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CHIEF COMPLAINT: nausea, abdominal pain, poor appetite PRESENT ILLNESS: Mr. [**Known lastname 15829**] is a 59 year old male with a history of a Schatzki's ring and intermittant chronic abdominal pain who presents with 3 weeks of abdominal discomfort, nausea, and decreased appetite. He has had intermittant abdominal pain for the past 4-5 years for which he stops eating for a day or two and then it goes away. Approximately 3 weeks ago, however, he developed a different kind of abdominal pain that is primarily epigastric and less intense that his usual bouts of abdominal pain, but much longer lasting. He denies any significant vomiting, but has been eating relatively little due to poor appetite. He has also been primarily bed bound during this period and now feels very weak overall. He does endorse weight loss, but is unsure how much he has lost. He had fevers and chills during the first 6 days of his illness but denies any within the last week. He had a bowel movement yesterday that was dark black in color. Urine is also darker and foul smelling, but no dysuria. MEDICAL HISTORY: 1. Schatzki's ring, most recent dilation [**1-/2156**] 2. Depression 3. Emphysema 4. Sciatica 5. Chronic back pain 6. History of left foot drop and peripheral neuropathy, resolved 7. Status post lipoma removal from the neck, ~20 years ago 8. History of multiple broken ribs, s/p falls MEDICATION ON ADMISSION: Prozac 60 mg daily Ibuprofen and aspirin prn back pain ALLERGIES: Iodine-Iodine Containing / Wellbutrin PHYSICAL EXAM: Vitals: T: 98.9 BP: 150/60 P: 96 R: 16 O2: 100% RA General: Alert, oriented, no acute distress, gaunt HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi, no CVAT CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, TTP in the epigastrium, non-distended, bowel sounds present, no rebound tenderness or guarding, negative [**Doctor Last Name 515**] sign. Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII intact; 5/5 strength in the biceps, triceps, hip flexors, foot flexors and extensors bilaterally. Sensation grossly intact throughout and equivalent bilaterally. FAMILY HISTORY: Mother - has "gallbladder problems" but still has her gallbladder in Father - healthy Diabetes in some great aunts. Maternal grandmother died of a MI in her 50s. No family history of cancer. Multiple suicides in the family. SOCIAL HISTORY: Former software programer, not currently working, lives alone. Drinks two 12 oz cans of beer daily, though none in the last few weeks. Smokes 1.5 - 2 ppd x 38 years, but no tobacco the last couple of weeks.

CHIEF COMPLAINT: Transfer from OSH for seizures, AMS PRESENT ILLNESS: Ms. [**Known lastname 3123**] is a 41 year-old lady w/ melanoma (dx [**2136**]) metastatic to breast s/p resection '[**42**], colon s/p R-colectomy '[**42**], and brain s/p L-frontal resection and XRT ([**6-24**]) who was recently hospitalized (d/c [**2146-5-10**]) for abdominal pain/ nausea/ vomiting thought to be secondary to an enlarging 12cm pelvic mass, treated with bupivicaine epidural who now presents for seizures and AMS. Per husband's report, patient had been feeling lightheaded and weak the day prior to presentation, w/ nausea and vomiting. She reportedly c/o "spinning rainbows" in her eyes all afternoon w/ both eyes. She was in the commode around [**2165**] that night and started seeing "Triple" per her husband. She then developed slurred speech followed by an episode of 10-15s of B/L arm shaking (not legs per husband). Her eyes were open and L-deviated and she also lost urine and bowel continence. She then became confused for around 30min. She was taken urgently to [**Hospital **] Medical Center, where she underwent head CT. CT revealed scattered areas of vasogenic edema along the anterior L-frontal lobe, B/L basal ganglia and B/L parieto-occipital lobes. A subtle mass was suspected along the R-anterior frontal [**Doctor Last Name 534**] w/ mild mass effect- no evidence of ICH. After the scan around 0100, she had another witnessed tonic-clonic seizure w/ B/L arm shaking and drooling. She was given Phenytoin 1gm IV x 1, Lorazepam 1mg IV x 1 and Dexamethasone 4mg IV x 1. She was transferred to [**Hospital1 18**] for further management. . In the ED, initial VS: T 98.7, HR 103, BP 162/105, RR 20 SaO2 100% RA. Patient was arousable but very lethargic/sluggish, not answering questions. CT Head was done which showed extensive supratentorial and infratentorial hypodensities, concerning for PRES or another toxic/metabolic abnormality- could also be related to edema from her metastatic disease. She was transferred to the ICU secondary to altered mental status, and was intially hemodynamicalyl stable, and was confirmed DNR/DNI. In the ICU, pt appears seriously ill, not responding to questions/commands or painful stimuli. She is [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing and continues to have B/L Leftward beating nystagmus. ROS unobtainable given pts mental status MEDICAL HISTORY: Metastatic Melanoma - First diagnosed in right lower back in [**2136**] for which she underwent wide local excision and inguinal lymph node biopsy; [**12-25**] lymph nodes were removed from inguinal lymph node dissection were without metastasis. She was enrolled in the group protocol S0008. In [**2137**] she had recurrence in the scar for which she had surgical resection and XRT. In [**2140**] she was found to have metastatic disease with multiple pulmonary nodules, and was on high-dose IL-2 showing some resolution and response. She had another metastasis in the breast in [**2143-10-17**], and then was diagnosed with a colonic mass for which she had a right colectomy and retroperitoneal exploration. She subsequently presented with confusion and difficulty in concentrating and was found to have a left frontal brain metastasis. She underwent resection and XRT. In [**2145**] she was found to have a 12-cm pelvic mass and underwent resection of abdominal wall metastasis. In [**2146-3-17**] she was started in a compassionate use ipilimumab trial. MEDICATION ON ADMISSION: Zofran Decadron Ativan Bupivicaine epidural Lansoprazole Amlodipine ALLERGIES: Naprosyn / Iodine / Adhesive Tape PHYSICAL EXAM: GEN: seriously ill-appearing pale F lying in bed w/ eyes closed and mouth open, not responding to commands or painful stimuli HEENT: + left horizontal beating nystagmus OU, sclerae anicteric FAMILY HISTORY: Maternal Aunt - Melanoma SOCIAL HISTORY: Home: lives with her husband and dogs, supportive family Occupation: previously employed as a financial analyst Tobacco: Denies EtOH: Denies Drugs: Denies

CHIEF COMPLAINT: confusion PRESENT ILLNESS: History obtained from [**Name (NI) **], pt's father and records from [**Hospital 28941**]. Patient is a poor historian. . Mr. [**Known lastname **] is a 35 year old right handed man with a history of hypertension and gout, who was in a GSOGH until 4 days ptp when he developed rhinorrhea, fevers to 102, L foot pain (which the patient attributed to gout), decreased appetite and po intake x 3-4 days. (Pt usually has a v good appetite). No sore throat or cough. His parents thought that he had the flu. He treated his sx with otc meds including tylenol. Parents do not report diarrhea but OSH ED notes do, nausea or emesis. On the morning PTP he reported strange dreams - being a pitcher in baseball game and strange comments "I've got to rest up and go to spring training with the Red Sox" but pt is not a baseball fan. "He also couldn't put a sentence together and was lethargic". He had one episode of incontinence of stool on the day prior to presentation. Reported L shoulder pain x 2 days with difficulty lifting it, but no headache, vomiting, or stiff neck. He was confused -along with comments liste above he also had a change in personality such that he was distant, much less tallkative than at baseline the morning ptp per his parents, with whom he lives, and was so weak that he could not come down the stairs of his house. They didn't notice any particular focal weakness of arms or legs but they had to give him step by step commands to move each extremity in order to enable him to come down the stairs. His parents called EMS and he was brought to [**Hospital3 **]. His vitals on presentation were: 121/70, HR = 68->111, RR = 18 and T = 99 -> 101 with O2 sat = 99% on RA. ECG demonstrated sinus tachycardia in the 120's, as well as LVH. His K was 2.0. He had an LP there that revealed (in tube 3) 170 WBC (91 PMNs 2 Lymph, 7 Mono), 18 RBC, Prot 52, and Gluc 81. Gram stain was negative. Serum glucose at the time was 162. HSV PCR, Lyme ab and VDRL was sent on the CSF. Other notable labs included wbc of 13 with 87% PMNs and 3.4 lymphs, sodium of 125, K of 2.6, BUN of 28, and Cr of 1.6. Lyme antibodies were sent as well and are pending. He had a head CT there that revealed areas of hypodensity in the right frontal lobe and in both thalami. Prior to transfer to [**Hospital1 18**], he was given acyclovir 800 mg, ceftriaxone, and potassium. In the ED he was given given vancomycin 1 g, Hydrocortisone 500 mg, Acyclovir 800 mg IV, Lorazepam 2mg IV prior to MRI . He has no history of recent travel, no ill contacts, and no known history of tick bites. He has no known history of immunosupression. . ROS per father Mr. [**Known lastname **] [**Last Name (Titles) **] night sweats or recent weight loss or gain. Denied headache, sinus tenderness, denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, + constipation, no abdominal pain. No dysuria. + L shoulder pain x 2 days- new never complained of shoulder paiin previously. Grimaces when I touch base of R toe which is red and erythematous- first noticed 1 day ptp by father. + rash on L hand x 2days and rash on ankles x 1 day. No h/o recent trauma, falls, seizures or headaches. MEDICAL HISTORY: Hypertension Gout- first episode 1 year ago - joint not tapped per patient s/p R arm surgery after injury sustained during opening the day in [**2139**] MEDICATION ON ADMISSION: Atenolol 25 mg daily started 6-8 months ago Tylenol prn for HA No recent NSAID or abx use. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS Tm = 103.4 in ED Tc=99.8, P = 69-112, BP = 113-150s/40-80s 117/58 RR O2Sat = 90% on RA, 95% on 4L. GENERAL: Young, ill appearing male, with rapid shallow breathing. HEENT: NC/AT, PERRL, EOMI without nystagmus, + injected sclerae without scleral icterus noted, dry MM, no lesions noted in OP Neck: supple- no mengismus, no JVD Pulmonary: Lungs CTA bilaterally anteriorly Cardiac: tachy, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 1. "I'm in [**Hospital1 189**]. I'm in [**Hospital1 3597**] NH" "I haven't the faintest idea why I am at the [**Hospital1 **]" -cranial nerves: II, III, IV, VI, X1, XII intact -motor: normal bulk and tone throughout. No abnormal movements noted. Strenght difficult to assess since pt could not obey commands consistently. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, intention or action tremor, -DTRs: 2+ biceps, triceps, brachioradialis, 3+ R patellar and 2+ L patellar reflexes. Plantar response was flexor bilaterally. FAMILY HISTORY: Father had TIA's in his 50's. No migraines, seizures, learning problems. One brother aged 41 in good health. No nieces or nephews. SOCIAL HISTORY: Lives with his parents in [**Location (un) 7661**] (lives with them due to convenience-per parents at baseline is independently functioning). Employed in cellular phone sales- manager of cell phone store x 6-8months- employed at the same company for 4 years. Occasional cigar q week, 1-2 beers q months at most, per friends no recreational drug use, including no IV drug use. Not married without children. Last travel was to [**State 108**] in [**Month (only) **]/[**2160-3-12**]. Since then in MA/[**Location (un) 5131**]. Does not spend much time outdoors. Practices archery in the backyard. Meets with a group of friends who play board games q week. Completed high school. Has taken classes at a local community college. No pets. Aunt next door with a cat but does not visit her regularly.

CHIEF COMPLAINT: SOB and fatigue PRESENT ILLNESS: This is a 66 year old male with known MVP/MR. [**First Name (Titles) 23278**] [**Last Name (Titles) 98326**] have shown worsening MR. Currently experiencing CHF symptoms..worsening shortness of breath, dyspnea on exertion, increasing fatigue and intermittent lower extremity edema. Denies chest pain, orthopnea and PND. MEDICAL HISTORY: Mitral valve prolapse, Paroxysmal atrial fibrillation, HTN, hypercholesterolemia, OSA, GERD, Asthma, Depression, Hypothyroid, Prodtatism, Essential Tremor , chronic diastolic heart failure MEDICATION ON ADMISSION: Primidone 250mg daily, Piroxicam 10 mg daily, Diltiazem 240 mg daily, Lipitor 40 mg daily, Omeprazole 20 mg daily, Levoxyl 200 mcg daily, Cozaar 50 mg daily, Remeron 15 mg daily, Fluoxetine 20 mg daily, Flomax 0.8 mg daily, Ventolin as needed, Aspirin 81 mg daily, Symbicort twice daily, and Vitamin D and B12. ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Penicillins PHYSICAL EXAM: Physical Exam Pulse: 76 Resp: 14 O2 sat: 97%RA B/P Right: Left: 139/88 Height: 72inches Weight: 104kg General: middle aged male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [**1-31**] holosystolic murmur Abdomen: Soft [x] non-distended [x] non-tender x bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema - trace Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 DP Right: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 2 Left: 2 Carotid Bruit Right: none Left: none FAMILY HISTORY: no history of premature cardiac disease. SOCIAL HISTORY: Lives with wife. [**11-29**] year here and [**11-29**] year in [**State 108**]. Tobacco- 10 pk year. quit 25 yrs ago. ETOH-rare

CHIEF COMPLAINT: STEMI PRESENT ILLNESS: [**Age over 90 **] yo with PMH of atrial fibrillation, ?SVT, Sjogren's disease, systemic HTN, GERD, who presented to [**Hospital6 3105**] on [**2153-6-18**] with left sided chest discomfort in the setting of rapid heartbeat. Episode lasted approximately one hour. She has had these episodes in the past, but they have usually lasted only a few minutes. Patient was found to have ST elevations in lateral leads (I and aVL) with ST depressions in aVR. CPK peaked at 1261 and troponin of 54.56. Underwent cath at [**Hospital1 487**] which demonstrated 80% stenosis of mid LAD, 100% occlusion of first diag, 50% left main stenosis, 50% left circumflex, 70% stenosis of PDA, LVEF of 35% with anterior and apical akinesis. Underwent angioplasty and BMS to her first diagonal artery. Transferred to [**Hospital1 18**] for CT [**Doctor First Name **] evaluation for possible CABG. . Pt is currently comfortable, she has no chest pain, shortness of breath, or dizziness. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, [**Doctor First Name **] at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. MEDICAL HISTORY: atrial fibrillation ?SVT Sjogren's disease systemic HTN GERD . . PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: - History of supraventricular tachycardia, atrial fibrillation 3. OTHER PAST MEDICAL HISTORY: - sjogren's syndrome - GERD MEDICATION ON ADMISSION: HOME MEDICATIONS: - aspirin 81mg PO daily - sotalol 40mg PO BID - amlodipine 10mg PO daily - colace 100mg PO daily - SL NTG PRN - omeprazole 20mg PO daily ALLERGIES: Penicillins / Ciprofloxacin / Sulfa (Sulfonamide Antibiotics) / Macrodantin PHYSICAL EXAM: Gen: alert, oriented, NAD HEENT: supple, no JVD CV: RRR, no M/R/G, distant HS. Left pacer site with drsg [**Name5 (PTitle) 767**] [**Name5 (PTitle) **] [**Name5 (PTitle) 2729**] in lab, no evidence of ecchymosis or swelling under dressing. RESP: [**Month (only) **] BS right base only, left now clear ABD: soft, NT/ND EXTR: no peripheral edema. NEURO: A/O Extremeties: no edema Pulses: FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. SOCIAL HISTORY: SOCIAL HISTORY: lives alone, has help with chores. has a nephew who is involved but [**Name (NI) **] sometimes is reluctant to involve him. -Tobacco history: None. -ETOH: None. -Illicit drugs: None.

CHIEF COMPLAINT: PRESENT ILLNESS: Patient is a 40-year-old male with history of hepatocellular carcinoma type 2 with hepatitis. Patient underwent an ex-lap on [**2160-3-7**] with attempts at resection. However, he had evidence of cirrhosis. Resection was not performed. He underwent radiofrequency ablation. Current MELD score is 22. He has not had encephalopathy, [**2160-6-18**] aFP 1.8, hepatitis A/B nonreactive, ALT 34, AST 34, alkaline phosphatase 75, total bilirubin 0.7. PT 13.3. Platelets 141. Albumin 4.5. Currently taking adefovir 10 mg nightly. Thus, HB viral load undetectable. Feeling well. Denies recent illness. MEDICAL HISTORY: End-stage liver disease secondary to hepatitis B cirrhosis stage 2, HCC, radiofrequency ablation [**2160-3-13**]. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: s/p fall down stairs PRESENT ILLNESS: 66F transfer from outside hospital after patient found down in front of her staircase. Patient had multiple signs of trauma including subarachnoid hemorrhage and orbital blowout fracture. Patient had alcohol onboard with alcohol level in the 200s. Patient was transferred for further care. Fall was unwitnessed, ?LOC. But responsive at the scene. GCS reportedly 15 at the scene. Intubated in the ED for airway protection 2/2 blood in the airway. MEDICAL HISTORY: PMH: breast CA PSH: CCY [**2112**], lumpectomy [**2133**] MEDICATION ON ADMISSION: Anastrozole 1mg QD, Armidex 1 mg QD, Fluoxetine 20mg QD, Citalopram 40mg QD, Campral 333mg 2 tabs QD ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: On arrival to [**Hospital1 18**]: FAMILY HISTORY: noncontributory SOCIAL HISTORY: 1ppd smoker almost 50 years, alcoholism 14-15 shots per day with recent detox, lives at home

CHIEF COMPLAINT: aspiration PNA, copious secretions PRESENT ILLNESS: 65 M with HepC/EtOH cirrhosis, HCC s/p orthotopic liver transplant [**2157**], DM2, CAD, tracheostomy [**1-9**] prolonged intubation s/p transplant, prior episode heart block c no pacemaker, [**Hospital **] transferred from OSH for ongoing management of aspiration pneumonia, ARF/CRI, and ongoing suctioning requirement. . Per OSH d/c summary, pt admitted to OSH [**8-12**] after being found in his nursing home "unresponsive." At OSH ED he was briefly intubated via trach, found to have a signficant amount of mucus plugging which was recovered with trach suctioning, after which pt rapidly improved. He was hemodynamically stable, sats 88-90% (unclear on what), and improved with suctioning and nebs to 96-99%3L NC. He was called out to the medical floor. . On [**8-17**] pt noted to have increased secretions, increased RR requiring frequent suction, ?aspiration. Sputum cx, BCx, UA negative. creatinine 1.9, pt noted to have fever 100.2, RR 24, sats 98%5L NC. CXR with ?infiltrate, started on levaquin/flagyl x 7d course. S&S revealed worsening swallow, NGT placed. Pt seen by renal for elevated BUN/Creatinine (up to 2.0), report of elevated K (6.5), and treated with IVF x 1L and 1U PRBC, d/c'd lasix, as was felt to be pre-renal etiology. . Of note, at OSH, also noted to have R elbow pain and found to have joint effusion over R elbow. Evaluated by ortho and found to hvae non-displaced right radial head fracture, R arm placed in a sling. Effusion not drained. Treated symptomatically with vicodin/oxycodone. . Decision was made to transfer pt to [**Hospital1 18**] hepatorenal service given his h/o liver transplant here. Prior to transfer, pt decline PEG tube placement for feeding. MEDICAL HISTORY: 1. Liver transplant for Hepatitis C/EtOH cirrhosis & hepatocellular carcinoma, on tacrolimus, mycophenolate, prednisone, bactrim followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]. 2. Tracheostomy: x2, [**8-11**] for chronic vent dependency, subglottic stenosis, tracheomalacia. Known to the IP service; tracheal dilation [**12-13**]. VATS [**2-10**] c organizing pneumonia [**1-9**] Rapamune. 3. DM2 4. OSA / Pickwickian syndrome 5. COPD 6. Diastolic dysfunction 7. CKD 8. Bipolar d/o 9. HTN 10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections 11. Hiatal hernia 12. Pulmonary hypertension 13. Hx of heart block - unable to have PM placed [**1-9**] infection, heart block resolved, avoiding nodal blockers MEDICATION ON ADMISSION: MEDICATIONS ON TRANSFER: insulin sliding scale glucerna TF heparin SC tid norvasc 5mg po qdaily clonazepam 0.5mg po qdaily levofloxcin 500mg po qdaily flagyl 500mg daily procrit 8000 units QMWF prevacid 30mg po qam nortriptyline 75mg po qdaily colace 100mg po bid senna [**Hospital1 **] zyprexa 15mg po qpm trazodone 25mg po qpm clonazepam 1mg po daily (?in addition to qhs) prograft 1mg po qam, 2mg po qpm cellcept 500mg po bid mvi vitamin b 1000mcg daily vitamin d 400 IU daily zinc sulfate 220 mg po qdaily mucomyst [**Hospital1 **] (unclear duration of treatment) dulcolax prn mom prn [**Name2 (NI) 48520**] carbonate 500mg qid oxycodone 5mg po q6hr prn scoplamine patches ALLERGIES: Penicillins / Nsaids / Rapamune PHYSICAL EXAM: VS: 100.1 96 161/71 18 100% on 35% TM. GEN: NAD, tracheostomy tube in place, minimal drainage. HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MM dry, no LAD, no carotid bruits. No JVD. CV: regular, nl s1, s2, no r/g. soft 2/6 SEM at LSB ?nonradiating PULM: CTA anteriorly, no r/r/w. ABD: scaphoid, soft, NT, ND, + BS, no HSM. EXT: warm, 2+ dp/radial pulses BL. no LE edema. NEURO: alert & oriented x 3, CN II-XII grossly intact. FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Quit tobacco 8 years ago. Quit alcohol 17 years prior to admission. Denies any recreational drugs.

CHIEF COMPLAINT: abdominal pain, suprapubic pain PRESENT ILLNESS: 67M with multiple medical problems with recent admissions for bleeding duodenal ulcer p/w vague complaints of lower abdominal and suprapubic pain. On work-up, found to have an enlarged AAA. He is taken emergently to the operating room for repair. He was recently admitted for Fournier's gangrene to his scrotum and perineum on [**2197-1-10**] requiring operative debridement by [**Date Range 159**]. Per family, reports indurated area increasing past several days with erythema. On examination, noticed purulent drainage on dressing. MEDICAL HISTORY: - large infrarenal AAA with b/l large common iliac aneurysms - Urethral abscess - DM - HTN - CAD s/p PCI - R hypogastric coiled embolization on [**2197-1-17**] - suprapubic urinary catheter placement [**2197-1-10**] - per pt has Hx of "stenting" of vessel after left arm pain, but does not believe stent in heart, thinks in arm. MEDICATION ON ADMISSION: Toprol xl 25mg daily, ASA 81mg daily, simvastatin 20mg daily, glyburide 2.5mg daily, lisinopril 5mg daily, hyoscyamine 0.125mg qid PRN ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAM: VS: 37.2, 87, 88/44, 19, 96% (30% face mask) General: pleasant, nad HEENT:PERRL, EOEMI, sclerae anicteric OP: MMM, no ulcers/lesions/thrush Neck: supple, no LAD, no thyromegaly Cardiovascular: RRR, normal S1, S2, + 2/6 M at RUSB Respiratory: CTA bilat w/o wheezes/rhonchi/rales Back: no focal tenderness, no CVAT; L. gluteus abscess with clean base and borders Gastrointestinal: +bs, soft, non-tender, non-distended; suprapubic cath with no surrounding drainage Musculoskeletal: moving all extremities Ext: Warm and well perfused, no edema. 2+ DP pulses palpable bilaterally Skin: no rashes, no jaundice Neurological: aaox3, cn 2-12 FAMILY HISTORY: Colon cancer in father SOCIAL HISTORY: Lives at home with wife and is retired. Quit smoking two months ago; previously 1 ppd x 50 years. No drugs.

CHIEF COMPLAINT: s/p Motorcycle crash PRESENT ILLNESS: 54 yo male s/p motorcycle crash; reportedly struck by a vehicle; denies LOC. He was taken to an area hospital where found to have a comminuted pelvic fracture and pelvic hematoma. He was then transferred to [**Hospital1 18**] for further care. MEDICAL HISTORY: Emphysema MEDICATION ON ADMISSION: ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: FAMILY HISTORY: Noncontributory SOCIAL HISTORY:

CHIEF COMPLAINT: Septic Unresponsive PRESENT ILLNESS: This is a 38 year old male transfer to [**Hospital1 18**] from OSH on [**2128-7-13**]. He was found unresponsive at home back on [**2128-6-13**]. This followed with a 2 month history of postprandial nausea, vomiting and abdominal pain, for which he refused to seek medical attention. He apparently had hemoptosisa t some point at home and was brought to the hospital where he was found to be in profound shock and circulatory collapse with a SBP in the 40's, hypoglycemic and a HCT of 13.5. He was taken to the OR where upon entering the abdomen, 3-liters of gastric contents were drained. A perforation was identified at the distal antrum, close to the pancreas with a 3 cm necrotic area eroding posterior to the pancreas. He is POD 31, s/p distal gastrectomy w/ Roux-en-Y gastrojejunostomy for perforated gastric/duodenal ulcer. He is POD 20, s/p subtotal colectomy and end ileostomy for sigmoid perforation and "atonic colon", as well as a tracheostomy for respiratory failure. He is POD 17, s/p exploratory laparotomy, revison of end ileostomy, small bowel resection, cholecystectomy and T-Tube placement, now transferred for sepsis w/ GPC in blood and WBC of 29. There is a concern for a possible common bile duct injury and now he has multiple enhancing intraabdominal collections (hepatic fluid collections) as seen on a CT scan. He was found to have an Aortic clot at the level of [**Female First Name (un) 899**] (infrarenal) and thought to be possibly infected. A sump drain is putting out bile and a T-tube is close to the pancreatic head. MEDICAL HISTORY: Bipolar MEDICATION ON ADMISSION: Morphine, Epogen 40,000 q weekly, Thiamine, ativan, Lovenox 40 q daily, Protonix, Diflucan ALLERGIES: Penicillins / Imipenem PHYSICAL EXAM: VS: 102.9, 105, 98/38, 15, 100% Trach mask Gen: Conversive, depressed mood HEENT: trach Chest: decreased breath sounds, coarse. CV: RRR, bradycardic Abd: soft, Nontender, nondistended, open abdomen with VAC in place, T-tube in place with bile draining. Ileostomy RLQ, pink. Ext: +2 edema FAMILY HISTORY: SOCIAL HISTORY: History of substance abuse - cocaine and ETOH. Rehab x 3. + Tobacco. Expelled from high school.

CHIEF COMPLAINT: abdominal pain PRESENT ILLNESS: HPI: 53F with 2 weeks of jaundice, presenting with nausea, vomiting and RUQ/epigastric pain since last night. Patient had not seen any doctor for her 2 weeks of jaundice. Developed nausea last night and had 5 episodes of vomiting overnight. Also felt some chills, but no objective fevers. Pain started early this morning, constant in nature and progressively worse. Pt went to to [**Hospital3 10310**], had a WBC of 18.5 (17% bands), Tbili 10.7, lipase 1131. An U/S showed a CBD 15 mm, gallstones, no gallbladder wall thickenning or pericholecystic fluid. In the ED patient was slightly confused and BP down to 80/60s, improved with 1L bolus of NS. MEDICAL HISTORY: Past Surgical History: laparoscopic exploration MEDICATION ON ADMISSION: Medications: calcium with vit. D 500 mg daily, dulcolax 5 mg bedtime, lopid 600 mg twice daily, zantac 150 mg daily, senakot 2 tabs twice daily, tylenol 650 mg as needed for h/a, body aches, clozaril 200 mg bedtime ALLERGIES: Penicillins PHYSICAL EXAM: Physical Exam: upon admission: FAMILY HISTORY: NC SOCIAL HISTORY: Social History: Lives alone, denies tobacco, EtOH, drugs

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is an 87-year-old female with a past medical history significant for atrial fibrillation and status post a stroke in [**2185-1-5**], who presented status post fall from her wheelchair. The patient is status post a stroke in [**Month (only) 404**]. She developed bilateral weakness (right greater than left) and aphagia. The patient had a prolonged hospital course complicated by pneumonia and recurrent urinary tract infections. She is incontinent of urine and feces and has an indwelling Foley catheter. Currently, her left side has recovered some function from the stroke in [**Month (only) 404**], the patient is left with residual right-sided paralysis and some speech difficulties. On [**2185-9-26**] (on the day prior to admission), the patient was being wheeled by her granddaughter down a ramp and fell out of her wheelchair. She rolled onto her neck. It was a mild fall; per her granddaughter. The patient denies loss of consciousness or a change in mental status. She did have persistent neck pain following the fall. She was taken to [**Hospital3 15174**] where she was noted to have full range of motion in her neck. However, she was transferred to the [**Hospital1 69**] after a computed tomography scan showed a C2 fracture. In the Emergency Department, at [**Hospital1 188**], she was noted to have elevated creatine kinase levels and troponin levels with a troponin level of 1.02 and a CK/MB level of 19. She was seen by Cardiology who felt no intervention was needed at this time. The patient was already anticoagulated on Coumadin due to her history of atrial fibrillation. She was also on a beta blocker and aspirin. In addition, the patient also aspirated in the ambulance on the way to [**Hospital1 69**]. She underwent a computed tomography scan which showed an oblique fracture involving the body of C2. The lamina of C2 on the right was fractured. A computed tomography scan of the head showed no acute intracranial hemorrhage of mass effect. There was a large left frontal scalpel hematoma. There were remote old infarctions identified. There was a calcified meningioma at the left posterior fossae. MEDICAL HISTORY: 1. Atrial fibrillation with an ejection fraction of approximately 20%. 2. Breast cancer; status post mastectomy in [**2178**]. 3. Colon cancer; status post hemicolectomy in [**2175**]. 4. Status post radiation therapy for a bone lesion in [**2180**]. MEDICATION ON ADMISSION: Celexa, lactulose, atenolol, lisinopril, digoxin, Coumadin, and Glyburide. ALLERGIES: SULFA. PHYSICAL EXAM: FAMILY HISTORY: No history of malignancy or coronary artery disease. SOCIAL HISTORY: The patient denies alcohol or recent tobacco use. She lives with her granddaughter who provides day-to-day care.

