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CHIEF COMPLAINT: Right internal carotid artery stenosis - symptomatic- with uncomplicated stent placement PRESENT ILLNESS: 70 yo F with ihistory of hypertension, hyperlipidemia, and supraventricular tachycardia who is s/p right ICA stenting for symptomatic high grade right carotid stenosis. She notes that starting 3-4 months ago, she has had intermittent blurry vision, felt like a veil was over her right eye and seeing "purple spots" especially in bright light. She denies facial numbness or droop or other neurological symptoms including muscle weakness. . Here, she underwent catheterization revealing 90% right ICA stenosis which was successfully stented. Nitroprusside was started due to hypertension in 200's in the lab to maintain BP in 100-150 range. Upon arrival to the CCU, her BP was within range off of nitroprusside. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. She 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: Symptomatic right carotid stenosis - with amaurosis fugax and purple spots seen Supraventricular Tachycardia - has received Adenosine 3 times over the past year, followed by Dr. [**Last Name (STitle) **] at [**Hospital1 112**] Cholecystectomy Anxiety MEDICATION ON ADMISSION: Plavix 75mg daily Prozac 40mg daily in the pm Atenolol 50mg [**Hospital1 **] Diovan 160mg daily in the pm Lipitor 40mg daily in the pm Aspirin 325mg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VSS, afebrile Gen: NAD, Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, unable to assess JVP as is lying flat. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death. Father had a CABG in his 70s. SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse, drinks 3-4 glasses wine/night.

CHIEF COMPLAINT: Spinal Cord [**Hospital 92077**] transfer from [**Hospital 8641**] Hospital PRESENT ILLNESS: 88-year-old male with penile SCC s/p hemiresection c/b blastic spinal cord disease (C2-4) who presented to [**Hospital 8641**] Hospital 1 day ago with difficulty walking x1 week. . The patient was in his usual state of health until 1 week ago (patient states 1 day ago). At that time he developed difficulty walking and urinary incontinence. He denies any back pain, saddle or lower extremity anasthesia. He presented to [**Hospital 8641**] Hospital. He had an MRI showing a large mass encompassing T2-T5 compressing the spine. Neurosurgery evaluated the patient, felt that he was not at acute risk for compression when supine so no steroids. He was transferred to [**Hospital1 18**] for neurosurgical evaluation and biopsy lesion to see if responsive to radiation therapy. . Currently, feels well. Denies fevers, headache, back pain, leg pain, leg weakness, numbness, stool incontinence. He does endorse urinary incontinence. MEDICAL HISTORY: MEDICAL & SURGICAL HISTORY: - HTN - mild dementia - Penile SCC in [**2162**], s/p hemi-resection - hearing loss - chronic kidney disease - anemia - gout - BPH - B12 deficiency - Skin cancer - GERD - Hypothyroidism - HLD - s/p left hip replacement - s/p tonsilecomy MEDICATION ON ADMISSION: MEDICATIONS ON TRANSFER: - Allopurinol 100mg PO daily - Protonix 40mg PO daily - Folic acid 0.5mg PO daily - Lavaza 2g PO BID - Hytrin 2mg PO qHS - Bicarbonate 650mg - Zocor 20mg PO daily - Synthroid 50mcg PO daily - Ferrous sulfate 325mg PO daily - Vitamin D [**2166**] units PO daily - Pocaltrol 1 mcg PO daily - Atenolol 50mg PO daily - Vitamin C 1000mg PO daily - Norvasc 2.5mg PO daily . MEDICATIONS AT HOME: - Amlodipine 2.5 mg PO daily - Atenolol 50 mg PO daily - B12 1000 mcg injection - Calcitriol 0.5mcg PO daily - Ferrous sulfate 325mg PO daily - Fish oil - Folic acid 800mcg PO daily - Furosemide 20mg PO daily - Kayexalate 15mg PO every other day - Levothyroxine 50mcg PO daily - Omeprazole 40mg PO BID - Sodium bicarbonate 650mg PO daily - Terazosin 2mg PO daily - Vitamin C 1000mg PO daily - Vitamin D 2000mg PO daily - Simvastatin 20mg PO qHS - Allopurinol 100mg PO daily - Aleve 200mg prn ALLERGIES: aspirin PHYSICAL EXAM: On Discharge: oriented x 2.5 (except yr) RUE trace [**3-11**] tric bicep, L IP and AT 4+ and tingling (baseline). otherwise [**4-10**]. no clonus FAMILY HISTORY: CAD, CA SOCIAL HISTORY: No smoking. No EtOH or illicits. [**Doctor Last Name **] in [**State **].

CHIEF COMPLAINT: Atrial Fibrillation PRESENT ILLNESS: Mr. [**Known lastname 39015**] is a 76yo gentleman with h/o AFib not on coumadin s/p recent craniotomy for resection of meningioma who presents with recurrent AFib with RVR. The patient was admitted to the cardiology service at [**Hospital1 18**] from [**Date range (1) 17433**] with AFib/RVR. His medications were adjusted such that he was discharged on metoprolol 50mg [**Hospital1 **], Amiodarone 200mg daily, and digoxin 0.125 every other day. His blood pressure was stable on this regimen and he was noted to be bradycardic in the 40s-50s. On the day of admission, his heart rate went back up to 130s-140s despite receiving his medications as ordered and [**Hospital1 **] sent him to the ED. In the ED, initial vitals were 97.1 130 123/77 17 95% RA. Tm was 99.9. He was given diltiazem 10mg IV without effect; increasing dose to 20mg did not control HR. He was then put on diltiazem gtt, which was increased to 15mg/hr without decreasing his HR. His SBP remained in the 110s. He is not able to answer ROS. 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: Afib s/p ablation on coumadin - Had Aflutter ablation [**2188-7-16**] Atypical recurrent right frontal meningioma s/p radiation and chemotherapy. Most recent resection [**2188-8-21**]. GERD Hypothyroidism MEDICATION ON ADMISSION: Digoxin 125mcg every other day Lisinopril 10mg daily Metoprolol 50mg [**Hospital1 **] Amiodarone 200mg daily Keppra 1000mg [**Hospital1 **] Levothyroxine 37.5mcg daily Famotidine 20mg [**Hospital1 **] NPH 14 units QAM, 12 units QPM Humalog SS Docusate Senna Nystatin 5ml TID ALLERGIES: Phenytoin / Decadron PHYSICAL EXAM: VS: Afebrile. Heart rate in 80s. BP 120/78. GENERAL: NAD. Breathing well on room air. Moving all four extremities. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: Per OMR, unable to answer questions. Family History: Mother died at 80 from stroke. Father died at 60's, unclear cause. Bother died 60 from lung cancer. SOCIAL HISTORY: Per OMR, unable to answer questions. Married with two children. Used to smoke a pack a day but quit in [**2151**]. Used to drink beer but stopped when he was put on Coumadin.

CHIEF COMPLAINT: Bleeding at right AV fistula site. PRESENT ILLNESS: The patient is a 74-year old female with end-stage renal disease secondary to IDDM and hypertension; on hemodialysis every Monday, Wednesday and Friday at the [**Location (un) **] Hemodialysis Unit. Her attending is Dr. [**Last Name (STitle) **]. She was transferred to [**Hospital1 18**] for bleeding from her AV fistula site. The first time was spontaneously. The second time was secondary to the patient disturbing the dressing. The bleeding was controlled in the ED with a stitch. She was in her usual state of health, although had an extra hemodialysis session for volume overload. MEDICAL HISTORY: Significant for Alzheimer's with vascular dementia, right AV fistula, post angioplasty, recent admission in [**2174-12-1**] for mental status changes and question encephalopathy and hypercalcemia. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: Unable to obtain. SOCIAL HISTORY:

CHIEF COMPLAINT: Chest Pain PRESENT ILLNESS: 71 year old male with extensive past medical history, incuding peripheral artery disease s/p multiple interventions who underwent stress test after complain of chest pain. Stress test was positive and therfore he underwent a cardiac cath which was noted for three vessel coronary artery disease along with peripheral artery disease. He was been referred for coronary artery bypass surgery. MEDICAL HISTORY: coronary artery disease IDDM Hypertension Dyslipidemia Chronic renal failure ( cr. 1.4) Peripheral arterial disease s/p multiple interventions/stents [**2153**] Obesity Carpal tunnel syndrome ( 4 yrs ago) Gastroesophageal reflux disease w/ gastritis/duodenitis hiatal hernia Depression/Anxiety Benign prostatic hypertrophy Volvulus [**2120**] Hepatitis [**2120**] Macular degeneration Diabetic retinopathy Trigger fingers s/p multiple cortisone inj. to B hands MEDICATION ON ADMISSION: Aspirin 325mg daily ***Plavix 75mg daily metoprolol 12.5 mg daily Protonix 40mg daily Lantus Insulin 90-100 units daily Humalog 12-17 units TID Cozaar 50mg daily HCTZ 25mg daily Toprol XL 12.5mg daily Lipitor 20mg daily Bupropion SR 150mg daily Saw [**Location (un) **] 480 mg [**Hospital1 **] Salmon oil 3000 mg daily Preservision 1 cap [**Hospital1 **] S-adenosylmethionine 600 mg daily ALLERGIES: Lovastatin / Famotidine PHYSICAL EXAM: Pulse:71 Resp: 16 O2 sat: 96% B/P Right: 125/76 Left: 124/80 Height: 6'0" Weight: 230# FAMILY HISTORY: NC SOCIAL HISTORY: Lives with:partner Occupation: real estate Tobacco: never ETOH: 1 drink/wk

CHIEF COMPLAINT: Bright red blood per rectum PRESENT ILLNESS: The patient is a 79 year old male with a history of PE, COPD, Atrial fibrillation, hypertension, diastolic dysfunction and hypothyroidism presenting with bright red blood per rectum. The patient was in his usual state of health until approximately three weeks ago when he developed sudden onset dyspnea and was hospitalized with pneumonia. The patient was discharged to a [**Hospital1 1501**] to complete a course of IV antibiotics. He was subsequently hospitalized from [**Date range (1) 61516**] with a pulmonary embolism and was treated with Lovenox and transitioned to Coumadin. . The patient was on both Lovenox and Coumadin prior to this admission. On the day prior to admission, he developed acute onset abdominal cramping and asked to use the commode. According to the [**Hospital 100**] Rehab records, the patient had a large grossly bloody bowel movement (approx 1 Liter). He was hemodynamically stable and transferred to the ED for further evaluation. He was feeling otherwise well, aside from continued dyspnea on exertion, and denies nausea, vomiting, chest pain, headaches, change in diet, dysuria, fevers or chills. . In the ED, his initial vitals were 97.6, BP 135/45, HR 74, RR 17, 94% on 4 L NC. He reports that his abdominal pain subsided to intermittent "rumblings," and his review of systems was otherwise negative. He denies a history of blood per rectum before. He had another soft, marroon stool while in the ED. He also developed some worsened shortness of breath during his ED course and was treated with 20 mg IV lasix. He was transferred to Medicine for furhter evaluation. MEDICAL HISTORY: COPD Atrial fibrillation (one brief episode recently, started on digoxin) HTN BPH Hypothyroidism s/p partial thyroidectomy CAD (per records, no h/o MI or cardiac cath) h/o Klebsiella, MRSA, Pseudomonas infections h/o VRE UTI . PSH: s/p appy s/p laminectomy s/p right partial hip replacement s/p bowel obstruction s/p SB resection MEDICATION ON ADMISSION: Prednisone 10 mg daily Lovenox 120 mg [**Hospital1 **] Spiriva daily Zyvox 600 mg [**Hospital1 **] Singulair 10 mg daily RISS Cardizem 480 mg daily Colace Lasix 40 mg daily Protonix 40 mg [**Hospital1 **] Aspirin 325 mg daily Lisinopril 20 mg [**Hospital1 **] Advair Digoxin 0.25 mg daily Flomax Senna Levoxyl 75 mcg daily ALLERGIES: Amoxicillin PHYSICAL EXAM: Vital signs: 99.7, 126/65, 95, 16, 94% on 4.5 L NC Gen: well appearing, elderly man, no distress, able to speak in complete sentences, nasal cannula in place HEENT: MM dry, OP clear Neck: no JVD Car: RRR no murmur Resp: diffuse wheeze and intermittent ronchi, R>L Abd: soft, distended, ventral hernia, + bowel sounds, nontender to palpation. dull to percussion on flanks Ext: 4+ edema with compression stockings (stable per patient-h/o lymphedema) FAMILY HISTORY: Father with lung CA. Mother with HTN, [**Name (NI) 10322**], and CVA. Sister with ovarian CA. Brother with brain CA. SOCIAL HISTORY: Positive for tobacco use for 67 yrs, 1.5 ppd. No EtOH or IVDU. Retired child psychiatrist and member of Army. Used to only use oxygen at night, now requiring approximately 4 liters after recent PE and pneumonia. Married, 3 children.

CHIEF COMPLAINT: left sided weakness PRESENT ILLNESS: Mr. [**Known lastname **] is a 60 year-old right-handed man with no significant PMH who presents with acute onset speech difficulties and left sided weakness. According to his son and daughter-in-law, who provide the history, he was last known well around 9:30 or 10 PM last night prior to going to sleep. His wife noted him moving in bed around between 12:30 and 1 AM and then reportedly tried to wake up him for about a half hour, but he was not speaking and she believed he was just sleeping. When the lack of speech persisted, and she believed his left side was weak, she awoke the rest of the family, who then proceeded to call 911. When they first found him, he was described as unconscious because his eyes were open, but he was not saying anything. He was also noted to not be able to move his left side. He was brought to OSH, where it was noted that he was out of the window for tPA as his last known well time was 9:30 PM last night and was then transferred to [**Hospital1 18**] for further management. MEDICAL HISTORY: none B12 deficiency - found during hospitalization Hyperhomocysteinemia - found during hospitalization MEDICATION ON ADMISSION: None ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: T: 97.5 P: 60 R: 14 BP: 102/63 SaO2: 100% on 4L NC per ED- LUE systolic BP 70s, RUE systolic BP 140s FAMILY HISTORY: No history of strokes SOCIAL HISTORY: He lives in [**State 108**] and has been visiting his family here. He smokes 1 pack of cigarettes every 2-3 days and has done so for about 30 years. Occasional alcohol use. No known illicit drug use.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 50-year-old male with a history of hepatitis B, hepatitis C, and intravenous drug abuse with recurrent aspiration pneumonia, schizoaffective disorder, and history of left greater than right peripheral neuropathy, admitted for acute dysarthria and chest pain at rest. MEDICAL HISTORY: (Significant for) 1. Chronic obstructive pulmonary disease. 2. Hypertension. 3. Hepatitis B. 4. Hepatitis C. MEDICATION ON ADMISSION: Home medications included albuterol 2 puffs p.r.n., Aristocort 0.5% p.r.n., doxepin hydrochloride 25 mg p.o. q.h.s., Flovent 110 mcg 2 puffs q.d., Neurontin 300 mg p.o. t.i.d., Prilosec 20 mg p.o. b.i.d., tramadol hydrochloride 50 mg p.o. b.i.d. p.r.n., Zestril 5 mg p.o. q.d., Prozac 80 mg p.o. q.d., Clozaril 225 mg p.o. b.i.d. ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Increased shortness of breath and malaise PRESENT ILLNESS: Pt is an 80 y/o M with a h/o metastatic poorly differentiated squamous cell CA, GERD who presented to [**Hospital **] hospital with 2-3 days of increasing SOB and fatigue, saying he was "gasping" for air by the time he got to the hospital. Over the days prior to admission, he complained of exacerbations of his "reflux" that seemed to be worse with urination/defecation, not worse with eating or supine position. At [**Hospital1 **], had elevate CK, MB, TnI and a CXR indicating possible pneumonia and mild CHF and was started on B-blocker, nitro drip, ASA, lasix, ceftazidime/azithromycin. His OSH echo showed 35-40% EF, septal/apical/inf wall hypokinesis, mild MR, trace TR. A CT of his torso showed mediastinal LAD, hilar LAD, B/L pleural effusions, multiple pleural calcifications c/w prior asbestos exposure, B/L LL infiltrates, RUL infiltrate, and a R inguinal fluid collection. A cath two days after admission showed 80% left main disease, extensie three vessel disease, prompting a transfer to [**Hospital1 18**]. At [**Hospital1 18**], pt had a cath with cypher and hepacoat stenting of RCA, PTCA to LAD and LCx with hepacoat in LAD and distal LM, hepacoat to ostium of LM. Pt's post cath course was complicated by two episodes of fever up to 101-102 with new diarrhea, RUL and RLL opacities. Also, pt has bilateral pleural effusions, L>R, s/p left thoracentesis that does not support empyema, though with pleural fluid appearing transudative in nature. MEDICAL HISTORY: 1.)Metastatic poorly differentiated squamous cell carcinoma 2.)GERD 3.)Arthritis 4.)BPH MEDICATION ON ADMISSION: Flomax Xanax Protonix ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: tm 101.0/tc 98.6, bp 78/45->94/60, hr 67 63-68, rr 18, spo2 96% ra gen- awake, a&o M, healthy appearing, looks own age, NAD HEENT- no scleral icterus/injection, op clear, poor dentition (1 tooth), dry mucosa neck- supple, v-wave jugular pulsation, no lad, no thyromegaly cv- rrr, s1s2, 2/6 systolic murmur loudest over ao region pul- good bilat air movement, rales in both bases L>>R, bronchial breath sounds in RUL abd- soft, NT, nabs, no organomegaly extrm- no c/c/e, warm, well perfused, r groin with 3x4cm firm painless mass with 1x1cm ulceration, nontender, no pus expressed, no erythema, left groin at cath site, no hematoma, no erythema neuro- a&ox3, fluent coherent speech, approriate affect, cn II-XII intact, motor [**4-25**] all extrm FAMILY HISTORY: non-contributory SOCIAL HISTORY: The patient is a retired bartender who lives alone, has a 40 pack year history, and quit smoking in [**2175**].

CHIEF COMPLAINT: Dyspnea, fatigue PRESENT ILLNESS: Mrs [**Known lastname 805**] is a pleasant 67 yo woman with hx of chronic anemia, OSA, HTN, HLD, rheumatic heart disease with mitral stenosis and regurg, who presents with 2 days of "heaviness" in arms and legs. Pt states that she came in today because she was feeling so tired that she couldn't do her usual stretching exercises prior to work. She denies any chest pain, palps, myalgias, malaise, bloody BMs, states they are always dark. She has not had any fevers, chills, N/V/D. She does endorse a cough which is chronic and she attributes to seasonal allergies and GERD. Pt had an EGD this year and [**Last Name (un) **] last year which were unremarkable, as well as a normal capsule study [**6-21**]. She does have a history of anemia (iron deficiency) thought to be secondary to chronic GI bleed, though never found a source. She has been followed by GI and heme for this and had been recently upped to two pills a day. In the [**Name (NI) **], pt was initially hypertensive to the 150s, HR to 109, BP decreased to the 110s and HR to the 80s on transfer. Guiac was positive. She was seen by GI who recommended EGD/[**Last Name (un) **] tomorrow. EKG was performed and showed sinus tach with no acute changes. 2 units were ordered but not hung on transfer, she was given 1 L of fluid and 2 PIVs were placed. CXR was unremarkable. On the floor, patient continues to c/o ongoing fatigue. She says that she looked up her sxs earlier today and then had a panic attack because she was concerned that she was dying. This was the first time that this has ever happened. During this event, she felt SOB and felt a pounding in her ears, however this resolved when she felt less anxious. MEDICAL HISTORY: Hypertension Hyperlipidemia Arthritis- L knee, feet, R thumb, s/p L thumb operation Mitral valve stenosis. Had rheumatic heart disease as a child. GERD Seasonal allergies MEDICATION ON ADMISSION: EXTROVEN - - 1 tablet daily evening EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth daily FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - 50 mcg Spray, Suspension - 1 spray at bedtime FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - one Tablet(s) by mouth daily NIACIN [NIASPAN EXTENDED-RELEASE] - (Prescribed by Other Provider) - 1,000 mg Tablet Extended Release - 1.5 Tablet(s) by mouth at bedtime OLOPATADINE [PATANOL] - (Prescribed by Other Provider) - 0.1 % Drops - 2 drops OS twice a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice daily POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq Capsule, Extended Release - three Capsule(s) by mouth daily VALSARTAN [DIOVAN] - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Last Name (STitle) 118**] - 160 mg Tablet - [**12-13**] Tablet(s) by mouth twice a day . Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth at bedtime for arthritis pain ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily CALCIUM CARBONATE-VIT D3-MIN [CALTRATE 600+D PLUS MINERALS] - (Prescribed by Other Provider) - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth twice a day CARBOXYMETHYLCELLULOSE SODIUM [REFRESH TEARS] - (Prescribed by Other Provider) - 0.5 % Drops - 1 drop in each eye as needed for dryness FERROUS GLUCONATE - 236 mg (27 mg iron) Tablet - one Tablet(s) by mouth each day with one tablet of vitamin C, 2 hours before or after other food or medications GLUCOSAMINE SULFATE - (OTC) - 1,000 mg Capsule - 1 Capsule(s) by mouth daily GUAIFENESIN [MUCINEX] - (Prescribed by Other Provider) - 600 mg Tablet Extended Release - one Tablet(s) by mouth at bedtime LORATADINE [CLARITIN] - (Prescribed by Other Provider; OTC) - Dosage uncertain MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth daily ALLERGIES: Penicillins / erythromycin / Cephalosporins / Latex PHYSICAL EXAM: ADMISSION EXAM: Vitals: T:99.1 BP:136/65 P:82 R: 18 O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, 2/6 SEM heard throughout the precordium, not radiating to the carotids, blunted S1/S2 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, no clubbing, cyanosis or edema Neuro: aaox3, CNs [**1-23**] intact, 5/5 strength throughout FAMILY HISTORY: Diabetes on maternal side of family, father died of black lung, mother died of bladder CA SOCIAL HISTORY: No tobacco, EtOH, illicits. She is married with one grown daughter. Currently works as a life insurance [**Doctor Last Name 360**]. Lives in [**Location **].

CHIEF COMPLAINT: nausea and vomiting for 4 days and weak legs x 1 day PRESENT ILLNESS: 52 yo male with PMH significant for alcoholism and hyperglycemia presents from home via EMS for collapse. He has been binge drinking for the last 2 weeks and felt nauseated and vomited blood over the last 4 days. On arrival, EMS found him to be naked on the floor. His initial blood pressure was 74/42 and he was brought to the ED. . ED course: Patient received 9 liters IVF and 2 units PRBCs. One dose of Flagyl and Levofloxacin. Pt underwent NGL, w/ dark red return, unable to clear. GI consulted, pt underwent EGD which revealed, blood in the antrum and body, grade IV severe esophagitis in the whole esophagus, congestion, erythema and erosions in the whole stomach compatible with erosive gastritis. Blood clot in the gastroesophageal junction, bleeding likely secondary to esophagitis and M-W tear. Patient also found to be in DKA w/ initial glucose in 800's, + ketones in urine and pH of 7.11. Insulin drip was started, and fluids continued. He was transferred to the MICU. . Currently the patient still has some nausea. He complains of falls over the last few days. He also has had nausea and vomiting with blood. He reports some nonproductive cough over the last few days. He has abdominal pain. He complains of a headache currently. He feels slightly shaky currently. He has been eating only Ensure over the last few days. MEDICAL HISTORY: 1. Alcohol abuse, history of withdraw seizures, DTs, and alcoholic and starvation ketoacidosis. 2.Chronic pancreatitis. 3.History of polysubstance abuse (cocaine, heroin, amphetamines, benzodiazepines). 4.History of pancytopenia secondary to chronic alcohol abuse. 5.Left gynecomastia with negative mammogram in the past. 6.Genital herpes. 7.Depression. 8.Right clavicular fracture in [**2185-4-6**]. 9.Peptic ulcer disease w/ UGIB 10.Left ulnar neuropathy entrapment syndrome 11. Bipolar disorder 12. lower back pain MEDICATION ON ADMISSION: (gets from CVS on Chestnut St in [**Location (un) **]) celexa 40 mg QD trazodone 150 po qd neurontin 800 po QID seroquel 25 mg QID depakote 250 po QID Aspirin 1000 mg po qd lamictal 100 po qd prilosec 20 mg po qd tylenol "very frequently" occasional ibuprofen ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: vitals: T98.9 BP 150/93 P112 R18 98% 2L NC GEN: no apparent distress. Conversant. Somehwat dishevelled HEENT: PERRLA. MM very dry. NECK: No LVD. right EJ in place. CV: RRR nl s1s2 no MGR LUNGS: clear to auscultation bilaterally ABDOMEN: Soft, diffusely tender to palpation. no rebound/guarding EXT: no edema. traumatic left knee, abrasion on abdomen NEURO: CN 2-12 intact. Strength 5/5 UE/LE. FTN intact. FAMILY HISTORY: Alcoholism in his parents and brother; father died secondary to cerebrovascular accident. Mother has [**Name (NI) 2481**] disease. Father and 2 paternal aunts with adult onset diabetes. SOCIAL HISTORY: The patient has been divorced since [**2176**]. He has one daughter and two step-daughters. [**Name (NI) **] sells art and antiques and is now retired. Smoked until 2 years ago, 1 PPD at the most, for 30 pack years. Has used cocaine and valium 3-4 years ago. Drinks alcohol to excess over last 20 years, was sober for 6 years once.

CHIEF COMPLAINT: Chest pain PRESENT ILLNESS: This is a 64 y/o male with a h/o left embolic stroke in [**3-15**]. During that hospitalization he experienced angina. Underwent cardiac cath that revealed severe three vessel disease. During work-up for stroke, was found to have severe left carotid stenosis. Therefore he is being admitted to undergo intervention on his left carotid artery and coronary arteries. MEDICAL HISTORY: History of Embolic Stroke, Coronary Artery Disease, s/p PTCA/stents [**2106**], Diabetes Mellitus, Hypertension, Emphysema, Chronic Pancreatitis, Gastroesophageal Refulx Disease, Chronic renal insufficiency, Hepatitis C, Trauma to left eye MEDICATION ON ADMISSION: In house: Plavix 75mg qd, Lipitor 80mg qhs, Glyburide 1.25mg qd, Imdur 30mg qd, Lopressor 50mg [**Hospital1 **], Aspirin 325mg qd, Nitro gtt, Neo gtt, Keflex 250mg q8hr, Percocet ALLERGIES: Protonix PHYSICAL EXAM: VS: 68 20 132/61 Gen: WDWN male in NAD Skin: W/D, -lesions HEENT: Blind Left Eye, Perrl right eye, Dentition fair Neck: Supple, FROM, 2+ Bilat Carotid Bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, -varicosities, 2+ pulses throughout Neuro: A&O x 3, MAE, non-focal FAMILY HISTORY: Mother had stroke in her 60s. SOCIAL HISTORY: Lives alone in Dochester. Distant alcohol abuse. No smoking. Going to school for his GED; until now functionally illiterate, but has learned to read, though basic math still difficult.

