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CHIEF COMPLAINT: Hypertensive emergency PRESENT ILLNESS: 64F with longstanding history of poorly controlled HTN and s/p hemorrhagic stroke presumably from HTN emergency at [**Hospital1 2177**], CAD s/p MI, CHF witH EF 35%, DM A1c 7.3%, who was seen at PCP's office with chest pain and intermittent 'gasping' over the last few days. Notes has had chest and back pain (cardiac equivalent in her) on and off for several days, as well as "gasping" particularly bothersome at night. Stable 2 pillow orthopnea. Shortness of breath and headache progressed over the past day, prompting her to keep a scheduled appt with her PCP. [**Name10 (NameIs) **] her visit earlier today, SBP found to be 220-235 and she was sent to the ED for further management. . In the ED, initial VS: 96 97 189/62 18 100% RA. CXR showed mild volume overload. She was given po hydral and metoprolol with no effect and started on a nitro gtt. She also received lasix 40mg iv once without much UOP. Her pressure came down to the 150's on the nitro gtt and it was decreased as goal bp 160-170. Her labs were remarkable for trop<0.01 and negative CK with creatinine at baseline. EKG showed sinus rhythm with TWI in the precordial leads. She denied any chest pain while in the ED and refused ASA. CT head wet read showed no evidence of any acute intracranial pathology but showed a large region of encephalomalcia in the right hemisphere suggestive of old right MCA infarction. . CXR final read showed engorged pulmonary hilar vasculature, with diffuse pulmonary vascular congestestion, no effusion. . On evaulation on the floor patient reports CP and SOB have resolved, HA present, but improved. She notes she has not been taking her diovan as prescribed, but maintains compliance with her other medications, including her beta blocker, hydralazine, coumadin, and CCB. . On review of systems, she notes some back pain and left-sided pruritis. Reports recent hospitalization at [**Hospital1 2177**] for "dizziness, feeling like she was going to black out." Denies any prior history pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, diarrhea black stools or red stools. She denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for positive features as above. Denies any current chest pain, ankle edema, palpitations, or syncope. MEDICAL HISTORY: 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: Cath [**1-23**]: 100% pLCx. STEMI Cath [**7-24**]: 20% LM, 30% D1, 100% in-stent pLCx, 50% mRCA. Cath [**8-27**]: chronic 30% LMCA, 50% LAD, 100% in stent LCx, 50% RCA. Cath [**5-1**]: LCx 100% (chronic), D1 50%, 30% prox 50% mid RCA, PTCA to mid RCA -PACING/ICD: none . 3. OTHER PAST MEDICAL HISTORY: Poorly controlled HTN Diabetes on insulin sCHF EF 45% (ischemic) H/O hemorrahgic CVA [**12/2117**] at [**Hospital1 2177**] Hypothyroid CKD baseline 1.2-1.3 Severe pulm HTN by R heart cath [**8-/2113**] ? H/o anoxic brain injury after prolonged ICU stay Anxiety MEDICATION ON ADMISSION: albuterol inh prn furosemide 20 mg [**Hospital1 **] hydralazine 30 mg tid glargine 55 units QAM lispro SSI isosorbide mononitrate ER 90 mg qd levothyroxine 50 mcg qd metoprolol tartrate 25 mg [**Hospital1 **] omeprazole 20 mg qd ? not taking simvastatin 20 mg qhs spironolactone 25 mg qd valsartan 320 mg qd ? not taking warfarin 5 mg qd aspirin 81 mg Tablet ALLERGIES: Penicillins / Cozaar / Ace Inhibitors / Lipitor PHYSICAL EXAM: PHYSICAL EXAMINATION: VS: BP= 186/86 HR= 71 RR= 23 O2 sat= 96% on RA GENERAL: obese AA woman slumped in stretcher. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: Father with CAD, siblings with 'heart problems'. Grandfather died of MI. SOCIAL HISTORY: SOCIAL HISTORY: Lives with her son and future daughter in law since her stroke in [**12-31**]. Tob: 2.5 pack year history; quit EtOH: Used to drink on the weekends. Quit. Drugs: Denies

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 57 year old woman with a history of recurrent ovarian cancer and deep vein thrombosis on Coumadin, who presents with hematemesis. The patient vomited "a pint" one day prior to admission and felt lightheaded although denied chest pain, dyspnea, syncope, abdominal pain or hemoptysis. In other words, this was nonbloody emesis. The night of admission she had another episode of [**First Name8 (NamePattern2) 8873**] [**Name8 (MD) **], M.D. MEDICAL HISTORY: 1. Ovarian cancer recurrent stage three, grade three papillary serous ovarian cancer. Status post exploratory laparotomy, radical hysterectomy and cytoreductive surgery in [**2173-10-10**]. The patient is status post six cycles of [**Doctor Last Name **] and Taxol with reduction in tumor mass, but second look laparoscopy showed periaortic lymphadenopathy in [**2174**]. The patient has had serial CA125s and this was noted to be elevated, which prompted a trial of Taxol. 2. History of deep venous thrombosis in [**2178-7-10**]. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Negative for coronary artery disease or stroke. SOCIAL HISTORY: The patient works at [**University/College **] as an electrical engineering secretary. She has no tobacco or drug use. She drinks about one drink per week.

CHIEF COMPLAINT: Asymptomatic PRESENT ILLNESS: 43 y/o female with positive ETT performed for cardiac clearance for hysterectomy. A cardiac catheterization was performed which showed severe left main disease. She is now admitted for surgical revascularization. MEDICAL HISTORY: HTN, DM2, lipids, PVD, obesity, L SFA atherectomy, R SFA stent with ISR, known lung nodule MEDICATION ON ADMISSION: Lipitor 40mg QD Lisinopril 10mg QD Aspirin 325mg QD Glipizide 10mg [**Hospital1 **] Metformin 500mg [**Hospital1 **] Lopressor 50mg [**Hospital1 **] Plavix 75mg QD ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: 91 18 144/72 GEN: WDWN in NAD SKIN: Warm, dry, no clubbing or cyanosis. HEENT: PERRL, Anicteric sclera, OP Benign. Poor dentition. NECK: Supple, no JVD, FROM. LUNGS: CTA bilaterally, mild kyphosis. HEART: RRR,Nl S1-S2 No M/R/G ABD: Soft, ND/NT/NABS EXT:warm, well perfused, no bruits, no varicosities, No peripheral edema NEURO: No focal deficits. FAMILY HISTORY: + For strokes. SOCIAL HISTORY: Quit smoking 3 months ago. Denies alchol use. Lives with husband and daughter. She is employed as a crossing guard.

CHIEF COMPLAINT: dry heaves, right-sided neck pain and hypotension PRESENT ILLNESS: 88-year-old female w/ HTN, HL, DM 2 who was admitted with dry heaves and right- sided neck pain to [**Hospital1 18**] [**Location (un) 620**]. She was seen initially seen by Neurology, Dr. [**Last Name (STitle) **], who diagnosed her with multifactorial cervical degenerative joint disease with resultant cervical radiculopathy. He recommended gabapentin and Lidoderm patch if tolerated. However, the patient's renal function started to deteriorate. Her creatinine went from 1.4 to 2.2 and then to 2.7. Her BUN rose to 34, anion gap rose to 16, and her lactic acid level was 5.0. In addition, her liver function worsened with ALT going up from 87 to 189 despite her abdominal ultrasound not showing any true liver disease. There was some trace free fluid in the abdomen and right pleural effusions but nothing acute. Her chest x-ray showed a right-sided pleural effusion. Her white count did go up from 8.9 to 11.8 despite being on empiric antibiotics. There was no true source of infection identified. Her UA was negative. There was no infiltrate. Her blood cultures were taken and are pending. Her glucose was out of control in the mid 200 range. Lantus was added despite her fasting. The patient's overall clinical status deteriorated. Her blood pressure continued to trend down into the high 80s. Her troponin T was sent which was 3.42 and creatine kinase was 377. Her EKG was difficult to interpret given her paced status. Her Hemoglobin was stable at 12.3, potassium 5.3. B12, TSH, and folate were normal. She was treansferred to [**Hospital1 18**] on heaprin drip. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. MEDICAL HISTORY: 1. Diabetes type 2 complicated by neuropathy. 2. SAH bilateral frontal with hemorrhagic contusion. 3. DJD of the C-spine. 4. Vertigo. 5. Hypertension. 6. Orthostatic hypotension, 7. Pacemaker for sick sinus syndrome/afib. 8. Dyslipidemia. 9. Skin cancer status post Mohs. 10. Left mastectomy. 11. Hypertension. 12. Depression. 13. Hearing loss MEDICATION ON ADMISSION: 1. Alaway 1 drop every 12 hours. 2. Altace 110 mg p.o. daily. 3. Amlodipine 2.5 mg p.o. daily. 4. Celexa 10 mg p.o. daily. 5. Clonazepam 0.5 mg p.o. daily as needed. 6. Humulin regular as directed sliding scale. 7. Lantus 0.2 mL daily at bedtime, that is 20 units. 8. Lipitor 40 mg p.o. at bedtime. 9. Metformin 500 mg p.o. b.i.d. 10. Timolol 1 drop every day. 11. TriCor 145 mg p.o. daily. 12. Wellbutrin SR 150 mg p.o. daily. ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: On admission: GENERAL: Oriented x3. Mood, affect appropriate. Appears to be in dpain and distress HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: non-contributory SOCIAL HISTORY: She lives in independent living in [**Doctor Last Name 5749**] [**Doctor Last Name **] Village. She was just recently at [**Hospital 100**] Rehab in [**Location (un) 2312**]. She is usually independent with her ADLs. No smoking, no alcohol or drugs.

CHIEF COMPLAINT: hypotension PRESENT ILLNESS: 76 yo M with ESRD on HD, CAD, AAA repair, Aflutter, AVR, COPD, [**Hospital **] transferred from [**Hospital **] hospital with sepsis. and weak. He was dialysed 5 times in the past 1 week as patient had gained around 9 kg. He also noted to have diarrhea, decreased PO intake. He also complained of left flank pain for the last 1-2 weeks. On the morning od admission, he felt really weak and slumped to the ground. His daughter checked his BP which was SBP of 30's. He was immediately taken to [**Location (un) **]. In the EMS, his SBP was in 60's. At [**Location (un) **], he got Fluid boluses and was started on pressors. They tried SCL but were not successful. He was then transferred to [**Hospital1 18**] for further management. In the ED, he got a fem line (under sterile precautions) and was started intially on Neo and then switched to Levo. His UA was dirty, he had leukocytosis and elevated CKs. He also received Vanc, Cefepime. MEDICAL HISTORY: atrial fibrillation/atrial flutter CAD s/p CABG thoracic ascending aortic aneurysm s/p AVR HTN CKD - on HD MWF s/p pacer s/p AAA repair ??????01 AF ?????? s/p cardioversion ??????03 COPD hypothyroid carotid stenosis possible renal artery stenosis kyphosis asthma asbestosis restless leg MEDICATION ON ADMISSION: ASA 81 mg Carbidopa-Levodopa 10-100 mg Tablet TID Atorvastatin 40 mg QD Morphine 15 mg [**Hospital1 **] Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] Metoprolol Succinate 25 mg Tablet SR QD Pantoprazole 40 mg Ipratropium Bromide Q6H Docusate Sodium 100 mg [**Hospital1 **] Ropinirole 1 mg [**Hospital1 **] Nephrocaps QD Levothyroxine 75 mcg QD ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: 97.8, 91/71, 66, 14, 100%/3L NC Gen: alert, oriented, in no acute distress HEENT: furrowed tongue, mild glossitis Neck: thick neck, no JVD appreciable Heart: S1/S2, many ectopic beats, 3/6 SEM at LUSB Lungs: bilateral wheezes, no crackles Abdomen: tense, no tenderness/guarding/rigidity, normoactive BS Flank: no tenderness Ext: no edema Neuro: no focal deficits FAMILY HISTORY: no h/o DM, HTN, no Cancer Mother died of heart disease at 90 SOCIAL HISTORY: Patient lives with his wife and one of his 3 children. He quit smoking 40 years ago ([**2090**]), smoked for 18 years. Retired salesman. Asbestos exposure in submarines 50 yrs ago. Denies any EtOH, no IVDU.

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 55 -year-old gentleman with end stage renal disease secondary to diabetes mellitus, who presented eight months status post cadaveric renal transplant. He was noted to have a rising creatinine on routine follow up. He was otherwise asymptomatic. His cadaveric renal transplant was from a 64 -year-old donor with occult ischemia times fifteen hours in [**2140-6-23**]. His best creatinine postoperatively was 2.1. His course has been complicated by a urinary tract infection in [**2140-10-23**] with a subsequent increase in creatinine. A renal biopsy at this time showed signs of rejection and he received a three day pulse of steroids and subsequently did well. MEDICAL HISTORY: Diabetes mellitus, chronic renal failure with end stage renal disease prior to transplant, peripheral vascular disease, hypertension. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: respiratory failure, hypotension, sepsis PRESENT ILLNESS: 74 y/o F with h/o COPD, CAD s/p CABG [**2113**], CHF (last echo [**11-11**] with EF 45-50%), with septic Right hip s/p hardware removal/irrigation on [**12-5**] at OSH, subsequent abx coverage with 6 weeks of Vanc/Levo (until [**1-19**]). Discharged to rehab initially where she was noted to have a new 02 requirement (not on oxygen at home previously), and presented from rehab on [**12-23**] to [**Hospital3 1280**] w/ acute SOB. Pt improved with diuretics and O2, but worsened over 24hrs and was transferred to [**Location (un) 620**] ICU on [**12-25**]. As pt had acute renal failure, no PE workup was done. Pt did not respond to Lasix or Natrecor. Pt developed fever to 101 on [**12-27**], with leukocytosis and was C diff positive. She was placed on Ceftaz in addition to coverage with Vanc/Levo, and rash developed, so ceftaz was discontinued. Repeat echo showed depressed EF at 30%. Pt had two episodes of chest pain where CE cycled and neg x 3 no EKG changes. BNP measured and noted to be increased to 1500, creatinine peak at 2.8 from baseline 1.3, and AIN was suspected in the setting of the reaction to Ceftaz. On [**12-29**] pt had an episode of hypotension and was started on dopamine because she was already so fluid overloaded. Pt was intubated at that time for persistant dyspnea and respiratory decline. MEDICAL HISTORY: 1. Cardiac: HTN, CHF, CAD s/p CABG [**2113**], most recent cath in [**2119**] with patent grafts; ECHO [**2120-12-5**] EF 45-50% 1+ MR, [**3-12**]+TR, Pulmonary HTN, hx of NSVT 2. Septic R hip, frank purulence discovered in OR on [**2120-12-5**] hardware removed at [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] Hospital, on Vanc/Levo until [**1-19**] 3. PVD: s/p AAA repair [**2114**] 4. CVA w/ no residual deficitsm, on coumadin for anticoagulation 5. Breast CA s/p R mastectomy in [**2110**] 6. COPD 7. Hypothyroidism 8. Anemia 9. Gout MEDICATION ON ADMISSION: meds on transfer: vancomycin by level ceftazidime (stopped [**12-28**]) flagyl 500mg IV tid dopamine 5mch RISS aspirin lopressor (held) lipitor 80mg po daily captopril (held) folate Celexa 20mg po daily multivitamin Synthroid 0.125mg daily levofloxacin 500mg po every other day lansoprazole iron sulfate 325mg po daily albuterol, atrovent nebs ALLERGIES: Ceftazidime / Zosyn PHYSICAL EXAM: on admission to [**Hospital1 18**] MICU: FAMILY HISTORY: non-contributory SOCIAL HISTORY: at rehab recently after removal of hardware from right hip.

CHIEF COMPLAINT: Increasing fatigue, melena, and epigastric pain PRESENT ILLNESS: Ms [**Known lastname **] is a 52F s/p gastric bypass in [**2126**], presenting with her 3rd episode of UGI bleeding from an anastomotic ulcer. She had an EGD on her last admission [**2130-1-10**], which demonstrated an area of bright red clot overlying what appeared to be an ulcerated area at the anastomosis just proximal to the patent [**Month/Day/Year 3099**]. This was friable and oozing slowly, but there was not obvious vessel. She was managed conservatively with high-dose PPI and carafate, as there was no active bleeding at that time. She returned to the ED today with increasing fatigue, as well as melena and epigastric pain that have not resolved since her discharge on [**2130-1-11**]. The epigastric pain was moderately improved with oral carafate. She denies nausea, vomiting, diarrhea, BRBPR, dizziness, or LOC. Upon presentation to the ED, her hematocrit was 23.9, down from 31.9 at the time of discharge on [**2130-1-11**]. Bariatric surgery is consulted for possible surgical management. Of note, she is a Jehovah's Witness and is refusing blood transfusion, though she states she would accept albumin, FFP, or platelets. MEDICAL HISTORY: PMH: - Peptic ulcer disease with hx of 4 ulcers in stomach and small bowel, requiring emergent endoscopy in the past (presented with syncope and blood per rectum) - s/p treatment for H. pylori - s/p gastric bypass in [**2126**] - Fatty liver disease - Obstructive sleep apnea - Hyperparathyroidism - Depression MEDICATION ON ADMISSION: 1. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Vital signs: T 97.9, HR 60, BP 104/62, RR 18, O2 98% RA FAMILY HISTORY: Non-contributary SOCIAL HISTORY: Works for [**Location (un) 86**] Public Schools. Jehovah's Witness. No EtOH or tobacco use.

CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: Ms. [**Known lastname **] is a 67 year old female with multiple medical problems including COPD on 2L home O2 and diastolic CHF, CAD s/p stents, DM, HTN, PVD s/p b/l amputations and now with 4 days of increased sleepiness, SOB, and orthopnea. She notes that she has been feeling more fatigued and sleepy associated with increased swelling of stumps of LE. She denies chills, fevers, chest pain, cough, increased sputum production, sick contacts, nausea, vomiting, or diarrhea. She denies medication non-compliance, although notes her PCP recently decreased her lasix to just in am. She also reports her diet has been stable. . In the ED, initial vitals were T: 98.6 BP: 167/65 HR: RR:26 O2 sat: 100% on 2L. Patient noted to have decreased breath sounds at bases bilaterally, crackles and pitting edema of L stump. Groin - erythematous, likely candidal infection being treated with Vagisil. Given 80mg IV lasix x1 with good output 300cc, duonebs, and solumedrol 125mg IV x1. ABG was obtained 7.43/67/103 with HCO3 stable at 41. Her BNP was elevated at 1309, CEs negative x1. . Of note, patient recently admitted and discharged for GI bleed, found to GAVE s/p Argon plasm coagulation [**7-21**]. Hematocrit has been trending up since that discharge. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. MEDICAL HISTORY: Diabetes Dyslipidemia Hypertension CAD s/p Drug eluting stent to mid RCA & angioplasty to distal RCA Diastolic Heart Failure EF 60% PVD s/p b/l lower extremity amputation(R BKA & L AKA) ?CVA vs. TIA h/o depression COPD with FEV1 45%, FEV1/FVC 82%, TLC 81%, on 2L home O2 Gastric antral vascular ectasia, treated by argon plasma coagulation (APC) [**7-21**] MEDICATION ON ADMISSION: Albuterol Sulfate neb Q6H as needed. Atorvastatin 10 mg PO DAILY Calcium Carbonate 500 mg PO TID Tiotropium Bromide 18 mcg DAILY Zolpidem 5 mg PO HS Acetaminophen-Codeine 300-30 mg 1-2 Tablets PO Q6H as needed. Ferrous Sulfate 325 mg PO BID Nitroglycerin 0.4 mg Sublingual Sublingual PRN Omeprazole 20 mg PO BID Lisinopril 20 mg PO DAILY Metoprolol Tartrate 25 mg PO BID Hydrocortisone 2.5 % Cream on Rectum twice a day prn pain Aspirin 81 mg PO DAILY Simethicone 80 mg PO QID as needed for gas. Furosemide 80mg QAm, 40mg QPM(has not been taking) Isosorbide Mononitrate 60 mg SR daily Lantus 64units Subcutaneous at bedtime. Humalog Subcutaneous at bedtime: FS 201-250 2 units; 251-300 4 units; 301-350 6 units 351-400 8 units. Humalog Brkfst, Lunch, Dinner: FS 151-200: 2 units; FS 201-250: 4 units; FS 251-300 6 units; FS 301-350 8 units; FS 351-400 10 units. ALLERGIES: Metformin PHYSICAL EXAM: Vitals: T: BP:130/44 HR:92 RR:22 O2Sat: 97% on 2.5L NC GEN: obese female, mildly tachypnic, able to speak in full sentences HEENT: EOMI, PERRL, sclera anicteric, mild injection of conj b/l, no epistaxis or rhinorrhea, MMM, OP Clear NECK: unable to assess JVD [**1-14**] neck girth, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, HS distant, no M/G/R appreciated, normal S1 S2, radial/dorsalis pedis pulses +2 PULM: bibasilar rales, no W/rhonchi, fair air movement, no prolongation of expiratory phase ABD: Obese, Soft, NT, ND, +BS, no HSM, no masses, no hepatojugular reflux EXT: +1 right BKA edema, trace on left. No cyanosis. NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. FAMILY HISTORY: diabetes, heart disease & HTN. Mother died of an MI, age unknown. SOCIAL HISTORY: No current tobacco use, quit ~5 yrs ago after 100 pack-year history. Denies ETOH. Lives with daughter who is primary care giver.

CHIEF COMPLAINT: ICD firing PRESENT ILLNESS: Mr. [**Known lastname **] is an 85 yo M with a history of Type 2 DM, paroxysmal afib, Chronic systolic CHF, severe LV dysfuntion (EF 20-25%), s/p BiV ICD placment in [**2108**], and VT s/p amiodarone and dofetilide who was transferred from an OSH on [**2115-4-29**] to the Cardiology service [**1-21**] to recurrent VT on mexilitine, transferred to CCU for further monitoring after VT x 2 terminated by ICD firing. Recently, he was admitted to an OSH ([**2115-4-9**] through [**2115-4-22**]) and his ICD was reprogrammed to treat Vt/VF with atp x 1 followed by 1 shock. On this admission he was started on mexelitine and sent home. The patient returned to the OSH [**2115-4-28**] with slow VT (rate of 120s - 130s) on the Mexilitine with pre-syncopal symptoms. The dizziness lasted several minutes while lying in bed. He denied chest pain, palpitations, shortness of breath. He was referred to [**Hospital1 18**] for further EP evaluation and possible VT ablation. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: hyperlipidemia 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS:none -PACING/ICD: BiV ICD placed in [**2108**]. This was a [**Company 1543**] Concerto. 3. OTHER PAST MEDICAL HISTORY: Chronic systolic congestive heart failure (EF 20%). Ventricular tachycardia treated with dofetilide. s/p BIV ICD Atrial fibrillation Chronic back pain Mild dementia with short-term memory deficits bladder CA, s/p tumor excision dyslipdiemia chronic venous insufficiency MEDICATION ON ADMISSION: Coumadin 5 mg daily Metolazone 2.5 mg twice a week Lasix 80 mg daily Lidoderm 700 mg 5% patch daily Imdur 7.5 mg daily Spironolactone 25 mg daily allopurinol 100 mg daily Dofetilide 0.25 mg daily Zocor 40 mg daily carvedilol 12.5 mg b.i.d. tramadol 50 mg t.i.d. PRN back pain Glyburide lantus 12 units daily albuterol nebulizer p.r.n. cough ALLERGIES: Penicillins PHYSICAL EXAM: VS: 96.8, 76 bpm, 93/82, 19, 100% on 2 L nc GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: NC SOCIAL HISTORY: -Tobacco history: patient smoked 1.5ppd x 50 years. Quit 20 years ago. -ETOH: No alcohol. -Illicit drugs: None.

CHIEF COMPLAINT: Fever, ureteral stone, hydronephrosis PRESENT ILLNESS: 79 F c hx of CAD, distant hx breast cancer ([**2123**]), IBS who underwent upper endoscopy day prior for persistent R sided abdominal pain and now presents with fever, tachycardia, abdominal pain. . Initially presented [**4-1**] to Dr. [**Last Name (STitle) 1940**] complaining of RUQ abdominal pain. Evaluated by ultrasound showing R sided hydronephrosis but no nephrolithiasis, CBD 6mm, increased echogenicity of portal triad. Underwent endoscopy showing gastric and duodenal erosions and EUS showing sludge in CBD. Scheduled for ERCP today. Instead, presented to ED with fever 103.2, MS changes, tachycardia, and elevated WBC to ED with bandemia (1%). U/A c/w UTI. CT in ED showing R ureteral stone. In ED, received levofloxacin, metronidazole. Plans made for percutaneuous placement of nephrostomy tube. Admit to ICU following nephrostomy tube placement. . On review of labs, pt. has had rising WBC over the previous week. MEDICAL HISTORY: 1. CAD - myocardial infarct by EKG (last MIBI [**2144**] - reversible perfusion defect lateral, inferior walls) 2. Breast cancer [**2123**] MEDICATION ON ADMISSION: Hydrochlorothiazide, folic acid, vitamins, calcium, aspirin, Zocor, Atenolol, [**Doctor First Name **], Phazyme (doses unknown) ALLERGIES: Penicillins / Codeine / Sulfa (Sulfonamides) PHYSICAL EXAM: Following placement of nephrostomy tube VS- 100.7, 135, 134/80, 97%, 30 HEENT- no elevation JVP, + scleral edema LUNGS- CTA anterior, apices HEART- tachycardic ABD- tender to palp R side, ND, BS+ EXTRE- wwp, 2+ DP/PT pulse NEURO- moving all extremities FAMILY HISTORY: FH: No hx of kidney stones SOCIAL HISTORY: SH: Married, two children. Does not smoke, drink alcohol or coffee

CHIEF COMPLAINT: Hypotension, Urosepsis PRESENT ILLNESS: 80 y/o M with PMHx significant for metastatic lung cancer, CLL/SLL. Was found to be unresponsive, twitching, and hypotensive at nursing home today. Was initially being brought to [**Hospital3 **]; however, en route, BP's dropped to 55/P and he was brought to [**Hospital1 18**]. . On arrival to the ED, the patient's VS were 94/P, 108, 20, 100% on 4L. Temp was 99.6, but then patient spiked to 102.8. CXR showed ? retrocardiac consolidation. Given the pt's AMS, CT head was performed and was negative for ICH. Labs were significant for a UA with 11-20 RBCs, >50 WBCs. Given the high suspicion for urosepsis, the patient was given vancomycin and zosyn. There was some uncertainty regarding the patient's code status. Per report, his wife and daughter reported that they felt that a DNR was warranted; however, the patient wants to remain full code. The decision was made to hold off on central line placement and to start treatment with peripheral pressors in the ED. He was given IVFs (5L total) as well as started on periperal levophed. By the time of transfer to the ICU, the patient's BP had improved to the low 100's. VS at the time of transfer: Temp 98.7 HR 101 P 106/52 RR 18 100% on 2L. . On arrival to the ICU, the patient's VS were: T: 99.3 BP: 137/88 P: 96 R: 16 O2: 98% on 4L. The patient was moaning and coughing and was only oriented to person. He was not able to provide much of a history. Per his wife, the patient has been less coherent than his baseline recently. She reports that he is normally quite coherent. She reports that she visited him today and that he wasn't feeling well. . . Review of sytems: Unable to obtain. The patient denies any complaints. MEDICAL HISTORY: (per [**Hospital3 **] records): - h/o sepsis secondary to aspiration pneumonia - h/o proteus mirabilis and [**Female First Name (un) **] albicans in drainage culture of the abdomen - h/o aspiration - gastroesophageal reflux disease - history of CLL and non-Hodgkin's lymphoma, also SLL lymphoma - nonsmall cell lung cancer resected in [**2175-2-26**], later found to be node positive. Patient was discovered to have metastatic adenocarcinoma/recurrent lung cancer with lymphangitic spread. He has progression of mediastinal lymphadenopathy, right upper lobe and left lower lobe lung nodules, prominent periaortic lymphadenopathy. - bedbound at baseline with history of decubitus ulcer - diverticulosis - G-tube dependent - depression - anemia of chronic disease - diabetes mellitus - history of recurrent pneumonia - right inguinal hernia repair. - history of upper GI bleed in [**10/2175**], which showed esophagitis on EGD in [**9-/2174**] - rectosigmoid polypectomy in [**2172**] - h/o appendectomy as a child - h/o frx of pelvic bone after a fall in [**2172**] - h/o facial abscess following dental work MEDICATION ON ADMISSION: - Benadryl 25 mg q8hrs PRN - Atropine 1% 2 drops SL q4hrs - HISS - Lantus 5 units qHS - Baclofen 10 mg q8hrs (for hiccups) - Pantoprazole 2mg/mL 20 mL [**Hospital1 **] - Guaifenesin 10 mL TID - Hyosyne 1mL SL q4hrs - Levothyroxine 112 mch dialy - Liquid Tylenol 640 mg q4hrs scheduled - Neurontin 100 mg (250mg/mL soln) TID - Sorbitol 70% solution 30mL daily - Tramadol 50 mg QID - Vitamin C 250 mg [**Hospital1 **] - Acetylcysteine 10% vial, inhale 4 mL [**Hospital1 **] for SOB - Artificial Tears - Albuterol nebs - Bisacodyl - Fleet enema PRN - Simethicone PRN - Lorazepam 0.5 mg q6hrs PRN - MOM 30 mL daily PRN - Morphine Sulfate 2.5 mg (0.125 mL) SL q4hrs PRN - Prochlorperazine suppository PRN ALLERGIES: Scopolamine / IV Dye, Iodine Containing / Levaquin PHYSICAL EXAM: Vitals: T: 99.3 BP: 137/88 P: 96 R: 16 O2: 98% on 4L General: Moaning, coughing, oriented to person only HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL Neck: JVP not elevated Lungs: exam limited by patient moaning; crackles noted in the lower lung fields on the left CV: exam limited by patient moaning; no murmurs, rubs, gallops appreciated Abdomen: gastric tube present and noted to be loose-fitting, some drainage from g-tube noted, soft, non-tender, non-distended, bowel sounds present GU: foley in place Ext: cool, 1+ radial pulses, no clubbing, cyanosis; trace pitting edema in the lower extremities; some difficulty palpating the pedal pulses FAMILY HISTORY: Per medical records, he has an estranged brother. His mother is deceased from old age. His father is deceased with a question of leukemia but never diagnosed. He has three children. SOCIAL HISTORY: Married for 58 years. Currently living at [**Hospital1 599**] since [**3-6**]. Has had some involvement with hospice there. Has not been living at home since [**4-5**], which he had his lung resection. Per medical records, pt has smoked in the part and drank occasionally (one to two beers a week). No illicit drug use.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 65-year-old male with a history of coronary artery disease and two myocardial infarctions in the past in [**2179**] and [**2186**]. He has a history of angina that goes back to the late [**2177**]. Of note, he has had several prior cardiac catheterizations, the most recent being in [**2193**] at [**Hospital 1474**] Hospital, when the patient presented with the complaints of chest pain. At that time, the ejection fraction was noted to be 45%. In addition, angiography then revealed a 50% LAD lesion and a 60% RCA stenosis. The patient has been medically managed since that time. The patient's most recent stress test was in [**2199-5-22**], which revealed a mild-to-moderate reversible defect of the posterolateral walls with a fixed inferior defect. Ejection fraction was noted to 47% with akinesis of the inferior base. A follow up echocardiogram reported mild left ventricular hypertrophy with ejection fraction of 60%. Prior to admission, the patient complained of intermittent back and chest discomfort. MEDICAL HISTORY: 1. Coronary artery disease times twenty years. 2. History of myocardial infarctions times two in [**2179**] and [**2186**]. 3. Gastroesophageal reflux disease. 4. Hypertension. 5. Hyperlipidemia. 6. Elbow fracture. MEDICATION ON ADMISSION: ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 73 year old female injured in a motor vehicle accident as a passenger. She had no loss of consciousness. Was found with laceration of her left ankle. Patient was admitted to [**Hospital1 18**] emergency room and was later found to have a comminuted distal femur fracture on the right, a fracture of the right hand and a trimalleolar fracture of the left ankle. MEDICAL HISTORY: Hypercholesterolemia. COPD. Obesity. Obstructive sleep apnea. MEDICATION ON ADMISSION: Aspirin and Lipitor. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Dyspnea on exertion, increasing fatigue PRESENT ILLNESS: Mr. [**Known lastname 1625**] is a 56 year old male who reported a dramatic increase in fatigue and dyspnea on exertion. Nuclear stress test on [**2175-10-21**] showed small apical ischemia with on evidence of infarct and an LVEF of 66%. He exercised 8 minutes 30 seconds with chest tightness at peak. The test was stopped due to dyspnea and premature ventricular contractions. Subsequent cardiac catheterization on [**2175-10-30**] revealed severe three vessel disease and normal left ventricular function. Based on the above results, he was referred for cardiac surgical revascularization. MEDICAL HISTORY: Hypertension, Non-Insulin Dependent Diabetes Mellitus, History of Cerebral Aneurysm - s/p surgical repair, s/p Tonsillectomy, Urinary Frequency with Nocturia MEDICATION ON ADMISSION: Metformin 1000 [**Hospital1 **], Avandia 10 [**Hospital1 **], Glipizide 10 qd, Lisinopril 10 qd, Aspirin 325 qd, Toprol XL 25 qd ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Admission: Vitals: BP 135/70, HR 86, RR 14, SAT 98 on room air General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, very soft systolic ejection murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Discharge: VS T 99.2 HR 107 BP 117/72 RR20 Sat 95% RA Gen-NAD Neuro-A&Ox3, nonfocal exam Pulm CTA-bilat CV-RRR, sternum stable, incision-CDI Abdm-soft/nt/nd/nabs Ext-warm , no edema. LLE EVH site w/steris CDI FAMILY HISTORY: Denies premature coronary disease before age 55. SOCIAL HISTORY: Admits to active tobacco, approximately 2 ppd for 6 years. Previously quit tobacco for about 10 years. He denies excessive ETOH. Single, lives alone. Works as an electric design engineer.

CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: [**Age over 90 **] yo M with a history of dCHF, severe CAD s/p CABG ([**2146**] and [**2156**]) LIMA->LAD, SVG->LPLB (posterior left ventricular branch), with numerous PCI's, most recently in [**2166**]. Last PCI [**2167-11-25**] showed native 3VD, multiple SVG->LPL stenoses, patent LIMA->LAD, a stent was placed to mid, prox, ostial SVG (to LPL). He has been managed medically since then. . For the past 1-2 weeks, patient has had upper back pain which he describes as either sharp or pressure. It has been on and off, and he has a hard time describing what makes it better or worse. This is quite different from his usual angina, which he hasn't experienced since his last hospitalization in [**2171-1-27**]. He saw his Cardiologist on [**8-28**]. This pain was thought to be musculoskeletal. He denied any other symptoms of orthopnea, PND, or LE edema, and lungs were clear at that time. [**8-30**] he called his PCP complaining of SOB. He was instructed to take an additional lasix. . On [**8-30**] patient noticed more dyspnea on exertion just walking around his [**Last Name (un) **] and getting into bed. He felt like his legs were heavy, and he was having trouble moving around. Denies any CP, diaphoresis, nausea, or associated back pain. He called EMS at that time. EMS administered full dose [**Last Name (un) **], SL nitro x2, and 40mg IV lasix. . At baseline, he does not have LE edema, orthopnea, or PND. Denies fevers, chills, diarrhea, dysuria. Has had more of a cough recently. . Per family, pharmacy accidentally filled imdur bottle with carvedilol for the past month. . . . On review of systems, s/he denies any prior history of bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, palpitations, syncope or presyncope. . . In the ED, vitals were HR 62 BP 120/47 RR 11 100% on Bipap (FiO2 of 40%). He was started on a nitro gtt, given IV morphine and 40mg IV lasix. EKG was unchanged from baseline. He is being admitted to the CCU for non invasive ventilation, however Bipap was weaned off on transfer from the ED. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: -CAD s/p CABG ([**2146**], [**2156**]): LIMA->LAD, SVG->LPLB (posterior left ventricular branch), Last PCI [**2167-11-25**]: native 3VD, multiple SVG->LPL stenoses, patent LIMA->LAD, Stent to mid, prox, ostial SVG (to LPL) . 1. Coronary artery disease as noted above. 2. Moderately severe mitral regurgitation. 3. Mild-to-moderate aortic stenosis by echocardiography. 4. Chronic diastolic congestive heart failure with recent exacerbation on beta blocker and diuretic therapy. History of intolerance to ACE inhibitors and ARBs related to hyperkalemia. 5. Hyperlipidemia. 6. Hypertension. 7. History of ischemic bowel disease and subsequent urgent right hemicolectomy subsequent to his last coronary intervention. 8. Chronic anemia -requiring Epo. - TIA - GERD - h/o UGI bleed (no NSAIDs aside from [**Month/Day/Year **]) - Glaucoma - Carotid stenosis: 60-69% stenosis of the bilateral internal carotid arteries. - Myelodysplastic Syndrome s/p BMB in [**2167**], followed by Dr. [**Last Name (STitle) 2539**] - Chronic Renal Failure baseline Cr. 1.2-1.4 - Gout MEDICATION ON ADMISSION: 1. Allopurinol 300 mg po daily 2. Atorvastatin 40mg po daily 3. Brimonidine 0.15 % Drops One Drop Q8H 4. Brinzolamide 1 % Drops, one gtt [**Hospital1 **] (). 5. Clopidogrel 75 mg po daily 6. Latanoprost 0.005 % One Drop Ophthalmic HS 7. Nifedipine 30 mg SR po bid 8. Nitroglycerin 0.4 mg SL PRN CP 9. Aspirin 325 mg po daily 10. Docusate Sodium 100 mg po bid 11. Folic Acid 1 mg po daily 12. Isosorbide Mononitrate 90 mg Tablet Sustained Release 24 hr po daily 13. Furosemide 80 mg po bid 14. Famotidine 20 mg po daily 16. Epoetin Alfa 20,000 unit/mL Solution Sig: 2ml Injection once a week. 17. Carvedilol 50 mg po bid 18. Insulin Glargine ALLERGIES: Indomethacin / Ace Inhibitors / Anti-Inflam/Antiarth Agents Misc. Classf PHYSICAL EXAM: VS: T=96.9 BP=124/54 HR=71 RR=15 O2 sat= 100% on 6L nc GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: Had family hx of CAD SOCIAL HISTORY: Lives with wife has some help that comes in several times a week. Has 3 children, one son is a retired OB/GYN. Never smoked cigarettes and rarely smoked cigars, none recently Denies alcohol consumption. Patient was in the Navy. Retired businessman.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 75-year-old woman with a history described in the past medical history, who was admitted to [**Hospital **] Hospital on [**2189-6-8**] with left-sided chest pain and ruled out for myocardial infarction. She was found to be in new onset atrial fibrillation. Persantine Thallium revealed a reversible defect, prompting transfer to [**Hospital1 188**] for catheterization. However, prior to catheterization, she had chest pain and fell, a mechanical fall resulting in a left intertrochanteric fracture. She had a negative head CT and cervical spine, and then was transferred to [**Hospital1 69**]. MEDICAL HISTORY: 1. Hypertension 2. Obesity 3. History of sick sinus syndrome status post pacemaker in [**2186**] 4. Depression 5. Cerebrovascular accident x 2 in [**2182**] and [**2183**] affecting the left side 6. Osteoarthritis 7. Gastroesophageal reflux disease 8. Intestinal bypass, cholecystectomy, appendectomy and hernia repair 9. Fibromyalgia MEDICATION ON ADMISSION: ALLERGIES: Sulfa drugs, which cause a rash. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: She has no tobacco or alcohol use. She lives in [**Hospital3 **].

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old African-American female with a history of hypertension, hypercholesterolemia, coronary artery disease, cerebrovascular accident, abdominal aortic aneurysm, and severe dementia who presents with a upper respiratory infection initially to the [**Hospital6 733**] Clinic on [**10-13**] and given azithromycin times five days. The patient was otherwise, she was in her usual state of health. On Saturday ([**10-15**]) in the evening, the patient was noted to have a large hard stool with dark blood. On Sunday morning, she had no blood in her diaper when changed but by the evening (at 6 p.m.) she had a large blood clot and dark blood saturating her diaper. The patient had no nausea, vomiting, abdominal pain, or hematemesis. In the Emergency Department, the patient's vital signs revealed a heart rate of 77, her blood pressure was 132/44, and her oxygen saturation was 97% on room air. Her hematocrit was 27.8 (with a baseline of 35.3 in [**2146-10-15**]) with normal platelets and coagulations. The patient was transfused 2 units of packed red blood cells. A tagged red blood cell scan showed an active hepatic flexure bleed. The patient went to angiogram for a possible embolization and was found to have a total superior mesenteric artery and internal mammary artery occlusion with no possible embolization intervention. Her hematocrit was stabilized after a total of 3 units of packed red blood cells were transfused. She was watched in the Medical Intensive Care Unit, and her hematocrit on [**10-18**] at 4 a.m. was 29% and remained in that range on [**10-19**]. She continued to ooze some blood from her rectal tube. The patient's two daughters have expressed the desire for no surgery or heroic measures. The patient's code status was to remain do not resuscitate/do not intubate. The patient was transferred to the floor initially for observation. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Fevers, altered mental status PRESENT ILLNESS: 76 yo F with a history of dementia, schizophrenia, DM and T12 burst fracture complicated by lower extremity paralysis admitted from a nursing home with fevers, hypotension and hypoxia. . The patient was found at her nursing home to be febrile to 101.4 104 140/90 tachypneic to RR 22, saturating at 85% on RA. She was noted to have a cough and to be less interactive than normal. Of note the patient was on Levofloxacin 250mg daily for 3 of a total 7 day course for UTI. Reportedly the nursing home was using a foley catheter more frequently in order to limit diaper time as the patient had developed a diaper rash and this was though to be exacerbating sacral decub. The patient is a poor historian. She denies all symptoms. . On arrival to the ED, T 105 rectal HR 139-150 BP 102/76 RR 30 86% 3L improved to 100% on NRB. The patient's bp declined to 75/53. She had a right IJ placed, received Vancomycin, Zosyn and 5-6L of NS. She was started on levophed 0.06mcg/kg/min. MAP ranged 66-89, CVP 10. She had 130cc of urine output over the first 1 hour. Prior to transfer her reported vitals were 103 121/79 26 99% 6L MEDICAL HISTORY: - Schizophrenia - Dementia - History of upper GI bleed with angioectasia in the stomach and duodenum, electrocauterized. Distant GI bleed in past, declined work-up. - GERD - COPD - Hyptertension - Diabetes Mellitus - Osteoarthritis - Neuropathy - Urinary incontinence - T12 burst fracture complicated by lower extremity paralysis - Sacral decubitus ulcer, previously graded as stage 3 - S/p PEG placement in [**2107-7-9**] MEDICATION ON ADMISSION: Metoprolol Tartrate 25 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO twice a day: via PEG tube HOLD for SBP< 110 and HR<60. Flovent HFA 110 mcg/Actuation Aerosol [**Name Initial (PRE) **]: Two (2) puffs Inhalation twice a day. Calcium Carbonate 500 mg (1,250 mg) Tablet [**Name Initial (PRE) **]: One (1) Tablet PO three times a day: via PEG tube. Heparin (Porcine) 5,000 unit/mL Solution [**Name Initial (PRE) **]: One (1) injection Injection TID (3 times a day). Combivent 18-103 mcg/Actuation Aerosol [**Name Initial (PRE) **]: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. Atorvastatin 20 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO once a day. Olanzapine 2.5 mg Tablet [**Name Initial (PRE) **]: Three (3) Tablet PO HS (at bedtime). Ferrous Sulfate 300 mg/5 mL Liquid [**Name Initial (PRE) **]: Five (5) mL PO DAILY (Daily). Multivitamin Liquid [**Name Initial (PRE) **]: Five (5) mL PO once a day. Senna 8.6 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. Docusate Sodium 50 mg/5 mL Liquid [**Name Initial (PRE) **]: Five (5) mL PO twice a day: Hold for diarrhea. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day. Gabapentin 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO HS (at bedtime). Mirtazapine 15 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at bedtime). Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Three [**Age over 90 **]y (320) mg PO Q6H (every 6 hours) as needed. Bisacodyl 10 mg Suppository [**Age over 90 **]: One (1) supp Rectal once a day as needed for constipation. ALLERGIES: Risperdal / Ace Inhibitors PHYSICAL EXAM: Vitals: T 105 rectal, HR 139-150, BP 102/76, RR 30, Sat 86% 3L Gen: Comfortable, NAD. HEENT: PERRL. Dry mucus membranes. Asymmetric facial appearance, slight droop and less responsive on the left. EOMI with the exception right upper field. CV: Systolic ejection murmur at right sternal border. Pulm: CTA bilaterally. Abd: Soft, g-tube in place without drainage. Ext: 1+ bilateral lower extremity edema. Back: 8x5cm stage 1-2 sacral decub. No exudate or surrounding erythema. Neuro: A&O x2 (to place and current president). Difficult to assess though appears to have left sided CN's deficits in VII otherwise appears intact. Proximal left lower extremity [**5-13**] strength, refusing and possibly unable to move the left lower and distal right lower extremity. 5/5 strength in the bilateral upper extremities. FAMILY HISTORY: Has siblings with schizophrenia, otherwise noncontributory. SOCIAL HISTORY: Longstanding mental illness, presently living in nursing home. Is wheelchair bound at baseline.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is an 87 year old man with a history of end stage renal disease from systemic lupus erythematosus (SLE) who was found to spike a temperature of 104 degrees at the end of his hemodialysis session on [**2173-4-23**]. He had been started on Vancomycin the day prior, that for a positive wound culture from a right Hickman's which was taken on [**4-15**], and was positive on [**4-18**] and grew Coagulase positive Staphylococcus which was sensitive to Oxacillin. He also did get a dose of Vancomycin of 500 mg at hemodialysis. The port site did appear erythematous and given his temperature of 104 degrees he was taken to the Emergency Room for further evaluation. En route to the Emergency Room the blood pressure was 110/58 with a heartrate of 106, and respirations were 20, however, in the Emergency Room his systolic blood pressure decreased to the low 80s; however, he was asymptomatic, maintaining well and had good urine output. He was given 1 liter of normal saline as well as started on a Dopamine drip. Systolic blood pressures remained in the 80s on this and he was therefore admitted to the Medicine Intensive Care Unit. The line was pulled by Interventional Radiology Service in the Emergency Room. The patient's white blood cell count was increased to 17 down to 7 from prior laboratory data, and he was also started on Levofloxacin and Flagyl in the Emergency Room. MEDICAL HISTORY: 1. End stage renal disease secondary to systemic lupus erythematosus on hemodialysis since [**2167**]; 2. Dementia; 3. Hypertension; 4. Anemia; 5. Depression; 6. Hyperthyroidism; 7. Coronary artery disease, status post myocardial infarction in [**2168**] and catheterization in [**2168**] showed three vessel disease with percutaneous transluminal coronary angioplasty stent to the left anterior descending. 7. Status post cerebrovascular accident. 8. Status post deep vein thrombosis. 9. Ejection fraction of 30% on echocardiogram in [**2168**]. 10. Osteoarthritis. MEDICATION ON ADMISSION: 1. Levoxyl 150 mcg q.d.; 2. Nephrocaps one tablet p.o. q.d.; 3. TUMS 650 mg t.i.d.; 4. Coumadin 5 mg q.d.; 5. Aricept 10 mg p.o. q.h.s.; 6. Atenolol 25 mg p.o. q.h.s.; 7. Tylenol prn; 8. Calcitonin spray one q.d. alternating nostrils; 9. Colace; 10. Effexor 75 mg q.h.s.; 11. Lisinopril 5 mg q.d.; 12. Sorbitol 70% 30 mg q.i.d. prn; 13. Ensure supplements. ALLERGIES: The patient is allergic to non-steroidal anti-inflammatory drugs, Aspirin, magnesium, laxatives and Plaquenil. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient has baseline dementia with intermittent hallucinations, however, is otherwise functional and those are at baseline. He has a very involved son, [**Name (NI) **] [**Name (NI) 23847**], home #[**Telephone/Fax (1) 23848**], work #[**Telephone/Fax (1) 23849**].

CHIEF COMPLAINT: Unstable angina. PRESENT ILLNESS: This is a 50 year old man with prior history of coronary artery disease, reports a two week history of increasing exertional dyspnea. He originally attributed his symptoms to a cold but then developed some burning in his chest. He started Protonic for reflux but his symptoms persisted. He went for a stress test on the day of admission and developed ST changes in his early precordial leads, borderline ST elevation in lead 3. Nuclear imaging revealed a severe, partially reversible, lateral inferior defect. He was transferred to [**Hospital1 188**] for a cardiac catheterization. MEDICAL HISTORY: His prior medical history includes gastroesophageal reflux, hepatitis B infection, gout. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Mother, father and brother all have coronary artery disease. SOCIAL HISTORY: He is divorced. He is a designer/architect. He used to drink alcohol but he has not had any in about a month. He has one daughter. [**Name (NI) **] does not smoke cigarettes.

CHIEF COMPLAINT: Left ischemic leg PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female who was recently on a lowered Coumadin dose because of a UTI and antibiotics who presented with acute pain of her left lower extremity. She had no palpable pulses in the femoral or distal. Of note, the patient in [**Month (only) 116**] of this year had a similar episode when she was subtherapeutic on Coumadin and required an embolectomy. The patient postoperatively had a hematoma and a groin wound dehiscence but this ultimately closed and granulated well. Today, the patient and her family decided that they wish to have another procedure in order to restore flow to her left leg. MEDICAL HISTORY: PMH: HTN, chronic atrial fibrillation, CHF, DVT, hypothyroidism, anemia, breast ca, Paget's disease, cholelithiasis MEDICATION ON ADMISSION: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO every twenty-four(24) hours. Tablet(s) 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PE: Afebrile A&Ox3, NAD. frail but energetic, hard of hearing CTAB, no wheezes/crackles/rhonchi irreg irreg, no M/R/G soft, NT, ND, protuberant. L groin with healed transverse incision, mild erythema, firmness sans fluctuance. L leg warm compared to right leg. cap refill < 2 seconds BL. non-tender to touch or passive motion. pt able to wiggle toes and flex ankles BL. R heel with beginning of pressure ulcer, skin intact. FAMILY HISTORY: NC SOCIAL HISTORY: Patient lives at [**Hospital 100**] Rehab. Has several children, grandchildren, and great-grandchildren. No tobacco, EtOH, recreational drugs.

CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: 43 year old male that presented in [**Month (only) 216**] with S. salivarius mitral valve endocarditis with multiple septic embolic on imaging including both kidneys, the spleen and a left parietal hemorrhage with additional acute infarcts in the right temporal and parietal region. He underwent a cerebral angiogram on [**9-20**] and was found to have a mycotyic aneurysm as cause of L parietal lesion and underwent embolization. The patient completed 14 days of gentamicin on [**9-22**]. He will have completed 6 weeks of ceftriaxone [**10-23**]. He presented in [**Month (only) **] with wrist pain and was treated for arteritis and thrombus of a branch of his left radial artery. Currently presents for valve replacement due to mitral regurgitation with symptoms of shortness of breath with minimal activity and chest pain that comes and goes occuring at rest and activity resolves quickly. He denies fever or chills. MEDICAL HISTORY: Streptococcus salivarius mitral valve endocarditis [**8-31**] with course complicated by severe MR, multiple septic embolic to bilateral kidneys, spleen, L parietal hemorrhage with underlying mycotic aneurysm s/p onyx embolization. Cerebral hemorrhage - R PCA territory with a L parietal intraparenchymal IVDU x 22 yrs (cocaine, oxycodone, heroin) EtOH Abuse last drink [**8-/2111**] HCV Ab + [**2108**], viral load negative myocardial infarction s/p MVR [**2112-2-4**] MEDICATION ON ADMISSION: ALPRAZOLAM 0.25 mg Tablet by mouth twice a day as needed BUPRENORPHINE-NALOXONE 8 mg-2 mg Tablet, Sublingual - 0.5 sublingually every morning CITALOPRAM 40 mg Tablet every morning CLONIDINE 0.1 mg Tablet by mouth twice a day GABAPENTIN 600 mg Tablet by mouth three times a day LEVETIRACETAM 500 mg Tablet by mouth daily every morning (currently tapering off) - discussed with neurosurgery [**2-3**] stop now FOLIC ACID 0.8 mg Tablet by mouth daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: General: no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [**3-27**] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Pulses: Femoral Right: band in place Left: +1 DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +1 Left: +1 FAMILY HISTORY: No family history of coronary artery disease SOCIAL HISTORY: -Owns tree clipping business -Tobacco history: 2-3ppd for unclear number of years -ETOH: 1-2 liters of rum daily -Illicit drugs: IV admin of cocaine and oxycontin, IVDA since [**22**] years old

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 69-year-old male with a long-standing history of poorly controlled hypertension, type 2 diabetes, and hypercholesterolemia, who presented to the [**Hospital6 256**] on [**2126-3-26**] on referral from his primary care provider for poorly controlled hypertension. The patient reportedly told his primary care provider that he was suffering several months worth of increased dyspnea on exertion associated with throat constriction that occurred following walking for less than two blocks. The patient denied any occurrence of symptoms at rest. The patient was advised to undergo a Persantine MIBI study at [**Hospital6 1597**]; however, the scheduled study had to be cancelled secondary to the patient's increased blood pressure. The patient was subsequently referred to the [**Hospital6 1760**] for further evaluation and was admitted to the Cardiac Medicine Service on [**2126-3-26**] for further evaluation and management. MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Type 2 diabetes. MEDICATION ON ADMISSION: ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient works as a stock broker. No history of alcohol or drug abuse. Twenty-five pack year history of smoking, however, the patient no longer smokes.

CHIEF COMPLAINT: Fatigue and dyspnea on exertion PRESENT ILLNESS: 62 year old woman with well known history of Aortic stenosis followed by serial echocardiograms. Recently noted increasing symptoms of DOE/SOB along with palpitations and postural lightheadedness. Recent echo showed progression of AS. MEDICAL HISTORY: AS ([**Location (un) 109**] 0.7) ^chol HTN Hypothyroid Bilat carotid bruit MEDICATION ON ADMISSION: HCTZ 12.5 Q M-W-F Lipitor 20' Levoxyl 75mcg' Lisinopril 5' ASA 81' ALLERGIES: Amoxicillin / Zithromax / Clarithromycin / Biaxin / Sulfa (Sulfonamides) / Erythromycin Base / Ofloxacin PHYSICAL EXAM: Admission VS HR 80 BP 124/70 RR 16 Ht 62" Wt 156 lbs Gen NAD Neuro grossly intact Skin unremarkable Chest CTA- bilat Cor RRR 3/6 SEM Abdm soft, NT/+BS Ext warm, well perfused. no edema or varicosities Discharge VS T 99.3 HR 74SR BP 114/64 RR 18 O2sat 98% RA Gen NAD Neuro A&Ox3, nonfocal exam Pulm CTA-bilat CV RRR no murmur Abdm soft, NT/+BS Ext warm, 1+ edema bilat FAMILY HISTORY: Father and mother died of cancer in their 60's SOCIAL HISTORY: Lives with husband in [**Name (NI) 47**]. Worked as daycare provider. [**Name10 (NameIs) 4273**] ETOH use. Remote tobacco- quit [**2109**].

CHIEF COMPLAINT: dysphagia PRESENT ILLNESS: Mr. [**Known lastname 81628**] is a 74 year old right handed male with myasthenia [**Last Name (un) 2902**] diagnosed [**2119-1-15**] who now presents with dysphagia, diplopia, nasal sounding voice. He was recently finished a maintenance round of IVIG two weeks ago for gradually worsening symptoms of dysphagia and trouble chewing since this summer. He did not derive any benefit from the IVIg ,and was planning to have barium swallow study performed. He denies any symptoms of regurgitation. His dosage of Pyridostigmine has not changed recently. He was in to see his urologist on Monday for symptoms of dysuria and difficulty initiating the urine stream. Cystoscopy was performed, and note made of normal sized prostate. The urologist prescribed a medication to "help relax my bladder." Solifenacin or brand name Vesicare, which notably antigonizes muscarinic Ach receptors. He took doses on Tuesday and Wednesday. He awoke today to note severely "nasal" sounding voice, diplopia, even worse dysphagia and difficulty chewing. Diplopia is mild, and notable in all directions, alleviated by closing one eye. He denies any difficulty breathing or c/o SOB at present. Per discussion with his wife via telephone the patient is a minimizer and only seeks care when he absolutely must. She thinks he may have confused the dosages of his medications a few weeks ago and was taking double the dose of atorvastatin. He stopped taking Cellcept altogether for two months Spring [**2121**] because he felt his symptoms of diarrhea were worsened by this medication. At present the pt denies headache, loss of vision. No lightheadedness, vertigo, tinnitus or hearing difficulty. Denied difficulties producing or comprehending speech (just nasal sounding). Denied focal weakness, numbness, parasthesiae. Chronic dysuria and difficulty starting the urine stream, unchanged recently. He has occasional bowel leakage when attempting to urinate, but otherwise no frank incontinence. Denied difficulty with gait. On review of systems, the pt denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, + chronic diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. + dysuria. Denied arthralgias or myalgias. Denied rash. In the ED, NIF was 50cm and VC 3.5 liters, pt can count to 43 on one breath. MEDICAL HISTORY: 1) Myasthenia [**Last Name (un) **]- (dx [**2119-1-27**])- diagnosed when pt was at a casino and could not chew/swallow his hamburger, had noted intermittent diplopia, initially seen by ENT then referred to his neurologist Dr. [**Last Name (STitle) **] in [**Doctor Last Name **], MA. Never intubated. Pt reports chest scan was negative for thymoma. He is unsure if he has Ach R ab or anti-MuSK. He Was initially on prednisone and then tapered to Imuran, then changed to Cellcept for reasons unclear to the patient (no apparent side effects that he was aware). He has had three cycles of IVIg periodically in [**2119**], [**2120**], then most recently nearly 2 weeks ago for worsening symptoms of dysphagia and trouble chewing. 2) Hypertension. 3) Hyperlipidemia 4) R total knee replacement MEDICATION ON ADMISSION: Allergies: NKDA ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAMINATION: Vitals: T 98, BP 128/82, HR 66, R 12, Sat 96% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no JVD or carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. FAMILY HISTORY: Mother- had CAD, died of ovarian CA [**Name (NI) 12238**] estranged. SOCIAL HISTORY: Social History: Pt lives with his wife, son and new grandson in [**Name (NI) **], MA, he is a retired 3rd-6th grade elementary school principal, he smoked cigars and pipes until his latest IVIg treatment two weeks ago, he rarely drinks small amounts of alcohol, no h/o IV or illicit drug use.

