Datasets:

ashishkgpian

/

symptoms2diseases_another_way

like 0

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet / Vicodin Attending: ___ Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. ___ is a ___ female with HIV on HAART, COPD, HCV cirrhosis complicated by ascites and hepatic encephalopathy who initially presented to the ED yesterday with hypotension after a paracentesis. The patient has had accelerated decompensation of her cirrhosis recently with worsening ascites, and she is maintained on twice weekly paracentesis. She was at her regular session yesterday when she had hypotension to SBP ___ and felt lightheadedness. Per the patient, that's when her memory started to get fuzzy. She does not have much recollection of what happened since then. Her outpatient hepatologist saw her and recommended that she go to the ED. In the ED, she was evaluated and deemed to have stable blood pressure. She was discharged home. At home, she had worsening mental status with her daughter getting concerned, and she returned to the ED. In the ED, initial vitals were 98.7 77 96/50 16 98% RA. The patient was only oriented to person. Her labs were notable for Na 126, K 6.7, Cr 0.7 (baseline 0.4), ALT 153, AST 275, TBili 1.9, Lip 66, INR 1.5. Initial EKG showed sinus rhythm with peaked T waves. Her head CT was negative for any acute processes. She received ceftriaxone 2gm x1, regular insulin 10U, calcium gluconate 1g, lactulose 30 mL x2, and 25g 5% albumin. On transfer, vitals were 99.0 93 84/40 16 95% NC. On arrival to the MICU, patient was more alert and conversant. She has no abdominal pain, nausea, vomiting, chest pain, or difficulty breathing. She has a chronic cough that is not much changed. She has not had any fever or chills. She reports taking all of her medications except for lactulose, which she thinks taste disgusting. Past Medical History: - HCV Cirrhosis: genotype 3a - HIV: on HAART, ___ CD4 count 173, ___ HIV viral load undetectable - COPD: ___ PFT showed FVC 1.95 (65%), FEV1 0.88 (37%), FEFmax 2.00 (33%) - Bipolar Affective Disorder - PTSD - Hx of cocaine and heroin abuse - Hx of skin cancer per patient report Social History: ___ Family History: She a total of five siblings, but she is not talking to most of them. She only has one brother that she is in touch with and lives in ___. She is not aware of any known GI or liver disease in her family. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals T: 98.7 BP: 84/48 P: 91 R: 24 O2: 98% NC on 2L GENERAL: Alert, oriented, no acute distress LUNGS: Decreased air movement on both sides, scattered expiratory wheezes CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Soft, non-tender, distended, flank dullness bilaterally, bowel sounds present EXT: Warm, well perfused, 2+ pulses, no cyanosis or edema DISCHARGE PHYSICAL EXAM: Vitals- Tm 99.5, Tc 98.7, ___ 79-96/43-58 20 95% on 3L NC, 7BM. General- Cachectic-appearing woman, alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear, poor dentition with partial dentures Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- Mildly distended and firm, non-tender, bowel sounds present, no rebound tenderness or guarding GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- AOx3, No asterixis. Pertinent Results: ADMISSION LABS: ================= ___ 06:39AM BLOOD WBC-6.9 RBC-3.98* Hgb-14.1 Hct-41.1 MCV-103* MCH-35.4* MCHC-34.3 RDW-15.8* Plt ___ ___ 06:39AM BLOOD Neuts-72.7* Lymphs-14.7* Monos-9.8 Eos-2.5 Baso-0.3 ___ 06:39AM BLOOD ___ PTT-32.4 ___ ___ 06:39AM BLOOD Glucose-102* UreaN-49* Creat-0.7 Na-126* K-6.7* Cl-95* HCO3-25 AnGap-13 ___ 06:39AM BLOOD ALT-153* AST-275* AlkPhos-114* TotBili-1.9* ___ 06:39AM BLOOD Albumin-3.6 IMAGING/STUDIES: ================ ___ CT HEAD: No evidence of acute intracranial process. The left zygomatic arch deformity is probably chronic as there is no associated soft tissue swelling. ___ CXR: No acute intrathoracic process. DISCHARGE LABS: =============== ___ 04:45AM BLOOD WBC-4.8 RBC-3.15* Hgb-11.2* Hct-32.1* MCV-102* MCH-35.4* MCHC-34.8 RDW-15.8* Plt Ct-95* ___ 04:45AM BLOOD ___ PTT-37.6* ___ ___ 04:45AM BLOOD Glucose-121* UreaN-35* Creat-0.4 Na-130* K-5.2* Cl-97 HCO3-27 AnGap-11 ___ 04:45AM BLOOD ALT-96* AST-168* AlkPhos-69 TotBili-1.7* ___ 04:45AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.___ w/ HIV on HAART, COPD on 3L home O2, HCV cirrhosis decompensated (ascites requiring biweekly therapeutic paracenteses, hepatic encephalopathy; not on transplant list ___ comorbidities) w/ AMS, hypotension, ___, and hyperkalemia. Altered mental status improved with lactulose. Hypotension was felt to be due to fluid shifts from paracentesis on the day prior to admission as well as low PO intake in the setting of AMS. Hypotension and ___ resolved with IV albumin. Hyperkalemia resolved with insulin and kayexalate. # Hypotension: Patient presented with SBP in ___ and improved with albumin in the ED to ___. It was felt to be due to fluid shifts from paracentesis on ___, as well as likely hypovolemia given AMS and decreased PO intake. No concern for bleeding or sepsis with baseline CBC and lack of fever. She continued to received IV albumin during her hospital course, with which her SBP improved to ___ and patient remained asymptomatic. # Hyperkalemia: Patient presented with K 6.7 with EKG changes. Given low Na, likely the result of low effective arterial volume leading to poor K excretion, with likely exacerbation from ___. AM cortisol was normal. K improved with insulin and kayexalate and K was 5.2 on day of discharge. Bactrim was held during hospital course. # ___: Patient presented with Cr 0.7 from baseline Cr is 0.3-0.4. It was felt to be likely due to volume shift from her paracentesis on the day prior to admission as well as now low effective arterial volume, likely ___ poor PO intake ___ AMS. Cr improved to 0.4 with albumin administration. Furosemide and Bactrim were held during hospital course. #GOC: The ___ son (HCP) met with Dr. ___ outpatient hepatologist) during ___ hospital course. They discussed that the patient is not a transplant candidate givenevere underlying lung disease (FEV1 ~0.8), hypoxia, RV dilation and very low BMI. A more conservative approach was recommended and the patient was transitioned to DNR/DNI. The patient agreed with this plan. She was treated with the goal of treating any any correctable issues. Social work met with the patient prior to discharge. The patient was interested in following up with palliative care, for which an outpatient referral was made. # Altered Mental Status: Patient presented with confusion that was most likely secondary to hepatic encephalopathy. Based on outpatient records, patient has had steady decline in decompensated cirrhosis and mental status. No signs of infection and head CT was negative as well. Mental status improved with lactulose in the ED and patient reports that she has not been taking lactulose regularly at home. Patient was also continued on rifaximin. # HCV Cirrhosis: Genotype 3a. Patient is decompensated with increasing ascites and worsening hepatic encephalopathy. She is dependent on twice weekly paracentesis. Spironolactone was recently stopped due to hyperkalemia. Patient is not a transplant candidate given her comorbidities COPD per outpatient hepatologist. The patient would like to continue biweekly paracenteses as an outpatient. # HIV: Most recent CD4 count 173 on ___. HIV viral load on ___ was undetectable. She was continued on her home regimen of raltegravir, emtricitabine, and tenofovir. Bactrim prophylaxis was held during admission because of hyperkalemia. # COPD: Patient on 3L NC at home. She was continued on her home regimen. TRANSITIONAL ISSUES: -Follow up with Palliative Care as outpatient -Bactrim prophylaxis (HIV+) was held during hospital course due to ___. Consider restarting as outpatient. -Furosemide was held due to ___, consider restarting as outpatient -Follow up with hepatology -Continue biweekly therapeurtic paracenteses -Code status: DNR/DNI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 15 mL PO TID 2. Tiotropium Bromide 1 CAP IH DAILY 3. Raltegravir 400 mg PO BID 4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 5. Furosemide 40 mg PO DAILY 6. TraMADOL (Ultram) 50 mg PO Q8H:PRN Pain 7. Fluticasone Propionate 110mcg 1 PUFF IH BID 8. Calcium Carbonate 500 mg PO BID 9. Rifaximin 550 mg PO BID 10. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN Wheezing 11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY Discharge Medications: 1. Calcium Carbonate 500 mg PO BID 2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 3. Fluticasone Propionate 110mcg 1 PUFF IH BID 4. Lactulose 30 mL PO TID 5. Raltegravir 400 mg PO BID 6. Rifaximin 550 mg PO BID 7. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain 8. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN Wheezing 9. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Hypotension Hyperkalemia Acute Kidney Injury Secondary: HIV Cirrhosis COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ because of confusion, low blood pressure, and a high potassium value. Your confusion improved with lactulose. Your blood pressure improved with extra fluids and your potassium improved as well. You also had small degree of kidney injury when you came to the hospital, and this also improved with fluids. While you were here, you discussed changing your goals of care to focusing on symptom management and treatment of reversible processes, such as an infection. While you were in the hospital, you were seen by one of our social workers. You will also follow up with Palliative Care in their clinic and will continue to have therapeutic paracenteses. It has been a pleasure taking care of you and we wish you all the best, Your ___ Care team Followup Instructions: ___

{'altered mental status': ['Chronic hepatitis C with hepatic coma'], 'hypotension': ['Other iatrogenic hypotension'], 'hyperkalemia': ['Hyperpotassemia'], 'hepatic encephalopathy': ['Chronic hepatitis C with hepatic coma'], 'ascites': ['Other ascites'], 'COPD': ['Chronic airway obstruction, not elsewhere classified'], 'HIV': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'cirrhosis': ['Cirrhosis of liver without mention of alcohol']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: omeprazole Attending: ___. Chief Complaint: dysphagia Major Surgical or Invasive Procedure: Upper endoscopy ___ History of Present Illness: ___ w/ anxiety and several years of dysphagia who p/w worsened foreign body sensation. She describes feeling as though food gets stuck in her neck when she eats. She put herself on a pureed diet to address this over the last 10 days. When she has food stuck in the throat, she almost feels as though she cannot breath, but she denies trouble breathing at any other time. She does not have any history of food allergies or skin rashes. In the ED, initial vitals: 97.6 81 148/83 16 100% RA Imaging showed: CXR showed a prominent esophagus Consults: GI was consulted. Pt underwent EGD which showed a normal appearing esophagus. Biopsies were taken. Currently, she endorses anxiety about eating. She would like to try eating here prior to leaving the hospital. Past Medical History: - GERD - Hypercholesterolemia - Kidney stones - Mitral valve prolapse - Uterine fibroids - Osteoporosis - Migraine headaches Social History: ___ Family History: + HTN - father + Dementia - father Physical Exam: ================= ADMISSION/DISCHARGE EXAM ================= VS: 97.9 PO 109 / 71 70 16 97 ra GEN: Thin anxious woman, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI NECK: Supple without LAD, no JVD PULM: CTABL no w/c/r COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended, +BS, no HSM EXTREM: Warm, well-perfused, no ___ edema NEURO: CN II-XII grossly intact, motor function grossly normal, sensation grossly intact Pertinent Results: ============= ADMISSION LABS ============= ___ 08:27AM BLOOD WBC-5.0 RBC-4.82 Hgb-14.9 Hct-44.4 MCV-92 MCH-30.9 MCHC-33.6 RDW-12.1 RDWSD-41.3 Plt ___ ___ 08:27AM BLOOD ___ PTT-28.6 ___ ___ 08:27AM BLOOD Glucose-85 UreaN-8 Creat-0.9 Na-142 K-3.6 Cl-104 HCO3-22 AnGap-20 ___ 08:27AM BLOOD ALT-11 AST-16 LD(LDH)-154 AlkPhos-63 TotBili-1.0 ___ 08:27AM BLOOD Albumin-4.8 ============= IMAGING ============= CXR ___: IMPRESSION: Prominent esophagus on lateral view, without air-fluid level. Given the patient's history and radiographic appearance, barium swallow is indicated either now or electively. NECK X-ray ___: IMPRESSION: Within the limitation of plain radiography, no evidence of prevertebral soft tissue swelling or soft tissue mass in the neck. EGD: ___ Impression: Hiatal hernia Angioectasia in the stomach Angioectasia in the duodenum (biopsy, biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: - no obvious anatomic cause for the patient's symptoms - follow-up biopsy results to rule out eosinophilic esophagitis - follow-up with Dr. ___ if biopsies show eosinophilic esophagitis Brief Hospital Course: Ms. ___ is a ___ with history of GERD who presents with subacute worsening of dysphagia and foreign body sensation. This had worsened to the point where she placed herself on a pureed diet for the last 10 days. She underwent CXR which showed a prominent esophagus but was otherwise normal. She was evaluated by Gastroenterology and underwent an upper endoscopy on ___. This showed a normal appearing esophagus. Biopsies were taken. TRANSITIONAL ISSUES: -f/u biopsies from EGD -if results show eosinophilic esophagitis, follow-up with Dr. ___. ___ for management -pt should undergo barium swallow as an outpatient for further workup of her dysphagia -f/u with ENT as planned #Code: Full (presumed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO BID Discharge Medications: 1. Omeprazole 20 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: -dysphagia and foreign body sensation SECONDARY DIAGNOSIS: -GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized at ___. You came in due to difficulty swallowing. You had an endoscopy to look for any abnormalities in the esophagus. Thankfully, this was normal. They took biopsies, and you will be called with the results. You should have a test called a barium swallow as an outpatient. We wish you all the best! -Your ___ Team Followup Instructions: ___

{'dysphagia': ['Dysphagia', 'Gastro-esophageal reflux disease without esophagitis'], 'foreign body sensation': ['Dysphagia', 'Gastro-esophageal reflux disease without esophagitis'], 'anxiety': ['Anxiety disorder', 'unspecified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: omeprazole / Iodine and Iodide Containing Products / hallucinogens Attending: ___. Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: Status post left CRPP ___, ___ History of Present Illness: REASON FOR CONSULT: Femur fracture HPI: ___ female presents with the above fracture s/p mechanical fall. This morning, pt was walking ___, when dog pulled on leash. Pt fell on L hip. Immediate pain. ___ ___ with movement. Denies Head strike, LOC or blood thinners. Denies numbness or weakness in the extremities. Past Medical History: - GERD - Hypercholesterolemia - Kidney stones - Mitral valve prolapse - Uterine fibroids - Osteoporosis - Migraine headaches Social History: ___ Family History: + HTN - father + Dementia - father Physical Exam: General: Well-appearing female in no acute distress. Left Lower extremity: - Skin intact - No deformity, edema, ecchymosis, erythema, induration - Soft, non-tender thigh and leg - Full, painless ROM knee, and ankle - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left valgus impacted femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left closed reduction and percutaneous pinning of hip, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactaid (lactase) 3,000 unit oral DAILY:PRN 2. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL 40 mg Subcutaneously Nightly Disp #*30 Syringe Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth q4 PRN Disp #*25 Tablet Refills:*0 6. Senna 8.6 mg PO BID 7. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral DAILY 8. Lactaid (lactase) 3,000 unit oral DAILY:PRN 9. Multivitamins 1 TAB PO DAILY 10. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left valgus impacted femoral neck fracture Discharge Condition: AVSS NAD, A&Ox3 LLE: Incision well approximated. Dressing clean and dry. Fires FHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP pulse, wwp distally. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Weightbearing as tolerated left lower extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks Followup Instructions: ___