CHIEF COMPLAINT: Unresponsiveness PRESENT ILLNESS: Ms. [**Known lastname 4886**] is a 78-year-old female with past medical history significant for hypertension,type 2 DM, distant breast cancer, TTP (lengthy hospitalization [**4-/2141**] which required corticosteroids, plasmapheresis, and rituximab), relapsing polychondritis and ANCA positive pulmonary vasculitis. The patient was in her usual state of health this evening at 6:30 PM, speaking to her son on the phone. He said, to EMS (from whom we got direct sign-out), that his mother sounded slightly tired, but this is her baseline and otherwise was normal. He then came to see her after running errands about 1 hr later and found her lying in emesis and stool. She was unreponsive and he could not wake her. EMS called and found to develop a generalized tonic-clonic seizure. The seizure lasted about 3.5 mintues, then stopped spontaneously. She was then given Ativan 2mg, then intubated with succinylcholine 100mg and etomidate 20mg, followed by Versed 2.5 mg given concern about airway protection. She was then brought to [**Hospital1 18**]. Of note, son reports that this presentation is almost identical to her prior presentation last year, which required pheresis, and believes this was TTP. In the field EJ and IO access was obtained. She was in sinus rhythm, in the 80s, blood pressure was 200/80 mmHg, and breathing spotaneously (before intubation and medications). Finger stick was 175. In the ED CT head/Neck showed no acute intracranial hemorrhage. She does have subtle areas of hypodensities in left basal ganglia, pons, and midbrain maybe artifactual or represent ischemia. CTA basilar artery appears patent. Sedation was continued with propofol. EKG showed 1st degree avb. She was noted to be febrile to 102. CXR without pna. She was started on vanc/ctx/amp/acyclovir, but no LP was done due to low plt. UA showed no bacteria or leuks, but did have large blood, 300 glucose, 300 protein Of note, pt noted to have trop of 1.03, with flat MB. Cardiology was conuslted who felt no need for urgent cardiac intervention in setting of unchanged EKG. On transfer, VS were 106 146/80s, 99% on CMV fi02 100, peep 5, RR 16, TV 500. On arrival to the MICU, VS were 100.1 109 106/63 100% on above vent settings MEDICAL HISTORY: - Diabetes, likely II - Hypertension, on several agents - Breast cancer, s/p left mastectomy, [**2100**]'s - GERD (inference, on omeprazole), and peptic ulcer disease - Gout - Coronary artery disease - H/o Shingles - Carpal tunnel - ANCA positive pulmonary vasculitis - S/P appendectomy - S/P cholecystectomy - S/P TAH-BSO, mastectomy, - S/P bilateral carpal tunnel release - Bone spurs MEDICATION ON ADMISSION: ALLOPURINOL - 100 mg Tablet - 2 Tablet(s) by mouth daily - No Substitution AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) GLIPIZIDE - 2.5 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by mouth daily HYDRALAZINE - 50 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours ISOSORBIDE DINITRATE - 20 mg Tablet - 1 Tablet(s) by mouth three times a day METOPROLOL SUCCINATE - 200 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily take with 200mg tablets OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day SITAGLIPTIN [JANUVIA] - 100 mg Tablet - 1 Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - 1,000 unit Tablet, Chewable - 1 Tablet(s) by mouth daily OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - 1,000 mg Capsule - 1 Capsule(s) by mouth daily ALLERGIES: Doxycycline / lisinopril PHYSICAL EXAM: INITIAL PHYSICAL EXAM FAMILY HISTORY: No early coronary artery disease. No other cancers SOCIAL HISTORY: Lives with her son. Doesn't smoke or drink.

CHIEF COMPLAINT: seizure PRESENT ILLNESS: 43M with reported PMH of TBI s/p craniotomy/VP shunt, seizure disorder, polysubstance abuse and depression, who was transferred here after intubation for seizures at [**Hospital **] [**Hospital 1459**] Hospital. . History was as below from OSH record: Pt was found down/unresponsive in a motel, given narcan by EMS and he became more responsive, was following some commands and was taken by ambulance to an OSH. There, he had an EKG done, which showed afib with RVR with HR of 150. He was given IV diltiazem 25 mg with improvement in his HR. He was also given 5mg of IV haldol for agitation, and was then drowsy with mildly slurred speech. He was sent for a CT of head/neck, which was read as probable postop changes from his known TBI and R frontal craniotomy. After returning from the CT, he went to the bathroom, and was noted to have 1 GTC as he was returning from the bathroom. Unclear duration of seizure. He was given 2mg of IV ativan. He then had another GTC when he was back on his stretcher, and was given 2 mg more of IV ativan, intubated for airway protection with etomidate/succ at 2315, and was noted to have pinpoint pupils (unclear if this was the initial exam also), and sent to [**Hospital1 18**]. While at the OSH, he was noted to have a tab of dilantin in his pocket. . Of note, his tox screen were positive for opiates and alcohol, and lithium level was <0.2. He also had an elevated AST of 65, and an elevated CPK of 614, but were otherwise unremarkable. . In ED, initial vitals were: HR: 86, RR: 13, BP: 136/80, O2Sat: 99, on vent, Temp: 100.6 ??????F (38.1 ??????C). He was intubated and unsedated, and following most commands per neurology note. He was then put on propofol as he was trying to remove his ETT, and became more sedated, not following commands. He had a phenytoin level drawn which was <0.6. He also had an elevated lipase of 61 and a lactate of 3.8. . Prior to transfer to ICU, patient noted to have temp of 103F, neurosurgery consulted at that time to access VP shunt given concern for intracranial/CNS infection. BCx also sent. Started on vancomycin and ceftriaxone. . On arrival to the ICU, patient is unable to give further history or complete ROS as he is intubated and sedated. MEDICAL HISTORY: Past Medical History (per OSH records): - depression - TBI s/p VP shunt - seizure disorder (no further info is available at this time) - EtOH and substance abuse - DJD - hepatitis C MEDICATION ON ADMISSION: Medications (per OSH records, uncomfirmed with patient): - lithium - keppra - fioricet - prozac - ? dilantin, pt had a pill in pt's pocket ALLERGIES: Penicillins / fish / Ativan PHYSICAL EXAM: ADMISSION EXAM: . General: intubated and sedated HEENT: Sclera anicteric, pinpoint pupils, unable to visualize oropharynx, ?dentures in place Neck: JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly, no wheezes/rales/rhonchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, quiet bowel sounds, no rebound tenderness or guarding, no organomegaly GU: +foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Left shoulder with erythematous abrasions, track mark along L forearm, scabs over left hip and left heel. shallow pink ulceration on medial aspect of right heel, clean base without drainage. . DISHCARGE EXAM: . AAOx3. Able to comprehend benefits of ongoing hospitalization, and risks of leaving the hospital against medical advice. Pt currently appears non-toxic. Linear thoughts, conversant. FAMILY HISTORY: unable to obtain SOCIAL HISTORY: positive for EtOH, tobacco and illicits

CHIEF COMPLAINT: palpitations PRESENT ILLNESS: 54 y/o with hx. MI age 35, EF 20-30%, [**First Name3 (LF) **] ICD, PAF, VT, s/p trials of amiodorone, dofetilide, quinidine, recently admitted ([**Date range (1) 42566**]) for MVR d/t 4+ MR presents with palpitations found to be in AFib with HR in the 120s and SBP 70's-80's (when discharged yesterday was in NSR), admitted to the CCU for further management. MEDICAL HISTORY: 1. Mitral valvuloplasty for MR ([**Last Name (un) 3843**]-[**Doctor Last Name **] Physio ring)[**2-21**] 2. MI vs viral myocarditis at age 35 3. EF less than 20% s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 19961**] ICD [**2108**] 4. Spleenectomy [**2106**] d/t ITP 5. Paroxysmal atrial fibrillation, intolerant of amiodarone, dofetilide and quinine therapy 6. Hypertension 7. Hyperlipidemia 8. noninsulin dependent DM 9. Chronic Kidney Disease MEDICATION ON ADMISSION: ASA 81 Pravastatin 20 Percocet prn Calcium Carbonate 500 qid Captopril 6.25 [**Hospital1 **] Metoprolol tartrate 50 [**Hospital1 **] Lasix 40 [**Hospital1 **] Warfarin 1 mg TTSS, 2 mg MWF ALLERGIES: Amiodarone / Quinidine PHYSICAL EXAM: Blood pressure was 99/58 mm Hg while supine. Pulse was 126 beats/min and irregular, respiratory rate was 14 breaths/min. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 7 cm. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. . Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, murmurs, clicks or gallops. . The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, clubbing or edema. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ FAMILY HISTORY: Father died of MI in his 70s and mother died of CRI in her 70s. There is no family history of premature coronary artery disease or sudden death. SOCIAL HISTORY: She is single and lives alone. She works as office manager for construction company. Does not smoke, social drinker.

CHIEF COMPLAINT: weakness and cough PRESENT ILLNESS: 80 yo M with PMH of HTN, congenital deafness and osteoporosis who presents with fevers, cough and weakness. History is taken from patient and his home caregiver and also his HCP by phone. . Patient was recently admitted after a fall and found to have a C7 fracture. He was placed in a [**Location (un) 2848**] J collar and returned to rehab. Per his caregiver, over the last two days he has become more weak (not using his walker but requiring a wheelchair to get around), coughing and sounded "congested." He has been noted to have poor PO intake and coughing with all liquids and foods. His HCP says that he had a speech and swallow in the past and they recommended crushing his medications in apple sauce and avoiding thin liquids. The patient has recently refused this and has been taking thin liquids and coughing signficantly with them. Today, his caregivers brought him to his PCPs office. They got a CXR and labs. His sodium returned at 115 and his CXR suggested aspiration pneumonia with bilateral basilar infiltrates. He was sent to the ED. . In the ED, his vital signs were T 98.6, BP 117/61, HR 103, RR 22, O2sat 96% RA. He had a rectal temp of 102 while in the ED. His blood pressure transiently dropped to 78/50 and responded to fluids. He received a total of 1.8L NS. He was also given levofloxacin and clindamycin for pneumonia. He was admitted to the ICU for further care. . Currently he complains of the mask from the nebulizer and of the [**Location (un) 2848**] J collar. He is coughing. He denies CP, SOB, n/v, f/c. Denies constipation or dysuria. He does have trouble with incontinence. He is congenitally deaf and reads lips. MEDICAL HISTORY: Frequent falls Hypertension Osteoporosis Congenital deafness Macular degeneration Vitamin B12 deficiency Benign prostatic hypertrophy Urinary incontinence Insomnia MEDICATION ON ADMISSION: tylenol 1g TID alendronate 70mg qsunday asa EC 325mg daily atenolol 25mg daily colace flomax 0.4mg [**1-12**] after meal folic acid 1mg daily lexapro 10mg daily metamucil in AM oxybutynin 5mg [**Hospital1 **] senna qhs trazodone 100mg qhs tums TID vit B12 1000mcg daily vit D 400 units [**Hospital1 **] ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Gen: NAD sitting up in bed with hard cervical collar in place. HEENT: PERRL EOMI. anicteric sclera, non-injected conjunctiva. dry MM, OP clear otherwise. JVP not assessed since collar in place. CV: RRR, no m/r/g Lungs: bilateral rhonchi with some wheeze on left side. Upper airway secretions as well. Abd: +BS, soft, NT, ND, no HSM. Extrem: No C/C/E. Neuro: CNIII-X and XII in tact except hearing- he reads lips. Did not assess [**Doctor First Name 81**] given collar in place. Poor muscle bulk in arms and legs bilaterally. Left arm rigidity. Toes mute bilaterally. Bicep, brachioradialis and patellar reflexes intact. Sensation to light touch appears to be intact. FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Retired acountant. Widowed. Lives in [**Hospital3 **]. Denies tobacco, EtOH. Congenital deafness and reads lips. Does not use sign language.

CHIEF COMPLAINT: Dyspnea PRESENT ILLNESS: 64-year-old man w/ OSA, AF, h/o CVA and CAD presents with progressive dyspnea x 3 weeks. He was in his USOH until 3 weeks ago, when he could no longer lie down without becoming short of breath, requiring him to sit sit with his elbows forward or to stand. He reports progressive orthopnea, PND, and DOE over the past 3 weeks; he now cannot walk more than 10 feet before becoming SOB. There is associated increased LE edema over the past few weeks. He has occasional cough that is non-productive. There is no chest pain, nausea, vomiting, abd pain, fever, or chills. At baseline, he uses home O2 at 2L/min mostly when lying down. He uses BiPAP at night prescribed by [**Hospital1 18**] sleep clinic. Of note, he has been admitted to [**Hospital 1263**] Hospital multiple times over the past 2 years for "fluid in my lungs." MEDICAL HISTORY: 1. AF - on chronic coumadin 2. OSA - uses BiPAP at night 3. Asthma 4. CHF 5. CVA MEDICATION ON ADMISSION: 1. coumadin 2.5 M/W/F, 5 t/th/s/[**Doctor First Name **] 2. allopurinol 300mg qd 3. zestirl 40mg qd 4. lasix 40mg [**Hospital1 **] 5. immodium prn 6. colchicine prn 7. percocet prn 8. protonix 40 qd 9. albuterol inh prn 10. quinine prn ALLERGIES: Penicillins / Aspirin PHYSICAL EXAM: 98.3, 97.3, 123/66, 61, 20, 98%/BIPAP Gen: sitting in tripod position on BIPAP, conversant, HEENT: large lipoma left posterior neck, anicteric, MMM, missing teeth Cor: irregularly irregular, unable to appreciate MRG over noise of BIPAP Chest: bilateral crackles Abd: obese, NABS, soft, NT, ND Ext: 1+ edema bilaterally Neuro: A & O x 3 FAMILY HISTORY: Nonp-contributory. SOCIAL HISTORY: 50 pack-years of smoking, quit 15 years ago. No alcohol use. Retired.

CHIEF COMPLAINT: vertigo PRESENT ILLNESS: This is an 83 y/o female who presented to an OSH yesterday evening around 7 pm with c/o dizziness and nausea with vomiting x 1. There, she was given 25 mg IV of phenergan and 25 mg meclizine which resulted in restlessness and leg dyskinesias. She was given 50 mg IV benadryl for the reaction, which resulted in further agitation. She was given another dose of 50 mg IV Benadryl and a dose of Ativan (unknown amount). Shortly after that, she became stridorous and was electively intubated for airway protection at midnight. . In the ED, VS on arrival were T 99.7 (rectal), BP 175/119, HR 75, RR 22, SaO2 98% on AC/500 x 12/FiO2 0.5, PEEP 5. She was given one bolus of fentanyl and two boluses of propofol for sedation. Labs were significant for an elevated troponin of 0.21 with flat CK's and no EKG changes. She was also noted to have a leukocytosis with a left shift, no bands. She is being transferred to the MICU for further management. MEDICAL HISTORY: PMHx: HTN Hypothyroidism Uterine CA s/p TAH Osteoarthritis (spine, hips) . PSHx: Kidney stone removal Cholecystectomy Benign breast mass removal MEDICATION ON ADMISSION: 1. ASA 2. Toprol XL 3. Cozaar 4. Levoxyl ALLERGIES: Morphine / Codeine PHYSICAL EXAM: VS: T 97.7, BP 119/78, HR 81, RR 17, SaO2 99%/AC 500 x 12/FiO2 0.5/PEEP 5 General: Intubated and partially sedated elderly female. Withdraws to pain. HEENT: NC/AT, PERRL. ETT at 19cm at lips. MMM, OP clear. OG in place. Neck: supple, no JVD appreciated Chest: CTA-B, no w/r/r CV: RRR, s1 s2 normal, no m/g/r Abd: soft, NT/ND, NABS Ext: no c/c/e, pulses 2+ b/l Neuro: FROM, withdraws to pain, downgoing Babinski's b/l FAMILY HISTORY: Non contributory. SOCIAL HISTORY: Lives at home alone, husband in [**Name (NI) **]. Son lives close by, involved in her care. Ambulates at baseline. Non-smoker. No EtOH, no illicits.

CHIEF COMPLAINT: BRBPR PRESENT ILLNESS: 73yoM with pmh sig for bleeding duodenal ulcer in setting of anti-coagulation, discharged on the day prior to presentation after a month long hospitalization, who presents to [**Hospital1 18**] ED from rehab with BRBPR. Denies abdominal pain, vomitting, dizziness, chest pain. . Recent hospitalization after being found on the floor 4 days after a fall. Hospital course included ARF in the setting of rhabdo, DVT treated initially with anti-coagulation but anti-coagulation discontinued and IVC filter placed when pt found to have guaiac positive stool. EGD revealed large duodenal ulcer with adherent clot (treated with Bicap three times and injection). [**Hospital 65303**] hospital course also complicated by NSTEMI/demand ischemia, facial wound, UTI. . On [**1-19**] in the [**Name (NI) **] pt was briefly hypotensive to sbp 80s, hct 22 (last Hct was 31 24hours prior), NG neg, blood started, 4L NS given, taken to GI suite where EGD w/o active bleed. After negative EGD went for tagged rbc scan which was negative. Admitted to MICU after having received 2 units of prbc MEDICAL HISTORY: Parkinson's disease Hypertension Errectile dysfunction Dyslipidemia MEDICATION ON ADMISSION: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Carbidopa-Levodopa 10-100 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 7. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. 8. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 9 days. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q8H (every 8 hours). 10. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic QID (4 times a day). 11. Papain-Urea 830,000-10 unit/g-% Spray, Non-Aerosol Sig: One (1) Appl Topical DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Tc=99 P=116 BP=137/P RR=16 96 % on 2L Gen - NAD HEENT - PERRLA EOMI Heart - RRR, no M/R/G Lungs - CTAB anteriorly Abdomen - Soft, NT, ND, hyperactive BS Ext - circular lesions across both legs Skin - wound with eschar; left side of face, chest, LLE Neuro - CN II-XII grossly intact, 4/5 strength x 4, pill-rolling tremor at baseline FAMILY HISTORY: NC SOCIAL HISTORY: Lives alone on [**Location (un) 470**] of 3 story multi-family home. No tobacco/EtOH.

CHIEF COMPLAINT: Found collapsed at home PRESENT ILLNESS: Patient is a 82 yo LHW with hx of HTN and hypercholesterolemia who was found down per family today and initially taken to [**Hospital3 3583**] where she was found to have a large left ICH with mass effect. She was hypertensive at [**Hospital1 46**] to 264/100 per records. Given the large ICH, she was transferred here for further evaluation. Per family, she was last seen well at 3pm yesterday and ROS completely negative including fever, cough, HA, N/V/D. She is an independently ambulating, still driving, highly functioning 82yo per family who did not want to have heroic measures to sustain life. Patient was seen per NSURG who advised about the pros and cons regarding neurosurgical intervention. MEDICAL HISTORY: 1. Hypertension 2. Hypercholesterolemia MEDICATION ON ADMISSION: 1. Lipitor 2. BP meds - names unknown; uses CVS on [**Location (un) 8072**] St per family 3. ASA 81mg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T 96.7 BP 182/63 HR 92 RR 16 O2Sat 100% 2L NC Gen: Lying in bed, NAD - desheveled appearing with poor skin care HEENT: [**Location (un) 2848**] J collar CV: RRR, no murmurs/gallops/rubs Lung: Coarse, transmitted upper airway sounds Abd: +BS, soft, nontender Ext: 1+ bilateral edema with venous stasis skin changes FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Lives alone and performs all ADLs and IADLs independently including driving. Was an administrative assistance before retiring. Remote tobacco hx and no EtOH per family. DNR/DNI per daughter, [**Name (NI) **] who is also her HCP.

CHIEF COMPLAINT: PRESENT ILLNESS: This is an 86 year old gentleman who has a recent history of increasing shortness of breath and dyspnea on exertion. The patient is status post coronary artery bypass graft times four in [**2150**], with known aortic stenosis followed by serial echocardiograms. The patient underwent cardiac catheterization on [**2162-10-6**], which showed severe native three vessel disease, moderately increased left ventricular end diastolic pressure at 26 with mild pulmonary hypertension as well as an occluded saphenous vein graft to R1, patent saphenous vein graft to OM with moderate anastomotic lesion, patent left internal mammary artery to left anterior descending with severe native lesion distal to the anastomosis. The patient was referred to Dr. [**Last Name (Prefixes) **] for aortic valve replacement and coronary artery bypass graft. MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Coronary artery disease. 3. Aortic stenosis. 4. Benign prostatic hypertrophy. 5. Status post coronary artery bypass graft in [**2150**]. 6 Status post tonsillectomy. 7. Status post right below the knee amputation secondary to a war injury in [**2103**]. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient denies tobacco or ETOH. The patient is married and lives with his wife.

CHIEF COMPLAINT: chronic abdominal pain and recurrent pancreatitis PRESENT ILLNESS: This 51-year-old gentleman presented to me within the last month with a 9-year history of abdominal pain and recurrent bouts of pancreatitis. His workup for this never took him to the extent of advanced imaging nor an ERCP until recently. He was referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for an endoscopic ultrasound and that examination showed gross cystic disease of the head of the pancreas. A CT scan confirmed this with macroscopic cystic disease in the head, inflammatory changes of the whole pancreas and a dilated pancreatic duct distally as well with lymphadenopathy. All these features put together were very suggestive of intraductal papillary mucinous tumor. MEDICAL HISTORY: pancreatic cystic dz., pancreatitis, GERD, multiple fractures, cataracts. Sz associated with alcohol withdrawal. PSH: rotator cuff rep air, R knee arthroscopy, EUS MEDICATION ON ADMISSION: ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: NAD AOx3 CTA b/l RRR soft, mild TTP, no distension +bs no c/c/e FAMILY HISTORY: SOCIAL HISTORY: heavy ETOH abuse, smoking

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 65-year-old white male with a history of type 2 diabetes and extensive peripheral vascular disease who was initially admitted to the Podiatry Service with a left forefoot cellulitis with associated fevers and chills. There was no trauma or foreign body associated with the cellulitis. Therefore, it was opened and drained. The patient was started on intravenous antibiotics. MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypertension. 3. Peripheral vascular disease. 4. Hypercholesterolemia. 5. Gastroesophageal reflux disease. MEDICATION ON ADMISSION: Glucovance 5/500 mg p.o. b.i.d., hydrochlorothiazide 25 mg p.o. q.d., metoprolol 100 mg p.o. b.i.d., Norvasc 2.5 mg p.o. b.i.d., Zestril 40 mg p.o. q.d., Lipitor 40 mg p.o. q.d., Prilosec 20 mg p.o. q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Fever & Chills PRESENT ILLNESS: Mr. [**Known lastname 20904**] is a 73 year-old man with a history of recent TURP ([**3-28**]) who presents with respiratory failure and UTI. . Per family, the patient was generally feeling well until one day prior to admission when he "wasn't feeling that great" and felt as though he was "coming down with something". A slight fever (100) was noted along with chills. Took tylenol and Dayquil. Additionally noted a burning sensation and blood in urine. Additionally noted a cough since last week with sputum, no blood. . Regarding his breathing, the family felt that this was generally unchanged. He has had increasing DOE, worsening over the last few months. He gets SOB after one flight of stairs. He does not get chest pains. Family has also noted significant weight over last few months, mostly in abdomen. . EMS reports show an initial BP of 124/103 with a RR of 30 and O2 of 89% on room air. Their notes indicate that the patient was "sitting in bed shaking violently. States he can't breath." . In the ED, BP was initially 224/91, HR 120, RR 35, 99% on unclear amount of oxygen. Spiked to 104.8. Blood pressures trended down (200s to 80s systolic). When an EKG showed inferior ST-elevations, a code STEMI was called. Before taking the patient to the cath lab, it was noted that BPs were unequal so a CTA was obtained. This was negative for dissection and initially was thought to show a PE. Soon thereafter, the patient was intubated with a propofol gtt started. Was also given labetolol IV for hypertension. Soon after, blood pressure fell to 118/56, then to 80s systolic. A total of 5+ liters of normal saline were given, along with the following medications: - Aspirin 325mg - Zofran - Levaquin 750mg IV MEDICAL HISTORY: 1. Diabetes 2. Dyslipidemia 3. Hypertension 4. Benign prostatic hypertrophy 5. Arthritis 6. Gout 7. Bladder stone MEDICATION ON ADMISSION: 1. Amlodipine 5 mg daily 2. HCTZ 25mg daily? 3. Atenolol 50 mg daily 4. Metformin 500mg daily 5. Glyburide 5mg daily 6. Simvastatin 40 mg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals - T 100.1, BP 138/48, HR 98, AC 600/16, PEEP 5, FiO2 100% GEN - Intubated. Does not respond to commands but is moving all extremities. HEENT - Surgical pupil on the right; 3mm -> 2mm on left. CV - Difficult to hear heart sounds. No obvious murmurs. PULM - No rales/wheeze. ABD - Soft. Non-tender. Guaiac + per ED. EXT - Warm. No edema. FAMILY HISTORY: Non-contributory. SOCIAL HISTORY: Previous history of smoking, quit 10 years ago. Not currently drinking. Worked as a cook.

CHIEF COMPLAINT: PRESENT ILLNESS: In brief, the patient is a 57-year-old white male with a history of known coronary artery disease, status post a non Q-wave myocardial infarction in [**2092-10-12**] with a cardiac catheterization at that time revealing 60% LAD stenosis, 60% OM2 stenosis and 60% RCA stenosis. The patient does not have any recent complaints of chest pain, but does have episodes of weakness associated with his Celebrex use. He was found to have hypertension and primary care physician referred patient for echocardiogram which showed a normal ejection fraction with moderate mitral regurgitation. This was followed by a stress test which was positive and the patient was again referred for cardiac catheterization which revealed 60% proximal RCA diffuse disease of the right PDA, 30% of the left main, 50% of the mid LAD, 100% of the circumflex with severe mitral regurgitation and an ejection fraction of approximately 55%. Thus, the patient was referred to the [**Hospital1 **] to cardiac surgery and coronary artery revascularization and mitral valve replacement. MEDICAL HISTORY: 1. Hypertension 2. Hypercholesterolemia 3. Non Q-wave myocardial infarction 4. Asymptomatic right carotid disease 5. Degenerative joint disease 6. History of Crohn's disease or ulcerative colitis 7. History of polio 8. History of hepatitis C 9. Benign prostatic hyperplasia MEDICATION ON ADMISSION: ALLERGIES: He has no known drug allergies. PHYSICAL EXAM: VITAL SIGNS: The patient was afebrile with stable vital signs. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Warm and no cyanosis, clubbing or edema. FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Chief complaint of status post ventricular fibrillation arrest. PRESENT ILLNESS: The patient is a 47-year-old male with a history of coronary artery disease, status post acute myocardial infarction 20 years ago, status post 4-vessel coronary artery bypass graft in [**2136**], status post myocardial infarction in [**2151**] (with an right coronary artery to saphenous vein graft stent), status post myocardial infarction in [**2152**] (with an saphenous vein graft to left anterior descending artery percutaneous transluminal coronary angioplasty; at that time had an ejection fraction of 40%), history of diabetes, and hypertension who was admitted to [**Hospital1 69**] after surviving a ventricular fibrillation arrest on a flight from [**Location (un) 86**] to Venezuelae. The plane landed in [**Male First Name (un) 1056**]. Per nephew, the patient had four to five weeks of progressive chest pressure with exertion with increased use of nitroglycerin. He refused to seek medical advice at that time. Per wife, the patient has had angina for several years but was told in [**State 2690**] there was no more they could do. On flight from [**Location (un) 86**] to Venezuelae, the patient had a ventricular fibrillation arrest on Thursday evening, automatic external defibrillator was used and with two to three shocks was delivered from ventricular fibrillation. No available strips at this time. The plane was diverted to [**Male First Name (un) 1056**] where his nephew met him. The patient was intubated on the airstrip, but answering questions appropriately at that time. He was transferred to a second hospital in [**Male First Name (un) 1056**] and started on amiodarone drip, heparin drip, and nitroglycerin drip. There, revealed an ejection fraction of 30%. It was reported that a maximum troponin of greater than 500 with a maximum creatine kinase of greater than 16,000. The patient was subsequently transferred to [**Hospital1 188**] from [**Male First Name (un) 1056**]. At [**Hospital1 **], the patient was lightly sedated, on a propofol drip. He recognized his wife and nephew and answered all questions appropriately. He denied any chest pain. MEDICAL HISTORY: 1. Coronary artery disease; status post myocardial infarction 20 years ago; status post 4-vessel coronary artery bypass graft in [**2146**] (saphenous vein graft to first obtuse marginal, saphenous vein graft to circumflex, saphenous vein graft to left anterior descending artery, saphenous vein graft to right coronary artery); status post myocardial infarction in [**2151**] and [**2152**]. 2. Diabetes. 3. Hypertension. MEDICATION ON ADMISSION: Medications on arrival included atenolol 50 mg p.o. q.d., Vascor 200 mg p.o. q.d., Imdur 20 mg p.o. q.d., sublingual nitroglycerin p.r.n., aspirin 81 mg p.o. q.d., Zantac 150 mg p.o. b.i.d., niacin 500 mg p.o. q.d., Zocor 40 mg p.o. q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives in [**Location 40655**]. He is an emergency medical technician physician. [**Name10 (NameIs) 40656**] use; quit 20 years ago. He is married with two children.