CHIEF COMPLAINT: PRESENT ILLNESS: MEDICAL HISTORY: 1. Coronary artery disease, status post inferior myocardial infarction [**2114**] complicated by left ventricular thrombus, status post left circumflex stent in [**2123-4-1**]. 2. Congestive heart failure. 3. Status post mitral valve and tricuspid valve prosthetic replacement [**2123-8-10**]. 4. AICD in [**2123-4-1**]. 5. History of cerebrovascular accident with residual left finger numbness. 6. History of Hodgkin lymphoma at the age of 27, status post radiation and splenectomy. 7. Hypercholesterolemia. 8. History of cervical diskectomy. 9. Tracheostomy in [**2123-8-1**]. 10. Gastrostomy tube placed in [**2123-8-1**]. 11. MRSA diagnosed in [**Month (only) **], [**2123**], with witnessed aspiration with p.o. medications and liquids. 12. Constrictive pericarditis. 13. Iron-deficiency anemia. MEDICATION ON ADMISSION: 1. Ceftazidime started [**10-19**]. 2. Epogen. 3. Amiodarone 400 p.o.q.d. 4. Aspirin 325 p.o.q.d. 5. Iron. 6. Lasix 20 mg p.o.q.d., 20 mg IV. 7. Spironolactone. 8. Levothyroxine 200 p.o.q.d. 9. Enoxaparin 40 subcutaneously b.i.d. 10. Kayexalate. 11. Ativan. 12. Morphine p.r.n. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: The patient's father died from colon cancer. No history of coronary artery disease. The patient is married. He used to self employed. He does not smoke or drink alcohol. He currently lives at [**Hospital **] Rehabilitation Center. SOCIAL HISTORY:

CHIEF COMPLAINT: SOB PRESENT ILLNESS: 86 F with PMH of HTN, dCHF, functional MS who presented to the ED with respirtory distress and HTN. Of note, she recently presented with similar symptoms of hypertensive urgency c/b pulmonary edema requiring a brief intubation from [**Date range (3) 96701**]. Her home nifedipine was discontinued and she was started on a BP regimen of carvedilol/ lasix/ lisinopril. . Since her discharge from the hospital, the patient reports that she had been feeling well and was able to do her ADLs without dyspnea. However, per VNA vital sign monitoring, her BP was "poorly controlled" and on Wednesday, her PCP increased her lisinopril to 20mg daily and lasix to 40mg daily. Although she thinks that her weight had been stable, does admit to increased lower extremity edema and orthopnea requiring her to sleep in an upright recliner (also helps back pain). Overall, she has been compliant with her low salt diet but yesterday went to a barmitzvah where she had lox, potatoe latkas, i.e. high sodium content. . This morning, patient was cleaning up a spill when she became acutely short of breath and diaphoretic. Denied any chest pain, palpitations, dizziness, headache or other complaints. + Productive cough since onset of symptoms. No fevers, chills, or other systemic symptoms. . VS on arrival to ER were 97.4 94 220/120 38 99% 10L NRB. Quickly desated to 70s with RR in 40s. Pt was placed on BiPAP. EKG with no acute changes with an old LBB and CXR with pulm edema. Pt was given SLN 0.4mg x 1 and started on a nitro gtt, lasix 100mg x 1, Morphine 4mg x 1, Levoflox IV, ordered for Cefepime x 1, and Vancomycin x 1. Foley was placed and so far 250ml of UO. Vital signs at transfer were improved to HR 96 BP 153/84 RR 28 O2 99% on CPAP [**9-21**] 50% fio2, and 0.5 mcg/ml/hr nitro gtt. . On review of systems, s/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. S/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, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: per OMR review 1. CARDIAC RISK FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Breast Cancer with mets to lung and bone, including skull bone, stable on anti-estrogen therapy, primary oncologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96699**]) at [**Company 2860**]. Has lumpectomy and left-sided LN dissection. - H/o DVT on Fragmin (has h/o allergy to Lovenox), currently dosed via [**Company 2860**] as part of a study protocol - Hypertension - [**Company **] cancer leading to a sigmoid resection in [**2109**]/[**2110**] - OA - severe glenohumeral osteoarthritis plus other joints - LUMBAR SPONDYLOSIS/SPINAL STENOSIS - GERD - Mild [**Doctor First Name **] Pos (1:40 titer) - clinically insignificant - Past Cdiff Pos ([**2139**]) PAST SURGICAL HISTORY - per OMR - s/p bilateral TKA - L hip replacement, pins in right hip, most recent surgery [**1-17**] yr ago - S/p TAH in [**2098**] MEDICATION ON ADMISSION: - Aspirin 81 mg DAILY - Omeprazole 20 mg Capsule qday - Fluoxymesterone 10 mg PO BID - Carvedilol 6.25 mg Tablet PO BID - Lisinopril 10 mg Tablet PO HS - Furosemide 20 mg Tablet PO once a day. - Scopolamine base 1.5 mg Patch Q 72 hours - Roxicet 5-325 mg Tablet PO four times a prn pain ALLERGIES: Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin / hydrochlorothiazide PHYSICAL EXAM: On admission: FAMILY HISTORY: Mother had [**Name2 (NI) 499**] cancer, died at age [**Age over 90 **]. Father died at 49 from coronary thrombosis. Sister with [**Name2 (NI) 499**] cancer. Another sister with pancreatic cancer. Niece and nephew (in same family) both with [**Name (NI) 4278**]. She is last surviving relative. SOCIAL HISTORY: She lives alone in [**Location (un) 96700**] and is very active at baseline. Ambulates independently. Spends Mon/Fri at the cultural center, Tues playing trumpet in a band, and Weds/Thurs running erands. Has 3 cars at home and drives. Retired teacher. Never married and without children. Smoked 2ppd x 10-15 years until [**2094**], glass of wine <1x/week. No other drug use. -Tobacco history: Past use, stopped [**2094**] -ETOH: <1 glass/wk -Illicit drugs: None

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 37 year old gentleman with a history of end stage AIDS complicated by multiple opportunistic infections and long history of cardiomyopathy of unclear etiology who had been managed for several weeks as an outpatient with increasing episodes of diarrhea and a weight loss of approximately ten pounds. Approximately ten days prior to admission, he had also begun to develop some shortness of breath associated with some chest tightness and coughing. He had been seen in the Emergency Department where a CT angiogram of his chest had been performed and revealed a pneumonia and he was treated over the next week with Augmentin for this. However, he continued to have pleuritic chest pain, shortness of breath and temperature of 102. On follow-up office visit to his primary care physician, [**Name10 (NameIs) **] was found to have collapse of the right middle lobe on chest x-ray. Given his ongoing pulmonary complaints as well as diarrhea and poor nutritional status, he was admitted to the hospital for further workup. MEDICAL HISTORY: 1. HIV complicated by end stage AIDS first diagnosed [**2142**], presumably secondary to heterosexual sex with wife complicated by multiple opportunistic infections including PCP times five, MAC and HSV, also with [**Doctor First Name **] brain abscess leading to seizure disorder complicated by DDI induced pancreatitis and complicated by peripheral neuropathy. 2. Questionable history of hypercoagulability, status post axillary vein thrombosis associated with PICC line in [**2154**], and status post deep vein thrombosis in [**2157-12-29**]. 3. History of cardiomyopathy of unclear etiology, status post echocardiogram [**2-/2157**], showing ejection fraction of 25% with focal wall motion abnormalities. 4. Hypertension. MEDICATION ON ADMISSION: 1. Acyclovir 400 mg p.o. b.i.d. 2. Atenolol 50 mg p.o. q.d. 3. Augmentin one tablet p.o. b.i.d. 4. Azithromycin 250 mg p.o. b.i.d. 5. Ciprofloxacin 500 mg p.o. b.i.d. 6. Claritin 10 mg p.o. q.d. 7. Dilaudid 2 mg p.o. q3hours p.r.n. 8. Erythropoietin 20,000 units subcutaneous q.week. 9. Ethambutol 400 mg p.o. t.i.d. 10. Flonase two sprays to each nostril b.i.d. 11. Glimepiride 150 mg p.o. b.i.d. 12. Lomotil p.r.n. 13. Mepron 250 mg p.o. q.d. 14. M.S. Contin 30 mg p.o. t.i.d. p.r.n. 15. Mycelex 10 t.i.d. used p.r.n. for thrush. 16. Neupogen 300 mcg subcutaneous biweekly. 17. Neurontin 800 mg p.o. t.i.d. 18. Tincture of Opium 10% strength 1 cc p.o. q.i.d. p.r.n. 19. Paxil 20 mg p.o. q.d. 20. Aerosolized Pentamidine 300 units q.month. 21. Keletra three capsules p.o. b.i.d. 22. Sporanox 200 mg p.o. q.d. 23. Stavudine 400 mg p.o. b.i.d. 24. Ultrase two capsules t.i.d. with meals. 25. Warfarin 5 mg p.o. q.d. ALLERGIES: Bactrim which leads to an aseptic meningitis. PHYSICAL EXAM: FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: The patient lives in an apartment with his girlfriend and has visiting nurses once a week. He is a current smoker of one pack per week, occasional alcohol and denies any intravenous drug use.

CHIEF COMPLAINT: MVA PRESENT ILLNESS: This is a 61 year-old female with a history of diabetes who was involved in a motor vehicle collision. She was transferred to the [**Hospital1 190**] by Life Flight. On initial evaluation, she was hemodynamically stable with a GCS of 15. She had a clearly identifiable right lower extremity injury. The right ankle had a compound fracture with the tibia protruding out over the skin and the whole right foot displaced anteromedially. There was clear avulsion of nearly all of the posterior and medial as well as lateral structures and the foot was tethered to the leg anteriorly by skin and connective tissue bridge. She also had a degloving injury to the right thigh as well as a laceration to the left thigh. She had bilateral Charcot foot and her vascular exam was significant for palpable femoral and popliteal pulses bilaterally. She had pulses to her left foot, however, there was no appreciable pulse on the right foot although the right foot did have capillary refill. Given the degree of the neurovascular injury in combination with the orthopedic injury, it was felt that there would be no meaningful recovery of function for this mangled extremity and the decision was made to amputate the foot after discussion with the patient and her son who agreed with the plan. MEDICAL HISTORY: -Asthma ?????? requiring steroid therapy for 13 years, never intubated -Breast cancer s/p L mastectomy in [**2123**] and XRT -CAD dx in [**2118**] on echocardiogram; negative stress test [**1-13**] -DM dx 1 year ago -HTN -GERD -History of MRSA and VRE -Anxiety -L Foot ulcer s/p multiple surgeries (most recent [**1-13**]) and infections. Recent use of vanc/levo/linezolid (>2 months rx) -Glaucoma MEDICATION ON ADMISSION: ALLERGIES: Sulfa (Sulfonamides) / Dilaudid / Percocet PHYSICAL EXAM: PE: AFVSS FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Ms. [**Known lastname **] is divorced, has a 38 year old son who lives in CT and several grandchildren. Her son has power of attorney and is her health care proxy. She owns a house in [**Location (un) **] where she lives with a roommate and many cats; however, she has been in rehab for a substantial portion of the past year. She expresses concern that her insurance many not cover continued rehabilitation.

CHIEF COMPLAINT: Abdominal pain. PRESENT ILLNESS: This is a 51 year old man who was recently evaluated by his primary care physician for complaints of atypical left upper quadrant abdominal pain. A CT scan was obtained which detected a large right common iliac aneurysm 4.5 by 4.5, along with a small left common iliac aneurysm. The patient had a cardiac work-up which revealed an essentially normal echocardiogram with an ejection fraction of 60 to 70% along with no ischemic symptoms by exercise tolerance. The patient underwent an arteriogram by Dr. [**Last Name (STitle) **] on [**7-28**] which demonstrated a right pseudo-iliac aneurysm and a left common iliac aneurysm. The patient now is admitted electively for repair. MEDICAL HISTORY: 1. Hay fever. 2. No previous surgeries. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: He is married; he is self-employed as a tile installer. He lives with his wife. [**Name (NI) **] ambulates independently.

CHIEF COMPLAINT: flail post. MV leaflet, mod.-severe MVP found on follow up echo. known MVP/MR [**First Name (Titles) **] [**Last Name (Titles) 10718**] of endocarditis in '[**18**]. PRESENT ILLNESS: 65yo male with known MVP/MR diagnosed '[**18**] after an [**Year (2 digits) 10718**] of endocarditis. He only admits to mild PND at high altitude. He now presents for surgical evaluation. Cardiac echo [**10-30**] reveals mod-severe MVP,3+MR with partial mitral post. flail leaflet. DR.[**Last Name (STitle) **] was consulted for MVrepair. MEDICAL HISTORY: MVP/MR, hyperlipidemia, endocarditis'[**18**], GERD, RLL nodule, Left periaortic mass c/w esoph. cyst vs. bronchogenic cyst stable since '[**19**], right knee surgery, torn left rotator cuff, ?OSA MEDICATION ON ADMISSION: Lipitor 5(1),Aciphex 15(1), Lisinopril 40(1),Amoxicillin prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Admission Physical Exam afebrile, Pulse:72, RR:14, BP:146/78, Ht:72",Wt:188lb General: A&Ox3, NAD HEENT: [**Last Name (un) **], NC/AT, carotids: neg. bruits/JVD CVS:RRR, Nl S1-S2, III/VI holosystolic murmur Lungs:CTA ABD:benign EXT:0 C/C/E, no varicosities Discharge EXAM T:99.1, P:81,BP:136/88, RR:18, O2SAT: 96%, Wt:85.9KG General:A&Ox3,NAD HEENT:AT/NC, [**Last Name (un) **] CVS:RRR Lungs:CTA ABD:benign EXT: neg. C/C/E FAMILY HISTORY: father with PPM at age [**Age over 90 **], brother and son with heart murmurs.lives in [**Location **] with wife. SOCIAL HISTORY: retired engineer, denies tobacco, 2-3 beers/week.

CHIEF COMPLAINT: Inflammatory carcinoma of the left breast diagnosed [**2131-8-6**] s/p neoadjuvant chemo and s/p left modified radical mastectomy on [**2132-1-18**] now with left breast defect. PRESENT ILLNESS: Mrs. [**First Name (STitle) **] is a 44-year-old Caucasian female with history of inflammatory carcinoma of the left breast diagnosed [**2131-8-6**]. She underwent neoadjuvant chemotherapy and then subsequently underwent a left modified radical mastectomy on [**2132-1-18**]. At the time of her mastectomy, she was found to have residual invasive ductal carcinoma, 6.5 cm, grade 2, five of six nodes positive for metastatic disease, the largest metastasis 0.9 cm with extranodal extension. Patient was then placed on Zoladex and monthly and tamoxifen for estrogen blockade as well as Zometa to prevent bone loss. She was encouraged to wait 6 months post mastectomy before considering reconstructive options. She now presents for a desired delayed left breast reconstruction. MEDICAL HISTORY: Depression Left breast cancer MEDICATION ON ADMISSION: effexor 75 mg po daily Ativan 0.5mg PRN zolidex implanted tamoxifen 20 mg daily xometa yearly viatamin C, B12 and calcium +D ALLERGIES: Amoxicillin / Bactrim PHYSICAL EXAM: Pre-procedure PE as per Anesthesia Record [**2132-9-15**]: General: overweight woman in NAD Mental/psych: cooperative, pleasant Airway: as documented in detail on anesthesia record Dental: good Head/neck Range of motion: free range of motion Heart: RRR Lungs: clear to auscultation Abdomen: soft, nontender, no bruits Extremities: no edema, skin warm and dry Other: R chest portacath, anicteric, neck supple FAMILY HISTORY: negative for breast and ovarian cancer. SOCIAL HISTORY: Ms. [**Known lastname 83070**] lives with her mother, brother, and sister. She is a substitute teacher in the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] system.

CHIEF COMPLAINT: Ventricluar Tachycardia PRESENT ILLNESS: Patient is an 84 yo woman w/ h/o CAD s/p MI x 2, HTN, hyperlipidemia, DM2, OSA who initially presented on [**2143-5-1**] with c/o chest pain -> on presentation to ED was found to have monomorphic VT, otherwise hemodynamically stable. Initial EKG demonstrated STE in V2-V4, which was unchanged from prior. Patient was given amiodarone load (150mg IV x 2) and was started on amio gtt, but VT persisted and pt was sedated and cardioverted with 200J in ED. CP resolved upon cardioversion. Patient was admitted to [**Hospital Unit Name 196**] service on [**Hospital Ward Name 121**] 3, where she remained in NSR, no other issues. Her amiodarone was held and patient went to EP lab today for VT ablation. In EP lab pt was found to have 3 VT sites, s/p ablation of 1 (ablated presenting VT). Following ablation, pt was found to have complete heart block and prolonged H-V conduction. Temporary pacing wire was placed. By end of study, pt was back to normal conduction, but pacing wire was left in place. Pt was transferred to CCU for further care. Currently pt feels well. Denies any CP/pressure, arm pain, SOB, any other complaints. MEDICAL HISTORY: CAD s/p MI ([**2115**], [**2120**]) Hypertension Hyperlipidemia OSA on BiPap Diabetes mellitus, type 2 Osteoporosis Recent shingles Vertigo MEDICATION ON ADMISSION: Lisinopril 5 mg PO DAILY Acetaminophen 325-650 mg PO Q4-6H:PRN Lorazepam 0.5-1 mg PO HS:PRN Aspirin 325 mg PO DAILY Metoprolol 25 mg PO TID Atorvastatin 40 mg PO DAILY Oxycodone-Acetaminophen 0.5-1 TAB PO Q4-6H:PRN Hydrochlorothiazide 25 mg PO DAILY Insulin SC (per Insulin Flowsheet) ALLERGIES: Coreg Cr PHYSICAL EXAM: Vitals - T 96.7, HR 60 (paced), BP 127/57, RR 16, O2 97% on 2L NC General - awake, alert, pleasant, lying flat, NAD HEENT - PERRL, EOMI, MMM Neck - flat JVP Chest - R chest wall with bandage/temporary pacer in place. Looks C/D/I CVS - RRR soft S1 S2 no noted m/r/g Lungs - CTA anteriorly, laterally Abd - soft, large, NT/ND, + BS Groin - R groin site w/ small amt eccymoses, no hematoma, no bruit Ext - No LE edema b/l . 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: see above SOCIAL HISTORY: Social history is significant for the absence of current tobacco use, but history of heavy use - smoked 3pks/day for 30yrs, quit 25yrs ago. There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death.

CHIEF COMPLAINT: PRESENT ILLNESS: Ms. [**Known lastname 102960**] is a 50-year-old woman with known seizure disorder status post partial lobectomy and ventriculoperitoneal shunt and SIADH from seizure medications, who presented with a seizure, which started in the parking lot of a grocery store. The patient experienced her usual aura followed by the usual seizure, left facial convulsions. EMS was called, found patient to be lethargic and postictal without any injury or loss of consciousness from the seizure. She was brought to the ED where she had another seizure and left face twitching as well as left leg movements were noticed. The patient was treated with 10 mg of Valium IM. Previous triggers for seizures have been low sodium. Sodium was checked and found to be 120, and then 116, and then 118. The MICU was called to admit the patient for 3% normal saline and frequent laboratory checks. Her last seizure was [**2149-6-6**]. Recently her sodium chloride tablets were decreased from 3 3x a day to one 3x a day. MEDICAL HISTORY: 1. Temporal lobe epilepsy status post two lobectomies. 2. SIADH secondary to Tegretol. 3. Low back pain. 4. Depression. 5. Obsessive-compulsive disorder. 6. Status post a VP shunt. 7. Peptic ulcer disease. 8. Incontinence. 9. Absent left hip secondary to infection status post hip removal. 10. Anemia, B12 deficiency. 11. Hypertension. 12. Osteoporosis. 13. Bilateral heel contractures. 14. Asymptomatic ASD. 15. Lower extremity edema. MEDICATION ON ADMISSION: 1. Amoxapine 50 b.i.d. 2. Baclofen 10 q.i.d. 3. Calcium carbonate 1.25 b.i.d. 4. Ditropan 10 q.d. 5. Fluvoxamine 25 q.h.s. 6. Phenobarbital 30 and 60. 7. Fluoxetine 60 q.d. 8. Sodium chloride tablet one t.i.d. 9. Magnesium citrate q week. 10. Ibuprofen 400 t.i.d. 11. Meclizine 12.5 b.i.d. 12. Risperdal two t.i.d. 13. Tegretol XR 200/200/300. 14. Bowel medications. 15. Tylenol. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Palpitations PRESENT ILLNESS: 50 year old man with prior MI and Cx stenting in [**2145**], HTN, + chol, GERD, admitted to Sturdy ER with complaints of palpitations since thursday. The palpitations are associated with pain in his throat and neck, and worsen with even mild exertion. He also describes worsening dyspnea on exertion over the past 2 weeks. He felt lightheaded while walking today. Today the palpitations seemed to be more frequent, occuring for minutes at a time. He had similar palpitations 6 months after his MI/Cath in [**2146**], that resolved spontaneously. He was seen by Dr. [**Last Name (STitle) 3100**] recently and had an outpatient stress test that was notable for inferolateral ischemia by pt report. In the OSH ER on telemetry, the patient was found to have multiple PVCs, including periods concerning for non-sustained V-Tach. Upon admission, he denies chest or throat pain. He does feel intermittant fluttering. He does not feel short of breath at rest. MEDICAL HISTORY: 1. Coronary Artery Disease - history of myocardial infarction and s/p PCI/stening to circumflex in [**2145**]. 2. Hypertension 3. Hyperlipidemia 4. Bifasicular block 5. GERD 6. Cholecystectomy MEDICATION ON ADMISSION: Atenolol 12.5 QD Zestril 2.5 QD Lipitor 20 QD Prilosec 20 QD B6-B12-folic acid Ecotrin 325mg ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, no JVD CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. FAMILY HISTORY: His father had a heart attack at age 50 SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. HI father had a heart attack at age 50

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 55-year-old male who was admitted to the Medical Intensive Care Unit on [**2139-7-5**], for shortness of breath and with a room air oxygen saturation of 72%. He had been admitted in [**Month (only) 956**] from [**3-16**] to [**3-26**] with hypoxia and bilateral pulmonary infiltrates. Work-up at that time involved bronchoscopy which was negative for PCP. [**Name10 (NameIs) 14174**] of tissue eventually grew out alpha Streptococcus. He improved clinically with diuresis, and an echocardiogram showed an ejection fraction of 40%, anterior septal akinesis, apical akinesis, anterior hypokinesis, and akinesis. Clinically, although he improved with diuresis during that admission, he was treated with Levaquin. Since that discharge, he has been started on Lasix and Lopressor with cardiologist Dr. [**Last Name (STitle) 20612**] on [**4-15**] and [**5-3**]; however, he continued to have increasing lower leg edema. On this admission in the Emergency Department, he arrived with an oxygen saturation of 72%, 92-96% on non-rebreather. An ABG done at that time showed a pH of 7.39, 30, 94 on non-rebreather. He had transient orthostatic hypotension because he missed his morning dose of Midodrine. At the time of admission in the Emergency Department, he was noted to be febrile to 101.5??????, otherwise with normal vitals signs. In the Emergency Department, he was treated with Levaquin, Prednisone, and intravenous Bactrim. He was then transferred to the Medical Intensive Care Unit where he was diuresed with intravenous Lasix, and urine output to that was over a liter. He became stable at 95% on 4 L with room air oxygen saturations of 88-92%, and the patient himself said that he felt much less short of breath. MEDICAL HISTORY: Significant for end-stage renal disease status post a living-related donor kidney transplant in [**2131-1-9**], diabetes mellitus with significant neuropathy with orthostatic hypotension, nephropathy requiring renal transplant, retinopathy with a history of retinal hemorrhages. The patient has a nephrostomy tube. He has obstructive sleep apnea and has been on BIPAP since [**Month (only) 1096**]. His left ankle is significant for Charcot joint, and he has a history of recurrent cellulitis. His ejection fraction in [**2139-3-12**] was as stated prior. He has had multiple skin cancers. Coronary artery disease by stress test. MEDICATIONS ON ADMISSION: Cyclosporin 200 b.i.d., Prednisone 5 mg q.d., Procardia XL 120 q.d., Pravachol 40 q.d., Neurontin 300 b.i.d., Lasix 40 q.d., Lopressor 50 b.i.d., ProAmatine 10 t.i.d., Niferex 150 q.d., NPH 32 U in the morning, 9 U in the evening, regular Insulin sliding scale. MEDICATION ON ADMISSION: Cyclosporin 200 b.i.d., Prednisone 5 mg q.d., Procardia XL 120 q.d., Pravachol 40 q.d., Neurontin 300 b.i.d., Lasix 40 q.d., Lopressor 50 b.i.d., ProAmatine 10 t.i.d., Niferex 150 q.d., NPH 32 U in the morning, 9 U in the evening, regular Insulin sliding scale. ALLERGIES: DICLOXACILLIN AND COMPAZINE. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: He quit smoking in [**2110**]. He drinks two beers a week. He lives at home with his wife. [**Name (NI) **] has children.

CHIEF COMPLAINT: Abdominal pain PRESENT ILLNESS: 73F with h/o AAA p/w 2 days of low abdominal/back pai. 6.5cm AAA seen on CT scan at OSH. AAA was followed by Vascular Surgery but pt has not gone for a CT scan for approx 45yrs, at which time it was around 5.0cm. She notes onset of very low abdominal pain along with constipation for the last 2 days. At worst pain is [**11-8**] constant crampy similar to previous bouts of diverticulitis. She is currently pain free after having a BM around noon today. Denies any dizziness or SOB, but did have diaphoresis/nausea/syncope x1 yesterday while straining to have a BM yesterday. + fever/chills x 1 day, last BM 2 days ago, dark at baseline [**3-3**] iron supplements, no hematoschezia, no dysuria or other urinary symptoms. MEDICAL HISTORY: AAA per above, DM, MI [**2131**], Diverticulitis, Neuropathy, Sciatica, Asthmatic, Bronchitis, Bursitis Rt shoulder, Rotator cuff tear, Dry eyes MEDICATION ON ADMISSION: Titralac 100mg' Avandia 30mg' Axid 150' Ferrous Sulfate 325' Tylenol Xtra strength prn Neurontin 300' Crestor 20mg' Cymbalta 30mg' Pulmocort 180mcg 1puff [**Hospital1 **] Albuterol 90mcg prn Foradil Theratears Mucinex MVI ALLERGIES: Sulfa (Sulfonamide Antibiotics) PHYSICAL EXAM: Vitals Gen: AOx3 CV: RRR Resp: CTAB Abd: soft, non-tender AAA, + tenderness to deep palpation in LLQ, mild distended Pulses: Rad Fem [**Doctor Last Name **] PT DP Rt 2+ 2+ 2+ 2+ 2+ Lt 2+ 2+ 2+ 2+ 1+ FAMILY HISTORY: NC SOCIAL HISTORY: Former smoker quit 17yrs ago 80pack/yr, no EtOH, no illicits.