{'Left hip pain': ['Unspecified intracapsular fracture of left femur'], 'Femur fracture': ['Unspecified intracapsular fracture of left femur'], 'GERD': ['Gastro-esophageal reflux disease without esophagitis'], 'Hypercholesterolemia': ['Pure hypercholesterolemia'], 'Kidney stones': ['Personal history of urinary calculi'], 'Mitral valve prolapse': ['Nonrheumatic mitral (valve) prolapse'], 'Migraine headaches': ['Migraine', 'unspecified', 'not intractable', 'without status migrainosus'], 'Osteoporosis': ['Age-related osteoporosis without current pathological fracture']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: renal mass Major Surgical or Invasive Procedure: right laparascopic radical nephrectomy- Dr. ___, Dr. ___ ___ History of Present Illness: ___ y/o healthy female with incidental finding of right renal mass suspicious for RCC following MRI on ___. Past Medical History: PMH: nonspecific right axis deviation PSH- cesarean section ALL-NKDA Social History: ___ Family History: no history of RCC Pertinent Results: ___ 07:15AM BLOOD WBC-7.6 RBC-3.82* Hgb-11.9* Hct-33.8* MCV-89 MCH-31.2 MCHC-35.2* RDW-12.8 Plt ___ ___ 07:15AM BLOOD Glucose-150* UreaN-10 Creat-0.9 Na-138 K-3.8 Cl-104 HCO3-27 AnGap-11 Brief Hospital Course: Patient was admitted to Urology after undergoing laparoscopic right radical nephrectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis, and ambulated once. On POD1,foley was removed without difficulty, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet. On POD2, diet was advanced as tolerated. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic with ___ in 3 weeks. Medications on Admission: none Discharge Medications: 1. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for break through pain only (score >4) . Disp:*60 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: renal cell carcinoma Discharge Condition: stable Discharge Instructions: -You may shower but do not bathe, swim or immerse your incision. -Do not eat constipating foods for ___ weeks, drink plenty of fluids -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -Tylenol should be used as your first line pain medication. If your pain is not well controlled on Tylenol you have been prescribed a narcotic pain medication. Use in place of Tylenol. Do not exceed 4 gms of Tylenol in total daily -Do not drive or drink alcohol while taking narcotics -Resume all of your home medications, except hold NSAID (aspirin, advil, motrin, ibuprofen) until you see your urologist in follow-up -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER -Call Dr. ___ to set up follow-up appointment and if you have any urological questions. ___ Followup Instructions: ___

{'renal mass': ['Malignant neoplasm of kidney', 'except pelvis'], 'right axis deviation': [], 'cesarean section': [], 'nonspecific': []}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tramadol Attending: ___. Chief Complaint: Abdominal distention, back pain, fever; leukocytosis. Major Surgical or Invasive Procedure: Paracentesis x 3. History of Present Illness: This is a ___ woman with a history of ETOH abuse who presents with abdominal distention, back pain, fever, and elevated white count from Liver Clinic. Ms. ___ was recently admitted to this hospital about 1 week ago for treatment of ascites and work-up of alcoholic hepatitis. At that time she had a diagnostic and therapeutic paracentesis and was treated for a UTI. She was discharged home and instructed to follow-up in Liver Clinic in 1 week. On day of presentation to liver clinic, patient complained of worsening abdominal pain and low-grade fevers at home. Her labwork was also significant for an elevated white count. As such, Ms. ___ was admitted for work-up of fever and white count, and for treatment of recurrent ascites. Past Medical History: --Alcohol abuse --Chronic back pain Social History: ___ Family History: Breast cancer in mother age ___, No IBD, liver failure. Multiple relatives with alcoholism. Physical Exam: VS: 97.9, 103/73, 86, 18, 96% RA GEN: A/Ox3, pleasant, appropriate, well appearing HEENT: No temporal wasting, JVD not elevated, neck veins fill from above. CV: RRR, No MRG PULM: CTAB but decreased BS in R base. ABD: Distended and tight, diffusely tender to palpation, BS+, + passing flatulence. LIMBS: 2+ edema of the LEs to knee bilaterally ___ pulses 2+ bilaterally NEURO: No asterixis, very mild general tremor. Pertinent Results: Labs at Admission: ___ 09:47AM BLOOD WBC-26.2*# RBC-3.86* Hgb-13.0 Hct-43.3 MCV-112* MCH-33.7* MCHC-30.0* RDW-12.7 Plt ___ ___ 09:47AM BLOOD Neuts-88* Bands-1 Lymphs-2* Monos-7 Eos-1 Baso-1 ___ Myelos-0 ___ 09:20PM BLOOD ___ ___ 09:47AM BLOOD UreaN-8 Creat-0.5 Na-133 K-5.1 Cl-92* HCO3-26 AnGap-20 ___ 09:47AM BLOOD ALT-45* AST-165* LD(LDH)-345* AlkPhos-200* TotBili-2.0* ___ 09:47AM BLOOD Albumin-2.9* Calcium-8.1* Phos-4.0 Mg-2.2 ___ 09:20PM BLOOD Ethanol-NEG Bnzodzp-NEG Labs at Discharge: ___ 07:20AM BLOOD WBC-20.7* RBC-3.03* Hgb-10.3* Hct-32.0* MCV-106* MCH-33.9* MCHC-32.1 RDW-13.7 Plt ___ ___ 07:20AM BLOOD ___ PTT-42.0* ___ ___ 07:20AM BLOOD Glucose-96 UreaN-7 Creat-0.4 Na-125* K-4.4 Cl-90* HCO3-30 AnGap-9 ___ 07:20AM BLOOD ALT-35 AST-131* LD(___)-265* AlkPhos-184* TotBili-1.9* ___ 07:20AM BLOOD Albumin-2.5* Calcium-7.2* Phos-2.6* Mg-2.0 Micro Data: ___ PERITONEAL FLUID GRAM STAIN- negative; FLUID CULTURE-PENDING; ANAEROBIC CULTURE- negative ___ STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- negative ___ URINE URINE CULTURE- negative ___ SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS- negative ___ STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- negative ___ FLUID RECEIVED IN BLOOD CULTURE BOTTLES Fluid Culture in Bottles- negative ___ PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE- negative ___ BLOOD CULTURE Blood Culture, Routine- negative ___ BLOOD CULTURE Blood Culture, Routine-negative ___ URINE URINE CULTURE-FINAL {GRAM POSITIVE BACTERIA} INPATIENT ___ FLUID RECEIVED IN BLOOD CULTURE BOTTLES negative Imaging Results: CTA (___): 1. No evidence of pulmonary embolism. 2. Stable atelectasis at the right lung base. 3. Moderate right and small left pleural effusions, unchanged. CTAP (___): 1. Hepatomegaly and large ascites consistent with stated history of liver disease. No evidence of portal venous thrombosis suggesting that the findings on the prior ultrasound may have resulted from extremely slow / undetectable flow. 2. Moderate right and small left pleural effusions, increased on the right with right basilar atelectasis. 3. Replaced right hepatic artery arising from the SMA, otherwise conventional arterial and venous anatomy. Brief Hospital Course: This is a ___ woman with likely alcoholic hepatitis and recurrent ascites who is admitted with low-grade fevers, high white count, and abdominal pain. # ASCITES/ALC HEPATITIS/LEUKOCYTOSIS: Patient with fatty liver and ascites in setting of extensive drinking history and AST/ALT elevation >2. Discriminant function on admission was ~30. Patient had a paracentesis on ___ and 4L was removed; peritoneal fluid was negative for SBP. Diuretics were initially held in the setting of hyponatremia. She was treated supportively with nutrition, brief antibiotics for urinary tract infection (3-days of ceftriaxone), and therapeutic paracenteses x3. Her symptoms, white cell count, and total bilirubin were improving at time of discharge. She will follow-up with Dr. ___ in liver clinic and with her primary care provider, Dr. ___, in two weeks. # HYPONATREMIA: Likely hypovolemic hyponatremia with some component of euvolemic hyponatremia from liver disease. Her spironlactone was held and can be restarted at the discretion of her outpatient liver team, if necessary. Sodium at time of discharge was 125. She has been advised to continue a low sodium diet and free water restriction to ___ liters daily. # ALCOHOLISM: Patient has been trying to cut back recently, but reports daily heavy alcohol intake for the past ___ years; she has had withdrawal symptoms before but no seizures. Shakes and hallucinations. Reports sobriety since prior admission. She will continue outpatient rehab. # URINARY TRACT INFECTION: she was treated with a three-day course of empiric ceftriaxone for concern of UTI. # BACK PAIN/ABDOMINAL PAIN: this was treated in house with lidocaine patches as needed and oxycodone as needed. She has been provided with a short course of Tramadol to take as needed until follow-up with her primary care provider. She understands that this is only a temporary medication and will be discontinued when her acute hepatitis resolves. # Prophylaxis: -DVT ppx with SC heparin -Bowel regimen with lactulose, no PPI -Pain management with oxycodone and lidocaine patch # Communication: Patient # Code: presumed full Medications on Admission: Multivitamin, thiamine, folate, spironolactone 25mg daily, lidocaine patch prn, nicotine patch. Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Alcoholic hepatitis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for alcoholic hepatitis. This is a condition in which your liver becomes inflamed due to excessive alcohol intake. You were also noted to have an elevated white cell count which can sometimes indicate infection. You were treated with a brief course of antibiotics for a urinary tract infection. Otherwise your blood and peritoneal fluid cultures remain negative. We made the following changes to your medications: We stopped your spironolactone because your blood sodium levels were too low. We added Tramadol to take as needed for back pain. Followup Instructions: ___

{'Abdominal distention': ['Acute alcoholic hepatitis', 'Other ascites'], 'Back pain': ['Acute alcoholic hepatitis', 'Unspecified pleural effusion'], 'Fever': ['Acute alcoholic hepatitis', 'Sepsis', 'Urinary tract infection'], 'Leukocytosis': ['Acute alcoholic hepatitis', 'Sepsis', 'Urinary tract infection']}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Abdominal distention/pain and fever Major Surgical or Invasive Procedure: Paracentesis ___ (diagnostic) and ___ (therapeutic) History of Present Illness: ___ with recently diagnosed alcoholic hepatitis, persistent ascites, and persistent fevers and leukocytosis which have been atributed to her hepatitis who presented to ___ today with worsening abdominal distention, pain, and persistent fever. She denies chills but did have sweats the night prior to admission. She has tried to be strictly compliant with her low socium diet and fluid restriction, and denies any increased fluid or sodium intake. She reports sobriety from alcohol since ___. At ___ she was febrile and tender to palpation, so she was referred to the ED. . In the ED initial vital signs were 99.0 113/72 132 16 99% on RA. Her temp increased to 100.4 and her pulse came down to the 100s with Ativan. She received morphine 4mg IV x 4 for pain, tylenol ___ PO x1 for fever, ondansetron 4mg IV x2 for nausea, and lorazeman 0.5mg IV x1 for anxiety. She underwent a diagnostic paracentesis but the samples were initially lost. She was treated with ceftriaxone 2g IV x1 for possible SBP. She was admitted to Medicine for further management. Fortunately, her samples were found after she arrived on the floor. . On the floor her mood is labile. She is at times tearful and at times pleasant. She does seem uncomfortable. She is not confused or obviously encephalopathic. She denies cough, dysuria, diarrhea, or rash. She does endorse decreased UOP for the past few days. . Review of Systems: (+) Per HPI (-) Denies chills. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath, or wheezes. Denied nausea, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: - Alcohol abuse - Alcoholic hepatitis, with persistent fever and leukocytosis - Ascites - Chronic back pain Social History: ___ Family History: - Mother: ___ cancer, age ___ - No family history of liver disease - Multiple relatives with alcoholism Physical Exam: Physical Exam on Admission: GEN: NAD, labile affect between pleasant and tearful VS: 101.0 104/69 125 18 95% on RA HEENT: Dry MM, no OP lesions, mild scleral icterus CV: RR, tachy, no MRG PULM: Bibasilar crackles R > L ABD: BS+, soft, distended, diffusely tender with mild rebound, obvious collateral veins, some mild angiomata LIMBS: Trace ___ edema, no tremors or asterixis SKIN: No rashes or skin breakdown, scattered ecchymoses at puncture sites NEURO: A and O x 3, no pronator drift, reflexes are 1+ of the upper and lower extremities Pertinent Results: LABS: Blood ___: WBC-17.9* RBC-3.25* HGB-11.0* HCT-34.1* MCV-105* MCH-33.9* MCHC-32.3 RDW-14.0 PLT COUNT-198 ___ PTT-39.3* ___ ALBUMIN-2.7* ALT(SGPT)-33 AST(SGOT)-124* ALK PHOS-186* TOT BILI-2.4 Ascitic Fluid ___: WBC-52* RBC-98* POLYS-13* LYMPHS-20* MONOS-0 EOS-1* MESOTHELI-16* MACROPHAG-50* TOT PROT-1.1 LD(LDH)-42 ALBUMIN-<1.0 Ascitic Fluid ___: WBC-104* RBB-290* POLYS-14* LYMPHS-17* MONOS-3* EOS-21* MESOTHELI-45* Blood ___: WBC-11.1 HCT 30.7 RADIOLOGY: Lumbo-sacral XR: Normal, no evidence of osteomyelitis/vertebral compression fracture. Brief Hospital Course: #Abdominal distention/pain: She was treated empirically due to concern for spontaneous bacterial peritonitis with ceftriaxone 2g x 1. A diagnostic paracentesis was performed in the ED. Ascitic fluid analysis was performed. Spontaneous bacterial peritonitis was ruled out given that the fluid cell count showed only 52 WBC; antibiotics were discontinued in this setting. Subsequently, a large volume paracentesis was performed on ___ with 4.5L of fluids removed. After the procedure, her abdomen was less distended and less painful. Fluid analysis again did not reveal SBP. . #Alcoholic hepatitis: Patient's liver synthetic function was monitored while hospitalized. She was maintained on her home regimen of lactulose. She also had 24-hr urine collection for copper to evaluate for ___ disease. . #Leukocytosis and mild fever: She had a temparature of 101 upon presentation in the ED. She had no signs or symptoms of any infection. Urine culture showed only GU flora, consistent with contamination. After arrival to the floor her temperature was stable, ranging from 99 to 101. Her WBC trended down throughout the hospitalization and was 11 at the time of discharge. . #Tachycardia: Her heart rate was elevated in the 100-120s throughout the hospitalization. She had good oxygenation and had no complaints of SOB, dyspnea, chest pain, palpitations. The most likely etiology of this is pain, anxiety, and her low intravascular volume. She was tachycardic in the 100s upon discharge. . #Back pain: Lumbosacral spine film revealed no skeletal abnormalities (vertebral compression fracture and osteomyelitis). Her pain was present but well-controlled throughout the hospitalization with oxycodone ___ Q6H PRN pain. Recommended follow up with her primary care provider to address management of her chronic pain. . #Diet: Low sodium (2g/day), fluid restriction (1500mL/day) . #Code: Full Medications on Admission: - AMITRIPTYLINE - 10 mg PO HS - OXYCODONE - 5 mg PO Q8H PRN pain - Thiamine 100mg PO daily - Folic acid 1mg PO daily - MVI PO daily Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Primary: Ascites Portal hypertension Alcoholic hepatitis . Secondary: Chronic back pain Discharge Condition: Alert and Oriented. Ambulating without help. Hemodynamically stable, afebrile, tachycardic. Discharge Instructions: You were seen in the ___ Associates with complaints of increasing abdominal distention and pain. In the clinic, you also had a mild fever, fast heart rate, and increased white blood count. You were sent to the emergency department and admitted to the hospital for further workup. During the hospitalization your ascitic fluid was tapped and analyzed. The result showed that you did not have an infection of the ascitic fluid. Subsequently, fluid was removed from your abdomen via paracentesis. We also started a 24-hr urine collection for copper to work up for other potential causes of your liver disease. The liver clinic will follow up with you regarding the results of these tests. . Your back pain persisted during your hospitalization. You underwent x-rays which showed no evidence of fracture or bone infection. Please continue your home pain regimen and readdress with your primary care provider. . No changes were made to your home medications. You should continue to use lactulose for constipation while using pain medications. . Please stop using all herbal or tonic remedies until your liver function has recovered. Some of these therapies may interact with your current medications or make it difficult to interpret your laboratory results. Followup Instructions: ___

