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CHIEF COMPLAINT: AMS, concern for toxic alcohol ingestion PRESENT ILLNESS: Mr. [**Known lastname 27389**] is a 39 year old man with h/o EtOH and polysubstance abuse, seizure disorder, who was found to be unresponsive while visiting his partner in the ICU earlier today. . The patient was visiting his partner in the ICU earlier today. He was awake and conversant in the morning with no acute complaints. He was noted to be sleeping on the floor, but walked to the chair by himself when he was awakened. Later in the afternoon, the patient was noted to still be asleep in the chair. He was unarousable with verbal stimuli or sternal rub, so he was taken down to the ED. . In the ED, the patient was initially altered, but was otherwise hemodynamically stable. No urine incontinence or e/o toxidromes. Labs notable for EtOH 86, Osms 366, anion gap 16, lactate 3.8. Utox positive for barbs, but Stox and Utox otherwise negative. Given high serum osmolar gap (60), toxicology was consulted for concern of toxic alcohol ingestion. Most likely isopropyl alcohol given osmolar gap with small anion gap (likely due to lactate) and access to CalStat in the hospital today. However, given a dose of Fomepizole 15mg/kg IVx1 in the ED for possible ethylene glycol vs methanol ingestion. Also given Diazepam 10mg x1 for EtOH withdrawal. EEG following, as the patient is enrolled in a study for AMS. Vitals prior to transfer: 97.5 103 120/60 22 RA 100% . On the floor, the patient is currently hungry and feels like he is going to withdraw. He is anxious and has some palpitations. No shortness of breath, chest pain. He denies ingesting anything today. He has had no PO intake x4 days. MEDICAL HISTORY: * Subdural hematoma ([**2204-4-12**]) from fall * Alcohol and polysubstance abuse * Hepatitis C virus infection * Mood disorder with multiple suicide attempts * ?PTSD, bipolar/anti-social personality/impulse/rage disorders * Migraines * Chronic lower back pain * MVA s/p chest tube placement in [**2200**] * Seizure disorder since [**08**] yo, alcohol withdrawal seizures MEDICATION ON ADMISSION: Phenobarbital ?34.2mg PO TID Klonopin 2mg PO TID Folate 1mg PO daily MVI 1tab PO daily Thiamine 100mg PO daily ALLERGIES: Gabapentin / Trazodone / Codeine PHYSICAL EXAM: On admission: Vitals: T: 95.9 BP: 123/84 P: 99 R: 18 O2: 94%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: diminished breath sounds throughout R>L, no wheezes, rales, rhonchi CV: tachycardic, S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: aaox3, CNs [**2-23**] intact, strength and sensation grossly nl. . On discharge: [**Name (NI) 4650**] Pt allert and oriented, walking without difficulty, R knee with large effussion, exam otherwise unchanged FAMILY HISTORY: Father was an alcoholic. SOCIAL HISTORY: Stays with his girlfriend in [**Name (NI) **]. - Tobacco: +intermittent tobacco use - Alcohol: 1/5th daily of hard liquour, has been drinking since 9 yo, has h/o DTs and alcohol withdrawal seizures - Illicits: Past use of cocaine, heroin, opiates, benzodiazepines documented in [**Name (NI) **], but patient currently denying any of this.

CHIEF COMPLAINT: abdominal pain PRESENT ILLNESS: 78 yo Russian speaking F with h/o pulmonary HTN, CHF, OSA on home O2 who initially admitted on [**2139-5-18**] from home with vomiting, loss of appetite x 1 month. Diarrhea x 1 week. Per ED notes, pt also c/o RLQ/RUQ pain; rates pain as [**8-26**] lasting several days. Pt is also chronically on home O2 2-3L NC for OSA, CHF and pulmonary hypertension. . ED COURESE: VS afebrile, HR 62, BP 144/85, RR 20, 95% RA. Exam notable for RUQ/RLQ tenderness to palp, guaic neg. Given zofran 8 mg IV x 1 with improvement in sxs. CT showed no new changes. Ready for d/c but then nauseous. No abx in ED. Given 10 mg compazine as well. . Admitted to medicine for diarrhea. On arrival, hx obtained from interpreter. Pt c/o of right > left abd pain for unclear duration of time, also with nausea/vomiting; diarrhea 3-4 days ago but none since. No chest pain/pressure, SOB, cough. No GU sxs. Poor appetite for several weeks. On floor pt found to be hypoxic on O2 4LNC O2 sats 85%, CXR c/w pulm edema, she was given 40mg IV x 2, nebs, and put out 1.5L UOP, she was also put on a NRB with improvement in O2 Sats to 95%. However, patient kept trying to pull off her NRB mask leading to [**Last Name (LF) 15780**], [**First Name3 (LF) **] was transferred to the [**Hospital Unit Name 153**] for more intensive care and monitoring. MEDICAL HISTORY: 1.Atrial septal defect repair [**6-17**] complicated by sinus arrest with PPM placement. 2. CHF 3. AF s/p cardioversion x 2 (on amiodarone) 4. HTN 5. GERD 6. TAH/BSO ('[**33**]) for fibroids 7. ?CVA 8. Pulm HTN 9. CRI (baseline 1.5) 10. OSA on home O2 (2-3L NC) 11. s/p APPY, s/p CCY ('[**33**]) 12. Gallstone pancreatitis s/p ERCP, sphincterotomy 13. Elevated alk phos secondary to amiodarone (All above per hospital records) MEDICATION ON ADMISSION: Meds: (per old d/c summary) home oxygen 2-3L amiodarone 200 mg qd lasix 40 mg qam/20 mg qpm paroxetine 10 mg qd ASA 81 mg qd atorvastatin vit toprol XL 25 mg qd levothyroxine 75 mcg qd PPI oxycodone 5 mg prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: ON ADMIT VS: T 98.1, 91-95% on NRB, HR 60-74, 116/48, RR 22-26 Gen: Russian speaking woman, lying in bed comfortable, not using accessory muscles, breathing comfortably on NRB HEENT: PERRL, + periorbital edema, JVP hard to assess [**12-19**] thick neck CV: RRR, nl s1/s2 LUNGS: pronounced crackles bilaterally 1/2way up lungs, R>L ABD: obese, soft, +BS, + discomfort with palp, no rebound/guarding, EXT: no LE pitting edema FAMILY HISTORY: NC SOCIAL HISTORY: Lives alone in senior living housing, has daughter in law who brings her groceries, has VNA once a week. No tob, EtOH, IVDU

CHIEF COMPLAINT: Bilateral Sub Dural Hematoma PRESENT ILLNESS: This is a 87 year old man with h/o CAD, s/p coronary artery bypass graft, sick sinus syndrome, s/p pacer insertion, AAA and cerebral aneurysm who presented to OSH with anorexia, nausea, and generalized weakness. He was recently noted to have been started on tetracycline in the outpatient setting then subsequently developed these symptoms. He had an INR of 5.9 and overnight he had an increase in agitation and combativeness. A Head CT was done and showed an extensive SDH extending along the tentorium, largest along the R frontal convexity. Neurosurgery was consulted. = = = = = = = = = = = = = = = = ================================================================ HPI from transfer to general medicine service: HPI: Mr. [**Known lastname 9449**] is an 87 y/o M with hx of CAD s/p CABG in [**2187**], SSS s/p PPM, atrial fibrillation on coumadin who presented to OSH on [**6-8**] with FTT, found to have bilateral SDH, and transferred to [**Hospital1 18**] for neurosurgical evacuation, currently POD#13. He was transferred to the MICU for increasing oxygen requirement and respiratory distress. . Hospital Course: The patient was previously living in an [**Hospital3 **] facility, independent with a baseline mental status of AOx3, and independent ambulation with mechanical limbs. The patient has has many falls in the past, and recently had a fall one month ago getting out of bed because he was not wearing his prosthetics at the time. Per discussion with his family, the patient had been complaining of symptoms of failure to thrive over the past two months prior to admission including fatigue and anorexia/decreased PO intake associated with dysphagia that has been present since he was intubated for his CABG a few years ago. A few weeks prior to admission, his symptoms worsened to include SOB, weakness, and headache. He saw his PCP two times prior to admission (once on [**5-29**] and had a Head CT that was negative at the time and once the day of his OSH admission). He had also been started on TCNs by his dermatologist for a presumed total body skin infection (doxycycline on [**5-8**], changed to minocycline after 2 days due to nausea, stopped after 10 days of treatment). Not taking meds for 3-4 days prior to admission. He presented to [**Hospital3 **] on [**6-6**] after being seen by his PCP, [**Name10 (NameIs) **] was found to have an INR of 5.9. He also reported galactorrhea for which is his spiranolactone was held. His dysphagia was treated with Reglan, PPI, and he had a barium swallow. He became aggitated and combative and a head CT showed bilateral subdural hematomas. He was transferred to [**Hospital1 18**] neurosurgical service for further care. . On [**6-9**] he was transferred to [**Hospital1 18**] and had a R crainiotomy to relieve the subdural hematoma. He was in the SICU and intubated from [**6-10**] for OR to [**6-11**]. He was extubated successfully but had a high O2 requirement on a face tent. He was noted to be less arousable, and a head CT was performed which showed stable subdural, subarachnoid and intraventricular hemorrhage and an ABG demonstrated a mixed respiratory and metabolic alkalosis (7.57/27/106/25). His subdural drain was d/c-ed on [**6-12**]. He was noted on [**6-16**] to have hypoxia to 88% which improved with 20 of IV lasix and increase in O2 requirement to 4 L NC. His Keppra was stopped on [**6-17**]. His mental status was noted to be waxing and [**Doctor Last Name 688**] during his post-operative course, at some points noted to be more lucid by his family 2 days prior to MICU transfer, but never returning to his baseline pre-operative mental status. On [**6-19**], patient had a speech and swallow consult which demonstrated diminished swallowing capacity with signs/symptoms of aspiration in the setting of altered mental status. However, decision was made to place a PEG for temporary nutrition to improve his healing post-operatively (with the understanding that it was not be a permanent method of nutrition, as patient has not desired this on previous admissions). He had 2 Head CTs post-op that showed stability/improvemnt of SDH, but a repeat Head CT on [**6-20**] demonstrated a new R infarction of the right medial temporo-occipital region, in the PCA territory, thought to be thrombo-embolic in the setting of his AF and lack of anticoagulation. . The day of transfer, the patient was noted to spike a low grade fever, more respiratory distress, with continued desaturations down to 80% on 70% face mask, and onset of tachycardia to 140s. He received deep suctioning without effect on his oxygenation, and lasix 10 mg IV x1 with resultant hypotension to 80s ((previously SBPs of 100s on the floor) so no further diuresis was performed. MERIT was consulted for treatment of his hypoxia and tachycardia, and recommended starting Vancomycin and Zosyn, and continuing his lasix 20 mg PO daily and metoprolol 50 mg PO BID (did not recommend up-titration due to his low blood pressures). However, the patient's hypoxia, tachycardia, and hypotension persisted, resulting in MICU consultation and transfer. . Pt.s respiratory distress improved and doboff tube placement was initially successful but pt. pulled out tube. It was retried several times but unsuccessful. MEDICAL HISTORY: CAD, s/p CABG, Sick sinus syndrome requiring pacer, AAA s/p repair. PVD, s/p Rt BKA and left TMA. Prior crani for SDH(LT) MEDICATION ON ADMISSION: synthroid 125mcg', flomax 0.4mg', lopressor 50mg", advair", ASA 81mg', Zantac 150mg", Lasix 20mg', Reglan 10mg"', Zocor 20mg' ALLERGIES: Demerol / Polysporin PHYSICAL EXAM: Exam on Admission: Sl agitated moving all fours and localizing, PERRL, does not open eyes to painful stimuli, however fights to open eyes when challenged. Pt is nonverbal moaning uncomprehensible words. FAMILY HISTORY: non-contributory SOCIAL HISTORY: living in independent living prior to this event ([**Hospital1 1680**] in [**Location (un) 2498**]); was independent in ambulation with prosthetic limbs. independent in ADLs and IADLs. unknown smoking or etoh history. 5 children, multiple grandchildren.

CHIEF COMPLAINT: Intracranial bleed PRESENT ILLNESS: 87 year-old French Creole speaking man with a history of HTN, Parkinson's disease was transferred from OSH with lethargy, difficulty speaking for 1 day and head CT with left basal ganglia hemorrhage for further management. Son reports that pt was fine when he went to bed Tuesday evening [**10-20**]. About 9:30AM [**10-21**], daughter-in-law woke pt up and noted that he had trouble sitting up, and was not speaking right. She put him back to bed and called pt's son. When son saw him, he was speaking gibberish, but did seem to understand what son was saying to him. Son gave him oatmeal and juice, which he seemed to swallow OK. Per son, there have been 2 similar episodes in the last few months, and they took pt to see doctor both times. By time had arrived at doctor's office, symptoms had resolved. Therefore, yesterday when this occurred, they simply put him back to bed. By 5:30pm yesterday, pt's symptoms had not resolved, and he reportedly said "I can't talk" so family called 911 and pt taken to [**Hospital 4199**] Hospital. At OSH, pt's BP 210s/110s on arrival. Exam with lethargy. head CT showed left basal ganglia bleed. He was given 1gm dilantin, and received IV labetalol 10mg x4 for BP control, though was still in 200s for most of stay. Labs with negative cardiac enzymes, INR 1.2. He was then transferred to [**Hospital1 18**] for further management. On arrival, BP 200/100, given 10 labetalol x1 and started on nipride gtt with good effect. Repeat labs here with INR 1.4 so no blood products given. Repeat head CT essentially stable. MEDICAL HISTORY: HTN Parkinsons Ds MEDICATION ON ADMISSION: Atenolol sinemet 25/100 TID vitamin C lisinopril 40mg qd coumadin 3.5mg qd prilosec 20mg qd asa 81mg qd ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T 97.0 BP 191/99-->140s/90s HR 69 RR 14 O2 99% 2L NC General: Thin elderly man, in no acute distress HEENT: NC/AT Sclera anicteric Neck: Supple Lungs: Clear to auscultation anterolaterally CV: RRR, nl S1, S2, no murmur. Abd: Soft, nontender, normoactive bowel sounds Extr: No edema, warm FAMILY HISTORY: Daughter died MI age 60. No stroke. SOCIAL HISTORY: Lives with son and daughter-in-law. Quit tobacco >30yrs ago. No EtOH.

CHIEF COMPLAINT: ischemic left foot PRESENT ILLNESS: *-71y/o female initally evaluated ([**4-29**] ) at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital for left foot ischemia which became progressive over several days prior to admission with foot pain with walking. No resat pain.workup included foot film whic was negative for osteomylitis or fracture. She was placed on leviquin for mild left heel erythemia. u/s of extremity negative for DVT.there was an acute change in pulse exam and foot color and temperature with increasing pain at rest.Patien was began on heparin and transfered to [**Hospital1 8482**] under the care of Dr. [**Last Name (STitle) 1391**] for further evaluaton and treatment on [**2164-5-1**] MEDICAL HISTORY: history of Dm2 history of chronic renal failure history of atrial fibrillation history of hypertension history of coronary artery disease with ischemic cardiomyopathy and systoic CHF history of gout history of DVt history of chronic venous stasis ulcerations history of osteoarthritis, degenerative s/p bilateral THR and rt. TKR history of depression history of hypercholestremia MEDICATION ON ADMISSION: meds added @ d/c to preadmit: bisacodyl 10 mgm qd prn dextromethorphan-guaifenesin 10/100mgm /5ml 5-10ml q6h prn albuterol inhallation q6h prn ipratropium bromide inhallation q6hprn hydromorphone 2 mgm q3-4 hprn percocet 5/325mgm q4-6h prn pain ALLERGIES: Penicillins / Sulfa (Sulfonamides) PHYSICAL EXAM: VITAL SIGNS: 98.9-84-18 134/72 )2 sat 95%@2L/NC GEN:oriented x3 HEENT: no LAD HEART: RRR no mumur, gallop or rub Lungs: clear to auscultation ABD: obese, soft nontender PV:paalpable femorals bilaterally, dopperable pedal pulses rt. absetn pedal pulses left with cool, dusky foot which extends to mid calf. FAMILY HISTORY: unknown SOCIAL HISTORY: married lives with spouse former tobacco user rare ETOH use

CHIEF COMPLAINT: PRESENT ILLNESS: This 52 year old white female has a history of coronary artery disease. She is status post myocardial infarction eight years ago and reported feeling well since this myocardial infarction and catheterization at that time with medical management. She now presents with shortness of breath with minimal exertion for the past six weeks and noted midsternal chest discomfort with radiation to the throat and upper back. She had a positive stress test with an ejection fraction of 51 percent and was referred for cardiac catheterization. An echocardiogram revealed akinesis of the anterior septum and inferior walls with a dyskinetic apex, ejection fraction of 35 percent and two plus mitral regurgitation. MEDICAL HISTORY: Hypertension. Coronary artery disease, status post myocardial infarction and catheterization in [**2127**]. History of gastroesophageal reflux disease. Status post tonsillectomy. Status post thyroidectomy. MEDICATION ON ADMISSION: 1. ____________10 mg p.o. each morning and at bedtime. 2. Aspirin 325 mg p.o. daily. 3. Wellbutrin. 4. Lipitor 10 mg p.o. daily. 5. Zestril 20 mg p.o. daily. 6. Synthroid 37 mcg p.o. daily. 7. Percocet three times a day p.r.n. ALLERGIES: She has no known allergies. PHYSICAL EXAM: FAMILY HISTORY: Significant for coronary artery disease. SOCIAL HISTORY: She lives alone. She has a thirty pack year history and currently smokes one pack a day and does not drink alcohol.

CHIEF COMPLAINT: Leg Swelling PRESENT ILLNESS: 56 yo man with history of hypertension and diabetes who had recent bilateral total knee replacements on [**11-24**] for osteoarthritis presents with bilaterall swelling and pain in his lower extermities. Patient states that 2 days ago while at [**Hospital 38**] rehab he developed [**5-17**] crampy pain and swelling in his legs bilaterally. Ultrasound at that facility showed extensive clot burden in his common femorals extending to the pelvis bilaterally. He was then transfered to [**Hospital1 18**] for further evaluation. He denies any associated chest pain, SOB, DOE, nausea or vomitting. Per the patient he has not been very mobile since the operation and has just reccently started physical therapy. His initiaiton was delayed by a post-operative illeus and admission to [**Hospital6 33**] for 2 days after discharge from [**Hospital1 18**]. This has since resolved and the patient is passing daily stools. . In the ED, initial VS were: 98.6 102 121/77 20 98%. Patient had been receiving lovenox injections for 10 days while at rehab and upon evaluation in the ED was noted to have a drop in his platelets from 287 at discharge on [**11-29**] to 137 today. CTA chest demonstrated several bilateral segmental and subsegmental filling defects with areas suggestive of infarction in the bases bilaterally. Vascular surgery was consulted and recommended CT venogram of abdomen and pelvis which showed extensive thrombosis of the left/right illiacs and common femorals. Patient was initially treated with heparin gtt until labs returned with the drop in platelets as above. Heme/Onc was consulted and recommended treatment with argatroban for possible HIT and PFT-4 antibody in the AM. Patient was admitted to the ICU for assymptomatic sinus tachycardia to the 110s. . On arrival to the MICU, patient was afebrile, p 91, 111/62 on 2L of NC, but sating 99% on RA. Patient had no new complaints and was breathing without difficulty. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. MEDICAL HISTORY: HTN Diabetes OSA s/p left and right total knee replacements ([**2144-11-24**]) MEDICATION ON ADMISSION: -enoxaparin 60 mg/0.6 mL once a day -docusate sodium 100 mg [**Hospital1 **] -oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H -aspirin, buffered 325 mg Tablet [**Hospital1 **] for 30 days after stopping lovenox. -acetaminophen 650 mg Q6H:PRN -multivitamin -metformin 1000 mg [**Hospital1 **] -hydrochlorothiazide 12.5 mg QD -lisinopril 10 mg QD ALLERGIES: Heparin Agents PHYSICAL EXAM: Vitals: T: BP: 111/62 P: 94 R: 18 O2: 97 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, wrapped in ace dressings with pitting edema to the thighs bilaterally. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact FAMILY HISTORY: Positive for diabetes, father, heart disease, father, everything else negative. SOCIAL HISTORY: He works for the [**Company 2318**] as a driver on the red line, does not smoke, never has. He drinks two to three cans of beer per week. Married.

CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: 64F active smoker with h/o CHF (EF 40% [**2103-12-12**])and COPD (on 3L at home when compliant) who presents with worsening dyspnea x 1 day. Patient reports a long standing history of COPD for which she has been on home oxygen. She reports that her breathing was tolerable in that she was able to perform activities of daily life up until a knee surgery in [**2104-9-15**]. Since the knee surgery, she has experienced worsening difficulty breathing and leg swelling. . She saw her [**First Name9 (NamePattern2) 99701**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**] on [**2104-12-12**], at which time he suspected she had a combination of left and right-sided CHF per notes and increased her lasix from 60 to 80 mg po. He recommended 24 hr-O2 although patient now reports that she only wears oxygen when her symptoms bother her. She was admitted [**Date range (1) 99702**] of this year for foot pain and worsening SOB thought to be secondary to a combination of CHF exacerbation and COPD. She was diuresed with IV lasix 80 [**Hospital1 **] and eventually refused further diuresis and requested to be discharged per notes. She was discharged on a steroid taper. She now reports that she was still having difficulty breathing at the time of discharge. . On [**2105-1-10**], she [**Date Range 653**] her PCP with complaints of difficulty breathing and was told to increase her lasix to 80 mg [**Hospital1 **] which she did over the weekend. She continued to have SOB and saw her PCP today who sent her to the ED after her sats were 80% at rest and 60s with ambulation. Of note, she only took 40 mg lasix this AM because she had decided that she would be coming to the hospital. . She also reports greenish sputum that differs from her normal sputum that is crystal white. She is unable to quanitfy how long she has had green colored sputum and says that it is complicated by her having been intermittently on antibiotics, although she cannot recall dates/durations. She denies fevers, runny nose, and sick contacts although she says that people around her have certainly had the common cold. . In the ED, she was given lasix 40 mg IV, prednisone 60 mg, albuterol/ipratropium, azithromycin 500 mg, and hydrocodone-acetaminophen. CTA r/o'd PE and LENIs were negative for DVT. CXR prelim read concerning for mild CHF and evidence of COPD. Per ED resident, her sx improved dramatically with above treament. . Currently, she reports feeling "not good". She continues to complain of shortness of breath and leg swelling. She feels that she has been unable to normally perform activities of daily life such as climbing a flight of stairs since her knee surgery and would like to have her breathing problems resolved this admission. She continues to smoke and thinks she should start drinking alcohol. Current VS: 124/60 rr16 94% on3L HR 74 afebrile. MEDICAL HISTORY: HTN CHF: systolic and diastolic Cardiovascular procedures/symptoms: echo w/low EF 25-30%, 42% by cath [**3-19**], has chronic LE swelling COPD pulmonary nodules and lymphadenopathy on CT Diabetes: diet controlled hypercholesterolemia GERD that she reports is better since partial colectomy RA X 15 years but no flares recently reports LBP for many reasons including weight but also reports OA MEDICATION ON ADMISSION: Lipitor 80 mg Tab 1 Tablet(s) by mouth at bedtime Calcarb 600 With Vitamin D 600 mg-400 unit Tab 1 (One) Tablet(s) by mouth twice a day hydrocodone-acetaminophen 5 mg-500 mg Cap 1 Capsule(s) by mouth four times a day as needed for pain Advair Diskus 500 mcg-50 mcg/Dose for Inhalation one inhalation twice daily Spiriva with HandiHaler 18 mcg & inhalation Caps Contents of one capsule inhaled once a day nystatin 100,000 unit/mL Oral Susp 5 ml by mouth three times a day Proventil HFA 90 mcg/Actuation Aerosol Inhaler 2 puffs inhaled up to four times a day as needed for shortness of breath or wheezing furosemide 40 mg Tab 2 (Two) Tablet(s) by mouth once a day Lisinopril 40 mg Tab 1 Tablet(s) by mouth once a day Omeprazole 20 mg Cap, Delayed Release 1 (One) Capsule(s) by mouth once a day prednisone 5 mg Tab 2 Tablet(s) by mouth once a day with food for one week and then one tab daily Methotrexate (Anti-Rheumatic) 2.5 mg Tabs in a Dose Pack 6 Tablets(s) by mouth one day per week potassium chloride SR 10 mEq Cap 2 (Two) Capsule(s) by mouth once a day Nitroglycerin 0.3 mg Sublingual Tab 1 Tablet(s) sublingually under the tongue prn chest pain Plaquenil 200 mg Tab 1 (One) Tablet(s) by mouth twice a day Metoprolol Tartrate 50 mg Tab 1.5 Tablet(s) by mouth twice a day Ultram 50 mg Tab 2 Tablet(s) by mouth tid prn Docusate Sodium 100 mg Cap 1 Capsule(s) by mouth twice a day oxycodone 5 mg Tab 1- Tablet(s) by mouth every 4-6 hours as needed for Pain do not drink, drive, or operate heavy machinery while taking this medication. take a stool softener Amlodipine 10 mg Tab 1 (One) Tablet(s) by mouth once a day Folic Acid 1 mg Tab 1 Tablet(s) by mouth once a day FreeStyle Test Strips for blood sugar testing once a day or as directed Aspirin 81mg daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: GENERAL - NAD, comfortable, appropriate, able to speak in full sentences HEENT - sclerae anicteric, MMM, LUNGS - bilateral rales, diffuse wheezes bilaterally, HEART - irregular rhythm, no MRG, nl S1-S2 ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - 3+ pitting edema, excoriations NEURO - awake, A&Ox3, CNs II-XII grossly intact At discharge: same as above except: LUNGS - poor air entry diffusely, no rales, faint end expiratory wheezes diffusely EXTREMITIES - 2+ pitting edema to 2/3 up calf b/l, R slightly greater than L, no calf tenderness Discharge weight: 84.2kg (standing)--this is not considered her dry weight FAMILY HISTORY: Non-contributory SOCIAL HISTORY: TOB [**1-16**] ppd X 30 years -> now smokes 1 cigarette every 2-3 days. Denies etoh, illicits. Lives with daughter.

CHIEF COMPLAINT: Recurrent left lower quadrant pain, PRESENT ILLNESS: 74-year-old female with a recurrent left lower quadrant pain, status post recent hospitalization for a recurrent diverticulitis. For the last three years, she has had increasing left lower quadrant pain. It all started on a trip to [**Location (un) 5354**] where she presented with fevers, chills and was diagnosed with ischemic colitis of unclear etiology. She does have a history of CREST syndrome. In the last year, however, she has had two hospitalizations for high fevers associated with left lower quadrant pain, anorexia, and fatigue. In the last two months she has lost 30 pounds because of lack of appetite. She underwent a recent colonoscopy by Dr. [**Last Name (STitle) 1940**], which revealed a very redundant sigmoid, as well as a very thickened sigmoid, which she was unable to completely traverse. Biopsies there were negative for malignancy. A CT scan at that time revealed a thickened colon with multiple diverticuli. A CT scan, as well as story, all confirmed recurrent diverticular disease that is now recalcitrant to medical therapy. For this reason, surgery was indicated, sigmoid colectomy for diverticulitis. MEDICAL HISTORY: Sleep apnea (uses CPAP at night), gastroesophageal reflux disease, Barrett's esophagus, CREST syndrome, hypertension. She had an open cholecystectomy in [**2121**] and an open hysterectomy in [**2131**]. She has also had cataract surgery. . [**Last Name (un) 1724**]: ASA 81 qd, omeprazole qd, norvasc 5 qd, lisinopril 60 qd, atenolol 50 qd, zyrtec prn, evista. . ALL: NKDA MEDICATION ON ADMISSION: Lisinopril 40, Norvasc 10, Atenolol 50, Evista 60, Zyrtec 10, Omeprazole 10, HCTZ 25 ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T 98.2 HR 81 BP 146/58 RR 18 SaO2 95%room air CTAB RRR Open wound with retention sutures, wet-dry dressings, appropriately tender. Ostomy w/brown stool. Trace peripheral edema FAMILY HISTORY: Family history is notable for diabetes mellitus and cervical cancer. SOCIAL HISTORY: Denies tobacco, drugs; occ EtOH. Recieves family support from Daughter, [**Known firstname 1787**] and son, [**Name (NI) **]. She is married, from [**Country 5976**], has three children, and denies tobacco use. She is currently retired.

