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CHIEF COMPLAINT: Chest Pain PRESENT ILLNESS: 67F smoker w/ no medical care in over 15 years was transferred from OSH with NSTEMI. Pt admitted to [**Hospital6 6640**] on [**5-9**] with acute episode of SOB and pain radiating down both arms and neck. EKG in ambulance demonstrated ST depressions in V2-V4, ST elevations in II, III, and her cardiac enzymes were positive with peak CPK 431 and troponin of 16.8. CTA was negative for PE. She was placed on heparin gtt, integrillin gtt, plavix load, beta blocker, high dose statin, and aspirin. Her ST segment changes resolved but small Q-waves present in II and III. She received lasix as needed for volume overload. MEDICAL HISTORY: Hyperlipidemia, Hypertension, Tobacco use, s/p Hemorrhoidectomy MEDICATION ON ADMISSION: OUTPATIENT: none . TRANSFER MEDICATIONS: Heparin gtt Integrillin gtt Plavix 75 mg daily Aspirin 325mg daily Protonix 40mg daily Nitroglycerin paste Metoprolol 50mg TID Simvastatin 80mg daily Ativan PRN ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Admission VS - 97.2 144/86 88 16 95% RA Gen: well-appearing, NAD HEENT: NCAT. Sclera anicteric. sclear anicteric, conjunctivae slightly pale, OP clear w/ dentures, MMM Neck: Supple with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. +s3, III/VI blowing SEM at apex Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. soft R > L crackles Abd: +BS. Soft, NTND. Ext: No c/c/e.. Skin: No rashes. Pulses: 2+ radial and 2+ DP pulses bilat Discharge VS T98.4 HR 97 SR BP 167/97 RR 18 Gen NAD Neuro Oriented x3, nonfocal exam Pulm scattered rhonchi CV RRR, sternum stable incision CDI Abdm soft, NT/+BS Ext warm, palpable pulses, 2+ pedal edema FAMILY HISTORY: Her FH is notable for father with MI in his 40s and cardiac deat at age 67. Mother died of old age at age [**Age over 90 **] and had thyroid dysfunction SOCIAL HISTORY: Patient is married to her husband for 50 years. She lives in [**Location 20291**]. She is retired and used to work as a buyer for a baby clothing company. She smokes [**2-12**] PPD currently, 40-pack-year hx. She denies any current EtoH use or prior abuse. She denies any ellicits.

CHIEF COMPLAINT: BRBPR PRESENT ILLNESS: HMED ATTG ADMIT NOTE . DATE [**2168-7-16**] TIME 2300 . PCP [**Name9 (PRE) **] GI [**Name9 (PRE) **] . 61 yo M with Crohn's disease on prednisone s/p total colectomy in [**2147**], complicated by perirectal abscess s/p internal drainage [**9-22**] and newly diagnosed DVT [**5-24**] on coumadin who presents to the ED with BRBPR. . Patient reports 16 bloody bowel movements yesterday ([**2168-7-15**]). Went to see PCP ([**Doctor Last Name 2472**]) and INR was 4.7. Patient instructed to hold coumadin. Went home, overnight had multiple bloody bowel movements. This am had 3 episodes of syncope where he awoke on his bathroom floor, denies any head trauma. Last bloody BM was around [**1-15**] pm today. No abdominal pain (has chronic rectal pain). No fevers, nausea or vomiting. Lightheadedness with standing. Denies any cp or sob. Endorses mild dysuria, s/p TURP 4 weeks ago. . Went to [**Hospital1 **]-[**Location (un) 620**] ED today and found to have INR 5.4 and Hct of 27 (hct two weeks ago at [**Hospital1 18**] was 36.8). CT abdomen performed which showed a 15 mm perirectal abscess connected to right lateral anal fistula, slightly enlarged from prior MRI in [**Month (only) 956**] of this year, at which time abscess was less organized. Given 4L of NS. Anoscopic exam performed in ED which showed moderate maceration of perianal region but no gross bleeding. Heme positive. No fistulas or fissures. Reported that patient received iv cipro/flagyl however patient states this was never given. . Transferred to [**Hospital1 18**] ED: 97.0 72P 104/76 16 100%RA; 5mg vit K po; 2 units of FFP; colorectal surgery consulted and reviewed image with radiology - abscess cavity similar to prior MRI in [**Month (only) 956**] - no fever or leukocytosis therefore no indication to urgently drain, needs management of LGIB first. GI made aware and will see patient in am. . ROS as per HPI, 10 pt ROS otherwise negative MEDICAL HISTORY: -Crohn's disease (had previously been diagnosed with UC and had totaly colectomy in [**2147**]) - uncontrolled, s/p internal drainage perirectal abscess [**9-22**] by [**Doctor Last Name 1120**] -LLE DVT dx [**2168-6-9**] on coumadin -Recurrent diarrhea -ADD -Anemia -Arthritis -Nephrolithiasis -BPH -Migraine headaches -TURP 4 weeks ago MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Allopurinol 300 mg PO DAILY 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Diphenoxylate-Atropine [**12-14**] TAB PO Q6H:PRN diarrhea 4. Hydrocortisone Enema 100 mg PR DAILY Duration: 21 Days 5. PredniSONE 12 mg PO DAILY 6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 7. Warfarin 5 mg PO DAILY16 8. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 9. Ferrous Sulfate 650 mg PO DAILY 10. FoLIC Acid 0.4 mg PO DAILY Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Allopurinol 300 mg PO DAILY 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Diphenoxylate-Atropine [**12-14**] TAB PO Q6H:PRN diarrhea 4. Hydrocortisone Enema 100 mg PR DAILY Duration: 21 Days 5. PredniSONE 12 mg PO DAILY 6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 7. Warfarin 5 mg PO DAILY16 8. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 9. Ferrous Sulfate 650 mg PO DAILY 10. FoLIC Acid 0.4 mg PO DAILY ALLERGIES: Purinethol / Remicade PHYSICAL EXAM: ADMITTING EXAM FAMILY HISTORY: Son, mother and sister with [**Name (NI) 4522**] disease SOCIAL HISTORY: Works as a divorce attorney. Married, lives with wife. [**Name (NI) **] tobacco, 1 beer per week and no illicits.

CHIEF COMPLAINT: Hypertensive urgency PRESENT ILLNESS: Pt is a 48 yo M with PMHx sig. for hypertension, hepatitis C who presents from PCP's office with asymptomatic hypertension. Blood pressure at PCP's office was 210/134. He was there for a refill of his lisinopril as he has currently been off of lisinopril for 1 week. . He denies any fever, chills, changes in weight, headache, lightheadedness, syncope, numbness/tingling, muscle weakness, vision changes, chest pain, palpitations, shortness of breath, N/V, abdominal pain, constipation, diarrhea, BRBPR, melena, pedal edema. No PND, orthopnea. No snoring, daytime somnolence. Awakes feeling refreshed. He may be more stressed with wedding planning. . In the ED, initial VS were: 98.5 69 185/123 19 98. EKG showed biphasic T waves in V4-V6. Cardiology reviewed the EKG, felt it was c/w hypertrophic cardiomyopathy and recommended echocardiogram. Nicardipine gtt was started and titrated up to 1.5. Pt also received ASA 325 mg. His current vital signs are 97, 210/107, 17, 100RA. MEDICAL HISTORY: Hypertension, diagnosed 2 years ago Hepatitis C, followed by Dr. [**Name (NI) **], liver biopsy from [**4-10**] showed grade 1 inflammation, stage 1 fibrosis Gastric ulcer s/p cauterization in 91 s/p appy [**2122**] MEDICATION ON ADMISSION: Lisinopril 40 mg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T 97.7, BP 186/94, HR 86, RR 19, 94% on RA GEN: pleasant man in no acute distress HEENT: PERRL, no papilladema Neck: supple without LAD, no carotid bruits, no JVD CV: RRR, no murmurs Pulm: CTAB Abd: +BS, soft, NT, ND Ext: no edema, 2+ DP pulses Neuro: CNs II-XII grossly intact, muscule strength intact, finger to nose intact, no gross sensory deficits, DTRs 2+/4 in BUEs and BLEs. FAMILY HISTORY: There is a family history of both diabetes and ischemic heart disease. No family history of sudden cardiac death, strokes. Mother with HTN and MI at 49yrs s/p ICD. Father healthy. SOCIAL HISTORY: He is single with six children. He works as a custodian in [**Location (un) 86**] Public School. He quit smoking, drinking alcohol 22 years ago. He was previously a heavy drinker. He also has a history of IVDA, marijuana use, also quit 22 years ago.

CHIEF COMPLAINT: Falls - found to have R cerebellar hemorrhage at OSH PRESENT ILLNESS: Mr [**Known lastname 61509**] is a LHM, and is a retired printer (former veteran), who normally does cross-word puzzles, Sodoku and plays Game Boy. He was in his usual state of health until 3 am on [**10-24**]. His step-son, [**Name (NI) **] [**Name (NI) 36913**], whom he lives with, found him sitting by the front door, drenched in blood, and trying to get out. Mr [**Name13 (STitle) 36913**] cleaned his step-father up, and noticed that he had hit the right side of his forehead and right forearm. Mr [**Name13 (STitle) 36913**] took his father back to bed, at around 4 am. Mr [**Known lastname 61509**] [**Last Name (Titles) **] up around 6:30 am, and had breakfast around 7 am which consisted of his usual bowl of cereal and two cups of coffee. Mr [**Known lastname 79898**] daughter-in-law [**Doctor First Name **] noticed that he had made a mess in the kitchen earlier that morning, taken the kitchen rug and tried to wrap the table in it. However, both Mr and Mrs [**Last Name (STitle) 36913**] left for work, requesting their daughter ([**Name (NI) **]) to look in on Mr [**Name (NI) 61509**]. [**Doctor First Name **] came by to give Mr [**Known lastname 61509**] lunch, and found that there was more blood in the house, in addition, he had vomited his breakfast up on the living room sofa. She noticed that while he was eating his bowl of soup, his soup spoon kept missing his mouth. In addition, she noticed that her grand-father's speech was slurred. [**Doctor First Name **] took her Grand-father to the [**Hospital3 **] [**Name (NI) **]. He had a CT of his brain which showed a right cerebellar hemorrhagic lesion with vasogenic edema and some compression of the fourth ventricle, so he was transferred to [**Hospital1 18**] ED. At the ED he was reviewed by Neurosurgery. MEDICAL HISTORY: 1. Asthma 2. Osteoporosis 3. Osteoarthritis 4. s/p bilateral catarect surgery MEDICATION ON ADMISSION: Fosamax Advair Serevent Albuterol as needed ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: T99, HR 40, BP 157/60, RR 16, SpO2 96% on room air General: right forehead and right arm bruises noted. HEENT: complained that it tickled when trying to examine the cervical lymph nodes. Resp: Poor air entry in the right middle zone CVS: difficult to hear the heart sounds clearly, as he would not stop talking GI: Soft, non-tender with normal bowel sounds. Neurological Examination Mental status: Awake and alert, multiple promptings for the exam. Oriented to person, [**Location (un) 86**] and [**2107**]. Normal repetition; no anomia. Moderate dysarthria. Registers 0/3,recalls 0/3 in 5 minutes. Right-left confusion. FAMILY HISTORY: Not known SOCIAL HISTORY: Lives with his step-son who is his only child and his HCP, his name is [**Name (NI) **] [**Name (NI) 36913**] and his cell phone number is: [**Telephone/Fax (1) 79899**]. According to Mr [**Last Name (Titles) 36913**], his step-father is DNR/DNI. His PCP is Dr [**Last Name (STitle) 27542**] at [**Location (un) **]. He is an ex-smoker, smoking up to two packs per day (not known over the number of years). Mr [**Known lastname 61509**] does not drink alcohol. His bedroom is on the [**Location (un) 1773**], and he normally manages his ADLs.

CHIEF COMPLAINT: tumor recurrance PRESENT ILLNESS: 48 yo gentleman who initially presented with h/a and was found to have right sided mass. He is s/p crani & resection on [**2155-3-17**] which diagnosed GBM. He is now s/p radiation and is on temodar. Recent MRI revealed tumor recurrance therefore he presents today for re-resection. MEDICAL HISTORY: mildly increased cholesterol Gout Epicondylitis MEDICATION ON ADMISSION: ALLOPURINOL, LEVETIRACETAM - 500 mg [**Hospital1 **], REISHI [**Last Name (un) **] 800 mg daily SIMVASTATIN 40 mg Tablet daily, calcium ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Physical Examination: AVSS. Neck is supple and without lymphadenopathy. Cardiac examination reveals regular rate and rhythms. His lungs are clear. His abdomen is soft with good bowel sounds. His extremities do not show clubbing, cyanosis, or edema. FAMILY HISTORY: No neurological or oncological history SOCIAL HISTORY: He is a salesman. He lives with wife and son. [**Name (NI) **] denies smoking, alcohol, or illicits.

CHIEF COMPLAINT: high grade dysplasia of the Barrett's Esophagus PRESENT ILLNESS: 61-year-old woman, with celiac disease and Barrett's esophagus, who is on a surveillance program. Her Barrett's has progressed to high-grade dysplasia confirmed on pathologic review. We discussed a variety of interventions for this as well as the risk that this could represent the presence of invasive cancer somewhere in the [**Doctor Last Name 15532**] segment. She elected to proceed with resection, and I recommended a transhiatal approach to which she consented. MEDICAL HISTORY: Hypothyroidism, celiac disease, s/p resection of thigh melanoma [**2114**], osteoporosis, high grade dysplasia of the Barrett's Esophagus MEDICATION ON ADMISSION: Aciphex, Levoxyl, Calcium, Vitamin D, MVI ALLERGIES: Gluten PHYSICAL EXAM: General- healthy appearing older middle age female HEENT- anicteric, no adenopathy of neck or supraclavicular Cor-RRR, no m/r/g Resp-CTAB Abd-soft, non-tender, + BS, no organomegaly Ext- 2+ RLE edema, chronic- wears compression stocking FAMILY HISTORY: mother- died [**Name2 (NI) 24817**] cancer. SOCIAL HISTORY: non- smoker-lifetime, etoh [**1-5**]/week lives in [**Location **] w/ husband [**Name (NI) 67540**] analyst w/ Citizens Bank

CHIEF COMPLAINT: Pruritis and rash Cirrhosis secondary to ETOH PRESENT ILLNESS: 70M with ESLD, h/o UGIB s/p variceal banding, s/p TIPS, cholangitis, and recent admission [**8-16**] with candidemia and coag negative staph bacteremia comes in with persistent pruritus and rash worse over the last two days. He was previously evaluated in the ED on [**10-24**] for these complaints and treated symptomatically with benadryl and ranitidine with report of some symptomatic relief. Apparently the rash began ~4 days PTA. At this point it involves most of his body, although with lesser involvement of his lower extremities. The rash begins as small erythematous papules which eventually become more confluent most noticeably on his bilateral upper extremities. He reports the rash is quite painful - even to light touch and is quite itchy. He has not noticed any vesicles or pustules. He denies any mouth sores or other mucus membrane involvement. He denies any arthralgias, myalgias, adenopathy, fevers, chills, or sweats. He has been taking he fluconazole consistently. . In the ED, his triage vitals were T97.8, P 90 Bp 98/55, RR 16, O2 99% on room air. He was given Benadryl 50mg IV once. Dermatology was consulted and obtained a punch biopsy of the rash. MEDICAL HISTORY: 1. ESLD with portal hypertension, formerly with refractory ascites requiring bimonthly paracentesis (now s/p TIPS, see below) 2. Upper GI bleed ([**2174**]) s/p variceal banding at [**Hospital1 2025**], second UGIB s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and TIPS on [**2174-1-14**] - EGD with varices in lower 3rd of esophagus, portal gastropathy 3. Candidemia [**8-16**] --no evidence of ocular involvement on exam, TTE clean --s/p IV fluconazole, to continue PO fluconazole ppx indefinitely (until transplant) 4. h/o alcohol abuse, quit with dx of liver disease 5. Biliary Colic s/p biliary stenting -- now removed 6. Cholangitis complicated elective ERCP 7. h/o hyponatremia as low as 119 8. Herniated discs between L3/L4 9. Psoriasis 10. Liver transplant [**2174-10-29**] MEDICATION ON ADMISSION: furosemide 20 mg daily spironolactone 50mg daily fluconazole 200mg PO BID lactulose protonix 40mg daily spectavite fluocinonide cream ALLERGIES: Penicillins / Macrolide Antibiotics / Quinolones / Ursodiol / Tape PHYSICAL EXAM: T 98 P 83 BP 110/60 RR 18 O2 100% on room air General: Elderly man sitting up eating dinner in no acute distress HEENT: Sclera white, conjunctiva pale. No oral lesions Neck: No adenopathy CV: Regular rate S1 S2 II/VI HSM LLSB Pulm: Lungs clear bilaterally Abd: Soft, +BS, umbilical and ventral hernia present. Very light touch of the rash over his abdomen is painful. Extrem: Warm, no edema Derm: Jaundice. Small erythematous papular rash diffusely located bilaterally on trunk, arms, and lower extremities to mid-calf. Not in any clear dermatomal or sun-exposed distribution. Palms and soles are spared. Erythema is more confluent over his forearms with bruising. No vesicles/bullae. The rash is - inconsistently - very tender. FAMILY HISTORY: His father was an alcoholic. There is no known family history of liver disease. SOCIAL HISTORY: Significant history of alcohol use, drinking from the age of 25 until recently, stopping approximately one year 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: DOE/Orthopnea PRESENT ILLNESS: 69 year old female with h/o AS with DOE who has had progressive worsening of symptoms over the past several months. Work-up revealed severe aortic stenosis withoit significant coronary artery disease. Given these findings she has been admitted for surgical management. MEDICAL HISTORY: cervical and lumbar spondylosis and rheumatoid arthritis / chronic steroid use secondary to asthma HTN AS Depression Toxic Multinodular Goiter Pulmonary fibrosis Anemia Asthma Lupus MEDICATION ON ADMISSION: Prednisone 10' Methimazole 5' Alphagan eye drops MVI Calcium/Vitamin D Glucosamine Omega 3 Ambien Diovan Prednisone eye drops ALLERGIES: Tape / Percocet PHYSICAL EXAM: 72 sr 14 164/70 150/72 67" 265 GEN: NAD SKIN: Unremarkable HEENT: Unremarkable NECK: Supple, FROM, No JVD LUNGS: Diminished BS at bases HEART: RRR, [**5-10**] holosystolic murmur ABD: S/NT/ND/NABS/Obese EXT: Warm, well perfused, 1+ Edema. Some varicosities noted. Faint DP/PT pulses bilaterall. NEURO: Nonfocal FAMILY HISTORY: Non-contributory SOCIAL HISTORY: lives with husband

CHIEF COMPLAINT: altered mental status PRESENT ILLNESS: This is a 76 year-old male with a history of sarcoid and recent admission who presents with altered mental status. . In the ED, the patient had initial vitals of 100.1 with BP 137/100 HR 80s rr 100% RA. While in the ED the patient was treated empirically for pneumonia with levofloxacin and vancomycin. O2 sats ranged from 90-100% eventually being placed on 100% NRB. He was given 0.5 mg ativan at 23:40. Due to hypoxia to 74% and increased work of breathing the patient was intubated at 1AM. He was sedated on propofol. The ED attempted to contact the nursing home without success to address code status. There is mention in the ED note that the patient may have taken oxycodone prior to presentation. . Upon discussion with the family the patient has not been feeling well for the last 1 week. He was not specific about his discomfort, but has been increasing his pain medications. The family is concerned that he has been increasing his intake of oxycodone and has become more confused as a result. The reason for his increased intake of oxycodone (i.e. the location of increased pain) is unclear. The family reports that he took at least 8 percocets in the last 36 hours. The do not recall any localizing symptoms including no fever, chills, chest pain, shortness of breath, diarrhea. The family was concerned about his general health such that they took him to his PCP on thursday and he saw his nurse practitioner [**First Name (Titles) **] [**Last Name (Titles) **]. Both health care practitioners were not concerned for any acute change in his health and are well known to the patient. . ROS: unable to be obtained as the patient is intubated and sedated. MEDICAL HISTORY: 1) Sarcoidosis 2) GERD 3) Paroxysmal atrial fibrillation 4) CVA with resulting memory difficulty 5) Hypertension 6) Anemia 7) Chronic Back Pain (post-herpetic neuralgia)on chronic prednisone MEDICATION ON ADMISSION: Discharge meds as of 11.24, family believes them to be correct 1. Percocet 2.5-325 mg up to 8/day per family 2. Lidocaine 5 %(700 mg/patch) 3. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 4. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO QPM (once a day (in the evening)). 5. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q48H (every 48 hours). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q48H (every 48 hours). 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY 8. Warfarin 5 mg 9. Docusate Sodium 100 mg 10. Senna 8.6 mg . 11. Omeprazole 20 mg Capsule, [**Hospital1 **] 12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO qhs 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID 14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY 15. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Inhalation Inhalation [**Hospital1 **] 17. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol 18. Calcitrate-Vitamin D 315-200 mg-unit Tablet Sig: Two (2) ALLERGIES: Penicillins PHYSICAL EXAM: Vitals: Afebrile, normotensive, satting well on room air, at times requires 1-2L NC. General Appearance: Thin Eyes / Conjunctiva: constricted pupils approx , mildly reactive Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent edema , Left: Absent edema Skin: small faruncle on left leg, no surrounding erythema Musculoskeletal: Skin: Warm Neurologic: Sedated, Tone: Not assessed, down going plantar reflexes, withdraws all extremities to pain FAMILY HISTORY: NC, no family history of sarcoid SOCIAL HISTORY: Retired physician, [**Name Initial (NameIs) **], 2 grandchildren. Son-in-law [**Name (NI) **] very supportive. Divorced from wife, who recently died. Patient has never smoked. Patient rarely consumes alcohol. Patient lives alone at [**Hospital1 100**] Senior Life. His meals are provided for him, he does go shopping on his own and is quite active. He ambulates with a walker since fracturing his acetabulum recently.

CHIEF COMPLAINT: leg swelling, sob PRESENT ILLNESS: HMED ATTENDING ADMISSION NOTE . ADMIT DATE: [**2161-12-23**] ADMIT TIME: 0200 . PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 16518**] [**Last Name (NamePattern1) 174**] . 72 yo F with CKD stage 5 peri-RRT, COPD, DM II with complications and hypertension who presents to the ED complaining of lower extremity edema nad shortness of breath. . Patient is a poor historian. Reports increased fatigue and lethargy x several days. Also with new dyspnea on exertion, lower extremity edema and orthopnea. Mild dry cough. No chest pain or fevers. Reports increased salt intake. . Patient was initially seen at [**Hospital3 **], bp was 206/102 - given 1 inch of ntp, 20 iv labetalol and 40 lasix with improvement in symptoms. Bilateral LENI's were negative. Patient transferred to [**Hospital1 18**] for further evaluation. . ED: 97.0 76P 197/106 20 98%4LNC; wheeze on exam thought to be consistent with copd exacerbation - given albuterol neb, ipratropium neb, methylprednisolone 125 iv and azithromycin 500mg. . ROS as per HPI, 10 pt ROS otherwise negative MEDICAL HISTORY: 1) Type II DM: neuropathy, nephropathy 2) Atypical CP X 16 years: Evaluated in [**State 760**] in [**2136**] with a stress test and cardiac catheterization, which the patient reports were normal 3) Hypertension 4) Emphysema 5) s/p discectomy 6) s/p bunionectomy and hammer toe repair 7) s/p hysterectomy and removal of one ovary/fallopian tube 8) CKD (Cr. 2.9 in [**Month (only) 404**] per [**Hospital3 **] ED) 9) Myasthenia [**Last Name (un) **] - diagnosed 1 year ago, on pyridostigimine - sees Neurologist Dr. [**Last Name (STitle) 37159**] 10) Diverticulosis MEDICATION ON ADMISSION: Meds per OMR - patient does not recall her medications albuterol prn bumetanide 2mg qam, 1mg qpm calcitriol 0.25mcg qMWF Aranesp Diltiazem 360mg daily Folic acid 1mg daily Hydralazine 50mg [**Hospital1 **] Lantus 14 units qam Isosorbide mononitrate 120mg daily Labetalol 400mg [**Hospital1 **] Reglan 10mg q8h prn Modafinil 200mg [**Hospital1 **] Oxybutynin 5mg daily Protonix 40mg daily Pyridostigmine 30mg [**Hospital1 **] Renvela 800mg TID Simvastatin 40mg daily Terazosin 10mg daily Venlafaxine 37.5mg [**Hospital1 **] ASA 325mg daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: admission exam VS: 97.4 157/88 18 93P 98%4L NC -> 87% on RA Appearance: drowsy but arousable, aaox3 Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmd, neck supple, difficult to assess JVD Cv: +s1, s2 -m/r/g, 2+ peripheral edema, 1+ dp/pt bilaterally, left UE AVF with palpable thrill Pulm: diminished at bases, scattered wheeze Abd: soft, obese, nt, nd, +bs Msk: 5/5 strength throughout Neuro: cn 2-12 grossly intact, no focal deficits Skin: no rashes Psych: appropriate, pleasant Heme: no cervical [**Doctor First Name **] . discharge exam VS - 98.3 154/62 (145/66-196/97) 56 (56-72) 18 97% RA GENERAL - African American female comfortable in NAD LUNGS - decreased breath sounds at bases bilaterally. Respirations unlabored, no accessory muscle use HEART - RRR, nl S1-S2, 2/6 systolic murmur ABDOMEN - NABS, soft. NT/ND. abdominal hernia noted. no rebound or guarding EXTREMITIES - WWP, 1+ pitting edema bilaterally, 2+ DP pulses SKIN - no rashes or lesions; right chest with tunneled line in place -no surrounding erythma NEURO - awake and interactive, A&Ox3. FAMILY HISTORY: Mother's sisters with Myeloma and leukemia SOCIAL HISTORY: Retired [**Location (un) 86**] Police Dept Detective. Lives with husband and two grandchildren. Smokes 1 ppd x 50 years. No etoh or illicits.

