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allergies: penicillins attending: chief complaint: dyspnea major surgical or invasive procedure: none. history of present illness: 81 yo m with dmii, ckd, htn, h/o dvt, recent admission for altered mental status and hypoglycemia, presenting with shortness of breath, wheezing, and confusion. during the past few days, patient has had worsening shortness of breath and wheezing. has known diagnosis of asthma. also agitated and not taking good po. . in the ed, initial vital signs were t 98.3 bp 122/42 hr 120 rr 26 sat 99%/8l. exam was notable for moaning, tachycardia, poor air movement, and bilateral wheezes. ekg unremarkable. labs notable for elevated troponin, acute renal failure. in the ed, the patient became hypotensive, with systolics in the 60s. given 2l ns with improvement in bp. the patient was also given vancomycin 1 gm iv, zosyn 4.5 gm iv (despite known penicillin allergy), methylprednisolone 125 mg iv, tylenol 650 mg pr, magnesium 2gm iv, and asa 300 mg pr. vital signs on transfer t 99 hr 91 bp 95/48 rr 12 97%/4l nc. past medical history: dmii ckd stage iii htn dvt sacral wound asthma hyperparathyroidism osteoporosis b12 deficiency social history: has a temporary guardian, attorney . friend, aka , was made hcp (). family history: non-contributory. physical exam: admission exam gen: agitated. not cooperative with nursing care. heent: mmm no mucosal bleeding cv: rrr no mrg resp: diffuse expiratory wheezes chest: pt with firm, slightly mobile mass around the r breast. abd: soft nt nd no masses ext: no edema skin: stage 2 decubitus ulcers on sacrum and scrotum. neuro: moving all extremities. speaking. not oriented. discharge exam vs: tc 97.3 tm 98.3 122/70 71 18 100%ra gen: cooperative, calm, alert, oriented to person, place, "it's the 1st or the 2nd", thought it was , knows the president heent: mmm, poor dentition, eomi, no erythema neck: supple, no jvd cv: rrr, no m/r/g, noraml s1, s2 lung: diffuse wheezes throughout, no rales abd: soft, nt/nd, +bs, no r/g, no hsm ext: warm, no lower extremity edema, decreasing edema in left upper extremity neuro: cn ii-xii intact, non-focal gu: foley catheter in place skin: stage 2 decubitus ulcers on sacrum and scrotum; no erythema, exudate or signs of infection. pertinent results: # laboratory data admission labs: 02:43pm blood wbc-8.1 rbc-2.96* hgb-8.4* hct-26.8* mcv-91 mch-28.3 mchc-31.2 rdw-15.3 plt ct-419# 02:43pm blood neuts-53.5 lymphs-30.4 monos-7.8 eos-7.9* baso-0.5 02:43pm blood pt-45.2* ptt-43.9* inr(pt)-4.7* 02:43pm blood fibrino-423* 02:43pm blood glucose-79 urean-45* creat-3.5*# na-146* k-5.1 cl-113* hco3-18* angap-20 02:43pm blood alt-15 ast-29 ld(ldh)-322* ck(cpk)-139 alkphos-42 totbili-0.2 11:13pm blood ck-mb-12* mb indx-7.7* ctropnt-0.63* 02:43pm blood ctropnt-0.90* 02:43pm blood ck-mb-8 02:43pm blood calcium-7.6* phos-5.7*# mg-2.2 02:43pm blood hapto-270* 02:54pm blood lactate-1.3 discharge labs 09:55am blood pt-26.7* ptt-37.1* inr(pt)-2.6* # imaging chest xray (portable ap) impression: new bibasilar patchy opacities which could represent aspiration or pneumonia. # microbiology gram stain (final ): <10 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. urine culture (final ): no growth. mrsa screen (final ): no mrsa isolated blood culture, routine: pending brief hospital course: 81 yo m with dmii, ckd, htn, dvt, asthma, presents with shortness of breath, wheezing, agitation, and confusion. . # dyspnea: secondary to bronchospasm from reactive airways disease and pneumonia seen on cxr. he received albuterol nebulizer treatments and a 3-day burst of steroids (solu-medrol x 1 dose, prednisone 40mg daily x 2 doses) for his bronchospasm, as well as broad spectrum antibiotics (vancomycin, cefepime and azithromycin) for hcap. he was switched to levofloxacin upon transfer to the floor and his symptoms continued to improve. he was continued on his home advair and singulair. satting 100% on room air at time of discharge. . # hypotension: he was briefly hypotensive in the er in setting of hypovolemia due to poor po intake. his hypotension was fluid-responsive, and there were no further episodes of hypotension in the icu or on the floor. . # h/o dvt: patient is on coumadin at home and presented with supratherapeutic inr, 5.6. coumadin was held throughout admission and his inr was 2.6 on discharge. he will need close monitoring of his inr in the context of taking antibiotics. . # acute on chronic renal failure: likely pre-renal given low urine chloride and bland urine sediment. his creatinine improved with hydration. . # delirium: patient was intermittently confused and agitated, however he was generally redirectable. likely related to steroids, infection and starting levofloxacin. steroids were stopped after 3-day burst and patient has 2 doses of levofloxacin remaining. did not receive any sedating medications while in-house. . # elevated troponin: his troponins were elevated in the setting of renal failure with mild ck-mb elevation that was flat. his ekgs were reassuring against acs and the patient denied any chest pain. . # stage 2 ulcers: on sacrum and scrotum. managed with frequent cleaning and dressing changes. no evidence of infection. . # dm2: patient had recent admission for hypoglycemia. glipizide was held while in house. his fingersticks were monitored, and he was on insulin sliding scale while in the hospital. he intermittently refused insulin, however, his blood glucose was controlled in the 100s-200s. . # dvt prophylaxis: systemic