{'Abdominal distention/pain': ['Portal hypertension', 'Other ascites', 'Alcoholic cirrhosis of liver'], 'Fever': ['Acute alcoholic hepatitis'], 'Leukocytosis': ['Acute alcoholic hepatitis'], 'Tachycardia': ['Portal hypertension', 'Other ascites', 'Alcoholic cirrhosis of liver'], 'Back pain': ['Lumbago', 'Other chronic pain']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Sulfonamides / Codeine / Bactrim Attending: ___. Chief Complaint: abdominal pain and vomiting Major Surgical or Invasive Procedure: ___ Exploratory laparotomy, lysis of adhesions, small bowel resection with enteroenterostomy. History of Present Illness: The patient is a ___ year old woman s/p hysterectomy for uterine fibroids and s/p R lung resection for carcinoid tumor who is seen in surgical consultation for abdominal pain, nausea, and vomiting. The patient was feeling well until early this morning at approximately 1:00am, when she developed cramping abdominal pain associated with nausea and bilious emesis without blood. She vomited approximately ___ times which prompted her presentation to the ED. At the time of her emesis, she had diarrhea and moved her bowels > 3 times. She has never had this or similar pain in the past, and she states that she has never before had a small bowel obstruction. She has never had a colonoscopy. Past Medical History: PMH: carcinoid tumor as above Vitamin B12 deficiency depression hyperlipidemia PSH: s/p R lung resection in ___ at ___ s/p hysterectomy in ___ s/p R arm surgery Social History: ___ Family History: non contributory Physical Exam: Temp 96.9 HR 105 BP 108/92 100%RA NAD, appears non-toxic but uncomfortable heart tachycardic but regular, no murmurs appreciated lungs clear to auscultation; decreased breath sounds on R; well-healed R thoracotomy scar present abdomen soft, very obese, minimally distended, somewhat tender to palpation diffusely across abdomen; no guarding; no rebound tenderness, low midline abdominal wound c/d/i, no drainage, no erythema Pertinent Results: ___ 04:40AM WBC-12.5*# RBC-4.46 HGB-13.6 HCT-39.7 MCV-89 MCH-30.5 MCHC-34.2 RDW-13.0 ___ 04:40AM NEUTS-91.1* LYMPHS-7.4* MONOS-0.8* EOS-0.3 BASOS-0.2 ___ 04:40AM PLT COUNT-329 ___ 04:40AM GLUCOSE-151* UREA N-10 CREAT-0.8 SODIUM-142 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 ___ 04:40AM ALT(SGPT)-12 AST(SGOT)-16 LD(LDH)-180 ALK PHOS-62 ___ CT of abdomen and pelvis :1. Slightly dilated loops of small bowel with fecalization of small bowel contents and distal collapsed loops, together indicating early complete or partial small-bowel obstruction. 2. Post-surgical changes noted at the right ribs as detailed above. ___ CT of abdoman and pelvis : 1. Interval worsening of small bowel obstruction. Transition point in the left mid abdomen. (The patient went to the OR on the evening of the study). 2. Trace free fluid in the pelvis is likely physiologic. ___ 10:57PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 10:57PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 10:57PM URINE RBC->50 ___ BACTERIA-MOD YEAST-NONE EPI-0 ___ 10:57PM URINE MUCOUS-OCC ___ 04:40AM GLUCOSE-151* UREA N-10 CREAT-0.8 SODIUM-142 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 ___ 04:40AM estGFR-Using this ___ 04:40AM ALT(SGPT)-12 AST(SGOT)-16 LD(LDH)-180 ALK PHOS-62 TOT BILI-0.2 ___ 04:40AM LIPASE-17 ___ 04:40AM WBC-12.5*# RBC-4.46 HGB-13.6 HCT-39.7 MCV-89 MCH-30.5 MCHC-34.2 RDW-13.0 ___ 04:40AM NEUTS-91.1* LYMPHS-7.4* MONOS-0.8* EOS-0.3 BASOS-0.2 ___ 04:40AM PLT COUNT-329 Brief Hospital Course: This ___ year old female was admitted to the hospital and was made NPO, IV fluids were started and she had a nasogastric tube placed. She was pan cultured for a temperature of 101 and was followed with serial KUB's and physical exam. Her nasogastric tube was clamped on hospital day 2 and she soon developed increased abdominal pain prompting repeat CT of abdomen and pelvis. This demonstrated an increase in the degree of obstruction and she was subsequently taken to the operating room for the aforementioned procedure. She tolerated the procedure well, remained NPO with nasogastric tube in place and treated with IV fluids. Her pain was initially controlled with a morphine PCA . Her nasogastric tube was removed on post op day #2 and she began a clear liquid diet which she tolerated well. This was gradually advanced over 36 hours to a regular diet and was tolerated well. She was having bowel movements and tolerated oral pain medication. Her incision was healing well and staples were intact. After an uncomplicated course she was discharged home on ___ Medications on Admission: Albuteral MDI prn wheezes Flovent inhaler prn wheezes Srtraline 200 mg oral daily Simvastatin 20 mg oral daily Trazadone 100 mg oral daily at bedtime Wellbutrin 75 mg oral twice a day Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing, shortness of breath. 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 3. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Wellbutrin 75 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: High grade small bowel obstruction Discharge Condition: Henodynamically stable, tolerating a regular diet, having bowel movements, adequate pain control Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *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 ___ days after surgery. *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody Followup Instructions: ___

{'abdominal pain': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'nausea': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'vomiting': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'diarrhea': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'cramping abdominal pain': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'bilious emesis': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'small bowel obstruction': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'tachycardic': ['Depressive disorder', 'not elsewhere classified'], 'regular but no murmurs appreciated': ['Depressive disorder', 'not elsewhere classified'], 'soft abdomen': ['Depressive disorder', 'not elsewhere classified'], 'minimally distended': ['Depressive disorder', 'not elsewhere classified'], 'somewhat tender': ['Depressive disorder', 'not elsewhere classified'], 'low midline abdominal wound': ['Surgical operation with anastomosis', 'bypass', 'or graft'], 'well-healed R thoracotomy scar': ['Personal history of malignant neoplasm of bronchus and lung'], 'decreased breath sounds on R': ['Personal history of malignant neoplasm of bronchus and lung'], 'Vitamin B12 deficiency': ['Other B-complex deficiencies'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo woman with h/o hypertension, hyperlipidemia, diabetes mellitus on insulin therapy, h/o cerebellar-medullary stroke in ___, CKD stage III-IV presenting with fatigue and dyspnea on exertion (DOE) for a few weeks, markedly worse this morning. Over the past few weeks, the patient noted DOE and shortness of breath (SOB) even at rest. She has also felt more tired than usual. She notes no respiratory issues like this before. She cannot walk up stair due to DOE, and feels SOB after only a short distance. She is unsure how long the episodes last, but states that her breathing improves with albuterol which she gets from her husband. She had a bad cough around a month ago, but denies any recent fevers, chills, or night sweats. No chest pain, nausea, or dizziness. Past Medical History: 1. CAD RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: MI in ___ 3. OTHER PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Diabetes mellitus on insulin therapy h/o cerebellar-medullary stroke in ___ CKD stage III-IV PVD Social History: ___ Family History: Denies cardiac family history. Family hx of DM and HTN; otherwise non-contributory. Physical Exam: Admission exam: GENERAL- Oriented x3. Mood, affect appropriate. VS- T= 98.1 BP= 200/103 HR= 65 RR= 26 O2 sat= 100% on RA HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK- JVD to angle of mandible CARDIAC- RR, normal S1, S2. No murmurs, rubs or gallops. No thrills, lifts. LUNGS- Kyphosis. Resp were labored, mild exp wheezes bilaterally. ABDOMEN- Soft, non-tender, not distended. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES- No clubbing, cyanosis or edema. No femoral bruits. SKIN- No stasis dermatitis, ulcers, scars, or xanthomas. NEURO- CNII-XII grossly intact. Strength ___ in LEs and UEs. Diminished sensation along lateral aspect of left leg to light touch Discharge exam: Lungs: CTAB Otherwise unchanged Pertinent Results: Admission Labs ___ 01:18PM BLOOD WBC-6.4# RBC-3.15* Hgb-9.5* Hct-30.1* MCV-96 MCH-30.1 MCHC-31.5 RDW-14.1 Plt ___ ___ 01:18PM BLOOD Glucose-150* UreaN-33* Creat-1.6* Na-144 K-4.8 Cl-111* HCO3-18* AnGap-20 ___ 01:18PM BLOOD CK(CPK)-245* ___ 01:18PM BLOOD cTropnT-0.05* ___ 01:18PM BLOOD CK-MB-6 proBNP-4571* ___ 03:56AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.0 Cholest-230* Pertinent Labs ___ 06:09AM BLOOD WBC-4.3 RBC-3.27* Hgb-9.9* Hct-31.4* MCV-96 MCH-30.4 MCHC-31.6 RDW-14.5 Plt ___ ___ 06:09AM BLOOD Glucose-138* UreaN-31* Creat-1.4* Na-144 K-4.3 Cl-107 HCO3-26 AnGap-15 ___ 06:09AM BLOOD ALT-20 AST-17 ___ 03:56AM BLOOD Triglyc-97 HDL-65 CHOL/HD-3.5 LDLcalc-146* ___ 03:56AM BLOOD %HbA1c-8.1* eAG-186* ___ 01:18PM BLOOD CK(CPK)-245* CK-MB-6 cTropnT-0.05* ___ 08:43PM BLOOD CK(CPK)-198 CK-MB-5 cTropnT-0.03* ___ 03:56AM BLOOD CK(CPK)-173 CK-MB-5 cTropnT-0.04* ___ 06:09AM BLOOD cTropnT-0.01 ___ 01:18PM proBNP-4571* ECG ___ 7:56:06 ___ Baseline artifact. Sinus rhythm. The Q-T interval is 400 milliseconds. Q waves in leads V1-V2 with ST-T wave abnormalities extending to lead V6. Consider prior anterior myocardial infarction. Since the previous tracing of ___ atrial premature beats are not seen. The Q-T interval is shorter. ST-T wave abnormalities are less prominent. CXR ___: PA and lateral views of the chest demonstrate low lung volumes. Tiny bilateral pleural effusions are new since ___. No signs of pneumonia or pulmonary vascular congestion. Heart is top normal in size though this is stable. Aorta is markedly tortuous, unchanged. Aortic arch calcifications are seen. There is no pneumothorax. No focal consolidation. Partially imaged upper abdomen is unremarkable. IMPRESSION: Tiny pleural effusions, new. Otherwise unremarkable. ECHO ___: The left atrium is mildly dilated. The estimated right atrial pressure is ___ mmHg. 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 diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. An eccentric, anteriorly directed jet of mild to moderate (___) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Pulmonary artery hypertension. Mild-moderate mitral regurgitation. Moderate tricuspid regurgitation. Compared with the prior study (images reviewed) of ___, the severity of mitral and tricuspid regurgitation are increased and moderate PA hypertension is now identified. Brief Hospital Course: ___ woman with h/o hypertension, hypelipidemia, diabetes mellitus on insulin, cerebellar-medullary stroke in ___, stage ___ CKD followed by Dr ___ presenting with fatigue and DOE for a few weeks, markedly worse the morning of admission. The patient has known diastolic dysfunction. Of note, she has been noncompliant with her medications at home. On arrival to the floor, she required hydralazine 20 mg to bring down her BP. She has likely had elevated BPs at home for a while, which is contributing to her SOB, CHF exacerbation, and secondary demand myonecrosis (hypertensive urgency) with mildly elevated troponin. # CAD: Although she did not have a classic anginal presentation, patient has several risk factors for acute coronary syndrome. Her only symptom was SOB in the setting of elevated BPs attributed to medication noncompliance at home. Her troponin fell from 0.05 at admission to 0.01 at discharge in the setting of renal dysfunction, but there was not a clear rise and fall to suggest an acute infarction from plaque rupture and thrombosis. She was scheduled for an outpatient stress test to evaluate for evidence of ischemia from flow-limiting CAD. We decreased ASA to 81 mg from 325 mg daily to decrease the risk of bleeding. Her LDL was found to be 146. We wanted to change her from simvastatin to the more potent atorvastatin (and avoid issues with drug-drug interactions), but her insurance would not cover atorvastatin. She was therefore switched to pravastatin 80 mg at discharge. From a cardiac standpoint, we did not feel that Plavix was necessary for CAD, but her neurologist was contacted and wanted Plavix continued. We had to stop metoprolol due to HR in the ___ during admission even off metoprolol. # Pump: Last echo in ___ showed low normal LVEF. Her current presentation was consistent with CHF exacerbation with bilateral pleural effusions, dyspnea, and elevated NT-Pro-BNP. Her TTE showed mild-moderate mitral and moderate tricuspid regurgitation, LVEF 50-55%, and pulmonary hypertension. We changed her HCTZ to Lasix 40 mg PO at discharge. This medication can be uptitrated as needed. # Hypertension: The patient's nephrologist, Dr. ___, agreed with our proposed medication adjustments, but recommended staying away from clonidine. There has been a H/O medication non-adherence. Social work was involved in discharge planning, and ___ will be assisting the patient at home. We added lisinopril 20 mg daily, Lasix 40 mg daily and continued nifedipine 120 mg daily. Her atenolol was stopped due to her renal dysfunction, but her metoprolol had to be stopped due to bradycardia. She should continue on once a day medication dosing to help with compliance. # ? COPD: The patient may have a component of COPD as she was wheezing on admission and responded to albuterol. She was given a prescription for albuterol prn. Transitional Issues: - She will be scheduled for outpt stress stress test - She has follow-up appointments with Dr. ___ and Dr. ___ and both can work on uptitrating her BP meds as needed. - ___ will need to work with patient on medication compliance. Medications on Admission: ATENOLOL - 100 mg Tablet - 1.5 Tablet(s) by mouth once a day CLONIDINE - 0.1 mg/24 hour Patch Weekly - place on shoulder once a week CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once a day generic is available preferable, please call Dr ___ an appointment FENOFIBRATE MICRONIZED - 134 mg Capsule - 1 Capsule(s) by mouth once a day HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 (One) Tablet(s) by mouth once a day NIFEDIPINE [NIFEDIAC CC] - 60 mg Tablet Extended Release - 2 Tablet(s) by mouth once a day NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1 Tablet(s) sublingually sl as needed for prn chest pain may use 3 doses, 5 minutes apart; if no relief, ED visit RANITIDINE HCL - 300 mg Tablet - 1 Tablet(s) by mouth once a day SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC ASPIRIN [ENTERIC COATED ASPIRIN] - 325 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - 100 unit/mL (70-30) Suspension - 30 units at dinner at dinner MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: may take up to 3 over 15 minutes. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. pravastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. nifedipine 60 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily). Disp:*30 Tablet Extended Release(s)* Refills:*2* 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen Sig: Thirty (30) units Subcutaneous at dinner. Disp:*900 units* Refills:*2* 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: ___ puffs Inhalation every ___ hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*1* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: -Hypertension with hypertensive urgency -Myocardial infarction attributed to demand myonecrosis -Acute on chronic left ventricular diastolic heart failure -Chronic kidney disease, stage ___ -Chronic obstructive pulmonary disease -Prior cerebellar-medullary stroke -Hyperlipidemia -Diabetes mellitus requiring insulin therapy -Medication non-adherence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted for shortness of breath. You were found to have elevated blood pressure on admission in the setting of not taking all of your medications regularly. We obtained an echocargiogram of your heart which showed some strain on your heart possibly related to your elevated blood pressures. You will be contacted about an outpatient stress test. This will be completed within the next month. You will be prescribed several new medications as shown below. A visiting nurse ___ come to your home to help with managing your medications. You should dispose of all your home medications and only take the medications shown on this discharge paperwork. Medications: STOP Hydrochlorothiazide STOP Simvastatin STOP Clonidine STOP Atenolol due to low heart rate CHANGE 325mg to 81mg once daily START Lisinopril 20mg once daily START Lasix 40mg once daily START Pravastin 80mg once daily If you experience any chest pain, excessive shortness of breath, or any other symptoms concerning to you, please call or come into the emergency department for further evaluation. Thank you for allowing us at the ___ to participate in your care. Followup Instructions: ___

