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CHIEF COMPLAINT: Acute onset nausea and vomiting PRESENT ILLNESS: The pt is a 77 y/o female transferred from Briarwod Nursing Facility recently discharged from [**Hospital 620**] Hosp for bilat DVTs on coumadin with an INR goal of [**1-23**]. Presents this am with 2-3 episodes of emesis with WBC 34K. In ED she became acutely hypotensive to 60/palp and tachy to 150s after IV contrast from CT scan. She was intubated, resuscitated, and transferred to [**Hospital1 18**] for further management. She was admitted to the surgical service under the care of Dr. [**Last Name (STitle) **]. MEDICAL HISTORY: Past Medical History: GERD Alzheimers-Dementia Bilat DVTs [**6-25**] H/O C.Diff [**7-26**] Spinal Stenosis Osteoporosis NIDDM HTN B/L LE Cellulitis MEDICATION ON ADMISSION: Coumadin Celexa Razadyne Fosamax ALLERGIES: Penicillins / Ivp Dye, Iodine Containing PHYSICAL EXAM: Upon admission: FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Transferred from [**Hospital3 16749**] Facility, she has a history of Dementia and Alzheimers.

CHIEF COMPLAINT: angina and palpitations PRESENT ILLNESS: 83 yo female presented to [**Hospital3 **] in [**5-17**] with angina and palpitations. Ruled out for MI with equivocal troponins. Echo showed worsening AS, and she was transferred here for a cath at that time. This revealed 3VD. Seen again in clinic [**6-28**] for surgical consultation. MEDICAL HISTORY: Aortic stenosis CAD elev. lipids HTN mild COPD mild memory impairment [**Last Name (un) **]. joint dz. mild PVD right shoulder pain panic attacks osteoporosis overactive bladder chronic low back pain cecal AVM with bleed [**7-16**] diverticulitis PSH; TAH, tomsillectomy;bil cataract [**Doctor First Name **] with IOLs, left knee [**Doctor First Name **] MEDICATION ON ADMISSION: lovastatin 20 mg daily omeprazole 20 mg daily ditropan 5 mg [**Hospital1 **] ECASA 81 mg daily toprol XL 25 mg daily lisinopril 20 mg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: 5'0" 150# HR 56 reg 116/76 NAD right thigh and calf ecchymotic PERRLA, EOMI, anicteric sclera, OP unremarkable neck supple, full ROM, no JVD CTAB RRR IV/VI SEM radiates throughtout precordium to carotids abd soft, NT, ND, no HSM or CVA tenderness, +BS 1+ BLE edema, no varicosities noted healed left knee scars moves BLE [**5-14**] strengths; moves LUE [**5-14**], RUE [**4-14**] neuro exam otherwise nonfocal 1+ bil. DP/PTs 2+ bil. radials 1+ right fem, 2+ left fem murmur radiates to carotids FAMILY HISTORY: brother with MI at 63 SOCIAL HISTORY: lives with husband retired quit smoking [**2154**];35 pack/yr hx no ETOH use

CHIEF COMPLAINT: PRESENT ILLNESS: This 65-year-old gentleman with a known history of hypertension, hypercholesterolemia is status post right carotid endarterectomy from [**1-17**]. He joined a fitness club approximately a month ago and began experiencing chest pain and back pain with exertion, which was relieved with rest. He had a positive thallium ETT and was referred for cardiac catheterization, which was done on [**2173-8-11**]. The results are as follows: the left main was widely open, the LAD had an 80 percent lesion, an occluded first diagonal, the RCA was dominant with a 90 percent moderate stenosis, ejection fraction was 70 percent with no mitral regurgitation, circumflex was nondominant with no stenosis. MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Status post right carotid endarterectomy, [**1-17**]. Question of mild renal insufficiency with a creatinine of 1.4 in the past. The patient was referred to Dr. [**Last Name (STitle) **] for a coronary artery bypass surgery. MEDICATION ON ADMISSION: ALLERGIES: He is allergic to NEOSPORIN, which caused a rash. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: He had a significant smoking history for 45 pack years. He quit 7 months prior to admission to this surgery and admitted to occasional alcohol use. He is retired and lives with his wife.

CHIEF COMPLAINT: MVC PRESENT ILLNESS: This is a 40 year old female unrestrained driver s/p MVC. Her vehicle hit a car that crossed the median. She reportedly had a prolonged extrication. She was intubated en route to an outside hospital, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], for GCS < 8. There were reports of movement of her upper extremities but not her lower extremities. She was intubated, sedated and paralyzed prior to transfer. OSH CT scans showed bilateral frontal SAH as well as multiple C spine/T spine fractures. There were no reports of intraabdominal pathology. A large scalp laceration repaired at the OSH. Neurosurgery was consulted for intracranial and spine injuries. MEDICAL HISTORY: fibromyalgia with peripheral nerve stimulator, HTN low back surgery of unknown type MEDICATION ON ADMISSION: Buspirone, Levothyroxine, Metoclopramide, Nortriptyline, Ultram ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: On Admission: PHYSICAL EXAM: O: T:97.8 BP: 110/80 HR:94 R 12 98% on 100% FIO2 Gen: intubated sedated HEENT: Pupils: PERRL EOMs unable to assess Neck: C-collar Extrem: Warm and well-perfused. Neuro: Mental status: GCS 3T FAMILY HISTORY: UNKNOWN SOCIAL HISTORY: 1ppd - quit 3 yrs ago, 2 beers/night, former cocaine use none for many years

CHIEF COMPLAINT: s/p fall PRESENT ILLNESS: This is a 21 year old female who fell down a flight of stairs and was found at the bottom with possible head trauma. Witnesses did not recall any seizure-like activity. On later questioning the patient reported having lost 25 pounds over the past month while taking Brazilian diet pills, with accompanying orthostasis, polydypsia, polyuria and dry mouth. She said she fell down the stairs in the context of presyncope and she believes she lost consciousness. She had no other syptoms prior to admission; no URI symptoms, UTI symptoms, shortness of breath, palpitations, chest pain, history of siezures, or focal neurologic complaints. MEDICAL HISTORY: None MEDICATION ON ADMISSION: Diet pill ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS T98.6 P80 BP104/70R20 98%RA Gen: well-appearing, asking to go home Chest: Clear bilaterally CV: Regular rate and rhythm Abd: Soft, nontender, nondistended Ext: Well perfused FAMILY HISTORY: CVA (father) no h/o seizure/sudden death SOCIAL HISTORY: occassional EtOH No tob/drugs

CHIEF COMPLAINT: transferred intubated and sedated PRESENT ILLNESS: 16F txfr from OSH after presumed high rate of speed, ejected MVA. Pt was found underneath the car, with extremities exposed. GCS reportedly 3 at the scene. She was intubated and [**Location (un) **] to [**Hospital1 18**] for definitive care. Upon arrival per trauma team(had just received vecc and propofol for respiratory issues), per trauma attending, she was not opening her eyes, weakly attempting to localize, and intubated and thereby unable to provide verbal response. MEDICAL HISTORY: 1. Anemia 2. Syncope 1 week ago MEDICATION ON ADMISSION: OCP ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: O: BP:109/63 HR:84 RR:16 O2Sats;100%CMV Gen: WD/WN, comfortable, NAD.responds to pain HEENT:blood within the right ear canal; however TM bilaterally grossly intact. No CSF rhinorrhea appreciate. Pupils: PERRL Neck collar in place, unable to assess Chest clear, swelling over right clavicle with some ecchymosis COR RRR Abd soft, not distended Ext. No abrasions or lacerations FAMILY HISTORY: non contributory SOCIAL HISTORY: Lives with [**Last Name (LF) **], [**First Name3 (LF) 1573**] in high school, works at [**Company **]'s ETOH none Tobacco none

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 32-year-old gravida 2, now para 2 who was transferred from [**Hospital 1474**] Hospital on postoperative day #1 status post emergent repeat Cesarean section that was complicated by post partum hemorrhage and DIC. The patient initially presented to [**Hospital 1474**] Hospital on [**8-5**] at term in early labor. On the morning of [**8-5**] the patient underwent an emergent repeat Cesarean section secondary to fetal bradycardia. Estimated blood loss during the procedure was 1500 cc. However, perioperatively the patient had drop in blood pressure that required pressor support with Levophed and Neo-Synephrine and Dopamine. She also received massive fluid resuscitation. Her lab studies demonstrated her PTT to be greater than 130 with an INR of 4.8. The fibrinogen was less than 20. Her platelets nadired at 109. The hematocrit nadired at 15. All these findings were felt to be consistent with DIC. Prior to transfer to [**Hospital1 188**], the patient had received a total of 17 units of packed red blood cells, 7 units of fresh frozen plasma, one pack of platelets as well as two units of cryo. Prior to transfer her Neo-Synephrine was also titrated off. The final hematocrit prior to transfer was 32.9 with platelets of 56 and INR of 1.3, PTT 51.6 and fibrinogen of 532. The patient was transferred to [**Hospital1 69**] for further evaluation, support and treatment. MEDICAL HISTORY: Negative. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: No tobacco, alcohol or drugs.

CHIEF COMPLAINT: Abdominal pain PRESENT ILLNESS: Ms [**Known lastname 9063**] is a 57F with h/o ovarian ca, POD #1 from laparoscopic IP port placement. She went home and had abdominal pain [**2-10**] hours after getting home. Pain bilateral lower abdomen near the groin and over the incision sites. Felt similar to prior episodes of pain with renal stones. Took 2 vicodin without significant improvement. She went to OSH where a CT without contrast showed some fat stranding and free air thought secondary to recent surgery. She was given meropenam and flagyl and transferred to [**Hospital1 18**]. . On presentation to [**Hospital1 18**], T 100.5, BP 86/58 HR 136 Was given 600cc IVF with SBP 120 and HR 110s. WBC of 37.4 and on exam noted to have significant abdominal pain, guarding so taken to OR for ex-lap. Prior to OR given Vanc/Cefepime and flagyl. . In the OR, patient noted to have a small bowel enterotomy, which was repaired. Recently placed port was removed and adhesions were lysed. There was no collection of pus or any abscess visualized. A JP drain was placed. Was given propofol for sedation. EBL 150, Received 3L LR and 1L NS. UOP 400 CC . ROS: received neulasta [**2140-5-24**]. Recent sinus infection 4 days ago. MEDICAL HISTORY: Ovarian cancer Nephrolithiasis Ureteral stents . Past surgical history: - [**2140-6-8**] - peritoneal shunt placed. - [**2140-4-25**] Ex-lap, lysis of adhesions, resection of sigmoid mesocolon nodule, bilateral pelvic and periaortic lymph node sampling, infracolic omentectomy - [**2140-4-1**] Vaginal hysterectomy, laparoscopic BSO MEDICATION ON ADMISSION: [**Doctor First Name **] Prilosec calcium citrate vitamin D Prochlorperazine Edisylate ALLERGIES: Penicillins / Levaquin / Ciprofloxacin / Sulfa (Sulfonamides) / Percocet / Codeine PHYSICAL EXAM: General Appearance: No acute distress FAMILY HISTORY: Significant for a mother who had breast and possibly ovarian cancer and died of one of these cancers at age 43. She also has a maternal aunt who died of a question of stomach cancer in her 40s. A maternal grandmother had bladder cancer. SOCIAL HISTORY: The patient has smoked one-half pack per day for 30 years. She does not drink. She is a nurse instructor.

CHIEF COMPLAINT: dyspnea PRESENT ILLNESS: 75 yo F hx DM II, presented to OSH ([**Hospital1 46**]) by EMS (7:30PM) for worsening dyspnea. Pt had been treated for pneumonia with resp sx's x2 weeks. On arrival, the patient was noted to have a LBBB. CE's significant for Trop T 1.91, CK 106. She was initially afebrile at 98.5, HR 100s, BP 90/, O2 sat 90% on RA. The patient was intubated for respiratory distress, ABG post 7.28/48/210, started on nitro drip, given IV lasix 40mg, lopressor, IV lovenox 90mg, ASA 324mg, plavix, and transferred to [**Hospital1 18**] for further care. On arrival, pt had low grade temp 100.2, HR 105, BP 94/64. Evaluated by cardiology fellow, felt that pt has LAFB with rate related QRS prolongation, cardiac enzymes flat. Given 80mg lasix IV, plavix 600mg, admitted to CCU for further care. MEDICAL HISTORY: DM2 HTN PNA Giant Cell Arteritis Rt Hip replacement Rt knee replacement CCY Rt carpal tunnel release MEDICATION ON ADMISSION: Glyburide 5mg [**Hospital1 **] Prednisone-stopped at latest on [**6-28**] but PCP is unsure Percocet PRN for pain Actonel CaCarbonate neurontin 300mg [**Hospital1 **] Keflex - 10 days . Allx Sulfa ALLERGIES: Sulfa (Sulfonamides) PHYSICAL EXAM: Admission VS: T 99.1 BP 113/74 HR 103 RR 18 O2 100% on PS 8/5, 50% FiO2 Gen: elderly female, intubated, sedated, well appearing, NAD HEENT: NCAT. Sclera anicteric. PERRL. Neck: thick neck, unable to see JVP. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: Resp were unlabored, no accessory muscle use. bibasilar crackles with good air entry b/l, no wheezes. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. No femoral bruits. Pulses:Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ FAMILY HISTORY: noncontributory SOCIAL HISTORY: Lives alone. Denies tobacco and ETOH

CHIEF COMPLAINT: cholangitis PRESENT ILLNESS: Mr. [**Known lastname **] is a 75 yo M with history of HTN, HL, Hodgkin's lymphoma (dx [**2121**]) and follicular lymphoma grade II (dx [**2127**]), s/p chemo and xrt, on IVIG therapy for hypogammaglobulinemia (last dose [**2133-12-9**]), and paroxysmal afib w/ RVR who presented yesterday with 36 hours of midepigastric abdominal pain, without radiation, [**2-6**] in pain scale, worse with deep inspiration. Denied nausea, vomiting, fever, chills, diarrhea, constipation, BRBPR, SOB, cough, chest pain, unexplained weight loss, fatigue/malaise/lethargy, pruritis or jaundice. Does note decreased appetite, pain not associated with food. Last BM 2 days ago. Patient took percocet x1 and later oxycodone x1, which helped pain. Notified Dr. [**First Name (STitle) **] who recommended he go to the ED. . In ED, VS 99.2 64 203/88 20 98%. Labs showed WBC 6.5, elevated LFTs (ALT 470, AST 278, AP 189, LDH 278, Tbili 9.8, Dbili7.5). RUQ US showed gallstones, sludge and a distended gallbladder but no pericholecystic fluid, CBD dilitation, GB wall thickening, and was negative Murphies. No history of biliary colic, cholecystitis, or liver disease. CT chest negative for PE. Patient was admitted to ACS for monitoring, overnight patient was hypertensive with SBP in the 180s, got hydralazine 10mg IV however developed Afib with RVR with HR into the 140s this morning, BP stable. EKG reportedly with ST depressions, CE negative (CKMB 3, Trop<0.01). Previous episodes of afib with RVR attributed to chemotherapy, fevers, volume overload. Patient's HR was stabilized with diltiazem 10mg x2 and 15mg x1, and metoprolol 10mg x3. Patient was transferred to the [**Hospital Unit Name 153**] with plans for ERCP for possible cholangitis, based on LFTs and elevated bilirubin, however patient is afebrile with a normal WBC and no CBD dilitation on RUQ US. Afib with RVR attributed to hepatobiliary process. . On arrival to the [**Hospital Unit Name 153**], VS: T 98.2, BP 123/71, HR 53, RR 18, 95% on RA. Patient without abdominal pain, resting comfortable in sinus rhythm. Patient has not received any pain medicine either in the ED or on the floor. MEDICAL HISTORY: 1. Hodgkin's Lymphoma (diagnosed [**2121**], relapsed [**2126**] treated with AVBD c/b Afib w/RVR, bleomycin lung toxicity, PCP [**Name Initial (PRE) 1064**]) and Non-Hodgkin's (follicular) lymphoma (diagnosed [**2127**], treated w/rituxan in [**2128**]). 2. Bleomycin toxicity 3. h/o PCP [**Name Initial (PRE) 1064**] 4. Paroxysmal A-Fib: Noted in clinic on day of his first dose of neupogen, [**2127-3-11**], has been recurrant in setting of pulmonary edema, chemotherapy, fever. 5. Hypertension 6. Hypercholesterolemia 7. Nephrolithiasis 8. Retinal detachment [**6-/2129**] 9. Peripheral neuropathy 10. psoriasis 11. Hypogammaglobulinemia . Onc history: - Left-sided neck adenopathy biopsied in [**5-/2122**]: Hodgkin disease with flow cytometry noted for monoclonal B cells which were CD5 positive,raising the possibility of CLL. This was felt likely due to persistence of germinal centers and he was treated for stage IA lymphocyte [**Doctor First Name **] Hodgkin disease with radiation therapy with a total dose of 3060 centigrade of modified mantle field with three fractions of left neck cone down completed in 09/[**2121**]. - CT on [**2127-1-20**] revealed a left pleural mass with biopsy consistent with relapsed classical Hodgkin lymphoma status post ABVD X 6 cycles with complications of neutropenia, necessitating the use of Neupogen, rapid atrial fibrillation, and bleomycin toxicity along with PCP [**Name Initial (PRE) 1064**]. Bleomycin was held after cycle two day one. Cycle six completed on [**2127-7-25**]. - Recurrent adenopathy noted in [**6-/2128**] with waxing and [**Doctor Last Name 688**] size that was followed over time with a slowly increasing adenopathy. Excisional biopsy of right neck adenopathy done by Dr. [**Last Name (STitle) 1837**] on [**2129-3-28**] revealed a follicular lymphoma grade 2. - Status post four weeks of Rituxan from [**2129-4-19**] to [**2129-5-10**] and one dose on [**2129-6-7**] followed by six cycles with Rituxan, Doxil, and Cytoxan on [**2129-7-8**], [**2129-7-29**], [**2129-8-19**], [**2129-9-8**], [**2129-10-14**] and [**2129-11-4**]. PET after 2 cycles with marked improvement. PET scan after 4 cycles with no FDG avidity. Doxil dose reduced to 25mg/m2 for 5th and 6th cycle due to hand/foot rash. - PET scan on [**2130-1-27**] revealed no FDG-avid disease. Treated with 2 doses of maintenance Rituxan on [**2130-3-31**] and [**2130-4-7**]. - Follow up PET scan on [**2130-5-16**] showed new FDG avid lymphadenopathy in the left infrarenal paraaortic and iliac regions, with the largest paraaortic node measuring 30 x 16 mm and SUVmax of 20.4, felt representing recurrent lymphoma but not amenable to biopsy. No other new focal FDG uptake in the chest, abdomen or pelvis. - Received 1 cycle of ICE on [**2130-5-31**] complicated by fluid overload and atrial fibrillation and flutter. - Received 1 cycle of ESHAP on [**2130-6-22**] complicated by bradycardia and repeat admission for atrial fibrillation. - Repeat FDG imaging on [**2130-7-20**] continued to show FDG avidity within the left paraaortic lymph node with SUV max of 11.2. Given prior history of Hodgkin's lymphoma and non-Hodgkin's lymphoma, he underwent a biopsy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] from Urology with laparoscopic surgery on [**2130-9-4**] which did not show any evidence for non-Hodgkin's lymphoma or Hodgkin's lymphoma. - Repeat PET scan in [**9-/2130**] revealed resolution of his lymphadenopathy and FDG avidity with no new areas. Follow up FDG tumor imaging on [**2130-12-11**] reveals no evidence for lymphadenopathy or recurrent lymphoma. - Further treatment with Rituxan held due to recurrent sinus infections which have been treated extensively with antibiotics under the guidance of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] from ID. Follow up sinus CTs finally showed resolution of his infection. - Last treatment with Rituxan in [**3-/2131**] for 2 doses. Receiving periodic IVIG for hypogammaglobulinemia, last given [**2132-12-30**]. - Follow up PET scanning in [**4-/2131**] and [**9-/2131**] notable for enlarging FDG avid subcutaneous lesion in the right posterior neck and new FDG-avidity in a tiny (3 mm) right level 5 lymph node. These were followed with examinations and scans and the right occipital node was increasing in size and proceeded with FNA on [**2132-7-8**] which was nondiagnostic. - Biopsy of right occipital mass on [**2132-7-31**] showed follicular lymphoma, Grade 3A and follicular lymphoma, Grade [**11-30**], diffuse(Extranodal extension) with concurrent lymphocyte-[**Doctor First Name **] classical Hodgkin's lymphoma. - Underwent XRT to right occipital area for total 3600cGy completing on [**2132-10-1**] as only area of disease. - PET CT on [**2133-2-4**] shows resolution of numerous previously seen sites of FDG-avid cervical lymphadenopathy and right suboccipital tissue nodal tissue with persistence of a 10 x 6 mm left level IIB node with significant FDG avidity (SUV max 5.4). MEDICATION ON ADMISSION: Albuterol prn Allopurinol 100' Bactrim DS 3xWeek (MWF) Lisinopril 5' Simvastatin 40' Metoprolol 25' Omeprazole DR 20' Cialis 5' Asa 325 Vitamin B MV Glucosamine 750' Fish oil '' Folic acid 400' hydrocortisone cream for psoriasis Occasional percocet or oxycodone for pain (rare) IVIG ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Exam (On admission to [**Hospital Unit Name 153**]): Vitals: T 98.2, BP 123/71, HR 53, RR 18, 95% on RA General: Alert, oriented, no acute distress HEENT: Sclera icteric, MMM, oropharynx clear Skin: jaundiced, psoriatic lesions over shins Neck: supple, JVP not elevated, no LAD Lungs: minimal bibasilar rales otherwise clear, no wheezes or rhonchi CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur, no rubs, gallops Abdomen: soft with some firmness in midepigastrium, minimally tender in mid epigastrium and RUQ, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. neg murphys sign. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3, CN II-XII grossly intact, moving all extremities FAMILY HISTORY: Denies FH of DM, heart disease/MI, stroke, cancer. Thinks father may have had a thyroid problem. SOCIAL HISTORY: He lives at home with his wife. They have 2 children and 7 grandchildren. He is a retired telecommunications engineer. No tobacco or alcohol use.

CHIEF COMPLAINT: Left sided weakness PRESENT ILLNESS: 70 RHW with PMH of HTN was transfered from OSH for evaluation of left sided weakness. She was at [**Company **] store this am and went to restroom. she was on toilet seat and strained for passing stools. When she tried to get up from the seat , she could not stand and fell on her left side owing to weakness of her let UE and LE. the husband gained entry in the restroom with the staff who called 911. She was taken to OSH. there, blood pressure was 190s/100s, HR was 113. she was given labetalol as well as esmolol for control of blood pressure which came down to 170s after these medications. (labetalol, 10 mg times 2 IV, and esmolol 500 mcg IV) She was noted to have 'left facial droop and left sided weakness." CBC, Chem 7, trop were normal. CT head showed ICH, hence she was sent to [**Hospital1 18**]. next, emergent neurology/ neurosurgery consult was called. MEDICAL HISTORY: HTN Not on any medications for this MEDICATION ON ADMISSION: Herbal medications ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: General: Awake, cooperative, HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no 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: HTN SOCIAL HISTORY: Lives with husband, [**Name (NI) **] smoking or alcohol, drugs

CHIEF COMPLAINT: headache PRESENT ILLNESS: Ms. [**Known lastname 91283**] is a 18 year-old healthy woman who presented to the ED this morning for evaluation of headache. She was well until a few days ago, when she began having intermittent sharp abdominal pains, associated with poor appetite, nausea, and vomiting. No change in bowel movements, no blood in stool. Also noted a new rash on her forehead a few days ago. This morning she noted severe global headache [**8-28**] - never had this type of headache before. +nausea, neck stiffness, and photophobia; no numbness, tingling, or focal weakness. She is a freshman at Pine Manor College and lives in the dorm; she says that many of her classmates have been ill with the "flu" recently. . In ED, initial vitals 100.3 100 142/90 18 100% RA. Lumbar puncture performed: CSF with 465 WBC in Tube 1, 1250 WBC in Tube 4. Received 2L NS, ketorolac 30 mg iv, vancomycin 1g iv, ceftriaxone total 2g iv, Percocet, and Zofran. CSF gram stain was negative. . At the time of examination, she has no headache, but does have neck stiffness, as well as R shoulder pain which began after lumbar puncture. . Review of Systems: as per HPI (+) Back pain (-) Denies chills, night sweats, recent weight loss or gain. Denies visual changes, rhinorrhea, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies diarrhea, constipation, BRBPR, melena. No dysuria, urinary frequency. Denies arthralgias or myalgias. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. MEDICAL HISTORY: Urinary tract infection, treated prior to admission MEDICATION ON ADMISSION: Multivitamin ALLERGIES: Peanut / Soy PHYSICAL EXAM: ADMISSION MEDICINE PHYSICAL EXAM: Vitals 100.0 100 145/81 20 100% RA Gen - lying comfortably in bed, no distress, pleasant HEENT - pupils equal, EOMI, no oral lesions Neck - no lymphadenopathy Pulm - CTAB, good air movement CV - RRR, soft systolic ejection murmur Abd - +BS, soft, nontender, nondistended Ext - warm, no edema Skin - multiple tiny flesh-colored, round, elevated lesions on forehead Neuro - alert, conversant, interactive, CN 2-12 intact, normal sensation to light touch, 5/5 strength bilateral UEs and LEs, normal finger-nose-finger, +nuchal rigidity, negative Kernig's sign, negative Brudzinski's sign FAMILY HISTORY: Father with diabetes mellitus. Mother died in [**2169-6-19**] of an "infection." SOCIAL HISTORY: Originally from [**Hospital1 189**]. Now a freshman at Pine Manor College in [**Location (un) 55**]. Studying communications. Lives in [**Location **]. No tobacco or illicit drugs. Occasional wine. Sexually active.

CHIEF COMPLAINT: Hypotension PRESENT ILLNESS: See hospital course MEDICAL HISTORY: 1. Obesity 2. Hypertension 3. Diabetes, poorly controlled, HbA1c 11, est. av. glucose 280. On oral agents at admission. 4. Chronic renal insufficiency (likely diabetic) 5. Hyperlipidemia, not clear that this was being treated. 6. History of smoking - remote, 20 pack years 7. Coronary artery disease s/p catheterization (at [**Hospital 2586**]). He had had a positive stress test and elective cath. in [**2117**]: Anatomy: LAD 50-60% stenosis distally. RCA mid 100% stenosis. LCx and LM without lesions. Excellent left to right collaterals. No stents placed. Last echo revealed LVEF of 55%, per [**Hospital3 **] Cath. report. No evidence of CABG (although in ED note - no evidence of incision and no sternotomy wires). 8. Obstructive sleep apnea 9. Hemorrhoids 10. Anxiety 11. Gridiron incision c/w past appendectomy. 12. Gout - fifth finger of right hand affected. MEDICATION ON ADMISSION: Unknown ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: FAMILY HISTORY: Unknown SOCIAL HISTORY: Unknown

CHIEF COMPLAINT: SAH PRESENT ILLNESS: 57 y/o male with history of migranes, Afib and HTN transferred here from an outside facility after a SAH was seen on CT. Patient was in his usual state of health per his wife, he had been having a mild headache for the past few days, but today developed a [**9-15**] headache in the back of his head expressed that he thought he was going to pass out, his wife got him to a chair and he became unresponsive and developed respiratory distress. EMS was called, he was intubated in the field and taken to a Hospital. Upon arrival he was hypotensive with HR in the 40's. outside records indicate that he recieved one amp. of Atropine. CT revealed a SAH in aneurysmal distribution and he was transferred to [**Hospital1 18**] for further care. MEDICAL HISTORY: Prostate CA Afib HTn OSA- sleeps with bypap MEDICATION ON ADMISSION: Sotalol HCTZ ALLERGIES: Penicillins PHYSICAL EXAM: Hunt and [**Doctor Last Name 9381**]: 5 [**Doctor Last Name **]:2 GCS 3 E: 1 V:1 Motor T: BP: 80/53 HR: 49 R 17 O2Sats100% CMV 100/450/16/10 Gen: intubated HEENT: Pupils: 5 to 4mm sluggish EOMs FAMILY HISTORY: non-contributory SOCIAL HISTORY: Works as computer programer. No Tobacco, social ETOH 2x week

CHIEF COMPLAINT: slurred speech PRESENT ILLNESS: 66yo RH M h/o Afib s/p cardioversion on coumadin, HTN, hyperlipidemia who woke in his usual state of good health this morning at 5:30am and went about his day. He was watching television around 8:00am when he noted the sudden onset of slurred speech and felt that his right arm felt heavy and a bit clumsy. He denies headache and has had no N/V or neck pain. Denies trauma. He stood and noted no difficulty walking and drove himself to [**Hospital **] Hospital, where a 3.1cm x 1.5cm left external capsule bleed was found. Systolic blood pressure was as high as 230's and he was given labetalol. He was given vitamin K 10mg sublingual, dilantin 1g IV x 1 and FFP 7 units after INR was found to be 2.3. He has had no diminishment in his level of consciousness. He feels that the speech has not gotten worse and the arm feels better. He denies difficulty with his vision or gait. No sensory symptoms. MEDICAL HISTORY: Afib s/p cardioversion [**2150-8-26**] HTN Hyperlipidemia s/p resection of C2-C4 neurofibroma at [**University/College **]-[**Last Name (un) 23424**] in [**2125**], with no loss of dexterity or deficits MEDICATION ON ADMISSION: Coumadin Amiodarone 200mg daily Metoprolol 150mg qam, 75mg qpm Lasix 20 Lipitor 40 Wellbutrin 150mg [**Hospital1 **] ? Quinapril at home ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS 98.1 49 238/126->180s 12 99% Gen Awake, cooperative, NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity Lungs CTA bilaterally CV RRR, nl S1S2, no M/R/G noted Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted NEURO MS Awake, alert. Fully oriented. MOYB intact. Speech fluent, with normal naming, [**Location (un) 1131**], writing, comprehension and repetition. Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. No apraxia. Interprets cookie theft picture appropriately. Moderate to severe dysarthria. CN CN I: not tested CN II: VFF to confrontation, no extinction. Pupils 3->2 b/l. Fundi clear CN III, IV, VI: EOMI no nystagmus or diplopia CN V: intact to LT throughout CN VII: R NLF flattening and droop CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [**Doctor First Name 81**]: shrug [**5-2**] and symmetric CN XII: tongue midline and but clumsy Motor Normal bulk and tone. No pronator drift D B T WE FE FF IP Q H DF PF TE ADM [**4-2**] on the right; [**5-2**] on the left Sensory intact to LT, PP, JPS, vibration throughout. No extinction. Reflexes Br [**Hospital1 **] Tri Pat Ach Toes L 2+ 2+ 2+ 2+ 2+ down R 2+ 2+ 2+ 2+ 2+ down Coordination FFM, RAMs, FTN, HTS all normal Gait narrow based and steady. FAMILY HISTORY: negative for head bleeds SOCIAL HISTORY: works as a dentist. Denies etoh/tob/illicits.