CHIEF COMPLAINT: chest discomfort PRESENT ILLNESS: 64 year old spanish speaking female who was watching television when she had onset of pain in her left neck that radiated to left arm and left chest. It lasted approximately 10 minutes and then resolved. She was evaluated at outside hospital including cardiac catheterization and was referred for surgical evaluation. MEDICAL HISTORY: arterial hypertension Diabetes mellitus type 2 hyperlipidemia reactive airway disease anxiety depression obesity left external carotid artery disease h/o "mini stroke" w/no residual s/p c-section x2 s/p bladder surgery MEDICATION ON ADMISSION: avandia 8 daily metformin 500mg [**Hospital1 **] plavix 75 daily - last dose 6/12 lisinopril 20 daily ASA 81 daily albuterol lipitor 80 daily zetia 10 daily niacin 50 daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Pulse:68 Resp:12 O2 sat:95 on RA B/P Right: Left: Height: 63" Weight:173 #'s FAMILY HISTORY: n/a SOCIAL HISTORY: lives alone and is on disability She does not smoke and while she used to be a heavy drinker she reports that she quit seven years ago

CHIEF COMPLAINT: Dizzyness PRESENT ILLNESS: Mr. [**Known lastname 349**] is an 89 year old man who presented with several months of dizziness, thirst, and increased urination. He was confused and found to be hyponatremic, head CT negative, CXR clear, UA negative. The patient is unable to recount a history due to word finding difficulties. He is however alert and oriented times three. When asked if there was someone to call to get more information about him, he responded that his sister would be unable to help, and he has no children as he was never married. . ED course: Vitals: T 98 80 134/90 12 100% on RA. He received IVF, 60 mEq of KCL, and was free water restricted. 1L normal saline over 3 hours. . On the floor, the patient is confused, but easily redirectable. He is aware he is in the hospital and has no current complaints. MEDICAL HISTORY: -HTN -Hypercholesterolemia -Unknown facial nerve condition - ?Trigeminal neuralgia -Tinnitis, hearing loss in L ear. MEDICATION ON ADMISSION: Gabapentin, HCTZ, Zolpidem, Atorvastatin ALLERGIES: Hydrochlorothiazide PHYSICAL EXAM: On admission: Vitals: T: 98.9 BP: 162/72 P: 83 R: 21 O2: 100 % on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally no rales, wheezes or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, trace bilateral LE edema Neuro: AAO x3 with significant word finding difficulties, Strength 5/5 in extensors and flexors of upper and lower extremities bilaterally. Confused at times, trying to get OOB. . On discharge patient is alert and oriented to name and place, but not date. He is appropriate, does not exhibit word-finding difficulties, unable to participate in Mini Mental Status Exam due to difficulty concentrating. FAMILY HISTORY: [**Name (NI) 351**] sister SOCIAL HISTORY: Originally from [**State 350**]. Owned a family business/factory. Has lived with sister for his entire life. Denies tobacco, alcohol or drug use.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 64 year old male with history of congestive heart failure, diabetes mellitus type II, status post aortic valve replacement and mitral valve replacement, on Coumadin. He was transferred from an outside hospital where he presented with nausea, vomiting and weakness and was found to be hypotensive with systolic blood pressure to the 70's, hyperkalemic with potassium of 6.9, Digitoxin toxic at a level of 2.9, and in acute renal failure with a BUN and creatinine of 96 over 10. The patient was coagulopathic with an [**Year (4 digits) 263**] of 8.9. The patient had recently been admitted on [**7-3**] to the same outside hospital with a mild congestive heart failure exacerbation. At that admission, the patient was diuresed with Lasix in house with good results and discharged on [**7-5**] with a BUN and creatinine of 20 over 1.1. The patient reports that after being discharged, he took Lasix 80 mg p.o. twice a day, Aldactone, Glucophage, and Lisinopril which was newly started at discharge. The day after discharge from the hospital, the patient noted increasing light headedness, nausea, vomiting, weakness. At the outside hospital, the patient underwent a renal ultrasound which was negative for hydronephrosis or other acute process. The patient was given [**Doctor First Name 233**]-Exalate, one amp Calcium gluconate, 500 mls of normal saline. The patient was also started on a Dopamine and Dobutamine drips for decreased systolic blood pressure into the 60's. The patient was also given one amp of Digibind for his high digitoxin level. The patient was then sent by ambulance from the outside hospital to [**Hospital1 69**], where in the parking lot, his blood pressure decreased to the 60's again. The Dopamine was increased to 5 mcg per kg per minute. The patient, at this time, also complained of chest tightness and vomited times one in the parking lot of [**Hospital1 190**]. MEDICAL HISTORY: Transient ischemic attacks. Anxiety. Rheumatic heart disease. Status post mitral valve repair and aortic valve repair in [**2110-3-10**]. Complicated by atrial fibrillation and period of asystole, requiring a DDD pacemaker placement, also complicated by a peri-cardial effusion and pleural effusions. Status post cardiac window and pleurodesis. Congestive heart failure. Ejection fraction of greater than 55% on year ago. Reportedly ejection fraction of 25 to 30% by the outside hospital. Benign prostatic hypertrophy. Esophageal dysmotility. Status post cholecystectomy. Coronary artery disease. Status post clear coronaries one year ago, found on catheterization. Diabetes mellitus, type II. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: Married, living with wife. Retired manager. Former alcohol and tobacco use but quit in [**2109**].

CHIEF COMPLAINT: Syncope, shortness of breath PRESENT ILLNESS: 89 F with history of breast cancer s/p lumpectomy in [**2145**], dementia, atrial fibrillation, PSVT, orthostatic hypotension and history of syncopal episodes and multiple falls with recent C2/3 spinous process fractures in [**10-5**], who presents after a syncopal episode with C2 spinous process fracture on CT. Patient was in USOH at rehab (where she has had several falls), when to the bathroom to urinate, became dizzy, syncopized and "hit the floor" quickly. She landed on her left side, and is not sure whether she actually lost consciousness. (event not witnessed). She cannot recall any prodromal symptoms other than dizziness. She was brought to [**Hospital1 **] [**Location (un) 620**], where she was found to be hypoxic to 87% on RA, Head CT neg, CXR showed fluffy bilateral infiltrates read as pulmonary edema, shoulder and pelvic XRay without fracture, and CT neck showed "subacute C2 fracture." She received Ceftriaxone and was sent to [**Hospital1 18**] [**Location (un) 86**] for further management. . The patient has had prior admissions for syncope, which is thought to be secondary to orthostatic hypotension. She has had a 24 hour holter monitor during a symptomatic episode, which showed sinus bradycardia in the 50s. She is followed by Dr. [**Last Name (STitle) **] of gerontology for her othostatic hypotension, who recently increased her florinef to 0.1 mg daily in [**Month (only) 1096**] [**2149**]. MEDICAL HISTORY: Atrial fibrillation Hypothyroidism Breast cancer s/p lumpectomy [**2145**] Anemia s/p CCY s/p shoulder surgery MEDICATION ON ADMISSION: -ALENDRONATE 70 mg PO weekly -AMIODARONE HCL - 200MG PO daily -Tylenol 1000 mg q6h prn -FLUDROCORTISONE [FLORINEF] - 0.1 mg daily (increased [**11-4**]) -Levothyroxane - 100MCG daily -phenylephrine 10 mg daily (started in [**Month (only) **]) -ASPIRIN - 325 mg daily -Niferex 150 mg daily -Vit D 1000 U PO daily -Prilosec 20 mg daily -Oscal 600/vit D [**Hospital1 **] -Prozac 10 mg daily ALLERGIES: Morphine / Bactrim / Sulfa (Sulfonamides) PHYSICAL EXAM: On admission: VS - Temp 96.5 F, BP 184/76, HR 76, R 20, O2-sat 97% 3L orthostatics neg per nursing GENERAL - well-appearing elderly female in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - fine crackles midway up b/l, with anterior rales b/l HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, decreased strength throughout, gait not assessed Rectal: stool guaiac + FAMILY HISTORY: Noncontributory - Mother died of MI in 80s. Father died of unknown type of cancer. SOCIAL HISTORY: widow of [**Hospital1 **] pediatrician Dr [**Known lastname 6174**], No ETOH, smoked for ~10 years, quit ~60 years ago, no illicit drugs. lives alone, functionally independent, no cane or walker

CHIEF COMPLAINT: Dyspnea, orthopnea, and lower extremity edema PRESENT ILLNESS: Mr. [**Known lastname **] is a 61 year-old male admitted with fevers 102.6, leukocytosis and Congestive Heart failure SOB and weakness. An echocardiogram revealed endocarditis with vegetation seen on the mitral leaflet. His blood cultures x2 with gram postive cocci in pairs and chains. OSH urine culture Enterococcus.Cardiac surgery consulted for surgical correction. MEDICAL HISTORY: Endocarditis mental disability: paramnesia (used to hear voices) Myopic Past Surgical History: none MEDICATION ON ADMISSION: FUROSEMIDE 20 MG TABS (FUROSEMIDE) one tablet po daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission Exam: General: Alert, oriented, flat affect, cachetic with temporal wasting HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP mildly elevated, no LAD CV: Irregular tachycardia, normal S1 + S2, no murmurs, rubs, gallops Lungs: Crackles at bases bilaterally, no wheeze Abdomen: soft, RUQ with fullness and mild tenderness, non-distended, bowel sounds present, no organomegaly GU: foley Rectal: external hemorrhoids, firm enlarged prostate, guaiac negative brown stool Ext: warm, well perfused, 2+ pulses, [**1-21**]+ pitting edema up to knees bilaterally, no rashes Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, finger-to-nose intact FAMILY HISTORY: father died of [**Name (NI) 6988**] disease age 47, mother died of a cardiac arrythmia. health of sisters is unknown. SOCIAL HISTORY: Lives alone in "complete isolation." Estranged from his two sisters and both his parents are deceased. He is unemployed and disabled from prior mental illness "paramenesia" and used to have auditory hallucinations. He spends his days working on his "project" which is [**Location (un) 1131**] philosophers such as [**Location (un) **] and [**Location (un) 5936**] and taking notes and making analyses. No longer has hallucinations. Quit smoking 15-20 years ago, was smoking [**12-20**] pack of non-filters daily for 3 years. Drinks 12 beers in 24 hours once every 2 weeks. History of cocaine use "to investigate the side effects of a friend who was using it". No illicit drugs currently.

CHIEF COMPLAINT: palpitations, shortness of breath PRESENT ILLNESS: The patient is a 61 year old white male with paroxysmal atrial fibrillation that is resistant to medical management. Symptoms have increased in severity and frequency recently and he is referred for surgical management. MEDICAL HISTORY: # Paroxysmal atrial fibrillation: s/p 10 cardioversions over the past several years, 2 at [**Hospital1 **], 2 at [**Hospital1 2025**], 3 at [**Hospital1 6687**], most recently in [**Month (only) 359**] and [**2157-12-26**]. # Severe gastroesophageal reflux disease: s/p Nissen fundoplication, lysis of adhesions, laparoscopic incisional hernia on [**2157-9-27**] # Left shoulder surgery # Lipoma left hip, removed [**2158-2-2**] at [**Hospital1 18**] MEDICATION ON ADMISSION: propafenone 325'' metoprolol 25' ALLERGIES: Adhesive / Nut Flavor PHYSICAL EXAM: VS: pulse- 54, rr- 16, bp- 169/108 Gen: NAD, WD, WN [**Male First Name (un) 4746**] Skin: unremarkable HEENT: unremarkable Neck: supple, full ROM Chest: lungs CTAB Heart: RRR, no murmur Abdomen: soft, non-distended, non-tender, +BS Ext: warm, well-perfused, no edema, no varicosities Neuro: grossly intact Pulses: 2+ bilaterally throughout no carotid bruits FAMILY HISTORY: No family history of early MI, father had MVR @ 75yo SOCIAL HISTORY: Patient married with teenage daughter. Lives [**1-27**] the year in [**Hospital1 6687**] and [**1-27**] the year in the [**Location (un) 4398**] of [**Location (un) 86**]. He is a CFO of a wine company. Denies smoking. Does drink wine; gives different estimates about how much, starting w 2 drinks/wk, but when I asked him if he was in a house on [**Hospital1 6687**] with his wife, how many bottles of wine would they go through in a week, he said 2-3 bottles. (equivalent to 5 x2-3 drinks) Later, also states he drinks several martinis each week as well.

CHIEF COMPLAINT: acute cholesystitis PRESENT ILLNESS: This 70-year-old female presented to the [**Hospital3 3583**] ED on [**2103-12-7**] with the complaint of chest pain which was not resolved with sublingal nitroglycerine. Pt is s/p known to have severe coronary artery disease, which is not amenable to stenting and acute cholecystectomy. Cardiac work-up was negative. She was found to have a distended gallbladder, thickened gallbladder wall, edema around the gallbladder, and a dilated comon bile duct. Her Creatitine was acutely elevated to 2.2. Given her relatively high risk for surgery she was transfered to [**Hospital1 18**] on [**2103-12-8**]. MEDICAL HISTORY: 1. coronary artery disease s/p cardiac cath [**2103-11-29**] (no intervention) 2. peripheral vascular disease 3. s/p myocardial infarction '[**98**], s/p CABG 4. hypertension 5. macular degeneration 6. h/o C. Diff. 7. dimentia 8. depression MEDICATION ON ADMISSION: lopressor 37.5mg [**Hospital1 **] asa 325 mg daily protonix 40 mg daily aricept 5 mg daily paxil 37.5 mg daily remeron 7.5 qhs prn nitrotab prn CP reglan 5 qam advil prn nitropatch prn ALLERGIES: Plavix / Penicillins / Codeine / Ticlid / Lamictal PHYSICAL EXAM: On Admission: 100.2, 100 102/60 20 93 RA AOx3, NAD RRR, no mumur CTAB B/L Abd obese, severely TTP in RUQ c deep palpation. + [**Doctor Last Name 515**]. lowwer abdominal scar from c-sections and appendectomy ext without c/c/e FAMILY HISTORY: Patient has 9 brothers and sisters. One brother died in his 40's from heart problems. Another brother with "heart problems". [**Name2 (NI) **] did not know specifics. SOCIAL HISTORY: Patient is widowed and lives alone. Her daughter [**Name (NI) 781**] is very involved in her care. [**Doctor First Name 781**] states that her mother has very poor short term memory and has significant variations in her ability to understand everything regarding her medical care. [**Doctor First Name 781**] is her health care proxy and has power of attorney. She will accompany her mother to the hospital.

CHIEF COMPLAINT: Low back pain PRESENT ILLNESS: 77 yo F w/ AF, htn, "enlarged heart," DM, hx UTI, multiple joint replacements, who transferred from [**Hospital **] w/ 1 week LBP (l-s and R paraspinal), nausea. UA + started on abx several days ago. l-s neg, CT abd w/o contrast showed no kidney stones. ESR [**Hospital 66783**] so transferred for concern of epidural abscess. Pt neuro intact. MR revealed no epidural abscess and CT abdomen revealed small right psoas phlegmon. Based on the initial admission imaging, radiology felt fluid collection too small and not amenable to percutaneous drainage. Also of note sodium as outpatient had been 124 2 days prior to admission per PCP's office. MEDICAL HISTORY: AS HTN chronic AF on coumadin DJD with multiple joint replacements (R hip [**2105**], R knee [**2108**], L knee [**2109**], R shoulder [**2111**]) NIDDM S/P cholecystectomy [**2106**] MEDICATION ON ADMISSION: atenolol 50 coumadin 2.5mg 5mg dig 0.125 qd hctz 25 qd relafen 750 mg [**Hospital1 **] actos 15 mg QD glipizide 5 mg QD lipitor 10 mg QD ALLERGIES: Morphine / Percocet PHYSICAL EXAM: On ADMISSION 99.7 109/56 89 AF 24 97%2L NC Gen: Non-toxic, A&O X 3, mild resp distress, Heent: EOMI, PERRL, MMM Neck: 8cm JVP, thick neck AP diameter Heart: Irregular, [**5-2**] HSM at R&L USB, different [**3-4**] end-sys murmur at LLSB Lungs: Poor air movement, no crackles Abd: Obese, soft, nt/nd, NABS Ext: No edema On TRANSFER FROM ICU PE: Tc 97.3 Tm 97.7 BP 132/85 (117-199/85- 98) HR 89(85-114) AF RR 22 97%2L NC Gen: Non-toxic, A&O X 3, mild resp distress, Heent: EOMI, PERRL, MMM Neck: 8cm JVP, thick neck AP diameter Heart: Irregular, [**5-2**] HSM at R&L USB, different [**3-4**] end-sys murmur at LLSB Lungs: Poor air movement, no crackles Abd: Obese, soft, nt/nd, NABS Ext: trace edema FAMILY HISTORY: NC SOCIAL HISTORY: 5 Children, very supportive. No tob/etoh/drugs.

CHIEF COMPLAINT: Status post PVI complicated by a pericardial effusion PRESENT ILLNESS: Patient is a 55 yo male with longstanding h/o atrial fibrillation and atrial flutter s/p afib ablation x 1, and aflutter ablation x 2 and multiple failed cardioversion attempts who was admitted today for a pulmonary vein isolation procedure. During his last admission, he underwent cardioversion and initiation of dofetilide and anticoagulation. After discharge, he went back into afib, despite dofetilide, therefore it was determined that he should undergo PVI. Today, he underwent PVI, and intially there was no evidence of pericardial effusion prior to procedure. A post procedure echocardiogram showed evidence of a 0.9 cm effusion anterior to the RV, without any echocardiographic evidence of tamponade. Post procedure, the patient was hemodynamically stable, in sinus rhythm, chest pain free, and was admitted to the CCU for further monitoring. On admission to the CCU, the patient denies any chest pain or shortness of breath. He denies significant groin pain. He is otherwise without complaints. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. He was experiencing palpitations at home when he went into afib. MEDICAL HISTORY: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: s/p afib ablation x 1 and aflutter ablation x 2; multiple cardioversions most recently on [**2186-11-1**] 3. OTHER PAST MEDICAL HISTORY: Paroxysmal atrial fibrillation s/p ablation x 1 Atrial flutter s/p ablation x 2 S/P multiple DCCV HTN Hyperlipidemia Mild AI MEDICATION ON ADMISSION: Dofetilide 250 mcg [**Hospital1 **] Lisinopril 20 mg [**Hospital1 **] Metoprolol Succinate 25 mg daily Warfarin 7.5 mg daily ASA 81 mg daily MVI Omega-3 ALLERGIES: Quinidine Gluconate / Amiodarone PHYSICAL EXAM: GENERAL: WDWN ** in NAD. Oriented x3. Mood, affect appropriate. FAMILY HISTORY: Father and brother with Afib. SOCIAL HISTORY: -Tobacco history: denies tobacco -ETOH: approx 10 ETOH drinks/week -Illicit drugs: none

CHIEF COMPLAINT: Weight gain since discharge on [**8-25**] and rash PRESENT ILLNESS: Pt is a 66 year old male with PMH of HTN, s/p knee surgeries, recently discharged from the hospital after treatment of pericardial effusion and anasarca. He was treated with a pericardial drain and diuresis with Lasix. He was discharged with 3 more days of lasix and prescriptions for meloxicam and omeprazole. He noted his weight was 1.5 lb heavier than yesterday, with development of a new rash. Pt presented to hism physician, [**Name10 (NameIs) 1023**] then referred him to the ED for evaluation. . The patient initially presented to [**Hospital1 18**] on [**8-19**] with left leg and scrotal swelling. He was noted to have a pericardial effusion and hypovolemic hyponatremia in the setting of poor cardiac output. He was treated with a pericardial drain. Hyponatremia slowly improved with fluids and treatment of pericardial effusion. He first noted weight gain developing after left knee replacement on [**2132-7-10**]. CTV done to eval for thrombosis, not ideal timing of contrast to establish presence of IVC clot, incidentally a large pericardial effusion, free fluid in abdomen and pleural effusions were found. TTE without tamponade physiology, large RA/RV, raised the question of pulmonary embolism. He underwent CTA which was negative for PE or aortic dissecction but showed persistent pericardial effusion and bilateral pleural effusions. He was admitted to theICU for pericardial drain, then transferred to the floor. Etiology of pericarditis remained unclear. MEDICAL HISTORY: Benign lesion removed from his right breast [**2125**] s/p 3 knee surgeries, LTR [**2132-7-20**] Normal stress test in [**2127**] Hyperlipidemia Pre-malignant skin lesions Tendonitis HTN MEDICATION ON ADMISSION: atorvastatin 10 mg daily mobic 7.5 mg [**Hospital1 **] lasix 20 mg PO x 3 days Omeprazole 20 mg daily benicar/HCTZ (Mobic, lasix and omeprazole are new medications that were started upon discharge on [**2132-8-25**]) ALLERGIES: Coumadin PHYSICAL EXAM: A & 0 x 3. VSS, afebrile. BP104/71 Cor- crisp heart sounds. SR @85. Lungs- clear. Sternum stable, cleans dry and intact incision. Abd- benign. Exts- trace edema RLE. Scant serous drainage from JP site. EVH incisions intact. FAMILY HISTORY: He has a strong family history of coronary artery disease. Father died of MI at age 51. SOCIAL HISTORY: Retired IRS attorney. Now runs own business as CPA/tax lawyer. Lives with wife. 2 grown children. [**Country 3992**] veteran. No h/o incarceration or known TB exposures. No IVDU. Very distant smoking history. 2 glasses wine/day.

CHIEF COMPLAINT: Respiratory Distress PRESENT ILLNESS: This is a [**Age over 90 **] year-old (by record though actually 86 years-old per brother) male with history of Afib, HTN, CVA's and severe dememntia (nonverbal at baseline) who presented with respiratory failure. Per nursing home documentation the patient was short of breath on the morning of admission AM and received azithromycin and and furosemide at his facility. In the evening he looked worse and was noted to be acutesly short of breath so he was taken by EMS to [**Hospital1 18**]. There he was in some extremis with mottled skin, a heart rate in the 180's in and hypoxia. He was intubated almost immediately for hypoxia and then had a central venous line placed after becoming hypotensive. HR improved to 80's with a single dose of diltiazem. He received 2L of fluid, vancomycin, levofloxacin, and metronidazole after a CXR showed multifocal pneumonia. Conversation with the brother and next of kln revealed he wished the patient to be full code. The patient was transferred to the MICU for further treatment, vitals prior to tx were T: 101.2 P 96 rr 20 bp 109/72 sa 02 100%. On arrival to MICU pt intubated and nonverbal at baseline so ROS not obtainable. Moves a small amount on own. MEDICAL HISTORY: -Atrial Fibrillation -R MCA embolic stroke [**8-22**] -Cerebellar hemorrhage s/p craniotomy [**2126**] -Alzheimers dementia and nonverbal / PEG fed since stroke in [**2161**] -Colon CA stage III s/p resection -Coronary Artery Dementia -Hypertension -Mitral Regurg -Left Ventricular Hypertropy -Cervical radiculopathy/myelopathy -T12 compression fracture -Gastroesophageal Reflux -Liver hemangioma -Chronic Kidney Disease -BPH s/p TURP -History of bowel obstruction -History of multiple falls -History of ETOH abuse -Remote History of Pulmonary TB ([**2103**]'s) MEDICATION ON ADMISSION: 1. Aspirin 325 mg Tablet [**Name2 (NI) **]: One (1) Tablet PO DAILY (Daily). 2. Brimonidine 0.15 % Drops [**Name2 (NI) **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 4. Calcitrate-Vitamin D 315-200 mg-unit Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 6. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2 times a day) as needed for constipation. 7. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day: in the morning. 8. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day for 10 days: in the evening. 9. Omeprazole 20 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: [**10-3**] mL PO Q6H (every 6 hours) as needed. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: 97.3, BP 106/47, HR 106, RR 22, O2 99%(AC 500, 20, 15/5, 80% FiO2) General Appearance: Thin, chronically ill appearing Eyes / Conjunctiva: Pupils dilated Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal tube, OG tube Lymphatic: Cervical WNL Cardiovascular: Tachycardic, normal S1 and S2 Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: Bilateral rhonchi L>R Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Warm Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds to: Verbal stimuli, Movement: Purposeful, Tone: Not assessed FAMILY HISTORY: Both parents died in [**2095**] in the [**Location (un) 25508**] ghetto. SOCIAL HISTORY: Immigrated from [**Country 532**] in [**2134**], at baseline speaks & understands limited English - translator needed. Positive h/o alcohol abuse, none for >1 yr. He does not smoke. Previously employed as a photographer. Brother states patient is a Holocaust survivor. Has lived in facility >1 yr. Nonverbal and fed by PEG.

CHIEF COMPLAINT: Shortness of breath PRESENT ILLNESS: 80M with a history of CAD s/p 5 vessel CABG in [**2098**], STEMI in [**2111**] multiple interventions the most recent being [**2113-8-22**] with PCI and BMS of native Lcx. He underwent implantation of dual chamber [**Company 1543**] pacemaker in [**2113-2-16**] due to Wenchebach Mobits type I heart block. Initially, he noted improvement in exercise tolerance with the pacer noting that he was able to walk [**2-17**] block without becoming fatigued or SOB. In the last two months he has had progressive worsening of DOE and SOB such that he is home bound and becomes dyspneic when walking from one room to another. He currently has LV dysfunction, with an EF of 20-25%, which is down from when the pacemaker was placed. He has class III heart failure symptoms with DOE with minimal exertion. On the day of admission, he was electively admitted for upgrade to a biventricular pacemaker. Unfortunately placement of the biV leads was unsuccessful, the previous RV pacer wires remain and his generator was up graded and changed to DDI-55. He was admitted to the CCU for post proceedural monitoring. . On arrive in the CCU his vitals were 97.0 67 100/70 95% 2L. EKG Prolonged PR interval AV conduction delay with rate of 80bpm a non conducted P and diffuse twave inversions. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension + Diabetes 2. CARDIAC HISTORY: - CABG: 5 vessel, [**2098**]: LIMA to LAD, SVG to Diag, SVG to RCA, SVG to OMI, SVG to Ramus - PERCUTANEOUS CORONARY INTERVENTIONS: 1) [**11-22**] STEMI with BMS x 2 to the SVG to the OM at B&W. 2) [**4-23**] PCI 80% LAD, patent LIMA, total occlusion of the OM and total Occlusion of the saphenous vein graft to the RCA. 3) [**8-24**] PCI with BMS to the native circumflex. - PACING/ICD: [**Company 1543**] dual chamber V-pacer, placed in [**2-/2113**] for asymptomatic AV Wenckebach with bradycardia 3. OTHER PAST MEDICAL HISTORY: - Mitral valve prolapse with mild MR - 5 vessel CABG [**2098**] - Hypertension - Hyperlipidemia - ESRD on HD M W F via Left arm [**Hospital3 39763**]dialysis in [**Location (un) 7661**]- Dr. [**Last Name (STitle) 39764**] - Celiac Sprue-not following gluten free diet currently - GI bleed on aspirin requiring transfusion [**5-24**] and [**9-23**] - ? arrhythmia, s/p EP study that was negative [**2112**] - Legally blind [**3-20**] macular degeneration MEDICATION ON ADMISSION: clopidogrel 75 mg Tablet Daily Vitamin B12 1,000 mcg/mL Solution Q month Darbepoetin alfa 25 mcg/mL Solution q friday at dialysis- every 3 weeks folic acid 5 mg/mL Solution monthly at pcp iron sucrose Dosage uncertain metoprolol succinate 12.5mg daily paricalcitol Dosage uncertain (at dialysis MWF) bisacodyl 5 mg Daily , calcium carbonate 500 mg TID ALLERGIES: Aspirin PHYSICAL EXAM: GENERAL: Elderly cachectic male appearing tired. HEENT: Temporal wasting, Sclera anicteric. NECK: Supple with JVP of 8cm. CARDIAC: Cachectic appearing, prominant ribs, s/p CABG, II/VI SEM at LUSB, Visable heave at 5th intercostal space, midclavicular line. LUNGS: CTABL, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. BS normoactive. EXTREMITIES: warm, wel perfused, no edema. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ FAMILY HISTORY: MOther: Diabetes Denies history of heart failure, early MI SOCIAL HISTORY: Married, does not work. Retired from the radio Broadcast and sales. One glass of wine once weekly. -Tobacco history: Never smoker

CHIEF COMPLAINT: Altered Mental Status PRESENT ILLNESS: 73yo m w/ hx of CAD s/p 4V CABG ([**2119**])and PCI w/ LAD stent, poorly controlled IDDM, HLD, COPD, and CKD (baseline cr 3.5)presented to [**Hospital3 **] Sunday AM after being found unresponsive at home. EMS FS at the scene was 63. In the [**Hospital3 5097**] ED was notable for BUN 98, Cr 5.0, troponin 1.85, Ck-MB 25.9 and BNP>5000. EKG was notable for Sinus tach, LVH with 1-2mm ST depressions in the lateral leads. Head CT was neg for intracranial pathology. He was started on a Hep ggt and given rectal aspirin and transferred to the OSH CCU. They could not plavix load or give beta blocker because not taking PO. He was evaluated by the renal team and given his acute on chronic renal failure with hyperkalemia (peak 5.5) metabolic acidosis and volume overload, a right IJ Vas-Cath was placed and he was emergently dialyzed with 1.2 kilos of fluid removed and creatinine fell to 3.7. His peak Troponin I 23.9 and CK-MB 57.1 (MB peaked on [**8-10**]). He was maintained on heparin ggt. A cardiac echo was done which demonstarated an EF of 38% hypokinesis of mid inferoseptal, mid inferior, mid inferolateral, basal inferolateral, basal anteroseptal, basal inferoseptal and basal inferior segments. His blood sugars fell into the 30's while in the CCU and he was placed on D10 and maintained his blood glucose in the 70's-90's. He was transefered to [**Hospital1 18**] CCU for further care. On arrival to the floor, patient remains altered. He is agitated and not oriented to person, place or time. He is unable to give any history at this time. His niece, his HCP, was [**Name (NI) 653**] and the situtation was discussed. She reports that his medication list is unchanged from his recent discharge from [**Hospital1 18**] and that the patient is responsible for administration of his own medication. She reports that he has a history of hypoglycemia episodes, most recently an admission to [**Hospital1 18**] from [**Date range (1) 23465**]/12. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: 4 vessel in [**11/2119**] -PERCUTANEOUS CORONARY INTERVENTIONS: cath with stent to LAD and LCx on [**4-/2119**] -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: CHF (EF <30%) CKD with baseline Cr (3.0-4.0) PVD s/p SFA and DP bypass left iliac stenting [**11-15**] s/p appendectomy s/p L 2nd toe amputation MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver [**First Name (Titles) **] [**Last Name (Titles) 581**]. 1. Clopidogrel 75 mg PO DAILY 2. HydrALAzine 25 mg PO BID 3. Isosorbide Dinitrate 30 mg PO TID 4. Metoprolol Tartrate 25 mg PO BID 5. Simvastatin 10 mg PO QHS 6. Tamsulosin 0.4 mg PO HS 7. Nephrocaps 1 CAP PO DAILY 8. Calcium Acetate 667 mg PO TID W/MEALS 9. Sodium Bicarbonate 1300 mg PO TID 10. Furosemide 80 mg PO DAILY 11. Aspirin EC 81 mg PO DAILY 12. Glargine 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission Physical Exam: VS: T=97.5 BP=163/57 HR=78 RR=16 O2 sat=99% on RA GENERAL: WDWN male in NAD. Not oriented to person, place, or time. Mildly agitated at times. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death. SOCIAL HISTORY: Social history is significant for current tobacco use, thenpatient has smoked up to 2 and [**1-13**] ppd for over 55 years, quit briefly for 6 months, now smoking again. There is no history of alcohol abuse.