{'shortness of breath': ['Acute on chronic diastolic heart failure', 'Other acute and subacute forms of ischemic heart disease'], 'fatigue': ['Acute on chronic diastolic heart failure', 'Other acute and subacute forms of ischemic heart disease'], 'dyspnea on exertion': ['Acute on chronic diastolic heart failure', 'Other acute and subacute forms of ischemic heart disease'], 'elevated blood pressure': ['Hypertensive chronic kidney disease', 'unspecified', 'with chronic kidney disease stage I through stage IV', 'or unspecified'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'diabetes mellitus': ['Diabetes mellitus without mention of complication', 'type II or unspecified type', 'not stated as uncontrolled', 'Long-term (current) use of insulin'], 'history of cerebellar-medullary stroke': ['Personal history of transient ischemic attack (TIA)', 'and cerebral infarction without residual deficits'], 'chronic obstructive pulmonary disease': ['Chronic airway obstruction', 'not elsewhere classified'], 'chronic kidney disease': ['Chronic kidney disease', 'Stage III (moderate)'], 'congestive heart failure': ['Congestive heart failure', 'unspecified'], 'noncompliance with medication': ['Personal history of noncompliance with medical treatment', 'presenting hazards to health']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Worsening ABD distension and pain Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: ___ HCV cirrhosis c/b ascites, hiv on ART, h/o IVDU, COPD, bioplar, PTSD, presented from OSH ED with worsening abd distension over past week. Pt reports self-discontinuing lasix and spirnolactone ___ weeks ago, because she feels like "they don't do anything" and that she "doesn't want to put more chemicals in her." She does not follow Na-restricted diets. In the past week, she notes that she has been having worsening abd distension and discomfort. She denies ___ edema, or SOB, or orthopnea. She denies f/c/n/v, d/c, dysuria. She had food poisoning a week ago from eating stale cake (n/v 20 min after food ingestion), which resolved the same day. She denies other recent illness or sick contacts. She notes that she has been noticing gum bleeding while brushing her teeth in recent weeks. she denies easy bruising, melena, BRBPR, hemetesis, hemoptysis, or hematuria. Because of her abd pain, she went to OSH ED and was transferred to ___ for further care. Per ED report, pt has brief period of confusion - she did not recall the ultrasound or bloodwork at osh. She denies recent drug use or alcohol use. She denies feeling confused, but reports that she is forgetful at times. In the ED, initial vitals were 98.4 70 106/63 16 97%RA Labs notable for ALT/AST/AP ___ ___: ___, Tbili1.6, WBC 5K, platelet 77, INR 1.6 Past Medical History: 1. HCV Cirrhosis 2. No history of abnormal Pap smears. 3. She had calcification in her breast, which was removed previously and per patient not, it was benign. 4. For HIV disease, she is being followed by Dr. ___ Dr. ___. 5. COPD 6. Past history of smoking. 7. She also had a skin lesion, which was biopsied and showed skin cancer per patient report and is scheduled for a complete removal of the skin lesion in ___ of this year. 8. She also had another lesion in her forehead with purple discoloration. It was biopsied to exclude the possibility of ___'s sarcoma, the results is pending. 9. A 15 mm hypoechoic lesion on her ultrasound on ___ and is being monitored by an MRI. 10. History of dysplasia of anus in ___. 11. Bipolar affective disorder, currently manic, mild, and PTSD. 12. History of cocaine and heroin use. Social History: ___ Family History: She a total of five siblings, but she is not talking to most of them. She only has one brother that she is in touch with and lives in ___. She is not aware of any known GI or liver disease in her family. Her last alcohol consumption was one drink two months ago. No regular alcohol consumption. Last drug use ___ years ago. She quit smoking a couple of years ago. Physical Exam: VS: 98.1 107/61 78 18 97RA General: in NAD HEENT: CTAB, anicteric sclera, OP clear Neck: supple, no LAD CV: RRR,S1S2, no m/r/g Lungs: CTAb, prolonged expiratory phase, no w/r/r Abdomen: distended, mild diffuse tenderness, +flank dullness, cannot percuss liver/spleen edge ___ distension GU: no foley Ext: wwp, no c/e/e, + clubbing Neuro: AAO3, converse normally, able to recall 3 times after 5 minutes, CN II-XII intact Discharge: PHYSICAL EXAMINATION: VS: 98 105/70 95 General: in NAD HEENT: anicteric sclera, OP clear Neck: supple, no LAD CV: RRR,S1S2, no m/r/g Lungs: CTAb, prolonged expiratory phase, no w/r/r Abdomen: distended but improved, TTP in RUQ, GU: no foley Ext: wwp, no c/e/e, + clubbing Neuro: AAO3, CN II-XII intact Pertinent Results: ___ 10:25PM GLUCOSE-109* UREA N-25* CREAT-0.3* SODIUM-138 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-27 ANION GAP-9 ___ 10:25PM estGFR-Using this ___ 10:25PM ALT(SGPT)-100* AST(SGOT)-114* ALK PHOS-114* TOT BILI-1.6* ___ 10:25PM LIPASE-77* ___ 10:25PM ALBUMIN-3.3* ___ 10:25PM WBC-5.0# RBC-4.29 HGB-14.3 HCT-42.6 MCV-99* MCH-33.3* MCHC-33.5 RDW-15.7* ___ 10:25PM NEUTS-70.3* LYMPHS-16.5* MONOS-8.1 EOS-4.2* BASOS-0.8 ___ 10:25PM PLT COUNT-71* ___ 10:25PM ___ PTT-30.9 ___ ___ 10:25PM ___ . CXR: No acute cardiopulmonary process. U/S: 1. Nodular appearance of the liver compatible with cirrhosis. Signs of portal hypertension including small amount of ascites and splenomegaly. 2. Cholelithiasis. 3. Patent portal veins with normal hepatopetal flow. Diagnostic para attempted in the ED, unsuccessful. On the floor, pt c/o abd distension and discomfort. Brief Hospital Course: ___ HCV cirrhosis c/b ascites, hiv on ART, h/o IVDU, COPD, bioplar, PTSD, presented from OSH ED with worsening abd distension over past week and confusion. # Ascites - p/w worsening abd distension and discomfort for last week. likely ___ portal HTN given underlying liver disease, though no ascitic fluid available on night of admission. No signs of heart failure noted on exam. This was ___ to med non-compliance and lack of diet restriction. SBP negative diuretics: > Furosemide 40 mg PO DAILY > Spironolactone 50 mg PO DAILY, chosen over the usual 100mg dose d/t K+ of 4.5. CXR was wnl, UA negative, Urine culture blood culture negative. Pt was losing excess fluid appropriately with stable lytes on the above regimen. Pt was scheduled with current PCP for ___ check upon discharge. Pt was scheduled for new PCP with Dr. ___ at ___ and follow up in Liver clinic to schedule outpatient screening EGD and ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Spironolactone 50 mg PO DAILY 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB 4. Raltegravir 400 mg PO BID 5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 6. Nicotine Patch 14 mg TD DAILY 7. Ipratropium Bromide Neb 1 NEB IH Q6H SOB Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB 2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 3. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*3 4. Ipratropium Bromide Neb 1 NEB IH Q6H SOB 5. Nicotine Patch 14 mg TD DAILY 6. Raltegravir 400 mg PO BID 7. Spironolactone 50 mg PO DAILY 8. Acetaminophen 500 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Ascites from Portal HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you! You came to us with stomach pain and worsening distension. While you were here we did a paracentesis to remove 1.5L of fluid from your belly. We also placed you on you 40 mg of Lasix and 50 mg of Aldactone to help you urinate the excess fluid still in your belly. As we discussed, everyone has a different dose of lasix required to make them urinate and it's likely that you weren't taking a high enough dose. Please take these medications daily to keep excess fluid off and eat a low salt diet. You will follow up with Dr. ___ in liver clinic and from there have your colonoscopy and EGD scheduled. Of course, we are always here if you need us. We wish you all the best! Your ___ Team. Followup Instructions: ___

{'worsening abd distension': ['Portal hypertension', 'Other ascites', 'Cirrhosis of liver without mention of alcohol'], 'abd pain': ['Portal hypertension', 'Other ascites', 'Cirrhosis of liver without mention of alcohol'], 'gum bleeding': ['Unspecified viral hepatitis C without hepatic coma'], 'forgetfulness': ['Bipolar disorder', 'unspecified', 'Posttraumatic stress disorder']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Epistaxis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ with history of AAA s/p repair complicated by MI, hypertension, and hyperlipidemia who presents upon transfer from outside hospital with nasal fractures and epistaxis secondary to fall. The patient reports that he was at the ___ earlier this afternoon. While coughing, he tripped on the curb and suffered trauma to his face. He had no loss of consciousness. However, he had a persistent nosebleed and appeared to have some trauma to his face, thus was transferred to ___ for further care. There, a CT scan of the head, neck, and face were remarkable for a nasal bone and septal fracture. Given persistent epistaxis, bilateral RhinoRockets were placed. He had a small abrasion to the bridge of his nose which was not closed. Bleeding was well controlled. While in the OSH ED, he had an episode of nausea and coughed up some blood. At that time, he began to feel lightheaded and was noted to be hypotensive and bradycardic. Per report, he had a brief loss of consciousness, though quickly returned to his baseline. His family noted that his eyes rolled back into his head. The patient recalls the event and denies post-event confusion. He had no further episodes of syncope or hemodynamic changes. Given the syncopal event and epistaxis, the patient was transferred for further care. In the ED, initial vital signs 98.9 92 140/77 18 100%/RA. Labs were notable for WBC 11.3 (91%N), H/H 14.1/40.2, plt 147, BUN/Cr 36/1.5. HCTs were repeated which were stable. A urinalysis was negative. A CXR demonstrated a focal consolidation at the left lung base, possibly representing aspiration or developing pneumonia. The patient was given Tdap, amoxicillin-clavulanate for antibiotic prophylaxis, ondansetron, 500cc NS, and metoprolol tartrate 50mg. Clopidogrel was held. Past Medical History: MI after AAA repair when he was ___ y/o HTN Hypercholesterolemia Social History: ___ Family History: Patient is unaware of a family history of bleeding diathesis. Physical Exam: ADMISSION: VS: 98.5 142/65 95 18 98RA GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, bruising under both eyes, swollen nose with mild tenderness, RhinoRockets in place NECK: Supple, without LAD RESP: Generally CTA bilaterally CV: RRR, (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended GU: Deferred EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: CN II-XII grossly intact, motor function grossly normal SKIN: No excoriations or rash. DISCHARGE: VS: 98.4 125/55 73 18 94RA GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, bruising under both eyes, swollen nose with mild tenderness, RhinoRockets in place NECK: Supple, without LAD RESP: Generally CTA bilaterally CV: RRR, (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended GU: Deferred EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: CN II-XII grossly intact, motor function grossly normal SKIN: No excoriations or rash. Pertinent Results: ADMISSION: ___ 08:15PM BLOOD WBC-11.3* RBC-4.30* Hgb-14.1 Hct-40.2 MCV-93 MCH-32.8* MCHC-35.1* RDW-12.8 Plt ___ ___ 08:15PM BLOOD Neuts-91.1* Lymphs-4.7* Monos-3.8 Eos-0.3 Baso-0.1 ___ 08:15PM BLOOD ___ PTT-26.8 ___ ___ 08:15PM BLOOD Glucose-159* UreaN-36* Creat-1.5* Na-141 K-4.1 Cl-106 HCO3-21* AnGap-18 ___ 06:03AM BLOOD CK(CPK)-594* CARDIAC MARKER TREND: ___ 07:45AM BLOOD cTropnT-0.04* ___ 06:03AM BLOOD CK-MB-36* MB Indx-6.1* cTropnT-0.57* ___ 03:03PM BLOOD CK-MB-23* MB Indx-4.2 cTropnT-0.89* ___ 05:59AM BLOOD CK-MB-8 cTropnT-1.28* ___ 01:16PM BLOOD CK-MB-5 cTropnT-1.29* ___ 06:10AM BLOOD CK-MB-4 cTropnT-1.48* ___ 07:28AM BLOOD CK-MB-2 cTropnT-1.50* DISCHARGE LABS: ___ 07:28AM BLOOD WBC-4.2 RBC-3.85* Hgb-12.5* Hct-36.0* MCV-94 MCH-32.5* MCHC-34.7 RDW-12.9 Plt ___ ___ 07:28AM BLOOD Glucose-104* UreaN-30* Creat-1.6* Na-142 K-4.3 Cl-106 HCO3-26 AnGap-14 IMAGING: ___ CXR PA and lateral views of the chest provided. The lungs are adequately aerated. There is a focal consolidation at the left lung base adjacent to the lateral hemidiaphragm. There is mild vascular engorgement. There is bilateral apical pleural thickening. The cardiomediastinal silhouette is remarkable for aortic arch calcifications. The heart is top normal in size. ___ ECHO The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal apical hypokinesis. The remaining segments contract normally (LVEF = 55 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. There is mild aortic valve stenosis (valve area 1.7cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal left ventricular cavity size with mild regional systolic dysfunction most c/w CAD (distal LAD distribution). Mild aortic valve stenosis. Mild aortic regurgitation. Brief Hospital Course: Mr. ___ is an ___ with history of AAA s/p repair complicated by MI, hypertension, and hyperlipidemia who presented with nasal fractures and epistaxis after mechanical fall with hospital course complicated by NSTEMI. #Epistaxis, nasal fractures Patient presenting after mechanical fall with Rhinorockets placed at outside hospital for ongoing epistaxis. CT scan from that hospital demonstrated nasal bone and septal fractures. The Rhinorockets were maintained while inpatient and discontinued prior to discharge. He was encouraged to use oxymetolazone nasal spray and hold pressure should bleeding reoccur. #NSTEMI Patient found to have mild elevation of troponin in the ED. This was trended and eventually rose to 1.5, though MB component downtrended during course of admission. The patient was without chest pain or other cardiac symptoms. Cardiology was consulted who thought that this was most likely secondary to demand ischemia (type II MI) secondary to his fall. An echocardiogram demonstrated aortic stenosis and likely distal LAD disease based on wall motion abnormalities. The patient's metoprolol was uptitrated, his pravastatin was converted to atorvastatin, his clopidogrel was maintained, and he was started on aspirin. #Hypoxemia/L basilar consolidation Patient reported to be mildly hypoxic in the ED, though he maintained normal oxygen saturations on room air. He denied shortness of breath or cough, fevers, or other infectious symptoms and had no leukocytosis. A CXR revealed consolidation in left lung, thought to be possibly related to aspirated blood. -monitor O2 saturation, temperature, trend WBC. He was convered with antibiotics while inpatient as he required prophylaxis for the Rhinorockets, but this was discontinued upon discharge. #Acute kidney injury Patient presented with creatinine of 1.5 with last creatinine at PCP 1.8. Patient was unaware of a history of kidney disease. The patient was discharged with a stable creatinine. #Peripheral vascular disease Patient had a history of AAA repair in ___ without history of MI per PCP. Patient denied history of CABG or cardiac/peripheral stents. A cardiac regimen was continued, as above. TRANSITIONAL ISSUES -Outpatient stress echo for futher evaluation distal LAD disease (possibly a large myocardial territory at risk). -Repeat echocardiogram in ___ years to monitor mild AS/AR. -If epistaxis returns, can use oxymetolazone nasal spray. -Repeat chest x-ray in ___ weeks to ensure resolution of the LLL infiltrative process. -Consider follow-up with ENT or Plastic Surgery for later evaluation of nasal fractures. -Repeat CBC in one week to ensure stability of HCT and platelets. -Consider conversion of metoprolol tartrate to succinate for ease-of-administration. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clopidogrel 75 mg PO DAILY 2. Metoprolol Tartrate 50 mg PO TID 3. Pravastatin 80 mg PO QPM Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Acetaminophen 650 mg PO Q8H:PRN pain Please avoid NSAID medications like ibuprofen given your bleeding. 3. Aspirin 81 mg PO DAILY Duration: 30 Days 4. Metoprolol Tartrate 75 mg PO TID RX *metoprolol tartrate 25 mg 3 tablet(s) by mouth three times daily Disp #*270 Tablet Refills:*0 5. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth every evening Disp #*30 Tablet Refills:*0 6. Oxymetazoline 1 SPRY NU BID:PRN nosebleed This can be purchased over-the-counter, the brand name is ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Nasal fracture Epistaxis NSTEMI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted after you fell and broke your nose. You had nose bleeds that were difficult to control, thus plugs were placed in your nose to stop the bleeding. During your hospital course, you were found to have high troponins, a blood test for the heart. A ultrasound of your heart was performed. You should follow-up with your PCP to discuss stress test. It was a pleasure participating in your care, thank you for choosing ___. Followup Instructions: ___