CHIEF COMPLAINT: transfer from OSH, GI bleed PRESENT ILLNESS: 46YO male with ETOH cirrhosis known varices with hx UGIB from ? esophagitis, hx partial portal vein thrombosis [**8-26**] who presented to [**Hospital **] Hospital with hematemesis on 4/. Pt was eating dinner/drinking ETOH and began having nausea and vomting. He vomited 2 x times each with "2 cups of blood". Hours later he vomited a 3rd time and "passed out" for "1 minute" injuring his head in the process. He then called 911. On arrival to ED his HR was 106 and his BP was 60/40. Per reports, his initial Hgb was 10.1/Hct 31.1 and INR 2.4. He had an NG lavage with bloody return that cleared after 500cc lavage. He was given IV fluids and PRBCS. A left facial lac was repaired. The next day he had EGD with significant blood in the stomach and bleeding from dieulafoys vs varix but no convincing fundic varices. In total he has received 6units PRBCs and 9 units of FFP. He was started on octreotide gtt. He was started on levofloxacin for SBP prophylaxis with GI bleed. On [**4-27**] he was transfered to [**Hospital1 18**] ICU for futher management. On arrival, pt is mentating well and HD stable. He has no pain. Denies fever, cough, SOB, CP,abd pain. He reports only have one bowel movement in past 3 days (unsure if it had blood). He denies having itchiness MEDICAL HISTORY: -ETOH cirrhosis with known portal HTN and hx Grade I varices and gastropathy -partial portal vein thrombosis [**8-26**] -hx alcoholic hepatitis -hx upper GI bleed from distal esophagitis -hx ascites with 2 large volume paracentesis (8liters each time per patient) in [**Month (only) 216**] and [**2157-9-22**] -recent lower GI bleed from hemorrhoids (pt reports recent colonoscopy) -iron deficiency anemia -umbilical hernia with recent reduction in ED -depression MEDICATION ON ADMISSION: Colace 100mg [**Hospital1 **] prilosec Metamucil QD Anusol cream PR [**Hospital1 **] iron sulfate (recently d/c'd) zoloft ALLERGIES: Lasix PHYSICAL EXAM: no distress, cooperative, tire-appearing VS: 99.4 77 136/66 15 97%RA HEENT: laceration on left side of face (intact) slight icterus, EOMI, mild moderately dry MM Neck: supple, -LAD, JVP not elevated lungs: CTA bilaterally heart: RRR -murmurs, -rubs abd: soft +spleen tip, mild distension, RUQ fullness but liver edge difficult to appreciate, mild RUQ tenderness of palpation -fluid wave + BS ext: -edema, -tremor neuro: CN intact, -asterixis, skin: diffuse erythematous rash + blanching on back and upper chest FAMILY HISTORY: alcoholism in mother and aunt SOCIAL HISTORY: Patient lives alone, he was employed as an electrician as recently at 7/05. hx [**Last Name (un) 20934**] he is divorced and has no children He is actively drinking ETOH, he reports usually drinking about 6pack of beer and 1pint of whiskey each day he has distant history of polysubstance use including cocaine, acid, THC. His last cocaine use was over 10 years ago

CHIEF COMPLAINT: Ruptured aneursym. PRESENT ILLNESS: This 70 year-old male who underwent a right nephrectomy for a benign lesion who noted one month prior to admission vague abdominal pain. On [**12-16**] noted sudden onset of sharp abdominal pain 10 out of 10 nonradiating without hematuria, leg numbness or melena. He called 911. He was taken to an outside hospital. A CT scan showed ruptured aneurysm. The patient was transferred here for emergent surgery. MEDICAL HISTORY: 1. Hypertension. 2. Prostate carcinoma. 3. Status post brachytherapy on [**2108-5-21**]. 4. Right nephrectomy, remote secondary to benign lesion. 5. Chronic renal insufficiency, baseline creatinine of 2.2. MEDICATION ON ADMISSION: Hydrochlorothiazide 25 mg q.d., Diltiazem 240 mg po q day, Lisinopril 10 mg po q day. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Fevers, Altered Mental status PRESENT ILLNESS: Patient unable to give history himself. Most history is from [**Hospital1 1562**]. 54M with a history of CABG, remote MI, hip/shoulder surgery, liver failure, hypertension, hyperlipidemia, depression, alcohol and tobacco abuse who is transferred from [**Hospital 1562**] Hospital after decompensating there. The patient is a 54-year-old man who was brought into [**Hospital1 1562**] from [**Location (un) 3244**] detox with significant juandice, lethargy, and an episode of syncope while exiting the bathroom. At [**Hospital1 1562**], his initial presentation was alert and oriented x 3 and speech clear. Pertinent labs at [**Hospital1 1562**]: WBC 19.6 Hct 29 Plt 210 INR 2.7 Lipase 20 K 3.2 Cl 88 Ammonia 66 Ca 7.9 CO2 37 K 3.2 Total bili 14.7 Direct bili 10.0 Total protein 6.3 Alb 2.6 AST 213 ALT 23. The patient then became febrile to nearly 102 and lethragic, only oriented to self. He became agitated as well, intermittently. At [**Hospital1 1562**] before transfer the patient had received 8mg Ativan, 1gm ceftriaxone, 600mg ibuprofen, 40mg K, 2g IV MG. The patient's urine output began to drop despite 3L NS. . In the ED, temp 98 Hr 120 Bp 123/84 RR 18 94% RA. Patient was given 1mg ativan for sedation, placed in wrist restraints. [x] EKG: sinus tachycardia with nonspecific ST-T changes [x] CXR: [x] RUQ ultrasound was performed. [x] Liver consult was called. [x] LFTs: [x] UA, Ucx: [x] Bcx: pending [x] Guaiac: Negative [x] ICU transfer requested [x] Serum, urine tox, tylenol [x] SIRS treatment: vancomycin, cefepime, flagyl . . On the floor, was intermittently agitated. BP was 92/52 HR ws 98 RR was 14 he was 100%on RA. . Review of sytems: could not be obtained as patient is not cooperative MEDICAL HISTORY: Per OSH history: history of CABG remote MI, hip/shoulder surgery, liver failure, hypertension, hyperlipidemia, depression, alcohol and tobacco abuse MEDICATION ON ADMISSION: n/a ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: VS: T: 97.9, P: 128, BP: 112/53, RR: 26, 91% RA General: Oriented to name only. Intermittently responsive. HEENT: Icteric Sclerae, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: tachycardic, normal S1 + S2, Chest: multiple spider angiomas throughout. Abdomen: tense, +bowel sounds, non-tender, no rebound tenderness or guarding, no organomegaly, without shifting dullness, tympanitic on percussion. GU: foley in place. Ext: mild palmar erythema, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox1, Cranial Nerves intact grossly, good strenght in his extremities, profound asterixis. Discharge FAMILY HISTORY: unknown. SOCIAL HISTORY: Tunnel worker. Speaking with sister, he drinks close to a quart a day of vodka with gatorade. [**Last Name (un) 5487**] last drink. Smokes a pack a day. Drugs:[**Last Name (un) **], but may have in the past. He lives with his gilfriend

CHIEF COMPLAINT: blurry vision, renal mass PRESENT ILLNESS: HPI: Mr. [**Known lastname 59304**] is a 45yo man with a PMHx significant for recently diagnosed RCC with bone mets, HTN, HL, anxiety, migraines and season allergies who presents to the ER after having had a transient episode of right lip and tongue numbness with blurred vision. He had been in his usual state of health until approximately 11:30am [**12-15**] when he was in his firehouse and had acute onset of right lip and tongue numbness and blurred vision. He describes his lip/tongue numbness as feeling as though someone had "poured novocaine on me". No tingling associated with this. It was focal, located specifically on the right lower lip and tip of the right side of his tongue. He also had acute onset of blurred vision. He reports that things seemed out of focus and that it resolved with closing each eye. No double vision. No HA, dysarthria, feeling of weakness of any limb, no lightheadedness or dizziness. In total, this episode lasted for seven seconds. He called his oncologist's office, who recommended that he come to the ED for urgent evaluation and Head CT (apparently unable to arrange as outpatient). On arrival to the floor, patient states he has no further symptoms and feels well. MEDICAL HISTORY: Past Medical History: 1. RCC -- recently diagnosed three weeks ago when found to have L abdominal mass. Has mets to L humerus, femur, and right ulna. Scheduled for nephrectomy and removal of tumor on [**2100-12-17**]. 2. Hypertension 3. hypercholesterolemia 4. anxiety -- has prior history of panic attacks 5. migraines -- last migraine was three weeks ago 6. seasonal allergies MEDICATION ON ADMISSION: 1. Lisinopril 5 mg p.o. daily 2. sertraline 50 mg p.o. daily 3. simvastatin 80 mg p.o. daily 4. vicodin 5/500 prn pain ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: VS: T 97.7 HR 88 bp: 143/87 RR 18 SaO2 96 RA GEN: NAD, awake, alert HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and without lesion NECK: Supple, no JVD CV: Reg rate, normal S1, S2. No m/r/g. CHEST: Resp unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABD: Soft, NT,slightly distended with left-sided abdominal mass > 5cm below costal margin which is hard, non-tender, no HSM, bowel sounds present MSK: normal muscle tone and bulk EXT: No c/c/e, 2+ DP/PT bilaterally SKIN: No rash, warm skin NEURO: no focal deficits except for "mild motor impersistence of tongue", see consult note for details PSYCH: cooperative FAMILY HISTORY: No history of renal cell carcinoma or other cancers. His mother died last month of a cardiac arrest with no significant cardiac history at age 66. Grandmother died of a stroke and coronary artery disease in her 80s. He has a brother who is alive and well. His biological father died when he was age 12 and he does not know his medical history. SOCIAL HISTORY: Divorced and lives in [**Location **]. He has two daughters ages 8 and 11. Has a girlfriend, [**Name (NI) **]. [**Name2 (NI) **] works as a firefighter and EMT. He recently quit smoking three months ago. He drinks alcohol socially. Denies illicit drug use.

CHIEF COMPLAINT: fever and jaundice PRESENT ILLNESS: Mr. [**Known lastname 110070**] is a 60M with history of advanced ALS, chronic trach/mechanical ventilation/PEG, DVT/PE on warfarin who is transferred to [**Hospital1 18**] now with concern for acute cholecystitis and need for ERCP. Patient initially admitted to [**Hospital1 392**] after presenting with fevers and jaundice. The pt is nonverbal so hx is per wife. Over past 10 days has noticed him to becoming increasingly more jaundice associated with darker colored urine and [**Male First Name (un) 1658**] colored stools. Went to PCP who referred him to the hospital. On arrival to [**Hospital3 5365**] pt was febrile to 101.5 w/ tachycardia. His initial labs were notable for WBC 20,000 w/ 16% bands, bili of 8.3, alk phos of 559 and INR supratherapeutic at 6.1. CT scan and RUQ at OSH revealed dilated intrahepatic biliary ducts. Patient was started on empiric antibiotics with vanc/zosyn. He remained hemodynamically stable with good UOP. He received FFP and vitamin K prior to transfer. . With regard to his ALS, he has been bed-ridden for 2 years. Currently communicates by raising his eye brows, up indicating "yes," and no movement indicating "no." He has a chronic trach and is on mechanical ventilation, and also has a PEG through which he receives nutrition and meds. His care is provided by his wife at home. . On arrival to the ICU,he was not in appearant distress although difficult to assess in this pt. He was notably jaundice on exam and was complaining of some abominal pain with palpation but difficult to assess exactly where in his abdomen. . Review of systems: per HPI MEDICAL HISTORY: ALS, chronic trach/mechanical ventilation/PEG DVT/PE Hypothryoidism MEDICATION ON ADMISSION: 1. Combivent 18-103 mcg/actuation Aerosol Sig: Four (4) puffs Inhalation q3h as needed for shortness of breath or wheezing. 2. omeprazole 2 mg/mL Suspension for Reconstitution Sig: Twenty (20) mg PO once a day. 3. Rilutek 50 mg Tablet Sig: One (1) Tablet PO twice a day. 4. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal EVERY 3 DAYS (). 5. glycopyrrolate 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO EVERY OTHER DAY (Every Other Day) as needed for constipation. 7. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAYS (MO,FR). 8. warfarin 3 mg Tablet Sig: One (1) Tablet PO DAYS ([**Doctor First Name **],TU,WE,TH,SA). ALLERGIES: Levofloxacin / metronidazole PHYSICAL EXAM: On admission Vitals: T:98 BP:162/70 P:110 R:12 O2: 100% General: Jaundice, Alert, no acute distress, non verbal, communicates with eye brow raising, rising eye brows indicates yes, no response is no movement of eyes. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not able to assess, trach in place Lungs: Clear to auscultation bilaterally on ant exam, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, hypoactive BS, no rebound tenderness or guarding, no organomegaly GU:foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema FAMILY HISTORY: Father had unknown type of cancer SOCIAL HISTORY: lives w/ his wife - [**Name (NI) 1139**]: denies - Alcohol: denies - Illicits: denies

CHIEF COMPLAINT: 30 foot fall onto tree stump PRESENT ILLNESS: This is a 40 year-old woman who was brought to the ED by [**Location (un) 1110**] EMS after a 30ft fall onto a tree stump. Initially there were concerns that the fall had been a suicide attempt. There was a failed intubation atttempt by EMS (for GCS=7 on scene) and a needle decompression of the left chest by EMS for decreased breath sounds on that side. MEDICAL HISTORY: Medical: h/o pyelonephritis h/o blackouts and head trauma h/o kidney stones while pregnant h/o alleged rape MEDICATION ON ADMISSION: ativan fluoxetine omeprazole dilantin ALLERGIES: Codeine / Demerol PHYSICAL EXAM: On discharege: T97.3 P90s/60s P76 R16 95% RA Gen: Alert and awake, pleasant. HEENT: Halo in place. Pin sites have no erythema, redness or swelling. Chest: Clear to auscultation bilaterally. CV: Regular rate and rhythm. Abd: Soft, nontender. Ext: Right LE surgical incision clean, dry and intact with no signs of infection. Extremities warm and well-perfused. FAMILY HISTORY: alcoholism in father, mother, 2 siblings, mother's maternal grandfather SOCIAL HISTORY: EtOH: long h/o EtOH abuse, with multiple hospitalizations at detox/rehabs and 6-month period of sobriety in [**2161**] drinking since age 14 h/o cocaine and marijuana, last used in [**2151**] daily cigarettes

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 43-year-old homeless man with a history of hyperthyroidism, who ran out of his propanolol and propylthiouracil three weeks ago, who presents with complaints of headache, diarrhea, chest palpitations, and chest tightness, flushing, feels of tremulousness over the past three days. The patient describes this chest tightness as coming in episodes lasting about 15 minutes associated with diaphoresis. The patient denies nausea, vomiting, abdominal pain, dysuria, hematemesis, hematochezia, shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. MEDICAL HISTORY: 1. Hyperthyroidism diagnosed in [**State 18250**] in [**2142**]. 2. Depression. 3. Bladder tumor. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: Vital signs in the Emergency Room: Temperature of 98.7, blood pressure 191/92, pulse 154, respirations 18, and saturating 99% on room air. On the floor, vital signs temperature 96.8, blood pressure 142/70, pulse 85, respirations not recorded, and saturating 100% on 2 liters. In general, this is a middle-age man in no apparent distress. HEENT: Face red and flushed. Oropharynx is clear. Mucous membranes moist. Neck: Diffusely enlarged, nontender thyroid with no masses or nodules. Chest: Wheeze in the left mid lung, few rales at the bases. Cor: Regular rate, normal S1, S2. Abdomen is soft, nontender, nondistended, normoactive bowel sounds. Extremities are warm and well perfused, no clubbing, cyanosis, or edema. Skin with multiple tattoos. Neurologic: Cranial nerves III through XII are intact. FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: SOB PRESENT ILLNESS: 69yo M PMHx Severe aortic stenosis ([**Location (un) 109**] 0.9cm2), s/dCHF (EF 20% [**8-/2138**]), recurrent L-sided pleural effusion attributed to CHF, AV node dysfunction s/p PPM ([**2-/2138**]), COPD, CKD, and multiple recent hospital stays for shortness of breath, notable for CABG/AVR w/u but subsequent refusal of surgical intervention, now presenting with SOB. Patient reports SOB has been worsening since discharge 1d prior to this presentation. He denies CP, palpitations, nausea/vomitting/diarrhea, HA, weakness. . Initial vital signs in the ED were 98.5 74 120/60 16 95%. Exam was notable for crackles throughout lung fields. Labs were significant for WCC 11.5 (6.1 at discharge), Hct 31.1, Cr 3.8 (3.7 at discharge), CXR demonstrated fluid overload w stable large L pleural effusion. CT [**Doctor First Name **] was consulted but given patient's refusal of surgical interventions in the past they recommended medicine admission. Patient was admitted to medicine for further management of shortness of breath. Vitals at time of transfer were 98.6 77 131/76 22 100%2LNC. . On arrival to the floor, initial vital signs were 96.3 143/70 73 28 93%4L. Patient denied any pain or discomfort, but his tachypnea interfered w conducting a full review of systems. On the day of admission the pt was transferred to the CCU due to concern for evolving sepsis in the setting of likely PNA and CHF exacerbation. MEDICAL HISTORY: CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension CARDIAC HISTORY:[**3-/2138**] cath 30% prox LAD. 100% first diagonal, 50% mid LCx, 40% OM1, 100% ostial RCA OTHER PAST MEDICAL HISTORY: - Chronic Diastolic and Systolic Congestive Heart Failure - Aortic Stenosis - Coronary Artery Disease - Chronic Renal Insufficiency (baseline Cr 2.5) - Chronic Obstructive Pulmonary Disease - Cerebrovascular event ([**2097**], per pt no residual deficits) - Type II Diabetes Mellitus (IDDM) - Post-traumatic stress disorder - Chronic Pain ( fractured lumbar vertebra) - Osteoarthritis left shoulder and leg - Benign prostatic hypertrophy - Left hand neuropathy - Glaucoma in left eye - Colon polyps - Recurrent left pleural effusion 4. PAST SURGICAL HISTORY - Permanent Pacemaker [**2138-3-10**] - C4-C7 spinal surgery - Right lower extremity vein stripping - Nasal surgery MEDICATION ON ADMISSION: - aspirin 81mg daily - metoprolol succinate 25mg daily - famotidine 20mg q24hrs - clonazepam 2mg Tablet daily - lactulose 10 gram/15 mL daily - prazosin 1mg qhs - Lasix 40mg [**Hospital1 **] - Zocor 20mg daily - glargine 20units qAM ALLERGIES: Dilaudid PHYSICAL EXAM: ADMISSION EXAM: VS: T 98 BP 91/52 HR 84 RR 14 O2 Sat 93% 3L NC GENERAL: Resting comfortably in bed. Unarousable. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, JVP to the angle of the mandible CARDIAC: PMI not palpable. RR, harsh crescendo/decrescendo systolic murmur best heard at the R 2nd intercostal space radiating to the carotids. LUNGS: Absent breath sounds and dullness to percussion at the L base. Scattered crackles. Using accessory abdominal muscles. ABDOMEN: Soft, NTND. No HSM or tenderness. AS murmur heard in the abdominal aorta. EXTREMITIES: 2+ pitting edema to the shin, 1+ pitting edema to the patellas bilaterally. Pulses 1+. SKIN: Bilateral abrasions of the forearms, confluent ecchymoses of the forearms PULSES: Right: Carotid 2+ Femoral 2+ Radial 2+ Left: Carotid 2+ Femoral 2+ Radial 2+ NEURO: Pupils 1-2mm bilaterally, equally round and reactive to light. Otherwise unable to participate [**3-12**] sedation. . DISCHARGE EXAM: GENERAL: 69 yo M sitting in bed in no acute distress HEENT: supple, no JVD sitting upright CHEST: Crackles bibasilar 1/2 up CV: S1 S2 Normal in quality and intensity with crescendo-decrescendo systolic murmur throughout precordium. ABD: firm, non-tender, distended with mild ecchymosis. Pos BS. EXT: wwp, 2+ edema 1/2 up calf. DPs, PTs 1+. NEURO: sleepy, arousable but quickly falls back asleep. Able to answer simple questions. SKIN: no rash, PICC d/c'ed PSYCH: lethargic, not agitated but restless. FAMILY HISTORY: Brother died of MI at 69. SOCIAL HISTORY: Tobacco: 1.5 ppd ( 75 PYHx); trying to quit ETOH: 2 per month Lives: Alone, has daughter who spends a lot of time hopitalized for psychiatric reasons Occupation: retired engineer Last Dental Exam: has 6 remaining teeth, uses partials

CHIEF COMPLAINT: Respiratory distress s/p elective lymph node biopsy PRESENT ILLNESS: 27 year old gentleman who presented for an elective axillary lymph node biopsy today and subsequently developed respiratory failure and VF and PEA arrests. . Regarding his lymphadenopathy, he reports he began to notice swelling over his left temple about 3 weeks ago that gradually migrated down the left side of his face and behind his jaw into his neck. He reports it is mildly painful over his temple as well as over his jaw while chewing. He also affirms it is tender to palpation. He was in contact with his PCP with these findings and underwent an ultrasound followed by a CT of his head and neck. The scan revealed adenopathy extending from the left ear into the mediastinum and right axilla and the patient was asked to return to the ED for further work up. He received a CT of chest, abdomen, and pelvis which revealed a mediastinal mass with multiple enlarged nodes in the mediastinum, right axilla, subclavicular and aortocaval nodes near the level of the kidneys. He was then admitted to [**Hospital1 18**], where he underwent VATS and mediastinal mass biopsy, which was nondiagnostic. He was readmitted from [**Date range (1) 9397**], where he had ENT, thoracics and ACS consults who all felt that there were no clear options for where his repeat biopsy should occur. It was felt that his lymph nodes could represent reactive lymphadenopathy from his SVC syndrome, but also that a mediastinal mass biopsy could be unrevealing as this was the case in his last VATS. Therefore he had PET CT to identify FDG-avid lymph nodes most appropriate for biopsy which revealed diffuse disease. He was discharged to home with plan for R axillary LN biopsy today. . Today, he was intubated for airway protection given his habitus prior to procedure. Initial intubation was difficult due to habitus. On extubation, he wasn't ventilating well with elevated end tidal CO2 despite 30-45 min of Ambu ventilation and was reintubated with difficulty. He had no documented episodes of hypotension throughout. Subsequent to re-intubation, he was found to be in VF and pulseless. Chest compressions were initiated and he was shocked once with ROSC. He subsequently went into PEA arrest and received 2 doses of epinephrine with ROSC. A left femoral a-line and IJ CVL were placed in the setting of the code. . On arrival to the ICU, the patient is intubated and sedated. MEDICAL HISTORY: h/o recent lymphadenopathy and a mediastinal mass polysubstance abuse morbid obesity previously difficult intubation s/p VATS MEDICATION ON ADMISSION: Home Meds (per recent discharge summary): albuterol sulfate 2 puffs q4h prn wheezing acetaminophen 650 mg qh4 prn pain/fever docusate sodium 100 mg [**Hospital1 **] prn constipation oxycodone 10 mg q4h prn pain ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission Physical Exam: Vitals: T: 96.6 BP: 154/83 P: 138 R: 25 O2: 95% on 100% FiO2, PEEP 10 General: Intubated and sedated, follows simple commands when sedation off HEENT: ETT in place, Sclera anicteric, PERRL Neck: supple, JVP not seen [**1-21**] habitus Lungs: Diffuse crackles, no wheezes, moderate air entry CV: Difficult to auscultate given ventilator, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, bowel sounds present, no rebound tenderness or guarding, no grimace with palpation GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema FAMILY HISTORY: No history of known malignancy. SOCIAL HISTORY: From [**Location (un) 86**], currently living in [**Location (un) 3146**]. Smoking [**12-21**] pack per day currently; previously was 1ppd x 6 years. Drinks 1 pint of brandy per day x7 months but has cut back to several watermelon nips per night. Smokes [**2-20**] blunts of marijuana daily. Denies other illicits. Has girlfriend x 7 years. Graduated high school, was previously working as a security guard but has not been working recently.

CHIEF COMPLAINT: Hia wife reports Mr [**Name (NI) 9955**] had three generalized clonic - tonic seizures PRESENT ILLNESS: The patient is a 73 year old man with a history of TIA in [**5-17**], left temporo-occipital stroke in [**2-15**] with severe left inferior MCA stenosis on Coumadin, hypertension, and hyperlipidemia who presents with 3 GTC seizures. This history is taken from the [**Hospital 228**] medical record. Per his wife, he was in his usual state of health when they went for a walk together, when he fell to the ground, became stiff, and had a GTC that lasted less than 5 minutes. This resolved, and the patient was taken to [**Hospital1 18**]. In the ED, vitals were temp 100, HR 140, bp 222/106, RR 20, SaO2 100% on NRB, FSBG 95. He was reportedly incontinent of urine, responded to name but was not following commands. Head CT showed no evidence of hemorrhage or acute edema, there was evolution of left temporal and parietal/occipital infarction, and sinus disease. At approximately 17:15 he had seizure activity and rigid body movements, and was given Ativan 2 mg IV x1. He was intubated with Etomidate 20 mg IV x1 and Succs 120 mg x1, but there was no color change, so the ET tube was removed and he was bagged. They attempted to place nasal tube for intubation, but there was trauma with insertion. Anesthesia was called to intubate, and he was given Etomidate 20 mg x1 and Succs 150 mg x1. He was started on a Propofol gtt. He had possible seizure activity after the intubation with his head moving side to side, and was given Ativan 1 mg IV x1. Neurology was consulted, and an LP was performed. He was started on Ceftriaxone 2 gm IV and transferred to the MICU. In the MICU, he was also started on Vancomycin 1 gm IV q12 hr, Ampicillin 2 gm IV q6 hr, Acyclovir 800 mg IV q8hr. All but the Acyclovir were subsequently discontinued when his LP came back with 0 WBC. MEDICAL HISTORY: - L inferior division MCA stroke here in [**3-18**], found to have soft clot in vertebral arteries, as well as L MCA intracranial stenosis of the inferior division. TEE was negative. He was discharged with residual Wernicke-type aphasia on coumadin after being admitted on aggrenox for a prior TIA in [**5-17**] - HTN - hyperlipidemia - Pernicious anemia/B12 deficiency - Hx prostate ca [**2169**] s/p radical prostatectomy - Hx L orbit lymphoma (malt-[**Female First Name (un) **]) [**3-15**] yrs ago, s/p XRT; had intracerebral lesion discovered on MRI, had further w/u including PET scan at Farber or [**Hospital1 112**] - felt to be small avm that bled - Hx tremor at rest x 3 mo, due to see Dr. [**Last Name (STitle) **] - PNA [**3-17**] - L5-S1 disc herniation - s/p ccy [**2167**] - s/p L inguinal repair MEDICATION ON ADMISSION: Outpatient Medications (per OMR): -Cyanocobalamin 100 mcg PO DAILY -Folic Acid 1 mg PO DAILY -Hexavitamin 1 Cap PO DAILY -Simvastatin 20 mg PO DAILY -Latanoprost 0.005 % Drops 1 Drop Ophthalmic HS -Timolol Maleate 0.5 % Drops 1 Drop Ophthalmic DAILY -Aspirin 81 mg PO DAILY -Irbesartan 150 mg qPM -Coumadin 6 mg alternating with 7.5 mg every other day ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: temp 101.7, bp 137/71, HR 90, RR 11, SaO2 100% on CPAP + PS Genl: Intubated, Propofol weaned off for exam. Opens eyes on command, does not squeeze bilateral hands on command HEENT: Sclerae anicteric, no conjunctival injection, nasal packing in right nare CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: CTA bilaterally anteriorly and laterally, no wheezes, rhonchi, rales Abd: +BS, soft, NTND abdomen FAMILY HISTORY: Father had MI age 58 yo; His mother reportedly had multiple TIAs and then had stroke or MI at age 75 years SOCIAL HISTORY: Lives with wife, formerly worked as ophthalmologist at [**Hospital1 18**]; no tob, rare etoh, drugs.

CHIEF COMPLAINT: Unresponsive PRESENT ILLNESS: 33 yo right-handed Portuguese-speaking man with hx HTN was drinking alcohol with friends in the late afternoon [**2126-11-30**], when he began complaning of progressive headache. He presented to an OSH at ~730 pm, was reportedly wheeled in a wheelchair and communicative. The headache worsened over this time and he deteriorated clinically. Within one hour, he was intubated and sedated with succinylcholine, etomidate, fentanyl x 1, ativan x 1 , and propofol. He reortedly had a run of VTach and was given a dose of lidocaine. His systolic blood pressures were in the 280's, and he was started on nipride gtts, with a dose of lopressor. He was loaded with 1 g dilantin and sent to CT. Imaging revealed an extensive hemorrhage in the right cerebellar hemisphere with spread into the 3rd and 4th ventricles. The patient was sent to [**Hospital1 18**] for urgent neurosurgical evaluation. In ED here, his BPs dropped on nipride; he became hypotensive and was started on dopamine. MEDICAL HISTORY: HTN Knee surgery MEDICATION ON ADMISSION: Unknown ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: V T 98.1F BP 85/48 P 93 RR 18 FIO2 100% AC 550, RR 18, PEEP 5, off sedation General: well nourished and in no acute distress HEENT: NC/AT, MMM Lungs: clear to auscultation CV: regular rate and rhythm no MMG Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, no edema FAMILY HISTORY: Unknown SOCIAL HISTORY: Patient lives here, but parents and siblings are in [**Country 4194**]. Divorced wife lives in [**Name (NI) 4194**]. A cousin and some friends were [**Name2 (NI) 75426**] seen at bedside. He drank alcohol this past evening, but no known history of EtOH or drug use.