CHIEF COMPLAINT: elective admission for radionecrosis resection due to radiosurgery of AVM PRESENT ILLNESS: Presents for resection of radionecrosis s/p radiosurgery for AVM MEDICAL HISTORY: seizures,h/o radio therapy for avm has resid edema causing seizures; Dysrhythmia (palps w/ panic attacks), Recent Upper Respiratory Infection MEDICATION ON ADMISSION: Acetaminophen, Effexor 50 [**Hospital1 **], Ibuprofen [Motrin, Advil], Keppra (Levetiracetam) (25oomg ALLERGIES: Codeine PHYSICAL EXAM: Upon discharge: The patient was alert and oriented. She followed commands easily. PERRL, EOMs intact. Face symmetric, tongue midline. Strength was full throughout and sensation was intact to light touch. Incision was clean, dry, and intact. FAMILY HISTORY: NC SOCIAL HISTORY: NC

CHIEF COMPLAINT: cough PRESENT ILLNESS: 51 y/o F COPD, Crohn's disease, AS s/p bioprosthetic aortic valve replacement who presents with worsening of chronic cough. Patient developed non-productive cough one week ago which continued to worsen. Patient describes associated fevers (according to patient 102), chills, fatigue, and mild nausea. Patient denies shortness of breath or chest pain. At home she wears 3 L of oxygen at night, and occasionally during the day - she has not had to increase her oxygen recently. Patient presented to [**Company 191**] today for an urgent care appointment to and was referred to the ED. . In the ED, initial vs were: T 98.4 P 93 BP 94/55 R 26 O2 sat 85%. BP ranged from 84-104/48-56. O2 sat 85% RA, patient was initially stable on 6L NC in the low 90s but dropped to 85% and consequently was started on non-rebreather. Patient was given NEBs, Solumedrol, Ceftriaxone, Levofloxacin, 1 L NS. Patient was admitted to ICU for further monitoring. . Patient reports her blood pressure has been low the past several weeks (SBP 90-100) and consequently has not been taking her atenolol. During this time she was experiencing significant diarrhea secondary to crohn's disease which mildy improved last week since starting Budesonide [**2151-2-18**]. MEDICAL HISTORY: MEDICATION ON ADMISSION: ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth once daily Hold if systolic blood pressure < 100 - not been taking recently ATORVASTATIN [LIPITOR] - 80 mg Tablet - 1 Tablet(s) by mouth once a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff inhaled twice a day FOLIC ACID - 1 MG TABLET - ONE TABLET BY MOUTH EVERY DAY HYDROMORPHONE - 4 mg Tablet - 1 Tablet(s) by mouth three times daily as needed as needed for pain 3 tabs/day - 28 day supply is 84 tabs IBANDRONATE [BONIVA] - 150 mg Tablet - 1 Tablet(s) by mouth q month LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily in the evening OXYGEN 3 LITERS AT NIGHT AND WITH EXERTION - (Prescribed by Other Provider) - Dosage uncertain PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet, Delayed Release (E.C.)(s) by mouth twice a day Budesonide 6 mg qd PREGABALIN [LYRICA] - 75 mg Capsule - 3 Capsule(s) by mouth twice daily PROMETHAZINE - 25 mg Tablet - 1 Tablet(s) by mouth every 6 hours as needed for nausea SUCRALFATE - 1 gram Tablet - 1 Tablet(s) by mouth twice daily with meals SULFASALAZINE - 500 MG TABLET - 2 tablets by mouth three times a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 capsule inhaled Once daily at hs TIZANIDINE - 4 mg Tablet - 1 Tablet(s) by mouth every 8 hours as needed for as needed for muscle spasm do not combine with cyclobenzaprine (flexeril). Do not take before driving or operating machinery. TRAZODONE - 100 mg Tablet - [**1-16**] Tablet(s) by mouth at bedtime as needed for insomnia Medications - OTC ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily CALCIUM - 500 mg Tablet - 1 Tablet(s) by mouth twice a day CYANOCOBALAMIN [VITAMIN B-12] - 100 mcg Tablet - 1 Tablet(s) by mouth daily FERROUS SULFATE [SLOW FE] - 160 mg (50 mg) Tablet Sustained Release - 1 Tablet(s) by mouth daily LIDOCAINE [LMX 4] - 4 % Cream - AAA ear at bedtime MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day ONE TOUCH II TEST - Strip - as directed twice a day ALLERGIES: Penicillins / Darvocet-N 100 / Aspirin / Amitriptyline / Wellbutrin PHYSICAL EXAM: Vitals: T: 98.1 BP: 98/70 P: 72 R: 19 O2: 95% NRB General: Alert, oriented, no acute distress, on non-rebreather HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Wheezes bilateral CV: Regular rate and rhythm, normal S1 + S2, systolic murmurs with click 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: Family History: No history of lung disease. SOCIAL HISTORY: - Tobacco: 1 pack a day past 34 years - Alcohol: Denies - Illicits: Denies

CHIEF COMPLAINT: Motorcycle crash PRESENT ILLNESS: Mr. [**Known lastname 20118**] is a 43 year old man who was a motorcycle drive who was involved in a crash with a car. He was taken by [**Location (un) **] from the scene to the [**Hospital1 18**] with a suspected right open tibia fracture. MEDICAL HISTORY: History of Heroin abuse (snorting) MEDICATION ON ADMISSION: methadone ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAMINATION FAMILY HISTORY: n/a SOCIAL HISTORY: Lives with wife and children Unemployed Lives in [**Location **] with 3 flights of stairs to enter

CHIEF COMPLAINT: hyponatremia, n/v PRESENT ILLNESS: 48 y/o F with h/o sjogrens, cryoglobulinemia, transferred from [**Location (un) **] [**Location (un) **] with hyponatremia to 112. Felt poorly for several weeks feeling weak, tired. Started vomiting (non-bloody, non-bilious) on wednesday with decreased apetite, nausea. No associated headache, abdominal pain, diarrhea, or fevers. However, also did have a non-productive cough with episode of bronchitis 5 weeks ago. She reports no similar prior episodes like this. Of note ,symptoms worsened after starting a trial of doxcycline on wednesday. She stopped after one day due to the N/V. No associated rash. She has a long history of sjogrens for which she has chronic dry eyes and dry mouth. She also has a history of cryoglubinemia for which she required cytoxan and plasmapheresis in [**2092**]. It was diagnosed after her toe went numb. She denies N/V at that time and reports no kidney involvement as far as she knows. And she has had no further problems since then. She says she was told her Na runs low, but she does not know her baseline levels. she went to her PCP where she was found to have a Na of 117, so she was sent to [**Hospital3 **]. There, her Na was 112, Cr 1.9, bicarb 19, k 4.3. Rec'd 800cc NS and transferred to [**Hospital1 18**]. Of note ,patient has never been here. Normally seen at [**Hospital **], where her PCP [**Last Name (NamePattern4) **]. [**Name10 (NameIs) 3081**] she admits she has never need hospital admission before. Even during her cytoxan treatments for cryoglobulinemia it was all outpatient. Of note, she reports being tested for hepb/c and was negative. Denies HIV risk factors. no history of thyroid disease or adrenal insufficiency that she knows of. In ER here, na 113, bicarb 17, cr 1.8. Given 3L NS in ER. Zofran 4mg IV. U/A with 21-50 RBC, large blood, 500 protein; serum osm 252, urine osm 245, urine Na 10 Admit to medicine MEDICAL HISTORY: sjogren's disease h/o cryoglobulinemia MEDICATION ON ADMISSION: doxycycline- stopped multivitamins melatonin ALLERGIES: Codeine PHYSICAL EXAM: 98.3, BP 134/70, HR 79, RR 16, 94% RA, 134 lb gen- awake, alert, pleasant, NAD heent- dry eyes, mouth. + swollen 2-3 cm, non-tender salivary glands b/l at angle of jaw b/l. neck- supple. no add'l swollen glands/lad pulm- CTA b/l. no r/r/w cv- RRR. no m/r/g abd- soft, NT/ND, NABS, no bruits auscultated ext- no rash, no edema, warm, 2+ pulses neuro- alert and oriented x 3. CNII-XII intact. motor strength full. normal sensation skin- no hyperpigmentation, no jaundice affect- normal FAMILY HISTORY: no fh of auto-immune disease. brother with gout SOCIAL HISTORY: denies tobacco, occ ETOH. no IVDU. denies HIV risk factors. no tattoos. Works at a private high school. Irish descent, lives in [**Location 246**] now.

CHIEF COMPLAINT: Multifocal pneumonia, Acute renal failure PRESENT ILLNESS: [**Age over 90 **] y.o. male with dementia, prior left frontotemporal CVA, atrial fibrillation on warfarin, COPD by radiograph who presents from nursing home with dyspnea and found to have multifocal pneumonia on chest radiograph new from prior admission 12 days ago. According to patient's wife, he was in his normal state of health the day prior, which is demented, unable to walk and or perform ADLs, but had eaten a full meal. He reportedly has had problems with swallowing his foods and has been noted to cough after eating and drinking. To the best of the wife's knowledge, he has not had any sick contacts. Today, he was noted to have a dyspnea and a low-grade fever and was thus brought in to the ED for further evaluation. . In the ED, initial vs were: 100.8, 124/104, 137, 28-40, 99% NRB (89% RA), blood pressure dipped to 78/29 at 2100 prior to transfer and lactate was elevated to 6.2. CXR showed multifocal PNA and patient was given vancomycin 1g, zosyn 4.5g, and 650mg tylenol along with 1 liter normal saline. After discussion with patient's wife and HCP, it was clarified that patient is DNR/DNI. Additionally, the patient's wife expressed a desire to have no central access or pressors. Given his dyspnea and tachypnea, BiPAP was started and the patient was more calm. He was admitted to the ICU for further management. . On the floor, patient appeared comfortable and denied pain. He was able to follow commands. The patient's wife and son were engaged in a lengthy conversation during which the wife revealed that she is confident that the patient would not want anything to prolong his life given his current mental status and quality of life. She and her son expressed a goal of keeping him comfortable with BiPAP since it had been started and morphine if necessary for air hunger. The wife eventually expressed an interest in discontinuing antibiotics since she felt that they were counterproductive in the goal of not prolonging his life. It was also decided to hold IVF. See above. MEDICAL HISTORY: CVA 9 years ago, had TPA at [**Hospital3 **] Dementia Atrial Fibrillation on coumadin BPH Cataracts COPD by radiograph Anemia MEDICATION ON ADMISSION: Coumadin 3.75 mg PO QD Aspirin 81 mg PO QD ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: T: 100.2, BP: 120/36, P: 87, R: 17, O2: 93% BiPAP General: Arousable, able to follow commands, oriented to self HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous Neck: supple, JVP not elevated, no LAD Lungs: Decreased BS bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses; + clubbing and 2+ pitting edema b/l. FAMILY HISTORY: NC SOCIAL HISTORY: Lives at [**Location 35689**] house, married.

CHIEF COMPLAINT: left-lower quadrant hernia, symptomatic PRESENT ILLNESS: 67yo F reports undergoing multiple repairs of ventral hernias throughout her abdomen over the past ten years, including left-upper quadrant, umbilical, and midline. She has had symptoms from the left lower quadrant, where a hernia was appreciated during an outpatient referral measuring ~10x15cm on exam. She presents for elective repair of these symptomatic hernias. MEDICAL HISTORY: COPD/emphysema from smoking IDDM depression s/p ventral hernia repair, open, with mesh, multiple. s/p appendectomy s/p TAH/BSO MEDICATION ON ADMISSION: Paxil 30' Avapro 150' Humulin 34units qam, 34units qpm Novalog sliding scale ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: In clinic: A&Ox3, NAD. VSS supple neck coarse BS decreased at bases BL RRR, no M/G. soft, NT, no R/G. large reducible hernias in LLQ, largest 10x15cm. FROM x4 extremities, nl gait and station. FAMILY HISTORY: SOCIAL HISTORY: + tobacco, 1ppd

CHIEF COMPLAINT: change in mental status PRESENT ILLNESS: 82 year old male with known cerebellar mass. He was imaged at the OSH and the mass has approximately doubled in size headache, no dizziness, no n/v, no visual changes. MEDICAL HISTORY: 1. Asthma 2. Osteoporosis 3. Osteoarthritis 4. s/p bilateral catarect surgery MEDICATION ON ADMISSION: Albuterol Inhaler, Colace, Advair, FoLIC Acid, Levothyroxine Sodium, Lorazepam, Metoclopramide, Pantoprazole, Risperidone, Trazadone ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Exam upon admission: T:96.3 BP:146/78 HR:104 RR:15 O2Sats:95% RA Gen: Patient is pleaseant, coopertive with exam and does not appear to be in pain HEENT: Pupils: PERRL EOMs-intact Neck: Very kyphotic, but no tenderness to palpation. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place. Speech fluent with good comprehension and repetition. No dysarthria or paraphasic errors. FAMILY HISTORY: non-contributory SOCIAL HISTORY: Lives with his step-son who is his only child and his HCP, his name is [**Name (NI) **] [**Name (NI) 36913**] and his cell phone number is: [**Telephone/Fax (1) 79899**]. According to Mr. [**Last Name (Titles) 36913**], his step-father is DNR/DNI. His PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27542**] at [**Location (un) **]. He is an ex-smoker, smoking up to two packs per day (not known over the number of years). Mr. [**Known lastname 61509**] does not drink alcohol. His bedroom is on the [**Location (un) 1773**], and he normally manages his ADLs.

CHIEF COMPLAINT: RLQ pain PRESENT ILLNESS: HPI: 74 y/o M with a PMHx of PVD, mild COPD, etoh/tob abuse, who presented to [**Hospital1 18**] with 1d of RLQ abdominal pain and worsening SOB. No N/V, +1 episode of nonbloody stools today. +chills, no fever. . In the ED, he had a RUQ U/S that showed concern for cholangitis. He was given CTX 1g IV x1, Flagyl 500mg IV x1. He was transfused 1u pRBC and transferred to the MICU for further management. Labs clotted and unable to be processed. Patient became hypotensiove requiring pressors. Smear was reviewed by heme-path and it was concerning for clostridium perfringens and started on broad Vanc, [**Last Name (un) **], [**Doctor Last Name **] & Clinda. MEDICAL HISTORY: 1) PVD 2) COPD FEV1 2.19L (85% pred) in [**2182**] 3) tob abuse 4) hyperlipidemia 5) Leukoplakia MEDICATION ON ADMISSION: HCTZ 12.5 qD Zocor 20 qD ASA 81 qD . Allergies: NKDA ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps FAMILY HISTORY: Father died at 92. Mother died of ? stomach cancer. SOCIAL HISTORY: He lives in [**Location (un) 538**] with his son. [**Name (NI) **] is widowed. ETOH: +4 etoh drinks/day. TOB: 1ppd

CHIEF COMPLAINT: dyspnea PRESENT ILLNESS: For a full admission note, please see MICU Green note. In brief, this is a 53 year old woman with PMH significant for T1-T2 paraplegia s/p MVC, recurrent UTI/PNA, chronically on 2L of oxygen at home, and anxiety who presented to hospital with shortness of breath and fevers. . Caretaker noted her to be breathing faster than normal prior to admission. She also reports recent dysphagia, concerning for aspiration pneumonia. At home does intermittently straight-cath, however she is unable to discern signs/sx of UTI. Per care taker, she was seen by Dr [**Last Name (STitle) 665**] several weeks again found to have +UA however no definite culture data so not treated. . In the ED she was found to have temp of 100.7 with O2 sat at 84% on 2L (baseline in low 90s) and SBP in 90s. Her WBC count was elevated and UA found to be positive. She got 2 L of fluid and was transferred to the MICU. Of note, she had a PICC line on admission. . While in the MICU, she started treatment for UTI with vanc and [**Last Name (un) 2830**] given hx of [**Last Name (un) 40097**]. She had a CXR that could not exclude pneumonia. She was also on levaquin for 3 days for legionella coverage but this was stopped on [**11-11**] when found to be negative. She has been getting chest PT and nebs and also reports some cough. Sputum culture growing coagulase positive staph and gram negative rods. She had 1 positive blood cx for coag negative staph and PICC line was pulled. . Prior to transfer to the floor her blood pressure was in low 100s, she was mentating well and had no active complaints. MEDICAL HISTORY: #T1 to T2 paraplegia status post a motor vehicle accident. #Recurrent pneumonia (followed by pulm - Last [**2149-4-9**]) - Per pulm, recurrent pneumonia likely from pulmonary toilet issues secondary to neuromuscular disease with improvement with consistent and aggressive bronchopulmonary therapy. - Prior sputum cultures + for MRSA, pan-sensitive Klebsiella, and Pseudomonas. #Recurrent UTIs in the setting of urinary retention requiring straight catheterization #COPD #Hx Pres syndrome #hepatitis C #anxiety #DVT in [**2142**] -IVC filter placed in [**2142**] #Pulmonary nodules #Hypothyroidism #Chronic pain #Chronic gastritis #Anemia of chronic disease #S/p PEA arrest during hospitalization in [**2147-10-3**] MEDICATION ON ADMISSION: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - one vial inh 4-6 hours prn BACLOFEN - 10 mg Tablet - 2 (Two) Tablet(s) by mouth in the morning; 1 (One) tablet at 4 pm and 2 (Two) tablets at bedtime CITALOPRAM - 20 mg Tablet - 2 Tablet(s) by mouth once a day CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - 2 Tablet(s) by mouth (1 mg) three times a day ESTRADIOL [ESTRACE] - 0.01 % Cream - apply to exterrnal gyn area twice a week IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90 mcg)/Actuation Aerosol - 2 puffs three times a day LEVOTHYROXINE - 112 mcg Tablet - 1 (One) Tablet(s) by mouth once a day LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply four patches to the affected areas once a day 12 hours off and 12 hours on - No Substitution LIDOCAINE HCL - 5 % Ointment - Apply externally to affected area once a day as needed for burning METHADONE - 5 mg Tablet - 1 Tablet(s) by mouth three times daily for pain METHENAMINE HIPPURATE - 1 gram Tablet - 1 Tablet(s) by mouth twice a day take with Vitamin C 500 OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth twice a day OXYBUTYNIN CHLORIDE - 5 mg Tablet - 2 Tablet(s) by mouth in the AM, one in the afternoon, and 2 in the evening OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for pain PREGABALIN [LYRICA] - 100 mg Capsule - 1 Capsule(s) by mouth three times a day SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth daily SUCRALFATE - (post d/c med) (On Hold from [**2148-8-27**] to [**2148-9-3**] for while taking levaquin) - 1 gram Tablet - 1 Tablet(s) by mouth four times a day TRAZODONE - 100 mg Tablet - 1 Tablet(s) by mouth at bedtime . Medications - OTC CALCIUM CARBONATE [CALCIUM 500] - (Prescribed by Other Provider) (On Hold from [**2148-8-27**] to [**2148-9-3**] for while taking levaquin) - 500 mg (1,250 mg) Tablet - 1 Tablet(s) by mouth twice daily pt unsure if 500mg or 600mg CATHETER [FOLEY CATHETER] - 14 Fr [**Year (4 digits) 12106**] - Use for urinary control/self catheterizaion as needed Dx: Neurogenic bladder, paraplegia (1 month supply) FACIAL-BODY WIPES [BABY WIPES] - [**Name2 (NI) 12106**] - USE AS DIRECTED PRN NEBULIZER - Kit - for use in home qd. dx: pneumonia NICOTINE - (Prescribed by Other Provider) (Not Taking as Prescribed) - 21 mg/24 hour Patch 24 hr - apply 1 patch daily as directed POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Not Taking as Prescribed: not on medication list provided by patient [**2146-6-15**]) - 17 gram (100 %) Powder in Packet - one pack by mouth once a day SURGICAL LUBRICANT JELLY [SURGILUBE] - Gel - as needed for straight cath ALLERGIES: Ativan PHYSICAL EXAM: Physical Exam on Arrival to the MICU VS: Tmax: 37.1 ??????C (98.7 ??????F) Tcurrent: 36 ??????C (96.8 ??????F) HR: 65 (62 - 80) bpm BP: 83/47(55) {83/45(55) - 93/74(77)} mmHg RR: 17 (12 - 23) insp/min SpO2: 99% General: Alert, oriented, agitated 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, mildly 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 Discharge exam VS 96.9 117/72 79 20 97% 2L General: Alert, oriented HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP difficult to assess, no LAD Lungs: few bibasilar crackles. good aeration CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, bowel sounds present, no rebound tenderness or guarding GU: + foley, no suprapubic tenderness Ext: warm, well perfused, 1+ LE edema halfway up shins. 2+ DP pulses FAMILY HISTORY: Mother passed away with lung disease. SOCIAL HISTORY: Lives at home with husband and 2 adolescent children. - Tobacco: 35-pack-years, quit several months ago, relapsed recently. - Alcohol: Denies. - Illicits: Denies.

CHIEF COMPLAINT: Fatigue PRESENT ILLNESS: 74 year old woman was diagnosed with aortic stenosis in [**2117**] after being worked up for a progressive decline in her activity tolerance due to fatigue. Echocardiogram in [**2117-10-1**] revealed moderate to severe aortic stenosis and mild to moderate aortic regurgitation. She was recently referred for stress testing where she was noted to have a progressive drop in systolic blood pressure with increasing workloads. She is now being referred for right and left heart catheterization to further evaluate. With regard to symptoms, she denies any chest pain or shortness of breath at rest or with exertion. She also denies lightheadedness, dizziness or syncope. Until recently, she was walking from a half a mile to a mile per day at a slow pace but she feels that her general energy level has declined significantly. She is now being referred to cardiac surgery for aortic valve replacement. MEDICAL HISTORY: Aortic Stenosis Hyperlipidemia Hx of shingles involving chest, neck and right shoulder COPD Depression Osteoporosis Arthritis D&C's Benign breast biopsies Right shoulder pain, ? Rotator cuff sprain Diverticulitis MEDICATION ON ADMISSION: HYDROCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth twice a day prn. Do not drive, operate machinery, or drink alcohol while taking this medication. As your pain decreases, take fewer tablets and increase the time between doses. Take a stool softener to prevent constipation. PAROXETINE HCL - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC ASPIRIN [ENTERIC COATED ASPIRIN] - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] - (OTC) - 500 mg (1,250 mg)-500 unit Tablet - 1 Tablet(s) by mouth twice a day MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain ALLERGIES: Amoxicillin PHYSICAL EXAM: Pulse:70 Resp:16 O2 sat: 100/RA B/P Right:149/69 Left:142/64 Height:5'1" Weight:135 lbs FAMILY HISTORY: Sister with a stroke in her early 70's. Father with "heart trouble", died at age 74. Mother died at age 70 with CHF, Sister with "valve problems". SOCIAL HISTORY: Lives with:son is currently living with her. Occupation:retired Tobacco:5-pack a day for approximately 50 years. She is attempting to quit, currently smoking 3 cigarettes per day ETOH:denies

CHIEF COMPLAINT: Heart murmur PRESENT ILLNESS: Mr. [**Known lastname **] is a 37 year old male who was recently noted to have a significant change in long standing history of heart murmur. A follow up echocardiogram revealed bicuspid aortic valve with severe aortic insufficiency. It was also notable for a dilated aortic root and ascending aortic aneurysm measuring 7.5 centimeters. Subsequent chest CT scan confirmed marked dilatation of the ascending thoracic aorta measuring up to 8.4 x 8.5 cm. In preperation for cardiac surgical intervention, he underwent coronary CT angiogram which showed a left dominant system and normal coronary arteries. MEDICAL HISTORY: Biscuspid Aortic Valve, Aortic Insufficiency, Aortic Aneurysm, History of Migraine Headaches, Asthma, Chronic Rhinitis MEDICATION ON ADMISSION: Atenolol 50 tid, Lyrica 50 [**Hospital1 **], Magnesium 250 qd, MVI, Wellbutrin 100 tid, [**Doctor First Name **] 180 qd, Advair, Albuterol, Astelin, Flonase ALLERGIES: Sulfa (Sulfonamides) / Bentyl / Demerol PHYSICAL EXAM: Vitals: 110/50, 76, 12 General: WDWN male in no acute distress HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm, [**4-19**] diastolic murmur throught precordium Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally(bounding) Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted FAMILY HISTORY: Denies premature coronary artery disease SOCIAL HISTORY: Denies tobacco. Admits to only social ETOH. Currently lives with his partner and works in data and information management.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 47 year old male with no significant past medical history who started vomiting after eating a buffet lunch the day prior to admission. He was sleepy when brought home and was found on the floor near the bed. It is unknown if he fell, but he was taken to bed, where he continued to vomit. The patient's wife brought him to a center for [**Doctor First Name **] Scientists, where he was observed and there he slept most of the night but continued to vomit. The patient was brought to the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Emergency Room. In the Emergency Room, his blood pressure was 220/140. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 39 year old Asian American male who was discharged from [**Hospital 10073**] [**Hospital 7637**] Hospital on the day prior to his admission to the [**Hospital1 69**]. He was found ambulating across the street in [**Last Name (un) 813**] with an unsteady gait and subsequently collapsed. There was no noted seizure activity per the EMTs who ultimately picked him up. He was taken by ambulance to the Emergency Department where he was found with eyes open but not responsive, GCS of 6. He was found to have two bottles of Benadryl, one open but none taken and the other apparently empty. In the Emergency Department at the [**Hospital1 190**], her vital signs were a blood pressure of 154/84, pulse of 184, and respiratory rate of 22, 100% on nonrebreather face mask. He was given an amp of Narcan without response. He had no response to painful stimuli. He was subsequently intubated for airway protection and was charcoal lavaged. He was also given five liters of normal saline via peripheral intravenous. The patient was subsequently transferred to the Medical Intensive Care Unit. MEDICAL HISTORY: Depression and question of hypercholesterolemia. MEDICATION ON ADMISSION: ALLERGIES: None known. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: As mentioned, he was recently released from [**Hospital 10073**] [**Hospital 7637**] Hospital after being admitted there from the [**Hospital 4415**]. He was admitted there for intent to poison himself. He is married for two years.

CHIEF COMPLAINT: Hypertension. PRESENT ILLNESS: (MICU Green Service) This is a 78 year old woman with a history of congestive heart failure, diastolic dysfunction, restrictive lung disease, who was in her usual state of health until the afternoon of admission when she woke up with mental status changes, increasing lethargy, and abdominal discomfort. The patient was noted to be clammy and afebrile on arrival to the Emergency Department. On arrival, she had a temperature of 100.8, systolic blood pressure 70s, heart rate 60 to 70s, and oxygen requirements of 90% on two liters. The patient was given two liters of normal saline with good blood pressure response, however, the patient had a desaturation to 70%. The patient responded with 100% nonrebreather. In the Emergency Department, the patient was given two grams of Ceftriaxone and 500 mg of Flagyl. Despite intravenous fluids, the patient's blood pressure continued to trend downward and the patient was started on Levophed drip for blood pressure control. Chest x-ray showed right lower lobe infiltrate. The patient had right internal jugular central line placed and the patient was transferred to the Intensive Care Unit. MEDICAL HISTORY: 1. Congestive heart failure, diastolic dysfunction with an ejection fraction greater than 70%. 2. Restrictive lung disease, FVC 0.6, 49% of predicted, FEV1 82% of predicted, FEV1/FVC ratio 69% of predicted. 3. Hypertension. 4. Gastroesophageal reflux disease. 5. Hyperlipidemia. 6. Mitral regurgitation. 7. Chronic renal insufficiency with a baseline creatinine of 1.3. 8. Degenerative joint disease/arthritis. 9. Iron deficiency anemia. 10. History of breast cancer. 11. Urinary incontinence. 12. Osteoporosis. 13. Diverticulosis. 14. History of right sided hiatal hernia. MEDICATION ON ADMISSION: 1. Fosamax 70 mg q.week. 2. TUMS 500 mg three times a day. 3. Protonix 40 mg once daily. 4. [**Doctor First Name **] 60 mg twice a day. 5. Lasix 80 mg p.o. twice a day. 6. Milk of Magnesia. 7. Lipitor 10 mg q.h.s. 8. Colace 100 mg twice a day. 9. Enteric Coated Aspirin 81 mg once daily. 10. Atenolol 25 mg twice a day. 11. Tylenol. 12. Flovent. ALLERGIES: Verapamil. PHYSICAL EXAM: FAMILY HISTORY: Significant for pulmonary embolus. SOCIAL HISTORY: The patient lives alone in [**Hospital3 **]. No history of tobacco and no history of alcohol.