CHIEF COMPLAINT: Complete Heart Block & Ventricular Tachycardia PRESENT ILLNESS: 64yo man w/ h/o multiple medical problems including [**Name (NI) 2320**], CAD, HepC/ETOH cirrhosis & HCC s/p orthotopic liver tx ('[**57**]) on prograf w/ post-transplant course complicated by renal insufficiency, tracheostomy, chronic colonization/infections w/ mult resistant organisms who was transferred from [**Location (un) 745**] [**Hospital 3714**] Hospital to [**Hospital1 18**] CCU for pacemaker/ICD placement. Pt initially presented to NWH on [**2159-10-13**] w/ & AV block in setting of hyperkalemia. Pt tx'd w/ RIJ temporary pacing wire at NWH, during which he developed Ventricular Tachycardia. Pt out of AV block, and in sinus rhythm upon arrival at [**Hospital1 18**]. MEDICAL HISTORY: 1. Liver transfusion for Hepatitis C/EtOH cirrhosis & hepatocellular carcinoma, on tacrolimus followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]. 2. Tracheostomy: x2, [**8-11**] for chronic vent dependency, subglottic stenosis, tracheomalacia 3. DM2 4. OSA/Pickwickian syndrome 5. COPD 6. Diastolic dysfunction 7. CKD 8. Bipolar d/o 9. HTN 10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections 11. Hiatal hernia 12. Pulmonary hypertension MEDICATION ON ADMISSION: Prograf 1 mg [**Hospital1 **] Bactrim DS one tablet per day Keflex 500mg PO q6H Diflucan 200mg PO daily Prednisone 5mg PO daily Norvasc 10 mg PO daily Protonix 40mg PO daily Olanzapine 2.5mg PO daily zinc sulfate 220 mg po daily sliding scale insulin PRN Heparin 5000 units subcutaneously TID Ativan 1mg PO q6H PRN Motrin 600mg PO PRN Hydromorphone 0.5-2mg IV q2H PRN Artificial tears Miconazole powder PRN ALLERGIES: Penicillins / Nsaids / Rapamune PHYSICAL EXAM: VS: T: 99.2 HR: 70 RR: 19 bp: 131/91 SpO2: 97% on ventilatory mask 0.35 FIO2 Gen: A&O*4, appears mildly distressed HEENT: PERRLA, EOMI, 2mm pupils Neck: trach, pacemaker insertion site C/D/I Heart: temp pacemaker set at HR 50/ 10mV, RRR Lung: coarse rhonchi louder on LLL than RLL Abd: soft, NT, ND Ext: 0.5cm pustule on distal lateral LLE surrounded by 1 cm erythematous border FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Quit tobacco 8 years ago. Quit alcohol 17 years prior to admission. Denies any recreational drugs.

CHIEF COMPLAINT: Hematemesis PRESENT ILLNESS: Mr. [**Known lastname **] is a 61 yo male with HCV cirrhosis followed at the [**Hospital1 756**] and chronic alcohol abuse with ESLD and history of varices. He reports feeling dizzy yesterday and having one episode of bright red bloody emesis. Then, last night he developed abdominal discomfort, and today noticed much worsening of his hematesis. He also passed out when bending over. He denies preceeding presyncope, SOB, CP. he was out for only a short time. He reports 2-3 days of chills and cough, but no other focal infectious symptoms. EMS was called and saw clots. They gave him 500cc IVF and brought him to the [**Hospital1 18**] ED. MEDICAL HISTORY: Nadolol 40 Lasix 20 daily PPI 40 [**Hospital1 **] Thiamine Folate 1mg MVI Iron Sulfate 325mg [**Hospital1 **] MEDICATION ON ADMISSION: Nadolol 40mg po daily Lasix 20mg po daily PPI 40mg po BID Thiamine daily Folate 1 mg daily MVI daily Iron Sulfate 325mg po BID ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Admission Physical Exam Vitals: 98.4 131/78 105 100% on 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. NGT in place with bright red blood Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1, pronounced S2, 3/6 SEM loudest at apex, rubs, gallops Abdomen: soft, non-distended, bowel sounds present. Mild TTP diffusely, no rebound tenderness or guarding. Liver tip felt below costal margin. Spleen not palpable. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema skin: diffuse psoriatic patches FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Reports 1-2 beers on the weekends. He lives with his wife. [**Name (NI) **] has a history of IVDU, which is how he contracted HCV.

CHIEF COMPLAINT: ST Elevations s/p fall PRESENT ILLNESS: 79 y/o M with PMH of DM type II, MI, TIA who presented to OSH with syncope. Pt reports feeling fatigued for past few weeks. Was walking back to bed from bathroom this am and fell. Does not recall lightheadedness of palpatations prior to fall. His wife heard him fall and called EMS and pt was taken to OSH. No OSH records available. Per report from [**Name (NI) **] pt was found to have troponin of 1.06 and ECG with 1mm STE v1-v2, ST depression II and AVF, V4-v6. Head CT negative. Pt transferred to [**Hospital1 18**] for further management. In the ED, initial vitals were T 97.4 HR 52 RR 18, O2 sat 100% BP 173/99. Pt evaluated by Cardiology. Given ASA 325mg. Given INR of 2.4 heparin gtt and plavix was held. As he was clinically stable and with Cr of 3.3, planned cath in am with renal consult. Repeat Head CT repeated with no evidence of acute infarct or bleed. . On review of systems, positive for prior history of stroke and TIA, no hx of 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. 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: 1. DM(II) c/b neuropathy s/p partial R toe amp ('[**65**]) 2. PVD s/p R AK [**Doctor Last Name **]-DP BPG ('[**65**]) and L [**Doctor Last Name **]-DP ('[**63**]) 3. HTN 4. lipid 5. seizure d/o 5. Fe deficiency anemia 6. CKD 7. h/o squamous cell carcinoma s/p excision MEDICATION ON ADMISSION: ATORVASTATIN [LIPITOR] 10 mg daily FUROSEMIDE [LASIX] - 40 mg Tablet - [**1-13**] tablet Tablet(s) by mouth twice daily ISOSORBIDE DINITRATE - 30 mg Tablet - [**1-13**] Tablet(s) by mouth twice daily METOPROLOL SUCCINATE - 100 mg Tablet [**Hospital1 **] NITROGLYCERIN prn WARFARIN - 5 mg VITAMIN A-VIT C-VIT E-ZINC-CU ALLERGIES: Penicillins PHYSICAL EXAM: VS: T 96.1, BP 144/90, HR 50, RR 20, 100% 4L NC GENERAL: elderly male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NC. Midline frontal scalp laceration. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to earlobe CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. bibasilar crackles ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. PULSES: Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+ FAMILY HISTORY: No family history of early MI, otherwise non-contributory. SOCIAL HISTORY: He quit smoking over 30 years ago and he does not drink alcoholic drinks. He currently lives at home with his wife. Retired sales marketing consultant.

CHIEF COMPLAINT: 1. Epigastric Pain 2. Chest pain PRESENT ILLNESS: 87M with significant cardiac history p/w 4 days of epigastric and chest pain radiating into the back. Patient presented to ED Friday evening after no improvement in the pain. He reports having subject fevers at home, though he never measured his temperature. Otherwise he denies nausea, vomiting, shortness of breath. He did report some constipation over the past few days though reports having a bowel movement today. MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [**2144**] and [**2142**] 2. Left ventricular aneurysm. 3. Congestive heart failure with ejection fraction less than 20% from the echocardiogram in [**2160-6-10**]. He had a biventricular implantable cardioverter-defibrillator placed in [**2160-6-10**]. 4. s/p IMI 5. AAA - repaired in [**2147**] 6. Chronic obstructive pulmonary disease. 7. Hypertension. 8. Hyperlipidemia status post appendectomy in [**2092**]. 9. BPH 10. DM2 MEDICATION ON ADMISSION: DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - (Dose adjustment - no new Rx) - 20 mg Tablet - 1 Tablet(s) by mouth every other day GLIPIZIDE - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 5 mg Tablet - 1 Tablet(s) by mouth in am and 2 tabs in pm LISINOPRIL - 5 mg Tablet - [**12-13**] Tablet(s) by mouth once a day LOVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day POTASSIUM CHLORIDE - 10 mEq Tablet Sustained Release - 1 Tablet(s) by mouth once a day SITAGLIPTIN [JANUVIA] - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 50 mg Tablet - 1 Tablet(s) by mouth once a day TAMSULOSIN [FLOMAX] - (Dose adjustment - no new Rx) - 0.4 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once a day WARFARIN [COUMADIN] - 2 mg Tablet - take Tablet(s) by mouth as directed ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day CYANOCOBALAMIN [VITAMIN B-12] - 1,000 mcg Tablet - 1 Tablet(s) by mouth once a day ALLERGIES: Penicillins / Sulfa (Sulfonamides) PHYSICAL EXAM: On Admission: T100.6 HR102 BP148/80 RR24 O299 RA NAD PERRL, EOMI b/l, sclera anicteric Neck supple CV: RRR, paced Pulm: CTA b/l Abd: soft, min TTP in RUQ, non distended, no rebound/gaurding, neg [**Doctor Last Name 515**] sign Ext: no edema FAMILY HISTORY: Significant for father dying of lung cancer and mother dying of myocardial infarction at age 65. SOCIAL HISTORY: 1 PPD x 30 years He grew up in [**Location (un) 3146**], [**State 350**]. He is a veteran of the Army. He was in the air corps. He is married, has a wife and three grown children. He is a retired fireman and insurance salesman. No tobacco use. He did smoke but quit 20 years ago. He is an ex-smoker for 50 pack per year, he quit in [**2142**]. No intravenous drug use. Social alcohol use. No drug use.

CHIEF COMPLAINT: intubated - seizure PRESENT ILLNESS: Patient is a 30 yo M who was at work earlier today, reportedly witnessed to bend down, then have a tonic clonic seizure. EMS witnessed two seizures per report in transport, observed R eye deviation. Patient was take to [**Hospital1 18**] and intubated upon arrival. Per ER report, prior to intubation the patient was withdrawing all 4 extremities to noxious stim. He was taken to CT where his head CT showed a punctate hemorrhage on the left posterior vertex. Neurosurgery was called to evaluate. They recommended Neuro c/s, EEG, dilantin loading. Pt also had INR 2 and was given FFP. Neuro consulted, recommended changing sedation to benzos, as thought this likely withdrawal related. Labs notable for plt 50, INR 2, pos urine benzos. Anion gap 17. ABG after intubation was 7.36/32/453/19 on AC 100% FIO2. Patient given dilantin 250, banana bag, propofol, midaz, fentanyl and naloxone. Ordered for 2 units ffp, did not get prior to transfer. On arrival to the MICU, patient intubated and sedated, unable to provide further information. MEDICAL HISTORY: EtOH abuse, No h/o withdrawal seizures. Tobacco use pancytopenia MEDICATION ON ADMISSION: folic acid 1 mg daily multivitamin thiamine omeprazole 20 mg daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: PE on Admission to MICU Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact FAMILY HISTORY: unknown SOCIAL HISTORY: + Hx of EtOH abuse - QUIT 2 months ago ([**5-/2169**]) - was hospitalized for detox and had not had EtOH since. Per PCP recs, patient originally from El [**Country 19118**]. In US since [**2157**]. Unmarried, limited english.

CHIEF COMPLAINT: CP PRESENT ILLNESS: 68-year-old woman haitian Crecole speaking only with history of type 2 DM, hypertension and hyperlidpedemia who presented to [**Hospital1 18**] ED with 3 days of chest pain. Patient reports that about three days ago while she was putting her clothes in the laundry she had suddedn onset of substernal chest pain with radiation to her neck, right arm and her abdomen. She attributed this pain to indigestion. The pain was [**4-16**] and remained constant. Today at 6:30am patient patient acutely worsened [**9-16**] associated with nasuea, diaphoresis and shonrtess of breaht. . In the ED, initial vitals were 45 96/45 16 100% RA. ECG showed ST Elevation Myocardial Infarction in inferior leads. She was given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1 and heparin 4000 units IV bolus. She was noted to be bradycardic and hypotensive and thus given atropine 1mgx2 and started on dopamine gtt which improved her blood pressure. She was transfer to Cath lab. . In the Cath lab, she was noted to acute mid RCA occlusion which was treated with angioplasty x 3 (10 mm/12 mm/14 mm) with residual thrombus which was exported and Promus DES was placed in mid RCA. His cath lab course was complicated by intermittent complete heart block requiring temporary pacemaker pre-stenting though she was conducting 1:1 in NSR after stenting. She was also noted to have AIVR. Dopamine at 5 mcg/kg/min was turned off at the end of her cath lab course. A small 1.5cm hematoma was visible at the RFV access site after the case, and manual pressure was applied for 10 minutes. . In the CCU, she did not report chest pain, discomfort, palpatations or shortness of breath. She desnies any history of chest pain. MEDICAL HISTORY: DM2 HTN TB peripheral neuropathy aseptic thrombophlebitis of the left internal jugular in [**2130**]. MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Aspirin 81 mg PO DAILY 2. Amlodipine 10 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Lisinopril 40 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Ranitidine 150 mg PO BID 7. NPH 32 Units Breakfast NPH 22 Units Dinner ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission Physical: GENERAL: Appears well NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL. MMM NECK: Supple with no JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: 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: Wamr and well perfused 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: non-contributory SOCIAL HISTORY: Lives with husband, ha two children who live in [**Country 2045**]. Creole speaking from [**Country 2045**] 14 years ago. Three children. No history of tobacco, ETOH or illicit.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 64-year-old woman who was admitted for an elective cardiac catheterization. The patient's cardiac history includes an anterior MI in [**2153-12-12**] which led to a VF arrest. On catheterization lesion was found in the LAD which was stented. In [**2154-12-13**] the LAD stent occluded and led to a recurrent anterior MI. The patient underwent PTCA of the LAD. On catheterization the patient's ejection fraction was found to be 25% and the post cath course was complicated by a groin bleed after the patient was discharged home and the patient was readmitted. An echocardiogram in [**2154-12-13**] revealed mild MR with severe systolic dysfunction. On admission the patient denied any chest pain or pressure or shortness of breath, no nausea or vomiting since the last procedure. She did have severe chest pain with her heart attacks. Her cardiac risk factors include hypertension, hypercholesterolemia, smoking history, but is negative for diabetes. MEDICAL HISTORY: Anterior wall MI times two in [**2153**] and [**2154**], coronary artery disease stenting [**2153**], reocclusion and PTCA [**2154**]. Upper GI bleed [**2155-3-13**] on Coumadin, requiring transfusion of three units packed red blood cells. Subdural hematoma. Status post appendectomy. Status post TAH BSO. Osteoporosis. Hiatal hernia. Esophageal ulcer. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient lives with her sisters and her brother. Another brother died one week prior to this admission.

CHIEF COMPLAINT: Transferred for cardiac catheterization from [**Hospital1 1474**] ER PRESENT ILLNESS: 72 year old man with htn, hyperlipidemia, DM, +FH, Many prior PCIs. Last here [**6-30**] with direct stenting of distal LAD with a 2.0 x 12 mm Bare metal [**Month/Year (2) **]. Recently off of aspirin and Plavix due to severe back pain and plans to have epidural injection to back. Today was exerting himself when had severe back pain and chest pain. Presented to OSH ([**Hospital 1474**] Hospital) w/in 10min c/o ([**8-5**]) midsternal CP, and was noted to be pale, diaphoretic. Troponin bumped to 1.1. CPK 186, MB 7.6. . At [**Name (NI) 1474**], pt started on heparin gtt, nitroglycerin gtt, 2mg morphine, sl nitro, asa 325, 300 plavix. Pt continued to have chest pain, so was transferred to [**Hospital1 18**] for cath. . Cath showed: TO pLAD, s/p PCTA of lesion, with IVUS of LAD MEDICAL HISTORY: - CAD. [**6-30**] PCI and bare metal [**Month/Year (2) **] to dLAD (90% distal lesion) (LV gram: nl EF) [**1-31**] PCI of mLAD with DES [**7-29**] PCI of mRCA with DES, PCI of OM1 with DES [**8-28**] instent restenosis of D1, 70% focal instent restenosis of RCA: brachytherapy to both lesions [**6-27**] TOd prox RCA 4 stents to RCA, rotational arthectomy and [**Month/Year (2) **] to D1 [**8-27**] PTCA and [**Month/Year (2) **] to RCA . Cath showed [**2189-11-30**]: The LMCA had a proximal 20% stenosis. The LAD was acalcified vessel which was totally occluded after D1 with no filling of the distal vessel by collaterals. The LCX was a nondominant vessel with mild diffuse disease and a wideply patent OM1 [**Month/Day/Year **]. The RCA was a dominant vessel with a distal 50-60% in-[**Month/Day/Year **] restenosis. Successful PTCA of the mid LAD. Final angiography revealed a 10% residual stenosis in the mid LAD and moderate diffuse disease in the distal vessel. . [**2189-12-1**] Repeat Cardiac CATH: -three vessel disease -LMCA w/ 20% stenosis -LAD widely patent with TIMI 3 epicardial flow. Moderate diffuse disease in the distal LAD was unchanged from [**2189-11-30**]. The LCX including the OM1 [**Month/Day/Year **] was widely patent. The dominant RCA had a 50-65% in-[**Month/Day/Year **] restenosis distally but no other angiographically significant disease. Limited resting hemodynamics revealed low normal systemic arterial pressures while on a TNG gtt. . - DM II. - HTN. - Gout. - LBP. MEDICATION ON ADMISSION: Home Medications: Metoprolol 50 mg PO BID Metformin 500 mg PO QID (held) Imdur 30 mg PO qd Plavix 75 mg PO qd ASA 81 mg PO qd ?Darvocet . Allergies: ?lipitor causes joint pain ALLERGIES: Indocin / Lipitor PHYSICAL EXAM: PE: VS: 98.7 BP 135/80 HR 55 R 16 98% 2L Gen: NAD HEENT: EOMI, PERRL Neck: supple, no LAD Chest: CTAB CV: RRR nl s1 s2 no mrg Abd: soft, NT, obese +bs Ext: no edema, full pulses at DP and PT bilaterally Neuro: CN 2-12 intact, moves all 4, sensation intact. No gross deficits. FAMILY HISTORY: F died MI at age 74, son had [**Name2 (NI) **] at age 48. SOCIAL HISTORY: Tob 100 py. Quit 13 y ago. Denies extensive EtOH use. Leaves with wife, has children and grandchildren, but no sick contacts. .

CHIEF COMPLAINT: Two week history of short term memory loss PRESENT ILLNESS: This is a 41 y/o African American female brought to the ED by her husband for a two week history of percieved short therm memory loss. Patient was driving to church in the past day or two and had to have her daughter tell her how to get there and when taken to see her PCP she did not remmber being in his office in the past. MEDICAL HISTORY: HTN, Hospitalized last year at [**Hospital3 5365**] for w/u hysterectomy for fibroids MEDICATION ON ADMISSION: Labetalol PO ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: On Admssion: PHYSICAL EXAM: O: T: 98.2 BP: 148/103 HR:71 R 17 O2Sats 100% RA Gen: WD/WN, comfortable, NAD. HEENT: NCNT Neck: Supple. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. FAMILY HISTORY: NC SOCIAL HISTORY: No Tobacco No ETOH Works as a manager

CHIEF COMPLAINT: Change in Mental Status PRESENT ILLNESS: 74 yo M w history of alzheimers dementia, CAD, noted to be increasing restless and his usual daycare. Was also agitated and combative. Upon nurses assesment, pupils noted to be rolled back in his head, and patient noted to have shaking tremors of lower extemities. All events witnessed by pt's wife and daughter who were at Day Care withthe patient. Temp taken at Day care registered at 103.1. BP 130/82. Family denied loss of continence. No LOC, family states that they were able to communicate with the patient during the shaking episode. . When EMS arrived to daycare, pt noted to be more restless, very talkative, twitching leg movements, agitated, combative. EMS arrived, found the patient FS noted to be 58, given [**1-17**] amp D50, BS improved to 166. Taken to [**Hospital1 18**] ED. . Pt baseline is not oriented, doesn't recognize family due to his dementia, but is able to take care of ADLs (shaving, toileting, eating). Family reports patient entirely at baseline day prior to admission, doing well, having gone to Temple during the [**Hospital1 **] Holidays. The lethargy and increased agitation is new for the patient and is especially concerning given the high fevers. . Unable to obtain ROS from the patient. Per family, pt does not have any CP, SOB, abd pain. They did mention that patient does occasionally c/o pain in his legs. Denied cough, headaches, dizziness, lightheadedness, nausea, vomiting, diarrhea. . In ED, T 103; HR 96; BP 130/70; RR 24; O2 sat 98% 2L NC. no localizing symptoms, but difficult to assess given pt's dementia. LP was peformed and was negative. BCx were taken. UA negative. A dose of ceftaz and vanco were given empirically given the pt's delta MS, fevers, bandemia. EKG significant for sinus tach 102, LAD, no significant ST-T segment changes. MEDICAL HISTORY: Dementia CAD s/p CABG [**49**] yrs ago Osteoarthritis B 12 deficiency H/O afib h/o recent toe cellulits RLE tx'd with 14 days of PO Keflex. MEDICATION ON ADMISSION: Lasix 80mg qd Simvastatin 40 mg qhs KCl MVI Vit B12 SC q month donepezil 5mg qhs ASA 81mg qday ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T 102.4R, T99.5 axillary, BP 94/62; HR 88; 99%RA Gen: lethargic male, diaphoretic in bed HEENT: dry MM. Perrla, EOMI, but has trouble following commands CV: tachy. reg s1 and s2. 2/6 systolic murmur best audible at RUSB CHEST: CTAB. No rales, rhonchi wheezes ABD: + BS. Soft, NT, ND, no HSM. EXT: bilat LE edema, but RLE > LLE signifcantly. warmth and erythema from R dorsal surface all the up to the knee. no palbable chords. No [**Last Name (un) 5813**] sign elicited. LLE: [**Name (NI) **] PT and DP RLE: [**Name (NI) **] PT and DP NEURO: not able to cooperate with neuro exam. patient is lethargic, but arousable, does not follow commands, but able to respond to the family (this is off baseline, family states). moves all 4 extremities (though not on command). no neck stiffness FAMILY HISTORY: non-contributory SOCIAL HISTORY: Pt lives at home with his wife and homemakers. Advance dementia, but pt is able to dress and toilet himself (including shaving his face and body). lifetime non-smoker and non-drinker. Baseline ambulatory and able to participate in daycare activities

CHIEF COMPLAINT: Acute Renal Failure PRESENT ILLNESS: On a prior admission, pt admitted w/ STEMI that was thought to have occurred 3-4 days prior admission. Because of timing, pt did not undergo stenting during cardiac cath, which showed. Following cath, she developed cardiogenic shock, for which she was temporarily treated with an intra-aortic balloon pump, levophed and milrinone. She was eventually weaned off all these. She was started on aspirin, atorvastatin and digoxin. (She had been on OCPs on admission which were dc'd). TTE from [**2147-3-8**] showed an EF of 25% with septal, anterior and apical akinesis. A repeat TTE was performed on [**2147-3-16**] to assess for interval improvement, but there was no change in cardiac function. Pt also had low-grade fevers throughout her hospitalization. Prior to last admission, she was treated with a full course of ciprofloxacin for a UTI. All blood cultures were negative and UA negative. She was put on a five day course of vancomycin empirically for possible line infection (it was thought that she may have had transient bacteremia from the catherization instrumentation, even thought cultures were negative). She was also given a five day course of azithromycin for a possible community acquired PNA given a LUL infiltrate on CXR. Despite the course of azithromycin, her fevers persisted and there was worsening of the left retrocardiac opacity. She was started on a seven day course of IV cefepime and vancomycin for hospital acquired pneumonia. A PICC line was placed in the left arm on [**2147-3-18**] for out-patient administration of IV antibiotics. During her stay, there was also concern for antiphospholipid antibody syndrome, given her MI at a young age, with few cardiac risk factors and given elevated PTT. Testing for antiphospholipid antibodies was deferred in the in-patient setting because of possible false positive results with acute illness and anticoagulation. . Since discharge, the patient has reportedly continued to have low grade fevers at [**Hospital1 **]. She had a R PICC line placed on [**2147-3-23**] (unclear indication for placement). [**Name8 (MD) **] Crt has slowly trended up over the past 7 days. The pt reportedly maintained normal PO intake. She had low urine output and reportedly 25cc on bladder scan. Her Hct dropped from 31.3 (on [**3-22**]) to 25.3 (on [**3-28**]). Her SBP at rehab ranged from high 80s-110s--she was in the 90s on discharge from [**Hospital1 18**] according to notes available. She then developed a rash--total body--on the day of presentation. . In the [**Name (NI) **] pt. was febrile to 101.6, HR 100, BP 91/45, 19, 100 on 2L. A pelvic exam was negative for foreign bodies. Renal US showed no hydro. She was given tylenol, vanc, ceftaz and ceftrioxone and 300cc of NS. . On admission patient denied pain or compliants, otherwise does not answer questions of verbally interact. MEDICAL HISTORY: Cardiac Risk Factors: -Diabetes, -Dyslipidemia, -Hypertension . Cardiac History: NONE . Other PMH: Mental Retardation Seizure disorder (?--listed in chart, but questionable per caretakers, [**Name (NI) 74959**] added recently for mood) Recurrent UTIs MEDICATION ON ADMISSION: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Omega-3 Fatty Acids 240-360-5 mg-mg-unit Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. BuSpar 30 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 12. Lactulose 10 gram Packet Sig: [**2-8**] Packets PO twice a day as needed for constipation. 13. Warfarin 4 mg Tablet PO HS (at bedtime). 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 15. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 6 days. 16. Cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q12H (every 12 hours) for 6 days. 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. . Meds on Transfer Insulin SC Sliding Scale Lactulose 30 mL PO Q8H:PRN Acetaminophen 650 mg PO Q6H:PRN MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Aspirin 300 mg PR DAILY Mirtazapine 15 mg PO HS BusPIRone 30 mg PO BID Ondansetron 4 mg IV Q8H:PRN nausea Digoxin 0.125 mg PO EVERY OTHER DAY Oxcarbazepine 300 mg PO BID Heparin 5000 UNIT SC TID . Allergies: NKDA ALLERGIES: Cefepime PHYSICAL EXAM: VS: 98.3 (Tmax 101.6), 104, 96/54, 24, 95% on room air Gen: huddled under blankets, cradling stuffed animal rabbit, responds to most questions w/ "no", follows some commands, overall in NAD HEENT: NCAT, PERRL, sclera anicteric, OP clear, no desquamtion of MM Neck: Supple, JVP flat CV: Tachy, S1/S2, no m/r/g Resp: CTA B Abdomen: Soft, NTND, BS+ Ext: No c/c/e. DP pulses are 2+ bilaterally Neuro: alert, answers some questions with no, moving all extremities Skin: diffuse pink/erythematous papular rash w/ some areas of confluence, no desquamation or bullae FAMILY HISTORY: Family history unknown. SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Pt resides in group home.

CHIEF COMPLAINT: abdominal trauma with projectil evisceration PRESENT ILLNESS: 59 year old male with work related injury invlving centrifuge rotor. The rotor broke and showered his lower abdomen with plastic shards, immediately eviscerating the patient. He had continuous nonpulsatile bleeding from his wound, and was alert and hemodynamically stable throughout his transport to [**Hospital1 18**]. MEDICAL HISTORY: 1. Prostate ca s/p seeds 2. uveal ca MEDICATION ON ADMISSION: None ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VITALS P 88 BP 150/palp RR 18 97% RA GCS 15 Alert RRR CTA B soft abdomen with small bowel protruding from LLQ Rectal - guaiac negative Foley - clear yellow urine EXTREMITIES - warm well perfused no deformities FAMILY HISTORY: nonsontributory SOCIAL HISTORY: married, non drug use.

CHIEF COMPLAINT: ESRD PRESENT ILLNESS: Ms. [**Known lastname 39143**] is a 46-year-old female with end-stage renal disease secondary to type 1 diabetes mellitus, who presents for a kidney transplantation MEDICAL HISTORY: Her past medical history is significant only for diabetes, hypertension, hypercholesterolemia, and end-stage renal disease. She has had two prior C-sections, a laparoscopic cholecystectomy, and then PermCath that is placed in the right internal jugular vein. MEDICATION ON ADMISSION: ALLERGIES: Morphine PHYSICAL EXAM: On physical examination, Mr. [**Known lastname 39143**] is a very pleasant 46-year-old female in no apparent distress. Chest is clear. Abdomen is soft, nontender, and nondistended. No cervical or supraclavicular adenopathy. No carotid bruits. Her abdominal incision site is clean, and intact with overlying abdominal pads for drainage control. She has had no recent fevers or chills or drainage. Her femorals are 2+ and equal bilaterally. She has 2+ to 3+ peripheral edema. No evidence of lower extremity ulcers or ischemic changes FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Respiratory distress. PRESENT ILLNESS: The patient is a 78 year old male with a history of chronic obstructive pulmonary disease, esophageal cancer, status post resection, parotid mass, status post resection and neck dissection, who presents with acute shortness of breath. The patient was found by daughter earlier on the evening of admission sitting on front porch with his head slumped over. The patient was able to answer questions but was lethargic. Per daughter, the patient has been complaining of increasing shortness of breath times two weeks prior to admission and also productive cough. EMS was called, and the patient was brought to the Emergency Department for further evaluation. EMS gave the patient nebulizers and placed on high flow oxygen. Oxygen saturation was 90 to 94%. The Emergency Department immediately placed the patient on CPAP for "hypoxemia" without arterial blood gases. The patient was given Levofloxacin 500 mg intravenous times one in the Emergency Department. MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease on home oxygen at five liters nasal cannula. 2. Meningitis. 3. History of esophageal carcinoma, status post resection in [**2150**]. 4. Status post right parotidectomy. 5. Status post right radical neck dissection with cervical advancement flap in [**10-25**]. MEDICATION ON ADMISSION: 1. Colace. 2. Remeron. 3. Nicoderm. 4. Prednisone 20 mg p.o. q.d. 5. Lasix 20 mg p.o. q.d. 6. Albuterol. 7. Atrovent. 8. Flovent. 9. Tremerase 25 mg. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Brother who died of liver or pancreatic cancer. Father died of "old age". SOCIAL HISTORY: The patient is widowed and lives alone in [**Location (un) 86**]. Positive tobacco, three packs per day, and positive ETOH, quit in [**2144**].