CHIEF COMPLAINT: RUQ abd pain, fever, nausea, vomiting PRESENT ILLNESS: 69 y/o M s/p spinal fusion surgery on [**9-1**], followed by hospitalization for sepsis/cholecystitis managed with percutaneous cholecystostomy, now presenting from [**Hospital 38**] Rehab with nausea, vomiting, abdominal pain. The abdominal pain is predominantly over his RUQ, at the site of his cholecystostomy tube. He also has lingering mild left sided pain that has been present since his surgery. Finally, he has had thigh pain and weakness while at the rehab facility. There, he had blood cultures drawn, and was transferred to [**Hospital1 18**] out of concern for bacteremia. Today's labs from rehab facility revealed WBC to 11.3 with 87.9 PMNs. His INR has been < 2 since [**10-16**]. Microbiology data from rehab (see below) featured wound culture with VRE and klebsiella, and UCx with yeast, presumptive c. albicans. During prior admission, patient was found to have cholecystitis on HIDA scan, polymicrobial bacteremia with e. coli and abiothropha, as well as enterococcus in abdominal wall wound culture. IR placed percutaneous cholecystostomy drain on [**9-18**], with plan to have patient undergo elective lap chole after renal failure had improved. The patient had an ED visit on [**10-13**] for left-sided colicky abdominal pain, for which CT ruled out nephrolithiasis or urolithiasis. He was started on amox-clav for u/a with 6-10 WBC and few bacteria, with no culture. In the ED today, vital signs were 101.1, 88, 150/54, 18, 95% 2L. The patient was AAO x3, with TTP in RUQ and RLQ, with cholecystostomy tube in place. Labs notable for WBC 12K, with normal LFTs and troponin. CXR, CT chest/abd/pelvis, and abd u/s were unrevealing for source of infection. The patient was seen by the surgical service, who felt no urgent surgical interventions were necessary at this time, but recommended that ortho spine be consulted for question of possible fluid collection in post-surgical site. The patient was given five liters NS with improvement of his systolic BP to the 110s. He had also had atrial fibrillation with RVR to 150s early in ED course, which resolved with the IV fluids. He was given two doses of pip/tazo 4.5g, and linezolid 600 mg IV, as well as one gram of acetaminophen. 2 18 gauge PIVs and a foley were placed. Prior to transfer to the MICU, his BP was 125/65 and he was satting 93% on room air. MEDICAL HISTORY: -Pafib -hypertension -insulin-dependent diabetes-A1C [**6-25**] 6.1% -hypothyroidism -GERD -peripheral neuropathy -Hyperlipidemia -obesity -Pneumonia - Viral - [**4-10**]- Hosp -GI bleed-upper from peptic ulcers - about [**2100**] - no transfusions thought [**2-3**] celebrex and plavix -psoriatic arthritis, right hand - s/p anterior/posterior L5/S1 fusion secondary to severe foraminal stenosis and isolated L5 radicular symptoms - [**9-11**]: episode of sepsis with cholecystitis complicated by e.coli and abiotrophia/granulicatella bacteremia, treated with pip/tazo MEDICATION ON ADMISSION: 1. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 11. polysaccharide iron complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day as needed for indigestion. 13. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 15. baclofen 10 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day) as needed for pain, back spasm. 16. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for Rash, affected areas. 17. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 18. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 20. insulin glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous at bedtime. 21. insulin lispro 100 unit/mL Solution Sig: as directed units Subcutaneous qACHS: as per sliding scale. ALLERGIES: Accupril / Ceftriaxone PHYSICAL EXAM: VS: 96.9 (99.4) 124/70 69 18 96%/RA GEN: well appearing, obese man, lying in bed, NAD HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. Cards: irregular rhythm, S1/S2 normal. no murmurs/gallops. Pulm: Bibasilar crackles Abd: soft, NT, +BS. no rebound/guarding. neg HSM. Cholecystostomy tube in place with dressing c/d/i. Extremities: wwp, no edema. DPs, PTs 2+. Skin: Erythema and peeling skin on shins bilaterally. FAMILY HISTORY: Father died of MI at age 70. Sister with MS. SOCIAL HISTORY: Retired from automotic industry. Lives with wife. Quit smoking 30 years ago after 30pack years of smoking, drinks ~1 alcoholic beverage a week, no drug use.

CHIEF COMPLAINT: Nauswa/vomiting PRESENT ILLNESS: MR [**Known lastname 107214**] is a 63M who presented to the ED with nausea/vomiting and diarrhea. CT was consistent with ischemia and perforation. With his past history of artificial heart valve requiring anti-coagulation, and extensive cardiac disease, he was a high operative risk. However, as bowel ischemia would proved fatal in this patient, it was decided to operate. MEDICAL HISTORY: EXTENSIVE CARDIAC HISTORY AS LISTED BELOW: bioprosthetic AVR in '[**80**] -> repeat in '[**83**] -> stenosed AVR -> mechanical AVR '[**96**] CABG [**2088**] SVG --pDA, SVG-LAD, SVG-LCX -CABG '[**96**] (redo bypass) SVG-D1, SVG-OM, SVG-RCA,SVG to PDA to PLB -97-removal of sternal wire due to protrusion into heart .. MIBI ( modified [**Doctor First Name **]; ETT-MIBI); stopped for fatigue; [**6-9**] CP and received 1 SL nitro; EF 27%, global HK, esp septal with fixed apical defect, transient ischemic dilitation of LV, and mod part reversible distal anterior, inferior and septal defects. .. -cath (1/03)90% SVG-RCA -> Ultra 4.5x28. SVG-D down, but native diag collateralized. SVG-OM down, but LCX disease moderate at that point. Unclear why no LIMA. .. Carotid u/s: ([**6-3**]): R minimal plaque. w <40% stenosis. L mod plaque w/ 59% carotid stenosis GERD hyperlipidemia severe COPD depression CVA'[**95**] h/o heamturia-neg cystocscopy diet controlled diabetes MEDICATION ON ADMISSION: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-1**] Puffs Inhalation Q4H (every 4 hours). 2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for fever. 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). ALLERGIES: Procainamide / Ivp Dye, Iodine Containing PHYSICAL EXAM: Physical exam on discharge: FAMILY HISTORY: SOCIAL HISTORY: + significant tobacco history, lives at rest home

CHIEF COMPLAINT: Right great toe ulcer. PRESENT ILLNESS: Pt is a 76F admitted s/p Right [**Doctor Last Name **]-DP BPG [**4-22**] w/ chronic Left heel ulcer and Right hallux gangrene. Pt is followed by Dr. [**Last Name (STitle) **] and was last seen in clinic [**4-1**] at which point the left heel ulcer was debrided and pt instructed to continue daily dressing changes. No evidence of infection was noted at that time. She denies any recent h/o fevers, chills, nausea, vomitting. She is c/o significant pain to BL LE. MEDICAL HISTORY: - DM2 - insulin dependent x30y, c/b neuropathy. - PVD - GERD - paroxysmal atrial fibrillation - h/o gastritis - h/o pancreatitis\ - h/o stress incontinence, urinary retention - h/o CVA (left occipital infarct) - s/p cervical fusion, lumbar disc surgery - glaucoma - R eye blindness . MEDICATION ON ADMISSION: Clopidogrel 75 mg' Gabapentin 500 mg' Gabapentin 600 QHS4. Metoprolol Succinate 50 mg SR'Simvastatin 20' Pantoprazole 40'Tolterodine 1 mg' Aspirin 81 mg' Calcium Carbonate 500 mg'' Docusate Sodium 100'' Ferrous Gluconate 325' Senna 8.6'' prn 1 Cyanocobalamin 500'' Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] Brimonidine 0.15 % Drops Sig: One Q8H Lisinopril 10' Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: 30 units Q AM, 20 units QHS Subcutaneous Q AM, and Q PM. Acetaminophen 325 mg Q6 prn ALLERGIES: Penicillins PHYSICAL EXAM: PHYSICAL EXAM . Tmax:99.0 Tc:99.0 Rate:74 BP:133/58 RR:20 P02:94% on RA Gen: NAD HEENT: PERRLA, EOMi, No carotid brui CV: RRR Chest: CTA Abd: sof, NT, ND, act BS Ext: [**1-4**]+ pedal edema bilaterally, right and left great toes with dry gangrene. Foul smelling. Small ulcers relatively c/d/i around lateral toes. Pulses: Fem DP PT p d d p d d VASCULAR Pedal Pulses: [] Palpable [x] Non-palpable. monophasic sig on L Sub-Papillary VFT: [x] < 3 sec. [] > 3 sec. [] Immediate Extremities: [x] pitting edema [] non-pitting edema [] Anasarca FAMILY HISTORY: noncontributary SOCIAL HISTORY: Pt lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] presently, denies tobbacco, alcohol, IVDU. Previously lived with daughter, [**Name (NI) **]. Was walking with walker and performing her ADLs fairly independently prior to recent hospitalization.

CHIEF COMPLAINT: Worsening pain PRESENT ILLNESS: 44 y/o male w/ metastatic renal cell carcinoma (extensive metastases to bone)who presented to clinic with worsening pain, particularly in his sacrum. After his last hospitalization (d/c on [**2125-1-8**]), he was able to ambulate with a walker and had achieved modest pain control with methadone (dose was increased to 60 mg PO TID) to the point where he was not using much dilaudid for breakthrough. However, since then, he has called the clinic multiple times for worsening pain not covered by medications at home. He's increased the use of dilaudid to approximately 24 mg PO daily and had also started using MS Contin 30 mg PO BID. Despite these medications, he has been essentially bed bound, to the point where he is not even able to stand and self cath. Since starting MS Contin, he has had nausea and emesis (brown, nonbloody, nonbilious). He has not eaten any PO solids in 2 days. He came to clinic today for a regularly scheduled appointment, during which he was supposed to get gemzaar and zometa. However, treatment was deferred and the pt was admitted to 7F for better pain control and possible [**Hospital1 1501**] placement. Discussions have been had during previous hospitalizations around hospice and what services are available at home. Other than his girlfriend, the patient does not have many supports and has come to the point where he needs more care at home than outpatient services can provide. MEDICAL HISTORY: ROS: + "feeling warm", w/ temp of 99; however taking RTC tylenol at home + chills, but denies night sweats ~30# wt loss since [**11-27**] denies CP, palp, SOB denies URI sx other than mild ear pain denies LH, headaches, dizziness denies abd pain + mild odynophagia, but able to take PO liquids OK + n/v (none since yesterday) normal BM, nonbloody, no melena + numbness and tingling in genitals/buttocks since [**2125**] denies leg swelling + urinary retenion but no dysuria or hematuria . PMH: Metastatic renal cell carcinoma (see below) Recent ? UGIB (felt to be due to esophagitis) Thoracotomy, ex lap after stab wound Herniorrhaphy Bilateral ankle injuries . ONC HX: In [**2124-5-22**], he was diagnosed with metastatic renal cell carcinoma following a pathological fracture of his left femur. His leg was stabilized at [**Hospital1 336**], and a biopsy of the left thigh mass was positive for clear cell carcinoma. His postoperative course was complicated by a PE and treated with Lovenox. A bone scan also revealed metastasis to the left distal femur and right acetabulum. From [**2124-5-29**] to [**2124-6-16**] he received palliative radiation to these areas. Subsequently, in a staging work-up, a torso CT also indicated two lung lesions, and a lesion in his right kidney. The patient transferred his oncological care to [**Hospital1 69**] in [**2124-8-22**] and started on Zometa and Sutent. Later that month, an MRI of the brain indicated a solitary enhancing mass in the right occipital lobe. The lesion was treated with Cyberknife radiosurgery on [**2124-9-18**] to 2,220 cGy in one fraction. On [**2124-10-9**] the patient presented to the ED with urinary retention, numbness of his perineal area, and leg pain. An MRI of the thoracic/lumbar spine indicated lesions in the sacrum and T5 vertebrae. Subsequently, he had external beam radiation to these areas from [**2124-10-10**] to [**2124-10-16**]. He has been intermittently on Sutent since [**8-27**]. During his last admission in [**11-27**], the Sutent was stopped as it was thought it was contributing to his neutropenia and esophagitis. The Sutent was restarted on [**2124-12-18**]. He had an MRI of his Lspine on [**2124-12-23**], which showed stable involvement of L3-L4 but increased involvement of the sacrum. His MRI head showed unchanged size of the right occipital and left temporal lesions compared with the previous MRI. MEDICATION ON ADMISSION: ambien 10mg PO QHS colace [**1-23**] tab PO QD diazepam 4mg PO QHS dilaudid 4mg PO q prn pain gelclair daily for mouth ulcers lidocaine (viscous) 5-10cc prn mouth ulcers lidoderm 5% 12hrs on/12 hrs off lomotil prn MS contin 30mg PO BID methadone 60mg PO TID protonix 40mg PO Q12 ALLERGIES: Tegaderm / Codeine / Penicillins / Neurontin / Lorazepam / Latex PHYSICAL EXAM: VS - T 97.6, BP 128/90, HR 75, RR 20, sats 95% on RA, 5'[**28**]", 170# Gen: WDWN middle aged male, cooperative and awake, in NAD. HEENT: Sclera anicteric, PERRL, EOMI. OP w/ small, millimeter size white lesions on roof of mouth, none under tongue/along sides of mouth. Conjunctival pallor. No LAD. CV: RR, normal S1, S2. No m/r/g. Lungs: CTA on left, but decreased BS at base on right. No crackles or wheezes. Abd: Soft, mildly distended, tender in suprapubic region. No masses. + BS. Ext: No c/c/e. 2+ PT, radial pulses bilaterally. No rashes. Neuro: CN II-XII grossly intact. Strength 5/5 in UE - triceps, biceps, adductors bilaterally. Grip strong and symmetric. In LE, [**4-26**] plantarflexion bilaterally, dorsiflexion 4-/5 bilaterally and symmetric; knee flexion/extension [**4-26**] on R, [**3-26**] on L but limited by pain. Can not lift legs off of bed due to pain, can not hold legs in air on own due to pain thus could not assess iliopsoas. Sensation intact to light touch, proprioception, pain bilaterally in LE to knees. Hyperreflexic at patella bilaterally 3+, symmetric. No clonus at ankles. Equivocal toes. Gait deferred [**2-23**] pain. FAMILY HISTORY: M died of embolus to brain post surgery; F died of MI/CAD. Has several brothers/sisters, all of whom are healthy. No fam hx of DM, CAD, HTN or lung disease. Positive for renal cell carcinoma. SOCIAL HISTORY: Lives w/ girlfriend [**Name (NI) 1258**] who is very involved in his care. Used to work in telecommunications, has been out of work since diagnosis 8 mo ago. No tob, occ EtOH.

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 61 year old male with a previous medical history significant for hypertension, dyslipidemia, who had intermittent episodes of chest pressure and pain over the past month that resolved spontaneously. The patient states that 24 hours prior to admission he developed increased chest pain intermittent while at rest. He notified EMS; the pain lasted one hour, seven out of ten and was dull. He did report diaphoresis; no nausea, vomiting, shortness of breath or palpitations. Initial blood pressure when patient arrived at outside hospital was 90/palpable. The patient was given two boluses of intravenous fluid and blood pressure improved to the 110s. EKG was remarkable for V5, V4 ST elevations. The patient was given two aspirin and Nitroglycerin was held secondary to decreased blood pressure. The patient was transferred to [**Hospital1 69**] for catheterization. Catheterization demonstrated a right dominant system. The LMCA was normal; left anterior descending with 90% occlusion after the first diagonal, left circumflex occluded after small high obtuse marginal. Right coronary artery was normal. The patient's left circumflex occlusion was across revealing a long severe lesion with marked tortuosity. It was dilated and stented with two overlapping Hepacoat stents with no residual and normal flow. The thrombotic occlusion resolved with wire manipulation with a final very distal occlusion. The patient's 90% ostial lesion of the small obtuse marginal 1 with normal flow was not treated at that time. Hemodynamic RA pressure mean of 9.0, PA pressure of 35/14 with a mean of 24, RV 35/6 and pressure of 11. TCW mean of 13. ......was 6.07 cardiac index 3.09. The patient received heparin and Integrilin during the catheterization and had one episode of bradycardia with heart rate to the 30s. Received 1 mg of Atropine and the heart rate increased to the 90s. Blood pressure was stable throughout the catheterization. Additional hemodynamics, SVR was 1082. MEDICAL HISTORY: 1. Gastroesophageal reflux disease. 2. History of hypercholesterolemia. 3. History of hypertension. 4. History of appendectomy. 5. Hemorrhoidectomy. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: The patient's father had an myocardial infarction at the age of 57. SOCIAL HISTORY: The patient is married; the patient is a former smoker who smoked 1.5 packs for 20 years but has quit. The patient reports moderate alcohol use. Denies any other drug use.

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 66-year-old woman with autoimmune hepatitis and secondary cirrhosis who presented to [**Hospital1 69**] on [**2116-8-5**] on advice from her PCP who noted [**Name Initial (PRE) **] sodium of 124, potassium of 6.4 on a scheduled appointment. She has been admitted and found to have also an increased bilirubin. Over her hospital stay, the patient as per the printout, the sodium remained in the mid 120s, potassium was reduced with Kayexalate, and aldactone was held. Coagulopathy PT of 18.6, INR of 2.4 on admission, was treated with fresh-frozen plasma and vitamin K. Prior to this admission in [**2116-3-9**], the patient developed lower extremity edema, fatigue, and decreased mobility. She was found to have increased LFTs and was started on Imuran, Lasix, and aldactone with some improvement of symptoms. MRI revealed cirrhosis. It was confirmed by biopsy one week prior to admission. Approximately one month ago, the patient is evaluated for transplant, and was given an increase in aldactone, and subsequently admitted for pyelonephritis. Then she was given levofloxacin and also an esophagogastroduodenoscopy was performed which revealed Grade I varices, and colonoscopy revealed multiple diverticulosis and two polyps. During this current hospital stay, the patient began developing low blood pressures systolics in the 80s-90s for approximately 24 hours before transfer to the MICU. Urine culture grew two species of Gram-negative rods. O2 sats remained in the mid 90s and mental status decreased with orientation only to person. MEDICAL HISTORY: 1. Autoimmune hepatitis. 2. Cirrhosis secondary to chronic hepatitis. 3. History of pyelonephritis one month ago. 4. Breast cancer status post lumpectomy and radiation therapy in [**2107**]. 5. Perirectal abscess. 6. Hypertension. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Mother deceased from colon cancer at 70. Father deceased in the 70s from stroke. Siblings with heart disease. SOCIAL HISTORY: Lives with husband in [**Name (NI) 5110**]. Has four children. No alcohol, or smoking, or drugs.

CHIEF COMPLAINT: Altered mental status PRESENT ILLNESS: 77 yo M from nursing home with hx parkinson's, and alzheimers, type 2 DM on ins, chinese speaking, LLL PNA found [**2185-5-20**] ago on treatment with azithro and levoflox. He was noted by family to be more confused, noted by nursing home staff to be diaphoretic, febrile and tachycardic. O2 sats to 80% so he was sent to ED for evaluation. MEDICAL HISTORY: - Parkinson's disease - Alzheimers disease - Glaucoma - legally blind - Type II DM - BPH MEDICATION ON ADMISSION: Glyburide 12 mg [**Hospital1 **] Metformin 500 mg [**Hospital1 **] Carbidopa-levodopa 25-100 1 tab TID Detrol LA 4 mg daily Lorazepam 0.5 Q6 PRN anxiety Aricept 10 mg HS Namenda 10 mg [**Hospital1 **] Simvastatin 20 mg HS Trazodone 25 mg HS Docusate 100 mg [**Hospital1 **] [**Name (NI) 10687**] PRN MOM 30 cc PRN Gaviscon 2 tabs PRN gas Dorzolamide-timolol 1 gtt to each eye TID Diclofenac 0.1% gtt to L eye daily Lumigan 0.03% gtt to L eye daily Acetaminophen 2 tabs PRN Azithromycin 500 mg x 3 days ended on [**2185-5-22**] Levoflox 500 mg started [**2185-5-22**] ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: T: 97.5 BP: 105/49 P: 104 Vent: AC Vt 450, Rate 14, PEEP 5, FiO2 50% General: Intubated, sedated HEENT: Sclera anicteric, MM dry, oropharynx clear, PERRL Neck: supple, JVP flat, no LAD Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi CV: Tachy, reg rhythm with premature beats, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, skin tenting present FAMILY HISTORY: Non-contributory SOCIAL HISTORY: Lives at [**Hospital6 **] center. Wife [**Name (NI) **] involved in care. No T/A/D

CHIEF COMPLAINT: Bilateral renal masses PRESENT ILLNESS: 29yF with ESRD secondary to SLE s/p failed renal transplant in [**2174**] now with bilateral renal masses noted on MRI. Consultations with radiology, transplant nephrology, and urology felt that the primary concern was need for tissue diagnosis and removal to facilitate relisting as transplant candidate. The least morbid and most efficient approach was considered laparoscopic bilateral nephrectomies. MEDICAL HISTORY: 1. SLE diagnosed [**2166**] complicated by lupus/nephritis, anemia, serositis and ascites 2. End stage renal disease secondary to lupus, HD T/Th/Sat 3. History of VSD s/p corrective surgery, age 13 4. Hypertension 5. ITP 6. MSSA endocarditis 7. Sickle cell trait 8. s/p left oophorectomy related to IUD associated infection 9. Restrictve lung disease noted on PFTs [**2166**]. In [**2173**], chest CT with diffuse ground glass opacities. 10. GERD 11. s/p cadaveric renal transplant on [**8-/2175**] complicated by rejection and capsule rupture 11/[**2174**]. 12. Right pelvic abscess s/p TAH/RSO 13. B/L renal solid masses MEDICATION ON ADMISSION: AMOXIL 500 mg--4 tablet(s) by mouth 4 tabs one hour prior to procedure then 1 tab every 8 hours 1 hour prior to procedure AZTREONAM 1 gram--1 gram iv q24 hours until [**11-26**] Amitriptyline 50 mg--1 tablet(s) by mouth at bedtime for neuropathy DILAUDID 4 mg--1 tablet(s) by mouth twice a day as needed for pain IBUPROFEN 600MG--One pill by mouth every 6-8 hours as needed for joint pain NEPHROCAPS 1MG--One by mouth every day PREDNISONE 5MG--Take as directed PROTONIX 20MG--One by mouth every day for gerd Sevelamer 800 mg--1 tablet(s) by mouth three times a day phosphate binder Amitriptyline 75 mg--1 tablet(s) by mouth at bedtime for neuropathy ALLERGIES: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Heparin Agents PHYSICAL EXAM: 98.6 84 130/72 18 94%RA GEN: AAOx3, NAD CHEST: CTAB CARDIOVASCULAR: RRR, 2-3/6 systolic murmur. Abd: soft, ND, min TTP Incision: c/d/i with steri strips Ext: no c/c/e FAMILY HISTORY: NC SOCIAL HISTORY: No smoking, occasional alcohol, no drug use. Lives at home with husband and son. Not currently employed.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 74 year-old G5 P414 diagnosed with grade [**1-13**] endometrioid type endometrial cancer by ultrasound guided dilatation and curettage on [**2127-3-5**] during an evaluation for post menopausal bleeding. The patient has been having postmenopausal bleeding since approximately [**2126-9-10**]. The patient was originally scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] for evaluation on [**2127-4-2**], but was admitted to the gyn/oncology service on [**2127-4-1**] for increased vaginal bleeding. The patient had a decrease in hematocrit from [**2127-2-28**] to [**2127-4-1**]. The patient's vaginal bleeding decreased substantially while in house. The patient did not require blood transfusion and remained hemodynamically stable. The patient was discharged to home on hospital day two and scheduled for staging procedure on [**2127-4-4**]. Anesthesia preoperative. Patient was admitted. During hospital stay the patient denies lightheadedness, fainting, abdominal pain or urinary symptoms. MEDICAL HISTORY: Asthma, type 2 diabetes, hyperlipidemia, obesity, hypertension, degenerative joint disease, anxiety, gout, glaucoma. MEDICATION ON ADMISSION: ALLERGIES: Penicillin. PHYSICAL EXAM: FAMILY HISTORY: No gyn or colon cancer. SOCIAL HISTORY: No alcohol or drugs. Chews tobacco. Lives alone.

CHIEF COMPLAINT: L hip pain PRESENT ILLNESS: Briefly, Ms. [**Known lastname **] is a [**Age over 90 **] yo female with a history remarkable for HTN, DM type 2, atrial fibrillation s/p pacemaker placement, not on Coumadin [**3-2**] history of hemorrhagic CVA, now brought in from home following a fall. . Per patient, she was on her way to the bathroom without her walker, and fell on her left side. She reports acute left leg pain, with inability to move it. She denies preceding lightheadeness, no palpitations, no chest pain, no shortness of breath. She did not hit her head. . She was brought in by EMS. In ED, HR 65, BP 117/44, RR 16, Sat 98% on RA. X-rays consistent with left subcapital fracture and left mid shaft fracture, as well as osteopenia. Given Morphine 1 mg IV X 3. . ROS negative for history of exertional discomfort, no history of shortness of breath, no orthopnea, no PND. She is currently undergoing investigation of multiple pulmonary nodules, and was scheduled for bronchoscopy on Monday with BAL for further eval. Diabetes well-controlled MEDICAL HISTORY: 1. Atrial fibrillation s/p pacemaker placement. Previously on Coumadin, discontinued [**3-2**] hemorrhagic CVA. 2. LV systolic dysfunction per echo [**3-/2131**], with EF 30-35%, 2+ MR and 2+ TR. 3. DM type 2, last hemoglobin A1c 7.1 on [**2135-4-1**] 4. Hypertension 5. Hypercholesterolemia 6. Chronic renal insufficiency with baseline creatinine 1.6-1.9 7. Mild dementia 8. Peptic ulcer disease 9. History of CVA X 3 10. Negative colonoscopy [**1-/2132**], negative EGD [**2-/2134**] 11. Multiple pulmonary nodules found on chest CT, under investigation. Planned for bronchoscopy with BAL on [**10-17**]. Differential includes vasculitis, malignancy or infection. MEDICATION ON ADMISSION: Glyburide 1.25 mg PO QAM FeSO4 325 mg PO BID [**First Name3 (LF) **] 20 mg PO QAM Lopressor 12.5 mg PO BID Avandia 4 mg PO QD Lasix 20 mg PO QAM Amiodarone 200 mg PO QAM Aspirin 325 mg PO QAM Tylenol qAM Timolol 0.5% 1 drop left eye qAM Xalatan 0.5% 2 drops OU qHS Albuterol MDI 2 puffs [**Hospital1 **] ALLERGIES: Neurontin / Keflex / Bactrim PHYSICAL EXAM: GEN: Appears comfortable at present. Lying flat in bed. Restraints in place. HEENT: Anicteric. PERRLA, EOMI. OP clear, MM dry. NECK: Distended EJV, JVP difficult to assess. RESP: Bilateral inspiratory crackles at bases, ?slightly improved from yesterday. CVS: RRR. Normal S1, S2. No S3, S4. faint SEM heard throughout precordium, loudest at lower sternal border. GI: Abdomen soft, mild LLQ tenderness. No rebound or guarding. NABS. EXT: 1+ pitting edema in both lower extremities. Distal pulses intact (by doppler), sensation to light touch intact, able to wiggle toes. RLE pain with hip flexion. Not externally rotated, no tenderness to palpation. Pain with palpation or passive ROM R knee, but improved. NEURO: limited sensorimotor examination intact in both LE, AA&Ox2 today (person and place) FAMILY HISTORY: noncontributory SOCIAL HISTORY: She currently lives with her daughter, and goes to day care 5 days a week. No tobacco, no EtOH. She ambulates with a walker at baseline.

CHIEF COMPLAINT: AMS, tachycardia PRESENT ILLNESS: 49 year old male with history of HTN, Hep C, alcohol abuse, epilepsy [**12-21**] TBI after motorcycle accident presents with AMS, tachycardia, and auditory and visual hallucinations. Patient had gone to a cognitive neurology clinic visit today, was noted to be acting strange, complaining of progressive short term memory loss for the last 6-8 weeks. His case worker accompanied him, says that this is very different from his baseline mental status. He was sectioned at cognitive neuro and sent to the ED. Patient reports having auditory and visual hallucinations for the last several months. Visual hallucinations are of bugs flying around his head, also states that he has been hearing voices; a few nights ago, felt that someone was hiding behind his chair trying to hurt him. Denies active SI; when asked about HI states "I feel like throttling someone". Endorses history of depression and anxiety, but denies previous psych hospitalizations or suicide attempts. Does not take psych meds or follow with a therapist. Baseline ETOH abuse (several "gallons" per day, beer and vodka), but states last drink 3 days ago. . In the ED, his initial vitals were: 98.7, 134, 134/93, 20, 98% RA. He was triggered for mental status and tachycardia. He got 3L of IV fluids, including a banana bag. Was treated with ativan 2mg IV x2, valium 10 mg PO x1, and valium 5 mg IV x1. His heart rate persisted in the 130's despite fluids and benzos. His blood pressure and respiratory rate remained stable. EKG was notable for sinus tachycardia. His neuro exam in the ED was nonfocal. He was confused and appeared to be hallucinating. Following the benzos, he was able to be aroused and have conversations, but was sleepy. Labs notable for white count of 13 and creatinine of 2.5 (baseline 1.0). Vitals prior to transfer were: 112/70, 130, 19, 99%. . In the MICU, patient was sleepy and occasionally fell asleep during the interview but was easily arousable. He had somewhat slowed speech and flat affect but did not appear to be actively hallucinating. His mini mental status score was 20/30. Pt [**Month/Day (2) 15797**] fever, chills, nausea, vomiting, abd pain, headache, stiff neck, weight loss. Did endorse intermittent racing heart. Tachycardia improved from 130 to 100 without further intervention. . 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, 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: 1. Obstructive sleep apnea. 2. History of gastric ulcer. 3. Status post appendectomy. 4. Hypertension. 5. Hepatitis C. 6. Alcohol dependence since the age of 15 7. Epilepsy [**12-21**] TBI MEDICATION ON ADMISSION: 1. multivitamin 1 tab daily 2. folic acid 1 mg daily 3. metoprolol succinate 25 mg daily 4. levetiracetam 1500 mg [**Hospital1 **] 5. hydrochlorothiazide 12.5 mg daily ALLERGIES: Penicillins PHYSICAL EXAM: Vitals: BP: 124/83 P: 95 R: 18 O2: 99% RA General: Alert, oriented x 2, drowsy but easily arousable, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, 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: strength 5/5, sensation intact, no dysmetria, no drift, CN 2-12 intact. FAMILY HISTORY: One sister with brain tumor. Substance abuse including alcohol in multiple family members including siblings and father. SOCIAL HISTORY: Lives alone in apartment, unemployed and on disability. H/o multiple arrests including A&B since adolescence and a charge of attempted murder (beating his stepfather) which was eventually dismissed. Reports biological father raped him multiple times when patient was four years old to get back at patient's mother. Lost custody of his children (multiple mothers) who are now in [**Doctor Last Name **] care. IVDU, cocaine, MJ and crack; last drug use 3 months ago (cocaine). Continues to drink heavily (as above). Denies smoking.

CHIEF COMPLAINT: Incisional hernia PRESENT ILLNESS: The patient is a 53-year-old male with a history of a giant incisional hernia, status post gastric bypass in [**2167**], complicated by perforated ulcer in 02/[**2168**]. Pt has begun having increased discomfort with plans for repair. MEDICAL HISTORY: Hypertension, Diabetes Mellitus, Depression, Degenerative joint disease Dyslipedemia asthma/bronchitis Chronic back pain Osteoarthritis Obesity Gerd Hepatitis A MEDICATION ON ADMISSION: prozac, xanax, zocor, cardura, B12, MVI ALLERGIES: Penicillins / Percocet PHYSICAL EXAM: PHYSICAL EXAM: GEN: NAD, A&Ox3 CV: RRR, no murmurs, rubs, gallops PULM: CTAB, mild decreased breath sounds at bases bilaterally ABD: Soft, Non-distended. TTP peri midline incision site. Incision site intact without wound dehiscense. JP drains x4 intact with sanguinous drainage. Binder intact. FAMILY HISTORY: Non contributory SOCIAL HISTORY: Ex nurse, works in real estate now. Married.

