:12AM BLOOD CK(CPK)-20* [**2170-11-14**] 05:12AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 98264**]* [**2170-11-14**] 05:45PM BLOOD Mg-1.7 [**2170-11-15**] 04:33AM BLOOD Digoxin-0.8* [**2170-11-14**] 06:42AM BLOOD Type-ART pO2-410* pCO2-79* pH-7.33* calTCO2-44* Base XS-12 [**2170-11-24**] 05:18AM BLOOD WBC-5.5 RBC-3.11* Hgb-8.3* Hct-25.7* MCV-83 MCH-26.5* MCHC-32.1 RDW-15.8* Plt Ct-317 [**2170-11-24**] 05:18AM BLOOD Plt Ct-317 [**2170-11-24**] 05:18AM BLOOD Glucose-87 UreaN-17 Creat-1.1 Na-127* K-4.7 Cl-89* HCO3-32 AnGap-11 [**2170-11-24**] 05:18AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.6 [**2170-11-24**] 05:18AM BLOOD WBC-5.5 RBC-3.11* Hgb-8.3* Hct-25.7* MCV-83 MCH-26.5* MCHC-32.1 RDW-15.8* Plt Ct-317 [**2170-11-25**] 06:25AM BLOOD WBC-5.7 RBC-3.00* Hgb-8.0* Hct-23.9* MCV-80* MCH-26.8* MCHC-33.6 RDW-16.2* Plt Ct-383 [**2170-11-26**] 05:28AM BLOOD WBC-6.5 RBC-3.16* Hgb-8.4* Hct-25.9* MCV-82 MCH-26.5* MCHC-32.2 RDW-16.1* Plt Ct-412 [**2170-11-27**] 06:06AM BLOOD WBC-5.3 RBC-3.04* Hgb-7.9* Hct-24.0* MCV-79* MCH-26.1* MCHC-33.1 RDW-16.3* Plt Ct-382 [**2170-11-25**] 06:25AM BLOOD PT-24.8* PTT-49.8* INR(PT)-2.4* [**2170-11-26**] 02:00PM BLOOD PT-19.9* PTT-45.4* INR(PT)-1.8* [**2170-11-27**] 06:06AM BLOOD PT-20.7* PTT-46.2* INR(PT)-1.9* [**2170-11-27**] 06:06AM BLOOD Plt Ct-382 [**2170-11-24**] 05:18AM BLOOD Glucose-87 UreaN-17 Creat-1.1 Na-127* K-4.7 Cl-89* HCO3-32 AnGap-11 [**2170-11-25**] 06:25AM BLOOD Glucose-84 UreaN-18 Creat-1.2 Na-120* K-4.8 Cl-86* HCO3-31 AnGap-8 [**2170-11-25**] 01:47PM BLOOD Glucose-109* UreaN-19 Creat-1.3* Na-125* K-4.6 Cl-86* HCO3-34* AnGap-10 [**2170-11-26**] 05:28AM BLOOD Glucose-87 UreaN-20 Creat-1.3* Na-120* K-4.6 Cl-88* HCO3-30 AnGap-7* [**2170-11-26**] 01:59PM BLOOD Na-120* [**2170-11-27**] 06:06AM BLOOD Glucose-106* UreaN-20 Creat-1.3* Na-123* K-4.9 Cl-85* HCO3-29 AnGap-14 [**2170-11-25**] 06:25AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.7 [**2170-11-26**] 05:28AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.7 [**2170-11-26**] 01:59PM BLOOD Osmolal-258* [**2170-11-14**] EKG: Ventricular paced rhythm with ventricular premature beat. Atrial mechansim is probably atrial fibrillation. Since the previous tracing of the same date no significant change. Imaging: [**2170-11-14**] CXR:IMPRESSION: Interval progression of congestive heart failure. Severe chronic lung disease. [**2170-11-15**] CXR: Moderate cardiomegaly is stable. Large right pleural effusion and small left pleural effusion are stable associated with adjacent atelectasis. Moderate pulmonary edema has improved, is asymmetric, greater in the right side. Of note, there are two more focal denser areas that could be edema or pneumonia in the right mid lung and increasing in the left upper lobe in the periphery. Left transvenous pacemaker leads terminate in a standard position. Right PICC tip is in the lower SVC. [**2170-11-19**] Chest CT: 1. Minimal degree of pulmonary edema. Significant improvement compared to the prior studies. The left upper lobe focal area of consolidation as described, might represent new pneumonia, also may represent a residue of the prior extensive consolidation seen in that area dating back to [**2170-11-15**]. 2. Interstitial changes in subpleural location, most of the upper lobes that might represent nonspecific interstitial pneumonia. 3. Minimal emphysema, affecting the upper lungs. 4. Severe cardiomegaly and extensive coronary and aortic calcifications. 5. Mild compression fracture of T12. 