CHIEF COMPLAINT: Aortic dissection and aneurysm PRESENT ILLNESS: This is a 41-year-old gentleman with Marfan's syndrome who initially presented with aortic arch aneurysm, underwent arch replacement and stent grafting of the arch and proximal descending thoracic aorta. He subsequently developed aneurysm of his thoracic aorta. However, he also suffered from a ruptured esophagus from Boerhaave syndrome. The dissection went down through the abdominal aorta to the iliac vessels bilaterally. The abdominal aorta and common iliac arteries were aneurysmal was well. In order to treat the thoracic aortic aneurysm with a stent graft we needed to develop the landing zone in the abdominal aorta by replacing it with the aortic tube graft and performing visceral de- branching. MEDICAL HISTORY: Thoracic Aortic Aneurysm s/p endovascular stent placement to ascending, arch, and descending aorta with right axillary - femoral bypass grafting and reconstruction of innominate and left carotid artery [**3-25**] Boerhaave's esophageal rupture s/p repair [**11-25**] Marfans Syndrome, History of Aortic Dissection s/p Aortic Valve Replacement and Ascending Aorta Replacement in [**2153-5-20**], History of Postop Deep Vein Thrombosis, History of Post-op Atrial Fibrillation, Asthma, Gastroesophageal Reflux Disease, Hiatal Hernia, s/p Hernia repair, s/p Foot surgery MEDICATION ON ADMISSION: lopressor 25", protonix 40", nortriptyline 20', lyrica 75", ASA 81', advair 250/50" ALLERGIES: Sulfa (Sulfonamides) PHYSICAL EXAM: VSS: 98, 108/70, 91%RA GEN: NAD Neuro: A+OX3 CVS: RRR RESP: CTA ABD: soft, NT EXT: No edema. B/L palp DP Incision C/D/I FAMILY HISTORY: Denies connective tissue disorders. No history of premature CAD. SOCIAL HISTORY: Denies tobacco. Admits to occasional ETOH. He is married and lives with his wife. [**Name (NI) **] is an electrical engineer.

CHIEF COMPLAINT: Shortness of breath PRESENT ILLNESS: The patient is a 63 yo male with h/o COPD, chronic bronchitis, tobacco use and CAD who presented to [**Hospital3 **] on [**3-25**] with c/o progressively worsening SOB x 2 weeks. He also c/o intermittent CP in the left ant chest that was mild and lasted for a few minutes and would disappear. At admission he was found to have evidence of pulmonary edema on CXR, ? LLL infiltrate and BNP was >5000. He had intial troponin I of 0.24 with CK [**Street Address(2) 66197**], Twave changes on EKG. He required bipap and was treated with morphine,Lasix and NTG. He diuresed well on this regimen. Wheezing also improved with Spiriva and Advair. While being diuresed his Cr went to 1.9 from 1.6 at admission. Lasix and Mavik were held after that and NTG gtt was continued. Per report he an echo with EF of 25-30% (EF of 46% in [**2170**]). Peak troponin I was 0.36. The patient notes that PTA he has had a productive cough with occ pale green sputum that has been present for months to years. In [**2177-1-12**] he was diagnosed with bronchitis. He then developed a spontaneous rib fracture, thought to be [**2-13**] to coughing. More recently, he was thought to have PNA and was treated with 21 days of levaquin with no improvement. 2 days PTA at OSH he was started on Ketek. Currently patient feels well with no CP, SOB, N/V, abd pain, fevers, chills, constipation or diarrhea. He denies orthopnea or recent LE edema. MEDICAL HISTORY: Bronchitis diagnosed in [**January 2177**] and spontaneous rib fx [**2-13**] to cough, developed PNA and started on levaquin for 21 days with no improvement. Then started on Ketek on [**3-24**]. COPD HTN Hyperlipidemia Ao Aneurysm (per pt is 5-5.5 cm) PVD and claudication, Chronic bronchitiS CHF - EF 25% Gout Kidney stones OA MEDICATION ON ADMISSION: ASA 325 lopressor 25 tid IV nitro lasix 40 qd Mavik 4 qd nicotine patch Lovenox 30 mg sq qd Mucinex 600 po BID ALbuterol nebs Rocephin 1 gm IV qd Advair Diskus 500/50 mg one puff [**Hospital1 **] Spiriva one capsule qd ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PE: BP 124/78 HR 85 R 20 O2 sat 96% 2L Gen: well appearing male in NAD, lying in bed post cath HEENT: normocephalic, anicteric sclera, MMM, pupils equal and round Neck: supple, no JVP Pulm: CTA B anteriorly Cardio: RRR, nl S1 S2, no m/r/g Abd: soft, NT, ND, + BS Groin: dressing c/d/i, no bruit, no hematoma Ext: no lower ext edema 2+ PT/DP pulses b/l Neuro: A&Ox3, neuro exam grossly intact FAMILY HISTORY: Denies heart disease, HTN or DM SOCIAL HISTORY: Works at a plastics corporation as an executive. Actively smokes - 2 ppd smoker x 46 years. Quit ETOH 15 years ago. Lives with wife, son and daughter.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 40 year old male with past medical history significant for Marfan syndrome and gastroesophageal reflux disease who presented to an outside hospital with the complaint of chest pain. Patient describes recurrent fleeting episodes of chest pain, lasting seconds, with radiation to the left neck, while at rest. Patient denies an exertional component as well as shortness of breath, nausea, vomiting, associated diaphoresis. Patient presented to the outside hospital to be evaluated by his primary care physician who sent him to the emergency department. He was subsequently transferred to [**Hospital1 18**] for further evaluation of his aorta. Patient has had prior CAT scan evaluation of his aorta, all negative for aneurysm. Patient has no known history of coronary artery disease and has had multiple negative stress tests in the past. On arrival to the emergency department patient was chest pain free and hemodynamically stable with blood pressure of 135/96, heart rate 81, oxygen saturation 98% in room air. Patient underwent a chest CT angiogram for evaluation of potential aortic aneurysm and/or dissection. The CT angiogram demonstrated mild prominence of the aortic root with no evidence of aneurysm or dissection. Patient was admitted to the cardiac intensive care unit for monitoring and evaluation. MEDICAL HISTORY: Marfan syndrome. Gastroesophageal reflux disease. MEDICATION ON ADMISSION: Lopressor 50 mg p.o. b.i.d., Prilosec 20 mg p.o. q.day. ALLERGIES: Penicillin, Demerol. PHYSICAL EXAM: FAMILY HISTORY: Significant for Marfan syndrome with two brothers who have undergone prior aortic surgery secondary to complications from Marfan syndrome, several uncles are also affected. SOCIAL HISTORY: The patient lives alone and is single. Patient reports a history of cigar use, however, denies current alcohol use.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 60 year old man who presented with a long-standing heart murmur. His primary care physician performed echocardiogram which revealed severe aortic stenosis. He underwent coronary angiography which revealed a 60% lesion left anterior descending and severe aortic stenosis. Ejection fraction was noted to be 70%. MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Hypertension. 3. Noninsulin dependent diabetes mellitus. 4. Chronic back pain. MEDICATION ON ADMISSION: 1. Lipitor 10 mg q.d. 2. Glyburide 2.5 mg q.d. 3. Accupril 20 mg q.d. 4. Flomax 0.4 mg q.d. 5. Aleve p.r.n. 6. Therapeutic multivitamin. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient is a former smoker. He quit twelve years ago.

CHIEF COMPLAINT: Dyspnea PRESENT ILLNESS: This is a 43 year old female with progressive dyspnea on exertion and lower extremity edema which required hosptitalization in [**2108-4-20**]. During that hospitalization, she was found to have severe pulmonary hypertension and mild mitral stenosis. Despite medical therapy, she has continued to experience dyspnea even at rest and especially with minimal exertion such as walking up one flight of stairs. Recent echocardiogram in [**2108-7-21**] revealed 3+MR and a PFO. Dr.[**Last Name (STitle) 914**] was consulted for surgical intervention. MEDICAL HISTORY: Hypertension Pulmonary Hypertension Possible Rheumatic heart disease - MR/MS [**First Name (Titles) 70393**] [**Last Name (Titles) **] Asthma/COPD Marked lower extremity edema/Lymph Edema Migraines Obstructive sleep apnea (CPAP- uses periodically) Depression/Bipolar disorder Possible Fibromyalgia on Percocet Osteoarthritis History of Bells Palsy, 10 years ago Past Surgical History: s/p cervical spine surgery in [**2103**] at [**Hospital1 1774**] s/p TAH for excessive bleeding in [**2105**] s/p C-section x 2 MEDICATION ON ADMISSION: Lasix 120mg po BID KCl 20mEq po daily Lisinopril 20mg po daily Metolazone 5 mg po daily Metoprolol Tartrate 100mg po BID Alprazolam PRN Albuterol Sulfate Inhaler 4 times a day PRN Advair Diskus [**Hospital1 **] Ipratropium PRN Combivent Inhaler 4 times a day PRN Nortriptyline 40mg po QHS Abilify 15mg po qHS Effexor XR 225mg po QHS Percocet PRN back pain Ibuprofen PRN Fioricet PRN ALLERGIES: Penicillins PHYSICAL EXAM: Pulse: 79 Resp: 22 O2 sat:94% RA B/P Right: 119/75 Left: 114/70 Height:5'6" Weight:360 lbs FAMILY HISTORY: Significant for fibromyalgia in her brother, mother and maternal aunt. History of ovarian, breast, and colon cancer in maternal side. Congenital heart dz in niece. Mother with RHD and MVR as well as MI in her 40s. MGF with stroke in 80s. SOCIAL HISTORY: She currently lives in [**Location 8985**], [**State 350**]. She is married with two daughters who are healthy. She smokes one to two packs per day for the past 21 years. Social alcohol use. No drug use. She is currently unemployed and not on disability

CHIEF COMPLAINT: Recurrent chest pain PRESENT ILLNESS: Mrs. [**Known lastname 19688**] is a 73 year old female who has undergone multiple percutaneous interventions and stent placement to her right coronary artery. Her most recent was [**2125-2-22**] at the [**Hospital1 18**]. She has been relatively chest pain free since that time. She presented to [**Hospital 1474**] Hospital with recurrent substernal chest pressure and heaviness with left arm/shoulder discomfort. She ruled in for a NSTEMI. She was stablized on medical therapy and transferred back to the [**Hospital1 18**] for further medical management. MEDICAL HISTORY: Congestive Heart Failure, NSTEMI, Coronary Artery Disease - s/p multiple RCA stents, Mitral Regurgitation, Diabetes Mellitus - on Insulin Therapy, Hypercholesterolemia, Cerebrovascular Disease - s/p CVA, Known Carotid Disease, Right Subclavian Stenosis, Peripheral Vascular Disease, History of Humeral Fracture, GERD, Depression, Prior Bladder Surgery MEDICATION ON ADMISSION: Aspirin 325 qd, Plavix 75 qd, Lasix 40 qd, Protonix 40 qd, Atenolol 25 qd, Lipitor 40 qd, Lisinopril 5 qd, Imdur 60 qd, Humulin Insulin 70/30 - 35 units qam and 20 units qpm, Advair MDI, Atrovent MDI, Eye gtts ALLERGIES: Penicillins / Sulfa (Sulfonamides) PHYSICAL EXAM: Vitals: T 97.5, BP 165/40, HR 53, RR 18, SAT 98% on 2L General: elderly female in no acute distress HEENT: oropharynx benign Neck: supple, no JVD, soft right carotid bruit noted Heart: regular rate, normal s1s2, soft systolic ejection murmur at LLSB Lungs: clear bilaterally Abdomen: obese, soft, nontender, normoactive bowel sounds Ext: warm, trace edema, no varicosities Pulses: decreased distally Neuro: alert and oriented, slight left facial droop, mild left sided weakness otherwise nonofocal FAMILY HISTORY: Denies premature coronary disease. SOCIAL HISTORY: Lives with her daughter. Denies tobacco, ETOH and recreational drugs. Ambulates with a walker.

CHIEF COMPLAINT: Colitis PRESENT ILLNESS: M with h/o COPD, s/p left lobectomy, rheumatic heart disease, PAF on coumadin, HTN who presented to OSH on [**1-21**] with bloody diarrhea, found to have collitis, transfered to [**Hospital1 18**] for potential surgical issues and hypoxia management. . Patient reports diarrhea beg [**1-15**] (6 days PTA). He was having [**6-15**] bowel movement per day - liquid. No f/c, no nausea, no sick contacts. BMs with occasional blood - 1-2 per day with 1-2 cc of blood 2 days prior to presentation to OSH. Patient was recently treated with ABX for bronchitis. CT scan at [**Location (un) **] showed pancolitis, with low suspicious for ischemic colitis. Patient was admited for hydration, Cipro/flagy were started. His INR was 4.2 upon admission. They had difficulty obtaining a stool sample due to lack of BMs. Subsequently, patient subsequently had a colonocopy on [**1-24**] which showed distal sigmoid with intense areas of pathacy, hyperemic mucosa with moderate inflammatory changes. Moderate diverticulosis was see in the sigmoid, no diverticulitis. The involvement was atypical for ischemic disease. There were not specific for C. Diff either. Patient's gastric distention improved with suctioning of air, functional stricture was appreciated at junction of sigmoid and distended colon - ? Ogilvies. Biopsies were taken from involved sigmoid colon/rectum. Patient was also evaluted for hemoptysis as he has h/o RUL spiculated nodule and LLL lobectomy. Patient coughed up 1 spood of blood, with resolution of hemoptysis. HIs INR continued to raise during his admission to 4.7. Patient waws also given 5 mg of Vitamin K. His Hct remained stable, no FFP was hgiven. It was felt that bronchoscopy was not indicated. Patient was subsequently transfered to [**Hospital1 18**] for potential surgical intervention, hypoxia/SOB, worsening liver, renal failure and on levophed for hypotension. . Patient denies any fevers/chills, he reports minimal PO intake with liquid diet, he also reports insertion of NGT on [**1-27**] without relief of his symptoms. He denies any cp, no current SOB, although overall has been more dyspnic x 3 days. He admits to persistent hemoptysis x 3 days, last episode 3 days ago. Minimal amount. He denies any current abdominal pain. Had a BM, well formed nonbloody this AM. He has a foley catheter that was inserted [**1-24**]. He also reports increased LE edema since [**Month (only) **]. MEDICAL HISTORY: COPD - FEV 1.5 - 2.0 L s/p Left lower lobectomy for benign tumor h/o of resolved spiculated RUL nodule - evaluated by Dr. [**Last Name (STitle) **] in [**Month (only) 216**], felt to be inflammatory with no follow up necessary. Nl bronchoscopy in [**Month (only) 216**] at [**Location (un) **]. H/O rheumatic heart disease MR (moderate) /Mitral stenosis - valve area 1.5 - 2.0 PAF on coumadin - patient had failed cardioversion in [**Month (only) **], due to persistence of Afib, increase in weight, SOB and worsening of NYHA class to IV. During OSH admission his HR was difficult to control with HR to 140s on BB, Digoxin. Patient is schedule for potential PVI in [**2125-2-6**] here at [**Hospital1 18**]. Has been on amiodarone in the past. CHF 2000Cardiac catherization w/o evidence of CAD h/o TIA HTN Hyperlipidemia Bilateral hernia repair Appendectomy Malignant tumor (?muscle) in his leg MEDICATION ON ADMISSION: MEDS ON TRANSFER TO CCU: Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Maalox/Diphenhydramine/Lidocaine 15-30 ml PO QID:PRN Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN MetRONIDAZOLE (FLagyl) 500 mg PO TID (since [**1-23**]) Ciprofloxacin HCl 500 mg PO Q24H (since [**1-23**]) Nystatin Oral Suspension 5 ml PO QID Dopamine gtt at 5 Pantoprazole 40 mg PO Q24H Docusate Sodium 100 mg PO BID Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **] Tiotropium Bromide 1 CAP IH DAILY . MEDS AT HOME: Coumadin 2.5 mg on Mon/Wed/Fri, 5 mg other days Lasix 40 mg Daily Digoxin 0.125 mg Daily Iron 65 mg daily Toprol XL 12.5 mg daily ASA 81 Spiriva Advair 100/50 one puff [**Hospital1 **] ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals on MICU Tx: 96.1 90(Afib) 105/64 95%2LNC RR 14-19 Vitals on Floor: 96.6 100/60 90 20 96%2LNC Gen: alert, though appears sleepy. HEENT: toungue moist, white exudate on posterior oropharynx NECK: Supple, No LAD, prominent V waves appreciated on exam, marked JVP, pulsitile CV: RR, NL rate. NL S1, S2. systolic murmur heard best @ apex LUNGS: Faint crackles bilaterally at bases ABD: Soft, NT, ND. NL BS. No HSM EXT: 2+ grossly pitting edema. 2+ DP pulses BL SKIN: No lesions FAMILY HISTORY: nc SOCIAL HISTORY: patient lives alone with his wife. Quit tobacco 16 years ago. 50 + pack years. No daily EtOH, several a week

CHIEF COMPLAINT: Chest pain and fatigue PRESENT ILLNESS: This is a 66yo M PMHx pericarditis w small pericardial effusion diagnosed [**2163-12-15**] at [**Hospital1 18**] ED, started on ibuprofen and colchicine, presenting with new onset chest pain. 1.5 wks prior to presentation patient presented to [**Hospital1 18**] ED with retrosternal chest pain, found to have diffuse PR depressions and ST elevations in the context of recent reported viral illness. Patient was started on ibuprofen and colchicine at that time and discharged from ED. Patient reports subsquent improvement in symptoms, and was seen by his PCP [**2163-12-22**], who ruled him out for a PE with a CT contrast given his persistant tachycardia, and performed a TTE [**2163-12-23**] that showed small circumferential pericardial effusion with slight right ventricular diastolic invagination c/w increased pericardial pressure. Patient was [**Last Name (LF) 7319**], [**First Name3 (LF) **] plan was to repeat TTE in 1wk to observe for change. However, at midnight on evening of this presentation, patient developed acute new onset, substernal chest pain, described as sharp and pressure-like, non-radiating, exertional, and pleuritic in nature. It was associated with diaphoresis and nausea. He denied associated cough, fevers, shortness of breath. . On initial presentation to [**Hospital1 18**] initial vital signs were 77 103/62 20 98%RA. Exam was significant for clear lung fields, elevated JVD. A bedside ultrasound performed by the ED staff reportedly demonstrated moderate-large pericardial effusion. Labs were significant for WBC 11.5 (N80%), Hct 31.5 (39.7 at discharge), platelets 554 (from 354), Cr 0.9. Patient was given ASA 325mg and cardiology consult was called. During this time, patient became increasingly tachycardic and hypotensive, requiring urgent placement of CVL and initiation of dopamine. Official echo demonstrated enlarged pericardial effusion, RV cavity appearing smaller but without collapse, suggestive of impending (early) tamponade. Patient was transferred to cath lab for urgent pericardiocentesis which was performed with opening pressure 24 mmHg, 320 cc bloody fluid taken off with resolution of symptoms and return of normal hemodynamics. Patient now with mild residual chest pain. . 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, 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 paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: none 2. CARDIAC HISTORY: - Pericarditis presumed [**3-16**] post-viral [**2163-12-15**] 3. OTHER PAST MEDICAL HISTORY: - Depression/Dysthymia MEDICATION ON ADMISSION: - Colchicine 0.6mg [**Hospital1 **] - Ibuprofen 600mg q8hrs - Fluoxetine 40mg daily - Trazodone 50mg qhs - ASA 81mg daily (on hold given initiation of ibuprofen) - Calcium Citrate / Vitamin D - Omeprazole 20mg daily ALLERGIES: Penicillins PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS T 98.7, HR 77 BP 103/62 RR 20 O2 Sat 98%RA GENERAL: NAD. AOx3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm above sternal angle. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Soft pericardial rub loudest near apex. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM: VITALS: 98.6, 65, 132/79, 18, 98% GENERAL: NAD. AOx3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 3 cm above sternal angle, continued kussmahl's sign which is becoming less prominent. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Soft pericardial rub has resolved. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ FAMILY HISTORY: Alzheimer in father, died at age 80 from SBO; he has three sisters, who are generally in good health although one had pericarditis with tamponade decades ago and has since had valve replacements for unclear reason. No family history of diabetes, heart disease, except for grandfather suffering an MI at age>70. SOCIAL HISTORY: Quit cigarettes 20-30 years ago, 14-pack-year history; ~3 glasses of wine per week, denies illicits; regularly exercises; has Masters in City and Regional Planning obtained from [**Location (un) 7320**], works as a career counselor at Career Source in [**Hospital1 8**]. Divorced without children.

CHIEF COMPLAINT: Abdominal pain. PRESENT ILLNESS: This is an 86 year old man with a history of coronary artery disease, myelodysplastic syndrome, aortic stenosis, aortic regurgitation, who presents with acute onset of midepigastric pain without radiation to his back. The pain was constant and ten out of ten. The patient came to the Emergency Department for further evaluation and he had dry heaves but without vomiting. He denies fever or chills at home. He has no history of postprandial pain. No recent changes in his medications. The patient denies chest pain and currently he has no palpitations. MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft of four vessels in [**2189**], at [**Hospital6 2121**]. 2. Hypertension. 3. Myelodysplastic syndrome with thrombocytopenia. 4. Gout. 5. Basal cell carcinoma. 6. History of dysplastic colonic polyps. 7. Glaucoma. 8. Cataract. 9. Anxiety. 10. Degenerative joint disease with disc herniation at L4-L5. 11. Parkinson's disease. 12. Aortic stenosis with moderate aortic insufficiency. Echocardiogram in [**2196**], demonstrated an ejection fraction of greater than 55% with aortic valve of 1.0 square centimeters and moderate aortic stenosis and moderate to severe aortic regurgitation. MEDICATION ON ADMISSION: 1. Isosorbide 20 mg once daily. 2. Potassium Chloride 20 meq once daily. 3. Lasix 40 mg twice a day. 4. Tricor 60 once daily. 5. Allopurinol 300 mg once daily. 6. Paxil 20 mg once daily. 7. Sinemet one tablet twice a day. 8. Protonix 40 mg once daily. ALLERGIES: The patient is allergic to Ciprofloxacin, Morphine, Demerol that causes nausea and vomiting. PHYSICAL EXAM: FAMILY HISTORY: Brother with muscular dystrophy. SOCIAL HISTORY: He is a retired fireman who lives alone in a duplex with his daughter living nearby.

CHIEF COMPLAINT: PRESENT ILLNESS: Chronic renal insufficiency, status post MI, status post CABG x5, hypertension, and dyslipidemia admitted with hypotension, acute renal failure, and altered mental status for approximately three days. The patient was recently diagnosed with pansensitive E. coli UTI on [**2-27**]. She was started on Bactrim double strength b.i.d. for a 10-day course. Her last dose was on the [**3-5**]. Several days prior to admission, the patient reportedly developed rhinorrhea, myalgia. No cough or fevers, however. The patient was noted by family to be increasingly confused, lethargic, weak, and required increased assistance. On presentation, the patient was hypotensive with a systolic blood pressure ranging between 70-80s with a BUN and creatinine of 84 and 7 respectively. Her baseline creatinine varies between 1.4-2. Her tox screen was negative. She received IV fluids, Solu-Medrol, and empiric ceftriaxone. After 4 liters of IV fluids, the patient was still hypotensive with a systolic blood pressure range in the 80s. CT of the head was negative. Renal ultrasound did show mild right hydronephrosis. The patient was transferred to the MICU. She was started on sepsis protocol. She was given stress dose IV steroids and empiric antibiotic coverage. MEDICAL HISTORY: As mentioned above. 1. Systemic lupus erythematosus. Remote history of lupus nephritis. 2. Chronic prednisone. 3. Chronic renal insufficiency. 4. CAD status post CABG in [**2136**]. 5. Peripheral vascular disease status post right BK to peroneal. 6. Type 2 diabetes diet controlled. 7. Glaucoma. 8. Cataract. 9. History of thrombocytopenia. MEDICATION ON ADMISSION: ALLERGIES: Flu vaccine. PHYSICAL EXAM: FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient denies any history of tobacco or alcohol use. She lives alone. Her family is involved in her care.

CHIEF COMPLAINT: Tylenol/barb Overdose PRESENT ILLNESS: 35 yo F w/Hx of depression and 4 prior suicide attempts, presenting after being found unresponsive (unclear for how long she was down, pt last seen the day before at 10 pm) in her group home on the morning of admission. A suicide note was apparently found. She was intubated in the field. Per pt's pharmacy, pt has access to Fioricet/trazodone/Effexor XR/clonazepam/lorazepam/risperdal. . In the ED, pH 7.25 ([**Last Name (un) **]), lactate 9.0, tox screen + for barbiturate and Tylenol level 267. Received activated charcoal and Mucomyst 10 gr PO. Hypotensive to the 60s (SBP), started on norepinephrine with good response. MEDICAL HISTORY: - Major Depression and anxiety disorder - s/p multiple suicide attempts w/OD, prefers Fioricet (this is the 5th attempt, 3rd in the last 18 months). She completed a fioricet detox program on [**3-6**], but then in [**Month (only) 205**] had another ICU stay at the [**Hospital1 112**] for Fioricet/Tylenol OD, peak tylenol level was 148 ~4h psot-injestion. No LFT abnormalities at the time. Graduated from a treatment program at the [**Hospital1 882**] [**7-13**]. Also has been hospitalized at the [**Hospital1 2177**], [**Hospital1 336**]. - Idiopathic Sz disorder - Eczema - Asthma - RA MEDICATION ON ADMISSION: Butalibitol-APAP-caffeine (picked up 50 pills on [**7-15**] from [**Company 25282**]) Effexor XR 150 [**Hospital1 **] Clonazepam 1 [**Hospital1 **] Risperdal Lorazepam Ambien Lamictal 50 [**Hospital1 **] ?Wellbutrin Ranitidine Metylprednisolone ALLERGIES: Sulfa (Sulfonamides) / Egg / Shellfish PHYSICAL EXAM: Vs: T 98.7 HR 77 BP 117/94 RR 18 O2Sat 97% RA FS 93 Gen: NAD at rest. HEENT: Pupils 5 mm, equal, reactive to light. EOMI. MM moist, OP clear. Lungs: few crackles at bases b/l CV: RRR, no MRG Abd: +BS, S/NT/ND Extr: warm, no LE edema FAMILY HISTORY: NC SOCIAL HISTORY: PO narcotic user (h/o fioricet abuse), never used IV drugs. + tob hx, no EtOH. Has a sister, who is involved. Recently broke up w/fiance 6 weeks ago. Lives in a boarding house or group home. On SSDI.

CHIEF COMPLAINT: hypotension PRESENT ILLNESS: 56 yo man with HCV cirrhosis and metastatic hepatocellular carcinoma who has been receiving cisplatin for his hepatoma; this was last dosed on [**5-9**]. On [**5-17**] he developed fevers and weakness; he denied focal symptoms but felt generalized "bony pain." He denied abdominal pain or increased increased girth. He did have poor po intake over the last several days prior to admission. He also had been having loose stools, likely due to ongoing treatment iwth lactulose. He denied chest pain, dyspnea, cough, or dysuria, but had noticed decreased urine output over the last several days prior to admission. . He presented to an OSH [**5-19**] where he was found to be hypotensive (78/52). He was given a 250 cc bolus, ceftriaxone, levofloxacin, and was sent here for further evaluation. Of note. labs at the OSH showed wbc 1.3, hct 15.5, plts 16, INR 2.5, TB 24.7, Na 126, K 5, Cl 97, HCO3 17, BUN 68, Cr 2.4. . In the ED here, the patient was hypothermic and hypotensive. He received two liters IV fluids, a femoral line was placed (low plts and INR >3), bear hugger was placed, and he was given cefepime. Levophed was started. CBC showed pancytopenia. He was found to be guaiac positive (noteworthy given upper GI bleed s/p banding of esophageal varices [**3-1**]). . He was admitted to the ICU where vancomycin and metronidazole were added to cefepime. He was transfused four units of pRBC and four units of FFP, and platelets. IV fluids were continued. . Given his poor prognosis, a family meeting was held [**5-20**], wherein the patient's code status was changed to DNR/DNI. The primary focus of care at this point is the patient's comfort. MEDICAL HISTORY: 1. HCV cirrhosis 2. hepatocellular carcinoma with bony metastases 3. esophageal varices s/p UGI bleed, banded [**3-1**] 4. gastric varices MEDICATION ON ADMISSION: ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Temp-96.9 BP-119/50 HR-92 RR-18 SpO2-94% 4L nc Gen: Pleasant, confused, obese HEENT: Icteric sclerae, moist mucosae CV: RRR, flow murmur RUSB, no r/g, normal S1 and S2 Pulm: CTA with wheezing anteriorly Abd: Significantly distended, soft, non-tender, active bowel sounds Ext: Pneumoboots in place, warm, 1+ pitting edema bilaterally Neuro: Confused, intermittently answering questions appropriately FAMILY HISTORY: Sister with ovarian cancer. SOCIAL HISTORY: Patient has been living with his wife. [**Name (NI) **] has a remote history of alcohol, tobacco, and IV drug use.