CHIEF COMPLAINT: found down PRESENT ILLNESS: 71 yo woman with a h/o HTN, who was transferred from OSH to [**Hospital1 18**] after being found unresponsive. Her husband relates the story. She was sleeping soundly at 7am on Saturday [**2188-6-28**] when the husband left to run some errands. He returned home and found her lying on her left side beside her bed at 2:30pm. No emesis, stool incontinence or tongue biting, but she was drooling and incontinent from urine. She was unresponsive, an abrasion was on her left cheek. At OSH she was occasionally responding to commands, given narcan without response. CT scan at OSH showed hypodensity of the cerebral [**Male First Name (un) 4746**] and vague hypodensities in the anterior aspects of the thalami. No hemorrhage. (all per report, no scans to assess for myself). Upon admission to the ED she was completely obtunded, given narcan with minimal reponse. Admitted to the ICU. In the ICU, she was given ASA PR, extubated on [**6-29**], found to have a LLL infiltrate on CXR with febrile to 102, started on levofloxacin [**2188-6-30**]. Per the husband, she is active at baseline walking unaided. No recent illnesses, no complaints such as recent HA, tinnitus, diplopia, fevers/chills, CP, SOB, abd pain, diarrhea, constipation, BRBPR. She has low back pain x "many years" and takes darvocet prn. MEDICAL HISTORY: 1. HTN 2. low back pain - per husband, has had MRI in the past that only showed osteoporosis/arthritis, takes darvocet and relafen, scoliosis 3. s/p CCY 25 [**Month/Day/Year 1686**] ago 4. s/p rupture of the esophagus after dilation therapy for stricture in [**2177**], resulting in 35 day hospitalization course 5. ovarian cyst removal 6. Hysterectomy at age 28, cervical cancer 7. h/o ulcers several years ago, this is why she is not takin aspirin MEDICATION ON ADMISSION: 1. relafen 500mg qD (NSAID) 2. Amitriptyline 25mg qD 3. Prinovil 5mg qD 4. HCTZ 25mg qD 5. Evista 60 mg 6. darvocet 100/650, takes 4-6 tabs qD, for low back pain ALLERGIES: Codeine / Vitamin K / Tagamet PHYSICAL EXAM: Upon transfer to the floor: MENTAL STATUS: hypersolmnolent, not following commands or answering questions, not opening eyes to voice or pain. CN: eyes midline but unable to assess doll's head with c-collar in place, pupils equal 2mm->1.5mm bilaterally, consenual to light, no RAPD, wrinkles forehead symmetrically with pain, + corneal reflex bilaterally, + gag with suction MOTOR: unable to assess at this time. DTR: 1 throughout, no clonus, no snout, upgoing toe on right, downgoing toe on left [**Last Name (un) **]: purposefully responds to painful stimuli (reaches for her sternum with rub, purposeful movements in all 4 limbs to pain. [**Last Name (un) 7058**] & GAIT: unable to assess FAMILY HISTORY: Dad passed away at age 76 of heart disease, infection. Mom passed away at age 54 of a tumor or brain. No h/o stroke in the family. SOCIAL HISTORY: no tob/etoh/drugs, lives with husband of 51 [**Name2 (NI) 1686**], walks unaided, home maker her whole life. 2 healthy daughters and 4 healthy grandsons.

CHIEF COMPLAINT: altered mental status PRESENT ILLNESS: Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] is a 66 year-old woman with history of diastolic CHF, Stage 1A NSCLC, COPD, presenting to the emergency room with cough and dyspnea. Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] has frequent dyspnea at baseline, but over the past four days patient had noted increased shortness of breath and ocugh. She was supposed to have an endoscopy done last Thursday but it was cancelled because she was complaining of cough and dyspnea and anesthesia was not available for the procedure. She has been taking her home dose of toresemide, but has noted decreasing urine output over the past day. She has not been eating or drinking as much at home as she typically does. Denies fevers or chills. This morning her daughter noted that she had a low grade fever of 100 and seemed more confused. FS was 119 at that time. She was also complaining of worsened dyspnea, so she called 911. Of note patient was last hospitalized in either [**Month (only) 205**] or [**Month (only) 216**], but has not been hospitalized in the last month. Her daughter, who she lives with, has also been sick at home over the past week and also has a bad cough. In the ED, initial VS were: 99.6 68 126/59 28 100% Non-Rebreather. On arrival exam was significant for b/l wheezing and the patient was slightly confused. Labs were significant for creatinine of 1.9 (baseline 0.6 - 1), troponin 0.05, BNP 3247 (last was 900 in [**2112-6-12**]), leukocytosis to 11.6. ABG was 7.3/56/69 - last ABG in [**11/2111**] was 7.44/38/66. CXR with low lung volumes, known-stable RLL mass, and concern for right mid-lung pneumonia. Patient required BiPAP while in the ED. In the ED patient received albuterol and ipratripium nebs, nitroglycerin 0.4 mg SL x1, methylprednisolone 125 mg IV x1, azithromycin 500 mg IV x1, and ceftriaxone 1 gram IV x1. On arrival to the MICU, patient is on BiPAP. She is lethargic, but opens her eyes to her name. Patient nods that her breathing feels better on the BiPAP. She denies any pain. MEDICAL HISTORY: s/p Left Lower Lobectomy ([**10/2110**]) for mass - Pathology returned as a 2.0 cm undifferentiated large cell carcinoma, pT1aN0Mx, neg nodes clear margins, stage 1a. Currently followed by thoracic surgery for spiculated RLL lesion, which has increased in size and is concerning for malignancy. - Diastolic CHF (also with mild MR, AS) - A. Fib on coumadin - Cirrhosis (likely [**1-14**] NASH vs. congestive hepatopathy) - DMII c/w peripheral neuropathy - pansenitive e.coli uti - c. diff currently on fidaxomicin - COPD - Chronic venous insuffiency LE cellulitis - depression - anemia baseline hct 28.7 - HLD - Gastritis - Nephrolithiasis - Psoriasis - History of choleycystectomy - Obesity - Osteoporosis - Hypercholesterolemia MEDICATION ON ADMISSION: The Preadmission Medication list is accurate and complete. 1. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **] apply to affected area 2. Duloxetine 20 mg PO DAILY 3. Enalapril Maleate 20 mg PO DAILY 4. fidaxomicin *NF* 200 mg Oral [**Hospital1 **] planned through [**9-30**] 5. NPH 52 Units Breakfast NPH 56 Units Bedtime 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Nadolol 20 mg PO BID 8. Mirtazapine 30 mg PO HS 9. Omeprazole 40 mg PO DAILY 10. Pregabalin 150 mg PO BID 11. Torsemide 80 mg PO DAILY 12. Warfarin 6.5 mg PO DAILY 13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 14. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 15. Aspirin 81 mg PO DAILY ALLERGIES: Amoxicillin / Glipizide / Ciprofloxacin / Bactrim / Soriatane / Potassium Chloride / Bupropion / Calcium Channel Blocking Agents-Benzothiazepines / atenolol PHYSICAL EXAM: Admission Physical Exam Vitals: T: 100.8 BP: 110/51 P: 71 R: 14 O2: 100% on BiPAP (30% FiO2) General: Lethargic, but arousable to voice, on BiPAP HEENT: Sclera anicteric, PERRL, psoriasis on scalp Neck: supple, unable to assess JVP 2/2 habitus CV: Regular rate and rhythm, S1, S2, no murmurs appreciated Lungs: Diffuse rhonchi anteriorly, no rales or wheezes. Abdomen: obses, soft, non-tender, non-distended, bowel sounds present GU: foley catheter in place Ext: erythema of lower extremity b/l likely consistent with chronic venous stasis changes, 1+ pedal edema, 1+ DP pulses, Neuro: Lethargic, arousable to voice, follows simple commands, PERRLA, reflexes symmetric, asterixis Discharge Physical Exam Vitals: wt 77.3kg 98.7, 138/70, 69, 19, 96%2L General: NAD, sitting up in bed in NAD HEENT: Sclera anicteric, PERRL, psoriasis on scalp, subconjunctival hemorrhage obscuring white of the eye on the left, not into the [**Doctor First Name 2281**] at all Neck: supple, JVD 5cm above the clavicle CV: RRR, III/VI SEM at the base and II/VI holosystolic murmur in the mitral area Lungs: Crackles [**12-16**] way up the bases bilaterally Abdomen: obsese, soft, non-tender, non-distended, bowel sounds present GU: foley catheter in place draining clear yellow urine Ext: erythema of lower extremity b/l likely consistent with chronic venous stasis changes, 1+ LE edema up to knees, 1+ DP pulses, Neuro: AAOx3. no asterixis, tongue fasiculations FAMILY HISTORY: +fh for diabetes, no FH for malignances SOCIAL HISTORY: Lives with daughter. Retired file clerk in a law office. Current smoker 1 to 1.5 ppd (60 pack year history). No alcohol or illicits. Ambulates with a cane because walker doesn't fit well in hallways.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 67-year-old man with a past medical history significant for coronary artery disease, Wegener's granulomatosis and myelodysplasia (please see past medical history below) who presented with chest pain over the prior three days, as well as fevers and chills. Regarding fevers, the patient has a history of Wegener's granulomatosis with treatment with prednisone (still on 5 mg q day) and Cytoxan (discontinued in [**2113-12-18**]) and several admissions for fever and neutropenia in the past. On presentation for this admission, the patient reported having had low grade temperatures and odynophagia for approximately three days prior to admission, as well as mild cough and fatigue. He was started on levofloxacin two days prior to admission without significant improvement in symptoms. Then, on the morning of admission, he reported having fevers to 104??????, as well as shaking chills, for which he presented to the [**Hospital6 256**] Emergency Department. There, he received a dose of vancomycin, gentamicin, ceftazidime and Flagyl in the Emergency Department. While in the Emergency Department, the patient's systolic blood pressure dropped to the 80s and this was accompanied by lightheadedness and left sided chest pain. The patient's blood pressure improved with hydration. Regarding the patient's chest pain, the patient has an extensive history of coronary artery disease and is followed for this by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (see below for more detail). The patient reported substernal chest pain with swallowing that he was felt was dissimilar to past anginal pain. The pain did not radiate, was not associated with dyspnea, palpitations, nausea or vomiting. However, in the Emergency Department, in the setting of hypertension, the patient's reported onset of his left sided chest tightness that was indeed similar to his prior anginal pain. An electrocardiogram in the Emergency Department showed ST depressions in V2 through V5, as well as T-wave inversions in leads 1, AVL and V1 through V6. The patient was given aspirin and sublingual nitroglycerin with improvement in his left sided chest pain from 6 out of 10 in severity to 1 out of 10 in severity in the Emergency Department. His pain resolved by the time he arrived in the Medical Intensive Care Unit. Electrocardiogram findings also resolved with repeat electrocardiogram taken in the Intensive Care Unit. MEDICAL HISTORY: 1. Coronary artery disease A. Status post multiple interventions: Coronary artery bypass graft in [**2105**] with left internal mammary artery to the LAD, saphenous vein graft to the PL and saphenous vein graft to the PDA. B. Multiple catheter procedures: Stent x2 to the left circumflex, stent to the LAD, distal to the left internal mammary artery touchdown. Most recent catheter procedure: [**2114-6-4**], normal hemodynamics. Angiography significant for occlusion of the LAD mid segment with a patent left internal mammary artery and a patent distal LAD stent. Old RCA occlusion. Saphenous vein graft to the PL was found to be widely patent. Saphenous vein graft to the PDA was found to have 70% mid vessel stenosis. The patient underwent stenting of the saphenous vein graft to the PDA with 0% residual stenosis. C. Last echocardiogram prior to current admission (performed [**2114-1-29**]): The study was of relatively poor quality and revealed a left ventricular ejection fraction of 35% to 40%. Mild concentric left ventricular hypertrophy was seen with moderate depression of LV systolic function. Dyskinesis of the basal inferior and mid inferior segments was noted, as was hypokinesis of the basal inferolateral and mid inferolateral portions. Right ventricular size and function was normal. The patient was found to have moderate mitral regurgitation. 2. Wegener's granulomatosis was initially diagnosed as RA, later felt to be Wegener's in [**2111**]. The patient had been treated with prednisone and Cytoxan. Cytoxan was started in [**2113-10-18**] and discontinued in [**2113-12-18**]. 3. Myelodysplasia, receives transfusions every one to two weeks. 4. Hypertension 5. Hyperlipidemia MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. REPORTS GASTROINTESTINAL UPSET WITH CODEINE. PHYSICAL EXAM: FAMILY HISTORY: The patient's brother has coronary artery disease. The patient's mother was diagnosed with [**Name (NI) 2481**] disease. SOCIAL HISTORY: The patient is married and lives at home with his wife. [**Name (NI) **] smoked one pack per day x20 years, quit about 17 years ago. The patient reports alcohol use of approximately one to two drinks per week.

CHIEF COMPLAINT: Ischemic toes of left foot, toes 1, 2 and 3. PRESENT ILLNESS: This 76 year old male is admitted with the history of peripheral vascular disease who presents with a two to three week history of left foot ischemia with mild cellulitis of the dorsal aspect of the MTP joints of the first, second and third toes. Denies any constitutional symptoms. He denies chest pain, shortness of breath or rigors. He has been followed by a Dr. [**Last Name (STitle) **] at [**Hospital3 20284**] Center in [**Hospital1 189**] and was referred to Dr. [**Last Name (STitle) **] for distal bypass of the lower extremity. The patient arrives with CD ROM of his left leg arteriogram and is now admitted for further vascular care. MEDICAL HISTORY: Hypertension, hypercholesterolemia, history of coronary artery disease, silent myocardial infarction, history of insulin dependent diabetes mellitus type 2, history of peripheral vascular disease. MEDICATION ON ADMISSION: Include Vancomycin, Levofloxacin and Flagyl, Percocet, regular insulin sliding scale, Lipitor 40 mg daily, Digoxin 0.125 mg daily, metoprolol 100 mg B.I.D., Folate 5 mg daily, Prazosin 1 mg B.I.D., aspirin 325 mg daily, Lantus insulin and Lasix, doses not recorded. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: FAMILY HISTORY: Is positive for mother who is diabetic, brother with coronary artery disease and myocardial infarction. SOCIAL HISTORY: Occasional alcohol use. He has not smoked for 30 years.

CHIEF COMPLAINT: asthma exacerbation PRESENT ILLNESS: 53F h/o HTN, asthma, with several recent asthma flares p/w acute dyspnea 4d ago. She was admitted to MICU but never intubated. She was started on high dose steroids and frequent nebs with slow improvement. No evidence of pneumonia. Her O2 requirement has decreased steadily. Currenlty, she states breathing is little better. Has been c/o dizziness since admit. MEDICAL HISTORY: 1. Asthma-has had multiple asthma exacerbations requiring 3 hospitalizations, steroids; no intubations 2. HTN 3. Hyperlipidemia 4. polio- uses crutches at baseline MEDICATION ON ADMISSION: 1. Acetaminophen 650 mg QID prn fever/pain 2. Albuterol 90 mcg IH, 2 puffs tid prn 3. Albuterol sulfate 0.83 mg/ml IH, 1 unit qid prn SOB/cough 4. Clonazepam 0.5 mg po bid prn for sleep 5. Crolom 4% 1 gtt each eye q 6 hr prn 6. Docusate sodium 100 mg, [**2-3**] capsules po @hs prn constipation 7. Flonase 50 mcg NS, qd each nostril 8. HCTZ 25 mg po daily 9. Lipitor 20 mg po daily 10. Lisinopril 10 mg po daily 11. Loratidine 10 mg po daily 12. Naprosyn 375 mg po bid prn pain 13. Predisone taper finished 14. Prilosec OTC 20 mg po daily 15. Pulmicort 0.5 mg/2 m IH, one unit [**Hospital1 **] ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals are 96.9---123/74---90----22---99% 2lNC PE: NAD OP clear and dry, no thrush Lungs: mod air flow, faint exp wheeze anteriorly CV: RRR, nml S1S2 Abd benign FAMILY HISTORY: Non contributory SOCIAL HISTORY: Lives with sister. Vietnamese-speaking. Goes to senior day care 3x/week with parents. No tob/ETOH.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 76 year old woman who was found on the floor in her nursing home at 3:00 a.m. on the day of admission, status post a fall out of bed. The patient was taken to an outside hospital where a head CT showed a right frontal contusion. The patient was transferred to [**Hospital6 256**] for further management. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: L SDH PRESENT ILLNESS: 55 y/o M with history of liver cirrhosis presents s/p 1 day of headache and unsteady gait per friend presents to OSH. Per OSH reports, patient was seen in ED where he seized 3 times and was found to have L SDH on CT scan of head. He was loaded with dilantin and intubated, then transferred to [**Hospital1 18**] for further evaluation and management. Patient is sedated on propofol with a platelet count of 48 upon arrival to [**Hospital1 **]. MEDICAL HISTORY: liver cirrhosis, bipolar, hepatitis C MEDICATION ON ADMISSION: on [**2128-5-4**] at 5:31 PM after being made CMO. ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: O: BP:125/73 HR:73 R:18 O2Sats: 100%CMV Gen: patient is intubated on propofol HEENT: atraumatic, normocephalic Pupils:4-3mm bilaterally Neuro: Minimal EO to stimuli Pupils 4-3 mm bilaterally BUE purposeful BLE w/d to noxious L>R FAMILY HISTORY: NC SOCIAL HISTORY: ETOH, drink beer daily Lives with friend

CHIEF COMPLAINT: Coronary Artery Disease PRESENT ILLNESS: 57 year old woman with hyperlipidemia has recently been evaluated for intermittent chest pressure/squeezing that has been occurring over the past several months. These symptoms are occurring both at rest and with activity, but do not consistently occur with exertion. She was found to have tight left main coronary artery disease on cardiac catheterization today, now referred for cardiac surgery. MEDICAL HISTORY: Past Medical History Hyperlipidemia Remote diagnosis of mitral valve prolapse. No evidence on most recent echo Osteoporosis Past Surgical History s/p resection of benign colon polyps Appendectomy C-section x 2 MEDICATION ON ADMISSION: Metoprolol succinate 25 mg daily Simvastatin 10 mg daily Aspirin 81 mg daily Calcium Carbonatee-Vitamin D3 600 mg-200 mg 2 tablets daily Multivitamin Estradiol 10 mcg 3 x week ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Pulse:57 Resp:17 O2 sat: 95 B/P Right: 113/62 Height: 5 feet 5 inches Weight: 150 pounds FAMILY HISTORY: Mother with cardiac history SOCIAL HISTORY: Married with two children. Occupation:She is employed as an assistant manager for an independent living facility. Tobacco: Remote, quit [**2088**] ETOH: 6 drinks per weekend

CHIEF COMPLAINT: Chest pain and increasing DOE. PRESENT ILLNESS: 77 yo woman w/ h/o CAD, s/p CABGx4, PVD s/p stent, DM, HTN, dyslipidemia presents with chest pain and SOB x2 days, off and on. Also feeling "exhaustion" with minimal exertion. Sharp-type pain, substernal in location, burning and traveling up to her throat. Similar to her anginal type pain. She says the pain has been coming and going intermittently during the last two days, sometimes occurring at rest. Typically her pain is relieved with nitroglycerin. . She presented to [**Hospital **] Hospital night of [**8-20**] because the pain had worsened and was not resolving with 3 SL nitro and an ASA. Her VS were T 98.4, HR 86, BP 118/63, RR 18, satting 96% RA. On exam she had clear breath sounds with normal cardiac exam. Labs were remarkable for hct 27, chem 7 notable for creatinine 1.2; LFTs were normal. CK was 49 with CKMB-I of 5.3. TropI was 0.07, repeat 0.14. Her EKG showed ST depressions in the lateral leads (I, aVL, and V4-V6). There was ST elevation in lead aVR. She was admitted to the ICU at OSH and started on heparin gtt, nitro gtt, Integrillin gtt, mucomyst and continued on amlodipine 10 mg, ASA 81 mg, Plavix 75 mg, Lasix 20 mg PO, metoprolol 50 mg TID, and simvastatin 80 mg qday. She was also started on 2units of blood for Hct <30 in setting of ischemia. She was then transferred to [**Hospital1 18**] for management. . She was transferred directly from OSH to CCU. At time of arrival to CCU, she is CP free. Denies palpitations, lightheadedness, or dizziness. . Of note, she presented to [**Hospital1 18**] with an NSTEMI in [**2157-4-24**] and underwent catheterization with BMS placed to a 90% stenotic but protected LM. The overlap segment was postdilated to 3.5mm. Final angiography revealed 0% residual stenosis, no angiographically apparent dissection and timi3 flow. The patient left the lab free of angina and in stable condition. She says that after this procedure she was CP free for several weeks, but believes that her anginal symptoms have worsened progressively since. . At baseline, says she can walk one flight of stairs before becoming SOB. Endorses lower extremity edema; sleeps on one pillow at night; denies orthopnea, paroxysmal nocturnal dyspnea. No new cough. No fevers. No melena or hematochezia. She has a history of anemia, says that "she is bleeding internally, but [**Last Name (un) 15025**] knows where." No fevers, chills, night sweats, weight loss of which she is aware. MEDICAL HISTORY: # (+) Diabetes, (+) Dyslipidemia, (+) Hypertension # Coronary Artery Disease s/p CABG x 4 # HTN # Peripheral Vascular Disease s/p stenting of her lower leg # Hyperlipidemia # Diabetes Mellitus x40 years, insulin dependent # s/p left tibial fracture 2 years ago # Hearing Impaired # Possible COPD vs Asthma - negative w/u for COPD as per patient. # Myelodyplastic syndrome - Hct on last hospitalization was mid 30's # Rotator cuff injury # Fib-tib fracture [**2154**] MEDICATION ON ADMISSION: # Lantus 10 U qhs # Regular insulin with meals # Norvasc 10 mg qday # Plavix 75 mg qday # Isordil 30 mg PO BID # Potassium 20 meQ qday # Simvastatin 40 mg qday # Avapro 150 mg [**Hospital1 **] # Metoprolol 100 mg PO BID # Lasix 20 mg qday # SL NG prn # ASA 81 mg qday # Fe Pills - unknown dose # Procrit qweekly for anemia ALLERGIES: Sulfa (Sulfonamides) PHYSICAL EXAM: VS: T97.6, HR 68, BP 153/46, O2 98% 2L NC GENERAL: elderly woman, hearing impaired, NAD HEENT: NCAT, pupils constricted, mildly dysconjugate gaze, NECK: JVD 2-3cm above clavicle at 45 degrees CARDIAC: RRR, no M/R/G LUNGS: Bibasilar rales, otherwise clear breath sounds ABDOMEN: softly distended, no masses, no rebound no guarding. EXTREMITIES: wwp, L>R non-pitting LE edema, SKIN: wwp, nevi on back PULSES: 2+ carotid pulsations, 1+ DP pulses bilaterally, FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death. SOCIAL HISTORY: Lives with son and two granddaughters. Independent in ADLs and IADLs. Tobacco history: has not smoked for 16 years. History of smoking 2PPD x40 years. ETOH: None. Illicit drugs: None

CHIEF COMPLAINT: Shortness of breath PRESENT ILLNESS: 77-year-old woman with known aortic stenosis and aortic insufficiency as well as mitral regurgitation and mitral stenosis presents with worsening CHF symptoms. She is well known to your practice and has been followed by you closely with serial echocardiograms, which have revealed worsening gradients and evidence of pulmonary hypertension. She does complain significantly of dyspnea on exertion, orthopnea, and increasing fatigue. She does deny any angina or syncope. MEDICAL HISTORY: Aortic stenosis/insufficiency, mitral stenosis/regurgitation(most likely rheumatic), hypertension, elevated cholesterol, atrial fibrillation, stroke with mild right-sided weakness, and osteoarthritis. She has undergone a hysterectomy and had a St. [**Male First Name (un) 923**] pacemaker placed in [**2180**]. MEDICATION ON ADMISSION: Atenolol 50 mg q.a.m. and 25 mg q.p.m., Digoxin 0.25 mg daily, Lasix 80 mg daily, Levothyroxine 100 mcg daily, Lisinopril 20 mg daily, Simvastatin 10 mg daily, Combivent inhaler, Coumadin daily as directed, Aspirin 81 mg daily, Multivitamin daily, and Tylenol p.r.n. pain. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: On examination, her heart rate is 60 and irregular, respiratory rate 18, blood pressure on the right 154/64 and on the left 153/60. She is 68 inches tall weighing 225 pounds. She is in no apparent distress. Skin was unremarkable as well as the HEENT examination. Neck was supple with full range of motion. Lungs were clear bilaterally. Heart was irregular in rate and rhythm with a mixed II/VI diastolic and systolic murmur. Abdomen was soft, nondistended, and nontender with positive bowel sounds. Extremities were warm and well perfused with 1+ peripheral. No obvious varicosities were noted. Neurologically, she is grossly intact with mild right upper extremity weakness. She has 2+ plus bilateral femoral pulses and radial pulses and 1+ bilateral DP and PT pulses. The systolic murmur transmits to both carotids. FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Mrs. [**Known lastname 6164**] is retired. She has a remote tobacco history. Her last dental examination was five months ago. She also denies use of any alcohol. She is currently living with her husband.

CHIEF COMPLAINT: Headache PRESENT ILLNESS: 73 year old female presents with a headache x 24 hours. She was recently on the neurosurgery service with bilateral SDH and she had the right one evacuated by Dr. [**Last Name (STitle) 548**] on [**2134-7-10**]. The patient did well post-operatively and was discharged on [**7-13**]. She was seen in the office for suture removal on [**7-20**] and was doing well and had no headache that day. The patient called neurosurgery in the evening of [**2134-7-30**] complaining of a headache that began the night before. She was told to go to the nearest ER. She had a head CT at the OSH that showed acute on chronic SDHs so she was transferred to [**Hospital1 18**]. The patient had a dilantin level of 3.0 and was given 500 mg at the OSH. She continues to have a headache that is behind her left eye but no other symptoms MEDICAL HISTORY: 1.Right sided subdural hematoma 2.DMII-insulin dependent 3.Osteoporosis 4.chronic low back pain 5.R sciatica pain MEDICATION ON ADMISSION: Lisinopril Dilantin Zantac ALLERGIES: Penicillins / Aleve / Ibuprofen / Valium / Codeine / Morphine / Oxycodone Hcl/Acetaminophen / Darvocet-N 100 / Vicodin / Levaquin / Rocephin / Cipro PHYSICAL EXAM: T:97.9 BP:126/58 HR:80 RR:16 O2Sats:100% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs-intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. 1+ bilateral pedal edema. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. FAMILY HISTORY: Mother and sister both had intracranial aneurysms SOCIAL HISTORY: Lives with daughter and husband in [**Name (NI) 1475**]

CHIEF COMPLAINT: respiratory failure/tylenol OD PRESENT ILLNESS: This is a 51 y/o female with PMH significant for HTN, NIDDM, hypothyroidism, who presented to an OSH early this morning with URI sx and cough x 2 weeks. Per the patient's husband, and later verified by the patient, she had been having URI sx and a non-productive cough for 2 weeks and occasionally low-grade temperature. She saw [**Name8 (MD) **] NP recently, who recommended OTC meds and also prescribed a "cough medicine", the name of which is not known. Her symptoms did not improve however and her cough progressed with symptoms of respiratory distress as well, prompting her to present at an OSH early this AM around 3 am. At the OSH, she was noted to be tachypneic in moderate distress, with VS of T 97.7, HR 77, BP 120's systolic, RR 26, SaO2 91%/RA. Her labs there was significant for WBC 17, Hct 31, tylenol level of 70 (at 4:40 am), Na 115 and ABG of 7.4/28/48 on ?room air. She received 400 mg moxifloxacin there, 125 mg IV solumedrol x 1, unknown dose of lasix, and a loading dose of IV NAC (10.5 gm). . Upon further history, the husband states that the patient has been taking NyQuil frequently due to her symptoms, however he is not sure how much she was taking as he is at work most of the day when she is at home. He notes that he thinks she finished an entire bottle of NyQuil on Friday (300 mL) and another half a bottle on Saturday (150 mL). It is unknown what formulation of NyQuil this was. He also does not know whether she was taking other cough/URI medications containing tylenol. Patient has a history of depression, however the husband denies any prior SI and does not believe the patient was trying to hurt herself with the NyQuil. . The patient was transferred to the [**Hospital1 18**] ED at 7 am due to lack of ICU beds at the OSH. Initial VS were T afebrile, BP 120's, HR 80's, 95%/4 L. The patient was in moderate resp distress with somnolent MS, so was electively intubated and set at AC 450x16, PEEP 5, FiO2 100%. An ABG was unable to be obtained prior to intubation. Tylenol level in the ED at 7:30 am was 45 (3 hours later from the initial level). She received vancomycin and doxycycline in the ED for CAP/ca-MRSA coverage. The patient was sent to the MICU for further management. Upon arrival, her ABG was 7.23/65/400's on the initial vent settings, so her RR was increased and TV was decreased. IV NAC was also started. . ROS unable to be obtained at this time. MEDICAL HISTORY: PMH (per husband) - DM II Hypothyroidism HTN Asthma Depression h/o Diverticulitis MEDICATION ON ADMISSION: (doses confirmed with the husband) Levothyroxine 50 mcg daily Singulair 10 mg po daily Atenolol 25 mg daily Lorazepam 2 mg PO QID prn (taking at least 3x/day) Metformin 500 mg [**Hospital1 **] Effexor XR 225 mg daily ALLERGIES: Codeine PHYSICAL EXAM: VS: Tc 96.6, BP 111/59, HR 70, RR 24, SaO2 95% on AC 350x30/0.6/5 General: intubated, sedated female HEENT: Pupils pinpoint and minimally reactive. Anicteric sclerae. ETT in place. Neck: supple, no JVD Chest: diffuse rhonchi throughout, no wheezes CV: RRR distant, no m/g/r Abd: soft, NT/ND, NABS, no HSM Ext: 1+ pitting pedal edema Neuro: sedated, does not withdraw to pain FAMILY HISTORY: FH - NC SOCIAL HISTORY: SH - Lives with her husband and son in [**Name (NI) **]. Does not work. Smokes 1 ppd x >20 years. Drinks approx 6 beers/week. Admits cocaine use, which was positive on tox screen at time of admission.