CHIEF COMPLAINT: mental status changes PRESENT ILLNESS: Ms. [**Known lastname **] is a 64 year old female with a history of COPD, htn who was brought to the hospital by her son with concerns of altered mental status. According to reports from her son, she has not left her bed at home for the last 7 days. She has been sleeping all day and he does not think she has been eating anything. She states that she vomited last Sunday, ~ 7 days ago, and since that time has not been taking in much although she has not had recurrent nausea or vomiting. According to her son's report, there is no sign that she has been drinking anything from the fridge, there are no empty glasses, bottles or cups around. She is intermittently confused, although she is sometimes able to self correct. According to the son she has also fallen a few times because of weakness. Her bedroom is on the [**Location (un) 1773**] and he doesn't think she has any strength to even try the stairs. She has a dog that she left out all night because she forgot to bring him in. Her son called her PCPs office today and it was recommended she be brought to the ED for evaluation. In the ED, she was afebrile. 106/55, 83, 18, 97% 3LNC. Labs remarkable for Hct of 51 (BL mid 40s- low 50s), WBC 8.9 with L shift (83% PMNs). Electrolytes revealed a Na of 111->109, Cl 66->73, K 3.1->2.8, BUN/Cr 7/0.3. CEs were negative x 1. U/A was negative with the exception of ketones. ALT and AST were elevated at 47 and 53 and had been normal in the past. Urine studies revealed urine Na of 71. She received 2 L NS, 40 meq po KCl, and 20 meq in 2nd liter of NS. Upon arrival to the ICU, she is pleasant and in NAD. She is vague regarding the events of the last week but is otherwise appropriate in answering questions. A+Ox3. Denies any fevers, chills, cough, SOB, CP, abdominal pain, dysuria. + vomiting x 1 as above. MEDICAL HISTORY: # htn # COPD on 3L NC - [**4-19**] PFTs: FEV1 0.57 (68%), FVC 2.07 (68%), FEV1/FVC 27 (38%) # depression MEDICATION ON ADMISSION: albuterol, atrovent, Advair 500/50 [**Hospital1 **] hctz 25 mg daily, lisinopril 40 mg daily, amlodipine 5 mg daily paroxetine 30 mg daily, spiriva 18 mcg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Physical Exam: T: 98.0 BP:125/67 HR: 80 RR: 23 O2 97% 3L NC dry MMs JVP low RRR. CTAB A+Ox3. Answers questions and follows commands. Neuro exam nonfocal. FAMILY HISTORY: Father with COPD SOCIAL HISTORY: Pt is a counselor and has a doctorate in education. She is divorced. + tobacco x80-100 pyhx. occ EtOH

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 37-year-old man with mild hypercholesterolemia, currently being treated only with exercise who presented to [**Hospital3 **] on [**2117-8-27**] complaining of crushing substernal chest pain that radiated to the left arm. The patient had been running that day and after one quarter mile of his normal six mile run, he was forced to stop, as the symptoms developed. Specifically, he had chest pain and felt a little lightheaded. He denies nausea, vomiting, diaphoresis at that time or dizziness at that time. He was then able to flag down another runner who was able to contact the Emergency Medical Services and have him brought to the hospital. At [**Hospital3 **], an electrocardiogram was obtained and the findings were as follows: ST segment elevations in the lateral limb leads, one in AVL and lateral anterior leads V2 through V5. He received oxygen, intravenous nitroglycerin, beta blocker, Lopressor 5 mg x1, Lipitor and a heparin drip. He was then transferred to the [**Hospital6 256**] for emergency cardiac catheterization. The patient reports having had a similar episode of chest tightness that had resolved after running five days before presentation. He had been in his normal state of health before then. At cardiac catheterization, a total occlusion of the proximal left anterior descending artery was found. The patient underwent percutaneous transluminal coronary angioplasty and a stent was placed. An intra-aortic balloon pump was also placed because the patient's wedge pressure was 26 mmHg and he then he was transferred to the Coronary Care Unit. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: FOUND DOWN PRESENT ILLNESS: 63 y/o male with PMHx history of alcoholism and traumatic brain injury who presents after being found down on the floor at his group home. He had an apparent fall and was found lying on the floor of the bathroom with diarrhea in the toilet and emesis in the trashcan. He was taken emergently to an OSH - on the way had a 15 second tonic-clonic seizure which spontaneously broke. Once he got to the OSH ED he was febrile to 100.4. He had another tonic clonic seizure with vomiting. He was given at least 6mg ativan IV without improvement. He was obviously aspirating and attempts were made for intubation, however the OSH ED was unsuccessful due to difficult anatomy and the amount of emesis. They placed an LMA for airway protection and sent him to [**Hospital1 18**] for further management. . In the [**Hospital1 18**] ED, his initial vitals were: HR 101 189/99 94%. He was actively vomiting and vomited up his LMA. Urgent intubation was done with direct laryngoscopy and a bougie - he had an anterior airway noted as well. After the ETT was in place, copious amounts of frank emesis were suctioned. A CXR was done which showed evidence of aspiration pneumonia/pneumonitis - he was given vancomycin and zosyn for coverage. Labs were unremarkable, serum tox was negative He had a CT head which showed no acute process, EKG showed sinus 80 NA NI NSST changes, PR depression. ABG showed 7.38/41/421/25. He also received 2L NS and was transferred to the MICU. On arrival to the MICU, patient's VS. 98.5 77 132/85 19 100%. MEDICAL HISTORY: TRAUMATIC BRAIN INJURY ALCOHOL ABUSE (CURRENTLY SOBER) MEDICATION ON ADMISSION: Benztropine 2mg qAM Fluphenazine 20mg qAM Ziprasidone 80mg qAM Aspirin 81mg daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION EXAM VS t 98.5 HR 77(regular) BP 132/85 RR 19 O2 sat 100%/CMV FiO2 40% 5 PEEP General: intubated and sedated HEENT: PERRL R 3-->2, L 2-->1 more sluggish, dried blood around nares Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: coarse breath sounds at bases Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: withdraws all 4 extremities to pain . DISCHARGE EXAM VS 98.9 127/77 89 18 99RA General: well appearing NAD HEENT: PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, soft systolic murmur LSB Lungs: CTABL Abdomen: soft, non-distended, NABSX4, no tenderness to palpation Ext: Warm, well perfused, 2+ pulses, no edema Neuro: AAOx 2 (person, place, not time), CN grossly intact, moves all extremities FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Lives in [**Location **] Group Home in [**Location (un) 745**], MA due to prior traumatic brain injury and alcohol abuse.

CHIEF COMPLAINT: Anorexia, nausea/vomiting PRESENT ILLNESS: 76yM diagnosed with a pancreatic head mass [**2-22**] s/p stenting presents with 3 weeks of nausea, vomiting and anorexia. Pt states that he has not been able to take anything by mouth for the past three weeks due to decreased appetite and more recently, nausea and vomiting. He reports a 50lb weight loss in the last 3 months. He also c/o vague diffuse bandlike abdominal pain. Otherwise, no fevers, normal bowel movements. He presents for further evaluation of his pancreatic head mass and rehydration. MEDICAL HISTORY: HTN ITP multiple orthopedic procedures pancreatic head mass s/p stenting x 2 MEDICATION ON ADMISSION: metoprolol 50', enalapril 10', prozac ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Gen elderly NAD Heent eomi, perrl, oropharynx without erythema/exudate Neck supple CV rrr Resp CTA bilaterally Abd soft NTND Ext bilateral groin with palpable lymph nodes, no LE edema Neuro aao x 4 FAMILY HISTORY: not contributory SOCIAL HISTORY: live with wife, retired engineer, 7 children, 13 grand children, hx of smoking, no etoh, no drugs, Independent on all ADL, IADLs except financing (wife does that).

CHIEF COMPLAINT: chest pain PRESENT ILLNESS: THis is a 69yo M with h/o CAD, DM2 and HTN who presented to the ED with chest pain. He woke up at 4am on the day of admission with left sided sharp 10/10 chest pain that radiates down his left arm. He took nitro with minimal relief.On route to [**Hospital1 18**] on the ambulance, he recieved multiple [**Last Name (un) 4070**] spray which brought the pain down. He complained of nausea but denies SOB/palpitation/dizziness. On arrival to ED, his SBP is 180 with HR 90. He recieved ASA, lopressor, morphine, nitro gtt, integrillin and plavix. Concerning with in stent thrombosis MEDICAL HISTORY: 1. coronary artery disease-CABG [**2113**]; stent in native OM [**2117-2-10**] 2. NIDDM with neuropathy 3. hypertension MEDICATION ON ADMISSION: 1. glucophage 2. lopressor 100 [**Hospital1 **] 3. amitryptilline 4. isosorbide 60 5. lipitor 20 6. neurontin 8. aspirin 9. plavix 10. lisinopril 10 13. metformin 100 [**Hospital1 **] 14. humalog SS ALLERGIES: Tetracyclines / Niacin PHYSICAL EXAM: T97 P83 BP137/69 R18 SpO2 99% Gen-very pleasant gentleman in NAD, A+O x3 HEENT-anicteric, mmm CV-RRR, 2/6 SEM loudest in right 2ICS, no heaves resp-CTAB(anteriro exam) [**Last Name (un) 103**]-soft, active BS, NT/ND skin-no rashes extremities-left groin site no hematoma, DP 1+ bilaterally FAMILY HISTORY: Coronary artery disease SOCIAL HISTORY: He lives with his wife in [**Name (NI) 620**]. Rare alcohol use and denies any cigarette smoking. He is a retired consultant (pharmacist).

CHIEF COMPLAINT: altered mental status PRESENT ILLNESS: Pt is a 82 yo woman with a hx of meningioma who had resection in [**6-27**] by Dr. [**Last Name (STitle) **]. She has been undergoing XRT Mon-Fri daily at [**Hospital1 18**]. She presented to [**Hospital6 5016**] with altered mental status. Found to be hypoxic in pulmonary edema and with rapid afib. She was sent here for further evaluation and care. MEDICAL HISTORY: ESRD stage, dialysis Mon-Wed-Friday Hypertension Renal vascular disease CAD, CHF Recurrent Meningioma Colon CA s/p colectomy MEDICATION ON ADMISSION: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: please do not drive while taking pain medications. Disp:*45 Tablet(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO AM (). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). ALLERGIES: Heparin Agents PHYSICAL EXAM: 97.4 104/80 110 20 97% RA Pt is awake and responds but not completely oriented. She knows she is at "[**Hospital **] HOspital" but unable to correctly answer any other questions. PERRL, EOMI CV-IRRR lungs - crackles at bases abd - soft, NT ext - no c/c/e + foley RUE with surgical wound approx 15 cm clean with sutures still in place moves all extremities does not cooperate with neuro exam otherwise FAMILY HISTORY: NC SOCIAL HISTORY: Lives at home with elderly husband. Denies Etoh. Quit tobacco [**2078**].

CHIEF COMPLAINT: PRESENT ILLNESS: Mr. [**Known lastname **] is a 64 year-old gentleman who presents for resection of melanoma. He originally had a melanoma excised from his back quite awhile ago, which was reported to have had positive margins at an outside facility. The purpose of this admission was more extensive excision of his back to achieve negative margins as well as to excise inguinal lymph nodes, which have become palpable and have been thought to represent metastatic disease. MEDICAL HISTORY: 1. Diabetes mellitus type 2 controlled with oral antihyperglycemics. 2. Hypertension. 3. Malignant melanoma [**Doctor Last Name 10834**] level 5 status post excision [**10-21**]. 4. Colonoscopy in [**2131**] notable for removal of two polyps showing low grade adenoma. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: The patient denies tobacco currently, however, smoked 20 years ago approximately five packs a day for six years. Denies alcohol consumption.

CHIEF COMPLAINT: Headache PRESENT ILLNESS: c/o severe headache with subsequent visual changes, went to OSH, CT showed large left occipitoparietal hemmorrhage. Pt began to have right weakness, was intubated and transferred to [**Hospital1 18**] ED for further evaluation and treatment. MEDICAL HISTORY: BPH, thyroid disease, Hypothyroidism CAD PPM ([**Company 1543**]) 08 for AV block BPH s/p colostomy and reversal in 05 for a sigmoid volvulus Meniere's (recurrent episodes of dizziness, not known to have falls) IBS Osteoporosis recent MMSE 26/30 ---> executive dysfunction in cognitive testing MEDICATION ON ADMISSION: Levox 88 mcg Florinef 0.1 mg Finasteride 5 mg UroXatral one per day ASA 81 mg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Mental status: intubated, ventilated Versed given at 6 am (2 mg), examined at 7 am, and again at 7:10 am. Cranial nerves Right pupil reactive 2.5--->2 mm, left pupil unreactive. Corneal present in the right eye weakly. No nasal tickle. No doll's head. Weak gag (suction tubing) Motor Does not withdraw to noxious stimuli throughout. Tone slightly increased in the right arm. Reflexes brisker on the right (+2) than on the left 2, plantars mute. Imaging CT head scan described above. FAMILY HISTORY: Noncontributory SOCIAL HISTORY: lives independently, retired executive, currently writing a book

CHIEF COMPLAINT: Patient was admitted for an operative procedure to repair ventral hernia, radical excision of squamous cell carcinoma, an excision of sinus tract. PRESENT ILLNESS: Patient is a 77-year-old gentleman with a history of left squamous cell carcinoma on his stomach and left flank, who underwent placement of tissue expanders on [**2150-10-26**]. The patient is returning for removal of the tissue expanders as well as excision of the left flank squamous cell carcinoma. MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Melanoma of the stomach. 4. Necrotizing fasciitis. 5. Status post nephrectomy. 6. Myocardial infarction x2. 7. Angina. MEDICATION ON ADMISSION: 1. Cartia 100 mg p.o. q.d. 2. Lopressor 50 mg p.o. b.i.d. 3. Prazosin 5 mg p.o. b.i.d. 4. Percocet 1-2 tablets p.o. q.4-6h. prn pain. ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: PRESENT ILLNESS: This 54-year-old white male has a history of coronary artery disease, hypercholesterolemia, and is status post MI times three in [**2168**], [**2170**], and [**2179**]. He underwent a stress test on [**2190-10-18**] and his EKG showed 2 mm depressions and ST segments in V5 and V6. The nuclear images showed large severe partially reversible lateral wall defect and severe fixed inferolateral wall defect. He was then referred for catheterization which he underwent at [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2190-11-16**] and revealed an EF of 30%, 40% left main stenosis, a 60-70% long LAD stenosis, an 80% major diagonal stenosis, a 95% OM1 stenosis, 90% [**Date Range 11641**] stenosis, and 100% midcircumflex lesion. His RCA was 100% occluded. He is now admitted for coronary artery bypass graft. MEDICAL HISTORY: 1. Status post MI times three in [**2168**], [**2170**], [**2179**]. 2. Status post catheterization times two in [**2174**] and [**2179**] without intervention. 3. History of left shoulder bursitis, status post thyroidectomy 30 years ago. 4. Status post TIA 20 years ago. 5. Left carotid studies within the last year. 6. Status post esophageal polyp removal. MEDICATION ON ADMISSION: ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Significant for severe coronary artery disease. SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] smokes six cigarettes a day and has an 80 pack year history. Does not drink alcohol.

CHIEF COMPLAINT: Fevers PRESENT ILLNESS: 33F with history of multiple sclerosis and recent admission in [**2177-1-27**] for fevers, fatigue, and wheezing, presenting with fevers and pain, as well as progressive weakness and numbness/tingling in the arm and leg. During her last admission, she was admitted for FUO and had an extensive workup, including TTE, multiple blood cultures, autoimmune workup, and multiple imaging studies. Multiple etiologies of her (then) low-grade fevers and asthma were entertained, including Churg-[**Doctor Last Name 3532**], eosinophilic pneumonia, ABPA, and infectious etiologies. . She was started on high dose steroids with improvement in wheezing and fevers; she was discharged with appropriate follow up. She was seen by an OSH rheumatologist who diagnosed her with Churg [**Doctor Last Name 3532**] clinically; her steroids were tapered to 80mg daily, and he started her on azathioprine. She took these medications for 10 days, but on or about [**3-22**] was seen by a pulmonologist, who did not feel her symptoms were related to vasculitis, and apparently instructed her to discontinue her prednisone. Within a few days, she started feeling more pain, and her fevers started two days prior to admission. The day prior to admission, she noted diarrhea and dizziness. She is frustrated with the different opinions she has received from all different providers. . In the ED, triage vitals were T106F, BP 123/101, HR 165, RR 16, Sat 100%. She was given 3L normal saline, morphine for pain, Zofran for nausea, Tylenol and Motrin, at which time her fever came down. Blood and urine cultures were sent, and she was admitted to the floor for further workup. . At the time of admission, she is complaining of chills, body pain, including nerve and muscle pain in her right arm and right leg, as well as a burning pain in her left hand and left toes. She also has a pain in her upper back. She denies cough, dysuria, diarrhea, abdominal pain, sore throat, neck pain, headache, and other signs of infection. MEDICAL HISTORY: # Relapsing-Remitting Multiple Sclerosis (first symptoms in [**2171**], diagnosed in [**11-1**] and initially treated with steroid followed by Tysabri, last infusion end of [**11-4**], no treatment for MS until 3 days prior to admission when she started Copaxone. Copaxone stopped on [**2-12**] by neurologist pending eval of fevers. Last on IV steroids in [**5-4**], and got prednisone 2.5 weeks ago for respiratory wheezing. # PCOS- on metformin # GERD # Obesity # s/p Lumbar Laminectomy # history of malaria as child MEDICATION ON ADMISSION: Provigil 100mg [**Hospital1 **] PRN Aciphex 20mg [**Hospital1 **] Baclofen 10mg TID OCP Metformin 1000mg [**Hospital1 **] Zantac 300mg daily Lantus 20 units once daily Bactrim DS 800mg-160mg three times weekly Valium 5mg daily Topamax 25mg daily Azathioprine 200mg daily Prednisone 80mg daily (until [**3-22**]) ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals T 99.4F, BP 93/55, HR 101, RR 24, Sat 96%RA General: Uncomfortable obese female, no acute distress HEENT: Flushed face Neck: No lymphadenopathy Heart: Tachycardic, no m/r/g Lungs: CTA bilaterally, no wheezes appreciated Abdomen: Obese, soft, non-tender, non-distended + bowel sounds Ext: WWP, 2+ pulses bilaterally Neuro: CN II-XII intact, strength decreased in lower extremities R>L FAMILY HISTORY: Mother has schizophrenia, substance abuse and liver problems Father has bipolar disorder, diabetes, HTN, stroke. SOCIAL HISTORY: Internationally known opera singer. No tob/etoh. Lives with husband. Lived in [**State 18559**] as child. Traveled all over south pacific with father in [**Name2 (NI) 18560**]. Most recent travel to [**Country 4754**] with international group of singers. Reports neg PPD 2.5 years ago prior to starting MS medications. No known TB exposures. No other recent travel.

CHIEF COMPLAINT: ATV rollover PRESENT ILLNESS: Mr. [**Known lastname **] is a 37 year old man who was on an ATV when he had a rollover with the ATV landing on him, he also had no helmet on. He was taken from the scene by [**Location (un) **] to the [**Hospital1 18**] for further evaluation and care. MEDICAL HISTORY: Denies MEDICATION ON ADMISSION: Denies ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Gen: AFVSS HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: open punctate lesion over middle of clavicle NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-20**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant FAMILY HISTORY: n/a SOCIAL HISTORY: +ETOH

CHIEF COMPLAINT: Abdominal pain PRESENT ILLNESS: 24 yo male who was involved in a Motor vehicle crash last [**Month (only) **] sustaining multiple orthopedic injuries and bowel injury. Returned to hospital with increasing abdominal pain. MEDICAL HISTORY: seasonal allergies asthma s/p Motor Vehicle Crash [**2164-12-23**]: ex-lap, sigmoid colectomy, L popliteal vein primary repair. L AK-[**Doctor Last Name **]/PT [**Name (NI) 65897**] graft, ORIF R knee dislocation, ex-fix L knee and ankle [**2164-12-25**]: L AKA, IVC filter placement [**2164-12-28**]: T10-L3 instrumented fusion, component separation/abd closure with Marlex mesh [**2165-1-2**]: L ureteroureteral anastomosis and repair of transected L ureter, L ureteral stent placement [**2165-1-16**]: ORIF R tibia pilon fx [**2165-2-12**]: Ex-lap/LOA, removal of Marlex mesh, closure of abd wall with Vicryl mesh [**2165-3-5**]: removal L ureteral stent [**2165-5-15**] Fistula takedown MEDICATION ON ADMISSION: ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: FAMILY HISTORY: Non-contributory SOCIAL HISTORY: +ETOH

CHIEF COMPLAINT: Enterocutaneous fistula PRESENT ILLNESS: 59 yo F with a history of endometrial cancer, s/p hysterectomy and radiation, presented to the hospital with a new enterocutaneous fistula. Her nutritional status was extremely poor, so she was admitted for TPN prior to surgery. MEDICAL HISTORY: 1. Stage IIIC high grade serous papillary uterine cancer with lymph node involvement. She completed four cycles of Taxol and carboplatin followed by six weeks of radiation therapy in [**2154-8-14**]. 2. s/p TAH in [**2153**]. 3. Chylous ascites as noted above. 4. Focal approximately 5-cm long stricture within the terminal ileum and increased fold in ileum, likely related to radiation bowel damage. MEDICATION ON ADMISSION: Calcium Carbonate TID Octreotide 100 SC q8h Epoetin 100mcg qWed Ativan 0.5 TID prn Ambien 5daily prn Tylenol #3 TPN @93cc/hr cycled 6p-6a ALLERGIES: Meperidine PHYSICAL EXAM: 98.4 105 118/70 18 98%RA Wt 100lbs Alert, oriented female in no acute distress Cachectic PERRLA, EOMI, Anicteric CV: Sinus tachycardia Lungs clear to ausculation bilaterally, no rales Abdomen soft, mild diffuse tenderness, non-distended, no rebound, hypoactive bowel sounds, 1.5-7cm RLQ enterocutaneous fistula w/ ostomy bag...bilious fluid in bag. Extremities without edema. Rt antecubital PICC without surrounding erythema or discharge. FAMILY HISTORY: NC SOCIAL HISTORY: Lives with her husband and has 2 children 29 and 22 one in [**State **] State and one living in [**Country 6171**]. Had been drinking [**12-15**] bottle wine until 1 month ago, now drinks one whisky cocktail every night. Had been banking executive prior to development of health issues. Smokes + [**12-15**] PPD for 19 years.

CHIEF COMPLAINT: shortness of breath and neck weakness PRESENT ILLNESS: HPI: Patient is a 56 yo RHW with hx of MuSK Ab positive MG here from [**Hospital 78874**] clinic with increased respiratory trouble concerning for MG exacerbation. Per patient, she developed worsening dyspnea on exertion with some tightness in chest about 2 weeks ago. In addition, she reports that her upper body felt heavier and more lead like. She spoke with Dr. [**Last Name (STitle) 78875**] (primary neurologist) who recommended increasing prednisone from 10 to 30 and increasing Imuran from 200 to 250. She was also scheduled for short IVIg therapy which started on [**2-23**]. She reports that with the above change in medications, upper body heaviness appears to improve but she reports that her respiratory issues only worsened especially over the weekend. Patient also had another kidney stone (2mm if L ureter) which started on [**2-22**] - the days she was supposed to begin IVIg. Hence, her IVIg was postponed to the next day and patient came to the ED where she received Percocet which she has taken ~[**2-23**] doses over the past 5 days. ROS otherwise negative including diplopia, ptosis, dysphagia or falls. She also denies any fever/chills, N/V/D, or sick contact. She feels that there may have been some urinary symptoms but she has baseline/chronic problems from prolapsed bladder and cystocele hence she is not sure if its worse than usual. Patient reports that her last intubation/MS flare may be about 1 year ago around the time her replaced trach stent was removed. She was initially stented in [**1-30**] because she was not able to be weaned off the ventilator. She has been followed per Dr. [**Last Name (STitle) 557**] and has been on Mestinon, Imuran and Prednisone. Prior to the increase 2 weeks ago, she was actually tapering down on her prednisone. MEDICAL HISTORY: 1. Myasthenia [**Last Name (un) 2902**] - MuSK Ab+, initial symptoms (dyspnea, diplopia, neck weakness) in [**2139-1-23**]. Transferred to [**Hospital1 18**] ICU in [**2139-4-23**] in myasthenic crisis. Underwent IVIg (at [**Hospital6 2561**] prior to transfer) then plasmapheresis at that time, also started on prednisone and CellCept. Due to difficulty to wean, she also underwent tracheostomy and placement of a PEG tube at that time. 2. Tracheobronchomalacia status post tracheal stent in [**2139-4-23**] - since replaced then removed. 3. GERD and hiatal hernia. 4. History of nephrolithiasis. 5. Anxiety. 6. Status post partial hysterectomy. 7. Status post bladder suspension at age 29. 8. Cystocele. 9. DM - prednisone induced. MEDICATION ON ADMISSION: 1. ALENDRONATE [FOSAMAX] - 70 mg Tablet Sunday 2. AZATHIOPRINE [IMURAN] - 150/100 3. ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 40 mg daily 4. FLUTICASONE [FLONASE] - 50 mcg Spray [**Hospital1 **] 5. FUROSEMIDE - 20 mg Tablet daily 6. HYOSCYAMINE SULFATE - 0.125 mg Tablet TID with Mestinon 7. INSULIN GLARGINE [LANTUS] - 14u daily 8. INSULIN LISPRO [HUMALOG] - 4 units before meals. 9. PAROXETINE HCL [PAXIL] - 20mg bedtime 10. POTASSIUM CHLORIDE [K-DUR] - 20 mEq [**Hospital1 **] 11. PREDNISONE - 30mg daily 12. PYRIDOSTIGMINE BROMIDE [MESTINON] - 60 mg QID 13. RANITIDINE HCL - 150 mg bedtime 14. CALCIUM CARBONATE [CALCIUM 500] TID 15. DEXTROMETHORPHAN-GUAIFENESIN [MUCINEX DM] - 1,200 mg-60 mg Tab [**Hospital1 **] 16. VITAMIN B12-VITAMIN B1 daily ALLERGIES: Adhesive Tape / Ativan PHYSICAL EXAM: T 99.1 BP 130/80 HR 80 RR 20 O2Sat 98% 2L NC NIF -80 VC 0.8L Gen: Sitting in the ED stretcher - mildly anxious appearing. HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM. CV: RRR, no murmurs/gallops/rubs Lung: Clear Abd: +BS, soft, nontender Ext: No edema FAMILY HISTORY: No FH of MG - multiple members with DM. SOCIAL HISTORY: Lives with son - does not work but was a former case manager. No tobacco, EtOH or illicit drug use.