CHIEF COMPLAINT: Melena, hypotension. PRESENT ILLNESS: This is a 70 year old gentleman with ischemic cardiomyopathy EF 20%, atrial fibrillation on coumadin, history of Barrett's esophagitis, colonic polyps, asthma, hypothyroidism, and depression. He presents with black loose stools for one day. Yesterday morning, the patient woke up and had diarrhea that was black and tarry in nature. He proceeded to have a loose stool movement every 15 minutes over the day. Over the course of the day he became more lightheaded and this morning felt like he was going to fall down prompting him to seek medical attention in the ED. He did not notice frank blood in his bowel movements. He also has had some nausea with poor appetite (has not eaten in two days) but no vomiting or hematemesis. No abdominal pain. No coldness in extremities. . The patient was bought in by his wife to the [**Name (NI) **]. There the patient was noted to have a low blood pressure in the high 80s systolic, P 105. Hct was 42 (baseline 31) and BUN/Cr 56/2.4 (baseline cr 1.5-1.8). NG lavage negative. Believed to be volume depleted. He received 3 L NS, 2 units pRBC, and 1 unit FFP (addtl' units ordered). Given IV protonix. Transferred to MICU, on transfer pt says he feels somewhat better. . Of note, he is known to have Barrett's Esophagus seen on [**2133**] EGD. In addition, he is s/p removal of adenomatous polyp (path with dysplasia) in [**2134**], no polyps seen on [**2135**] colonoscopy. MEDICAL HISTORY: 11. CAD, s/p 1-vessel CABG and ascending aortic arch repair. Last cath in [**8-/2136**] with no significant CAD, patent LIMA to LAD. P-MIBI in [**6-/2137**] with slight worsening of partially reversible, moderate perfusion defects in the basilar anterolateral, mid anterolateral, basilar posterolateral, mid posterolateral, and lateral walls (entire lateral portion of the left ventricle). 2. Ischemic cardiomyopathy with EF 15-20%, NYHA class III. 3. Chronic renal insufficiency, baseline creatinine around 1.5-1.7 4. Atrial fibrillation 5. Hypothyroidism 6. Status post AICD placement, multiple firing episodes, last at [**Hospital1 2025**] in [**9-/2137**] in setting of hypokalemia. 7. Asthma 9. Hyperlipidemia 10. Depression 11. Dementia 12. Anemia, baseline hct around 30. 13. Barrett's Esophagus seen on [**2133**] EGD 14. s/p removal of adenomatous polyp (path with dysplasia) in [**2134**], no polyps seen on [**2135**] colonoscopy. MEDICATION ON ADMISSION: 1. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aldactone 25 mg Tablet PO once a day. 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR 4. Digoxin 125 mcg Tablet Daily 5. Atorvastatin 20 mg PO DAILY 6. Aspirin 81 mg Tablet, PO Daily 7. Clopidogrel 75 mg PO daily. 8. Lisinopril 5 mg PO Daily 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS adjusted accordingly to INR. 10. Levothyroxine 112 mcg PO Daily. 11. Citalopram 60 mg PO Daily. 12. Pantoprazole 40 mg E.C. PO Q24H (every 24 hours). 13. Mexiletine 150 mg PO Q8H. 14. Docusate Sodium 100 mg PO BID. 15. Senna 8.6 mg PO BID prn. 16. Quetiapine 50 mg Tablet PO QAM, 25 mg PO QPM, 225 mg QHS. 17. Clonazepam 0.5 mg PO TID (3 times a day). 18. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **] 19. Trazodone 25 mg Tablet PO HS PRN. 20. Donepezil 5 mg PO HS. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T 97.6 P 77 BP 109/71 RR 22 O2 98 RA Gen: WD/WN male Caucasian, NAD. Eyes: Sclerae anicteric, PERRL. Mouth: No bruising, no petechiae. Neck: Obese, no JVD (JVP to 6 cm) Chest: Lungs CTA b/l no wheezes, fair air movement Abd: Obese, non tender, some nausea elicited with palpation. Ext: No edema, faint but palpable DP pulses Neurol: alert and oriented to time,place, and person FAMILY HISTORY: Non-contributory. SOCIAL HISTORY: Married, lives with wife, has five children. Formerly drank alcohol but not since [**48**] years ago. No smoking or illicit drug use. Retired painter.

CHIEF COMPLAINT: Fever and tachycardia PRESENT ILLNESS: 88M with advanced dementia, DM, recently admitted to surgical service [**Date range (1) 87117**] with perforated duodenal ulcer c/b abdominal abscess s/p IR guided drainage re-presenting from NH with tachycardia and fever to 102. At [**Name (NI) **], pt was given lopressor for HR 160s and vanco/zosyn/flagyl/ctx. He spiked fever to 102 and was sent in to evaluate whether drain had been dislodged. MEDICAL HISTORY: Celiac disease Esophageal strictures duodenal ulcer perforation c/b Abdominal abscess DM2 Dementia Hypercholesterolemia Pneumonia MEDICATION ON ADMISSION: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 6. Pantoprazole 40 mg IV Q24H 7. Fluconazole in NaCl (Iso-osm) 200 mg/100 mL Piggyback Sig: Two Hundred (200) mg Intravenous once a day: thru [**2192-10-17**]. 8. Zosyn 4.5 gram Recon Soln Sig: 4.5 Gm Intravenous every eight (8) hours: thru [**2192-10-17**]. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T: 98, BP: 138/72, P: 99, RR: 22, 96% on 2L GEN: elderly male in NAD, does not follow commands CV: distant heart sounds, tachycardic, regular rhythm PULM: loud breath sounds, only able to asculate anterior lungs, ABD: soft, non-distended, BS+ x4, no guarding, no organomegaly, patient tries to push hand away when palpating epigastric, LUQ, PEG tube in place, JP drain x2 in place at LUQ GU: foley in place EXT: DP, PT pulses 1+ bilaterally FAMILY HISTORY: Mother with [**Name2 (NI) **], father with heart disease, first at age 79. SOCIAL HISTORY: - Tobacco: smoked for 40+ years, quit at age 79 - Alcohol: none currently - Illicits: denies

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 59 year old female with a past medial history significant for hypertension, seizure disorder since age 3 with last seizure 2 years ago, chronic obstructive pulmonary disease, obesity, pneumonia with last episode in [**2150**], questionable lung nodule with negative biopsy in [**2148**], and prior tobacco use who presented to [**Hospital3 **] on [**2153-8-20**] after 2 days of blurred vision, nausea/emesis, and unsteadiness on her feet. The patient denied any dysarthria, headache or focal weakness associated with her presenting symptoms. The patient was seen and evaluated in the Emergency Room at [**Hospital3 **] and found to have a systolic blood pressure in the 200's with a CT scan showing a large right cerebellar infarct. The patient was admitted to the Intensive Care Unit at [**Hospital3 14565**] and was seen in consultation by cardiology and neurology. A magnetic resonance angiogram of the neck and brain was done which showed an acute right cerebellar infarct as well as 70-80 percent stenosis of both internal carotid arteries with severe atherosclerotic disease at the carotid bifurcations. A TEE was done on [**8-24**] which showed a mobile atheroma in her ascending aorta as well as an EF of 58 percent. The patient was started on Heparin drip in consultation with neurology. In corroboration with the neurology service and the cardiology service, the decision was made to transfer the patient to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for further evaluation for possible surgical treatment of this mobile atheroma. The patient arrived at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2153-8-24**]. MEDICAL HISTORY: Hypertension. Pneumonia. Lung nodule with negative biopsy in [**2148**]. Chronic obstructive pulmonary disease. Seizure disorder since age 3, last seizure 2 years ago. Peripheral vascular disease. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: Prior tobacco use. Quit in [**2148**]. No ETOH use.

CHIEF COMPLAINT: Upper GI Bleed PRESENT ILLNESS: HPI: 55 y/o male with h/o EtOH cirrhosis, continuing EtOH use, multiple prior upper GI bleeds secondary to grade III esophagitis, esophageal ulcer, portal gastropathy, and h/o grade I esophageal varices, transferred from OSH with UGIB. Patient presented to OSH with hematemesis x2 and syncope, and found to have Hct 14, pltl 13. He reports vomiting red and coffee ground hematemesis, passing out without head trauma, and wife called EMS. At OSH he was treated with 4units PRBC, 1unit FFP, started on an octreotide gtt, and was transferred to [**Hospital1 18**] ED. On arrival to [**Hospital1 18**] vitals T 97.5 HR 105 BP 100/80. He received PRBC and platelet transfusion prior to transfer to the MICU. . Patient's last drink was today at 4pm. He continues to drink a 12pack beer daily. +history of withdrawals, but denies history of DTs or seizures. Recent h/o nausea, dizziness, and dark formed stools. He denies having chest pain, abdominal pain, headache, or SOB. He is alert and oriented x3. MEDICAL HISTORY: EtOH cirrhosis (Prior variceal bleed in [**2161-5-10**]. In [**1-15**] had upper GIB from ? portal hypertensive gastropathy and not variceal bleed.) EtOH abuse Barrett's esophagus Upper GI bleed x 3 - Esophagitis, Portal gastropathy, grade I varices Psoriasis Hypertension Pancytopenia - suspected EtoH marrow suppression, cirrhosis Inguinal hernia repair '[**59**] HTN MEDICATION ON ADMISSION: 1. Multivitamin Daily 2. Sucralfate 1g po QID 3. Nadolol 20 mg Daily 4. Folic Acid 1 mg Daily 5. Thiamine HCl 100 mg Daily 6. Pantoprazole 40 mg Daily 7. Effexor 75 mg Daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Exam: T 98.5 HR 100 BP 152/78 RR 17 99%RA Gen: alert, cooperative, tremoring HEENT: PERRL, mildly icteric, conjunctiva pale, dry MM Neck: supple, no LAD, JVP nondistended CV: RRR, no mrg Resp: CTAB Abd: +BS, soft, ttp RLQ, no rebounding/guarding, no masses, ND, no fluid wave Ext: no edema, 2+ DPs, 2+ radials Neuro: A&Ox3, CN II-XII intact, strength 4+/5 throughout, +pronator drift bilaterally, no asterixis Skin: urticaria on face, neck, abdomen, and back FAMILY HISTORY: n/c SOCIAL HISTORY: EtOh: 12 beers/day No tobacco Lives with wife in [**Name (NI) **], worked as a meat cutter 32yrs. states sober for 6 wks after his last variceal bleed but started drinking after this because of the stress of his job and caring for his mother and father-in-law

CHIEF COMPLAINT: Hypoxemia, altered mental status PRESENT ILLNESS: Ms. [**Known lastname 10145**] is an 86 y/o F with PMH COPD and ulcerative colitis a/w with worsening dyspnea and hypoxia at [**Hospital3 **] home. According to reports from the nursing home she was noted to have worsening dyspnea with O2 saturation of 86% on room air. She had a chest xray that did not show any evidence of infiltrate. Pt reported fall at nursing home, however staff present and denied fall. V/S prior to transfer 86% RA -> 93% 2L, BP 97.8 130/74 HR 64, RR 20. Of note, she had a recent admission from [**2156-4-23**] - [**2156-4-29**] for ulcerative colitis flare and C.diff. She was discharged on Vancomycin 250 mgPO Q6H for 14 days. In the ED VS T98.1 HR 113 BP 150/58 RR 40 99% NRB. She was given solu medrol 125mg IV, duoneb x3. She had ABG showing hypercarbia and acidosis and was cocnerned that becoming progressively tachypnic with increased work of breathing. She had a CTA to r/o PE which did not show any evidence of pulmonary embolism or pneumonia. She was initially sedated with propfol after intubation and became hypotensive to 80's / 40, given IV bolus, switched to Versed IV which also caused hypotension. She was given total of 2L NS. MEDICAL HISTORY: 1. Ulcerative colitis - f/b Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3708**] of [**Hospital1 18**] 2. Diverticulitis 3. Hypertension 4. TAH 5. COPD 6. DJD 7. C. difficile infection MEDICATION ON ADMISSION: -Balsalazide 750 mg PO TID -Spiriva once daily -lasix 40mg daily -KCL 20mEq daily -maalox 30mg po q4hrs prn -milk of mag prn -Acetaminophen 650 mg Tablet PO Q6H prn -levofloxacin 500mg daily x -duonebs q4hrs prn -Mesalamine 4 gram/60 mL Enema QHS -iron 325mg daily -biscolax supp daily -vancomycin 250mg QID x4 weeks (started [**5-11**]) ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Asacol / Rowasa / Percocet / Percodan PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS: T96.8 HR 82 BP 113/54 RR 20 99% VC 40% / 400 / 20 / 5 GEN: Frail, intubated, sedated HEENT: PERRL, dry MM NECK: JVP flat HOB @ 30 deg CV: RRR occas extra beats nl S1S2 no m/r/g PULM: LUL rhonchi, clear elsewhere ABD: soft, mildly distended, NT, no BS, no guarding EXT: warm, dry, no edema, +PP, 1 cm ulcer with necrotic center on right lateral leg NEURO: responds to tactile stimuli FAMILY HISTORY: Father - [**Name (NI) **] ca Mother - COPD Daughter - Ulcerative colitis SOCIAL HISTORY: Lives at [**Location **]. Daughter [**Name (NI) 2048**] is involved in her care. No smoking currently but smoked for many years, quit 30 years ago. Denies alcohol use except at Hanukah and Passover. No illicit substances. Husband died.

CHIEF COMPLAINT: PRESENT ILLNESS: Mrs. [**Known firstname **] [**Known lastname 13534**] is a 73 year-old female with a past medical history remarkable for chronic obstructive pulmonary disease and coronary artery disease and type 2 diabetes who has been experiencing worsening exertional angina for the past several years. The patient has noted that the pain is currently occurring once monthly with exertion typically located midsternal and radiating to the back. A stress test that was done on [**2119-5-11**] showed the patient had [**Street Address(2) 48360**] depressions during stage 2 exercise while the patient developed chest pain consistent with prior anginal symptoms. Imaging during this period revealed an inferolateral and apical ischemia with an EF of 78%. At this time the patient underwent cardiac catheterization for further evaluation for coronary revascularization. The patient's left anterior descending coronary artery showed 80% compromise, LCX showed 80% compromise and right coronary artery showed 80% compromise with an EF of 60%. Given these findings the decision was made to take the patient back to the Operating Room for three vessel disease coronary artery bypass graft on [**5-18**] with Dr. [**Last Name (STitle) 70**]. MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Gastritis. 3. Irritable bowel syndrome. 4. Cerebrovascular accident with decrease in left eye vision. 5. Psoriasis. 6. Arthritis. 7. Type 2 diabetes. 8. Asthma. 9. Hypercholesterolemia. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient has been married living with her husband, two children.

CHIEF COMPLAINT: AFib with RVR PRESENT ILLNESS: Ms. [**Known lastname 101707**] is a 63 yo F with history of liver transplant and paroxysmal Afib, admitted from the ED with AFib with RVR and tenuous blood pressure. The patient initialy presented to [**Hospital1 **] [**Location (un) 620**], where she was unsuccessfully electrically cardioverted twice (50 J and 100 J with INR 3.4) and given lopressor 5 mg IV x 1. She was transferred here for further management. In the ED here, VS were T 101, heart rate of 120-140. She was given hydrocortisone 100 mg IV (for presumed adrenal insufficiency with chornic prednisone for liver transplant) as well as lopressor 5 mg IV and calcium gluconate. Cardioversion was again attempted with 200 J and then 300 J. Her blood pressure dropped after a dilt drip was started, and then she was tried on amio drip which also dropped her pressures. She has received a total of 6L IVF. She was supposed to go to the CCU, but they have no beds currently. She denies preceeding viral symptoms including HA, fever, chills, myalgias, cough, rhinorrhea. She developed two "spells" of non-bloody vomiting today and has loose stools, but not frank diarrhea and no ill contacts. She denies feeling unwell over the last few days. She reports acute onset of paroxysmal AFib over the last few weeks, which is worsening of her AFib, and is scheduled for an ablation at the end of the month with Dr. [**Last Name (STitle) **]. MEDICAL HISTORY: Liver transplant [**2095**], [**1-21**] primary biliary cirrhosis (vs. atresia-- records contradict) Paroxysmal Afib Hypertrophic cardiomyopathy, normal EF Ascending aortic aneurysm, 4.2 x 4.3 cm in [**3-28**] Hypertension Thyroid colloid cyst Stable Lung nodules Rosacea Retroperitoneal adenopathy Skin cancer Raynaud's syndrome Cellulitis of thumb and left lower extremity Keratosis on Left LE which has tract Hernia repair Portal shunt C-section MEDICATION ON ADMISSION: Atenolol 50 mg daily Disopyramide 300 mg b.i.d. CellCept [**Pager number **] mg b.i.d. Prednisone 5 mg daily Quinapril 40 mg b.i.d. Prograf 1 mg b.i.d. Coumadin as directed Vitamin C 500 mg b.i.d. Colace Magnesium oxide 400 mg b.i.d. Multivitamin Calcium ALLERGIES: Erythromycin Base / Lactose PHYSICAL EXAM: GEN: comfortable in bed, NAD HEENT: JVP8cm H2O, MMM,OP clear, decent dentition LUNGS: crackles at bases that clear with cough COR: irreg irregular, tachycardic, no murmurs appreciated Abd: + Bs, soft, NTND Ext: No edema, WWP FAMILY HISTORY: non-contributory SOCIAL HISTORY: distant smoker; denies ETOH and IVDU; married with two sons; elementary school social worker

CHIEF COMPLAINT: Hypoxia PRESENT ILLNESS: The patient is a 71 yo man with h/o IPF, followed by Dr. [**Last Name (STitle) **], who presents with one week history of worsening SOB. Per the patient and his family, his symptoms began last Tuesday when he developed a sore lesion on the right side of his buttock. He was seen by his PCP, [**Name10 (NameIs) 1023**] started him on Cefalexin for possible bacterial infection. Shortly thereafter, as he was unable to take deep breaths secondary to the pain from this lesion, he began to experience increased shortness of breath and a non-productive cough. Over the past few days, he has had increased dizziness and his O2 sats dropped to the low 70s and high 60s (baseline in the 80s on 2L O2 at home). Yesterday, he had a low-grade fever of 100.2 and an episode of fecal incontinence. Per the patient, he has also been experiencing a "tingling" sensation in his legs for the past three days, and he had an associated mechanical fall last night while walking to the kitchen. Given concerns over these events, the patient's wife and daughter brought him to the [**Name (NI) **] this morning. . Of note, the patient was diagnosed with IPF in [**2100-12-26**]. He had biopsies performed at [**Hospital1 2177**] and is currently followed by Dr. [**Last Name (STitle) **]. Per the patient, he has had a significant clinical decline since this time and was most recently hospitalized at [**Hospital3 3583**] in [**2101-1-23**] for PNA. . In the ED, his VS were T 98.2, P 109, BP 118/65, R 20, O2 87% on 3L. He was had 3 word dyspnea and was placed on 4L, and his O2 sat increased to 91-92%. CXR showed new area of opacity in LUL, so he was started on Ceftriaxone and Levofloxacin for CAP. . On the floor, the patient continues to complain of increased SOB and tingling in his legs. He admits to increased lower back and abdominal pain, as well as difficulty swallowing for the past three days. Finally, he states that he has had increased urinary retension over the past week. MEDICAL HISTORY: Idiopathic Pulmonary Fibrosis (FVC 1.6, FEV1 1.53, FEV1/FVC 96%, DLCO 42% pred) Trigeminal Neuralgia Hyperlipidemia h/o Duodenal Ulcer h/o Rheumatic fever Borderline DM2 Appendectomy Tonsillectomy Lumbar spinal fusion in [**10-2**] MEDICATION ON ADMISSION: Acetylcysteine 600 mg TID Alendronate 70 mg qweek Azathioprine 25 mg daily Lorazepam 0.5 mg qhs prn Percocet 1-2 tablets q4-6h prn for pain Pantoprazole 40 mg daily Prednisone 40 mg daily Simvastatin 80 mg daily Calcium 600 mg daily Colace 100 mg [**Hospital1 **] Multivitamin Omega-3 Fatty Acids 1000 mg daily Bactrim 400 mg-800 mg M/W/F Cephalexin 500 mg qid ALLERGIES: Lyrica / Ambien PHYSICAL EXAM: Vitals: T: 98.4, BP: 118/70 P: 104 R: 29 O2: 90% on 4L General: Three-word dyspnea, AAOx3, in obvious respiratory distress. HEENT: PERRL, EOMI, oropharynx clear, dry mucous membranes Neck: Supple, JVP not elevated, no LAD, clear use of accessory muscles Lungs: Diffuse crackles over all lung fields CV: Tachycardic, sinus rhythm. Normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, soft, diffusely tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place Ext: 3/5 strength in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]. warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: erythematous ulcerated rash in the S2-S3 dermatomal distribution FAMILY HISTORY: The patient's sister and mother died from lung disease (unclear history). No h/o CAD. SOCIAL HISTORY: He was previously a welder and he designed [**Holiday **] ornaments with his wife. [**Name (NI) **] currently lives with his wife in [**Name (NI) 8072**], MA. He never smoked, though he was exposed to significant second hand smoke as a child. No drugs, occ EtOH.

CHIEF COMPLAINT: s/p fall down 16 stairs w multiple injuries PRESENT ILLNESS: 88F s/p fall down 16 stairs. Neighbors heard a thud, then whimpering, then nothing. 911 was called, and the door had to be broken down. The patient was found upside down at the bottom of her stairs. She was intubated for a GCS of 9 at the scene and brought to [**Hospital1 18**] ED. She was found on imaging to have a type 2 dens fracture with canal narrowing, C1, C2, and C6 fractures, bilateral nasal bone fractures, right globe ulceration, right medial canthus laceration with duct involvement, right microhyphema, and right lower lid partial thickness laceration. CTA revealed traumatic vertebrobasilar occlusion. The patient was admitted to the TICU for management of her injuries. MEDICAL HISTORY: PMH: uterine ca, colon ca, CVA, HTN, hyperlipidemia, lacunar infarct, SBO, osteoporosis, OA MEDICATION ON ADMISSION: ASA 81mg PO QOD, lopressor 50mg PO daily, prevastatin 20mg PO daily ALLERGIES: Penicillins / Amoxicillin / Codeine / Egg / Iodine PHYSICAL EXAM: Intubated and sedated, withdraws all 4 to noxious stimuli, no apparent hyperreflexia, normal rectal tone, facial and post scalp lacs, ecchymosis. FAMILY HISTORY: unknown SOCIAL HISTORY: Lives alone. Has family that lives in the area.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 47 year old male who presented as a transfer from [**Hospital 8**] Hospital for subarachnoid hemorrhage. He was in his usual state of health until 10:30 p.m. on the evening prior to admission when he had the sudden onset of severe right neck and head pain going to his brain. He had never had a severe headache like that before. He presented to the outside hospital where a CT of the brain demonstrated subarachnoid hemorrhage in the right basal cistern greater than left. Blood pressure was elevated at that time to 189/100. He was given morphine, Ativan and nifedipine for blood pressure control and transferred to [**Hospital1 18**]. Upon arrival he was without complaints of visual changes, headache, nausea, vomiting, however, was sleepy at the time of admission. MEDICAL HISTORY: Significant for a helicopter accident at approximately 23 years of age with resultant head trauma. MEDICATION ON ADMISSION: ALLERGIES: Penicillin. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient is married. He is originally from El [**Country 19118**].

CHIEF COMPLAINT: Sent to the Emergency Department for chest pain during a stress test. PRESENT ILLNESS: This is a 77-year-old male with a history of coronary artery disease status post coronary artery bypass graft surgery, insulin dependent-diabetes mellitus, congestive heart failure, chronic atrial fibrillation, and chronic renal insufficiency, who is sent to the Emergency Department after having chest pain and bilateral arm weakness during his stress test. He did not have any associated nausea, vomiting, or diaphoresis. He did not experience any palpitations. He describes the chest pain as more heaviness rather than chest pain. MEDICAL HISTORY: 1. Atrial fibrillation on Coumadin. 2. Coronary artery disease status post coronary artery bypass graft surgery. 3. Insulin dependent-diabetes mellitus. 4. Anemia. 5. Gout. 6. Systolic congestive heart failure with an ejection fraction of less than 20%. 7. Status post pacemaker ICD placement. 8. Chronic renal insufficiency. MEDICATION ON ADMISSION: 1. Gemfibrozil 600 mg twice a day. 2. Lasix 20 mg daily. 3. Altace 5 mg daily. 4. Coumadin 5 mg daily except Sundays 2.5 mg. 5. Digoxin 0.125 mg Monday, Wednesday, [**Last Name (LF) 2974**], [**First Name3 (LF) 1017**]. 6. Allopurinol 150 mg daily. 7. Colchicine 0.5 mg q day. 8. Folic acid 1 mg daily. 9. Zebeta 5 mg. 10. Aspirin 325 mg daily. 11. Humalog insulin-sliding scale. 12. NPH insulin, 18 units in the morning, 5 units hs. ALLERGIES: Morphine causing nausea. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: No tobacco, occasional alcohol [**3-10**] drinks per month, retired systems engineer.

CHIEF COMPLAINT: Acetaminophen Overdose PRESENT ILLNESS: Ms. [**Known lastname 78000**] is a 46-year-old woman with no significant PMH who presents with acute confusion and vomiting, now transferred to MICU for acetaminophen OD. She came home from work yesterday ([**2-22**]) at 5:30 pm and appeared normal to her husband. She took a nap at 6 pm. When she awoke at 8, she complained of nausea. She walked to the bathroom and vomited several times. She appeared to walk without difficulty. Her husband says she then began speaking non-sensically. She was forming words and was not slurring her speech, but her words did not make sense to him. He observed no focal deficit. He became concerned and called 911. . She was transported to [**Location (un) 620**], where her initial temperature was 97.3. Head CT showed no intracranial pathology. A code stroke was called for dysarthria (although again, her husband in speaking to me denies that she was slurring her speech). . She was transported to [**Hospital1 18**]. Because of the history from [**Location (un) 620**], a Code stroke for dysarthria was called at 11:58; Neurology was at the bedside at 11:56 (they had paged with the consult earlier at 11:51). Admitted to neuro ICU w/ concern for stroke. LP neg for meningitis. Now found to have acetaminophen toxicity and Neuro ICU requesting transfer for further management. . According to her husband, she had a febrile illness last week and had been complaining of bilateral leg pain and HA for the last few days. He thinks she may have been feeling depressed secondary to some work stress but has had no prior suicide attempts. MEDICAL HISTORY: Leg fracture 20 yrs ago MEDICATION ON ADMISSION: None ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: Temp: 97.7 BP: 141/71 HR: 71 RR: 20 O2sat 99% on AC 50%/5 PEEP; 500/12, breathing at 20 GEN: intubated and sedated HEENT: PERRL, anicteric, ETT in place NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, NABS, soft, + hepatosplenomegaly to 1-2 cm below costal margin, ? tender to palpation in RUQ EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: intubated and sedated FAMILY HISTORY: No known strokes or neurologic disease in family according to husband. SOCIAL HISTORY: [**1-7**] ppd tob, no alcohol, no drug use. Lives with husband and daughter.