6. Bilateral moderate pleural effusions accompanied by bibasal areas of atelectasis. [**2170-11-21**] u/s calf: IMPRESSION: Small fluid collection corresponding to palpable abnormality. The appearance is nonspecific. Considerations might include resolving hematoma or small abscess. This collection should be able to be targeted for aspiration by palpation, given its superficial location. Brief Hospital Course: 75 yo M with a history of HTN, HL, Afib, with 2 recent admissions for multilobar pneumonia and CHF exacerbation 1. Respiratory distress: Initially presented from rehab with increased peripheral edema, dyspnea and O2 sats in 60s on baseline 2-4L NC. Respiratory distress was felt to be multifactorial, from recent pneumonia and acute on chronic CHF exacerbation. a. acute on chronic systolic CHF exacerbation: Upon admission, patient was placed on BiPAP and transferred to the MICU. Quickly weaned to 40% O2 by nasal canula, with good diuretic response to 40 mg IV furosemide [**Hospital1 **]. Net fluid balance of -2.283 L during ICU course of 1.5 days. The patient was transferred to the floor, where diuresis was continued using lasix 40mg IV prn to maintain a fluid balance of -1 to 1.5 L/day. As patient approached euvolemia, he was transitioned to home dose of lasix 60mg daily. Throughout hospitalization, maintained on B-blocker, [**Last Name (un) **], loop diuretic and digoxin. b. multilobar pneumonia: Patient admitted on meropenem and continued on 2 week antibiotic course for MDR Klebsiella Pneumonia, ending on [**2170-11-16**]. On final day of meropenem, patient became febrile to 101, unchanged WBC count, and stable respiratory status. Blood cultures and urine cultures remained negative. Repeat chest CT showed minimal degree of pulmonary edema and a left upper lobe focal area of consolidation representing new pneumonia vs residue of prior pneumonia. Meropenem was continued for an additional week of therapy for recalcitrant/ recurrent pneumonia and patient remained afebrile. Induced sputum culture grew extensive commensal respiratory flora and stenotrophomonas maltophilia sensitive to bactrim. Throughout hospital stay, patient was maintained on outpatient COPD medications: albuterol, ipratropium, advair. Encouraged pulmonary toilet with incentive spirometry and Guaifenesin for expectoration. Upon discharge, patient denied any shortness of breath and was at his baseline 2. Atrial fibrillation: Patient rate controlled by A- pacing (s/p ICD implantation for CHF). Admitted with a supratherapeutic INR of 4.4 likely secondary to warfarin interaction with antibiotics. Coumadin was held until INR trended down into therapeutic level and patient was monitored closely for any evidence of occult hemmorhage (see below). Discharged on home dose of coumadin with instruction to follow PT/INR closely. 3. Acute on chronic Anemia: Admitted with hematocrit of 28.1, at baseline. Through hospital course, hematocrit slowly trended down to nadir of 22.3 in the setting of supratherapeutic INR although no source of active bleed was identified. Patient remained hemodynamically stable throughout with no symptoms of endorgan ischemia. Transfused 1 UpRBC with bolus of lasix 40mg with transfusion to prevent volume overload. Hematocrit at discharge was 24.0. 4. Left calf hematoma: On [**11-18**] patient was noted to have a tender nodule on left lateral calf. Ultrasound showed small fluid collection consistent with resolving abscess versus hematoma. Incision of nodule revealed a hematoma and the collection was left in place to resorb spontaneously. 5. Hyponatremia: Patient developed hyponatremia from 127 to 130s following diuresis with furosemide. Of note, patient had prior history of hyponatremia secondary to SIADH from chronic lung disease. 6. Hyperlipidemia: Continued atorvastatin 10mg po daily. 