CHIEF COMPLAINT: Sternal drainage PRESENT ILLNESS: 82M who underwent AVR (tissue); CABG X3 on [**2163-5-5**] who was discharged to rehab on [**2163-5-17**]. He was then transferred to [**Hospital 5279**] hospital on [**2163-5-18**] with sternal drainage and a leukocytosis of 23,000. He was started on broad spectum antibiotics and then transferred back to [**Hospital1 18**] after 4 days at [**Hospital 5279**] Hospital. MEDICAL HISTORY: s/p AVR(#25 tissue)CABG x3(LIMA-LAD, SVG-PM, SVG-dRCA/PDA)[**5-5**] insulin-dependent diabetes mellitus severe dilated cardiomyopathy macular degeneration (partially blind) emphysema neuropathy left leg MEDICATION ON ADMISSION: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-4**] hours as needed for temp. 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours) for 5 days. 12. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection [**Hospital1 **] (2 times a day). 13. Potassium Chloride 20 mEq Packet Sig: Twenty (20) mEq PO Q12H (every 12 hours). 14. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous once a day. 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for wheezes. 16. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day as needed for a fib: adjust dose daily to target INR 2-2.5***2mg to be administered on [**5-17**]. Last 3 days recieved 5/5/5.* Tablet(s)* Refills:*0* 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). ALLERGIES: Benadryl / Ace Inhibitors PHYSICAL EXAM: Admission: FAMILY HISTORY: NC SOCIAL HISTORY: retired lives alone 20 pack-years -quit many years ago no recent ETOH use

CHIEF COMPLAINT: Displaced Nephrostomy Tube, Hyponatremia PRESENT ILLNESS: Ms. [**Known lastname **] is a 52 y/o F with a h/o stage IV appendiceal adenocarcinoma recently complicated by pseudomonal urosepsis from bilateral hydronephrosis requiring the placement of bilateral nephrostomy tubes who presents from home after one of the tubes has been displaced. She was recently discharged from [**Hospital1 18**] on [**2104-9-3**], at which time she was found to have pseudomonal urosepsis and was discharged on ciprofloxacin 400mg IV BID to complete a 14 day course, during that hospital stay she was also found to be hyponatremic with a sodium in the high 120's, thought to be due to SIADH. Today when her family was helping move her from the couch her right nephrostomy tube got caught on something and was accidentally pulled out so her family brought her to the ER to have the tube replaced. She currently feels weaker than her baseline but has trouble describing how she feels, denies any fever/chills, CP, SOB, n/v/d, HA or changes in her vision, denies any changes in her ostomy output. . In the ED, initial vs were: 98.7, 76, 92/72, 16, 98% RA. The initial plan had been to have IR replace the nephrostomy tube tonight, however when her labs returned this was put off. Her labs were notable for a white count of 33.7, Na of 114, K of 6.4, lactate of 3.8, and a BUN of 35. Her EKG was NSR at 97bpm, no peaked T-waves or PR prolongation, poor R wave progression. She was given 10 units of IV insulin, 1 amp of D50, calcium gluconate, her scheduled dose of ciprofloxacin, along with cefepime and vancomycin for her leukocytosis. A repeat K after treatment was 5.4 and her sodium was 116. While in the ER it was noted that her left sided nephrostomy tube was not draining anymore either. By report, after multiple discussions in the ER she refused kayexelate and placement of a peripheral IV, although she would like the nephrostomy tubes replaced for comfort, as she is no longer seeking treatment for her underlying cancer and is DNR/DNI on home hospice. VS on transfer were: 106, 104/74, 10, 100% on RA. . On arrival to the ICU her initial VS were: 95.8, 99, 101/75, 9, 99% on RA. She says that her pain is improved after the pain medication, she has no other complaints. Also on arrival to the ICU it was noted that her left sided nephrostomy tube was not draining or flushing. . Review of systems: (+) Per HPI and for anorexia (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation or changes in bowel habits. MEDICAL HISTORY: Stage IV appendiceal adenocarcinoma (pT3 Nx pM1b); K-Ras mutation confirmed - [**2102-11-3**]: Presented to [**Hospital1 18**] ED for progressive abdominal/pelvic discomfort. CT demonstrated "marked abnormal distention of the endometrial cavity measuring up to 6.5 cm" which was filled with high-density fluid. There was a possible mass within the cervix as well as a 2.2 x 3.2 cm cystic lesion within the right adnexa. Of note, the appendix was described as normal. TVUS revealed an enlarged right ovary with a complex cyst thought to be hemorrhagic, as well as an abnormal endometrial cavity containing a heterogeneous lesion with mixed solid and cystic elements, thought to be concerning for neoplasm. She was recommended to follow up with GYN. - [**2102-12-11**]: Endometrial biopsy demonstrated adenocarcinoma, endometroid type, grade I. - [**2102-12-12**]: Re-presented to [**Hospital1 18**] ED with continued lower abdominal pain as well as about a month's worth of vaginal bleeding. - [**2103-1-17**]: CA-125 elevated at 113 - [**2103-1-23**]: Went to the operating room with Dr. [**Last Name (STitle) 2028**] for a planned hysterectomy, bilateral salpingo-oophorectomy, and staging procedure for presumed endometrial adenocarcinoma. Intraoperatively, her appendix was noted to be "pulled down in towards the right adnexa." The right adnexa itself was completely adherent to the pelvic side wall and right fallopian tube. There was evidence of gross tumor on the anterior surface of the uterus. The left fallopian tube and ovary were also replaced by hemorrhagic mass. There was also a 2 cm nodularity on the omentum, worrisome for metastasis. Intraoperatively, she underwent rigid proctoscopy which showed no evidence of intralumenal tumor. Peritoneal washings were negative for malignant cells. Surprisingly, the pathology from this operation revealed the primary source of her cancer to actually be the appendix with a 1.5 cm histologic grade II primary lesion invading through the muscularis propria and into the subserosa/mesoappendix (pT3). This stained positive for cytokeratin 7, cytokeratin 20, ER, and CDX2, confirming this as an appendiceal primary. The same adenocarcinoma was found to be involving the right fallopian tube and ovary, uterus, cervix, omentum, and the serosal surface of the bowel wall (pM1b). There was no perineural invasion. K-Ras mutation confirmed. - [**2103-3-21**]: Began cycle 1 of FOLFOX; required 20% dose reduction of all medications after cycle 1 due to neutropenia; oxaliplatin stopped after 4 cycles due to neuropathy; completed sixth cycle on [**2103-8-22**] - [**2104-1-5**]: Presented to [**Hospital1 18**] ED with small bowel obstruction, thought to be due to intraperitoneal relapse. PET CT confirmed FDG-avidity of multiple peritoneal/pelvic implants and several liver masses. - [**2-/2104**]: Underwent evaluation by Dr. [**Last Name (STitle) 12982**] at [**Hospital1 336**] for hyperthermic intraperitoneal chemotherapy (HIPEC). Underwent debulking of intraperitoneal carcinomatosis by HIPEC was deferred given obvious hepatic metastases. - [**2104-5-15**]: Began cycle 1 of palliative FOLFIRI and bevacizumab; on day 27, was admitted to the hospital with a colovaginal fistula after complaining of stool per vagina - [**2104-7-15**]: Underwent a complicated surgical takedown of the enterovaginal fistula, diverting ileostomy, and repair of a bladder perforation with Dr. [**Last Name (STitle) **]. - [**2104-8-2**]: Presented to the ED with abdominal pain and leukocytosis. Found to have diffuse enteritis with new bilateral obstructive hydronephrosis and progression of peritoneal and hepatic metastases. Eventually discharged on home hospice on [**2104-8-10**]. MEDICATION ON ADMISSION: oxycodone 5 mg: 1-2 Tablets PO Q4H as needed for pain acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever: Max of 3 grams daily. Ativan 0.5 mg: One Tablet PO at bedtime as needed for insomnia ciprofloxacin 400 mg IV every 12 hours to end on [**2104-9-13**] ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Physical Exam on Admission: Vitals T 95.8 BP 101/75 HR 99 O2 99% on 2L NC General Appearance: Anxious, cachetic Eyes / Conjunctiva: PERRL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : throughout ) Abdominal: Soft, Bowel sounds present, Distended, Tender: throughout Extremities: Right lower extremity edema: 4+, Left lower extremity edema: 4+ Musculoskeletal: Muscle wasting Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person, place, time , Movement: Purposeful, Tone: Not assessed . Physical Exam on Disharge: Vitals T 96.1 BP 94/67 HR 96 O2 100% on 2L NC General Appearance: Anxious, cachetic Eyes / Conjunctiva: PERRL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : throughout ) Abdominal: Soft, Bowel sounds present, Distended, Tender: throughout Extremities: Right lower extremity edema: 4+, Left lower extremity edema: 4+ Musculoskeletal: Muscle wasting Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person, place, time , Movement: Purposeful, Tone: Not assessed FAMILY HISTORY: She denies any family history of breast cancer, ovarian cancer, uterine cancer, or colon cancer. SOCIAL HISTORY: She is married. She denies tobacco, drug, or alcohol use. She lives with her husband and son. She reports feeling safe at home.

CHIEF COMPLAINT: GI bleed Respiratory distress PRESENT ILLNESS: (History obtained from son and OSH record) 76 yo F with history of CKD recently started on hemodialysis (2 cycles as of [**7-20**]), h/o CVA x2, h/o RCC s/p nephrectomy, and recent known [**Hospital **] transferred from the OSH to the ICU for planned GI work-up; however, was in respiratory distress requiring intubation in the [**Hospital1 **] ED. . Per the son, she has been having increased lethargy, decreased energy, as well as LE swelling. Patient reported having had at least 1 week of melena and 1 day of hematemesis on [**2129-7-15**]. This led to her admission to [**Hospital **] Hospital on [**2129-7-15**]. At the OSH ED, she was noteded to have BRBPR and initial Hct of 25.3 from 30.5 on [**7-12**] and 34.4 on [**6-7**]. Per OSH record, her NG lavage in the ED was negative. Her hemodynamics remained stable. Subsequently, she was on Protonix gtt and IV hydration with GI consult. Her plavix was held. She apparently underwent an endoscopy by DR. [**Last Name (STitle) 30885**], which showed a bleeding friable large pyloric channel stalk polyp 4-5 cm as well as gastric mucosal friability. Per discharge summary, patient vomited blood on [**7-19**] and received DDAVP. During her time in the OSH, she was initiated on hemodialysis per her nephrologist's recommendations. Per the son, patient was supposed to be transferred over on [**7-19**] but did not get here until [**7-20**]. . Per the son, she had a colonoscopy that was not remarkable, except for polyps, last year. . Patient received a cycle of dialysis today before transfer. . Per ED report, patient became hypoxic en route to the 70s to endoscopy, so was rerouted to the ED. At triage, HR 69, BP 167/66, RR 25, O2Sat 85% on BiPAP. There was concern of pneumonia vs. fluid overload. She was placed on BiPAP then was intubated for hypoxic respiratory distress on fentanyl and propofol. Apparently, OG tube lavage did not show blood. Per ED report, patient had a living will from [**2117**] with DNR/DNI, but this was discussed with patient prior to intubation, and she agreed to it. She was given protonix 80 mg IV 1x, vancomycin, levofloxacin, and zosyn. Nephrology and GI were made aware of her. Bedside echocardiogram showed small pericardial effusion with left sided pleural effusion. Upon transfer, HR 58, BP 142/58, RR 16, O2Sat 100% on FiO2 80%, TV 400, RR set 18, and PEEP of 10 with fentanyl and propofol for sedation. . In the [**Hospital Unit Name 153**], she was quickly extubated without complication on [**7-21**] after HD ultrafiltration. She has been on 2L NC since. Echo showed EF 50% with apical hypokinesis attributed NSTEMI during this admission although trop elevations are only modest considering renal function and CK/MB not elevated. EKG notable for non-specific t-wave changes. She is on plavix as an outpt for hx of CVA, but this has been held in setting of GIB. . In terms of her GI bleed, she was found to have a large polyp leading to obstruction of pylorus. She was transfused [**2129-7-23**] 1 unit of pRBCs. Patient also noted to have bleeding [**Doctor First Name **]-[**Doctor Last Name **] tear on EGD on Monday [**2129-7-25**], after which she had 20 cc hematemesis but has had none since and has been hemodynamically stable the entire hospitalization throughout [**Hospital Unit Name 153**] stay. She has been on [**Hospital1 **] IV PPI, transitioned to PO PPI today and tolerating po intake. Her last transfusion was today [**7-27**] with HD, at which time she got 1 unit PRBC. She has received total 2 units (one today, one on [**7-23**]). . Her course was also complicated by MSSA bacteremia and a hematoma next to her AV fistula. Blood cultures drawn on admission to [**Hospital1 18**] grew MSSA, one out of four bottles. She is on cefazolin with Hemodialysis (2/2/3 g after HD on M/W/F, today day 7 of 14 - last day [**8-3**]). Initial concern for infected fistula given mild tenderness but ultrasound ok and vascular felt it was very unlikely (no graft). Subsequent cultures x 6 days no growth to date. . She also had thrombocytopenia and Plt 142 on presentation, that decreased to nadir of 69. Patient has not been on heparin at [**Hospital1 18**], but unclear if received at OSH or with hemodialysis. PF4 neg. Plts since rose to 110. In terms of ESRD, patient received HD session prior to transfer to the floor. Vitals in [**Hospital Unit Name 153**] prior to transfer to floor were as follows: T 98.7, BP 128/64, P 70, RR 14, O2sat 99% 2L. Pt arrived at the floor with no complaint of pain. MEDICAL HISTORY: (per [**Hospital **] Hospital record) - Upper GIB from bleeding large pyloric channel stalk polyp with diffuse gastric friability - Lower GIB - history of CVAs x2, was on plavix (until OSH admission. Initially on ASA-> Plavix. Did not tolerate Aggrenox per OSH record) - CKD stage 4, on dialysis (2 cycles as of [**7-20**]) - h/o renal cell cancer s/p nephrectomy - HTN - HLD - Anemia of chronic disease MEDICATION ON ADMISSION: Upon transfer from [**Hospital **] Hospital: - labetolol 100 mg po BID - Crestor 40 mg daily - Vitamin B12 1000 mcg po daily - Renvela 800 mg with meals TID - Sodium bicarb 648 mg po TID - Prilosec 20 mg po BID - nephrocaps 1 cap daily - Tylenol 650 mg q6h prn - Ambien 5 mg po qHS prn - Zofran 4 mg IV q6h prn . Home medications (per OSH record) - labetolol 200 mg [**Hospital1 **] - Crestor 40 mg daily - Plavix 75 mg daily - Calcitriol 0.25 mcg daily - B12 1000 mcg daily ALLERGIES: Hydralazine / Heparin,Porcine PHYSICAL EXAM: On admission: Vitals: T:97.1 BP:109/67 P:77 R:17 O2: 97%, CMV Vt450, PEEP 10, RR set at 18 General: intubated HEENT: Sclera anicteric, MMM Neck: supple, no LAD Lungs: bronchial breath sounds, clear to auscultation, no w/c/r appreciated CV: RRR, normal S1 and S2, soft [**2-10**] holosystolic and diastolic murmur, no rub or gallops Abd: soft, NT, ND, BS present, no guarding, no organomegaly, + old scar GU: Foley draining clear urine Ext: Cool extremities, 1+ edema to the thighs, 2+ DP and radial pulses bilaterally, no clubbing or cyanosis. FAMILY HISTORY: - father deceased at 66 with MI - mother deceased at 91 to colon cancer - 1 sister is in good health SOCIAL HISTORY: - lived at home with son - has 3 grown children: son [**Name (NI) **], daughter [**Name (NI) **] and another daughter - no tobacco or alcohol use per son - has been physically inactive for at least 1 year - stays at home most of the time, but has a good friend that she talks to twice a day

CHIEF COMPLAINT: fevers/chills, gastrointestinal distress PRESENT ILLNESS: 30 year old male well known to cardiac surgery with a history of AV endocarditis with MSSA in [**2137**] and [**2140**], enteroccocus in [**2142**], s/p AVR x 2 in [**2140**] and [**2142**] who presented to [**Hospital 57051**] medical center on [**2145-4-2**] with 1 week of intermittent crampy abdominal pain, fatigue, chills, diarrhea, loose stools, headache and neck pain. He states his pain originated 5-7 days ago, is sharp and constant in intensity, and was not relieved by over the counter analgesics. The pain in his head and neck with worse with changing positions. Upon arrival to the OSH, he was febrile to 100.7, found to have a WBC of 9 wtih bandemia to 18%, with blood cultures growing GNR in [**4-11**] bottles. He was started on vancomycin amikacin and cefepime (vancomycin was discontinued after GNR were discovered on culture). TTE demonstrated EF 55% with LVF, AV not well visualized, but no vegetations observed. Now found to have most likely recurrent endocaridits given progression on TEE, continuing to spike fevers and dital embolism secondary to vegetation. He was referred to cardiac surgery for redo AVR x4/+/-possible Bentall. MEDICAL HISTORY: 1. Bicuspid Aortic Valve- s/p Aortic Valvuolplasty at age 15 2. MSSA Recurrent Aortic Valve Endocarditis, ([**2137**], [**2139**]) ----[**12/2137**]: MSSA endocarditis: with a 6 week course of nafcillin and ultimately [**Year (4 digits) 1834**] a Bentall procedure utilizing homograft along with VSD closure and debridement of aortic root abscess. ----[**3-/2140**]: MSSA? Endocarditis: Redo aortic valve replacement with a size 27 mm Onyx mechanical valve and ascending aortic interposition graft with a size 24 mm Dacron graft 3. History of Septic Emboli to Spleen, Kidney and Cerebrum; hepatic pseudoaneurysm embolization in [**2137**] 4. Intravenous Drug Abuser; patient states last time used IVDs was prior to his last surgery in [**2139**]. 5. History encephalomalacia of the right parietal lobe from a prior infarct, and minimal chronic microvascular ischemic changes. 6. Chronic systolic heart failure MEDICATION ON ADMISSION: Carvedilol 12.5mg [**Hospital1 **] ASA 81mg daily Ferrous sulfate 325mg daily Warfarin 10mg daily ALLERGIES: Zosyn / Gentamicin PHYSICAL EXAM: Pulse:90 Resp:18 O2 sat:98/RA B/P 117/74 Height:5'[**43**]" Weight:100.9 kgs FAMILY HISTORY: Patient adopted and does not know family history. SOCIAL HISTORY: Quit tobacco just prior to admission h/o [**2-8**] ppd for 12 years. Denies ETOH over the last year. He currently lives with his parents. Several years of IVDU but denies since last AVR.

CHIEF COMPLAINT: Hypotension during platelet transfusion PRESENT ILLNESS: Mrs. [**Known lastname 3273**] is a 75 year old woman with amyloidosis (dx in [**2149**]) w/ restrictive cardiomyopathy on Revlimid and decadron, thrombocytopenia (suspected ITP), who was admitted for fevers and hypotension during a platelet transfusion. . Recent hisory, adapted from OMR: On day 17 of her 3rd cycle of Revlimid and Decadron, she presented to clinic for routine follow-up and was noted to have a dramatic drop in her platelet count from 173K to 5K over a two week period. She was admitted for a likely diagnosis of ITP and was initiated on a course of Decadron. She was discharged home the following day and on repeat count check on [**2151-11-5**] her platelet count was improved at 36K. She continued on a Decadron taper and upon her visit on [**2151-11-11**] her platelet count had dropped to 20K. The decision was made to start her on 4 weekly doses of Rituxan, which she received on [**2151-11-12**]. She was also switched to a prednisone taper at an initial dose of 60 mg po daily. On [**2151-11-16**] her platelets had dropped even more to 14K. Prednisone was stopped and she was started back on a Decadron course of 40 mg po x 8 days, which she completed on [**2151-11-23**]. She received her 2nd and 3rd doses of weekly Rituxan on [**11-18**] and [**11-25**], which she tolerated well without any infusion reactions. She was seen in clinic on [**2151-11-25**] and was noted to have a platelet count of 9k. About 10m into a unit of platelets, she developed a temp to 100.3 and was hypotensive to 87/49. She received fluids and the transfusion was stopped, however her pressures remained low. Cultures were drawn and her fever responded to tylenol. . In the [**Hospital Unit Name 153**], she was stabilized with fluid, 1u of platelets, and was given cefepime. She did not have any fevers. . Currently, she is feeling well. She has no complaints. She denies any obvious signs of bleeding including epistaxis, gingival bleeding, hematuria, melena, or BRBPR. She does note periorbital and perioral bruising. She denies fevers/chills, syncope, pre-syncope, abdominal pain, shortness of breath and chest pain. She has not had any increase in ostomy output, and had been started on fluconazole recently for thrush. She does note that during the event of hypotension/fever, she felt a "vacant" feeling. She states this resolved with tylenol and fluids. She has not had this sensation while admitted. MEDICAL HISTORY: # PAST ONCOLOGIC HISTORY: She initially presented in the fall of [**2149**] with four to five months of easy bruising and mild dyspnea on exertion. In [**Month (only) **], she was diagnosed with amyloidosis by bone marrow biopsy and an abnormal UPEP and was subsequently started on treatment with Velcade, melphalan, and Decadron. She completed six cycles of this with a plateau in her response. She then started on subcutaneous Velcade due to her neuropathy and GI intolerance. Shortly after she received this treatment, she was admitted for hemianopsia and found to have a TIA, from which she recovered without any sequelae. Further treatments with Velcade was deferred given her TIA, but she was noted to have a rise in her light chains and well as worsening kidney function and hypercalcemia concerning for progression of her amyloidosis. She was therefore started on Revlimid 15 mg daily for 21 day cycle with aspirin for DVT prophylaxis in addition to 20 mg po Decadron weekly. In summary of recent events: -[**11-12**]: D1 weekly rituxan for ITP, also steroids increased to decadron 40 mg daily x8 from [**Date range (1) 92781**] -[**11-25**]: D15 rituxan and platelets -[**11-26**]: 10 minutes into platelet transfusion BP 87/49, temp 100.3.Given dex 40. . # PAST MEDICAL HISTORY: -Amyloidosis with progressive restrictive amyloid cardiomyopathy -TIA (suspected secondary to Velcade) -Ulcerative colitis followed by total colectomy and ileostomy since [**2108**] -Dyslipidemia -Cholecystectomy -Left knee surgery -Urinary incontinence -Hypothyroidism MEDICATION ON ADMISSION: -ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth twice a day -DEXAMETHASONE - 4 mg Tablet - 10 Tablet(s) by mouth once a day (total dose 40 mg) for 8 days, last dose [**2151-11-23**]. -FLUCONAZOLE - 200 mg Tablet - 1 (One) Tablet(s) by mouth once a day for 7 days (started on [**2151-11-25**]) -FUROSEMIDE - 20 mg Tablet - by mouth daily -LENALIDOMIDE [REVLIMID] -On Hold from [**2151-11-1**] to unknown for low platelets) - 15 mg Capsule - 1 (One) Capsule(s) by mouth once a day x 21 days. -LEVOTHYROXINE [LEVOXYL] - 75 mcg Tablet - one Tablet(s) by mouth once a day - No Substitution -LORAZEPAM - 0.5 mg Tablet - [**11-22**] Tablet(s) by mouth every 8 hrs as needed for nausea, sleep, anxiety -METOPROLOL TARTRATE - 25 mg Tablet - 1.5 Tablet(s) by mouth twice a day -PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily -SIMVASTATIN - 10 mg Tablet - 0.5 (One half) Tablet(s) by mouth daily -ASPIRIN 81 mg - On Hold from [**2151-11-1**] to unknown for low platelets) - -CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Capsule - 1 (One) Capsule(s) by mouth once a day ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: On admission to the [**Hospital Unit Name 153**]: GENERAL: A well-appearing 75-year-old female in no acute distress, alert and oriented x3. HEENT: Anicteric sclerae. Extraocular movements are intact. Oral mucosa is moist, areas of echymosis, small white plaque on the back of [**Last Name (un) 46081**] mucosa. No ulcerative lesions, no gingival bleeding or thrush noted. NECK: Supple without adenopathy or thyromegaly. No JVD elevation (~ 9 cm) LUNGS: Clear to auscultation bilaterally without rhonchi, rales, or wheezes. Normal respiratory effort. HEART: RRR, + SEM [**12-27**] on LUSB. No murmurs, rubs, or gallops. ABDOMEN: Soft, nontender, and nondistended with normoactive bowel sounds throughout. Ostomy bag is in place (unable to see color of stool). Dressing is clean, dry, and intact. EXTREMITIES: Without edema and warm and well perfused. Pulses 2+ throughout SKIN: Scattered petichiae on ankle area, and multiple echymotic areas on her face (over right eye) on arms and legs. No rashes. FAMILY HISTORY: Son: had thyroid cancer mother: HTN, DM, CVA and died at the age of 63 Father: had prostate cancer with metastasis to the bone SOCIAL HISTORY: -Very independent woman who currently lives with her husband. She has 2 grown children. -Denies tob, etoh