CHIEF COMPLAINT: CC:[**CC Contact Info 110970**] PRESENT ILLNESS: 57yoM with h/o CVA in [**2153**] (thought to be [**12-30**] PFO, on coumadin) presenting with 24-48 hours of dark black tarry stools. Was in USOH last week however over weekend developed change in bowels with associated with light headedness and fatigue. Denies any BRBPR, nausea or vomiting however endorses "gas-like" pain in mid epigastric area. No recent use of NSAIDs (other than daily aspirin) or excessive ETOH use (drinks 1 glass of red wine/day). Also endorses feeling very thirsty. Denies CP, SOB, palpitations, LE edema, headache, or URI symptoms. Given symptoms, patient presented to ED. . In the ED, initial VS: 98.4 110 126/83 16 100%. Evaluation was significant for supratherapeutic INR to 3.9, BUN 34 and Hct 32 (no baseline). Pt received 1 unit of FFP and vitamin K (5mg) for INR. GI was consulted who recommended PPI gtt and EGD in AM. Vitals prior to transfer were 98.3po 119/81 87 16 98% RA. . Currently, patient stated that he was feeling very well however noted that he was significant less active today. Denied any pain. . Following this initial presentation, he was sent to the west procedural suite for EGD where he was found to have a fairly large, high-risk ulcer in his pre-pyloric channel as well as a precipitous hematocrit drop over a period of a few days from a prior baseline crit in the 40's to 26 and requiring 1 unit of pRBC's. He underwent injection and thermal therapy and was transferred to the unit for close monitoring overnight. Patient describes head ache that feels similar to his usual migraine pain but denies CP, SOB, Abd pain, N/V, or bloody BM's since the procedure. He otherwise feels well but is upset that he will be missing out on a business trip this upcoming weekend. . Review of systems: (+) Per HPI, otherwise negative. MEDICAL HISTORY: - CVA ([**12-30**] PFO, on coumadin) MEDICATION ON ADMISSION: - Warfarin - Atrovastatin 5mg daily - Diazepam 5mg prn ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS - Temp 98.6F, BP 100/70, HR 116 (90s on telemetry), R 16, O2-sat 100% RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no JVD, no carotid bruits HEART - PMI non-displaced, tachycardic, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/ND, no masses or HSM RECTAL - empty vault EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-2**] throughout . DISCHARGE PHYSICAL EXAM: VS - Temp 98.3 F, BP 115/60, HR 97, R 16, O2-sat 96% RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - MMM, OP clear NECK - Supple HEART - RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh ABDOMEN - soft/NT/ND EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-2**] throughout FAMILY HISTORY: No family history of GI issues or bleeding problems. SOCIAL HISTORY: Lives with partner in [**Name (NI) 789**]. [**University/College **] Law professor. No tobacco or illicit drug use. 1 glass of wine per night.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 30-year-old woman who was admitted to the [**Hospital1 188**] on [**2110-6-2**] with hyperemesis. The patient is 6.5 weeks pregnant, started on [**5-31**] with severe nausea, vomiting and and was admitted on the third day for observation. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Fever, pancytopenia, RUQ pain. PRESENT ILLNESS: HPI: 46 yo M with h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2905**] [**Last Name (un) **] s/p thymectomy on Imuran who initially presented to his PCP [**Name Initial (PRE) 151**] T103 and dry cough treated with Amoxicillin and Augmentin without improvement. He was then admitted to an OSH on [**2118-10-25**] for pancytopenia (WBC 2.6, 18% bands, plt 104) and elevated LFTS c/w cholestasis. He was treated with Azythromycin and Atovaquone for suspected tick borne illness. He had a positive monospot test. Hepatitis serologies were negative. . Patient was admitted to the surgical service at [**Hospital1 18**] on [**2118-10-30**] for persisitent fever and an elevated direct Tbili thought to be secondary to cholangitis. He was started on Unasyn. He underwent an ERCP on [**10-31**] which did not show biliary tract obstruction, however, a CBD stent was placed. He was transfused 1 Unit of PRBC's, 3 bags of FFP, and 3 bags of plts. . Prior to the ERCP he developed repsiratory distress and was intubated. CXR revealed bilateral patchy pulmonary infiltrates. He became hemodynamically unstable and he was started on Norepi gtt. ID was consulted and Ceftriaxone/ Doxycyclin were added; Zosyn was d/c'ed. He spiked a temp to 105.3. He was transfered to the MICU on [**10-31**] for further managament. MEDICAL HISTORY: - Myasthenia [**Last Name (un) 2902**] for 19 years s/p thymectomy [**2103**] - Migraines - Prednisone induced osteoporosis - Low back Pain MEDICATION ON ADMISSION: Imuran, Imitrex, Amoxicillin, Augmentin, Atovaquone, Azithromax ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Upon transfer to [**Hospital Unit Name 153**]: Tm 102.2 Tc 97.6 BP 175/92 (108-175/52-92) HR 89 (71-111) PS 5/0 FiO2 35% Vt 850 (700-850) RR 16; ABG 7.44/33/173/23 Fentanyl 125; Off Midaz since [**11-6**] Gen: Sedated/intubated, appears comfortable on ventilator, occasional hiccups HEENT: ET tube in place, Eyes with lubricant, PERRL, pupils pinpoint CV: distant heart sounds. No murmurs appreciated. Resp: anteriorly - crackles throughout Abd: Soft, distended, decreased BM, unable to appreciate HSM Skin: Warm. Well Perfused. Ext: hyperreflexic, Spastic, 5 beats of myoclonus, Toes upgoing, strong DP/PT pulses Access: Right IJ triple lumen placed [**11-6**], Left IJ temp dialysis cath placed [**11-3**] by IR FAMILY HISTORY: Mother has HTN. SOCIAL HISTORY: Has a girlfriend. [**Name (NI) **] a 14 yo son who recently had a cold. Lives with girlfirend and step children. Smokes and drinks EtOH occassionally. No hx of IVDU. Lives in [**Location 4310**] near a swamp. Breakheart reservation is 2 miles away. No hx of tick bites.

CHIEF COMPLAINT: Ingestion PRESENT ILLNESS: 21 y/o F with h/o bipolar d/o, presented to ED reporting ingestion of 70 tabs of 325mg acetaminophen in suicide attempt. . On arrival to ED approx 2.5 hrs after ingestion, acetaminophen level 180. Repeat level at 12:50am (4 hrs after ingestion), level 170. Received 80g activated charcoal by NGT. N-acetylcysteine 11.2g IV loading dose. . Per various reports, pt states that she was either upset after an argument with a friend, or that she had not seen the friend, but was upset about the friend. [**Name (NI) **] home, and took Tylenol 10 at a time, with a total of 70 tabs with the intent of suicide. Then, changed her mind at presented to the ED. . At the time of this interview, she denies suicidal or homicidal ideation. MEDICAL HISTORY: Bipolar disorder - patient states she has a psychiatrist and therapist, but does not recall their names or location MEDICATION ON ADMISSION: Clozaril 50mg PO BID and 200mg QHS Effexor XR 75mg PO qAM ALLERGIES: Lamictal PHYSICAL EXAM: VS - T 97.7, BP 135/81, HR 86, RR 23, O2 sat 99% RA, wt 113 kg gen - obese female, somewhat somnolent, but easily arousable to voice; extremely poor historian HEENT - NGT in place, with dried blood at nose and mouth; no active bleed. PERRL, EOMI, MMM, no LAD, no JVD CV - RRR, no m/r/g chest - poor inspiratory effort, but CTAB abd - soft, obese; diffusely tender to palp, but no g/r; no CVAT back - no tender to palpation ext - no edema, 2+ distal pulses neuro - no asterixis FAMILY HISTORY: NC SOCIAL HISTORY: Lives with an "agency" with two roommates. Smokes ~1PPD x "a long time". Drinks EtOH. Denies illicits.

CHIEF COMPLAINT: mental status changes noted by family PRESENT ILLNESS: 81 year-old male initially presented to [**Last Name (un) 1724**] with mental status changes noted by family members. Initial [**Name2 (NI) 430**] CT from [**Hospital3 29818**] with left SD collection with midline shift out of proportion to size of SD collection. Must consider underlying mass with that type of MLS and effacement of structures (subfalcine herniation). No hydrocephalus or acute hemorrhage noted. Patient was on coumadin for afib.Was very independent at home prior to hospitalization.SBP up to 225mmHg in [**Last Name (un) 1724**], requiring pressors.Admitted from ER for evacuation of SDH. MEDICAL HISTORY: PMH: HTN, DVT, AFIB, ENLARGED PROSTATE, HIGH CHOLESTEROL. PSH: none (per family - No IVCF for DVT) MEDICATION ON ADMISSION: Meds: coumadin, liptor ALLERGIES: Penicillins PHYSICAL EXAM: PE: VS 194/93,64,13, HEENT:no carotid bruits, neck supple Lungs: CTA CVS:irregular, no M/G/R Abd: soft NT ND Ext: No c/c/e. FAMILY HISTORY: noncontributary SOCIAL HISTORY: Soc:social ETOH, Quit tobacco(pipe) 20+yrs ago.

CHIEF COMPLAINT: ischemic left leg PRESENT ILLNESS: Onset ofleft toe pain seven days prior to admission with known pvd s/p bilaterl lower extremity bpg's ( left fem-PT with issvg) with increasing leg and thigh pain 24hrs prior to admission. Evaluated at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ER , no dopperable pulses left leg. IV bolus heparin given and patient transfered to [**Hospital1 8482**] for further evaluation. MEDICAL HISTORY: history of dyslipdemia histroy of CAD,3Vessel disease by cardiac cath with Aortic valve stenosis history of hyponatremia histroy of ESRD [**1-22**] DM on hemodialysis (Tu,[**Last Name (un) **],Sat) hisory of anemia of chronic disease history of chronic systolic CHF,compensated history of gout,asymptomatic history of degenerative arthritis histroy of lumbar disc disease s/p laminectomy histroy of depression histroy of DVT ? Lower extremity history of polymyalgia rheumatica histroy of nephrolithiasis history of BPh history of recurrent UTi histroy of carotid disease [**Doctor First Name 3098**] <40%,[**Country **] nl histroy of lucnar infract histroy of left menisectomy histroy of left inguinal herinaorrphy MEDICATION ON ADMISSION: imdur 30mgm daily colace 100mgm [**Hospital1 **] ducolax supp prn minocycline 100mgm [**Hospital1 **] gabapentin 100mgm [**Hospital1 **] levothryoxine 50mcg daily nepro caps daily vitamin c folic acid lopressor 12.5mgm [**Hospital1 **] pholso asa 325mgm daily lantus 6 units @ HS humalog sliding scale simvistatin 80mg HS clexa 10mgm HS seroquel 12.5mgm q6h prn regland prn ALLERGIES: Sulfa (Sulfonamides) / Penicillins PHYSICAL EXAM: Gen: no acute distress, dementied Lungs: CTA Heart: RRR ABD:bengin EXT: Left cold from foot to knee with blue toes. poor capillary refill. necrotic toe tips. Rt. Ext warm pulse exam: palpable femorals bilateral.left DP monophasic graft palpable at knee.rt. DP and Pt dopperable graft palpable. Neuro: Ox1, nonfocal FAMILY HISTORY: unknown SOCIAL HISTORY: nursing home resident former tobacco and ETOH abuser

CHIEF COMPLAINT: PRESENT ILLNESS: (Per admitting Intensive Care Unit intern) Ms. [**Known lastname 9449**] is a 36-year-old woman with metastatic breast cancer to subcutaneous tissue, lung, liver, bone, and brain who presented from [**Hospital3 417**] Hospital for endoscopic retrograde cholangiopancreatography for bile leak, status post cholecystectomy for a perforated gallbladder. On the evening of [**2144-2-25**], the patient developed the acute onset of epigastric pain and presented to [**Hospital3 418**] Hospital on [**2144-2-26**]; where she was found to have an acute abdomen. She was tachycardic to 140 and had a white blood cell count reportedly to 22. The patient was taken to the operating room for exploratory laparotomy. She underwent a cholecystectomy. Intraoperatively, the patient was found to have free bilious fluid in the abdomen as well as adhesions of omentum to the posterior surface of the gallbladder, through which the bile was leaking. There was no obvious gallbladder metastases. However, there was a large palpable mass in the retroperitoneum (felt to be either pancreatic mass versus retroperitoneal lymphadenopathy). At that time, the decision was made to pursue internal stenting via endoscopic retrograde cholangiopancreatography at a later date. Thus, a biopsy of a liver metastases was obtained. There were no intraoperative cholangiogram. There was no obvious indication of biliary obstruction; though, a right upper quadrant ultrasound on [**2-27**] revealed 3.6-cm dilatation of the common bile duct, as well as dilatation of the intrahepatic bile ducts. Postoperatively, the patient complained of shortness of breath. A chest x-ray revealed total opacification of her left lung and was felt to represent infiltrates plus effusion. The patient's oxygen saturation dropped to less than 90%, and the patient was given intravenous Lasix. The patient's left-sided pleural effusion was drained by thoracentesis; the fluid from which was found to be exudative. Postoperatively, the patient was put on levofloxacin and metronidazole. She was still on levofloxacin on transfer to [**Hospital1 69**], where she was meant to undergo an endoscopic retrograde cholangiopancreatography. MEDICAL HISTORY: 1. Metastatic breast cancer; diagnosed approximately two years ago. Metastatic to the liver, bone, lung, brain, small bowel, and other areas. Status post two cycles of Navelbine, status post two cycles of Taxol and carboplatin (last cycle ended on [**2144-2-24**]). Status post radiation therapy for brain metastases. 2. Echocardiogram on [**2144-2-29**] revealed an ejection fraction of 65%. No wall motion abnormalities were found. Normal right ventricular function was noted. There was some mild pulmonary hypertension. MEDICATION ON ADMISSION: Outpatient medications included Percocet, Decadron, Ativan, Zofran, Duragesic patch. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives at home with her husband. They have pets. The patient worked for [**Doctor Last Name **] Elevator Company. The patient has a positive smoking history. She denies alcohol abuse.

CHIEF COMPLAINT: polymicrobial sepsis PRESENT ILLNESS: 21yoM with polysubstance abuse, depression, multiple sclerosis with deep brain stimulator placed at [**Hospital1 18**] 2208 for severe dystonia presenting for fever and hypotension. Regarding his DBS, the patient had a prior left sided lead fracture is s/p revision. On [**2133-6-15**], he presented for bilateral battery replacement for low voltage and subsequently had his sutures removed by his PCP. [**Name10 (NameIs) **] returned for a wound check on [**7-3**] and was found to have a left sided wound infection, and was admitted for a removal and washout of the distal left IPG and connecting wire on [**7-5**]. The left sided electrode was left in place. He was discharged on Nafcillin and Keflex, which was completed [**7-21**] and was to transition to po antibiotics subsequently. The patient gives a limited history but per his mother, the patient was in good health until [**Month/Day (4) 766**] [**7-20**], when he was found to have an infected left PICC which was removed. He had a PIV placed in his right arm which became significantly swollen and erythematous per his mother. The IV was removed on [**7-21**] and a right PICC was placed in the same arm at that time, which was reportedly difficult to place due to the swelling in his arm. The patient's mother reports that the patient began having fevers to 106.5 and rigors later that day and she called his ID fellow, Dr. [**Last Name (STitle) 6137**]. She then brought the patient to [**Hospital 41128**] Hospital in [**State 1727**]. The patient denies other complaints including headache, vision changes, cough, nausea/vomiting, abdominal pain, diarrhea, rash, myalgias or arthralgias. The patient denies swelling or pain at his right and left DBS incision sites. At [**Hospital 41128**] Hospital, the patient was found to be hypotensive despite 3L IVF and Neosynephrine, and he was started on Levophed. Cultures were drawn and he was given Vanc, Zosyn, and Ceftriaxone. He was transferred to [**Hospital1 18**] for further evaluation. In the [**Hospital1 18**] ED, initial VS: 100.4, 86, 65/47, 19, 99% on 2L The patient was A&Ox3. Neurosurgery was consulted, and felt the wound site was unconcerning and recommended obtaining head CT with and without contrast to r/o infection. Blood and urine cultures were drawn and CXR was obtained, and femoral CVL was placed. He received a total of 8L NS and was on Levophed 0.15 mcg/kg/hr with SBP 110's. He spiked to 102.3 while in the ED and was given Tylenol. Transfer VS: 111, 23, 126/66, Levo at 0.12, 96% RA. In the MICU, the patient denied any symptoms including headache, n/v, abdominal change, or pain different from his typical chronic total body pain. MEDICAL HISTORY: bilateral deep brain stimulators placed [**6-/2130**], revised in [**2130-11-15**] as a lead fracture was found s/p recent battery replacement in early [**2133-6-14**] s/p Botox injections for cervical dystonia anxiety depression s/p sepsis from [**Female First Name (un) 564**] and Bacillus MEDICATION ON ADMISSION: - Lorazepam 2 mg q4h prn anxiety, discomfort - Percocet [**2-15**] tablet q4h prn pain - Trihexyphenidyl 3 mg po bid (patient reports he was not taking at home) ALLERGIES: Pollen Extracts / Cat Hair Std Extract / Banana / Mold Extracts / Grass Pollen-Bermuda, Standard / vancomycin PHYSICAL EXAM: (per admitting resident) GEN: Pleasant, comfortable, well-appearing, NAD HEENT: PERRL, sclera anicteric, MMM, op unable to be clearly visualized [**3-18**] poor patient cooperation RESP: CTAB with good air movement throughout, no wheezes/rales/rhonchi CV: RRR, S1 and S2 wnl, split S2, no m/r/g ABD: Soft, minimal left sided diffuse tenderness, non-distended, +BS, no masses or hepatosplenomegaly appreciated EXT: No c/c/e, 2+ DP pulses b/l SKIN: No rashes/no jaundice/no splinters NEURO: AAOx3. Deferred for now. FAMILY HISTORY: - 2 maternal uncles with cerebral palsy - 3 cousins that have now been diagnosed with DYT1 dystonia SOCIAL HISTORY: Tobacco: Recent smoking [**2-15**] cigarettes/day, reports quit 2 weeks ago. - EtOH: Drinks 2 alcoholic drinks weekly. - Illicit Drugs: Marijuana several times weekly, h/o polysubstance abuse including prescription medications. Denies recent IVDU or intranasal drug use. Functional at baseline, currently lives by with his mother at home. He finished high school but is not currently working, on disability. Divorced. He has been arrested twice including a charge of hit and run with possession of prescription drugs. His licence was previously taken away for several MVAs.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is an 87 year old woman with a history of lung cancer, status post resection and radiation therapy admitted to an outside hospital with shortness of breath. Chest x-ray demonstrated bilateral infiltrates and new endobronchial lesion. The patient while in the hospital had an episode of hemoptysis and was transferred to [**Hospital1 69**]. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 74 year-old female with a history of insulin dependent diabetes mellitus times 45 years, hypertension, who was admitted to the MICU after being transferred from an outside hospital after being found unresponsive at home. The outside hospital, [**Hospital 882**] Hospital, the patient was found to have a glucose of 1224, bicarbonate of 7 and a pH of 7.04 with positive urine ketones. She was subsequently given 6 liters of normal saline, 1 unit of packed red blood cells, 1 amp of bicarbonate and insulin drip and given a dose of Ceftriaxone and transferred to the [**Hospital1 69**] MICU. At the [**Hospital1 69**] MICU she was found to have an arterial blood gas of 7.29/34/112 with a glucose of 688 and increased amylase of 789 and lipase of 1033. She was also found to have a positive troponin of 12.7 and MB of 13.4 consistent with a non ST segment elevation myocardial infarction. Her subsequent peak CK was 207 and peak troponin was 25. The patient was found at home with a low level of responsiveness and found to have blood in her mouth. There is a question of whether she had coffee ground emesis. She had an negative lavage that showed coffee grounds apparently at the outside hospital that cleared upon her nasogastric lavage at the [**Hospital1 69**] MICU. The patient upon transfer to the floor complained of fatigue, but no chest pain, shortness of breath or abdominal pain. MEDICAL HISTORY: Hypertension, insulin dependent diabetes mellitus times 45 years, cerebrovascular accident, seizure disorder, open reduction and internal fixation of her ankle complicated by a wound infection. MEDICATION ON ADMISSION: ALLERGIES: Compazine. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives with her son. She performs all activities of daily living. No tobacco. No alcohol in greater then one month.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 76-year-old male who presented to the emergency room with worsening abdominal pain, nausea, and vomiting x 4. The patient had recently been undergoing an evaluation for painless jaundice. In early [**Month (only) 116**] the patient had an abdominal CT at an outside hospital which demonstrated intrahepatic ductal dilatation. On [**2101-6-10**] the patient came to [**Hospital1 1444**] and underwent an ERCP by the GI team which demonstrated a pancreatic duct stricture, which was compatible with a mass, a biliary stricture, and a stent placement in the biliary system. The patient tolerated this procedure well and during the admission when told that the most likely [**Hospital1 **] was cancer, signed out against medical advice. At home over the next several days the family reported the patient developed worsening abdominal pain accompanied with nausea and vomiting. When this continued to worsen the family brought the patient to the emergency room for further evaluation. MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. MEDICATION ON ADMISSION: Unknown. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: cardiac arrest PRESENT ILLNESS: 39 yo female history of HTN, IDDM, NiCMY with EF 45%, nonobstructive CAD, and ESRD s/p HD today heard to release a large yelp with an agonal breath and subsequently found to be unresponsive and pulseless. There are no strips from HD. CPR was initiated for three minutes until AED was applied and advised shock with return of spontaneous circulation, a perfusing rhythm, and 100% sat. EMS reports that she was responsive only to painful stimuli, with a GCS of 6. EKG at that time was reported as NSR 70-80 withuot ectopy and antiarrythmic deferred. In the ED, she was found to have gurgling breath sounds, poor tone, was not coherent and appeared to be "out of it" so she was intubated with atomidate and vecuronium. She was started on 150mg IV amio bolus with drip at 1mg/minute. She was sedated with propofol. She was hypertensive at 170's/100's, with multiple runs of PVC's including 10 run beats of VT. Her ectopy decreased with amio. After head CT and guaiac were negative, a cooling protocol was initiated with goal temp of 33. A full strength rectal aspirin was administered. Blood gas upon admission was 7.43/49/108/34. En route to the CCU, 2mg of Ativan were given for questionable tongue twitching representing seizure activity. . Of note, recently seen at [**Hospital1 2177**] for febrile viral illness for which she was given doses of vanco, levo, and flagyl. Her potassium at that time was listed as 4.1. EKG at that time was noted to be NSR at 75, with multiple PVC's and no acute ST-T changes. . In the CCU, she is unable to complete a review of systems or voice her complaints as she is intubated. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: Nonobstructive CAD with 30% mid RCA stenosis, 30% PLB stenosis in [**2192**]. In [**2-6**], LAD, Lcx with minor irregularities - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -NiCMY, LVEF 45% -ESRD due to IDDM and HTN, on HD MWF via RUE AVG since [**2195**] -HTN, difficult to control -IDDM -Pulmonary HTN (PASP above 50 mmHg on echo [**5-/2198**], at least partially due to OSA -HL -Obesity -Hypothyroidism -GERD -Epilepsy -Recent viral infection on levaquin -Chronic back pain -Anxiety and Depression MEDICATION ON ADMISSION: confirmed with her pharmacy and PCP [**Name9 (PRE) **] [**Name9 (PRE) 16695**] 50 qhs -nitrostat 0.4 mg -ambien 10 mg hs, -amlodipine 10 daily -ASA 81 daily -lisinopril 40 [**Hospital1 **] -labetalol 400 [**Hospital1 **] -clonidine 0.3 [**Hospital1 **] -hydral 100 tid -isosorbide mononitrate 30 daily -keppra 500 [**Hospital1 **] -keppra 500 at 2pm mwf -ferrous sulfate 325 tid -synthroid 150 daily -phoslo 667 two caps [**Hospital1 **] -calcitriol 0.5 daily -simvastatin 40 daily -colace 100 [**Hospital1 **] -lorazepam 1 daily for mood -albuterol neb .083% QID prn -epogen in HD ALLERGIES: Penicillins / Amoxicillin / clindamycin / clavulanic acid / Aztreonam / Sulbactam / tazobactam / Cephalosporins PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS: GENERAL: Intubated and sedated with low tone. Vent: AC TV 450 RR 12 FiO2 60% PEEP 5. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: Unknown. SOCIAL HISTORY: -ASA 81 -lisinopril 40 [**Hospital1 **] -labetalol 500 [**Hospital1 **] -clonidine 0.6 [**Hospital1 **] -hydral 100 tid -amlodipine 10 daily -isosorbide mononitrate 30 daily -keppra 500 [**Hospital1 **] -keppra 500 at 2pm mwf -ferrous sulfate 325 tid -synthroid 150 [**Hospital1 **] -phoslo 667 two caps [**Hospital1 **] -calcitriol 0.5 daily -simvastatin 40 daily -colace 100 [**Hospital1 **] -metoclopramide 5 prn prior to meals -lorazepam 1 daily for mood -tramadol 50-100 [**Hospital1 **] prn pain -omeprazole 40 [**Hospital1 **] -levemir 2 units qAM -humalog 2U small, 3U medium, 4U large

CHIEF COMPLAINT: The patient was admitted with a chief complaint of transfer from [**Hospital3 27946**] with a chronic positive cardiac enzymes. PRESENT ILLNESS: The history was obtained from medical records and family. Per the family, the patient had shortness of breath for two days prior to admission at [**Hospital3 27946**]. She had increased cough over her baseline. She then presented to [**Hospital3 27946**] on blood gases at that time was 7.20, pCO2 64, pO2 278, with a respiratory rate of 32 and the patient then was intubated as she began tiring. She failed a trial of BiPAP prior to intubation. An electrocardiogram at that time then showed ST elevations in V2 and a tachycardia to approximately 130 to 140 with a changing P wave morphology. Cardiac enzymes were positive with a CK of 342, MB of 16.9 with an index of 4.9, and a troponin I was 3.1. Twenty-four hours later, CK was 500, MB 27.2, index 4.4 with troponin of 4.89. The patient denied any chest pain when she first presented to the Emergency Department per the records. Heparin was started at that time when she began ruling in and then stopped secondary to guaiac positive stool. The tachycardia in the Emergency Department was initially controlled with Diltiazem drip and the patient was transferred to the Intensive Care Unit at the outside hospital. At that time, a right heart catheterization was performed with pulmonary artery pressures of 34/16, pulmonary capillary wedge pressure of 11, cardiac output of 4.68. White blood count was elevated at 20.8 and 8% bandemia. A sputum gram stain showed greater than 25 PMNs with 0-1 epithelial cells and gram positive cocci in pairs. Given the lack of resolution of the cardiac enzymes and concern for acute myocardial infarction, the patient was transferred to [**Hospital1 1444**] for cardiac catheterization. MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. The patient is on home oxygen two liters nasal cannula for her chronic obstructive pulmonary disease. 2. History of pneumonia. 3. History of epistaxis. 4. History of Bell's palsy. 5. Hypertension. 6. Hyperlipidemia. 7. Osteoporosis. 8. Depression. MEDICATION ON ADMISSION: 1. Plendil 5 mg p.o. q.d. 2. Pravachol 10 mg p.o. q.d. 3. Paxil 20 mg p.o. q.d. 4. Uniphyl 400 mg p.o. q.d. 5. [**Doctor First Name **] 60 mg p.o. b.i.d. 6. Multivitamin q.d. 7. Fosamax 70 mg p.o. q.d. ALLERGIES: The patient has allergy to Simvastatin for which she has a myositis. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives alone. She denies any alcohol or intravenous drug use. She quit tobacco approximately ten years ago with a sixty pack year history. The family contacts are a son, [**Telephone/Fax (1) 36993**] for cell phone, home [**Telephone/Fax (1) 36994**] and a daughter, [**Name (NI) **], [**Telephone/Fax (1) 36995**].

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 60-year-old male with a history of diabetes mellitus who was admitted for cardiac catheterization. The patient has been having exertional substernal chest pain and short of breath for months and on the morning prior to admission experienced an episode of chest tightness while leaving the parking lot to have his stress test done. The ETT which was done showed ST segment depression in 2, 3 and AVF and V2 through V5 after 5 minutes and 49 seconds. The patient also had substernal chest discomfort and short of breath which persisted resulting in him being rushed to the [**Hospital3 **] emergency department. On electrocardiogram there was resolution of the ST segment abnormalities. He received nitropaste which relieved his symptoms. CKMB at that hospital was 3.7, troponin were flat and he was transferred to [**Hospital1 188**]. MEDICAL HISTORY: 1. Diabetes mellitus Type 2. 2. Hypertension. 3. Hypothyroidism. 4. Status post right radical nephrectomy in [**2103**]. 5. Arthritis. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: He stopped tobacco in [**2090**] and has occasional cigars. Drinks one beer per day.