CHIEF COMPLAINT: Chest pain. PRESENT ILLNESS: The patient is a 46-year-old male admitted on [**2152-10-23**] to [**Hospital1 188**] with acute coronary syndrome and LMCA 80% thrombosis. The patient had an intra-aortic balloon pump placed immediately and underwent an urgent CABG the same day with LIMA to left anterior descending artery and saphenous vein graft to OM graft placed. The patient was recently admitted for 10/10 chest pain radiating to the left arm with numbness and right arm numbness. The patient also experiencing nausea and shortness of breath at this time, but no diaphoresis or palpitations. He was given aspirin, beta blocker, nitroglycerin, Heparin, Morphine, and tirofiban at an outside hospital with persistent 10/10 chest pain and ST depression. Therefore, he was Med Flighted to [**Hospital1 69**] on [**2152-12-29**]. His symptoms and ST depressions resolved completely at this time. MEDICAL HISTORY: 1. Borderline diabetes. 2. Hypercholesterolemia. 3. Myocardial infarction status post CABG in [**2152-10-29**]. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Patient is a bricklayer with one daughter from a previous marriage, who is also engaged.

CHIEF COMPLAINT: Right leg claudication. PRESENT ILLNESS: 55-year-old gentleman with severe peripheral vascular disease has had severe disabling claudication of his right lower extremity. He has some iliac disease, diffuse common femoral disease, a long segment right superficial femoral artery occlusion with reconstitution of a below-knee popliteal artery and good 2-vessel runoff to the foot. MEDICAL HISTORY: - vocal cord CA s/p radiation/laryngectomy/trach - chronically elevated WBC (on prednisone for Rx) - HTN - R knee replacement - tonisllectomy MEDICATION ON ADMISSION: ASA 325, zoloft 100', quinine sulfate 325, atenolol 100, prednisone 5', doxepin 10', tramadol 50', nexium 40', celebrex 200', gabapentin 300am/100pm ALLERGIES: Demerol PHYSICAL EXAM: FAMILY HISTORY: non-contrib SOCIAL HISTORY: non-contrib

CHIEF COMPLAINT: Hypothermia at Dilaysis PRESENT ILLNESS: The patient is a 84 y.o. female with h/o ESRD on HD recent admission for C diff colitis in [**2161-8-6**], a resident at [**First Name4 (NamePattern1) 4233**] [**Last Name (NamePattern1) **], admitted [**2161-9-22**] after she was found to be hypothermic during HD yesterday. The patient with recent stool positive for cdiff at nursing home (C.Diff +[**2161-9-19**]). The patient with h/o nausea and vomiting and diarrhea prior to admission. On the day of admission, the patient was found to be hypothermic c/o chills at HD and was sent to ED for eval. EKG with new T wave inversions in in c/w prior EKG [**2161-8-30**]. In the ED, the patient was treated with ASA, metoprolol 50mg, oxycodone, and dextrose. The patient was admitted to the general medical floor and had T 94.4 on admission BP 124/50; HR71; RR24; O2 sats 93% on RA and 99% on 4L NC. She was placed on a bear hugger and was mentating fine. The patient received Vancomycin IV x one dose, Levaquin x one dose and she is also on Flagyl po. At 5 am today, she found to be confused, persistently hypothermic with T min 93.7, hypotensive with SBP 94/60 in Trendelenberg and intermittent SBP down to 70's, and hypoglycemic to 34 on random finger stick check. She was given NS boluses and dextrose and one hour after dextrose hypoglycemic again. Patient placed on NRB after desatting to 80's on 4L NC. She denies pain, SOB, chest pain, or any discomfort. The patient's mental status has waxed and waned. MEDICAL HISTORY: 1. ESRD on HD since [**2149**] (Dr. [**Last Name (STitle) 1860**]; MRSA bacteremia from fistula [**5-10**] 2. Atrial Fibrillation 3. Renal Mass on CT since [**2159**] 4. Right Hip Erosive Arthritis; now s/p R hip surgery (hemiarthroplasty) complicated by mental status changes and decreased BP 5. Osteoporosis 6. Anemia 7. Asthma 8. GERD 9. Hypertension 10. PVD/Heel Ulcers - refusing angio 11. C.Diff [**8-10**] treated with Flagyl. C.Diff positive on [**9-19**] at nursing home. 12. Poor PO Intake 13. Depression 14. Low Phos, Mag, and Potassium MEDICATION ON ADMISSION: Amiodarone 200mg QD Coumadin 1mg QD Toprol XL 50mg [**Hospital1 **] Protonix 40mg QD MVI Nephrocaps Lisinipril 30mg QD Combivent Albuterol PRN ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T 94; HR 70; BP 106/58; RR 18; 93-95% on NRB General: thin, [**Last Name (un) 1425**] AA female lying in bed with NRB HEENT: PER small and RL, EOMI, no scleral icterus Neck: supple, no JVD CV: regular, S1S2, normal Chest: bilateral crackles Abdomen: +BS, soft, [**Last Name (un) **]-tender, mildly distended, no rebound or guarding Extr: 1+ pitting edema bilaterally; bilateral heel ulcers with dressing c/d/i Family History: Unknown FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Pt currently lives at rehab center but prior to fracture lived alone in [**Location (un) 86**] with a house cleaner who comes several times a week to clean her house. Pt reports quiting smoking 8 years ago. However, the patient does have a 60+ pack year history of smoking. Pt has occasional alcohol use.

CHIEF COMPLAINT: Patient presented to ED s/p witnessed fall, unresponsive PRESENT ILLNESS: 80yo M s/p fall, non responsive, GCS 3 at OSH and [**Hospital1 18**]. MEDICAL HISTORY: Alzheimers Dememtia "Mini strokes" MEDICATION ON ADMISSION: ALLERGIES: Penicillins PHYSICAL EXAM: FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Married and lives with wife

CHIEF COMPLAINT: ESRD PRESENT ILLNESS: Mr. [**Known lastname 46505**] is a 50-year-old gentleman with end-stage renal disease and significant cardiac history. After an extensive workup and extensive discussion of the risks and benefits of the transplant, he strongly desired to proceed with a living-related renal transplant. MEDICAL HISTORY: * CAD, s/p acute anterior MI with CABG at [**Hospital1 2177**] [**2134**] * ischemic cardiomyopathy: [**5-20**] TTE: EF 15-20% with global HK; 2+MR, [**12-19**]+TR, pulm HTN * HTN * DMII. Last A1c 6.8 [**10-23**] * CRF, creatinine slowly rising over past few years * anemia * thrombocytopenia MEDICATION ON ADMISSION: coreg 6.25", ASA 325', lipitor 40', avandia, erytropoeitin, phoslo, lasix80', lisinopril 5 ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: (on discharge) 97.9 69 174/76 20 100%RA RRR CTAB soft, appropriate tenderness incision C/D/I with staples in place no edema FAMILY HISTORY: His mother has diabetes. His father died of stomach cancer. maternal GF died at age 48 of likely MI SOCIAL HISTORY: former tobacco use, quit [**2129**]. Runs two restaurants. Has 5 children. social etoh twice a month

CHIEF COMPLAINT: BRBPR PRESENT ILLNESS: Patient is a 77 yo M with multiple medical conditions including Stage IV NSCLC (adenocarcioma) s/p chemoradiation, CAD and PVD on [**Hospital **] transferred from [**Hospital6 **] ED for BRBPR. . Patient began having BRBPR last night. He presented to [**Hospital1 112**] ED and was found to have a Hct of 20 (baseline in high 20s/low 30s). He received 1U PRBC there. Given that he receives most of his medical care here, including treatment for his NSCLC, he was transferred to [**Hospital1 18**] to further management. . In the ED, initial vs were: T- 100.3, P- 84, BP-151/64, RR-18, SaO2- 100% on RA. Patient complained of abdominal pain, mainly in the suprapubic region. CT scan was negative but did show significant fecal load. He received 3L NS in the ED. In addition, he received IV PPI. His temp went up to 103.0 so he was given tylenol and cultured. UA was positive so he was started on Cipro. He was also given a dose of flagyl for abdominal pain and fever. He complained briefly of chest pain so troponins were sent- came back at 0.04. . On the floor, patient was fatigued but arousable. Vital signs: T- 99.0, HR- 103, BP- 124/65, RR- 19, SaO2- 98% on 2L. He did not complain of any abdominal tenderness. MEDICAL HISTORY: 1. Stage IV non-small cell lung cancer. Histology: adenocarcinoma. Status post 5 doses of chemotherapy with carboplatin AUC of 2 and paclitaxel 50 mg/m2 weekly with radiation, for 6 weeks. Week 2 was held for evaluation of chest pain. Completed daily fractionated radiation to 5040 cGy in 5/[**2194**]. . Other PAST MEDICAL HISTORY: - HTN - Peripheral [**Year (4 digits) 1106**] disease s/p R CIA stent and L EIA angioplasty [**8-30**] and s/p R SFA balloon angioplasty and stent x2 [**9-30**] and right lower extremity claudication status post right common femoral to above knee popliteal graft with PTFE on [**4-10**], [**2193**]. - S/p bilateral shoulder displacement. - CAD s/p MI '[**85**] - Hypercholesterolemia, - GI bleed '[**87**] - Gout - Osteoarthritis - Herniated L4-5 disc - L5-S1 stenosis MEDICATION ON ADMISSION: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Oxycodone 5 mg Tablet Sig: 3-5 Tablets PO Q2H (every 2 hours) as needed for pain. 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO every eight (8) hours as needed for constipation. 17. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: One (1) tsp PO every 4-6 hours as needed for cough. 18. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 19. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 20. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 21. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1) tablet Sustained Release 12 hr PO twice a day. 22. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea/anxiety. . ALLERGIES: Heparin Agents PHYSICAL EXAM: Physical Exam: Vitals: T- 99.0, HR- 103, BP- 124/65, RR- 19, SaO2- 98% on 2L General: Fatigued but arousable. 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: Tachycardic. Regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. TTP to suprapubic region. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema FAMILY HISTORY: Sister that died from a throat cancer apparently. There is no other history of cancer in the family. There is history of coronary disease in the family. SOCIAL HISTORY: The patient started smoking at age 15 and continues smoking now. He smoked less than a pack per day for most of his life and recently smokes only approximately five cigarettes a day. He currently lives alone in [**Location (un) 538**]. He consumes alcohol on occasion. He previously consumed significant amounts of rum. He has been in the United States for over 20 years. He was born and raised in [**Country 5976**]. He only speaks Spanish. He is a retired musician and automobile mechanic. .

CHIEF COMPLAINT: dyspnea/chest pain PRESENT ILLNESS: 56 year old male with past history of and recent hip replacement 2 weeks ago, transferred from [**Hospital6 33**] for bialteral PE's. He presented this morning with chest pain and syncope - fell forward on face. Found down, with pulse. EMS called and transfered to [**Hospital6 **]. At OSH, found to be tachycardic with hypotension (SBP 85). CTA showed large bilateral PE's. Troponin negative. CT Head with no evidence of acute infartion, acute hemorrhage or mass lesion. He was tranferred to [**Hospital1 18**] for further management. Patient arrived to [**Hospital1 18**] ED with hypoxia on 4L O2 satting 94% and requiring peripheral levophed for blood pressure support. Bedside echo showed RV strain, but no impingement on left ventricle. Continued to be tachypnic, oxygen requirement increased to 6L NC. Vitals prior to transfer 96.7 100/76 26 94% on 4L. On arrival, patient is comfortable. States has some shortness of breath. Chest pain, described as pressure on center chest has resolved. Stopped lovenox 2 days prior. Swelling in left leg, improved. Has been ambulatory since day after discharge from THR. ROS: + per HPI. + feeling cool. Denies fever, chills, nightsweats. No headache or vision change. No N/V/D. No cough. No hematachezia, melena, dysuria, hematuria. No weakness. No parasthesias MEDICAL HISTORY: s/p Total Hip Replacement 2 weeks ago Hypertension Hyperlipidemia MEDICATION ON ADMISSION: Atenolol 25 mg qday Lipitor 10 mg daily ASA 81 mg daily ALLERGIES: No Allergies/ADRs on File PHYSICAL EXAM: ADMISSION VS: Temp: 96.2 BP: 126/76 HR: 111 RR: 24 O2sat 95% 4L NC GEN: pleasant, comfortable, lying in bed HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no jvd. laceration on right side of cheek. RESP: CTA b/l with good air movement throughout anteriorally CV: tachycardic, regualr rhythm. S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: dependent edema in left thigh, incision over left thigh appears well healed with no sign of drainage or infection. right leg without edema. no cyanosis. peripheral pulses palpable in bilateral radial position. SKIN: no rashes/no jaundice/no splinters noted NEURO: AAOx3. Cn II-XII intact grossly intact. no facial droop, speech fluent and appropritate. spontaneously moving all 4 extremities. FAMILY HISTORY: Strong family history of heart disease in mother and brother. [**Name (NI) **] clotting disorders. No diabetes. SOCIAL HISTORY: Married, wife RN at [**Hospital1 18**] [**Name (NI) **]. Works as structural engineer. 1 alcoholic beverage per day, no smoking history, no drug use.

CHIEF COMPLAINT: s/p NSTEMI PRESENT ILLNESS: Patient is an 87 year old woman with PMH of DM, HTN, and AFib s/p PPM admitted to [**Hospital3 4107**] on [**2175-8-15**] with non-healing gangreonous right fourth toe for consult regarding amputation. Patient was started empirically on vancomycin, levofloxacin, and flagyl until wound culture grew MRSA, and levofloxacin and metronidazole were D/C'd. . The morning prior to admission, at [**Hospital1 **], patient developed SOB without CP or EKG changes and was diuresed with relief of SOB. Later in the day, she developed chest tightness and troponins bumped 1.2/1.26/1.04. The patient was placed on heparin drip along with plavix and aspirin. TTE showed possible anterior wall dysmotility. The morning of admission she developed recurrent left shoulder pain relieved with NTG and morphine and TWI on EKG. It was decided to transfer patient to [**Hospital1 18**] for cardiac catheterization. . VS on transfer: 132/68 HR 78 R 18 sat 97% 2Lnc. 0/10 pain. In the cath lab, patient was noted to have 3 vessel disease. Cardiac surgery was consulted and recommended CABG on Monday. Patient was transferred to the floor in good condition, complains of a mild headache, denies any chest pain or SOB. . On review of systems, she complains of chronic nonproductive cough, decreased sensation in her feet, claudication, and chronic diarrhea self treated with lometil, and increased urinary frequency. She denies any prior history of stroke, TIA, deep venous thrombosis, or pulmonary embolism. She denies recent fever or chills. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, ?Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: Afib s/p PPM [**2165**] 3. OTHER PAST MEDICAL HISTORY: Retinopathy Neuropathy LVH AFib s/p PPM for sick sinus syndrome GERD DJD Anxiety Osteoporosis Pernicious anemia s/p C-section x2 and Hysterectomy Cataracts Vulvar condylomata Diverticulosis MEDICATION ON ADMISSION: TRANSFER MEDICATIONS: . NTG 0.4 SL prn ASA 325 daily Vicodin q4 prn Heparin gtt Lexapro 10 daily Latanoprost eyedrops Bactrim DS [**Hospital1 **] Tylenol 650 q6 prn Verapemil 240 daily metoprolol XL 25 daily Losartan HCT 50/12.5 [**2-5**] pill daily Glimepiride 4 mg [**Hospital1 **] Zetia 10mg daily Colace 100 daily Digoxin 0.125 daily Plavix 75 daily Humalog sliding scale ALLERGIES: doxycycline / Erythromycin Base / ibuprofen / indomethacin / lovastatin / Pravastatin / brilliant blue FCF / Penicillins / Latex / tetracyclines / NSAIDS / HMG-CoA-R Inhibitors / macrolides / Statins-Hmg-Coa Reductase Inhibitors / ketolides PHYSICAL EXAM: ADMISSION PHYSICAL EXAM VS: T=98.7 BP=134/49 HR=61 RR=16O2 sat=98% GENERAL: Thin elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: Anicteric sclerae. PERRL, EOMI. Dry mucus membranes. Nares and oropharnxy clear. NECK: Supple without LAD, thyromegaly or JVD. CARDIAC: normal S1, S2. II/VI systolic murmur over left sternal border. No S3 or S4. LUNGS: Resp were unlabored, patient lying on back post cath. Auscultation of anterior chest was clear. ABDOMEN: Soft, NTND. No HSM or tenderness. Normoactive BS EXTREMITIES: Right foot dressed up to ankle. Bandage clean. No CCE noted on left foot SKIN:Stasis dermatitis noted over left foot, well healed midline abdominal scar. No ulcers or scars noted. PULSES: Right: Radial 2+ Left: Radial 2+ DP 0 PT 0 . DISCHARGE EXAM: GEN: NAD NECK: JVP flat CV: Irregular rate and rhythm, no m/r/g appreciated PULM: no crackles, good air movement, resp unlaboured ABD: NABS, soft, non-tender even with deep palpation. EXT: No edema. Wound on right foot largely unchanged, lambs wool between toes at site of kissing ulcer sticking to ulcer site this am. Eschar material coming loose from toe with minimal drainage. Toe much less TTP. Feet warm. Dopplerable pulses. NEURO: A/Ox3, non-focal FAMILY HISTORY: Father and 2 brothers with MI. Otherwise noncontributory SOCIAL HISTORY: -Lives at [**Location 89168**] senior living. -Tobacco history: Never -ETOH: None -Illicit drugs: Never -Herbal Medications: None

CHIEF COMPLAINT: head trauma s/p fall PRESENT ILLNESS: Patient is a 67 yo male with unknown PMH who suffered a [**9-19**] foot fall while on his boat. He struck his head on concrete and was believed to have been found 30 minutes later. Was in agonal breathing and was reportedly moving all four extremities. EMS attemtpted intubation but was unable. Was taken to outside hospital where was noted to have one pupil fixed and dilated. Was then med-flighted over to [**Hospital1 18**] where in ED on initial evaluation was noted to have bilateral pupils fixed and dilated with corneal reflex intact only on the left. No other history available at this time. Family reportedly en route from [**State 2748**]. MEDICAL HISTORY: unknown MEDICATION ON ADMISSION: flomax, diovan ALLERGIES: No Drug Allergy Information on File PHYSICAL EXAM: VS: BP: 156 /104 HR:110 R 16 vent O2Sats 100 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: fixed and dilated at 8mm bilaterally. EOMs absent Neck: C collar. Left head lac and blood. Also blood exiting left external auditory canal. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Unresponsive. GCS 3. No purposeful movements. No response to pain except bilateral tripple flexor. Cranial Nerves: I: Not tested II: Pupils fixed and dilated at 8mm bilaterally. Pupils re-examined about 30 minutes after receiving 100gram Bolus of Mannitol and no change seen. No blink to threat. Not tracking and no EOM. III, IV, VI: Extraocular movements absent. V, VII: NA. VIII: NA. IX, X: NA. No gag. [**Doctor First Name 81**]: NA. XII: Tongue midline without fasciculations. FAMILY HISTORY: unknown SOCIAL HISTORY: unknown

CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: 44 y/o M w/no past med hx who was brought by EMS to the ED tonight c/o SOB and told them he did "a lot of cocaine". Per the ED triage note (as pt was unable to give further history once in the ED), he had SOB, was c/o feeling "antsy and jumpy", was diaphoretic, and denied chest pain. . His vitals in the ED were 99.4, 142/79 (140s-170s/70s), 94 (90s-110s), 27 (17-27), 92% on unclear amt of oxygen. He was initially given ativan and then valium, but continued to be agitated, trying to kick the staff, requiring four point leather restraints. He received a total of 6 mg ativan and 30 mg valium. Due to continued agitation, the decision was made to intubate him. He was given etomidate and succinylcholine. He then had an LP and required vecuronium 10 mg IV x2 during this procedure. At this point he was admitted to the MICU. MEDICAL HISTORY: none per ED triage note. Prior ED visit [**1-21**] for cocaine and methamphetamine intoxication MEDICATION ON ADMISSION: none ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T: 97.4 BP: 132/91 P: 84 AC 600x14 0.4 SpO2 100% peep 5 Gen: intubated/sedatated, does not respond to pain, intermittently moving all extremities HEENT: NC, AT, anicteric, conjunctivae injected, pupils pinpoint, OGT in place Lungs: CTA anteriorly CV: RRR, no m/r/g Abd: soft, nt/nd, +bs Ext: no edema, 2+ distal pulses bilaterally FAMILY HISTORY: NC SOCIAL HISTORY: Used "a lot" of cocaine tonight but not a daily user per ED triage note. Remainder of soc hx unobtainable.

CHIEF COMPLAINT: Trauma patient with multiple injuries including: 1.Left-retro-orbital hematoma 2.posterior right subgaleal hematoma 3.large midline frontal laceration to the skull 4.multiple facial fx 5.amputated Left(3rd) finger (DIP) PRESENT ILLNESS: 21 year old male s/p assault w/ a baseball bat and machette, initially GCS 15, obvious L-orbit/scalp trauma- at [**Hospital1 1474**] Hosptial 10 hrs prior to arrival developed confusion/combativeness- intubated and transferred to [**Hospital1 18**]. MEDICAL HISTORY: None MEDICATION ON ADMISSION: none ALLERGIES: Chlorpromazine PHYSICAL EXAM: On admission the patients physical exam was: FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Lives with family in [**Hospital1 1474**]

CHIEF COMPLAINT: Back/Chest Pain PRESENT ILLNESS: 74 yo male with HTN,PMIBI in [**2134**] demostrating mild reversible decrease in tracer uptake in inferolateral myocardial wall, with EF of 48%, who presented to Dr.[**Name (NI) 10962**] office with a complaint of back pain. The EKG from that office is unavailable, but patient stated that Dr. [**Last Name (STitle) 3357**] told him that back pain such as his could be a sign of an MI and he was sent to [**Hospital1 18**] ED for evaluation. Patient states that last thursday he was swimming in the pool, as he usually does for 40 minutes, afterwards went to the sauna, and once he was done was wiping his sweat and felt that he had some back pain while moving his arms about. He states that the pain was different from the usual musculoskeletal pain that he gets with movement (around his ribs in the axilla, which he had for years). The pain never went away and was worse with movement, especially with movement of back muscles. The area between the scapulas is also slightly tender to deep palpation. What helps is the Solaraze gel (diclofenac) cream that he got from a Russian doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 15158**]. The help subsides but never goes away completely. His current pain is not associated with diaphoresis, does not radiate to his arm, neck or jaw. He does not report dysphagia, or trouble walking. Patient states that at baseline he can walk for as far as the eye can see, and his swims quite regularly. He has had a nuclear exercise stress test in [**2134**] when his complaint of rib pain was further evaluated, At peak exercise (mid Stage 2 onset) there was 3.0-3.5 mm of gradual upsloping, horizontal ST segment depression noted in V4-V6 and inferiorly. In recovery (minute 1 onset) these ST depressions became diffusely downsloping before resolving gradually with rest by minute 10. Of note, the exercise induced ST depressions were noted in the setting of baseline prominent voltage in the absence of strain. Appropriate hemodynamic response to physiologic stress. IMPRESSION; Marked ischemic EKG changes in the setting of prominent voltage. No anginal symptoms. On nuclear report the following findings were identified: 1. Mild reversible perfusion defect involving inferolateral wall. 2. Normal left ventricular size, EF 48%. . In the ED, initial vitals were 98.6-74-140/80-14-99%2L . Labs were significant for Trop neg x 1. Concern is "high risk" so getting admitted. CXR without acute process. Gave ASA 325 mg. . EKG in the ED: Sinus at 52, 1st degree AV block, ST elevations in V2, V3 . On arrival to the floor, patient was complaining of mild back pain with movement, but otherwise had no complaints. His vitals were 97.7-140/93-58-18-95% . REVIEW OF SYSTEMS On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: Hypertension Dyslipidemia Diabetes Mellitus GERD TURP in [**2137-12-18**] Appendectomy as child MEDICATION ON ADMISSION: 1. Toprol XL 20mg.? 2. ASA 81 Daily 3. Vitamin B complex 4. Nexxium 5. Foic Acid 6. Flomax (not taking) ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: VS:97.7-140/93-58-18-95% GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: FAMILY HISTORY: Dad - died in WW2. Mom - Died in [**2089**]. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. SOCIAL HISTORY: SOCIAL HISTORY Retired, Lives alone. -Tobacco history: Never -ETOH: Occasionally -Illicit drugs: None

CHIEF COMPLAINT: palpitations PRESENT ILLNESS: 85 year old female with history atrial fibrillation admitted for dofetilide initation. Has known history of mitral stenosis based on echocardiogram. MEDICAL HISTORY: Paroxysmal atrial fibrillation Rheumatic heart disease Moderate-to-severe mitral stenosis Hypertension Hypothyroidism Glaucoma Osteoporosis MEDICATION ON ADMISSION: Toprol-XL 25 mg once daily, Aspirin 81 mg once daily, Coumadin for therapeutic INR of 2 to 3, Levoxyl 75 mcg once daily, Evista 60 mg once daily, Effexor XR 75 mg once daily ALLERGIES: Protamine Sulfate / Gluten / Milk / Wheat Flour PHYSICAL EXAM: VS - 97.9, 125/69, 70s, 97% RA Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: non contributory SOCIAL HISTORY: She currently lives alone but has a daughter Retired [**Name2 (NI) 1139**] denies ETOH denies

CHIEF COMPLAINT: Lower GI bleed. PRESENT ILLNESS: The patient is an 88-year-old male known to our hospital who was transferred here with a history of a lower GI bleed from an outside hospital. He was admitted there for five days in work-up for this lower GI bleed and both endoscopies from above and colonoscopy failed to reveal the source of the bleed, so he was transferred to our hospital. At that hospital, he received four units of blood. MEDICAL HISTORY: MEDICATION ON ADMISSION: Benicar 20 mg once a day, pravastatin 10 mg once a day, paroxetine 20 mg once a day, levothyroxine 50 mcg once a day, propranolol 40 mg once a day, metoprolol 25 mg once a day, Flomax 0.4 mg once a day, aspirin 81 mg once a day. ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Altered mental status Diaphoresis Abdominal pain PRESENT ILLNESS: This 78 year old russian speaking female presented to the emergency department on [**2152-3-30**]. Her family memebers stated that she was found at home with altered mental status and diaphoresis. She is diabetic. Mental status improved after binasal cannula oxygen applied, at which time she localized right upper quadrant pain. She developed leukocytosis and transaminasemia. MEDICAL HISTORY: DM on insulin HTN gerd pvd osteo-arthritis osteoporosis anemia cholelithiasis left humeral fracture b/l cataracts s/p surgery s/p uterine myomectomy MEDICATION ON ADMISSION: Tramadol 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Buspirone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 17. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 18. Insulin sliding scale Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-60 mg/dL [**1-4**] amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 3 Units 141-160 mg/dL 5 Units 161-180 mg/dL 7 Units 181-200 mg/dL 9 Units 201-220 mg/dL 11 Units 221-240 mg/dL 13 Units 241-260 mg/dL 15 Units 261-280 mg/dL 17 Units 281-300 mg/dL 19 Units 301-320 mg/dL 21 Units > 320 mg/dL Notify M.D. 19. Lantus 30 units Lantus insulin with breakfast ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T: 99.2 HR 97 BP 131/68 RR: 20 Spo2 100% on RA FAMILY HISTORY: denies cad SOCIAL HISTORY: distant tobacco drinks often- including vodka walks without cane trained engineer in [**Country 532**] Has brother, nephew and daughter in law near by.

CHIEF COMPLAINT: Diarrhea PRESENT ILLNESS: 31 y/o man with a PMH of relapsed AML who has received alloSCT x2 from his brother who presents today after a week of progressive diarrhea x 6 days with fevers today. Today c/o > 20 episodes copious non-bloody, yellow green watery diarrhea. He also c/o increased fatigue x 1 dy. He has also noticed increased ankle edema x 1 dy. In ED found to be febrile to 101.7. Yellow/green nausea and emesis x T. his dysuria has resolved completely. Does not report back pain. Of note ROS also positve for a cough and low grade fevers x1 week for which he was started on levoquin/inhalers on [**2158-10-16**]. He has noticed that his breathing is slightly more labored w/o inhaler but denies increasing dyspnea on exetion, PND, chest discomfort, or orthopnea. Does not report abdominal pain. Strict adherence to neutropenic diet. His father has been sick but does not have diarrhea. No recent travel. . meds in ED: On DOA Today 20:55 Magnesium Sulfate 2g Today 20:59 NS (Mini Bag Plus) 100mL Bag 1 Today 21:23 Acyclovir 200mg Cap 2 Today 21:23 Metoprolol 50mg Tab Today 21:23 Prednisone 10mg Tablet Today 21:24 Levofloxacin 500mg Tablet Today 21:24 Dolasetron Mesylate 12.5mg Vial Today 21:39 Phenazopyridine HCl 100mg MEDICAL HISTORY: AML as above s/p Cholecystectomy [**10/2157**] h/o pleural effusions b/t. tapped in [**10-26**] . His AML course is significant for diagnosis of AML in [**2151**] and underwent an alloBMT. His course was complicated by severe chronic cutaneous GVHD causing a scleroderma-like process. This was treated with photopheresis, pentostatin, and Rituxan. In [**4-/2158**] he was noted to have blasts in his peripheral blood counts and he was re-admitted for reinduction with VP-16 and Ara-C followed by a second allogeneic transplantation with bu/cy. This transplant was complicated by b/l pleural effusions, pericarditis, and infection. He was d/c on [**9-16**]. He was then admitted again on [**11-4**] with hemorrhagic cystitis which resolved with ditropan, pyridium and narcotics. MEDICATION ON ADMISSION: Folic Acid 1 mg qd Pantoprazole 40 mg qd Oxycodone 5 mg q 4 hrs prn Triamcinolone prn Cyclosporine liquid form (neoral) 200 mg [**Hospital1 **] Ditropan 5 mg qd Pyridium 200 mg [**Hospital1 **] Acyclovir 400 mg tid Ursodiol 300mg [**Hospital1 **] Zolpidem 5 mg qhs prn Ativan 1 mg prn Metoprolol 50 mg [**Hospital1 **] Fluconazole 200 mg qd Prednisone 5 mg 3T qam and T qhs Levoquin 500 mg po qd started [**2158-10-17**] for low grade temps and cough along with advair and combivent- plan was to f/u with Dr. [**First Name (STitle) 1557**] this Tuesday to confirm duration of course. ALLERGIES: Penicillins / Bactrim / Vancomycin And Derivatives / Cellcept PHYSICAL EXAM: T 97.8 BP 93/54 HR 116 RR 20 O2Sat 95% CMV Vt 550x16 PEEP 5 FIO2 100% Gen: sedated but responsive HEENT: EOMI, PERRL, intubated Neck: -LAD Chest: diffuse ronchi throughout CV: Tachy RR, S1/S2 intact, -M/R/G Abd: S/distended, +BS in all four quadrants, scrotal edema Ext: generalized anasarca, +3 pitting edema in UE and LE FAMILY HISTORY: No hx of oncolologic dx. CAD in grandparents. SOCIAL HISTORY: He lives with parents and brother. Is a nursing student. Denies tob, EtOH, or illicits.