CHIEF COMPLAINT: see previous PRESENT ILLNESS: Mr. [**Known lastname 57230**] is a 61 year old male with a history of HTN, CAD-s/p angioplasty x2, TIA (x2 in [**2130**] and [**2135**]), high cholesterol, paroxysmal Afib, and hx of PFO and Atrial septal aneurysm with both right to left and left to right shunts (on Coumadin) who was transfered from an outside hospital for evaluation of intracranial hemorrhage. He was in his USOH until Wednesday evening ([**10-26**]) at 7:15 when he had an acute onset of speech difficulty. He was having a conversation with his wife, when he noticed that he "couldn't get his words out". According to his wife, he was making sounds (some words and some nonsense), but not saying complete phrases. He was responding inappropriately to questions (i.e. saying "no" when he meant to say "yes"), but appeared to understand what was being said to him. He was aware of his deficit and frustrated by his inability to communicate. He denies associated numbness, weakness, dysarthria, visual deficits or swallowing problems. [**Name (NI) **] did not have CP, palpitations, or dizziness prior to this episode. His wife called EMS. He was at the OH ER in about 30 minutes by which time his symptoms had resolved. He had a head CT there which showed 2.5 cm left temporal hemorrhage. He was then transferred here for further management. On arrival to the [**Hospital1 18**] ER, his BP was 220/98 and his speech was normal. Then, around 3:00AM he had another episode of language problems which lasted for a minute or so, then spontaneously resolved. He has been asymptomatic since. He was started on nipride in the ER for BP control. He developed a headache and chest pain (right sided, radiating to neck). This resolved with BP was better controlled. He has had similar episodes of language problems in the past. The first episode was in [**2130**] when he had an episode of slurred speech and mild right facial droop. He had a second episode of "inability to talk" in 8/[**2135**]. He was found to have "aphasia" and mild right hemiparesis at that time. He had a head CT which was negative and echo which showed PFO and atrial septal aneurysm. He was started on coumadin at that time. MEDICAL HISTORY: 1. CAD, s/p PTCA in [**2115**] (s/p angioplasty x2) 2. HTN (historically difficult to control) 3. Hypercholesterolemia 4. TIA (x 2) 5. Paroxysmal Afib 6. PFO with ASD on echo with right to left and left to right shunts MEDICATION ON ADMISSION: ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Pt weighs 283 lbs!!!Make sure he is losing weight at follow up visit! FAMILY HISTORY: Uncle: Died of MI in 70's Father: Leukemia, MI at age 65 Uncle: Died of MI in 40's SOCIAL HISTORY: Lives with his wife. His is a high school buisness and government teacher. He has a 20 year old son who is in college. He denies smoking, EtOH or drugs

CHIEF COMPLAINT: Severe bilateral foot gangrene requiring prior bilateral guillotine below-knee amputations PRESENT ILLNESS: Mr. [**Known lastname 29179**] presented on the [**1-23**] at [**Hospital1 **] with severe bilateral foot gangrene. He has had a history of long standing bilateral foot infection and gangrene (wet and dry) extending to his ankle bilaterally. He now presents for revision of his prior below-the-knee guillotine amputations. The remainder of the right BKA was non-viable and necessitated above knee amputation. MEDICAL HISTORY: CAD s/p cardiac cath [**2105-1-21**] with diffuse, minor LAD disease, OM1 80% and RCA 70-99%. PVD with 90% right femoral lesion, stented and right posterior tibial s/p PTCA. Tobacco abuse ESRD on dialysis Diabetes Mellitus Chronic Hepatitis C (unknown genotype) MEDICATION ON ADMISSION: calcium acetate 667mg 2 capsule prior to meals, cozaar 25mg QD, nephrocaps 1 capsule QD, lasix 20mg [**Hospital1 **], senna QD, colace 100mg [**Hospital1 **], omeprazole 20mg QD, simvastatin 40mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 81mg QD, carvedilol 6.25mg [**Hospital1 **], lantus 12U QHS, Humalog SSI ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: PHYSICAL EXAMINATION: VITAL SIGNS - Temp 98.5, BP 119/82, HR 65 BPM, RR 18, O2-sat 100/RA GENERAL - well-appearing man in NAD, Oriented x3, comfortable, Mood, affect appropriate. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK - supple, no thyromegaly, JVD flat, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR NL S1, loud S2, no m/r/g. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES - Doplerable A. femoralis pulses in both extremities right AKA amputation: skin dry over suture, no drainage, no signs of infection left BKA: amputation: skin over suture with some bloody serous drainage, NEURO - awake, A&Ox3, CNs II-XII grossly intact FAMILY HISTORY: No family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Siblings with CABG in their 40s. SOCIAL HISTORY: approx 50 pack year smoking history, currently does not smoke, heavy alcohol use in past but denies current use, denies illicit drug use.

CHIEF COMPLAINT: PRESENT ILLNESS: This 78-year-old white male was in his usual state of health until three weeks ago when he began experiencing chest pressure on exertion. He saw his PCP and was referred to a cardiologist. He had a positive adenosine stress test and an echocardiogram on [**2139-1-23**] revealed LVH with normal left ventricular function. A cardiac catheterization was performed on [**2139-1-29**], which revealed three-vessel disease, which the patient was referred to Dr. [**Last Name (Prefixes) **] for surgery. The catheterization showed a right dominant system with a 90% diagonal-1 lesion, 80% diagonal-2 lesion, a 30-40% LAD lesion, a 30-40% left circumflex lesion, a 60% OM-2 lesion, and a 90% RCA lesion, 85% PDA lesion, and a 95% PLV lesion. He has an EF of 60%. He is now admitted for elective CABG. MEDICAL HISTORY: 1. Hypertension. 2. Esophageal spasm. 3. Elevated blood sugar. 4. Hypothyroidism. MEDICATION ON ADMISSION: 1. Tricor 160 mg p.o. q.d. 2. Omeprazole 20 mg p.o. q.d. 3. Levoxyl 150 mcg p.o. q.d. 4. Isosorbide 30 mg p.o. q.d. 5. Nitroglycerin prn. 6. Metamucil 6 q.d. 7. Multivitamin. 8. Ecotrin 325 mg p.o. q.d. 9. Atenolol 25 mg p.o. q.d. ALLERGIES: He is allergic to clindamycin, he gets a rash. PHYSICAL EXAM: On physical exam, he is a well-developed elderly white male in no apparent distress. Vital signs stable and afebrile. HEENT exam: Normocephalic, atraumatic. Extraocular movements are intact. Oropharynx is benign. Neck was supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids were 2+ and equal bilaterally without bruits. Lungs are clear to auscultation and percussion. Cardiovascular exam: Regular rate and rhythm, normal S1, S2 with no murmurs, rubs, or gallops. Abdomen was soft, nontender, was obese with positive bowel sounds, no masses or hepatosplenomegaly. Extremities are without clubbing, cyanosis, or edema. Neurologic examination was nonfocal. Pulses were 2+ and equal bilaterally throughout with the exception of the DP, which was 1+ and equal bilaterally. On [**2-16**], he underwent a CABG x3 with a LIMA to the LAD, reverse saphenous vein graft to the OM and PDA. Cross-clamp time was 64 minutes. Total bypass time 92 minutes. He is transferred to the CSRU on propofol and Neo-Synephrine. He was extubated the morning of postoperative day #1, and he had his Neo-Synephrine weaned. He received a unit of blood on postoperative day #2 and remained on the Neo-Synephrine. On postoperative day #3, his chest tubes were D/C'd. He was transferred to the floor in stable condition. He was also seen by [**Last Name (un) **] for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult. He continued to slowly progress, but required aggressive physical therapy. He had his pacing wires D/C'd on postoperative day #4. [**Last Name (un) **] liberalized his sliding scale, and then he did not require insulin, so they felt he needed to be diet controlled and follow up with them for teaching. On postoperative day #7, he was discharged to rehab in stable condition. His laboratories on discharge: Hematocrit 24.2, white count 8,000, platelets 308,000. Sodium 135, potassium 4, chloride 100, CO2 27, BUN 36, creatinine 1.4, blood sugar 128. FAMILY HISTORY: His family history is unremarkable. SOCIAL HISTORY: He lives with his wife. Does not smoke cigarettes and has a drink about once a month.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is an 88-year-old female nursing home resident with mild mental retardation who presented to [**Hospital3 1196**] with a temperature of 103 degrees Fahrenheit per rectum, hypertension, and rigors in the setting of one week of upper respiratory symptoms (which included a cough) and malodorous urine in the Foley catheter. The patient was found to be hypotensive to 70/48 which was unresponsive to fluid boluses. The patient was given moxifloxacin and started on a dopamine drip. The patient was also given vitamin K for an INR of 7.2 at [**Hospital3 20445**]. She was then transferred to the [**Hospital1 188**] Emergency Department. The patient was admitted to the Intensive Care Unit for presumed sepsis from a urinary tract infection versus pneumonia. A chest x-ray on admission showed a left lower lobe infiltrate versus atelectasis. An additional of normal saline was given at [**Hospital1 69**], and a central line was placed. The patient was started on Levaquin to treat pneumonia and urinary tract infection. MEDICAL HISTORY: 1. Congestive heart failure. 2. Atrial fibrillation (on Coumadin). 3. Insulin-dependent diabetes mellitus. 4. Mental retardation. 5. Hypertension. 6. History of zoster. 7. Urinary tract infection. 8. Gastroesophageal reflux disease. MEDICATION ON ADMISSION: 1. Regular insulin sliding-scale. 2. Novolin 40 units subcutaneously in the morning. 3. Coumadin 2.5 mg by mouth once per day. 4. Digoxin 0.125 mg by mouth once per day. 5. Lasix 80 mg by mouth in the morning. 6. Lovastatin 20 mg by mouth once per day. 7. Sublingual nitroglycerin. 8. Zoloft 25 mg by mouth once per day. 9. Iron sulfate 325 mg by mouth three times per day. 10. Zantac 150 mg by mouth at hour of sleep. ALLERGIES: PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed the patient's sodium was 147, potassium was 3.6, chloride was 111, bicarbonate was 27, blood urea nitrogen was 28, creatinine was 1.2, and blood glucose was 87. Her hematocrit was 41.1 and her white blood cell count was 36.5. Differential revealed 84% polys, 11% bands, 2% monocytes, and 3% lymphocytes. Urinalysis showed [**Location (un) 2452**] cloudy urine, large blood, negative nitrites, small leukocyte esterase, and a few bacteria, greater than 50 red blood cells, and greater than 50 white blood cells. Serial cardiac enzymes were followed with a documented troponin leak to 0.26 with flat creatine kinase levels. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Hypoxia, Perforated sigmoid diverticulitis, sepsis, respiratory distress PRESENT ILLNESS: Patient is a 60 year-old woman with history of diverticulosis, asthma, significant smoking (>60 pack years) who developed diarrhea on New Year's Day of this year and then subsequently on [**12-10**] acute severe rectal and pelvic pain followed by multiple episodes of vomiting admitted to [**Hospital6 **] on [**12-10**] for perforated proximal rectum by CT. Patient subsequently underwent emergent partial resection of perforated sigmoid colon with diverting colostomy on evening of admission. Transferred to ICU postoperatively with hypotension Hospital course since that time has been complicated by sepsis with bacteroides bacteremia, E. Coli and pseudomonal peritoneal isolates, S. aureus pneumonia and likely ARDS, respiratory failure, coagulopathy. Patient transferred to [**Hospital1 18**] on [**12-14**] night for worsening hypoxia, intubated before transfer. MEDICAL HISTORY: diverticulosis, last colonoscopy in [**4-9**] benign polyps TIA [**4-/2121**] R face, hand and foot paresthesias/MRI at time showed b/l lacunar infarcts in basal ganglia by MRI osetoporosis dx [**9-6**] T12 compresssion fracture and scoliosis [**2124**] sacral fracture hyperlipidemia asthma depression remote alcohol abuse, sober since [**1-8**] got pneumovax in [**11-9**] tobacco 1.5 packs per day since [**2085**] peptic ulcer disease seizure [**1-8**] valium vs. alcohol giant cell tumor in forearm DVT but undocumented (?[**2081**]'s) cholecystectomy kyphoplasty breast biopsy with atypical hyperplasia Echo [**12-13**]-EF of 70%, trace mr, pleural effusions, normal pulm art pressure Pulm function testing [**2126-3-8**]-normal FEV1, FVC MEDICATION ON ADMISSION: TO OSH: ecottrin 81, paxil 10, fosamax 70, singulair 10, flovent and albuterol (not using last 3), muxinex 600BIDprn, ultram 50 q6 hr prn, xanax 0.25 mg prn flying calcium 500 with vitamin D, [**Hospital1 **] ALLERGIES: Penicillins / Biaxin / Vioxx / Erythromycin Base / Wellbutrin / Trazodone / Advair Diskus / Benadryl PHYSICAL EXAM: VS: temp 99.3, BP: 102/53 HR 121 RR 16-no pressors, weight 65 kg Vent: AC 500 x 14, PEEP 7, Fio2 100%, spo2 100% general: intubated, sedated, diaphoretic HEENT:neck is supple, RIJ c/d/i, no JVD, no carotid bruits, no cervical or supraclavicular lymphadenopathy, op without lesions lungs: coarse breath sounds heart: distant, hard to assess over vent/coarse breath sounds abdomen: hypoactive bowel sounds, distended, staples C/D/I, JP drain with serosanguinous fluid, colostomy with stool, dressing C/D/I extremities:no edema, pneumoboots, 2+DP pulses skin:warm, damp, no mottling, no petechiae or rashes neuro:intubated, sedated, FAMILY HISTORY: Mother-alive with hypothyroidism and hyperlipidemia Father-died at 71 from prostate cancer and ALS Paternal aunt with breast cancer. Alcohol abuse among her father, brother and son SOCIAL HISTORY: 1.5 packs per day since [**2085**] (intermittent periods of quitting) history of alcohol abuse, sober since [**1-8**] as per some reports, but nursing notes from OSH note 2 vodka tonics per day. Lives with her daughter and works as a nurse [**First Name (Titles) **] [**Name (NI) 58990**] State Hospital

CHIEF COMPLAINT: s/p Fall PRESENT ILLNESS: 80F with history of COPD on home O2 who was found to have a UTI a week ago and started on Macrodantin by her urologist. She took 3 days of Macrodantin and felt very nauseated and dizzy. On [**5-7**] while walking to the bathroom, she fell and started complaining of hip pain. Four people at [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] rehab helped her up and put her back into bed. She denied any loss of consciousness, blurry vision, chest pain, shortness of breath. A CT scan done showed multiple pelvic fractures, a question of a pulmonary embolism in the RLL and a bladder pollyp. She had seen her urologist one week prior for cystoscopy for hematuria. At [**Last Name (un) 1724**] she had an IVC filter placed [**2172-5-7**] as well as a PICC line. Her Urine Cx from [**2172-5-4**] was ESBL E.Coli for which she has been treated with Imipenem/Cilistatin. MEDICAL HISTORY: COPD, CO2 retainer on home oxygen 2 liters, GERD, DVT 6 years ago, spinal stenosis, CHF, hypertension, osteoporosis, anxiety, bladder cancer, UTI, and shingles. PSH: varicose vein ligation, hysterectomy, IVC filter [**2172-5-7**] MEDICATION ON ADMISSION: Advair 250/50 b.i.d., Spiriva INH, dilt 240 daily, Ativan 0.5 b.i.d. p.r.n., Neurontin 300 b.i.d., Protonix 40 daily, Tylenol, Celexa 10 daily, Colace 100 b.i.d., prednisone 5 daily, Mucinex 600 b.i.d., calcium 600, vitamin D 400, omeprazole 20, MiraLax, senna 2tabs q.h.s., bisacodyl suppository as needed, milk of magnesia 30 mL ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Penicillins / Quinolones PHYSICAL EXAM: Upon admission: Afebrile, BP 111-141/48-70, HR 88-101, RR 19-29, Sat 89-98% on 4L General: Elderly Caucasian Female with pursed lip breathing, mild tacypnea Pulmonary: Inspiratory crackles noted at the bases but overall is markedly improved from yesterday. Cardiac: RR, nl S1 S2, systolic ejection murmur noted over sternum, no rubs or gallops appreciated Abdomen: distended, soft, non-tender, tympanetic to percussion Extremities: No edema noted in lower extremities Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. . FAMILY HISTORY: Noncontributory SOCIAL HISTORY:

CHIEF COMPLAINT: coffee-ground emesis PRESENT ILLNESS: 53M with multiple medical problems, transported from nursing home to [**Hospital1 18**] ED for coffee-ground emesis, hypotension, and tachycardia noted after dialysis. He was found to have an upper GI bleed in the setting of fevers and sepsis. The upper GI bleeding resolved. Once stabilized, a CT scan was obtained which revealed free air and a dilated thickened cecum. Because of this, he was taken emergently to the operating room for exploration. MEDICAL HISTORY: ESRD on HD, left AV fistula clotted DM Dementia Anemia Seizure disorder HTN Depression Pneumonias MEDICATION ON ADMISSION: ASA, Lanthanum, Prozac, Lisinopril, Lopressor, Kayexalate, Nephrocap, Lopid, Estraderm ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: On admission: T 96.1 HR 135 BP 79/52 RR 17 O2sat 88% Gen: intubated and sedated CV: reg rhythm, tachycardic Lungs: CTAB Abd: soft, mildly distended, no tenderness elicited, no masses Rectal: no tenderness elicited, no masses noted, heme neg . ON DISCHARGE: T: 98.1 HR: 81 BP: 149/63 RR: 19 Sat: 97% trach mask NAD, alert and awake RRR coarse bilateral breath sounds soft, mildly distended, wound healing well with grannulation tissue, clean no edema of extremities FAMILY HISTORY: noncontributory SOCIAL HISTORY: per daughter - no ETOH, "a lot" cigarettes

CHIEF COMPLAINT: hypotension, fever PRESENT ILLNESS: Ms. [**Known lastname 70847**] is a 50 year old woman with h/o rectal ca s/p radiation, chemotherapy, and surgery, radiation-induced damage s/p ileostomy, HIV on HAART (last CD4 263 in [**1-26**]), obstructive renal failure from radiation fibrosis with b/l nephrostomy tubes and h/o recurrent obstructions, DVTs on Coumadin, sacral decubitus ulcer with coccygeal osteomyelitis, who was sent to the ED with Na 115, K 6.3, Cr 4.8 on recent outpatient labs, now admitted to the ICU with hypotension. The patient endorses feeling some fatigue, malaise, abdominal cramping. She has had increased vaginal discharge for the past couple week. Occasional nausea and vomiting, nonbloody/nonbilious. She notes increased watery ostomy output for 1-2 weeks and decreased urine output from her b/l nephrostomy tubes for 1-2 days. She had decreased PO intake over the past day. She does receive IV Mg and 1LNS every other night at home. One fever to 100.8 several days prior to admission, but no recurrence. Of note, she was started on Ciprofloxacin 5 days prior for a UTI by her PCP. [**Name10 (NameIs) **] has also been closely monitored for hyperK and ARF for the past 2 weeks as an outpatient, which was being treated with Lasix and IVF at home. MEDICAL HISTORY: ONCOLOGIC HISTORY: 1) Rectal cancer: - late [**2139**]: 6 months of intermittent rectal bleeding, rectal pressure and a sensation of incomplete emptying. - [**2141-1-26**]: colonoscopy revealed a polyp in her sigmoid colon and a 2.5 cm distal rectal mass arising from the anal verge in the posterior rectum with a large area of induration. - [**2141-1-31**]: CT torso revealed an exophytic rectal mass measuring 4.8 x 3.8 cm, bulging posteriorly into the presacral space and anteriorly towards the uterus. There were enlarged lymph nodes in the perirectal fat adjacent to the mass, a 9-mm enhancing lymph node in the left pelvic sidewall, and enhancing lymph nodes in the right external iliac region. There was also a 7-mm hypodensity in the caudate lobe of the liver. Rectal ultrasound on [**2141-1-31**] and rectal MRI on [**2141-2-7**] were compatible with T3 disease. There were at least four abnormal perirectal lymph nodes seen on MRI, in addition to multiple bilateral enlarged pelvic sidewall lymph nodes, concerning for extensive disease. - [**2141-2-20**]: began chemoradiation - [**2141-3-10**]: 5-FU was discontinued due to mucositis, neutropenia, and abdominal cramping - [**2141-3-13**]: 5-FU was restarted at a reduced dose - [**2141-3-22**]: 5-FU was again stopped due to mucositis, perirectal skin changes, diarrhea, and electrolyte abnormalities. - [**Date range (3) 70844**]: Radiation was also held - [**2141-3-27**]: 5-FU was restarted at a further reduced dose - [**2141-3-31**]: completed radiation - [**2141-4-3**]: completed chemotherapy - [**Date range (3) 70845**]: hospitalized for bowel rest and the initiation of TPN due to presumed radiation enteritis. - [**2141-5-31**]: found to be HIV positive and began on HAART - [**Date range (1) 70846**]: required hospitalization for an SBO, underwent laparotomy, ileocecectomy, end-ileostomy, and placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube on [**2141-6-16**]. Pathology from this surgery revealed severe radiation-induced acute ischemic enteritis. She recovered from this surgery, but continued to require TPN. - [**7-/2141**]: Once her CD4 count had recovered, she underwent laparotomy, lysis of adhesions, ileal resection, proctosigmoidectomy, colonic jejunal pouch to near-anal anastomosis with EEA, takedown splenic flexure, resection of ileostomy and creation of new end-ileostomy. Pathology from the surgical specimen revealed no residual carcinoma and all 14 lymph nodes sampled were free of disease. - [**9-/2141**], [**10/2141**]: Subsequent imaging of the abdomen & pelvis showed no evidence of recurrence. - [**2142-2-14**]: CT abdomen showed "hyperdense thickening in the lumen near the anastomatic site, new since the earlier study. Local recurrence cannot be excluded, although possibly the appearance is associated with endoluminal debris." . OTHER MEDICAL HISTORY: 2) HIV CD4 count 124 on [**12/2143**] 3) Short gut syndrome secondary to bowel surgery for CA. 4) Obstructive renal failure from radiation fibrosis, in the past necessitating b/l nephrostomy tubes which have required multiple revisions. 5) Lower extremity neuropathy, likely secondary to radiation fibrosis, uses a wheelchair since 4/[**2141**]. 6) Pancreatic insufficiency. 7) Anemia. 8) Chronic pain. 9) DVT in LE X2: requires lifelong coumadin, most recent [**4-24**]. MEDICATION ON ADMISSION: Abacavir-Lamivudine 600-300mg 1tab PO daily Darunavir 800mg PO daily Norvir 100mg PO daily Albuterol 1neb q4-6h prn Ciprofloxacin 250mg PO BID (start [**2144-5-5**]) Vitamin D 50,000units PO daily Fentanyl lozenges 200mcg PO q6h prn Folic acid 1mg PO daily Furosemide 20mg IV prn Dilaudid 32mg PO q2h prn IVF - NS prn Lansoprazole 30mg PO daily Lidocaine-Diphenhydramine-Maalox 10-15mL q4-6h prn Magnesium sulfate 2g IV 3x/week Methadone 15mg PO q6h Mirtazapine 15mg PO qhs Nortriptyline 50mg PO daily Zofran 4-8mg PO q6h / 4mg IV q6h prn Phenytoin 100mg applied to open wound daily Lyrica 50mg PO TID Ranitidine 300mg PO qhs Triamcinolone 0.1% paste TD TID prn Warfarin as directed Ascorbic acid 500mg PO daily Vitamin B12 1000mcg PO daily Ferrous sulfate 325mg PO daily Loperamide 4mg PO prn Miconazole 2% ointment [**Hospital1 **] prn ALLERGIES: Codeine / onions PHYSICAL EXAM: ADMISSION EXAM Vitals: 98.2 106/72 91 20 99%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL FAMILY HISTORY: Father died at age 72 from MI. Mother is alive and well. Remote family history of breast cancer. Daughter with ulcerative colitis. SOCIAL HISTORY: Lives in [**Location 17566**] with her husband and several children. No tobacco or EtOH use. Used to be account manager, now on long-term disability. Has [**First Name9 (NamePattern2) 269**] [**Location (un) 5871**], with skilled nursing 1h X 3/week + aid 1h X2/week. She is wheelchair bound.

CHIEF COMPLAINT: left sided weakness PRESENT ILLNESS: This is a 57 year-old male with a history of NSCLA lung cancer with brain mets, known pontine lesion, who presents with hypoxia and worsening L sided weakness (arm, leg and facial droop). Patient was [**Last Name (un) 4662**] to the ED by his wife after she noted worsening left sided weakness on the am of admission that has been progressing over the last week. When she was unable to get him out of bed, she called EMS. . Of note, patient was seen by his PCP [**Last Name (NamePattern4) **] [**2152-9-7**] for left arm weakness and reported coughing episodes with liquids. During that visit, his PCP noted more slurred speech and was suspicious for aspiration. An outpatient MR [**First Name (Titles) **] [**Last Name (Titles) 93516**] his known pontine lesion was scheduled for the day of admission and an outpatient speech and swallow was planned. His wife noted that he had a persistent cough w/sputum production last week which she feels is improved over the past few days. There have been no fevers or chills, nausea, vomiting, diarrhea. He has urinary frequency at baseline. . In the ED, VS T 99 HR 77 BP 99/67 RR 20 POx 87% on RA which improved with NRB to 100%. A Head CT was negative for acute change. A CTA demonstrated multifocal PNA for which he received a dose of cefepime and levofloxacin. It was negative for PE. . ROS: The patient [**Last Name (Titles) **] 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, headache, rash or skin changes. MEDICAL HISTORY: - Nonsmall cell lung cancer with metastases to brain, s/p VATS to right lower lung on [**2150-7-24**], surgical resection of brain tumor on [**2141-12-19**], s/p whole brain irradiation from [**2142-1-8**] to [**2142-2-5**]; now with pontine metastases getting Cyberknife treatments - Hypothyroidism - Depression/Anixety - CAD s/p CABG [**2139**] - Non sustained VT on Amiodarone - Ischemic cardiomyopathy with EF of 20-30% [**8-3**] by echo - Bilateral cataract surgery - Erectile dysfunction - Avascular necrosis of right humerus - S/P Cholecystectomy - S/P Right shoulder surgery x 2 - Tremor MEDICATION ON ADMISSION: AMIODARONE - 200 mg Tablet [**Hospital1 **] ASPIRIN - 81MG Tablet daily CLONAZEPAM [KLONOPIN] - 0.5mg [**Hospital1 **] DEXAMETHASONE - 4 mg qAM 2mg QPM DIGOXIN - 125 mcg Tablet - daily FOLIC ACID - 1 mg Tablet daily GEMFIBROZIL - 600 MG TABLET - [**Hospital1 **] LEVOTHYROXINE - 100 mcg Tablet - daily PAROXETINE HCL [PAXIL] - 40 mg Tablet daily PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg Tablet - q6 hours prn PROPRANOLOL - 20mg [**Hospital1 **] SIMVASTATIN [ZOCOR] - 40 mg Tablet - daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Vitals: T:97.6 BP:93/58 HR:74 RR:14 O2Sat: 94% on 3L NC GEN: Chronically ill, well-nourished, no acute distress HEENT: EOMI, pupils 4mm, right briskly reactive, left minimally reactive, sclera anicteric, no epistaxis or rhinorrhea, MMD, OP w/ white plaques on tongue/hard palate NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: HS distant, RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: scattered rhonchi left >right, no wheezing or rales ABD: obese, Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords, WWP NEURO: alert, oriented to person, place, and time. repeatedly asking same questions. speech slurred. tongue deviates to left, left eye lids weak. Strength in left upper/lower extremity [**4-1**]. Strength on right [**5-1**]. Hyperreflexic at petellar/achilles/brachial on left. Plantar reflex upgoing on left. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. FAMILY HISTORY: There is no family history of breast, ovarian, uterine, colon, or lung cancer. His brother did have pancreatic cancer at the age of 70. His mother died at age 83. He does not know of any specific medical problems that she had. His father died at age 52 of a myocardial infarction. He also had a sister who died of an aneurysm. SOCIAL HISTORY: He is married. He has 3 children between the ages of 20-30. He used to work for NSTAR and has a history of asbestos exposure. He smoked 2-1/2 packs per day for 20 years, but quit 10 years ago. He does not drink alcohol.

CHIEF COMPLAINT: Fluid overload. PRESENT ILLNESS: This is a 72 year-old gentleman with a history of coronary artery disease status post coronary artery bypass graft, atrial fibrillation, congestive heart failure, with ejection fraction about 10 to 15% followed by the Heart Failure Clinic who presented with congestive heart failure exacerbation. He was initially admitted to Coronary Care Unit for Swan-Ganz placement and diuresis with Nitrocor. He had gained about 15 pounds from his baseline and he has been feeling lousy for the past two weeks prior to his admission. He complained of increased dyspnea on exertion, unable to climb six stairs without stopping. He has been on congestive heart failure diet with fluid restriction. He has been drinking less then 1 to 1.5 liters of fluid a day and takes less then 2 grams of sodium a day. He denies episodes of orthopnea or paroxysmal nocturnal dyspnea, but did report getting up one to two times per day to urinate. He also had occasional nonproductive cough, but denied any fevers or chills or night sweats. He has had constipation for which he took two Fleet's enemas [**2-22**] with good relief. His last bowel movement was the day before admission. He denies nausea, vomiting, bleeding per rectum. He also reports a brief episode of associated chest pain starting from the left side radiating to the right side. MEDICAL HISTORY: 1. Congestive heart failure with an ejection fraction 10 to 15%. 2. Coronary artery disease status post coronary artery bypass graft with redo in [**2167**], saphenous vein graft to left anterior descending coronary artery, saphenous vein graft to right coronary artery, saphenous vein graft to obtuse marginal. 3. Hypertension. 4. Atrial fibrillation. 5. Chronic renal failure. 6. Post polio syndrome at age 5. 7. Mitral and tricuspid valvuloplasty. 8. AV block status post pacer placement in [**2168-1-4**] upgraded to ICD and biventricular pacer in [**2169-12-3**]. 9. Type 1 diabetes. 10. Gastroesophageal reflux disease. 11. Peripheral neuropathy. MEDICATION ON ADMISSION: Bumex 3 mg po b.i.d., Hydralazine 40 mg q.i.d., Imdur 30 mg q.d., Coreg 3.125 mg po b.i.d., Protonix 40 mg po q.d., Synthroid 25 micrograms po q.d., Amiodarone 200 mg po q.d., Neurontin 100 mg po q.d., aspirin 81 mg po q day, Coumadin one tablet po q.h.s. ALLERGIES: Lipitor and Welchol with arthralgias. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Decreased exercise tolerance PRESENT ILLNESS: This is a 58 year old gentleman with a history of mitral valve prolapse followed by serial echocardiograms. He is mainly asymptomatic except for a decreased exercise tolerance. On a routine stress echo in [**2197-12-22**], he was found to have inferior-posterior ischemia and cardiomyopthy (LVEF 36%). A cardiac catheterization was performed which showed mild coronary artery disease and severe mitral regurgitation with an LVEF of 55%. Given the progression and severity of his mitral valve disease, he has been referred for surgical evaluation. MEDICAL HISTORY: Mitral Valve Prolapse, Mitral Regurgitation Dyslipidemia History of SVT - Asymptomatic s/p Right knee arthroscopy [**2196**] MEDICATION ON ADMISSION: Lipitor 20mg daily Metoprolol succinate 12.5mg daily Aspirin 81mg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Preop Exam: Height: 72" Weight: 215lbs Pulse:69 Resp: 16 O2 sat: 99% BP Right: 142/95 Left: 149/83 FAMILY HISTORY: Grandfather died at young age of MI SOCIAL HISTORY: Lives with: Wife. [**Name (NI) **] 2 grown children. Occupation: Works for Globe Tobacco: Never ETOH: 1-2 beers/drinks daily

CHIEF COMPLAINT: 65 year-old female with multiple medical problems status-post open cholecystectomy on [**2191-7-12**], transferred from outside hospital with wound infection. PRESENT ILLNESS: Ms. [**Known lastname **] is a 65 year-old female with extensive past medical history including right mastectomy, CAD, CHF, COPD, stroke with residual left hemiparesis, schizoaffective disorder, mental retardation, AAA and arthritis. She had an open cholecystectomy for gallstone pancreatitis on [**2191-7-12**]. She was discharged to a nursing home. She is being readmitted with a wound infection, transferred from [**Hospital1 55475**] Hospital. MEDICAL HISTORY: S/p Open cholecystectomy on [**2191-7-12**] 1.Gallstone pancreatitis 2.Mechanical aortic valve 3.Chronic obstructive pulmonary disease 4.Abdominal aortic aneurysm 5.Schizoaffective disorder 6.Non insulin dependend diabetes mellitus 7.Congestive heart failure: LVEF 63% with normal wall motion on [**6-/2191**] nuclear test. 8.s/p R masectomy 9.Known MRSA colonisation by nasal swab s/p CVA with L hemiparesis MEDICATION ON ADMISSION: Ferrous sulfate 325 mg PO daily Folic acid 1 mg PO daily Risperdal 2 mg PO qAM, 3 mg PO qpm Albuterol 90 mcg 2 puffs q 6 hours prn Tylenol 2 tabs PO q 4 hours prn Kayexalate 15 mg/60ml PO 5x/week Coumadin 4 mg PO qday Valproic acid 750 mg PO qam, 100 mg PO at 1400 and qhs Cogentin 0.5 mg PO BID Flovent 110mcg 2 puffs [**Hospital1 **] Traxodone 50 mg PO TID Atrovent inhaler 2puffs QID ALLERGIES: Mellaril / Lithium / Thorazine PHYSICAL EXAM: On [**2191-9-7**] per surgery note: Vitals: Temperature 97.2; BP:112/50; P:84; RR: 20. Baseline confused. Dyskinetic movements. Regular rhythm Lung with decreased air entry bilaterally--- difficult to examine Abdomen: Erythema, wound fluctuance. Periwound tenderness. On [**2191-9-16**], per medical intern note: General: Elderly female, short stature, sitting up in chair, tachypneic, screaming for swabs and juice. HEENT: MMM. NCAT. Sclera anicteric Neck: Supple, R IJ line in place. No pain on palpation. No LAD. CV: RRR Mechanical S2. ? mumur at LUSB. Lungs: Uncooperative. Poor air movement. Abdomen: +BS. Soft, NT, ND. Dressing removal revealed open wound ~ 7 cm in length. Mildly erythematous on edges. Ext: Pneumoboots in place. DP 2+. Pitting in form of pneumoboots so hard to access. 1+ b/l. Neuro: Alert and oriented: Hospital, though did not know which one. Knew it was [**2191-8-21**] though not exact date. FAMILY HISTORY: Non contributory SOCIAL HISTORY: Lives at [**Hospital **] Healthcare Center.