CHIEF COMPLAINT: Left radius/ulnar fracture PRESENT ILLNESS: The pt is a 32 y/o male who was involved in a MVA one month ago and had a fracture to his right radius and ulna. He presented to the [**Hospital1 18**] ED and had a closed reduction of his fractures and had a splint placed. He continues to have pain with his forearm. Follow-up x-rays 4 days prior to admission revealed malalignment. The patient presents for ORIF. MEDICAL HISTORY: Venous malformation right upper extremity being treated with sclerotherapy MEDICATION ON ADMISSION: None ALLERGIES: Penicillins PHYSICAL EXAM: T 97.8 P 83 BP 125/64 R 16 SaO2 97% Gen - nad Lungs - clear Heart - RRR Abd - soft, NT, ND, BS+ Extrem - right upper extremity splinted, diffusely edematous, some numbness to light touch in right thumb, right upper extremity otherwise neurovascularly intact FAMILY HISTORY: Non-contributory SOCIAL HISTORY: He is a nonsmoker.

CHIEF COMPLAINT: leg pain PRESENT ILLNESS: 50 yo w/MMP, significant for HIV, sacral decubitus ulcer, chronic vaginal discharge and hydronephrosis with bilateral nephrostomy tubes and urinary incontinence presents with 1 day of R thigh pain and swelling. Pt reports that pain is [**6-23**] feels "like my leg is going to burst", constant, worse with touch or movement, non-radiating. Leg is more swollen than usual, hot to touch and red. She has had fever for 7 days w/temp ranging from 101-102. Denies SOB, CP, abd pain, change in nephrostomy or colostomy output. She has had an increase in her chronic vaginal discharge, no vaginal pain, no new sexual partners. Chronic nausea is unchanged. All other ROS negative MEDICAL HISTORY: ONCOLOGIC HISTORY: 1) Rectal cancer: - late [**2139**]: 6 months of intermittent rectal bleeding, rectal pressure and a sensation of incomplete emptying. - [**2141-1-26**]: colonoscopy revealed a polyp in her sigmoid colon and a 2.5 cm distal rectal mass arising from the anal verge in the posterior rectum with a large area of induration. - [**2141-1-31**]: CT torso revealed an exophytic rectal mass measuring 4.8 x 3.8 cm, bulging posteriorly into the presacral space and anteriorly towards the uterus. There were enlarged lymph nodes in the perirectal fat adjacent to the mass, a 9-mm enhancing lymph node in the left pelvic sidewall, and enhancing lymph nodes in the right external iliac region. There was also a 7-mm hypodensity in the caudate lobe of the liver. Rectal ultrasound on [**2141-1-31**] and rectal MRI on [**2141-2-7**] were compatible with T3 disease. There were at least four abnormal perirectal lymph nodes seen on MRI, in addition to multiple bilateral enlarged pelvic sidewall lymph nodes, concerning for extensive disease. - [**2141-2-20**]: began chemoradiation - [**2141-3-10**]: 5-FU was discontinued due to mucositis, neutropenia, and abdominal cramping - [**2141-3-13**]: 5-FU was restarted at a reduced dose - [**2141-3-22**]: 5-FU was again stopped due to mucositis, perirectal skin changes, diarrhea, and electrolyte abnormalities. - [**Date range (3) 70844**]: Radiation was also held - [**2141-3-27**]: 5-FU was restarted at a further reduced dose - [**2141-3-31**]: completed radiation - [**2141-4-3**]: completed chemotherapy - [**Date range (3) 70845**]: hospitalized for bowel rest and the initiation of TPN due to presumed radiation enteritis. - [**2141-5-31**]: found to be HIV positive and began on HAART - [**Date range (1) 70846**]: required hospitalization for an SBO, underwent laparotomy, ileocecectomy, end-ileostomy, and placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube on [**2141-6-16**]. Pathology from this surgery revealed severe radiation-induced acute ischemic enteritis. She recovered from this surgery, but continued to require TPN. - [**7-/2141**]: Once her CD4 count had recovered, she underwent laparotomy, lysis of adhesions, ileal resection, proctosigmoidectomy, colonic jejunal pouch to near-anal anastomosis with EEA, takedown splenic flexure, resection of ileostomy and creation of new end-ileostomy. Pathology from the surgical specimen revealed no residual carcinoma and all 14 lymph nodes sampled were free of disease. - [**9-/2141**], [**10/2141**]: Subsequent imaging of the abdomen & pelvis showed no evidence of recurrence. - [**2142-2-14**]: CT abdomen showed "hyperdense thickening in the lumen near the anastomatic site, new since the earlier study. Local recurrence cannot be excluded, although possibly the appearance is associated with endoluminal debris." . OTHER MEDICAL HISTORY: 2) HIV CD4 count CD4 263 in [**1-26**] 3) Short gut syndrome secondary to bowel surgery for CA. 4) Obstructive renal failure from radiation fibrosis, in the past necessitating b/l nephrostomy tubes which have required multiple revisions. 5) Lower extremity neuropathy, likely secondary to radiation fibrosis, uses a wheelchair since 4/[**2141**]. 6) Pancreatic insufficiency. 7) Anemia. 8) Chronic pain. 9) DVT in LE X2: requires lifelong coumadin, most recent [**4-24**]. MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. [**Name (NI) 70848**] *NF* (abacavir-lamivudine) 600-300 mg Oral daily 8am 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 3. Darunavir 800 mg PO BID Start: In am 4. Vitamin D 50,000 UNIT PO LUNCH 5. fentaNYL citrate *NF* 200 mcg Buccal q30min pain 6. FoLIC Acid 1 mg PO DAILY 7. Furosemide 40 mg PO DAILY 8. HYDROmorphone (Dilaudid) 32 mg PO Q4H:PRN pain 9. Lorazepam 1 mg PO Q4H:PRN anxiety 10. Magnesium Sulfate 2 gm IV 3X/WEEK (TU,TH,SA) 11. Methadone 20 mg PO TID 12. Mirtazapine 15 mg PO HS 13. Nortriptyline 25 mg PO HS 14. Ondansetron 4-8 mg PO Q8H:PRN nausea 15. Ondansetron 4 mg IV Q8H:PRN nausea 16. Phenytoin Infatab 100 mg PO DAILY dose not take PO. Crush tab, mix with saline and apply to wound bandage 17. Pregabalin 50 mg PO TID 18. RiTONAvir 100 mg PO BID 19. Warfarin 4 mg PO DAILY 20. Ferrous Sulfate 325 mg PO DAILY 21. Loperamide 4 mg PO QID:PRN diarrhea 22. Multivitamins W/minerals 1 TAB PO DAILY 23. sodium chloride 0.45 % *NF* 1 L Injection 3x/week ALLERGIES: Codeine / onions PHYSICAL EXAM: ADMITTING EXAM VS: 98.8 99/54 122 20 95% on RA GEN: mild distress, laying in bed HEENT: no scleral icterus SKIN: R thigh w/red, hot, indurated, tender, stage 4 sacral decubitus ulcer, stage 2 R heel ulcer CHEST: ctab CV: tachy, regular, no m/r/g ABD: nabs, soft, nt/nd EXT: pitting edema to groin +DPs GENITALIA: mons red (acute), firm (chronic) NEURO: alert, answering questions appropriately PSYCH: pleseant, appropriate DISCHARGE EXAM FAMILY HISTORY: Father died at age 72 from MI. Mother is alive and well. Remote family history of breast cancer. Daughter with ulcerative colitis. SOCIAL HISTORY: Lives in [**Location 17566**] with her husband and several children. No tobacco or EtOH use. Used to be account manager, now on long-term disability. Has [**First Name9 (NamePattern2) 269**] [**Location (un) 5871**], with skilled nursing 1h X 3/week + aid 1h X2/week. She is wheelchair bound.

CHIEF COMPLAINT: Chronic prostatitis PRESENT ILLNESS: [**First Name4 (NamePattern1) **] [**Known lastname **] a 60-year-old man with a long history of chronic prostatitis status post two transurethral resection of the prostate procedures in [**2165**] and [**2169**]. He also has a diagnosis of interstitial cystitis and more significantly has a history of coronary artery disease with a recent catheterization, supraventricular tachycardia, and a progressive mitochondrial myopathy. He has had symptoms of dribbling, stress incontinence, hematuria, but has no dysuria. He was preadmitted for cardiac clearance by Dr. [**Last Name (STitle) **], his cardiologist. MEDICAL HISTORY: 1. Coronary artery disease (s/p stents to LAD and 3rd OM) 2. Supraventricular tachycardia (on a beta blocker). 3. Mitochondrial myopathy. 4. History of orthostasis with tilt table testing done in the past. 5. Status post transurethral resection of prostate times two (in [**2165**] and [**2169**]). 6. Interstitial cystitis. 7. Pericarditis. 8. Hypertension. 9. Hypercholesterolemia. 10. Gastrointestinal bleed MEDICATION ON ADMISSION: ALLERGIES: Sulfonamides / Penicillins / Tetracyclines / Azithromycin / Iodine / Shellfish / Ace Inhibitors / Ciprofloxacin PHYSICAL EXAM: Gen: NAD HEENT: MMM CV: RRR, no m/r/g Lungs: CTAB Abd: soft, +distension with tympany, no HSM, hyperactive BS Ext: no c/c/e Neuro: A&Ox3. ECG: NSR at 62, nl axis, nl intervals, Q waves in III, avR, V1. TWI's in III, V1. FAMILY HISTORY: Father had MI at 42 Mother died of MI at 76 SOCIAL HISTORY: denies any tobacco. Divorced, lives in [**State 108**]

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 35 year-old male admitted on [**2115-9-17**] status post motor vehicle accident head on collision, unrestrained driver with positive loss of consciousness, no air bag deployment. GCS of 15 upon EMS arrival. He was hemodynamically stable in route to [**Hospital1 1444**] Trauma Room. His only complaint was of a left head pain where he had an obvious avulsion of his scalp. Initial vital signs afebrile, heart rate 76, 140/74, 100% on room air. GCS of 15. Pupils are equal, round and reactive to light. Extraocular movements intact. There was a large left parietal laceration avulsion down to the galea starting at the left forehead 3 cm inferior to the hairline extending back in a crescent shape to an area just proximal to the left ear. The mid face was stable. The oropharynx was clear. Tympanic membranes were clear bilaterally. The mandible was stable. The trachea was midline. There was no crepitus in the neck, chest. He had good breath sounds bilaterally and a regular cardiac rate was heard. The abdomen was soft, nontender, nondistended. Rectal examination was with normal tone with the prostate in the normal spot. The extremities were without any gross deformities and he was able to move them without any pain. Back was without any thoracic tenderness or step off. MEDICAL HISTORY: Chronic back pain. MEDICATION ON ADMISSION: ALLERGIES: None. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: Occasional tobacco and alcohol use.

CHIEF COMPLAINT: s/p mechanical fall PRESENT ILLNESS: [**Known firstname **] [**Known lastname 64472**] is a 74 yo female w/ PMHx sig for atrial fibrillation, colon ca, DVTs who was transferred from OSH for subdural hemorrhage. Patient had witness fall two days ago when she tripped putting on a sock and hit her face against the wall. She did not lose consciousness. She did have some residual swelling and bruising over her lower lip. This AM she was noted by daughter to be slightly confused. She was unable to name color of a shirt or tell a complete story. She also was noted to be weak on her right side. After calling PCP, [**Name10 (NameIs) **] was brought to an outside hospital. She was found to have a left frontal SDH. She was then noted to be increasingly lethargic. As a result, she was intubated for airway protection. Patient was dilantin loaded and recieved 4 units of FFP. She was transferred to [**Hospital1 **] for further management. MEDICAL HISTORY: Atrial fibrillation, Colon ca, DVTs MEDICATION ON ADMISSION: Atenolol 25 [**Hospital1 **] Protonix Xeloda ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: On Admission Vitals: T 99.8; BP 127/46; P 73 RR 16; 100 % Ac FiO2 .50 Tv 600 RR 16 PEEP 5 FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Abdominal pain, diarrhea, GI bleed, rash PRESENT ILLNESS: Patient is a 44 yo female with a h/p Crohn's, recent PE on coumadin, HTN, and depression who presents with abd pain and diarrhea, c/w Crohn's flare. Pt was recently hospitalized [**Date range (1) 29493**] for similar symptoms. She was started on colestipol, levo/flagyl, prednisone 40mg and underwent a sigmoidoscopy with biopsy showed which showed cryptitis in the colon. Patient was started on a prednisone taper, currently on 15mg qd (has longstanding hx of prednisone intake), with report of flares when tapered. Patient has been having [**7-17**] loose, non-bloody BMs per day, with worsening abd pain over past 4 days. Two days prior to admit, patient noted blood in her stools, which is new for pt. . In [**Hospital1 18**] ED, VSS, T 98.1 BP 144/69 HR 87 RR 16 100% RA. Abdominal CT showed ileitis. Surgery evaluated the patient and felt there was no indication for surgical intervention. Received 3gm IV unasyn x1, dilaudid 1mg IV x2, morphine 4mg IV x1, zofran 4mg IV x1, and 125mg solumedrol. . On the floor, the patient's pain was controlled. She had continued stooling with blood streaking, and passed "large" blood clots. She had stable hemodynamics on floor with sbp 130s, 2 PIVs in place. Received 1uFFP and vitamin K IV. GI contact[**Name (NI) **], plan for possible scope in AM. Transferred to MICU for hemodynamic monitoring. . In the MICU, the patient received 4 U RBCs. She also developed a rash on her upper torso, which was believed to be due to Cipro. Her Cipro was discontinued, and she was continued on Levo. MEDICAL HISTORY: 1. Crohn's dx 20 years ago, s/p partial sm. bowel and partial colon resection, c/b anastomotic leak and sepsis. Has been on 6MP, which led to pancreatitis; also on Pentasa, Azulfidine, Asacol, Cipro and Flagyl in past, with chronic prednisone. Was on Humira summer ([**2121**]), with no help, stopped [**3-7**] to lung infection. On MTX for 2-3months with no help. 2. s/p diverting ileostomy, reversed [**4-11**] 3. h/o c diff colitis 4. depression 5. HTN 6. incisional hernia 7. tobacco abuse 8. migraines 9. +PPD treated with inh x 6 months 10. PE in [**4-11**] during hosp - (on coumadin) MEDICATION ON ADMISSION: 1. coumadin 5mg daily 2. prednisone 15mg daily 3. prozac 20mg daily 4. HCTZ 25mg daily (on hold by PCP) 5. balsalazide 2250mg tid 6. hydromorphone 2-4mg q4-6 prn 7. colestipol 4gm daily 8. klor con 10 daily 9. clonazepam 0.5 mg [**Hospital1 **] prn ALLERGIES: Codeine / Ciprofloxacin PHYSICAL EXAM: VS: T 97.6, BP 136/60, HR 56, RR 23, 94% RA Gen: Middle-aged woman, pleasant, in NAD HEENT: EOMI, PERRL, OP clear, MMM Neck: No JVD, no thyromegaly, no LAD Cor: Bradycardic, no m/r/g, normal S1 and S2 Pulm: CTAB, no wheezes, rhonchi, or crackles Abd: hypoactive BS, large vertical scar with incisional hernia, diffusely tender, no rebound or guarding. Extrem: no c/c/e Skin: Morbilliform rash on upper torso, medial legs, and abdomen. Neuro: CN II-XII intact. 5/5 strength in extremities. Gait exam deferred FAMILY HISTORY: father died at 36 w/ PE (during hospitalization) Mother die of renal failure in her 40's brother- crohn's/UC 2 aunts- [**Name (NI) 4522**] 1 cousin- [**Name (NI) 4522**] SOCIAL HISTORY: Patient lives with her children. Currently going through separation from her husband. Smoked 1ppd since age 13. Denies EtOH. Currently under significant stress with her relationship.

CHIEF COMPLAINT: Hematochezia PRESENT ILLNESS: 73 y.o. F w/ DM, ESRD on HD, CHF presenting with BRBPR. underwent a colonoscopy on [**5-21**] (Dr. [**Last Name (STitle) 6880**] for ongoing diarrhea with biopsy x2. The colonoscopy showed: A single sessile 7 mm polyp of benign in the cecum. A single-piece polypectomy was performed using a hot snare. AS per recent note, polyps coagulated and unavailable for retrieval. A single semi-pedunculated 1.4 cm polyp of benign appearance was found in the distal ascending colon. A piece-meal polypectomy was performed using a hot snare. . Recent admission from [**Date range (1) 33900**] with BRBPR, episode of lightheadedness and syncope in that setting. HCT to 28.5 lowest, responded to 2 units PRBC, and pt stable at discharge monday. Wednesday daughter reported [**3-16**] painless clot fulled bowel movements, dark colored, not black. Associated mild nausea, and one episode of non bloody, non bilious emesis. This AM, pt felt lightheaded at HD. 30 minutes into session. Given concern to ED. Denies fever/chills/abdominal pain/mucus in stool/sick contacts. . In ED T 97, HR 58, BP 145/55, 18 stable, 100%RA. Protonix 40 mg IV given. 300 cc NS given. HCT 26.7 from 33. One unit PRBC given. GI consulted. Admitted for further work up. MEDICAL HISTORY: -Post polypectomy bleed recent admission [**Date range (1) 35112**] for BRBPR MEDICATION ON ADMISSION: -Allopurinol 100 mg Tablet Sig EOD -Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. -Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). -Pravastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). -Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). -Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). -Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). -Cinacalcet 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). -Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). -Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). -Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). -Irbesartan 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 75mg PO BID on dialysis days tue/[**Last Name (un) **]/sat. -Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) unit Subcutaneous qam. ALLERGIES: Colchicine / Atorvastatin PHYSICAL EXAM: 98.4, 138/74, 67, 99% RA GEN: well appearing female in no acute distress HEENT: OP clear, dry MM NECK: difficult to assess JVP CHEST: CTAB, no wheezes, rales CV: III/VI systolic murmur throughout ABD: soft, redundant skin, +bowel sounds, non tender, non distended EXT: no edema, cyanosis or clubbin NEURO: AO x3 Rectal: in ED, BRB, no pain. Defer exam as just performed FAMILY HISTORY: HTN, DM SOCIAL HISTORY: Patient lives with her daugther. She denies tobacco, alcohol or illicit drug use.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 16-year-old man, unrestrained passenger of high speed motor vehicle crash, ejected from the vehicle and thrown. The patient was found unresponsive at the scene. Med Flight responded, intubated the patient. Per Med Flight records, the patient was unresponsive, no spontaneous movement of any extremities were noted. Pupils were fixed and dilated. They did note an intact gag reflex, however. MEDICAL HISTORY: Unknown. MEDICATION ON ADMISSION: ALLERGIES: Unknown. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: syncope and bradycardia PRESENT ILLNESS: Mr. [**Name13 (STitle) 61671**] is a 71 year old man with a past medical history significant for hypertension and hypercholesterolemia who presented to the [**Hospital1 18**] on [**2150-9-25**] with a chief complaint of loss of consciousness. Earlier that day, the patient was getting up from a chair to get a drink when he felt faint. He states that he fell to his knees and lost consciousness. He does not think that he sustained trauma to his head. When he awoke, the patient felt confused. In association with this event, the patient denies any chest pain, shortness of breath, or nausea though he did report significant diaphoresis and a few minutes of shaking chills. He denies having any bowel or bladder incontinence. The patient returned to his chair and EMS was called. EMS found the patient to be diaphoretic with a HR in the 40's, BP 80/palpable. He was given atropine x 2 without effect. . In the [**Hospital1 18**] ED, the patient's heart rate was 43 and his SBP was 105. He was started on calcium gtt and his symptoms resolved spontaneously before he could receive glucagon for suspected beta blocker toxicity. His SBP returned 120-130 though his heart rate continued to be in the 40's. As such, the patient was transferred to the MICU for further evaluation and treatment. . On review of systems, the patient denied any recent chest pain, nausea, vomiting, diarrhea, abdominal pain, change in appetite, or weight loss. He denies any recent weakness, change in vision, or change in hearing. He does note occasional spells of "dizziness" every week or so. He has not had any recent changes in medication. In particular, his atenolol dose has not been changed for at least one year. . Of note, the patient has been taking 75 mg of atenolol for the last year. He was told by his new PCP [**Last Name (NamePattern4) **] [**9-7**] to stop taking the medication because of "low potassium" but continued to take it. . While in the MICU, the patient ruled out for MI with tropnin T negative x 3. His HR initially ranged 39-46. His atenolol, terazosin, and timolol eye drops were held. His blood pressure was controlled with IV hydralazine. The patient developing wheezing and was started on nebs and then advair. His bradycardia resolved (HR 59 on leaving the MICU) and was felt to be due to beta blocker toxicity. His work-up included an echocardiogram which showed left atrial dilation and normal LV function (LVEF >55%) as well as a TSH that came back as high with a normal total T4. Based on the resolution of his bradycardia, the patient was transferred to the [**Hospital1 139**] B general medical service. His terazosin and timolol were restarted and the patient was started on a regular dose of lisinopril. MEDICAL HISTORY: Hypertension Asthma BPH Hypercholesterolemia Right eye cataract s/p surgical repair in [**2148**] Right eye macular hole s/p surgical repair in [**2148**] MEDICATION ON ADMISSION: Atenolol 75 mg (patient has been taking "as needed" but PCP told him to stop taking it recently) Terazosin 5 mg per day Lipitor 10 mg per day Hydrochlorothiazide 25 mg per day Timolol eye drops Lisinopril 40 mg ("as needed" for headache, has not taken for > 1 week) Norflex 100 mg ("as needed" for headache, has not taken for > 1 week) . ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T 98.6, BP 100/71, HR 93 (80-93), RR 20, O2Sat 96-99/RA Gen: In bed, comfortable, NAD HEENT: Sclera anicteric, R pupil less reactive than left (s/p cataract surgery on R) with oval shape of right pupil, OP clear without exudate or erythema, neck supple with no LAD, no JVD, carotid pulses 2+ bilaterally with no bruit CV: RRR, II/VI SEM, no r/g, radial, brachial, DP and PT pulses 2+ bilaterally Pul: CTA B Abd: obese abdomen, s/nt/+bs, no HSM Ext: no LE edema Neuro: A&Ox3, CN II-XII intact, strength 5/5 in all muscle groups (extensors and flexors in upper and lower extremities), 2+ patellar, biceps, and brachioradialis reflexes bilaterally, sensation to light touch intact bilaterally in upper and lower extremities. FAMILY HISTORY: Father died at a young age from prostate cancer. Brother died of stomach cancer. SOCIAL HISTORY: Works in construction but is semi-retired (only works occasionally). Lives at home with his wife and daughter. Quit smoking 20 years ago and does not drink alcohol.

CHIEF COMPLAINT: 30 year old male s/p near drowning PRESENT ILLNESS: HPI: Patient is a 39 yo man with PMH of depression with suicide attempt in [**2152**] who arrived by [**Location (un) **] after a near drowning incident. We are consulted for episode of jerking consistent with myoclonus. The patient was reportedly found face down on a [**Doctor Last Name **] in [**Location (un) 3320**] MA. There is some report that he was witnessed to fall or jump out of the canoe and that this might have been a suicide attempt. He was found by a bystander in a boat and was thought to be responsive initially. However, while being towed to shore he became unresponsive. When EMS arrived, he was unresponsive and in respiratory distress. He was taken to [**Hospital3 6265**] where he was sedated, paralyzed and intubated. He had a head CT and C-spine CT while there. Overnight, he was witnessed to have some jerking of the arms which was seen and thought by the overnight neurology resident to be myoclonus. Currently, he is on propoful gtt and noted to grimace, resist eye opening and move non purposefully but is not noted to follow commands. According to patient's brother, Mr [**Name (NI) 16471**] and his wife had a confrontation yesterday where he was asked to leave the house. Reason unclear. MEDICAL HISTORY: PMH: Depression with suicide attempt last year by burning house down. Also was at [**Hospital1 2025**] under lock down for 1 month. Takes meds as below but compliance unknown (they were recently filled by Rx though). Followed by out patient psych in [**Hospital1 14211**]. The patients brother and father don't think that he has any neurological history or other medical history. They don't know of him every having had seizure. MEDICATION ON ADMISSION: Citalopram, bupropion, and olanzapine as outpatient. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Exam: T- Tm 101.6 Tc101.3 (on arrival was 93.1) BP- 90-115/55-75 HR- 116-140 RR- O2Sat 92-100 vented Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema FAMILY HISTORY: NAD SOCIAL HISTORY: SH: Married with 5 children. Lives with parents. Two brothers. Some ETOH abuse in [**Month (only) 404**], but family unaware if this has been a recent issue or not. His brother does not think that he has used any illicit drugs in the past.

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 27 year old female who presented with a left-sided headache for two weeks, also associated with left facial and tooth pain and with some amount of double vision. A CT scan done at the outside patient was transferred to [**Hospital1 188**] for further evaluation. MEDICAL HISTORY: 1. Not significant. MEDICATION ON ADMISSION: ALLERGIES: She had no drug allergies. PHYSICAL EXAMINATION: On examination, her pupils were equal, round and reactive. There was no lateral gaze past midline in the left eye. There was no nystagmus. There was Grade five muscle strength in all muscle groups. Sensation was grossly intact. Cranial nerves: She had a left sixth nerve palsy. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Bradycardia, dyspnea PRESENT ILLNESS: 86 y/o M with PMHx of dilated cardiomyopathy (EF of 20-25%), mitral regurgitation s/p MVR with bioprosthetic valve, paroxysmal AF, atrial tachycardia, CAD s/p remote inferior MI who presents with SOB, dizziness, and bradycardia to the 30's. He had recent medication increases to his metoprolol, digoxin, and lasix doses. Patient has had a few weeks of shortness of breath, acutely worse over the last couple of days. He presented to physical therapy today, was found to have a HR in the 40s and BP in the 90-100s. His PCP advised him to present to the ED. . In the ED his initial vitals were: 97.6, 35, 14, 135/51, 99% on 3L . He was able to ambulate from chair to bed, mentated well, and had stable blood pressures. He was found to have HR in 20-30s. Did not receive any atropine. Patient was given 1 liter of IVF. He had no crackles, edema, or hypoxia on exam. Patient was admitted to CCU for further management. . 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. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, palpitations, syncope or presyncope. MEDICAL HISTORY: - CRI - baseline cre 1.8 since [**12-27**], etiology unknown per pt. - CAD - s/p inferior/post MI [**2092**], LHC [**11-26**] no flow limiting disease. - dilated cardiomyopathy (EF 30-35% [**8-27**]) - h/o MR - s/p MVR ([**12-27**] 33mm bioprosthetic) - h/o embolic CVA (loss of peripheral vision in left eye) felt [**12-23**] afib [**2092**]. - paroxysmal atrial fibrillation/flutter - s/p DCCV [**4-27**], trial of amiodarone. - hyperlipidemia - h/o trigeminal neuralgia s/p trigeminal ablation procedure - h/o ?esophageal mass (13 x 8 mm) - [**2-25**] EGD showed gastritis, duodenitis, but no mass. - OA - s/p rotator cuff repair - s/p orchiectomy for a benign left testicular mass '[**74**] - h/o diverticula on colonoscopy (no bleeds) . - denies h/o DM, PE/DVT, malignancy MEDICATION ON ADMISSION: Atorvastatin 20mg daily Digoxin 125 mcg daily Lasix 40mg and 20mg daily alternating Lisinopril 2.5mg daily Lorazepam 0.5mg qhs Toprol 37.5mg daily Warfarin as directed Aspirin 81 mg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: 96.9, 118/52, 34, 17, 96% RA GENERAL: WDWN male in NAD. AAO x3 HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. JVP to earlobe CARDIAC: PMI located in 5th intercostal space, midclavicular line. Bradycardic, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles bibasilarly. Upper respiratory end expiratory wheeze. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ edema to mid shins bilaterally. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ FAMILY HISTORY: Denies renal disease. . No premature CAD. Brother and mother died of MI in their 70's. SOCIAL HISTORY: lives with wife and daughter, independent of adls, former probation officer. denies tobacco/ivdu. 5 glasses wine/week. no regular exercise over past 2-3 months [**12-23**] increased fatigue/DOE.