CHIEF COMPLAINT: Syncope PRESENT ILLNESS: 84 year old female who was brought to the ED after syncope/fall, and is admitted to medicine due to elevated troponin. At her baseline, she feels well and is active, able to climb a few flights of stairs without complaints. She was brought to [**Hospital1 18**] Ed for further evaluation. During admission an echocardiogram was done and she was found to have aortic stenosis [**Location (un) 109**]=0.4 and is now being referred to cardiac surgery for an aortic valve replacement. MEDICAL HISTORY: -s/p fall a few years ago with small SAH fall MEDICATION ON ADMISSION: None ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission Exam: VS - Temp 99.7 F, BP 113/64, HR 72, R 20, O2-sat 96% RA GENERAL - well-appearing lady in NAD, comfortable, appropriate HEENT - EOMI, MMM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - CTA bilaterally HEART - PMI non-displaced, RRR, nl S1-S2 , grade 3 systolic crescrndo-decrescendo murmur that radiates to carotids; no loss of S2 and murmur is not late-peaking ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) --no pulsus parvus et tardus; left knee with 3cm area of erythema at site of impact but knee has full ROM and is not very tender NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-12**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, gait deferred FAMILY HISTORY: No MI, stroke. Mother died of "lung problems," father died of colon cancer. SOCIAL HISTORY: -Home: Married, lives with husband. Three grown kids. -Occupation: Retired dressmaker. -Tobacco: None -EtOH: None -Illicits: None

CHIEF COMPLAINT: Respiratory Distress PRESENT ILLNESS: The patient 71 year old female with a hx of breast cancer, recent dx of esophageal cancer (SCCa) approx 1 month prior, TE fistula s/p esophageal and Bronchus Y stent placement two weeks ago, who is followed by Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital3 **]. Please see admission note for full details. Briefly, she had a recent diagnosis of esophageal cancer. She presented to an OSH on [**7-17**] w/ acute onset wheezing and underwent endoscopy that reavealed large esophafeal mass and TE fistula. A esophageal and left main stent were placed on [**7-26**] and she was stent was placed on [**7-26**] and was intubated on [**2177-8-5**] for respiratory distress and left main stem obstruction. It was thought she had an aspiration pna and dislodgement of her bronchus stent. She was then transferred to [**Hospital1 18**] on [**2177-8-6**]. On [**2177-8-7**] she underwent Rigid bronchoscopy, flexible bronchoscopy, tumor destruction with mechanical forceps,tumor destruction with cryotherapy, and Y-stent placement. She was discharged home on tube feeds on [**2177-8-11**] following stent placement. She presented to clinic on [**8-19**] with severe nausea/ vomiting, treated with anti-emetics, dexamethasone and IV fluids without significant effect, and transferred to [**Hospital1 18**] for pallitative treatment. . Overnight she was having severe "retching" and was increasingly agitated. At baseline she is oriented x3, but per nursing she was confused, only oriented x1, and pulling and difficult to settle. She remained tachycardic in the 130's, with HR as high as 160's. She was given a total of ativan 0.25mg x2 and morphine 1mg this morning. She then triggered this AM for respiratory distress with O2 sats as low as 75%. She remained tachy in the 130's and BP 160/100. The patient had was refusing secreations and increasing agitated. The patient was spitting up clear secreations and complaining of not getting enough air. She was transferred to the [**Hospital Unit Name 153**] for emergent bronch to assess her airway. . On arrive to the [**Hospital Unit Name 153**] she was 100% on RA, tachypneic with RR 30's, tachy to the 130's. She was initially calm, but escalated with episodes of stridous breathing, increasing secreations and agitation. She refused suction due to pain. She also states that she "just want's to go home." . Spoke with the patient's husbnad over the phone and discuss her situation at length. He said she had similar episodes in the past when she is agitated and delerious that she will refuse treatment. However, he emphasized that when she is mentating clearly that she wanted everything performed including intubation and other invasic procedures. MEDICAL HISTORY: Stage II T2N0M0), left breast CA in [**2162**], s/p left mastectomy and 4 cycles of chemo with adriamycin/cytoxan limited due to Gi toxicity, and tamoxifen 20 mg for 5 years until [**2170**]. -Esophageal Cancer: dx [**2177-7-17**]. An endoscopy ([**7-21**]) and a CT scan were performed and showed a large esophageal ulcerating mass with TE fistula. Pathology revealed squamous cell carcinoma. . Depression. Chronic back pain with opioid addiction (per prior notes) GERD Hypertension Migraines Hiatal hernia with severe reflux status post pyloroplasty. palpitations Status post hysterectomy, status post cholecystectomy and status post left mastectomy. MEDICATION ON ADMISSION: 1. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for agitation or anxiety. Disp:*30 Tablet(s)* Refills:*0* 2. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1) Tab, Multiphasic Release 12 hr PO twice a day for 2 weeks. Disp:*28 Tab, Multiphasic Release 12 hr(s)* Refills:*0* 3. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three times a day as needed for cough for 2 weeks. Disp:*60 Capsule(s)* Refills:*0* 4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal Q72H (every 72 hours). 5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Transdermal once ALLERGIES: Codeine / Bactrim / Erythromycin Base / Penicillins / Prochlorperazine / Nalbuphine / Iodine / Phenothiazines / Aspirin PHYSICAL EXAM: Vitals - T:97.9 BP:145/92 HR:124 RR:18 02 sat: 100%RA GENERAL: extremely agitated and short shallow breathes. Episodes of stridrous breath sounds and expectoring clear secreations. Pt saying "I want to go home," thin frail appearing SKIN: warm and well perfused, no rashes visible HEENT: anicteric sclera, pink conjunctiva, patent nares, MMM CARDIAC: tachycardic, regular rate, S1/S2, no mrg LUNG: coarse rhonchi, episodes of stridorous upper airway sounds FAMILY HISTORY: non-contributory SOCIAL HISTORY: Married, lives in [**Location **], MA. Husband extremely supportive and is primary caregiver. [**First Name (Titles) 1817**] [**Last Name (Titles) 1818**], quit [**2148**].

CHIEF COMPLAINT: Mitral Regurg/SOB PRESENT ILLNESS: Mr [**Known lastname 6884**] is a 34yo male with a history of rheumatic heart disease, IV drug abuse, and recently enterococcal endocarditis in [**May 2174**]. He now has severe mitral regurg associated with increasing shortness of breath with minimal activity.Dr.[**Last Name (STitle) 914**] was consulted for MVR. MEDICAL HISTORY: 1.Rheumatic Fever 2. s/p endocarditis [**2163**] (IVDU) 3. s/p pericarditis [**2161**] 4. s/p ear surgery 5. s/p foot debridements for MRSA infection 6. negative for HIV at [**Hospital3 **] [**5-13**] 7. Hepatitis C 8. Enterococcal Endocarditis diagnosed at [**Hospital1 3494**] in [**Month (only) **], patient non compliant with antibiotics, admitted here late [**Month (only) **], c/b valve destruction and renal septic emboli 9. fungemia with PICC line 10. tooth abcesses 11. CKD stage II 12. ADHD 13. bipolar disorder 14. CT scan in [**6-/2174**] showed emphysematous changes and a right lower lobe nodule 15. h/o injection drug use 16. fibromyalgia MEDICATION ON ADMISSION: Methadone 20(2), Lyrica NF 100(2),Zolpidem 10qhslisinopril 10(1), Atenolol 25(1), Colace 200(2), Dilauded ?dose ALLERGIES: Penicillins / Erythromycin / Compazine / Aspirin / Ssri &Antipsych,Atyp,Dop&Serotonin Antag / Maois Non-Selective & Irreversible / Codeine PHYSICAL EXAM: Discharge Physical Exam: VSS: T:98'2,BP:100/61, P:63,RR:18, O2SAT:94% R/A General: A&O x3, NAD HEENT: AT/NC, wnl CVS:RRR LUNGS: decreased at right base, ess. CTA, Right thoracotomy site C/D/I ABD: soft, NT, +BS, midline incision with steri strips/C/D/I. EXT:warm, neg. C/C/E Right groin: staples intact, incision C/D/I FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death. SOCIAL HISTORY: Social history is significant for current tobacco use- 2cig/day. He has been drinking 1 qrt vodka/day for the last 2 weeks because he ran out of lyrica for pain, but says he normally drinks moderately. He is presently living his male partner independently. [**Name2 (NI) **] has smoked two to six cigarettes daily over the past 20 years. He states he has not used any illicit drugs since using amphetamines approximately 2 yrs ago.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 74-year-old woman, with a complicated medical history which includes a meningioma resection in [**2143**], [**2152**], breast cancer with lumpectomy in [**2154**] and [**2136**] with metastasis to the liver, and an AV fistula that was embolized in [**2156-3-1**] and then again in [**2156**]. The patient is again admitted for repair of AV fistula. The patient has been complaining of increased occipital pain due to this AV fistula. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: She appears her stated age. She is awake, alert and oriented x 3. Cardiac is regular rate and rhythm. No murmur, rub or gallop. Her lungs are clear to auscultation. Abdomen soft, nontender, nondistended, with a midline scar. Extremities - no clubbing, cyanosis or edema. FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Shortness of breath. PRESENT ILLNESS: This is a 54 year old gentleman with multiple medical problems including coronary artery disease, congestive heart failure, prosthetic mitral valve placement. The patient was admitted with shortness of breath and pulmonary edema. The patient was status post mitral valve replacement and tricuspid valve replacement, pericardial stripping on [**2123-8-10**]. He had a prolonged postoperative course complicated by failure to wean from ventilator with tracheostomy and percutaneous endoscopic gastrostomy tube placement and Methicillin resistant The patient was transferred to the rehabilitation center on [**2123-9-6**]. At that time, his weight was 184 pounds and he was on 40% trach mask. The patient has had problems with mild to moderate pulmonary edema since transfer. The patient had his right chest tube discontinued today on the day of admission. He had worsening shortness of breath afterwards. He was noted to be in pulmonary edema on examination and was transferred to the [**Hospital1 69**] for evaluation and treatment of his pulmonary edema and possible transfusion for low hematocrit. In the Emergency Department, the patient was found to be with a oxygen saturation in the low 90s on 50% trach mask. He was vigorously suctioned. Afterwards, he was 99% on 40% FIO2. He also was given Lasix 60 mg times one with good urine output 500 cc in the first two hours and 750 cc total. MEDICAL HISTORY: 1. Coronary artery disease, status post inferior myocardial infarction in [**2115**], complicated by left ventricular thrombus, status post left circumflex stent in [**4-1**]. 2. Congestive heart failure. 3. Status post mitral valve replacement and tricuspid valve replacement [**2123-8-10**]. 4. AICD [**4-1**]. 5. History of cerebrovascular accident secondary to coronary artery disease, residual left finger numbness. 6. History of Hodgkin's lymphoma at the age of 27, status post mantel radiation and splenectomy. 7. Hypercholesterolemia. 8. History of cervical discectomy. 9. History of nasal treatment. 10. Tracheostomy [**2123-8-25**]. 11. Gastrostomy tube placement [**2123-8-25**]. 12. Methicillin resistant Staphylococcus aureus pneumonia diagnosed [**2123-9-2**]. 13. Constrictive pericarditis. 14. Iron deficiency anemia. MEDICATION ON ADMISSION: 1. Amiodarone 400 mg q.d. 2. Captopril 6.25 mg q.d. 3. Thyroxine 125 mcg q.d. 4. Potassium Chloride 10 meq q.d. 5. Ranitidine 150 mg q.d. 6. Oxazepam q.h.s. 7. Coumadin. 8. Lasix 60 mg q.d. 9. Lovenox 60 mg subcutaneous b.i.d. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Father died from colon cancer. No history of coronary artery disease. SOCIAL HISTORY: The patient is married. He does not smoke or drink alcohol. He currently lives in [**Hospital1 **] Rehabilitation Center.

CHIEF COMPLAINT: Gait imbalance PRESENT ILLNESS: Ms. [**Name14 (STitle) 83615**] is a 75 yo RH woman with a PMH remarkable for HTN and migraines who is transferred from another hospital with a RIGHT cerebellar bleed. This information is collected through the patient and the prior conversation the ED team had with her sister. [**Name (NI) **] sister is the only next of [**Doctor First Name **]. She was in her USOH at 3:00 am as per her sister. She then woke up early in the am (unknown time) and felt fine till she got up to go to the restroom. She then felt unsteady and her vision was impaired ("things were out of place, upside-down"). She initially told me that things were spinning around, and then she told Dr. [**First Name (STitle) **] that was not the case. There was no double vision, no trouble speaking (not slurred or unable to produce proper speech) or understanding her sister as per the patient. She had no weakness or numbness. She did not vomit. She reports she sat down in the floor at the restroom. Her sister apparently reported that she had fallen. There was no LOC, though. No seizure-like activity. No Cp or SOB. She was transferred to [**Hospital 19672**] Med Center were she was running SBNPs 210-180 and received labetalol 10 mg iv when her CT CNS showed a Right cerebellar stroke. At the time exam was normal as per ED report. No events while transferred by EMS. Once at [**Hospital1 18**], her SBPs were still 200s and she received 10 mg labetalol and then subsequently was started on a labetalol drip. She received platelets also as far as she was on daily ASA. Seen by neurosuregery (Dr. [**First Name (STitle) **] who felt the pt was not surgical now. Rest of ROS is negative otherwise. MEDICAL HISTORY: HTN, migraines. CNS bleeds ( ), brain aneurisms ( ), avm ( ) Strokes (-) Procoagulant conditions (-) CAD (-) , AF (-) DM (-), HLD (-), OSA (-) Seizures (-), migraine (-), CNS tumors (-) MEDICATION ON ADMISSION: ASA (Fioricet) ALLERGIES: Codeine PHYSICAL EXAM: Per Admitting Resident- BP 150-140/ 80. HR 80 bpm. Off ventilator: RR 12. SO2 100% RA. FAMILY HISTORY: CNS bleeds ( ), brain aneurisms ( ), avm ( ) Hx of early strokes (-) Seizures (-) CNS tumors (-) Demyelinating conditions (-) Autoimmune conditions (-) Procoagulant conditions (-) CAD (-) SOCIAL HISTORY: Does not really exercise, Tobacco (-), ETOH (-), Drugs (-)

CHIEF COMPLAINT: unsteady gait, slurred speech, headache, fall from bed PRESENT ILLNESS: 77 yo W h/o DM2, HTN, hyperthyroidism admitted [**8-17**] and p/w unsteady gait, slurred speech and HA on [**8-12**], fall out of bed on [**8-13**] which prompted hospitalization, and further decompensation on [**8-14**] with nonresponsiveness, likely due to R proximal MCA occlusion causing completed R entire MCA infarction MEDICAL HISTORY: Diabetes mellitus type 2 Hypertension Hyperthyroidism Colonic polyps s/p appendectomy s/p bilateral cataract surgeries MEDICATION ON ADMISSION: ASA 325 mg amiodarone 150 mg IV daily enalapril 1.25 mg IV q8h Lovenox 72.5 mg SC daily hydralazine 10 mg q6 Keppra 250 mg q12 metoprolol tartrate 50 mg PO daily Protonix ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: At Admission: General: Asleep, NAD, lying in bed comfortably. Head: NC/AT, no scleral icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity Cardiovascular: RRR, soft aortic murmur radiating to the carotids bilaterally Pulmonary: Equal air entry bilateraly, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema, palpable radial/dorsalis pedis pulses FAMILY HISTORY: Not known SOCIAL HISTORY: Divorced, has two children. No tobacco or ETOH.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 78-year-old woman with a history of hypertension, depression, anxiety and dementia who was admitted to the [**Hospital6 3872**] on [**2101-7-5**] with several day history of nausea, vomiting and and emesis of coffee ground material. At the outside 17,000 and was started on initially Levofloxacin and then the addition of Ampicillin and Flagyl. A CT scan performed on [**6-6**] showed dilated common bile duct with gallstones. She was thought to have bowel obstruction and was treated with bowel rest and hydration. On [**7-9**] she had respiratory distress and to have new left lower lobe infiltrate on chest x-ray. Nasogastric tube was placed with return of 2500 cc of bilious have increased lipase on [**7-7**] which was noted to be trending downward. She was transferred to [**Hospital1 190**] for further management and was admitted to the medical Intensive Care Unit. MEDICAL HISTORY: Includes hypertension, depression, history of left hip fracture, anxiety, legally blind, dementia, remote history of atrial fibrillation. MEDICATION ON ADMISSION: ALLERGIES: Pneumococcal pneumonia vaccine. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Hyperkalemia PRESENT ILLNESS: Mr. [**Known lastname 61289**] is a 25M with DM, ESRD on HD, recent PE at [**Hospital1 112**] [**3-8**] mo ago, who was sent in after routine labs showed hyperkalemia. MEDICAL HISTORY: Diabetes mellitus, type I. Diagnosed in [**2162**]. Poorly controlled with past DKA. Complicated with retinopathy, nephropathy. Hypertension, poorly controlled ESRD on HD MWF - nephrologist is [**Doctor Last Name 4090**] Pericarditis and pericardial effusion ?minoxidil related per renal note PE dx at [**Hospital1 112**] ~1mo ago per patient Chronic constipation Chronic anemia Oppositional defiant disorder MEDICATION ON ADMISSION: patient says he gets refills at [**Company 4916**] pharmacy [**Hospital1 8**] St in [**Location (un) 577**]. **many medications on hold as has not picked up for per [**10/2185**] DC summary he endorses names (with exceptions noted below) but can't recall doses. Lisinopril 40mg daily - on hold, not picked up since [**2186-2-22**] Clonidine 0.3mg patch qwednesday - on hold, last on [**2186-1-23**] Labetalol 800mg TID - last filled [**2186-2-23**] and picked up Hydral 10mg TID - last filled [**2186-2-13**] ASA 81mg daily - pt denies taking Sevelmer 667mg TID - on hold Famotidine 20mg QHS - last filled [**12/2185**] Simvastatin 20mg daily - last filled [**12/2185**] Metaclopramide 5mg q6h - not seen in system Insulin glargine 14 units [**Hospital1 **] and humalog sliding scale - picked up [**2-/2186**] Nephrocaps daily - on hold Colace [**Hospital1 **] prn - on hold Zofran prn Coumadin 8mg daily - on hold, not picked up Neurontin 300mg QHS - on hold, not picked up Celexa 20mg daily - on hold, last picked up [**2186-1-23**] Minoxidil 5g daily - on hold, last picked up [**1-/2186**] Iron - last picked up [**12/2185**] s/p Nifedipine 90mg XL . MEDICATIONS ON DISCHARGE [**Hospital1 112**] [**4-18**] Labetalol 400mg TID Lisinopril 40mg daily Losartan 50mg daily Coumadin 7.5mg QPM Tylenol 650mg Q6h Aspirin 81mg daily Clonidine 0.3mg/day Qweek patch Benadryl 25-50mg PO Q6hr Colace 100mg PO BID Fluocinonide 0.05% cream topical [**Hospital1 **] Folic acid 1mg PO daily Gabapentin 400mg QAM, 400mg PM, 600mg QHS Dilaudid 1-2mg Q4hr Hydroxyzine 25mg QID Ibuprofen 600mg PO TID Lantus 25units QAM Aspart [**2188-9-14**] Reglan 10mg TID with meals Nephrocaps 1 tab PO daily Nicotine patch Omeprazole 20mg daily Sarna lotion daily prn Senna [**Hospital1 **] Sevelamer 1600mg PO TID with meals ALLERGIES: Codeine PHYSICAL EXAM: Vitals 97 80 [**Telephone/Fax (2) 61292**]% on RA General Young man, scratching at body, no acute distress HEENT Anicteric, conjunctiva pale, MMM. PEARL, EOMI. +Bruxism Neck no JVD appreciated Pulm lungs clear bilaterally, no rales or wheezing CV regular S1 S2 no m/r/g +S4 Abd soft bowel sounds present nontender no bruit Extrem warm no edema palpable distal pulses. legs symmetric, nontender Neuro eyes closed but following commands, CN 2-12 intact aside light-only vision, full strength in bilateral upper and lower extremities, sensation intact to light touch, no pronator drift, able to sit up when asked to do so. Skin Multiple tattoos, nodules at sites of itching R tunneled catheter without tenderness or purulence. FAMILY HISTORY: Father, grandmother with diabetes mellitus. No relatives currently on dialysis. Mother with [**Last Name **] problem, details unknown to him. No history of clot. SOCIAL HISTORY: Lives with mother. On disability. Smokes since age 16 - he can't say amount. Denies recent alcohol use. Denies illicit drug use including meth or cocaine.

CHIEF COMPLAINT: Chest pain. PRESENT ILLNESS: 72 year old male with known CAD s/p CABG in [**2175**] (see below) and MI/PCI in [**2187**], chronic chest wall pain, who presented to [**Hospital 24356**] Hospital with complaints of worsening chest pain radiating to left arm and back, associated with diaphoresis and presyncopal symptoms. Given ASA, NTG, heparin, plavix load, zofran, morphine, lopressor 50 mg at OSH. Trop I up to 20; EKG showed antero-lateral ST depressions. Guaiac negative at the OSH. Of note, there was a question of pulmonary infiltrate on CXR, so patient was given CTX and azithromycin for CAP. MEDICAL HISTORY: 1. Coronary artery disease: a. Anterior STEMI / CABG ([**2175**]) - LIMA to LAD - SVG to OM - SVG to PDA - SVG to D2 b. Percutaneous coronary intervention ([**2177**]) - No intervention with one occluded SVG c. NQWMI / Percutaneous coronary intervention ([**2187**]) - LAD total occlusion proximally - LCx 90% occluded prox --> s/p stenting (3.0 x 18mm BX Velocity) - RCA total occusion proximally - SVG --> PDA patent - SVG --> OM total occlusion - SVG --> D2 90% distal stenosis --> s/p stenting (4.0 x 18mm BX velocity) 2. Hypertension 3. Chronic obstructive pulmonary disease 4. Gastroesophageal reflux disease: s/p Billroth II gastrectomy 5. Bipolar disorder 6. s/p diskectomy 7. s/p carotid endarterectomy 8. Chronic chest wall pain, followed at the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] management center 9. Splanchnic neuropathy s/p spinal cord stimulator implantation [**2191**]-removed in [**2192**] 10. s/p right hernia repair MEDICATION ON ADMISSION: Atenolol 25mg daily Captopril 12.5mg TID Percocet PRN ASA 81mg daily ALLERGIES: Ampicillin PHYSICAL EXAM: Blood pressure was 94/65 mm Hg while supine, intubated/sedated. Pulse was 64 beats/min and regular, respiratory rate was 15 breaths/min. Generally the patient was well developed, well nourished. There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 7 cm. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, murmurs, clicks or gallops. The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, clubbing or edema. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. FAMILY HISTORY: Non-contributory. SOCIAL HISTORY: Social history is significant for current tobacco use (1 pack every other day). There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death.

CHIEF COMPLAINT: Dysphagia PRESENT ILLNESS: 80F w hx Zenker's diverticulum s/p cricomyotomy/diverticulopexy [**8-12**] and now with recurrent dysphagia. Barium swallow was consistent with recurrent Zenker's diverticulum and patient presents now for surgical management. MEDICAL HISTORY: PMH: HTN, DM2, ^chol, OA/DJD, angioedema MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: ASA 81 QOD, Amlodipine - dose uncertain, HCTZ 25', Lovastatin 40', Qvar 80mcg 2INH [**Hospital1 **], ICaps MV, fish oil, Caltrate 600(1500)-400, Centrum silver MVI, metformin 1000mg [**Hospital1 **] ALLERGIES: Lisinopril / anti-bacterial soap / Unasyn PHYSICAL EXAM: Discharge P/E: VS: T: 98.8 P: 93 BP: 140/88 RR: 18 O2sat: 95% 2L GEN: WD, WN in NAD HEENT: NCAT, EOMI, anicteric CV: RRR, +S1S2 w no M/R/G PULM: CTA B/L w no W/R/R, normal excursion, no respiratory distress BACK: no vertebral tenderness, no CVAT ABD: soft, NT, ND, no mass, no hernia PELVIS: deferred EXT: WWP, no CCE, no tenderness, 2+ B radial/DP/PT NEURO: A&Ox3, no focal neurologic deficits DERM: no rashes/lesions/ulcers FAMILY HISTORY: No h/o DM. No other contrib fam hx SOCIAL HISTORY: Occupation: retired Drugs: none Tobacco: 1ppd for 60 years Alcohol: 1glass [**Doctor First Name **] or wine/night, no prev withdrawal Other: Lives in senior community, retired, daughter [**Name (NI) **] [**Telephone/Fax (1) 63926**] next of [**Doctor First Name **]

CHIEF COMPLAINT: Fever PRESENT ILLNESS: This is a 57 year old female with history of bipolar disorder and psychosis who had a TKR on [**2134-6-15**] and had been in rehab until she developed fevers to 104 and swelling in the left lower extremity yesterday. She was started on cephalexin and ciprofloxacin but continued to be febrile up to 104 today so she was brought to the ED. In the ED intial VS T 99.9, P 108, BP 106/57, RR 22, O2 96% on 4L. Exam notable for a very swollen left lower extremity that was quite warm with some erythema. Maximum heart rate was in the 130s. She received 3 liters IV fluid with improvement of her tachycardia to the 90's. She also received vancomycin and piperacillin-tazobactam for empiric coverage of infection. Ortho was initially concerned about septic arthritis and tapped the joint, but thought fluid was very clear and unlikely to be infected and therefore triaged patient to MICU. VS prior to tx BP 93/41,P 100, RR 25, O2 99% on 2L, CT w/o air. LENI negative. . Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. MEDICAL HISTORY: Bipolar disease with psychosis and an episode of NMS in [**2116**] Non-healing cellulitis in [**2129**] R TKR [**2132-8-18**] Spinal stenosis cholecysectomy OA Delirium Left Knee TKR [**5-/2134**] MEDICATION ON ADMISSION: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. Disp:*100 Tablet(s)* Refills:*0* 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 6. risperidone 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily). Disp:*28 syringe* Refills:*0* 8. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a day for 10 days. Disp:*30 Capsule(s)* Refills:*0* ALLERGIES: Haldol PHYSICAL EXAM: Physical Exam on Presentation: General: Tired and somnolent, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Left lower Ext: warm, swollen over right, no erythema, incision intact, adeqaute ROM FAMILY HISTORY: NC SOCIAL HISTORY: The patient denies tobacco or alcohol use. The patient has been at [**Hospital3 **] post-surgery but normally she lives alone and has two children. The patient's sister assists her during exacerbations of her bipolar disorder. Sister is HCP.