CHIEF COMPLAINT: altered mental status PRESENT ILLNESS: Patient is a 52 year old female with history of Type I DM (off insulin since [**2103**]) s/p kidney/pancreas transplant, glaucoma, and HTN who presents from home with altered mental status. History obtained per report and via patient's husband. [**Name (NI) **] unable to provide history [**1-20**] somnolence. Husband reports leaving patient a little after 12 p.m. yesterday to visit his son. [**Name (NI) **] did not want to accompany him, which is unusual, as she is normally social. [**Name (NI) **] husband returned home in the evening and found her sleeping. He woke this morning and found her unresponsive, and was unable to wake her. He then called 911. . EMS arrived and found the patient unresponsive. FSBG was 64. D50 was given, without improvement. Her initial vitals were 120/80 HR 80 99% RA. Narcan was also given, without improvement. In the ED, vitals were 98.3 121/70 78 12. CT head was obtained and was negative. She desaturated to 81%, with sat improved to 100% with sternal rub. She received 2 liters in ED. She was then transferred to the ICU. RR 13, 100% on 2 liters n/c, HR 76 BP 145/79 . Upon arrival to the ICU, she was somnolent, eyes closed, and resonsive to her name. Her husband accompanied her, and stated that she was slightly more alert now than earlier in the day. . [**Name (NI) **] husband notes that patient was recently upset with worsening renal function and eyesight over the past few weeks. He does note that she has been depressed in the past, but does not report any recent SI. . Review of systems: per patient's husband (+) Per HPI (-) Denies fever, chills, headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. MEDICAL HISTORY: Type I DM s/p kidney/pancreas transplant; off insulin since [**2103**] h/o HTN h/o dyslipidemia diabetic retinopathy with glaucoma h/o DVT on chronic anti-coagulation, has IVC filter per family MEDICATION ON ADMISSION: Codeine unknown dose, not sure if active med Hydrocodone unknown dose, not sure if active med Doxazosin 1 mg tab PRN clorazepate unknown dose Oxycodone unknown dose, not sure if active med ranitidine 150 mg [**Hospital1 **] warfarin 5 mg daily cyclosporine 75 mg [**Hospital1 **] Cosopt 0.5% to 2% [**Hospital1 **] OD prednisolone 1% drops 1 gtt ou qd prednisone 5 mg daily pravastatin 10 mg QHS estradiol 0.01% cream QHS ALLERGIES: Dicloxacillin PHYSICAL EXAM: VS: 145/72 HR 78 RR 12 100% RA GA: unable to assess orientation, somnolent, opens eyes to voice, follows commands HEENT: right pupil reactive, left pupil ovaloid following surgery. MMM. no LAD. no JVD. neck supple. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTA anteriorly no crackles or wheezes Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, no edema. DPs, PTs 1+. small degree of ecchymosis over right trochanter Skin: chronic venous stasis changes Neuro/Psych: CNs II-XII intact. unable to assess strength/sensation. withdraw to pain, arousable, follows commands. FAMILY HISTORY: non-contributory SOCIAL HISTORY: lives in [**Location **] with husband. has one step-son. rare EtOH. [**12-20**] PPD for many years. no other drug use

CHIEF COMPLAINT: Abdominal pain, concern for mesenteric ischemia PRESENT ILLNESS: Transfer from OSH with concern for mesenteric ischemia HNP 64 yo male with 14 days of colicky abdominal pain now constant. Associated with brown maroon vomiting, and melena. No [**Month/Year (2) **]. Patient was admitted to [**Hospital3 26615**] hospital with a WBC of 5 increasing to 28. Ct scan was concerning for mesenteric ischemia showing fluid around the spleen, [**Female First Name (un) 899**] not identified, SMA severely diseased. Patient was reported to have a Troponin leak at outside hospital, concerning for myocardial ischemia. MEDICAL HISTORY: PVD DM Bladder CA COPD Surgical History: Open Chole Aorto [**Hospital1 **] Fem Bypass MEDICATION ON ADMISSION: Albuterol, aspirin ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: GEN: Pt alert, in NAD HEENT: PERRLA, trach in place, no erythema or drainage, on ventilator RESP: Slight wheezing bilaterally CV: RRR AB: + BS, soft, non tender, non distended. Abdominal incision healing by secondary intention, no erythema or drainage. Dressed with gauze and ab binder EXT: 2+ edema, chronic changes on lower legs bilat Neuro: follows commands FAMILY HISTORY: non-contributory SOCIAL HISTORY: 90 pack/year smoker 6-12 beers/week Retired highway heavy equipment operator

CHIEF COMPLAINT: PRESENT ILLNESS: Mr. [**Known lastname 111**] is a [**Age over 90 **]-year-old gentleman who was initially admitted to [**Hospital3 4527**] Hospital with chest pain that was radiating to his left arm. He complained of no shortness of breath, nausea, vomiting, or diaphoresis. There he was started on aspirin, nitroglycerin, Lopressor, Lovenox, Integrilin, and captopril. There were no changes on his electrocardiogram, however, he did rule in for a non-ST elevation myocardial infarction with peak troponin-I of 7.8 and peak CK of 149. Subsequently, he was transferred to [**Hospital1 69**] for cardiac catheterization. MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Chronic renal insufficiency with a baseline creatinine of 1.6. 4. PMR on chronic prednisone. 5. Interstitial cystitis with chronic Foley. MEDICATION ON ADMISSION: ALLERGIES: Sulfa, Tequin. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: fever and SOB PRESENT ILLNESS: 49 year old male with CLL dx [**2137**], followed by Dr. [**First Name (STitle) 1557**], s/p matched sibling donor allo-[**First Name (STitle) 3242**] in [**2-16**], and h/o HTN, CM with EF 20% (Echo in [**8-20**] with EF 50-55% and in [**9-19**] with EF 20-25%). The patient was recently admitted from [**2142-11-28**] to [**2142-12-26**] for resistant HSV c/b CHF exacerbation and aspergillus/enterobacter on BAL. Pt was also recently discharged on [**2142-12-30**] after presenting with nausea, chills, tachypnea, hypoxia, and tachycardia after being given platelet transfusion and IVIG, thought to be CHF exacerbation (improved with diuresis). He was admitted again on [**12-5**] for shortness of breath due to likely early signs of tamponade and had a pericardial drain placed (removed after 1 day with no signs of reaccumulation). Pt now presents with c/o fever and increased O2 requirement. Much of the history was obtained from the pts wife. 3 days PTA, the pts wife noted that the pt suddenly turned pale and his sats were 78% on RA, HR 130s. After he layed down, his sats returned to the 90s with HR in 120s. The pt started to use home O2 (delivered to his house) 3days PTA and was satting at 97% on 2L. 2 days PTA the pts wife again noted the pt turned pale and was satting at 93% while watching TV. She placed him back on O2. One day PTA the pt became increasingly SOB, even at rest and was seen in clinic. He was told that his CXR appeared improved from prior. Blood cultures were drawn on [**1-21**] now with 1/2 bottles + for staph aureus. The pt has had low grade temps of 99.2/99.7 over the past several days. On ROS, both the pt and his wife note increasing fatigue since his last discharge. He has had a 3 lb weight loss over the past several days, a persistent [**Month/Day (4) **] (at times productive of light colored sputum) for several weeks, continued chronic diarrhea. The pt also c/o pleuritic CP with inspiration on the R side of his chest which started again today, but he had noted during his last admission. Per the pts wife, the pt also has increased leg pain and weakness which has progressed to the point that the pt is unable to stand. . In the [**Name (NI) **], pt was noted to have a temp of 100.5, HR 140s-150s, ANC 256. The pt was given Cefepime and Vancomycin, 1L fluids. Lactate was 1.5. CXR revealed a R pleural effusion increased in size from prior. CTA showed no PE, however did show BL patchy and nodular opacities c/w an infectious process as well as a large R pleural effusion TTE showed a small pericardial effusion (no tamponade)new from [**1-10**]. The pts R PICC line was d'c/d given + blood cx for coag +staph aureus from [**1-21**]. VBG: 7.43/48/39. MEDICAL HISTORY: Oncologic history: CLL, diagnosed in [**2137**] when incidentally noted to have elevated WBC count. Treated with fludarabine then relapsed and required four cycles of PCR and then again had five cycles of PCR, but had persistent disease. He underwent reduced intensity allo-[**Year (4 digits) 3242**] from his brother in [**2-16**] that was relatively uncomplicated, though he did have grade I skin and hepatic GVHD, and febrile neutropenia. In [**7-19**] his CLL relapsed and he underwent DLI in [**9-18**] and [**10-19**]. in [**7-20**] his WBC rose and he developed lyphadenopathy. It was decided to start campath (last dose [**2142-10-16**] with total of `4 doses). He received 1 dose of rituxan [**2142-12-8**] in lieu of campath. He has suffered from oral HSV lesions, and has been on famvir and valacyclovir. Pt has now been receiving IVIG. . Recent Admissions as per HPI: The patient was recently admitted from [**2142-11-28**] to [**2142-12-26**] for resistant HSV c/b CHF exacerbation and aspergillus/enterobacter on BAL. During that admission he was started on captopril and BB. Pt was also recently discharged on [**2142-12-30**] after presenting with nausea, chills, tachypnea, hypoxia, and tachycardia after being given platelet transfusion and IVIG, thought to be CHF exacerbation (improved with diuresis). He was admitted again on [**12-5**] for shortness of breath due to likely early signs of tamponade and had a pericardial drain placed (removed after 1 day with no signs of reaccumulation). . Other Medical History: -HTN -Klebsiella sepsis -C. Diff -2nd degree, Mobitz I, heart block. -s/p inguinal hernia repair -Cardiomyopathy: Moderate pericardial effusion and markedly reduced EF (20%) noted on echo in [**9-19**], presumed viral vs. chemotherapy induced. Followed by cardiology. s/p pericardial drain. . cardiac cath [**2143-1-2**]: RIGHT ATRIUM 5 RIGHT VENTRICLE 30/5 PULMONARY ARTERY 25/15 PULMONARY WEDGE 14 . MEDICATION ON ADMISSION: 1. Metronidazole 500 mg TID 2. Valacyclovir 1000 mg [**Hospital1 **]--for HSV acyclovir and gancyclovir resistance 3. Metoprolol Succinate 50 mg qday 4. Ciprofloxacin 500 mg q12hrs--for neutropenia ppx 5. Captopril 25 mg TID 7. Voriconazole 200 mg q12--for aspergillus 8. Prednisone 5 mg qday--for GVHD 9. MVI 10. Lasix 20 mg po qd 11. Folic acid 12, Pentamadine q 2 wk ALLERGIES: Pseudoephedrine / Sulfa (Sulfonamides) / Ativan / Morphine Sulfate PHYSICAL EXAM: Vitals-Tm 100.7 BP 124/73 HR 131 R 33 Sat 98%5L NC CVP 2 Gen-pale, cachetic, chronically ill appearing man, slightly tachypneic HEENT-dry MM, PERRL, healing ulceration in R buccal mucosa and inner lip Neck-no JVD, RIJ c/d/i, no cervical LAD Lungs-absent BS R lung base 1/2 up R lung with rales 1/2 up R lung base, rales L lung base CV-tachy, no m/r/g Ab-soft, NTND, NABS, no palpable HSM Extrem-full DP/PT pulses, extrem warm, no c/c/e Neuro-a and ox3 Skin-no rashes FAMILY HISTORY: Father and uncle died of MI in 50s SOCIAL HISTORY: Married to a nurse, with 3 sons. Worked as a software engineer and math teacher. No tobacco or etoh

CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: 88 yo F s/p CABGx3 in [**2101**] Medical Center with complaints of occasional dizziness and progressive dyspnea on exertion. Recent echocardiogram revealed critical aortic stenosis. She underwent a cardiac catheterization which revealed native three vessel disease with two occluded vein grafts out of three. Given the severity of her disease, she has been referred for consideration of a redo CABG/AVR. MEDICAL HISTORY: acute systolic heart failure Hyperlipidemia paroxysmal atrial fibrillation complete heart block coronary artery disesae aortic stenosis hypertension Colon Cancer Arthritis MEDICATION ON ADMISSION: Amlodipine 10mg po daily Fosinopril 20mg po daily Nadolol 60mg po daily Klor-Con 10mEq po BID Simvastatin 80mg po qHS ASA 81mg po daily Naproxen Sodium 220 PRN: back pain Dipyridamole 50mg daily ALLERGIES: Percocet PHYSICAL EXAM: General: Skin: Dry [x] intact [x] well healed median sternotomy incision HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 systolic- loudest at left sternal border, radiates to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: trace edema bilateral ankles, superficial varicosities, well healed scars of open GSV harvest bilaterally ankle to knee Neuro: Grossly intact x Pulses: Femoral Right: 1+ Left: 1+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: Left: not palpable [**3-8**] edema Radial Right: 2+ Left: 2+ FAMILY HISTORY: 3 sons with CAD, s/p MIs and stents in their 50s SOCIAL HISTORY: Lives with:alone in [**Location (un) 3307**]; has 4 grown children Occupation:Retired Tobacco:1ppd x 10 years, quit 50+years ago ETOH:denies

CHIEF COMPLAINT: Dyspnea PRESENT ILLNESS: [**Age over 90 **] year old female with history of metastatic gallbladder carcinoma, advanced vascular dementia, CVA with subsequent aphasia/bedridden presenting with respiratory distress in the setting of 7 days of decreased PO intake, decreased bowel movements, cough and sputum production. The family has been unwilling to discuss code status or her possible death and have been ambivalent about hospitalizations. They want everything to be done, except for a feeding tube. Recent hospitalization in [**2145-3-19**] addressed many of these issues, but they were unable to convince the family otherwise. In the [**Hospital1 18**] ED, initial vitals were: 99.3 (re-check rectally 102.9), 89, 157/77, 30, 100% 15L Non-Rebreather. Exam was notable for crackles in the left greater than right base. CXR did not show any focal opacities, but did show a mild left-sided pleural effusion. She was started on broad antibiotic coverage with Cefepime/Vancomycin/ levofloxacin. While trying to avoid intubation, the patient was weaned to 4L NC, still satting 99% with improving tachypnea. . In the ICU, the patient opens her eyes to her daughter's voice and does not appear to be in any respiratory distress, satting 100% on 2L NC. Her daughter speaks limited English, but says that she looks much better now than she did this AM. MEDICAL HISTORY: Advanced vascular Dementia Right temporal & left parietal infarcts Hypertension Diastolic CHF (per [**Hospital1 2177**] records) Diabetes mellitus, diet controled Unsteady Gait with history of falls Mid-thoracic compression deformity Laser surgery for glaucoma MEDICATION ON ADMISSION: 1. clonidine 0.3 mg/24 hr Patch q Thurs 2. amlodipine 2.5 mg daily 3. hydrochlorothiazide 12.5 mg daily 4. acetaminophen 650 mg q6h PRN ? compliance with PO medications given difficulty swallowing ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission Physical Exam: Vitals: T: 97.4, BP: 150/69 P: 83 RR: 18 SpO2: 100% 2L General: opens eyes to voice, responds to pain; otherwise cachectic and nonverbal HEENT: sclera anicteric, pale conjunctivae, unable to assess oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: difficult exam due to inability to sit forward, but clear to auscultation bilaterally in apices and lateral lung fields, no wheezes, rales, rhonchi appreciated 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 Neuro: contract right arm at elbow and fingers with rigidity on extension, non-responsive to voice/commands Ext: warm, well perfused, 1+ DP pulses, no clubbing, cyanosis or edema . Discharge Physical Exam: Vitals: afebrile, O2 saturation in high 90s on RA General: opens eyes to voice, responds to pain; otherwise cachectic and nonverbal HEENT: sclera anicteric, pale conjunctivae, unable to assess oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: difficult exam due to inability to sit forward, but clear to auscultation bilaterally in apices and lateral lung fields, no wheezes, rales, rhonchi appreciated 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 Neuro: contract right arm at elbow and fingers with rigidity on extension, non-responsive to voice/commands Ext: warm, well perfused, 1+ DP pulses, no clubbing, cyanosis or edema FAMILY HISTORY: Seven living children, 5 in [**Location (un) 86**] area. Unknown cancer history in family. SOCIAL HISTORY: Totally dependent for all ADLs. Lives at home with daughter [**Name (NI) 71549**], other daughter helps during the day. Per daugher, all food is liquid and has 6 cups of food in total daily generally. Limited communication with groaning. VNA makes home visits. Has [**Name6 (MD) **] Med NP home visits. No drugs/tobacco.

CHIEF COMPLAINT: abdominal pain PRESENT ILLNESS: 71 yo F with new diagnosis of pancreatic adenocarcinoma with liver mets in [**4-/2166**], HTN, DMII, and recent admission for septic shock/klebsiella bacteremia who presented with abdominal pain and was found to be hypotensive in the ER. She initially went to [**Hospital3 **] ER initially and was transferred to [**Hospital1 18**]. She stated that she woke up at 2am on the day of presentation with severe pain. The pain felt "like gas" and was in the distribution of "a circle" around lower abdomen and lower back. She also had pain in the epigastrium radiating around to the back and between the shoulder blades. The pain was [**9-8**], nothing made it better. She denied fevers, chills, nausea, diarrhea. Last bowel movement was the day before presentation, well formed, not [**Male First Name (un) 1658**] colored. Reported having dark brown colored urine on the day before presentation. In addition to her abdominal symptoms she reported a "soreness" between her breasts just above the incision line. This soreness did not radiate and was not accompanied by SOB. She had had this pain in the past and prior to the surgery. She stated that she usually had this pain with exertion and it resolved with rest. MEDICAL HISTORY: -Pancreatic AdenoCA presented with pancreatic jaundice and s/p initiation of a Whipple procedure during which metastatic disease to the liver was discovered -DM2 with neuropathy -Glaucoma -[**Male First Name (un) **], with history of Myxedema -[**Male First Name (un) 88948**] Hernia -Hypercholesterolemia -HTN -Anemia -Bipolar affective disorder -Clostridium Perfrigens Infections -History of PUD/Gastritis/Duodenitis -Renal Mass: [**2162-5-1**] -Limb cramps -Leiomyoma of uterus MEDICATION ON ADMISSION: Levothyroxine 125 mcg Tablet PO QD Lithium carbonate 300 mg PO QHS Diovan HCT 80mg-12.5mg qd Humulin 24 u qAM, 32 qPM Dorzol/timolol 2-0.05%OP PID Lumigan Calcium carbonate-Vitamin D3 600 Ca-400U D ALLERGIES: amlodipine / Cephalosporins / Codeine / lisinopril / pioglitazone PHYSICAL EXAM: Admission Physical Exam: Vitals: T: 99.9 BP:122/65 P: 77 RR:22 SpO2: 100% on 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: well healing, non erythematous incision across abdomen along epigastrium, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place, urine is yellow Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema FAMILY HISTORY: Mother: brain cancer at age [**Age over 90 **]. Father: metothelioma - 75 first in his testes. Brother in good health. Sister with superficial melanoma on his breast. Sister with stomach tumor which was removed 40 years ago and now in good health. Tumor assumed to be benign. No h/o GI disorders of GI cancers. 2 maternal aunts with [**Name (NI) 2481**] disease. SOCIAL HISTORY: Lives with her partner of 31 years. She has 2 children, a son and daughter. She previously smoked for 13 pack years and quit in [**2143**]. Denies EtOH or illicits. She is a teacher's aide for grades [**12-4**].

CHIEF COMPLAINT: chest pain PRESENT ILLNESS: 64 year old male with CAD s/p anterior MI [**2150**], h/o recurrent DVT, recent DVT RLE s/o IVC filter admitted to OSH for TKR done 6 days prior developed chest pain, found to have myocardial infarction and transferred to [**Hospital1 18**] urgently for cardiac cath. Patient staes on [**6-21**] (one day prior to transfer to [**Hospital1 18**]), he developed SSCP which gradually worsened with associated shortness of breath. He states this was similar to his heart attack pain from [**2150**] (cath at [**Hospital1 2025**]). . Patient was originally supposed to have bilateral total knee replacement, left was performed, however, the right side was aborted as the air-conditioning in the OR was malfunctioning. On further evaluation, per patient a DVT was found in the RLE and decision was made to anticoagulate first (coumadin/lovenox) and plan for future TKR. He was supposed to go to rehab on [**6-21**], the day he developed chest pain. . [**6-21**] OSH EKG: NSR HR 65, Nl axis/intervals, poor R wave progression, 1mmST elevated V2-3, TWIs II-III, aVF [**6-22**] OSH EKG: sinus bradycardia HR 53 Nl axis/intervals, poor R wave progression (resolved TWIs) . baseline EKG shows sinus rhythm, poor R-wave progression consistent with antecedent anterior MI . MEDICAL HISTORY: PAST MEDICAL HISTORY: CAD s/p MI [**2150**] (2 stents placed at [**Hospital1 2025**]) hypertension chronic deep venous thrombosis s/p 2 ivc filters (one prior to TKR) renal calculi GERD hiatal hernia depression osteoarthritis chronic low back pain bowel adhesions and intermittent SBO DJD . PAST SURGICAL HISTORY: s/p Total knee replacement [**5-/2154**] In [**2150**], he had two stents placed in his heart. GI surgery unspecified in [**2149**] s/p cervical fusion in [**2139**] hemorrhoid surgery in [**2133**] [**2132**] a lumbar fusion with complications of DVT . Cardiac Risk Factors: - Diabetes, Dyslipidemia, + Hypertension . Percutaneous coronary intervention, in [**2150**] anatomy as follows: unknown - done at [**Hospital1 2025**] LAD [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] . Stress ECHOCARDIOGRAM performed on ?[**3-/2154**] demonstrated: Per NEBH reports prior to surgery: His baseline echo shows mild left ventricular hypertrophy, disproportionate to the septum, normal wall motion, and ejection fraction greater than 55%. He had no significant Doppler lesions. He was able to walk for 5 minutes 45 seconds and heart rate of 132, which is 85% max. He had no chest pain, no ST depression. Echo showed augmentation of wall motion in all regions of the left ventricle. . MEDICATION ON ADMISSION: HOME MEDICATIONS: Omeprazole 20 mg daily sular 10 mg daily Zetia 10 mg b.i.d. Percocet 5/325 t.i.d. ASA 325 iron [**Hospital1 **] . MEDICATIONS ON TRANSFER: nitro gtt heparin gtt coumadin 3mg po qhs lovenox 100mg sc bid celebrex 200mg po bid diovan 160mg qday lyrica 75mg po q8hr MVI oxycodone 5-10mg po q4-6hrs prn oxycontin 40mg po bid senna/dulcolax ambien prn phenergan prn/tigan prn lidoderm patch 5% low back daily valium 5mg po q8hrs prn . ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: afebrile HR 64 BP 114/62 RR 19 100%/2L O2 Gen: WDWN middle aged male in NAD. Oriented x3. Appear in some discomfort (back pain). HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. FAMILY HISTORY: non-contributory SOCIAL HISTORY: Retired, lives at home with his wife. < 1 drink EtOH/day. Quit tobacco in [**2114**].

CHIEF COMPLAINT: PRESENT ILLNESS: Ms. [**Known lastname 59980**] is a 64-year-old woman who was in her usual state of health until about 1 week prior to admission when she developed shortness of breath and orthopnea. She had substernal chest pain and presented to [**Hospital6 6640**] on [**12-27**] in respiratory distress. Her heart rate was in the 130's and she had marked JVD. She was in congestive heart failure and had diffuse inferolateral ST depressions. She was intubated and admitted to the ICU at [**Hospital3 **]. Her hematocrit was found to be 22.9 and she was transfused with 2 units of packs cells. The patient underwent cardiac catheterization on [**1-1**], which revealed 50 percent ostial left main stenosis and LAD with diffuse disease and diagonal with 90 percent stenosis, circumflex with 70 percent proximal stenosis and distal occlusion and an RCA with 70 percent stenosis. An echo done at that time showed her EF to be 20 to 25 percent with an akinetic apex and global hypokinesis, mild to moderate MR and mild TR with mild pulmonary hypertension. She then had a colonoscopy which was negative and she was transferred to [**Hospital1 69**] for cardiac surgery. MEDICAL HISTORY: The patient's past medical history is significant for hypercholesterolemia, status post cholecystectomy, status post exploratory laparotomy for small bowel obstruction, history of diverticulitis and abdominal abscess, history of cecal polyps and iron deficient anemia as well as chronic diarrhea. MEDICATION ON ADMISSION: ALLERGIES: The patient states an allergy to Cipro, which causes a rash. PHYSICAL EXAM: FAMILY HISTORY: Significant for CAD. SOCIAL HISTORY: The patient has a long smoking history. She has recently cut back and she currently smokes one cigarette a day. Denies alcohol use. Lives at home with husband.

CHIEF COMPLAINT: unresponsiveness, dysuria, chills PRESENT ILLNESS: 54 yr old quadraplegic from MVA with suprapubic catheter, CRI, recurrent UTI's, hx of seizures. Presenting from NH after episode of unresponsiveness x three minutes. Documented as non responsive to tactile stimuli or command. At that time VS 98% RA, 118/64. Was two days into Macrobid treatment for UTI. Brought to [**Hospital1 18**] though receives most of care at [**Hospital1 59561**]. In ED AOx 3, denies episode or mental status change. Initially 120/60, 93% then to 89% RA- 98% 5L (patient and brother reports NC 2 liters at baseline for COPD), 99.8 axillary. AO x 3 on arrival. Audible breath sounds and upper respitory sounds. Erythema, swelling right thigh. EKG NSR 73, ST depressions v1-v2 no comparison, but in ED reported as no change from prior. WBC 9.1, Cr 1.5, Hct 35 unknown baseline. CXR with no evidence of infiltrate. 3L NS given, vancomycin 1 gram, Zosyn 4.5 grams given. Right IJ placed. Admitted for further work up. Patient reported feeling fine, no worsening SOB from baseline, and alert. No diarrhea, no BM x 2 days. Reportedly denied abdominal pain, fevers, chest pain, SOB. + chills. Given patient with waxing MS, admitting resident obtained an ABG PH 7.26/86/81. lactate to 3.4. . Stat MICU consult for transfer, concern for impending hypercarbic respiratory failure. Mixed disturbance perhaps in the setting of lactic acidosis from sepsis of several sources, urine, abdomen, lung. Did not receive any narcotics, benzos. When arrived in room patient unresponsive. Abdomen increasingly distended. Code called stat. Patient with pulse but respirations to [**4-7**]/minute. BP stable, 85% on 6L. Non rebreather, labs with ABG repeat at 7.27/86/50. Lytes stable. Crit to 30 (down 5pts from prior). Immediately prior to intubation patient intermittently awoke and was conversant but then would quickly become somnolent. EKG unchanged. Decision made with anesthesia to intubate given waxing and waining mental status. Patient intubated and transferred to the unit. Discussed with brother via phone. Patient is full code. . Upon arrival to the MICU, VS 96.1, 113/56, 70, 17 on 100% on CMV ventilation, FIO2 100%. Patient is intubated and sedated. Bloody mucous is being suctioned from airway. No obvious pain MEDICAL HISTORY: : from patient and brother, no clear records of pmhx. C6 Quadraplegia with suprapubic catheter Hx of UTI frequent Hx of seizure, not on antiseizure medications ?pseudoseizures neurogenic bowel ?CRI urinary incontinence GERD Gingivitis Osteopenia Neuropathic pain Abdominal aortic aneurysm Paranoid schizophrenia Chronic pressure ulcers R BKA MEDICATION ON ADMISSION: taken from documents brought with patient Docusate 100 mg [**Hospital1 **] Gabapentin 100 mg TID Baclofen 10 mg QID Trazodone 25 mg PO QHS PRN Lorazepam 0.5 mg TID PRN Acetaminophen 1 gram Q6 hrs prn Albuterol/Ipratropium nebs q4 hrs prn Oxycodone 10 mg PO Q4 Risperdal 4 mg daily Omeprazole 40 mg daily Bisacodyl supp MVI Amitriptyline 100 mg at bedtime Lactulose 30 mg PO BID Senna one tab [**Hospital1 **] Ascorbic acid 500 mg [**Hospital1 **] Guiafenisin 10 mg Q6 prn Proair 90 mcg inh ALLERGIES: Bactrim / Dilantin / Tegretol / Iodine; Iodine Containing / Latex PHYSICAL EXAM: Gen: chronically ill appearing male, intubated HEENT: MM dry, EOMI, no vertical nystagmus. Reactive pupils Neck: No JVD, no thyromegaly, no LAD, IJ in place on right Cor: RRR no m/r/g Pulm: rhoncorous sounds apically. Abd: distended, no shifting dullness, +BS Extrem: Amputee right LE, Right thigh with marked erythema swelling. warm to the touch. Area demarcated previously. No palpable cords. Neuro: Unable to assess [**3-7**] sedation. Contracted hands. FAMILY HISTORY: NC SOCIAL HISTORY: Was living at home with wife and daughter. Nursing home [**Doctor Last Name **] on the Commons x 2 weeks as wife away on business. 1 pack per 4 day smoker x several years. Veteran. Social support good.

CHIEF COMPLAINT: nausea, vomiting, diffuse abdominal pain PRESENT ILLNESS: Pt is a 62 yo M transferred from [**Hospital3 **] Hospital for possible necrotic pancreatitis. Pt was in his usual state of health until 2 days ago, when he developed [**9-23**] abdominal pain. Pt was nauseated and had dry heaves. He also felt weak for a few days prior. Pt usually drinks [**1-14**] pints of rum (Captain [**Doctor Last Name **]) daily, last drink 2d PTA. Pt tried taking pepto-bismol and maalox, but these did not relieve pain. Also feels that his abdomen is larger than normal. Denies any fevers, sweats, reports mild chills. No cough, no shortness of breath, no chest pain. No diarrhea or constipation, no urinary symptoms. No focal numbness or weakness. Pt initially presented to [**Hospital3 **] Hospital, where his vitals were 152/87, HR 119, RR 28, Temp 100.9F, Sat 97% RA. He was found to have a lipase of 3000, AP 35, and Tbili 1.6, AST 118, ALT 117. Lactic acid 4.4, WBC 9.3, Hct 42, Plt 156. Troponin < 0.046. Potassium 2.7, Cr 1.05. He was given potassium repletion, 2L NS and had a CT abdomen w/ IV contrast, which showed an edematous pancreas w/ "slightly decreased enhancement of the tail, peripancreatic fat stranding, and small amount of ascites." Question of possible early necrosis of the tail vs decreased enhancement secondary to edema. Pt had difficult to control pain. Pt was then transferred to [**Hospital1 18**] ED. . In the [**Hospital1 18**] ED inital vitals were, 99.3 126 149/87 18 96%. Pt received K repletion and another 3L fluid bolus. . On arrival to the ICU, vitals were 99.6F, 119, 157/87, RR 23, 96% 2L nc. Pt reports having [**7-23**] generalized burning abdominal pain that does not change with palpation. . Review of systems: Per HPI MEDICAL HISTORY: type 2 diabetes - oral meds hypertension alcohol abuse - no h/o DTs, no seizures chronic bilateral hip pain hepatitis C, cleared w/ treatment hyperlipidemia severe spinal stenosis w/ radiculopathy hypogonadism MEDICATION ON ADMISSION: simvastatin 10mg qhs amlodipine 5mg daily doxyzosin 2mg daily metformin 1000mg [**Hospital1 **] norco 10/325 1 tab tid hydrochlorothiazide 25mg daily ALLERGIES: lisinopril / Penicillins PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: Vitals: 99.6F, 119, 157/87, RR 23, 96% 2L nc. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx normal Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Distant heart sounds, tachycardic rate, normal rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, moderately distended / obese, moderate pain in upper abdomen but not noticeably worse w/ palpation. No masses. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Exam on day of transfer to [**Hospital3 **] Hospital: Vitals: Tm 101 Tc 99.9 BP 110s-120s/80s HR 100s, RR 18-22, 95-98% on RA General: Alert, oriented, no acute distress. He is pleasant and speaks in full sentences HEENT: Sclera anicteric, MMM, oropharynx normal Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Distant heart sounds, tachycardic rate, normal rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, moderately distended / obese, no pain with deep palpation. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema FAMILY HISTORY: DM in father's side. No cancer or heart disease. SOCIAL HISTORY: lives in [**Location 3615**], MA. Works as a security guard. Has a long-term girlfriend. - Tobacco: rare - Alcohol: drinks [**1-14**] pints of rum daily for 20 years - Illicits: prior heroin use. None in decades.