CHIEF COMPLAINT: s/p motor vehicle collision PRESENT ILLNESS: The patient is an 81 yo male brought by EMS to the ED s/p restrained moderate speed (~40 mph) MVC versus several parked cars. The patient was intoxicated. + airbag deployment. ? LOC. Vital signs were stable during transport. MEDICAL HISTORY: 1. Atrial fibrillation 2. HTN 3. Arthritis 4. S/p bilateral hip replacement 5. s/p R knee replacement 6. s/p inguinal hernia repair x 3. MEDICATION ON ADMISSION: Toprol Coumadin Mobic ALLERGIES: Hydromorphone PHYSICAL EXAM: VITALS: 100.0 110/palp 80 20 95% RA GEN - A+Ox3, some confusion about events HEENT - large laceration to R of vertex, actively bleeding. PERRL, EOMI, no nystagmus. CHEST- Clear to auscultation bilataerally, good aeration. HEART - regular no murmurs ABD - firm, muscle tenderness in lower quandrants R>L. RECTAL - good tone, heme negative. EXTR - ~6cm L hand laceration between 3rd and 4th digits extending to dorsum of hand. R knee ecchymosis. R hand bruising. NEURO - Answering questions appropriately, following all commands. No facial assymetry. Strength 5/5 UE+ LE bilaterally. Sensation intact to light touch. FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Lives alone. ? being evicted from home. + EtOH.

CHIEF COMPLAINT: chest pain PRESENT ILLNESS: 45 y/oM w/ a h/o tobacco abuse and premature CAD in his family presents with crushing chest pain to [**Hospital1 **] [**Location (un) 620**] ER. He states that his chest pain developed while lying in bed, following sexual intercourse with his wife, the pain felt like someone standing on his chest, he took [**3-28**] ASA 81mg, the pain transiently improved but then worsened while walking down stairs. The pain radiated to both his shoulders and his jaw, he felt some SOB as well as nausea and diaphoresis. He had no palpitations or LOC. He went to [**Hospital1 **] [**Location (un) 620**] ER where he was found to have ST elevations in his precordial leads, he was then transferred to the cath lab at [**Hospital1 18**] [**Location (un) 86**] for intervention. . At baseline the patient is active, able to walk up at least 4 flights of stairs without any symptoms, works as a carpenter. He had a stress test two years prior for exertional angina while exercising and found to have some "small occlusion which could be treated with medications", he has used NTG SL x 2 in the past two years, last 7 months ago. . He denies any orthopnea, PND, pedal edema. No claudication symptoms. No TIAs or CVA in the past. . Rest of ROS is negative. In the cath lab he was found to have a total occlusion of his proximal LAD, this was stented with a DES, no other significant coronary disease. 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: none MEDICATION ON ADMISSION: Toprol XL 50mg daily ALLERGIES: Penicillins PHYSICAL EXAM: VS: HR 102 BP 112/74 RR 14 O2 96% on 2L NC GENERAL: NAD, AOX3 HEENT: MMM, OP clear, unable to assess JVP CARDIAC: RRR, no m/r/g LUNGS: CTAB anteriorly, No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ (no bruits) DP 2+ PT 2+ Left: Carotid 2+ (no bruits) DP 2+ PT 2+ FAMILY HISTORY: Father w/ an MI in his 30s, paternal uncle with a CABG age 52 and maternal uncle with a CABG age 52. SOCIAL HISTORY: -Tobacco history: 2ppd, prior was 1ppd, x 18 years -ETOH: occ -Illicit drugs: none -occupation: carpenter

CHIEF COMPLAINT: PRESENT ILLNESS: [**Known firstname 487**] [**Known lastname 36421**] is a 71-year-old man with the past medical history significant for only hypercholesterolemia and no allergies. He was admitted to the Trauma Service of [**Hospital1 69**] after being struck with a car at about 40 miles per hour. He had positive loss of consciousness at the scene, but his [**Location (un) 2611**] Coma Scale was 15 upon arrival to trauma bay. Her was perseverating and he was complaining of pain in the right lower quadrant, right hip, and left chest. He was found to have open laceration in the left parietal region. The blood pressure, at the scene and upon arrival, was in the 90s. Heart rate was 60. He underwent trauma series in ER; CT of the head and T-spine, CT of the chest and abdomen. His injuries included left temporal-frontal laceration of the scalp, fracture of his left radial diaphysis, multiple left rib fractures with pulmonary contusion. He had splenic laceration. He had a left inferior pubic ramus fracture. He received two units of packed red blood cells in the ER and two liters of IV fluid and two liters of crystalloids with little response of his blood pressure. Therefore, he was taken to the operating room for exploratory laparotomy and splenectomy. He was transfused additional two units of packed red blood cells in the operating room plus cell [**Doctor Last Name 10105**] and two units of FFP. He was then transferred to the Surgical Intensive Care Unit. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Cellulitis PRESENT ILLNESS: 31 year old male with spina bifida, s/p spinal fusion, hydrocephalus s/p shunt, bilaterally dislocated hips and clubbed feet presented to OSH with chills/night sweats and a known likely infected left foot (has a history of many lower extremity infections in the past). At the OSH, noted to be septic with HR in the 120s, hypotensive to the 70s responsive to IVF, afebrile with source likely cellulitis in his left leg; UA and CXR negative, blood cultures NGTD. Initially was put on vanc/clinda however pt continued to be septic with WBC count trending upwards (17 on [**8-2**] to 33 on [**8-4**], day of transfer) and with spreading of his cellulitis, so his abx were changed to vanc/zosyn. He was seen by surgery at the OSH who felt that he likely did not have nec fasc and recommended adding IV diflucan. Skin/wound cultures reportedly growing group G strep, blood cultures negative. He was transferred for further multidisciplinary workup; normally he is seen at [**Hospital1 2025**] for his lower extremity infections, it is unclear why he was not transferred there. His custom wheelchair recently broke and he has since been in one that is not well fitted to him. He developed lower extremity abrasions and sacral skin breakdown complicated by lower extremity and sacral cellulitis for the past few weeks. On the floor he appears tired and ill but not toxic, intermittently falling asleep. He is oriented to person and time but not place, and exhibits [**Doctor Last Name 688**] concentration. Endorses chills, night sweats, mild shortness of breath. States that he can feel his lower extremities but does not feel pain in them currently. Endorses dysuria. Pt was initially admitted to HMED service. He became increasingly toxic overnight and was transferred to the MICU for dropping pressures in the setting of afib with RVR. On arrival to the MICU, pt was hypotensive to 70s systolic, still in RVR. MEDICAL HISTORY: PMH: Spina bifida, chronic lymphedema, hydrocephalus s/p shunt, lower extremity paralysis with bilateral clubbed foot deformities MEDICATION ON ADMISSION: Medication on transfer from Medical service: metrogel q12h to face tylenol prn albuterol nebs prn oxycodone 5-10mg q3h prn pain zosyn 3.375g q6 vancomycin 2g q12 diflucan 200 qd ALLERGIES: peanut / latex PHYSICAL EXAM: 97.2 108/42 110 26 94%2L Admission Exam: GEN Alert, oriented to person/time, states he is at [**Hospital1 2025**], no acute distress HEENT NCAT dry MM, EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Only able to auscultate anteriorly due to habitus, good aeration, CTAB no wheezes, rales, ronchi CV regular tachycardia normal S1/S2, no mrg ABD obese soft NT ND normoactive bowel sounds EXT L: massive lymphedema with club foot deformity, capillary refill <2sec distally, over medial thigh and lateral club foot area of skin with cellulitic appearance with skin sloughing and weeping of serous fluid, dermis underneath appears beefy red, nontender to palpation, no area of fluctuance noted. No crepitus. Some areas with dark purple discoloration. Fungal appearing coat over some areas of skin. R: mild lymphedema with club foot deformity, no areas of skin breakdown noted. Sacrum: erythematous non-necrotic ulcer noted without penetration to bone/muscle. Non purulent. NEURO CNs2-12 intact, upper motor function grossly normal GU fungal appearing discharge from meatus FAMILY HISTORY: Mother with chronic fatigue syndrome and allergies, Dad unknown SOCIAL HISTORY: Lives with parents who are caregivers. Worked in the past at kiosk in the mall, but not currently employed. Not married, no children. No tobacco, ethanol, drugs.

CHIEF COMPLAINT: Abdominal pain PRESENT ILLNESS: Ms. [**Known lastname **] is a 62 yo female with a h/o IDDM, ESRD on HD, diastolic CHF, multiple thrombi on coumadin, s/p recent admission for HD catheter infection who presents with a complaint of abdominal pain x 1 week. She describes anorexia and vomiting with any PO intake. She localizes the abdominal pain to the RLQ, radiating to the RUQ. Per report from The [**Hospital3 2558**], morning vitals were notable only for a HR 122. Patient requested transfer to [**Hospital1 18**]. . On arrival to ED, T 95.6 PO, HR 122, BP 104/55, RR 17. Morphine 4 mg IV and Zofran 4 mg IV were administered on arrival for symptom control. Following a stat lactate of 6.3 she received Vancomycin 1 gram and Ceftazadime 2 g IV. Patient became hypotensive to 63/31 and a CVL was placed in the right groin. Levophed was started. CT abdomen was performed given her complaint of abdominal pain which revealed large pericardial effusion. Cardiology was called, and stat TTE was performed at bedside, indicating tamponade physiology. She received Vitamin K 10 mg PO, and 1 mg IV. 4 units FFP were transfused, and she received Profil nine 1120 units IV x 1. . She was taken urgently to the cath lab where 700 cc of bloody fluid was drained. Initial pericardial pressure in 40's down to 11 s/p drainage. Patient was started on Dopamine gtt at 5mcg/kg/min and transferred to the CCU for further management. . On review of symptoms, she denies any prior history of stroke, TIA, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: PAST MEDICAL HISTORY: - Bilateral internal jugular thromboses, restarted on coumadin [**8-24**] - h/o bilateral lower extremity DVT's - ESRD on HD T, Th, Sat - IDDM - Diastolic heart failure - Pulmonary hypertension - Hypercholesterolemia - OSA, noncompliant with CPAP as outpatient - OA - h/o C. Diff - GERD - Depression - Morbid obesity - Fibroid uterus; vaginal bleeding - h/o Osteomyelitis at the T9 Vertebrae [**5-24**]; tx with Vanc - h/o Multiple line infections **[**2135-12-17**]: Providencia, treated with 4 wk course of aztreonam **[**2135-4-17**]: Staph coag positive, sensitive to both vancomycin and gentamicin **[**2136-5-17**]: Staph bacteremia tx with vanc x 6 weeks **[**2136-8-17**]: Proteius mirabilis and MSSA, treated with ceftaz and vanc . PAST SURGICAL HISTORY: - L forearm radial-basilic AV graft, s/p infection, thrombosis and abandonment ([**12-21**]) - Multiple lines in L upper arm with AV graft - 1/07 L femoral PermaCath placed - L upper arm thrombectomy, revision, of LUE AV graft ([**3-23**]) - [**4-23**] Excision of left upper arm infected AV graft; associated MRSA bacteremia treated with 6 weeks vancomycin. - Right upper extremity AV fistula creation [**10-23**] s/p revision - [**2135-12-14**] Right AV fistula repair, Right IJ PermaCath rewiring and IVC filter removed MEDICATION ON ADMISSION: CURRENT MEDICATIONS: 1. Warfarin 2 mg daily 2. Simvastatin 20 mg daily 3. Paroxetine 20 mg daily 4. Sevelamer 2400 mg [**Hospital1 **] 5. Ascorbic acid 500 mg [**Hospital1 **] 6. Colace 100 mg [**Hospital1 **] 7. Cinacalcet 30 mg daily 8. Albuterol neg q6 PRN 9. Midodrine 10 mg TID 10. Folic acid 1 mg daily 11. Glargine 10 units qHS 12. RISS 13. Reglan 5 mg IV q6h PRN 14. ASA 81 mg daily 15. Senna 1-2 tabs [**Hospital1 **] PRN 16. Dulcolax 10 mg daily PRN ALLERGIES: Penicillins / Ceftriaxone PHYSICAL EXAM: VS: T 96.7, BP 127/53, HR 102, RR 16, O2 97% on 1 L NC Gen: obese black female, supine in bed, in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: Tunneled HD cathter in left anterior chest wall with dressing intact. No scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, with tenderness in all 4 quadrants. + [**Doctor Last Name 515**] sign. No abdominial bruits. Ext: Trace lower extremity edema. No femoral bruits. TLC in left groin with clean dry dressing intact. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP FAMILY HISTORY: Not obtained. SOCIAL HISTORY: Patient denies a tobacco, alcohol or illicit drug use. She lives in a nursing home (?[**Hospital3 2558**])

CHIEF COMPLAINT: non-healing ulcer LLE PRESENT ILLNESS: 83yo M, h/o IDDM, CKD (stage 3) and PVD, who presents for elective angiogram. The patient is a poor historian. He has a history of calf claudication for which he received a right femoral to peroneal bypass with in situ saphenous graft in [**2153**]. He has done well until ~3-4 months ago when he noticed LLE pain in the calf and foot with an ulcer developing on the left outer border of the foot. He was seen in the clinic. Given his renal insufficiency, he is being admitted pre-procedure for renal protective measures for a scheduled angiogram tomorrow. MEDICAL HISTORY: PMH: DM-2, PAD, HTN, HLD, GERD, CKD (stage 3) PSH: Pacemaker, Left hip replacement, L knee Arthroscopy, R femoral to peroneal in situ saphenous vein graft [**1-/2153**] ([**Doctor Last Name **]), CABG, appendectomy MEDICATION ON ADMISSION: Prilosec 20'', Lantus 5u QAM, Bumetanide 1', ASA 81', Coreg 6.25'', MVI', Vit C', Zocor 40', Tums 500 Q6H prn, Cosopt 1gtt each eye QAM, lisinopril 2.5', glipizide 10' ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: AFVSS Gen: NAD CV: reg Chest: sternotomy incision well healed Pulm: no resp distress Abd: R sided vertical incision well healed, S/NT/ND Ext: bilateral edema R/L. L foot dusky with dry skin and medial aspect of foot with dry eschar ~2.5 cm in diameter tender to palpation, no drainage or fluctuance Fem DP PT graft Left palp faint dop Right palp dop dop palp FAMILY HISTORY: Patient was an orphan and thus is not aware of family hx of cardiac diseases. His adult children, however, are healthy and without cardiac diseases. SOCIAL HISTORY: Patient lives with his wife in [**Name (NI) **], MA. He reports smoking a pipe for 20 years but quit 20 years ago. Denies any EtOH use or recreational drugs.

CHIEF COMPLAINT: chest pain and R flank pain PRESENT ILLNESS: 50 yo M with history of HTN, CAD, CHF with EF of 30%, s/p ICD pacemaker in [**2182-1-29**] for VT, and biploar, who presents with chest pain and R lower flank pain. Pt was admitted for similar sx's in [**3-5**]. Pt states on the morning of admission at about 9 a.m. he developed R flank pain. States he had intense pain on urination and noticed that his urine had blood in it. States the pain has been constant since it began and was only partially relieved by IV dilaudid which he received in the ED. States it is sharp in nature and is equally as strong if he lies still vs. moving around. . Pt states around 12:30p.m. on the DOA he also developed chest pain while he was sitting watching t.v. States it was an [**9-7**] located in the center of his chest and radiated to his L jaw, L neck, and L arm. States he also had SOB, nausea, and diaphoresis. Took 2 SL nitro's and the pain decreased to a [**5-8**]. He presented to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and was subsequently transferred to the [**Hospital1 **] for cath. However, given his history of allergy to aspirin (states he gets SOB and his whole body swells) he was transferred to the CCU for asa desensitization prior to cath. On ROS pt denies any recent vomiting, diarrhea, BRBPR, melena. No fevers, chills, night sweats or changes in weight. States legs occasionally get swollen but this has not occurred lately. States at baseline he can only walk a short distance before getting SOB. Sleeps on one pillow and denies any PND or orthopnea. . On review of the online records from the [**Hospital1 **], [**Location (un) 620**] and Mt. [**Location (un) **], it was found that the patient has had 4 admissions in the past 4 months for these exact same sx's. Each admission makes note of a completely negative workup including negative cardiac enzymes, no ECG changes, and CT scans which show no evidence of nephrolithiasis. His last [**Hospital1 **] admission documents malingering in which the patient was found cutting his hand and placing drops of blood in his urine and then denying this act later. All four admissions document his IV dilaudid seeking behavior, and in the most recent admission to [**Hospital3 **] on [**2185-4-29**], he left AMA after he was refused IV dilaudid and offered only po or IM. MEDICAL HISTORY: PAST MEDICAL HISTORY: 1. CAD. M.I. x 2 ([**2182**], [**2183**]). Catherization @ [**Hospital1 336**] [**2185-2-17**]. LAD proximal 40% lesion, mid 30% lesion. DIAG1 proximal 50% lesion. mid 40% lesion. LCA CX proximal diffuse 50% lesion. RCA ostial 30% lesion. Conclusion. Moderate non-obstructive cornary disease. ECHO [**5-2**] at [**Hospital1 **]. Enlarged LV with hypokinesia of inferoseptal wall. EF 40% enlarged LA. Trileaflet aortic valve. Enlarged aortic root [**3-2**] HTN. Stress test [**5-2**] at [**Hospital1 **]. Dipyridamole injection. Normal uptake of radioisotope without perfusion defect. EF 34%. 2. Dyslipidemia. Cholesterol panel [**2185-6-11**]. trig 312. HCL 37. LDL cal. 18. 3. History of hypertension. 4. Syncope. Hospitalization [**5-/2182**] @ [**Hospital1 18**] for an episode of syncope and palpitations. 5. Status post ICD pacemaker implantation for VT in [**2182-1-29**] @ [**Hospital1 336**] 6. Nephrolithiasis [**2183**] 7. Status post cholecystectomy. 8. Chronic back pain due to degenerative disc disease. Seen on CT at L4-5 and S1 [**10-2**] 9. Bipolar diagnosed [**2183**]. 10. multiple hospitalizations [**2182**]-[**2185**] around the area for chest pain, flank pain, hematuria. 11. PE in [**3-5**] at [**Hospital1 **], treated with coumadin, then pt reports he had a filter placed at [**Hospital **] hospital in [**4-2**] and since has not been taking coumadin. MEDICATION ON ADMISSION: Trazodone 100 mg PO qhs Sertraline (Zoloft) 200mg PO daily Toprolol (Metoprolol XL) 200 mg PO daily Verapamil SR 240 mg PO daily Depakote (divalproex sodium) 750 mg PO qpm. 500 mg PO qam oxycontin 80mg PO bid plavix 75mg PO daily SL nitro prn ALLERGIES: Motrin / Compazine / Morphine / Toradol PHYSICAL EXAM: 98.4 91 111/73 15 97% 2L NC Gen: repetitively complaining of pain, but easily moves in bed and appears comfortable. HEENT: MMM, OP clear Neck: no stiffness or limited ROM CV: RRR, no m/r/g Lungs: CTAB Abd: s/nt/nd, +bs. Back: + R CVA tenderness. Ext: no c/c/e. DP and PT pulses 2+ bilaterally. Neuro: A&Ox3. FAMILY HISTORY: Family history is significant for heart disease. Father died from an M.I. at 70 years old. [**Name (NI) **] brother has heart problems. Aunts on his father??????s side have unstable angina. Mother died at 62 years old from breast CA, which metastasized to the bone. There is no family history of clotting disorders. SOCIAL HISTORY: On admission pt stated he currently lives with his wife their two children, a 17 year-old daughter and a 15 year-old son, with her. However, later he disclosed that his wife left him for another man in [**2-2**] and took their children with her. States he lives alone and has little social support. He used to work as a commercial fisherman and as licensed auto mechanic, however he stopped working in [**2182**] s/p his ICD pacemaker placement. Last year he started receiving disability benefits. He is on Mass Health.Patient??????s diet consists primarily of meat and potatoes. He is unable to exercise because of his back pain. He has a 15 pack-year smoking history, but recently stopped 4 months ago. He denies alcohol use but admitted to the social worker that he used to drink heavily and occasionally attends AA meetings. He used pot in high school, but denies any additional recreational drug use.

CHIEF COMPLAINT: L ICA aneurysm PRESENT ILLNESS: 64 y/o F presents for elective coiling of L ICA aneurysm MEDICAL HISTORY: Depression Hypertension Hyperthyroidism with multinodular goiter MEDICATION ON ADMISSION: Amlodipine 2.5 mg qd, Atenolol 50 mg qd, Fluoxetine 40 mg qd Methimazole 5mg qd ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / Paper tape PHYSICAL EXAM: On Discharge: FAMILY HISTORY: Father: pancreatic cancer Siblings: Brother in good health SOCIAL HISTORY: Single lives alone. Tobacco: 45 pack-year quit 1/[**2196**]. ETOH none

CHIEF COMPLAINT: fatigue/DOE PRESENT ILLNESS: 77 year old female who has been followed for several years for atrial fibrillation and mitral regurgitation. She has undergone PVI in [**2098**] with atrial fibrillation recurrence in [**2099**] requiring DC cardioversion. In addition, she required a pacemaker in [**1-7**] for symptomatic bradycardia. Most recent echocariogram showed worsening mitral regurgitation, now moderate to severe. In addition, she had markedly increased tricuspid regurgitation, now 3+. Referred for surgery. MEDICAL HISTORY: mitral regurgitation s/p MV repair/TV repair/res. Left atrial appendage tricuspid regurgitation - Paroxysmal atrial fibrillation status post cardioversion in [**2096**], pulmonary vein isolation on [**2098-3-11**]. Recurrent atrial fibrillation post PVI requiring DC cardioversion, [**2099-7-31**] - Prior antiarrhythmic therapy with amiodarone discontinued due to lung toxicity (increased DLCO) - Prior antiarrhythmic therapy with dofetilide discontinued due to QT prolongation - Coronary Artery Disease s/p prior MI [**2076**], - Hypertension - Hyperlipidemia - Congestive Heart Failure - Cardiomyopathy - Mild emphysema/COPD - Hypothyroidism - Anxiety Past Surgical History: - St. [**Hospital 923**] medical dual-chamber pacemaker on [**2099-1-21**], [**Hospital3 **], for symptomatic bradycardia. - s/p Back surgery - s/p Tonsillectomy - Left breast biopsy - (Benign) MEDICATION ON ADMISSION: ALLOPURINOL - (Prescribed by Other Provider) - 100 mg Tablet - 1.5 Tablet(s) by mouth daily AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day AZITHROMYCIN - 500 mg Tablet - 1 Tablet(s) by mouth 1 hour prior to the dental procedure as needed BUMETANIDE - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth once a day CLONIDINE - (Prescribed by Other Provider) - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day LEVOTHYROXINE - (Prescribed by Other Provider) - 75 mcg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once daily PRAVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1 Tablet(s) by mouth once a day ***WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth once a day- LAST DOSE 11/10 ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1 Tablet(s) by mouth once a day ALLERGIES: Penicillins / Amiodarone / Dofetilide PHYSICAL EXAM: Pulse: 70 Paced Resp: 16 O2 sat: 96% B/P Right: 131/77 Left: 140/86 Height: 65" Weight: 127lb FAMILY HISTORY: Denies premature coronary artery disease Father died of CAD in 70's SOCIAL HISTORY: Lives with: Husband Contact: Phone # Occupation: Retired Cigarettes: Smoked no [] yes [X] Hx: quit [**2076**] 35 pack-years Other Tobacco use: ETOH: < 1 drink/week [X] [**3-8**] drinks/week [] >8 drinks/week [] Illicit drug use: None

CHIEF COMPLAINT: urosepsis PRESENT ILLNESS: 89 yo F with h/o DM II, htn, diastolic CHF and recent admit for fractured ankle in [**6-1**] p/w [**Date Range 18003**] MS [**First Name (Titles) **] [**Last Name (Titles) 3080**] on [**2127-7-1**]. Discharged from rehab 1 wk PTA with hospice and a dx of end-stage dementia. At home, pt. became progressively more confused and less communicative. [**Name (NI) 1094**] friend and [**Name2 (NI) 18004**] contact[**Name (NI) **] pt's PCP who told her to come to ED. Apparently, per PCP, [**Name10 (NameIs) 18003**] MS was far from pt's baseline and was more c/w delirium. In [**Name (NI) **], pt was found to ahve hypotension and qualified for [**Name (NI) 3080**] protocol. She was noted to be febrile with a lactate of 4.4 and a U/A c/w urosepsis. SHe ahd a cr of 1.8, c/w ARF, that improved with hydration. She was given levo/vanc/flagyl and aggressive hydration. EKG with ST, LAD, LVH with TWI in I, L, but not V5-6. Pt. ruled out for MI. In MICU, pt. continued to get 4 L IVF. Had hematuria with hct drop from 31.3 to 26.1, guaic neg. Pt. given bladder irrigation, urology consulted. No clots, cleared. Continued on levoflox, renal U/S without hydro. Pt. developed hyperglycemia requiring insulin gtt until [**7-2**], then transitioned to long acting sq insulin. Noted to have cough, got swallow eval. MEDICAL HISTORY: osteoarthritis hypertention hyperlipidemia DM2 CHF with EF >55% gastritis MEDICATION ON ADMISSION: MOM prn [**Name2 (NI) 17339**] 20 [**First Name9 (NamePattern2) **] [**Last Name (un) **] 1g qd lasix 20 qd ? bowel regimen ALLERGIES: A.C.E Inhibitors PHYSICAL EXAM: t-97.8, hr-91, bp-125/55, rr-22, 94 % on 2L gen - NAD, weak HEENT - EOMI, arcus senilus neck no JVD, supple lungs - CTAB, no w/r/r/ C/V - RRR abd - s/nt/nd, NABS extr - R - no edema, L in cast neuro - A+O x 1, otherwise nonfocal FAMILY HISTORY: n/c SOCIAL HISTORY: no tob, ETOH. Lives at home with [**Month/Day (4) 18004**]/friend, who helps care for her. Also gets VNA.

CHIEF COMPLAINT: Hallucinations, tremulousness PRESENT ILLNESS: 55 y/o w/ PTSD, anxiety and ETOH abuse presents with report of unwitnessed seizure following ETOH use. She originally presented to [**Hospital 8**] hospital earlier today and was discharged shortly after. She then went back to her group home where she endorsed auditory hallucinations. She stated voices were telling her to commit suicide. She then was transported to [**Hospital1 18**] ED. Of note, she has a remote history of DTs in the setting of ETOH withdrawl. . In the ED, initial vitals were 98.2 138 151/107 20 98% RA. She triggered on arrival for HR 140 bpm. Serum ETOH 295, otherwise tox screen negative. CXR showed no acute cardiopulmonary process. ECG showed sinus tachycardia. CBC and chem 7 within normal limits. ETOH level was elevated. She was given 3L NS, but despite this was still tachycardic 100-130s and endorsed sensation of her skin crawling. She received 2mg ativan x2, followed by 10mg diazepam x2. She also received PO thiamine, folate and MVI. There was no observed seizures in the ED. Vitals prior to transfer were 107 14 97% on RA, 133/86. No evidence of seizure activity in the ED. . On arrival to the MICU, she complained of feeling anxious, tremulous, and diaphoretic. Feels like bugs are crawling on her skin. Denies hallucinations (although had auditory hallucinations earlier today). Also has mild sternal "squeezing" sensation, no radiation, no associated SOB, no known exacerbating factors, happens at rest and with exertion, started several weeks ago. Cannot recall this mornings events, but seems to think she had a seizure. States she has a remote history of seizures, details unknown. Last drink was approximately 24H prior to admission. Normally drinks 2-3 pints of vodka daily. MEDICAL HISTORY: - anxiety/post-traumatic stress disorder - HTN - leukemia as a child (per patient) - Chronic hepatitis C - confirmed on serology [**Month (only) **]/[**2136**] - H/o atypical chest pain - H/o cocaine use - has not used in several years - H/o EtOH use - personality disorder - [**Hospital1 18**] hospitalization [**2141-8-18**], [**7-20**], [**8-18**] x2,12/08,7/08,121/04,3/00,1/99,1/98,[**4-/2127**] x2,[**7-/2126**] all for ETOH and risk for self harm - eczema MEDICATION ON ADMISSION: None ALLERGIES: Neurontin / Sudafed / Benadryl Decongestant / Seroquel / Nicotine Transdermal / Haldol / Geodon / Zyprexa PHYSICAL EXAM: ON ADMISSION ------------ General: Alert, oriented, anxious, at times tearful, tremulous HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear Neck: supple, JVP flat, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no wheezes, rales, rhonchi Abdomen: NABS, NT/ND, no HSM GU: Ext: warm, well perfused, 2+ pulses, no edema Neuro: PERRL, EOMI, CN2-12 intact, 5/5 strength throughout, no focal sensory deficits . Labs: 141 105 6 97 CBC 5.7, 36, 183 3.5 26 0.6 ETOH: 295 . Images: CXR: no acute cardiopulmonary process . EKG: sinus tachycardia FAMILY HISTORY: Her father passed away from MI at age 64. Mother and sister with depression. SOCIAL HISTORY: [**3-15**] pints of Vodka daily. Smoker. Last used cocaine several years ago, denies other illicits. Currently residing in shelters in [**Hospital1 8**]. Has a brother nearby and a women's sponsor for support systems.