CHIEF COMPLAINT: Pleuritic chest pain PRESENT ILLNESS: 85M with a PMh s/f severe COPD on chronic O2, complete heart block s/p PMP [**7-21**], PVD s/p bilateral carotid endarterectomies in [**2111**], HTN, HLD presents to presented to [**Hospital3 7569**] w/chief complaint of chest pain and shortness of breath since the AM. He had a recent hospitalization for MI and PNA, and had completed a 2 week course of PNA on Sunday. At home, he denied any F, C, N/V, but endorsed pleureitic L sided chest pain and shortness of breath. . He initally was taken to [**Hospital3 **], and was given nitro gtt, briefly was on a heparin gtt, and was given Levofloxacin for a worsening LLL PNA. The plan was then to transfer to [**Hospital1 **] since this is where he receives his cardiology care, for sats 70's-80's on facemask prior to switching to nrb, then improved to low 90s for a cards evalulation. While he was in the ambulance, radiology at [**Location (un) **] stat notified our ED of a finding of a 30% left PTX. The ambulance was thus directed to the nearest hospital, which turned out to be [**Hospital1 **]. At [**Hospital1 **], his left PTX was relieved with a Heimlich valve device, which on our repeat CXR shows resolution. The patient then reported improved SOB, but still some mild L CP with inspiration. . In the ED, initial VS were: 99.0 110 170/91 20 98% cont neb . Labs were notable for HCT 36.2, INR 1.4. . He was given Aspirin 325mg, and 4 mg Morphine Sulfate. . CXR was notable for interval resolution of the PTX. . On arrival to the MICU, he is AAOx3, surrounded by his family, and comfortable. His family says that he had a slightly worse cough,a lthough he has a chronic cough at baseline, although he denies his cough is any worse. MEDICAL HISTORY: Severe COPD on chronic oxygen treatment Complete heart block, status post pacemaker implantation in [**7-/2116**], peripheral vascular disease, status post bilateral carotid endarterectomies in [**2111**]. Hyperlipidemia HTN MEDICATION ON ADMISSION: Oxygen 3-liters/hr aspirin 81 mg Daily Alphagan 0.15% Eye dropps 1 [**Hospital1 **] Plavix 75 mg Daily Advair 250-50 1 inh [**Hospital1 **] Lasix 20 mg QAM Lasix 10 mg QPM Prinivil 10 mg Daily Multivitamin 1 capsule Mirapex 0.5 mg QHS Zocor 10 mg Daily Atenolol 50 mg PO/NG DAILY Tiotropium Bromide 1 CAP IH DAILY Terazosin 2.5 mg PO DAILY ALLERGIES: Penicillins PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: Vitals: T:afebrile BP:142/63 P:90 R:20 O2:96% 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition, R eye corneal scar, L lower eye lid scar from prior surgery Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema GU:foley in place . DISCHARGE PHYSICAL EXAM Vitals: T:96.2 BP:90s-110s/40s-60s P:70s-80s R:18 O2:95% 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition, R eye corneal scar, L lower eye lid scar from prior surgery Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema GU:foley in place FAMILY HISTORY: Mother and father passed from CAD. SOCIAL HISTORY: He is married. His wife lives at home. He has a former 40 pack-year history of smoking; he has not smoked for 19 years. He has rare alcohol intake.

CHIEF COMPLAINT: Generalized malaise, increased fatigue, adn chest discomfort on [**3-12**]. On [**3-16**] severe chest pain prompting presentation to ED. PRESENT ILLNESS: Mr. [**Known lastname 11270**] is a 52 yo male patinet s/p AVR on [**2119-2-20**] with Dr. [**Last Name (STitle) **]. He was discharged home on [**2119-3-1**] after a post-op course complicated by atrial fibrillation. He notes that at hoemon [**3-12**] he noticed increased fatigue, maliase, and sternal pain. On [**3-16**] he awoke with extreme chest pain and was brought to an OSH via ambulance. Workup for PE via chest CT was negative but revealed mediastinal fibrosis and left pleural effusion. Later that day he began draining large amounts of purulent drainage from his sternal icision. He was startedon vancomycin and was transferred to the [**Hospital1 18**] for further management and treatment. MEDICAL HISTORY: aortic stenosis Type 2 DM HTN s/p L fem bypass [**2095**] s/p MVA with multiple orthopedic injuries nephrolitihiasis Hyperlipidimia MEDICATION ON ADMISSION: Serax. Vicodin Vancomycin 1 gram IV BID. Ceftazidine 1 gm IV q8h. Glipizide 5 daily. Colace 100 [**Hospital1 **]. Crestor 10 daily. Lopressor 25 [**Hospital1 **]. ALLERGIES: Zestril PHYSICAL EXAM: On presentation: General: male patient in siginificant pain. Neuro: Grossly intact. Pulm: CTAB. Decreased bilateral bases with left greater tahn right. CV: RRR. Abd: soft, non-tender. Extremities: warm. Sternal incision: reddened areas at upper aspect. Small open area draining copious amounts of purulent drainage. FAMILY HISTORY: SOCIAL HISTORY: ETOH: socially. Tob: quit 4 years ago.

CHIEF COMPLAINT: SOB, nausea, diarrhea PRESENT ILLNESS: 46M h/o CAD s/p CABG [**2127**] (LIMA->LAD; SVG->D1,OM1), HTN, DM2, hyperlipidemia, CRI, obesity presents with progressive weakness, nausea, SOB, diaphoresis, non-bloody diarrhea, and lightheadedness x 24 hours. Denies CP, vomiting, fevers, or chills. Endorses cough. No sick contacts. [**Name (NI) 25122**] all meds. . In the ED, vitals were T 97.0, HR 40, BP 125/50, RR 21, SaO2 100%, and FSBG 350. ECG revealed ventricular escape rhythm with new wide QRS and peaked T-waves. K+ 5.9, AG 14, lactate 7, Cre 2.1 (baseline 1.7), and WBC 17. Given 8U insulin sc, 2.5L NS, and 1mg IV glucagon given concern for BB toxicity. Intubated and sent to cath lab for emergent placement of temp pacer wire where he was started on dopamine gtt for bradycardia and given calcium, bicarb, insulin for hyperkalemia and presumed DKA. Temp wire set at 80bpm. Transferred to CCU for further management. MEDICAL HISTORY: CAD s/p CABG [**2127**] (LIMA->LAD; SVG->D1,OM1) DM2 with gastroparesis HTN Hyperlipidemia CRI (baselin Cre 1.7; renal bx [**2138**] c/w diabetic etiology) BPPV OSA on BiPAP Obesity MEDICATION ON ADMISSION: Aspirin Plavix 75mg qd Lisinopril 30mg [**Hospital1 **] Atenolol 50mg qd Verapamil SR 240mg [**Hospital1 **] HCTZ 25mg qMWF Metformin 1g [**Hospital1 **] Glyburide 5mg [**Hospital1 **] Meclizine 12.5mg q8h Protonix 40mg qd Cozaar 25mg qD Crestor 20mg qD Clonidine 0.1mg qD ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T 95.2 HR 64 BP 120/49 RR 19 SaO2 100% on AC/600/12/5/100% General: Intubated, NAD HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink Neck: supple, trachea midline, +ET tube, right IJ temp wire Cardiac: RRR, s1s2 normal, no m/r/g, unable to assess JVD Pulmonary: coarse BS b/l Abdomen: +BS, soft, nontender, obese Extremities: warm, 1+ DP/PT pulses, 1+ bilateral ankle edema Neuro: Intubated and sedated, follows commands appropriately, moves all extremities FAMILY HISTORY: mother with CAD s/p CABG at age 70, mother with DM, no cancer, no strokes SOCIAL HISTORY: Lives at home with wife. [**Name (NI) 1403**] in office. No tobacco, no EtOH.

CHIEF COMPLAINT: cardiac arrest PRESENT ILLNESS: 47 year old male who complains of CARDIAC ARREST. 47-year-old man transferred from outside hospital per a friend he is only a history of hypertension and was normal all weekend. Today while riding a bike race he had a witnessed collapse. Bystander CPR was in nearly started and within 5 minutes a basic life support team arrived and placed in the AED was recommended a shock. After one shock it return spontaneous circulation. At the outside hospital he was hypertensive and withdrawn only to painful stimuli. An EKG showed Q waves inferiorly and anteriorly. A CT head neck and abdomen was negative. A chest CT was not performed. MEDICAL HISTORY: Hypertension MEDICATION ON ADMISSION: Lisinopril 40 mg daily Atenolol 50mg daily ALLERGIES: Zosyn / Seroquel PHYSICAL EXAM: VS: T (on Arctic Sun) 91.2 (Bladder), 92.1 (Rectal) BP=157/109 HR=56 RR=16 O2 sat=100% on CMV/Assist GENERAL: Intubated and sedated. HEENT: NCAT. Sclera anicteric. ET tube in place. Pupils 2mm and sluggish bilaterally. NECK: In cervical collar. CARDIAC: RR, normal S1, S2. No m/r/g appreciated, though difficult exam on this patient who is intubated. LUNGS: Occasional inspiratory wheeze. ABDOMEN: Soft, nondistended, +BS. EXTREMITIES: No c/c/e. Cool to the touch. NEURO: Not assessed in sedated and paralyzed patient other than pupils as above. FAMILY HISTORY: non contributory SOCIAL HISTORY: Mr. [**Known lastname 9579**] is divorced with two children Per friends he does not smoke, use drugs, or drink alcohol.

CHIEF COMPLAINT: chest pain PRESENT ILLNESS: 76 yo female who underwent a cardiac catheterization in [**Month (only) 404**] [**2114**] (atherectomy and cypher stent to proximal LAD). She was discharged on aspirin and plavix. However the patient has refractory anemia with excess blasts in transformation to acute myelogenous leukemia (last chemotherapy was last week, diagnosed in [**Month (only) 596**]), PLT 31, and plavix and aspirin was stopped under the direction of her oncologist and cardiologist. Yesterday patient presented to [**Hospital1 1806**] ER with c/o CP at rest,radiating to her right shoulder and in to her back, worsening throughout the day. EKG showed inferior lead ischemia, Trop peaked at 3.58. Has been having intermittent chest pain since this AM, [**9-3**] in intensity, was given 2 slnitro's, 1mg Morphine x's 2, dilaudid w/relief of the pain. This AM EKG showed ST elevation in inferior leads. . On route to [**Hospital1 18**], the patient was experiencing nausea and vomiting. On arrival to the floor, EKG showed juncional rhythm at 50, with 1-3mm ST elevation in II, III, avF with reciprocal changes in anterior leads. No aspirin or heparin given due to pt's low platelets. She was given morphine with some relief of pain. After speaking to pt's oncologist, Dr. [**Name (NI) **], pt was given baby aspirin. Overnight, the patient's creatinine bumped to 3.1 from 1 and she was oliguric. She was transferred to the CCU for a temporary pacer as it was thought that increasing her heart rate and subsequently her cardiac output, she would have greater perfusion to her kidneys and increased UOP. Before placing the pacer, she was tried on Dopamine which did result in a higher HR and increased UOP but caused 10/10 chest pain. Once in the CCU and assessed by EP, it was decided that she would not have a pacer placed at that time. MEDICAL HISTORY: 1. HTN 2. Hypercholesterolemia 3. Left total hip replacement 4. Left Nephrectomy [**12-27**] kidney stones 20 years ago 5. Partial hysterectomy. 6. Renital disease (detached retina which led to workup of blood problems) 7. MDS with blasts in transformation to AML 8. CAD: [**2114-12-5**]: ROTA and Cypher stent to pLAD 9. s/p hysterectomy MEDICATION ON ADMISSION: Meds at home: Lopressor 100mg Daily Danazol 50mg QID Predisone 5mg daily . Meds on transfer: Lopressor 100mg [**Hospital1 **], Prednisone 5mg daily, Lisinopril 5mg daily, Zocor 40mg daily, Nitro paste [**11-26**]" ALLERGIES: Sulfa (Sulfonamides) / Shellfish PHYSICAL EXAM: VS: BP 100/50 HR 50 RR 16 98% 2L Gen: having chest pain, resting in bed, partly relieved by morphine HEENT: R pupil minimally reactive, L pupil reacts. OP clear Neck: + JVD, no LAD Lungs: CLAB Heart: bradycardic, S1S2, no murmur, rub, gallop Abd: +BS, soft, ND/NT Extrem: no edema FAMILY HISTORY: CAD: brother died of MI in 60's, sister died 59y/o heart dz, son MI at 49y/o. sister with [**Name2 (NI) 500**] CA M died of uterine CA F died of stroke, +HTN. SOCIAL HISTORY: She is a widow and lives alone in [**Hospital1 1806**], Mass. She does have a 20 pack-year smoking history but quit 7 years ago. She denies alcohol use. She has two children.

CHIEF COMPLAINT: Acute myocardial infarction. PRESENT ILLNESS: The patient is a 36-year-old man who has had on and off left arm discomfort for the past month which he has treated with NSAIDs. Today, while the patient was driving, he noted the onset of chest pain. Initially it was [**3-23**] and then escalated to [**8-23**]. At that point, the patient pulled over to the side of the road and called EMS on his cell phone. When EMS arrived, they transported him to [**Hospital3 417**] Hospital where he had a V-fib arrest in the Emergency Department. He was given atropine, amiodarone and defibrillated, and shocked back into normal sinus rhythm. An EKG done after the arrest demonstrated sinus tach with anterior ST elevations. At that point, he was started on heparin, given morphine, and intubated and transferred to [**Hospital1 **] Hospital for emergent cardiac catheterization. Cardiac catheterization revealed pulmonary artery pressures of 49/29, with a mean of 37, a wedge of 41, a cardiac output 4.3, and a Fick calculated cardiac output of 2.3. Angiography revealed a 90% proximal LAD lesion and discrete 90% OM1 lesion. The LAD lesion had evidence of clot. While undergoing the cardiac catheterization, the patient again went into ventricular fibrillation and was defibrillated. The patient was given another bolus of amiodarone, and a balloon pump was placed. The patient was transferred to the CCU. MEDICAL HISTORY: 1. High cholesterol. 2. Hypertension. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: No history of early CAD. SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] is a truck driver. He has three children.

CHIEF COMPLAINT: Hypertension. PRESENT ILLNESS: This is a 68-year-old woman with history of diabetes type II, with end-stage renal disease, malignant hypertension, CAD, CHF, CVA, admitted on [**5-2**], with worsening dyspnea on exertion even at dialysis, improved with increased ultrafiltration at dialysis. Stress MIBI showed new reversible inferior wall defect with decision made not to re-catheterization. The patient now presents with increased shortness of breath x1 day even at rest, worsening with orthopnea, also complaints of right-sided chest pain, 5- [**8-8**], different from her myocardial ischemic pain, which is left-sided at baseline, no anginal symptoms, able to walk 2 blocks before getting short of breath, baseline blood pressure runs at 170/100, prior to dialysis and 150/80 to 90, postdialysis. No change in blood pressure medications recently. Taking of about 3 liters of hemodialysis per session recently. The patient denies missing any doses of her blood pressure medications. No headache, visual change, dry cough for a day, no fever, positive chronic diarrhea, and no lower extremity edema. In the ED, her vitals were temperature of 98.3 degrees, pulse of 92, blood pressure of 248/118, 80% on room air and 95% on 2 liters. Labs were unremarkable. Initially, received Norvasc dose, aspirin, nitroglycerin x3, Lopressor IV x3 5 mg doses and 50 mg p.o., once, Diovan 160 mg. Blood pressure still 228/112, saturations improved to 99% on 2 liters. She was started on nitroglycerin drip more than 200 mcg per minute, got at least 40 and 80 IV, little to no output. Her chest x-ray with volume overload. Afterwards, blood pressure still elevated, improved to 180/90, around her baseline after hydralazine 10 mg IV once, received 0.5 mg morphine. Chest pain improved to [**2178-1-31**], brought to the MICU for emergent dialysis. In the MICU, the patient was ultrafiltrated with 3 liters, blood pressure 120-150/70-90. Chest pain briskly resolved still on max nitroglycerin drip. MEDICAL HISTORY: Diabetes type II, diet-controlled, end- stage renal disease on dialysis q. [**Month/Day/Year 766**], Wednesday, [**Month/Day/Year 2974**], CHF, EF of 40% in [**8-1**], CAD, 2-vessel disease, RCA, and LAD, [**2171-6-5**], catheterization unchanged, history of DVT, history of CVA and TIA, increased homocystine, cervical spondyloarthropathy, status post C4 and C7 fusion, refractory hypertension requiring hemodialysis, macrocytic anemia. Admission chest x-ray showed CHF, cannot rule out pneumonia. EKG normal sinus at 90 beats per minute, normal axis intervals, possible LVH, [**Street Address(2) 4793**] depressions in V5-V6, consistent with LV strain. Stress test from [**5-3**], with 8 minutes on [**Doctor Last Name 4001**] protocol without chest discomfort. This study demonstrated what appears to be a new reversible defect inferior wall perfusion defect. Her echocardiogram from [**8-1**], showed EF of 40-50%, catheterization from [**8-1**], EF of 40%, 2-vessel disease as described above, LAD 50% occluded, RCA totally occluded, unchanged from [**12/2158**]. MEDICATION ON ADMISSION: 1. B complex. 2. Vitamin C. 3. Folate. 4. Atropine 2.5 and 0.25 mg 1 tablet b.i.d. p.r.n. 5. Vioxx 12.5 mg q.d. 6. Dipyridamole. 7. Aspirin 325 mg 1 capsule b.i.d. 8. Valsartan 160 mg p.o. b.i.d. 9. Atorvastatin 40 mg p.o. q.d. 10. Amlodipine 10 mg p.o. q.d. 11. Sertraline 50 mg p.o. q.d. 12. Metoprolol 75 mg p.o. q.i.d. 13. Isosorbide dinitrate 10 mg b.i.d. 14. Sevelamer 800 mg, three tablets b.i.d. 15. Plavix 75 mg p.o. q.d. 16. Terazosin 1 mg p.o. q.h.s. 17. Nephrocaps. ALLERGIES: ACE INHIBITOR REACTION CAUSE COUGH. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: Widow, retired English professor, lives with her son and daughter, denies any drinking, drugs, or tobacco. Ambulates with a cane.

CHIEF COMPLAINT: Headache, left sided numbness and left sided vision loss PRESENT ILLNESS: Neurology at bedside for evaluation after code stroke activation within: 1 minutes Time (and date) the patient was last known well: 15:15 (24h clock) NIH Stroke Scale Score: 7 t-[**MD Number(3) 6360**]: Yes Time t-PA was given bolus;19:26 and infusion;19:27(24h clock) I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. NIH Stroke Scale score was 7: 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 2 4. Facial palsy: 1 5a. Motor arm, left: 1 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 1 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 2 NEUROLOGY RESIDENT CONSULT NOTE MEDICAL HISTORY: HTN, aneurysm in [**2107**] s/p cliping MEDICATION ON ADMISSION: Cozaar 50mg [**Hospital1 **] ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Physical Exam: Vitals 97.3, pulse 98, resp 18, bp 191/87, o2 sat of 98% : General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities:warm and well perfused Skin: no rashes or lesions noted. . Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Inattentive requring frequent redirection. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. had no anomia if object placed in right visual field. Able to read right half of sentenses without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. +neglect to the left hemispace. FAMILY HISTORY: no family history of strokes or aneurysms SOCIAL HISTORY: lives alone, no children, smoke [**1-7**] pack per day, drinks socially, no illict drug use.

CHIEF COMPLAINT: LAD Perforation PRESENT ILLNESS: 73 yr old male w/ COPD, HTN, Hypercholesterolemia, h/o silent [**Hospital **] transferred from [**Hospital1 **] after LAD perforation. The patient had one month of intermittent left sided chest pain, right arm pain and SOB. He underwent a persantine thallium stress test that was abnormal showing large anteroseptal, apical, and inferoseptal, inferoapical and anteroapical partially reversible defects (EF 45%). He was scheduled for outpatient cath at [**Hospital1 **] on [**1-11**] (Wednesday), but presented Monday ([**1-9**]) with chest pain to the [**Hospital1 **] ED. He did not have any acute ECG changes and CE were negative x1. The patient underwent cath today that showed 100% occulsion of the LAD. He received 325mg ASA, 600mg plavix in the cath lab. A stent was deployed and resulted in perforation of the mid LAD. The stent balloon was inflated in LAD and was transferred for coated stent placment. The bivalirudin was turned off after his perforation. He remained hemodynamically stable with BP 160/70, sinus 70s, sat 92-96% 2L NC. . On arrive here to the cath lab the balloon was deflated. There was severe dissection of mid LAD after the first diag and just proximal to mid LAD stent with reduced flow in the mid LAD stent and a possible dissection distal to the stent edge with a significant step down from the LAD stent into the LAD with reduced outflow. There was no evidence of continued perforation. During the case the LAD stent thrombosed, but chest pain improved. The distal LAD filled with collaterals. There was also a small pericardial effusion seen and ECHO was performed that did not show RV collapse. A pericardiocentesis was attempted, but no fluid was able to be drained. The LAD remained completely occluded and it was decided to manage him medical overnight. . On arrive the patient had complaints of sharp pain across his chest that was not similar to his anginal pain. He rated the pain [**2169-3-15**]. He otherwise had no other complaints. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: MEDICATION ON ADMISSION: Spiriva 18mcg one daily Clonazapam 1mg hs Lisinopril 5mg daily Theophylline 200mg ER one tab [**Hospital1 **] Nexium 40mg daily Crestor 10mg daily percocet prn Combivent nebs q 4 hours during day Symbicort 4.5 mg 2 puffs in am. Performist inhaler 160/4.5 neb at hs Aspirin 81 mg daily ALLERGIES: Penicillins / Bactrim / Codeine / Prednisone / Lipitor / Vytorin / Tricor PHYSICAL EXAM: T 35.4 ??????C (95.8 ??????F) HR: 75 (67 - 75) bpm BP: 144/79(105) {122/67(88) - 144/79(105)} mmHg RR: 19 (14 - 19) insp/min SpO2: 95% 4L NC Heart rhythm: SR (Sinus Rhythm) FAMILY HISTORY: Mother with MI at 86 SOCIAL HISTORY: Retired, lives with his wife. Worked in construction -Tobacco history: quit 30 yrs ago, [**2-12**] ppd x20yrs -ETOH: occasional -Illicit drugs: denied

CHIEF COMPLAINT: elective admission for surgery PRESENT ILLNESS: The patient is 58-year-old female who was recently referred to me from her oncologist. The patient has developed a large high frontal skull metastasis that is progressively growing on sequential scans despite systemic therapy. The lesion has completely eroded the inner and outer table of the skull and is penetrating through the dural compressing the right frontal lobe. The patient is in need of surgical decompression and subsequent repair of the skull defect to adequately treat this lesion prior to further systemic/radiation treatment. The patient was extensively counseled. The patient was taken electively to the OR. Informed consent was obtained. MEDICAL HISTORY: Breast CA treated in [**Country 651**] s/p R radical mastectomy Axillary lymph node dissection/chemo/radiation therapy Bone & liver mets [**12-27**] T8 transthoracic vertebrectomy & T7-T9 fusion, T7-T9 cage insertion, Pyramesh, ant. instrumentation, Kaneda, rib autograft TAH and bilateral salpingo-oophorectomy, appendectomy MEDICATION ON ADMISSION: tylenol, dilaudid ALLERGIES: Ativan / Oxycodone PHYSICAL EXAM: A & O x3, mae to command, PERRL 2.5-2mm, tongue deviates slightly to right, no drift, + right droop, + nausea/headache. Incision clean, dry, and intact. FAMILY HISTORY: non-contributory SOCIAL HISTORY: lives with husband; originally from [**Country 651**] but speaks some English

CHIEF COMPLAINT: Palpitations PRESENT ILLNESS: 44 yo male with history of HTN presented to his PCP today complaining of weakness, intermittent fatigue, and occassional cough for one week. Over the past 2 days, he has had trouble lying flat and has slept sitting in a chair. He reports palpitations; feels like his heart is "beating like racehorse," but denies dizziness, or lightheadedness. Reports that palpitations will last for few seconds and then self resolve. He denies CP, but reports orthopnea. Also reports worsening dyspnea on exertion. In the past was able to walk long distances without any SOB, but in the last few days the patient reports that he has not been able walk more than ten minutes for the last two days without stopping [**1-23**] shortness of breath. The patient denies ever having shortness of breath. Of note, the patient also reports developing a dry cough, mostly during the day. Started this past Wednesday. Denies any recent fevers/chills, no sick contacts. . Of note, he has not been taking lisinopril and HCTZ for past 6 months, as he reports not knowing he needed to continue these. He reports occaisional NSAID/ibuprofen use for headache. Reports that [**Last Name (un) **] has been his "second home." . Patient was first noted to have hypertension in [**2150**], initially started on HCTZ 25 mg daily, and then lisinopril 10 mg added on. The patient has not been compliant with his medications; also has had dietary indiscretions, even after being counseled about the importance of low salt diet and exercise. . At [**Company 191**], he was found to have a HR in 150-160's with a narrow complex SVT seen on EKG. Vagal maneuvers were attempted but were unsuccessful. BP at the time was 150/100. He was sent to the ED for further evaluation of his tachycardia. . Upon arrival to the ED, initial vitals were 98.0 120 170/160-200/130 18 100% on unclear amt of oxygen. Exam revealed markedly elevated JVP, diffuse crackles, abdominal distension, and [**12-23**]+ pitting edema. EKG revealed a narrow compelx tachycardia. At 4pm, 12mg of adenosine was given through a small right hand PIV, with conversion to sinus tachycardia at 140. IVF were started for tachycardia with total 1.5L given. At 6pm, he was still tachy to the 180's with another dose of adenosine 12mg given. He reverted to sinus brady at 50-60 for 10 seconds, then went back into sinus tachycardia. CXR was obtained and revealed volume overload so IVF were stopped. Bedside TTE revealed no effusion. EP was consulted and felt this was likely acute heart failure [**1-23**] hypertension and SVT [**1-23**] atrial stretch. They recommended lasix 20mg x2, nitro gtt, and bipap for recruitment. RT started CPAP instead. Vitals prior to transfer: 139 142/102, 20, 100% on CPAP. . On review of systems, denies any abdominal pain, n/v/d, changes in BM, denies any urinary sx, no blood in stool. 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: ** Patient states that he had not been taking for at least 6 months prior to admission. ** 1. Lisinopril 10 mg PO daily 2. Hydrochlorothiazide 25 mg PO daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission PE: . GENERAL: NAD. Oriented x3, tachypneic on NC, slightly flushed HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: DM, denies any cardiovascular disease, no h/o MIs. SOCIAL HISTORY: Denies tobacco, EtOH, illicits, not currently sexually active.

CHIEF COMPLAINT: Tachycardia PRESENT ILLNESS: The patient is a 47 yo man with h/o epilepsy s/p vagal nerve stimulator, AFib, recent diagnosis of stage IV lung CA and PE on Lovenox and Coumadin, and a recent pericardial effusion who presents with one-week of worsening SOB, chest pain, and abdominal pain. The patient was initially brought in by EMS after being noted to be tachycardic to the 130's. He took 30mg Diltiazem PO and was transferred to the BIED. In the ED, he received Diltiazem 25 mg IV and 60 mg PO, and his HR remained in the 180s. Bedside TTE demonstrated a moderate pericardial effusion without evidence of tamponade and pulsus was difficult to obtain secondary to tachycardia. CXR demonstrated a right-sided pleural effusion. . Cards recomended amiodarone drip, with up escalation to dilt as needed. He also received 5 L of NS. He was admitted to the MICU for further management. His VS at the time of transfer were P 184, BP 98/83, 27, 98% on 3L. . On HD 1 the patient was taken for a pericardial window by csurg, in which they removed 200cc of pericardial fluid and 1400cc of fluid from his left lung. He returned intubated from the pericardial window. Amio was stopped and metoprolol was uptitrated. The patient d/c'd his own chest tube. Several times the patient was agitated, requiring zydus 5 mg and haldol. . On HD 3 the decision was made to focus on comfort only. MEDICAL HISTORY: - epilepsy and nonelectrographic seizures (petite mal with rare secondary generalization) - s/p right temporal lobectomy - s/p VNS placement - Mood disorder and likely borderline personality organization - Multiple suicide attempts in past (largely overdose) - DM due to medication, now apparently resolved - cervical strain - Rosacea - [**Last Name (un) 865**] esophagus - Polysubstance abuse: EtOH, MJ, cocaine/crack binges with resultant unsafe sexual practices - h/o atrial fibrillation (not on medication) MEDICATION ON ADMISSION: Lovenox 100 mg/mL SQ [**Hospital1 **] Oxcarbazepine 600 mg PO BID Clonazepam 1 mg PO qid Omeprazole 20 mg PO daily Warfarin 5 mg PO daily Diltiazem HCl 120 mg PO daily Divalproex 1250/1500/1500 mg daily Nicotine 14 mg/24 hr patch daily Metoprolol Succinate 200 mg PO daily ASA 81 mg daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission Physical Exam Vitals: BP: 115/73 P: 150's R: 20 O2:86% General: Unresponsive HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse expiratory wheezes, R sided crackles CV: distant heart sounds. pulsus of 16 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly FAMILY HISTORY: States has FH of diabetes and 'cancer in everyone' but no FH of CAD, HTN, sudden death or cardiac dysrhythmias SOCIAL HISTORY: Unemployed, lives alone. Smokes 1pk/day, occasional ETOH and OMR records indicate some history of Crack Cocaine use.