CHIEF COMPLAINT: Worsening mental status and respiratory failure. PRESENT ILLNESS: 70 M with multiple lung co-morbidities including severe kyphoscoliosis resulting in severe restrictive physiology, severe sleep disordered breathing, hypoventilation syndrome, severe pHTN, chronic dHF who presents with worsening confusion over the past 4 weeks which prompted her daughters to bring her into the ER by 911 this evening. History is taken through daughter's who state their mother has become more confused throughout the past 4 weeks. They state she denies any dyspnea, fever, cough, URI symptoms, and that she takes her medications on her own. They state she has refused to wear the BiPaP machine since it was brought into the household in [**Month (only) 1096**] after she was diagnosed with the severe sleep disordered breathing. In the ER she was tachypneic into the 30s and had decrease in O2 saturation into 70s, she was given multiple neb treatments with minimal improvement. An ABG was drawn 7.13/107/38 and she was then placed on BIPAP and transferred to the ICU. Vitals prior to ICU arrival were 129/64, 92, 20s, 86-96% on bipap, only on 10 minutes. Upon arrival the patient has no complaints and is able to state her name, the year, and her location. When asked regarding her code status she is not able to express understanding. MEDICAL HISTORY: Severe kyphoscoliosis s/p operative repair in [**2140**] Severe sleep disordered breathing Hypoventilation syndrome due to severe restrictive lung disease Asthma Chronic hypercapneic, hypoxic respiratory failure- resting ABG pH of 7.40 and PCO2 of 85 on continuous home oxygen Chronic diastolic heart failure Pulmonary hypertension Large hiatal hernia GERD Hypertension h/o severe skin burns as child Osteoporosis h/o hip and back pain MEDICATION ON ADMISSION: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - 1 nebulizer inh q4-6h as needed for shortness of breath or wheezing ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs(s) inhaled four times a day as needed for shortness of breath or wheeze ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth once a week take first thing in am with water, do not eat for 30-60 min after taking, sit upright after taking pill FEXOFENADINE [[**Doctor First Name **]] - 180 mg Tablet - 1 Tablet(s) by mouth daily During allergy season FLUOCINONIDE - 0.05 % Cream - apply to affected area once a day FLUTICASONE - 50 mcg Spray, Suspension - [**1-11**] spray(s) each nostril daily FLUTICASONE [FLOVENT HFA] - (Dose adjustment - no new Rx) - 220 mcg Aerosol - 1 puffs(s) inhalation twice a day FUROSEMIDE [LASIX] - 40 mg Tablet - 2 Tablet(s) by mouth once a day LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day at night METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth 30 mins before meals and hs for reflux esophagitis NAPROXEN - 250 mg Tablet - [**1-11**] Tablet(s) by mouth twice a day as needed for pain up to 3 days a week OVERNIGHT OXIMETRY - - Please perform on 2L O2 via NC; Fax results to Dr. [**Last Name (STitle) 217**] at [**Telephone/Fax (1) 9730**]. Thank you! OXYGEN MONITORING - - Please check O2 sats while ambulating with portable unit on pulsed 2L to ensure O2 sats are maintained >90%. PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily no substitutions POWER OPERATED SCOOTER - SALMETEROL [SEREVENT DISKUS] - 50 mcg Disk with Device - 1 puff inhaled at bedtime Medications - OTC CALCIUM - (OTC) - Dosage uncertain CALCIUM CARBONATE [TUMS] - (OTC) - 300 mg (750 mg) Tablet, Chewable - 2 Tablet(s) by mouth daily COENZYME Q10 - (OTC) - 50 mg Capsule - 1 Capsule(s) by mouth daily DOCUSATE [**Telephone/Fax (1) 11516**] [COLACE] - 100 mg Capsule - 1 Capsule(s) by mouth once a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - Dosage uncertain MULTIVITAMIN WITH IRON-MINERAL - Tablet - 1 Tablet(s) by mouth daily OMEGA-3 FATTY ACIDS-FISH OIL - (OTC) - 360 mg-1,200 mg Capsule - 1 Capsule(s) by mouth daily OXYGEN-AIR DELIVERY SYSTEMS - Device - Use as directed with nasal cannula. 2L/min with activity, 1 L/min at rest and while sleeping. Please assess for oxygen conservation device. POLYETHYLENE GLYCOL 3350 - (OTC) - 17 gram (100 %) Powder in Packet - 1 packet by mouth daily with juice ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: General Appearance: Respiratory distress; tachypneic. Cachectic. Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, normal appearances. MMM. Cardiovascular: Dual sounds with fixed split of S2, no M/R/G Respiratory / Chest: Very severe kyphosis. Diminished sounds and very little expansion. Clear with some crackles only at left base. Abdominal: Soft, non-tender, bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Warm Neurologic: Attentive, Oriented to name, year, hospital. CN II-XII intact. Movement: Purposive. Tone: Normal. Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present). Some venous statis. FAMILY HISTORY: Father died of liver cancer. Daughter with breast cancer at 45. Also history of colon cancer. No history of pulmonary disease. SOCIAL HISTORY: Prior smoke (X 11 years) but quit in [**2138**]. No alcohol. Lives with daughter and performs own ADLs (bathing, dressing, cooking). Previously worked as a home health aide. Widowed.

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 60-year-old man with CAD, PVD who had difficulty speaking after left carotid endarterectomy in [**2133-2-16**]. The patient has had bilateral carotid stenosis. On [**2-21**] while he was sitting in a chair he developed sudden onset of right arm and leg numbness, followed by right arm and leg weakness. He also had difficulty speaking. He was admitted to [**Hospital3 **] and underwent a left carotid endarterectomy on [**2-26**] and afterwards began having severe left sided headache behind his left eye that lasted for hours and was constant. Nevertheless, he visited [**Hospital3 **] for continued headaches and nausea and vomiting. During one of those visits he had a contortion of his right face and bilateral arm jerking and was started on Dilantin with presumptive diagnosis of seizures. He has recovered from that event when was again discharged home. On [**3-13**] he again presented with persistent headaches, confusion and inability to talk. He had difficulty getting his words out. He had a head CT at [**Hospital3 **] which showed a linear hyperintense region in the left central temporal lobe but also other lesions in the left posterior parietal lobes. At that time he was transferred to the [**Hospital1 69**]. MRI of his head showed left MCA/ACA and left MCA/PCA watershed strokes with acute and subacute hemorrhage conversions. It was thought at that time that he had extended his watershed infarcts after carotid endarterectomy leading to a carotid hyperperfusion syndrome. The patient was discharged from the neurologic Intensive Care Unit to a rehab facility. On Thursday, [**2133-3-26**], patient's wife noticed erythema on patient's face. On [**3-27**] the visiting nurse [**First Name (Titles) 8706**] [**Last Name (Titles) 11282**] of a rash on his arms as well. The patient was noted to be febrile and was admitted to the [**Company 191**] Firm. In the EW, patient's Dilantin was discontinued and he was given Tegretol instead. MEDICAL HISTORY: 1) Left CEA in [**2133-2-16**]. 2) CVA in [**2133-2-16**]. 3) Paroxysmal atrial fibrillation. 4) CAD. 5) PVD. 6) Hypercholesterolemia. 7) History of amaurosis fugax. 8) Status post lymph node removal. MEDICATION ON ADMISSION: ALLERGIES: Iodine. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives in [**Location 3146**], tobacco since [**2126**], one pint of alcohol per day. The patient works as a carpenter.

CHIEF COMPLAINT: Right thigh hematoma. PRESENT ILLNESS: This is a 75 year old female a bioprosthetic mitral valve for rheumatic heart disease, with known chronic atrial fibrillation, anticoagulated. The patient traumatized her right thigh two days prior to admission and noted a small, bruised area which has increased in size and was associated with increasing pain. The patient was evaluated in the Emergency Room. She received if and p.o. Morphine sulfate for pain control with episode of hypertension. Hematocrit was 31.9 and dropped to the 26.0. Her thigh hematoma continues to increase and the thigh is tense with bloody bullae. The patient received four units of FFP, five mg of Vitamin K and two liters of intravenous fluid. The patient was transferred to the vascular service for continued care. MEDICAL HISTORY: Rheumatic heart disease; status post mitral valve times three; last valve was in [**2109**]. History of congestive heart failure with ejection fraction of 25 to 30%, in [**2117-11-10**]. P-MIBI on the [**2120-1-12**] showed an ejection fraction of 69%. Hypertension. Hypercholesterolemia. Atrial fibrillation, rate controlled. Femoral-femoral bypass in [**2114**]. MEDICATION ON ADMISSION: ALLERGIES: Penicillin. Inderal. (Manifestations unknown.) PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives in [**Location 26931**] with her grandson.

CHIEF COMPLAINT: acute NSTEMI PRESENT ILLNESS: This 72 year old old male underwent laproscopic appendectomy on [**8-21**] at [**Hospital6 19155**] after acute episode of abdominal pain. He subsequently had post-operative EKG changesrevealing ST changes and he was started on The acute coronary syndrome protocol. His troponin peaked at 3.13 and CPK 812.He was cathed at [**Hospital3 **] to demonstrate significant triple vessel disease and was transferred to [**Hospital1 18**] for evaluation and consideration for revascularization. MEDICAL HISTORY: Hypertension dyslipidemia remote Syncopal episode, benign prostatic hypertrophy s/p appendectomy [**2150-8-21**] MEDICATION ON ADMISSION: Hctz 12.5mg daily Crestor 20mg daily fish oil daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Pulse:61 regular Resp: 16 O2 sat: 100% on RA B/P Right:160/70 Left: 170/70 Height: 5ft 9" Weight:171lbs Five Meter Walk Test #1_______ #2 _________ #3_________ FAMILY HISTORY: Family History:Premature coronary artery disease Father MI < 55 [x]father died at at 52 from MI SOCIAL HISTORY: Race:Caucasion Last Dental Exam:[**2150-4-15**] Lives with:Married wife [**Name (NI) 2048**] Contact: [**Name (NI) 2048**] Phone #[**Telephone/Fax (1) 91060**] Occupation:retired engineer from [**Company 2676**] Cigarettes: Smoked no [] yes [x] 20 pack year history quit in [**2118**] ETOH: denies < 1 drink/week [] [**12-22**] drinks/week [] >8 drinks/week [] Illicit drug use: None

CHIEF COMPLAINT: Ongoing chest pain and positive cardiac enzymes transfer for cardiac catheterization PRESENT ILLNESS: Pt is a 75 yo male with DM, ESRD, on HD for 18 months , HTN, high cholesterol, PAF, with dual chamber pacer for heart block, transferred to [**Hospital1 18**] for urgent cath due to ongoing CP and + cardiac enzymes. Patient was admitted to [**Hospital3 **] yesterday with N/V/D. He notes that he had bilateral upper chest pain 2 weeks ago that was attributed to pleuritic CP secondary to pneumonia. He did have a hacking cough with minimal sputum for the past 2 weeks. He was treated for CAP. On day of transfer to [**Hospital1 **], he c/o SOB, sats 83-84% which resp to nonrebreather ->high 90's and upon further questioning said that he had been having chest and shoulder pain for several days at home. Cardiac enzymes were drawn 1st trop I was 18.32, given plavix, lopressor, nitro drip. Cardiac catheterization showed CO 4.09, CI 1.95, PCWP 21, RA 12, PA 51/22 LMCA normal LAD: midsegment 80% lesion with modest calcium LCX: non-domninant vessel with mid-segment 90% lesion after OM1. OM 1 TO with bridging and retrograde L-L collaterals RCA: dominant vessel with occlusion proximally. Distal flow from L-R collaterals. Transferred to CCU for observation and treatment of ? pneumonia. He denies CP, SOB, abd pain, palpitations. MEDICAL HISTORY: PMH: 1. A fib during dialysis 2.? wenkebach to complete heart block, 2:1 AV block; pacer placed 3/12/043.DM 4. neuropathy 5. ESRD on dialysis for past 18 months 6. Retinopathy 7. Anemia 8. Hypercholesterolemia 9. Hypertension MEDICATION ON ADMISSION: 1. Sertraline 50 mg po qd 2. ASA 325 mg po qd 3. Losartan 100 mg po qd 4. Insulin Glargine 21 U QHS, aspart 5 units afternoon dose, aspart 13 units Sun, M,W,F 5.Famotidine 20 mg po qd 6. Calcium acetate 1334 mg po TID with meals 7. Norvasc 8. Vancomycin ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: General: HEENT: CV: Pulmonary: Abd: Ext: Neuro: FAMILY HISTORY: non-contributory SOCIAL HISTORY: Social history: Lives with wife. HAs 3 children. Never smoked. occasionally drinks

CHIEF COMPLAINT: Chest Pain PRESENT ILLNESS: 62 y/o male with abnormal EKG during stress test. Underwent cardiac cath which revealed three vessel disease. Referred for surgical revascularization. MEDICAL HISTORY: Diabetes Mellitus, Hypertension, Myocardial Infarction, Right Knee surgery MEDICATION ON ADMISSION: Toprol XL 50mg qd, Lisinopril 10mg qd, Metformin 500mg [**Hospital1 **], Plavix 75mg qd (stopped), Crestor 5mg qd, Aspirin 81mg qd, MVI ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: 75 16 159/83 Gen: WDWN malw in NAD Skin: WD intact HEENT: EOMI, PERRL NCAT Neck: Supple, FROM -JVD, -bruits Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused -edema Neuro: A&O x 3, MAE, non-focal FAMILY HISTORY: Father with "heart problems" SOCIAL HISTORY: 1/2ppd since age 17. Quit several early [**2121-10-2**]. Rare ETOH

CHIEF COMPLAINT: lightheadedness at clinic neutropenic fever myelodypslastic syndrome PRESENT ILLNESS: This is a 78 year old male with a history of aplastic anemia requiring chronic transfusions who presents from clinic where he was getting his labs drawn. Pt states that after getting his blood drawn, he became lightheaded, felt weak and shaky. He was helped down by the staff and an ambulance was called. Pt states that he has felt weak and shaky for about the past week. He has also had some cold sweats and shaking chills, but has not taken his temperature. He states his temperature was elevated at clinic, and was 100.7 orally in ED. Patient admits to a chronic, non-productive cough, but reports no recent increase in its severity. No abdominal pain or diarrhea. Last BM was this morning. Denies dysuria, urinary frequency, or urgency. Denies any sore throat, rash, myalgias, or arthralgias. MEDICAL HISTORY: 1) Aplastic anemia dx [**4-19**] by bone marrow biopsy. Given some questions about a history of TB, he was treated with INH for one month and then started on prednisone 60mg daily on [**2192-7-5**]. He requires platelet transfusions weekly, and blood transfusions every few months. Complicated by retinal hemorrhage. 2) Pt remembers living in a sanitorium from age [**2-25**]. This prompted an investigation for TB, with subsequent sputum and bone marrow negative for acid fast bacilli. However, given a concern for this in face of starting steroids, Mr. [**Known lastname 22093**] is being treated with Isoniazid and Pyridoxine since [**2192-5-29**]. Chest CT showed evidence of granulomatous disease in the past, but no active disease. 3) kyphoscoliosis 4) L inguinal hernia. It is reducable and has been present for a long time. It is not painful MEDICATION ON ADMISSION: Prednisone 60mg PO daily (since [**7-5**]) pantoprazole 40mg PO daily folic acid 1mg PO daily, isoniazid 300mg PO daily (since [**5-29**]) pyridoxone 50mg PO daily (since [**5-29**]) ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAMINATION: VITAL SIGNS: ED: Tmax: 100.7 HR: 111 BP: 126/83 RR: 20 O2: 99% RA T: 98.5 HR: 95 BP: 127/71 RR: 16 O2: 99% RA GENERAL: elderly male, comfortable lying in bed, No acute distress. HEENT: Conjunctivae are pink. Oropharynx is moist and clear, without petechiae. Neck: supple, no JVD, no LAD. LUNGS: Clear to auscultation and percussion bilaterally. HEART: RRR nl s1, s2, no gallops, rubs, or murmurs. ABDOMEN: Soft, distended (unchanged per pt) nontender, normoactive BS. Spleen not enlarged. Groin: reducible large L inguinal hernia. EXTREMITIES: no edema NEUROLOGIC: Alert and oriented with coherent speech and comprehension. CN II-XII nonfocal. Motor [**4-19**] upper and lower bilaterally. FAMILY HISTORY: There is no history of blood disorders. SOCIAL HISTORY: Lives with wife in [**Name (NI) **]. Has two grown daughters nearby. [**Name2 (NI) **] tobacco, quit 40 years ago Rare alcohol when he goes out

CHIEF COMPLAINT: Fevers and shortness of breath. PRESENT ILLNESS: The patient is an 81-year-old man with a history of coronary artery disease, congestive heart failure, end-stage renal disease on hemodialysis, type 2 diabetes, peripheral vascular disease (numerous lower extremity bypass surgeries). He was admitted with a one day history of fever and shortness of breath. The patient reports sudden onset of shortness of breath at rest and he was feeling feverish on the day of admission. He denied chills, night sweats, headaches, changes in vision, cough, nasal congestion, nausea, vomiting, diarrhea, chest pain or urinary symptoms. He called for EMS and on arrival they found him to have a blood pressure of 160/100, a pulse of 58, a respiratory rate of 48 and oxygen saturation of 83. His skin was warm to touch. The oxygen saturation increased to 95% on 100% nonrebreather. His fingerstick blood glucose was found to be 265 at that time. In the Emergency Department his temperature was found to be 105.1, his pulse was 124, his blood pressure was 105/65, respiratory rate 24. His oxygen saturation was 90% on nonrebreather. Chest x-ray revealed a right lower lobe and right middle lobe infiltrate. Blood cultures were also sent. The patient received ceftriaxone 1 gram IV, metronidazole 1 gram IV and Tylenol 1 gram by mouth. MEDICAL HISTORY: 1. Coronary artery disease status post percutaneous coronary intervention of left anterior descending artery. Status post non-Q wave myocardial infarction in [**2122-7-18**]. He did not undergo cardiac catheterization at that time because of renal disease and his stress echocardiography was unremarkable and his ejection fraction was 20%. 2. Cardiac catheterization in [**2120-2-17**] showed two vessel disease with an ejection fraction of 35%. 3. Global hypokinesis was appreciated on the echocardiogram. 4. End-stage renal disease on hemodialysis Tuesday, Thursday and Saturday for six months prior to presentation. He has a history of diabetes and renal artery stenosis. 5. Type 2 diabetes. He has required insulin for over 15 years. 6. Hypertension secondary to bilateral renal artery stenosis. 7. Hypercholesterolemia. 8. Anemia of chronic disease. 9. Status post abdominal aortic aneurysm repair. 10. Peripheral vascular disease status post bilateral femoral artery to popliteal artery bypass grafting in [**2122-8-17**]. He underwent excision of a left femoral pseudoaneurysm. 11. Status post bilateral cataract surgery. 12. Status post bilateral toe amputations. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] quit tobacco in [**2122-8-17**]. He smoked half a pack a day for 60 years. He does not drink alcohol. He is a retired engineer. Prior to presentation he was able to perform all his activities of daily living independently except for limitation from chronic hip pain.

CHIEF COMPLAINT: hypoglycemia/ARF PRESENT ILLNESS: Mr. [**Known lastname 12543**] is a 70 yo M with DM2 and CKD baseline Cr 3.5-4.2 up to 9.0 [**6-28**] not on dialysis found by family to be altered with hypoglycemia now with ARF. He was given orage juice and milk by family. Pt vomited, unable to hold down food and fluid. [**Hospital **]hosp fsbs 38, got 1mg IM glucagon. Repeat FSBS 58. Has not seen PCP [**Name Initial (PRE) 14169**] [**6-28**]. Has been feeling in normal state of health up until today. His medications have been managed by a nurse and one of his sons. H . In ED 95.4 51 146/100 17 96% on RA found to be cool and dry and awake to voice. Pt has chronic edema, noted to be worsening. CXR found new left sided pleural effusion. Prior to leaving ED,9 7.2 52 125/77 17 100% on RA. Access 22 and 18 G access. Got 700cc IV. EKG sinus brady, TWI in v4-v6. Per ED makes urine. BCx drawn. . Currently, patient feels well. He denies chest pain, shortness of breath, cough, fever, chills, nausea/vomiting or abdominal pain. Endorsed diarrhea that started this am. He says he feels cold but usually feels this way. He denies orthopnea and PND. He is wheelchair bound at baseline. Patient was informed of kidney failure and refused to accept dialysis. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. MEDICAL HISTORY: -5/08 L BKA for gangrene -DM2 -Hypertension -CKD baselin 3.5-4.2, up to 9 in [**6-28**] -blindness -neuropathy, possibly demyelinating polyneuropathy -systolic CHF EF 50% as of [**4-28**] MEDICATION ON ADMISSION: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day for pressure ASPIRIN - 325 MG TABLET (ENTERIC COATED) - TAKE ONE TABLET EACH DAY ATORVASTATIN [LIPITOR] - 40 mg Tablet - [**12-22**] Tablet(s) by mouth once a day for cholesterol FUROSEMIDE [LASIX] - 40 mg Tablet - 3 Tablet(s) by mouth qam IBUPROFEN - 600 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for pain Same as MOTRIN INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 35 q am INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - sliding scale before breakfasst, lunch and supper sugar greater than 150 give 6 units BS >200 give 8 units BS>250-300 give 10 units METOPROLOL SUCCINATE [TOPROL XL] - 200 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day ONE TOUCH ULTRA MINI - - test Three times daily ONE TOUCH ULTRA MINI TEST STRIPS - - test blood sugar three times a day no substitution SOCK SHRINKER - - use once a day for fluid one for foot, one for bka leg Medications - OTC ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - take one Tablet by mouth daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals - T: rectal BP:150/88 HR:79 RR:16 02 sat:97%RA GENERAL: Pleasant, frail and chronically ill elderly male in NAD FAMILY HISTORY: 2 sons with DM2, one who died from MI SOCIAL HISTORY: originally from [**Location (un) 4708**]. Remoted history of smoking in 20s and rare alcohol use. Denies drugs. Wheelchair bound, has nurse visit 3x/day and supportive family

CHIEF COMPLAINT: PRESENT ILLNESS: This 62 year old white male presented from his doctor's office following an electrocardiogram which revealed changes from previous electrocardiograms. He stated that he had been experiencing burning chest pain which was with exertion for the past three to four weeks. The pain also radiated to his jaw but was not associated with shortness of breath, nausea, vomiting or diaphoresis. He went to his doctor's office and he had Q waves on his electrocardiogram in leads II, III and aVF and was transferred to [**Hospital1 69**]. MEDICAL HISTORY: Hypercholesterolemia. MEDICATION ON ADMISSION: 1. Lipitor 10 mg p.o. once daily. 2. Multivitamin one p.o. twice a day. ALLERGIES: He has no known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: His family history is unremarkable. SOCIAL HISTORY: He does not smoke cigarettes. He drinks alcohol occasionally.

CHIEF COMPLAINT: Agitation/MS changes/Aspirin Overdose PRESENT ILLNESS: 50F with history of refractory depression/anxiety (recent [**Doctor First Name **] hospitalization), HTN, DM, Breast CA who presents after aspirin injestion. Pt reports taking aspirin continuously last night into this morning. She is unable to quantify amount. She reports vomiting this morning, unsure if she vomited up pills. Arrived in ED tachycardic and diaphoretic. Her initial VS: T97.8 HR 160 BP 121/74 16 98% RA. On initial evaluation pt was in sinus tach with old BBB on ECG. She had an ASA level of 54 with an elevated ion gap. She was given activated charcoal and seen by toxicology who recommended initiation of bicarbonate drip. At the time of transfer to the ICU her HR had improved to 110-120s. She was alert and oriented. At time of arrival to [**Hospital Unit Name 153**] the patient is extremely agitated. She is tachycardic and very anxious. She is intermittently incoherent and unable to give a clear history. She is paranoid and becomes very angry with her mother during the history and demands that she leave the room. She states that she took various pills last night "to sleep", although at another point in the history she states she felt like "I have no purpose," and endorsed trying to hurt herself. She was unable to tell me coherently which pills she took, stating she took seroquel, aspirin, perhaps oxycodone and ativan, it is unclear. On review of systems pt denies headache, but says she felt dizzy and unable to stand, no vision changes, but she does endorse new difficulty hearing and persistently pulls at her ears during the interview. No chest pain, mild shortness of breath. No nausea, although she does mention vomiting this morning. She feels thirsty. + Chronic constipation. She complains of discomfort from the foley. No joint pains. + Depression and anxiety. Her mother is with her during the interview and reports that the patient had been herself with her baseliene depression and anxiety and her cymbalta was switched to effexor on [**3-14**] at which point she began to notice that the patient's mental status began to be more altered. She noted some increased confusion and agitation yesterday. MEDICAL HISTORY: -HTN -Depression: Multiple hospitalizations at [**Doctor First Name 1191**] in [**2110**], [**2112**], [**2113**] and did an outpatient program for several weeks at [**Doctor First Name **] in [**2128**]. Reports just being hospitalized in [**3-4**]. -Parathyroid adenoma s/p resection [**2134-3-1**] -Breast CA IIB/p mastectomy [**1-3**] s/p chemoXRT -HL -DMII -Hypothyroidism -Ideopathic cardiomyopathy, EF 50%, mild MR - H/o Left Bundle Branch Block MEDICATION ON ADMISSION: Lipitor 10 mg daily metoprolol 50 mg [**Hospital1 **] Lisinopril 5 mg daily Levoxyl 75 mcg daily Quetiapine 350mg QHS Duloxetine 30mg QAM stopped on [**3-14**] Venlafaxine 37.5mg daily Aripiprazole 5mg QAM Trazadone 150 mg qhs Ativan 0.5mg [**Hospital1 **] glucophage 500 mg QAM ALLERGIES: Sulfa (Sulfonamides) / Soybean PHYSICAL EXAM: Vitals: T:100 BP:98/66P:143 R:23 SaO2: 97% RA General:Anxious, emotionally labile, very distressed. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM dry with residual activated charcoal in oropharynx. b/l cataracts. Neck: supple. No LAD. s/p thyroid surgery with mild erythema at incision site, mild swelling, no drainage or tenderness. Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales. Tachypnea. Cardiac: Tachycardic. Regular Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted Extremities: No edema, 2+ radial, DP pulses b/l Skin: no rashes or lesions noted. Hot and damp. Several excoriations on hands. Neurologic/Psych: Alert, oriented to place, self, date is "[**3-19**], [**2133**], [**Last Name (un) 2753**]", she has some inattention and is hard of hearing. She responds to questions, has frequent neologisms, very emotionally labile, occasionally tangential speech. Paranoia. Able to name items, can spell world backwards, unable to recall 3 items after 1 minute. FAMILY HISTORY: Family history is negative for breast and ovarian cancer. Her mother is 81 and in good health with hypertension and elevated cholesterol, but still mows the lawn and shovel the driveway. Father is 82, has a history of a CVA and diverticulosis. She has two brothers, 44 and 46, who are alive and well. Her maternal grandmother died of stomach cancer at 55. SOCIAL HISTORY: No tobacco. Occasional EtOH. Increased stress due to divorce proceedings.

CHIEF COMPLAINT: Mr. [**Known lastname 35123**] is a direct admission to the operating room for coronary artery bypass grafting and preadmission testing done [**2105-5-1**]. The patient's chief complaint was dyspnea on exertion, shortness of breath, and chest pain x 2 weeks. PRESENT ILLNESS: The patient is status post cardiac cath done for a complaint of increasing shortness of breath and chest pain with known CAD, status post PTCA of the circumflex and OM1, as well as RCA and LAD in [**2102**]. MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Hypothyroidism. 4. Insulin dependent diabetes mellitus. 5. Coronary artery disease. 6. Status post right shoulder surgery. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: Temperature 97.8, heart rate 64/sinus rhythm, blood pressure 124/64, respiratory rate 16, O2 sat 98% on room air. NEUROLOGICALLY: Awake, alert and oriented x 3. Pupils equally round and reactive to light. Extraocular movements intact. Strength was equal in the upper and lower extremities bilaterally. CARDIOVASCULAR: Regular rate and rhythm with no rubs or murmurs. RESPIRATORY: Clear to auscultation bilaterally. ABDOMEN: Flat, nontender, nondistended with positive bowel sounds. EXTREMITIES: No edema. No varicosities. PULSES: Femoral 2+ with no bruit bilaterally. Popliteal 1+ bilaterally. Dorsalis pedis and posterior tibial 2+ bilaterally. Radial 2+ bilaterally. Carotids without bruits, and no stenosis by ultrasound. FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: found down PRESENT ILLNESS: Patient is a 65 year old woman who was found down in [**Location (un) 583**] by the police early on the morning of admission. There were no obvious signs of trauma. She was unresponsive in the field and had a temperature of 31.9 rectal. She briefly awoke in the ED and could say her name was "[**Known firstname 2048**]" and her birthday. She followed commands but was otherwise aphasic. Moved all four extrmities. She was put on a bear hugger and given warmed saline and warmed humidified air. CXR showed possible bilateral lower lung infiltrates. Lactate was initially 8.0 with a gap of 25, bicarb 14, creatinine of 1.6, CK of 324, wbc 9.1 with 73% neutrophils, 9% bands. She received 6 liters of normal saline and lactate improved to 2.5. She had a CT scan that showed no bleed. . After the CT scan she became rigid and then had tonic clonic activity for 10 seconds. She was intubated for airway protection. She was given ativan 4 mg and 3 amps of bicarbonate as her urine tox was positive for tricyclics. Serum ethanol level was 17 with an acetominophen level of 6.1. She also received vancomycin, ceftriaxone, acyclovir and ampicillin. She also received 10 mg IV decadron. She had 2 liters of urine output in the ED. An LP was performed which showed 4 wbc, 52 rbc, 3% poly, 80% lymph. Protein 56 and glucose was 87. . In her jacket there was bupropion 150 mg SR, lipitor 10 mg, lisinopril 2.5 mg, amitriptyline 25 mg. MEDICAL HISTORY: MEDICATION ON ADMISSION: Home Meds: lisinopril 7.5 mg po qday atorvastatin 10mg po qday amitriptyline (given by orthopedics for bilateral knee pain since fall) wellbutrin 150 mg po TID (per pt not given by her PCP, [**Name10 (NameIs) **] can't remember doctor's name who prescribed it. not in PCP's records.) ALLERGIES: Naprosyn PHYSICAL EXAM: VS: T 96.6 rectal -->99.9 HR 106 BP 96/50 RR 16 O2 sat 100% Vent: AC 550/600 x 16/16 FiO2 100% PEEP 5 --> 7.48/39/208 Gen: Intubated and unresponsive. Not responsive to commands. Withdraws to pain in all extremities. HEENT: PERRL, sclera anicteric, MMM. Neck: No LAD, JVD or thyromegly. CV: RRR with no m/r/g Lungs: CTA bilaterally anteriorly Abd: soft, NT, ND active BS, no hepatosplenomegly. Rectal: incontinent of guaic negative stool. ext: No clubbing, cyanosis or edema. Neuro: Sedated. Withdraws to pain in legs bilaterally and left arm. PERRL. 4 mm--> 3mm. Reflexes 2+ bicepts. 0 in patella bilaterally. + 5 beats clonus on the left. Toes upgoing bilaterally. + gag. FAMILY HISTORY: Unknown. SOCIAL HISTORY: Unknown - pt refusing to give history.