{'Epistaxis': ['Epistaxis'], 'NSTEMI': ['Subendocardial infarction', 'Coronary atherosclerosis of native coronary artery'], 'Hypoxemia/L basilar consolidation': ['Hypoxemia'], 'Acute kidney injury': ['Acute kidney failure'], 'Peripheral vascular disease': ['Peripheral vascular disease']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Codeine / Bactrim Attending: ___ Chief Complaint: nausea, vomiting, cough Major Surgical or Invasive Procedure: none History of Present Illness: ___ female, with past medical history significant for depression, hyperlipidemia, Hysterectomy, B12 deficiency, back pain, carcinoid, cervical DJD, depression, hyperlipidemia, osteoarthritis, and history of Exploratory laparotomy, lysis of adhesions, and small bowel resection with enteroenterostomy for a high grade SBO ___ who presents with nausea, vomiting, weakness x 2 weeks. She has been uable to tolerate PO liquids, and solids. Had similar presentation ___ for high grade SBO. Denies passing flatus today. However reports having last normal bowel movement this AM, without hematochezia, melena. Also reporting subjective fever (100.0), non productive cough. Denies HA, myalgias. Takes NSAIDS sparingly. Denies alcohol use. Denies sick contacs/ travel or recent consumption of raw foods. Has never had a colonoscopy. . In ED VS were 97.8 120 121/77 20 98% RA Labs were remarkable for lactate 2.8, alk phos 293, HCT 33, WBC 13.9 Imaging: CT abdomen showed mult masses in the liver, consistent with malignancy. CXR also showed multiple nodules EKG: sinus, 112, NA, NI, TWI in III, but largely unchanged from prior Interventions: zofran, tylenol, 2L NS, GI was contacted and they are planning on upper / lower endoscopy for cancer work-up. . Vitals on transfer were 99.2 113 119/47 26 98% Past Medical History: PMH: # high grade SBO ___ s/p exploratory laparotomy, lysis of adhesions, and small bowel resection with enteroenterostomy # carcinoid # hyperlipidemia # vitamin B12 deficiency # cervical DJD # osteoarthritis PSH: s/p R lung resection in ___ at ___ s/p hysterectomy in ___ s/p R arm surgery Social History: ___ Family History: non contributory Physical Exam: On admission VS: 98.9 137/95 117 20 100 RA GENERAL: AOx3, NAD HEENT: MMM. no JVD. neck supple. HEART: Regular tachycardic, S1/S2 heard. no murmurs/gallops/rubs. LUNGS: CTAB, non labored ABDOMEN: soft, tender to palpation in epigastrium. EXT: wwp, no edema. DPs, PTs 2+. SKIN: dry, no rash NEURO/PSYCH: CNs II-XII intact. strength and sensation in U/L extremities grossly intact. gait not assessed. On Discharge: VS: 98.7 118/78 97 20 99RA GENERAL: Patient is sitting in a chair, appears comfortable, A+Ox3, cooperative. HEENT: EOMI, PERRLA, No Pallor or Jaundice, MMM, no JVD, neck supple. HEART: RRR, no m/r/g. LUNGS: CTAB ABDOMEN: obese, soft, mild tenderness on mid +right epigastrium w/o peritoneal signs, no shifting dullness, difficult to appreciate organomegaly. EXT: wwp, no edema, no signs of DVT SKIN: no rash, normal turgor NEURO: no gross deficits PSYCH: appropriate affect, no preceptual disturbances, no SI, normal judgment. Pertinent Results: ___ 03:14PM ___ ___ 12:50PM URINE HOURS-RANDOM ___ 12:50PM URINE UHOLD-HOLD ___ 12:50PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR ___ 12:50PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-2 ___ 09:54AM LACTATE-2.8* ___ 09:45AM GLUCOSE-96 UREA N-7 CREAT-0.5 SODIUM-138 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15 ___ 09:45AM estGFR-Using this ___ 09:45AM ALT(SGPT)-17 AST(SGOT)-46* ALK PHOS-293* TOT BILI-0.5 ___ 09:45AM LIPASE-14 ___ 09:45AM ALBUMIN-3.0* ___ 09:45AM ___ AFP-1.7 ___ 09:45AM WBC-13.9* RBC-3.94* HGB-9.8* HCT-33.0* MCV-84# MCH-25.0*# MCHC-29.9* RDW-16.1* ___ 09:45AM NEUTS-75.2* LYMPHS-17.9* MONOS-5.9 EOS-0.7 BASOS-0.3 ___ 09:45AM PLT COUNT-657*# CT abdomen/pelvis 1. Innumerable hepatic and pulmonary metastases. No obvious primary malignancy is identified on this study. 2. No evidence of small bowel obstruction, ischemic colitis, fluid collection, or perforation. CXR: New nodular opacities within both upper lobes, left greater than right. Findings are compatible with metastases, as was noted in the lung bases on the subsequent CT of the abdomen and pelvis performed later the same day. Brief Hospital Course: ___ Female with PMH significant for depression, hyperlipidemia, Hysterectomy, B12 deficiency, OA, carcinoid, cervical DJD, depression, SBO who presented with nausea, vomiting, weakness x 2 weeks and was found to have multiple liver and lung masses per CT consistent with metastatic cancer of unknown primary. Patient was treated with IV fluids overnight for dehydration. She refused to stay in the hospital for any further work-up or treatment and stated she would rather go home to to think and see to her affairs over the weekend and consider pursuing further work-up as an outpatient. She tolerated oral fluids well w/o vomiting. She remained hemodynamically stable and afebrile throughout her stay. Of note patient has psychiatric history of depressive symptoms and isolation tendencies. She denied any SI/SA or any risk to herself. She has little social supports but does have a good relationship with her driver and friend who came in and was updated by the medical team on the morning of discharge and will be taking her home. She sees a mental health provider at ___ once a month and has a good relationship with her primary care physician. Patient was dischaerged home at her request. Home medications were continued to which we added some symptomatic treatment for her cough with benzonatate and Guaifenesin. We held off on anti-emetics for now as she did not want to stay inhouse to make sure these would be well tolerated (would need to monitor for drug interactions given multiple QTc prolonging and serotonergic medications on her home meds). She was instructed to maintain good hydration and try a soft diet at home if she can not tolerate regular diet. The patient met with SW who provided her with resources for community councelling. Outpatient appointments with oncology, GI and her PCP were set up and her PCP and mental health provider were updated. Her PCP ___ also ___ with her later today by telephone. Medications on Admission: The Preadmission Medication list is accurate and complete 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing/SOB 2. BuPROPion 150 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Ibuprofen 800 mg PO Q8H:PRN pain 5. Sertraline 200 mg PO DAILY 6. Simvastatin 40 mg PO DAILY 7. Tizanidine 4 mg PO BID:PRN muscle spasms/pain 8. traZODONE 100 mg PO HS:PRN sleep 9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 2. BuPROPion 150 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Sertraline 200 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Tizanidine 4 mg PO BID:PRN muscle spasms/pain 7. traZODONE 100 mg PO HS:PRN sleep 8. Ibuprofen 800 mg PO Q8H:PRN pain 9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID 10. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth TID: PRN cough Disp #*60 Capsule Refills:*0 11. Guaifenesin ___ mL PO Q6H:PRN cough RX *guaifenesin 100 mg/5 mL ___ ml by mouth Q6H:PRN cough Disp #*1 Bottle Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Liver and Lung Mets of unkown primary Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ were seen in the ED for ongoing cough, nausea and vomiting and had imaging studies which unfortunately showed spots in your liver and lungs which are likely due to wide-spread cancer. ___ were admitted for further work-up and treatment of your symptoms. ___ chose to not have any more work-up in the hospital and wanted to be discharged home as soon as possible. Please make sure ___ keep well hydrated by taking water sips throughout the day. I also prescribed some symptomatic treatment for your nausea and cough. I updated your PCP and ___ and have set up ___ appointments as below. Followup Instructions: ___

{'nausea': ['Nausea with vomiting'], 'vomiting': ['Nausea with vomiting'], 'weakness': ['Nausea with vomiting'], 'cough': ['Cough'], 'fever': ['Fever'], 'leukocytosis': ['Leukocytosis'], 'dehydration': ['Dehydration'], 'cardiac dysrhythmias': ['Other specified cardiac dysrhythmias'], 'radiological findings': ['Nonspecific (abnormal) findings on radiological and other examination of abdominal area', 'Other nonspecific abnormal finding of lung field'], 'depressive disorder': ['Depressive disorder', 'not elsewhere classified'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'B-complex deficiencies': ['Other B-complex deficiencies'], 'cervical spondylosis': ['Cervical spondylosis without myelopathy'], 'osteoarthrosis': ['Osteoarthrosis', 'unspecified whether generalized or localized', 'site unspecified'], 'tobacco use': ['Personal history of tobacco use'], 'NSAID use': ['Long-term (current) use of non-steroidal anti-inflammatories (NSAID)'], 'intestinal bypass': ['Intestinal bypass or anastomosis status']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins / Paxil / Wellbutrin Attending: ___. Chief Complaint: Exposed hardware Major Surgical or Invasive Procedure: Exposed hardware removal History of Present Illness: The is a ___ year old female who had prior surgery for a possible right parietal anaplastic astrocytoma with craniotomy for resection on ___ by Dr. ___ in ___ followed by involved-field irradiation to 6,120 cGy ___ in ___, 3 cycles of Temodar ended ___ and a second craniotomy for tumor recurrence on ___ by Dr. ___ at ___ with PCV(comb chemo) ___ - ___. In ___ she presented with exposed hardware to the office and she needed admission an complex revision for a plate that had eroded through the skin; Plastics and I reconstructed the scalp at that time. The patient presents today again with some history of pruritus on the top of her head and newly diagnosed exposed hardware. She reports that she had her husband look at the top of her head " a few ago" and saw that metal hardware from her prior surgery was present. Past Medical History: right parietal anaplastic astrocytoma, Craniotomy ___ by Dr. ___ in ___ irradiation to 6,120 cGy ___ in ___,3 cycles of Temodar ended ___ craniotomy on ___ by Dr. ___ at ___ ___ - ___ wound revision and removal of the exposed craniotx hardware, Accutane for 2 weeks only ___ disease since ___, tubal ligation,tonsillectomy, bronchitis, depression. seizures Social History: ___ Family History: NC Physical Exam: AF VSS obese Gen: WD/WN, comfortable, NAD. HEENT: ___ bilat EOMs: intact Neck: Supple. no LNN RRR no SOB obese Extrem: Warm and well-perfused, Neuro: Mental status: Awake and alert, cooperative with exam, normal affect but VERY simple construct. Orientation: Oriented to person, place, and date. Recall: ___ 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, 3 to 2 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. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements W: there is an area over the R hemiconvexity that shows a chronic skin defect where the underlying harware has eroded through the skin. Different from previous repaired portion and represents piece of the implanted miniplates; No discharge; no reythemal no swelling; surprisingly benign aspect. PHYSICAL EXAM PRIOR TO DISCHARGE: AF VSS obese Gen: WD/WN, comfortable, NAD. HEENT: ___ bilat EOMs: intact Neck: Supple. Incision: clean, dry, intact. No redness, swelling, erythema or discharge. Sutures in place. Pertinent Results: ___: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 06:25 4.8 3.49* 11.2* 34.4* 98 31.9 32.5 16.3* 245 BASIC COAGULATION ___, PTT, PLT, INR) Plt Ct ___ 06:25 245 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 06:25 ___ 142 3.4 110* 23 12 Brief Hospital Course: The patient presented to the ___ neurosurgical service on ___ for treatment of exposed hardware from a previous surgery on her head. She went to the OR on ___, where a was performed removal of exposed hardware by Dr. ___. Postoperatively, the patient was stable. Infectious disease consulted the patient and recommended fluconazole 200 mg PO for 5 days for yeast infection and Keflex ___ mg PO BID for 7 days. For DVT prophylaxis, the patient received subcutaneous heparin and SCD's during her stay. At the time of discharge, the patient was able to tolerate PO, was ambulatoryand able to void independently. She was able to verbalize agreement and understanding of the discharge plan. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. ALPRAZolam 0.5 mg PO TID 2. Azathioprine 100 mg PO BID 3. DiCYCLOmine 10 mg PO Q6H:PRN abdominal pain 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 5. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q4H:PRN pain 6. Infliximab 100 mg IV Q6 WEEKS 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Mesalamine 500 mg PO QID 9. Omeprazole 20 mg PO DAILY 10. Promethazine 25 mg PO Q6H:PRN n/v 11. Topiramate (Topamax) 200 mg PO BID 12. Venlafaxine XR 150 mg PO DAILY 13. Zolpidem Tartrate 15 mg PO HS Discharge Medications: 1. ALPRAZolam 0.5 mg PO TID 2. Azathioprine 100 mg PO BID 3. DiCYCLOmine 10 mg PO Q6H:PRN abdominal pain 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Mesalamine 500 mg PO QID 6. Omeprazole 20 mg PO DAILY 7. Topiramate (Topamax) 200 mg PO BID 8. Venlafaxine XR 150 mg PO DAILY 9. Zolpidem Tartrate 15 mg PO HS 10. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q4H:PRN pain 11. Acetaminophen 325-650 mg PO Q6H:PRN temperature; pain 12. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 100 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 13. Fluconazole 200 mg PO Q24H Duration: 4 Days RX *fluconazole 200 mg 1 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN for moderate pain RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 15. Cephalexin 500 mg PO Q12H Duration: 7 Days RX *cephalexin 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Hardware removal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: • Please take Fluconazole 200mg once daily for 4 days. Please take Keflex for 7 days for wound infection. Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING •New onset of tremors or seizures. •Any confusion 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. •Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. •Fever greater than or equal to 101.5° F. Followup Instructions: ___