7. History of adrenal insufficiency: asymptomatic, no need for steriods. Patient discharged on home dose of hydrocortisone but would recommend reassessment by primary care physician whether need to continue steriod replacement Medications on Admission: 1. Digoxin 125 mcg po daily 2. Warfarin 5 mg po daily 3. Acetaminophen 325 mg mg po q6h PRN pain, fever 4. Atorvastatin 10 mg po daily 5. Docusate Sodium 100 mg po bid 6. Senna 8.6 mg po bid 7. Ascorbic Acid 500 mg mg po bid 8. Multivitamin 1 po daily 9. Metoprolol Succinate 100 mg po daily 10. Guaifenesin 600 mg po bid PRN cough 11. Ertapenem 1 gram IV daily -last day [**2170-11-16**] 12. Furosemide 60 mg po daily 13. Losartan 25 mg po daily 14. Albuterol nebs q 4-6 h PRN SOB 15. Tiotropium Bromide 18 mcg Capsule daily 16. Hydrocortisone 10 mg po daily 17. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day as needed for sputum clearance. 10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 11. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB. 13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 14. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 15. Hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary diagnosis: - Acute on chronic systolic heart failure. - Multilobar klebsiella pneumonia. - Hyponatremia/SIADH Secondary: - Non-ischemic dilated cardiomyopathy. - Ventricular tachycardia s/p AICD. - Atrial fibrillation s/p AVN ablation - History of pulmonary embolism - Anemia NOS - Rectal adenocarcinoma s/p transanal excision [**2166**] - Subclavian artery steonsis with decreased left arm BP - Left saphenous vein ablation c/b insufficiency and ulceration. - Osteoarthritis s/p knee surgery. - Umbilical hernia repair with mesh. Discharge Condition: afebrile, hemodynamically stable. Discharge Instructions: You came to the hospital because you were having shortness of breath. You were found to have a pneumonia as well as fluid overload from your CHF. You were transfered to the MICU where you were put on a BIPAP machine and diuresed to get extra fluid off of your lungs. You did well on this and were transferred out to the medicine floor when you were breathing better. On the floor, you continued treatment with antibiotics for your pneumonia and medicines for your CHF which both improved. You completed a course of antibiotics while here for pneumonia, which has resolved. You were also found to have a nodule on your left lower extremity. This was found to be a hematoma, or collection of blood, which should resolve spontaneously. You were also restarted on your home dose of steroids. No changes have been made to your medications Please follow-up with your cardiologist, Dr. [**Last Name (STitle) **], on [**2170-12-12**] at 11:20am. His phone number is [**Telephone/Fax (1) 62286**]. Please follow-up with Dr. [**Last Name (STitle) 98254**] on [**2170-12-20**] at 10:30am. You can contact him at [**Telephone/Fax (1) 67474**]. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet and a fluid restriction of 1500ml per day Please call your doctor or return to the hospital if you experience worsening shortness of breath, cough, chest pain, palpitations, feeling like you are going to pass out, fever above 101.5, increased swelling in your legs or weight gain above 3 lbs in a few days, bleeding, or any other symptoms of concern. It was a pleasure taking part in your care. Followup Instructions: Please follow-up with your cardiologist, Dr. [**Last Name (STitle) **], on [**2170-12-12**] at 11:20am. His phone number is [**Telephone/Fax (1) 62286**]. Please follow-up with Dr. [**Last Name (STitle) 98254**] on [**2170-12-20**] at 10:30am. You can contact him at [**Telephone/Fax (1) 67474**]. Completed by:[**2170-11-29**]