CHIEF COMPLAINT: cough/fever PRESENT ILLNESS: [**Age over 90 **] y.o. man with h/o seizure, orthostatic hypotension on hydrocort, prostate ca, and chronic cough, p/w worsening cough productive of sputum x 3 days. He has difficult getting the sputum out of his lungs. He also c/o right pleuritic chest pain only with coughing or movement, as well as fever at home. Also c/o increased weakness and difficulty using his walker. Denies sub-sternal CP, abd pain. . Upon arrival to ED, he had a rectal temp of 103.4, was tachycardic to 100 and tachypneic so code sepsis was called. His initial BP was 146/57 but dropped to 88/30. A right IJ was placed and he was given 3L NS. CXR revealed left retrocardiac and LUL pneumonia. He was given CTX and Azithromycin. His is requiring 4L NC. Per his PCP (Dr. [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 1313**]) his baseline SBP is in the 90s, last office visit, 98/60. . MICU Course: Patient was initially hypotensive and placed on neosynephrine for 12 hours for blood pressure support. After adequate hydration this was weaned successfully. He was started on stres dose steroids given he is on hydrocort 10mg [**Hospital1 **] at baseline for orthostatic hypotension. This was reduced back to his home dose within 24 hours. His O2 was weaned from 4L at the time of admission to RA by the time he was transferred to the medicine floor. Creatinine trended down from 1.4 to his baseline of 1.0. MEDICAL HISTORY: 1. Complex partial seizures 2. Prostate cancer, diagnosed 5 years ago. Being followed expectantly and treated with Proscar. 3. Sleep apnea with daytime sleepiness and sleep disordered breathing noted in past. Trialed on Modafanil but this caused oral buccal dyskinesias. Did not tolerate BiPap. Daytime sleepiness improved after discontinuation of Depakote. 4. History of orthostatic hypotension in remote past, on Cortef 5. Left eye cataract status post surgery 6. Ptosis on right as a result of surgery for detached retina 7. Peripheral neuropathy 8. ? Esophageal diverticulum 9. Pacemaker MEDICATION ON ADMISSION: MULTIVITAMIN TAB one po qd COLACE CAP 100MG one po tid RESTASIS 0.05% Oph OU [**Hospital1 **] AZOPT 0.1% Oph OU [**Hospital1 **] ASPIRIN TAB 81MG EC daily PROSCAR TAB 5MG one po qhs KEPPRA 750 MG TAB 1 [**Hospital1 **] CORTEF 10 MG TAB (HYDROCORTISONE) One po bid- NO SUBSTITUTION [**Doctor First Name **] CAP 60MG one po bid MUCINEX 600 po bid ALLERGIES: Depakote Er PHYSICAL EXAM: VS T 102 (rectal) BP 105/38, HR 97, RR 23, 92% 4L NC Gen: ill appearing, conversant HEENT: moist discharge from b/l eyes. PERRL, OP dry. No JVD Lungs: poor air mvmt. scattered crackle on left Heart: RRR nl S1S2, no M/R/G Abd: +BS, soft, ND/NT Ext: 2+ pitting edema of ankles b/l Neuro: AAO x 3 FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The pt is widowed since [**2151**]. Retired at age 70. Was on the Board of Directors at [**Hospital1 18**]. Former smoker of 10 pack years but quit 50+ years ago. Drinks one shot or cocktail nightly. Has 24 hour housekeeping and homecare assistance, driver. Walks with cane for past one year.

CHIEF COMPLAINT: The patient was admitted to the MICU service after a code. PRESENT ILLNESS: The patient is a 60-year-old male with diabetes, borderline hypertension, with a three week history of nocturnal cough elicited when supine as well as recent peripheral edema who presented to the Emergency Room with the complaint of fatigue, malaise, and collapse in the Triage Area. After collapse, the patient was found to be ashen in color, unresponsive. Paddle showed questionable artifact versus ventricular fibrillation. The patient was shocked and went into sinus bradycardia and was given epinephrine and Atropine. She went into wide complex tachycardia that seemed to be a left bundle branch block supraventricular tachycardia. He was shocked three times. He was given Amiodarone 300 mg. He went into sinus tachycardia. The patient was intubated after the first shock. D50 was given during the code. The ABG was 7.20, 49, 93, 16. After intubation, the ABG improved to 7.31, 37, 242, and 20. The family reports a three week history of dry cough at night when supine. No paroxysmal nocturnal dyspnea. He slept on two pillows. He has had recent leg edema bilaterally for the last several days. He also had shortness of breath on the morning of admission. He denied any fevers or chills, no nausea, vomiting, or chest pain. After the code, the patient's heart rate was 110, blood pressure 232/110, glucose 451. Cardiology did a bedside echocardiogram that showed good wall motion. The patient was taken to the Cardiac Catheterization Laboratory emergently which showed moderate elevated right and left-sided filling pressures, high-normal cardiac index, mild anterolateral hypokinesis of the LV. No mitral regurgitation. EF of about 50%. Pulmonary wedge pressure was 25. There was 80% stenosis in the small third diagonal and 80% in the ostium of the oblique marginal II, but otherwise diffuse disease. PA pressures were 40 systolic, 18 diastolic, with a mean of 28. The pulmonary capillary wedge pressure was again 25. MEDICAL HISTORY: 1. Diabetes. 2. Borderline hypertension. 3. Recent peripheral edema. MEDICATION ON ADMISSION: ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: The patient's mother had [**Name (NI) 2481**]. No other known family history. He is a former smoker, quit 30 years ago. Occasional alcohol. He is a retired tailor. He is married with several children. SOCIAL HISTORY:

CHIEF COMPLAINT: s/p motorvehicle crash PRESENT ILLNESS: Mr. [**Known lastname 70305**] is a 19 year old man who was a restrained driver of a car which was hit head on. MEDICAL HISTORY: denies MEDICATION ON ADMISSION: denies ALLERGIES: Augmentin PHYSICAL EXAM: Upon admission: Alert and oriented Cardiac: Regular rate rhythm Chest: Clear to auscultation Abdomen: Soft non-tender non-distended Extremities: Right arm open area, + pulses, +sensation/movment, Right leg, 1cm open wound on lateral thigh + deformity, + pulses, + sensation/movement FAMILY HISTORY: N/A SOCIAL HISTORY: Lives with mother on [**Location (un) 470**] of a house

CHIEF COMPLAINT: Tracheobronchomalacia PRESENT ILLNESS: Ms. [**Known lastname 85974**] is a 53-year-old woman who has had multiple admissions for respiratory trouble. She was found to have severe, diffuse tracheobronchomalacia. She underwent stent trial and her dyspnea improved. She had undergone a fundoplication for GERDwhich she tolerated well; but had no effect on her airway symptoms. She is being admitted for trachaelplasty. MEDICAL HISTORY: right breast cancer s/p lumpectomy (clear margins) and radiation [**2166**] fibrocystic breast disease Irritable bowel syndrome fybromyalgia gastroesophageal reflux disease asthma (on daily Prednisone) tracheobrochomalacia - as above; triggered by exercise, yelling, weather changes; had a recent negative exercise stress test (due to work-up of recent chest discomfort) anxiety disorder depression insomnia iron deficiency anemia B12 deficiency anemia Hysterectomy [**2137**]'s umbilical hernia repair [**2157**] MEDICATION ON ADMISSION: Advair 250-50 mcg [**Hospital1 **] [**Doctor First Name **] 60 mg [**Hospital1 **] Ambien 10 mg QHS Clonazepam 0.5 mg [**Hospital1 **] Calcium carbonate/Vit D 500 mg QD Singular 10 mg Daily Tricor 145 mg daily Venlafaxine XR 300 mg daily Xopenex NEbs [**3-26**] x day ALLERGIES: Latex / Penicillins / Codeine / Albuterol Sulfate / Demerol / Xanax / Monosodium Glutamate / Sulfa (Sulfonamide Antibiotics) / Dilaudid PHYSICAL EXAM: VS: T 97.6, BP 136/84, HR 95 reg, O2 sat 98% RA, wt 181.6 lbs, ht 167 cm Physical Exam: Gen: pleasant in NAD Lungs: clear t/o CV: fast RRR S1, S2 no MRG or JVD Abd: soft, NT, ND, incisions healed. Ext: warm without edema FAMILY HISTORY: Mother was diagnosed with thyroid cancer Father was diagnosed with coronary artery disease in his 60's (s/p 3vCABG), also DM and prostate CA Brother has HTN SOCIAL HISTORY: Used to be a medical assistant. Lives with husband and [**Name2 (NI) **] in [**Name (NI) **]. Has children, all healthy. Denies tobacco, EtOH or illicits.

CHIEF COMPLAINT: hyperglycemia PRESENT ILLNESS: Patient is a 54 year old male with PMH of type II diabetes on insulin(previous presentation for hyperglycemic, hyperosmolar state), hypertension, chronic kidney disease, and diastolic congestive heart failure presenting with hyperglycemia in the setting of not taking his insulin for 4 days. Patient states that he normally take 16 units insulin in the evening, but forgot the last few days. He glucometer broke and he got a new one that he did not know how to use. He says that over the last few days he has felt weak with poor po intake. Also on day prior to admission experienced abdominal pain and then n/v on morning of presentation. Patient denies fevers, cough, chest pain. He does report some nausea. He denies dysuria but does report urinary frequency and thirst. EMS initial blood sugar report was >600. . In the ED, initial vital signs were 98.0 83 165/76 16 100%. Glucose was noted to be >1000. Patient was noted to be drowsy, but arousable to voice. His lungs were clear to auscultation bilaterally. His abdomen was tender diffusely. Potassium was 4.4 with a creatinine of 5.9. Anion gap was noted to be 20. Chest X-ray was performed and showed no acute process. Urinalysis showed no evidence of infection, and no ketones. VBG was performed and showed 7.35/48/58/28 with a lactate of 1.7. Insulin 10 units IV were given and patient was started on an insulin gtt at 7 units per hour. He received 2 liters NS in the ED. Renal was consulted and requested urine electrolytes. . On arrival to the MICU, patient feels improved from presentation but still weak. MEDICAL HISTORY: 1) CKD Grade 5, currently being evaluated for transplant 2) Diabetes. He says he has had this for 23 years and has been on insulin for several years. He has a history of retinopathy and is status post laser surgery, and has some mild neuropathy. 3) Hypertension. He has had this about five years. 4) High cholesterol. 5) History of small CVA in [**2174**]. He said it was characterized by tongue heaviness and he has no residual. 6) History of congestive heart failure requiring admission in [**2181-1-10**]. 7) History of latent TB by PPD that was treated 15 yrs ago and then again he was started on INH in [**2180-10-11**]. 8) History of right Charcot joint surgery with hardware in place 9) Glaucoma MEDICATION ON ADMISSION: AMLODIPINE - 10mg qd CALCITRIOL - 0.25 mcg qd CALCIUM carbonate 200 mg PO BID CHLORTHALIDONE - 25 mg Tablet qd FUROSEMIDE - 80 mg [**Hospital1 **] INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen - per new sliding scale outlined in brief hospital course. INSULIN GLARGINE [LANTUS] - 16 units qhs Toprol XL - 200 mg qd Lisinopril 20 mg daily Niacin PO daily Fish oil PO daily ALLERGIES: Penicillins / simvastatin PHYSICAL EXAM: Physical Exam on Admission: Vitals: T: 99.1 BP: 177/84 P: 95 R: 22 O2: 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, 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 . FAMILY HISTORY: Family History: His family history is significant for HTN secondary to DM; no CAD. Both parents passed away from what he feels were complications from DM. He has had a brother and sister both pass away in [**2174**] from DM related complciations. He has 2 other brothers and 2 other sisters who are alive. SOCIAL HISTORY: From [**Country 2045**], lives with wife and 2 sons in [**Location (un) 686**]. Works for meals on wheels. Denies tobacco, etoh, illicits.

CHIEF COMPLAINT: weakness and syncope PRESENT ILLNESS: Mr. [**Known lastname **] is a 60 yo man with a history of CAD, nonischemic cardiomyopathy with an ejection fraction of 20% and ICD, DM, recent admission for decompensated CHF, who is transferred from [**Hospital3 **] for initial complaint of weakness and subsequent VT storm. . This afternoon, the patient reported sudden onset of lightheadedness followed by a fall, striking his head but without LOC. He called EMS. On transfer to the stretcher, his AICD fired. It subsequently fired 4 more times within 30 minutes. He was initially taken to an OSH and thought to be in a paced rhythm. It fired a fifth time there, at which time he was started on an amiodarone bolus of 150mg IV and started on a 1mg/min gtt. He was later given a second amiodarone bolus of 150mg IV. OSH Labs notable for hyponatremia to 122 and hypokalemia to 3.1. He received K 40mEq po, Mg 2gm IV. He also received morphine 4mg IV, ativan 1mg IV x 2, and 1 inch of nitro paste, then transferred to our ED. . On ED arrival, VS were: P 105, 116/82, RR 20, O2sat 92% on RA. EKG showed a wide paced rhythm. He had a transient episode of VF with a sixth firing, then conversion back to sinus. He was given K 40mEq po and 40mEq IV and continued on the amiodarone gtt. Interrogation of his ICD confirmed the 6 firings today as well as an additional firing each on [**1-21**] and [**1-23**] which the patient did not recall. He also has increasingly been ATP paced out of VT/VF since the end of [**Month (only) **]/beginning of [**Month (only) 1096**]. BNP 5317. His CXR showed fluid overload. Lasix 120mg IV was given with UOP of 350 cc within an hour. A NCHCT was done given his fall on coumadin; no acute intracranial findings were seen. VS on transfer: P 96, BP 94/69, RR 23, O2sat 98 on 3LNC. . Of note, the patient was recently admitted to our CCU from [**Date range (1) 87244**] after undergoing coronary angiography at LGH and being found to have a tight RCA lesion and occlusion of a large OM. The cath was complicated by hemodynamic instability and acute pulmonary edema requiring transfer here. Echo showed severe global hypokinesis with regional variation and mild AS. He was in afib and VT during his hospital course and was shocked by his defibrillator multiple times, so he underwent AV nodal ablation followed by a BiV pacer upgrade. He also underwent successful rotablation of the large RCA with IABP support intraop; attempt to open the OM was unsuccessful. His hemodynamics improved and patient was aggressively diuresed with improvement in his CHF. He was initially discharged on torsemide, but since his discharge from rehab, he has been on lasix 160mg [**Hospital1 **], which he felt has been more efficacious. He denies any dyspnea on exertion; no orthopnea (1-pillow), PND, edema. He saw his cardiologist 1 week ago, at which time he was noted to be hypokalemic. He was started on potassium 60mEq [**Hospital1 **] although as noted above, K was low on presentation. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. MEDICAL HISTORY: CARDIAC HISTORY: Positive for non-ischemic cardiomyopathy with ejection fraction 16%. -PACING/ICD: VVI AICD implated on [**2180-4-26**] 3. OTHER PAST MEDICAL HISTORY: Diabetes type II on insulin Hypercholesterolemia Peripheral neuropahty Hypertriglyceridemia Chronic systolic CHF Afib on coumadin Dilated non-ischemic cardiomyopathy Multinodule goitor likely due to amiodarone Past surgical history: Appy Chole Epigastric hernia repair Tonsillectomy AICD/pacemaker implanted [**2180-4-8**] MEDICATION ON ADMISSION: Metolazone 2.5mg Q Wed AM (was holding) Amiodarone 200mg daily Metoprolol succinate 12.5mg daily Lisinopril 5mg daily Lasix 160mg [**Hospital1 **] Potassium 60mEq [**Hospital1 **] Gemfibrozil 600mg [**Hospital1 **] Lipitor 40mg qhs Niaspan 500mg qhs Aspirin 325mg daily Plavix 75mg daily Coumadin 5mg as directed Famotidine 20mg [**Hospital1 **] Novolog 2 units qAC sliding scale Lantus 10 units qhs Vitamin D [**2172**] units qAM Multivitamin daily ALLERGIES: Penicillins / Actos / Percocet / Cephalosporins PHYSICAL EXAM: On Admission VS: T=96.2 BP=140/83 HR=93 RR=25 O2 sat=97% 3L NC GENERAL: Somewhat chronically ill-appearing Caucasian male appearing uncomfortable. Oriented x3. Mood, affect appropriate. FAMILY HISTORY: Father died with rectal cancer Mother has [**Name2 (NI) **] of colon ca, rheumatic valvular dz No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. SOCIAL HISTORY: -Tobacco history: Former smoker -ETOH: no etoh Is not married. Lives alone and was driving prior to admission. Has an elderly aunt and uncle who try to help him at home but pt has been very frustrated with them. Does not appear to have any other family. Has been compliant with therapy

CHIEF COMPLAINT: VT storm PRESENT ILLNESS: Pt is a 74-year-old male with a history of idiopathic dilated cardiomyopathy s/p CRT/D (ICD), VT on amioderone, admitted to OSH with [**Hospital **] transfered to [**Hospital1 18**] for possible VT ablation. Patient is poor historian, and information taken from transfer paperwork. Patient began to experience ICD firing 2 months prior to presentation. At that time, he was advised to take amioderone/mexiletine, but patient declined mexiletine due to concern of polypharmacy. On [**12-24**], patient's ICD again fired, and was admitted to [**Hospital 27292**] hospital. It appears that patient was asymptomatic to VT, and only felt a premonatory fluttering before shock. He denies any chest pain, SOB, lightheadedness, or syncope. While admitted, patient had recurrent VT, and was transfered to [**Hospital 33663**] Hospital for VT ablation on [**12-31**]. During that hospitalization, he was on azithro/zosyn, but does not appear patient had any clear infection. . At [**Location (un) 33663**], despite being managed on amioderone/lidocaine, patient had recurrent VT, which was reportedly broken with both ATP pacing and ICD firing. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 81446**] attempted a VT ablation. The patient became hypotensive and hypoxic during the procedure, and case was aborted. The patient was continued on amiodarone/lidocaine, and intially transitioned to mexiletine, but with recurrent VT, lidocaine was re-intiated. Patient transfered to [**Hospital1 18**] for further manegement. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. The patient says he has been experiencing a productive cough. All of the other review of systems were negative. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:: Dyslipidemia 2. CARDIAC HISTORY: -PACING/ICD: BiV-ICD 3. OTHER PAST MEDICAL HISTORY: . Idiopathic CM with NYHF III Mod-Sev MR Mild AS VT on amioderone B/L Knee OA s/p R Knee replacement [**2169**] Gout Unclear why on coumadin MEDICATION ON ADMISSION: Home Medications: Lipitor 40mg daily Lorazepam 0.25mg PRN Spironolactone 50mg daily Lasix 60mg qam; 20mg qPM Amiodarone 200mg daily Digoxin 0.125mg daily Cozaar 25mg daily Coreg 3.125 [**Hospital1 **] Coumadin Allopurinol . Medications at Transfer: Spironolactone 50mg daily Lasix 20mg qpm Lasix 60mg qam Carvedilol 3.125mg [**Hospital1 **] Lipitor 40mg daily Losartan 25mg daily Allopurinol 100mg [**Hospital1 **] Lidocaine gtt Baclofen 10mg q8 PRN Alprazolam 0.25mg q12 PRN Amiodarone ggt ALLERGIES: Codeine / Demerol / Heparin Agents PHYSICAL EXAM: VS: T=98 BP=114/63 HR=92 RR=14 GENERAL: Diaphoretic male, appears uncomfortable, moaning in pain. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Right pupil RRL, Anasacoria of left pupil EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI laterally displaced RR, normal S1, ? paradoxically spit s2, + s4, [**2-15**] early intiated blowing murmur loudest at apex. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Trace UE edema, no pre-tibial edema SKIN: ? infected papule in LUE, LLE slightly cool PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP diminished Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP diminished FAMILY HISTORY: No family history of early MI, otherwise non-contributory. SOCIAL HISTORY: -Tobacco history: No Quit smoking: -ETOH: Denies -Illicit drugs: No

CHIEF COMPLAINT: Slurred speech, nausea, vomiting PRESENT ILLNESS: Patient is a 53 year old right handed Italian American man with past medical history of left parietal stroke 1 year ago with slurred speech, right sided incoordination (followed at [**Hospital1 2025**]), obesity, atrial fibrillation on coumadin, diabetes, hypertension, hypercholesterolemia, CAD status post angioplasty, who presented to ED today for evaluation of several day history of slurred speech and 1 day of vertigo, nausea, vomiting. Patient is unable to give a history so history taken from his girlfriend. She states that she has noticed intermittent slurring of his speech for past 3 days. Yesterday, he seemed off balance and unsteady when walking. Then this morning, he had a right sided headache radiating from his right posterolateral neck up to over the vertex. Then around 10am, he started to have nausea and vomiting of non-bloody, non-bilious material. He became diaphoretic. He felt dizzy, like sensation room was spinning and felt unsteady when walking. EMS was called and he was transported to ED. Finger stick en route 175. Patient able to tell me that he has had double vision and problems with his hearing for months. No dysphagia. He feels like he is off balance and that he has to hold onto things to walk. His right side is clumsier than usual. He states this is exactly how he felt during his stroke, with exception of the nausea and vomiting. No recent illnesses, fevers, chills, chest pain, shortness of breath, palpitations, cough, sputum, abdominal pain, increased urinary frequency, dysuria. No new visual changes (states diplopia has been going on for months), comprehension difficulty, focal numbness, weakness, paresthesias. No bowel or bladder incontinence. MEDICAL HISTORY: 1. Stroke 1 year ago with slurred speech, right sided incoordination 2. Atrial fibrillation, on coumadin 3. Obesity 4. Diabetes mellitus 5. Asthma 6. Obstructive sleep apnea 7. Hypertension 8. Hyperlipidemia 9. CAD status post angioplasty 10. History of melanoma resection over abdomen, remotely 11. COPD MEDICATION ON ADMISSION: 1. Effexor 2. Lasix 3. Verapamil 4. Ativan 5. Cialis 6. Metformin 7. Nasacort 8. Percocet 9. Zantac 10. Digoxin 11. Potassium chloride 12. Coumadin 13. Magnesium oxide 14. Topamax (for mood) 15. Singulair ALLERGIES: Sulfa (Sulfonamides) / Penicillins PHYSICAL EXAM: PHYSICAL EXAM: Tc: 96.6 BP: 164/83 HR: 68, irregular RR: 16 O2Sat.: 100%/2 liters Gen: WD/WN obese male, diffusely diaphoretic, uncomfortable, in moderate distress. Stops at several points during exam to vomit. HEENT: NC/AT. Anicteric. MMM. Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No carotid bruits. Lungs: CTA bilaterally. No R/R/W. Cardiac: Irregularly irregular. S1/S2. No M/R/G. Abd: Soft, obese, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. No C/C/E. . Neuro: Mental status: Awake and alert, but extremely inattentive. Defers to girlfriend to answer questions. Cannot relate coherent history. Unable to recite [**Doctor Last Name 1841**] forwards and backwards. Did not register despite multiple attempts. Speech fluent with fair comprehension and repetition. Impaired naming for low frequency naming. Moderate dysarthria. No apraxia, no neglect. . Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Unable to cooperate with formal resistance testing. Blinks to threat bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus but complains of diplopia in all fields of gaze. Gets frustrated and looks to girlfriend when I ask him to explain further. V, VII: Right nasolabial lobe flattening. Facial sensation intact and symmetric. VIII: Hearing grossly intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Shoulder shrug strong bilaterally. XII: Tongue midline without fasciculations. No tongue weakness. . Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-30**] throughout. No pronator drift. . Sensation: Intact to light touch. Inattentive during rest of sensory exam. . Reflexes: Trace but symmetric. Left toe is downgoing. Right toe is upgoing. . Coordination: Right finger-nose-finger with mild dysmetria. Dysrhythmia on rapid alternating movements, fine finger movements. Normal on finger-nose-finger, rapid alternating movements on left. . Gait: Did not assess. Out of concern for possible posterior circulation problem, kept patient in bed with [**Name (NI) **] <30 degrees. FAMILY HISTORY: Girlfriend not aware if any history of neurologic disease. SOCIAL HISTORY: Divorced. 3 kids. Lives with girlfriend of 14 years. Smoker, quite several years ago. No tobacco, alcohol, drug use currently. Moved here from [**Country 2559**] 30 years ago.

CHIEF COMPLAINT: S/p cardiac arrest PRESENT ILLNESS: 46yoM with no cardiac history who was in the outpatient waiting area of [**Hospital6 2910**] on [**2117-8-4**], waiting for his wife who was having a procedure. He collapsed, had reported seizure-like activity and urinary incontinence, then had subsequent cardiac arrest, was intubated with ETT #7, received 1mg Epinephrine via ET tube, shocked once with return of palpable femoral pulses within 15-30 secs after first shock, and then given second 1mg Epinephrine. He began to move afterwards, but pupils were noted to be "midsized and not responsive to light." He was noted to have "spontaneous respiration" and then transferred to ICU. Review of the strips was concerning for VFib but ICU MD thinks maybe PEA. . Through his ICU course: ABG there showed 7.31/37/477/19; normal BMP/Ca/Mg, WBC 14.9, Hct 44, Plts 269. He was given 1gm Mg and started on Propofol gtt. L subclavian CVL was placed. ? infiltrate in RML on CXR for which he is on Clindamycin; there was also concern for ? L clavicle fracture that per discussion may be old (he is a steel worker and was seeing a doctor and PT for L shoulder pain previous to this). He is ventilated with 500 Tv, PEEP 5, FiO2 50%, and has had no issues on the vent. Exam on admission significant for pupils 2mm equal but not responsive to light, no doll's eyes, decerebrate posturing, fine tremor in BUE's, irregular rhythm with systolic murmur, wheezy lungs. Out of concern for the "seizure" they have CT'd his head which was negative, and did an EEG which did not show any seizure activity; per discussion they did not feel that he actually had any seizure. . Per discussion with NEBH ICU physician, [**Name10 (NameIs) **] was Wellens pattern in V3-4 with deep symmetric T waves. Echo significant for PASP 25-30, EF 55%, HK of mid to distal anterior free wall and anteroseptum. Initial Trop on ICU admission was 2.5 but was risen to 5 last night, and 11 this am. He has had no arrthymic issues. . This am, he continues on Heparin gtt 1300 (with prolonged PTT), Amiodarone 0.5mg/min gtt, and has been on 325 ASA, was Plavix loaded 600 and 75 daily, Atorvastatin 80 daily, Lopressor 25 q6, still intubated on Propofol. Just this am he has developed mild hypoTN to the 90's for which he is being bolused with IVF's, no pressors. Plan is to transfer to CCU and have cardiac cath at 11a today with Dr. [**Last Name (STitle) **]. . The pt's wife arrived and confirms he has no cardiac history, no h/o HTN, HL, DM, FHx, but does actively smoke a few cigarettes daily. His cardiac ROS was entirely negative before the event, is very active without complaints of angina, DOE, syncope, dizziness, swelling. . ROS otherwise with some musculoskeletal complaints; he had a herniated disc and subsequent lower extremity radiculopathic pain. She states he was doing PT, who wanted him to do some weight lifting, and then for the past week was having L shoulder pain (? L clavicle fx on CXR?). Also with some depression/anxiety from being on disability and not being able to work, otherwise all negative. . MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Former heavy smoker but has no cut down to a few cigs per day, but no h/o HL/HTN/DM/FHx 2. CARDIAC HISTORY: No prior known cardiac disease [**7-/2117**]: cardiac arrest requiring shock, ICU admission, echo showing WMA concering for LAD lesion, transfer to [**Hospital1 18**] for cath 3. OTHER PAST MEDICAL HISTORY: - Herniated vertebral disc and radicular sxs - L clavicle fracture incidentally noted on plain film - EtOH 14 yrs ago - ? depression/anxiety MEDICATION ON ADMISSION: - Trazadone 50 hs occasionally - Neurontin 100 occasionally - Flexeril prn ALLERGIES: Statins-Hmg-Coa Reductase Inhibitors PHYSICAL EXAM: Temp 100 p84 117/79 99% Vent settings AC 500x14, PEEP5, and 100% FiO2 Average, not-obese M in no distress, diaphoretic, intubated, not responding to verbal stimuli. PERRL from 4 -> 3, but no oculovestibular reflex. No scleral icterus. Deferred mouth exam. Internal jugular pulsations noted at 6cm above sternal notch at 30 deg, and prominent external jugulars noted, no Kussmaul's sign. CTAB on the anterolateral chest, looks synchronous with the vent but occasionally coughing, with tan-white thick secretions suctioned RRR with no murmurs, gallops, strong S1/S2, bilateral palpable DP and PT's Abd overweight but not obese, soft, NT ND, benign BLE's without edema, no chronic venous stasis changes. Extremities are all warm, not mottling. Neuro exam deferred FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: Deceased when pt was 3yo from multiple sclerosis - Father: Alive at 78, healthy SOCIAL HISTORY: Born in [**Country 4754**], has a brother in [**Name (NI) 4754**], married with 13 yo son. Wife = [**Name (NI) **]. Disabled sheet metal worker, currently not working due to L shoulder injury. Fairly active, walks his dog daily. Has one brother in [**Name (NI) 4754**]. - Tobacco history: Wife and pt share 3 packs of cigs per week - ETOH: Drank heavily but quit 14 yrs ago - Illicit drugs: None

CHIEF COMPLAINT: dyspnea on exertion, known aortic stenosis PRESENT ILLNESS: 81yo woman w/known AS, worsening dyspnea over last several months referred for AVR. Scheduled for preop cardiac catheterization prior to surgery MEDICAL HISTORY: 1. Aortic Stenosis 2. Mechanical fall c/b Subdural hematoma [**8-20**] and right orbital and nasal fracture, s/p ORIF and closed reduction 3. Anemia with baseline HCT around 30 4. Hypertension 5. DM II 6. CHF [**12-20**] Echo: EF 55-60%. Moderately severe AS with [**Location (un) 109**] 0.7cm2, peak aortic gradient 43mmHG, mean gradient 23mmHG. Mild AI. 2+MR (may be underestimated), [**1-17**]+TR. Moderate LAE, mild [**Last Name (un) **]. Moderate to severe pulmonary artery systolic hypertension. EF 55-60%. 7. Breast cancer s/p Left Mastectomy [**2148**] 8. Total abdominal Hysterectomy [**2152**] 9. Carpal tunnel surgery [**61**]. Urge/Stress incontinence: pt straight caths self 3x/day 11. Multiple urinary tract infections 12. Left femoral neck fracture [**2154**] s/p left hip hemiarthroplasty MEDICATION ON ADMISSION: 1. Quinapril 20 QD 2. Atenolol 100 QAM/50 QPM 3. Lasix 40 QD 4. Lovastatin 20 QD 5. Protonix 40 QD 6. Ativan 1 QHS/prn 7. Glucophage 500 TID 8. Folate 9. Vit B&E 10. Darvocet N-100 prn ALLERGIES: Reserpine / Phenobarbital / Niacin PHYSICAL EXAM: Preop: Gen- NAD Skin- Unremarkable HEENT- PERRL-EOMI, MMM- oropharynx benign, neck supple- no lymphadenopathy Pulm- CTA C/V- RRR Abdm- Soft, NT/ND/NABS Ext- warm well perfused Neuro- grossly intact FAMILY HISTORY: Mom had diabetes and HTN. No h/o heart disease. Breast cancer in mom and daughter. SOCIAL HISTORY: retired. Lives alone in [**Location (un) 620**]. Lost 2 husbands, the last in [**2147**]. has 3 daughters. Remote h/o smoking [**1-17**] gigarettes/day. No alcohol or illicit drug use.