CHIEF COMPLAINT: postmenopausal bleeding, fever PRESENT ILLNESS: 55 yo G0 initially presented to care in the emergency department [**11-3**] with PMB. She had a pelvic US and CT abdomen and pelvis which demonstrated a thickened heterogeneous endometrium. Her HCT was 36. She was felt to be hemodynamically stable and was discharged with close GYN f/u. She returned shortly thereafter with heavier vaginal bleeding, a low grade fever, and low abdominal discomfort. MEDICAL HISTORY: OB/GYN: no paps/ pelvic exams, never sexually active, last regular menses ~ age 40-42, PMB started in [**2162**], heavy since [**Month (only) **], +[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 4585**] PMH: pulmonic stenosis, likely HTN PSH: sternotomy with repair of pulmonic stenosis MEDICATION ON ADMISSION: tylenol ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline Hcl PHYSICAL EXAM: On admission: Physical Exam: Vitals - T:100.7 BP:153/73 HR:115 RR:16 O2sat:100% r/a General: NAD, resting comfortably CV: tachycardic, regular rhythm Lungs: CTAB Abdomen: soft, non-distended, mild lower abdominal TTP, no rebound/guarding Pelvic: attempted exam, with one finger had significant discomfort, was unable to palpate cervix/uterus, introitus quite narrow, no active bleeding, moderate amount of blood on exam glove FAMILY HISTORY: F - HTN, CAD, CLL, carcinoid tumor, died 9/02 M - mitral valve regurgitation, s/p valve replacement; CHF; ?vaginal cancer MGF, MGM - coronary artery disease SOCIAL HISTORY: No tobacco, alcohol, or illicit substance use. Lives alone, has never been sexually active, works at the radiology department at [**Hospital1 18**] as a transcription coordinator although does not have regular patient contact.

CHIEF COMPLAINT: Bilateral leg pain. PRESENT ILLNESS: The patient is a 46 -year-old African American male with a history of chronic obstructive pulmonary disease, obstructive sleep apnea, cor pulmonale, hypertension, chronic renal insufficiency, and chronic venous ulcers. The patient has a complaint of three days of worsening bilateral lower extremity pain, left greater than right. The patient has noticed increased pain and increased swelling, as well as increased erythema, especially when weight bearing. The patient has a left lower extremity ulceration that gets dressing changes every other day by [**Hospital6 1587**]. The patient has stopped taking Lasix because he has an increased bicarbonate level and it was restarted a few days ago. The patient denies any fever or chills, rigors, and upper extremity swelling. The patient also has a complaint of a cough for approximately one month that is productive of white clear sputum. The patient states this is unchanged. The patient is oxygen dependent, three liters at home, has chronic obstructive pulmonary disease, and CPAP at night for his obstructive sleep apnea. The patient denies any shortness of breath or green sputum production. The patient uses metered dose inhalers at home. The patient also complained of substernal chest pain on the left which was non-radiating, which lasted minutes, and had no associated symptoms. The patient denies shortness of breath, abdominal pain, diarrhea, melena, hematochezia, hematemesis, upper respiratory infection symptoms, or palpitations. The patient has noticed a decrease in urine output without any associated dysuria. The patient is unclear when Lasix was held and restarted. The patient has chronic renal insufficiency with a creatinine baseline at 2.5. MEDICAL HISTORY: 1. Obesity. 2. Obstructive sleep apnea, requiring CPAP. 3. Hypertension. 4. Pulmonary hypertension. 5. Chronic obstructive pulmonary disease, requiring O2 of three liters at home. 6. Cor pulmonale. 7. Chronic renal insufficiency. 8. Venous ulcers. 9. The patient had an echocardiogram on [**2139-6-16**] which showed an ejection fraction of over 55% with a dilated right ventricle and hypokinesis and 3+ tricuspid regurgitation. MEDICATION ON ADMISSION: ALLERGIES: Keflex and oxacillin which he reports is not anaphylactic. PHYSICAL EXAM: FAMILY HISTORY: Sister and brother both had strokes. Mother died of bone cancer. SOCIAL HISTORY: He is a heavy drinker, quit at age 20. Previously used marijuana, cocaine, but quit ten years ago. He has a 15 pack year history of tobacco. He is married, does not work.

CHIEF COMPLAINT: Hyperkalemia PRESENT ILLNESS: 57 year old male with history of EtOH and HCV cirrhosis (genotype 1, treatment-naive) complicated by ascites, hepatic encephalopathy, with most recent EGD in [**2163**] showing no varices, as well as seizure disorder, polysubstance abuse on methadone, with recent admission for hepatic encephalopathy, now referred from his PCP's office for hyperkalemia and acute renal failure. He admits that he is often noncompliant with her medications, and is almost completely reliant on his sister [**Name (NI) **] to administer them (he can't even say which meds he's on). His last admission ([**9-13**] - [**2165-9-19**]) was notable for hyponatremia, hyperkalemia, acute kidney injury, and encephalopathy. He underwent large volume paracentesis (4.7L), from which the peritoneal fluid grew GPCs and he was treated with vancomycin for 48 hours until cultures returned showing one bottle growing peptostreptococcus (believed to be a contaminant). Antibiotics were discontinued at that time and he had no further signs of infection for the remainder of his hospital stay. His acute kidney injury was thought to be related to hypovolemia from overdiuresis, improved with IV albumin. His hyperkalemia was treated with kayexylate and the hyponatremia improved with fluid restriction (132 on discharge). His hepatic encephalopathy resolved with lactlose. He was given ciprofloxacin 250mg daily for SBP prohpylaxis (given low peritoneal fluid protein) and spironolactone was decreased from 200 to 100mg + furosemide decreased from 80 to 40mg. Since discharge, patient has had 3 weekly, large volume paracenteses ([**9-24**] - 5L, [**10-3**] - 4.75L, [**10-7**] - 3L). He was seen by his PCP today who checked routine labs, which showed K+ of 6.8 along with acute kidney injury (creatinine of he was referred to the ED for further management. In the ED, triage vitals were 96.7 73 109/65 20 97%. He was AAox3 and without complaints. Labs showed K 6.8, Na 121 (ranging 121-132 in past 20 days) Cr 1.9 (baseline ranging 0.9- 1.8 in past 20 days) INR 1.7, AST 47 ALT 89 tbili 1.4, Lactate 2.1. EKG reportedly had no peaked T waves, He was given calcium gluconate, dextrose + insulin, kayexelate, and 1L IV NS. His blood glucose dropped and he started having terrible muscle cramps, requiring morphine and lorazepam to calm him down. He is being admitted to the ICU after he received too much insulin and concern for hypoglycemia. On arrival to the MICU, he is awake, oriented, but sleepy. His muscle cramps are much improved and he is having lots of diarrhea. His electrolytes have started to normalize. MEDICAL HISTORY: - Cirrhosis [**2-21**] EtOH and HCV (genotype 1, treatment naive) --- Decompensations: hepatic encephalopathy, ascites requiring weekly paracenteses, --- IV drug abuse (quit in [**2151**]) --- Alcohol abuse (quit in [**2151**]) --- Confirmed by biopsy in [**2159**] --- Being actively considered by transplant - Seizure disorder, not on any AEDs - Polysubstance abuse, on methadone MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Methadone 100 mg PO DAILY Hold for sedation 2. Lactulose 30 mL PO TID 3. Rifaximin 550 mg PO BID 4. Ciprofloxacin HCl 250 mg PO Q24H 5. Furosemide 40 mg PO DAILY hold for SBP<90 6. Spironolactone 100 mg PO DAILY Hold for K>5.5 7. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) ALLERGIES: Iodine PHYSICAL EXAM: On admission: Vitals: T: 97.7, BP:121/62, P: 113, R 20, O2:97% RA General: alert, oriented, no acute distress, but requires re-directing to keep his attention; temporal wasting HEENT: Sclera anicteric, MMM, oropharynx clear, edentulous; EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops; chest remarkable for gynecomastia Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: markedly distended and tympanitic, non-tender, bowel sounds present, significant splenomegaly palpated with some ascites leaking from umbilicus and prior paracentesis sites GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: + asterixis, CNII-XII intact, 5/5 strength upper/lower extremities (able to sit himself up for lung exam), grossly normal sensation, gait deferred FAMILY HISTORY: Father - unknown Mother - deceased age 71, ?cancer, hypercholesterolemia Siblings - AIDS, hypercholesterolemia SOCIAL HISTORY: Tobacco history: [**3-24**] ppd currently. 40 years total. -ETOH: None since [**2151**] -Illicit drugs: Previous Heroin, none since [**2151**] -Home: Lives with brother and sister. Does hobbies around the house.

CHIEF COMPLAINT: decreased responsiveness PRESENT ILLNESS: 68yo woman with PMH significant for seizure disorder, schizoaffective disorder, mental retardation, hypercholesterolemia, and depression, who presents with decreased responsiveness. Per notes, she was noted to have "seizure activity with tremors of upper and lower extremities, incontinent" with VS T 99.2ax, SaO2 84%/RA. This lasted 25 minutes, after which she opened her eyes but did not speak. She was brought to [**Hospital1 18**]. In the ED, she was noted to have shaking movements, though she withdrew during the shaking. She was given ativan 1mg IV x 1. Initially she was opening her eyes to stimuli, but has not since the ativan. MEDICAL HISTORY: seizure disorder - generalized disorder with GTCs, myoclonic jerks, drop attacks, tonic seizures, subclinical seizures tremor schizoaffective disorder mental retardation hypercholesterolemia depression anxiety MEDICATION ON ADMISSION: Medications: colace 100mg daily lipitor 10mg daily folic acid 1mg daily topamax 25mg qam, 150mg qpm calcium carbonate 500mg tid MVI aspirin 81mg daily valproic acid liquid 750mg qam, 1000mg qpm vitamin B12 500mcg daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: T 100.7 temporal, HR 101, BP 111/47, RR 20, SaO2 100%/4L Genl: lying in bed HEENT: NCAT, MMM, OP clear Neck: supple, no bruits CV: RRR, nl S1, S2, no m/r/g Chest: CTAB anteriorly Abd: soft, NTND, BS+ Ext: warm and dry FAMILY HISTORY: Son with generalized seizures and grandson with [**Name2 (NI) 43826**] mal seizures. SOCIAL HISTORY: She states that she has a 6th grade education from [**Male First Name (un) 1056**]. She lives in a group home, [**Doctor First Name **] (home case manager). She does not smoke, drink, or use drugs.

CHIEF COMPLAINT: Shortness of breath PRESENT ILLNESS: This is a 62 year old diabetic woman with CAD s/p [**2157**] CABG (LIMA to LAD, SVG to D1, SVG to D2, SVG to OM. SVG to PDA), s/p catheterization in [**2162**] with LAD stent in [**2162**] and revealing occluded SVG to D1, SVG to D2, SVG to OM and patent LIMA and patent SVG to rPDA. Also with systolic CHF with EF 40-45%, PPM in [**8-/2168**], carotid stenosis/TIAs, and s/p living-related renal transplant in [**2161-9-13**] with baseline Cr 1.6--2.0. . She presented to [**Hospital6 5016**] on [**2169-3-28**] with complaints of of shortness of breath. Per the patient, she had been feeling worsening shortness over the prior few days to the point she could only take a few steps. She was ruled out for myocardial infarction by cardiac enzymes. She had elevated CK's but low MB fraction and negative troponins. The patient was noted to be anemic and received two unit packed RBC's. The patient was also noted to be hyperkalemic and hyponatremic; she was presumed to have aldosterone insufficiency and was, was placed on florinef and salt tablets. The patient was diuresed on a day to day basis and her oxygenation and volume status would improve with diuresis. Her volume status, however, would worsen soon after the diuretic wore off Today was in respiratory distress and hypoxic. Chest X-ray revealed pulmonary edema. Placed on non-rebreather, ABG 7.31/46/113. Patient given lasix 80mg IV and zaroxylyn with improved oxygenation. Concern was raised for new ischemic event leading to L heart failure and pulmonary edema. For this reason, transfer to [**Hospital1 18**] was requested for possible cardiac catheterization. . On arrival, the patient reports her breathing is still uncomfortable. She denies having had any chest pain the past few weeks but does report continued epigastric pain and nausea (also reported at the outside hospital). No palpitations or lightheadedness MEDICAL HISTORY: type I diabtes s/p renal transplant as above hypertension congestive heart failure with EF 45% coronary disease s/p cabg and PCI as above symptomatic bradycardia s/p PPM bilateral carotid stenosis Severe gastroparesis. Bilateral internal carotid stenosis. History of colonic polyps. History of erosive gastritis. Tertiary hyperthyroidism. History of transient ischemic attacks. Nephrotic syndrome. Depression with panic attacks. Diabetic retinopathy s/p laser surgery, due to undergo more laser surgery . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Cardiac History: CABG, in [**2157**] anatomy as follows: LIMA to LAD, SVG to D1, SVG to D2, SVG to OM. SVG to PDA . Percutaneous coronary intervention, in anatomy as follows: . Pacemaker, in [**8-/2168**] for symptomatic bradycardia . MEDICATION ON ADMISSION: 1. Clopidogrel 75 mg daily. 2. Aspirin 325 mg E.C.daily. 3. Atorvastatin 80 mg PO Daily. 4. Carvedilol 12.5 mg PO BID. 5. Isosorbide Mononitrate 60 mg Tablet SR daily. 6. Nitroglycerin 0.3 mg Tablet, PRN 7. Furosemide 20 mg PO Daily. 8. Lisinopril 5 mg PO Daily). 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Lantus 24 units SC qHS 11. Prednisone 5 mg PO daily. 12. Tacrolimus 1 mg PO Q12H 13. Phenytoin Sodium Extended 100 mg QAM, 200 mg qPM. 14. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 15. Gabapentin 300 mg PO TID. 16. Citalopram 40 mg PO daily 17. Pantoprazole 40 mg E.C. PO Q24H. 18. Metoclopramide 10 mg PO TID. 19. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID as needed. 20. Calcitriol 0.25 mcg PO every Other day 21. Iron 325 daily. . On transfer the patient was also on 1) NaCL tablet 1 g [**Hospital1 **] 2) Florinef 0.1 mg PO daily 3) Nephrocaps she was not on lisinopril metoprolol 25 [**Hospital1 **] carvedilol ALLERGIES: Erythromycin Base / Percocet / Codeine / Zithromax PHYSICAL EXAM: VS - T 98.9 P 70-80 BP 172/82 RR 26 O2 100% on NRB Gen: Elderly female in NAD. Oriented x3. Anxious. Mood, affect appropriate. Head: NCAT. Eyes: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, Mouth: MM dry No xanthalesma. Neck: Supple with JVP of 9 cm. CV: RR, normal S1, S2. No thrills, lifts. No S3 or S4. Chest: Poor air movement. CTAB, no crackles, wheezes or rhonchi. Mildly decreased BS at bases bilaterally Abd: Soft, mild epigastric tenderness. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 1+ Femoral 1+ Popliteal 1+ DP 1+ Left: Carotid 1+ Femoral 1+ Popliteal 1+ DP 1_ FAMILY HISTORY: FAMILY HISTORY: Diabetes, hypertension, and coronary artery disease. * SOCIAL HISTORY: SOCIAL HISTORY: 60 pack year history of tobacco use. Quit in [**2161-9-13**]. No ethanol use. Lives with at [**Hospital3 **]. *

CHIEF COMPLAINT: intracranial hemorrhage, possible seizure & hypotension PRESENT ILLNESS: 50 year-old man with history of EtOH abuse who was transferred from an OSH. The history was obtained from the medical record and is not clear. Pt may have had a fall from standing vs. possible seizure activity vs. possible assault. It is not clear whether this was a witnessed event or if pt was presumed to have fallen foward, because of injuries to his face. Pt was taken to an OSH yesterday morning where he was initially alert and talking. Head and neck CTs and CXR were negative per report from OSH records. Pt was seen by ENT who repaired a lip lac but did not document any facial fractures. Throughout the course of the day, pt became increasingly agitated. EtOH level was <10, and given his ETOH history, pt was believed to be in withdrawal. He received increasing doses of ativan and was put on an ativan gtt (prior to intubation). Given the increasing agitation as well as increased facial swelling, pt was ultimately intubated for airway protection. Pt was first started on propofol but became hypotensive with a HR in the 140s to 180s and was then switched to fentanyl and versed with some improvement in hemodynamics. Pt was also given Thiamine, Folate, MVI & approx 2L of NS, then transferred to [**Hospital1 18**]. . In the ED here, VS: T 97, HR 130, BP 144/74, RR 20, 98%. He was noted to have minimally reactive pupils and was moving when off sedation (pt had been given fentanyl, ativan, and versed for sedation). Pt had a repeat head CT which showed a small intracranial hemorrhage, pt was then noted to be in Afib with RVR of 160s. Pt received a total of 5L NS. FAST exam was negative. Pt received a total of 15mg diltiazem IV with SBP to 90s and HR 110, he was then started on a dilt gtt with HR 120s and SBP 100s. Initial ABG was 7.38/46/369 & vent was adjusted. . MEDICAL HISTORY: H/o ETOH Abuse h/o falls ? seizure history Chronic subdural hematoma MEDICATION ON ADMISSION: Pt was unable to recal his medications & his pharmacy did not have any records of his prior medications. ALLERGIES: Penicillins PHYSICAL EXAM: On transfer to medicine floor T 98.6 BP 105/68 HR 105 RR 19 O2Sat 94% 2LNC Gen: NAD HEENT: lip laceration with stiches, +dried blood over left perioral area, PERRLA, EOMI NECK: no LAD, no JVD CVS: + S1S2, no M/R/G, RRR PULM: CTA b/l, no wheezing or rhonchi ABD: + bowel sounds, soft, nd, nt Skin: warm extremities, no rash EXT: 2+ DP, no edema/c/c Neuro: AA0x1 to self, pt thinks he is at [**Hospital1 2025**], date is [**2112**], cannot give name or telephone numbers of friends or family, moving all extremities, CN II-VII grossly intact, pt does not follow all commands-difficult to assess neuro exam FAMILY HISTORY: NC SOCIAL HISTORY: Born and raised in El [**Country 19118**]. Oldest of 9 siblings. Moved to USA in [**2085**] with entirefamily. Never married, no children. Lives in [**Location (un) **] with his mother. [**Name (NI) 1403**] at a supermarked stocking shelves. Has been at risk of losing job due to ETOH use. Pt has been to jail "many times" but "only for a few hours" due to being intoxicated in public.

CHIEF COMPLAINT: Necrotic second right toe PRESENT ILLNESS: 87 y/o female with PMH significant for PVD who was admitted to the vascular surgery service on [**6-21**] who is now transferred to medicine after suffering a NSTE MI and a GI bleed. Pt was admitted with a nonhealing foot ulcer on her right foot and a gangrenous toe. Pt underwent angiography of the right on [**6-22**]. This showed a patent CFA and profunda. The SFA and popliteal were diffusely diseased. AT with multiple regions of stenosis along its length. There was also an occluded distal AT and reconstitution of the distal DP an dlateral tarsal. The PT and peroneal were occluded. The pt underwent PTA of the entire AT with a 3x10 balloon. Pt had recanalization of distal AT and DP artery with a PTA with a 2x2 balloon. The procedure went well and the pt was started on ASA and plavix postop. In the early morning of [**6-23**], the pt's postop course was complicated by rapid atrial fib. Cardiology was consulted and per their recs, her beta blocker was increased to 25 mg [**Hospital1 **], electrolytes were followed closely, and an echo was checked. This showed a LVEF of 50%, 3+ MR, and 3+ TR. The pt's troponin started to trend up at this time going from 0.09 to 0.1 on [**6-24**]. A podiatry consult was obtained on [**6-25**] for evaluation/treatment of right second toe gangreen with cellulitis. Plans were made to amputate the toe on [**6-27**] but the pt was not cleared by cardiology and her stools became guiac positive. It was noted that over the hospitalization her Hct had fallen from 33 to 22. She had been transfused 3 units of PRBC during the stay. A GI consult was obtained and plans were made for the pt to undergo and EDG and colonoscopy. Given these ongoing issues, the pt will be transferred to the medicine service for further care. MEDICAL HISTORY: 1. Anemia 2. S/P right LE bypass 3. Cataracts 4. S/P removal of cyst on the left arm 5. Bilateral carotid stenosis MEDICATION ON ADMISSION: 1. ASA 325 mg daily 2. Atorvastatin 20 mg daily 3. Plavix 75 mg daily 4. Docusate 100 mg [**Hospital1 **] 5. Epoetin alfa 4000 units SC Mon-Wed-Fri 6. Ferrous sulfate 325 mg daily 7. Lasix 20 mg daily 8. Metoprolol 25 mg [**Hospital1 **] 9. Multivitamin tab 1 cap daily 10. Pantoprazole 40 mg daily 11. Zosyn 2.25 mg IV Q6H 12. Vancomycin 500 mg IV daily PRNs- Tylenol Bisacodyl Calcium carbonate Percocet Miconazole powder ALLERGIES: Penicillins PHYSICAL EXAM: 97.8 102/58 74 18 94% Gen- Alert and oriented x2 (person, place). Resting in bed. Upset because could not understand that she had a catheter in her bladder. HEENT- NC AT. MMM. Cardiac- RRR. S1 S2. II/VI SEM. Pulm- CTA anteriorlly and laterally. Abdomen- Soft. Mild diffuse tenderness. No rebound or gaurding. Positive BS. Extremities- No c/c/e. Warm. Right foot bandaged but visable necrotic second toe. Per vascular, pus expressed from it earlier today. Faintly palpable DP pulse on the left. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Pt has an involved daughter (Health Care Proxy). Her name is [**Name (NI) **] [**Name (NI) **]. Her phone numbers are [**Telephone/Fax (1) 64126**] and [**Telephone/Fax (1) 64127**]. Past remote tobacco history. No ETOH. The pt's PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 64128**] [**Telephone/Fax (1) 64129**] and her hematologist is Dr. [**Last Name (STitle) 64130**] [**Telephone/Fax (1) 64131**].

CHIEF COMPLAINT: Mental status changes, ARF PRESENT ILLNESS: 70F h/o COPD, OSA on BiPAP at night, HTN, DM2, morbid obesity, chronic pain who presents from NH after being found to be lethargic, confused and unable to ambulate, with 'tongue hanging out of mouth'. Of note pt recently seen in the pain clinic and started taking Morphine 2 days ago. . ED COURSE: Initial VS T 97.7 HR 60 BP 90/50 RR 20 SaO2 99%RA then desated to 86%RA, placed on NRB O2 improved to 100%. FS 105. on 50% ventimask. Pt was hypoxic on RA placed on NRB. U/A positive and serum tox negative. CXR without clear. She was given ceftriaxone 2gm for UTI, solumedrol and pepcid for "enlarged tongue", narcan 0.2mg x2, 0.4mg narcan x1 with minimal response in mental. 1.7L IVFs infused with improvement of lactate to 0.2. Pt was hypotensive and started on peripheral dopa with improvement in SBP to 120s. Initial labs notable for ARF Cr 5.6, K 6.7, phos 8.8. She received Bicarb 1amp, Insulin 10Units, and 1amp D50 for hyperacute TW. She was placed on BiPAP for 1hr in ED for initial ABG 7.19 pCO2 83 pO2 247. She was admitted to MICU for closer monitoring. . MEDICAL HISTORY: -morbid obesity -hypertension -diabetes - diet controlled -osteoarthritis -obstructive sleep apnea on Bipap at home -COPD -gout -depression -hypothyroidism -GERD MEDICATION ON ADMISSION: Meds (per NH records): -MS Contin 45mg [**Hospital1 **] -Advair Diskis 250/50 [**Hospital1 **] -Combivent -Lisinopril 20mg daily -Atenolol 25mg daily -Levoxyl 50mcg daily -Paxil 20mg daily -Wellbutrin 100mg TID -Gabapentin 300mg TID -Allopurinol 100mg daily -Edecrine 100mg daily -ASA 325mg daily -Colace/senna/dulcolax -Folic Acid 1mg daily -Ambien 10mg HS ALLERGIES: Sulfonamides / Vioxx / Celebrex / Lasix PHYSICAL EXAM: T 96.6 HR 66 BP 141/65 (on dopa 5) RR 12 SaO2 99% on 15L, FiO2 30% ventimask General: Obese, somnolent, arousable intermittently HEENT: pinpoint PERRL, anicteric sclera, nasal trumpet and ventimask, tongue protruding from mouth, crusted tongue surface very dry MM CV: Reg Nml S1, S2, no M/R/G RESP: Distant BS, poor air movement, no crackles or wheeze appreciated anteriorly Abdomen: soft, obese, ND, +BS, tender to palpation LLQ, Umbilical area no rebound/no guarding Extremities: warm, trace bilateral edema, dopplerable pulses Neuro: Somnolent, arousable to voice, follows simple commands, moves all extremities, involuntary twitching of extremeties. FAMILY HISTORY: Mother with HTN SOCIAL HISTORY: Social History: Lives temporarily at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Lost housing at [**Known firstname 553**] [**Last Name (NamePattern1) 7143**] in [**2174-4-14**]. 30-40 ppd smoking history. No EtOH, IVDU, or illicit drugs. Patient is not sexually active. Does not excercise, but is very careful about what she eats.

CHIEF COMPLAINT: Atrial Myxoma PRESENT ILLNESS: 66 yo Haitian woman (recently moved from [**Country 2045**], French Creole speaking) presented to [**Hospital3 1443**] on [**2153-2-21**] with progressive exertional dyspnea and fatigue, as well as chest pain and decreased appetite. A TEE [**2153-2-22**] showed a large mass attached to the interatrial septum-4x3cm. Since admission she has been stable without symptoms of chest pain or shortness of breath. She ruled out for a myocardial infarction. She will undergo a cardiac catheterization and possible cardiac surgery. MEDICAL HISTORY: Hypertension Gastroesophageal reflux disease Migraine Headaches MEDICATION ON ADMISSION: Transfer mediciations: HCTZ 25mg daily, protonix 40mg daily, Lopressor 50mg [**Hospital1 **]. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Afeb 72 175/63 20 98%RA No acute distress, alert and orientedx3, lying on bed post cath History taken by creole translator. Poor dentition, no Lymphadenopathy, no JVD RRR with II/VI SEM Clear lungs soft, nontender, nondistended, +Bowel sounds No cyanosis or edema, Warm FAMILY HISTORY: non-contriubutory SOCIAL HISTORY: recently moved from [**Country 2045**] in [**11-29**], speaks French Creole only, currently living with her son.