CHIEF COMPLAINT: Presyncopal episodes and dyspnea on exertion PRESENT ILLNESS: 80 y/o female with long h/o PSVT and AS followed by serial echo's who has been having pre-syncopal episodes along with dyspnea on exertion. Most recent echo and cath showed severe Aortic Stenosis. MEDICAL HISTORY: Aortic Stenosis, Hepatitis C, PSVT, Varicose veins s/p stripping, Macular degeneration, Osteoporosis, s/p Tonsillectomy, s/p Total abdominal hysterectomy, s/p Umbilical hernia repair and abdominoplasty, s/p Spinal fusion and laminectomy, s/p Bilateral cataract surgery MEDICATION ON ADMISSION: Atenolol 12.5mg qd, Protonix 40mg qd, Calcium 600 + D [**Hospital1 **], Selenium 200 qd, Vit B6, Vit C, Magnesium, Ocuvite, Zinc, [**Last Name (LF) 106379**], [**First Name3 (LF) **]-3 ALLERGIES: Ampicillin PHYSICAL EXAM: VS: 76 130/70 5'2" 113# Gen: NAD Skin: Ecchymosis right leg/groin HEENT: PERRLA, EOMI, OP benign Neck: Supple, FROM, -JVD Chest: CTAB -w/r/r Heart: RRR 3/6 SEM w/ radiation to carotids Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, 2+ edema Neuro: Grossly intact, MAE, right foot drop FAMILY HISTORY: Brother died of CHF at age 75. SOCIAL HISTORY: Retired lab tech. Denies tobacco use. Also denies ETOH use in 20 yrs.

CHIEF COMPLAINT: PRESENT ILLNESS: Patient is a 66 year-old gentleman who started having angina in [**2187-4-26**]. He underwent prior catheterization at the time and was found to have a mid LAD stenosis which was stented. He presented to he Emergency Room in [**2189-11-26**] and was found to have electrocardiogram changes. He again underwent cardiac catheterization and had stenting of his left main into the circumflex. Patient did well and was discharged on Plavix and Lopressor. He again underwent an elective cardiac catheterization as follow up on [**2190-5-7**]. He has had some progression of his symptoms of dyspnea. The cardiac catheterization revealed diffuse 50 percent restenosis of his LMCA. This extended into the ostial circumflex stent which showed restenosis up to 60 percent. The LAD had a 90 percent ostial stenosis. His ejection fraction preoperatively was 55 percent. Patient was referred to the cardiac surgery service. MEDICAL HISTORY: Is significant for coronary artery disease. Status post percutaneous interventions as above, hypertension, pancreatitis, hypercholesterolemia, colon surgery times two for diverticulitis and hernia repair. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: pancreatic pseudocyst PRESENT ILLNESS: Patient is a 56 year old gentleman who recently underwent an exploratory laparotomy and debriedment of abdominal wall abscess at [**Hospital3 3583**] in setting of prior subtotal gastrectomy and and partial colon resection in past. HIDA scan at [**Hospital1 3325**] was consistent with biliary leak. Patient complained of epigastric abdominal pain and was found to have pancreatits with amylase 1035, lipase 2280 and CT scan showing significant peripancreatic inflammatory changes consisitent with pancreatitis. He improved and was discharged home on [**2187-2-21**] from [**Hospital3 3583**] but returned on [**2-24**] with lower extremity edema. He was found to hava a R popliteal vein thrombosis extending to the superficial femoral vein. Repeat CT scan showed extensive perihepatic fluid collections consistent with pancreatic psuedocysts and pancreatic necrosis. Patient was subsequently transferred to the [**Hospital1 18**] for further management. MEDICAL HISTORY: Atrial fibrilation Pancreatitis DM (recent) DVT (recent) HTN bilateral CEAs MEDICATION ON ADMISSION: ALLERGIES: Heparin Agents PHYSICAL EXAM: NAD Tracheostomy capped Bibasilar crackles, good air entry abdomen soft, non-tender, healing midline open incision with overlying wound drain FAMILY HISTORY: non-contributory SOCIAL HISTORY: non-contributory

CHIEF COMPLAINT: Hepatitis C with cirrhosis here for liver transplant offer PRESENT ILLNESS: 58 year old male with history of hepatitis C and cirrhosis and hepatocellular carcinoma presents for liver transplant offer. Pt was most recently evaluated for declined liver transplant offer on [**2140-2-14**]. Since then pt noted no changes in his overall health status other than continued improvement of his bronchitis after Z pack treatment 2 weeks ago noted at his last evaluation. Also of note Earlier in an anterolateral right-sided hemi-diaphragmatic hernia was reported with herniation of the hepatic flexure, the middle colonic artery, and mesenteric fat. He has evidence of splenic and esophageal varices. On ROS he notes LE edema, nocturnal cough since his bronchitis. He has been afebrile, without chills, nausea/ vomiting diarrhea, constipation, no episodes of encephalopathy He continues on Methadone 8 years out from heroin relapse, no other drugs used recently. He walks five miles daily and can ascend 2 flights of stairs with ease. MEDICAL HISTORY: PAST MEDICAL HISTORY metabolic bone disease hepatic encephalopathy chronic hepatitis C resultant cirrhosis chronic pancreatitis. Interstitial lung disease Reflux Chronic pain BLE edema fatigue psoriasis . PAST SURGICAL/PROCEDURAL HISTORY [**2138**] RFA of liver lesion [**2132**] lung biopsy [**2131**] Extensive burns&#[**Numeric Identifier 25684**];skin graft surgeries [**2140-2-28**] liver transplant with repair of chronic diaphragmatic hernia. [**2140-3-1**] Exploratory laparotomy, repair of ventral hernia with mesh and liver biopsy. MEDICATION ON ADMISSION: Creon-10 2 cap with meals Furosemide 40 mg per day (last [**10-10**]) spironolactone 200 mg per day Lactulose 10G/15ml [**Hospital1 **] prn (last [**10-10**]) methadone85 mg once a day (took dose today) omeprazole 20 mg per day rifaximin 200 mg 3 [**Hospital1 **] magnesium oxide 400 mg b.i.d. Creon 10 249 mg 10K-37.5k unit [**Unit Number **] capsule by mouth with meals Testosterone 5mg/24hrs Caltrate 600-plus Vitamin D3 600mg 400Unit Itab [**Hospital1 **] Boniva 3mg IVevery other month (not currently taking) ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: 98.4 70 114/65 18 99 % RA General: NAD, A & O X3. HEENT: PERRLA, EOMI, mild scleral icterus, MMM Card: RRR, II/VI systolic murmur at LSB. Lungs: CTAB no w/r/r Abdomen: No scars noted, + BS, no distention or tenderness no organomegaly. Extr: 1+ bilateral lower extremity edema, 2+ DPs, warm, well perfused with significant skin scaling b/l LE from knee down. Skin: burn scars on back scars. Neuro: No Focal deficits FAMILY HISTORY: Mother, 85: No known illness Father, dead 76: Liver cancer Twin brother, dead 18: Murdered Brother, 35: No known illness Brother, 46: No known illness SOCIAL HISTORY: Patient lives alone in subsidized housing on modest social security income. He has a supportive brother [**Doctor First Name **]. He spends time at a motorcycle repair shop helping with repairs. Mother lives on [**Location (un) **]. History of IVDA and ETOH abuse. He has abstained from both for over 5 years each. + smoker (1PPD x 48 years). Daily methadone.

CHIEF COMPLAINT: Fever of unknown origin PRESENT ILLNESS: 43 year old male firefighter who was struck by an auto which left him with anoxic encephalopathy, seizure disorder, atrial fibrillation, and multiple extremity wounds. He returns from his rehab facility with fevers of unknown origin, which have persisted despite antibiotic treatment with Vancomycin, Fluconazole, and Amikacin. Cultures at the rehab facility were positive for gram negative staphylococcus bacteremia and acenitobacter in his sputum. Urine and stool cultures were negative. MEDICAL HISTORY: Polytrauma requiring multiple operative interventions Anoxic brain injury Placement of IVC filter, percutaneous gastrostomy, tracheostomy MEDICATION ON ADMISSION: 1. Keppra [**2141**] QHS, 1500 QAM 2. Folate 1g daily 3. Colace 100 [**Hospital1 **] 4. Metoprolol 50mg TID 5. Diflucan 400mg daily 6. Vancomycin 1.25g Q12h 7. Amikacin 1175mg daily 8. Dilantin 100mg QID 9. Topamax 100mg 5x daily 10. Dilaudid 4mg IV Q4hPRN 11. Sodium bicarbonate 2 tabs TID 12. Magnesium oxide 400 mg daily 13. Senna 2 tabs [**Hospital1 **] 14. Lansoprazole 30 mg [**Hospital1 **] 15. Potassium chloride 16. MVI daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: Temp 100.6, BP 145/68, HR 110, RR 16, O2 sat 100% on 10L trach mask GEN: NAD, cachectic, responsive but mildly confused Lungs: CTA B/L, mild upper airway transmission Heart: S1S2 RRR, no murmurs, gallops, or rubs. Abd: Soft, NT/ND, + Bowel sounds. Gtube in place. Back: 7x7 cm sacral decubitus ulcer with fibrinous base, nonpurulent. Ext: B/L LE with vacs intact. R arm cast. FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Firefighter Married with children

CHIEF COMPLAINT: Transfer from OSH for concerns with abdominal hematoma, pancreatitis, ARF, hypovolemic shock,and Pulmonary Edema PRESENT ILLNESS: MEDICAL HISTORY: PMH: HTN, dyslipidemia, hypothyroidism, diverticulitis, colon Ca, large ventral and parastomal hernias, chronic renal failure (baseline Cr 1.6-1.8), gout, Nephrotic Syndrome ?? . PSH: L breast Ca s/p lumpectomy '[**97**], now s/p needle guided lumpectomy and SLNBx [**3-16**]; s/p appy, s/p cholecystectomy, s/p hysterectomy, s/p tonsillectomy. s/p L colectomy for colon Ca, revision of colostomy, multiple ex laps for adhesions. MEDICATION ON ADMISSION: Meds at OSH: Amlodipine 5', Temazepam 15-30 QHS, Synthroid 50', Simethicone 80'''P, Tylenol PRN, Zofran PRN, Esomeprazole 40', Morphine PRN, Lopressor 2.5-5 PRN . ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Upon Discharge Pale, obese female in NAD, A and O VS: 97.9 82 136/62 24 96% TM Anicteric, no JVD, pale conjunctiva, EOMi RRR no m/r/g CTAB (ant) left breast well healed lumpectomy scar no sign infection abd large midline scar, massive left abdominal hernia, soft NT/ND + BS stoma is clean, protudes above skin, + gas and stool in bag, no signs infection, no parastomal hernias no c/c/e right first finger DIP swollen, blanching erythema, + TTP right metatarsal 2nd/3rd + TTP , erythema Neuro grossly intact, able to move all four extremities Psych flattened affect FAMILY HISTORY: N/C SOCIAL HISTORY: SocHx: 30 pack year history but quit 30 yrs ago; 1 drink/week, no recreational drugs. Lives at home with daughter

CHIEF COMPLAINT: Transfer from OSH for multiorgan system failure PRESENT ILLNESS: The patient is a 33 yo M with h/o asthma (no attacks since childhood) and oxycodone abuse (on methadone maintannce) transferred from an OSH for for worsening respiratory failure and multiorgan system failure. The patient presented to the OSH 2 days prior to transfer after waking up with resp distress and looking cyanotic to his girlfriend. [**Name (NI) **] was driven to the hospital and becamse unresponsive in the car. He was intubated at the OSH and had a large aspiration event at the time (received etomidate 25mg IV and succinochline 200mg IV). A central line was placed at that time and was flushed with heparin. At the OSH, vital signs on admission to the ICU were T 101.1, HR 119, BP 100/58, O2 100% on AC 600x12 PEEP 7 FIO2 100%. Given his fevers and elevated WBC count on admission (WBC = 14.9), he was started on vancomycin, imipenom, and levofloxacin to broadly cover for pneumonia. CXR revealed large left sided aspiration PNA. He continued to need increasing levels of PEEP and FIO2. . He was also found to be in acute renal failure at the time of admission with a creatinine of 1.7 with a K of 6.0. His creatinine continued to rise throughout his hospital course. He was followed by the renal service at the OSH and it was felt to be either pre-renal azotemia or ATN. . Also, of note, the patients central line was flused with heparin at the time of presentation to the OSH ED. His platelets then dropped from 190 to 67. All other heparin products were avoided. . Cardiac enzymes were also found to be positive with troponins peaking at 4.228. An ECHO was significant for an EF of 40% and hypokinetic right ventricle and septal area. Cardiology was consulted and did not think this was a primary cardiac event, but secondary to possible hypotension and pulmonary insults. . Given his continued respiratory failure and multiorgan system failure, the patient was transferred to [**Hospital1 18**] on the evening of [**2191-11-4**]. On arrival to the MICU, the patient was found to be hypoxic with O2 sats in the high 80's on AC 380 x 26 100%FIO2 and a of PEEP 18. An ABG at that time was 7.27/53/52. His O2 sat's continued to drop to the 70's. Recruitment was attempted without improvement in his oxygenation. He was tried on APRV at P-high 38, P-low 10, T-high 1.5 and T-low 0.5 FIO2 100% and continued to be hypoxic. A repeat gas was 7.19/62/46. A CXR was obtained that showed LLL collapse and left sided infiltrate. Because of concern for PE, the patient was started on argatroban. His broad spectrum antibiotics were continued and he was started on steroids for possible asthma exacerbation. He was switched to pressure controlled ventilation at pressure 42, PEEP 22, rate 36 and FIO2 100% with mild improvement in his O2 sat's to around 80. He was then tried on nitric oxide at 40ppm with dramatic improvement of O2 sat's to the high 90's. His nitric oxide was titrated down to 20ppm during the evening. Also, the patient was found to have an elevated potassium thgouth due to both his ARF and acidosis. An EKG did not show evidence of peaked t waves. The patient received kayexalte, insulin, glucose, and bicarb. . MEDICAL HISTORY: -- Respiratory Distress (not requiring intubation) and ARF (short term HD) in [**January 2191**] -- HIT + [**January 2191**] -- Oxycodone abuse; currently on methadone maintence MEDICATION ON ADMISSION: Medications: (at the time of transfer) Protonix 40mg IV daily Propofol Combivent Levaquin Primaxin Vancomycin Morphine . Home Medications: Methadone 155mg per day ALLERGIES: Heparin Agents / Codeine PHYSICAL EXAM: Vitals - T96.8 HR86 BP115/70 O285% (FIO2 100% AC) General - young man, sedated and paralyzed HEENT - PERRL Neck - supple, LIJ in place CV - RRR, no murmur appreciated Lungs - decreased breath sounds throughout L>R Abdomen - soft, NT ND Ext - no edema FAMILY HISTORY: noncontributory SOCIAL HISTORY: Per family report patient has a history of oxycodone abuse and has been on methadone maintanence for 3 years. ? of benzo abuse as well. Family reports the patient did not use IV drugs. + smoking. Lives with his girlfriend. Smokes 2ppd x years. Has 1 daugther.

CHIEF COMPLAINT: dyspnea on exertion PRESENT ILLNESS: 67 yo F with h/o aortic stenosis followed by serial echocardiograms with complaints of dyspnea on exertion and occasional dizziness. MEDICAL HISTORY: 1. aortic stenosis 2. hypertension 3. hypercholesterolemia 4. hypothyroidism 5. s/p incisional hernia repair 6. retroperitoneal mass resected in [**10-17**], found to be a 15cm cystic mass most consistent with paraganglioma on pathology 7. obesity 8. osteoarthritis 9. osteoporosis MEDICATION ON ADMISSION: Alendronate 70 mg Tablet once weekly (Not Taking as Prescribed: patient not able to take a full glass of water so has not taken the med for 3 months ) Atorvastatin [Lipitor] 40 mg daily Cyanocobalamin 1,000 mcg/mL Solution IM injection once a month Levothyroxine [Levoxyl] 100 mcg daily Lisinopril 20 mg Tablet TID Calcium Citrate-Vitamin D3 [Calcium Citrate + D] 315 mg-200 unit Tablet 2 Tablet(s) by mouth twice a day ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Physical Exam FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Lives with husband. Denies tobacco, alcohol, or IVDU.

CHIEF COMPLAINT: GI Bleed PRESENT ILLNESS: 50 y.o. female presenting with weakness for 3 days. 3 days ago had episode nausea followed closely by "bright red" emesis, but she did not think this was blood. Since then, has been having black stool and diarrhea and feeling progressively weak and nauseated. This morning she gagged on her toothbrush and had another episode of emesis that had blood specks in it so she came to the ED. Denies any NSAID use, no history of GI bleed or ulcer, no ETOH, no recent abdominal pain, nausea or retching. . She was managed medically for UGIbleed and underwent an EGD in the ICU. EGD revealed On arrival to the ICU, patient reports feeling more SOB and having a lot of discomfort with the NG tube. She denies abdominal pain, nausea or more emesis or diarrhea. She has had no new medications recently. . MEDICAL HISTORY: eczematous dermatitis (previously thought to be psoriasis, but biopsy on [**1-17**] showed subacute eczematous dermatitis) Heart Murmur MEDICATION ON ADMISSION: clobetasol cream ALLERGIES: Latex PHYSICAL EXAM: Vitals: T: BP: 145/90 P:121-105 R:26 18 O2:100% on RA General: Alert, oriented, appears uncomfortable HEENT: Sclera anicteric, NG tube in place Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachy, regular and rhythm, 2/6 systolic murmur Abdomen: soft, non-tender, non-distended, bowel sounds hyperactive, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Mild scaling over left elbow. FAMILY HISTORY: father with PUD, brother with GERD SOCIAL HISTORY: Divorced, works as an office professional. - Tobacco: 30pack year history - Alcohol:denies - Illicits:denies

CHIEF COMPLAINT: pericardial effusion, chest pain PRESENT ILLNESS: Mr. [**Known lastname 6515**] is a 37yo male with PMH s/f recent porcine AVR for congenital bicuspid valve who is now being tranferred from and OSH ED for evaluation for pericardial tamponade. Patient reports having had a congenital bicuspid aortic valve repaired on [**2197-11-21**]. There were no immediate complications of the surgery although patient was noted to have two small PE's around time of the surgery. Following the procedure he was maintained on coumadin and aspirin with a goal INR of 2.5-3.5 (despite aortic porcine valve). Patient had been in good health, although tending to run high by INR since the surgery until this weekend when he developed bilateral shoulder pain. He describes the pain as very similar to a muscle aches, and that it radiates down into his chest. Occasionally has radiated to the back as well. Is pleuritic, but not exertional. This morning patient noted marked exertional dyspnea with an exercise limitation of 20-30 yards which prompted him to present to the [**Hospital1 2436**] ED. Patient initially seen at [**Hospital3 2783**] where VS were T98, Bp 100/77, HR 136, RR 24, O2 sat 99%RA. Labs notable for anemia, and INR 6.8. Bedside USD at that time showed no RV collapse and ECG interpreted as nml (although shows electrical alternans). CT chest showed no dissection but large pericardial effusion. Impression was for pericarditis. Patient was given IVF bolus to prevent progression to tamponade and transferred to [**Hospital1 18**] for further evaluation MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (+)Hypertension 2. CARDIAC HISTORY: -Bicuspid Aortic Valve Repair [**11/2197**] -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: None. -PACING/ICD: None. Additional PMH -Pulmonary Emboli x 2 at time of surgery MEDICATION ON ADMISSION: Metoprolol XL 50mg daily Aspirin 81mg daily Coumadin 5mg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T97.8, 134/83, HR 103, 20, 100%2L, Pulsus 16-18mmHg GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: Father with CABG in his late 50's Paternal GF and PGM w/ CABG in 60's. Mother died last month of breast cancer. No h/o valvular disease. 3 healthy brothers SOCIAL HISTORY: Moved from [**State 33977**] to [**Location (un) 86**] 1 year ago for work, he works for Cintas uniform company. -Tobacco history: chews 2 pack per day equivalent -ETOH: social -Illicit drugs: denies

CHIEF COMPLAINT: Failure to thrive PRESENT ILLNESS: 78 yo F w/ hx of depression, with worsening sx. not eating, not walking. in bed most of day xweeks. She reports that this bout of depression began 3-4 years ago. Could not specify a specific trigger. "Its hard not to be depressed." + deconditioning. Passive SI, no active HI. In the ED her VS on presentation were: 98.4, 84, 198/83, 98% on RA. Her blood pressure then rose to 224/63 in the ED. She received lopressor 5 mg IV x2, 10 mg IV x 1, 1 mg ativan, 10 mg hydralazine IV and 400 mg IV cipro. FS = 141 on presentation. She was also given 1L NS MEDICAL HISTORY: Chronic depression- Long hx of depression, with her first hospitalization when she was around 25 yo. The patient has had [**1-1**] hospitalizations after that (unsure exactly how many). She denied any suicide attempts in the past. She currently has a psychiatrist Dr. [**Last Name (STitle) 48416**] ([**Telephone/Fax (1) 48417**]. No therapist.The patient has had ECT treatments for her depression in the past that had been successfull DM HTN Likely CAD Vitamin B12 def-dx this admission Anemia MEDICATION ON ADMISSION: Risperdal 1 mg qhs Atorvastatin 10 mg qd Calcium + D 1250/200 [**Month/Year (2) **] 81 mg Lisinopril 5 mg qd Vitamin D 400 IU qd Glipizide 10 mg qd Metformin 500 mg qd Toprol 200 mg qd Effexor 150 mg qd ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: on discharge Vitals: 98.5 132/60 84 18 99%RA Access: PIV Gen: nad, thin female lying in bed HEENT: mm dry, missing teeth CV: RRR, no m Resp: CTAB, no crackles or wheezing Chest: ecchymosis over right anterior chest and breast, mild tenderness over swelling of soft tissue Abd; soft, nontender, +BS Ext; no edema psych: flat affect FAMILY HISTORY: Father with depression. SOCIAL HISTORY: Pt born and raised in [**State 350**]. She describes childhood as good. She attended school until the 10th grade and worked as a [**Last Name (un) 19441**] after that. She never married and has no children. She is currently living in a house with her sister (who is also demented per Dr. [**Last Name (STitle) 48416**] and her nephew. She collects SSI. ADLS: Independent of ADLS when not depressed.

CHIEF COMPLAINT: fall PRESENT ILLNESS: HPI: 78yo M, with h/o Alz Dz, who presented with gait disturbance and fell x 3 this am. He also got lost in his apt building and bladder incontinence, which had not happened before. He walks leaning to the left side and decreased left arm swing. Per family, he fell 3 weeks ago. Denied headache. Patient dose not remember the falls. His CT head today showed large left acute on chronic (lobulated) SDH with 1.2 subfalcine herniation. MEDICAL HISTORY: PMHx:HTN, Alzheimer's dz, back pain. MEDICATION ON ADMISSION: All: NKDA ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAM: O: T: afebrile BP: 130/86 HR:113 R 22 Gen: Spanish spoken, entire interview is interpreted via [**Name8 (MD) **] RN [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Patient appears non-distressed. He is awake and alert, but only oriented to self (not to age, says he is 32yo now), not to year/place. He can not completely follow commands and claims he is tired. HEENT: Pupils: PERRLA EOMs full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, follow simple commands inconsistently. Orientation: Oriented to person (his name, not age), not to place, and date. Recall: [**12-27**] objects at 2 minutes. Language: Speech fluent, but sometime just repeat what was said to him. FAMILY HISTORY: noncontributory SOCIAL HISTORY: Social Hx: Lives with wife in [**Hospital3 **] home. Nonsmoker, Nondriker.

CHIEF COMPLAINT: Hepatocellular carcinoma, hepatitis C virus-related cirrhosis. PRESENT ILLNESS: 58-year-old male who presented with a history of hepatitis C first diagnosed in [**2139**]. He has a history of esophageal cancer status post esophagectomy in [**2163**]. He was noted to have a right hepatic mass on a CT scan in [**2165-4-17**]. At that time it was 0.7 cm. Initially this was thought to represent metastatic esophageal carcinoma. However, this was reevaluated on a scan on [**2165-8-9**] and the mass was now 5 cm in diameter. A biopsy was consistent with hepatocellular carcinoma. His AFP was 30. He has no evidence of recurrent esophageal cancer. MEDICAL HISTORY: - Barrett's esophagus - Esophageal carcinoma - Asthma Past Surgical History: - Bilateral hernia repair - Cholecystectomy in [**2150**] - Esophageal CA with resection in [**2163**] - Elbow surgery in [**2146**]. MEDICATION ON ADMISSION: albuterol, alprazolam 0.25 mg po qd prn, Symbicort inhaler 2 puffs [**Hospital1 **], hyoscyamine sulfate 0.375 mg po bid, Provigil 50 mg po qd prn, omeprazole/ sodium bicarbonate combined capsule 40 mg/1.1 gm po qd, oxandrolone 2.5 mg po bid, and Aciphex 20 mg po qd. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: 98.8, 85, 111/50, 14, 96%RA Gen: NAD, sleep but arousable Card: RRR Lungs: CTA bilaterally Abd: Soft, non-distended, appropriately tender, JP with serosanguinous drainage Extr: No C/C/E FAMILY HISTORY: N/C SOCIAL HISTORY: Married, remote history of IVDU and snorted cocaine. More recent use of marijuana. Multiple tattoos

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 70 year old male with end stage renal disease on hemodialysis with a question of coronary artery disease who was initially admitted to [**Hospital3 9683**] on [**2110-11-20**] with a clotted arteriovenous fistula. He was taken to the Operating Room and declotted. Subsequently he had a Quinton catheter placed and was dialyzed from [**11-21**] until [**11-24**] without any incident. On [**2110-11-24**] the patient had an episode of dyspnea with atrial fibrillation and rapid ventricular response. He subsequently developed chest pain with that arrhythmia and ruled in for troponin-positive myocardial infarction. His atrial fibrillation was resolved with Beta blocker treatment. He was then transferred to [**Hospital6 1760**] for further care and cardiac catheterization. The patient was brought to [**Hospital6 1760**] on [**2110-11-24**]. Upon presentation to [**Hospital6 256**] the patient was transferred to the Cardiac Intensive Care Service. MEDICAL HISTORY: Significant for end stage renal disease, hypertension, question of remote myocardial infarction as well as new myocardial infarction, obstructive sleep apnea. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: Negative for heart disease or cancer. SOCIAL HISTORY: Significant for cigar smoke and alcohol. He lives with his wife.

CHIEF COMPLAINT: nausea, chills PRESENT ILLNESS: [**Age over 90 **]F Russian speaking (poor historian) who went to bed at 10pm yesterday with nausea and chills. No diarrhea/vomitting. She awoke with cough, fever, and nausea was found soaked in urine and feces. Son in [**Name2 (NI) 7349**] who is HCP but the pt lives alone here but has vna 3 hrs/day. She was presumably sent to ED by her home aids where she was found to have BP in 180s-190s, VS 158/72, 65, 24, 99%3L, CXR with retrocardiac density concerning for PNA. She received [**Last Name (LF) 14990**], [**First Name3 (LF) **], BB and 750cc IVF. She had a new R bundle and TW inversions on her EKG, cards was consulted and not concerned, her 1st set CEs were negative. She was admitted to medicine for further workup. . On the floor for 3 days, the pt was treated with antibiotics but then developed AF with [**First Name3 (LF) 5509**] x2 (the first time converting back to sinus rhythm after lopressor and dilt boluses). During the second major [**First Name3 (LF) 5509**] episode the pt received dilt 10 IV x2, HR was in fib in 90-100s, BPs went from 130 to 100-110 and pt required face mask oxygenation (up from 4L NC). MICU was called given the pt's full code status and her worsening oxygen requirement. CXR at the time was at baseline, ABG showed pO2 64, CO2 35, pH 7.43. She was transferred to the ICU where she was placed on metop 50 TID and converted spontaneously to sinus. She was diuresed with 20 and 10 IV lasix and put out net -1.2L. Now pt is doing well on the floor on 2L NC and ready for transfer back to the floor. Pt is reported to not have BM for last 5 days. . ROS: (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. MEDICAL HISTORY: Gout Hypercholesterolemia hypertension Colon CA Mild LV systolic and diastolic dysfunction. LVEF 40-45 (echo [**2136**]). COPD Depression Psoriasis Eosinophilia Hyperlipid Hypertension Afib MEDICATION ON ADMISSION: Metoprolol tartrate 12.5 b.i.d. ECASA 325 Citalopram 20 colchicine 0.6 Voltaren gel p.r.n. fluticasone spray lactulose lidocaine patch SLTNG 0.4 p.r.n. polyethylene glycol acetaminophen vitamin C docusate 100 MVI one daily, senna 8.6 vitamin A and D ointment. ALLERGIES: Ampicillin / Cephalexin PHYSICAL EXAM: Vitals: T:96.1 P:158/84 BP:68 R:24 SaO2:96 2L NC General: Awake, alert, belabored breathing HEENT: NC/AT, EOMI without nystagmus, no scleral icterus noted Neck: supple, no JVD or carotid bruits appreciated Pulmonary: b/l crackles and exp wheeze Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Neurologic: -mental status: follows commands, poor historian. -motor/sensory: grossly intact FAMILY HISTORY: No family history of early MI, otherwise non-contributory. SOCIAL HISTORY: Lives at home. Has VNA services through [**Hospital6 1952**] (nurse visits 2x per week, with personal care and cleaning services daily). Son in [**Name2 (NI) **]. No tobacco or EtOH.