CHIEF COMPLAINT: UGIB PRESENT ILLNESS: 77 year old man with locally advanced, unresectable pancreatic cancer s/p cyberknife and current rx with gemcitabine here UGIB. He had mild abd pain and nausea on Sunday and went to the ED. Stones noted in GB. Then had improvement in sx for a few days. He went to clinic this am for chemo but felt fatigued. POS orthostatics so received IVF. This evening he awoke at 9pm feeling nauseated. He fell and hit his head. Subsequently had large bout of hematemesis. Called EMS and brought to ED. Also noted weakness but denied any diarrhea, black/bloody stool. Denies recent NSAID use, heavy etoh, steroids, or tobb abuse. EGD in [**3-6**] showed tumor infiltration seen in the duodenal bulb. . In the ED, initial BP 84/48 w HR 103. Received 4L IVF and BP improved to 120s systolic. NGL positive clots then BRB which did not clear for >2L. 2 18g and 1 16g placed. HCT 31 (down from 40 in am). given Protonix 40 IV, 2u pRBCs, 3u FFP. . Currently, he feels fairly well. Mild nausea. no abd pain. No F/C/SOB/CP. MEDICAL HISTORY: Pancreatic cancer - dx [**9-23**]: HOP mass. CBD obstruction. Invasion of celiac axis and near commencemnet of the SMV and portal vein. - [**8-3**]: ERCP w stent to CBD for malignant stricture. Cytology c/w adenoca - 10 cycles of gemcitabine. Cyberknife rx [**4-4**] Diabetes HTN MEDICATION ON ADMISSION: Lisinopril 5 Metformin 1000 [**Hospital1 **] Compazine 10 q4-6h prn ASA 81 MVI Ranitidine 150 [**Hospital1 **] ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] VS: 98.4 82 135/65 95% RA RR17 GEN: dry MM. AAOx3, appropriate and interactive HEENT: MM dry. JVP 6cm. NGT w bloody output CARDS: RRR no MGR RESP: slight rales right base. nl effort. otherwise clear ABD: no epigastric discomfort. no rebound or guarding. BS+. no tenderness anywhere. no masses. no organomegaly. EXT: no edema NEURO: AAOx3. follows commands. cn ii-xii intact. motor [**6-1**] bilat upper/lower. [**Last Name (un) 36**] light touch. toes down bilat ACCESS: 2 18s and 1 16 RECTAL: brown OB positive stool FAMILY HISTORY: breast ca SOCIAL HISTORY: 100 pack yrs tobb. Quit 8 yrs ago. Occas etoh. Married w 6 children. Retired painter at [**University/College **]

CHIEF COMPLAINT: Vomiting/diarrhea PRESENT ILLNESS: Ms. [**Known lastname 93749**] is a 77 yo nun with h/o CHF and DM who presents with fevers, nausea, vomiting and diarrhea x 1 day. Pt states she was able to eat breakfast this afternoon but throughout the day she developed severe diarrhea and episodes of emesis. She thinks she vomited 5-6 times and had multiple episodes of watery diarrhea. She did not note blood in her emesis or stools. She did have chills but no fevers prior to presentation. She was unable to keep any food down during the day. She does note another sister had diarrhea and vomiting recently for 2-3 days that resolved on its own. She believes their symptoms were d/t food poisoning but does not recall eating any "funny" foods. She denies fevers, abdominal pain, CP, SOB, recent travel or abx. EMS was called and found her in a pool of diarrhea. She was then brought to [**Hospital1 **]. In the ER she was initially afebrile with HR 107 and BP 84/60. Rectal temp was then noted to be 103.2 and istat lactate 6.5. Pt was given 2 L of IVFs and SBPs trended was in the 80s. She had a subclavian line placed and was treated with levaquin and flagyl. She was given a dose of toradol for chronic backpain and tylenol for fever. Her CVP was noted to be 2 so she was given an additional liter of IVFs and levophed gtt was started. Repeat lactate was 3.4. MEDICAL HISTORY: CHF (EF unknown) Arthritis Chronic back pain, has DJD bilateral knee replacements Peripheral neruopathy Dm type II Glaucoma s/p appy/hysterectomy MEDICATION ON ADMISSION: lasix 40 mg qd digoxin 0.25mg po qd lisinopril 2.5mg po qd glucophage 500mg po tid Timolol eye drops, one gtt OU QD or [**Hospital1 **] ? potassium 10 mEq qd Afrin prn percocet/darvocet prn aspirin prn ambien 10mg po qhs prn vitamin B1 100mg po qd micronase (glyburide) 5mg po tid Benadryl 25mg po bid ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: Temp 99.7 BP 96/48 HR 97 RR 18 O2 sat 97% GEN: Pale,tired appearing female in NAD HEENT: dry MM, anicteric sclera Neck: supple, pt unable to lie flat on back d/t backpain, so JVP not assessed Cardio: RRR, nl S1 S2, no m/r/g Pulm: CTA b/l Abd: soft, ND, + epigastric tenderness, hypoactive BS, no rebound or guarding Ext: trace peripheral edema, 1+ DP pulses b/l Neuro: A&O x3, Cn 2-12 intact Moves all extremities well FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Has been a nun x 60 years, denies ETOH, tobacco, drugs.

CHIEF COMPLAINT: PRESENT ILLNESS: Patient is a 42-year-old male who was involved in a high speed roll over motor vehicle crash. There was a question of whether the patient was restrained. On the scene he was combative and was intubated by the EMTs. He had obvious open left femur fracture, but remained hemodynamically stable in the field and on arrival to the emergency room at the [**Hospital1 188**]. On arrival, pulse was 98, blood pressure 108/palp. MEDICAL HISTORY: 1. Low back pain. 2. Anxiety. MEDICATION ON ADMISSION: ALLERGIES: Penicillin. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: Patient has a wife and sister who are able to converse with physicians in the emergency room.

CHIEF COMPLAINT: Diabetic ketoacidosis. PRESENT ILLNESS: Mr. [**Known lastname 111154**] is a 33-year-old black male with a history of type 1 diabetes who presented to the Emergency Room with complaints of feeling sick for a few weeks, congestion, with increased somnolence over the past week, and a decreased oral intake. The patient reported bilious vomiting on the day of admission with increased urination and increased thirst. He reports having a cough, chills (not measuring temperatures), and flu-like symptoms for the past two weeks, headache, dry mouth, and a cough productive of brown/yellow phlegm. The patient claims he checks his glucoses six times per day. He has been following his Humalog sliding-scale but denies taking NPH yesterday. The patient only takes 25 units each morning and 15 units at night. The patient denies abdominal pain. No diarrhea. No dysuria. No hematuria. In the Emergency Department, the patient was noted to have a glucose of approximately 600 with an anion gap of 32. He received two liters of fluid, 10 units of insulin, and was started on an insulin drip. MEDICAL HISTORY: 1. Type 1 diabetes with a history of diabetic ketoacidosis. 2. Depression with a history of suicidal gestures. 3. Asthma. MEDICATION ON ADMISSION: (Outpatient medications included) 1. Lipitor 10 mg p.o. once per day. 2. Lisinopril 5 mg p.o. once per day. 3. Flovent 220. 4. Albuterol as needed. 5. NPH 25 units subcutaneously q.a.m. and 15 units subcutaneously q.p.m. with a Humalog sliding-scale. ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Grandmother with diabetes. SOCIAL HISTORY: The patient is married with two children. Quit alcohol in [**2197-9-7**]; prior to that drank approximately one pint of brandy per day. He smoked half a pack per day; stopped two weeks ago.

CHIEF COMPLAINT: Decreased responsiveness, Left Basal Ganglia hemorrhage PRESENT ILLNESS: Ms. [**Known lastname 73959**] is a 61 year old with a history of progressive cerebellar degeneration, Type II DM, remote hx of HTN, but not currently hypertensive or on AEDs, who presents with a L BG hemorrhage. History is largely per EMS and OSH records as pt. is unable to relay history due to severe dysarthria. She is accompanied by her sister, who was not present earlier today. Pt. was at her day care center today when they noticed that she seemed to be choking at lunch. She was pale and diaphoretic, and although she was awake she was lethargic and slower to respond than normal. They checked her fingerstick and it was elevated at 464, and they gave her 6 [**Location **]. Her BP was elevated at 220/110. They were concerned so they brought her to an outside hospital. No neurologic exam was documented at that time. At the OSH they describe her as awake and following commands. Her FS on arrival had come down to 309 after the Humalog. Her UA showed glucose of 1000 but no ketones. She was given Labetalol 10 mg IV for her elevated blood pressure. She was taken to Head CT. This showed a hyperdense focus in the L BG c/w parenchymal hemorrhage, hyperdense fluid in the occipital [**Doctor Last Name 534**] of the L lateral ventricle, cerebellar atrophy, and small vessel ischemic disease. She was therefore transferred here for further management. Her sister reports that she feels that her speech is at her baseline right now. She reports that she was with her on Sunday (which is her caregiver's day off) and that she was her normal self. She did not notice any focal weakness (though she thinks it would be hard to pick up with her ataxia), facial droop, confusion, N/V, or worsening speech at that time. The caregiver did tell her that she'd had some urinary incontinence on Saturday, which was unusual for her. She did not have any on Sunday. She has not had any fevers or chills that she is aware of. She thinks she might be slightly confused right now, in that she was a day off on the date, which she would normally know. Pt. denies any headache, focal weakness, nausea, vomiting, abd pain, numbness, or tingling on ROS (with Y/N questions) MEDICAL HISTORY: Progressive Cerebellar Degeneration, previously diagnosed as Olivopontocerebellar Atrophy Iron deficiency anemia Hypothyroidism Type II DM History of HTN, sister reports that she took anti-hypertensives in the past, but then lost alot of weight with the DM and her BP came down, and she has not required medications for several years. She thinks they take her BP at day care and that it's been normal. MEDICATION ON ADMISSION: Baclofen pump Humulin 24 U QAM, 6 U QPM Levoxyl 100 mcg QD Crestor 10 mg QD Zoloft 50 mg QD Metformin 1000 mg [**Hospital1 **] ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T- 100.8 BP- 140/92 HR- 88 RR- 24 O2Sat- 97% on 2L Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema FAMILY HISTORY: Daughter, sister, brother, mother and father have HTN. Daughter had a "malformation of the blood vessels" and has had a stroke [**1-15**] this. Mother and father both had heart attacks. Great aunt had episodes of "acting drunk" despite not drinking, esp falling to side - family wonders whether this was similar to patient's disorder. SOCIAL HISTORY: Has a 24 hour caregiver, goes to a day care during the day, wheelchair bound

CHIEF COMPLAINT: belly pain PRESENT ILLNESS: 57yoF with ESRD with chroni abdominal pain presents with ad ay of abdominal pain feeling worse. Described as vague with nausea and vomiting and yellow diarrhea. No fever no chills no icterus. MEDICAL HISTORY: Diabetic myonecrosis or diabetic muscle infarction. End-stage renal disease. Type 1 diabetes. Hypertension. Cardiomyopathy. EF 35-40%. Heart murmur History of methicillin-sensitive Staphylococcus aureus bacteremia. Septic arthritis. Depression. MEDICATION ON ADMISSION: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:*60 Tablet(s)* Refills:*2* 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). Disp:*15 Capsule(s)* Refills:*2* 3. Mirtazapine 15 mg Tablet Sig: half Tablet PO HS (at bedtime). Disp:*20 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 6. Pantoprazole 40 mg IV Q24H 7. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 9. Epogen 10,000 unit/mL Solution Sig: One (1) Injection once a week. Disp:*1 * Refills:*2* 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:*1 * Refills:*2* ALLERGIES: Compazine / Reglan / Elavil / Captopril / Droperidol PHYSICAL EXAM: temp 98 pulse 61 bp 145/61 Alert and oriented no icterus regular rate and rhythm lungs clear to auscultation abdomin no crepitus, obese, distended, tender- distractable FAMILY HISTORY: grandmother with DM, mother with HTN SOCIAL HISTORY: lives with son, no [**Name2 (NI) **]/alc.

CHIEF COMPLAINT: PRESENT ILLNESS: Mr. [**Name14 (STitle) 18015**] is a 63 year-old male with a history of coronary artery disease status post coronary artery bypass graft in [**2166**], aortic insufficiency status post aortic valve repair in [**2166**], diastolic congestive hypertension, diabetes mellitus, end stage liver disease, cirrhosis secondary to hepatitis B and chronic alcoholism who presents with increased shortness of breath for two weeks. There is also a positive thirteen pound weight gain in the past two weeks. He was told to increase Lasix from 42 mg po q day one week ago. The patient still with increased weight and shortness of breath and positive orthopnea. There is exertion. There is bilateral arm tingling for two weeks. There is a history of positive bloody stool possibly secondary to a history of internal hemorrhoids. Positive chronic cough, but this is unchanged. He has no diarrhea. No fevers or chills or dysuria. Positive increased lethargy over the last ten months. The patient does use home oxygen. He uses it at night, but for the last two weeks he has been using it around the clock. In the Emergency Department vital signs were 96.4 temperature. Heart rate 98. Blood pressure 120/70. Respiratory rate 20. Oxygen saturation was 84% on room air improved to 99% on 2 liters. The patient was given 80 mg of Lasix intravenous with 600 cc of urine output and improved shortness of breath subsequently to this. On electrocardiogram new onset atrial fibrillation in the 90s. The patient was in normal sinus rhythm as recently as [**2170-9-20**] while on the Holter monitor. MEDICAL HISTORY: The patient was considered for placement on the transplant list secondary to cirrhosis, secondary to hepatitis B and liver disease secondary to chronic alcohol use. History of hepatic encephalopathy. Coronary artery disease status post coronary artery bypass graft in [**2166**], aortic insufficiency, status post AVR repair in [**2166**], diastolic congestive heart failure, chronic obstructive pulmonary disease, hypertension, diabetes mellitus, home O2 admitted [**2170-7-19**] with pneumonia and cellulitis, positive reversible defect in the inferior at apex. Stress test in [**2170-8-12**] Holter monitor, no electrocardiogram changes and mild apical hypokinesis, medium to high grade AEA. Episodes of sustained supraventricular tachycardia initiated by APB. Echocardiogram in [**2170-8-12**] showed more or less moderate left LA plus [**Last Name (un) **] and mild symmetrical left ventricular hypertrophy. Normal LVS function with ejection fraction over 60%. MEDICATION ON ADMISSION: Lasix 80 mg po q.d., potassium chloride 20 milliequivalents po q.d., Pepcid mg po b.i.d., Atenolol 12.5 mg po q.d., Lactulose 30 cc b.i.d., aspirin 81 mg po q day, vitamin E, multiple vitamin, NPH 20 units subQ q.a.m., 10 Units subQ q.p.m., Os-Cal 500 mg po q.i.d., Maalox t.i.d., Neomycin 250 mg po q.i.d. ALLERGIES: Penicillin. Intolerant to sleep medications. Motrin. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: Three cigarettes per day.

CHIEF COMPLAINT: unintentional calcium channel blocker overdose PRESENT ILLNESS: 51 year-old man with Hep C/ETOH cirrhosis, IVDA with history of epidural abscess, chronic back pain, and HTN, who presents after overdosing inadvertantly on calcium channel blocker. He took 10 tabs of pills that he bought on the street (that he thought were methadone) 3 days before admission. The next day he felt lightheaded and nauseous. Then the day of admission he fell out of his bed several times which prompted his mother to call EMS. He denied head strike or loss of conciousness. Denied chest pain, palpitations, shortness of breath, abdominal pain, headache. He initially presented to [**Hospital6 **]. There they discovered the tabs he took were amlodipine 10mg tabs after investigation by a pharmacist. Shortly after arrival, his HR dropped to <20 and he became unresponsive. One round of chest compressions was completed and his HR improved and his pulse returned without further intervention. Medications administered at the OSH included glucagon 8mg, amp bicarb, amp D50, 40 units insulin IV, 30g kayexelate, 3 amps calcium gluconate, 4L NS. He was then med-flighted to [**Hospital1 18**]. En route he was started on levophed for SBP 70/20 MAP 30s. At [**Hospital1 18**], initial vitals were 97.9 83 82/29 on levophed 18 93%4L. Labs were notable for K 5.3, Na 132 HCO3 10 BUN 93 Cr 5.3, INR 1.3, WBC 7.7, HCT 38.3, Plt 155. Serum tox negative. AST 115, ALT 54, Tbili 0.8, Alb 2.9, Lip 50. Lactate 6.6. L CVL placed. Urine output was ~30cc/hr. His levophed was continued, insulin drip started at 40 units/hr, started on calcium chloride drip 2g/hour, D10 75/hr, and was given 1 bolus of intralipid (120cc). He was seen by toxicology who recommended continued high dose insulin, intralipid gtt needed if hemodynamics worsened, and glucose checks every hour. He was started on vanc/Zosyn for possibility of infection. In the MICU he was bolused with 6L IVF for suspected prerenal [**Last Name (un) **] and was seen by Renal who recommended bicarb gtt for acidosis. Vanc/Zosyn were stopped and levophed was weaned. He was started on thiamine, folate, and a MVI for h/o alcoholism. CXR showed no evidence of PNA, and Abdominal U/S showed cirrhosis with a patent portal vein and normal kidneys. He was started on a CIWA protocol for withdrawal. Of note, his hct and platelets dropped following aggressive fluid resuscitation, but his hct has remained stable at 29. He also complained of new rash and pain in L antecubital region; ultrasound showed no evidence of DVT or fluid collection. When transferred to the medical floor, he reported chronic back pain but denied dizziness and headache. He confirms that this was an accidental overdose and denies suicidal ideation. MEDICAL HISTORY: Cirrhosis secondary to EtOH and hepatitis C polysubstance abuse including IV heroin Epidural abscess and osteomyelitis, s/p back surgery at [**Hospital1 2177**] [**2133**] Chronic back pain HTN nephrolithiasis MEDICATION ON ADMISSION: lisinopril 5mg daily methadone 30mg TID clonipin 1mg PO BID HCTZ 12.5mg daily bactroban cream for 7 days percocet 5/325 mg 1 tab PO Q4-6hrs bactrim DS 1 tab [**Hospital1 **] Benadryl PRN itching ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: Vitals: 98.1 91 99/31 16 98% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP flat, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops, no spider angiomata Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, no asterixis FAMILY HISTORY: Father heavy ETOH drinker, died of MI. Mother had breast cancer in 80's and an arrhythmia. Sister with substance abuse and hepatitis C. SOCIAL HISTORY: Lives with mother. Unemployed for many years. Used to work in carpentry. Smokes 1 pack/week. ETOH 1-2 times per month, history of heavy ETOH prior to [**2125**], IVDA last used heroin 6 months ago, prior to that used cocaine, crystal meth and "everything in the book".

CHIEF COMPLAINT: hepatocellular carcinoma PRESENT ILLNESS: Patient is a 72-year-old Chinese-speaking male with chronic HBV and who in the past has had an undetectable viral load. He notes a recent history of right upper quadrant abdominal pain for the past six to eight weeks. This is relatively constant and there is no exacerbating or alleviating factors. On [**2138-10-10**], he underwent a CT scan of the abdomen that demonstrated multiple cysts throughout the liver. However, in the right lobe, there is a less well-defined multicentric low density and it was unclear by report whether this was a cystic or solid, and an MRI was recommended. An MRI on [**2138-10-24**] demonstrated again multiple cysts throughout the liver measuring up to 2.7 cm in diameter. There was a multifocal solid mass in the right lobe of the liver measuring 3.3 x 4.8 cm. There is less than 1.5 cm arterial enhancing focus in the right lobe of the liver. This was thought to be a tumor thrombus in a branch of the right portal vein, but the main right, right anterior, and right posterior portal veins are patent. His hepatitis A antibody was positive. His hepatitis B core antibody was positive, hepatitis B surface antigen positive and HBV quantitative was 17,433,484 and AFP on [**2138-10-28**], was 110. He currently is doing well clinically. He is eating and tolerating a regular diet, having normal formed bowel movements, and remains fully active in spite of his discomfort. MEDICAL HISTORY: PMHx 1. hepatocellular carcinoma 2. hepatitis B 3. benign prostatic hypertrophy, elevated PSA 4. chronic obstructive pulmonary disease 5. obstructive sleep apnea on CPAP PSurgHx 1. appendectomy MEDICATION ON ADMISSION: 1. Viread 300 mg daily 2. Albuterol prn wheezing 3. calcium 4. glucosamine 5. vitamin E ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: post-op exam: T 97.1 HR 112, BP 96/61, RR 23, SpO2 96% on 3L NC gen: drowsy but awake, oriented X3 neck: supple chest: CTAB cardiac: nl S1S2, no murmurs, rubs, or gallops abdomen: soft, appropriately tender without rebound; dressings clean, serosanguinous fluid in JP ext: wwp, no edema FAMILY HISTORY: His mother committed suicide at age 60, and his father was murdered in [**Name (NI) 651**] at age 40. SOCIAL HISTORY: He is married with 2 children. He is a retired cook. He has a history of drinking one beer per day for 10 years, but quit several months ago. He has a history of smoking half pack of cigarettes per day for 20 years, but quit 30 years ago. He has no history of IV drug use, marijuana use, tattoos, or piercing. He has had blood transfusions 40 years ago.

CHIEF COMPLAINT: Syncope PRESENT ILLNESS: [**Age over 90 **] year old man with history of seizures, prior CVA, bilateral carotid endarterectomies, hypertension, prostate cancer, CAD s/p NTEMI, presenting after syncopal episode at home. Patient was having dinner with his family when he was noted to slump down on his arm chair and becoming unresponsive. Drooling was noted from the left side of his mouth. Patients grandson is a police officer and reports not being able to find a pulse or to arouse him. Patient did not receive CPR, EMS was called and he was taken to nearby hospital. At [**Hospital6 **], VS 211/120, HR 90, RR 26. Pt given IV labetalol 10mg x 2 with BP 185/92 at time of transfer. Non contrast head CT with preliminary read of no acute intracraneal hemorrhage. Pacer pads, brady to 15s hypertensive 200's/.100's. NSGY BP goals less than 140, on nicardipine drip, lateral ST changes. Needs repeat head CT in AM. Per neurosurgery, no immediate intervention needed. Patient will need repeat head CT in the morning. Although he received aspirin 325mg in ED, does not need platelets at this time. Asked to hold any further aspirin and plavix. MEDICAL HISTORY: [**2096**]- CVA with residual speech impairments Seizure disorder, on tegretol Bilateral Carotid Endarterectomy Prostate Cancer treated with Casodex Hypertension Inguinal Hernia Aortic Sclerosis Arthritis [**2100**]- Upper GI bleed Psoriasis on elbows Depression BPH MEDICATION ON ADMISSION: tegretol 200mg [**Hospital1 **] flomax .8mg plavix, sertraline 100 lopressor 25mg [**Hospital1 **] simvastatin 80 finasteride Digoxin 0.125 Bicalutamide 50mg Aspirin 325mg ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: GENERAL: Pleasant, well appearing elderly man in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. (+) Tongue ecchymoses. Neck Supple, No LAD, No thyromegaly. Bilateral scars over carotid artery, no bruits. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. II/VI Systolic crescendo murmur. No rubs or gallops. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. Large inguinal hernia, partially reducible, non tender or discolored. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: Bruise on posterior scalp, shoulder and arm. NEURO: A&Ox3. Speech slurred, word finding difficulties (per family at baseline) Appropriate. CN 2-12 grossly intact although with poor effort on exam. Preserved sensation throughout. [**6-10**] strength throughout. [**2-8**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Lives with his daughter, retired, no services at home. Independent with use of a cane, wife is in nursing home. Attends daily meetings and is able to perform ADL's. No current alcohol or drug use.

CHIEF COMPLAINT: Abdominal Pain PRESENT ILLNESS: 72yo M awoke at 3am last night with severe sudden onset adbominal pain. Patient cannot recall any history of trauma. Patient states that pain was constant in nature. He was brought by EMS to [**Hospital **] Hospital where he was noted to have abdominal pain and was slightly hypotensive with blood pressure of 102/54. Abd CT showed bleeding liver mass. Hct was 26.6 and patient was transfused 2U PRBCs. Patient was transferred to [**Hospital1 18**] for further management MEDICAL HISTORY: ? CAD: stress test a week ago, ? positive Diabetes HTN Hyperlipidemia Colonoscopy 1 week ago: s/p polypectomy MEDICATION ON ADMISSION: Metformin 500mg [**Hospital1 **] Lisinopril Simvastatin ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: NAD, A&O RRR CTAB Abd soft, non-tender No peripheral edema FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Quit smoking thirty yrs ago, drink 5 beers a day for many years consistently. No history of withdrawal. No IV drug use, does not believe he could have Hep B or C

CHIEF COMPLAINT: s/p motorcycle accident PRESENT ILLNESS: Patient is 32 yo man who presents s/p motorcycle collision vs car, with helmet, speed unknown. + EtOH. No loss of consciousness. Brought to ED by EMS. MEDICAL HISTORY: s/p Right finger fx with pin placement MEDICATION ON ADMISSION: None ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T=99.8 rectal HR=98 BP=98 Large laceration on chest Equal BS bilaterally Abdoment soft, nontender Extremities - large laceration R wrist. Wound exploration showed radial artery laceration, FPL, FCR, EPL lacerations, median nerve transection. L wrist visibly deformed. Pulses 2+ bilaterally. No spinal stepoffs, no abrasions FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: + EtOH. Lives with girlfriend.

CHIEF COMPLAINT: respiratory distress PRESENT ILLNESS: HPI: 42 y/o male with PMH of recently diagnosed celiac disease ([**2-12**])w/ associated T cell NHL s/p Promace and CytaBOM, due for cycle six on [**2150-7-8**] in preparation for stem cell collection [**2150-7-19**], who presented with fevers and diarrhea on [**7-6**], initally sent home on Levofloxacin. Patient presented to clinic [**7-7**] with persistent fevers up to 104 and diarrhea and was re-admitted. Torso CT demonstrated ground glass opacities bilaterally, and "tree-[**Male First Name (un) 239**]" pattern opacities ?for fungal vs viral etiology. Bronch on [**7-8**] was negative. Pt developed septic physiology on [**7-9**] and was transferred to the MICU for management. CXR at that time consistent with ARDS/capillary leak. Hickman d/c and pt defervesced. Had bx of duodenum to r/o recurrent lymphoma. Was sent to floor on [**7-12**] afebrile and normotensive but still hypoxic. On floor, progressively more hypoxic from [**Date range (1) 9845**] despite diuresis and added empiric coverage for PCP. [**Name10 (NameIs) **] to MICU for closer monitoring. Electively intubated. ECHO with new pericardial effuison with no HD significance on ECHO. Developed hypotension and started on vasopressin with LR fluid boluses. Also developed ARF with Cr peak at 5.1 and started on CVVH. LDH and lactate slowly trending upwards since [**7-14**] (date of transfer to MICU). LDH thought initially to be secondary to hemolysis with increased lactate secondary to sepsis/hypotension. However, values cont to climb as pt's BP and resp status improved. It was then thought that the increased LDH may be secondary to recurrence of lymphoma and noted that lactic acidosis can also occur with recurrence due to inc production of lactate by the tumor and [**Month (only) **] metabolism by the liver. Sternal bx was done on [**7-19**] which showed recurrence of lymphoma. MEDICAL HISTORY: Chronic back pain - herniated L4-L5 NHL- T cell s/p double hernia repair T + A as infant Celiac disease and gluten intolerance H/o staph epi line infection MEDICATION ON ADMISSION: ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Gen: lying in bed with increased resp rate, in moderate distress HEENT: PERRL, EOMI CV: tachy, reg rhythm, no g/m/r Lungs: coarse BS throughout Abd: +BS, mildly distended, nontender, no masses Ext: trace edema, warm, 2+ pulses Neuro: CN 2-12 intact, strength equal and symmetric FAMILY HISTORY: Father - [**Name (NI) **] cancer SOCIAL HISTORY: Never smoked No ethanol Finance job, not currently working

CHIEF COMPLAINT: rectal bleeding PRESENT ILLNESS: 57F with rectal bleeding pod 13 from hemorrhoidectomy for bleeding internal hemorrhoids by Dr. [**Last Name (STitle) 1120**]. She said the week after her surgery she was fine. However this last week she has had increasing spotting and bleeding with bms. Earlier this week her inr was 4.5. Her goal is 2.5 - 3.5. This last day it has been fairly constant and she has to keep changing pads. She feels occasionally lightheaded. MEDICAL HISTORY: Significant for alcohol abuse Status post AVR and MVR in [**2123**] (due to rheumatic HD) Migraines Depression Hepatitis C Status post hysterectomy Hypertension Anemia with a baseline hematocrit in the low 30s to mid 30s MEDICATION ON ADMISSION: amlodipine 2.5', fioricet q6 prn, premarin cream, anusol supp'', lisinopril 80', metoprolol 100'', mirtazapine 45', percocet prn, trazodone 200 qhs, coumadin as dir. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: On Admission: 98.2 94 117/68 16 100 NAD RRR CTAB Abd soft Rectal - no external hemorrhoids, small amount of bleeding from anus, unable to pass an anoscope due to patient discomfort. Ext - no edema FAMILY HISTORY: Mom had breast cancer in her 50s. No h/o abdominal/GI diseases. Family h/o DM. SOCIAL HISTORY: Works in a multidisciplinary clinic on [**Hospital Ward Name **] for patients with melanoma. Married, no children. - Tobacco: 1 pack per week - EtOH: Couple of drinks every night but hasn't drank in a week, has been in detox in the past - Illicits: Denies

CHIEF COMPLAINT: PRESENT ILLNESS: Mr. [**Known lastname **] is an 82-year-old male admitted to the Medical Intensive Care Unit for gastrointestinal bleed, hypotension. This gentlemen was recently admitted one month ago for chronic obstructive pulmonary disease flare, deep vein thrombosis and pulmonary embolus and was discharged to [**Hospital3 7**] where he was noted today on the day of admission to have 300 cc of bright red blood per rectum and hypotension systolic in the 80s. He had been started on Lovenox in the hospital and on Coumadin prior to being discharged for his venous thromboembolic disease. His last documented INR was 2.6 two days prior to admission. Patient denied any fevers, abdominal pain, nausea or vomiting, chest pain, shortness of breath, dizziness or lightheadedness. He has never had gastrointestinal bleeds in the past. MEDICAL HISTORY: 1. Recent deep vein thrombosis/PE and discharged for same condition on [**2115-12-23**]. He also has a remote deep vein thrombosis several years ago. 2. Chronic obstructive pulmonary disease on two liters of home 02 at night. Never intubated, and not on chronic steroids, however, is frequently on steroid tapers. He is also status post blood resection. 3. Hypertension. 4. Prior CVA with right-sided weakness. 5. Benign prostatic hypertrophy. 6. Osteoporosis. 7. A neuropathy. 8. Status post appendectomy. 9. Ventricular ectopy and nonsustained ventricular tachycardia and he did have an echocardiogram in [**2115-3-21**] showing an ejection fraction of 50%. 10. Right upper lobe mass seen on CT on the most recent admission and also noticed on chest x-ray of this admission whose cause is unknown, but is most likely felt to be malignant in nature. MEDICATION ON ADMISSION: ALLERGIES: Patient denies any medical allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: He lives with his wife of 40 years and he quit smoking 30 years ago after an extensive pack year history. He is a retired lawyer in the area.