CHIEF COMPLAINT: S/P Fall, pericardial effusion PRESENT ILLNESS: 62F h/o CML on maintenance hydroxyurea in remission for 15 years with recent relapse, followed at [**Hospital1 **], who is s/p fall last night, found to have SAH/SDH and possible brain mets at OSH, as well as pericardial effusion. The patient reports progressively worsening difficulty breathing for the past couple weeks. Today she reported SOB then falling and hitting her head. She does not remember the time before after very well but does state that she lost consciousness. She does not recall bladder or bowel incontinence or tongue/lip biting. The fall was not observed though her mother heard her fall. Her mother is not here now. The patient went to [**Hospital3 **] and had CT showing e/o SAH with possible brain mets and edema, as well as pericardial effusion, and was transferred to [**Hospital1 18**]. . In the ED, initial vitals were 98.3 77 142/89 20 98% 8L. The patient was given decadron 10 mg IV, and a bedside ECHO was done showing large pericardial effusion with RV wall bowing and the patient was taken to the cath lab for pericardial drain placement. V/S prior to transfer to cath lab: 142/82 84 27 95% on 5L NC. In the cath lab, 750cc removed, clear and straw colored fluid. Post Echo with small posterior collection, much improved from prior. Large left pleural effusion still present. Pericaridal pressures were 18, now 3. . Currently, she is reporting some pain at the drain site as well as irritation in her neck from the C-Spine collar but no pain in the neck itself. She also denies HA. She still c/o SOB but denies cough, hemoptysis, fevers, chills, urinary or bowel symptoms. . Of note she has recently started desatinib for CML recurrence. She has required multiple PRBC and plt transfusions recently including 1 uPlt in the ED. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: CML ?psoriasis ?Stomach problem MEDICATION ON ADMISSION: Dasatinib 100mg once daily (last dose two weeks prior to admission) Doxepin 10mg once daily Venlafaxine 75mg once daily Bmega for dry eye Multivitamin Caclium tablet clobestol ointment Furosemide 20mg once daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION EXAM: VS: HR 86 BP 115/79 RR 25 sat 93% on 6L GENERAL: S/P fall with echymoses over forehead, eye, head. C-collar in place. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. NECK: In C collar CARDIAC: RR, normal S1, S2. No m/g, Audible rub. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, mild epigastric tenderness. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: + DP 2+ PT 2+ Left: DP 2+ PT 2+ . DISCHARGE EXAM: ########################### FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: Alive at 85 - Father: Father MI 60s SOCIAL HISTORY: - Tobacco history: Never - ETOH: None - Illicit drugs: None Lives with 85 year old mother

CHIEF COMPLAINT: Vomiting, malaise, increasing LE edema PRESENT ILLNESS: Mrs. [**Known lastname 63845**] is a 80 year-old female with a history of chronic AF, diastolic CHF, DM, hyperlipidemia, CRI, who presents with increasing LE edema and erythema, x 10days. In addition to the erythema, the pt had blisters that burst b/l. Pt was started on Levo 10 days ago for LE cellulitis. Pt also had vomiting, decreased PO intake. + fatigue, malaise, and abd distention. Some MS changes over past few days along with some LLE thigh ache/stiffness. Some DOE and lightheadedness. + baseline orthopnea. No PND. No CP. Pt denies fevers, palpitations, diarrhea, hemetemesis. During an admission for N/V/D on [**10-20**], pt was also found to have prolonged QT 700ms and her Amiodarone was d/c. She was started on Atenolol 12.5 [**Hospital1 **]. In the ER the patient was found to be in acute on chronic RF with Cr from baseline 1.6-1.9 to 4.4, Bun 130, mild CHF, K of 6.5. bradycardic to 20s with stable BP,w/ relative [**Name (NI) 63846**] SBP 80s. INR 3.0. Pt got atropine, glucagon, kayexalate. Temporary transvenous pacer was placed. MEDICAL HISTORY: 1. Diabetes mellitus 2. CHF (diastolic) 3. Hypothyroidism 4. Gout 5. Hyperlipidemia 6. H/O bilateral DVT 7. Atrial fibrillatin 8. B12 deficiency 9. OP 10.Carotid artery stenosis: CEA on left (2-3 years prior) 11. CRI (baseline SCr of 1.6) MEDICATION ON ADMISSION: 1. Warfarin 2/3 mg PO QAM QOD 2. Docusate Sodium 100 mg Capsule PO BID 3. Montelukast 10 mg PO DAILY 4. Aspirin 81 mg Tablet, Chewable PO DAILY 5. Atorvastatin 10 mg PO DAILY 6. Donepezil 5 mg Tablet PO HS 7. Fluticasone 50 mcg/Actuation Aerosol, Spray Nasal DAILY 8. Levothyroxine 112 mcg Tablet PO DAILY 9. Nitroglycerin 0.4 mg Tablet, 10. Atenolol 12.5 mg Tablet PO once a day. 11. Alendronate 70 mg PO QFRI 12. glyburide 5mg Qpm 13. Furosemide 160 mg PO DAILY 14. Spironolactone 25 mg PO DAILY 15. Metolazone 2.5 mg PO once a week. 16. Avandia 2mg [**Hospital1 **] ALLERGIES: Penicillins / Quinidine;Quinine Analogues PHYSICAL EXAM: vital signs: T 97.5, BP 114/40, HR 60, RR 13, O2 sat 100% 3L GEN: obese female lying in bed HEENT: PERRL, MM very dry, poor dentition, no OP lesions, no LAD CV: brady; distant heart sounds; II/VI systolic murmur PULM: diffuse crackles b/l, no rhonchi or wheezes. ABD: soft, non-tender, obese, ventral hernia on exam; reducible, superficial epidermal abrasion under pannus on R. EXT: warm, + erythema bilaterally to knees, and evidence of previous ulcerations; no current ulcers noted Neuro: oriented x 2. No focal deficits. FAMILY HISTORY: NC SOCIAL HISTORY: Lives with daughter; former fish packer Tobacco: quit >20 years ago EtOH: denies

CHIEF COMPLAINT: chest pain PRESENT ILLNESS: 79 yo female with PMH DM, hyperlipidemia, HTN admitted with one week history of chest pain and EKG changes. Pt states that CP started on Monday. It is intermittent and occurring with exertion. Sharp, substernal, radiating to right chest and back, [**10-25**], associated with SOB. Initially relieved with BenGay. This AM, severe pain not relieved with BenGay. States pain is different from anginal pain. +peripheral edema at baseline. +PND. -orthopnea. MEDICAL HISTORY: asthma DM2 hypercholesterolemia hypertension CAD s/p cholecystectomy MEDICATION ON ADMISSION: Plavix 75 mg qd Singulair 10mg qd Cardizem LA 180 mg qd Folic acid 1mg qd Avapro 150mg qd Lasix 20mg qd Humalin 25 u qAM ALLERGIES: Iodine / Beta-Adrenergic Blocking Agents PHYSICAL EXAM: p63, rr18, 100%2L FAMILY HISTORY: Denies CAD +HTN SOCIAL HISTORY: Denies tobacco, ETOH, drugs. Lives alone, but has family in the area - she has 13 children

CHIEF COMPLAINT: Cholangitis, Afib w/ RVR (transfer from [**Hospital Unit Name 153**]) PRESENT ILLNESS: 87M h/o CVA on coumadin, PAF, porcine AVR initally presented to OSH with 5 days of fever (Tmax 104) and chills where he was found to have cholangitis. He was hypotensive at presentation with elevated LFTS (Tbili 4.7, D bili 3.9, AP 641, AST 117) and WBC 22K. RUQ U/S revealed a distended gallbladder with multiple stones and common duct measuring 1.5 cm associated with dilated and intra and extrahepatic ducts. Blood cultures 1/2 bottles grew gram negative rods and he was treated with ampicillin, levofloxacin, and flagyl. The patient was transferred to [**Hospital1 18**] [**Hospital Unit Name 153**] for ERCP notable for pus and underwent removal of a stone and placement of CBD stent. While in the [**Hospital Unit Name 153**], he developed unstable Afib with RVR and was started on amiodarone gtt and then given digoxin 0.125mg x2 with improvement in his rate. He was transferred to the medicine floor. On presentation, he has no complaints. ROS was negative for abdominal pain, fevers, chills, palpitations, LH, chest pain. MEDICAL HISTORY: -HTN -Aortic Valve Replacement for aortic stenosis (porcine graft) 22 years ago. Rheumatic valve disease. Last ECHO [**1-15**] bioprosthetic valve functioning normally. Has normal EF per that report. -HTN -LBBB -CVA, TIA -Left Sided Hemiparesis -Hx of elevated PSA-BPH -PAF -GERD -CHF MEDICATION ON ADMISSION: Lasix PO 40 qd Coumadin KCl po Zocor 20 qd Losartan 25 mg qd NTG sl PRN Tylenol PRN MVI Ranitidine 150 [**Hospital1 **] ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T 95.4 HR 120 BP 97/63 RR 18 SaO2 93-94% on RA Weight 62.2kg General: NAD, breathing comfortably HEENT: PERRL, EOMi, anicteric, conjunctivae pink Neck: supple, trachea midline, no thyromegaly or masses, no LAD Cardiac: [**Last Name (un) **] [**Last Name (un) 3526**], tachy, s1s2 normal, JVP ~12cm, no carotid bruits Pulmonary: Bibasilar crackles, no wheeze Abdomen: +BS, soft, nontender, nondistended, no HSM Extremities: warm, no edema Neuro: A&Ox3, CN II-XII intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps Skin: Pink, warm, no jaundice, multiple stuck-on lesions on back FAMILY HISTORY: brother died of cancer, mother was alcoholic SOCIAL HISTORY: married , 2 children , was a [**Doctor Last Name 9808**] operator, no alcohol, no drug use. quit smoking 40 years prior (only 1 year of limited use).

CHIEF COMPLAINT: Progressive dypnea on exertion PRESENT ILLNESS: 43 year old woman who has experienced progressive dyspnea on exertion. AN echocardiogram in [**1-14**] revealed moderate MR [**First Name (Titles) **] [**Last Name (Titles) **] with prolapse of the posterior mitral valve leaflet. A cardiac catheterization revealed no significant coronary artery disease. MEDICAL HISTORY: Hypothyroid Nephrolithiasis MEDICATION ON ADMISSION: Aspirin Synthroid ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: HEART: RRR, [**3-15**] holosystolic murmur LUNGS: Clear ABD: Benign PULSES: 2+ throughout SKIN: No lesions or rashes FAMILY HISTORY: Non-contributory SOCIAL HISTORY: From [**Country 4194**]. Lives alone and works in cleaning. Has a 10 year old son.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 58-year-old gentleman, who was going to an outside hospital for preoperative testing for right cataract surgery when his left prosthetic leg slipped and he fell hitting his back. He developed back pain, which persisted. He denied weakness, numbness, or bowel or bladder changes. MEDICAL HISTORY: Fibrosarcoma of the upper back, which was resected in [**2089**]. Type 2 diabetes. Hypertension. Left below the knee amputation. Neuropathy. Right cataract. Cellulitis in the right leg in the past. MEDICATION ON ADMISSION: 1. Metoprolol 100 b.i.d. 2. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 q.d. 3. Metformin 500 b.i.d. 4. Glipizide 10 b.i.d. 5. Actos 15 q.d. 6. Lasix 40 b.i.d. 7. SubQ Heparin 5000 q12. 8. Decadron 4 q.6. ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: chest pain PRESENT ILLNESS: Mr. [**Known lastname 10743**] is a 59 M with history of HTN, HLD, and gout who is presenting with acute onset of chest pain that started the day of admission. The patient reports that he was walking around his apartment when he felt acute onset of upper midchest compression chest pain; describes it as heaviness and he felt like something was "off." Also had associated nausea and diaphoresis. Denies any palpitations, light-headedness, dizziness or shortness of breath. The patient reports radiation of the pain to the shoulders; unsure of which side, but just reports that his entire upper body felt funny. The sensation did not resolve in [**6-24**] minutes and the patient decided to go to the ED. . The patient has never had symptoms like this in the past; has never had chest pain with exertion in the past. Denies angina like symptoms. Denies any orthopnea, LE edema, PND. Is generally an active man, exerices regularly, up to 3-5 times per week-bikes, swims, and walks. Limited exercise in the last month [**3-19**] Achilles tendinitis. . On ROS, denies any headache, acute changes in vision, no shortness of breath, no vomit/diarrhea, no abdominal pain, no changes in BMs, no blood in BMs. Reports occassional urinary hesitancy, no hematuria. No PND, no orthopnea, denies LE edema, no syncope, light-headedness, or dizziness in past. . In the ED, 96.0 39 117/80 17 100 on 2L, appearing pale and diaphoretic. EKG with STE in inferior leads, given ASA, morphine, Zofran, plavix and heparin drip started. Sent to cath lab, found to have proximal RCA occlusion s/p DES x1, now on integrillin drip. . On transfer to CCU, pt feeling well, chest pain free. No trouble breathing. Resting comfortably. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - gout, HTN, HLD MEDICATION ON ADMISSION: allopurinol 300 mg daily gemfibrozil 600 mg [**Hospital1 **] quinapril 20 mg daily ASA 81 daily glucosamine chondroitin ergocalciferol 50,000 q Thursday Vitamin C ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION: VS: 144/89 (103) 67 14 99 on 2L GENERAL: NAD. Oriented x3. Mood, affect appropriate, obese pleasant gentleman laying comfortably in bed, breathing comfortably HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: father passed away at 69 y/o with MI SOCIAL HISTORY: Lives alone, no children, has girlfriend. Smoked 1 ppd for [**6-24**] years, quit in [**2148**]. Denies any etoh, drugs. Works in marketing firm for software company, recently company got bought out by another firm.

CHIEF COMPLAINT: GI bleed PRESENT ILLNESS: 84M history of CAD s/p coronary stenting x 3 with the latest placed 4 weeks ago on Plavix, CHF, superficial bladder cancer s/p resection in [**2113-10-20**] and completed mitomycin chemo in [**Month (only) **], and diverticular disease 50 years ago with partial colectomy who presented to his outpatient gastroenterologist with 2 days of painless bright red blood per rectum. Of note the patient is on aspirin and plavix for his CAD as well as aleve and ibuprofen for back pain. He denies abdominal pain or rectal pain, denies prior history of radiation to his pelvic area and describes mostly brown stool with some red blood in the bowl. He states the bleeding has been off and on for the past 2 days but apparently when in his gastroenterologists office he had a bowel movement that was frank blood. He denies any black, tarry, or sticky stools. Also denies fevers, chills, chest pain, has had shortness of breath recently but none now, N/V/D, weakness, numbness, or tingling. . In the ED, initial VS were: 97.4 70 84/52 99%RA Triggered for hypotension. Given 1.5L and BP 100s. Not tachycardic. Guiac positive. Access: two 18g. Type and cross 2 Units but not transfused. Labs: HCT 33 (Baseline 44 but has been 29-35 in the past), Hb 11, WBC 7, PLT 230. INR 1.1, PTT 26. Na 132, K 3.8, Cl 88, HCO3 34, BUN 86, Cr 2.1 (up from baseline of 0.8-1.0), Mg 3, Ca 9.5, P 4.5. Trop 0.08. UA neg. GI consulted: recc prep and colonoscopy in the AM. Vitals on transfer: 97.4, 67, 107/59, 20, 100%on RA . On arrival to the MICU, patient is calm, comfortable, and asymptomatic. He confirms the above history and states that 50-60 years ago he had a colectomy due to diverticulitis and had a colostomy bag and ultimately re-anastamosis. He states that 8 years ago he had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 placed at Ft [**Hospital **] Hospital in [**State 108**] for an MI (primary symptom chest pain) and had no issues since then until 5 months ago when he started developing shortness of breath. He was diagnosed by his cardiologist at [**Hospital1 3278**] with CHF and underwent c. cath 1 month ago for what sounds like optimization with another stent placed (unclear type, he believes it was a [**Hospital1 **]) and has been on plavix. He has had persistent issues with shortness of breath, especially with exertion which his cardiologist has been treating with escalating doses of lasix from 20mg PO BID up to 100mg PO BID. He states that despite this he hasn't been urinating as much as he ought to be. . Review of systems: (+) Per HPI, otherwise negative. MEDICAL HISTORY: -CAD s/p MI 8 years ago with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 (Ft [**Hospital **] Hospital) and C. cath with stent x [**2115-2-20**] -CHF (unclear subtype, no echo's in our system) -Bladder cancer s/p resection in [**2113**], s/p mitomycin chemo which ended [**2114-11-20**] -Diverticulitis 50 years ago with emergent partial colectomy and later re-anastomosis -GERD -HTN -HLD MEDICATION ON ADMISSION: -Enalapril 10mg PO daily -Tamsulosin 0.4mg PO QHS -Nitropatch 0.4mg daily -Simvastatin 20mg PO daily -Avadart 0.5mg PO Daily -Metoprolol succinate 25mg PO daily -Aspirin 81mg PO daily -Plavix 75mg PO daily -Ginko Biloba 60mg PO BID -Vitamin D 1000units PO daily -Dulcolax 100mg PO BID -Centrum Silver 1 tab PO daily -Ocuvite 1 tab PO BID -Furosemide 100mg PO BID -Tylenol PRN -Advil PRN -Nyquil PRN -Dayquil PRN -Aleve PRN -Fluticasone 2 sprays daily PRN ALLERGIES: Penicillins PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: Vitals: T: 97.0 BP: 106/58 P: 71 R: 14 18 O2: 95% RA General: Alert, oriented, no acute distress, somewhat slow and tangential but not abnormally so HEENT: Sclera anicteric, dryish MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, soft systolic murmur loudest base right, no rubs, no gallops Lungs: Clear to auscultation bilaterally, course crackles about [**1-23**] way up lung fields bilaterally Abdomen: soft, non-tender, non-distended, hyperactive bowel sounds, no organomegaly, well healed chronic scars GU: no foley Ext: warm, well perfused, dopplerable pulses bilaterally, no clubbing, cyanosis or edema, chronic scarring to R hand from reconstructive surgeries Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, slow arthritic gait. . DISCHARGE PHYSICAL EXAM: FAMILY HISTORY: Prostate Ca, otherwise NC SOCIAL HISTORY: Lives with his wife. Used to own an oriental rug business. - Tobacco: 25 pack-year smoking history, quit 15 years ago - Alcohol: Occasionally - Illicits: None

CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: 75 year old female with a past medical history of Rheumatic heart disease, atrial fibrillation-on Coumadin,type II Diabetes Mellitus, Hypertension, hyperlipidemia, and congestive heart failure who was admitted to an outside hospital for exacerabation of COPD/CHF with progressive shortness of breath and cough. She ruled out for myocardial infarction. Upon further evaluation, cardiac echo and catheterization were performed. Severe pulmonary hypertension and Mitral stenosis was noted. Per report from OSH, coronaries are clean. Pt was transferred to [**Hospital1 18**] for evaluation of Mitral Valve repair vs. Replacement. MEDICAL HISTORY: anemia secondary to arterio-venous Malformation bleed 2' Coumadin use, congestive heart failure, Atrial fibrillation, type 2 diabetes mellitus, depression, hypertension, hypothyroidism, peripheral neuropathy, hyponatremia, glaucoma, chronic obstructive pulmonary disease, vascular disease-s/p carotid endarterectomy, obstructive sleep apnea-sleep study x2-does not use recommended CPAP at home, irritable bowel syndrome w/ chronic constipation/diarrhea MEDICATION ON ADMISSION: Amitriptyline 10 HS, Coumadin 4 mg Mon- Thurs,2 mg Fri and Sunday, Digoxin 0.125(1),Glucophage 500 mg (2), Isosorbide Dinitrate 20(2), Lasix 20(1), Protonix 40(1), Synthroid 100 mcg (1), Zocor 20(1), Lisinopril 20(1), Procardia XL 60(1),Colace 100(1), Calcium Carbonate 1000(2), Vit D 1000(1), Magnesium ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Pulse:78 Resp:20 O2 sat: 99% B/P Right:150/78 Left: Height: 63" Weight:52.4kg FAMILY HISTORY: non-contributory SOCIAL HISTORY: Tobacco: intermittent tobacco x 60yr, [**7-17**] cigs/day x last 2 months ETOH:+2 beers/day

CHIEF COMPLAINT: cough, chills PRESENT ILLNESS: The patient is an 84M w/ DM2, afib, HTN who was transferred from [**Hospital6 302**] per his request after presenting [**8-10**] with persistent cough and fevers x2days. He noted shaking chills after mowing his lawn 2days PTA and went to an urgent care clinic where he was given IVF and Tylenol and sent home with a diagnosis of gastroenteritis. He returned on [**8-9**] to the clinic with persistent symptoms, CXR showed a left-sided PNA and he was given Levaquin and sent home. He took one dose last night and again this morning but still had symptoms, so he PCP told him to go to a local ER. There, he was given a dose of Zosyn and scheduled to be admitted but he requested transfer to [**Hospital1 18**] ED. . Here, CXR confirmed dense LML and LLL consolidations. He was afebrile (although he had gotten Tylenol before being transferred) and O2 sat was 89% on RA, improving to 95% on 4L. BCx were drawn. Troponin was 0.02. He was admitted for further management of his PNA. MEDICAL HISTORY: HTN dyslipidemia afib on coumadin DM2-diet controlled Diastolic HF remote tobacco MEDICATION ON ADMISSION: procardia XL 60mg qd warfarin 5mg qd lescol 40mg qd lisinopril 40mg qd HCTZ 12.5mg qd digoxin 0.125mg qd ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: T: 100.7 BP: 129/77 HR: 72 RR: 22 O2: 98% 4 liters O2 Eyes: EOMI, PERRL, conjunctiva clear, noninjected, anicteric, no exudate ENT: Moist Neck: No JVD, no carotid bruits Cardiovascular: irreg irreg, nl S1/S2, II/VI HSM RUSB Respiratory: decreased BS left lower two-thirds, comfortable, rhonchi and coarse breath sounds throughout, no wheezes Gastrointestinal: soft, non-tender, non-distended, no hepatosplenomegaly, normal bowel sounds Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint swelling, no edema in the bilateral extremities Neurological: Alert and oriented x3, fluent speech, sensation WNL Integument: warm, no rash, no ulcer Psychiatric: appropriate, pleasant On discharge; Vitals: 96.5 133/93 92 22 98%6Lnc Pain: 0/10 Access: PIV Gen: nad, pleasant, [**Name8 (MD) **] NP[**MD Number(3) **] HEENT: o/p clear, mmm, nasal canula in place CV: irreg irreg, [**2-2**] SM at LSB Resp: bilateral crackles, L>R Abd; soft, nontender, +BS Ext; trace b/l edema Neuro: A&OX3, nonfocal Skin: no changes psych: appropriate FAMILY HISTORY: NC SOCIAL HISTORY: Occupation: retired electrician and light house keeper Living situation: lives w/ wife in 9 room house, kitchen, bedroom, bathroom all on [**Location (un) 448**], 2 stairs to enter house Key relationships: wife Smoking, EtOH: quit in [**2092**], previously 12 yrs x [**12-29**] ppd, [**12-29**] drinks per month Walks without assistive device. No h/o falls in past year. Wears glasses. No hearing aides or dentures.

CHIEF COMPLAINT: PRESENT ILLNESS: This is an 85 [**Hospital **] nursing home resident with a history of cerebrovascular accident, coronary artery disease, status post coronary artery bypass graft who presents with shortness of breath and respiratory distress. The patient has been a nursing home resident for two years, is wheel chair bound times eight months prior to admission according to his son, had a fever and shortness of breath earlier the week prior to admission. The patient was started on Levofloxacin on [**8-7**] at the nursing home and Flagyl was also added. The morning prior to admission the patient was noted to have increased respiratory distress, diaphoretic, complaining of shortness of breath. This was the morning of [**2144-8-11**]. The patient's O2 sats in the Emergency Room were found to be in the low 70s on 4 liters nasal cannula. The patient was felt to be in severe respiratory distress and was intubated emergently in the Emergency Room. According to the physician, [**Name10 (NameIs) **] patient was alert prior to intubation. Subsequently after intubation the patient's blood pressure decreased and the patient was started on Dopamine and his heart rate increased into the 150s. The pressures were changed to Neosinephrine with significant decrease in blood pressure without any excessive tachycardia associated with it. The patient was given Vanco, Ceftriaxone, Flagyl in the Emergency Room. An nasogastric lavage was performed in the Emergency Room, which was significant for coffee ground, which were OB positive. The patient was also grossly OB positive from below. The patient was transferred to the MICU sedated, intubated with a left groin catheter. MEDICAL HISTORY: 1. History of cerebrovascular accident in [**2141-8-1**] with associated left sided weakness. 2. Dementia. 3. Coronary artery disease status post four vessel coronary artery bypass graft in [**2136**]. 4. Diabetes mellitus type 2. 5. Peptic ulcer disease. 6. Atypical psychosis. 7. Prostate cancer. 8. Hypercholesterolemia. 9. Mild congestive heart failure with an EF between 40 and 50% and an echocardiogram in 9/98 showing left ventricular hypertrophy and moderate aortic stenosis, moderate mitral regurgitation with global decrease in contractility. 9. Aortic insufficiency status post AVR. MEDICATION ON ADMISSION: 1. Cardura 4 mg q.o.d. 2. Glipizide 5 mg q day. 3. Lipitor 10 mg q.d. 4. Norvasc 5 mg q.d. 5. Prevacid 15 mg q day. 6. Dulcolax 5 mg b.i.d. 7. Depakote 500 mg b.i.d. 8. Lopressor 25 mg b.i.d. 9. Ultram 50 mg b.i.d. 10. Risperdal 0.25 mg q.h.s. 11. Senna two tablets q day. 12. Vitamin E. 13. Allopurinol 100 mg q.d. 14. Coumadin 0.5 mg q.d. 15. Levofloxacin. 16. Flagyl. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient has been living at [**Hospital3 7511**] for two years. The patient denies any tobacco or alcohol use.

CHIEF COMPLAINT: Right hand weakness. PRESENT ILLNESS: The patient is a 63 year old right-handed African American man with past medical history of stroke in [**2147-1-26**] with right arm weakness, treated at [**Hospital 1263**] Hospital, with complete resolution and no residual symptoms, IDDM, tobacco abuse, obesity, who presented to [**Hospital1 18**] ED on [**2148-7-30**] at 5:29pm as a CODE STROKE. The patient reported sudden onset of right hand weakness sometime between 4 and 4:30pm on the day of admission. He was riding in a car at that time, and noted that he couldn't manipulate car door handle in order to open door. He told his brother, also in car, who drove him home and called EMS. On EMS arrival, finger stick 68. Gave patient dextrose with no change in right hand weakness. Transported to [**Hospital1 18**] ED for evaluation. On review of systems, the pt. denied any headaches, visual changes, speech or language disorder, numbness, paresthesias, gait instability, dizziness, lightheadedness. No recent illnesses, fevers, chills, chest pain, shortness of breath, nausea, vomiting, abdominal pain, diaphoresis. On arrival here, finger stick 106, HR 84 and regular, BP 112/86, RR 15, O2 90%/RA. NIH stroke scale score of 2 with points for impaired motor function right arm and right arm ataxia. CBC, Chem, CK, Coags within normal limits except for wbc 12.2 but no left shift. Given risk/benefits of tPA, decision was made not to initiate lysis due to minimal severity of deficits. MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus 2. Stroke [**2348-1-27**] with right arm paresthesias. Treated at [**Hospital 1263**] Hospital. Patient states symptoms resolved after a few days. Discharged on ASA 81 and Plavix. 3. Tobacco abuse MEDICATION ON ADMISSION: 1. Plavix 75 mg po qd 2. ASA 81 mg po qd 3. Insulin Humulin R 9 units qAM, 7 units qPM and Insulin Humulin N 30 units qAM, 28 units qPM ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: T: 97.3 P: 78 R: 20 BP: 142/70 SaO2: 99% RA General: Awake, alert, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. FAMILY HISTORY: Remarkable for a number of family members with hypertension and diabetes mellitus. SOCIAL HISTORY: The pt. is widowed. He has 2 children, not in area. Retired auto body worker. Former smoker of 1ppd>50 years, but quit 2 years ago. Social alcohol. No drug use.