CHIEF COMPLAINT: Increasing fatigue and pre-syncope PRESENT ILLNESS: This is an 84 year old year old female with known aortic stenosis and coronary artery disease since [**2133**], who recently complained of worsening presyncopal episodes and progressive dyspnea on exertion and fatigue. Her most recent echocardiogram showed an aortic valve area of 0.76cm2 with a peak of 64 and mean of 38mmHg. There was no aortic insufficiency, mild mitral regurgitation and an LVEF of 65%. Cardiac catheterization in [**2141-1-9**] confirmed severe aortic stenosis and three vessel disease. Based on the above, she was referred for cardiac surgical intervention. MEDICAL HISTORY: Aortic Valve Stenosis, Coronary Artery Disease, Mild COPD, Hypertension, Insulin Dependent Diabetes Mellitus, Dyslipidemia, Mild Chronic Renal Insufficiency, Esophagitis, Recurrent UTI, Osteoporosis, Obesity, s/p Nephrectomy, Colon Cancer - s/p Colectomy, s/p Total Hip Replacments, s/p Chole, s/p Appendectomy, s/p Vein Stripping, s/p Cataract Surgery MEDICATION ON ADMISSION: Atenolol 50 qd, Avapro 150 qd, Diltiazem XT 120 qd, Evista 60 qd, Lasix 20 qd, Metformin 750 [**Hospital1 **], Zocor 20 qd, Aspirin 81 qd, Nitrofurantoin 100 qd, Lantus, Humalog SS, MV ALLERGIES: Sulfa (Sulfonamides) PHYSICAL EXAM: Vitals: T 97.3, BP 160/66, HR 66, RR 20, SAT 97 on room air General: Elderly female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, 4/6 systolic ejection murmur throughout precordium, radiating to carotids Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, 1+ edema, Pulses: 1+ distally Neuro: nonfocal FAMILY HISTORY: Brother died of MI at age 50. Father died of MI at age 62. SOCIAL HISTORY: Remote history of tobacco. Admits to only rare ETOH. She lives alone.

CHIEF COMPLAINT: abdominal pain, hematochezia PRESENT ILLNESS: 74 yo male w/ h/o esophageal CA s/p esophagogastrectomy was not feeling well last night, couple pf episodes of bilious vomiting, abdominal pain and nausea. Went to [**Hospital3 **] where he vomited 2L of BRB. Intubated ther. CT scan showed dilated jejunum/duodenum w/ pneumatosis proximally suggesting ischemic bowel. He was transferred here for further management. MEDICAL HISTORY: Past Medical History: IDDM, gastroparesis, HTN, depression, esophageal cancer, esophageal stricture MEDICATION ON ADMISSION: Lisinopril 5mg qd Lopressor 12.5 [**Hospital1 **] ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Physical Exam: Vitals: HR 130s BP 130/70mmHg intubated on the vent GEN: Sedated HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, Tenderness possibly in the upper abdomen but patient sedated so not a good exam. no rebound or guarding, Prominent epigastric pulsation DRE: Not done Ext: No LE edema, LE warm and well perfused FAMILY HISTORY: non-contributory SOCIAL HISTORY: dairy farmer, former smoker (quit 4 yrs ago) married, lives with wife

CHIEF COMPLAINT: Hematemesis PRESENT ILLNESS: 69 year old male with a two-year history of cirrhosis secondary to alcohol abuse. He presented to [**Hospital 1326**] Clinic at [**Hospital1 18**] on the afternoon prior to admission, at which time he reported that he had been feeling well. He has been sober for ~ 6 months and is undergoing evaluation for liver transplant. Lab values at this visit were hct 33.3, T.Bili 3.3, AST 70, ALT 21, INR 1.3. . Later on the same afternoon, he had an episode of unquantified coffee ground emesis at home and was taken to [**Hospital3 10310**] Hospital. At OSH, he was found to have a hematocrit of 27.8. NG lavage was performed with dark red liquid aspirated. He had another witnessed episode of hematemesis with report of ~300 cc's of bright red blood with clots. He received Octreotide gtt at 50 mcg/hour, Zofran 4 mg IV x 1, 2 Liters NS, 2 PIV's, 2 units PRBC's and was transferred directly to the [**Hospital1 18**] MICU for further care. MEDICAL HISTORY: 1. ESLD with portal hypertension, ascites requiring bimonthly paracentesis 2. h/o alcohol abuse 3. UGIB ([**2103**]) s/p variceal banding at [**Hospital1 2025**] 4. h/o hyponatremia as low as 119 5. Herniated discs between L3/L4 6. Tobacco abuse 7. colonoscopy performed in [**2173**] that showed two colonic adenomas and one hyperplastic polyp MEDICATION ON ADMISSION: 1. Prilosec 2. Lactulose 3. Lasix 40 mg per day 4. Aldactone 50 mg per day ALLERGIES: Penicillins / Macrolide Antibiotics / Quinolones / Ursodiol PHYSICAL EXAM: T 97.8, HR 101, BP 101/56, SpO2 100% Gen - cachectic [**Male First Name (un) 4746**], agitated HEENT - icteric sclera CV - tachy, regular rhythm. [**2-15**] SM. Chest - He has mild gynecomastia. Lungs CTA. Abdomen - protuberant abdomen with an evert umbilicus. There is no evidence of any palpable liver or spleen. He has evidence of shifting dullness consistent with ascites. Extrem - Extremities warm and well-perfused, no edema, 2+ peripheral pulses Skin - Jaundiced to mid-torso. No cutaneous stigmata of chronic liver disease. FAMILY HISTORY: His father was an alcoholic. There is no family history of liver disease that is known. SOCIAL HISTORY: Significant history of alcohol use, drinking from the age of 25 until recently, stopping approximately six months ago. He has no history of illicit drug use. He smoked half a pack of cigarettes per day for 20 years, but has been off them for 20 years. He never received a blood transfusion prior to [**2157**].

CHIEF COMPLAINT: Right arm and leg weakness PRESENT ILLNESS: Patient was admitted [**Date range (1) 19867**] to Neurology after presenting with acute onset of R arm and leg weakness with significant resolution of deficits. According to patient, he had full strength at discharge. During that admission, MRI revealed a small acute stroke in the L anterior centrum semiovale and a large old L frontal stroke. Carotid US showed 70-79% stenosis. Echo showed no thrombus. He was taking aspirin at time of stroke and Plavix was added. However, abnormal signal of the clivus on MRI prompted a a bone scan which revealed multiple foci of abnormal uptake in long bones. This led to a torso CT which showed B/L infiltrating renal masses. His antiplatelets were stopped in anticipation of a biopsy which was performed [**5-11**], results of which are pending. He has remained off any aspirin or Plavix since. He went to sleep at 1AM this morning with normal strength. He woke at 730AM and fell when trying to get out of bed, with R arm and leg weakness. After about 30 minutes, he was able to get up, eat breakfast, and then drive his cab. His details are somewhat unclear based on his account, but he called 911 at some point when his weakness was not improving. He arrived at [**Hospital1 18**] at 11AM code stroke page went out at 1116AM. I arrived at 1120AM and he was in CT scanner. When CT scan completed, he complained of R arm and leg weakness and numbness but denied visual changes, facial weakness, dysarthria, dysphagia, L sided symptoms, fever, SOB, CP, palpitations, headache or neck pain. MEDICAL HISTORY: 1) L centrum semiovale stroke [**4-2**] 2) L frontal stroke on MRI 3) HTN 4) Hypercholesterolemia 5) S/p CABG 6) Gout 7) DM 8) B/L 70-79% ICA stenosis 9) B/L renal masses MEDICATION ON ADMISSION: 1) Iron 150mg QD 2) Allopurinol 150mg QD 3) Simvastatin 40mg QD 4) Atenolol 25mg QD 5) Lisinopril 10mg QD 6) Lasix 20mg QD 7) Metformin 850mg [**Hospital1 **] 8) Insulin (70/30) 28 units AM and 20 units PM ALLERGIES: Nitroglycerin PHYSICAL EXAM: Vitals 97.8 BP 119/56 P 67 R 19 O2 sat 99% FAMILY HISTORY: SOCIAL HISTORY: Cab driver Lives alone Occassional ETOH (drinks [**12-1**] scotch every few months) Hx of 50 pack year smoking, quit several years ago

CHIEF COMPLAINT: fall PRESENT ILLNESS: 40M fell while intoxicated w/ alcohol from the [**Location (un) **] and broke his leg, open tib-fib. MEDICAL HISTORY: noncontributory MEDICATION ON ADMISSION: none ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: 119 181/108 100% on O2 bag Combative, subsequently intubated. RRR CTA bilaterally anteriorly abd soft nd pelvis stable rectal tone: nl; guaiac neg Neck/back: no stepoffs, no deformity extr: palp distal pulses; RLE 1cm lac c/w bone, not puncture wound; RLE externally rotated. FAMILY HISTORY: noncontributory SOCIAL HISTORY: +etoh denies illicits denies tob

CHIEF COMPLAINT: GI bleed PRESENT ILLNESS: The Pt is a 61y/o M with a PMH of primary sclerosing cholangitis dx w/ cholangiocarcinoma [**8-28**] during routine change of stent placed for recurrent biliary obstruction (CA19-9 at diagnosis about 3). Cholangiocarcinoma found when CT scan [**9-27**] demonstrated a 2.4 x 3.2 cm diameter low attenuation mass surrounding the common duct, extending into the region of the pancreatic head and through the retroperitoneum down to the renal vein and encasing the proximal portal vein as well as the hepatic artery. There was evidence also that the duodenum was encroached upon by the tumor, although not circumferentially. Based on the CT findings he was deemed unresectable. Received 6 cycles of Gemcitabine/oxaliplatin [**10-28**] to [**4-28**]. Pt found to have progression of pulmonary disease and chemo regimen was changed to second line of cisplatin/5FU [**4-28**]. Course complicated by thrush and fatigue. . Pt presented to ED with hematochezia and hematemesis with BRB. Hct 19 at OSH from 26 yesterday. Here hemodyamically stable. S/p 2U PRBC, 2LIVF at OSH in the setting of SBPs of 70s-->90s. MEDICAL HISTORY: Onc history: Dx [**8-28**] with cholangiocarcinoma -- local extension including encasing the portal vein and hepatic artery, extending into the head of the pancreas and encircling the duodenum. (Not surgical candidate) -- Chemotherapy: 6 cycles Gemcitabine/Oxaliplatin with progression ([**Date range (1) 111295**]), 1 cycle 5FU and cisplatin (Currently day 16 cycle 1) Other PMHx: -Primary sclerosing cholangitis (followed by Dr. [**Last Name (STitle) 497**] -melanoma resection mid back approx 10 years ago with negative sentinel node -Cholecystectomy >20 years ago MEDICATION ON ADMISSION: pancrease suppl qac ursodiol 300mg tid Dexamethasone Compazine Clotrimazole Zofran ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: afebrile, HR 90s, BP 110s/60s, 100% RA NAD- alert and talkative, jaundiced lungs clear RRR, soft SM abdomen protuberant, liver edge palpable just below costal margin, splenomegaly not detected no peripheral edema FAMILY HISTORY: Married x 30 years. 2 children. No smoking, no etoh SOCIAL HISTORY: Physics teacher at [**Location (un) 5028**] High School.

CHIEF COMPLAINT: Melena PRESENT ILLNESS: 31 year old previously healthy male was seen at the office of his PCP today for complaint of melena (black stools), lightheadedness and mild ?coffee ground emesis. Patient states he woke up on Sunday at 3am and had an episode of dark brown emesis; given that he had just had BBQ for dinner, he was unsure of the significance. The following morning, he had a solid black, foul smelling, formed but slightly soft bowel movement. He did not have any abdominal cramping but did have some discomfort, so he started taking Pepto Bismo. The patient proceeded to have two more episodes of tarry black stools on Tuesday morning prior to going to his PCP's office. Throughout Tuesday, he felt light headed and short of breath with mild chest pressure when exerting himself (ex: walking up stairs to his apartment). Labs at his PCP's office showed hemoglobin 7.6 and hematocrit 22.6. Patient was advised to come to the ER for further work-up and management. Of note, patient denies significant alcohol, NSAID, coffee consumption; also denies significant retching with episode of emesis on Sunday or significant history of GERD. . In the ED, patient was tachycardic to 110 although abdominal exam was benign; patient was complaining of exertional chest pressure/shortness of breath but cardiac enzymes were negative X1. On rectal exam, no bright red blood or tarry stools were found in the rectal vault but patient was guaiac positive. NG lavage was performed which yielded coffee ground emesis that would not clear after 400cc, no bright red emesis was noted. Patient was given 1L intravenous fluid boluses and transfused 2 units of pRBC, type and crossed for 4 units. Two 18 gauge peripheral IVs were placed and intravenous PPI started. GI was informed of the patient and plans to do EGD in the morning unless the patient is still tachycardic. VS upon transfer: were afebrile, heart rate 102, BP126/65, RR20, 100%RA. . Upon arrival to the ICU, patient was resting comfortably in bed. He denies current light headedness, chest pressure or shortness of breath. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, rhinorrhea or congestion. Denies coughor wheezing. Denies chest pain, palpitations, or weakness. Denies nausea, diarrhea, constipation, abdominal pain. Denies dysuria, frequency, or urgency. MEDICAL HISTORY: Bilateral ankle fractures MEDICATION ON ADMISSION: Occasional Centrum, Advil ~1X/week (up to 4 tabs ALLERGIES: Penicillins PHYSICAL EXAM: Vitals: T: Afebrile BP: 156/84 P: 109 R: 18 O2: 98% RA General: Alert, oriented, no acute distress, well-nourished HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema FAMILY HISTORY: Diabetes Mellitus, no history of Peptic Ulcer Disease or malignancies . SOCIAL HISTORY: Social History: Third year law student at [**University/College 86617**]T - Denies A - [**1-24**] drinks every other weekend D - Denies illicit drug use

CHIEF COMPLAINT: chest pain PRESENT ILLNESS: Ms. [**Known lastname **] is a 73 year old woman who has a history of chest coronary artery disease s/p a myocardial infarction in [**2131**] and a large abdominal aortic aneurysm. She recently had an abnormal dobutamine stress test and then a cardiac catheterization revealed three vessel coronary artery disease. MEDICAL HISTORY: Abdominal aortic aneurysm, diabetes mellitus, myocardial infarction in [**2131**], Diverticulitis, Neuropathy, Sciatica, Asthmatic, Bronchitis, Bursitis Rt shoulder, Rotator cuff tear, Dry eyes MEDICATION ON ADMISSION: Albuterol Sulfate [Proventil HFA] 90 mcg HFA Aerosol Inhaler 1-2 puffs IH q 4 hrs as needed for prn Budesonide [Pulmicort Flexhaler] 180 mcg/Actuation (160 mcg delivered) Aerosol Powdr Breath Activated 1 puff IH twice a day Duloxetine [Cymbalta] 30 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by mouth once a day Formoterol Fumarate [Foradil Aerolizer] 12 mcg Capsule, w/Inhalation Device 1 cap IH twice a day as needed for prn Gabapentin 300 mg Capsule 1 Capsule(s) by mouth once a day Nizatidine 150 mg Capsule 1 Capsule(s) by mouth twice a day Rosiglitazone [Avandia] 4 mg Tablet 1 Tablet(s) by mouth once a day Rosuvastatin [Crestor] 20 mg Tablet 1 Tablet(s) by mouth once a day Acetaminophen [Tylenol Arthritis] 650 mg Tablet Sustained Release 2 Tablet(s) by mouth twice a day Aspirin [Ecotrin] 325 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by mouth once a day Calcium Carbonate [Titralac] 420 mg Tablet, Chewable 1 Tablet(s) by mouth once a day Calcium Carbonate [Tums] 500 mg Tablet, Chewable 1 Tablet(s) by mouth three times day Carboxymethylcellulose Sodium [Thera Tears] 0.25 % Drops 2 gtts OD 2-3 times daily as needed for prn Ferrous Sulfate 325 mg (65 mg Iron) Tablet 1 Tablet(s) by mouth once a day Loratadine 10 mg Tablet 1 Tablet(s) by mouth once a day (Prescribed by Other Provider) [**2155-6-12**] Multivitamin Tablet 1 Tablet(s) by mouth once a day Simethicone [Gas Relief] 180 mg Capsule 2 Capsule(s) by mouth once a day ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Flagyl PHYSICAL EXAM: Pulse:80 Resp:20 O2 sat: B/P Right:108/63 Left: 113/63 Height:5'0" Weight:137 lbs FAMILY HISTORY: noncontributory SOCIAL HISTORY: Ms. [**Known lastname **] is a former smoker who quit 17 yrs ago, with an 80 pack/yr history. She denies drinking alcohol or illicits.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 75-year-old white gentleman who was in his usual state of health until the day prior to admission; when, after eating, the patient felt nauseated and vomited three times. The patient denies hematemesis. On the morning following this episode of emesis, the patient experienced a syncopal episode characterized as dizziness and lightheadedness. He awoke with emergency medical technicians putting him in an ambulance. He denies a postictal state. He denied loss of bowel or bladder continence. The patient was taken to [**Hospital 26200**] Hospital where a head computed tomography demonstrated a subdural and subarachnoid hemorrhage. He was then transferred to [**Hospital1 1444**] for evaluation by Neurosurgery. In the Emergency Department, the patient vomited bright red blood one time. In the Emergency Department, the patient received fresh frozen plasma, activated factor VII, and two units of packed red blood cells. Of note, the patient had a mechanical aortic valve for which he was taking Coumadin and was found to supratherapeutic on admission. MEDICAL HISTORY: (Past medical history is significant for) 1. Aortic valve replacement in [**2187**]. 2. Coronary artery disease; status post 4-vessel coronary artery bypass graft in [**2187**]. 3. Hypercholesterolemia. 4. Benign prostatic hypertrophy. MEDICATION ON ADMISSION: PHYSICAL EXAMINATION ON PRESENTATION: On admission physical examination the patient's temperature was 99 degrees Fahrenheit, his heart rate was 123, his oxygen saturation was 100% on three liters, and his blood pressure was 134/76. In general, the patient was well-appearing, in no apparent distress. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. The mucous membranes were slightly dry. The neck was supple. Cardiovascular examination revealed a regular rate and rhythm. A 3/6 systolic murmur at the left upper sternal border and a metallic click. Pulmonary examination revealed the lungs were clear to auscultation bilaterally. Abdominal examination revealed the abdomen was soft, nontender, and nondistended. Normal active bowel sounds. Extremity examination revealed no cyanosis, clubbing, or edema. Good distal pulses. Neurologic examination revealed cranial nerves II through XII were intact. Motor strength was [**5-16**] bilaterally in all muscle groups. Sensation was intact throughout. Reflexes were 2+ bilaterally throughout. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 34-year-old man with a lifelong history of severe asthma with multiple admission, status post multiple intubations, who now returns with a presumed asthma exacerbation. He was in his usual state of health until the morning of [**7-20**] when he awoke with increasing shortness of breath, a cough productive of yellow sputum; otherwise no fever, chills, abdominal pain or chest pain. The patient's dyspnea worsened, but he went to work anyway and upon return home took several nebulizer treatments without relief. He presented to the Emergency Room with increasing tachypnea. He was treated with magnesium sulfate and intravenous Solu-Medrol 80 units, and continued to receive nebulizer treatments. His dyspnea improved from a [**7-7**] to a [**5-7**], and a peak flow at this time was 275. He was transferred to the Medical Intensive Care Unit for close observation and treatment with Solu-Medrol 60 mg q.8.h. and nebulizer treatments q.2h. In the morning he showed significant improvement with no tachypnea. The patient has multiple asthma triggers which are detailed in previous notes. He feels that this flare was triggered by change in the weather. MEDICAL HISTORY: 1. Asthma with multiple admissions, multiple intubations, and chronic prednisone use; followed by Dr. [**Last Name (STitle) 217**]. Peak flows normally 350 to 600. 2. Question of gastroesophageal reflux disease. MEDICATION ON ADMISSION: 1. Prednisone 30 mg p.o. q.o.d. 2. Accolate 20 mg p.o. b.i.d. 3. [**Doctor First Name **] 60 mg p.o. b.i.d. 4. Albuterol inhaler. 5. Albuterol nebulizer. 6. Triamcinolone 0.5 mg intramuscular every month. 7. Serevent 4 puffs q.i.d. 8. Flovent 2 puffs b.i.d. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: Lives with his wife and children. The patient continues to smoke tobacco. Drinks 4 to 10 drinks of alcohol per week. Works as an automobile mechanic at a VW dealership.

CHIEF COMPLAINT: MVA PRESENT ILLNESS: This patient was transferred from an outside hospital following a motor scooter accident where she was driving a motor scooter and was struck by a car; there was positive loss of consciousness; she was taken to [**Hospital **] Hospital where she was evaluated there in the emergency department; she had a CT of her head, chest, abdomen, neck, and was found to have an intracranial hemorrhage, multiple rib fractures on the left, left clavicle fracture, and a small left-sided pneumothorax; no chest tube was placed at the outside hospital due to concern for bleeding; she was given FFP as she is on Coumadin; on arrival here in the emergency department her mental status was normal, her GCS was 15, she was complaining of pain in her chest and left arm; her O2 sat was in the low to mid 90s on [**3-16**] L of nasal cannula at [**Hospital **] Hospital, in the emergency department her O2 sat dropped to the high 70s and needed to be supplemented with nonrebreather facemask which brought her O2 sat up to 100%. MEDICAL HISTORY: Type 2 diabetes Opiate dependent chronic pain syndrome on methadone maintenance Hepatitis C History of embolic stroke x 2 On coumadin Migraine headaches MEDICATION ON ADMISSION: - methadine 60 mg po q 7am, 12 pm - levemir 20 mg sc daily - coumadin 10mg/1mg po daily - asa 325 mg po daily - percocet 5/325 mg 1-2 tabs po q6h - bupropion 150 mg po daily - lisinopril 5 mg po daily - vit D 5000 iu po daily - lovastatin 20 mg po daily - methadone 60 mg po daily - insulin ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Temp:98.6 HR:106 BP:182/90 Resp:16 O(2)Sat:94 FAMILY HISTORY: unkown SOCIAL HISTORY: - Tobacco Use: positive - Alcohol Use: unkown - Recreational Drug Use: opiates

CHIEF COMPLAINT: Large Left cerebellar hemorrhage PRESENT ILLNESS: 84F who presented to OSH after a two day history of nausea and vomiting. She went to the ED earlier this evening for ongoing nausea and vomiting and increased drowsiness, with an "inability" to get OOB. Of note patient takes Coumadin 2.5mg daily for an unknown condition. MEDICAL HISTORY: 1. Unknown cardiac condition requiring anticoaguation 2. Insomnia 3. Hypertension 4. s/p CVA 5. s/p THR MEDICATION ON ADMISSION: 1. Prednisone 5mg daily 2. Warfarin 2.5mg daily 3. Lunesta 2mg QHS ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: On Admission: O: T: afebrile BP:207/122 HR: 85 RR:18 O2Sats: 97% ventilated Gen: intubated. HEENT: normocephalic, atraumatic Pupils: equal bilaterally, minimally reactive to light. EOMs: unable to assess Extrem: Warm and well-perfused. Neuro: Mental status: Spontaneously moving all four extremities, briskly withdrawing LE to noxious>upper extremities. Brisk corneals, +gag to deep suction with associated facial grimacing. FAMILY HISTORY: non-contributory SOCIAL HISTORY: non-contributory

CHIEF COMPLAINT: Left upper quadrant pain. PRESENT ILLNESS: Mr. [**Known lastname 14779**] is a 48 year old man with a significant past medical history who presents to his primary care physician on the day of admission with a one week history of fever and malaise. The patient had home temperatures of 101.0 F., on [**5-7**], which briefly improved over the next few days; however, then again on [**5-9**], the patient began feeling poorly with aches and fevers. Denies upper respiratory or gastrointestinal symptoms. The day prior to admission, the patient did note some slight stomach ache with some dry heaves. On the morning of admission, he had worsening malaise. The patient noted an episode of sharp upper left quadrant pain exacerbated by laying on his left side, after which the patient said he had feelings of being slightly nauseated and anxious and as he was walking to the bathroom, fell to the floor. The patient denies trauma. He had brief loss of consciousness, no confusion, no incontinence. After this episode, the patient went to see his primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 679**], and was found to have hematuria in the office and was referred to the Emergency Room. In the Emergency Room, the patient underwent an abdominal CT scan and was noted to have a large pericardial effusion. He underwent further evaluation for this finding by echocardiogram which demonstrated tamponade physiology. The patient was brought to the Cardiac Catheterization Laboratory for emergent pericardiocentesis which was performed, and 450 cc. of bloody fluid removed, with suction bulb drain left in place. The patient was noted to have hemodynamics including pulmonary artery pressure of 26/15 with a wedge of 15, right atrium 13, right ventricle 25/9. Cardiac output 2.7 with an index of 1.5, which improved to a cardiac index of 2.4 after removal of fluid. Of note, the patient denies any history of chest pain; no shortness of breath and reports stable recent exercise tolerance for which at baseline he is able to walk flights of stairs without limitations. The patient denies prior tuberculosis exposure and has no risk factors. He has no travel history. The patient does note sick contacts with his wife and daughter. MEDICAL HISTORY: 1. Kidney stones; two prior episodes treated with pain relief. 2. Health maintenance including a within normal limits colonoscopy within the past two years, demonstrating only hemorrhoids. 3. Stress test in [**2139-9-6**] for costochondritis type chest pain which demonstrated at 100% of maximum heart rate eleven minutes of [**Doctor First Name **] protocol. The patient stopped for fatigue with no ischemic EKG changes, within normal limit hemodynamic response. MEDICATION ON ADMISSION: ALLERGIES: To contrast dye given for prior CT scan. REVIEW OF SYSTEMS; No vision changes, no upper respiratory system symptoms; positive slight nausea, positive sharp left upper quadrant pain; no diarrhea; no constipation. No melena, no bright red blood, no urinary frequency, no burning or frank hematuria. No rashes, no joint pain, no weight loss. The patient reports a stable weight of 133. Night sweats only with fevers. Of note, the patient does report two prior febrile illnesses in [**Month (only) 1096**] and [**Month (only) 956**] of the past year with five to six days of fevers and aches. PHYSICAL EXAM: FAMILY HISTORY: Mother status post mastectomy. Father is 85 years old with a history of a gland removed in his abdomen. Brother who is healthy. Positive coronary artery disease in his uncles. SOCIAL HISTORY: The patient works in giftware sales. No occupational exposures. No tobacco. Drinks a few drinks per week. No illicit drugs. He has two daughters, ages 11 and 18 and a son 26. He lives with his wife and children.