CHIEF COMPLAINT: Severe aortic stenosis and coronary artery disease. PRESENT ILLNESS: The patient is an 83-year-old gentleman who has been followed for aortic stenosis for several years who presented with progressive symptoms of congestive heart failure. Cardiac catheterization was performed which revealed critical aortic stenosis and severe two-vessel coronary artery disease. He was admitted electively for surgery. MEDICAL HISTORY: Hypertension. Mild nephritis. Carotid stenosis with right internal carotid artery at 30-60%, left internal carotid artery 30-50%. MEDICATION ON ADMISSION: ALLERGIES: NO KNOWN DRUG ALLERGIES. SHELLFISH AND DYE. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: ?intracranial bleed PRESENT ILLNESS: Mr. [**Known lastname 85507**] is a 33 year old man with hepatitis C and bipolar disorder who presented to an OSH with symptoms of meningismus, and was transferred to [**Hospital1 18**] for evaluation of possible intracranial hemorrhage. Patient was admitted to [**Hospital1 18**] [**Location (un) 620**] on [**6-17**] with fever to 103, photophobia for 2 days. He reported fatigue and a diffuse headache. He was initially covered emperically with CFTX and Vancomycin. His LP was negative for acute bacterial meningitis. His blood cultures grew MSSA, and his antibiotics were switched to Oxacillin. He underwent a thorough endcarditis work-up: TTE and TEE were negative for endocarditis; CT torso showed inflammation of the R lower quadrant mesentary and trace free fluid without free air, cannot rule out acute appendicitis, acute aortic coarctation, and a 1.8 cm indeterminant lesion in the spleen. Head CT with possible parietal hyperdensities. The patient today c/o of the worst headache of his life, then was noted to become decorticate and have a blown L pupil. He was emergently intubated and transferred without head imaging to [**Hospital1 18**] for further work-up. On arrival tothe ICU, patient was intubated, sedated, and unable to answer questions regarding review of systems. Emergent Head CT non-contrast was obtained which showed a L subdural hematoma and 2 areas of ICH ?occipital lobe. MEDICAL HISTORY: Bipolar Disorder Hepatitis C ?Co-arctation of aorta MEDICATION ON ADMISSION: Medications: Lithium 30 mg PO BID Paxil 30 mg PO daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: General: intubated, sedation HEENT: Sclera anicteric, MMM, oropharynx clear, pupils pinpoint and symmetric. Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Neuro: purposeful movements R>L. obeys commands such as blinking or squeezing hands. toes upgoing on R, mute on L. FAMILY HISTORY: unknown SOCIAL HISTORY: - Tobacco: none - Alcohol:unknown - Illicits: unknown

CHIEF COMPLAINT: line infection and bradycardia PRESENT ILLNESS: Patient is a 42yo male with PMH of Down's Syndrome, sick sinus syndrome, and hypothyroidism who presented to OSH because of increased drainage from a shoulder wound associated with recent manipulation of his pacemaker. . Patient received the dual-chamber [**Company 1543**] Sigma, serial number PJD [**Numeric Identifier 91991**], placed initially in [**2146-10-17**], insertion of a new [**Company 1543**] atrial lead because of fractured wire was done on [**2153-1-10**]. In [**2155-12-14**], the tie down sleeve of the atrial lead was noted to be visible at the site of the right clavicle. There had previously been granulation tissue/eschar there since [**Month (only) 116**] the previous year. He reportedly is always picking at the site. He presented to his PCP and was treated with a 10-day course of Keflex 500mg PO QID for 10 days. Wound culture was negative before that treatment. He presented to his electophysiologist on [**2156-1-9**] where he was noted to have an obviously exposed pacemaker lead. A lead extraction was planned on [**2156-1-22**]. However, patient noted increased drainage from the wound site prior to the scheduled date and presented to OSH on [**2156-1-15**] for evaluation. At that time he had no fevers/chills, no abdominal pain, no nausea and vomiting, and no other pain. He was placed on mupirocin ointment and IV cephazolin. He was transferred to [**Hospital1 18**] for lead removal. . On arrival to the floor, patient is accompanied by two people who work for his home aid/group home services. His vitals on arrival are T98.1, BP123/77, HR59, RR20, O2sat 98%RA. He reports diffuse pain symptoms but staff that know him and report that his expression of "pain" is in fact an obsessive/compulsive discomfort with the sticky leads on his body. He reportedly will point and react with grimace when is feeling pain. He knows not to pick at the leads. . ROS: difficult to assess, but staff reports he has not had pain, shortness of breath, or fever. MEDICAL HISTORY: Down's Syndrome Hypothyroidism Sinus Node dysfunction s/p pacemaker with lead revision MEDICATION ON ADMISSION: Lithobid 600 mg q.h.s Buspirone 10 mg twice a day Topamax 100 mg in the morning and 50 mg in the evening Levoxyl/Synthroid 75 mg daily Metamucil two tablets daily Colace 100 multivitamins potassium 20 mEq b.i.d. folic acid 1 mg daily ferrous gluconate 325 Lamisil cream hydrocortisone ointment ketoconazole cream, Lactaid acetaminophen Eucerin cream Denorex shampoo. ALLERGIES: Amoxicillin / Paxil / Sulfa(Sulfonamide Antibiotics) / Penicillins PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION: VITALS: T98.1, BP123/77, HR59, RR20, O2sat 98%RA GENERAL: NAD, resting comfortably in chair HEENT: prominant facial features stereotypic of Down's Syndrome, large, semi-protuberant tongue, atraumatic skull, PERRL, EOMI, MMM NECK: no JVD, no LAD CHEST WALL: dime to quarter-sized area of exposed granulation tissue over the right anterior chest wall HEART: RRR, no M/R/G LUNGS: CTAB ABDOMEN: soft, nontender, nondistended, NABS, no organomegaly EXTREMITIES: no peripheral edema, no [**Last Name (un) **] lesions or splinter hemorrhages. PHYSICAL EXAM ON DISCHARGE VITALS: T:97.7, BP:99/59, HR68, RR18, O2sat:100%RA CHEST WALL: steristrips covering a wound that appears clean, dry, intact with no surrounding erythema EXTREMITIES: venous catheter in place on left arm FAMILY HISTORY: Father had leukemia, mother has multiple cardiac stents, no FH of pacemaker SOCIAL HISTORY: lives in a group home no tobacco no alcohol

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 79-year old female who is status post coronary artery bypass grafting times three on [**2196-3-14**] - performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] - with a left internal mammary artery to the left anterior descending, a saphenous vein graft to the obtuse marginal, and a saphenous vein graft to the right posterolateral. Possibly, the patient started developing abdominal pain. An exploratory laparotomy was performed which was negative. The patient was subsequently transferred to a rehabilitation facility and then to [**Hospital1 69**] for evaluation of her for a possible sternal nonunion. The patient is on peritoneal dialysis for end-stage renal disease; which was changed to hemodialysis after her exploratory laparotomy and then back to peritoneal dialysis. MEDICAL HISTORY: This is a 79-year old female with a past medical history significant for hypertension, insulin- dependent diabetes mellitus, coronary artery disease, end- stage renal disease, hypercholesterolemia, peripheral vascular disease, gout, hypothyroidism, and a history of lung nodules. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Right lower leg cellulitis PRESENT ILLNESS: 73 yo M with history of CAD, HTN who presented today to outpatient physician with persistent cellulitis, fevers (to 102.3 in PCP [**Name Initial (PRE) 3726**]), and chills despite 7 days of treatment with cephalexin. Patient notes that his leg had improved initially, though in last two days he has lost his appetite and has had subjective fevers at home. Also reported that he had shaking chills night prior to admission that woke his wife from sleep. Patient notes that on the day of admission he could hardly drive home from work as his rigors were so severe. He denies any sick contacts. Does report loss of appetite. Denies abdominal pain, nausea, constipation. Denies cough, rhinorrhea, sore throat. . Per confirmatory report from outpatient physician [**Name9 (PRE) 7421**] to [**Name9 (PRE) **], patient had fever to 102.3, BP 113/63, HR 116, nausea, malaise, excess thirst, frequent urination, pain under wound on shin, and fluctuance under wound. Also reportedly had an xray of leg with no evidence of osteomyelitis. Had a UA at outpatient clinic with no nitrite or leuk esterase on dip in setting of absence of urinary symptoms. . In the ED, initial vs were: T 101, HR 109, HR 110/52, RR 16, O2Sat 95% RA. Almost immediately febrile to 105 in the observation portion of ED. Patient had two sets of blood cultures drawn. Was given empiric Vancomycin and [**Name9 (PRE) **]. BP dropped to 80s systolic despite two liters of NS. RIJ central line placed. Also has two 18g PIVs. MAP in the 60s. Patient placed on a NRB. Patient refused a foley, though a UA was sent. In all, received 4L NS. CXR was obtained. Prior to transfer to the ICU vitals were: T 100.9, HR 84, BP 94/50, RR 24, O2Sat 100% on NRB. Patient notes that he has new dyspnea since fluid resuscitation in the ED. MEDICAL HISTORY: 1) CAD s/p MI in [**2161**] 2) Hypertension 3) Hyperlipidemia 4) Urticaria 5) Sciatica 6) Actinic keratosis 7) Screening for diabetes MEDICATION ON ADMISSION: 1) Atenolol 25 mg daily 2) Simvastatin 40 mg QHS 3) Nitroglycerin 0.4 mg SL PRN 4) Aspirin 81 mg daily 5) Loratadine 10 mg daily 6) Multivitamins daily 7) Cephalexin 500 mg QID (day 7 of 10 planned) ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: GEN: Well appearing elderly male sitting up in a chair eating dinner in NAD HEENT: PERRL, EOMI, anicteric sclera, MMM NECK: supple, no appreciable JVP elevation PULM: CTAB CARD: RRR, no m/r/g ABD: soft, NT/ND, BS+ EXT: Right anterior tibia has traumatic skin lesion with granulation tissue and scab formation, no exudate from wound, not warm, area around wound is slightly tender to palpation, DP and PT palpable bilaterally NEURO: A+Ox3, CN 2-12 intact, motor strength and sensory grossly equal and intact bilaterally FAMILY HISTORY: Patient denies any family history of heart disease, diabetes, or cancer. Has a mother who is [**Age over 90 **] years old. SOCIAL HISTORY: Patient lives with his wife. [**Name (NI) **] no pets. Plays tennis 4 times weekly. - Tobacco: Patient smoked off and on for many years, though can not quantify well. Quit in [**2161**] after diagnosis of MI. - Alcohol: Rare, approximately 1 glass of wine weekly - Illicits: Denies

CHIEF COMPLAINT: acute onset of shortness of breath PRESENT ILLNESS: 66F who was recently hospitalized on [**2196-8-4**] for right breast hematoma sustained in a MVC who now presents with acute onset shortness of breath secondary to bilateral pulmonary emboli. Her symptoms began on the morning of admission and the patient went immediately to an OSH where the diagnosis of pulmonary embolus was made. The patient has been feeling well otherwise since she was discharged from [**Hospital1 18**] on [**8-12**]. She does recall a slight pain in right calf which began last evening but denies swelling. She is ambulating periodically as an outpatient, but has not yet met her baseline. MEDICAL HISTORY: PMH: afib, LBBB, hypothyroidism, hypertension, NIDDM, uterine cancer MEDICATION ON ADMISSION: asa 81', amiodarone 200', colace 100mg", felodipine 5', levoxyl 100', lisinopril 40', metformin 500", toprol 150', rosuvastatin 20' ALLERGIES: Bacitracin PHYSICAL EXAM: ON ADMISSION: FAMILY HISTORY: NC SOCIAL HISTORY: Patient lives with her husband of 34 years, they have five children, 1 daughter in [**Name (NI) 4754**], 2 daughters in [**Name2 (NI) **], and twin sons who also live in [**Name (NI) **], [**Name (NI) **].

CHIEF COMPLAINT: abdominal pain PRESENT ILLNESS: 68 Yo male with Hep B, hx choledocholithiasis requiring ERCP [**2165**] who presents with abdominal pain, jaundice and fever. Pt reports onset on [**1-26**] severtiy dull pain during dinner(fish and tofu) last night at 7pm. He noted onset of fever/chills shortly after. He denies CP, SOB, n/v/d. He had normal BM this AM, no blood. Pain is less severe than with his choledocholithiasis in past. Pt denies itching of skin but did have dark urine. Pt said pain subsided after 3-4 hours. He noted nothing that helped or exacerbated the pain. He has no pain currently. In ED he recieved IV fluids, levofloxacin, flagyl and ampicillin MEDICAL HISTORY: [**2165**] Choledocholithiasis s/p ERCP and sphincterotomy with resultant bleeding from papilla requiring EGD with epinephrine injection to stop bleeding - post-ERCP pancreatitis HTN high cholesterol Type II DM Hepatitis B CRI 1.3-1.5 MEDICATION ON ADMISSION: pt does not no names of his BP, cholesterol and DM meds ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS; 100.0 84 123/75 16 96% RA HEENT: EOMI, mildly icteric, mildly dry MM Neck: supple, JVP not elevated, -lad lungs: CTA bilat heart: RRR nl s1 s2, abd: soft ND, NABS + RUQ tenderness with + [**Doctor Last Name 515**] sign, -guarding, rebound ext: -edema neuro: CN intact skin: mild jaundice FAMILY HISTORY: SOCIAL HISTORY: retired, no ETOH, tobacco, drugs

CHIEF COMPLAINT: Dyspnea PRESENT ILLNESS: [**Known firstname 25368**] [**Known lastname 73102**] is a 68-year-old man with a past medical history of coronary artery disease, congestive heart failure, hypertension and hypercholesterolemia who was admitted for prehydration prior to cardiac catheterization. His main complaint is of dyspnea. He gets moderate dyspnea with exertion that is readily relieved with rest. This occurs nearly every day. It got somewhat better after starting Lasix. He also has thigh pain with exertion that is relieved with sitting down. This also occurs nearly every day. He denies orthopnea, PND, leg edema, lightheadedness, syncope, and palpitations. He otherwise feels well. All other systems were reviewed and negative. He brought with him his medical records from [**State 4565**]. He had an anterior myocardial infarction on [**2199-1-13**] that was complicated by cardiogenic shock and managed expectantly. His expectant management was apparently due to esophageal bleeding (possibly variceal, but no evident liver disease) that occurred two days prior to this. He underwent angiography a month later. There was no report, but some images are included in his papers. There is LAD and LCx disease evident, but the clinical notes only refer to the LCx disease. Echocardiograms variously showed LVEFs from 15% to 30%, generally around 20%. He also underwent a cardiac MR. The report is not included in his paperwork, but the clinic notes describe it as showing an LVEF of 10% with anterior scar. No mention is made of viability in the other territories. He was considered for an ICD but was apparently turned down. He was told that it wasn't worth it for him. MEDICAL HISTORY: Ischemic Cardiomyopathy, Systolic Congestive Heart Failure, Coronary Artery Disease, Mitral Regurgitation, Prior MI [**2198**] complicated by cardiac arrest, Chronic Renal Insufficiency, COPD, History of Upper GI Bleed secondary to esophogeal varices - s/p cauterization, History of ETOH abuse MEDICATION ON ADMISSION: Albuterol MDI, Alprazolam prn, Aspirin 81 qd, Ambien prn, Atrovent MDI, Coreg 3.125 [**Hospital1 **], Digitek 125 mcg qd, Diovan 40 qd, KCL, Lasix 40 qd, Lovastatin 40 qd, Paxil 20 qd, Nitro prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: T 96.6, BP 112/58, HR 66, RR 20, SAT 97% on room air General: Well developed man, no distress Eyes: PERRL, pink conjunctivae, no xanthelasma ENT: MMM without pallor or cyanosis Neck: Normal carotid upstrokes, no carotid bruits, no jugular venous distention, no goiter Lungs: Clear, normal effort Heart: RRR, normal S1 and S2, no m/r/g, lateral PMI, precordium quiet Abd: Soft, NTND, NABS, no organomegaly, normal aorta without bruit Msk: Normal muscle strength and tone, normal gait and station, no scoliosis or kyphosis Ext: No c/c/e, normal femoral and absent pedal pulses Skin: No ulcers, xanthomas or skin changes due to arterial or venous insufficiency Neuro: A and O to self, place and time, appropriate mood and affect FAMILY HISTORY: Denies premature coronary artery disease. SOCIAL HISTORY: Former smoker, 50 pack year history of tobacco. Former heavy alcohol abuse, none since [**2198**]. He is a former carpenter and Marine Corp Veteran. Lives in [**State 4565**] and is here visiting for the summer. Currently living with his daughter.

CHIEF COMPLAINT: Fall with trauma to back Loss of strength in both legs. PRESENT ILLNESS: Sudden loss of sensation and strength in both legs following trauma and fall. MEDICAL HISTORY: History of lumbar discectomy History of spinal cord trauma with paraplegia in [**2100**] MEDICATION ON ADMISSION: ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: 0/5 in bilateral hip abductors, iliopsoas, quadriceps, hamstrings, [**Last Name (un) 938**], TA, FHL Sensations absent below T10. Reflexes absent. Blbocavernous reflex absent. FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Blocked picc line and fever PRESENT ILLNESS: HPI: The patient is a 52 year old female with a history of Crohn's disease and multiple abdominal surgeries, now with short gut syndrome on chronic TPN. The patient also has a history of difficulty with chronic venous access. She reports that for the past few weeks, she has noted that one of the lumens of her PICC is "clogged." Earlier today, the patient went to [**Hospital **] Hospital for further evaluation. The patient states that she was informed that the other lumen of her PICC was "blocked." The patient has undergone previous recanalization of her veins by IR in the past, so she was transferred to the [**Hospital1 18**] ED. On presentation, she was noted to have a SBP in the 60s. She reported having a T=104 at home earlier in the day. She also reported feeling "weak" over the past few days. Multiple attempts were made to obtain L subclavian access, yet these attempts were unsuccessful, so a L femoral line was placed and the patient was given aggressive IVFs (5 L total in ED). She was also placed on Levophed. Her BPs improved to 90s/50s. Of note, the patient states that her baseline SBP is around 90. The patient's labs were notable for a leukocytosis and a positive UA. The patient was administered doses of Vanco, Levo, and Flagyl. She has been transferred to the [**Hospital Unit Name 153**] for further management. MEDICAL HISTORY: PMH: Crohn's disease Sarcoidosis Avascular necrosis of the R hip, complicated by chronic pain TPN dependent S/p C-section X 2 S/p hysterectomy, oopherectomy, and lysis of adhesions, which was complicated by colon perforation ([**2120**]) S/p multiple abdominal surgeries (18 in total), including a colostomy in [**2125**], after which she developed a fistulous tract Depression Anxiety HTN "Irregular heart beat" H/o SVC occlusion secondary to chronic central access, s/p superior vena cava recanalization by IR ([**4-10**]) Chronic diarrhea . ALL: Remicade-> anaphylaxis MEDICATION ON ADMISSION: OUTPT MEDS: BusPIRone 30 mg PO TID Clopidogrel Bisulfate 75 mg PO Metoclopramide 10 mg PO QIDACHS Diphenoxylate-Atropine 4 TAB PO QID Ferrous Sulfate 325 mg PO BID Oxycodone 30 mg PO Q8H:PRN Fluoxetine HCl 40 mg PO BID Pantoprazole 40 mg PO TID Promethazine HCl 25 mg PO Q6H:PRN Loperamide HCl 2 mg PO TID ALLERGIES: Remicade PHYSICAL EXAM: [**Hospital Unit Name 25564**] NOTE . CC:[**CC Contact Info 25565**]. HPI: The patient is a 52 year old female with a history of Crohn's disease and multiple abdominal surgeries, now with short gut syndrome on chronic TPN. The patient also has a history of difficulty with chronic venous access. She reports that for the past few weeks, she has noted that one of the lumens of her PICC is "clogged." Earlier today, the patient went to [**Hospital **] Hospital for further evaluation. The patient states that she was informed that the other lumen of her PICC was "blocked." The patient has undergone previous recanalization of her veins by IR in the past, so she was transferred to the [**Hospital1 18**] ED. On presentation, she was noted to have a SBP in the 60s. She reported having a T=104 at home earlier in the day. She also reported feeling "weak" over the past few days. Multiple attempts were made to obtain L subclavian access, yet these attempts were unsuccessful, so a L femoral line was placed and the patient was given aggressive IVFs (5 L total in ED). She was also placed on Levophed. Her BPs improved to 90s/50s. Of note, the patient states that her baseline SBP is around 90. The patient's labs were notable for a leukocytosis and a positive UA. The patient was administered doses of Vanco, Levo, and Flagyl. She has been transferred to the [**Hospital Unit Name 153**] for further management. . PMH: Crohn's disease Sarcoidosis Avascular necrosis of the R hip, complicated by chronic pain TPN dependent S/p C-section X 2 S/p hysterectomy, oopherectomy, and lysis of adhesions, which was complicated by colon perforation ([**2120**]) S/p multiple abdominal surgeries (18 in total), including a colostomy in [**2125**], after which she developed a fistulous tract Depression Anxiety HTN "Irregular heart beat" H/o SVC occlusion secondary to chronic central access, s/p superior vena cava recanalization by IR ([**4-10**]) Chronic diarrhea . ALL: Remicade-> anaphylaxis . OUTPT MEDS: BusPIRone 30 mg PO TID Clopidogrel Bisulfate 75 mg PO Metoclopramide 10 mg PO QIDACHS Diphenoxylate-Atropine 4 TAB PO QID Ferrous Sulfate 325 mg PO BID Oxycodone 30 mg PO Q8H:PRN Fluoxetine HCl 40 mg PO BID Pantoprazole 40 mg PO TID Promethazine HCl 25 mg PO Q6H:PRN Loperamide HCl 2 mg PO TID . SH: The patinet lives with her ex-husband. She has 2 sons. She is not working at this time. She denies use of tobacco or illicit drugs. She notes occasional ETOH use. . FH: N/C . ROS: The patient notes a low grade temp yesterday, and she states that she had a temp = 104 earlier today. She denies any chills, cough, rhinorrhea, SOB, CP, abd pain, rash, or change in her bowel/bladder habits. She reports that she has chronic diarrhea. She has felt "weak" for the past few days. . PHYSICAL EXAMINATION: Gen: Patient is lying in bed in NAD. VS: 97.1 100/54 with MAP 70 (on Levophed 0.05) 84 17 100% RA Heent: NC/AT. PERRL. EOMI. MMM. OP clear. Cards: RRR. S1, S2. No m/r/g. Lungs: CTAB. Abd: Soft, NT. Patient has a ventral hernia. She has multiple scars from previous abdominal surgeries, including a skin graft. Ext: No c/c/e. Warm. PICC site in R arm w/o erythema or tenderness. L femoral line in place. Skin: No rashes. . LABORATORY DATA: . [**2135-1-22**] 12:21a . Venous gas pH 7.26 pCO2 60 pO2 42 HCO3 28 BaseXS -1 Type:Mix Lactate:1.0 O2Sat: 71 . [**2135-1-21**] 10:26p Lactate:1.1 . [**2135-1-21**] 10:25p . 131 95 21 87 AGap=14 3.7 26 0.8 . Color Yellow Appear Clear SpecGr 1.015 pH 5.0 Urobil Neg Bili Neg Leuk Sm Bld Tr Nitr Neg Prot Neg Glu Neg Ket Tr RBC 0-2 WBC [**7-16**] Bact Many Yeast None Epi 0 . [**2135-1-21**] 9:22p Lactate:2.1 . [**2135-1-21**] 9:15p 129 94 21 86 AGap=15 3.8 24 0.9 . 95 21.4 9.8 271 28.5 N:92.6 Band:0 L:3.8 M:3.0 E:0.3 Bas:0.3 . PT: 12.5 PTT: 28.0 INR: 1.0 . RADIOLOGY DATA: CXR: ? retrocardiac opacity. . A/P: The patient is a 52 year old female with a h/o Crohn's disease and multiple abdominal surgeries, with short gut syndrome and chronic venous access issues. She has been admitted to the [**Hospital Unit Name 153**] for management of sepsis. . #Sepsis: Likely due to line infection, though there is also the possibility of an early LLL pneumonia. Patient cites a h/o chronic diarrhea, but would also consider possibility of C diff colitis. Will continue empiric coverage with Vanco, Flagyl, and Levaquin and f/u blood cx data. Will also obtain fungal cx given h/o chronic TPN use and risk of fungemia. At present, pt's hypotension is responding to IVF resuscitation, so will wean Levophed with goal to keep SBP>90 (pt's baseline) and UO>30 cc/hr. , #Access: Pt currently has L femoral line due to difficulty obtaining L subclavian vein access. Will need to contact IR re: venous access issues. PICC will need to be removed and tip sent for culture. , #Chronic diarrhea: Will send sample for C diff, though suspect her diarrhea is related to her short gut syndrome. Will continue patient's antidiarrheal medications. Patient is on empiric Flagyl. . #Anxiety/depression: Will continue outpt Psych meds. . #Chronic pain: Confirmed pain medication dosages with patient. Will continue her methadone and oxycodone. . #Anemia: Patient has h/o anemia with baselne HCT 26-29 w/ MCV 95. Anemia likely related to her chronic illness, but possible nutritional deficiency. Will continue Fe supplement. Will check B12/folate levels. . #Metabolic acidosis: VBG notable for CO2=60, possibly related to pt's somnolence. Will obtain repeat VBG. . #Prophylaxis: PPI and SQ Heparin. . #Dispo: ICU. . #Code status: Full. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] pager [**Numeric Identifier 25566**] FAMILY HISTORY: FH: Noncontributory SOCIAL HISTORY: SH: The patinet lives with her ex-husband. She has 2 sons. She is not working at this time. She denies use of tobacco or illicit drugs. She notes occasional ETOH use.

CHIEF COMPLAINT: fevers, headache, diarrhea, hypoxia PRESENT ILLNESS: The paitent is a 43-year-old male with a longstanding history of HIV/AIDS who presented to the ED after a week long history of high grade fevers and worseing dyspnea with exertion. The patient was diagnosed in [**2095**] with HIV and has been on and off HAART therapy since that time. Most recently, he was on steady treatment for 3 years until this spring when he decided to take a self decided medication holiday. He reports he has not taken HAART medications in about 6 months. About 2-3 months ago the patient also started having watery diarrhea intermittently [**2-18**] times weekly. About one and a half weeks ago, he started noticing high fevers and night sweats. The diarrhea worsened and instead of having it on and off, it became constant. The fevers also continued to worsen and peaked at a temp of 103.6 today, the morning of his admission. Two days prior to admission he started noticing shortness of breath with simple tasks such s climbing a few stairs at home. He also describes a non-productive dry cough and some chest "tightness" associated with this increased work of breathing. He could barely walk from the kitchen back and forth to the couch due to his dyspnea. He has also noticed daily headaches. He denies neck stiffness/rigidity, photophobia or any new skin rashes. He describes some mild blurry vision when he would try to focus on [**Location (un) 1131**] but this would subside after a minute or so. He now complains of diffuse weakness and lightheadedness today. He denies any syncope. Of note, he has lost about 25 pounds over the last couple months which he attributes to a decreased appetite and his diarrhea issues. . In the ED, initial vitals were T 99.4, BP 97/56, P 98, R 22, 85% on RA with only a slight improvement to 91% on 2L. The patient received 1000 mg IV Vancomycin, 750 mg PO Levofloxacin, and 40 mg oral [**Location (un) 2768**]. He was ordered for Pentamidine 225 mg but did not receive it in the ED. An ABG was done and showed a low pO2 of 72. CXR showed multiple small patchy opacities bilaterally which were immediately concerning for PCP. . On the floor, the patient continued to feel short of breath. He was eventually comfortable on [**4-21**] L NC O2 but noticed he got very winded walking to and from the bathroom. He denied any nausea, vomiting. No abdominal pain. No diarrhea on day of admission. He still felt weak "all over" and had diffuse muscle aches. No headaches on arrival to floor. The patient had an acute exacerbation of his shortness of breath with associated tachypnea and tachycardia soon after admission to the medical floor. This acute episode of respiratory distress was soon after an induced sputum sample and thus, likely due to associated bronchospasms. The patient was hypoxic on labs and was therefore transferred to the MICU for a brief one day stay in order to watch his airway closely while he improved. Fortunately, he improved significantly following nebulizer treatments and high flow supplemental oxygen. He did not require any intubations. He was transferred back to the general medical floor once he was more hemodynamically stable and breathing comfortably on 4L oxygen via nasal cannula with oxygen saturations >95% consistently. MEDICAL HISTORY: HIV/AIDS anemia HSV Depression, ? Bipolar disorder HPV h/o PCP h/o recurrent aphthous ulcers h/o oral candidiasis h/o esophageal ulcer h/o zoster h/o molluscum MEDICATION ON ADMISSION: Reyataz - 300 mg, 1 tab daily Norvir - 100 mg, 1 tab daily Truvada 200/300 mg tab, 1 tab daily Dapsone - 100 mg, 1 tab daily Oxandrin - unknown strength - 1 tab as needed ALLERGIES: Penicillins / Bactrim / Baclofen PHYSICAL EXAM: VS: T99.5 HR 80 BP 101/59 RR 18 93% 4L NC Gen: Alert and orieted to person/time/place. He is mildly winded speaking in full sentences, no acute distress, no accessory muscle use noted HEENT: NC/AT, PERRLA, EOMI, scattered yellowish, thick patches over posterior tongue consistent with oral candidiasis, no tonsillar exudates Neck: supple, no lymphadenopathy, 2+ carotid upstrokes, JVD 3-4cm CV: S1/S2 regular, no murmurs/rubs/gallops noted. No S3/S4. Lungs: Diffuse crackles at the right base, bilateral rhonchi noted anteriorly across right and left apices and posteriorly at mid-lung fields. Abd: Soft, NT/ND, normoactive bowel sounds, no HSM. Ext: warm, no edema, DP and PT pedal pulses 2+ bilaterally, no cyanotic features Skin: no rashes, no bruising FAMILY HISTORY: Noncontributory SOCIAL HISTORY: He lives alone in [**Location (un) 686**] MA. He works as an indoor/outdoor painter and has been functioning well until about one week prior to this admission when he really started feeling poorly. Currently smokes about a pack per day, no recent ETOH use, no recent drug use; has used cocaine in the distant past, denies IVDU history.