CHIEF COMPLAINT: Right upper quadrant and epigastric pain without fever or nausea/vomiting PRESENT ILLNESS: The patient is an 81 year old female who was transferred from an outside hospital after presenting with complaint of persistent, dull, severe abdominal pain x10 hours. The pain was primarily loacalized to the right upper quadrant and epigastric region, and radiating to the back. The patient denied any nausea or vomiting, and denied fevers or chills. She was noted to have an elevated bilirubin at the OSH and with RUQ ultrasound demonstrating stones in the gallbaldder, a dilated common bile duct, and pericholecystic fluid. She was transfered to [**Hospital1 18**] for likely cholecystitis/choledocolithiasis and for further care. MEDICAL HISTORY: Past medical history: End-stage renal disease on hemodialysis (T/Th/Sa) secondary to Good Pasture's Syndrome Hypothyroidism Coronary artery disease s/p stent placement x1 CHF Atrial fibrillation on Coumadin and with pacemaker in place HTN Hyperlipidemia MEDICATION ON ADMISSION: Coreg 3.12mg [**Hospital1 **] Synthroid 0.112mg daily Coumadin 2.5mg daily Lipitor 40mg daily Digoxin 0.125mg every other day Nephrocaps 40mg daily PhsLo Prilosec 20mg [**Hospital1 **] Cardizem 360mg daily Amiodarone 200mg daily ALLERGIES: Bactrim / Cipro / Lactose PHYSICAL EXAM: GENERAL: No acute distress; alert and oriented; responsive and cooperative HEENT: Mucous membranes moist and pink; sclera anicteric; MMM, no ocular or nasal discharge NECK: No thyroid enlargement or masses; JVP not elevated; no carotid bruit CARDIAC: Regular rate and rhythm; normal S1 + S2; no murmurs, rubs, or gallops LUNGS: Clear to auscultation bilaterally; no wheezes, rales, or ronchi ABDOMEN: Soft, non-distended, non-tender; +bowel sounds; no rebound or guarding; liver and spleen not palpable EXTREMITIES: Warm and well perfused; 2+ dorsalis pedis pulses bilaterally; no swelling/edema bilaterally; left thigh AV graft with thrill and bruit FAMILY HISTORY: Denies family history of cancer or hepatobiliary disease SOCIAL HISTORY: The patient lives with her husband. She denies any alcohol, cigarette, or recreational drug use

CHIEF COMPLAINT: GI Bleed PRESENT ILLNESS: 80M w/ MMP including dementia, CAD, chronic Afib, CHF, CRI, and diverticulosis, who initially presented to OSH with BRBPR. At [**Hospital **] Hospital, where he had an additional 2 episodes of BRBPR. BP was 70/palp and NG lavage was reportedly negative, so he was transfused 4 units PRBCs and 2 units FFP, and given Vitamin K and 2.5 L NS. Hct was 34 at [**Name (NI) **] (unclear when this was in relation to transfusions). He had a CT to evaluate his endovascular AAA repair, which was intact. He was transferred to [**Hospital1 18**] ED on [**2182-8-25**] where SBPs were stable in 90s, HR 80s. Given Protonix 40mg IV. GI and surgery were consulted and he was dmitted to the MICU for further care. . In the MICU, received 5 units pRBC with last transfusion yesterday AM. Hct has remained stable x24h. Colonoscopy today with left and right diverticulosis but no active bleeding. Has mild O2 requirement thought to be [**2-9**] CHF from multiple transfusions. Not on ASA or plavix at baseline, unable to contact PCP as to why, and not on coumadin for Afib [**2-9**] falls. Given stability, transferred to the floor. Currently feels well. States no new issues. No CP/SOB. No N/V. No further episodes of BRBPR . MEDICAL HISTORY: - dementia - CAD s/p CABG [**2173**], cardiac stents x2 - chronic atrial fibrillation (not on coumadin [**2-9**] falls) - congestive heart failure - h/o tachy-brady syndrome s/p pacemaker - s/p endovascular AAA repair - hypertension - hyperlipidemia - chronic renal insufficiency (Cr 2.0) - h/o GI bleeds - diverticulosis - prostate ca s/p prostatectomy - osteoarthritis - gout - s/p knee replacement - incisional hernia repair - h/o Staph aureus infection - h/o interstitial nephritis MEDICATION ON ADMISSION: Protonix 40mg qd quinapril 10mg qd Namenda 10mg qd Metoprolol XL 25mg [**Hospital1 **] Razadyne 4mg [**Hospital1 **] Sertraline 50mg qd Simvastatin 80mg qd Tylenol prn ALLERGIES: Penicillins PHYSICAL EXAM: Vital: afebrile, 110/63, HR 87, RR 26, 99%RA Gen: well appearing in NAD HEENT: NCAT. no pallor, no icterus. MMM. OP clear Neck: Supple, no JVD, no LAD Pulm: CTA bilat. bilateral basilar rales Cor: s1s2 irreg irreg. no murmur. hx sternum removed. Abd: obese, soft. nt/nd Ext: R hand markedly swollen, TTP ulna. No pain on axial loading. TTP along MCP joints/DIP joints. No BLE edema. DP 2+ Bilat Neuro: AAOx4. MAE. no gross deficits. FAMILY HISTORY: Father w/ leukemia, mother w/ CVA. SOCIAL HISTORY: Resident at [**Hospital3 **] facility. 4 daughters, 2 nearby and 2 in NH. +Tobacco hx, denies EtOH.

CHIEF COMPLAINT: PRESENT ILLNESS: MEDICAL HISTORY: 1. Rheumatoid arthritis 2. Coronary artery disease with an ejection fraction of 40% to 45% 3. Status post right total hip replacement in '[**08**] 4. Status post left knee surgery 5. Status post cholecystectomy MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: nausea, vomiting PRESENT ILLNESS: 78 M presents with 24 hours of nausea, multiple bouts of emesis, and abdominal pain. Has thrown up non-stop overnight. Reports not passing gas today but has had loose stool. Denies fevers, chills, or any urinary sypmtoms. MEDICAL HISTORY: - DM - HTN - Dyslipidemia - Laser surgery to both eyes - Bilateral cataracts - ESRD on dialysis MWF - Atrial flutter/atrial fibrillation s/p ablation. He is reportedly not on anticoagulation because of renal insufficiency and concern for high risk of bleeding. - s/p pacemaker placement with history of tachy-brady syndrome - Prostate cancer, diagnosed 12 years ago s/p orchietctomy and hormone therapy - Renal cell cancer, s/p right nephrectomy - Secondary hyperparathyroidism - Small bilateral pleural effusions noted on [**2172-1-17**] admission, no longer noted on recent chest x-ray from [**2172-9-24**] - Percutaneous thrombectomy of his left forearm AV graft, fistulogram, arteriogram, and a balloon angioplasty of multiple venous outflow stenoses and angioplasty of the arteriovenous graft anastomosis in [**2172-6-16**] -s/p surgical removal of upper GI obstruction per patient MEDICATION ON ADMISSION: coumadin [**3-22**], amiodarone 100', cinacalcet 30', hydralazine 25"', metoprolol 25", nifedipine 30', ranitidine 150", simvastatin 20', ASA 81, januvia 25", fosrenol 1000"' ALLERGIES: Cozaar PHYSICAL EXAM: 97.6 99/48 78 18 100% RA Awake, alert, oriented x 3, NAD NG tube in place PERRL, anicteric RRR CTAB Abdomen soft, distended, tender along midline incision and left side of the abdomen, hypoactive bowel sounds, + guarding LE warm, no edema FAMILY HISTORY: Family History: States that his siblings are healthy, but unsure on health of other family members SOCIAL HISTORY: Retired foundry worker who lives at home in [**Location (un) 669**] with his wife. Stopped smoking cigarettes over 20 years ago, smoked intermittently for years before that, but has difficulty quantifying use. Has not had alcohol in over 20 years, drinking only socially prior to that time. Denies a history of drug use.

CHIEF COMPLAINT: malaise, fevers, weight loss and weakness PRESENT ILLNESS: 64 yo M w/ no significant PMH presenting with 3 weeks of generalized weakness and found to have elevated LFTs. He has been generally healthy, approx 3 wks ago he experienced the gradual onset of fatigued, decreased appetite, "bad" taste in mouth, and some fever/chills. He finally went to ED 2 days prior, CXR neg, was diagnosed with UTI, discharged on levoquin at [**Hospital1 **] [**Location (un) 620**]. Symptoms persisted until today, so he returned to the ED at [**Location (un) 620**]. UA was neg but he was found to have elevated LFTs. US showed hypoechoic lesions in liver and spleen and he was transferred here for inpatient workup and MRCP/ERCP. . This has never happened before and he denies any past hx. of jaundice, blood transfusions, IV drug abuse, or new sexual partners. [**Name (NI) **] has not been sexually active with his wife for at least 6 months. He drinks alcohol [**12-28**] X per week at dinner with his wife. [**Name (NI) **] has been taking Tylenol [**2-28**] X per day since this past Wed as instructed over the counter. He did travel to his summer home at [**Hospital3 **] 3 weeks ago, but denies any tick bites. He does have pet dogs and lives in semi wooded area outside [**Location (un) 86**]. . In the ED initial vitals were:97 102 97/65 18 100% NS x 1 liter in ed and was transferred to the floor. Heme/onc on board, he was ruled out for TTP and DIC. ID recommended started zosyn and doxy for tick borne or hepatobiliary causes. Pt found to be tacycardic to the 160s while going to bathroom which resolves to the 100s. EKG with sinus tachycardia and rate related v3 ST depressions. He was bolused 4L and hemodynamics improved to HR 110s, 115/67, but continued to be more work for nursing. MEDICAL HISTORY: Left Hip replacement. Depression MEDICATION ON ADMISSION: HOME MEDICATIONS: Levofloxacin X 2 days Citalopram 20mg QD ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission exam: Vitals: T:103 BP:121/70 P:114 R:42 O2:87% on RA, returned to 98% on 4L NC. Pt confused, mumbling, oriented x1. Denied any pain. FAMILY HISTORY: No hx of liver or autoimmune disease SOCIAL HISTORY: denies blood transfusion hx, no illicit drugs. Drinks alcohol socially [**1-29**] X per week with wife. [**Name (NI) 1139**] use for "few years" last as teenager. Last sexually active with wife at least 6 months ago.

CHIEF COMPLAINT: fever, lethargy and hypotension PRESENT ILLNESS: 61 year-old male with a history of obstructing left renal stone, suprapubic catheter (neurogenic bladder s/p CVA), numerous UTIs who presents from day care center with fever, lethargy and hypotension. . In the ED, T 104.8, BP 74/44 HR 110 97%/2l. He recd 2 L of IVF and the SBP came up to 110s but dropped again to 80s. Total he recd 8 L of IVF and after placement of RIJ, was started on neosynephrine. He also recd vanc/ctx/levoflox initially. After noting that his last Ucx grew psudomonas which was not susceptible to CTX/levoflox, he recd zosyn x 1. . Currently, pt alert but not oriented. follows commands. denies pain, headache, CP/SOB/dizzy, abd pain/N/V. MEDICAL HISTORY: s/p CVA Neurogenic bladder s/p suprapubic cath Recurrent UTIs with Klebsiella/Pseudomonas Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03 (s/p R-CHOP x 6 cycles) Bells Palsy BPH Hypertension Partial Bowel obstruction s/p colostomy Hepatitis C Cryoglobulinemia SLE with transverse myelitis, anti-dsDNA Ab+ Insulin Dependant Diabetic Fungal Esophagitis Stage IV? Urinary Tract Infections-pseudomonas & enterococcus MEDICATION ON ADMISSION: -Senna 8.6 -Docusate -Citalopram 20 mg qd -Folic Acid 1 mg qd - Simvastatin 10 mg qd -Multivitamin qd -Omeprazole 20 mg qd -Gabapentin 300 mg tid -Simethicone 80 mg Tablet -Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): for oral thrush. -Zolpidem 5 mg qhs -Acetaminophen 325 mg -Oxycodone 5 mg Tablet Q4H prn -Lantus 18 units Subcutaneous at bedtime. -Insulin Lispro Four (4) Units Subcutaneous TID before meals: Also sliding scale. -Miconazole Nitrate 2 % Topical TID -CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1) Tablet PO at bedtime. -Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: General Appearance: Well nourished, No acute distress FAMILY HISTORY: Non-Contributory SOCIAL HISTORY: Lives in a nursing home since [**3-9**]. Denies smoking, ETOH, drug use. Has sister close by ([**Name (NI) 79061**]) who he is close to. Is a Jehova's Witness and does not agree to blood transfusions.

CHIEF COMPLAINT: Abdomnal pain PRESENT ILLNESS: Mr. [**Known lastname **] is a 79yoM with a history of HTN, HLD, and previous bladder neoplasm who developed acute RUQ pain two days ago. It occurred suddenly, has been constant, dull, and nonradiating in nature. He has been anorexic but denies nausea or vomiting. He notes subjective fevers. He had confusion per his wife. His urine has been cola-colored, but denies changes in his stool. Has not noticed yellowing of skin. No previous history of biliary or hepatic disease. Denies previous gall stones. He saw his PCP, [**Name10 (NameIs) 1023**] referred him to the [**First Name4 (NamePattern1) 5871**] [**Last Name (NamePattern1) **]. There he was febrile to 103.8F with systolic blood pressures in the upper 80s which responded well to fluid resuscitations. He had a RUQ US showing acute cholecystitis with a CBD diameter of 5mm. A CT showed pneumobilia with scattered hepatic densities concerning for abscesses. He was transferred to [**Hospital1 18**], initial VS were T99.4 BP83/42 HR80 RR18 Sat97RA. His lactate was elevated to 4.4, he received 2L NC. His initial labs showed transaminitis of AST/ALT 198/167, Tbili 4.9 Dbili 4.0, AP 34, Lipase 86. Surgery was consulted for suspicion of cholangitis. He received zosyn, and was admitted to [**Hospital Unit Name 153**] briefly before undergoing ERCP, which revealed only sludge in the gallbladder without note of stone. A stent was placed, and he received tetracycline/clindamycin for suspected claustridium given his pneumobilia. He was transferred back to the [**Hospital Unit Name 153**] in stable condition. On arrival back to the [**Hospital Unit Name 153**], his initial VS were T95.6 P82 BP118/39 RR14 Sat94%RA. He has mild RUQ pain but he is comfortable and has no acute complain. On ROS, denies chest pain, shortness of breath, N/V/D, no palps, myalgias, arthralgieas, dysuria, hematuria. MEDICAL HISTORY: PMH: - HTN - hyperlipidemia - ? bladder neoplasm MEDICATION ON ADMISSION: - HCTZ 25 mg PO qd - cetirizine 10 mg PO qd - citalopram 20 mg PO qd ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: on admission: gen: NAD, pleasant, jaundiced sclera, flushed in the face, uncomfortable in pain VS: 99.4 80 83/42 16 97% Nasal Cannula CV: RRR pulm: CTA b/l abdomen: mildly softly distended, + BS, tender in the RUQ tolight palpation, also tender in RLQ to deeper palpation extremities: no LE edema, no cyanosis FAMILY HISTORY: No family history of biliary or hepatic disease, gallstones, pancreatitis SOCIAL HISTORY: Lives with wife, retired, smoked a pack a day for about 40 years, quit several years ago

CHIEF COMPLAINT: transfer from OSH with traumatic SAH PRESENT ILLNESS: 85F PMH of AFib who presents as a transfer from OSH with a traumatic SAH on CT. Pt has amnesia surrounding the fall and last remembers being outside. Per report, a neighbor saw the police responding at pt's house and they found her lying on the floor in the bedroom. Apparently, the pt hit her head on the bed frame after falling- blood was found on the frame and on the floor next to the bed. +LOC, pt first remembers the OSH, but cannot recall the ambulance ride. MEDICAL HISTORY: paroxysmal atrial fibrillation, rheumatoid arthritis, s/p B hip replacement [**10-12**] MEDICATION ON ADMISSION: aspirin 81, prednisone 5 qod, MVI ALLERGIES: Levofloxacin PHYSICAL EXAM: T: 98.0 BP: 124/96 HR: 104AF RR: 16 100% on RA Gen: WD/WN, comfortable, NAD. HEENT: PERRL 3-2mm, EOMI Neck: Supple. Lungs: CTA bilaterally. Cardiac: Irregularly, irregular. no MRG Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person and date. Did not know hospital name, but recalled being at [**Hospital **] Hospital. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. FAMILY HISTORY: NC SOCIAL HISTORY: Lives alone in Ipswitch. Occasional Etoh, no tobacco.

CHIEF COMPLAINT: PRESENT ILLNESS: Mr. [**Known lastname 14218**] is a 45-year-old man who presented to the Trauma Service following injury to his right eye. The patient was operating a nail gun when a nail ricocheted and penetrated into his right face. It apparently went through his right maxilla, through his orbit and his eye, and into his brain. He sustained a loss of consciousness and no further injury. His [**Location (un) 2611**] Coma Scale on presentation was 15. MEDICAL HISTORY: Negative. MEDICATION ON ADMISSION: He takes no medications on a daily basis. ALLERGIES: He is allergic only to PENICILLIN. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: abdominal pain PRESENT ILLNESS: This is a 55 year old female with ICM (EF 20%), s/p AICD, STEMI, CRI (Cr baseline 1.5), adrenal insufficiency, hemorrhagic pancreatitis, recent complicated hospital course ([**8-2**] -[**10-19**]) after transfer from OSH with large pancreatic pseudocyst, phlegmon and right flank fluid collection (VRE, pseudomonas, strep viridans) s/p drainage and multiple abx, course c/b ARF requiring CVVH, hypotension, VT, C diff, UTI, respiratory distress with intubation, then trach, now presents from rehab with abdominal pain. Pt is DNR/DNI. Her abdominal pain has been similar in quality for several weeks but worsening yesterday. No fevers/chills. Chronic diarrhea. C diff positive at rehab. . Please refer to recent discharge summary for detailed course of her hospital stay from [**8-2**] to [**10-19**]. Of note, she has been treated with Flagyl, then PO vanc for C diff colitis; with linezolid, then daptomycin (b/o leukopenia on linezolid) for VRE in fluid collection; with Zosyn, later aztreonam for Pseudomonas; with meropenem for Pseudomonas and Klebsiella UTI and Pseudomonas in her sputum. . At rehab, she has been on the vent (AC 500x10, FiO2 28%, PEEP of 5) with difficulties to wean due to hypoxia. No increased secretions per verbal report from rehab. She has been maintained on IV Flagyl for positive C diff in her stool. She was on Imipenem until [**11-1**]. In adddition, she was started on Levaquin on [**10-8**] for a 5 day course per rehab records. Her chronic abdominal pain worsened on day of admission when it was decided to reverse her DNH status. . In the ED, her VS were T95.6, HR76, BP 120/80, RR21, 100% on TM. No rebound or guarding but tender to RUQ. Greenish stool that was guaiac negative. General surgery was consulted. Next of [**Doctor First Name **] was [**Name (NI) 653**], confirmed DNR/DNI but abx and lines okay. UA was positive for infection. Lactate was 2.1. Cr 3.4 up from 1.7. WBC 18.2 with left shift. Normal pancreatic enzymes and AST, ALT. AP of 489 and LDH of 405. Trop 0.76 but normal CK and MB. EKG without acute changes. CXR and portable abdomen with no acute findings. . 30 minutes after she arrived in the ED, her BP dropped to 60s systolic. A RIJ cordis was placed during which a NE gtt was transiently infused. She received a total of approximately 7 L IVF with stabilization of her BP in the 100s/60s. Pt received one dose of Meropenem, Vanc and Aztreonam and was admitted to the ICU for further management. MEDICAL HISTORY: PMH: hemorrhagic pancreatitis and pancreatic pseudocyst, HTN, CAD w/ ischemic cardiomyopathy (EF=15-20%) s/p STEMI, NSTEMI [**5-10**], CHF, IDDM, SLE, CRI [**1-5**] SLE ?lupus nephritis vs. DM, baseline Cr=1.5, hypothyroid, ? embolic CVAs in [**6-9**], obesity, dyslipidemia, adrenal insufficiency [**1-5**] chronic steroid use . PSH: s/p AICD placement [**Hospital1 **]-v pacer [**2112**] (for A-fib), cardiac cath [**2106**], h/o trach/PEG, c-section, [**2114-8-13**] CT-guided pigtail catheter placement into R flank fluid collection, [**2114-8-17**] upsizing of R flank catheter & CT-guided placement of peripancreatic drainage catheter [**2114-8-29**] CT-guided exchange of L drainage catheter [**2114-9-4**] CT-guided exchange of R drainage catheter, upsizing of L drainage catheter, [**2114-9-18**] tracheostomy, [**2114-9-20**] CT-guided flushing/aspiration of both drainage catheters, [**2114-10-11**] Dobhoff feeding tube placement MEDICATION ON ADMISSION: RISS Levaquin 250 daily PO (until [**11-12**] for 5 day course) PPN EPO 4000 sc weekly Fentanyl patch 25 mcg q72h Heparin sc 5000 daily IV lopressor 2.5 mg q12h IV protonix 40mg dialy IV aminosyn daily IV flagyl 500mg q8h Kayexelate 30gm prn Lasix 40mg IV prn Dulcolax supp PR prn Zofran 4mg IV q4h prn Dilaudid 0.5mg IV q8h prn ALLERGIES: Linezolid / Betalactams PHYSICAL EXAM: VS: Temp: 91.5, BP: 76/56 HR: 100 Vpaced RR: 23 O2sat: 95% on AC 500x10, FiO2 28%, PEEP 5 GEN: Morbidly obese female in mild distress HEENT: PERRL, EOMI, anicteric, dry MM, OG tube in place NECK: very obese neck, difficult to assess JVP, trach in place RESP: CTA b/l, no wheezes, rales or rhonchi CV: RR, S1 and S2 wnl, no m/r/g ABD: morbidly obese, +b/s, soft, diffusely tender througout all four quadrants but no rebound or guarding, R flank drain in place, nontender, nonerythematous EXT: UE and LE b/l 3+ edema, warm, 1+ pulses SKIN: small, open wounds in her skin folds (no purulence), no rash/no jaundice NEURO: moves all extemities, responds appropriately to questions with head nodding FAMILY HISTORY: N/C SOCIAL HISTORY: 20ppy tobacco history - stopped in [**2106**] Resides in nursing care facility

CHIEF COMPLAINT: PNA PRESENT ILLNESS: Ms. [**Known lastname 5395**] is a 53 year-old female with a recent diagnosis of non-small cell lung cancer who admitted to OSH on [**7-27**] for dyspnea for 1-2 days PTA. In addition, she reported increased respiratory secretions, fevers and chills. At OSH, she was found to have PNA and there was concern about a possible stent obstruction so she was transferred to BICMC on [**7-29**] for urgent bronchscopy and stent evaluation. On [**7-29**] she underwent rigid bronchoscopy and it was found that her y-stent migrated so it was removed was removed. She was noted to have thrush in her trachea. She was intubated for the procedure and it was decided to keep the patient ventillated post-bronch given the severity of her PNA. . Currently, she has been mildly hypotensive this morning, but is currently off pressors thought to be secondary to a medication effect. She is intubated and sedated and appears comfortable. . Review of systems: unable to obtain [**12-22**] sedation . MEDICAL HISTORY: # NSCLC - Received her first cycle of carboplatin and Taxol chemotherapy [**2178-7-9**] & Silicone Y-stent placed [**2178-7-4**] # tracheal stent placement # SVC obstruction on CT scan # GERD MEDICATION ON ADMISSION: HOME MEDS Decadron 8mg PO BID Klonopin 0.5 mg PO QHS Percocet-dose unknown Mucinex -dose unknown MEDS ON TRANSFER FROM OSH # Fluconazole 400 mg PO Q24H # Heparin 5000 UNIT SC TID # Hydrocortisone Na Succ. 100 mg IV Q8H # Insulin SC # Albuterol Inhaler [**2-23**] PUFF IH Q4H:PRN wheezing # Pantoprazole 40 mg IV Q24H # Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **] # Piperacillin-Tazobactam 4.5 g IV Q6H # Ciprofloxacin 200 mg IV ONCE # Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO sedation # Ciprofloxacin 400 mg IV Q12H # Clonazepam 0.5 mg PO QHS # Docusate Sodium 100 mg PO BID # Vancomycin 1000 mg IV Q 12H # Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: General: intubated, sedated, responds to noxious stimuli. HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated, no LAD Lungs: rhonchi in RUL and LLL. ventilated breath sounds. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. A-line in place and 2 PIVs. FAMILY HISTORY: per [**Name (NI) **], father c MI SOCIAL HISTORY: per records TOB: [**11-21**] PPD for 20 years. Occasional EtOH. NO drug use. Currently living with parents.

CHIEF COMPLAINT: overdose (found down) suicide attempt PRESENT ILLNESS: The patient is a 44 yo Brazilian male with HIV on HAART found down at 7 am [**2-7**] accompanied by a suicide note. EMS found him unresponsive, pale, and cool. His male partner had last seen the patient at midnight the night before. His BP on admission was 62/40 HR 78 RR 8 100% on 15L FS 90 in ambulance. He was given 2 mg narcan as EMS had found an empty bottle of Percocet and ativan. His SBP increased to 100s with little effect on his responsiveness. In the ER, he was moving all extremities. There, he was given activated charcoal and an additional 2 mg narcan with no increased responsiveness. He was also noted to have a diffuse rash and thus given 50 mg IV Benadryl. In the ED, his serum tox was notable for + cocaine with no benzos or opiates. ETOH 89. No tylenol. His Partner states the patient has access to percocet, ketamine, bottle of clonazepam 0.5 mg, ultracet, ativan, bupropion. He had a negative head CT on admission. MEDICAL HISTORY: HIV since [**2121**] on HAART MEDICATION ON ADMISSION: Outpatient Medications: Meds: Norvir, Epivir, Reyataz, Viread, Bupropion, Percocet ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: on admit to ICU from ED: general: unresponsive except to sternal run and rectal probe HEENT: PERRL; ngt in place CV: RRR Abd: active BS, soft Resp: coarse bs at left lung base Neuro: toes downgoing b/l Day 2 ICU: gen: alert and oriented middle age M HEENT:PERRL. MMM moist. + charcoal in mouth CV:RRR, NlS1, S2. no m/r/g. Resp: CTAB Abd: active BS. soft NT, ND. no HSM L arm: c/o tenderness to elbow, swelling, no erythema, no pitting edema, good radial pulse and capillary refill Right leg: swelling lateral of tibia; no erythema. good DP bilaterally On transfer to Floor [**2133-2-10**] Tc=97.9 P=84 BP=122/68 RR=20 97% O2 Gen - NAD, AOX3 HEENT - PERLA, EOMI, small aphthous ulcers on uvula otherwise no lesions/thrush, no oropharyngeal exudate. No LAD. Heart - RRR, Grade II/VI systolic holosystolic murmur at apex. Lungs - CTAB with decreased breath sounds at right base Abdomen - Soft, NT, ND + BS, no hepatomegaly Ext - LUE with brace and RLE with brace s/p fasciotomoy, all four extremities warm to touch Skin - No rashes/lesions Neuro - CN II-XII intact, 5/5 strength x 4 FAMILY HISTORY: Father - leukemia [**Name2 (NI) **] family history of depression, suicidal attempts. SOCIAL HISTORY: Born in [**Country 4194**], immigrated to US in [**2114**]. Famils in [**Country 4194**]. Currently in long-term stable relationship with male partner. [**Name (NI) **] high school education. Works in condominium management at Four Seasons Hotel. Has used ketamine and ecstasy in past and has current access to ketamine. Denies tobacco or IV drug use.

CHIEF COMPLAINT: weakness, confusion PRESENT ILLNESS: Ms. [**Known lastname 73200**] is a 33 year old female with end stage metastatic melanoma admitted for weakness and confusion/somnolence. Patient has had slowly declining functional status over the past few weeks and has been more somnolent and dozing off during conversations. She is appropriate when awake, but frequently falls asleep. Today, she presented to [**Hospital 5871**] Hospital for confusion and weakness. At [**Location (un) 5871**], she was noted to be tachycardia and to have a positive UA, so was given vancomycin and Zosyn. She had a head CT which was negative and CXR which was normal. Her lactate was noted to be 5.8. She was noted to be in ARF and so was given 500 cc of NS. She was sent to [**Hospital1 18**]. . In the ED, vitals were T96.6, HR 130, BP 100/63, RR 18, 97% on 3LNC. Hr blood pressure was 98/54 at its lowest and her HR was 128 at it's highest. She was given 3LNS for dehydration and ARF. She underwent V/Q scan for workup of tachycardia, shortness of breath, and metastatic melanoma which was found to be low prob. Bilateral LENIs were also negative. She cannot get a CTA due to iodine allergy. She got a CT abd/pelvis which showed new significant ascites from [**2161-8-7**]. CXR showed low lung volumes, but lung cuts on abdomen CT showed moderate plerula effusions with atelectasis. Labs were notable for acute renal failure and newly elevated LFTs. . Upon arrival to the floor, patient denies shortness of breath, though is speaking in short sentences. She denies chest pain, abdominal pain, fevers, chills, headache, change in vision. Her husband notes increased somnolence over one week. Patient reports lightheadedness and thirstiness over the past few days. MEDICAL HISTORY: Metastatic melanoma. Patient was diagnosed with melanoma 2 years ago when she noted an enlarging groin node found to be positive for metastatic melanoma. Patient underwent lymphadenectomy and was found to have positive inguinal, pelvic, ileac, and peri-aortic nodes. She began IL-2 chemotherapy in [**8-13**] with disease progression. She then began ipilimumab on the compassionate use protocolat [**Hospital1 1012**] with disease progression on her week 12 scans. She then enrolled in the RAF-265 clinic trial on [**2161-4-7**],but had disease progression. She was then treated with two cycles of DTIC unsuccesfully. She is now being treated by NIH Surgery Branch for adoptive cellular immunotherapy. She is now approximately 1.5 months out from conditioning regimen and 1 month out from receiving TIL. MEDICATION ON ADMISSION: Cipro completed on Tuesday for UTI Morphine 15-30 mg prn MS contin 30 mg [**Hospital1 **] Compazine PRN Ranitidine Scopolamine Detrol [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] Colace 100 mg [**Hospital1 **] Senna ALLERGIES: Iodine; Iodine Containing / Zofran PHYSICAL EXAM: Gen: cachectic, tachypneic HEENT: temporal wasting, o/p clear CV: Tachycardic, no m/r/g Pulm: diminished breath sounds at bases bilaterally Abd: soft, NT, distended, + fluid wave, bowel sounds present Ext: 2+ bilateral pitting edema Neuro: somnolent, falling asleep mid-sentence FAMILY HISTORY: She has no family history of melanoma, no family history of cancer. SOCIAL HISTORY: She is former English professor [**First Name (Titles) **] [**Last Name (Titles) 73201**] [**Location (un) **]. She does not smoke. She does have an occasional glass of wine or beer. .

CHIEF COMPLAINT: weakness and lethargy PRESENT ILLNESS: The pt is a 72 yo female with h/o MCA embolic stroke in [**1-13**], HTN, tachy-brady syndrome, breast CA, PAF, DM II, Diastolic HF, and UTIs who presented to her PCP's office yesterday with LE edema and was called into the ED tonight when labs came back pertinent for hyperkalemia. Her son picked her up at home and on transport to the hospital she became weak and lethargic and required being carried out of the car into the OR. . On arrival to the ED vitals were T97.2 HR77 BP137/61 RR17 o2 99% RA. She was found to have a UTI and given her previous cx data was started on vancomycin and CTX. Her exam was noticle for lethargy, but arousable, not speaking, and poor capillary refill. Her CXR showed bilateral pleural effusions and ? of old femur fracture. Her lab was notable for a lactate of 5.4, WBC of 10.5, creatinine of 1.4 (recent baseline 1.2). EKG with no evidence of hyperkalemia. While in the ED her SBPS remained stable with lowest SBP in the 110s. She received a total of 2.5 L of fluid in the ED including abx). Vitals prior to transfer were 97.2 77 137/61 17 99% on 2L. . On arrival she was somulent but arousable. Vitals on arrival were 95.6 162/78 16 84% on RA. Her o2 sat improved to the high 90s on a non rebreather. Her gas on arrival to the floor was ph7.19 pCO281 pO2 255 HCO3 32. She was placed on BiPAP and her gas improved to pH7.30 pCO264 pO2 86 HCO3 33. She then dropped her pressures to SBP to 80s which responded to IVF bolus. She dropped her pressures 2 more times during her centralline placement which responded to bolus. A left IJ was attempted and a R IJ was ultimately placed. . Review of systems: unable to obtain secondary to pt's mental status MEDICAL HISTORY: 1: MCA embolic stroke c/b hemorrhagic transformation on coumadin [**1-13**]. (residual aphasia & R sided weakness) 2. Hypertension 3. Tachy-brady syndrome s/p pacemaker 4. Paroxysmal atrial fibrillation 5. DM2 6. Diastolic HF ([**2169**]) 7. Enterrococcal bacteremia treated with Amp/Gent, suspected source suspected RLE cellulitis 8. Breast cancer s/p axillary dissection and chemo/radiation 9. Depression 10. Endometriosis 11. Shoulder pain 12. Incontinence MEDICATION ON ADMISSION: ATORVASTATIN 80 mg PO daily FUROSEMIDE 10 mg PO every 2 days GABAPENTIN 100 mg PO BID LISINOPRIL-HYDROCHLOROTHIAZIDE - 10 mg-12.5 mg Tablet PO daily METFORMIN 1,000 mg PO BID (breakfast and lunch) Metformin 500 mg PO QHS METOPROLOL TARTRATE 100 mg PO BID OMEPRAZOLE 20 mg PO daily VENLAFAXINE 37.5 mg PO BID WARFARIN 4 mg tablets as directed (daily per most recent [**Company 191**] anticoagulation sheet) Humalin ISS MAGNESIUM OXIDE 400 mg Tablet PO daily ALLERGIES: Gentamicin PHYSICAL EXAM: 95.6 162/78 16 84% on RA. Gen: initially opening eyes, later no longer opening eyes to command HEENT: pupils equally round, periorbital edema, mmm, oropharynx clear Neck: supple, elevated JVD Lungs: No breath sounds at bases, decreased air movement throughout, no crackles, no rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +bs, soft, non-tender, non-distended, no rebound tenderness or guarding Ext: 1+ radial and DP pulses, 1+ pitting edema to the knees with ulcers in the lower extremities with clean bases FAMILY HISTORY: Father died at stroke at 74. SOCIAL HISTORY: Russian-speaking.45 yr smoking hx. [**12-7**] PPD. No EtOH or illicits per her son.