CHIEF COMPLAINT: Syncope ? cardiac arrest - cooled as per protocol PRESENT ILLNESS: 74 yo M with unknown past medical history suffered an episode on unresponsiveness at a casino, underwent 5 minutes of chest compressions prior to regaining a pulse without defibrillation, and was ultimately started on a cooling protocol at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] prior to transfer to our ED. . Records of the event and his initial treatment are limited. We know that he was standing when he collapsed and suffered a minor laceration to his head. Chest compressions were started immediately and were continued for 5 minutes prior to rhythm analysis by an AED which did not advise shock. 300cc NS given by EMS and he was intubated prior to transport; unknown if any meds were given by the initial EMS team. . At [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], cooling protocol was started and pt given a dilantin load for question of seizure-like activity. NCHCT in OSH ED showed significant chronic microvascular changes, but nothing acute. CT PA showed no PE and borderline aneurysmal dilation of the ascending aorta (4cm). EKG showed atrial fibrillation with a ventricular response in the 120s, occ PVCs, IVCD (QRS 120). . Pt transported by [**Location (un) **] to [**Hospital1 18**]. Enroute he received 350mg fentanyl, 8mg pancuronium, 1mg ativan, 20/kg/min propofol. Cooling continued. . In our ED, he received 4.5 g zosyn IV for possible LUL infiltrate, ASA 325, plavix 300, heparin drip, metoprolol 25 po x1 and tylenol 1g PR. His EKGs were c/w atypical atrial flutter with 2:1 conduction. By the time he arrived in the CCU, he had converted to sinus rhythm. . Initial labs were notable for trop 0.23, ck 288, mb pending, cr 1.2, leukocytosis witha left shift, noraml coags. MEDICAL HISTORY: Pos H pylori 2 weeks before admission, treated with prevacid pack Hyperlipidemia Hypertension MEDICATION ON ADMISSION: Lisinopril 5mg QD Prevastatin 80mg QD Vitamin D unknown dose ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Gen: alert, oriented x [**3-1**], corrected wrong answers, poor recall of hospital events. HEENT: supple, no JVD CV: RRR, no M/R/G RESP: crackles left base, no wheezes. ABD: soft, NT, pos bs EXTR: feet warm, trace diffuse peripheral edema. NEURO: no focal defects, speech clear, poor short term memory but improving distant memory Extremeties: Groin Pulses: Right: DP 1+ PT 1+ Left: DP 2+ PT 1+ Skin: intact Access: PIV Tubes: Foley, placed 2 days ago for urinary retention. FAMILY HISTORY: positive for early cardiac disease SOCIAL HISTORY: He and his wife own a frame shop Functionally Independent before admission. pt is usually active at baseline, plays cards after work, goes to casino often WIFE: [**Name (NI) **] [**Known lastname 4777**] [**Telephone/Fax (1) 85049**] [**Location (un) 4047**], MA ([**Hospital1 **] / [**Hospital1 3597**])

CHIEF COMPLAINT: Shortness of breath PRESENT ILLNESS: 45 year old male with history of severe asthma requiring numerous hospitalizations and intubations in the past, now re-presenting with recurrent dyspnea and cough for 2 days. His productive cough started about 2 days ago, in the absence of any other URI symptoms. His shortness of breath began yesterday, for which he usually tries his nebulizer and a Z-pack. His nebulizer machine was not working overnight, he actually went to work the next day and he called [**Company 191**] in the morning to try to get another script to replace it. When this did not work, he drove himself from work to the pharmacy to pick one up and then gave himself a treatment on the way home. Before he got a chance to take his high-dose prednisone, he decided to come to the ED. He has been taking 50mg prednisone in a slow taper, but the goal dose was 30mg every other day until he was able to get off steroids entirely. . He was previously discharged from [**Hospital1 18**] after a similar presentation and ICU admission, felt to be consistent with a combination of asthma and COPD exacerbations. He received albuterol/ipratropium nebs q6h with clinical improvement in wheezing, azithromycin for antibiotic coverage, and was discharged on a prednisone taper to be determined by his outpatient pulmonologist, Dr. [**Known firstname **] [**Last Name (NamePattern1) **]. Prior peak flows were 350 on [**8-24**] and 300 on [**8-25**]. Prior admissions this year have followed a similar pattern, none of which have required intubations and have lasted 1-2 days. . In the ED, initial vitals were: 101.4, 137, 148/127, 92% on 4L O2. He received solumedrol 125mg IV, Magnesium 2g IV, Cefepime 1g IV, Levofloxacin 750mg IV, Combivent + albuterol nebs, and 1g tylenol for fever. Given his continued tachypnea and tachycardia as well as his prior history of severe asthma, the decision was made to admit him to the ICU for further monitoring. On transfer to the MICU, vitals were: Sats 91% RA, RR 28, HR 120, BP 121/102 (151/96 prior). . On arrival to the MICU, he is still very wheezy, but comfortable on RA. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. MEDICAL HISTORY: - Severe asthma --- [**2177**]: 6 hospitalizations since beginning of the year, all lasting 1-2 days --- More than 100 lifetime hospitalizations with multiple intubations (17) --- Most recent prolonged admission was in [**2169**], which was complicated by MRSA and xanthomonas bronchitis - OSA on CPAP at night - GERD - Avascular necrosis of the hip s/p left TKR [**6-/2175**] and shoulder repair from prolonged steroid use - L Achilles tendon rupture s/p repair MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Fluticasone Propionate NASAL 2 SPRY NU DAILY 2. Montelukast Sodium 10 mg PO DAILY 3. Omeprazole 20 mg PO BID 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 6. Loratadine *NF* 10 mg Oral daily allergies 7. Tiotropium Bromide 1 CAP IH DAILY 8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 9. Fluticasone Propionate 110mcg 12 PUFF IH [**Hospital1 **] home dose of 220mcg, 6 puffs [**Hospital1 **] 10. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation q4h SOB 11. Magnesium Oxide 400 mg PO DAILY 12. Guaifenesin ER 1200 mg PO Q12H 13. PredniSONE 50 mg PO DAILY for the last 3 days. Goal dose 30mg every other day for now, until able to taper. ALLERGIES: Fish Product Derivatives / Shellfish Derived / Peanut / Grass Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract PHYSICAL EXAM: Admission Physical Exam: Vitals: T: BP: 138/77 P: 93 R: 24 O2: 95% on RA General: Alert, oriented, mild respiratory distress HEENT: Sclera anicteric, MMM, oropharynx clear but mildly difficult to visualize, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: diffuse inspiratory and expiratory wheezing with prolonged expiratory phase. No crackles or rhonchi 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: nonfocal exam with CNII-XII grossly intact and full strength and sensation bilaterally FAMILY HISTORY: Maternal history of cancer and asthma. SOCIAL HISTORY: Smokes five cigarettes a day, ~30 pack-year history. Drinks ~1 bottle of wine per week. Occasionally uses marijuana. He is currently living with his wife and young daughter in his mother's house in [**Location (un) 583**], previously in [**Location (un) 5503**]. Currently has a lot of social stressors; his house in [**Location (un) 5503**] is being foreclosed. He lost his job as a Volkswagen car mechanic due to his asthma and has been a bus driver since then. He is married, has three children

CHIEF COMPLAINT: Hematemesis and fevers PRESENT ILLNESS: 67 yo M with history of COPD, CVA with residual left sided weakness, history of aspiration, hypertension. Was admitted to the MICU due to concerns for upper GI bleed, fevers, and hypotension. Patient was at his [**Hospital3 **] facility when discovered to have temp of 102 and was vomiting "blood and coffee grounds". Patient reports multiple sick contacts in his nursing home. Could not be more specific. He corraborates ED and EMT story of coffee ground emesis; however, cannot further elaborate. Denies current nausea or abdominal pain and denies seeing blood in his stool. . Upon arrival to the ED, patient's vitals were T 100.8, BP 106/60, HR 70, RR 18, O2sat 91% RA. Received total of 2 L NS due to blood pressures transiently to 90s systolic on several occasions. Pressures were minimally fluid responsive and systolics were never above 110. Had one rectal temp of 103 in ED. Was given Vancomycin and Zosyn in ED due to question of pneumonia. Blood cultures were sent prior to initiation of anitbiotics. Had UA sent, which was positive by dipstick, no culture was sent. Also received ondansetron and pantoprazole. Stools were noted to be dark brown and guaiac positive. NG lavage in the ED with small coffee ground specs, but otherwise clear. Type and screen was sent, two 18G IVs were placed. GI was made aware of the patient; however, did not officially consult in the ED. . ROS: (+)ve: coffee ground emesis, cough, fevers (-)ve: chest pain, dyspnea, orthopnea, hematochezia, abdominal pain, nausea, sputum production, constipation, diarrhea MEDICAL HISTORY: COPD HTN CVA with residual left sided weakness Dysphagia and aspiration pneumonitis h/o ETOH abuse MEDICATION ON ADMISSION: 1. Aspirin 325 mg daily 2. Multivitamin daily 3. Folic Acid 1 mg daily 5. Mirtazapine 45 mg at bedtime 6. Calcium Carbonate 500 mg chewable twice daily 7. Cholecalciferol 400 unit tab, two daily 8. Alendronate 70 mg PO every Tuesday 9. Docusate Sodium 100 mg twice daily 10. Simvastatin 10 mg daily 11. Psyllium one packet daily ALLERGIES: Shellfish PHYSICAL EXAM: VS: T 98.7, BP 99/40, HR 61, RR 18, O2sat 95% 2L NC GEN: NAD HEENT: PERRL, EOMI, oral mucosa moist NECK: Supple, no LAD, JVP at ~8 cm PULM: Inpiratory squeaks bilaterally anterior, decreased breath sounds throughout CARD: RR, nl S1, nl S2, no M/R/G ABD: BS hyperactive, soft, non-tender, non-distended, no organomegaly EXT: No C/C/E NEURO: Oriented to "hospital", date, year, current president SKIN: stage I on sacrum - skin is erythematous, boggy, no area of ulceration noted. FAMILY HISTORY: Reviewed and non-contributory SOCIAL HISTORY: Pt is a resident at [**Hospital3 2558**] nursing home. He is a former heavy smoker, prior alcoholic who has been abstinent for 5 yrs.

CHIEF COMPLAINT: C5 Fracture PRESENT ILLNESS: Mr. [**Known lastname 85633**] is a 20 yo RH man with no significant PMH. He states that he was drinking with friends [**2139-4-17**] ([**12-24**] drinks) and "did something stupid" jumping into the shallow end of a [**Doctor Last Name **]. He immediately felt that "there was something wrong" and struggled to get to the surface. He had severe pain and tingling in his arms and was transferred in C collar. He currently feels severe painful paresthesias in his arms and hands. They also feel weak as does his L leg. He denies neck pain. MEDICAL HISTORY: Denies MEDICATION ON ADMISSION: None ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Physical Exam: Vitals: T: 97.2 P: 87 R: 16 BP: 96/38 SaO2: 100% on RA General: Awake, cooperative, appears in pain, grimacing HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: C collar in place Pulmonary: CTAB Cardiac: nl S1 S2 Abdomen: soft, NT/ND Extremities: no edema FAMILY HISTORY: NC SOCIAL HISTORY: -in culinary school, mother is a physician [**Name Initial (NameIs) 85634**]: occasional (not on a daily basis) -tobacco: occasional -drugs: occasional MJ

CHIEF COMPLAINT: Respiratory Distress PRESENT ILLNESS: 79y/o F w/ dementia, non-verbal p/w respiratory distress and diarrhea. Pt. was recently treated for recurrent respiratory infection w/ augmentin and then developed diarrhea. She had been having diarrhea for several days and then today her son noted respiratory distress and brought her to [**Location (un) 620**] ED. At [**Location (un) **] her VS were initially 116/66, 89, 21 and 100%. Labs came back w/ bicarb of 10 and then lactate of 9. She was given 5L NS, levo and flagyl. U/A had >100 WBCs. WBC was 19 w/ 26% bands. Hct 36. She was intubated after discussion w/ son re: goals of care transferred to [**Hospital1 18**] ED and started on levophed at 0.8 for SBP 76. she got 2L more NS, cefepime and vanc IV. At [**Location (un) 620**] she had hyperkalemia w/o EKG changes and got insulin, D50. MEDICAL HISTORY: Dementia, nonverbal at baseline Left hip decubitus ulcer Sacral decubitus ulcer diabetes urinary retention CVA 8 years ago Recurrent pulmonary infections Old necrotic left great toe MEDICATION ON ADMISSION: Metformin 500mg QD Jenuvia tube feed MVI Vit C oral [**Name (NI) 10687**] MOM Artificial Tears Tylenol ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: T: BP: 110/55 P: 98 R: 22 O2: 97% FiO2 100%, CMV TV 400, PEEP 5 General: Unresponsive to stimuli, on vent and levophed drip at 0.8mcg/min. Extremities contracted. HEENT: Sclera anicteric, MMM, oropharynx clear, TMs impacted w/ wax. Pupils equal and reactive to light. Neck: Left triple lumen 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: foley present w/ cloudy urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, large decubitus ulcer/burn wound on L hip. L foot w/ necrotic great toe. FAMILY HISTORY: NC SOCIAL HISTORY: Living at home with the son. Immigrated from [**Country 651**] 18 years ago. Dependent on all ADLs. No smoking, no alcohol known.

CHIEF COMPLAINT: 71 year old female s/p laparoscopic ventral hernia repair on [**2105-5-4**] presents with nausea and vomiting and weakness. PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname **] is a 71-year-old woman who underwent a laparoscopic hernia repair approximately a month ago. She developed abdominal pain, nausea, vomiting and symptoms consistent with ileus versus bowel obstruction. She was initially treated with nonoperative management. She developed abdominal pain as well as leukocytosis necessitating surgical treatment. MEDICAL HISTORY: [**Known firstname 103294**] past medical history is significant for a possible heart attack, mitral valve prolapse, and a stroke in [**2096**]. She is uncertain as to whether she had a heart attack or not. She has had several echos of the heart, which have been negative. She has had stress test in the past. After her stroke in [**2096**], she underwent an endarterectomy. Diagnosed with ovarian cancer in [**2103**]. MEDICATION ON ADMISSION: avapro 225', citalopram 40', ASA 81', colace, percocet prn ALLERGIES: Shellfish PHYSICAL EXAM: 97.7 heartrate 144 blood pressure 80/60 respiratory rate 20 96% on room air. NAD comfortable NCAT slight anterior cervical LAD RRR Decreased breath sounds at right base Abdomen: Non-distended, normal active bowel sounds, soft, nontender throughout, well healing scars, no hernias Rectal guiac negative, no masses, small amount of brown stool. FAMILY HISTORY: FAMILY HISTORY: She denies any family history of cancer. SOCIAL HISTORY: SOCIAL HISTORY: She smoked in the past, but denies tobacco use for the past 5 years. She denies IV drug use or alcohol. She lives alone and has four cats.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 64-year-old female with a history of hypertension, type 2 diabetes, subarachnoid hemorrhage status post left middle cerebral artery clipping, left craniectomy, and VP shunt, who presents from [**Hospital 582**] nursing home with decreased responsiveness per her daughter for the past few days. The patient was diagnosed with proteus urinary tract infection on [**2196-4-18**]. She was started on amoxicillin 500 mg p.o. t.i.d. x7 days, but the sensitivity also showed proteus resistant to ampicillin. The fingerstick blood sugar prior to [**Location (un) 582**] had been 538 for which she was given 12 units of insulin on the date of presentation. She was also found to have a temperature of 100.3 at [**Location (un) 582**]. On arrival to the Emergency Room, she was thought to have urosepsis, and was given one dose of vancomycin IV given her history of MRSA, but no additional antibiotics. She was also found to have a sodium of 164, which when corrected was 170 and a glucose of 463. She was treated with 2 liters of normal saline. MEDICAL HISTORY: 1. Hypertension. 2. Type 2 diabetes. 3. Subarachnoid hemorrhage in [**2195-11-14**] status post a left middle cerebral artery aneurysm clipping status post a left craniectomy due to mass effect. 4. Status post a PEG and tracheostomy in [**12-16**]. 5. Status post a VP shunt in [**12-16**]. 6. GPC meningitis in [**2196**], which has coag-negative Staph x3. VP shunt was then removed and replaced. 7. Congestive heart failure. 8. Tracheal stenosis/severe tracheomalacia. 9. Anemia. 10. Colonization with MRSA and VRE. 11. Hypernatremia. 12. Nonverbal baseline. MEDICATION ON ADMISSION: 1. Prevacid 30 mg p.o. q.d. 2. Glucophage 1000 mg p.o. b.i.d. 3. Glyburide 5 mg p.o. b.i.d. 4. Dilantin 200 mg p.o. t.i.d. 5. Captopril 25 mg p.o. t.i.d. 6. Hydralazine 50 mg p.o. t.i.d. 7. Lopressor 50 mg p.o. t.i.d. 8. Free water flushes 300 cc via PEG tube t.i.d. 9. Tube feeds 70 cc an hour. 10. Zantac 150 mg p.o. q.d. 11. Sliding scale insulin. 12. Senna 2 mg p.o. q.d. 13. Vicodin 1-2 tablets q.4h. prn. 14. Amoxicillin 500 mg p.o. t.i.d. She was on day #4 for her UTI. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Lives at [**Hospital 582**] nursing home.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 78 year old gentleman with a complicated medical history who was transferred from [**Hospital 38**] Rehabilitation after being diagnosed with an L5-S1 epidural abscess and disc infection from an outside MRI scan. MEDICAL HISTORY: Includes: 1. Right popliteal dorsalis pedis bypass graft here at [**Hospital1 35990**] on [**2114-10-10**]. 2. Clostridium difficile colitis. 3. Diabetes mellitus, type 2. 4. Hypertension. 5. Stroke in [**2112**] with questionable left facial droop. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Bright Red blood per rectum PRESENT ILLNESS: MC is a 78 year old woman with significant PMH of IDDM, HTN, elevated cholesterol, CRI. She was in her normal state of health until 2 days prior to admission when she noticed bright red blood coming from her rectum. She spoke with her PCP who arranged outpatient colonoscopy. However, on the day of admission she had a BM with a large amount of bright red blood. She reported weakness at that time ??????my legs gave out?????? and she was brought to the emergency room. MEDICAL HISTORY: IDDM HTN elevated cholesterol CRI bilat TKA multiple skin lesions removed by general and plastic surgery hypothyroid MEDICATION ON ADMISSION: Lasix Synthroid Lipitor ASA prozac atenolol Metolozone Insulin ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Physical Exam: T 98.7, HR 90, BP 120/74, RR14, Sat 100% No acute distress, obese African American woman Mildly pale conjuntiva MMM 3/6 SEM, no S3,S4 Soft, NT, ND, no masses, normo-active bowel sounds No rashes or edema FAMILY HISTORY: No colon CA, otherwise unremarkable SOCIAL HISTORY: Lives at home with husband, non-[**Name2 (NI) 1818**], no ETOH Retired

CHIEF COMPLAINT: i have pain in my back and it goes to my neck PRESENT ILLNESS: This 45 y/o white male presents to ER at [**Hospital1 22160**] transferred from [**Hospital1 487**] ER for MRI. Pt states he has LBP radiating to neck x 2-3 weeks with progressive weakness. He went to PCP about [**Name Initial (PRE) **] week ago for this pain/ although not as weak at that time/ and was given antibiotics for a soft tissue mass at left clavicular region. He is not sure what kind of abx. He states the last two days have been the worst with regards to pain and weakness. Presented to outside ER via ambulance. Pt states able to void and move bowels / difficulty ambulating and moving around his home. He admits to fever, IVDA of coccaine that started 6months ago and he stopped two weeks ago ("heavy use"). he admits to 6pack beer per day. Denies trauma, sob, chest pain, incontinence. Pt received antibiotics in ER MEDICAL HISTORY: PMHx:denies MEDICATION ON ADMISSION: none ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAM: on arrival O: T: 101.3, 153/84, 84, 24 sat 99% O2Sat Gen: WD/WN, appears stressed and uncomfortable HEENT: Pupils: errl EOMs intact Neck: Supple. Lungs: scattered inspiratory wheeze and LLL decreased BS. Cardiac: RRR. S1/S2. Abd: Soft, + tender to RLQ - ? bladder distention BS+ Extrem: Warm and well-perfused. No C/C/E. + track marks noted to B/l UE FAMILY HISTORY: Family Hx:noncontrib SOCIAL HISTORY: Social Hx: IVDA, ETOH

CHIEF COMPLAINT: Fever and emesis. PRESENT ILLNESS: This is a 64-year-old woman with a past medical history notable for endocarditis resulting in aortic valve replacement and mitral repair and tricuspid repair in [**2196-1-25**], Evans' syndrome, recent sepsis while at [**Hospital6 1708**] secondary to bilateral lymphoceles, atrial fibrillation with rapid ventricular response, cerebrovascular accident, and endometrial cancer, who presents from [**Hospital3 2558**] with a fever to 104 and a systolic blood pressure of 70. The [**Hospital 228**] medical issues, again, in [**2196-1-25**] when the patient developed and endocarditis resulting in a Bovine aortic valve replacement and mitral and tricuspid repair at an outside hospital (presumably [**Hospital6 15291**]). Her postoperative course was complicated by a left-sided cerebrovascular accident which left her with mild aphagia and right hemiparesis. Somewhere along this course it is the time it is felt that the patient developed atrial fibrillation with a rapid ventricular response which was controlled on beta blockers. The patient was rehabilitating at home when she developed lymphoceles in her groin in [**2196-8-24**] resulting in sepsis and requiring a 1-month hospitalization at [**Hospital6 1708**]. The lymphoceles were felt to be secondary to groin catheter placements during her cardiac surgery in [**Month (only) 404**] of this year plus related to history of groin radiation from the endometrial in her past. The patient was being rehabilitated at [**Hospital3 2558**] since the end of [**Month (only) **] with long-term antibiotics when she developed this current episode of sepsis. On the evening of [**11-4**], the patient notes feeling quite well after having dinner with her son; although, she does admit to feeling a little bit "flushed." She went to sleep but woke up with extreme/severe nausea and uncontrollable emesis. The patient was diverted to [**Hospital1 190**] as there were no beds available at [**Hospital6 8866**] or [**Hospital 882**] Hospital. She was found to have a temperature of 104 and be hypotensive with a systolic blood pressure in the 70s in the Emergency Department. She received 3 liters of normal saline with an increase in her systolic blood pressure to the 90s and was given stress-dose steroids and a dose of levofloxacin and Flagyl. She was admitted to the Medical Intensive Care Unit for management of her sepsis. The patient was also noted to have heme-positive emesis and a guaiac-positive rectal examination in the Emergency Department, as well as decreased platelets, and this was to be managed in the Medical Intensive Care Unit. MEDICAL HISTORY: 1. Evans' syndrome which is autoimmune hemolytic anemia and thrombocytopenia associated with rheumatoid arthritis. 2. Atrial fibrillation, rate controlled with Lopressor. 3. Hypertension. 4. Bovine aortic valve replacement with mitral and tricuspid repair in [**2196-1-25**]. 5. Endocarditis in [**2196-1-25**] resulting in aortic valve replacement. 6. Left-sided cerebrovascular accident in [**2196-1-25**]. 7. Endometrial cancer; status post total abdominal hysterectomy, chemotherapy, and radiation. 8. Lymphocele infection with methicillin-resistant Staphylococcus aureus, Proteus, carinii bacterium at [**Hospital6 4193**]; hospitalized from [**Month (only) 216**] through [**10-2**]. Status post splenic infarct at [**Hospital6 15291**] during past hospitalization in [**2196-9-24**]. MEDICATION ON ADMISSION: 1. Compazine 10 mg p.o. q.d. 2. Plavix 75 mg p.o. q.d. 3. Celexa 10 mg p.o. q.d. 4. MS Contin 15 mg p.o. b.i.d. 5. Lasix 80 mg p.o. q.d. 6. Ativan p.r.n. 7. Trazodone 25 mg p.o. q.d. 8. Prednisone 20 mg p.o. q.d. 9. Prilosec 40 mg p.o. q.d. 10. Milk of Magnesia. 11. Dulcolax p.r.n. 12. Folate 1 mg p.o. q.d. 13. Atenolol 37.5 mg p.o. q.d. 14. Danazol 400 mg p.o. b.i.d. 15. Atrovent. 16. Multivitamin. ALLERGIES: PENICILLIN causes anaphylaxis, SULFA, AZTREONAM. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Hypoxia PRESENT ILLNESS: This is a [**Age over 90 **] yo M with COPD, PAF, dementia, with a recently diagnosed bilateral PNA at nursing home who presents with hypoxia. He was started on levofloxacin at the NH, changed to CTX today. The pt was initially hypoxic to 80's on RA, placed on 4L NC, desated again to 80's, and then was placed on NRB satting 91% at NH. . In the ED the pts vitals were: T98 HR 110 BP 108/72 RR 20-26 Sat 95-100% on NRB. The pt was noted to have rhonchi on exam, rales left base, otherwise speaking in short sentences, somewhat labored breathing, sinus tachy. CXR showed dense confluent airspace opacities, air bronchograms, butterfly distribution, no significant cardiac enlargement, no vascular congestion. He received 1 L NS, Ceftaz, Clindamycin, and Vanc in the ED. In addition, he was noted to have an NSTEMI with CK 471, MBI 7.9, and Tpn T 1.88. BNP was 25,131. His EKG however had no clear changes. He was given ASA but no BB. MEDICAL HISTORY: 1. h/o Paroxysmal atrial fibrillation 2. HTN 3. h/o falls 4. BPH 5. L ear deafness 6. R eye cataracts s/p lens replacement 7. Arthritis bilateral knees and L hip 8. Mild dementia, unspecified type MEDICATION ON ADMISSION: -Aricept 10mg qHS -ASA 325mg daily -Citalopram 10 mg daily -Vitamin B12 q month -Finasteride 5 mg daily -Metamucil -Tylenol 1g tid ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T: 97 BP 100/63 P 94 RR 31 Sat 94% on 100% NRB General: This is a elderly male, sitting up in bed, tachyneic, oriented x3 HEENT: anisocoria w/ right pupil 3->2 mm and left 2->1 mm. EOMI without nystagmus, anicteric; MMM, no erythema/exudate Neck: supple, no JVD Pulmonary: diffuse rales with end expiratory wheezing Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: trace BL ankle edema, 2+ radial, 1+DP and PT pulses b/l Neurologic: AAOx3. CNII-XII grossly intact. MAFE FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Mr. [**Known lastname 40370**] lives in the [**Hospital3 15333**] facility. Daughter [**Name (NI) **] (work: [**Telephone/Fax (1) 40371**]) is his HCP. Smoked for 30 years, [**1-21**] pack/day. Denied EtOH use. No recent smoking or alcohol.