{'pruritus': ['Disruption of external operation (surgical) wound'], 'exposed hardware': ['Disruption of external operation (surgical) wound', 'Other disorders of bone and cartilage'], 'chronic skin defect': ['Disruption of external operation (surgical) wound', 'Other disorders of bone and cartilage'], 'eroded through the skin': ['Disruption of external operation (surgical) wound', 'Other disorders of bone and cartilage'], 'hardware has eroded': ['Disruption of external operation (surgical) wound', 'Other disorders of bone and cartilage'], 'wound revision': ['Disruption of external operation (surgical) wound', 'Other disorders of bone and cartilage'], 'tubal ligation': ['Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain'], 'tonsillectomy': ['Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain'], 'bronchitis': ['Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain'], 'seizures': ['Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain'], 'depression': ['Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: Penicillins / Paxil / Wellbutrin Attending: ___. Chief Complaint: exposed craniotomy hardware Major Surgical or Invasive Procedure: Right scalp flap with split thickness skin graft and wound VAC placement History of Present Illness: ___ year old female with multiple prior surgeries for right parietal anaplastic astrocytoma diagnosed in ___. She has also undergone chemo and radiation. She presented to ___ in ___ with ___ month history of pruritus on the top of her head. She reports that she had her husband look at the top of her head and her found her metal hardware from her prior surgery was present. On ___ Dr. ___ metal hardware (removal of harware but not the bone flap). She presented today for a rotational flap and skin graft for proper coverage of wound. Past Medical History: right parietal anaplastic astrocytoma,Craniotomy ___ by Dr. ___ in ___ irradiation to 6,120 cGy ___ in ___,3 cycles of Temodar ended ___ craniotomy on ___ by Dr. ___ at ___ ___ - ___ wound revision and removal of the exposed craniotx hardware, Accutane for 2 weeks only ___ disease since ___, tubal ligation,tonsillectomy, bronchitis, depression. seizures Social History: ___ Family History: NC Physical Exam: Afebrile. vital signs stable. Right scalp incision clean, dry and intact with xeroform dressing in place. Right STSG site with bolstered xeroform dressing in place. No drainage or bleeding. Pertinent Results: None this admission. Brief Hospital Course: The patient was admitted to the plastic surgery service on ___ and had a flap and skin graft to your scalp defect. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient received vicodin with good pain relief noted. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. . ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cefadroxil for discharge home. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD#1, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Her scalp graft site was clean and pink and she had xeroform dressing intact. Her right thing graft donor site had original xeroform dressing in place to left open to air to dry out. Medications on Admission: ___: azathioprine, Pentasa, topiramate, alprazolam, omeprazole, zolpidem, venlafaxine hcl er 30, popylthiouracil, promethazine, keflex Discharge Medications: 1. azathioprine 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for abdominal pain. 3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 4. mesalamine 250 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO QID (4 times a day). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. topiramate 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3) Capsule, Ext Release 24 hr PO DAILY (Daily). 8. propylthiouracil 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical BID (2 times a day). Disp:*1 tube* Refills:*2* 10. cefadroxil 500 mg Capsule Sig: One (1) Capsule PO twice a day for 7 days. Disp:*14 Capsule(s)* Refills:*0* 11. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain: Max 8/day. . Disp:*40 Tablet(s)* Refills:*0* 12. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for anxiety. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: exposed craniotomy wound Status post hardware removal, split thickness skin graft application to scalp, donor site from leg Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -The hemovac drain should always be collapsed so as to apply constant suction to the wound. Does not need to be emptied unless not collapsed and does not have suction. -Your skin graft site on your scalp should be covered with a Xeroform dressing and you should apply bacitracin ointment with Qtips UNDER the xeroform dressing twice a day. WARNING: do NOT change the xeroform that is sewn/sutured in place already...leave that in place. -Please keep your skin graft site free of any pressure or extreme temperatures (cover with loose hat that does not sit on your graft site). -You may shower 48 hours after surgery but do not let water run on your head/scalp area. You may shower from the neck down only. -your thigh 'donor site' should be left 'open to air' and left to dry out. The old xeroform dressing will peel back/fall off on its own. When you shower you must cover your thigh 'donor site' with Plastic wrap to keep it free of water while you shower. You may remove plastic wrap when you are done and leave the donor site open to air again to dry out. . Diet/Activity: 1. You may resume your regular diet. 2. DO NOT bend over, avoid heavy lifting and do not engage in strenuous activity until instructed by Dr. ___. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take your antibiotic as prescribed. 6. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 7. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. 8. do not take any medicines such as Motrin, Aspirin, Advil or Ibuprofen etc . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, welling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: ___

{'pruritus': ['Regional enteritis of unspecified site', 'Depressive disorder', 'Epilepsy unspecified without mention of intractable epilepsy'], 'exposed craniotomy hardware': ['Encounter for planned post-operative wound closure', 'Personal history of irradiation', 'Personal history of antineoplastic chemotherapy', 'Personal history of malignant neoplasm of brain']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins / Paxil / Wellbutrin Attending: ___. Chief Complaint: exposed craniotomy hardware Major Surgical or Invasive Procedure: wound revision and hardware removal History of Present Illness: This is a ___ year old female with prior surgery which includes right parietal anaplastic astrocytoma with Craniotomy for resection on ___ by Dr. ___ in ___ followed by involved-field irradiation to 6,120 cGy ___ in ___, 3 cycles of Temodar ended ___ and a second craniotomy for tumor recurrence on ___ by Dr. ___ at ___ with PCV(comb chemo) ___ - ___. The patient presents today with ___ month history of pruritus on the top of her head. She reports that she had her husband look at the top of her head ___ days ago and saw that metal hardware from her prior surgery was present. The patient and her husband presented to their local Emergency and was told to follow up here. The patient denies fever, chills, nausea vomiting, nuchal rigidity, numbness or tingling sensation, vision or hearing changes, bowel or bladder incontinence. She denies new onset weakness. She reports baseline tremors in arms due to her hyperthyroid disease and baseline left sided weakness since her initial surgery. She does not ambulate with a walker Past Medical History: right parietal anaplastic astrocytoma,Craniotomy ___ by Dr. ___ in ___ irradiation to 6,120 cGy ___ in ___,3 cycles of Temodar ended ___ craniotomy on ___ by Dr. ___ at ___ ___ - ___ for 2 weeks only ___ disease since ___, tubal ligation,tonsillectomy, bronchitis, depression. seizures Social History: ___ Family History: NC Physical Exam: O: T:96.7 BP: 139/73 HR:114 R:20 O2Sats: 100% ra Gen: WD/WN, comfortable, NAD. HEENT: Pupils:3-2mm bilat EOMs: intact Neck: Supple. Extrem: Warm and well-perfused, arms hands tremulous- (patient states this is her baseline due to hyperthyroid disease) Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: ___ 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, 3 to 2 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. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ on right 4+/5 on left. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: CT Head 1. No evidence of abscess formation. 2. Stable appearance of postoperative changes related to right frontal mass resection with residual encephalomalacia and edema in a similar distribution as ___ MR exam. Brief Hospital Course: patient presented to the ED at ___ on ___ with complaints of itchy head and exposed hardware. She was admitted to the floor for observation and pre-operative planning. On 3.5 she was taken to the OR for wound revision and removal of the exposed hardware. She tolerated the procedure well and was transferred to the ___ post-operatively. She was transferred to the floor for further management and remained stable. On the morning of ___ she was deemed fit for discharge and was given instructions for close follow-up of her incision. Medications on Admission: azathioprine, Pentasa, topiramate, alprazolam, omeprazole, zolpidem, venlafaxine hcl er 30, popylthiouracil, promethazine- patient does not have doses at the time of the exam. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. alprazolam 1 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for anxiety. 4. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 13 days. Disp:*52 Capsule(s)* Refills:*0* 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for for sleep. 9. mesalamine 250 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO QID (4 times a day). 10. topiramate 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 12. propylthiouracil 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 13. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 14. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO DAILY (Daily). 15. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q8H (every 8 hours) as needed for back pain. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: exposure of craniotomy hardware and infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: •Have a friend/family member check your incision daily for signs of infection. •Take your pain medicine as prescribed. •Exercise should be limited to walking; no lifting, straining, or excessive bending. •You may wash your hair only after sutures and/or staples have been removed. •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, and Ibuprofen etc. •Clearance to drive and return to work will be addressed at your post-operative office visit. •Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING •New onset of tremors or seizures. •Any confusion 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. •Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. •Fever greater than or equal to 101° F. Followup Instructions: ___

{'pruritus': ['Disruption of external operation (surgical) wound'], 'tremors': ['Personal history of malignant neoplasm of brain'], 'exposed hardware': ['Disruption of external operation (surgical) wound'], 'fever': [], 'chills': [], 'nausea vomiting': [], 'nuchal rigidity': [], 'numbness or tingling sensation': [], 'vision or hearing changes': [], 'bowel or bladder incontinence': [], 'new onset weakness': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending: ___ Chief Complaint: Wound Infection Major Surgical or Invasive Procedure: Right Craniotomy and Evacuation of Abscess on ___ History of Present Illness: Ms. ___ is a ___ y/o woman with a past medical history of MS, and a right parietal brain abscess which was discovered approxiamtely one month ago, when she presented with left arm and face numbness. The abscess was drained in the OR on ___, and she was initially started on broad spectrum antibiotics until culture data returned with S. anginosus and fusobacterium, she was then transitioned to Ceftriaxone 2g IV q12h, and flagyl 500mg TID, which she has been on since through her PICC line. On ___, she was seen in ___ clinic and a repeat MRI was performed which revealed increased edema with persistent ring enhancing abnormality at the right parietal surgical site, concerning for ongoing abscess. She was therefore scheduled for repeat drainage on ___. She was seen as an outpatient in the infectious disease office today, ___, and it was recommended that she be admitted to the hospital one day early for broadening of her antibiotic regimen prior to drainage. She states that over the past month, her symptoms, including left upper extremity weakness and numbness, have come and gone, although she thinks that overall they have worsened slightly. She denies any fevers/chills, or headaches. No changes in vision, leg weakness or trouble with coordination or balance. She denies shortness of breath, chest pain, abdominal pain. Past Medical History: Multiple sclerosis Social History: ___ Family History: Mother with pancreatic cancer, brother-lung cancer, two sisters with brain cancer. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: General Physical Exam: General - Appears comfortable HEENT - MMM, no scleral icterus, no proptosis, sclera and conjunctiva with no edema/injection. Neck is supple. CV - RRR, no murmurs, rubs, or gallops. No carotid bruits Pulm - CTA b/l Abd - soft, non-tender, normal bowel sounds Extremities - no cyanosis, no edema Skin - warm and pink with no rashes Neurologic Exam: MENTAL STATUS: Awake and alert, oriented x 3, responds to multi-step commands which cross the midline. Knows recent and distant events. No hemisensory or visual neglect. PHYSICAL EXAMINATION ON DISCHARGE: XXXXXX Pertinent Results: MRI Brain for Operative Planning: ___ Decrease in size of known right frontal vertex rim-enhancing lesion, but unchanged vasogenic edema and mass effect. Non-Contrast Head CT: ___ POST-OP SCAN IMPRESSION: Status post redo right parietal vertex craniotomy with no evidence of hemorrhage. Stable vasogenic edema extending in the right frontal and parietal lobes. Brief Hospital Course: Ms. ___ is a ___ y/o F who was admitted to the neurosurgery service on the day of admission, ___ from the Infectious Disease Clinic in anticipation for evacuation of the brain abscess. She underwent a MRI prior surgery for operative planning. She underwent a right craniotomy and evacuation of abscess on ___. She tolerated the procedure well and was extubated in the operating room. She was then transferred to the ICU for recovery. She underwent a post-operative non-contrasat head CT which revealed normal post operative changes and no new hemorrahge. On ___, she was sitting in the chair, hemodynamically and neurologically intact. She transfered to the floor in stable conditions. Mrs. ___ was followed by Infectious Disease. They recommended that the patient be started on vancomycin and meropenem until culture data from her head wound was obtained. On ___, cultures revealed no growth. The patient was continued on Vancomycin, meropenem was changed to ertapenum. The patient continued to progress well, although she had some residual left-sided weakness. She also complained of some left-handed numbness and pain. On ___, the patient had a MR head with and without contrast including DWI, which showed slight improvement. She was discharged home on ___ with appropriate follow-up, and all questions were answered before discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CeftriaXONE 1 gm IV Q12H 2. MetRONIDAZOLE (FLagyl) 500 mg PO TID 3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 4. Acetaminophen 325-650 mg PO Q6H:PRN pain 5. LeVETiracetam 1000 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Brain Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: •Your staples should stay clean and dry until they are removed. •Have a friend or family member check the wound for signs of infection such as redness or drainage daily. •Take your pain medicine as prescribed if needed. You do not need to take it if you do not have pain. •Exercise should be limited to walking; no lifting >10lbs, 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. •DO not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. until follow up. •You have been discharged on Keppra (Levetiracetam) for anti-seizure medicine; you will not require blood work monitoring. •Do not drive until your follow up appointment. Followup Instructions: ___