CHIEF COMPLAINT: Dyspnea on exertion PRESENT ILLNESS: The patient is an 85 year old gentleman with hypertension who presented with decompensated heart failure. He originally noted dyspnea on exertion two months prior to admission. He experienced shortness of breath after walking one city blood and experienced mild sporadic chest pain with and without activity. He also developed bilateral lower extremity edema and vascular congestion with increased neck veins. In [**10-17**] patient had an ETT MIBI which showed partially reversible defects in the area of the PDA and LAD, new since [**2099**]. EF was 35-45%. In [**2099**] EF had been 50%. MIBI showed moderate global LV hypokinesis, mild asymm LVH, mild PA HTN. During that MIBI patient had AVNRT and sinus tachycardia. Patient presented for elective cath which showed normal coronaries but the following pressures: RA 32/RV 64/21 PA 72/32, wedge 35. PA sat 46%. CO 2.9 and CI 1.6. Pt was given 100 lasix in lab and put on natrecor drip at 0.01 and milrinone at 0.325. Transfered to CCU. Of note, INR was 1.8, and there was significant oozing from groin post sheath pull. MEDICAL HISTORY: 1) Hypertension 2) s/p open prostatectomy secondary to BPH [**2097**] 3) s/p hernia repair 4) s/p hydrocele repair MEDICATION ON ADMISSION: Hydrochlorothiazide 12.5 mg po daily Captopril 50 mg po bid Vitamin E 400 IU daily Ecotrin 325 mg po daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: FAMILY HISTORY: No family history of coronary artery disease. SOCIAL HISTORY: Married. Quit smoking 15 years ago.

CHIEF COMPLAINT: unstable angina PRESENT ILLNESS: 62 y/o male with h/o PAF, tachy-brady syndrome (s/p PPM), CAD (s/p IMI), and CRI presented with exertional angina failing medical therapy. Nuclear stress test non diagnostic 2nd not achieving optimal HR. Notes worsening SOB and dypsnea over past several month. Unable to walk more than a few blocks before getting SOB. Has had some dizziness and lighnheadness. LVEF 40$. Patient also s/p aorto-bifemoral bypass and renal artery stents bilaterally with right renal bypass. Cath today showed totally occluded RCA, diffuse LAD disease and tight ostial LCX lesion. Dr. [**Last Name (STitle) **] has asked cardiac surgery to evaluation for CABG [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-risk PCI. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -PACING/ICD: s/p Dual chamber pacemaker implantation 3. OTHER PAST MEDICAL HISTORY: Hypertension Hypercholesterolemia Paraxysmal atrial fibrillation Tachy-Brady Syndrome s/p Dual chamber pacemaker implantation CAD s/p IMI LVEF of 40% Chronic Renal Insufficieny MEDICATION ON ADMISSION: plavix 75 mg daily, metoprolol 200 mg [**Hospital1 **], cardura 12 mg daily, ventolin HFA 90 mcg/inh 2 puffs q 4 hours prn, simvastatin 40 mg daily, coumadin 5 mg daily, aspirin 81 mg daily, diltiazem ER 240 mg AM and 120 mg q hs ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Admission Physical Exam: T - 98.3 BP - 149/48 HR - 60 RR - 20 Sat - 100% on RA General - NAD, alert, cooperative, comfortable lying flat HEENT - EOMI, PERRLA Lungs - CTA Cardio - I/VI SEM 2nd LICS, no S3 or S4 Bilateral carotid bruits Abdomen - well healed midline scar, no bruits noted Pulses: Radial arteries - +2 right +2 left Femoral arteries - +2 right +2 left DP - +1 right +1 left PT - +1 right +1 left Neuro - oriented x 3, answers questions appropriately, follows commands, nl muscle tone/strength FAMILY HISTORY: He has a family history of early atherosclerosis, with siblings requiring vascular interventions at early ages. SOCIAL HISTORY: -Tobacco history: Curently smoking 1pack/day for 40years -ETOH: Takes 3 drinks a day -Illicit drugs: occasional marijuana

CHIEF COMPLAINT: Hypotension. PRESENT ILLNESS: Mr. [**Known lastname 77869**] is a 77 y.o. M well known to the MICU [**Location (un) **] team with h/o afib on coumadin, dementia, DM, CHF, recent right hemiarthroplasty of the hip who presented to and OSH after being found unresponsive and hypotensive in the setting of oxycodone at NH. Before admission, pt was being treated for C. diff, with positive assay noted at NH 2 weeks PTA (had a course of PO flagyl but still had diarrhea so was changed to PO vanc). At OSH CT ABD showed pan colitis. Pt was stabilized with IVF digoxin for a fib and transfered to [**Hospital1 18**]. At BICMC surgery evaluated and felt the collitis to be most likely infectious. Pt was hypotensive in the ED so went to the MICU. In the MICU PO vanc was continued and PO flagyl was added for C. Diff. BP stabilized to basline of SBP 90-100 with fluid resuscitation - no pressors were required. All cultures negative since admission. C. Diff assay has been negative here, but he has continued to have diarrhea. He was transferred to the floor with stable VS. . On the floor, he has had a worsening polyarticular gout flare. He was restarted on his home colchicine and probenacid with little relief of symptoms. Rheumatology was consulted and recommended a steroid taper, but the floor team decided to hold off on this in the setting of infection. UA was positive after transfer and cipro was started empirically. . On the afternoon after transfer, he triggered for low urine output. This was felt to be due to hypovolemia and he was given 1L of 1/2NS because of concern for hypernatremia. By 10pm he had made ~500cc urine since midnight. He was then hypotensive to mid-80s systolic. At that time he was afebrile and it was felt that hypotension was still most likely due to hypovolemia. He received 500cc NS with good effect (SBP to 100s). Following this he became febrile to 100.8, BP returned to mid-80s systolic. Continue to have very poor urine output. Blood pressure and urine output did not respond to a further 1L of NS. Mental status grossly the same although patient has baseline dementia. Was unable to swallow pills however which is reportedly new. On repeat exam patient was felt to have mild guarding although he denied pain, he did not have rebound tenderness. CXR did not show free air. Given possibility of urosepsis with resistant organism, Cipro was broadened to Zosyn. With volume resuscitation, patient began to get more edematous in lower extremities and scrotum. He continued to breathe comfortably on room air however O2 saturation went from 99-100% to 94-95%. On arrival, he was unable to give additional details of history. He denies CP, SOB, orthopnea, PND, cough, abdominal pain, N/V. He does complain of joint pain and stiffness in his arms especially. MEDICAL HISTORY: Atrial Fibrillation Diabetes Mellitus CHF - EF 50% with 1-2+MR and 2+TR Dementia Parkinson's disease HTN RA gout s/p open appy -remote s/p R total hip 6 weeks ago MEDICATION ON ADMISSION: MEDICATIONS AT HOME: -lasix 40 daily -enablex 15 daily -atenolol 25 -iron 325 daily -colace 100 daily -exelon 3 [**Hospital1 **] -remeron 7.5 hs starting [**3-5**] for 1 week, then 15mg hs -vanco 250 q6 (started [**3-7**]) -RISS -colchicine 0.6 [**Hospital1 **] -probenecid 500 tid -coumadin 1.5 daily (on hold [**3-8**], [**3-9**]) -prilosec 20 -ativan 1mg tid prn -MOM prn -tylenol prn -[**Female First Name (un) 1634**]-Lanta prn -oxycodone 5-10mg q4h prn -dulcolax prn -acidophilus 2 tabs [**Hospital1 **] ensure pudding [**Hospital1 **] ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VS: 97.7, 78/48, 80, 95% on RA GEN: NAD lying in bed at rest. HEENT: PERRL, anicteric, MM sl dry CV: irreg irreg, no m/r/g LUNGS: few crackles at left base, otherwise clear ABD: +BS. soft. NTND. No rebound or guarding. EXT: Warm. 2+ LE edema. Warm, erythematous MCPs of both hands. Erythematous warm toes on B feet with tenderness to palpation (c/w podagra). Tenderness, warmth, and erythema of bilateral tibial tuberosities. NEURO: A&Ox1 to person. Moving all extremities, but with pain on ROM. Following commands. BACK: Stage I/II sacral decubitus ulcers. FAMILY HISTORY: Non-contributory. SOCIAL HISTORY: Married. Living at nursing home since hip surgery.

CHIEF COMPLAINT: CHIEF COMPLAINT: vaginal bleeding PRESENT ILLNESS: HPI: 42 yo F with PMH of Freidrich's Ataxia, muscular dystrophy, afib who presents with vaginal bleeding and clots. She notes that her menses began about 7 days ago and she states that she had increased bleeding compared to normal. For the last 3-4 days she notes blood clots as well. Her husband who changes her diaper notes that the bleeding has been much worse than usual. She notes some lightheadedness. Denies acute change in vision, palpitations, chest pain, SOB, n/v, diaphoresis. She does have a history of uterine fibroids. MEDICAL HISTORY: PMH: Friedreich's ataxia Muscular dystrophy DM insulin dependent from age 31 atrial fibrillation/flutter hypothyroidism gastroparesis major depression urinary incontinence HTN systolic CHF with LVEF 40-45% Uterine fibroid CKD baseline Cr 1.2 s/p spinal fusion for scoliosis s/p CCY MEDICATION ON ADMISSION: Medications: 1.Amiodarone 400 mg PO DAILY 2.Aripiprazole 10 mg PO DAILY 3.Carvedilol 6.25 mg PO BID 4.Coenzyme Q10 900 mg daily 5.Coumadin 2mg on Wed and 3mg all other days 6.Digoxin 0.0625 mg PO DAILY 7.Escitalopram Oxalate 20 mg PO DAILY 8.Ferrous Sulfate 325 mg PO DAILY 9.Furosemide 80 mg PO DAILY 10.Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose 11.Levothyroxine Sodium 125 mcg PO DAILY 12.Lisinopril 5 mg PO DAILY 13.Lyrica *NF* 75 mg Oral daily 14.Magoxide 400mg 15.Myrapex 0.125 daily 16.Potassium liquid 15ml [**Hospital1 **] 17.Tizanidine HCl 4 mg PO BID 18.Tolterodine 2 mg PO BID 19.Topiramate (Topamax) 25 mg PO QAM 20.Topiramate (Topamax) 50 mg PO QPM 21.TraMADOL (Ultram) 50 mg PO Q6H:PRN pain ALLERGIES: Bactrim PHYSICAL EXAM: PE: vitals: T 98.2, BP 102/58, HR 58, RR 20, O2sat 97% RA General: obese female in NAD, lying in bed. A&O x3 HEENT: NCAT, anicteric sclera, non-injected conjunctiva. dry MM, OP clear without erythema or exudate. PERRL. EOMI. neck supple CV: RRR, no m/r/g Lung: CTAB no w/r/r Abdomen: +BS, soft, NTND Ext: no e/c/c. both legs flexed at knees and hips Neuro: speech slow but clear. Patient can not move legs and limited arm movements (baseline per patient and husband) FAMILY HISTORY: brother died of [**Name (NI) 22988**]. mother died of lung cancer (was a smoker). 3 cousins with [**Name (NI) 22988**]. SOCIAL HISTORY: married and lives at home. Her husband cares for her along with a PCA. No tobacco history. No alcohol or IVDU.

CHIEF COMPLAINT: off balance since one day; Tx for ICH PRESENT ILLNESS: The patient is a 73 yo R-handed woman with mild dementia, HTN and emphesema (on O2 at home), who is transferred from OSH for ICH. History from her sister and her husband, as well as patient (but she cannot remember all details). The patient has been feeling "dizzy" for the last week, which she decribed as "lightheaded", no spinning sensation, on and off, no factors that bring it on. She saw PCP last week for this, and her BP appeared not well controled (cannot tell how high). She was told to increase cartia XT from 120mg daily to 360mg daily. She has not yet done that. This morning ([**3-4**]), after she woke up, her husband noticed that her gait was off (he cannot tell if she was veiring to the right or left). He hasn't wittnessed any falls and the pt also denies any falls. She developed a brifrontal headache, [**4-28**], pounding. When asked when it started she says: 10 minutes ago. However, per her husband she had the headache earlier during the day. Unable to tell how it started. These problems [**Name (NI) 66735**] them to go to the [**Name (NI) **]. She had no slurred speech, no wordfinding problems, no focal weakness or numbness. No nausea, no vomiting. She has been having pain in her eyes for about a month, on and off, not specifically when moving her eyes. Blurry vision since a month, also on and off. Problems with writing since a month according to her husband: she writes her words, and then halfway through a word she continues with a scribbled line. She had ringing in her ears a couple of times this month. Tingling in her R-hand, at times (during the day; cannot give specifics) during the last month. The CT at OSH showed a L-temporal SAH (per report of Neurosurgery here and radiol. resident; the disc could not be found later), unclear whether acute or subacute. At OSH, it was read as intraparenchymal hemorrhage. After transfer, upon arrival in the ED here, her SBP ran in the 250's. An a-line was put in and nypride gtt was started. Her SBP then dropped to 60's during which episode the Pt was diaphoretic. Currently her BP in well controled in 140's. She still has her headache. According to her family she is at baseline (not oriented for time; forgetful). MEDICAL HISTORY: - HTN, not well controled - COPD, emphesema: home O2 - mild dementia since 2 yrs MEDICATION ON ADMISSION: - cartia XT 120mg (should have been 360mg) - advair 100/50 [**Hospital1 **] - combivent TID ALLERGIES: Aspirin PHYSICAL EXAM: VITALS: Tafebrile HR84 BP221/114 --> 143/90 RR20 sO296% 4l GEN: NAD, in bed HEENT: mmm, no icterus NECK: no LAD; no carotid bruits; neck supple LUNGS: distant bs bilaterally, clear HEART: Regular rate and rhythm, normal S1 and S2, no murmurs ABDOMEN: normal bowel sounds, soft, nontender, nondistended EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema SKULL AND SPINE: no bruits. FAMILY HISTORY: - SAH mother, died at age 58 - prostate ca dad SOCIAL HISTORY: Smoking: stopped 6yrs ago; smoked 1.5 ppd since her teens; occasional EthOH; no drug abuse. Level of activity: independent in ADLs; drives; no walker or cane; home O2 day and night. Married and has 2 adopted children.

CHIEF COMPLAINT: Shortness of breath. PRESENT ILLNESS: The patient is a 56 year-old female with a history of stage 4 non-small cell lung cancer with brain metastasis diagnosed in [**2103-2-17**], SVC syndrome and coronary artery disease, status post a myocardial infarction who presented to the Emergency Room with acute shortness of breath on [**2103-4-23**]. The patient had been in her usual state of health until three days prior to admission when she began experiencing shortness of breath and mild chest pain. She had had decreased p.o. intake for the day prior to admission and was seen in oncology clinic the day of admission and referred to the emergency department. In the emergency department the patient was saturating approximately 70 percent on room air with cyanosis. After being placed on a nonrebreather the patient's saturation improved to the 80s. Chest x-ray revealed a right pleural effusion and an increased heart size. The patient was escalated to BiPAP and then mask ventilation and eventually was intubated. Her electrocardiogram showed diffuse ST changes and a stat echocardiogram was performed which showed a large pericardial effusion without signs of tamponade. However. the patient was taken to the cardiac catheterization laboratory where she had a brief cardiac arrest. Her rhythm remained sinus tachycardia but she had no blood pressure. The pericardial drain was placed for pericardial tamponade and 260 cc of pericardial fluid was removed. The patient was resuscitated with this drainage and with 3 amps of epinephrine. Patient was subsequently put on dopamine. Her electrolytes were checked and her potassium was found to be 6.1. She was given insulin, D50 and Kayexalate at that time and brought to the Medical Intensive Care Unit. At the time of admission she was unresponsive off sedation with blood pressures in the 80s on Dopamine at maximum dose and was saturating 80 percent with an FIO2 of 100 percent on her ventilator. MEDICAL HISTORY: Is significant for non-small cell lung cancer stage 4 diagnosed in [**2103-2-17**], for brain metastasis being treated with radiation treatment in [**2103-3-20**], status post Taxol and carboplatin treatment in [**2103-3-20**]. She had superior vena cava syndrome also treated with radiation treatment on [**2103-4-16**]. Her history aside from her oncologic history includes hypertension, coronary artery disease, status post myocardial infarction, osteoporosis, esophagitis and status post appendectomy and status post total abdominal hysterectomy. MEDICATION ON ADMISSION: ALLERGIES: No known drug allergies. PHYSICAL EXAM: FAMILY HISTORY: Both parents died of lung cancer. SOCIAL HISTORY: The patient has an 80 pack-year smoking history.

CHIEF COMPLAINT: Cholangiocarcinoma PRESENT ILLNESS: Ms. [**Known lastname 122**] is a 57-year-old woman who experienced a recent 30-pound weight loss over the last month. She has had no abdominal or back pain, denies diarrhea, diabetes, and notes only reduced appetite. She subsequently developed jaundice and pruritus, and presented for an ERCP, which demonstrated a 1.5-cm distal biliary stricture. Brushings were performed and negative for malignant cells. A 10 French 7 cm biliary stent has resolved her jaundice. Her serum CA [**91**]-9 is 63. A CT scan of her chest, abdomen and pelvis demonstrates no evidence of pulmonary or hepatic metastasis. She has a replaced left hepatic artery, with a dilated pancreatic and bile duct above what appears to be a heterogeneous and somewhat subtle mass in the uncinate portion of the pancreas immediately adjacent to the portal vein. The lesion measured 1.9 cm in diameter. The superior mesenteric artery is not involved. There is no teardrop malformation of the vein or evidence of encasement. The patient was evaluated by Dr. [**Last Name (STitle) **] in his [**Hospital 45932**] clinic for possible surgical resection of this mass. After discussion of all risks, benefits and possible outcomes, the patient was scheduled for elective Whipple resection. MEDICAL HISTORY: -HTN -HLD -s/p hysterectomy -s/p 2 ectopic pregnancies (removal of ovaries and fallopian tubes bilaterally) MEDICATION ON ADMISSION: Amlodipine 10 mg once a day, aspirin 81 mg once a day. The patient was on atenolol, but due to normal blood pressure and bradycardia, the atenolol was held during recent hospitalization ALLERGIES: Bactrim / Penicillins PHYSICAL EXAM: Upon Discharge: VS: 98.5, 79, 106/75, 12, 100% RA GEN: NAD, AAO x 3 HEENT: Neck incision well healed CV: RRR PULM: CTAB ABD: Subcostal incision with moist-to-dry dressing. RLQ JP drain x 2 to bulb suction, site with DSD and c/d/i. LUQ GJ tube capped and site c/d/i. EXTR: Warm, LUE PICC dressing c/d/i FAMILY HISTORY: Mother has HTN, diabetes, and multiple myeloma. No other known familiy history of malignancy SOCIAL HISTORY: The patient is originally from Montserrat in the Caribbean and immigrated to the US in [**2147**]. Has been married for 4 years, husband is a chef at [**Name (NI) 104207**]in NY. Had 1 child at age 16, died at 9 months of unknown cause. Currently living with sisters and mother in [**Name (NI) 2268**]. Works as nurse's assistant at Newbridge on the [**Hospital **] Rehab. -tobacco - never -EtOH - rare -illicits - never

CHIEF COMPLAINT: Diabetic ketoacidosis. PRESENT ILLNESS: Mr. [**Known lastname 22484**] is a 51-year-old male with diabetes mellitus and end-stage renal disease (status post renal transplant times two) who presented to the [**Hospital6 1129**] on [**2142-1-7**]. Mr. [**Known lastname 22484**] also has a history of multiple admissions for diabetic ketoacidosis. On presentation to [**Hospital6 1129**], he was noted to be lethargic and with an increased blood glucose. He was transferred [**Hospital1 69**] because his medical care was coordinated at [**Hospital1 **]. On admission to [**Hospital6 1129**], he was noted to have a temperature of 101.4, a heart rate in the 110s, and hypotension reported in the 90s/40s. There was concern for sepsis, and he was treated broadly with antibiotics including vancomycin, ceftriaxone, and Levaquin. On transfer to [**Hospital1 69**], he was admitted to the Medical Intensive Care Unit for management of diabetic ketoacidosis. An initial blood glucose was 370. He was also noted on admission to have a creatinine of 3 (which was well above his baseline of around 1). Other findings on admission included a swollen and painful left elbow. On admission, Mr. [**Known lastname 22484**] noted general malaise and tiredness. He denied any chest pain, shortness of breath, nausea, vomiting, diarrhea, fevers, chills, dysuria, hematuria, abdominal pain, numbness, weakness, or tingling. MEDICAL HISTORY: 1. Insulin-dependent diabetes mellitus; complicated by retinopathy, nephropathy, and neuropathy. 2. End-stage renal disease. 3. Status post living-related kidney transplant in [**2128**]; rejection in [**2134**]. 4. Status post cadaveric renal transplant in [**2136**]. 5. Right index finger osteomyelitis. 6. Chronic low back pain. 7. Status post transurethral resection of prostate. 8. Peripheral vascular disease. 9. Status post multiple toe amputations and lower extremity bypass grafts. MEDICATION ON ADMISSION: 1. Insulin sliding-scale. 2. Aspirin 325 mg p.o. q.d. 3. Allopurinol 500 mg p.o. q.d. 4. Midodrine 2.5 mg p.o. q.d. 5. Lopressor 12.5 mg p.o. b.i.d. 6. Heparin subcutaneously. 7. Protonix 40 mg p.o. q.d. 8. Colace 100 mg p.o. b.i.d. 9. Celexa 20 mg p.o. q.d. 10. Prograf 3 mg p.o. b.i.d. 11. Depakote 500 mg p.o. q.d. 12. Lasix 80 mg p.o. b.i.d. 13. Zaroxolyn 5 mg p.o. b.i.d. 14. Prednisone 10 mg p.o. q.d. ALLERGIES: PENICILLIN. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: He lives in [**Hospital3 **]. He denies alcohol or tobacco use.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 52 year old man, unrestrained driver, high speed motor vehicle collision into guardrail, found unresponsive at the scene, combative, and was brought to [**Hospital6 302**] where a chest x-ray and pelvic films, MedFlighted to [**Hospital6 649**], intubated for airway protection. [**Location (un) 2611**] coma scale initially was 3 at the scene. MEDICAL HISTORY: Significant for hepatitis C and diabetes. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: SOB PRESENT ILLNESS: [**Age over 90 **] yo female with hx of HTN, afib, ? PE, multiinfarct dementia and recurrent UTI who presents with lethargy, hypoxia, and LE erythema. Pt is aphasic at baseline. Per notes from ED and PCP coverage, the patient was being treated for recurrent UTI with a course of levofloxacin started on [**6-7**] but was otherwise doing well. Last night she was noted to be more lethargic than normal with increasing SOB. She was noted to be hypoxic with O2 Sats of 80% so was transferred to the ED. In the ED she had a fever to 101.8 with intermittent hypoxia that improved to 98% with 4LNS oxygen . She was given Clindamycin 600mg IV x1 for LE cellulitis and a dose of Levofloxacin 500mg IV for possible UTI. For her hypoxia, she was given 20mg IV Lasix and a combivent neb with significant improvement with CTA neg for PE and LENI neg for DVT. She continued to have intermittent hypoxia of unclear etiology so was transferred to the [**Hospital Unit Name 153**] for closer monitoring. . In the MICU, the patient was treated with CTX and Vanc for UTI/cellulitis. Also diuresed. Patient improved and sent to floor [**6-11**] on 2L NC. Patient noted to have increased Eos in blood and urine so CTX stopped and placed on levo/macrodantin. . [**6-13**] Patient decompenstated on the floor. Patient desatted to 80's on 6L NC. ABG 7.46/52/63 on 6L NC. Patient initially with HR in 80's. Patient given lasix 20mg IV x 1 and an alb neb. Then went into afib with RVR into the 140's maintaining her pressure. Patient given 5mg IV lopressor x 3 with out response in HR. Transferred back unit for further mgt of HR and hypoxia, where she was started on a diltiazem drip; CTA was without evidence of PE. Course complicated by persistent hypotension requiring multiple fluid boluses; this resolved after the discontinuation of the diltiazem drip. She was started on an amiodarone load with conversion into NSR. Her O2 sat improved with diuresis. A picc line was placed and she was started on aztreonam (instead of macrobid) for UTI. She was transferred back to the general medical floor on [**2175-6-16**]. Currently, she has a new rash over her trunk and arms bilaterally--thought to be from Ceftriaxone. MEDICAL HISTORY: CVA-with multiinfarct dementia-aphasic at baseline Afib UTI Zoster-L thorax Syncope PE Hypothyroidism DJD MEDICATION ON ADMISSION: Ciprofloxacin 250mg [**Hospital1 **] Amoxicillin 500mg PO tid ? d/c'ed Lopressor 25mg tid Lasix 40mg alt 20mg qd held Neurontin 100mg [**Hospital1 **] Levofloxacin 250mg qd-started on Tylenol prn Erythromycin eye ointment Levalbuterol Nebs q6h prn Nortryptilline 25mg qhs MVI Digoxin 0.125mg qd KCl 10 meq qd Celexa 10mg qd Colace Levothyroxine 50mcg qd Macrodantin 50mg qid-completed ALLERGIES: Sulfa (Sulfonamides) / Ceftriaxone PHYSICAL EXAM: T 98 HR 93 BP 100/37 RR 24 O2Sat 99 (3LNC) Gen: chronically ill, in bed listing to left side, NAD HEENT: R nasolabial flattening, Edentulous, Dry MM, Neck: JVP to mandible Heart: regular with occasional premature beats, no MRG, no heave, not parvus et tardus Lungs: Marked kyphosis, Bilateral crackles throughout, decreased breath sounds at R base- not dull to percussion. Abd: soft, NT, ND, BS+ Extrem: 2+ LLE with erthema to midshin, 1+ RLE, 1+ DP pulses bilaterally. Neuro: expressive aphasia- unintelligable speech, follows verbal commands "close your eyes" "wiggle your toes" Pupils 2-->1cm bilaterally, arcus senilis, moving all 4 extremities. Skin: Large 3x4cm SK's over thorax, crusted raised lesions in T4 distribution on Left back and chest. FAMILY HISTORY: NC SOCIAL HISTORY: Divorced, lived alone in [**Location (un) 7349**] until fall at home with hip fx then moved to NH here in [**Location (un) 86**] because son lives in [**Name (NI) 392**], had CVA at [**Name (NI) **], never smoker, no ETOH, no illicits.

CHIEF COMPLAINT: abdominal pain PRESENT ILLNESS: 69 year old Italian speaking gentleman diagnosed with non-operable pancreatic CA in [**12-12**], s/p multiple CBD stent placements, who is admitted with abdominal pain with N/V x2 days. Pt also c/o heartburn. Abdominal pain sharp with radiation to back/right shoulder baldes and right flank. [**5-19**] severity unable to control pain with pain pills. 10 lb wt loss this month. FSBS increased recently. +CHest tightness- unclear if different than heartburn, not exertional in nature associated with abdominal pain. Denies F/C, black/bloody stool, dysuria, hematuria. MEDICAL HISTORY: 1. Pancreatic CA, as above 2. PUD 3. Ventricular ectopy, possibly secondary to small MI at age 40 4. Osteoarthritis 5. Emphysmea 6. Anxiety MEDICATION ON ADMISSION: Megestrol Mirtazapine RISS protonix pancreas Cholecalciferol ALLERGIES: Iodine / Penicillins / Iodine; Iodine Containing PHYSICAL EXAM: VS: Tmax 98.3 pulse 93, BP 110/72, RR 22, sats 95% on 3L. GEN: The patient is a cachectic, NAD, speaking in full sentences, frail appearing. HEENT: Anicteric, MMM, OP clear, PERRL, EOMI Upper teeth, lower molars missing. NECK: supple, no LAD. No Virchow's node appreciated. PULM: Reduced breath sounds bilaterally. Tympanitic. End expiratory wheezes throughout. CV: NSR, no MRG. ABD: soft, NT/ND, no rebound or guarding. No masses appreciated. No organomegally. No periumbilical nodes appreciated. EXT: warm, 2+ pulses B at radius and DP. Varicosity noted on anterior aspect of R crus. NEURO: AAOx3, FAMILY HISTORY: CAD in mother, father, and sister. Cerebral aneurysms in sister. Negative for pancreatic, colorectal, or any other CAD. SOCIAL HISTORY: Italian-speaking. History of heavy smoking, currently several cigarettes per day. [**1-11**] glasses wine per day, no hx heavy EtOH. Lives with sister and her husband in [**Name (NI) 1475**]. Single, without children. Retired shoe-factory worker.