CHIEF COMPLAINT: Hypertension, headache PRESENT ILLNESS: Mr. [**Known lastname 784**] is a 44 y/o man with h/o malignant hypertension and ESRD on HD (s/p recent removal of failed transplanted kidney in [**7-19**]) who presents with headache X 5 days and hypertension. The patient noted occipital headache for past 5 days. Similar in character & location to prior headaches associated with high blood pressure. No visual symptoms. No numbness/tingling of either arm or leg. No fevers or neck stiffness. Did not take any meds for the pain. Took blood pressure which was 190s/110s at home; tells me that last week, when he was feeling well, he saw blood pressures in the range of 115-120 systolic. Contact[**Name (NI) **] PCP office today and seen at [**Company 191**] where his BP was 180/120 on the L and 190/110 on the right. He was directed to the emergency room at that time for further workup and treatment. In the ED, the patient's initial BP was 241/130 with HR 62. He was treated with 40 mg IV labetalol and a nitroglycerin drip. He complained of headache and was treated with IV dilaudid after which time he was nauseous and vomited several times. He received zofran for his nausea and was given 2 L NS. His blood pressure improved to 170s-180s/90s and he was transferred to the MICU. On arrival to the MICU, the patient is complaining of [**4-20**] posterior headache. No visual symptoms. Slight shortness of breath (for past several days). No chest pain. No abdominal pain, dysuria, fevers, constipation/diarrhea, or blood in his stool. No particular precipitating event per his report. He has been compliant with all medications by his report. He denies any increased salt intake or alcohol intake. He also denies illicit drug use. He is dialyzed on MWF so is due on [**8-16**]. MEDICAL HISTORY: - ESRD secondary to chronic ureterovesical junction obstruction leading to bilateral hydronephrosis, on hemodialysis - S/p living-related renal transplant [**2134**] ([**Name (NI) 106515**] brother), failed, now on hemodialysis since [**12-18**] - Malignant hypertension - PRES - s/p SAH - Gout - Peptic Ulcer disease - Bladder neck stricture - Atypical chest pain MEDICATION ON ADMISSION: Renagel 1600 mg TID Omeprazole 20 mg daily Renal caps (renal MVI) daily Lisinopril 40 mg [**Hospital1 **] Nifedipine ER 120 mg daily carvedilol 50 mg [**Hospital1 **] diovan 160 mg [**Hospital1 **] hydralazine 50 mg PO q6h labetalol 400 mg TID clonidine patch 0.3 weekly ALLERGIES: Ciprofloxacin / Hydralazine PHYSICAL EXAM: VS - Temp 96.6 F, BP 185/113, HR 53, R 12, O2-sat 99% 2L NC GENERAL - alert male, pleasant, appropriately interactive, in no acute distress HEENT - PERRL bilaterally, EOMI, no scleral icterus, MMM, tongue midline NECK - supple, no thyromegaly or lymphadenopathy, JVD at 7 cm LUNGS - clear bilaterally without crackles or rhonchi, good inspiratory effort HEART - RRR, normal S1 & S2, loud crescendo-decrescendo murmur heard best at LUSB radiating to carotids ABDOMEN - normoactive bowel sounds, nondistended, soft, no appreciable tenderness to palpation, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no peripheral edema, 2+ DP & radial pulses bilaterally NEURO - A&O X 3. CN II-XII intact. Strength 5/5 bilateral biceps, triceps, hand grip, hip flexors, ankle dorsiflexion & plantarflexion. DTRs 2+ bilaterally at biceps. Sensation to light touch intact bilateral upper & lower extremities. No pronator drift. Finger to nose testing intact. FAMILY HISTORY: Father had MI mid 50s. No DM. Brother had cancer of jaw which was resected. SOCIAL HISTORY: 40py, quit 2 yrs ago. No EtOH or other drugs. Lives in apartment building with his wheelchair-bound wife where he works as superintendent.

CHIEF COMPLAINT: Transfered from OSH s/p cholecystectomy with bile leak followed by ex lap with drainage of bilious fluid, and pneumothorax s/p CVL placement being transferred for [**First Name3 (LF) **] to correct continue leak PRESENT ILLNESS: 61 yo female with h/o DM2, COPD on home O2, h/o DVT/[**Hospital **] transferred from [**Hospital3 4107**]. She underwent cholecystectomy on [**2-1**] then represented to [**Hospital3 4107**] for abdominal pain. She was found to have significant ileus and ascites, and underwent exploratory laparotomy which showed a 2cm hole in the base of the systic duct with 1 Liter bilious ascites. There was ischemic bowel with massive ileus and distention due to bile peritonitis. Her hospitalization was also complicated by a CVL placement with subsequent pneumothorax. A left sided chest tube was place, and also a right femoral line was placed. She is being transferred here for [**Hospital3 **] in AM to fix the continued bile leakage. Of note, she has been treated with vancomycin, metronidazole, and levofloxacin at [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] for peritonitis. . Currently, she states she is having severe pain in her abdomen. She denies CP. Her breathing is slightly labored, but she thinks that's secondary to her large abdomen. She otherwise denies fevers, chills, headache, or any other symptoms. She request pain medications. She was on a dilaudid PCA at the OSH. . Also on chroinc steroids for COPD. MEDICAL HISTORY: 1. Diabetes 2. Chronoc obstructive pulmonary disease 3. T9-10 vertebral fractures. 4. h/o DVT/PE 5. Chronic back pain 6. Right knee osteonecrosis s/p right knee replacement [**Doctor First Name **] 7. Hyperthyroidism 8. Anxiety 9. Enterococcus bactermia MEDICATION ON ADMISSION: MEDICATIONS ON TRANSFER: 1. Fortical 1 spray each nostril every 48 hrs 2. Vitamin B12 1000 mcg every 30 days 3. Dilaudid PCA (dose unclear) 4. Narcan PRN 5. Zofran 4 mg IV q6H PRN 6. Dilaudid 1 mg q4H PRN 7. tylenol 650 mg Q6H PRN 8. Lopressor 5 mg IV q2H PRN HR>120 9. Fentanyl Citrate 25 mcg q30 mins PRN 10. HISS 11. Solumedrol 20 mg IV x 3 days 12. Spiriva inhaler 1 puff daily 13. Advair 500/50 puff [**Hospital1 **] 14. Xopenex 1.25 mg q4H PRN 15. Coumadin 2 mg daily (currently held) 16. Protonix 40 mg IV daily 17. Levofloxacin 500 mg IV daily 18. Metronidazole 500 q8H 19. Vancomycin 1 gm q12h 20. TPN daily . ADMISSION MEDICATIONS: 1. KCL 40 meq 3 x daily 2. Spiriva 18 mcg INH daily 3. Fortical 1 spray alternating nostrils daily 4. Vitamin D 400 units daily 5. Prednisone 30 mg daily 6. Mag oxide 400 mg [**Hospital1 **] 7. MVI daily 8. Trazadone 50 mg qhs 9. Advair 1 puff [**Hospital1 **] 10. Amoxicillin 500 mg [**Hospital1 **] 11. Neurontin 300 mg TID 12. Oxycodone 50 mg q6H PRN 13. Singulair 10 mg daily 14. Cymbalta 60 mg daily 15. Lasix 40 mg daily 16. Protonix 40 mg [**Hospital1 **] 17. Synthroid 112 mcg daily 18. B12 1000 mcg IM monthly 19. Iron 325 mg daily 20. Oxycontin 20 mg [**Hospital1 **] 21. Xopenex 1 puf q4H PRN 22. Dilaudid 2 mg PO q4H PRN 23. Coumadin 2 mg daily 24. Ativan 0.5 mg [**Hospital1 **] 25. Albuterol INH q4h prn 26. Atroven neb q4H PRN ALLERGIES: Celebrex / Zithromax / Sulfa (Sulfonamides) PHYSICAL EXAM: vitals - T 98.8 P 120 ST BP 154/74 RR 17 89% O2 sat on 4L NC gen - Alert awake, heent - MMM, No icterus, no signs of conjunctivitis cv - S1S2 RRR pulm - Coarse breath sounds anteriorly, Decreased BS b/l, few scattered rhonci. left chest tube in place with no air leak noted abd - BS hypoactive; TTP diffusely but particulary in RLQ. bandage in place with JP drain with bilious fluid. + tympany to percussion ext - warm, no edema. Multiple echymosis. neuro - alert and awake. No focal abnormalities. FAMILY HISTORY: NC SOCIAL HISTORY: Widowed. lives independently. Denies alcohol, smoking.

CHIEF COMPLAINT: Hematemesis, abdominal pain, pancytopenia PRESENT ILLNESS: 42M w/anemia and abdominal pain, referred by Dr. [**Last Name (STitle) **] from clinic in [**Hospital1 **]. Pt complains of frequent hematemasis, abdominal pain, and weakness. Patient is poor historian, but relays 1 month history of small amounts of bright red hemoptysis and hematemesis, x 2 times daily. Frequently wakes up with blood around mouth, neck. Today he had 3 such episodes. Per ED, he had < 1 cup hematemesis, but per patient, may have been hemoptysis. Accompanied by abdominal pain that is pressure-like but occasionally has sharp epigastric pain. Has also been feeling weak, and found to be pancytopenic over last few months. Has been following up care at [**Hospital3 33953**] Community Health Center because of "blood" labs and hematemesis. Was following with him, but was sent here by taxi today because of ongoing hematemesis. Was admitted either in [**Month (only) 205**] or last year to [**Hospital3 **] where he had CT scan, bone marrow biopsy, and potentially paracentesis as well. Uncertain of results. He may have also had both EGD and colonoscopy during that time that was positive for some finding, but uncertain what. MEDICAL HISTORY: EtOH abuse Chronic abdominal pain ? Ascites ? s/p bone marrow bipsy ? Diabetes ? Hypertension ? Hypercholesterolemia MEDICATION ON ADMISSION: B12 1000 mcg daily folic acid 1 mg daily thiamine 100 mg daily iron tablet daily omeprazole cap 40 mg daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, Poor dentition Neck: Supple, no LAD CV: Regular rate and rhythm, normal S1 + S2. Systolic ejection murmur loudest at right upper sternal border Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Mildly distended but soft. Tender to palpation in RLQ, otherwise nontender. Bowel sounds present. No hepatomegaly appreciated. Spleen tip ~2 cm below costal margin. No shifting dullness. No r/g. GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No axillary or inguinal lymphadenopathy. Mild ecchymosis bilaterally shins. Neuro: CNII-XII intact, strength/sensation grossly intact, gait deferred. Exam on discharge remained unchanged compared to admission. FAMILY HISTORY: Diabetes - Mother, Father Liver disease - Brother (deceased) No cancer hx SOCIAL HISTORY: Works on and off as landscaper. Lives with friends. Denies tobacco use. Drinks 2 24 ounce Natural Ice beer per day after work. Denies admissions for EtOH withdrawal or withdrawal seizures. Last drink this morning. Distant hx of cocaine use.

CHIEF COMPLAINT: Admitted for migraine, fever, back pain, and left sided chest pain PRESENT ILLNESS: The patient is a 34yo woman with history of complicated migraines, [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease, DM, hypercholesterolemia, asthma, and stroke in [**12-20**] who came to the ED on [**2110-9-2**] for evaluation of headache, and left sided chest pain. She was a questionable historian and much of the following history was obtained from prior records. . During late [**Month (only) 205**] she experienced heat exhaustion and was admitted to [**Hospital **] [**Hospital 68352**] Hospital in [**Doctor First Name 26692**]. At discharge she developed pain, erythema, and swelling on the dorsum of her right wrist (the site of her IV). She was prescribed po keflex as an outpatient. Her symptoms persisted and she was admitted to [**Location (un) 60883**]Hospital on [**2110-7-18**] for thrombophelbitis/cellulitis. She complained of nausea, vomiting, and abdomimal pain. She experienced no fevers, chills, headache, SOB, or cough. She was started on IV Vancomycin and IV clindamycin. Her symptoms improved though did not completely resolve. She was switched to PO Augmentin (7 day course 875 po BID) and discharged on [**7-20**]. During her hospitalization she was also found to be anemic, with no evidence of a "gross bleed." Her anemia work-up was deferred to her PCP. . She went back to the hospital at the beginning of [**Month (only) **] because her wrist symptoms had not completely resolved. She was given IV vancomycin and prescribed Linezolid. She [**Month (only) 20227**]'t afford the medication and was switched to an unknown dose/course of levaquin. . Despite numerous antibiotics, she notes the persistence of mild erythema, pain, and swelling of her left wrist. She lives in CT, and denies any recent outdoor hikes, camping, or tick bites. She came to [**Location (un) 86**] to visit her sister whose husband was recently injured in [**Country 2451**]. On Saturday she experienced an aura of flashing lights and developed an intense migraine. She tried taking an extra dose of neurontin but it didn't help. She was able to sleep,but notes ongoing nausea, vomiting, and photophobia. The migraine pain has been localized mainly on the right side, throbbing, and currently feels as if her eye is "going to [**Doctor Last Name **] out." According to the neurology note she developed R-arm heaviness a few hours after the onset of her headache. Ms. [**Known lastname **] [**Last Name (Titles) 36665**]'t comment when asked about this. Her symptoms persisted and on Monday she developed left upper chest and upper back pain. She [**Last Name (Titles) 20227**]'t describe the pain further. She denied any sensory changes, motor changes, numbness or tingling. She has no neck pain, facial droop, or slurred speech. . She came to the ED on Tuesday ([**2110-9-2**]) after her sympoms didn't improve. She has had minor migraine relief with dilaudid and phenergan. During her time in the ED, she noted ongoing constant left sided chest pain, which is not affected by breathing. At 6:00 am on [**2110-9-3**] she developed fever (103), tachycardia (141), and shaking chills. An EKG was done and showed no ST changes and one set of cardiac enzymes was negative. She was given 1 gram IV Vanco, had an LP that was unimpressive. A PICC was placed due to difficulty establishing access. She was given 2 liters of NS and was transferred to medicine. . Upon arrival to the floor, she was tachycardic (108), afebrile, and 96% on room air. She was lying in the dark, looking mildly uncomfortable in bed. She was a poor historian and somnolent througout the interview. She required frequent reminders to stay on subject and often responded inappropriately to questions. Her major complaints were right sided migraine and left upper chest and back pain. She also states that her left wrist continues to be mildly painful. Shortly after the interview, she developed shaking chills, tachycardia (130), and fever to 103. Blood cx and ABG were drawn, tylenol was given, and ice was applied. She was given on 1 L normal saline. . ROS: She denies weight loss, infectious contacts, IVDU, recent tampon use,no tick bites (though she lives in CT and has a dog), trauma, heavy lifting, SOB, DOE, PND, chest pressure, hemoptysis, jaundice, abdominal pain, bowel-bladder changes, vaginal pain/problems, dysuria, hematuria, or bright red blood per rectum. MEDICAL HISTORY: - Migraine: These began in her late teens and she usually gets at least once a month. She often has auras of flashing lights. Her associated symptoms include N/V, photo-and phonophobia. Prior to this migraine, her longest migraine lasted 2-3 days. - [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease: diagnosed at age 17 during tonsillectomy pre-op workup. Multiple bleeding complications through life (bloody noses, heavy periods bleeding from gums, bleeding post-op). She has 3 children, delivered vaginally, and had significant bleeding during and following the deliveries. She ultimately had a hysterectomy due to heavy menstrual bleeding. ASA is contra-indicated. She has been treated in the past with whole blood transfusions, DDAVP and Humate (factor VIII). - Stroke: [**12-20**], had R-facial droop and was not talking properly-resolved over time. Had a headache prior to her symptoms. - ARDS in [**2108**], required intubation. Woke up on [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1017**] [**2108**] and [**Year (4 digits) 20227**]'t breathe. She was told she had respiratory failure, ARDS, Pneumonia, EColi sepsis. - asthma-developed after her ARDS in [**2108**] and has been poorly controlled and required numerous hospital visits. - HTN-diagnosed via routine blood work - DM type 2: diagnosed via routine blood work 3-4 years ago. Controlled with Glucophage. She has no associated eye, kidney, or sensory problems. She doesn't get -asthma-developed after her ARDS in [**2108**] and has been poorly controlled and required numerous hospital visits. - hypercholesterolemia-diagnosed via routine blood work - obesity . Surgeries: - tonsillectomy age 17 significant for early and delayed bleeding. - one ovary removed in [**2100**] with bleeding complications - cholecystectomy and hysterectomy in [**2101**] with late bleeding - Back surgergy (L5,S1--herniated discs) [**2103**] and [**2106**], bleeding complications MEDICATION ON ADMISSION: Atenolol 50mg [**Hospital1 **] PO HCTZ 25mg PO BID Glucophage 500mg PO daily zocor 40mg PO daily advair 50/500 [**Hospital1 **] combivent neurontin 900mg PO 4 times daily (for migraine proph) ativan 1mg PO qHS PRN ALLERGIES: Demerol / Topamax / Codeine / Compazine / Aspirin / Nsaids / Toradol / Reglan PHYSICAL EXAM: VITALS: T 100.1 HR 108 BP 118/70 RR 18 O2sat96%ra FSBS not recorded GEN: obese, lying in bed HEAD: NC/AT, EYES: PERRLA, sluggish extraocular movements, patient would not open right eye, no scleral icterus, no conjunctival injections EARS: canals not visualized NOSE: septum midline, no exudate, epistaxis MOUTH: MMM, symmetrical palatal elevation NECK: no carotid bruits;no JVD appreciated due to thick neck, neck supple, able to touch chin to chest NODES: no occipital, pre-auricular, cervical, submandibular, axillary, epitrochlear, or inguinal adenopathy LUNGS: Clear to auscultation bilaterally, breathing rapidly. Pressure applied to anterior left chest was mildly tender. Pressure applied to upper left paravertebral region was not tender to palpation. HEART: Heart sounds muffled by increased breath sounds. Regular rate and rhythm, normal S1 and S2, no murmurs, gallops and rubs. ABDOMEN: obese, bowel sounds present, soft, nontender, nondistended, no rebound tenderness. Large midline scar and central ecchmoses. EXTREMITIES: erythema L-hand (still swollen, erythematous and warm-No cords detected, tender to palpation), no clubbing, cyanosis, no splinter hemorrhages, [**Doctor Last Name **] spots, [**Last Name (un) **] lesions. Raising either leg elicited extreme pain (localizing to her left upper back) and nausea. . Neuro exam deferred by patient. FAMILY HISTORY: DM, HTN, CAD, Migraines, Cancer(unsure of types), no other hx of bleeding Two grandparents had strokes. Her mother and father are in their 60's and have both had MI's. Her mother and sister both have migraines. She has 3 brothers and [**Name2 (NI) 20227**]'t comment on their health. She has 3 daughters and had one miscarriage. SOCIAL HISTORY: On admission, her social history was as follows: Lives in CT with her fiance [**Doctor First Name 892**], 3 daughters ([**Name (NI) 2331**], [**First Name3 (LF) **], and [**Name (NI) 636**]), and their (indoor) dog Copper. She works as an Alcohol/drug counselor. She divorced the father of her 3 children after experiencing several years of physical abuse (she left her husband in [**2096**] and the divorce was finalized two weeks ago). Her eldest brother was an addict, and he abused her as a child. She currently feels safe and secure in her home environment and states that her fiance is a "good man." She is not sexually active. . Habits: Cigaretts: none Ethanol: none Drugs: none . Exposures: She is not aware of any toxin exposure. . Trips: She visit [**Doctor First Name 5256**] over the summer and went on a fishing trip. She lives in CT. She is not aware of any tick, mosquito, spider bites. . Health Maintanence: She has not received regular medical care. She has seen a physician for her [**Name9 (PRE) 68353**]. [**First Name (STitle) **] [**Name (STitle) 68354**]. She has no PCP. [**Name10 (NameIs) **] saw an OB/GYN Dr. [**Last Name (STitle) 1182**] in [**Location (un) **] for her deliveries and hysterectomy. She recieved her primary care from a staff of rotating Doctors at the [**Name5 (PTitle) 68352**] Hospital for the past several years, but due to the recent finalization of her divorce, she has lost her benefits. She plans to start care at the Women's Medical Center near her home, if they accept her insurance.

CHIEF COMPLAINT: Reason for MICU admission: respiratory distress s/p intubation in ED PRESENT ILLNESS: This is an 85 year old man with PMH significant for HTN, CHF, chronic kidney disease who presents with repiratory distress. He had been hospitalized multiple times recently at [**Hospital1 18**], beginning in [**11-24**] with a mechanical fall then re-presented that month with pneumonia. In [**2-25**] he returned with a DVT in the right common and deep common femoral veins and CHF exacerbation, as well as troponin elevations and a bibasilar pneumonia. . He now presents following a fall at home. Per his wife and notes, he was at home for the last three days following discharge from rehab. He was reportedly sitting in a chair at home, then fell off the chair. His wife found him on the ground, awake and talking, and called EMS to get him to [**Hospital1 18**] for evaluation. He did not have any obvioud trauma. His wife says he noted chest heaviness and heart racing earlier in the day, and had seemed short of breath since discharge from rehab. . In the ED, he was noted to be in respiratory distress, tachypnic to 35, and O2 sat was 80%. His extremities were cool. He denied chest pain, nausea, vomiting, incontinence, fevers, chills, palpitations. Due to his respiratory distress, code status was confirmed and the patient was intubated. Antibiotics were started with vancomycin, levofloxacin, and flagyl, then blood cultures were sent. CXR was felt to not have a striking pneumonia. CT angiogram was considered but not done due to elevated creatinine, and VQ scan was also considered. He got 1.8 liters of fluid and was empirically started on heparin because his INR was 1.8, then transferred to the MICU. MEDICAL HISTORY: 1. HTN 2. CKD: baseline around 2.3 3. bipolar disorder - on lithium previously 4. hyperlipidemia 5. prostate surgery many years ago - indication not specified 6. Patient reports hospitalization in [**2111**]'s for MI but does not know details. 7. Urinary incontinence 8. MI ([**2111**]) and a recent NSTEMI in [**Month (only) **]/06 9. DVT 10. CHF with EF [**2-25**] 30-40% with multiple hypokinetic walls 11. UTI's 12. Anemia 13. Possible reactive airway disease with response to prednisone [**2-25**] 14. Hematuria 15. Pneumonia [**2-25**] MEDICATION ON ADMISSION: Acetaminophen 325 mg Tablet PO Q4-6H Aspirin 325 mg PO DAILY Divalproex 125 mg PO QAM, 250 mg PO HS Furosemide 40 mg PO DAILY Clopidogrel 75 mg PO DAILY Atorvastatin 80 mg PO DAILY Metoprolol Tartrate 75 mg PO TID Hydralazine 50 mg PO Q6H Isosorbide Dinitrate 10 mg PO TID Ipratropium Inhalation Q6H (every 6 hours) as needed. Senna 8.6 mg PO BID Docusate Sodium 100 mg PO BID Pantoprazole 40 mg PO Q24H Calcium Acetate 1334 mg PO three times a day: with meals. Coumadin 4 mg PO QD ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: V: T101.2 100/50 P85 98% AC 500x18 100% Gen: intubated, sedated, in no distress HEENT: pupils small, reactive Neck: JVP elevated at 30 degrees Resp: lungs with crackles diffusely bilaterally CV: irreg irreg, normal S1s2 no murmurs Abd: soft NTND +BS Ext: cool extremities, 2+ pitting edema bilaterally Neuro: sedated. FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Patient lives with his wife of > 60 years in an [**Hospital3 **] senior facility in [**Location (un) **]. Has 2 grown children, one is [**State **] and one in [**State 760**]. Remote history of tobacco. No alcohol.

CHIEF COMPLAINT: Ampullary adenoma PRESENT ILLNESS: Mr. [**Known lastname 112231**] is a 61M who was evaluated to have a pancreatic ductal dilatation and a bulging ampullary mass that showed low-grade dysplasia on biopsy. This was after he developed a vague abdominal pain and a weight loss over the past several months. He had no prior abdominal surgical history, but he has relatively new diagnoses of coronary artery disease that was being evaluated and chronic obstructive pulmonary disease from 50 years of smoking cigarettes. He also drinks a considerable amount. He had mild jaundice, back pain, abdominal pain and weight loss, but no steatorrhea. He is not diabetic. He does not have any chest pains, palpitations. He is on aspirin and which was be held preoperatively. MEDICAL HISTORY: PAST MEDICAL HISTORY: - [**7-/2168**] Cardiac cath - no CAD, mild LV dysfunction without MR LVEF 45%, non-ischemic cardiomyopathy - [**1-/2168**] Stress MIBI with abnormal gated scintigraphy. EKG 2mm ST depression. Occasional PVCs. Perfusion abnormaloty with mild anterior wall LV and apex with reversibility. Mild global hypokinesis. - Hypertension - Hyperlipidemia - 50 pack year h/o tobacco abuse - h/o impair fasting glucose - COPD - h/o ampullary adenoma with pancreatic ductation dilation - recent 25lb unintentional weight loss since [**2168-2-24**] MEDICATION ON ADMISSION: ASA 81 mg daily Atenolol 50 mg daily Nitrostat - PRN; has never used Nicotine patch 21 mg daily ALLERGIES: Thiazides / ACE inhibitors / Terazosin PHYSICAL EXAM: Upon Discharge: Vitals: 98.2, 56, 136/70, 12, 96% RA Gen: AAo X 3, NAD CV: Sinus bradycardia Resp: CTAB, diminished bases b/l Abd: Bilateral subcostal incision with staples and open to air, moderate erythema around staples line with minimal swelling. Right lateral portion open with moist-to-dry dressing and moderate serosanguinous drainage. Old JP site with occlusive dressing and c/d/i. Ext: Warm, no c/c/e FAMILY HISTORY: Uncle premature CAD and death in 50s Mother alive, no known heart disease Father died from ETOHism and ?CAD Brother died from AIDS Sister unknown health status, estranged SOCIAL HISTORY: ETOH: [**2-26**] rums/d for 30+ years. Pt does not endorse problem with [**Name (NI) 31483**] Tobacco: quit 12 days ago smoked 1.5 ppd for 40+ yrs Illicits: prior marijuana, denies cocaine, no IVDU Living: In townshend with wife Working: [**Name (NI) **] worker driving the [**Name (NI) 68444**] bus

CHIEF COMPLAINT: dyspnea on exertion PRESENT ILLNESS: This is a 61 year old male with exercise intolerance and dyspnea on exertion. Nuclear stress testing showed inferolateral ST depressions with exercise. SPECT revealed an LVEF of 59% with reversible defects in the anterolateral, inferior and inferolateral regions. Subsequent cardiac catheterization was notable for severe three vessel disease and normal LV function. Based upon the above results, he was referred for surgical revascularization. MEDICAL HISTORY: Coronary Artery Disease Diabetes mellitus type II Hypertension Hypercholesterolemia Chronic back pain Carotid bruits s/p Shoulder surgery MEDICATION ON ADMISSION: Avapro 150 qd, Toprol XL 100 qd, Omeprazole 20 qd, Lipitor 80 qd, Tricor 145 qd, Avandia 8 qd, Aspirin 81 qd, Coenzyme Q10 ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: BP 114/58, HR 54, RR 12, SAT 98 on room air General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, bilateral carotid bruits noted Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, trace edema, no varicosities Pulses: 1+ distally, bilateral femoral bruits noted Neuro: nonfocal FAMILY HISTORY: Denies premature CAD. SOCIAL HISTORY: 45 pack year history of tobacco, quit approximately 1 month prior to admission. Denies ETOH. He is a mechanic. Currently lives with his wife.

CHIEF COMPLAINT: s/p fall from sink PRESENT ILLNESS: 73 yF fell from kitchen counter and hit head and back, unsure about LOC, able to recall events surrounding fall. Pt called 911, taken to OSH where she had BP 220/110, Tx with lasix and found to havd a SDH, so she was transferred to [**Hospital1 18**] for further care. MEDICAL HISTORY: HTN dyslipidemia MEDICATION ON ADMISSION: ASA 81 mg Zestril Zocor ALLERGIES: Penicillins PHYSICAL EXAM: 97.1 108/63 89 16 89%on RA/100%on 2L gen: NAD HEENT: hematoma on L occiput, PERRL 3->2 Neck: supple, no midline TTP with full ROM and no pain Chest: CTAB CV: distand HS Abd: soft, NT, ND, +BS Extrem: WWP Neuro: AOx3, coop with exam, appropriate, fluent speech with good comprehension and repetition CNII-XII tested and intach bilat Motor- strength 5/5 throughout, no pronator drift Sensation- intact throughout, reflexes intact bilat Coordination- normal FAMILY HISTORY: non-contrib SOCIAL HISTORY: smokes 1.5 PPD x50 yrs, occ EtOH, no drug use

CHIEF COMPLAINT: transferred from OSH after airway compromise following CABG [**2138-5-11**] for eval of TBM seen on bronchoscopy. PRESENT ILLNESS: 68 yo male s/p CABG [**2138-5-11**] c/b inominate artery compromise. Post op had airway compromise and bronch revealed TBM-transferred for eval. MEDICAL HISTORY: PAST MEDICAL HISTORY: CRI, baseline Cr 1.2 Diabetes with peripheral neuropathy. paroxysmal A-fib on coumadin H/O multiple myeloma(Dr. [**Last Name (STitle) 66059**], last chemo 3 weeks ago); ?left femur hypertension CAD-stentx2 [**2135**] MEDICATION ON ADMISSION: NPH 48units QAM, 20units Q10pm; Novolog 12units QAM, 20units Q5pm; Coumadin 7.5mg QHS -Patient and wife deny that pt is taking coumadin. I have called his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 73038**]-awaiting call back. Tricor 160' Metoprolol 50" ASA 81' Temazepam 30 QHS PRN Procrit PRN Velcade? (Chemo Every other week) Zometta? ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAMINATION: T96.9 P87 BP107/44 R18 97% 4L Gen- pleasant Caucasian male in no apparent distress HEENT- anicteric, PERRLA, moist mucus membrane, normal oropharynx, neck supple CV- regular, no r/m/g RESP- clear bilaterally(anterior) ABDOMEN- soft, nontender, nondistended EXT- no edema NEUROLOGICAL: . Mental status: AAOx2. He thinks that this is [**2108**]. Able to say month of year forward but not backward. Comprehension intact; follows commands. Speech fluent. Normal affect. . Cranial Nerves: I: Not tested II: PERRL, 2->1 mm III, IV, VI: EOMI V: Facial sensation intact and symmetric to PP, LT. VII: Face symmetric with intact strength. VIII: Hearing intact bilaterally to finger rub IX, X: Palatal elevation symmetric [**Doctor First Name 81**]: SCM, trapezius strength intact XII: Tongue midline without fasciculations . Motor: Normal bulk. No pronator drift. . Delt Tri [**Hospital1 **] WE FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB RT: 5 4 5 5 5 5 5 5 5 5 5 5 5 LEFT: 5 4 5 5 5 5 5 4 4 5 5 5 5 . Sensation: decreased sensation in lower extremities bilaterally up to level of ankle, decreased proprioception in lower extremity, normal sensation and proprioception in upper extremity . Reflexes: Bic T Br Pa Ac Right 0 0 0 0 0 Left 0 0 0 0 0 Toes equivocal . Coordination: FNF, H->S intact . Gait: Deferred because patient is very afraid to stand. . FAMILY HISTORY: CAD in family SOCIAL HISTORY: smoke [**1-21**] ppd for 30-40 years, quit 20 y ago, used to drink but quit in his 30s. Was in the navy once, then became meat cutter. now retired. no drug use. currently lives with wife.