{'left arm and face numbness': ['Intracranial abscess', 'Multiple sclerosis'], 'wound infection': ['Intracranial abscess', 'Streptococcus infection in conditions classified elsewhere and of unspecified site', 'Other specified bacterial infections in conditions classified elsewhere and of unspecified site'], 'increased edema with persistent ring enhancing abnormality': ['Intracranial abscess', 'Cerebral edema'], 'left upper extremity weakness': ['Intracranial abscess', 'Multiple sclerosis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: IV Dye, Iodine Containing Attending: ___. Chief Complaint: nausea, vomiting x 1 day Major Surgical or Invasive Procedure: none History of Present Illness: ___ s/p sigmoid colectomy for recurrent diverticulitis on ___ discharged home on ___ after tolerating a low residue diet and po antibiotics for a wound infection. She returned one week after discharge with 1 day of intense nausea and emesis (non-bloody, non-biliary). The nausea is associated with a slight increase in epigastric abdominal pain without any significant tenderness on exam. Past Medical History: diverticulitis s/p lap sigmoid colectomy c/b wound infection Migraines Left finger cellulitis Social History: ___ Family History: father with h/o colitis Physical Exam: afebrile, vital signs within normal limits NAD, talkative EOM full, PERRL, anicteric sclera Chest clear RRR, no murmurs Abdomen soft, round, non-tender, non-distended with 6cm of open transverse incision through the subcutis with intact deep fascia; no erythema or induration; minimal serous output. ___ without edema, 2+ DP pulses Pertinent Results: CT ABDOMEN W/O CONTRAST ___ 6:___BDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: r/o abscess-NO IV contrast, PO only Field of view: 40 UNDERLYING MEDICAL CONDITION: ___ year old woman with h/o divertic s/p colectomy here with elevated WBC and nausea REASON FOR THIS EXAMINATION: r/o abscess-NO IV contrast, PO only CONTRAINDICATIONS for IV CONTRAST: RF INDICATION: ___ woman with elevated white blood cell count and nausea, history of recent colectomy for recurrent diverticulitis. COMPARISON: CT abdomen and pelvis of ___. TECHNIQUE: MDCT acquired axial images were obtained through the abdomen and pelvis after the administration of oral contrast. No intravenous contrast was administered. Multiplanar reformatted images were also obtained. FINDINGS: The lung bases are clear. A 4-mm calcified granuloma in the right lung base is unchanged. Limited images of the heart are unremarkable. There is no pericardial effusion. In the abdomen, the liver, gallbladder, spleen, kidneys, adrenal glands, pancreas, stomach, and intra-abdominal loops of small and large bowel are unremarkable. There is no mesenteric lymphadenopathy. There is no free fluid or free air in the abdomen. Immediately adjacent to the left common iliac artery, is a linear focus of hyper-attenuating material, with the appearance of suture material, largely unchanged from the prior examination. In the pelvis, suture material is seen in the distal sigmoid colon, unchanged in appearance from prior examination and consistent with colonic anastomosis. There is no evidence of stricture or obstruction at this site. There is no local fluid collection to indicate abscess. There are no signs of inflammation. The intrapelvic loops of small and large bowel are unremarkable, containing air and stool in a normal pattern without bowel dilatation. The appendix is visualized and is normal. The urinary bladder, uterus, and adnexa are unremarkable. There are no abnormally enlarged lymph nodes in the pelvis. A fat-containing left inguinal hernia is unchanged. Examination of soft tissues reveals stranding and subcutaneous air of the soft tissues along the midline lower anterior abdominal wall, slightly larger in size than on the prior examination of approximately 2 weeks ago. Additionally, a small focus of fluid attenuating material now extends from the abdominal wall musculature through the subcutaneous tissues, and appears to drain into an external collecting device. No discrete fluid collection is identified to indicate abscess formation, or that would be amenable to drainage. However, this appearance suggests continued cellulitis. Examination of osseous structures reveals mild degenerative disease at L5-S1 and are otherwise unremarkable. IMPRESSION: 1. Stable appearance of sigmoid colon anastomosis without obstruction or abscess formation. 2. Stranding and subcutaneous air along the lower abdominal wall in the midline, indicating cellulitis, but without discrete or drainable fluid collection The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ ___. ___: SUN ___ 9:36 AM ____________________________________________ ___ 03:45AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 02:20AM GLUCOSE-124* UREA N-20 CREAT-1.4* SODIUM-138 POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-30 ANION GAP-15 ___ 02:20AM estGFR-Using this ___ 02:20AM ALT(SGPT)-38 AST(SGOT)-20 ALK PHOS-107 TOT BILI-0.6 ___ 02:20AM LIPASE-62* ___ 02:20AM WBC-15.4*# RBC-3.17* HGB-9.4* HCT-28.2* MCV-89 MCH-29.7 MCHC-33.4 RDW-13.7 ___ 02:20AM NEUTS-85.8* LYMPHS-10.0* MONOS-2.5 EOS-1.2 BASOS-0.5 ___ 02:20AM PLT COUNT-730*# Brief Hospital Course: GI: Admitted in early morning on ___ the pt was made NPO with IVF resuscitation. A abdominal/pelvic CT was done and demonstrated a stable sigmoid anastomosis without any fluid collections or free air. Over the first night her urine output increased and a foley was not placed. Due to her constant loose stools, toxin screens of C.diff were sent and returned negative. By HD2, the nausea persisted an a GI consult was obtained. The GI service believed the nausea to be related to baseline reflux exacerbated by her postop course, including a wound infection. Per their recommendations, she was started on an antacid and upon discharge she will follow up with a gastroenterologist to determine her H.pylori status. Prior to discharge, she was tolerating a low residue diet and able to hydrate herself. Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*0 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Disp:*0 * Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: nausea and vomiting Discharge Condition: Followup Instructions: ___

{'nausea': ['Esophageal reflux', ' Diverticulosis of colon (without mention of hemorrhage)'], 'vomiting': ['Esophageal reflux', ' Diverticulosis of colon (without mention of hemorrhage)'], 'epigastric abdominal pain': [' Diverticulosis of colon (without mention of hemorrhage)'], 'wound infection': ['Other specified aftercare following surgery']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Bladder cancer Major Surgical or Invasive Procedure: robotic anterior exenteration and open ileal conduit History of Present Illness: ___ with invasive bladder cancer, pelvic MRI concerning for invasion into anterior vaginal wall, now s/p robotic anterior exent (Dr ___ and open ileal conduit (Dr ___. Past Medical History: Hypertension, laparoscopic cholecystectomy six months ago, left knee replacement six to ___ years ago, laminectomy of L5-S1 at age ___, two vaginal deliveries. Social History: ___ Family History: Negative for bladder CA. Physical Exam: A&Ox3 Breathing comfortably on RA WWP Abd S/ND/appropriate postsurgical tenderness to palpation Urostomy pink, viable Pertinent Results: ___ 06:50AM BLOOD WBC-7.6 RBC-3.41* Hgb-10.6* Hct-32.5* MCV-95 MCH-31.1 MCHC-32.6 RDW-14.4 RDWSD-50.2* Plt ___ ___ 06:50AM BLOOD Plt ___ ___ 06:45AM BLOOD Glucose-117* UreaN-23* Creat-0.6 Na-136 K-4.4 Cl-104 HCO3-23 AnGap-13 ___ 06:45AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0 Brief Hospital Course: Ms. ___ was admitted to the Urology service after undergoing [robotic anterior exenteration with ileal conduit]. No concerning intrao-perative events occurred; please see dictated operative note for details. Patient received ___ intravenous antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin. The post-operative course was notable for several episodes of emesis prompting NGT placement on ___. Pt self removed the NGT on ___, but nausea/emesis resolved thereafter and pt was gradually advanced to a regular diet with passage of flatus without issue. With advacement of diet, patient was transitioned from IV pain medication to oral pain medications. The ostomy nurse saw the patient for ostomy teaching. At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. Her drain was removed. The ostomy was perfused and patent, and one ureteral stent had fallen out spontaneously. ___ was consulted and recommended disposition to rehab. Post-operative follow up appointments were arranged/discussed and the patient was discharged to rehab for further recovery. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Heparin 5000 UNIT SC ONCE Start: in O.R. Holding Area 2. Losartan Potassium 50 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Levothyroxine Sodium 175 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID take while taking narcotic pain meds RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills:*0 3. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*28 Syringe Refills:*0 4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY take while ureteral stents are in place RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth daily Disp #*14 Capsule Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn Disp #*30 Tablet Refills:*0 6. Atorvastatin 10 mg PO QPM 7. Levothyroxine Sodium 175 mcg PO DAILY 8. Losartan Potassium 50 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Bladder cancer Discharge Condition: WdWn, NAD, AVSS Abdomen soft, appropriately tender along incision Incision is c/d/I (steris) Stoma is well perfused; Urine color is yellow Ureteral stent noted via stoma JP drain has been removed Bilateral lower extremities are warm, dry, well perfused. There is no reported calf pain to deep palpation. No edema or pitting Discharge Instructions: -Please also refer to the handout of instructions provided to you by your Urologist -Please also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy -You will be sent home with Visiting Nurse ___ services to facilitate your transition to home care of your urostomy -Resume your pre-admission/home medications except as noted. Always call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor -___ you have been prescribed IBUPROFEN, please note that you may take this in addition to the prescribed NARCOTIC pain medications and/or tylenol. FIRST, alternate Tylenol (acetaminophen) and Ibuprofen for pain control. -REPLACE the Tylenol with the prescribed narcotic if the narcotic is combined with Tylenol (examples include brand names ___, Tylenol #3 w/ codeine and their generic equivalents). ALWAYS discuss your medications (especially when using narcotics or new medications) use with the pharmacist when you first retrieve your prescription if you have any questions. Use the narcotic pain medication for break-through pain that is >4 on the pain scale. -The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 4 grams (from ALL sources) PER DAY and remember that the prescribed narcotic pain medication may also contain Tylenol (acetaminophen) so this needs to be considered when monitoring your daily dose and maximum. -If you are taking Ibuprofen (Brand names include ___ this should always be taken with food. If you develop stomach pain or note black stool, stop the Ibuprofen. -Please do NOT drive, operate dangerous machinery, or consume alcohol while taking narcotic pain medications. -Do NOT drive and until you are cleared to resume such activities by your PCP or urologist. You may be a passenger -Colace may have been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -You may shower 2 days after surgery, but do not tub bathe, swim, soak, or scrub incision for 2 weeks -If you had a drain or skin clips (staples) removed from your abdomen; bandage strips called “steristrips” have been applied to close the wound OR the site was covered with a gauze dressing. Allow any steristrips/bandage strips to fall off on their own ___ days). PLEASE REMOVE any "gauze" dressings within two days of discharge. Steristrips may get wet. -No heavy lifting for 4 weeks (no more than 10 pounds). Do "not" be sedentary. Walk frequently. Light household chores (cooking, folding laundry, washing dishes) are generally “ok” but AGAIN, avoid straining, pulling, twisting (do NOT vacuum). Followup Instructions: ___

{'Bladder cancer': ['Malignant neoplasm of bladder neck'], 'Hypertension': ['Essential (primary) hypertension'], 'Laparoscopic cholecystectomy': [], 'Left knee replacement': [], 'Laminectomy of L5-S1': [], 'Two vaginal deliveries': [], 'Invasion into anterior vaginal wall': ['Malignant neoplasm of bladder neck'], 'Emesis': [], 'Nausea': [], 'Pain': ['Malignant neoplasm of bladder neck'], 'Constipation': []}

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamides) / Penicillins Attending: ___ Chief Complaint: Facial weakness Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ RHF w/ hx GERD, mild depression, and prior migraines, presents now with episode of facial numbness. She had been lying on her left face, watching TV, and noticed when she got up that her left face was numb as if she were injected with novacaine, in a distribution that she traces along mid-V2 down to her jaw line. She initially thought it was ___ the way she was lying, but became concerned when it persisted. She endorsed a mild diffuse dull HA that is not unusual for her. She states in some ways, it felt as though a migraine were coming on, though the HA she had was not typical of her past migraines. The numbness lasted 90 minutes, and has now resolved completely. There was no associated weakness, no sensory changes outside of her face, no VC, vertigo, or language impairment. She cannot recall something like this happening before, and states that her day was otherwise routine. On ROS, she notes that about 2 weeks ago she had diarrhea for 1 week which resolved spontaneously. She also endorses feeling "achey" 4 days ago, otherwise, her health has been normal. Past Medical History: GERD mild depression migraines (throbing HA's assoc with visual flashes of light), last ___ years ago bunions Social History: ___ Family History: Father with HD, sustained a stroke after a cardiac cath. Later in life father developed a meningioma and subsequent seizures. Physical Exam: 98.4F 69 134/79 15 100%RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no c/c/e; equal radial and pedal pulses B/L. Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive, says ___ backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. Reading intact. No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. Retinas with sharp disc margins B/L. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3 to both LT and PP. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor No pronator drift Del Tri Bi WF WE FE FF IP H Q DF PF TE TF R ___ ___ ___ ___ 5 5 L ___ ___ ___ ___ 5 5 Sensation: Intact to light touch, pinprick, and proprioception throughout. Reflexes: +2 and symmetric throughout. Toes downgoing bilaterally Coordination: finger-nose-finger normal, heel to shin normal, FT and RAMs normal. Gait: Narrow based, steady. Able to tandem walk without difficulty Romberg: Negative Pertinent Results: ___ 06:10AM BLOOD WBC-5.3 RBC-4.38 Hgb-11.5* Hct-36.1 MCV-82 MCH-26.2* MCHC-31.8 RDW-13.3 Plt ___ ___ 11:14PM BLOOD Neuts-52.1 ___ Monos-4.7 Eos-2.0 Baso-0.5 ___ 11:14PM BLOOD ___ PTT-33.7 ___ ___ 06:10AM BLOOD Glucose-82 UreaN-16 Creat-0.8 Na-140 K-4.0 Cl-105 HCO3-26 AnGap-13 ___ 11:14PM BLOOD ALT-13 AST-19 CK(CPK)-69 AlkPhos-70 TotBili-0.2 ___ 11:14PM BLOOD CK-MB-NotDone cTropnT-<0.01 ___ 11:14PM BLOOD TotProt-7.1 Albumin-4.5 Globuln-2.6 Calcium-9.5 Phos-3.7 Mg-2.1 ___ 02:26AM BLOOD %HbA1c-5.7 ___ 11:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Radiology Report MRA BRAIN W/O CONTRAST Study Date of ___ 9:44 AM 1. No acute intracranial abnormality; specifically, there is no evidence of either acute or previous ischemic event. 2. Normal cranial and cervical MRA, with no significant mural irregularity or flow-limiting stenosis. Brief Hospital Course: Ms. ___ is a ___ yo woman with a hx of depression, GERD and migraines, presenting with an episode of facial numbness. 1. Facial numbness. As this episode preceeded a headache, suspect likely due to a migraine equivalent, however episode could also be due to a TIA in the thalamus. The patient had an MRI, which showed no signs of ischemia, and normal vasculature, making migraine equivalent a much more likely diagnosis. However, given the possibility of TIA, she has been started on a daily aspirin for future stroke prophylaxis. Exam on discharge was notable for mild symmetric hyperreflexia in the lower extremities, but otherwise normal neurological exam, with no residual sensory deficits. Medications on Admission: NEXIUM 40 mg--1 capsule(s) by mouth once a day PROZAC 20 mg--1 capsule(s) by mouth once a day 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. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Migraine Discharge Condition: Mild symmetric hyperreflexia in the lower extremities, otherwise normal neurological exam. Discharge Instructions: You were admitted for left sided facial numbness. You had an MRI which showed no signs of ischemia. It is suspected that this was related to migraine headaches, but we recommend that you start taking a full dose of aspirin. If you notice new numbness, weakness, worsening headaches, or other new concerning symptoms, please return to the nearest ED for further evaluation. Followup Instructions: ___

{'Facial numbness': ['Other forms of migraine'], 'Mild diffuse dull HA': ['Other forms of migraine'], 'Achey': [], 'Diarrhea': [], 'Feeling achey': [], 'Abnormal reflex': ['Abnormal reflex']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins Attending: ___. Chief Complaint: neck pain s/p fall Major Surgical or Invasive Procedure: None on this Admission History of Present Illness: ___ male transferred from outside hospital for evaluation of cervical ___ fracture. Today the patient was attempting to use the bathroom and bent forward and fell hitting the back of his head. There was no loss of consciousness. The patient complains of headache and neck pain. The outside hospital the patient had the head laceration stapled. A CT scan did demonstrate the fracture. The patient denies any numbness, tingling in his arms or legs. No weakness in his arms or legs. Denies any bowel incontinence or bladder retention. No saddle anesthesia. Denies any chest pain, shortness of breath or abdominal pain. Past Medical History: PMH: a. fib, colon ca, htn, copd MED: warfarin, allopurinol, asacol ALL: pcn, sulfa Social History: ___ Family History: NC Physical Exam: C collar in place UEC5C6C7C8T1 (lat arm) (thumb) (mid fing) (sm finger) (med arm) Rintact intact intact intact intact Lintact intact intact intact intact T2-L1 (Trunk) intact ___ L2 L3 L4 L5S1S2 (Groin)(Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) Rintactintactintactintact intactintact Lintactintactintactintact intactintact Motor: UEDlt(C5)Bic(C6)WE(C6)Tri(C7)WF(C7)FF(C8)FinAbd(T1) R 5 5 5 5 ___ L 5 5 5 5 ___ ___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___ R ___ 5 5 5 5 L ___ 5 5 5 5 Babinski: negative Clonus: not present Brief Hospital Course: Patient was admitted to the ___ ___ Surgery Service for observation after a C2 fracture. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Diet was advanced as tolerated. The patient was tolerated oral pain medication. Physical therapy was consulted for mobilization OOB to ambulate. He remained hypertensive from 160 - >180. Medicine consult appreciated - felt this was long standing. recommended PRN antihypertensives but cautioned against bringing pressure too low too quickly. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain, temp >100.5, headache 2. Allopurinol ___ mg PO DAILY 3. Mesalamine ___ 400 mg PO TID 4. Metoprolol Tartrate 25 mg PO BID 5. Omeprazole 20 mg PO DAILY 6. Warfarin 1 mg PO DAILY 7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain 8. Diazepam 2 mg PO Q12H:PRN spasms Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: C2 fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You have undergone the following operation: Anterior Cervical Decompression and Fusion Immediately after the operation: -Activity: You should not lift anything greater than 5 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. oIsometric Extension Exercise in the collar: 2x/day x ___xercises as instructed. -Swallowing: Difficulty swallowing is not uncommon after this type of surgery. This should resolve over time. Please take small bites and eat slowly. Removing the collar while eating can be helpful – however, please limit your movement of your neck if you remove your collar while eating. -Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. -Wound Care: Monitor laceration at scalp for drainage/redness. Your PCP may take these staples out. -You should resume taking your normal home medications. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. -Follow up: oPlease Call the office ___ and make an appointment with Dr. ___ 2 weeks after the day of your operation if this has not been done already. oAt the 2-week visit we will check your incision, take baseline x rays and answer any questions. oWe will then see you at 6 weeks from the day of the operation. At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions. Physical Therapy: activity as tolerated C-collar full time for 12 weeks may use ambulatory assistive devices for safety no bending twisting, or lifting >5lbs Treatment Frequency: monitor skin at chin and back of head for breakdown in C-collar Followup Instructions: ___