CHIEF COMPLAINT: Abdominal pain/ pancreatitis PRESENT ILLNESS: 33 year old gentleman with h/o polysubstance abuse (EtOH, cocaine, Xanax), DM2, seizure disorder (? withdrawal), severe depression, alcoholic pancreatitis in [**6-/2162**] admitted to OSH w/ hypertriglyceridemic pancreatitis on [**12-18**]. Initially intubated for agitation, ? withdrawal, course complicated by respiratory failure and development of ARDS. The patient initially presented on [**12-18**] with report of 24 hours of acute onset abodominal pain accompanied by nausea. While he denied EtOH use, a close friend endorsed recent EtOH abuse. Serum and urine tox were negative on presentation. He denied hematemes, BRBPR. Labs on presentation WBC 11, hct 31.2, lipase 1500, triglycerides >3600 (greater than assay), cholesterol was over 1000 and normal LFTs. CT scan demosntrated acute pancreatitis, with peripancreatic fluid wihtout loculated collections in addition to a fatty liver. The patient was seen by GI c/s who felt sx c/w severe pancreatitis likely [**2-3**] hypertriglyceridemia. Felt transfer to tertiary care center for plasma exchange of triglycerides if no improvement demosntrated. The patients hospital course was complicated by severe agitation and question of withdrawal seizure. On HD 3 he was intubated due to sedation for agitation/management of withdrawal. He was started on TPN for nutritional support and a triple lumen PICC line was placed. He was started on gemfibrozil 600mg [**Hospital1 **]. Since intubation serial chest xrays have demonstated worsening bilateral infiltrates that have become diffuse in nature. He was initially treated with aggressive IVF. He became febrile by HD3, and was started on vancomycin and zosyn for empiric anti-microbial coverage of hospital acquired pneumonia. By HD 5, he developed worsening hypoxia, and was noted to be asyncronous with the vent requiring high PEEPs. His fluids were decreased to 120cc per hour and he was given 40 of IV lasix for concern that volume overload was contributing. 7.26/51/69 while AC Vt 500 RR18 Fio2 of 80% and PEEP 10. His hospital course has further been complicated by hyponatremia which corrected with NS boluses in addition to acute on chronic anemia. Hemolysis labs on HD2 were negative. He was transfused a total of 4 units of pRBC. On HD 5, at the request of his family, transfer to [**Hospital1 18**] was initiated. His labs on transfer were WBC 9.6, Hct 25.9, pts 157, bands 33, Na 134, Creatinine 1.6, cholesterol 463, triglycerides 1477. MEDICAL HISTORY: 1. Insomnia 2. Obstructive Sleep Apnea 3. Major Depression 4. Seizure Disorder, ? [**2-3**] alcohol withdrawal 5. Pancreatitis [**2162-6-2**] (EtOH) 6. Etoh/cocaine abuse 7. Anemia MEDICATION ON ADMISSION: Medications: (home) 1. Celexa 20mg daily 2. Omeprazole 20mg [**Hospital1 **] . Medications: (transfer) 1. Combivent Inhaler 4 puff q4hrs 2. D5W and D5NS 3. Thiamine 500mg IV q24 hrs 4. Folic acid 1mg IV q24hrs 5. Vancomycin 1.5gms? 6. Zosyn 7. Tylenol 8. Vasotec 1.25mg q6hrs prn for SBP > 180 9. Fentanyl 13mcg q1hr prn sedation 10. lopid 600mg [**Hospital1 **] 11. haldol 1mg IV prn 12. dilaudid 0.5-2mg q2hrs for pain 13. Humulog prn q4hrs 14. Humuloh N 8 units q12 hrs 15. Ativan 2mg q4hrs prn anxiety 16. Mylanta 30mL q4hrs 17. Narcan 0.4 mg prn 18. IV zofran 4mg prn 19. Protonix 40mg q24hrs 20. TPN ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: Admission exam: VS 101.1; HR 120; BP 138/68; RR 18, O2 sat 96% General: Intubated, sedated, not responsive to commands HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse crackles bilaterally, no wheezes. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: distended, hypoactive bowel sounds, no organomegaly GU: foley in place Ext: trace edema to ankles, warm, well perfused, 2+ pulses FAMILY HISTORY: No family history of hypertriglyceridemia or pancreatitis SOCIAL HISTORY: Single, lives with roommates, works with his sister. [**Name (NI) **] been struggling with polysubstance abuse for many years. - Tobacco: Denies - Alcohol: Heavy alcohol abuse per roommate - Illicits: H/o cocaine, xanax abuse

CHIEF COMPLAINT: Respiratory distress PRESENT ILLNESS: 61 year old female with h/o SCLC dx'ed '[**88**] s/p XRT, chemo, stem cell rescue, and prophylactic TBI recently admitted for respiratory failure with recurrent nonmalignant R pleural eff. and pseudomonas pna. s/p intubation, trach/PEG, now returns from rehab with respiratory distress per the physician caring for her. The patient had been weaned to trach collar before d/c to rehab. At rehab, she was placed on IMV and then switched to AC on account of respiratory distress. She had no increase in secretion, cough, or fever. She was noted to have PIPs in the 50s, RR 20-30, and diaphoresis. At rehab, she had been diuresed heavily, started on diltiazem, digoxin, andlopressor for rate control of sinus tachycardia, prednisone for possible COPD exacerbation. She presented with a bicarbonate of 50 upon return to the [**Hospital1 18**] MICU. MEDICAL HISTORY: 1. SCLC dx'ed '[**88**] s/p XRT, chemo, stem cell rescue, and prophylactic TBI 2. COPD 3. hypothyroidism 4. atypical pna's 5. recurrent R pleural eff s/p multiple taps (cytology negative) 6. cognictive impairment since TBI 7. recurrent R pneumonia secondary to pseudomonas 8. sinus tachycardia 9. met alkalosis MEDICATION ON ADMISSION: ceftazidime 2g TID flovent MDI atrovent MDI albuterol MDI heparin SQ levoxyl 125 mcg QD tylenol colace senna captopril 12.5 mg TID humalog sliding scale lorazepam 1-2 mg q4 prn prevacid prednisone 60 mg QD lopressor 12.5 mg [**Hospital1 **] diltiazem 30 mg TID morphine sulfate prn dulcolax digoxin .125 mg QD lasix 20 mg [**Hospital1 **] ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Afebrile 108/60 91 13 99% Vent: AC 500 x 8 5 .4/ 400-500 13 GEN: well-appearing NAD, trach'ed HEENT: MMM PERRL EOMI NECK: No LAD, trach C/D/I CARD: RRR NL S1S2 no MRG PULM: decreased BS at R base, coarse BS, no wheezes ABD: soft NT ND (+) BS XTRMT: R > L LE edema NEURO: alert, cooperative, responsive FAMILY HISTORY: mother- DM, father- HTN. SOCIAL HISTORY: Daughter [**Name (NI) **] is HCP. Former [**Name2 (NI) 1818**] 70 pack-yrs. Quit '[**88**]. No EtOH or drugs.

CHIEF COMPLAINT: Decompensated CHF PRESENT ILLNESS: 85 yoM with AF on coumadin s/p pacemaker [**2-/2192**] admitted for decompensated CHF and transferred to the CCU s/p PEA arrest. See [**Hospital1 1516**] note for more details, but in summary, pt admitted for worsening DOE and LE swelling over several days. His outpatient cardiologist did a TTE which he read as normal. Pt admitted to the [**Hospital1 1516**] service where a TTE was repeated, showing mild apical hypokinesis but preserved EF. Given the focal area of involvement, an ischemic etiology was considered although per Dr.[**Doctor Last Name 3733**], this may have been related to dyssynchrony. The patient was diuresed and coumadin held while awaiting cardiac catheterization tomorrow. In the interim, he did have a witnessed fall yesterday - reported by roommate to have collapsed; no event on telemetry, and CT head unremarkable. His mental status seemed to have waned somewhat today, so CT head was repeated, which again was unremarkable. . This evening around 5pm, the pt developed chest pain. His EKG showed new lateral TWI. Pt was then noticed to become cyanotic; O2 sat 60% on pleth but tracing poor. He subsequently became pulseless, and a code blue called. Compressions were initiated, and pt received epinephrine x1. Rhythm strips showed narrow complex waveforms. A right femoral line was placed, and IV fluids were hung with improvement in his BP. During intubation, large food particles were aspirated. There was return to spontaneous rhythm within 10 minutes. A bedside echo during code reportedly showed preserved LV function. Pt was transferrred to the CCU for further management. . He also underwent speech & swallow evaluation which showed evidence of aspiration. Per his wife, he is usually monitored while eating but did have a hamburger today without supervision. He reported to her not feeling well with neck pain, chest pain, coughing and emesis after that meal. On further suctioning in the ICU, he was found to have multiple pieces of hamburger in his ET tube. . Unable to obtain ROS as pt intubated and sedated. MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diet-controlled diabetes, - Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: AF with slow ventricular response s/p ppm 3/[**2191**]. 3. OTHER PAST MEDICAL HISTORY: Cardiac Risk Factors: (-)Diabetes (diet controlled), (-)Dyslipidemia, (+)Hypertension, (+) Smoking, (-) FH early MI or sudden cardiac death . Cardiac History: AF with slow ventricular response, s/p pacemaker [**2192-3-17**] . OTHER PAST MEDICAL HISTORY: -Dementia -Thoracic Aortic Aneurysm [**3-/2192**] 5.2 cm < 5.5 threshold for surgery -Anxiety -Depression -S/p surgery on his left outer ear for removal of a skin cancer -Blind left eye MEDICATION ON ADMISSION: Lisinopril 20 [**Hospital1 **] Amlodipine 5 Coumadin 5,5,7,5,7,5 (6 day cycle) Diazepam 2.5 AM, 5 PM Namenda 10 [**Hospital1 **] Aricept 10 QHS Celexa 20 QHS Vit E 400 daily ALLERGIES: Penicillins PHYSICAL EXAM: On Admission to MICU VS: T=96.8 BP=134/73 HR=75 RR=15 O2 sat=98% on FiO2 of 100% GENERAL: Chronically ill-appearing elderly Caucasian male intubated and sedated. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 13 cm. CARDIAC: Very distant heart sounds. IIR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTAB ant/lat with no audible rales. ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: 1+ pitting edema b/l to mid calf. R 3rd and 4th toes cyanotic. R femoral CVL in place. PULSES: Right: Carotid 2+ Femoral 2+ DP dopp PT dopp Left: Carotid 2+ Femoral 2+ DP dopp PT dopp FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. SOCIAL HISTORY: -Smoking/Tobacco: 120 PY (2 x 60y), quit 10 years ago -EtOH: None -Illicits: None -Lives at/with: Wife at home, who cares for him. Veteran of WWII Navy), retired [**Location 27256**] Sugar Refinery worker.

CHIEF COMPLAINT: Metabolic encephalopathy. PRESENT ILLNESS: [**Known firstname 449**] [**Known lastname 65495**] is is well known to OMED service as he was admitted to our service and transferred on day of admission to [**Hospital Unit Name 153**]. Briefly, he is a 54-year-old man with a h/o recurrent GBM, s/p resection, XRT, and chemotherapy. His treatmetn was complicated by pulmonary embolism, seizure, and steroid myopathy resulting in frequent falls who presented to clinic today with increased somnolence and episodes of syncope. He was then directly admitted after CT angiogram was negative for pulmonary embolism and MRI of the head was performed. He was accompanied by his wife who provided most of the history. His wife explains that he has had progressive weakness, mainly in his bilateral lower extremities, over the past 2 weeks. He also had become more somnolent over the past several days. Patient has had episodes of "passing out," a total of 4 time, the first this past Sunday. Wife reports that while he was being moved, he had loss of consciousness for minutes. He then awakened without any deficits. There was no evidence of seizure activity. His wife also reports incontinence with his loss of consciousness episodes; one episode was witnessed by EMT's and they reported no evidence of seizure activity, just loss of consciousness for several minutes. Patient has been involved in a research study to try and decrease his Decadron usage secondary to to steroid complications. Since his initiation in the trial, his mental status and weakness has become worse. Wife reports that he would awaken for a few minutes and then returned to sleep. Patient was admitted to OMED and placed on high-dose steroids, given IVF's, and diuretics were held. Labs revealed severe hypokalemia and hyponatremia and he was transferred to MICU for closer monitoring. In [**Hospital Unit Name 153**], he recieved aggressive potassium repletion and normal saline, PICC line was placed, and renal was consulted. His Na improved from 120 to 130 and K from 1.7 to 3.8, and he is called out to the floor. Currently the patient is feeling well and when asked if he has any complaints, he responds 'just you' - a common response for him per his wife. ROS is negative for chest pain, SOB, F/C/N/V/D/C. He is eating and drinking now. MEDICAL HISTORY: Patient was referred to the Brain [**Hospital 341**] Clinic on [**2193-1-28**] for a newly diagnosed glioblastoma multiforme. Neurologic problems began on [**2193-1-3**] when he bumped his head at work. After that, he was dizzy, forgetful, and had blurry vision for a few days. He had a head CT that showed a mass in the left parietal white matter. Subtotal resection performed on [**2193-1-10**]. Radiation was initiated on [**2193-1-25**]. Medical oncologist is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**], M.D. in [**Location (un) 61553**], MA. - s/p a gross total surgical resection by [**Name6 (MD) **] [**Name8 (MD) 65496**], M.D. at [**Hospital **] Hospital performed on [**2193-1-10**] - s/p chemo-irradiation at [**Hospital6 7472**] in [**Location (un) 61553**], MA from [**Month (only) 956**] to [**2193-2-13**] - s/p 3 cycles of adjuvant monthly temozolomide under the direction of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**], M.D. in [**Location (un) 61553**], MA. - [**2193-7-29**] tumor returned on surveillance head MRI seizure on [**2193-7-8**], started on Depakote at 1,500 mg po twice daily pulmonary embolism after 3 cycles of monthly temozolomide, on Coumadin, started on Lasix for pedal edema - s/p 2 monthly cycles of metronomic temozolomide at 75 mg/m2/day - s/p Cyberknife radiosurgery to recurrence in the left occipital lobe cavity - started Xerecept protocol on [**2194-1-24**] - Keppra at 1,500 mg po 3 times daily, pedal edema requiring Lasix and Zaroxylyn MEDICATION ON ADMISSION: Temozolomide 200 mg po daily Dexamethasone 2 mg PO BID Coumadin 5 mg po 4 times per week and 4 mg po 3 times per week Lasix 40 mg po a.m. and 20 mg po p.m. Compazine 5 mg po daily (before chemotherapy) Pepcid 20 mg po q a.m. Keppra 1,500 mg po twice daily Ativan 0.5 mg po 2 tabs at bedtime Bactrim DS 1 tab po 3 times weekly Zaroxylyn 2.5 mg po daily Celexa 20 mg PO daily ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: VITAL SIGNS: Temperature is 98.1 F, blood pressure 118/64, heart rate 99, respiratory rate 17, and oxygen saturation 99% in room air. FAMILY HISTORY: His mother had hypertension, and both parents died of myocardial infarction. One brother has hypertension while a sister had breast cancer that was treated. His children are healthy. SOCIAL HISTORY: He works as a painter at [**State 1558**] at [**Location (un) 5169**]. He has been smoking cigarettes 2.5 pack-per-day for 30 years. He stopped drinking alcohol 9 to 10 years ago. He does not use illicit drugs.

CHIEF COMPLAINT: Thoracic and abdominal aortic atheroma with history of embolic disease to the left foot, as well as the spleen PRESENT ILLNESS: The patient is a 43 year-old female transferred from [**Hospital 8**] Hospital c infarct to spleen secondary to thrombus in descending aorta diagnosed by CT scan. She presented to [**Hospital 8**] hospital with abdominal pain, nausea, vomiting, and diarrhea thought to initially have been caused by acute gastritis. A CT scan was performed in the workup and she was transferred to Dr. [**Last Name (STitle) **] for further evaluation. MEDICAL HISTORY: Hypertension Depression MEDICATION ON ADMISSION: HCTZ, Celexa, Motrin ALLERGIES: Penicillins / Ambien PHYSICAL EXAM: ON DISCHARGE: Vitals; 98.0 82 132/74 18 94% room air NAD A&O x 3 RRR CTAB soft, ND, apporpriately TTP, NABS Incision clean, dry, intact, steristrips present. No cyanosis, cords, or edema FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Currently a smoker. Denies EtOH or illicit drug usage.

CHIEF COMPLAINT: Coffee ground hematemesis PRESENT ILLNESS: 78F w/ h/o small cell lung ca s/p radiation and chemo in [**2116**], gastric AVMs, left CVA w/ residual R hemiparesis and aphasia who presents from nursing home w/ abdominal pain and coffee ground emesis. Per nursing home records, patient vomited coffee grounds x2 positive for occult blood. Also with large "coffee ground BM." Of note, is on aspirin and lovenox (0.7 mL [**Hospital1 **]) per nursing home records. She was sent to ED for further evaluation. At time of transfer, VSS w/ BP 111/56, HR90, RR18, T97.3, O2 sat 77%?. . Of note, patient has h/o gastric AVMs noted in [**2-/2121**] at [**Hospital1 3278**] when she was admitted for GI bleed. During that admission she underwent EGD which showed four areas of AVMs in body of stomach and fundus which were anticoagulated with Argon beam. Also w/ h/o cecal mass s/p right hemicolectomy in [**2111**]. was recently admitted in [**2123-5-19**] for MRSA pneumonia, requiring MICU stay and intubation. During this hospitalization it was noted that patient had elevated LDH as high as 611, concerning for recurrence of her small cell ca and outpatient follow up at [**Hospital1 3278**] was recommended. . In the ED, initial vs were: HR 95 BP 80/40 (triage), 106/58 repeat RR 30 O2 sat 99% RA. Patient triggered for hypotension and was bolused 1.5 L NS. Exam was notable for diffuse abdominal tenderness w/o peritoneal signs and melanotic stools in diaper. Labs notable for hct of 19.3 (baseline 23) and WBC 12.4; BUN 69, creatinine 0.8. Potassium was 5.9 with slightly peaked T waves on EKG, for which she received D50, insulin and calcium gluconate w/ improvement to 4.7. PEG tube lavage was performed and notable for coffee grounds, which cleared after 350 ccs. She was started on IV PPI gtt and received 2 units of pRBCs. She was seen by GI who recommened NPO status and plan to scope today. She empirically received cipro and flagyl for concern for colitis as well as zofran and morphine 6mg total. KUB was performed which showed normal placement of PEG and CXR with worsened R pleural effusion. Patient underwent CT Abd/Pelvis which was notable for new large retroperitoneal mass engulfing aorta, SMA, celiac, and renal arteries, as well as IVC and left portal vein thromboses. VS on transfer were: 99.0, 90, 105/50, 18, 99% RA. . On arrival to the ICU, patient appears comfortable. She is aphasic, but moves all extremities spontaneously. MEDICAL HISTORY: - L capsular CVA with right sided hemiparesis and aphasia - Small cell lung cancer s/p XRT to RUL and 4 cycles cisplatin in [**2116**] - Gastric AVMs on EGD in [**2-/2121**] - HTN - HL - Depression - Hypothyroidism - s/p R hemicolectomy for h/o cecal mass in [**2111**] - Osteopenia - s/p PEG placement for failed speech and swallow in [**5-29**] MEDICATION ON ADMISSION: Admission Medications (per nursing home records): levothyroxine 50 mcg Tablet PO DAILY lovenox 70 mg q12hr aspirin 81 mg ipratropium bromide 0.02 % 1 Neb q6HRs PRN albuterol sulfate 2.5 mg /3 mL (0.083 %) 1 neb Q6H prn bisacodyl 10 mg PR prn percocet 1-2 tabs q4hr prn lactulose 15 mL daily PRN famotidine 40 mg NG qHS loperamide 2 mg PO TID prn simvastatin 20 mg PO daily atenolol 50 mg PO DAILY multivitamin 1 Tablet PO DAILY ferrous sulfate 300 mg (60 mg iron) po Daily sertraline 50 mg NG daily senna 8.6 mg Capsule PO BID PRN docusate sodium 100 mg PO BID acetaminophen 1000 mg [**Hospital1 **] ALLERGIES: Sulfa (Sulfonamide Antibiotics) / hydrochlorothiazide / Enalapril PHYSICAL EXAM: Admission Physical Exam: Vitals: T: 98.4 BP: 103/56 P: 67 R: 19 O2: 92% on RA General: Alert, oriented to place, but minimally verbal, following simple commands no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally anteriorly, crackles in FAMILY HISTORY: Sister with CVA. Father with h/o HTN. SOCIAL HISTORY: Lives in nursing home. Has lived there since stroke. Ex-smoker. No alcohol or illicit drug use.

CHIEF COMPLAINT: shortness of breath PRESENT ILLNESS: 69F h/o primary biliary cirrhosis,chronic LE edema on chronic furosemide, remote h/o breast cancer s/p XRT, obesity, and depression who presented to an OSH ([**Hospital 4199**] Hospital) from rehab on [**2187-1-26**] with acute onset of shortness of breath and desaturation to 80% SpO2 on room air. CXR was notable for large right sided pleural effusion that was attibuted to hepatic hydrothorax given her history of liver disease. CT was negative for PE. There was initial concern for MI given the patients shortness of breath however troponins were negative x 2 and EKG did not exhibit ST segment changes. Diuresis was initiated with bolus doses of 80 mg IV lasix [**Hospital1 **] with good response ( patient was 1.5 L negative per day) however her symptoms failed to resolve and she ultimately underwent thoracentesis with removal of 1.5 L of fluid (cell count [**Pager number **] RBCs, 0 WBCs, pH 8.2, protein < 1 glucose 107) was consistent with a transudative process. Paracentesis was not performed. The patient was seen by GI who recommended transfer to a tertiary care center for referral for possible TIPS. Over the course of her hospitalization there was also concern for a GI bleed given hemoglobin drop from 12 to 8.9 in the setting of guaiac positive stools. She was transfused 2 units PRBCs with maintainence of stable HCTs. The patient was also noted to have a urine culure for which she was empirically started on ceftriaxone 1 gram daily on [**2186-2-1**]. Subsequently demonstrated proteus and citrobacter for which the patient was switched to zosyn. Vitals on transfer were 98, 64, 20, 95% 3L, 102/53. . Of note Patient had been discharged from [**Hospital1 18**] on [**2187-11-9**] after being admitted for c.diff and cellulitis. She was found to be living was found to be living in a filthy and unsafe home at that time. There was a question of her safety at home. Ultimately after a long discussion with the patient and social work her son was made her health care proxy. . On arrival patient was extremely confused with slowed speech. She was alert and oriented to person only. She was able to deny pain but was otherwise unable to participate in an interview. . ROS: patient was uable to participate in a review of systems MEDICAL HISTORY: PER OMR/EPIC: PBC diagnosed 20 yrs ago HTN Breast Ca s/p XRT Obesity Hypothyroidism CREST GERD Depression Migraine headaches MEDICATION ON ADMISSION: Home medications 1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 3. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO DINNER (Dinner). 7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 8. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 9. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). . medications on transfer IV lasix 80 mg [**Hospital1 **] ceftriaxone 1 gram q 24 first dose [**2187-1-31**] spironolactone 100 albuterol PRN levothyroxine 150 mcg daily nadolol 40 mg daily protonix 40 daily ursodiol 600 qam 300 qpm vitamin D 800 daily lorazepam 0.25 tid prn magnesium oxide 400 PO BID MVI ALLERGIES: aspirin / NSAIDS PHYSICAL EXAM: ADMISSION EXAM VS: 96.8 105/57 66 22 98% 3L NC GENERAL: ill appearing female only intermittently responding to questions, A+O to person only HEENT: Sclera anicteric. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Mildy tachypneic, no accessory muscle use, mild crackles bilaterally, BS decreased at bilteral bases R > L ABDOMEN: Distended but Soft, non-tender to palpation. Dullness to percussion. + Fluid wave, umbical hernia present, No HSM or tenderness. EXTREMITIES: Cool, no clubbing or cyanosis. 2+ peripheral edema bilaterally to the knees with assoicated erythem and dry flaking skin, no warmth. . DISCHARGE EXAM VS: T98.1, BP91-106/56-61, HR 64-76, RR 18, 97-100% on 2L [**Telephone/Fax (1) 85957**], 3BM Gen: Chronically ill appearing woman in no acute distress, AOx3, no asterixis HEENT: MMM, OP clear CARDIAC: RRR, no wheezing/rhonchi/rales LUNGS: Diffuse crackles b/l, decent air movement on left, dullness to percussion of right lung up 1/2 up the lung fields, no egophony ABDOMEN: Distended but Soft, non-tender to palpation, no hepatosplenomegaly EXTREMITIES: 2+ pitting edema to the knee b/l lower extremities FAMILY HISTORY: Mother colon cancer, father pancreatic cancer. SOCIAL HISTORY: [**Hospital 8735**] medical [**Doctor Last Name **]/IT specialist, smoked PPD but quit >40 yrs ago, does not drink, no drug use.

CHIEF COMPLAINT: Bright red blood per recturm with hemodynamic instability PRESENT ILLNESS: 30 y/o female with history of AML s/p allo BMT in [**12-7**] and relapse detected in [**5-8**] now s/p MEC treatment ([**6-8**]) and DLI on [**7-29**] and GVHD (leg pain, high LFT's) admitted to [**Hospital1 18**] [**2106-8-17**] for hematochezia. She is now transferred to the [**Hospital Unit Name 153**] for BRBPR and hemodynamic instability. . The current presentation started on Sunday, [**2106-8-15**], when the pt recalls that she had 1 episode of painless, bright red bloody emesis. She says that the amount was small, less than 1 cup. Monday, [**2106-8-16**], she had dark clotted blood with BM and less yesterday [**2106-8-17**]. She was transferred from an OSH today for further management. . On transfer to [**Hospital1 18**], she appeared comfortable to the admitting resident and had no complaints (and specifically denied abdominal pain). At about 2:30 am today, she had a large, marroon stool mixed with melena. Her BP, which was 120s/70s on arrival went to 90/60; her HR which was 70s on arrival went to 130s. 2 emergency-released units of prbcs were initiated. She was bolused 1000cc NS and an 80 mg pantoprazole bolus was ordered. . On arrival to the [**Hospital Unit Name 153**], HR had decreased to the 90s but BP was 86/39. She was mentating well and c/o rle pain and mild nausea. Pt denied current LH/dizziness, abd pain, CP, dyspnea/SOB. 2 events quickly ensued. . First, the blood bank called to let us know that the 2 units running were JKB incompatible. The transufusion was stopped, the BMT fellow and blood bank resident on call were apprised and 2 units of cross-matched blood were rapidly procured. . Next, as the units ran in, the pt c/o LH and vomited approximately 200c BRB. A femoral line was inserted and 3 units were rapidly transfused. The GI fellow, who had been called on transfer to the [**Hospital Unit Name 153**], arrived with the attending for emergent EGD. MEDICAL HISTORY: ONCOLOGY HX: She was first noticed to have leukocytosis and thrombocytosis several years ago and a bone marrow bx at that time revealed reactive marrow without dysplastic changes. At the time of the birth of her daughter in [**12-6**] she was found to be anemic and thrombocytopenic with immature circulating blasts and a bone marrow showed 9% blast forms and cytogenetics showed an 8;21 translocation. She underwent 7+3 induction in [**1-7**] followed by consolidation with HiDAC times three. She underwent an alloSCT with cyto/TBI on [**2105-12-3**]. Her course was c/b mucositis, neutropenic fever, and vaginal bleeding, resolved by the time of her discharge. She had a positive blood cultures thought due to line infection with coag-neg. Staph in [**2-8**] and [**3-8**], and her Hickman was d/c'd. She had some acute stage I skin GVHD in [**4-7**] that responded to low dose steroids. . Relapse detected in [**5-8**], confirmed with FISH. During admission in [**2106-6-3**], patient received MEC therapy with good result; repeat bone marrows have been without evidence of AML. She is status post DLI on [**7-29**]. . PMH: 1. AML/MDS: as above 2. HTN 3. s/p gastric bypass 2 yrs ago 4. s/p tonsillectomy 5. h/o MRSA, VRE, C.diff 6. Line sepsis CNS Ox resistant [**3-8**] with hickman removal 7) hx MRSA bacteremia late [**2105**] MEDICATION ON ADMISSION: Prednisone 60 mg daily Fluconazole 200 mg daily Cell Cept ALLERGIES: Compazine / Cefepime PHYSICAL EXAM: Vitals: t 97.3/ Hr 96// BP 86/39// RR 22// O2 Sat 100% RA Gen: Anxious female, quietly crying, AAOx3, speaking in full sentences, pale but jaundiced, odor of melena HEENT: MMM, OP with palatal petecchiae vs ulcer, otherwise clear, no blood in mouth, icteric sclera Neck: Obese and fleshy, no JVD Heart: Tachy, rr, no m/g/r appreciated Lungs: CTAB Abd: Soft, obese, NT/ND, hypoactive BS, melena and blood emerging from anus Ext: No c/c/e, warm, weak DPs FAMILY HISTORY: MGM - CLL, mom DM [**Name (NI) **], HTN, dad HTN, sister asthma SOCIAL HISTORY: Originally from [**Country 3587**] but moved to the US when she was 2 yrs old, currently lives in [**Doctor Last Name 792**]with her husband and daughter, used to work as a [**Name (NI) **] and phlebotomist until [**9-6**]. +Tobacco- ~10pk-yrs, quit 2 yrs ago. Denies EtOH and drugs.

CHIEF COMPLAINT: 47M admitted for liver transplantation. Most recent hospitalization for R VATS biopsy of a lung nodule concerning for metastatic HCC. PRESENT ILLNESS: MEDICAL HISTORY: HBV Heptocellular Carcinoma s/p RFA Hamartoma. Hypertension. MEDICATION ON ADMISSION: Active Medication list as of [**2143-11-17**]: Medications - Prescription CLOTRIMAZOLE [MYCELEX] - 10 mg Troche - 5 daily x5 daily NIFEDIPINE [NIFEDICAL XL] - (Prescribed by Other Provider) - 60 mg Tablet Extended Rel 24 hr - 1 Tab(s) by mouth once a day TENOFOVIR DISOPROXIL FUMARATE [VIREAD] - 300 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC CALCIUM CARBONATE [CALTRATE 600] - (OTC) - 600 mg (1,500 mg) Tablet - 1 Tablet(s) by mouth twice a day ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: 98.4 111 135/98 18 97% RA Gen: NAD HEENT: EOMI, not jaundiced, mucous membranes moist, no cervical lymphadenopathy, no supraclavicular lymphadenopathy, no JVD Chest: CTAB, RRR, no M/R/G Abdomen: soft, non-tender, non-distended Extremities: no edema, 2+ radial pulses bilaterally, fully ambulatory without difficulty Neuro: A&Ox3, MAE FAMILY HISTORY: His family medical history is significant for his mother who is alive and healthy. His father died of unknown causes. SOCIAL HISTORY: Cantonese and has a high school education. He is married and has two children, ages 15 and 17. He is a restaurant cook. He has no history of alcohol use. He smoked one pack of cigarettes per day in the past but quit 10 years ago. He has no history of IV drug use, marijuana use, blood transfusions, tattoos, or piercing.

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 57-year-old female with a past medical history of hypothyroidism and hypercholesterolemia. She presented with chest pain. For the past one year the patient has been having exertional angina on fast walking. She felt this was related to her breathing. On [**2105-4-10**] the patient felt a short episode of chest pain at rest, sharp substernal pain, no radiation, associated with diaphoresis. The pain would wax and wane over the weekend but got worse on the night prior to admission. She presented to an outside hospital and was transferred here for catheterization which showed severe three-vessel disease with total occlusion of the distal right coronary artery. She described no orthopnea and no paroxysmal nocturnal dyspnea, no edema, no claudication, no recurrent illnesses or recent illnesses, no urinary symptoms, no diarrhea, no melena, no bright red blood per rectum. MEDICAL HISTORY: 1. Hypothyroidism. 2. Hypercholesterolemia. 3. Recurrent bronchitis. 4. The patient is blind in her right eye from birth secondary to trachoma. MEDICATION ON ADMISSION: 1. Aspirin, which she was not taking. 2. Lipitor, not taking although both prescribed. 3. Levoxyl 100 mcg per day. ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: No tobacco, occasional glass of wine with dinner; self-employed. Of note the patient is a Jehovah's Witness, no blood products.