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 63 year-old female with a history of Prednisone dependent sarcoid, cirrhosis, ascites with SBP who presented with one day of nausea, vomiting, diarrhea and change in mental status. She was discharged to nursing home on [**2145-6-28**] after admission for back pain. She has had multiple admissions including three day admissions for compression fracture of the spine, which was complicated by pneumonia and ascites with a 7 liter tap. She also had azotemia and hypophosphatemia as well as urinary tract infection, right tibia fibula fracture and that admission date was from [**5-22**] until [**6-11**]. The patient was doing well at nursing home, eating well and comfortable one night prior to admission when this morning had nausea, vomiting and diarrhea, initially presented to [**Hospital3 1442**] and was transferred to [**Hospital1 188**]. She received enema twice yesterday and had diarrhea since then. In the Emergency Department her vital status was heart rate 120, blood pressure 100/68, respirations 18, and then she became hypotensive. Her blood pressure dropped down to the 80s. Her regular blood pressure ranging between 90s to 110. She was given Phenergan and her abdominal x-ray was concerning for obstruction. We recommended to have an abdominal CT, but the patient did not tolerate NG tube placement. Her blood culture was sent and we also gave her 1 liter of normal saline. She was seen by surgery who recommended broad spectrum antibiotics. CT scan was later done without any contrast. MEDICAL HISTORY: Cirrhosis, sarcoid, osteoporosis, hyperlipidemia, hypertension, portal hypertension, thrombocytopenia, esophageal varices and aortic stenosis. MEDICATION ON ADMISSION: ALLERGIES: She has multiple allergies including Penicillin, Oxacillin, Percocet, Keflex, intravenous iodine, Oxycontin, Flagyl, and Codeine. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient is divorced with many children. She currently lives with children prior to being at rehabilitation. She denies tobacco and alcohol.

CHIEF COMPLAINT: Valproic acid overdose PRESENT ILLNESS: This is a 32 year old woman w/ h/o bipolar disorder, anxiety, ETOH, heroin abuse transferred from OSH for valproic acid overdose. . She was initially found unresponsive in the bathroom by her father. She had vomited and was laying on the ground. She was not answering questions and EMS was called. An empty bottle of valproic acid was found. She was taken to OSH, where her labs were notable for: Valproic acid 170, bicarbonate 16, ammonia was 1359, ETOH 48, salicalyte/tylenol negative and anion gap of 21. She received lactulose and ativan, and was transferred to [**Hospital1 18**]. . At [**Hospital1 18**] ED, initial VS were: HR 92, RR 17, BP 113/62, 100% RA. She was intubated for airway protection. Toxicology was consulted who recommended activated charcoal, l-carnatine. Her ECG was sinus tachycardia, Qtc 428. Her labs were notable for: ammonia 59, inr 1.3, alt/ast [**10-8**], tbili 0.2, hco 18, AG 19, serium tox neg for asa/etoh/tylenol/benzo/barb/tca, valproate 150, abg 7.37/32/511, lactate 4.9. She received 20gm activated charcoal, loading dose of l-carnatine iv, and NS. Current vent settings: FiO2 100%, 450, 20, 5. . In the MICU, pt l-carnatine was continued, and Toxicology recommended stopping after ammonia and valproate levels continued to trend downward. She had an elevated lactate that improved with IVF. She was successfully extubated on [**11-16**], and she was placed on an ativan CIWA scale and given a bannana bag given her h/o Etoh abuse. A psychiatry consult was ordered, and the patient was started on a 1:1. . On the floor, patient complaining of some throat pain that has been present since extubation. She also notes some mild epigastric discomfort. When asked to describe the pain, she states that it feels more like she wants to throw up than it does actual pain. She denies fevers/chills, congestion. She states she had not been feeling sick recently. MEDICAL HISTORY: -Depression -ETOH dependence -Marijuana Abuse -Tobacco Abuse -s/p 2 c-sections -s/p internal anal sphincterotomy MEDICATION ON ADMISSION: Unclear which medications patient is taking, the following have been noted: Geodon Lithium Valproic acid Chlorpromazine Benztropine Cymbalta Naltrexone Seroquel Propranolol ALLERGIES: SSRI PHYSICAL EXAM: Adm PE: General: intubated HEENT: Sclera anicteric, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley . Discharge PE: Vitals: 98.2 95/49 55 18 98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, PERRL, oropharynx with erythema, few palatal hemorrhages likely related to recent intubation Neck: supple, mild cervical [**Doctor First Name **], some tenderness of submandibular area. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, mild tenderness to palpation in epigastric region. non-distended, bowel sounds present, no organomegaly, no peritoneal signs, no rebound or guarding. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes FAMILY HISTORY: Alcoholism, no history of gallstones SOCIAL HISTORY: - Tobacco: [**1-25**] PPD - Alcohol: Drinks 2 pints per day, most recent drink on Sunday per the pt. - Illicits: iv heroin has been documented in past, pt denies current use.

CHIEF COMPLAINT: Seizure, hyperglycemia PRESENT ILLNESS: 59yoF with h/o DM but not on medications, hypothyroidism, Hyperlipidemia Coronary Artery Disease, and Hypertension presented to OSH with Altered Mental Status and seizure found to have HHS and transferred to [**Hospital1 18**] for further management. Per the patient's daughter over the last few months the patient has lost a lot of weight, not been able to go 5 mins without using the bathroom, and has felt fatigued. she was started on a new thyroid medication in the last few weeks. She was supposed to see the doctor [**First Name (Titles) **] [**Last Name (Titles) 20212**] but postponed to today. However, last night she was "not herself" but she said she was fine. This morning her daughter still thought she was altered but the patient insisted that she go to work this afternoon at 2pm. at 6:30 a police officer drove the patient home and reported that she had driven her car into a pole, was confused but had refused to go to the hospital. Then the patient went to her room and fell asleep, while her dtr went to get the car (about 1 hour). After this the daughter insisted they go to the hospital. On the car ride she began losing consciousness and as they arrived to the hospital had a seizure. (documented as GTC by OSH). REceived ativan and dilantin. Head CT normal. at OSH labs notable for glucose in 1400s and Na 139. ABG 7.19. Then reportedly became apneic and was intubated at [**Hospital1 **]. Given SC insulin and insulin gtt at 6 units /hr. Got 4L NS at OSH. Never hemodynamically unstable MEDICAL HISTORY: Diabetes mellitus not on medication Hypertension "Holes in her heart s/p surgery" Hypothyroidism Hyperlipidemia Coronary Artery Disease MEDICATION ON ADMISSION: Lasix 20 mg po daily Fosinopril 40 mg po daily Levothyroxine 0.1 mg po daily Lovastatin 20 mg po daily Flucinonide cream 0.05% ALLERGIES: Latex PHYSICAL EXAM: Admission: VS: Temp:97 BP:153 /67 HR:99 RR: O2sat 92% on AC 420X16 peep 5 FIo2 100 GEN: Intubated sedated HEENT: PERRL at 2mm, anicteric, MMM, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: crackles at the right base CV: RR, S1 and S2 wnl, no m/r/g CVP 5 ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice NEURO: Intubated and sedated. Pupils 2mm and reactive. When sedation off awake and fighting the tube . Discharge: Vitals - Tm: 100.0 Tc:98.8 p:80 (72-97) bp:116/76 (108-118/68-74)rr20 98% RA. GENERAL: elderly female appearing comfortable and in no acute distress HEENT: left trapezius tender and tense, no increased warmpth CHEST: CTABL no wheezes, no rales, no ronchi CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: Overweight, non-distended, BS normoactive, soft, non-tender FAMILY HISTORY: Mom with diabetes. SOCIAL HISTORY: Lives with her daughter, works as a home health aide. Non-smoker, non-drinker.

CHIEF COMPLAINT: PRESENT ILLNESS: This is an 82-year-old gentleman with past medical history of hypertension, COPD, hypercholesterolemia, and diabetes, who presents with acute onset of shortness of breath at 1 a.m. that morning without chest pain, but with associated nausea and diaphoresis. He presented to an outside hospital. Initial vital signs by the EMTs showed him to be tachypneic with a respiratory rate of 28-30 and O2 saturations to 91% on nonrebreather and cyanotic nailbeds were noted. At the outside hospital Emergency Department, he was given CPAP and his O2 saturation increased to 97% with resolution of his cyanosis. EKG at that time showed [**Street Address(2) 1766**] elevations in V1 and V2 and V5 and V5 had ST depressions. Initial laboratories showed a white count of 26.5. ABG of 7.42/43/263/27. Cardiac enzymes were as follows: CK 201, troponin less than 0.1. Patient was given aspirin at home and at the outside hospital. He was transferred to [**Hospital3 **] for further evaluation and management. An echocardiogram was done on presentation, which showed an ejection fraction of 30-35% and wall motion abnormalities including basal mid inferior and inferolateral and septal hypo and akinesis. There is focal hypokinesis of the apical free wall of the right ventricle. Aortic regurgitation 1+. MEDICAL HISTORY: 1. COPD without baseline O2 requirement. 2. Hypertension. 3. Hypercholesterolemia. 4. History of hemoptysis with pneumonia in [**2096**]. 5. Diabetes. 6. Status post cholecystectomy. 7. Asthma. 8. History of diverticulosis status post partial colonic resection 25 years ago. 9. Status post appendectomy. MEDICATION ON ADMISSION: Doses not listed. 1. Lipitor. 2. Cartia XL. 3. Cozaar. 4. Hydrochlorothiazide. 5. Aspirin. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: Patient has 120 pack year history of cigarette smoking. He stopped approximately 20 years ago. He is a former insurance salesman. He has a fiancee. His son lives in the area and is involved in his care.

CHIEF COMPLAINT: Community acquired pneumonia PRESENT ILLNESS: Mr. [**Known firstname 4580**] [**Known lastname 109123**] is a 62 year old Caucasian male in his usual state of well health when he awoke to right back pain last Saturday. He had this similar back pain 2 years ago relieved by mattress change. He also fell playing tennis which he thought might have exacerbated this. His pain progressed until evaluated by his PCP Wednesday and admitted to [**Hospital6 **]. He developed fevers, leukocytosis, and CT chest [**2195-6-24**] revealed right small pleural effusion. He was started on levaquin. He also had CTA [**2195-6-25**] for ongoing right sided back and chest pain, which ruled out pulmonary embolus, but revealed increasing right pleural effusion and right basilar atelectasis since [**2195-6-24**]. The patient also developed chest congestion, cough and diaphoresis. He denies any prior URI's, major flu's, fevers, chills, nightsweats. He now has cough with congestion, and overall does not feel well. He was referred to Dr. [**First Name (STitle) **] for possible surgery. MEDICAL HISTORY: Hypertension MEDICATION ON ADMISSION: Home Meds: Aspirin 325 mg daily, Zestril 10 mg daily, MVI. fish oil ALLERGIES: Demerol PHYSICAL EXAM: VS: T: 97.2 HR: 68 SR BP: 142/74 Sats: 93% RA General: 62 year-old male no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple Card: RRR normal S1,S2 Resp: diminshed breath sounds on right > left no crackles GI: bowel sounds positive, abdomen soft non-tender/non-distended Extre: warm no edema Incision: Right VATs site clean dry intact, 2 chest tube remain Neuro: non-focal FAMILY HISTORY: Mother- colon and liver CA. Father- died suddenly in hospital of "some cardiac issue" Siblings- healthy Offspring- healthy SOCIAL HISTORY: Single, has one son. [**Name (NI) 1403**] as a lawyer. 60 pk yr smoking hx- current. No cigarrettes since Wednesday. 4 glasses of wine/month. No illicit drugs.

CHIEF COMPLAINT: Found down in bathroom PRESENT ILLNESS: Ms. [**Known lastname **] is a 80 yo LHW with history of 2 prior strokes who presents with intraparechymal and intraventricular hemorrhage after being found down in bathroom this morning. The patient is currently living in a nursing home after recent discharge from [**Hospital1 **] [**Hospital3 **] Rehab via [**Hospital3 **] Hospital, where she was admitted 2 months ago for a stroke. Her recent baseline is ambulatory with walker without assistance, mild word finding difficulty, otherwise no residual deficits. Her friend and son think she was at her baseline yesterday, both spoke with her and she was laughing and making full sentences appropriately. Her son does mention she expressed the wish to join her deceased husband and daughter, so he was worried about depression. The rehab staff heard a thud at 5:30 am and found patient on floor in bathroom, jumbled up with her walker. Her eyes were open and she followed commands, but her speech was garbled and she was weak on the right side. She was brought to [**Hospital3 **] first, NIHSS 21, BP 175/63. She was awake, following commands, with R sided weakness, verbal output mostly incomprehensible except for her name and yes/no to some questions. Head CT showed approx 5.5 x 2.5 cm left parietal hemorrhage with some intraventricular extension. Patient was then transferred to [**Hospital1 18**]. In [**Hospital1 18**] ED, patient did not require any antihypertensives, she remained with SBP 150-160s. Her mental status and exam remained stable through her stay in the ED. She slept for some time but was awake with eyes open when examiner entered the room. She did vomit once, bright yellow bile, and did not cough or desat. She received antiemetics for this. Hip X-ray was done for complaint of hip pain, but showed no fracture or dislocation. On ROS (obtained from son and friend) no recent fever, SOB, CP, abdominal pain, N/V/D, headaches, vision changes, vertigo. MEDICAL HISTORY: - 2 prior strokes, 12 years ago p/w R weakness that completely recovered, 2 months ago p/w aphasia which recovered except for word finding difficulties, family unclear of stroke etiology or what was done for treatment, not on ASA per paperwork we have here - HTN - cataract surgery (L) done week before her stroke - legally blind in R eye - ?venous thrombosis (seen in OSH list of ICD9 codes but family not aware of this) MEDICATION ON ADMISSION: atenolol 50 mg [**Hospital1 **] hydralazine 10 mg PO QID ofloxacin eye drops OS [**Hospital1 **] ALLERGIES: hydrochlorothiazide / Penicillins / Sulfa(Sulfonamide Antibiotics) / Macrolide Antibiotics PHYSICAL EXAM: On Admission: VS T 96.8 HR 87 BP 150s-180s/60-70s RR 18 02 99/RA GEN: eyes open, awake, regards examiner. NAD. In C-collar. HEENT: R eye closed at baseline, scarred over, no pupillary response. CV: RRR, no m/r/g PULM: CTAB anteriorly AB: NT/ND soft EXT: no edema FAMILY HISTORY: Noncontributory SOCIAL HISTORY: was living independently at home until stroke 2 months ago, now residing in nursing home ([**Hospital3 **] rehab in [**Location (un) 10072**]). Widowed few years ago. Has 1 adopted son who lives in FL. Her adopted daughter was killed by drunk driver in her 20s. Patient was a talented singer and pianist. No tobacco, EtoH.

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 69 year-old man who presents again for a chief complaint of rectal bleeding. He was recently admitted on [**2157-2-27**] to [**2157-3-3**] for rectal bleeding and he represents for continued episodes of rectal bleeding. Colonoscopy performed on the previous admission was noted to have an ulcer at the anorectal verge and then was transfused a total of 7 units of packed red blood cells. His esophagogastroduodenoscopy revealed mild gastritis. Surgery was also consulted at that time for evaluation and recommended conservative management. He was hemodynamically stable when he was discharged and was given the time for his ulcer to heal since it may have been secondary to rectal tube trauma and a biopsy was to be performed at four to six weeks post discharge. However, at the nursing home on the morning of admission the staff noted a large episode of bright red blood per rectum. He was transferred back to the [**Hospital1 69**] Emergency Department for further management and evaluation. He denies any abdominal pain, lightheadedness, shortness of breath, chest pain, fevers, throughout this process. On arrival to the Emergency Department he had a blood pressure of 43/25, heart rate of 70, aggressive fluid hydration was given as well as 2 units of packed red blood cells. His blood pressure rose to 120/55. His admission hematocrit was 30.1. Gastrointestinal and surgery consults were obtained in the Emergency Department. MEDICAL HISTORY: 1. Anorectal ulcer. 2. Diabetes mellitus type 2. 3. Hypertension. 4. Obesity. 5. Obstructive sleep apnea. 6. Depression. 7. Status post left parietal cerebrovascular accident. 8. Gout. 9. Rhabdomyolysis. 10. Decubitus ulcers. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: He is estranged from his wife, not a smoker, former alcohol use, former real estate worker.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is an 85 year old man with a history of bilateral carotid artery stenosis who has had several recent episodes of left arm numbness and was referred to Dr. [**Last Name (STitle) 1132**] for angiogram with possible procedure for this carotid artery stenosis. MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [**2150**], status post coronary angioplasty in [**2150**]. 2. Hypertension. 3. Glaucoma. 4. Wheezing. 5. Status post bilateral hip surgery. 6. Occasional heartburn. 7. Hypercholesterolemia. 8. Status post cataract surgery bilaterally in [**2160**]. MEDICATION ON ADMISSION: 1. Naprosyn 500 mg p.o. twice a day, that was stopped on [**2168-6-10**]. 2. Hydrochlorothiazide 25 mg p.o. once daily. 3. Detrol 2 mg p.o. once daily. 4. Lipitor 10 mg p.o. once daily. 5. Trental 400 mg p.o. three times a day. 6. Levoxyl 112 mcg p.o. once daily. 7. Cardizem 240 mg p.o. once daily. 8. Diovan 40 mg p.o. once daily. 9. Aspirin 325 mg p.o. once daily. 10. Plavix 75 mg p.o. once daily. ALLERGIES: Erythromycin. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: worsening pain, weakness, and low grade fever PRESENT ILLNESS: The patient is a 47 yo F with multiple sclerosis and metastatic melanoma p/w FTT at home. Known metastatic disease to brain, spleen, spine. Patient with chronic back pain secondary to metastatic disease. The patient reports that it has been difficult to manage at home since around [**Holiday **] when she discovered the recurrence of the melanoma in her left axilla. Over the past 1-2 weeks she has had persistent lower back pain and poor PO intake. She reports low grade fevers to 99 at home with difficulty sleeping over the last few weeks. Poor PO intake over last few weeks. She was seen in the Pain [**Hospital 9085**] clinic and started on oxycontin and oxycodone for her back pain without much relief. This morning her family felt that it was becoming too difficult to manage her symptoms at home and felt it was necessary to bring her to the ED. . In the ED, initial vitals were 97.7, HR 130, BP 132/66, RR19, 96% RA. While in the ED, the patient spiked to 102. UA was negative. Blood and urine cultures were sent. An initial lactate was 4.0. She received 4L IVF and her lactate improved to 2.3. She was empirically treated with vancomycin and cefepime. A CT scan was performed and did not show any drainable abscess from her left axilla. The patient declined central access. MEDICAL HISTORY: # Metastatic Melamoma - [**2162-2-8**], underwent an excisional biopsy for what was felt to be a 7.2 thick, [**Doctor Last Name 10834**] level IV, nonulcerated melanoma with 10 mitoses/m2 on her left shoulder. There was evidence of lymphovascular invasion and a question of perineural invasion. She underwent a wide local excision and left axillary sentinel lymph node biopsy on [**2162-3-12**] with pathology revealing melanoma in 4 sentinel lymph nodes with evidence of extracapsular extension. She underwent a completion left axillary node dissection on [**2162-3-26**] with pathology showing no melanoma in 3 lymph nodes identified. She received radiation therapy to the left axilla without difficulty, completing in [**2162-5-9**]. She was placed on interferon alpha-1a (Rebif) for multiple sclerosis on [**2162-7-6**]. She presented to Clinic on [**2163-1-26**] with multiple nodules in the left axilla consistent with recurrence within the radiation field. Subsequent head MRI showed multiple CNS metastases. About to begin a phase II clinical trial of sorafenib + temazolomide therapy for her CNS metastatic melanoma. # Multiple Sclerosis - Diagnosed in [**2154**], relapsing/remitting MEDICATION ON ADMISSION: Dexamthasone 4mg [**Hospital1 **] Ambien 10mg PRN Oxycontin 20mg [**Hospital1 **] Oxycodone 5mg prn Neurontin 300mg , uptitrating Xanax 0.5mg PRN Fiorinal 50-325-40mg cap 1 cap daily prn headache Ibuprofen 600mg q8h compazine 10mg tab q6h prn nausea ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals - 98.0 141/100 118 17 100% RA General - ill appearing middle aged female, lying in bed HEENT - PERRL, dry MM Neck - supple, no lympadenopathy CV - tachycardic, regular, no murmur appreciated Lungs - CTA B/L Abdomen - soft, non-tender, non-distended Ext - extensive soft tissue nodularity in the left axilla with venous congestion. No drainage appreciated. Neuro - CN 2-12 intact, sensation intact upper and lower extremities, RLE [**4-13**], LLE 4+/5, RUE/LUE 4+/5 FAMILY HISTORY: Father died of heart disease. Mother with hypertension. SOCIAL HISTORY: The patient lives with her husband and youngest son (age 17). She has 2 older children ages 27 (daughter) and 25 (son). She used to work as a teachers aid. She denies ETOH/smoking/drugs.

CHIEF COMPLAINT: FUO, altered MS PRESENT ILLNESS: Ms. [**Known lastname 13304**] is a 63 yo F with a h/o EtOH abuse, hemochromatosis, and recent hospitalization for ETOH pancreatitis, who was transferred to the ED from rehab with acute altered mental status. According to her husband she was in her usual state of health when he last spoke to her at 9pm on the evening of admission. He was called by the rehab 2 hours later and informed that she was not making sense and that she was being sent to ED for further evaluation. He reported that when he saw her in the ED she was speaking non-sensically; he had never seen her like this before. On [**2138-5-22**] she was discharged from [**Hospital1 18**] to rehab after a month-long hospitalization, including intubation, for severe alcoholic pancreatitis. In the ED, VS were T 97.6, HR 104, BP 156/88, RR 20, 100% on NC. She was initially evaluated for stroke, noted to have B/L mydriasis, sluggishly reactive to light; but no evidence of herniation/hemorrhage or other acute process on head CT. Negative tox screen except for benzos which were given in the ED. She spiked a fever to 102.4 in ED and had an LP performed, which was normal. She was treated with vanco 1g IV x1, levofloxacin 750mg IV x1, flagyl 500mg IV x1. She was also given NS IV x2L, Bannana bag, mag 2g IV x1, 1mg Ativan x2, tylenol 1g PR, ASA 325. MEDICAL HISTORY: #. Pancreatitis-- hospitalization [**4-29**] - [**2138-5-22**], on levo/flagyl; MICU stay w/intubation #. EtOH abuse-- heavy drinking of [**1-21**] to whole bottle of wine per day every day for 4-5 years; unclear if she has been drinking since recent discharge from hospital #. Peptic ulcer disease #. Hemochromatosis-- requiring therapeutic phlebotomy (no h/o organ dysfunction) #. OSA-- per sleep study on [**2138-4-2**], patient should be started on auto CPAP with a pressure ranging from 6-10 cm of water; however she hasn't started using CPAP at home yet #. Cognitive impairment-- per husbands report she has been reporting short term memory impairment x3 years; h/o abnormal neuropsych testing MEDICATION ON ADMISSION: -Acetaminophen 1000 mg Capsule Sig: [**11-20**] Capsules PO every [**2-23**] hours as needed for pain. -Heparin 5000 SQ TID -Quetiapine 50 mg Tablet PO at bedtime -Oxycodone 5 mg Tablet PO Q4H prn for pain. -Folic Acid 1 mg Tablet PO DAILY -Thiamine HCl 100 mg PO DAILY -Loperamide 2 mg PO QID prn for diarrhea. -Fentanyl 25 mcg/hr Patch Q72 hr -Aspirin 81 mg PO once a day -Omeprazole 20 mg po daily -Venlafaxine 75 mg PO daily -Amlodipine 7.5mg po qhs -psyllium powder 3.7gm [**Hospital1 **] prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS in the [**Hospital Unit Name 153**]: T 103.2, HR 121, BP 155/67, RR 30, 99% NC Gen: appears agitated, non purposeful movements, muttering, moans in response to questions/exam Skin: warm, flushed, no rashes or lesions noted HEENT: pupils 3mm, equal, sluggisly reactive, roving eye movements, will not open mouth, dried blood on tongue/[**Last Name (LF) **], [**First Name3 (LF) **] not open mouth for examination Neck: supple, no LAD, no thyromegaly or thyroid nodules CV: tachycardic, regular rhythm, no appreciable murmur Lungs: unable to cooperate with exam, CTAB Abd: soft, appears to be tender to deep palpation primarily in RLQ, +Bowel sounds, no guarding Ext: no pedal edema FAMILY HISTORY: non-contributory SOCIAL HISTORY: Up until the past month she had been drinking 1 whole bottle of wine per day +/- scotch every day for 4-5 years. Last drink was [**2138-4-26**], husband denies any access to alcohol since. No h/o tobacco or drug use. Prior to her recent pancreatitis she had been working part time as a therapist, previously as a professor. Lives with husband who does not drink.

CHIEF COMPLAINT: intractable low back pain and R hip pain PRESENT ILLNESS: Mr. [**Known lastname 17562**] is a 43 year old man with renal cell carcinoma metastatic to the R sacral ala s/p IL2 and Cyberknife therapy on the sacrum. Since [**Month (only) **] he developed numbness to the R toes, which progressed to numbness up to the calf and some dysesthesia. He was started on Neurontin without significant benefit. Finally on [**10-20**] he underwent pelvic MRI which showed progression of the sacral lesion. He had developed intractable low back pain that seemed to be positional as well as right lower extremity radiculopathy in an S1 distribution. MEDICAL HISTORY: 1. History of recurrent kidney stones dating as far back as [**2146-2-19**]. 2. History of asymptomatic bradycardia which was thoroughly evaluated by cardiology and no therapy was indicated. Of note, during anesthesia for his nephrectomy, he required atropine treatment for bradycardia. 3. GERD. 4. Degenerative disc disease in the C-spine region. MEDICATION ON ADMISSION: tylenol, prevacid, oxycodone, neurontin,zoloft ALLERGIES: Codeine / Iodine / Glucocorticoids,Systemic Classifier / Dilaudid PHYSICAL EXAM: AOx3. Follows commands. Speech intact. Face symetric. No drift. PERRLA. EOMI. Sensation intact in all four extremities. Moving all extremities with full strength. FAMILY HISTORY: nc SOCIAL HISTORY: never smoked, [**12-27**] beer/month married,kids

CHIEF COMPLAINT: S/P pulseless VT PRESENT ILLNESS: 72 year old female with h/o HTN, inferior silent MI in past, s/p Left pneumonectomy for lung cancer who is transferred from [**Hospital **] adter V fib arrest. Per notes, patient at baseline is an active person and night prior to admission at [**Hospital3 **] she c/o SOB and gurgling in throat. While daughter drove patient to hospital, [**2-14**] way there patient became unresponsive and slumped over. Brought to ED pulseless and unresponsive- in VT-- shocked at 200 J and converted to NSR. Bolused with amio and started on amio drip. Patient was subsequently intubated amd BP were labile 20- 200 and after sedation noted to be 44- patient was started on dopamine. Trop: 0.06 and Ck's- 100's MEDICAL HISTORY: s/p left lung pneumonectomy s/p silent MI in past HTN osteoporosis Glaucoma Hypothyroidism MEDICATION ON ADMISSION: Levothryoxine Lescol Lisinopril Timolol eye drop Xalatan fosamax ALLERGIES: Ivp Dye, Iodine Containing PHYSICAL EXAM: Temp: 101.2 HR: 65 BP: 143/64 RR: 19 HEENT: PERRLA, no bruits, no JVD CV: RRR, nl s1, s2, 1/6 SEM heard best at apex Lung: CTA on right side ABd: soft, ND, NABS, No HSM EXT: no c,c,e 2+ DP pulses FAMILY HISTORY: non-con SOCIAL HISTORY: occ alcohol