{'neck pain': ['Closed fracture of third cervical vertebra'], 'headache': ['Closed fracture of third cervical vertebra'], 'loss of consciousness': [], 'numbness': [], 'tingling': [], 'weakness': [], 'bowel incontinence': [], 'bladder retention': [], 'saddle anesthesia': [], 'chest pain': [], 'shortness of breath': [], 'abdominal pain': []}

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Gait instability, multiple falls Major Surgical or Invasive Procedure: None History of Present Illness: Mr ___ is a pleasant right handed ___ year old male with Afib, on coumadin, who is quite independent, living with his wife and was in a good state of health until mid last year. At that time his wife reports that he began having periods of disorganized speech and gait instability. He did not have a fall until 3 months ago when he broke several ribs on his coffee table. He did not have any head trauma and was not scanned at an OSH. His garbled speech and unsteadiness have waxed and waned over the past 6 months and his wife reports that they are much improved when he takes his diuretics. Over this period he has lost ~20 lbs. Last night he was sorting papers at the dining room table when he fell from standing because of the dizziness. He reports no LOC, no head trauma and was able to stand back up and continue his work. His wife placed him on the couch, but he got back up and fell in the bathroom - again he denies any LOC or head trauma, blaming his instability and ___ weakness. He had no tongue biting or loss of bowel/bladder continence. He went to bed last night, but the morning of presentation his wife was concerned about his falls and brought him to the ED. He does have a diagnosis of DM II from just over a month ago and has started oral hypoglycemics for which he reports having low ___ at home. He was seen by an outside neurologist the week prior who had ordered a CT head to be completed the following week. In the ED his head was scanned which revealed no bleed but a 3x3 L frontal lobe extra-axial mass with compressive effect but no midline shift. Neurosurgery was contacted for evaluation of the mass and its possible role in the patient's recent symptoms. Past Medical History: DM II, HTN, HL, MI (in past), AF on coumadin, prostate CA treated non-operatively Social History: ___ Family History: Non-contributory Physical Exam: At Admission: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 4->3 EOMs intact b/l Lungs: CTA bilaterally. Cardiac: irreg irreg with ___ holosystolic murmur. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: ___ objects at 5 minutes. Language: Speech is fluent, good comprehension. Difficulty with repitition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 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. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. Mild R sided pronator drift. Gait unsteady, rhomberg test with unsteadiness. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right ___ 1 1 Left ___ 1 1 Toes downgoing bilaterally Coordination: heel to shin intact, finger nose-finger slowed and overshooting with R hand. Difficulty with rapid alternating movements with R hand. AT DISCHARGE: Afeb, VSS Gen: NAD. HEENT: Pupils: 3->2 EOMs intact b/l Lungs: clear b/l Cardiac: irreg irreg with ___ holosystolic murmur. Abd: non-tender/non-distended Extrem: no edema or erythema, warm well perfused. Neuro: Mental status: Awake and cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech is fluent, good comprehension. Cranial Nerves: II-XII tested and intact b/l Motor: ___ strength b/l in UE and ___. No pronator drift. Gait steady, walking without assistance. Sensation: Grossly intact b/l. Reflexes: B T Br Pa Ac Right ___ 1 1 Left ___ 1 1 Toes downgoing bilaterally Pertinent Results: ___ 04:55AM BLOOD WBC-3.9* RBC-4.39* Hgb-13.5* Hct-40.7 MCV-93 MCH-30.7 MCHC-33.1 RDW-15.5 Plt ___ ___ 04:55AM BLOOD ___ ___ 04:55AM BLOOD Glucose-115* UreaN-33* Creat-1.2 Na-142 K-3.7 Cl-104 HCO3-33* AnGap-9 ___ 06:25AM BLOOD Albumin-3.2* ___ 02:39PM BLOOD %HbA1c-7.7* eAG-174* ___ 06:25AM BLOOD Phenyto-4.6* CT Head ___: IMPRESSION: 1. Extra-axial lesion, containing foci of calcifications measuring up to 3 cm, which likely reflects an extra-axial mass such as a meningioma. An extra-axial hematoma, which would be subacute to chronic, is considered less likely. 2. Loss of gray-white differentiation in the high left frontoparietal lobe, could reflect an acute infarct. MRI Head ___: Acute to subacute bilateral infarctions with the largest focus in the left post-central gyrus. Appearance of the post-gyrus lesion is somewhat heterogeneous however and recommend attention on followup imaging for further evaluation to exclude the presence of an underlying mass. Two meningiomas in the left frontal region without significant mass effect. ECHO ___: Marked symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. Mild aortic valve stenosis. Mild aortic regurgitation. Right ventricular free wall hypertrophy. Pulmonary artery systolic hypertension. Dilated ascending aorta. CLINICAL IMPLICATIONS: The patient has mild aortic stenosis. Based on ___ ACC/AHA Valvular Heart Disease Guidelines, a follow-up echocardiogram is suggested in ___ years. Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. MRA Head/Neck ___: Mild atherosclerotic disease of the basilar artery. There is no evidence of acute vascular abnormalities involving the intracranial arteries Brief Hospital Course: Mr. ___ was admitted to the neurosurgical service on ___ from the emergency room after having a series of falls on ___. A CT of the head demonstrated a left frontal extra-axial mass as well as a more acute lesion in the parietal lobe on the left. Because of his recent falls, his coumadin was held and he was placed on an insulin sliding scale as there was some concern for hypoglycemia contributing to the unsteadiness. An MRI of this head was obtained which confirmed a meningioma overlying the L frontal lobe and a sub-acute infarct in the post-central gyrus on the left. While he did have distinct right sided weakness in the emergency room, on hospital day #2 this weakness had nearly completely resolved and his confusion was also better. A neurology consult was obtained given what appeared to be a sub-acute stroke on his MRI - they recommended restarting the pt's coumadin, holding the dilantin and checking an EEG, these were done while he was an inpatient. He also underwent a surface echo and an MRA of the brain and neck given the likely embolic nature of his strokes. Neurology will see him in 3 months with a repeat head MRI. ___ also saw him for his diabetes managment and recommended changing his glipizide to 10 BID, and not starting insulin. His sugars were well controlled while in house and he did not have any episodes of hypoglycemia. From a neurologic standpoing, in-house he did quite well with resultion of his right sided weakness although his unsteadiness continued and he needed support while ambulating. ___ recommended he go to a short term rehab until he was better able to compete transfers and ambulate with a walker. He will follow up with neurology and neurosurgery to discuss how to best manage his ischemic strokes and address the meningioma, respectively. Medications on Admission: Coumadin 2.5', prandin 0.5''', glipizide 5'', isosorbide dinitrate 10'', lisinopril 20, allopurinol ___, torsemide 5, metoprolol 50''', lipitor 10' Discharge Medications: 1. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 ___. 7. Torsemide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: Left frontal meningioma, left parietal sub-acute infarct, Diabetes Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You should take your coumadin as prescribed. You do not need anti-seizure medications any longer. You should follow up with Dr. ___ Dr. ___ as listed below. You will need a follow up MRI to evaluate the small stroke you had on the left side of your brain. Take all medications as prescribed and follow up with Dr. ___ this week to check in. General Instructions/Information •Take your pain medicine as prescribed. •Exercise should be limited to walking; no lifting, straining, or excessive bending. •Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. • If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. •Clearance to drive and return to work will be addressed at your post-operative office visit. •Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING •New onset of tremors or seizures. •Any confusion 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. •Fever greater than or equal to 101° F. Followup Instructions: ___

{'symptom1': ['disease1', 'disease2'], 'symptom2': ['disease2', 'disease3', 'disease4'], 'symptom3': ['disease1', 'disease3', 'disease5', 'disease6']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Atypical chest pain Major Surgical or Invasive Procedure: Stess Echo History of Present Illness: ___ y/o woman with intermittent chest pain past several months. Pain is located on left posterior shoulder and radiates down arm to fingers where it turns into "pins-n-needles" symptom. No SOB/N/V. Patient does endorse some minimal diaphoresis and gerd like symptoms accompanying it. Pain has been controlled with tylenol #3. Past Medical History: HTN Asthma Diverticulitis several years ago R hip replacement in ___ Social History: ___ Family History: Mother: ___, HTN Father: ___ CA Brother: CA? Brother: ___ Physical ___: Vtals: T: 97.6 BP: 167/88 P: 83 R: 20 O2: 99% 2L 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, ronchi 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 Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ___ 03:20PM BLOOD WBC-6.2 RBC-4.51 Hgb-13.1 Hct-38.6 MCV-86 MCH-29.1 MCHC-33.9 RDW-15.4 Plt ___ ___ 07:15AM BLOOD WBC-6.0 RBC-4.91 Hgb-13.8 Hct-41.7 MCV-85 MCH-28.1 MCHC-33.0 RDW-15.1 Plt ___ ___ 07:50AM BLOOD WBC-5.2 RBC-4.67 Hgb-13.4 Hct-39.4 MCV-84 MCH-28.7 MCHC-34.1 RDW-15.2 Plt ___ ___ 03:20PM BLOOD Glucose-95 UreaN-21* Creat-0.8 Na-139 K-3.5 Cl-100 HCO3-30 AnGap-13 ___ 09:10PM BLOOD Glucose-120* UreaN-17 Creat-0.9 Na-137 K-3.3 Cl-99 HCO3-31 AnGap-10 ___ 07:15AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-138 K-4.4 Cl-98 HCO3-35* AnGap-9 ___ 03:20PM BLOOD cTropnT-<0.01 ___ 09:10PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 07:15AM BLOOD CK-MB-4 cTropnT-<0.01 . ___ ___ F ___ ___ Cardiology Report Stress Study Date of ___ EXERCISE RESULTS RESTING DATA EKG: SINUS WITH AEA, LBBB HEART RATE: 68 BLOOD PRESSURE: 146/86 PROTOCOL MODIFIED ___ - TREAD___ STAGE TIME SPEED ELEVATION HEART BLOOD RPP (MIN) (MPH) (%) RATE PRESSURE 0 ___ 1.0 8 100 176/88 ___ 1 ___ 1.7 10 114 178/92 ___ 2.5 12 126 184/98 ___ TOTAL EXERCISE TIME: 9 % MAX HRT RATE ACHIEVED: 83 SYMPTOMS: ATYPICAL PEAK INTENSITY: ___ INTERPRETATION: ___ yo woman was referred to evaluate an atypical chest discomfort. The patient completed 9 minutes of a Gervino protocol representing a fair exercise tolerance for her age; ~ ___ METS. The exercise test was stopped at the patient's request secondary to fatigue. During exercise, the patient reported a non-progressive, isolated upper left-sided chest discomfort; ___. The area of discomfort was reportedly tender to palpation. This discomfort resolved with rest and was absent 2.5 minutes post-exercise. In the presence of the LBBB, the ST segments are uninterpretable for ischemia. The rhythm was sinus with frequent isolated APDs and occasional atrial couplets and atrial triplets. Resting mild systolic hypertension with normal blood pressure response to exercise. The heart rate response to exercise was mildly blunted. IMPRESSION: Fair exercise tolerance. No anginal symptoms with uninterpretable ECG to achieved workload. Resting mild systolic hypertension with appropriate blood pressure response to exercise. Suboptimal study - target heart rate not achieved. SIGNED: ___ Brief Hospital Course: ___ ___ with several month history of left sided arm and chest wall pain in the setting of LBBB presenting for ___. . . # Chest Pain:The patient's symptoms were not typically anginal in nature to suggest ACS. However she does have several cardiac risk factors and a LBBB, so physicians could not r/oMI with EKG alone. Trop. results were negative x3. Stress Echo revealed new regional dysfunction with hypokinesis of the inferior and inferolateral walls consistent with single vessel disease in the PDA distribution. A cardiology consult was obtained and they felt she could be managed medically. Patient was already on an aspirin, and a statin. Given history to suggest asthma B-blocker was contraindicated. She was discharged on 120 mg extended release diltiazem with instructions to follow up in cardiology and with her PCP. . # Supraventricular tachycardia: The patient had multiple runs of SVT that was likley MAT in the setting of severe obstructive lung disease and chronic theophylline use. Cardiology reccomended that we discontinue her theophylline. We spoke with her pulmonologist who agreed this would be the best course of action for her. She was discharged with instructions to discontinue use of theophylline and follow up with her pulmonologist and cardiology. Medications on Admission: Tylenol ___ Q4h PRN pain Albuterol Sulfate 2 puffs q4-6h PRN SOB Fluticasone 50 mcg spray/suspension 2 whiffs PRN allergies Adviar 500/50 1 INH BID HCTZ 50mg One PO daily Singulari 10mg tablet One PO QD omeprazole 20mg 1 PO QD simvastatin 20mg 1 PO QD theophylline 200mg sustained release one PO TID spiriva 18 mcg w/ inhalation ASA 81mg Calcium sig unknown Cod liver oil Sig unk Multivitamin Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB wheeze. 3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: ___ Nasal once a day as needed for allergy symptoms. 5. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once a day. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. diltiazem HCl 120 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* 12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 min as needed for chest pain: take one at onset of chest pain. ___ repeat every 5 min x3 with continued chest pain. Call PCP if chest pain persists. Disp:*30 tabs* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ because you had back and arm pain that was worrisome for heart disease. A strees test found that you have coronary artery disease. You were started on a new blood pressure medication and tolerated this well. You should keep all of you follow up appointments as listed below. . While you were here we made the following changes to your medications: . We STARTED you on Diltiazem 120mg once a day . We STOPPED ___ theophylline . We STARTED nitroglycerine to take when you have chest pain . YOU NEED TO STOP SMOKING. IT WILL KILL YOU. Followup Instructions: ___

{'Chest pain': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'Arm pain': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'Radiates down arm to fingers': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'Pins-n-needles symptom': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'Minimal diaphoresis': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'Gerd like symptoms': ['Coronary atherosclerosis of native coronary artery', 'Other chest pain'], 'HTN': ['Unspecified essential hypertension'], 'Asthma': ['Chronic obstructive asthma'], 'Diverticulitis': ['Diverticulosis of colon (without mention of hemorrhage)'], 'R hip replacement': ['Hip joint replacement'], 'CA': ['Tobacco use disorder'], 'Family history': ['Other left bundle branch block', 'Other specified cardiac dysrhythmias', 'Antiasthmatics causing adverse effects in therapeutic use']}