CHIEF COMPLAINT: Hypoxia, fever PRESENT ILLNESS: Patient was unable to give much history at presentation due to possible delirium and aphasia. Information she was able to provide as well as notes were used to formulate HPI. This is an 80 year-old female with past medical history of CAD s/p CABG, left CVA with residual right sided weakness and expressive aphasia, and multiple bouts of pneumonia who presented from [**Hospital **] [**Hospital **] Nursing Home with lethargy and fever to 102. Patient had been noted to be falling asleep at nursing home and had a non-productive cough. She had labs drawn that showed a WBC of 28 and was sent to the emergency. MEDICAL HISTORY: H/o stroke with expressive aphasia and R hemiparesis s/p cardiac cath Obesity Depression HTN Hyperlipidemia Bladder spasm CAD s/p CABG (details of anatomy not available) PVD s/p fem-[**Doctor Last Name **] bypass Adrenal adenoma MEDICATION ON ADMISSION: Per Nursing Home records Vit D3 [**Numeric Identifier 1871**] units weekly for 6 weeks Aspirin EC 81 mg daiy Ferrous sulfate 325 mg daily Lasix 40mg PO qAM Glipizide 2.5mg PO daily Plavix 75mg PO daily Gemfibrizil 600mg [**Hospital1 **] Omeprazole 20mg [**Hospital1 **] Colace 100mg [**Hospital1 **] Baclofen 20mg TID Senna 8.6 mg 2 tabs qHS Simvastatin 80 mg qHS Paxil 60mg daily Seroquel 12.5 mg q1300 Neurontin 600mg qHS Tylenol 650mg [**Hospital1 **] ALLERGIES: Lamictal / Niaspan Starter Pack PHYSICAL EXAM: On admission: Vitals: 100.0 106/53 104 22 93%1L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, dry oral mucosa, clear OP Neck: supple, no LAD Lungs: Decreased breath sounds LLL, diffuse expiratory wheezing throughout, dullness to percussion CV: tachycardic, regular, +S1, S2, no m/r/g Abdomen: soft, tenderness to moderate palpation of left abd, bowel sounds present, no rebound tenderness or guarding, no organomegaly, +left CVA tenderness GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, right sided paresis, able to wiggle toes slightly, no movement of right arm. 4/5 strength left leg, [**5-13**] left arm. FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Lives in nursing home since [**2174**]. Widowed. Eats regular diet, takes meds in pudding or applesauce.

CHIEF COMPLAINT: Headache PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] had undergone recoiling of a large left internal carotid ophthalmic segment aneurysm. MRI and MRA shows early recanalization of the aneurysm and she is electively admitted for a stent-assisted recoiling. MEDICAL HISTORY: left ICA aneurysm HTN hypercholesterolemia osteoporois gastritis MEDICATION ON ADMISSION: ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - Dosage uncertain METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day ALLERGIES: Lactose PHYSICAL EXAM: On examination today, she is awake, alert, and oriented x3.Cranial nerves II-XII are intact. Motor strength is [**4-5**] in all four extremities. Gait and coordination is normal. FAMILY HISTORY: no aneurysms. No strokes. Son who died or renal/cardiac disease. SOCIAL HISTORY: Spanish speaking only. Lives alone. no ETOH. No tobacco. No illicits

CHIEF COMPLAINT: BRBPR PRESENT ILLNESS: The patient is an 85 yo F with h/o htn who p/w new onset BRBPR. The patient awoke on the morning of [**10-19**] and had a large bowel movement followed by BRBPR which she is unable to quantify but reports that it did not fill the bowl, but was "a lot". She then went to visit her husband in stroke rehab and continued to have bloody BM's, this time of significantly smaller volume. Also had tenesmus. She denied any light-headedness, abdominal pain, chest pain, nausea, vomiting, reflux. She had not used NSAIDS recently nor EtOH. She has no history of reflux, hematemesis, hematochezia, melena, change in stool caliber, fevers/chills, or night sweats. She has lost 6lbs over the last several weeks which she attributes to increased activity. She has never had a colonoscopy but has what sounds likes a sigmoidoscopy in the [**2158**] which per her her report showed a polyp. She denies any history of epistaxis or gingival bleeding after brushing teeth. At OSH, initial HR 76 and BP 182/92. Labs significant for HCT 38.9, INR 1.0. She received 1L NS and PIVs x 2 placed. She had ongoing oozing from rectum and passed approx 50cc of maroon colored stool so was transferred to [**Hospital1 18**] for further evaluation. . In the ED, initial vs were: 97.9 75 128/69 98%RA. She denied CP, SOB, N/V, abd pain. NG lavage was negative. She received pantoprazole 40mg IV and 1LNS. There was some T wave flattening on ECG but no prior for comparison. One troponin was negative. . In the MICU, she had several more maroon BM's. and her hct fell from 34 to 30, at which point she was transfused one unit of RBCs. She was seen by GI who recommended colonoscopy for Monday morning. She is currently being prepped. . On transfer to the floor she feels quite well. She is without complaint except for frequent loose stools after starting GoLytely. Tenesmus has resolved. Review of systems: (+) Per HPI. Also notes red rash under breasts bilaterally. (-) 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. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. MEDICAL HISTORY: Hypertension Past Surgical History: s/p cholecystectomy, s/p R salpingoophorectomy MEDICATION ON ADMISSION: Atenolol, Vitamin C and E. No OTC or herbal medications. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: T: 98.4 BP: 121-154 / 37-77 P: 60s-80s R: 16 O2: 95% on RA General: Alert, oriented, no acute distress, speaking in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear, no conjuctival pallor 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, hyperactive BS, mildly distended, non-tender, no rebound tenderness or guarding, no organomegaly GU: foley draining yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Erythematous rash in intertriginous area with maceration under breasts bilaterally. FAMILY HISTORY: No FH of GI malignancies or illnesses. No FH CAD. SOCIAL HISTORY: Lives at home with son. Married to husband of 64 years who currently lives in rehab after 3rd stroke. Formerly worked as nurse's aid and telephone operator. - Tobacco: <10 pack year history , quit many years ago - Alcohol: None - Illicits: None

CHIEF COMPLAINT: Non-responsive PRESENT ILLNESS: The pt is a 86 year-old right-handed female with a past medical history of dementia, DM2, PAD who presents with was reported normal this morning at her inpatient dementia unit. By report she is able to walk and interacts at baseline, although we were not able to get a full sense of her baseline, she is in an inpatient dementia unit and requires full assistance in eating, dressing and bathing and requires 24/7 care. This morning she was noted to be walking around normally but at 9am (by report she has been seen normal minutes before) she was found on the ground. It was assumed that she had fallen. On the floor she was noted not to be moving her right arm or right leg, and she had a right facial droop. She was not responding to commands and was getting increasingly non-responsive. She was sent to [**Hospital1 18**] ED where she was called as a code stroke with an NIH stroke scale of 25. On arrival she was not responsive to voice, and extensor postured to pain with both her arms to sternal rub. She had an enlarged left pupil. As she had vomited she was intubated and a stat CT was done which revealed a large left IPH. MEDICAL HISTORY: per OMR, patient unable to verify Dementia Gerd Osteoporosis CAD DM2 PAD- multiple stents in LE arteries MEDICATION ON ADMISSION: Aricept 10 mg qd ASA 325 mg qd FeSO4 325 mg qd Glipizide 10mg qd Lisinopril 20mg qd Metformin 500 mg [**Hospital1 **] Metoprolol 50 mg qd MVI Nystatin to buttocks [**Hospital1 **] Plavix 75mg qd Ranitidine 150 mg qd Simvastatin 40 mg qd Torsemide 20 mg qd Acetominophen 325 mg PRN Nitrotab PRN ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Vitals: T:98 P:55 R: 16 BP:122/77 SaO2:100 General: eyes closed not responsive HEENT: NC/AT, Neck: Supple, no carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2 Abdomen: soft, NT/ND, normoactive bowel sounds FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Lives at [**Hospital3 **].

CHIEF COMPLAINT: BRBPR PRESENT ILLNESS: Patient is a 54 yo M with h/o hypertension and asthma who presents with BRBPR after colonscopy with biposy yesterday. He had a repeat colonscopy for the purpose of polypectomy yesterday. He had a sessile 2 x 3.5 cm polyp in the cecum that was biopsied. He woke up this morning with some lower abdominal cramping that was somewhat relieved by passing gas. He had a normal, brown bowel movement this morning. Then at 4PM, he developed further abdominal cramping and when he went on the toilet he noted fresh blood, no clots. Then while he was driving, he had crampy abdominal pain, felt dizzy, and was incontinent of blood clots. . He presented to Sturdy ED. HCT was 38.1. He was hemodynamically stable. He was transferred to [**Hospital1 18**] given his procedure here. . In the [**Hospital1 18**] ED, initial VS were: 98.8, 98, 134/88, 14, 100% RA. During his ED visit, he became diaphoretic, nauseous and BP fell to 67/48. His SBP came up to 120s during a fluid bolus. Bloody stool was noted on the pad. HCT was 35.9. Coags were normal. He has received about 2L IVFs and 2 units PRBCs. GI has been consulted and is requesting a prep (Golytely) for tomorrow. For access, he has 2 18 and 1 16 PIVS. VS on transfer are: 86, 120/82, 17, 97%. . (+) Per HPI + urinary retention (-) Denies fever, chills, headache, shortness of breath, wheezing, chest pain, palpitations. Denies dysuria, frequency, or urgency. MEDICAL HISTORY: 1. Hypertension 2. Asthma 3. H/o colonic polyps MEDICATION ON ADMISSION: Lisinopril 10 mg daily Advair Albuterol prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: T: BP: P: R: 18 O2: Orthostatics: supine 81, 152/80; sitting 94, 129/93 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, RLQ tender to palpation, no guarding, no rebound, non-distended, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema FAMILY HISTORY: Colon cancer and polpys on both sides of the family SOCIAL HISTORY: Patient is a truck driver. He denies any tobacco, etoh, and IVDA

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 43-year-old right-handed woman with a history of left breast cancer with dural metastasis and leptomeningeal disease. She was treated with chemotherapy in [**2191-5-15**] for recurrent disease in the dura. She was seen on [**2191-10-24**] for recurrent dural mets that were found on MRI scan which was done on [**2191-7-8**]. MEDICAL HISTORY: Left craniotomy times three, lumpectomy in [**2184**] and Ommaya reservoir placement. She has a past medical history of a DVT and a PE in [**2188**] and nephrolithiasis, also seizures. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: CC:[**Last Name (NamePattern1) 41182**] Major Surgical or Invasive Procedure: None. PRESENT ILLNESS: 69yoM with h/o prostate ca s/p radiation and hormonal therapy and radiation induced proctitis who presents with sudden onset of 20 episodes of BRBPR/clots and watery stool starting around 530pm and occuring q 15-30 mins, for which he called EMS and was brought to [**Hospital1 18**] ED. Denies melena. MEDICAL HISTORY: - depression - hypertension - hypercholesterolemia - prostate cancer s/p radiation treatment (completed [**9-/2156**]) and hormone shots (last [**12/2156**] per OMR notes) - diarrhea and abdominal pain responsive to pancreatic extracts - rectal bleeding with colonoscopy [**4-3**] showing radiation proctitis; acute anemia in [**8-/2158**] with repeat colonoscopy again showing radiation proctitis s/p Argon therapy of proctitis [**2158-10-27**] - Stress test/echo [**2156-3-29**] resting inferior wall abnormality c/w old MI. Exercise induced ischemia in distal LAD distribution. - Nuclear perfusion [**9-/2158**] depressions on treadmill and reversible inferobasilar perfusion defect on nuclear MEDICATION ON ADMISSION: reconciled with pt Simvastatin 80 mg daily Coreg 6.25 mg twice daily aspirin 81 mg daily B12 1000 mg daily fish oil Lipase-protease-amylase (pancrelipase 5000) 5000-[**Numeric Identifier 6085**]-[**Numeric Identifier **] unit capsules --> pt takes [**11-28**] as needed for diarrhea ocuvite Celexa 40 mg daily ambien 10 mg prn Vitamin D 3000 units Tamsulosin 0.4 mg daily Iron 325 mg twice daily Lisinopril unclear dosage, pt is unsure ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: 96 67 115/61 13 100% 2L NC Well appearing gentleman in no distress, doesn't look ill, clear historian. Appears euvolemic to mildly hypovolemic. EOMI, no scleral icterus No JVD CTAB no w/c/r/r RRR with clear S1 and S2, no murmurs or gallops. Radial pulses are easily palpable Abd obese NT ND, BS+, benign Extrems are without edema, 2 well placed 18 g PIV in bilateral AC's, warm and well perfused, no palmar cyanosis and good cap refill CN2-12 intact, no focal neuro deficits noted, moving all extremities, mental status lucid and conversant FAMILY HISTORY: Father - deceased from AMI and had tuberculosis Mother - deceased from AMI Brother - emphysema Sister - DM Sister - deceased recently from "many medical problems" SOCIAL HISTORY: Lives at home with his wife and has 2 sons, 2 daughters. [**Name (NI) **] working in a warehouse that he runs and apparently is still doing very physical labor with a lot of lifting. Is easily ambulatory and able to do his ADL's. No cigarettes ever, drinks 2-3 bottles of wine per week, no drugs/herbal medications

CHIEF COMPLAINT: Asymptomatic. PRESENT ILLNESS: This 42WF has a h/o bicuspid aortic valve which was detected on a chest xray. She had an echo [**11-13**] which revealed a bicuspid aortic valve, an ascending aorta of [**3-14**] cm , mild AI, and trace MR. A chest CT showed an ascending aorta of 5.2x5.1 cm. She now presents for ascending aorta replacement/AVR. MEDICAL HISTORY: COPD HTN Asthma Obesity Sleep apnea OA Herniated disc R carpal tunnel [**Doctor First Name **]. Ganglio cyst of R wrist T+A C section Partial hysterectomy MEDICATION ON ADMISSION: Atenolol 25 mg PO daily Norvasc 5 mg PO daily Prevacid 20 mg PO daily Advair PRN ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Gen: WDWN WF in NAD HR: 75 R: 12 BP: 140/80 HEENT: NC/AT, PERLA, EOMI, poor dentition Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+= bilat. without bruits Lungs: CTA CV: RRR without R/G, soft diastolic murmur Abd: +BS, soft, obese, nontender without masses or hepatospenomegaly Ext: tr. bil. pedel edema, no C/C, pulses 1+= throughout Neuro: nonfocal FAMILY HISTORY: Unremarkable SOCIAL HISTORY: Pt. is on disability for back problems. Cigs: 30 pk yr smoker, current ETOH: rare Lives with children.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 68 year-old woman with a history of multiple cerebral aneurysms. She is status post a coiling attempt, which was not done secondary to problems with a wide-necked aneurysm and severe fibromuscular dysplasia which did not allow for safe use of the balloon- MEDICAL HISTORY: Hypertension, fibromuscular dysplasia, transient ischemic attack. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: shortness of breath, airway stenosis PRESENT ILLNESS: 40F with history of airway amyloidosis, s/p multiple bronchoscopies and stents. She has stenosis of left main stem stent. She is admitted for repeat bronchoscopy and stent revision/removal attempt. on ROS, denies chest pain/SOB/orthopnea/abd pain/dsyuria/changes in BM MEDICAL HISTORY: 1. airway amyloidosis: Outpatient pulmonologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital6 **] and interventionalist Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital1 18**]. MEDICATION ON ADMISSION: 1. nexium 40mg po qd 2. prednisone taper down to 10mg po qd until tomorrow, f/b 5mg po qd ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: gen: slightly obese female in NAD, extremely pleasant, speak in complete sentences without SOB HEENT: anicteric, no conjunctival pallor, oral mucosa moist, neck supple, trach with collar in place, clean chest: rhonshi and stridor diffusely over all lung field cv: RRR, S1/S2 nml, no m/r/g, no pedal edema, no carotid bruit abd: +BS, slightly obese but s/nt/nd ext: no c/c/e neuro:A/O x 3, [**Last Name (LF) 3899**], [**First Name3 (LF) 13775**], moves all 4 extremities FAMILY HISTORY: Father with [**Name2 (NI) 2320**] SOCIAL HISTORY: lives in [**Doctor First Name 5256**]; former surgical floor nurse; lives with her husband and two children; occasional etoh; no smoking ever; no IVDA; sexually active with husband. [**Name (NI) **] to [**Location (un) 86**] exclusively for her pulmonary care.

CHIEF COMPLAINT: s/p fall with loss of consciousness PRESENT ILLNESS: The patient is a 74 year old gentleman with multiple medical problems who was found down on the sidewalk this afternoon. He reportedly had upper respiratory tract infection symptoms in the morning. Had a positive head "lac" and change in mental status on EMS arrival. The patient was unresponsive and incontinent of stool. MEDICAL HISTORY: He has a history of prostate carcinoma status post prostatectomy, hypertension, history of deep vein thrombosis in [**2153-8-1**], emphysema and depression. On physical examination, the patient was in no acute distress, awake, alert and oriented x 3. Bilateral orbital ecchymosis. Pupils equal, round, reactive to light, 5 down to 3 mm bilaterally. Extraocular movements full, tongue midline. The patient was in a hard collar. His cardiovascular - regular rate and rhythm. Chest was clear to auscultation bilaterally. Abdomen was soft with positive bowel sounds. Neurologically, he was awake, alert and oriented, following commands. Speech was fluent. Pupils equal, round, reactive to light. His face was symmetric. Strength - Right side deltoids 3 bilaterally, biceps 4+ on the right, 4 on the left, triceps 3 bilaterally, grasp 0, wrist extension 0, wrist flexion 0 bilaterally. IPs [**4-4**] in all muscle groups bilaterally. The patient had a CT of the cervical spine that showed spinal cord edema at the C3-C4 level, but no evidence of fracture. The patient also had bilateral nasal fracture seen on sinus CT. No other injuries. The patient was put on Solu-Medrol protocol for 24 hours. His strength continued to remain weak in his upper extremities, 4+ in the deltoids, 3 in the biceps, 4 in the triceps, finger extension 2's, grasps 2's, but with some improvement. The patient was monitored in the ICU for 2 days, then transferred to the floor. The patient will be followed by oral and maxillofacial surgery for his nasal fracture at a later date, once the swelling is reduced. The patient also was found to have an L1 corner fracture and was fitted for a TLSO brace. He should wear the TLSO brace at all times when head of bed is greater than 30 degrees in bed or he is out of bed ambulating. When he is in bed, he should be flat in bed. His medications at the time of discharge include currently on 4 mg p.o. every 8 hours of Decadron, hydrochlorothiazide 25 p.o. daily, metoprolol 25 p.o. b.i.d. (hold for heart rate less than 60, SBP less than 110), lisinopril 40 p.o. b.i.d., Percocet 1-2 tabs p.o. every 1-2 hours p.r.n., famotidine 20 mg p.o. b.i.d., heparin 5000 units subcutaneously t.i.d., Colace 100 mg p.o. b.i.d., clindamycin 600 mg IV every 8 hours, insulin sliding scale. The patient's condition was stable at the time of discharge. He will followup with Dr. [**Last Name (STitle) 739**] in [**3-6**] weeks with repeat scans of his cervical and lumbar spine, and follow up with OMFS surgery for his nasal fracture. His condition was stable at the time of discharge. [**Hospital Ward Name **],CHRISTPHERE C. M.D.02-AAK MEDICATION ON ADMISSION: MVI Norvasc 5mg [**Hospital1 **] lisinopril 40mg po bid HCTZ 25mg po qd Lopressor 25mg po BID Paxil 25mg po qd ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: General: NAD HEENT: PERRLA,EOMF CHEST: CTA bilat Cardiac: RRR ABD: soft, BS+ ext: no clubbing/cyanosis/edema Neuro: awake and alert and oriented x 3 Bilat upper extremity weakness B T WF WE IO FF IP AT [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Left 4- 3 2 2 2 2 5 5 5 5 right 4- 3 2 2 2 2 5 5 5 5 No clonus toes up going bilat sensation intact to light touch and pin prick bilat upper and lower extremities FAMILY HISTORY: SOCIAL HISTORY: lives with wife no etoh no smoking

CHIEF COMPLAINT: Seizures PRESENT ILLNESS: Mr. [**Known lastname 5903**] is a 68 year old man well known to the neurology service from multiple admissions in the past for seizures who has a history of left parieto-occipital and right occipital hemorrhages and subsequent seizure disorder. He was brought to the emergency room today by EMS for seizures at home. Unfortunately the patient is extremely lethargic due to benzodiazepine administration and unable to provide any history. I was able to reach his daughter to obtain a history (though somewhat limited by her lack of knowledge of the [**Hospital 228**] medical problems). [**Name2 (NI) **] was apparently in his usual state of health until 2:30PM when he was watching the [**Company **] on television. His daughter noticed that he was staring to the left side of the room (not looking at the television). Around that time, he asked his wife for a dilantin pill. She gave it to him. He then told them that he thought he was going to have a seizure. He laid on the floor of the living room and, a few minutes later, had the onset of facial and left arm shaking. The movements were "jerking" and rhythmic. He was awake and conversant through the seizure. The first seizure lasted approximately 5 minutes. Afterwards, he said that he felt that it was "over". A few minutes later, however, he had another seizure (also with facial and left arm jerking). This episode lasted 5-6minutes. He went on to have a total of 4 seizures in the next 30 minutes. Per the daughter, the seizures were becoming longer and becoming more "violent". His family called EMS. When they arrived, he was noted to have "jaw clenching" and biting movements. He was not medicated en route to the hospital. When he arrived here, he was noted to have biting movements and was moaning, but otherwise non verbal. He was given a total of 6mg of ativan. ED staff considered intubation for airway protection and "decreased gag" and called me to assess the patient prior to intubation. At this point, he is no longer having clinical seizure activity, but it completely uresponsive. In lieu of intubation, an oral airway was placed and he was taken emergently to CT Scan. His usual seizures consist of an aura of left arm tingling followed by left sided shaking or generalized tonic clonic seizure. Afterwards, he remains "groggy" usually for an entire day. He has also been noted in the past to have a post ictal Todds paralysis on the left. He has been admitted to the neurology service several times for such seizures, last in [**8-9**]. He is followed by Dr. [**First Name (STitle) **] as an outpatient. Per his daughter, he has been feeling well, no complaints of fever/chills, cough, n/v, cp, palpitaions or dysuria. He has been taking his medications as prescribed. His family is not aware of any recent alcohol consumption, though state that he was drinking rum last weekend. He has apparently had several "small seizures" since his last admission-most recently 4 weeks ago. These episodes apparently consisted of a "funny feeling" about which his daughter does not know the details. He did speak with his doctor (? neurology vs PCP) about these events. She does not know if any changes in his medications were made. As of his last admission, he remained on dilantin monotherapy with plan to enroll him in the Lamictal trial run by KBK. He has not yet followed up with epilepsy clinic. MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [**2089**]. 2. Strokes in [**2092**] and [**2093**] with left parietal occipital and right occipital hemorrhages. Also left pontine infarct. 3. Hypertension. 4. Hypercholesterolemia. 5. History of deep vein thrombosis treated with coumadin x 6 months. 6. History of small bowel obstruction. 7. Seizure disorder x 4-5 years after strokes. 8. Chronic renal insufficiency. MEDICATION ON ADMISSION: Labetalol 100mg [**Hospital1 **] Digoxin 0.125 mg qd Lipitor 10mg qd HCTZ 25mg qd Lisinopril Dilantin 100mg QID ASA 325mg qd ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T-[**Last Name (un) 98006**] BP-251/136-->128/64 HR-117-->86 RR-17-21 O2Sat 97-99% (on NRB) Gen: Lying in bed, NAD HEENT: NC/AT, dried blood in mouth Neck: supple CV: RRR, Nl S1 and S2 Lung: Course BS bilaterally Abd: +BS soft, nontender Ext: no edema . Neurologic examination: Mental status: Unresponsive to verbal or noxious stimulation (occasionally moans to sternal rub) . Cranial Nerves: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. No blink to visual threat. Eyes conjugate and midline. +dolls. Face appears symmetric (limited by mask/airway). +corneals bilaterally. +gag. . Motor: Increased tone on left, muscle bulk normal. Withdraws right arm and leg briskly to noxious stimulation. No withdrawal on left. . Sensation: Withdraws to noxious on right, grimaces to pain on right arm and leg. Localizes pain on left. . Reflexes: +3 on left, +2 on right. Toes mute bilaterally . Coordination/Gait: Unable to assess FAMILY HISTORY: Father - stroke and MI Mother - ?cerebral anneurysm 2 children with IDDM, adult onset 1 sister with metastatic breast ca SOCIAL HISTORY: Lives at home with wife. Former restaurant and bakery owner in [**Location (un) 686**]. History of heavy alcohol use but claims none since [**2089**]. Denies tobacco and drugs.

CHIEF COMPLAINT: altered mental status PRESENT ILLNESS: HPI: Mr. [**Known lastname 4542**] is an 80 y/o man with PMH notable for ESRD on HD and recent SDH s/p Burr hole sent to the ED for altered mental status. He was at his nursing home and found to have altered mental status at 8:30 am. At that time, T 96.5, P 123, BP 120/70, RR 40, 93% on NRB and 88% on NC (later reported 83% on RA). He was diaphoretic at the time FSBS 145. Per NH reports, he had dialysis on [**10-13**]. He was sent to the [**Hospital 1474**] Hospital emergency room for further evaluation. There, he was noted to have a rectal temp 100.7, RR 30, P 117, and BP 112/90. His O2 sat was 98% on NRB. CXR showed left base atelectasis versus infiltrate; CT head demonstrated SDH and he was then transferred to [**Hospital1 18**] for further evaluation with neurosurgery. . In the ED, initial vitals BP 85/48, HR 110, RR 24, 100% on NRB. He was found to be hyperkalemic and received calcium gluconate, D50/insulin. Due to decreased mental status, he was intubated with 20 mg etomidate and 40 mg rocuronium. He was hypotensive to the 70s/50s and started on levophed gtt. Right femoral CVL was placed for IV access. He was noted to have dark brown output (400 cc in total) from his NGT. He received 2 U FFP and vitamin K as well as profilin (activated factor 9). He received vancomycin 1 g X 1 and zosyn. On arrival to the ICU, the patient he was intubated and sedated with markedly distended abdomen. . ROS: unable to obtain MEDICAL HISTORY: * ESRD on HD (L AVF), dialyzed MWF * Left SDH s/p evacuation on [**2151-9-30**] * CAD s/p MI and pacemaker placement, CABG [**53**] years ago * ? AAA * Hypothyroidism * Hypercholesterolemia * s/p left carotid endarterectomy, with right carotid stenosis and a small aortic aneurysm (4.4 cm), followed by vascular surgery in the past MEDICATION ON ADMISSION: renagel 800 TID with meals levothyroxine 50 mcg daily amlodipine 5 mg daily simvastatin 10 mg daily omeprazole 20 mg daily terazosin 2 mg QHS furosemide 40 mg [**Hospital1 **] tylenol 650 mg PO q4h prn ri-gel suspension 30 mL q4h prn dyspepsia bisacodyl 10 mg PR prn MVI daily keppra 500 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] hep 5000 U SC TID colace 100 mg [**Hospital1 **] oxycodone 5 mg PO prn pain oxycodone 10 mg PO prn severe pain zofran 4 mg PO q8h prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: FAMILY HISTORY: Family History: unable to obtain SOCIAL HISTORY: Previously lived with daughters but recently at nursing facility.