CHIEF COMPLAINT: dyspnea PRESENT ILLNESS: This is a 25 year old woman with a history of asthma and Ehrlers-Danlos syndrome and currently undergoing IVF treatment who presents as a transfer from [**Hospital6 33**] with acute onset shortness of breath. She had 2 embryos implanted on Monday in her first cycle of IVF. She had ongoing abdominal pain since the Friday before and had been seen at [**Hospital6 33**] although it is not clear what happened there. On the morning of admission she started feeling short of breath, cough, and pleuritic chest pain that radiated to her back. She took two puffs of her ProAir which did not significantly help. Her shortness of breath got worse and so she called EMS. When EMS arrived they administered an epi pen, nebulizers and magnesium given concern for an allergic reaction or asthma. At the outside hospital they started her on steroids. They also did a CT chest w/contrast to rule out a dissecting aortic aneurysm given her description of the pain. The timing of the contrast however was unable to evaluate for a PE. An ABG at OSH showed a respiratory alkalosis. She was transferred to [**Hospital1 18**] for further workup. On arrival at [**Hospital1 18**] she was breathing in the 60s and noted to be very anxious. She had an expiratory wheeze that was felt to be forced due to her tachypnia. A creatinine was uptrending 0.6 -> 0.9 and a lactate was 8.1. She noted that she had made minimal urine for the 24 hours prior to coming to ED. A chest x-ray showed pulmonary edema and bilateral pulmonary effusions. She received a total of 2mg of ativan for anxiety. Briefly on bipap, 20-25 min, then switched to high flow O2. No actual desats. A FAST exam (modified because sitting up) but has some fluid in bilateral lower abdominal quadrants which was felt to be more than just physiologic. Her VS at the prior to transfer were hr 138 rr 26 sat 97/30% BP 129/70. On arrival to the MICU she was in visible respiratory distress breathing about 40 times per minute on a high flow face mask and complaining of ongoing chest and abdominal pain. MEDICAL HISTORY: Asthma Right shoulder pain Multiple joint surgeries Ehlers Danlos MEDICATION ON ADMISSION: Dilaudid PO 4-6mg prn Trazadone 100mg QHS Oxycodone 10mg as needed (takes about 1/week) Prenatal Vitamins Cyclobenzaprine Progesterone Cream ALLERGIES: Morphine / Hydrocodone / Iodine PHYSICAL EXAM: Admission Physical Exam: Vitals: afebrile hr 112 bp 145/77 rr 44 100%/high flow face mask General: Alert, oriented, moderately acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: decreased breath sounds at bases, expiratory wheezes in upper lung fields Abdomen: soft, mildly distended, bowel sounds present, no organomegaly, mild tenderness to palpation, no rebound or guarding GU: foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. FAMILY HISTORY: No FH of blood clots. Mother and multiple other family members with breast cancer. Multiple family members with strokes. Uncle with brain aneurysm. SOCIAL HISTORY: Works as a nanny. Lives with her husband. [**Name (NI) **] tobacco, alcohol or drugs.

CHIEF COMPLAINT: Hypotension PRESENT ILLNESS: 83 year old female with a history of HTN, CKD, anemia presents to the ER with worsened bilateral hip pain. Apparently she fell on Friday and was seen at [**Hospital3 **] and discharged home after she had slipped on ice. She now has worsening bilateral hip pain and also R knee and right scapula pain since her fall. Has been immobile since accident. In the ER her vitals 99.5, 88, 86/62, 20, 92% RA 102/57 when seen by ER resident, then to 80s, FAST negative. Getting a TTE being done currently. A right IJ was placed and started on Levophed. Received 2 liters of IVF. Non operative fractures. She received vancomycin, levofloxacin, ASA, morphine, ativan and was started on Levophed for hypotension. A blood cx was sent and a non contrast CT Torso was obtained which showed a non displaced fracture of the right inferior pubic ramus, body of pubis and possible fracture at anterior lip of right acetabulum. In the ICU patient looks fatigued but has no dyspnea or chest pain. Her only complaint is pain in the hips. MEDICAL HISTORY: Hypertension Chronic kidney disease Normocytic anemia [**2-3**] CKD s/p CCY infrarenal AAA GERD MEDICATION ON ADMISSION: Percocet Atenolol 50mg daily Triamterene/HCTZ 50/25mg once daily Lansoprazole 30mg once daily Losartan 50mg once daily ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Shellfish Derived / Aspirin PHYSICAL EXAM: Admission: 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 GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema FAMILY HISTORY: Father died in his 80's of a CVA after a long history of hypertension Mother with kidney disease SOCIAL HISTORY: NC

CHIEF COMPLAINT: Elective surgery for kyphoscoliosis PRESENT ILLNESS: This is a 53-year-old woman without significant past medical history, who was in her usual state of health until about two months ago. On [**2120-5-31**], she suffered an L1 burst fracture and left rib fracture secondary to a fall from a ten foot ladder (per patient) or from a second-floor window (per patient's daughter) at home. She was initially seen at an outside hospital two days later, after the incident. She was transferred to [**Hospital1 69**] immediately for surgical intervention. She had a relatively uneventful perioperative course except for one unit of packed red blood cell transfusion postoperatively. She had a total L1 vertebrectomy, fusion and segmental instrumentation of T12 to L3, cage placement at L1, and autograft during the first surgery. She was evaluated by Psychiatry at that time for possible paranoia and questionable suicidal ideation postoperatively. Medical workup at that time included a negative RPR, normal thyroid function tests, and a head MRI showing possible chronic microvascular ischemia. She was sent to a rehabilitation facility on [**2120-6-7**], in stable condition. About one month later, on [**2120-7-9**], she was readmitted for elective second operation to correct kyphoscoliosis. Again she had an uneventful operative course. The second operation included a posterior fusion of T9 to L3, multiple thoracolumbar laminectomies, segmental instrumentation of T9 to L3, and right iliac crest graft. Postoperatively, however, she suddenly decompensated in the Post-Anesthesia Care Unit while she was receiving a transfusion of one unit of packed red blood cells. She complained of sudden onset of chest pain and shortness of breath with oxygen saturations dropping to 70%, blood pressure dropping to 70/40. She was intubated immediately, and transferred to the Surgical Intensive Care Unit for further management. Progressive loss of bilateral translucency on chest x-ray and positive anti-HLA and anti-granulocyte antibodies on hematological workup were all consistent with TRALI (transfusion-associated lung injury). While in the Surgical Intensive Care Unit, her postoperative course was further complicated with methicillin-sensitive staphylococcus aureus bacteremia, pneumonia, and wound infection (which were documented with positive cultures on [**7-17**]). These events eventually led to a prolonged intubation. After she was started on intravenous oxacillin on [**7-20**], she had very good response, with decreased fever and decreased white blood cell count, as well as clearing of bacteremia which was documented by several blood cultures drawn on later days. She also underwent incision and drainage of posterior wounds on [**7-23**]. Wound cultures showed decreased colonization of methicillin-sensitive staphylococcus aureus and rare colonies of E. coli. She also had a diagnostic pleural tap on [**7-26**] for persistent left pleural effusion. The final culture was negative. She had repeated TTE on [**7-22**] which showed no vegetation and left ventricular ejection fraction greater than 55%. She also had a CT of the chest, abdomen and pelvis on [**7-25**], which showed improving effusion and normal bowels with old splenic infarct. CT angio was also performed, which showed improving atelectasis and effusion without evidence of pulmonary emboli. She was extubated on [**7-28**], and transferred to Medicine on [**7-30**] in stable condition. MEDICAL HISTORY: Uterine fibroids MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Schizophrenia SOCIAL HISTORY: Works full-time as an insurance underwriter. Lives alone. Questionable alcohol.

CHIEF COMPLAINT: Decreased responsiveness and respiratory distress PRESENT ILLNESS: Mr. [**Known lastname 27218**] is a 77yo M with history of COPD, DM and ischemic cardiomyopathy with EF of 10% ([**4-22**]) who was transferred to the cardiology service for ICD placement. . Patient was recently hospitalized at [**Hospital6 3105**] in [**Month (only) 958**] for altered mental status and discharged to rehab on [**2163-5-4**]. During this hospitalization, he was in the ICU for hypercarbic respiratory failure s/p intubation/extubation, acute systolic CHF exacerbation and required pressors for hypotension. A TTE done at that time showed an EF of 10% with akinetic motion of the anteroseptal wall and markedly hypokinetic motion of inferior wall of the LV. At that time, transfer to [**Hospital1 18**] for ICD placement but offered but declined. Discussion was had with outpatient cardiologist, Dr. [**Last Name (STitle) **], and patient finally agreed to ICD and catheterization so direct admission was planned. . Upon admission to [**Hospital1 18**], he was found to be minimally responsive with FSBS in the 40s for which he received an amp of D50. Patient remained minimally responsive and ABG showed 7.21/79/207/33. He was placed on O2 with sats in the low 90s. Repeat FSBS was 150s without change in mental status and ICU transfer was initiated. He received 40mg IV lasix prior to transfer. . In the ICU, he is more alert and answers some questions appropriately. He is able to say the year is "211" but does not oriented to place or month/day. . Review of systems: Endorses some difficulty breathing. Denies chest pain and abdominal pain. Otherwise unable to obtain secondary to confusion. MEDICAL HISTORY: Diabetes Dyslipidemia Hypertension CABG: 6 vessel CABG in [**2145**] CHF [**3-16**] ischemic cardiomyopathy last EF of 15% on most recent Echo [**10/2162**] GERD COPD Peripheral neuropathy Vitamin B12 deficiency Chronic kidney disease Dementia Recurrent falls MEDICATION ON ADMISSION: ASA 325mg daily Multivitamin daily Vitamin B12 1000mcg daily Pantoprazole 40mg daily Spiriva 18mcg daily Vitamin D3 1000units daily Diovan 40mg [**Hospital1 **] Carvedilol F/C 25mg [**Hospital1 **] Vicodin w/ APAP 5-500mg [**Hospital1 **] Colace 100mg TID Gabapentin 300mg TID Xopenex HFA 45mcg 2 puffs q6 Simvastatin 80mg qHS Lidoderm patch Tums PRN Vicodin q6 PRN Lactulose with MOM with prune juice PRN Novolog 70/30 28units qAM, 18units qHS Novolog SSI ALLERGIES: Iodine-Iodine Containing / Shellfish / Oxycodone PHYSICAL EXAM: Admission: Vitals: T: 96 BP: 139/70 P: 69 R: 18 O2: 96% 1 L NC General: Alert, oriented to person only, mild respiratory distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP difficult to appreciate secondary to body habitus, no LAD Lungs: Bilateral lungs with coarse crackles anteriorly CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops appreciated over lung sounds Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, 1+ pitting edema to knees bilaterally, moving all 4 extremities FAMILY HISTORY: Mother with kidney problems Father with liver cirrhosis SOCIAL HISTORY: He is a resident of Nevins Home. He is a former smoker but quit in [**2145**]

CHIEF COMPLAINT: left renal mass PRESENT ILLNESS: 53F s/p right radical nephrectomy 20years ago. Pathology was determined to be benign. She presented with a left exophytic renal mass in the lower pole of the left kidney. She underwent left partial nephrectomy. MEDICAL HISTORY: Diabetes mellitus diagnosed in [**2128**] Asthma RCC, s/p Right nephrectomy [**2121**] s/p CCY Depression Post traumatic stress disorder; Iron deficiency anemia Hypertension Hyperlipidemia schizoaffective d/o h/o breast and LE skin ulcers (?necrobiosis lipoidica) CAD (MI [**57**] yrs ago) MEDICATION ON ADMISSION: ALLERGIES: Sulfa (Sulfonamides) PHYSICAL EXAM: FAMILY HISTORY: Mother died of CVA. CAD; CHF SOCIAL HISTORY:

CHIEF COMPLAINT: 1. Acute bleed 2. Acute on chronic renal failure 3. Hypernatremia/Diabetes Insipidus PRESENT ILLNESS: 72yo male with h/o A Fib, HTN, AAA, CRI, L renal cysts, recent urosepsis treated with levofloxacin, who p/w an acute bleed from L kidney when INR was 4.6. Since admission, pt??????s INR and Hct have stabilized, has had acute on chronic renal failure which is resolving, had hypernatremia which is resolving, and had a L pleural effusion which was tapped on [**7-26**], results c/w tracking of L renal bleed. Elevated WBC, chronic cough. MEDICAL HISTORY: ?????? Atrial Fibrillation/Flutter: rate controlled?????? Hypertension?????? AAA (6 x 6.5cm): being watched?????? CRI: baseline Cr ~2.5?????? Bipolar D/O: tx??????d w/Li for many yrs?????? Renal cysts/unidentified lesions: dx??????d 3y PTA by Dr. [**Last Name (STitle) 9125**], pt refused further w/u?????? Gout?????? Urosepsis (recent): treated with levofloxacin MEDICATION ON ADMISSION: Meds ?????? RISS?????? Pantoprazole 40 mg PO Q24H ?????? Acetaminophen 650 mg PO Q6H ?????? Docusate Sodium 100 mg PO BID ?????? Senna 1 TAB PO BID:PRN ?????? Diazepam 5 mg PO Q6H:PRN ?????? Morphine Sulfate 2 mg IV Q4H:PRN ?????? Metoprolol 25 mg PO TID ?????? 1000 ml D5W Continuous at 100 ml/hr for [**2152**] ml?????? Lithium (held) ALLERGIES: Iodine / Inderal PHYSICAL EXAM: PE Vitals T 9 P 71, reg BP 140/80 Resp 20, 98% on RA Gen Obese patient lying in hospital bed with mild SOB, A+O x 3 HEENT PERRL, EOMI Neck Obese, no LAD Thorax Bibasilar rales, cough CV RRR, nl s1s2, no murmurs/gallops/rubs Abd Obese, nondistended, normoactive BS, no rebound/guarding Ext No clubbing/cyanosis/edema, nontender Neuro Nonfocal; pleasant affect, A+O x 3 FAMILY HISTORY: FH Brother ?????? ? RCCFather ?????? CVA SOCIAL HISTORY: SH: lawyer [**Name (NI) 1139**] 50 pack-year habit EtOH 14 drinks/week

CHIEF COMPLAINT: fever and abdominal pain PRESENT ILLNESS: The patient is a 65 year old male who was recently discharged from [**Hospital1 18**] on [**2107-4-1**] (please see discharge summary for details) with a known colovesical fistula, with the idea to continue bowel rest and antibiotics and return to [**Hospital1 18**] at a later date for planned surgery. He returned to [**Hospital1 18**] 2 days prior to his scueduled operation with a fever and abdominal pain and the diagnosis of candidemia from an OSH. MEDICAL HISTORY: bipolar d/o, paranoia, anxiety, HTN, PMIBI [**2-7**] EF 55%, 1MR, LVH, known diverticulosis, GERD, CBP MEDICATION ON ADMISSION: risperidone 0.5', trazadone 50', protonox 40', lop 100", albuterol/combivent prn ALLERGIES: Buspar / Percodan PHYSICAL EXAM: VS- T102.7, HR100, BP100/P, RR20, SO298% Gen- NAD, AxOx3 Heart: RRR, S1S2 Lungs: CTA b/l Abd: soft, NT/ND Skin: diffusely red (Redman's syndrome from Vancomycin) FAMILY HISTORY: non-contributory SOCIAL HISTORY: Patient lives alone. Habits: Patient is a current smoker. Has a history of alcohol abuse. Has a history of marijuana use.

CHIEF COMPLAINT: respiratory distress, mental status change PRESENT ILLNESS: Ms. [**Known lastname 84176**] is a 25yo woman with history of anxiety and heroin abuse who was found apneic and unresponsive. Ms. [**Known lastname 84176**] has a long history of heroin abuse, which she usually takes intranasally. After two weeks of sobriety, she relapsed today and decided to take heroin IV around 1:30pm. She was in the company of two other heroin users, who noticed sometime later that she was unresponsive and not breathing. They called EMS; by report, her oxygen sat was in the 50s when they arrived. She responded well to 1mg of IV narcan, and was taken to the ED. Of note, she admits to snorting some cocaine earlier in the day. She attributes her relapse to uncontrolled anxiety as she has been unable to get a regular Rx for xanax since she has no PCP and no health insurance. In fact, she reports multiple admissions to [**Hospital1 2025**], [**Hospital1 112**], and [**Hospital 2079**] Hospital for seizures after missing her xanax doses. According to what she has been told by witnesses, she falls down, loses consciousness, and begins shaking all over. +Bladder incontinence and tongue biting. She was most recently seen in the ED at [**Hospital1 112**] and still has some of the xanax pills with her from that ED stay. MEDICAL HISTORY: Anxiety with h/o Panic Attacks and Cutting Behaviors Heroin abuse, maintained on suboxone in the past h/o seizures from benzodiazepine withdrawal per patient's report Tobacco Abuse Cocaine Abuse -- snorts h/o Depression but no suicidal attempts h/o Bulimia MEDICATION ON ADMISSION: MEDICATIONS (does not know doses): Seroquel Xanax . . ALLERGIES: NKDA ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: 96.7 114/64 85-96 19->12 94% RA GENERAL: Somewhat anxious but pleasant young woman who becomes increasingly sleepy during interview. HEENT: No conjunctival pallor. No scleral icterus. Pupils equal but small b/l, EOMI, no nystagmus. MMM. OP clear. Neck Supple. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Respiratory rate slowing during drowsy periods. CTAB, initially with inspiratory wheezes, which resolved with deep breaths, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis pulses. Superficial cutting marks on lateral aspect of legs just superior to ankles b/l. Left shoulder range of motion is intact. There is some prominence to the distal aspect of the clavicle with mild tenderness on exam. No warmth or erythema. No fluctuance. SKIN: No rashes/lesions, ecchymoses. NEURO: Oriented but increasingly sleepy as above. Appropriate. CN 2-12 intact b/l. 5/5 strength throughout. Difficulty with finger to nose b/l with imprecision when asked to go at typical speed; able to improve when she focuses. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, demonstrates fair insight but poor judgment, very concerned about impact of hospital stay on her ability to finish classes FAMILY HISTORY: both parents with hx of etoh abuse SOCIAL HISTORY: Her father raised her as her mother lost custody when she was young. She has been recently returned to a psychology program in [**Location (un) 86**] after previously dropping out and spending several months in [**State 760**]. +Tobacco, 1PPD. Denies alcohol use. Snorts cocaine and heroin, rarely uses IV drugs.

CHIEF COMPLAINT: chest pain PRESENT ILLNESS: Mr. [**Known lastname 18801**] is a 48 yo M with a history DM, IGA nephropathy, hypertension who presented with chest pain and orthopnea. The patient reports that over the last 1 week he has been feeling unwell with decreased appetite and general malaise. He then reported that on friday he began to feel more frustrated about his illness and having to take medicaitons and decided to stop taking them. At this time he did not have any suicidal thoughts, just did not feel like taking his medications. However, he did express feeling depressed about his medical condtion. . Within approximately 24 hours of stopping his meds he began to have symptoms of chest pain (pleuritic, positional, pressure in chest), dry cough, dyspnea at rest, orthopnea, blurry vision and right-sided, throbbing headaches. He decided to get medical care today for these symptoms. He reported nausea with emesis x 1. Also had palpiations. . In the ED he got SL NTG, nitro gel with improvement of his sx, but unchanged BP. He then was started on a nitro gtt and given 80 mg IV lasix, diltiazem SR 360 mg x 1, hydralazine 100 mg once. ED resident spoke with cards who recommended giving the home meds. No ECG changes per ED with exception of TWI. BPs initially 241/114, HR 90 02 sat 99 % RA . Not yet on dialysis, renal consult fellow notified. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of syncope or presyncope. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: cath in [**5-11**] with no interventions needed 3. OTHER PAST MEDICAL HISTORY: -Diabetes mellitus for over 20 years. History of retinopathy and laser treatment as well as neuropathy. He also has a history of peripheral vascular disease -Hypertension. -Hyperlipidemia: He had been on atorvastatin for at least three years before discontinuing this and Zetia due to elevated CK. -Chronic kidney disease due to IgA nephropathy. Stage 5. -Status-post left great toe amputation, right knee surgery, and right wrist surgery (the latter two for injuries sustained from falls). MEDICATION ON ADMISSION: DILTIAZEM HCL - 360 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day FUROSEMIDE - 80 mg Tablet - one Tablet(s) by mouth two tablets in the AM and one in the afternoon HYDRALAZINE - 50 mg Tablet - two Tablet(s) by mouth three times a day INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - take 20 units daily INSULIN LISPRO [HUMALOG] - (Dose adjustment - no new Rx) - 100 unit/mL Solution - Per sliding scale with meals LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day POTASSIUM CHLORIDE - 20 mEq Tab Sust.Rel. Particle/Crystal - one Tab(s) by mouth daily PREGABALIN [LYRICA] - (Prescribed by Other Provider) - 50 mg Capsule - 1 Capsule(s) by mouth three times a day VALSARTAN [DIOVAN] - 320 mg Tablet - one Tablet(s) by mouth daily at night ASA 325mg QDAY ALLERGIES: Lipitor / Zetia PHYSICAL EXAM: VS: T=98.3 BP=167/87 HR=94 RR=18 O2 sat= 98%RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. AA male HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: His mother died of breast cancer at 59, had DM and HTN. His father is 68 and has HTN. He has two siblings, one sister with diabetes and one brother with hypertension. He has a healthy 20-year-old son. SOCIAL HISTORY: He lives alone. He worked previously as a cook. He stopped when he went on disability about three years ago. He smoked [**2-8**] to 1 ppd since a teenager, but quit 6 weeks ago. He rarely drinks alcohol. He smokes marijuana occasionally.

CHIEF COMPLAINT: Neutropenic fever, diffuse large B-cell lymphoma. PRESENT ILLNESS: Mr. [**Known lastname **] is a 59 year-old man with a history of diffuse large B-cell lymphoma s/p IVAC D11 who presents with fever, nausea and vomiting of 1 day duration. He was feeling overall well until this morning when he developed a fever of 102. He vomited twice (bilious, non-bloody). Denies abdominal pain or diarrhea. Denies cough, sore throat, rhinorrhea or headache. Denies sick contacts though was concerned his milk was old. Denies shortness of breath or chest pain. Denies rashes. Does report increased urinary frequency but no dysuria. Yesterday he went to his outpatient oncology appointment, received 1 unit platelets with no complications and felt well enough to walk home. . In the ED, initial vitals were T 100.3, BP 112/89, HR 94, RR 18, 100% NRB. During ED course Tmax 102.7. He was noted to be in AFib at a rate of 135-160 which improved without intervention. O2 sat 98-100% 2L. BP dropped to 76 and he was given 5L NS and started on levophed. He received vancomycin and cefepime before being transferred to the ICU. On arrival to the ICU patient was actively rigoring. . Patient recently admitted [**Date range (3) 21959**] and treated with IVAC chemotherapy x 5 days which was complicated by neutropenia, thrombocytopenia, dizziness and diarrhea. Hospital stay was also complicated by Atrial Fibrillation treated with metoprolol and digoxin. Patient also has history of pulmonary embolism ([**10-15**] admission) felt to be secondary to right atrial catheter-associated thrombus complicated by likely TIA/amaurosis fugax. Patient was treated with fondaparinux but this was then stopped last admission due to thrombocytopenia. . ROS: The patient denies melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. MEDICAL HISTORY: ONCOLOGIC HISTORY: Mr. [**Known lastname **] initially presented in early [**6-/2197**] with fever, weight loss, and muscle and joint aches. He was diagnosed with PMR and started on prednisone with improvement in his symptoms. During the preceding six months, he reported a history of the generalized body pain as well as fatigue, weakness, and poor appetite. He also reported periodic fevers, drenching night sweats, and a 25-pound weight loss also over the same six months. Marked improvement of both his musculoskeletal and constitutional symptoms after prednisone treatment. He then presented to the emergency room on [**2197-7-17**] with palpitations and dizziness and was found to be in atrial fibrillation. He has had a history of PAF in the past. He was febrile to 101.6 with a heart rate of 126. CT scan of the chest, abdomen, and pelvis on showed multiple low-attenuation lesions within the liver, spleen, and kidneys with characteristics felt atypical for lymphoma. A follow-up MRI of the abdomen showed hypovascular masses in both kidneys and spleen of various sizes consistent with lymphoma. Mr. [**Known lastname **] then underwent bone marrow aspirate and biopsy on [**2197-7-26**], which showed extensive necrosis with focal involvement by a high-grade B-cell lymphoma, diffuse large B-cell type. FISH translocation was notable for c-Myc and Bcl-2 indicating a "double hit" lymphoma characterized by a Burkitt's-like lymphoma. . Mr. [**Known lastname **] has overall tolerated his chemotherapy relatively well. He has continued on his Fondaparinux daily when on [**2197-11-16**], he noted sudden onset sudden of a dark cover in the lower half of the visual field in his right eye, which lasted [**10-20**] minutes, then self-resolved. He presented to the emergency room for evaluation. TEE revealed thrombus at the tip of his right atrial catheter, with no PFO. Ophthalmology work up was negative and the episode was attributed to TIA with recommendation to continue fondaparinux. He was discharged on [**2197-11-18**] with no further episodes. . TREATMENT HISTORY: 1. Initiated treatment with [**Hospital1 **] chemotherapy on [**2197-7-29**] with two doses of Rituxan on [**2197-8-2**] and [**2197-8-3**]. Follow up CT imaging on [**2197-8-5**] showed stable lymphomatous lesions in the kidney, spleen, and abdominal nodes. 2. Rituxan 500 mg given on [**2197-8-10**] with a fever that evening and admission for neutropenia. During admission, noted for atrial fibrillation with RVR and was started on digoxin at 0.125 mg daily along with metoprolol 200 mg daily. 3. Readmitted on [**2197-8-18**] for his second cycle of [**Hospital1 **] chemotherapy, which was delayed for two days due to hypotension and cough. A CT of the chest showed bilateral lower lobe opacities, right greater than left, concerning for infection and he was treated with a course of Levaquin. 4. On [**2197-8-30**], received Rituxan at 375 mg/m2. 5. Follow up PET scan on [**2194-9-6**] showed no evidence for lymphoma but was notable for multiple peripheral base pulmonary opacities with rims of soft tissue density and relative central lucencies most of which were new. He underwent CT of the chest for further evaluation, which showed multiple filling defects within the segmental and subsegmental branches of the right lower lobe arteries compatible with pulmonary emboli. 6. Admitted on [**2197-9-7**] for initiation of anticoagulation with fondaparinux and began third cycle of treatment with [**Hospital1 **] on [**2197-9-8**](dose level 2) 7. Received Rituxan 375 mg/m2 on [**2197-9-25**]. 8. Admitted on [**2197-9-29**] for fourth cycle of treatment with [**Hospital1 **](dose level 3). 9. Received Rituxan 375 mg/m2 on [**2197-10-17**]. 10. Admitted on [**2197-10-20**] for fifth cycle of treatment with [**Hospital1 **](dose level 3 with Adriamycin at dose level 2. Received Rituxan on [**2197-11-7**]. 11. Admitted on [**2197-11-23**] for high-dose cyclophosphamide. 12. Admitted on [**2198-1-15**] for IVAC (originally admitted for high-dose MTX, but PET scan showed progressive disease). . OTHER MEDICAL HISTORY: 1. Diffuse large B-cell lymphoma, Burkitt's like with c-Myc and Bcl-2 positivity s/p [**Hospital1 **] x 5 cycles and multiple rituxan infusions. He has had recurrent disease within 2 - 3 months of his last treatment. Patient recently admitted [**Date range (3) 21959**] for CNS prophylaxis with high-dose MTX for his aggressive lymphoma. However, PET scan prior to admission was concerning for rapidly progressive disease and CT torso on admission agreed with these findings and his LDH continued to rise. He was therefore started on IVAC chemotherapy x5 days and discharged on neupogen. 2. PAF diagnosed in [**2180**] with now chronic atrial fibrillation in the past several months. He had no history of treatment with anti-arrhythmia or anticoagulation prior to his admission in [**8-/2197**], currently receiving treatment with metoprolol and digoxin. 3. Pulmonary embolism, currently receiving treatment with fondaparinux. 4. Polymyalgia rheumatica diagnosed in [**2197**] and managed by Dr. [**Last Name (STitle) **], although further treatment on hold while getting treatment for lymphoma and unclear if his symptoms were related to lymphoma and not PMR. 5. Remote history of syphilis, gonorrhea, and genital herpes in [**2160**]. 6. Tonsillectomy and adenoidectomy in the [**2137**]. 7. Myopia. 8. Recent probable TIA with from thrombus on right atrial catheter tip MEDICATION ON ADMISSION: 1. G-CSF (Neupogen) 300mcg SC daily 2. Levofloxacin 500mg PO daily 3. Acyclovir 400mg PO Q8H 4. Sulfamethoxazole-trimethoprim 800-160mg PO MWF 5. Digoxin 125mcg PO DAILY 6. Metoprolol succinate 100mg PO HS 7. Fondaparinux 7.5mg/0.6mL Syringe SC daily, on hold since [**2198-1-25**] 8. Oxycodone 5-10mg PO Q4H prn pain 9. Calcium carbonate 200 mg (500 mg) PO TID 10. Cholecalciferol (vitamin D3) 400 unit PO DAILY 11. Famotidine 20mg PO Q12H 12. MVI one Tablet PO DAILY 13. Ondansetron 4mg PO TID prn ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION EXAM: Vitals: T: 98.8 BP: 100/53 HR: 64 RR: 18 O2Sat: 94% 2L GEN: Pale, thin, no acute distress. HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear, pale conjunctiva NECK: No JVD, COR: Irregular rate, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, ND, +BS, mild tenderness on LLQ and RUQ but described as "tightness" and not overt abdominal pain, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. Moves all 4 extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. . DISCHARGE EXAM: GEN: Cachectic, NAD CV: RRR, nl s1 and s2, no m/r/g Chest: CTAB ABD: Soft, NTND, +BS FAMILY HISTORY: Father had an MI in his 70s and his paternal grandfather had an MI in his 40s. His mother is status post aortic valve replacement. His younger brother had probable schizophrenia and died from suicide at age 18. There is no family history of cancer. SOCIAL HISTORY: Mr. [**Known lastname **] is married and lives in [**Location **]. He previously worked as a software engineer, but now works without pay from home contributing to open source software projects. He gas two adult children but has minimal contact with them. He is a nonsmoker, drinks alcohol on occasion, and denies any history of illicit drugs.