CHIEF COMPLAINT: Fvers, admitted from rehab PRESENT ILLNESS: HPI: Mr. [**Known lastname **] is a 67 yoM trached, h/o Pseudomonas/Acineterbacter MDR PNA who is admitted from [**Hospital 100**] Rehab with T 102.4 and altered MS. Of note, he was recently admitted at [**Hospital1 18**] MICU green from [**Date range (1) 95399**]/09 for similar system of complaints; he was followed closely by ID and has been on a course of amikacin/inhaled colistin for MDR PNA. His course was complicated by ARF thought to be [**2-6**] colistin side effect and persistent fevers, for which no cause other than the PNA was ever identified (numerous BCx were negative). . His wife reports that he was doing well this week at rehab with improving MS. It is unclear whether he was still having intermittent fevers throughout the week, but this morning he spiked and became less arousable. He was noted to have thick secretions. ABG from 3:45 this afternoon showed 7.41/53/101 on 50% trach collar. He had a set of BCx from [**1-26**] that are NGTD. In the ED on arrival, VS were T, HR 108, BP 120/60, RR 24, RA 100%. Head CT was negative for acute hemorrhage/edema, though there is some question of mastoiditis b/l on the prelim read. The ED staff touched base with ID who said to leave him on amikacin/colistin. He got a dose of amikacin 750 mg IV x 1. MEDICAL HISTORY: - [**8-/2168**] fall + subdural hematoma c/by S. bovis endocarditis. Tx 6 weeks ceftriaxone. Course c/by MRSA, Enterococcal thought to be line-related bacteremia. - [**11/2168**] PCN/Vanc sensitive Enterococcal aortic valve endocarditis. Tx 6 weeks vancomycin (pcn allergic) - completed 6 weeks tx [**2168-12-21**]. - [**11/2168**] admit c/by Acinetobacter in sputum (? colonization versus VAP), treated with tobramycin and unasyn (plan was to d/c on [**12-1**]). - [**Date range (3) 95358**], one day after discharge, resp failure, re-intubated. ESBL Klebsiella pna: treated with Meropenem x 12 days. Tracheostomy. Sputum later grew Acinetobacter on [**2168-12-10**] -> unasyn and tobramycin as above. [**Date range (3) 95400**]. DC [**12-16**] on trach mask. - Morbid obesity - DM type 2 poorly controlled with complications - Chronic renal insufficiency (new baseline as of [**12-12**] - Cr 1.6-2) - HTN - reactive airways disease - h/o asbestos exposure with pleural plaques - GERD - Parkinson's disease - detrusor instability - gout - hypothyroidism - aortic stenosis, valve area 0.9cm2, peak gradient 24, median gradient 48 - Anemia - h/o nephrolithiasis MEDICATION ON ADMISSION: MEDICATIONS ([**Hospital 100**] Rehab list): Combivent Q8 hours std Acetazolamide 250 mg [**Hospital1 **] Amikacin 750 mg QOD ASA 81 mg QD Carbidopa/levodopa 25/250 Q4 hours ? colistin 75 mg nebs Q8 hours Senna Colace Fondaparinux 2.5 mg QOD Lantus 34 units QHS SSI syntrhoid 88 mcg QD Omeprazole 40mg QD Ropinirole 3 mg QID Simvastatin 20 mg QD Miconazole powder PRN Tylenol PRN Morphine PRN ALLERGIES: Tagamet / Ditropan / Penicillins / Lisinopril / Heparin Agents PHYSICAL EXAM: PHYSICAL EXAM: VS on arival to MICU: T 100.2, HR 102, BP 143/91, RR 21, 96% on 35% trach collar General: apears comfortable but ill; obese HEENT: PERRL; trached LUNGS: crackles at bases b/l anteriorly; does not cooperate for full exam; some referred upper airway breath sounds CARDIO: RRR, no m/r/g appreciated ABD: + BS, obese, soft, no rebound/guarding, difficult to assess whether TTP EXTREMITIES: 1+ [**Location (un) **], WWP, no rashes; left arm PICC NEURO: somnolent, does not arouse to voice for me (but do so for wife [**Doctor First Name **]; stimulates with pain. reflexes 2+ throughout; down-going Babinksi's FAMILY HISTORY: non-contributory SOCIAL HISTORY: -- has wife, [**Name (NI) **], who is HCP; also with two daughters -- no alcohol or tobacco use -- currently resides at [**Hospital 100**] Rehab -- formerly owned pizzaria restuarants

CHIEF COMPLAINT: PRESENT ILLNESS: This is a 66-year-old man with a past medical history significant for coronary artery disease, status post coronary artery bypass grafting in [**2128-10-21**], at which time they performed a left internal mammary artery to the left anterior descending, saphenous vein graft to the OM-I and OM-II sequential and saphenous vein graft to the PDA. He is also status post stenting of his saphenous vein graft to the OM-I, OM-II territory in [**2135-3-21**], and PTCA and brachytherapy to the saphenous vein graft to the OM-I, OM-II in [**2137-12-21**]. The patient also has a past medical history significant for insulin-dependent diabetes mellitus, hypertension, hypercholesterolemia, depression, mild dementia, history of TIA, status post bilateral carotid endarterectomies in [**2134**]. The patient is a 66-year-old male with a long-standing history of coronary artery disease, who was admitted [**2138-12-2**] due to unstable angina with a troponin level ranging between 4.5 and 5.9. Cardiac catheterization was performed on [**2138-12-2**] which revealed a patent left internal mammary artery graft, occluded OM-1 and OM-2 graft, and a 90% occlusion in the in-stented segment of the PDA. The last echocardiogram was performed in [**2137-5-21**] which revealed a left ventricular ejection fraction of 40%. MEDICAL HISTORY: MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Seizure, CP PRESENT ILLNESS: Pt is a 61 y/o male with IDDM, s/p CABG a few months ago; sz d/o on lamictal presented to ED after tonic-clonic sz at home; per wife has h/o hypoglycemic sz that result in post-sz hyperglycemia (EMS FS was 320, pt seemed post-ictal). Pt did not have BM or urinate during seizure, and did not have a "feeling of this seizure" happening, no strange smells/color changes. Pt was afebrile, missed single dose of lamictal last night. He related no CP/SOB assoc with sz, but developed CP while in ED; initial ECG on arrival was like prior but repeat ECG with T changes in lateral, I, aVF (lead placement not changed), no ST elevations. Pt explains CP as a non-radiating right sub-sternal pain, [**2-21**], that felt like an ice-cube resting on his chest. He had no SOB/diaphoresis/dizziness but did remember nausea. Pt received SL nitro, lopressor, ASA which relieved his symptoms in the ED. Pt was started on Hep, bolused with 600mg Plavix and admitted to the [**Hospital1 1516**] service. MEDICAL HISTORY: -DM-1: for 47 years. Retinopathy but no neuropathy, nephropathy MEDICATION ON ADMISSION: Lantus 27 units AM Humalog SS Atorvastatin 20 mg PO DAILY Lamotrigine 150 mg PO BID Moexipril HCl 7.5 mg PO BID Metoprolol 12.5 mg PO BID Aspirin 325 mg PO DAILY ALLERGIES: Tegretol / Dilantin / Penicillins / Sulfonamides / Bactrim PHYSICAL EXAM: vitals: 96.9, 122/56, 64, 18, 98%RA Gen- NAD, alert/conversational HEENT- No LAD, MMM, EOMI, no JVD, thyromegaly Cv- RRR, s1s2, 2/6 systolic murmur (AS?), no r/g Pul- CTA b/l Abd- NT/ND, no bruits L extrm- no edema, palpable pedal pulses neuro- AAO x3, CN 2-12 intact groin site: stable, no hematoma, no ozzing, no bruits FAMILY HISTORY: Father: MI @40 Sister: MI @50 SOCIAL HISTORY: 2 cigars per week (equivalent to a 25 py hx) but has stopped within the past year. EtOH 1 drink with dinner. Retired H.S. English teacher. Lives with wife. [**Name (NI) **] 6x/week-about half mile at a time.

CHIEF COMPLAINT: fever, RUQ pain PRESENT ILLNESS: Ms. [**Known lastname 48684**] is a [**Age over 90 **] y/o woman with PMH of HTN, COPD, and dementia who presented to [**Hospital1 **] from her nursing home with complaint of L-sided chest pain not relieved by 2 SL nitroglycerin. Per OSH reports, the patient stated the pain radiated to her back earlier in the day and was associated with nonproductive cough and shortness of breath. In the BIDN ED, the patient also complained of LLQ pain at which point a CT scan of the abdomen was obtained which demonstrated a dilated CBD to 14 mm. Following this finding, the patient underwent RUQ ultrasound which (by verbal report) showed a CBD at 8 mm with questionable opacity (stone versus sludge) in the gallbladder. . In the evening, she was nauseous and vomited X 2. At about the same time, she was tachycardic on the floor to the 130s and subsquently given 20 mg IV diltiazem X 1. Labs were repeated demonstrating WBC up to 28.7 with bandemia, elevated liver enzymes (normal on admission), and lactate 3.6. At that time, she was transferred to the ICU for further care with surgical consult for presumed cholangitis. In the ICU, the patient maintained HRs in the 90s-100s with SBPs in the 120s-140s. She received IVF (NS at 200 cc/hour then LR 500 cc bolus and 150 cc/hour). She received IV vancomycin, flagyl, and levofloxacin prior to transfer. . On arrival to the [**Hospital Unit Name 153**], the patient denies any abdominal pain, nausea, or vomiting. She tells me she did have diarrhea earlier in the evening. She denies any shortness of breath or chest pain. MEDICAL HISTORY: Dementia HTN COPD/asthma CHF (EF unknown) h/o anemia h/o tibial fracture MEDICATION ON ADMISSION: ASA 325 daily lasix 20 mg daily diltiazem 240 mg daily lidoderm patch to right knee daily (on 12 hours/off 12 hours) KCL 10 mEq daily saline nasal spray Tylenol 650 mg [**Hospital1 **] lactulose 30 mL [**Hospital1 **] Advair 250/50 1 puff [**Hospital1 **] Refresh eye drops Ciprofloxacin eye drops to R eye at bedtime Tylenol 650 mg Q4H prn pain Robitussin prn Prochlorperazine 10 mg PO q6H prn nausea guaifenesin/hydrocodone syrup prn albuterol neb q6H prn ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: T: 98 BP: 117/69 HR: 95 RR: 14 O2 99% on 2L NC Gen: Pleasant, elderly female in NAD HEENT: No icterus. Mucous membranes dry. NECK: Supple, No LAD, JVD < 10 cm. No thyromegaly. CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: clear to auscultation bilaterally with no crackles or rhonchi ABD: hypoactive bowel sounds with tenderness to palpation in the RUQ EXT: Warm throughout, no peripheral edema. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox2 (oriented to self and place "[**Hospital1 **]" but not date). Appropriate. Face symmetric and speaking in clear sentences. Moving all extremities without difficulty. PSYCH: Listens and responds to questions appropriately, pleasant FAMILY HISTORY: Reports that mother and sister had "heart problems." SOCIAL HISTORY: Lives at nursing home. No smoking history per patient. No alcohol use.

CHIEF COMPLAINT: Chest pain PRESENT ILLNESS: This is a 76 year old man with Type 2 diabetes, hypertension who had a melanoma excised from his back on the day of admission, and was driving back to [**Location (un) 86**] when he had an acute onset of 5 out of 10 substernal chest pain with radiation to the neck which was associated with some mild shortness of breath. He went to the Emergency Department at [**Location (un) 620**] where an electrocardiogram showed normal sinus rhythm with significant ST elevation in 2, 3, AVF and ST depression in V1 and V2 which was consistent with an acute inferior posterior myocardial infarction. He was given Aspirin, heparin, beta blockade, intravenous nitroglycerin and had resolution of both of his chest pain and ST changes. A couple of weeks prior to admission the patient does report that he had an abnormal exercise tolerance test. MEDICAL HISTORY: Hypertension, diabetes mellitus Type 2, melanoma and recent back surgery. He also has hypercholesterolemia and hypertension. MEDICATION ON ADMISSION: ALLERGIES: PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY: He does not smoke, he does not drink, he does not use drugs, he is single. He is an active man and likes to ice skate.

CHIEF COMPLAINT: paresis of extremities and cervical pain PRESENT ILLNESS: Pt was struck by a wave and developed severe motor deficits. Pt was care flighted to [**Hospital1 18**]. MRI + cord contussions/edema. MEDICAL HISTORY: Denies MEDICATION ON ADMISSION: ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: A+O x 3 NAD. C-collar intact. anterior and posterior incision is intact. [**Date range (1) 64373**] motor Left uext. [**1-26**]- [**2-26**] Right uext. [**Date range (1) 64374**] b/l lower exts FAMILY HISTORY: N/C SOCIAL HISTORY: Married with children. Pt works as an attorney

CHIEF COMPLAINT: Fever and hypotension PRESENT ILLNESS: The pt is an 84 yo female with past hx significant for DM type II, CHF, HTN, hypothyroidism, A-fib, chronic leg ulcers, and chronic renal insufficiency who presented to the ED on [**10-21**] with fever to 102 F and hypotension. She was transferred to the ICU where the hospital course was as follows: Sepsis protocol was initiated. Coverage of multiple possible sources was begun with vancomycin, levofloxacin, and metronidazole. Pt was aggressively fluid resuscitated. Norepinephrine drip was required to maintain blood pressure in adequate range. Urine culture was positive for Klebsiella pneumoniae, and the patient also had stool positive for C. diff toxin. Vancomyin was discontinued after osteomyelitis was ruled out as a possible infection in this patient. The patient's blood pressure was stable and the norepinephrine drip was discontinued. She was transferred to 12R on the am of [**2179-10-26**]. On arrival to the floor her temp was 100, hr 90-110, bp 100/60. MEDICAL HISTORY: - Hypertension - DM II - Atrial Fibrillation - Gastroesophageal Reflux Disease - Total abdominal hysterectomy, bilateral salpingoophorectomy - Anemia - Chronic renal insufficiency (baseline 1.4 - 1.5) - Chronic leg ulcers - Anemia - Hypothyroidism MEDICATION ON ADMISSION: citalopram 20 mg po daily mirtazapine 15 mg qhs docusate 100 mg po senna po bid bisacodyl 2 mg daily prn levothyroxine 125 mcg daily glipizide 25 mg daily regular insulin protonix 40 mg daily albuterol MDI q6 prn simethicone qid prn metoprolol 75 mg tid tylenol750 mg q6 tramadol 25 mg q6 prn coumadin 1 mg qhs enalapril 10 mg daily lasix 40 mg po daily oxycodone/APAP fentanyl zinc keflex MVI ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Exam on arrival to the floors: VS: 97.8, 110/80, 78, 18, 98% on 4L NC Gen: lying in bed moaning, leaning to the right side, with preferential right gaze, difficult to understand speech HEENT: NC/AT, perrl, mmd, o/p clear Neck: L IJ CVL in place CV: irreg irreg, s1 and s2, no m/r/g Pulm: crackles bilaterally Abd: obese, soft, nt, nd, active bs Extr: 2+ edema throughout arms, legs, eye-lids; multiple deep ulcers bilaterally that are bandaged, bandages c/d/i FAMILY HISTORY: Non-contributory SOCIAL HISTORY: - Denies smoking, EtOH, or drinking history. - Pt was independent until recent stay at [**Hospital3 2558**] - POA is [**Name (NI) **] [**Name (NI) 71227**]

CHIEF COMPLAINT: PRESENT ILLNESS: The patient is a 23 year old male transferred from [**Hospital 48951**]Hospital with the diagnosis of splenic rupture. The patient fell from a standing position while snow boarding. Denied loss of consciousness. The patient was able to get up, drove himself to an outside hospital where he obtained an abdominal CT showing a grade 4 splenic laceration. He was at the outside hospital for approximately three hours, GCS of 15, never hemodynamically unable, hematocrit of 44. Given 500 cc of IV fluids and transferred by Med-Flight. The patient complained of left upper quadrant pain, no dyspnea. MEDICAL HISTORY: Only includes asthma. MEDICATION ON ADMISSION: ALLERGIES: Theophylline. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: s/p Motor vehicle crash PRESENT ILLNESS: 34 yo F passenger s/p high speed auto crash vs. embankment, restrained + airbag self extricated. + LOC. She was transported to [**Hospital1 18**] for further care. MEDICAL HISTORY: Denies MEDICATION ON ADMISSION: None ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: FAMILY HISTORY: Noncontributory SOCIAL HISTORY:

CHIEF COMPLAINT: PRESENT ILLNESS: This is an 84-year old gentleman with a long history of tobacco use, hypertension, hypercholesterolemia in family history until about eight months ago when he noticed the requirement of needing more frequent sublingual nitroglycerin for increasing chest pain. At 1:00 a.m. on [**10-2**], while at rest in bed, he developed substernal chest pain radiating to his left shoulder with shortness of breath. He took four sublingual nitroglycerins with minimal relief. The pain kept him awake throughout the night. At 6:00 a.m. he took eight nitroglycerins without relief and also tried his albuterol inhaler. He called his daughter and she activated the emergency system and he was brought to [**Hospital3 **] at 9:00 a.m. At [**Hospital3 **], his electrocardiogram showed anterior ST elevations with lateral T-wall inversions and reciprocal inferior ST depressions. He was given aspirin, heparin, Aggrastat, and nitroglycerin. He was transferred to [**Hospital1 43634**]. At [**Hospital6 43635**], he underwent emergent cardiac catheterization, results to follow. MEDICAL HISTORY: 1. Hypertension. 2. Angina. 3. Hypercholesterolemia. 4. Aortic stenosis. 5. Asthma. 6. Peptic ulcer disease, status post gastrectomy 30 years ago. 7. Colon cancer, status post colectomy with radiation therapy 4 years ago. 8. Peripheral vascular disease with history of bilateral lower extremity claudication. MEDICATION ON ADMISSION: ALLERGIES: None known. PHYSICAL EXAM: FAMILY HISTORY: SOCIAL HISTORY:

CHIEF COMPLAINT: Non-ST elevation MI, h/o known CAD. PRESENT ILLNESS: 65M initially evaluated at [**Hospital3 3583**] for non-ST elevation MI in setting of known CAD. S/p cardiac cath x2 prior. Stopped taking his meds 2 weeks prior to admission for insurance reasons. Echo showed EF 30%, severe MR, and severe TR. Transferred to [**Hospital1 **]-[**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] cardiac cath, which showed an 80% proximal RCA lesion. Repeat TEE showed 3+ MR, 2+ TR, moderate global LV hypokinesis. MEDICAL HISTORY: 1. CAD 2. DM 3. HTN 4. MR 5. TR 6. Cardiomyopathy 7. Hypercholesterolemia 8. s/p appy MEDICATION ON ADMISSION: (on transfer) 1. Coreg 12.5 mg PO BID 2. Protonix 40 mg PO QD 3. Glucophage 4. NPH insulin 5. Aldactone 12.5 mg PO QD 6. Lasix 40 mg PO QD 7. Lisinopril 40 mg PO QD 8. ASA 81 mg PO QD 9. Plavix 75 mg PO QD 10. Imdur 30 mg PO QD 11. Glipizide 10 mg PO QD 12. Lipitor 40 mg PO QD ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: Afebrile, VSS NAD, alert Neck: no bruits Heart: RRR, 3/6 SEM at apex Lungs: CTAB but decreased BS at bases Abd: soft, NT, ND, + BS Ext: no edema FAMILY HISTORY: Noncontributory SOCIAL HISTORY: Former cigarette smoker (quit [**2130**]) No EtOH

CHIEF COMPLAINT: palpitations PRESENT ILLNESS: Mr. [**Known lastname 24614**] is a 69 year old gentleman with a known dilated ascending aorta and aortic regurgitation who has recently been experiencing increased palpitations. He was therefore referred to [**Hospital1 18**] for surgical evaluation. MEDICAL HISTORY: hypertension aortic regurgitation dilated ascending aorta (5.5 cm) asthma psoriasis liver hemangioma/cysts gall bladder polyps elevated PSA with normal biopsy MEDICATION ON ADMISSION: lisinopril 10mg daily vitamin D aspirin 81mg daily viagra PRN MVI ALLERGIES: Atenolol PHYSICAL EXAM: At the time of discharge Mr. [**Known lastname 24614**] is awake, alert, and oriented. His heart is of regular rate and rhythm. His lungs are clear to auscultation bilaterally. His sternal incision is clean, dry, and intact. His sternum is stable. His abdomen is soft, non-tender, and non-distended. He has trace edema in his lower extremities. FAMILY HISTORY: Mr. [**Known lastname 24615**] son passed away at the age of 25 of hypertrophic cardiomyopathy SOCIAL HISTORY: Mr. [**Known lastname 24614**] is a retired electrical engineer. He lives with his wife.

CHIEF COMPLAINT: Hypertension and chest pain. PRESENT ILLNESS: The patient is a 41-year-old female with a history of lupus, end-stage renal disease times 12 years, severe hypertension who recently hospitalized for high blood pressure and chest pain management in the setting of volume overload who went to Radiology for arteriovenous fistulogram in preparation for a renal transplant evaluation this morning. Since her last hospital admission, the patient's blood pressures at home have been ranging from 190 to 200 systolically. The patient did not take her blood pressure medications this morning secondary to instructions; and at procedure was noted to have chest pain described to 7/10 chest pain that was left-sided, radiating to back; which is her usual pain distribution. At this time, her blood pressure was noted to be 230/120 and was sent to the Emergency Room at this time. In the Emergency Department, the patient was started on Nipride initially and then was switched to nitroglycerin. In the Emergency Department, she was found to have atypical chest pain without electrocardiogram changes, and her initial cardiac enzymes were negative. The patient was also given 1 mg of morphine sulfate with relief. The patient had a CT angiogram of her chest that was negative for dissection. Her systolic blood pressure became elevated again, as the patient did not get her evening times medications, and pressure rose to 270/130 in the Emergency Room. The patient then received her nightly medications. Of note, her blood pressure decreased to 202/100 in the Emergency Room. She was admitted to the Coronary Care Unit for monitoring. On examination currently, has a headache since starting the nitroglycerin drip; but has since then slightly improved. MEDICAL HISTORY: 1. Systemic lupus erythematosus. 2. End-stage renal disease; the patient receives hemodialysis on Tuesday, Thursday, and on Saturday. 3. Severe hypertension. 4. Gastroesophageal reflux disease. 5. Hyperparathyroidism. 6. Endometrial cyst. 7. Migraines. 8. Gout. MEDICATION ON ADMISSION: 1. Prevacid 30 mg p.o. q.d. 2. Claritin 10 mg p.o. q.d. 3. Accupril 30 mg p.o. b.i.d. 4. Nifedipine-XR 120 mg p.o. q.h.s. 5. Clonidine 0.2-patch q.h.s. 6. Hydralazine 10 mg p.o. t.i.d. 7. Lopressor 125 mg p.o. b.i.d. 8. Aldomet 500 mg p.o. t.i.d. 9. Allopurinol 100 mg p.o. q.d. 10. Fioricet as needed for migraines. 11. Klonopin p.o. q.h.s. as needed. 12. Singulair 10 mg p.o. q.d. 13. Paxil 10 mg p.o. q.d. ALLERGIES: PENICILLIN, VANCOMYCIN, LEVAQUIN, KEFZOL. PHYSICAL EXAM: FAMILY HISTORY: Family history is notable for systemic lupus erythematosus and hypertension. SOCIAL HISTORY: The patient denies tobacco, alcohol, or intravenous drug use.

CHIEF COMPLAINT: bilateral ear pain, cough, shortness of breath PRESENT ILLNESS: Mr. [**Known lastname 88348**] is a 24 y/o M with remote history of childhood asthma presenting with worsening cough and shortness of breath over the past two weeks. His illness began with bilateral ear aches [**2-19**] weeks ago. This was also accompanied by fevers measured to be 103 degrees. His ear pain resolved somewhat, but he has had ongoing dyspnea and productive cough with large amounts of yellow sputum since then. He had one episode of blood-tinged sputum, in the setting of blowing his nose and coughing frequently. He presented to an outpatient provider approximately two weeks prior to admission who prescribed him a six-day course of azithromycin. He had a mild improvement in his symptoms and also took amoxicillin. One day prior to admission, his symptoms progressed. He presented to the [**Hospital1 **] [**Location (un) 620**] Emergency Dept with worsening dyspnea. In the ED, his initial vital signs were 98.0, 96, 111/72, 88% RA. Exam was notable for pale skin, diminished lung sounds at left base, no wheezes or rhonchi. CXR was notable for LLL PNA, but no cavitary lesions. He was transiently placed on TB precautions, which were discontinued after his CXR came back. He was given doxycycline 100 mg IV ceftriaxone 1g IV, vancomycin 1g, and levofloxacin 500 mg PO, as well as multiple doses of duonebs and 2 liters of IV fluids. CTA was obtained, showing complicated PNA. He was transferred to the [**Hospital1 18**] [**Hospital Unit Name 153**] for closer monitoring. Upon arrival to the ICU, he felt his breathing was improved and he was not feeling dyspneic as long as his oxygen mask is on. He endorsed a poor appetite, a 20 lb weight loss, and drenching sweats over the past two weeks. He reported no nausea, vomiting, or abdominal pain. MEDICAL HISTORY: Childhood asthma 1 episode of pneumonia as an infant MEDICATION ON ADMISSION: None ALLERGIES: Diphenhydramine PHYSICAL EXAM: On Admission: Vitals: Temp: 98.5 BP: 129/73 HR:89 RR:25 O2sat: 91% on 80% high flow oxygen GEN: pleasant, speaking in full sentences, taking shallow breaths, appears generally ill and pale, but in NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd RESP: +Bronchial breath sounds over left base. Decreased BS over right base. No wheezes or rhonchi. No crackles. Deep inspiration interrupted by frequent coughing. CV: RRR, S1 and S2 wnl, no m/r/g ABD: NABS, soft, nt, no masses or hepatosplenomegaly, no rebound tenderness or guarding. EXT: no c/c/e SKIN: mild erythematous patches at site of prior telemetry leads. No other rashes/jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch. FAMILY HISTORY: No known lung disease. Grandmother with CHF and adult-onset diabetes. SOCIAL HISTORY: Current smoker until onset of this illness. Has been smoking 0.5-1 ppd since age 10. Lives at home with parents. Works as supervisor in CVS.

CHIEF COMPLAINT: CHIEF COMPLAINT: chest pain REASON FOR ADMISSION TO CCU: inferior STEMI PRESENT ILLNESS: Mr. [**Known lastname 405**] is a 59y/o gentleman with no significant PMH besides obesity and [**Known lastname **] who presented to the ED due to chest pain and is being admitted to the CCU s/p cardiac cath with RCA stenting for inferior STEMI. . He was in his otherwise good state of health until 2AM today when he developed acute onset of chest pain that woke him up from sleep. It is described as substernal/left sternal pressure radiating to the jaw. Was associated with mild SOB but no nausea or diaphoresis. He was concerned that he might be having a heart attack so he took an ASA and called EMS. Received another ASA by EMS and arrived to the ED at 4:40AM. . In the ED, initial vitals were HR 63, BP 168/95, RR 16, POx 99% 2L NC. Over the next hour his BP increased to 196/114, HR up to 120. Labs and imaging significant for Trop-T 0.07. Cr was 1.7. EKG showed ST elevations in II, III, aVF and ST depressions in I, aVL as well as V1-V2. Patient was given 1L normal saline, Morphine 5mg IV, Plavix 600mg PO, was started on Heparin gtt and was taken to the cath lab. There, he was found to have RCA 95% lesion which was stented as well as a mid-LAD 80% lesion with no intervention. He was still hypertensive and tachycardic. He was started on a NTG drip for hypertension and received Metop 5mg IV x4 for tachycardia. Right groin was angiosealed, right venous sheath in place. After the procedure he complained of some chest tightness similar to his [**Known lastname **] symptoms and he was given Lasix 20mg IV. . On arrival to the CCU, patient feels well. No more shortness of breath. No chest pain. He is glad that he called EMS. He mentions that though he does not exercise, at his baseline he is very active at work as a landscaping contractor. He can usually walk more than 5 flights of stairs before becoming short of breath, and he has never had chest pain before today. . REVIEW OF SYSTEMS On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. MEDICAL HISTORY: [**Known lastname **] obesity ED visits for minor cuts/injuries no surgeries MEDICATION ON ADMISSION: Primatene inhaler PRN (Epinephrine 0.22 mg [**Name10 (NameIs) **]), no longer available in the USA ALLERGIES: No Known Allergies / Adverse Drug Reactions PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION: VS: T=98 BP=152/102 HR=98 RR=12 O2 sat=90-95% 4L NC GENERAL: obese gentleman in NAD HEENT: EOM intact, MMM NECK: supple, no JVD CARDIAC: S1 and S2, no murmur, no heave LUNGS: CTA throughout all fields bilaterally; no wheezes ABDOMEN: soft, nondistended, no mass EXTREMITIES: no edema SKIN: no rash PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ . DISCHARGE PHYSICAL EXAM: Vitals - Tm/Tc:99.1/98.7 HR:107-114 BP:148-176/105-115 RR:18-20 02 sat: 96% RA GENERAL: obese gentleman in NAD HEENT: EOM intact, MMM NECK: supple, no JVD CARDIAC: S1 and S2, no murmur, no heave LUNGS: CTA throughout all fields bilaterally; no wheezes ABDOMEN: soft, nondistended, no mass EXTREMITIES: no edema SKIN: no rash PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ FAMILY HISTORY: No known h/o MI. Father had hypertension. Mother had hypertension and died of ovarian cancer. Sister died of an [**Known lastname **] attack. SOCIAL HISTORY: -Home: Lives alone with his dog. Close with his brother and sister. -Occupation: Landscape contractor. -Tobacco history: Never smoked. -ETOH: Very occasional use (a few drinks per year); no h/o heavy use in the past. -Illicit drugs: Never used any illicits.

CHIEF COMPLAINT: Myocardial Infarction PRESENT ILLNESS: Mrs. [**Known lastname **] is a 77-year-old female with unstable anginal symptoms and a troponin leak was brought emergently to the cath lab and underwent cardiac catheterization that showed a distal left main disease and a 99% offset left anterior descending with very poor flow through the LAD. She also had a tight right coronary artery stenosis. Her pulmonary artery pressures were elevated and the LV gram showed severe hypokinesis of the anterior wall. Intraaortic balloon pump was placed in the cath lab and she was brought emergently to the operating room for coronary arterial bypass surgery. MEDICAL HISTORY: Osteoarthritis Hypothyroid MEDICATION ON ADMISSION: Vitamins Advil ALLERGIES: Patient recorded as having No Known Allergies to Drugs PHYSICAL EXAM: BP: (R) 130/50 (L) 122/96 HR 89 EXAM: HEART: RRR, Normal S1-S2, no murmur LUNGS: Clear ABD: Benign EXT: Pulses intact. IABP in right groin NEURO: Grossly intact FAMILY HISTORY: SOCIAL HISTORY: Lives alone [**Location (un) 6409**]

CHIEF COMPLAINT: Asymptomatic, known type B Aortic Dissection PRESENT ILLNESS: Mr. [**Known lastname 37557**] is a 72 year old male who developed an enteric vesiculocutaneous fistula following a prostate resection several months ago. He was found on evaluation to have a chronic Type B aortic dissection, with a 6 cm ascending aortic aneurysm. Chest CTA in [**2176-5-9**] revealed an unchanged Type B aortic dissection. He has a history of coronary artery disease with a prior MI back in [**2165**]. An echocardiogram in [**2176-3-9**] showed no aortic insufficiency, normal left ventricular function and only trivial mitral regurgitation. On admission, he denied chest pain, dyspnea, snyncope, abdominal symptoms, or back pain. His ostomy site is on the left and a foley catheter remains in place. The plan is for cardiac catheterization prior to cardiac surgical intervention. MEDICAL HISTORY: Ascending Aortic Aneurysm with Chronic type B aortic dissection Hypertension Coronary Artery Disease, prior MI Hypercholesterolemia BPH, Prostate Cancer - s/p Prostatectomy Colon Cancer, Rectourethral Fistula - s/p Transverse Loop Colostomy History of Diverticulosis HTN, hyperlipidemia, Diverticulitis ([**10-13**]), h/o MI ('[**69**]) h/o colon cancer, prostate ca MEDICATION ON ADMISSION: Aspirin 81 qd, Atenolol 50 qd, Lipitor 20 qd, Zantac 150 [**Hospital1 **], Lisinopril 5 qd, Lasix 20 qd, Norvasc 10 qd ALLERGIES: Penicillins PHYSICAL EXAM: Vitals: BP 122/63, HR 45, RR 14, General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, no carotid bruits Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, 1+ edema bilaterally, no varicosities Pulses: 2+ distally Neuro: nonfocal FAMILY HISTORY: Denies premature CAD SOCIAL HISTORY: Quit tobacco over 60 years ago. Drinks 1-2 beers per week, denies history of ETOH abuse. Currently lives with his wife. [**Name (NI) **] is retired.