CHIEF COMPLAINT: "I have been running a fever and I was not feeling well, then my left face started drooping." PRESENT ILLNESS: Patient is a 62 yo L handed man with a history of SAH in [**Month (only) 404**], aortic valve stenosis s/p mechanical AVR (complicated by subsequent new Afib) who presented to our hospital on [**2142-8-11**] complaining of fever and generalized malaise. Patient was in his usual state of health until [**2142-8-10**] when he noticed that he was not feeling well. Specifically, the patient noticed that he had a decreased appetite, fever, and felt fatigued with a generalized malaise. His symptoms continued through the night, and on the morning of admission ([**8-11**]) he woke with severe frontal headache with chills and fever of 101.6F (measured at home); he was not experiencing nausea, vomiting, abdominal pain, or chest pain. Throughout the day, his symptoms progressed and he eventually realized that he was having difficulty using swipe text (w/ his Left hand) on his smart phone. Specifically, he was leaving his finger on letters for a prolonged period of time without fluid swiping and he was also missing and incorrectly dialing many letters. His visual field, vision and comprehension were all intact; however he felt that his L hand was slow and responsible for the newfound deficit. Furthermore, patient reports that he and his wife noticed that while he was drinking from a soda can, he would set the can on its side rather than upright. Lastly, the patient noticed that he was having difficulty putting his pants on because his left leg felt clumsy and weak. In the ED he had a CT which showed a small intraparenchymal bleed in the right frontal opercular cortex. He got ceftriaxone, acyclovir and vancomycin for empiric meningitis treatment. Patient denies photophobia or new/worsening neck stiffness. He was admitted to Neurology for further care. With regard to the left superior frontal SAH in [**Month (only) 404**], the patient had been on coumadin and aspirin. He was managed conservatively on the neurosurgery service. His angiogram did no show any source of his bleeding. His aspirin was stopped but coumadin was continued with a lowered goal of INR 2-2.5 (previous goal was 2.5-3.5). On neuro ROS, the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. Denies difficulty with gait. On general review of systems, the pt denies recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Denies rash. +Recently endorses palpitations MEDICAL HISTORY: - Aortic Stenosis: Congenital aortic stenosis s/p Open valvulplasty [**2091**] and Bentall [**2132**] - Aortic pseudoaneurysm s/p Redo Sternotomy/Bentall/Prox.Arch repl. (homograft to Gelweave)) [**2132**] (Dr. [**Last Name (STitle) 1290**] - Ascending aortic aneurysm - Benign prostatic hypertrophy - Erectile dysfunction - Hypertension - Vasectomy MEDICATION ON ADMISSION: Metoprolol ER 200mg daily Coumadin 5mg 5 days a week and 2.5mg two days a week Enoxaparin 70 mg every 12 hours ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: PHYSICAL EXAM (on admission to Neurology): Vitals: T100.3 BP 83-164/47-80 HR 67-109, RR 18-20 98% on RA General: Awake, cooperative, NAD, constricted and flattened affect HEENT: NC/AT, No [**Doctor Last Name **] spots on exam Neck: Supple, No nuchal rigidity, mildly painful Pulmonary: CTABL Cardiac: Irregular rate and rhythm, systolic murmur; No [**Last Name (un) **] lesions or osler's nodes Extremities: no edema Skin: no rashes or lesions noted FAMILY HISTORY: Sister with valvular disease SOCIAL HISTORY: Lives with: Wife Occupation: [**Name2 (NI) **] works for a federal agency that performs audits and financial analyses of federal contractors. Cigarettes: Smoked no [] yes [X] Hx: Quit [**2132**] ETOH: < 1 drink/week [X] Illicit drug use: None

CHIEF COMPLAINT: Abdominal Pain PRESENT ILLNESS: 70 yo female with a past history of DM, CHF, PVD, CAD s/p CABG who p/w abd pain on [**4-27**] to [**Location (un) 1459**]. She presented to [**Hospital1 18**] as a transfer for further management of acute pancreatitis. On presentation at the OSH patient was found to have an elevated lipase 14,510 and amylase 4290 with a CT abdomen consistent with pancreatitis. She does not have a history of abominal pain on pancreatitis. Ultrasound confirmed the presence of gallstones and there was some mild CBD dilitation. She was managed supportively with pain medication, IVFs and TPN. Fluid resusication was complicated by thirdspacing and new pleural effusions on CXR. On [**4-30**], patient developed bradycardia, so she received epi/atropine/calcium with compressions, and was intubated and transferred to the ICU. EKG showed transient lateral STDs which improved without intervention, and enzymes remained flat. The following day she was started on vanco/clinda and later cipro for presumed aspiration pneumonia. CXR showed volume overloaded, so she was diuresed and extubated on [**5-2**]. She was transitioned to bipap. Amylase, lipase and LFTs normalized on [**5-3**]. A repeat CT scan was performed on [**5-3**] to evaluate for pseudocyst given rising WBC and fevers to 102.2, but this was negative. patient had some anemia with a nadir hct of 24.9 and received 2 u PRBC. Patient also developed [**Last Name (un) **] while in the hospital, but this improved to 1.2 prior to transfer, which was felt to be secondary to ATN per renal consultation. In addition to renal, surgery, GI and critical care were involved with the patient's care. . On transfer, patient is sedated but responds to verbal stimuli. She is denying abdominal pain. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. MEDICAL HISTORY: -uncontrolled DM c/b retinopathy, nephropathy, neuropathy-refuses insulin -CAD s/p MI and s/p CABG 2-3yrs ago; [**2167**] persantine stress showed no large WMAs -CHF (borderline LVEF, mod diastolic dysfxn) with mult exacerbations -CKD [**3-9**] DM (Baseline Cr=2.0) -Legally blind -COPD -Gout -PVD -HTN -HL -severe OA -Hemorrhoids -h/o tubular villous adenoma on [**2-/2167**] [**Last Name (un) **] -s/p hip replacement MEDICATION ON ADMISSION: 1. Januvia 100mg daily 2. Amlodipine 5mg daily 3. Isosorbide Mononitrate ER 60mg daily 4. Furosemide 80mg daily alt with 60mg daily 5. Carvedlil 25mg [**Hospital1 **] 6. Captopril 25mg TID 7. Glizide 10mg [**Hospital1 **] 8. Simvastatin 80mg QHS 9. Citalopram 20mg daily 10. Allopurinol 100mg daily 11. Colchicine 0.6mg PRN gout 12. Tramadol prn gout pain 13. Omeprazole 20mg daily 14. Miralax prn ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) PHYSICAL EXAM: Admission Exam: Vitals: T: 99.5 BP: 135/51 P: 74 R: 31 O2: 97% bipap 15/5 FiO2 0.5 General: arouses to verbal stimuli and follows general commands HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: rhonchi bilaterally louder on expiration CV: Regular rate and rhythm, 3/6 SEM, normal S1 + S2, no rubs or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ LE edema, warm, well perfused, 2+ pulses, no clubbing, cyanosis FAMILY HISTORY: DM, HTN SOCIAL HISTORY: Single, support from brother and his children, no tobacco or EtOH

CHIEF COMPLAINT: transfer from OSH for further oncologic workup PRESENT ILLNESS: 42 y/o male with a 30+ pk year smoking history who was transferred from [**Hospital6 3105**] and admitted to the thoracic surgery service on [**2132-1-9**] for evaluation of a 3-4 cm mass at the GE junction. . He first noted symptoms in late [**2131-11-6**] including mid-epigastric pain, heartburn, dysphagia and weight loss. He established care with a Gastroenterologist, Dr. [**Last Name (STitle) 21448**] affiliated with [**Hospital6 3105**] (LGH) and was treated for H. pylori. His symptoms however progressed and in [**Month (only) 1096**] he started having nausea/vomiting initially only to solids and then with liquids. The vomiting was essentially immediate upon eating. During this time he also developed heavy sweats during the day and night. He estimates he has lost 15-25 lbs over the last months. Due to severe pain and inability to tolerate PO, he presented to the ED at LGH and was admitted for dehydration and further work-up. . CT abd/pelvis [**2132-1-7**] revealed a 3.8 X 5.0 cm soft tissue mass at GE junction as well as diffuse soft tissue deposits and adrenal nodules. The following day, [**2132-1-8**] he underwent EGD and biopsy of the mass from OSH reports low grade adenocarcinoma. He was transferred to [**Hospital1 18**] on [**2132-1-9**]. MEDICAL HISTORY: PAST MEDICAL HISTORY: - metastatic cancer, as above - R knee arthroplasty ([**2122**]) MEDICATION ON ADMISSION: - Nicotine patch - Protonix 40 mg PO bid ALLERGIES: Heparin Agents PHYSICAL EXAM: Vitals - T 98.6 HR 90 BP 110/73 RR 18 O2 97%RA GENERAL: NAD, well appearing SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: Patient with midline incision posterior occipital area c/d/i, orpharynx wnl, multiple palpab lymph nodes that are hard in the neck bilaterally, large supraclavicular nodule slightly erythematous, indurated and nontender to the touch CARDIAC: RRR, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly, G tube without erythmea or surrounding excoriation M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, mild ptosis on L side no visual field defects noted, finger to nose and heel to shin normal bilaterally, no difficulty with rapid alternating movements, strength 5/5 in upper and lower extremities, DTR's [**2-9**] in b/l biceps, [**2-9**] b/l patellar, babinskis negative, no sensation abnormalities detected, gait deffered FAMILY HISTORY: Father - Deceased from an MI in his 80s. Mother - Deceased of unknown causes in her 60s, unexpected death. Brother - testicular cancer Not aware of any other history of malignancy in his family. SOCIAL HISTORY: Born and raised in the area. Works as a bus driver for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Lives with his girlfriend [**Name (NI) **]. [**Name2 (NI) **] children. Notes that his HCP is his brother and the alternate is his sister-in-law; believes he gave documentation to the primary team. + Tobacco 30 pk yrs, quit 6 weeks ago, + ETOH [**1-8**] times/wk, no IVDA

CHIEF COMPLAINT: mild dyspnea on exertion PRESENT ILLNESS: Ms. [**Known lastname 105066**] is a 57 year-old woman with known mitral valve regurgitation and mitral valve prolapse which has been followed by serial echocardiograms for several decades. Her most recent echocardiogram revealed an increased diastolic dimension and a subsequent MRI showed an effective forward EF of 46%. She was referred for surgical correction of this pathology. MEDICAL HISTORY: mitral valve prolapse mitral valve regurgitation atrial tachycardia hyperthyroidism thyroid cancer depression vitiligo s/p thyroidectomy s/p c-section s/p tonsillectomy MEDICATION ON ADMISSION: levoxyl 100 (except 50 on Sunday) zoloft 75 calcium 400 amoxicillin prn for dental procedures ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: At the time of discharge Ms. [**Known lastname 105066**] was awake, alert, and oriented. Her lungs were clear to auscultation bilaterally. Her heart was of regular rate and rhythm. Her sternum was noted to be stable and her mediastinal incision was clean, dry, and intact. Her abdomen was soft, non-tender, and non-distended. Her extremities were warm and she had trace edema. FAMILY HISTORY: Ms. [**Known lastname 105067**] father underwent a coronary artery bypass grafting at age 60. SOCIAL HISTORY: Ms. [**Known lastname 105066**] is a school secretary. She is married and has ten children.

CHIEF COMPLAINT: Abdominal pain, diarrhea PRESENT ILLNESS: 68 y/o male with past medical history significant for COPD, PE, hypertension who presents with sudden onset abdominal pain and diarrhea. Patient reports recent bronchitis flare treated with azithromycin and then levofloxacin approx 2 weeks ago. Patient state yesterday 4 hours after eating a restaurant salad dinner, he got sudden onset abdominal pain that brought him to [**Location (un) 620**] [**Hospital1 18**] ED. In this setting he was standing by the side of the wall and suddenly "want black" and landed on his behind on the floor. Patient denies LOC. Patient denies head trauma. Patient was noted to be in Aflutter and was cardioverted *2 with no success. At [**Location (un) 620**] patient reports filling 3 toilet bowels full of liquid diarrhea. And [**Location (un) 620**] notes NGT with brown fluid returning. Patient was given levo/flagyl/vanco and sent to [**Hospital1 18**] ER on levophed due to low pressures. Patient received 7 liters of fluid Upon transfer to [**Hospital1 18**] ER patient on levophed w pressures to the 100s-130s, tachy to the 140s, satting well all the time. chest x ray neg, urine neg, abdominal CTA no mesenteric ischemia. WBC 35; redosed on flagyl. Noted to have INR of 6.0. Got two units of FFP. Lactate from 4 to 1 with fluids. The patient was transferred to the ICU. MEDICAL HISTORY: 1. Atrial fibrillation/flutter diagnosed in [**2128**] on coumadin 2. PE in the setting of knee surgery. 3. Hypertension. 4. COPD. 5. Dyslipidemia. 6. BPH. 7. Hypercholesterolemia 8. s/p L TKR on [**2-7**] MEDICATION ON ADMISSION: Aspirin 81MG Tablet daily Atorvastatin 10 mg Tablet daily Desloratadine 5mg daily Diltiazem240 mg SR daily Finasteride 5 mg Tablet daily Fluocinolone 0.025 % Cream Advair Diskus 500 mcg-50 mcg 1puff [**Hospital1 **] Folic Acid 1 mg Tablet daily Hydrochlorothiazide 25mg daily DuoNeb prn Lisinopril 5 mg Tablet daily Mom[**Name (NI) 6474**] 50mch 2puffs daily Prilosec 20 mg [**Hospital1 **] Sildenafil [Viagra] 50 mg Tablet prn Flomax 0.4 mg daily Spiriva 18 mcg Warfarin 8 mg Tablet daily Zolpidem [Ambien CR] 12.5 mg Tablet, Multiphasic Release 1 Tablet(s) by mouth q.h.s. p.r.n. ALLERGIES: Percocet / Sulfonamides / Vicodin PHYSICAL EXAM: General Appearance: Well nourished, No acute distress FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death. SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse.

CHIEF COMPLAINT: Transfered from OSH for Aspiration PNA and gastric outlet obstruction [**1-11**] migrated gastric band. PRESENT ILLNESS: The pt. is a 38 year-old mle with significant h/o Myoclonus Opsoclonus on chronic ACTH and h/o of Lap. gastric banding in [**2122**], who initially presented to OSH with long h/o N/V since [**Month (only) 1096**]. Per his mother, since [**11-13**], patient has had cough, weakness, lethargy and multiple episodes of vomitting "brownish liquid". He was initially treated a month ago for community acquired pneumonia from [**Date range (1) 43171**] with levo. He finished a course of abx, but symptoms did not resolve, and he presented to [**Hospital 1562**] Hosp. on [**12-28**]. At that time he was found to have miliary pattern of infiltrate on CXR. Given his chronic steroid use and risk of immunocompromise, the patient was started on broad spectrum abx, as well as antiPCP and CMV coverage. Was taken for bronch on [**12-29**], that noted friable Right bronch. c/w asiration. Post bronch, noted to be hypoxic; CXR noted right PTX with right chest tube insertion. Was started on broad spectrum abx including PCP coverage, [**Name9 (PRE) 54460**], [**Name9 (PRE) **] and CMV. On [**12-29**], on review of rads data, was noted to have large gastric/esoph. distension c/w gastric outlet obstruction [**1-11**] to migrated gastric band. Attepmts were made by surgery and IR at OSH to relieve gastric band without success. Was arrange to be transfered to [**Hospital1 18**] for further intervention. Was intubated for airway protection on [**12-30**] for transfer to [**Hospital1 18**]. Planned to go to OR [**12-31**]. MEDICAL HISTORY: Myoclonus. Opsoclonus [**3-/2123**] Lap Gastric Banding MEDICATION ON ADMISSION: Medications at OSH: Cosyntropin 0.2mg po qd hydrocortisone 50mg q12 Lovenox 40mg qd PPI Fluconazole 200mg po qd Levo 500mg qd Ganclyclovir 380mg q12 Bactrim q8 Cefepine 2gm iv q8 RISS/klonopin/baclofen/lasix/triamterene ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: T:98.5 P:75 R:14 BP:101/64 SaO2: AC 650/14/5/ 60% 7.37/42/82 General: intubated and sedated; HEENT: no scleral icterus noted, MMdry , no lesions noted in OP FAMILY HISTORY: SOCIAL HISTORY: SH: lives indep. no tob/etoh/drugs . FH: Mother with HTN breats CA, PE father with [**Name (NI) 54461**] HTN: All siblings healthy

CHIEF COMPLAINT: Respiratory failure, blast crisis PRESENT ILLNESS: 72M h/o Non-Hodgkin's lymphoma, secondary AML (M4) (transfusion dependent), transferred to [**Hospital1 18**] ED from [**Hospital1 1474**] after developing hypotension, fever and respiratory distress after transfusion. . After receiving a blood transfusion on the day of admission, pt developed dyspnea (88% on 4L NC), chills and diaphoresis, with T 100.1, and creatinine 3.9 from 1.8 earlier in [**Month (only) 958**]. Pt was transferred to the [**Hospital1 1474**] ED where he was found to be tachycardic, febrile to T 103, increasingly dyspneic, and vomiting. Pt underwent elective intubated, after which he was transferred to the [**Hospital1 18**] ED. En route, patient became hypotensive despite 1.5 L NS bolus, and phenylephrine was started. . Prior to admission, pt had been recently treated for a sinus infection with levofloxacin and amoxicillin/clavulanate. . [**Hospital1 18**] ED course: # VS: T 101.8, HR 130, BP 78/40, ventilated, O2 sat 10O%. # Meds: Vancomycin, ceftazidime, diphenhydramine 50 mg IV x1, acetaminophen. # Notable labs: WBC 73.2 (blasts 26%), Cr 3.9, Na 132., LDH 1001, uric acid 15.8. MEDICAL HISTORY: # Non-Hodgkin's lymphoma ([**2097**]), s/p fludarabine x 6 ([**2102**]), rituximab [**11-8**] # Acute myelogenous leukemia (M4), diagnosed [**5-/2106**] --[**10/2106**]: Splenic radiation (2500cGy) --12/10-18/07: Decitabine x4 c/b persistent cytopenias MEDICATION ON ADMISSION: # Epoetin alfa weekly # HCTZ 25mg daily # Dutasteride (Avodart) 0.5mg daily # Tamsulosin (Flomax) 0.4mg daily # Esomeprazole 40mg daily # Glipizide 10mg daily # Insulin # Vit D/Calcium # Vitamin C # Cyclosporine ophthalmic emulsion (Restasis) # Bupropion (Wellbutrin) 100mg # Eszopiclone (Lunesta) 2mg daily # Gabapentin 600mg daily # Acetaminophen PRN # Celecoxib (Celebrex) 200mg # Oxycodone PRN ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T 100.1, P 121, BP 85/95, SaO2 99% on vent A/C 550/22/5/100% General: Sedated, intubated, NAD HEENT: NCAT, small pupils, slow reaction to light bilaterally Neck: Left IJ. JVP not noted Chest: B rhonchi anteriorly Cardiac: RRR, S1S2, holosytolic murmur heard throughout precordium, best at RUSB Abdomen: Soft, NT/ND, BS+ Extremities: 1+ BLE edema Skin: No rashes or lesions noted Neurologic: Sedated FAMILY HISTORY: # Mother, died: GI malignancy # Father, died 60s: Alcohol-related complications SOCIAL HISTORY: # Personal: Lives in [**Location 1475**], [**State 350**], with wife # Professional: Retired elementary school principal # Tobacco: Past, quit [**2059**] # Alcohol: Social

CHIEF COMPLAINT: swallowed glass PRESENT ILLNESS: Pt is a 24 y.o female with extensive psych history including aspergers, schizoaffective d/o, bipolar who was transferred from [**Hospital3 3583**] for further management after recently swallowing glass. Per pt, she swallowed 2 pieces of glass from an unleaded window frame last Thursday ([**12-19**] dollar size, about 2-3 cm), unclear if ever passed, reports she had RLQ sharp pain at that time. She states that this was intentional but review of OSH records states that voices told her to do this. Unclear if any work-up was done but apparently she was discharged to [**Location (un) 22870**]. At 3pm today, she swallowed another [**12-19**] dollar size glass (leaded window glass). She denies any dysphagia, odynophagia, or N/V, diarrhea, bloody stools/melena, reports +flatus. She reports sharp LUQ pain since 1600 today. She denies SI/HI and reports that she ate the glass b/c she was impulsive. She was brought to [**Hospital3 3583**] but then transferred to [**Hospital1 18**] for endoscopy. . In the ED, initial vs Time Pain Temp HR BP RR Pox 19:59 5 98.3 87 118/77 16 100. GI was consulted, KUB and CXR performed, showing ?foreign object in the stomach. . On the floor,pt reports [**4-26**] sharp abdominal pain but denies other ROS. MEDICAL HISTORY: Asbergers Disorder Schizoaffective disorder Bipolar disorder Epilepsy Urinary incontinence Asthma GERD Hypothyroidism MEDICATION ON ADMISSION: Medications: Haldol 2mg PO BID Prilosec 20mg PO daily Ativan 2mg PO QHS Colace 100mg PO QHS Topamax 100mg PO BID Famotidine 40mg PO daily Calcium and vitamin D 600mg PO BID Prozac 20mg PO daily Vesicare 5mg PO daily Strattera 80mg PO daily Azithromycin 250mg PO daily x 5d Lactaid Multivitamin ALLERGIES: No Drug Allergy Information on File PHYSICAL EXAM: Vitals: T. 97.8, BP 104/65, HR 74, RR 15 sat 100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: b/l ae +bibasilar crackles. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: CN2-12 intact, pupils asymmetric R>l . FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Lives at group home. No tobacco, ETOH, IVDA. Parents are deceased.

CHIEF COMPLAINT: left sided weakness PRESENT ILLNESS: 54 yo F weakness on left x1 week now with significant left weakness and multiple falls over 2-3 days. CT head shows large right chronic SDH with considerable mass effect and significant MLS. Pt notes that the past week she has had difficulty with concentration. No Nausea or vomiting. MEDICAL HISTORY: -HTN -Depression: Multiple hospitalizations at [**Doctor First Name 1191**] in [**2110**], [**2112**], [**2113**] and did an outpatient program for several weeks at [**Doctor First Name **] in [**2128**]. Reports just being hospitalized in [**3-4**]. -Parathyroid adenoma s/p resection [**2134-3-1**] -Breast CA IIB/p mastectomy [**1-2**] s/p chemoXRT -HL -DMII -Hypothyroidism -Ideopathic cardiomyopathy, EF 50%, mild MR - H/o Left Bundle Branch Block MEDICATION ON ADMISSION: ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth once a day - No Substitution BREAST PROSTHESIS RIGHT - - use as needed daily LEVOTHYROXINE [LEVOTHROID] - 125 mcg Tablet - 1 (One) Tablet(s) by mouth once a day LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth three times a day for anxiety MASTECTOMY BRA - - wear as needed daily METFORMIN - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once a day at suppertime PERPHENAZINE - (Dose adjustment - no new Rx) - 4 mg Tablet - 1 Tablet(s) by mouth qday QUETIAPINE [SEROQUEL] - (Prescribed by Other Provider) - 300 mg Tablet - 1 Tablet(s) by mouth at bedtime SERTRALINE - (Dose adjustment - no new Rx) - 100 mg Tablet - 2 Tablet(s) by mouth daily SITAGLIPTIN [JANUVIA] - 50 mg Tablet - 1 Tablet(s) by mouth qday TRAZODONE - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 150 mg Tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - 8.6 mg Tablet - 3 Tablet(s) by mouth Senokot extra as needed ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Soybean / Xanax PHYSICAL EXAM: O: T:97.3 HR: 101 BP: 121/92 RR: 18 Sat: 98% RA Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic Neck: Supple. No midline tenderness Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, odd 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: Family history is negative for breast and ovarian cancer. Her mother is 81 and in good health with hypertension and elevated cholesterol, but still mows the lawn and shovel the driveway. Father is 82, has a history of a CVA and diverticulosis. She has two brothers, 44 and 46, who are alive and well. Her maternal grandmother died of stomach cancer at 55. SOCIAL HISTORY: No tobacco. Occasional EtOH. Increased stress due to divorce proceedings.

CHIEF COMPLAINT: L knee pain PRESENT ILLNESS: (Per Orthopedic Admission Note) Mr. [**Known lastname **] previously had a total knee replacement performed in [**2174**] by Dr. [**Last Name (STitle) 26181**]. This was revised due to loosening in [**2184**] by Dr. [**Last Name (STitle) 82679**]. He required an allograft prosthetic reconstruction. At that point in time, the allograft fractured following a fall. In addition, the [**Doctor Last Name 3549**] taper between the tibial component and the tibial stem has become disengaged and has been disengaged for several years. Mr. [**Known lastname **] presents with chronic pain and requires a revision. As pt presented for elective surgery other review of systems unremarkable and feeling well. MEDICAL HISTORY: aortic stenosis coronary artery disease hypertension hyperlipidemia benign prostatic hyperplasia s/p resection of left acoustic neuroma s/p left tibial rodding s/p bilateral total knee replacements revision of left knee bilateral cataract surgery bilateral carpal tunnel release tonsillectomy/adenoidectomy excision of left upper extremity lipoma MEDICATION ON ADMISSION: Metoprolol 25 mg twice a day, simvastatin 40 mg once a day, terazosin 5 mg once a day, aspirin 81 mg once a day, - Held for OR potassium 20 mg once a day, furosemide 40 mg once a day, Zantac 150 mg twice a day. ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: On Admission: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm FAMILY HISTORY: brother with MI, RHD father suffered MI SOCIAL HISTORY: retired lives with wife tobacco: quit 40 yrs ago EtOH: 1 drink per month

CHIEF COMPLAINT: Fever PRESENT ILLNESS: 89 yo F h/o alzheimers dementia, COPD, bipolar disorder who presents from her [**Female First Name (un) **]-psych facility with fever, tachycardia, tachypneic to the mid-20s. For the past few days has been somnolent at her facility, and was recently diagnosed with a UTI, and started nitrofurantoin. In speaking with her case manager, she has been feeling unwell for several days with stomach distension, increased leg swelling and redness of which lasix was started recently. Due to fever, tachycardia and cough this morning, the patient was transferred to [**Hospital1 18**] for further management. . In the ED, initial VS were: 101.2 96 117/60 18 98% 2L nc. c/o sob. BLE new swelling/erythematous and excoriations c/f cellulitis. Labs notable for Cr 1.7 (baseline around 1.0), lactate of 5.1 which improved to 2.0 with 3 liters NS. CT scan of abdomen showed no acute process. CXR: can't rule out PNA. Received 1 gram of tylenol, Vancomycin and zosyn. Access: 2 PIVs. VS prior to transfer 101.8 122 117/68 20 96% 2L . On arrival to the MICU, the patient states she is comfortable without pain or shortness of breath. She states she is in a hospital, but is not clear why she is here. She states she came from home. . Review of systems: unable to obtain accurate review MEDICAL HISTORY: Per the records, and health care proxy: Breast cancer, s/p mastectomy Alzheimer's dementia Bipolar Disorder Orthostatic Hypotension and Syncope COPD Osteoporosis Hyperlipidemia Bifascicular block Borderline Diabetes MEDICATION ON ADMISSION: Medications: Per [**Doctor First Name 1191**] [**Month (only) 16**] Citalopram 20 mg Once Daily docusate sodium 100 mg at bedtime donepezil 10 mg qhs MVI Omeprazole 20 mg daily Simvastatin 20 mg daily Gabapentin 100 mg TID Divalproex 125 mg [**Hospital1 **] (0900 and 1400) Divalproex 250 mg qhs Nitrofurantoin 100 mg [**Hospital1 **] Saliva Substitute 2 mL QID after meals and HS Fluocinolone acetonide [**Hospital1 **] Acetaminophen 650 daily Maalox q4H prn MgOH daily prn Quetiapine 12.5 mg q6h PRN and 25 mg q6H prn Albuterol prn bisacodyl 10 mg PRN Lasix 60 mg daily ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Vitals: T:99.8 BP: P:107 R: 23 O2: 97% General: Alert, oriented to person, no acute distress HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated 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: moving all extremeties FAMILY HISTORY: NC SOCIAL HISTORY: Previously sociology professor [**First Name (Titles) **] [**Last Name (Titles) 3278**], retired. Never married. No current tobacco. Occasional alcohol. Resident ot [**Last Name (un) 35689**] House in JP, due to recent aggressive behaviour, she was sectioned and staying at [**Hospital 1191**] Hospital