CHIEF COMPLAINT: Vomiting, diarrhea REASON FOR MICU ADMISSION: fever, hypotension PRESENT ILLNESS: 56M with CAD s/p CABG, CKD b/l Cr ~2.0 presented to [**Hospital 107**] Hospital of [**Doctor Last Name 792**]with 3 days of profuse vomiting and diarrhea. Felt subjective fevers at home but did not take his temperature. Had mild shortness of breath beginning on the evening prior to admission. No chills, sweats, headache, neck stiffness, cough, sore throat, myalgias, arthralgias, chest pain, palpitations, hematemesis, hematochezia, melena, dysuria, rash, sick contacts, recent antibiotic use, or recent travel. Upon arrival at OSH, SBP nadir 69/42 with HR 98. 3L IVF with improvement in BP to 106/63 HR 102. WBC 10.2 BUN 86 Cr 5.9 CKMB 12.7 (ref range <6.3) %CKMB 1.5 (ref range 0-4), tropI 0.44 (0-0.05). EKG showed sinus tach LAD LAE LVH. Given ASA/heparin transferred to [**Hospital1 18**] for further cardiac evaluation. In the ED, triage V/S 102.3 109 106/72 20 100%2L. Tmax 104 PR, BP nadir 86/57 HR 99. BUN 82 Cr 5.5 K 5.7 CO2 10 AG 15 WBC# 9.8 lactate 1.6. Given vanco 1 g IV, zosyn 4.5 g IV, kayexelate 30 mg, D50 1 amp, insulin 10 U, tylenol, and 5+ liters IVF. EKG showed ST 110 LAD LAE LVH nonspec IVCD nonspecific <[**Street Address(2) 50379**] depressions. Cardiology evaluated EKGs and recommended stopping heparin gtt. Vital signs prior to transfer T 102 HR 99 BP 90/54 RR 23 O2sat 97%RA. MEDICAL HISTORY: CAD s/p CABG in [**2144**] (LIMA to LAD, free RIMA from LIMA to OM and SVG to PDA) CKD b/l Cr ~2.0 attributed to Buerger's disease HTN hyperlipidemia gout pituitary tumor diagnosed early [**2131**] MEDICATION ON ADMISSION: 1) ASA 325 mg daily 2) lisinopril dose unknown 3) crestor 20 mg daily 4) allopurinol 100 mg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals - T 100.2 BP 90/60 HR 98 RR 25 02sat 96%3L GENERAL: Ill-appearing obese man appears flushed & diaphoretic HEENT: OP clear dry MM NECK: JVD difficult to assess due to habitus CARDIAC: reg tachy no m/r/g LUNGS: diminished at bases no w/r/r ABDOMEN: soft obese nondistended diffusely tender to deep palpation no rebound, guarding heme+ in ED EXT: warm, damp +PP no edema NEURO: awake, alert, conversing appropriately DERM: no rash FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Owns a cutlery business. Drinks 2-3 beers/day. Last drink 3 days prior to admission. Occasional MJ use. No tobacco.

CHIEF COMPLAINT: status epilepticus PRESENT ILLNESS: 39 yo M with history of seizure disorder, traumatic brain injury [**12-23**] MVC [**2168**], alcoholism, transferred from [**Hospital1 9191**] for ? status epilepticus. EMS was called after patient was reported to have had a seizure at home. Records state he was sitting and talking to family when he became unresponsive, foaming at the mouth. Unfortunately no further details are available at this time. Family reported in chart he had been noncompliant with medications (takes keppra 1000 mg [**Hospital1 **] at home). Upon arrival by EMS he was found to be lying in chair and thought to be postictal and taken to [**Hospital3 **]. Upon arrival he was noted to have bp 202/132, P 157, and afebrile. He was reported to be stuperous but with LE rigidity, jaw clenched, and not following commands or responding to verbal stimuli. He was noted to have "disconjugate eye movements" and pupils were 4 mm and fixed. Shortly after arrival, he was noted to be "actively seizing" with body clenched and lower extremity rigidity, with a generalized seizure lasting 3 minutes. He continued to have activity concerning for seizure for unclear duration and was intubated, received several doses of ativan (initially reported to be 18 mg total, but in med sheets only appears to have 6 mg administered), vecuronium 4 mg, propofol, versed, phenytoin 1500 mg, succinylcholine, and etomidate. He was taken via [**Location (un) **] and given additional propofol, fentanyl, and 2 mg ativan. At [**Hospital1 **] he was noted to have etoh level of > 400 and a CT head which was negative for acute process, and urine tox was negative. He was noted to have been hospitalized at that facility ten days prior after seizure in setting of alcohol intoxication. ROS unobtainable. Since arrival to the ED, the patient has been started on levophed, versed, fentanyl, and received naloxone and ceftriaxone. MEDICAL HISTORY: -seizure disorder -hx traumatic brain injury [**12-23**] MVC in [**2168**] -alcoholism -HTN -cirrhosis -pancreatitis -GERD -anxiety -depression MEDICATION ON ADMISSION: Not clear if he is taking any of these medications -keppra 1000 mg [**Hospital1 **] (however notes indicate he has been non-compliant) -paxil 50 mg daily -remeron 30 mg qhs -seroquel 100 mg qhs -clonidine 0.1 mg qhs -lopressor 25 mg daily ALLERGIES: Penicillins / Cephalosporins / Carbapenem PHYSICAL EXAM: Physical Examination; VS; BP 80/57 P 87 RR 16 100% on vent, afebrile Gen; intubated, lying in stretcher HEENT; NC/AT CV; RRR, no murmurs Pulm; CTA anteriorly Abd; soft, NT, ND Extr; no edema Neuro; Mental status; Eyes closed, unarousable to noxious stimuli CN; Eyes in mid position, conjugate gaze. Pupils 3mm and minimally reactive. Occasional nonryhtmic conjugate downward jerking movements of eyes. Corneals present. Unable to assess gag. Motor; normal bulk. Normal tone in upper extremities, increased tone in lower extremities. No movement to noxious stimuli Sensory; does not withdraw to noxious stimuli Reflexes; 2+ at R and L bicep, tricep, brachioradialis, 3+ patellars, 2+ achilles, symmetric. Sustained clonus at ankles. Toes are mute. FAMILY HISTORY: NC SOCIAL HISTORY: alcoholism. Lives with parents, unemployed, divorced, has had recent admission for alcoholisms at [**Hospital 17436**] hospital, not compliant with medications,

CHIEF COMPLAINT: MVA PRESENT ILLNESS: He is a 62 yo RHM with PMH of Hep c, chronic pain in both shoulders with "baseline: weakness in the right arm , who has been admitted to Trauma service for evaluation. He was involved in MVC on [**2138-5-31**] in am. It seems that he was driving and lost the control of his car and hit the tree. he denies LOC or wekaness preceding the accident. He says that " I have problems with my right eye, I cant see well". He denies any LOC or seizure like activity. He was taken to OSH after EMS arrived at the scene. at OSH , 6 50, he was noted to be alert, in pain and screaming for pain meds. His vitals were 128, 26,\ 146/70, 98 RA. He became progressively agitated and was intubated after ativan, haldol and versed. he was transfered to [**Hospital1 18**] for further care. At OSH, the urine was positive for BZD, THC and opiates, none of which are on the medication list of patient at home. MEDICAL HISTORY: Hep C, HTN IV drug abuse in the past, denies at present Chronic right rotator cuff injury with baseline weakness in right arm ?h/o vitreous bleed in right eye with a large black spot in front of it and poor vision with right eye for [**2-12**] yrs, details unclear as patient does not know at this moment MEDICATION ON ADMISSION: Atenolol 100'; Valsartan/HCTZ 160/25'; Nifedipine CR 60'; Codeine 30 " prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS; 100.9, 152/90, 115, 18, 100 RA General: Awake, lying in bed with C collar on. c/o pain in right knee and R fore arm. HEENT: NC/AT, mild scleral icterus noted, MMM, no lesions noted in oropharynx Neck: No nuchal rigidity. in cervical collar Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally. No tenderness to palpation of spine or muscles. Skin: no rashes or lesions noted FAMILY HISTORY: No seizures. Has h/o HTN, DM, in parents. stroke in father in 60s SOCIAL HISTORY: Not married, no children, used to work as operation manager, says that " I quit alcohol 15 yrs ago, 1-2 drinks per week before that." denies smoking in last 15 years. [**4-14**] cigarattes per day for 4-5 years before that. admits of IVDA -heroin in the past. Uses Marijuana sometimes.

CHIEF COMPLAINT: weakness and nausea --> transfer from OSH for cholangitis PRESENT ILLNESS: Mr. [**Known lastname 62993**] is an 80 year old who has generally been in relatively good health, with ongoing issues of HTN, hypercholesterolemia, and GERD, but otherwise well, who for the last six days has been feeling poorly. Starting on Tuesday of last week (6 days prior to admission), he started feeling nauseous and weak, had loss of appetite, and had some vomiting. This improved by Saturday, and on Saturday he had enough of an appetite to eat a hamburger, and enough energy to go out with his family, which he had not had previously. On Sunday he began feeling nauseous again, and started having abdominal pain which continued to worsen and became quite severe by Monday morning. He was also having severe shaking chills throughout Sunday during the day and night. He again had anorexia. He presented to [**Hospital3 3583**], where one note suggests a temp of 105.9;; a RUQ U/S showed a dilated CBD and liver labs confirmed an infectious (notable bandemia) and cholestatic (high bilirubin, etc) picture consistent with cholangitis. . At [**Hospital1 46**], his WBC was 4.9 with bands of 21%. Creatinine was 1.7 with a BUN of 31. A UA was performed that had epithelial cells; but of note, "finely granular casts" were seen. He was hypotensive to the 80s. A central line was placed, zosyn was given, and fluids were administered; levophed was started. He was transferred to [**Hospital1 18**] by [**Location (un) **] helicopter for further management. . In the [**Hospital1 18**] ED, initial vs were: T 101 (taken 1 hr after arrival); BP 88/52; RR 20; O2 sat 100% on 2L NC; and on levophed. Patient was given 3 L NS; appears that per signout and our ED records, total of NS from the 2 EDs was 6 cm. . He was evaluated by the surgical service and the ERCP service; it was agreed that he was a good ERCP candidate and thus should be transferred East for ERCP; he was admitted to the [**Hospital Unit Name 153**] in advance of his procedure. His vitals on arrival, on 0.2 mcg/kg/min of levophed, were T 100.5; HR 102; BP 116/53; RR 17; O2 sat 97% on 3L NC. . He reported that his abdominal pain was much improved. In a review of systems, he was complaining of some shortness of breath, and feeling that he had to force his breaths out to some degree. He denied wheezing. He noted that he had some diarrhea recently in the ED but had not had abnormal bowel movements prior. He had no dysuria. MEDICAL HISTORY: Hypertension Hypercholesterolemia hx of malaria while in [**Country 10181**], [**2052**]. hx Pilonidal cyst hx hernia repairs x 2 MEDICATION ON ADMISSION: (e is not sure of doses): Lisinopril Niacin Omeprazole ALLERGIES: Valium / Simvastatin PHYSICAL EXAM: Admission: Vitals: as above: on 0.2 mcg/kg/min of levophed: T 100.5; HR 102; BP 116/53. RR 17 and O2 sat 97% on 3L NC. General: Alert, oriented, conversing easily and in full sentences HEENT: Slightly icteric sclera, dry mucus membranes; no lesions FAMILY HISTORY: Mother: died gastric cancer, 72 Father: died age [**Age over 90 **]; asthma SOCIAL HISTORY: Retired at age 55 from insurance sales. Drinks "four highballs a week." Does not smoke. Lives at home with wife. [**Name (NI) **] pets. No recent travel. No one sick at home.

CHIEF COMPLAINT: Achalasia PRESENT ILLNESS: Achalasia for many years with dilated esophagus MEDICAL HISTORY: PMH: Autoimmune hepatitis, OSA, DM, GERD, Obesity, [**Doctor Last Name 1193**] Chiari malformation PSH: Appy, R Knee, R rotyator cuff MEDICATION ON ADMISSION: Albuterol, Imuran 150', lasix 20', lisiopril 10', insulin, QVar, oxbutynin 5', roprinerole 1'', Flomax 0.4' ALLERGIES: Advil / Hayfever PHYSICAL EXAM: FAMILY HISTORY: Mother age [**Age over 90 **] died with Alzheimer's. Father was aged 69 and died of multiple medical problems. SOCIAL HISTORY:

CHIEF COMPLAINT: PRESENT ILLNESS: Patient is a 52-year-old man with a past medical history significant for diabetes, who presents after an episode of substernal chest pain. Patient states that he developed sudden onset of chest pain radiating to his jaw at 6 p.m. on [**2128-11-2**]. The patient returned home from work with persistent substernal chest pain. The following day on [**2128-11-3**], with persistent chest pain, the patient presented to [**Hospital1 1474**] ED for evaluation at 4:30 p.m. on [**2128-11-3**]. At this time, an EKG was obtained, which demonstrated likely inferior infarct with inferior Q waves and ST segment elevations. The patient was started on aspirin, Plavix, sublingual nitroglycerin, and nitroglycerin drip. On this regimen, the patient had persistent chest pain. In addition, his blood pressure markedly decreased. The patient was then started on IV fluids and thrombolytic therapy. Because the patient's pain also radiated to his back, he underwent a chest CT to rule out aortic dissection. The chest CT was negative for aortic dissection. He was then transferred to the [**Hospital1 1444**] for urgent cardiac catheterization. Selective coronary angiography demonstrated a right dominant system with two vessel coronary artery disease. The proximal RCA was totally occluded. The LAD had a 60% mid vessel stenosis. Resting hemodynamics demonstrated elevated left and right sided filling pressures. Mean RA pressure was 23. Mean wedge pressure was 32 mm Hg. The patient underwent successful stenting of the RCA. The patient was then transferred to the CCU team for further management. MEDICAL HISTORY: 1. Type 2 diabetes mellitus. 2. Right leg varicose veins. MEDICATION ON ADMISSION: 1. Metformin 1,000 mg b.i.d. 2. Glipizide 10 mg b.i.d. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: [**Name (NI) **] father died of cancer. Patient states that both he and his father have very low cholesterol. SOCIAL HISTORY: Patient denies significant tobacco, alcohol, or illicit drug use. He is married and works two jobs.

CHIEF COMPLAINT: Exertional angina PRESENT ILLNESS: 66 y/o male with known aortic stenosis. Serial echocardiograms have shown progressively worsening aortic stenosis. Currently admits to exertional angina. MEDICAL HISTORY: Hypercholesterolemia, Hypertension, Hemochromatosis, Rosacea, Gout, Hemorrhoids, s/p Mole removal, s/p Anal fistula, s/p Tonsillectomy, s/p Dental implants, s/p Liver biopsy MEDICATION ON ADMISSION: Crestor 10mg qd, Allopurinol 300mg qd, Minocycline 5mg [**Hospital1 **], Metrogel oint, Aspirin 325mg qd, MV, Folate, B6, B12, Fish Oil ALLERGIES: Tetracyclines PHYSICAL EXAM: VS: 58 14 135/67 Gen: WDWN male in NAD Skin: Unremarkable HEENT: Poor dentitian Neck: Supple, FROM, -JVD Chest: CATB -w/r/r Heart: RRR 3/6 sem Abd: Soft, NT/ND +BS Ext: Warm, well-performed, 1+ edema Neuro: A&O x3, MAE, non-focal FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Quit smoking [**2116**]. Denies ETOH.

CHIEF COMPLAINT: ETOH and medication overdose PRESENT ILLNESS: The patient is a 55-year-old male with PMH of alcoholism who presents after a dangerous combination of alcohol intoxication and accidental medication overdose. Per report, patient's partner says he "fell off the wagon" 2-3 days ago after being sober for years. He drank large quantities of port wine and took extra medications reportedly "by mistake." The partner is pretty sure that the patient was intoxicated when he multiple tablets of wellbutrin, seroquel, propranolol and klonipin but he is uncertain of specific amount. He later stated that he was not absolutely certain whether the patient actually ingested any wellbutrin and propanolol. Ultimately, the amount and combination of pills taken was unclear. The patient's longtime partner of nearly thirty years came home and found him semi-alert and called EMS immediately. . According to his partner, Mr. [**Known lastname 6418**] had been coughing/wheezing for several months now but had no complaints of fevers or chills. He had been complaining about pain in his neck since a fall down a few stairs a few days prior to this current incident. . In our ED, initial vital signs were T97.3 BP 90/54 HR 68 RR 12 oxygen saturation of 95% via NRB. He was placed on NRB for low oxygen saturations <90. He was somnolent on arrival to hospital but still responsive to tactile stimuli. Fingerstick glucose was 140 on arrival. He quickly became hypotensive to SBP 73/47. He was given IVF x3L total. EKG was normal, without any alarming ST changes. Peripheral dopamine was started for rapid BP correction and he was intubated for hypoxia and airway protection. Toxicology consult was called and they recommended that the pressor choice be switched to Levofed. He was also given narcan x2 with no effect. Once the medication history was flushed out, he was given calcium which did increase his rate from 58 to 88 and his SBP increased by 10. He was given glucagon 1mg with no further effect. Toxicology consult recommended trying high dose glucagon 5mg and if that works, starting a glucagon gtt at 1-5mg/hr. They also recommend serial EKGs for monitoring. He was also given Vancomycin and Ceftriaxone due to initial concern for possible sepsis. . He had chest xray which showed question widened mediastinum and patient reported some chest discomfort on arrival. CTA was done which showed normal aorta. FAST scan was done which showed no pericardial effusion, and no intra-abdominal bleeds. CXR/CT did show bilateral infiltrates consistent with an aspiration. Hemodynamic instability was worrisome and he was transferred to the intensive care unit for close monitoring. . On arrival to the ICU he was hypoxic with O2 saturation of 85% on FIO2 of 50%, HR in 50's. He was suctioned, ET tube pulled back 2cm and PEEP increased to 14, FIO2 to 100% with slow recovery of O2 saturation. He was continued on Levophed and an arterial line was placed for better hemodynamic monitoring. . MEDICAL HISTORY: Alcoholism Hypertension Depression MEDICATION ON ADMISSION: Wellbutrin 150mg daily (decreased from twice daily) Seroquel 150mg daily klonopin 1mg [**Hospital1 **] (recently decreased) propranolol 40mg [**Hospital1 **] 55/60 (started [**9-27**]) Prozac 20mg QID (recent increase in dose from TID -QID over last week) Lotral 5/20mg one daily Diclofenac sodium 100mg daily fenofibrate 134mg daily allopurinol 300mg daily tramadol 50mg [**Hospital1 **] neurontin 300mg 1-2 tabs prn melatonin 5mg qhs advil prn for migraine ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: INITIAL ADMISSION EXAM: vitals: BP 110/48, HR 58 regular w/occasional PVC's, RR 15 100% FIO2 100% VC 100%/500/16/14 , weight of 97kg, 70" . General: sedated, intubated, not responding to verbal commands HEENT: NC/AT, pupils pinpoint but equal and reactive bilaterally CV: Bradycardic, regular, no appreciable murmur Lungs: decreased breath sounds at right base, otherwise good air movement bilaterally Abdomen: slightly distended, BS+, no HSM, no apparent tenderness Ext: DP's palpable bilaterally, trace edema bilaterally Neuro: unable to assess [**12-26**] sedation FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient lives in [**Location 86**] with his partner of over 30 years. He has local family but has limited contact with them. He reports that he and his partner do not work because they have enough money to allow them not to need to work. Mr. [**Known lastname 6418**] reports drinking only one glass of wine a day, yet also endorses drinking enough prior to admission that he got confused when taking his medications. Thus, history somewhat questionable. Denies illicit drug use. He reports having been sober for a stretch of 14-15 years in the past (w/ help of rehab, AA), but started drinking again about 13 years ago in the context of a few deaths in the family. Per his partner, his drinking has been much more heavy in recent months.

CHIEF COMPLAINT: Recurrent squamous cell carcinoma of the vagina PRESENT ILLNESS: The patient is a 55 yo G2P2 female with a history of stage [**Doctor First Name **] squamous cell carcinoma of the vagina. She presented in [**2093**] and underwent radical chemoradiation and an open interstitial implant. In [**2101**], she developed right groin pain and was found to have several vulvar lesions (squamous cell carcinoma on biopsy). She was scheduled to undergo a radical vulvectomy on [**2102-11-15**], but it was abandoned when new palpable and visible lesions were seen on the rectovaginal septum. MEDICAL HISTORY: PMH: Vaginal cancer PSH: Splenectomy, tonsillectomy, broken elbow, LAVH-BSO, open interstitial implant. Gyn History: Last mammogram normal 1 yr ago. OB History: Vaginal delivery X 2 MEDICATION ON ADMISSION: Prevacid ALLERGIES: Iodine; Iodine Containing PHYSICAL EXAM: Multiple left vulvar lesions consistent with squamous cell carcinoma. Rectovaginal examination reveled a firm rectovaginal tumor, about 2 cm above the anus with ulceration through the posterior vaginal wall. No other vulvar lesions were noted. FAMILY HISTORY: Significant for a sister with breast cancer. SOCIAL HISTORY: Quit smoking 8 yrs ago No ETOH Drinks [**2-20**] caffeinated beverages/day

CHIEF COMPLAINT: PRESENT ILLNESS: Patient is a 74-year-old male with a recent hospitalization for ablation and pacer placement, discharged on [**8-6**], who presents with complaints of syncope, no dizziness, chest pain, heart palpitations, nausea, vomiting, shortness of breath. He has had similar episodes in [**2153-7-26**] and [**2155-5-27**] same progression in terms of he presented to the Emergency Room with dropped hematocrit and needed to be transfused. In [**2153-7-26**], patient was on Coumadin for atrial fibrillation. Work up showed hemorrhoids, diverticulosis, but no specific bleeding lesion, however, he needed eight units of packed red blood cells. In [**2155-5-27**] he had syncope with subsequent low hematocrit and he needed two units of packed red blood cells as no specific source was found with colonoscopy, esophagogastroduodenoscopy or small bowel follow through. He did have a hyperplastic polyp removed in [**2155-5-27**]. He also has a history of recurrent epistaxis. MEDICAL HISTORY: Upper gastrointestinal bleed and gastroesophageal reflux disease, atrial flutter, status post ablation and pacemaker in [**2155-7-27**]. Porcelain gallbladder shown on CT in [**2155-5-27**], iron deficiency anemia, insulin dependent diabetes mellitus with peripheral neuropathy, status post many foot infections, peripheral vascular disease with bilateral claudication, hypertension, coronary artery disease, status post coronary artery bypass graft, recurrent epistaxis, degenerative joint disease of the right hip and bilateral cataracts. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Widowed and lives alone.

CHIEF COMPLAINT: feeling unwell, hypotension PRESENT ILLNESS: 50 yo bedbound morbidly obese female with history of IDDM2, HTN, HL, OHS on 4L at home, and prior PE who presents with chills and weakness x 1 day. She reports feeling hot and sweaty at home, with burning noted in bilateral legs. She has new LLE swelling and redness. She denies overt fevers at home. She reports a cough with occaisional yellow sputum. She reports one episode of coughing a small clot of blood. She denies SOB or CP currently. She reports dizziness and lightheadedness. She denies abdominal pain, dysuria, N/V/D. She notes neck and upper back pain since the top of an ambulance stretcher lowered quickly while she was on it last week. She has been taking valium and percocet that was prescribed at a recent epi visit. In the ED, initial vitals were pain 10 100.3 105 96/40 18 96% 2L. - hypotensive with sBP in 80's - meets SIRS criteria - CBC - WBC 22.1, Chem 7, lactate 1.3, blood cultures - 3.5L of IVF - pt cannot fit inside CT scanner so CTA not done - CXR - central pulm vasc mildly prominent - suggestive of mild pulmonary vasc congestion, no definite pleural effusion or pneumo, pleural thickening lateral L lung apex - not signficantly changed. - b/l LE ultrasounds ordered but inconclusive - Tx for presumed cellulitis of LLE - IV vanc and clinda - c/s surgery - concern for LLE nec fasc - exam consistent with cellulitis, cont abx, leg elevation. ACS will continue to follow. - BP around lower forearm, readings unreliable - febrile to 101, 1gram of tylenol - 1500mg of UOP reported in ED Most recent vitals prior to transfer: afeb 109 30 98/61 99% on 4L. On arrival to the MICU, she is reporting burning in her left lower leg. MEDICAL HISTORY: # Morbid obesity -- over 600 lbs, bedbound # Diabetes mellitus type II # Hypertension # Hyperlipidemia # Hypothyroidism # Obesity hypoventilation syndrome, on home O2 3-4 L # Likely OSA -- refused sleep study # Asthma # Pulmonary Embolism ([**2163-4-27**]): suspected and treated but unable to image # Tracheostomy ([**2163-4-19**]) -- later removed at rehab # VRE UTI -- during admission ([**Date range (3) 105005**]) # Chronic Lymphedema # Developmental / Behavioral Issues # Depression # Chronic Low Back Pain # GERD MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**]. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheezing 2. Diazepam 5 mg PO Q12H:PRN pain, spasm 3. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **] 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 5. Furosemide 80 mg PO BID 6. Levothyroxine Sodium 150 mcg PO DAILY 7. lisinopril-hydrochlorothiazide *NF* 20-12.5 mg Oral [**Hospital1 **] 8. Nystatin Powder *NF* 100,000 unit/gram Mucous Membrane prn irritation 9. Pantoprazole 40 mg PO Q24H 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Prochlorperazine 5-10 mg PO Q6H:PRN nausea, vomiting 12. Rosuvastatin Calcium 40 mg PO HS 13. Aspirin 81 mg PO DAILY 14. Docusate Sodium 200 mg PO BID 15. Naproxen 250 mg PO Q8H:PRN pain 16. Senna 1 TAB PO BID:PRN constipation ALLERGIES: Flagyl / Sulfa (Sulfonamide Antibiotics) / Penicillins / Dilaudid PHYSICAL EXAM: Admission physical exam: Vitals: 101 107 79/22 20 96% on 4L General: Alert, oriented, difficulty with moving in bed HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops heart sounds muffled Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi Abdomen: +BS, obese, soft, non-tender, non-distended GU: +foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, LLE with warm erythematous confluent rash and small nontender nonfluctuant bullae Skin: bilateral erythematous patches under nipples Neuro: CNII-XII intact, moving all 4 extremities FAMILY HISTORY: Father with "belly" cancer. Mother alive & healthy, 2 grandparents w/DM. Brother died of illicit drug related causes. SOCIAL HISTORY: Lives alone, with 24 hour home health aide. She endorses only rare social alcohol intake and she smokes [**12-19**] cigarettes daily. She was previously wheelchair bound, but is now bed bound. Her mother bought her a new [**Name (NI) 2598**] lift but her aides have not been taught how to use this yet. Home health aide helps her with cooking, cleaning, and bathing. Patient has a long psychiatric history including counseling since childhood, learning disabilities, she has left the hospital AMA on multiple occasions, she has had Code Purples called for aggressive behavior, she has been accused of calling EMS inappropriately (several times per month at one point) for factitious complaints, and she has reported history of sexual assault. There have been SW involved to try to have this patient live in rehab or another situation to better care for herself but these attempts have all failed.

CHIEF COMPLAINT: Left Scapular/Shoulder Pain PRESENT ILLNESS: 63F with history of type B dissection repaired in [**2115**] at [**Hospital1 1012**] now presents to [**Hospital1 18**] ER after being transferred from [**Hospital3 7569**] with a possible Type A dissection. Patient reports an acute onset of left shoulder pain on Sunday. The pain was located near the upper scapula and was described a sharp, severe pain that was intermittent and occurred 1-2 times an hour. Patient states the pain was so severe that she has been unable to get out of bed for the past 2 days and has only done so to use the bathroom and eat. She was evaluated by her PCP today who recommended a CT scan of her chest to evaluate for possible nerve impingement and the preliminary findings revealed a type A dissection in the arch near the takeoff of the left subclavian. She was started on an Esmolol gtt and transferred to [**Hospital1 18**] for further care. MEDICAL HISTORY: PMH: Type B aortic dissection, Osteoporosis, Hyperparathyroidism MEDICATION ON ADMISSION: Accupril prn, Magnesium and Calcium supplements ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: On Admission: VS: T 98.4 P 70 BP 127/71 RR 18 O2 100%RA PE: Gen - A&Ox3, NAD CV - RRR Pulm - CTAB Abd - S/NT/ND, no rebound, guarding Ext - Warm, well perfused Pulses: Carotid Rad Fem [**Doctor Last Name **] DP PT R palp palp palp palp palp palp L palp palp palp palp palp palp Patient left against medical advice. At time of egress: VS: 96.5 74 116/56 22 93% on RA FAMILY HISTORY: FH: Mother and uncle with thoracic aneurysms SOCIAL HISTORY: SH: Married, denies tobacco, EtOH, drugs

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is an 83-year-old female with history of myelodysplastic syndrome, hypercholesterolemia with recent diagnosis of bilateral adrenal masses found during a workup for acute renal failure in an outside hospital, who was transferred from an outside hospital ([**Hospital3 **]) after developing fever, tachycardia, and hypotension. Apparently, patient presented on [**4-18**] at [**Hospital3 **] with acute renal failure, hyperkalemic with K of 7.3 and hyponatremic with a sodium of 130. During workup of patient's acute renal failure at [**Hospital3 **], patient had an abdominal CT, which showed bilateral adrenal masses measuring up to 7.5 cm in AP diameter on the left and 6 cm in AP diameter on the right. Patient was then discharged and represented for an adrenal mass biopsy on [**4-28**], and was sent back to [**Hospital1 **] Transitional Care Unit. On [**4-29**], then patient then developed tachycardia and fever at [**Hospital3 **]. Chest x- ray was consistent with CHF. Patient was given nitro paste and Lasix, and then became hypotensive to the 60's. Dobutamine was started at outside hospital and patient received levofloxacin for a question of UTI as well as vancomycin. She was also given a dose of Solu-Medrol for a question of adrenal insufficiency. Prior to Solu-Medrol administration, serum cortisol was checked at outside hospital and was low at 13. Patient also had an aldosterone checked at that time, which was low at 3.0, normal range is 4 to 31. Patient was started on dobutamine and dopamine at the outside hospital. Dobutamine was then discontinued and Neo- Synephrine was started. Patient had only received a 250 cc normal saline bolus prior to the start of pressors. Abdominal CT scan was performed, which showed no bleed. The patient was then at this point transferred to the [**Hospital1 346**] Medical Intensive Care Unit for further management. On arrival to the MICU, patient was on dopamine and Neo- Synephrine, and her blood pressure was 81/39, heart rate 120s, and was saturating 100 percent on nonrebreather. Over the course of her MICU stay for one night, patient was aggressively fluid resuscitated with 2-3 liters of normal saline and her pressors were weaned to off. She was continued on broad-spectrum antibiotics of vancomycin, levofloxacin for a question of urinary tract infection and sepsis. She also received 1 unit of packed red blood cells for a hematocrit of 26. She was continued on empiric stress-dosed steroids of 100 mg of IV hydrocortisone q.8. for question of adrenal insufficiency. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] stim test was not checked since the patient had received Solu-Medrol at an outside hospital. Since patient's blood pressure was stable and she had no acute ICU issues, patient was transferred to Medicine floor on [**5-2**] for further management. MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Myelodysplastic syndrome being managed by patient's outpatient oncologist, Dr. [**Last Name (STitle) **]. 3. Bilateral adrenal masses recently diagnosed on [**4-28**] at [**Hospital **] Hospital. Biopsy results from the adrenal glands revealed a poorly differentiated malignant neoplasm with vague epithelioid features, although no pigment is identified, the prominent nucleoli suggested the possibility of malignant melanoma, however, a germ cell neoplasm or large cell lymphoma could not be excluded. Additional immunohistochemistry stains were sent and are still pending at the time of this dictation, and will not be available for at least a week. MEDICATION ON ADMISSION: 1. Lipitor 10 mg p.o. q.d. 2. Neupogen 300 mg subQ q.d. 3. Vancomycin and levofloxacin started at outside hospital. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: Patient lives alone in [**Hospital1 392**], but prior to her transfer here, had been living at the [**Hospital1 **] Transitional Care Unit after her adrenal gland biopsy. Patient has a daughter and son, who are active in her care. Her daughter's name is [**Name (NI) **] [**Name (NI) **], phone number [**Telephone/Fax (1) 101677**] and is her healthcare proxy. [**Name (NI) **] also has a sister and son, who are close to her.