CHIEF COMPLAINT: Fever PRESENT ILLNESS: This is an 80 y/o Cantonese-speaking male with PMH significant for ESRD on HD, DM II, atrial fibrillation, CAD, who presented from hemodialysis on [**2183-11-18**] with a reported fever of 105.7. The patient only complained of fatigue and weakness, starting yesterday morning. At around 2pm [**2183-11-18**], he began feeling very tired at HD and was having chills so EMS was called. Per EMS, the patient was hypotensive during transport but upon arrival to the [**Hospital1 18**] ED, was hypertensive to the 170's systolic. . In the ED, initial VS were T 102.3, BP 174/60, HR 102, RR 16, SaO2 88%/RA. Due to the temperature, sepsis protocol was initiated. R IJ was placed because he has poor access. CXR and head CT were unremarkable. UA showed many bacteria but was otherwise unremarkable. The patient reported symptoms of a headache and neck stiffness during his ED course, however LP was negative. Prior to the LP, he received Vancomycin 1 gm, CTX 2 gm IV, Ampicillin 2gm IV. He also received 10 mg Dexamethasone and a random cortisol level was sent which was normal (=8). His SBP trended down from the 160's to 90's-100's while in the ED and he received a total of 3 L IVF. His O2 requirement increased from 2 L NC -> 4 L NC and his SvO2 ranged from 91-97. His CVP was documented from [**6-24**] (after approximately 2 L NS). He also received 325 mg ASA and 2 mg IV morphine for his headache. He was admitted to the MICU for further management. Of note, the patient has had prior admissions for fever (101-102) in [**6-21**] and [**7-22**] which after a thorough work-up, was attributed to gouty flares and improved with a steroid taper. He recently saw his rheumatologist 1 week ago, who increased his allopurinol from 200 to 300 mg daily due to acute flares through the prior dose and increased the patient's steroid taper. . In the MICU, he was continued on vancomycin and ceftriaxone. Ampicillin was discontinued given low likelihood of meningitis. He remained hemodynamically stable and did not require fluids. His steroid dose was increased to 32mg methylprednisolone daily, per discussion with his outpatient rheumatologist Dr. [**Last Name (STitle) **]. During the afternoon of [**2183-11-19**], he became dyspneic and wheezy with elevated JVP and mild increase in CHF on CXR. He was felt to be volume overloaded [**1-17**] volume resuscitation and was sent to HD for ultrafiltraion, 2.3 L was taken off. He was transferred to the floor in stable condition and continued on the antibiotics. His urine cx grew out likely >100,000 Enterococcus. . This morning on the floor at 6:30 am, the patient triggered for a HR in the 160's and mild respiratory distress. He received 5 mg IV metoprolol and neb treatments with improvement in his HR to the 110's and resolution of his respiratory distress. Around 7:30 am, he was noted to be tachypneic in the 40's, extremely wheezy, tachycardic to the 160's (a fib with RVR), and hypertensive to the 190's systolic. He was hypoxic and placed on a NRB, with improvement of his SaO2 to the 90's. ABG on the NRB was 7.33/51/73. He was felt to have gone into flash pulmonary edema and he received a total of 200 mg IV lasix with 225 cc UOP, 1.5 mg IV morphine, 10 mg IV hydral, 5 mg IV dilt, 10 mg IV metoprolol, and 1" nitropaste. He was initiated on BiPAP on the floor and ABG [**4-19**] was 7.44/38/305. He received 25 mg metoprolol po x 1 upon arrival to the MICU for persistent tachycardia in the 140's. MEDICAL HISTORY: 1. CAD - reported as single vessel disease s/p catheterization in [**5-20**] following ETT-MIBI demonstrating an inferolateral perfusion defect. Mid LCX was stented with a Drug Eluting Stent with successful rescue of the OM1 with balloon angioplasty. Also has history of catheterization more than 20 years ago. 2. Diabetes Mellitus Type II - for more than 30 years. His blood glucose levels are usually 97-100. His most recent HbA1C was 6.6 in [**2183-7-16**]. Has nephropathy and proteinuria, as well as mild distal neuropathy. 3. Atrial fibrillation - paroxysmal atrial fibrillation diagnosed in [**2170**]. On long-term anticoagulation. 4. Hypertension 5. History of GI bleed - History of gastric ulcers. Presumed lower GI bleed on [**1-20**]. 6. Chronic renal insufficiency - Probable diabetic nephropathy. Baseline creatinine 2.7. Has seen been seeing Dr. [**Last Name (STitle) 1860**] for possible initiation of peritoneal dialysis. 7. Sleep apnea 8. Musculoskeletal problems: (a) Bilateral severe carpel tunnel (b) Polyneuropathy of hands (c) Right flexor tendon nodules/ contracture (d) OA of DIPs, PIPs, and 1st CMC (e) Gout - recent admission in [**2-18**] for gout flair. (f) Pseudogout. (g) osteopenia MEDICATION ON ADMISSION: 1. Allopurinol 300 mg daily 2. ASA 81 mg daily 3. Atorvastatin 10 mg daily 4. Renal caps 1 tab daily 5. Coumadin 2.5 mg 2d/wk, 1.25mg 5d/wk 6. Folic acid 1 mg daily 7. Levemir insulin 16 units qhs 8. Novolog insulin sliding scale 9. Imdur 30 mg daily 10. Levothyroxine 75 mcg daily 11. Methylprednisolone 8 mg daily 12. Lopressor 25 mg [**Hospital1 **] 13. NTG SL prn 14. Protonix 40 mg daily . ALLERGIES: Lovastatin PHYSICAL EXAM: VS: Tc 98.7, BP 91/44, HR 120-130, RR 19-20, SaO2 96%/4L NC General: Elderly Asian male in NAD, lying comfortably in bed HEENT: NC/AT, PERRL, EOMI. +dentures. MMM, OP clear Neck: supple, +right IJ CVL in place Chest: crackles and expiratory wheezes to the apices CV: irregularly tachycardic, s1 s2 normal, [**1-21**] SM at the base Abd: soft, NT/ND, NABS, no HSM Ext: no c/c/e, several ecchymosis over the upper extremities; left AV fistula with palpable thrill and bruit - no erythema, tenderness or swelling Neuro: Non-focal, moving all extremities. FAMILY HISTORY: Both parents deceased. Father had diabetes. He has 2 children who are well and no siblings. SOCIAL HISTORY: Mr. [**Known lastname **] is Cantonese speaking. He lives with his wife. [**Name (NI) **] has a remote 20-year history of tobacco smoking. He quit 20 years ago. No alcohol or illicit drug use. Performs most ADLs at baseline.

CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: 59 y/o male with Hyperlipidemia, Mild Emphysema, GERD, and Obstructive Sleep Apnea presented to [**Hospital1 **] [**Location (un) 620**] on [**2195-7-15**] with shortness of breath described as inability to get in a satisfying breath. Patient has been experiencing symptoms for last 4-5 days. Symptoms associated with increased fatigue, subjective fevers/chills, swollen neck glands, and palpitations. Patient denies any chest pain or light-headedness. In the last week, patient had developed of a vesicular rash, which began on abdomen, with 2-3 areas of patchy involvement progressing towards back. He began taking acyclovir for presumed herpes zoster. . Initial vitals at [**Location (un) 620**] were T 98.5, HR 99, BP 109/79 RR 16 SAT 98% RA. Found to be in rapid AFib with HR in the 190's. Given two pushes of lopressor, which did induce improvement ventricular rate, but precipitous fall in systolic blood pressures to 70-80s. Patient was cardioverted with 50, 100, and finally three hundred joules, with successful breaking of atrial fibrillation. The patient re-entered AFibb within one hour, and was loaded with amiodarone. Patient's CXR showed an enlarged cardiac silloute, and CT showed large pericardial effusion. Patient was transfered to [**Hospital1 18**] CCU for further manegement. . Patient denies any history of arrythmias, joint pain, cancer, past heart attack, cardiac surgery, hemoptysis, or recent thoracic trauma. He reports recent intentional weight loss of 30 pounds in last nine months. On two previous CT's patient had small noted 4mm non-calcified lung nodule, which has not increased in size. MEDICAL HISTORY: Hyperlipidemia Obstructive Sleep Apnea Mild Emphysema PFT's [**2-20**] showed mild obstructive ventilatory defect GERD Hiatal Hernia Celiac Disease Colon Polyps Diverticulosis No known drug allergies MEDICATION ON ADMISSION: ASA Lipitor Androgel Prevacid MVI Fishoil Flomax ALLERGIES: Gluten PHYSICAL EXAM: T 99.1 HR 105 BP 113/89 RR 18 SAT 96% PULSUS 15 HEENT: No scleral icterus, injected conjunctiva, PERRL, no submandibular, sublingual, ant/post cervical adenopathy. Oralpharynx without edema or erythema, no purulence. No oral lesions noted. NECK: No jugular venous distension, no lyphadenopathy, no hepatojugular reflex CHEST: No axillary lymphadenopathy noted. Slight cardiac rub appreciated in RLL upon expiration. HEART: Tachycardic. S1S2. No murmurs or gallops appreciated. Cardiac rub appreciated, best at apex, with patient leaning forward. ABD: Soft, non-tender, non-distended. Normoactive bowel sounds. No pulsitile mass noted. 2cm by 2cm escar noted on LLQ of abdomen. EXT: No edema noted in extremities. 2+ DP/PT/Poplitieal/Femoral/and Radial pulses. No cycanosis. Neuro: Answers appropriatly to questioning. AAOx3. No focal motor/sensory deficits. Cranial Nerves intact. FAMILY HISTORY: There is a family history of sudden death, with his father dying of cardiac arrest at age 75. His mother died at 79 of cancer. He has a brother with seizure disorder and another with crohns disease. SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. He is a former smoker of two packs a day for twenty years, quit 17 years ago. There is no history of alcohol abuse.

CHIEF COMPLAINT: s/p fall PRESENT ILLNESS: 89yo woman on asa/plavix for Afib was in usual state of health until she had a mechanical fall from the toilet this evening. denies LOC but left facial ecchymosis so son called EMS. OSH CT revealed SDH. Transferred to [**Hospital1 18**] for evaluation. Pt examined with son who states that the patient appears to be at her baseline. MEDICAL HISTORY: UTI CVA with L hemiplegia HL HTN GERD shingles cholecystectomy PEG hernia repair depression MEDICATION ON ADMISSION: asa 325 plavix 75 nasonex dexilant fioricet pravastatin lidoderm patch glycolax lisinopril 5 erythromycin eye ointment ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: On admission: PHYSICAL EXAM: O: T:97.2 BP: 146/56 HR: 70 R 18 O2Sats 98% 2L NC Gen: WD/WN, comfortable, NAD. HEENT: Pupils: R 3-2 L surgical EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: afib 80's Abd: Soft, NT, Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person and place only. Language: Speech slurred but baseline per son. FAMILY HISTORY: NC SOCIAL HISTORY: Lives with son & his family. Wheelchair bound but ambulates with walker 100ft per day with son. [**Name (NI) **] tobacco/etoh/drugs

CHIEF COMPLAINT: Chest Pain PRESENT ILLNESS: Mr. [**Known lastname 22656**] is an 85 year-old man with a history of hypertension and coronary artery disease who presented with angina, now being transferred to the CCU after bieng found to have left main coronary artery disease. Six months prior to admission, began experiencing "palpatations", described as chest pressure over the left nipple. It would occur in the morning and occasionally throughout the day and would be worsened by his morning weight lifting. Each episode would last ~5-10 minutes. They were not associated with SOB, diapheresis or nausea. He contact[**Name (NI) **] his PCP he referred him to a cardiologist (Dr. [**Last Name (STitle) **]. A stress MIBI was performed and reportedly positive per the patient though we do not have the report. He was then prescribed SL nitro which he took twice daily, with or without symptoms though he does believe that taking it with symptoms did help. Four months ago he underwent cataract surgery, at which time he stopped aspirin. The surgery was uneventful. Three months prio to admission, the angina resolved and he ran out of nitro. Two weeks prior to admission he stopped aspirin in preparation for spinal stenosis surgery. Five days prior to admission, he again began to experience palpatations. He was in [**State 108**] for his surgery and, upon describing his symptoms to the anesthiologist, was cancelled. He flew back to [**Location (un) 86**] on [**11-13**] and called his PCP who referred him to the ED for further evaluation. In the ED VSS, EKG showed old LBBB per his PCP. [**Name10 (NameIs) **] CP resolved with SL NTG x1. He was given ASA 325mg and started on a heparin gtt. Overnight, he was continued on nitro and heparin gtts and had stuttering chest pain. On the morning of transfer he was loaded with Plavix 600mg and sent for cardiac cath where he was found to have a 80% ulcerated left main lesion. ROS (-) PND/orthopnea (+) Edema, chronic (-) Fevers/chills/weight change (+) Sinus congestion with Flomax (-) Cough (+) Occasional heart burn (+) Constipation (BM every 2-3 days) (-) Nausea/vomiting/diarrhea (-) Bloody stools (+) "Black stools" (+) Chronic leg pain, anteriorly, though secondary to spinal stenosis Negative colonoscopy in [**2155**], per patient PSA normal, per patient MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (-) Diabetes (-) Dyslipidemia (+) Hypertension 2. CARDIAC HISTORY: -CABG: None. -PCI: None. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: - Old LBBB (old per PCP) - History of paroxysmal atrial fibrillation (patient denies) - BPH - Spinal Stenosis - Cataracts, s/p surgery - History of nephrolithiasis - History of bilateral hip fracture, s/p repair (right in [**10-3**]; left in [**12-4**]) MEDICATION ON ADMISSION: Norvasc 10mg daily flomax quinapril 20mg daily Aspirin 81mg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: Afebrile, 127/55, 56, 12, 95% on room air GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: MMM. NCAT. Sclera anicteric. Right pupil 3mm --> 2mm and left faintly reactive, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8 cm. CARDIAC: Regular rate, normal S1, S2. II/VI systolic murmur at LUSB LUNGS: Anteriorly clear. ABDOMEN: Soft, NTND. EXTREMITIES: 2+ edema bilaterally; 2+ DP pulses BUTTOCK: 4x3cm tan discolorated area on right buttock; blanches; skin intact. SKIN: No rashes. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ FAMILY HISTORY: (+) HTN, (+) CAD. SOCIAL HISTORY: Orginially from [**Country 2784**]. Retured from teaching mechanical engineering at [**University/College **]. Quit smoking 45 years ago, rare EtOH, no drugs. Married.

CHIEF COMPLAINT: Worst headache of his life PRESENT ILLNESS: 54 y/o male who was transferred from an [**Hospital1 **] [**Location (un) 620**] after a CT revealed subarachnoid hemorrhage. Patient presents a history of having a mild headache this evening, going to bed around 10 pm and upon laying down developing a bad headache that gradually worsened over 4 to 5 min. He says he wouldn't describe the headache as the worst headache of his life, or thunderclap in nature. He denies visual changes, nausea, vomiting or loss of consciousness. MEDICAL HISTORY: PMHx:Afib MEDICATION ON ADMISSION: Atenolol 100mg daily, ASA 81mg ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: PHYSICAL EXAM: Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]:2 GCS 15 E: 4 V: Motor6 O: T: BP:124 /80 HR:60 R12 O2Sats 100RA Gen: WD/WN, comfortable, NAD. HEENT: NCNT Neck: Nuchal rigidity, pain with lateral movements Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. FAMILY HISTORY: NC SOCIAL HISTORY: Social Hx:Married, has two children. Works in computer sales. Smokes cigars socially. Drinks one glass of wine daily.

CHIEF COMPLAINT: Transfer [**Hospital1 100**] MACU for hemodialysis line replacement for poorly functioning catheter PRESENT ILLNESS: 71yo F with ESRD on HD, respiratory failure s/p trach on vent, s/p PEG, COPD, recurrent aspiration PNA, and C.diff colitis is transferred from [**Hospital 100**] Rehab MACU for poorly functioning HD catheter and thus HD catheter change. She tolerated HD today well at [**Hospital 100**] rehab and removed 1.7kg. She has multiple medical problems as above, but all has been stable. . For respiratory failure, she is on pressure support and has had 30 minutes trial of trach mask this past weekend which was stopped due to hypoxia. Rehab has been slowing weaning her from the vent. Pt is on PS 4/5/50%. . For PVD, pt has necrotic, dry gangrene that is auto-amputating. Getting pain meds/prn and lidoderm patch. . For AF, pt is on digoxin. Last level checked on [**12-12**] was 0.8. Pt is not anticoagulated. MEDICAL HISTORY: #. ESRD on HD of unclear etiology. ? d/t chronic pyelo and uncontrolled HTN. Outpatient nephrologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] #. Respiratory failure s/p trach in [**2-11**], on vent dependent chronically on PS at rehab with currently underogoing trach collar trials. #. COPD #. Recurrent aspiration PNA #. PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of toew bilaterally and autoamputating #. HTN #. Hypothyroidism #. h/o GI bleeding #. CHF no previous echo here, so unclear [**Name2 (NI) **] #. h/o Cholesterol emboli syndrome #. Paroxysmal AF # Anemia # s/p multiple embolic CVA # Dementia # Adenocarcinoma of the colon s/p resection in [**2186**] # s/p PEG # h/o MRSA colonization # h/o VRE infection # C.diff colitis MEDICATION ON ADMISSION: 1. Hydromophone 0.75mg q2h/prn during HD sessions only 2. Vancomycin 125mg QID GT 3. Oxycodone 2.5mg q6h/prn GT 4. Benadryl 25mg [**Hospital1 **]/prn GT 5. Benadryl 25mg qhs GT 6. Tums 650mg po QID 7. colace 100mg [**Hospital1 **]/prn GT 8. Digoxin 0.125mg every other day GT, last dose given today ([**2187-12-17**]) at the rehab 9. Mucomyst 200mg TId inh 10 Tylenol Q6h/prn GT 11. Albuterol 2 puffs q6h/prn inh 12. Synthroid 125 mcg daily GT 13. Aspirin 81mg qday Gt 14. Combivent 6 puffs q6h inh 15. Lactinex 1 tab [**Hospital1 **] GT 16. Prilosec 20mg GT 17. Reglan 10mg TID GT 18. Lidoderm patch top daily 19. Lactobacillus 1 tab [**Hospital1 **] 20. Epogen at HD ALLERGIES: Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines PHYSICAL EXAM: VS: 98.7, 84, 110/50, 28, 95% on PS 5/5, 50%, Tv 525 GEN: Awake, opens eyes spontaneously. Does not follow commands. FAMILY HISTORY: Per rehab d/c summary, her parents lived until old age. One brother died of an MI in his 60s. Another brother with schizophrenia. Son with hypothyroidism SOCIAL HISTORY: Per rehab d/c summary, she has been bouncing around various long term care facilities since her tracheostomy and vent dependency. She is divorced. She is a former smoker 3 packs per day x 13 years. Occasionally used alcohol. Has 3 adult children. Her son [**Name (NI) **] is her health care proxy and is very involved in her care.

CHIEF COMPLAINT: Sudden onset severe headache PRESENT ILLNESS: 74F spanish speaking, with HTN, experienced sudden onset severe HA on [**2168-4-26**] in R temporal region, but also with some neck discomfort. No trauma. Pt apparently had not taken any BP meds that day. EMS called and initial SBP 220-248. Pt brought to [**Hospital1 18**] where Pt alert and neurologically intact by report. Placed on Nitroprusside and labetalol gtt. CT revealed SAH in basal cisterns B/L. CTA performed revealed no obvious aneurysm. MEDICAL HISTORY: 1. DM 2. HTN MEDICATION ON ADMISSION: Synthroid 200mcg daily Lipitor 80mg daily Zetia 10mg daily Labetolol 200mg daily Citalopram 20mg daily Meclizine 25mg daily Enalapril 20mg daily Tizanidine 2mg Insulin Lente 35-40units twice daily ASA 81mg daily Folic Acid 800mg daily MVI daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: afeb bp130/70 (on admission 220-248/90-119) hr60-80 rr20-22 General: WNWD HEENT: Anicteric, MMM without lesions, OP clear Neck: Supple, no carotid bruits CV: RRR s1s2 no m/r/g Resp: CTAB no r/w/r Abd: +BS Soft/NT/ND no HSM/masses Ext: No c/c/e, distal pulses intact Skin: No rashes, petechiae FAMILY HISTORY: non-contribuitory SOCIAL HISTORY: resides at home with daughters, denies tobacco use

CHIEF COMPLAINT: PRESENT ILLNESS: Ms. [**Known lastname 12933**] is a 65-year-old female, with multiple medical problems including COPD, diabetes mellitus, history of a DVT, and hypothyroidism, who was transferred from [**Hospital 1562**] Hospital on [**1-16**], after failing to wean from the ventilator. The patient, according to the hospital transfer, had a sore throat for four or five days, and symptoms of a lower respiratory tract infection. She presented to [**Hospital 1562**] Hospital on [**1-10**] and proceeded to rapidly decompensate with hypoxemic and hypercapnic respiratory failure. She was found to have a left lower lobe consolidation and required mechanical intubation. The hospital course there was notable for thick pulmonary secretions, an MSSA growing out of sputum, and a chest CT showing extensive alveolar interstitial process involving both the left and right lung, with left greater than right. The patient underwent bronchoscopy. It was notable just for the thick secretions. She received aggressive antibiotics including vancomycin, piperacillin, tazobactam, Levofloxacin and clindamycin, but was unable to be weaned from the ventilator for persistent hypoxemia. She was transferred to [**Hospital6 256**] for further evaluation and treatment of her hypoxemic and hypercapnic respiratory failure. MEDICAL HISTORY: 1. Hypothyroidism. 2. COPD. 3. Diabetes mellitus. 4. History of DVT several years ago. 5. Peptic ulcer disease. 6. GERD. 7. Chronic lower back pain, on narcotics for spinal stenosis. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: On presentation, the patient's vital signs were as follows: Temperature 99.9, blood pressure 156/93, heart rate 77, respirations 14, satting 97% on room air. She was on AC 550x18 with pressure support of 10, PEEP 5, FIO2 0.5. GENERAL: She was an obese female, intubated, following simple commands, in no acute distress. HEENT: Normocephalic, atraumatic. Pupils 2 mm and reactive, anicteric. Oropharynx clear with moist mucous membranes. NECK: Supple. No lymphadenopathy appreciated. I was unable to assess her JVP. There were no bruits. CARDIOVASCULAR: Regular rate and rhythm with occasional premature beats, a II/VI systolic murmur at the left sternal border. No rubs or gallops. LUNGS: She was moving a good amount of air bilaterally with the exception of the right base, but she had crackles at the midlung fields bilaterally. There were no wheezes. ABDOMEN: Obese, soft, diffusely tender to palpation at that point. No rebound or guarding. Normal bowel sounds. No masses or hepatosplenomegaly appreciated. EXTREMITIES: Trace pitting edema, bilateral lower extremities. NEUROLOGIC: Squeezes both hands. There was 4/5 strength. Wiggles toes bilaterally. Toes were downgoing. FAMILY HISTORY: SOCIAL HISTORY: The patient does not work. She lives with her husband on [**Hospital3 **]. She has a remote tobacco history and minimal alcohol use. No intravenous drug use.

CHIEF COMPLAINT: Rectosigmoid colon cancer PRESENT ILLNESS: [**Known firstname **] is an 88-year-old female with a history of lower abdominal pain, heme positive stool who initially did not want evaluation and workup but then conceded to a sigmoidoscopy. Sigmoidoscopy demonstrated a large rectosigmoid mass that was biopsied and showed high-grade dysplasia with likely adenocarcinoma. CT scan showed a large mass in the pelvis. She was seen in the hospital and as an outpatient and offered low anterior resection with possible colostomy. Risks and benefits of the procedure were discussed. Consent was reviewed and signed. MEDICAL HISTORY: MONOCLONAL GAMMOPATHY DEMENTIA HYPERTENSION ? of ANGINA, STABLE- PERSANTINE THALLIUM NEGATIVE [**4-18**] OSTEOARTHRITIS BACK PAIN- S/P LUMBAR DISC [**Doctor First Name 147**]. S/P ARTHROPLASTY KNEE, TOTAL REPLACEMENT, BILAT HEADACHE ESOPHAGITIS, REFLUX OSTEOPOROSIS ? of GOUT- LEFT GREAT TOE ATOPIC DERMATITIS S/P INGUINAL HERNIA REPAIR, BILAT S/P TOTAL HYSTERECTOMY [**2075**] S/P REMOVE GALLBLADDER S/P REMOVAL OF APPENDIX ? of POLYMYALGIA RHEUMATICA SHOULDER PAIN, RIGHT, CHRONIC RESTLESS LEG SYNDROME . MEDS: ATENOLOL TAB 100MG one tab po qd \ FOSAMAX TABS 70 MG 1 tab po qweek PROTONIX 40 MG Daily MULTIVITAMIN one po qd CALCIUM CARB CHW 500MG 2-3 per day METROCREAM 0.75 % CREAM apply qd DOXEPIN HCL 50 MG CAPS 1 cap po qhs TRAMADOL HCL 50 MG 2 tabs po qd 4- 6 hours prn--not using FUROSEMIDE TAB 20MG po qam LISINOPRIL 5 MG TABS po qhs REQUIP 2 MG TABS po 1 hour before bedtime . NKDA MEDICATION ON ADMISSION: Lopressor 150', Mirtazapine 15', Prilosec 20', Trazadone 75', Ca 500''', Vit D, Colace 100', Fe, MVI ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: AVSS Gen: nad CV: RRR Chest: CTAb Abd: S/ND, appropriately tender, surgical incision intact with no signs of infection, stoma pink Ext: WWP, non-tender FAMILY HISTORY: unknown SOCIAL HISTORY: Married. Two sons who live in the area. Currently at [**Location (un) 8220**] NH. Pt is a holocaust survivor.