CHIEF COMPLAINT: Abdominal pain PRESENT ILLNESS: 37 yo M w/ history of epilepsy since childhood (GTG), Obesity, who presented on [**5-9**] to OSH, diagnosed with pancreatitis and is transferred to [**Hospital1 18**] given concern for worsening hemodynamic instability. Patient was in USOH until AM of [**5-9**], when after eating breakfast, noted rapidly escalating epigastric pain, which eventually radiated to below the umbillicus and down to bilateral flanks. After several episodes of emesis, he drove himself to OSH ED for an evaluation. At OSH, initial VS were 97.8F 65 151/89 99% RA. He received Zofran 12mg, Dilaudid 3mg, 1L NS. Labs were notable for lipase of > 4000, and thus admitted to the floor for management of pancreatitis. On the floor, he received NS at 1200cc bolus then 150cc/hr x 48hrs. Per patient, UOP has been declining over the past two days, he has developed difficulty breathing and pleuritic type chest pain. On day of transfer, he developed a fever to 102.6F, HR increased to sustained 110s and RR to 20s on RA. At OSH, labs Lipase > 4000 -> [**2077**] , Amylase 363. Ca 9.7 -> 6.5, Cr 1.1 -> 1.6, BUN 17 -> 36, Na 144 -> 138, Cl 107 -> 106, HCO3 23 -> 23, Alb 4.3 -> 2.8, AST/ALT 27/12, TG 98, HCT 55 -> 48, WBC 14.7 -> 19K. UA SG < 1.005, Ket neg, pH 5, neg WBC/RBC. Ct abd. was notable for fatty liver, edema at head and uncinate process, no necrosis, peripancreatic [**Doctor First Name **] and mild bowel wall thickening of 2/3rd portions of duodenum. Because of tachycardia, fever and worsening UOP, patient was transferred to [**Hospital1 18**] for further treatment. In ICU, initial VS were 97.8F 114 139/68 22 98% 2L NC. Patient appeared in NAD, he was c/o of abdominal pain, orthopnea, pleuritic CP and concentrated urine. He notes that he consumes only 1-2 drinks per week, denies FHx of pancreatitis, abdominal cancers, gall stones. Has not taken any new medications or ingestions. MEDICAL HISTORY: Epilepsy MEDICATION ON ADMISSION: Home: -Lamictal 300mg [**Hospital1 **] ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission exam: General: Obese, frustrated appearing man, alert, no acute distress HEENT: Sclera anicteric, Obese, dMM, oropharynx clear Neck: supple, JVP 7, no LAD CV: RR, normal S1 + S2, no murmurs, rubs, gallops Lungs: decreased breaths b/l, L > R. Abdomen: Obese, diffusely tender to palpation in Lower quadrants > upper quadrants, bowel sounds present, no organomegaly, no rebound or guarding, but reports some tenderness with passive movement of the bed. GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Alert, oriented to place and time. MOYb intact. EOMI, Face symmetric, palate elevates symmetrically, tongue is midline. Moves all extremities antiresistance. FAMILY HISTORY: No malignancy, no etoh abuse CAD/CABG in mother in sixties. SOCIAL HISTORY: Lives on [**Hospital1 6687**]. Commercial driver, married, has 2 children. - Tobacco - 1/2ppd - EtOH - 1/wk - Drug use - denies.

CHIEF COMPLAINT: abdominal pain, nausea, vomiting, decreased PO intake PRESENT ILLNESS: The patient is a 55y man with a history of EtOH cirrhosis who experienced nausea and vomiting for 24 hours prior to presentation. He had decreased appetite and PO intake as well as dizziness. He denied fever or chills. MEDICAL HISTORY: #. Alcoholic cirrhosis, not on transplant list - complicated by ascites and hepatic encephalopathy - doses of his diuretics reduced due to hypotension - undergoes paracentesis approximately every 2 weeks - intermittently nadolol due to hypotension previously #. UGIB [**2-9**] secondary to gastric vacices #. Hepatic sarcoidosis #. Abdominal and inguinal hernia (s/p bilateral inguinal herniorrhaphies) #. CKD #. history of HSP #. Anemia #. Gout #. History of colon adenoma - 6mm adenomatous polyp by biopsy [**3-8**] MEDICATION ON ADMISSION: rifaximin 400 mg TID Colchicine 0.6mg daily Hexavitamin Lactulose 30ml titrated to 4-5BM /day Lasix 20mg daily Nadolol 20gm daily Spironolactone 100mg daily Protonix 40mg daily Zinc Vit A Calcium carbonate 500mg [**Hospital1 **] Cholecalcierol 400u Daily albuterol PRN Acetaminophen PRN ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: On Admission: VS: 98.1 88 77/48 18 100% General: NAD Cardiac: RRR, S1 S2 Lungs: CTA bilaterally Abd: Soft, distended, faint bowel sounds, diffuse tenderness to palpation Extr: Bilateral lower extremity edema FAMILY HISTORY: Father w/ HTN, early CAD, alcoholism. Brother with alcoholism. Mother w/ HTN. SOCIAL HISTORY: Patient lives with wife but is not working, lives in [**Name (NI) 745**]. He performs all ADLs but does not drive. He is married with a good social support system. He has two children living in [**State **]. Tobacco: None ETOH: Prior alcoholic, No Etoh since [**Month (only) **] (6 months) Illicts: No drug use

CHIEF COMPLAINT: rectal bleeding PRESENT ILLNESS: 60F w/ history of MGUS, COPD, HCV cirrhosis, iron deficiency anemia and previous admissions for GI bleed now being admitted to [**Hospital Unit Name 153**] for presumed lower gi bleed. Somewhat of vague historian but pt reports 4-5 episodes of bright red per rectum x 2 days. Denies melena. Also reports persistent nausea and non-bilious, non-bloody emesis. Reports metallic taste. Subjective fevers and chills. Has history of hemorrhoids and constipation that has been treated successfully with magnesium oxide. Not clear that she has experienced more constipation over the last several days preceding her bleeding from rectum. She has experienced some rectal pain which she attributes to hemorrhoids - this has now resolved. Good appetite but decreased po's for unclear reasons. Denies chest pain but reports dyspnea on exertion over the last several days. No cough. Reports light headed when standing. Of note, pt was hospitalized on 2 occasions in [**2166-2-12**] for bright red blood per rectum. Work-up included EGD which demonstrated duodenal angioectasias, Schatski's ring and duodenitis and portal gastropathy. A colonoscopy had been performed which was significant for large internal hemorrhoids without stigmata of recent bleedng. She did have a colonoscopy in [**1-16**] which demonstrated sigmoid diverticulosis. She required red cell transfusions on both admissions. It was felt that her bleeding was most likely related to hemorrhoidal bleeding and she had been advised to follow up with surgery. In ed, noted to be afebrile and hemodymically stable. She was found to be orthostatic however and crit was 23 and then 19 on recheck. She was guiac positive on rectal exam. NG lavage was negative. She received 1 unit prbc, Protonix 40, and benadryl MEDICAL HISTORY: 1) iron deficiency anemia 2) GI bleed - presumed secondary to hemorrhoids 3) Sigmoid diverticulosis 4) Schatzki's ring 5) Duoenal polyps and duodenitis 6) MGUS 7) ?etoh/ HCV cirrhosis followed by Dr. [**Last Name (STitle) 497**] (vl 9k in [**5-15**]) 8) psychotic disorder 9) remote polysubstance abuse - etoh, cocaine, marijuana 10) COPD 11) compex partial seizures MEDICATION ON ADMISSION: protonix 40 qd senna colace hydrocortisone 2.5% [**Hospital1 **] ferrous sulfate 325 qd camphor-menthol prn ALLERGIES: Haldol / Darvon / Keppra PHYSICAL EXAM: Physical exam on admission (to [**Hospital Unit Name 153**]) PE: 118/70 89 16 100ra gen: cachexic african american female, lying in bed, looking uncomfortable secondary to pruritus, o/w pleasant heent: dry mm, anicteric sclera, flat jvp cv: s1, s2 regular w/ soft 2/6 sem throughout pulm: ctab abd: nabs, soft, ntnd, no cvat, guiac positive per ed extr: decreased skin turgor, no edema FAMILY HISTORY: M-asthma, GM-CAD, HTN, denies any h/o liver disease or bleeding disorders; great aunt with epilepsy; SOCIAL HISTORY: Lives alone in [**Location (un) **], has home physical therapy and a homemaker. She reports that she has quit tobacco ~ 1 month ago. She denies recent EtOH, howevert reported to have heavy drinking 6 months ago. She denies recent marijuana, cocaine use. Contacts: daughter ([**Doctor First Name **] [**Telephone/Fax (1) 99373**])' son (mark [**Doctor Last Name **]) [**Telephone/Fax (1) 99374**]

CHIEF COMPLAINT: CC: Fever; admit from ED for ? hypotension PRESENT ILLNESS: Ms. [**Known lastname **] is a 37 year-old woman with history of severe Crohn's disease (of small bowel and ? colon with 2 recent hospitalizations for flares) on TPN (started [**9-20**]), Celiac disease, who presents from OSH with 2 days of fever. She had initially presented to [**Hospital **] Hospital in [**State 1727**] with these symptoms; her PICC was dc'd there and tip was sent for culture. Patient reports that she was in her usual state of health (which includes being NPO, limited activity, [**1-18**] chronic diffuse abdominal pain) until 2 days ago, when she started developing fever and tachycardia. Fever was associated with chills. She contact[**Name (NI) **] her gastroenterologist at [**Hospital1 **] (Dr. [**Last Name (STitle) 13534**] who advised her to reprot to ED if fever broke 100, which it did - 101.0. No cough, shortness of breath, increased abdominal pain, headache, chest pain, redness/erythema around PICC line, rashes, outside travel, or diarrhea at time of presentation. . In our ED, VS on arrival were 98.4; 110; 94/60; 100% RA. She was given 1 L NS, hct was sent and was 22.1, repeat was 22. She received protonix, 1g Vancomycin, and another 3 L of NS for BP ranging from 68-85 systolic and tachycardia to 116. She was given 1U PRBCs. . Of note, patient was admitted [**2160-9-9**] for Crohn's flare with abdominal pain, malnutrition, hypoalbuminemia, and severe Crohn's disease of the jejunum and ileum and distal colon per enteroscopy, flex sig, and CT scan. Patient re-presented on [**2160-9-20**] with another flare associated with increased abdominal pain and rectal bleeding. ROS: chronic abdominal pain, diarrhea that began in our ED today after receiving course of antibiotics (had been having regular BMs 1-2x/day since being started on TPN). Otherwise, negative. BP usually runs 90/60s. MEDICAL HISTORY: 1. Severe Crohn's disease of small bowel/colon 2. Severe malnutrition 3. Iron deficiency anemia 4. ? Celiac disease MEDICATION ON ADMISSION: - TPN - Solumedrol 15 IV q8h - Insulin - Mesalamine 1000mg PO BID - Fluoxetine 20mg PO qd - Glutamine - Calcium - bactrim - Recently on Levaquin/Flagyl empirically - Methotrexate SC weekly - Folate ALLERGIES: Remicade / Prednisone / Gluten PHYSICAL EXAM: VITALS: T 99.9; HR 102 (sinus tachycardia); BP 94/57; RR 8-12; 99% RA GEN: Pleasant, thin woman in no acute distress, comfortable HEENT: sclerae anicteric. MMM. OP clear. No JVD. LUNGS: Clear to auscultation bilaterally HEART: S1S2 RRR. No MRG ABD: Soft, distended. Ventral hernia. Mild diffuse tenderness, no rebound or guarding (at baseline per patient). No appreciable hepatosplenomegaly EXT: 2+ DPs. No edema, cyanosis, or clubbing NEURO: AOx3. No focal deficits FAMILY HISTORY: Daughter with VSD. Mother with history of breast CA. Two younger brothers are healthy. SOCIAL HISTORY: Married, lives with husband and 2 children. Former 5th grade teacher. No alcohol, tobacco, or IVDA.

CHIEF COMPLAINT: Pancreatic head mass PRESENT ILLNESS: This is a 62-year old Female who presented initially with obstructive jaundice. She underwent ERCP at [**Hospital3 417**] Hospital on [**2151-3-29**] with sphincterotomy, brushings and stent placement across a mid-biliary duct stricture. Fine-needle aspiration biopsy performed on [**2151-4-23**] revealed necrotic debris, with remaining concerns for malignancy given the findings of a pancreatic head mass on endoscopic ultrasound. She was admitted electively on [**2151-5-18**] following her pancreaticoduodenectomy (Whipple procedure). MEDICAL HISTORY: PMH: former smoker (20 pack-year), obesity, Meniere disease, MEDICATION ON ADMISSION: Tylenol 1000 mg PO BID, calcium carbonate PRN, Naprosyn PRN ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: VITALS: Afebrile, vitals signs stable. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. Neck supple without lymphadenopathy. CVS: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2. RESP: Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. ABD: soft, obese-appearing, appropriately tender, non-distended, with normoactive bowel sounds. No masses or peritoneal signs. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses INCISION: transverse incision is clean, dry and intact, without evidence of erythema or drainage. Minimal serosanguinous drainage noted. Staples open to air with steristrips between. FAMILY HISTORY: non-contributory SOCIAL HISTORY: Attests to 0.5 packs-per-day for 40-years (20 pack-year), rare alcohol use ([**5-4**] drinks/year), denies recreational substance use

CHIEF COMPLAINT: Biliary hilar stricture c/w concern for cholangiocarcinoma PRESENT ILLNESS: 76 y.o. F with multiple CV problems transferred from [**Name (NI) **] for concern of cholangiocarcinoma. Over 2 weeks, patient had increased pruritus. U/S of liver showed ductal dilatation with bilirubin elevation. GI at [**Hospital1 **] performed ERCT [**2138-2-5**] with sphincterotomy with stent (8.5Fr 12 cm). ERCP findings concerning for cholangiocarcinoma with hilar stricture c/w cholangiocarcinoma on right side MEDICAL HISTORY: CAD s/p pacemaker, s/p cath [**2133**]: 70% stenosis, HTN, DM, h/o DVT/PE, pancreatitis PSH: s/p TKA [**2135**], SBR ? diverticulitis MEDICATION ON ADMISSION: asa 81', labetalol 200'', lasix 20', simvastatin 400', metformin 1000', glyburide 2.5' ALLERGIES: Codeine / Ibuprofen PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: widowed with children denied etoh/smoking/illicit drugs independent at senior living

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 62 year old gentleman who underwent an exercise treadmill test for screening through the [**Hospital **] Clinic. The test was positive for EKG changes and shortness of breath. The patient has no history of chest pain; no history of myocardial infarction. The patient was referred to [**Hospital1 69**] for cardiac catheterization. Cardiac catheterization showed an ejection fraction of 50%, left ventricular end diastolic pressure of 20, 90% left anterior descending lesion, 80% left circumflex lesion, 80% mid right coronary artery lesion and 80% distal right coronary artery lesion. The patient was referred to Dr. [**Last Name (STitle) **] for coronary artery bypass grafting. MEDICAL HISTORY: 1. Hypertension. 2. Type 2 diabetes mellitus. 3. Hypercholesterolemia. 4. Thirty pack year tobacco history, quit one month ago. 5. Gout. 6. Gastroesophageal reflux disease. 7. History of salivary gland removal. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Cerebrovascular accident PRESENT ILLNESS: Delightful 34 year old gentleman who had a stroke in [**Month (only) 404**] of [**2185**]. He was admitted to [**Hospital **] Hospital where work-up revealed a large PFO. He has thus [**Doctor First Name **] referred to Dr. [**Last Name (Prefixes) **] for minimally invasive surgical management. MEDICAL HISTORY: ASD MVP with mild MR [**Name13 (STitle) 430**] trauma as child with Burr holes. Calcified right vertebral artery aneurysm Depression/Anxiety Vertigo Hyperlipidemia MEDICATION ON ADMISSION: Aspirin Fish oil Multivitamin Flax seed oil ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: 70 122/66 GEN: WDWN in NAD HEENT: Unremarkable HEART: RRR, Nl S1-S2 LUNGS: Clear ABD: Benign EXT: Warm, well perfused , no edema. Pulses intact. NEURO: Slight speech impairment, MAE, 5/5 strength FAMILY HISTORY: Maternal uncle with MI at age 45. SOCIAL HISTORY: Worked in Sales. Currently unemployed. Lives with wife in [**Hospital1 **], MA. Never smoked.

CHIEF COMPLAINT: Transfer to [**Hospital1 18**] for further care of post-ERCP pancreatitis PRESENT ILLNESS: Per MICU Admit Note: The patient is a 76 yo female with a history of hyperlipidemia and hypothyroidism presenting from [**Hospital3 417**] Hospital with acute pancreatitis. She was being worked up for chronic nausea, vomitting, and epigastric pain, for which she had a RUQ U/S on [**1-18**] which showed sludge in the gallbladder and a prominent pancreatic duct with a possible stricture in the head of the pancreas, and dilation of the common bile duct. This was confirmed by MRCP. She thus underwent an ERCP on [**2179-3-8**] for further evaluation. The ERCP showed a dilated common bile duct, ductal ectasia and evidence of mild chronic pancreatitis. No sphincterotomy was done, only brushings. Unfortunately post procedure the patient developed acute abdominal pain, nausea, and vomiting. Labs revealed an acute pancreatitis with [**Doctor First Name **]/lip of 2100/1500, respectively. A CT scan revealed non-enhancement of the body and tail of the pancreas, consistent with necrosis. She was treated with antibiotics, aggressive IVF, and a dilaudid PCA, but developed an O2 requirement, mild ARF, and a significant leukocytosis, though she remained afebrile and hemodynamically stable. She was then transferred to [**Hospital1 18**] for further treatment and surgical evaluation. MEDICAL HISTORY: PMH: hypothyroidism, hypercholesterolemia, s/p appy MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: ativan 0.5', Ca, cymbalta 30', FeSO4, prilosec 20', zocor 80', singulair 10', [**Last Name (LF) 82671**], [**First Name3 (LF) **] 81', avapro 150', florinef 0.05', toprol 50' ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Statins: Hmg-Coa Reductase Inhibitors / Naprosyn PHYSICAL EXAM: Upon discharge Alert, Oriented, but quiet, NAD 98.7 94 140/80 97% RA EOMi, anicteric, no JVD CVL L chest RRR no m/r/g CTAB soft NT/ND + BS no c/c/e Neuro grossly intact FAMILY HISTORY: N/C SOCIAL HISTORY: Married, with children. Lives with her husband, very active, energetic. + long term hx of tobacco (but quit 3 years ago), rare EtOH, no illicits.

CHIEF COMPLAINT: PRESENT ILLNESS: This 17-year-old male was an unrestrained driver in a motor vehicle accident with loss of consciousness in a spider windshield. He was found to be ambulating at the scene. He was unable to recall events but was hemodynamically stable, complaining of back pain. He was brought into the Emergency Room for evaluation. MEDICAL HISTORY: Past medical history was negative. MEDICATION ON ADMISSION: He has no medications. ALLERGIES: He has no known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Respiratory distress. Transfer from floor. PRESENT ILLNESS: The patient is a 53-year-old female, with a history of advanced multiple sclerosis complicated by quadriplegia, prior history of tracheostomy, now DNR/[**Hospital 24351**] transferred from outside hospital on [**3-24**] with evaluation for recurrent cholangitis in the setting of hepaticojejunostomy and cholecystectomy. The patient is now postoperative day #2, status post percutaneous transhepatic cholangiography and biliary drain placement. On the evening of [**3-29**], the patient had acute shortness of breath and hypoxia with desaturations to 80% on 4 liters, improving to 97% on nonrebreather, despite Atrovent nebulizations x 1, lasix 80 mg IV x 1, and morphine 2 mg IV x 2, and deep suction with minimal secretions. She had a chest x-ray which was suggestive of a left lower lobe collapse. The patient declined intubation and bronchoscopy, and was transferred to the ICU for mask ventilation and aggressive chest physical therapy with intent to re-expand left lung. At the time of initial ICU eval, the patient is in mild distress on mask ventilation. She symptomatically feels less dyspnea. Denies chest pain, fevers, and chills. MEDICAL HISTORY: 1) Multiple sclerosis diagnosed 14 years ago and followed by quadriplegia for the last five years. 2) Cholecystectomy performed in [**2134-9-30**] at [**Hospital 1263**] Hospital complicated the contained leak of bile. 3) Hepaticojejunostomy performed at [**Hospital 1263**] Hospital [**10-30**] with Roux-en-Y jejunal limb attached to the site of biliary leak. 4) Recurrent cholangitis: greater than four episodes over the last year usually evaluated at [**Hospital6 33**]. 5) Chronic hepatitis: work up has included negative viral serologies, negative [**Doctor First Name **], negative smooth muscle antibodies as well. Recent liver biopsy at [**Hospital6 33**] as described. 6) Ileal loop conduit urostomy: with right ureteral stent for recurrent episodes of urosepsis. 7) PEG placement. 8) C. difficile colitis. 9) Pseudomonas bacteremia. 10) Recurrent urinary tract infection. 11) Chronic anemia. 12) Chronic back pain. 13) Multiple decubitus ulcers requiring surgical repair. 14) Depression. MEDICATION ON ADMISSION: ALLERGIES: None known. PHYSICAL EXAM: FAMILY HISTORY: No history of GI disease in family. One nephew with multiple sclerosis. SOCIAL HISTORY: Lives at Life Care [**Location (un) 3493**], retired payroll administrator. Greater than 20 pack year smoking history although quit ten years ago. Moderate alcohol intake but quit many years ago. No history of intravenous drug use.

CHIEF COMPLAINT: emergency Type A aortic dissection PRESENT ILLNESS: 45 yo male transferred in emergently from [**Hospital **] [**Hospital **] hospital ER. He presented in their ER 6 hours prior to transfer here. He was intubated there with noted paraplegia and hypotension. MEDICAL HISTORY: ([**First Name8 (NamePattern2) **] [**Hospital1 **] ER record): CAD MI past IVDA smoker MEDICATION ON ADMISSION: unknown ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: unresponsive, cyanotic, mottled BP 60 systolic extremities rigid and cool fixed and dilated pupils FAMILY HISTORY: unknown SOCIAL HISTORY: unknown

CHIEF COMPLAINT: chest pain PRESENT ILLNESS: 63 yo female with history of depression and suicide attempt plus NSTEMI s/p Cath (30% LAD, 60% RCA) in [**2108**] presenting with chest pain, found to have anterolateral STEMI s/p cath with BMS in LAD and IABP placed. . Patient describes feeling chest pressure starting two days ago as well as some difficulty breathing. She came to the ED and was found to have an anterolateral STEMI. She was taken to the cath lab and had BMS in LAD, also found to have 60% stenosis of RCA. She developed hyoptension in the cath lab and an IABP was placed and dopamine drip started. . On review of systems, she denies cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: (per OSH records): 1.) Depression 2.) Migraine HA 3.) Chronic pain 4.) 100 lb weight loss over past year - pt has undergone extensive w/u including colonoscopy, GYN exam, HIV test, cardiac w/u, stool studies, celiac studies negative. Also had abd CT negative, Chest CT demonstrated LUL nodule which was monitered. Had recent scan that demonstrated increase in size of LUL nodule from 3mm->7mm, PET scan in [**12-11**] negative - scheduled to have repeat Chest CT this month. MEDICATION ON ADMISSION: -prozac 60 -bupropion 100 mg [**Hospital1 **] -topomax 150 mg [**Hospital1 **] -lasix 20 q day -HCTZ --> unsure of dose -oxycodone --> unclear dose -believes may be taking other medications but does not recall at this time . Pharmacy at which pt gets prescriptions was consulted and the following prescriptions were current for the pt: furosemide 20mg daily simvistatin 20mg daily provigil 100mg [**Hospital1 **] HCTZ 25mg daily oxcodone/acetaminophen 5/325 [**1-9**] tab TID PRN : prescriber Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], last filled [**2112-8-29**] 42 tabs gabapentin 400mg [**Hospital1 **] seroquel 25mg 1-2 tabs qHS omeprazole 20mg daily flexeril 10mg TID PRN topiramate 100mg [**Hospital1 **] fluoxetine 20mg 3 tabs daily well butrin SR 100mg [**Hospital1 **] ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Physical Exam on Admission: GENERAL: NAD. Oriented x3. Mood, affect appropriate. [**Name2 (NI) 4459**]: Sclera anicteric. EOMI. no oral lesions NECK: Supple CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. exam limited, IABP LUNGS: Resp unlabored on face mask, no accessory muscle use. CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. femoral line in place, mildly tender SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . Physical Exam on Discharge: PHYSICAL EXAMINATION: VS: T 98.2 BP 101/61 (70-105/38-79) HR 83 (68-85) RR 18 O2Sat 94-96% RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. [**Name2 (NI) 4459**]: Sclera anicteric. EOMI. no oral lesions NECK: Supple,no carotid bruits appreciated CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. exam limited, IABP LUNGS: Resp unlabored, no accessory muscle use. CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. FAMILY HISTORY: mother-CHF, passed from alzheimers at age 80 father-passed from lung cancer SOCIAL HISTORY: Patient is married, lives w/ husband and 14 [**Name2 (NI) **] grandson. + family stress due to death of her son from heroin overdose about 2 years ago. Also has daughter w/ current substance abuse problems. Remote tobacco history.

CHIEF COMPLAINT: Diarrhea. PRESENT ILLNESS: The pt. is a 72 year-old male with a history of alcoholic cirrhosis complicated by chronic LE edema and cellulitis who presented with a 4 to 5 day history of diarrhea and decreased p.o. intake. The pt. stated that he was in his USOH until [**Month (only) **] of this year when he began to develop watery, non-bloody diarrhea after being treated with clindamycin for lower extremity cellulitis. At that time, he was empirically treated with flagyl for suspected c. difficile enterocolitis and his diarrhea abated. He subsequently experienced diarrhea again in [**Month (only) 359**] under the same circumstances which also improved with flagyl. The pt. reported that the same sequence of events occurred again beginning 4-5 days prior to admission. The pt. stated that his diarrhea is watery and brown and primarily occurred after meals. He has not noticed any blood in his stools. He had been unable to tolerate p.o. for the past [**12-29**] days and stated that any time the pt. would attempt to take p.o., he would experience copious diarrhea. The pt. admitted to a roughly 10 pound weight loss over this time period. The pt. denied fever or diaphoresis but did complain of chills during the past four days. He has also noticed increased redness and swelling of his lower extremities, more marked on the right. He had been unable to ambulate secondary to lower extremity pain. On ROS, the pt. complained of a mild headache but denied chest pain, shortness of breath, nausea, dysuria. In the ED, the pt. was a total of 2 liters of IV fluid, 60g of kayexelate for elevated serum potassium and IV oxacillin for lower extremity cellulitis. An ultrasound of the pt's. RLE was performed and was negative for DVT. He was admitted to the MICU for dehydration secondary to presumed c. difficile enterocolitis. MEDICAL HISTORY: -cirrhosis [**12-28**] alcohol abuse c/b grade 1 esophageal varices, gastric varices and thrombocytopenia; has been abstinent since [**2121**] -chronic LE edema and cellulitis as a result of cirrhosis -HTN -normocytic anemia, thought to be [**12-28**] CRI, on aranesp injections -AAA, dx. in [**1-26**] and measured 3.5x3 by U/S (stable as of [**5-29**]) -chronic constipation -BPH, S/P TURP in [**2133**] -agoraphobia -chronic renal insufficiency with a baseline Cr. of 2 -lipomas -ED MEDICATION ON ADMISSION: -atenolol 25mg po daily -aranesp 50mcg sc qweek -lasix 40mg po daily, recently d/c'ed -moexipril 7.5mg po daily -spironolactone 100mg po daily, recently d/c'ed ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T: [**Age over 90 **]F P: 84 R: 18 BP: 110/32 SaO2: 100% RA General: awake, alert, NAD HEENT: PERRL, EOMI, MM dry, no lesions in OP Neck: supple, no JVD appreciated Pulmonary: lungs CTA bilaterally Cardiac: RRR, S1S2, no m/r/g appreciated Abdomen: soft, NT/ND, hyperactive bowel sounds, no masses or organomegaly appreciated Extremities: 2+ pitting edema of LLE with pretibial erythema and 2+ DP pulse; 4+ pitting edema of RLE with marked pretibial erythema and skin breakdown, 1+DP pulse Neurologic: Alert and oriented x 3. No asterixis noted. Skin: Skin changes over BLE as described above. Otherwise, hemangiomas noted over trunk. FAMILY HISTORY: Mother died of colon cancer in her 90's. SOCIAL HISTORY: The pt. lives at home with his wife and son. [**Name (NI) **] has been abstinent from alcohol since [**2121**] after a history of alcohol abuse. He has a distant history of tobacco use (quit 30 years ago). Denied illicit drug use.