anticoagulation (supratherapeutic inr throughout admission). . # communication: has temporary guardian . friend, (aka ), was made health care proxy during this admission. . # code status: full code (discussed with patient & hcp). medications on admission: singulair 10 mg daily albuterol inhaler prn oxycodone 10 mg q4h prn severe pain lisinopril 5 mg daily zinc sulfate 220 mg daily vitamin c 500 mg daily coumadin 5 mg daily aspirin 325 mg daily ferrous sulfate 325 mg daily flonase 2 sprays each nostril daily vitamin b12 1000 mg monthly (due ) fosamax 70 mg weekly vitamin d 800 units daily cardura 4 mg daily advair 250/50 1 puff colace 100 mg lactulose 30 ml daily albuterol nebs q6h prn wheezing or sob multivitamin with mineral 1 tab daily senna 8.6 mg daily prn constipation dulcolax 10 mg suppository prn constiaption fleet enema prn constipation acetaminophen 650 mg q4h prn pain or fever glipizide xl 5 mg daily discharge medications: 1. singulair 10 mg tablet sig: one (1) tablet po once a day. 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation every 4-6 hours as needed for shortness of breath or wheezing. 3. oxycodone 5 mg tablet sig: 1-2 tablets po every four (4) hours as needed for severe pain. 4. lisinopril 5 mg tablet sig: one (1) tablet po once a day. 5. zinc sulfate 220 mg tablet sig: one (1) tablet po once a day. 6. ascorbic acid 500 mg tablet, chewable sig: one (1) tablet, chewable po once a day. 7. coumadin 5 mg tablet sig: one (1) tablet po once a day: 8. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 9. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 10. flonase 50 mcg/actuation spray, suspension sig: two (2) sprays nasal once a day. 11. vitamin b-12 1,000 mcg tablet sig: one (1) tablet po once a month: next dose due . 12. fosamax 70 mg tablet sig: one (1) tablet po once a week. 13. vitamin d-3 400 unit tablet, chewable sig: tablet, chewables po once a day. 14. cardura 4 mg tablet sig: one (1) tablet po once a day. 15. advair diskus 250-50 mcg/dose disk with device sig: one (1) puff inhalation twice a day. 16. colace 100 mg capsule sig: one (1) capsule po twice a day: hold for loose stools. 17. lactulose 10 gram/15 ml solution sig: thirty (30) ml po once a day: hold for loose stools. 18. multivitamin with minerals tablet sig: one (1) tablet po once a day. 19. senna 8.6 mg tablet sig: 1-2 tablets po once a day as needed for constipation. 20. bisacodyl 10 mg suppository sig: one (1) suppository rectal once a day as needed for constipation. 21. fleet enema 19-7 gram/118 ml enema sig: one (1) enema rectal once a day as needed for constipation. 22. acetaminophen 325 mg tablet sig: 1-2 tablets po every hours as needed for fever or pain. 23. glipizide 5 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po once a day. 24. ammonium lactate 12 % lotion sig: one (1) appl topical (2 times a day): to affected area. 25. outpatient lab work check bun & cr on , and send information to patient's pcp. 26. levofloxacin 750 mg tablet sig: one (1) tablet po q48h (every fourty-eight (48) hours) for 4 days: due for two more doses: on . tablet(s) 27. outpatient lab work check inr on , and adjust coumadin dose accordingly. discharge disposition: extended care facility: healthcare center - discharge diagnosis: primary diagnoses: # healthcare associated pneumonia # asthma exacerbation secondary diagnoses: # type ii diabetes mellitus # delirium discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: # you were admitted to the hospital for shortness of breath and agitation. you were found to have pneumonia as well as worsening of your asthma. you received nebs, steroids and antibiotics and your breathing improved. # you were also found to have worsening of your kidney function. this improved with iv fluids. # your inr was very high, so we stopped your coumadin. it is very important that you have your inr checked frequently to make sure that it doesn't get too high. the antibiotics that you are currently on can also increase your inr, so it needs to be checked , . # we made the following changes to your medications: - started levaquin (levofloxacin) 750mg every other day, last dose # it is important that you complete your course of antibiotics. # it is important that you keep all of your follow up appointments and your medications as prescribed. followup instructions: you should follow up with your pcp (dr. , ) in the next 1 week. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Abnormal coagulation profile Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Other B-complex deficiencies Chronic kidney disease, Stage III (moderate) Long-term (current) use of insulin Osteoporosis, unspecified Long-term (current) use of anticoagulants Pressure ulcer, lower back Personal history of venous thrombosis and embolism Hyperparathyroidism, unspecified Lump or mass in breast Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Chronic obstructive asthma with (acute) exacerbation Anticoagulants causing adverse effects in therapeutic use Delirium due to conditions classified elsewhere Pressure ulcer, stage II

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: pcp: . at . chief complaint: fever. reason for micu admission: sepsis, mechanical ventilation. major surgical or invasive procedure: intubation history of present illness: mr. is a 67 y.o. m from with recent history of pneumonia, presented with fever, tachycardia, and increased lethargy. history from rn at and faxed medical records. the patient lives at and was recently hospitalized at from to and diagnosed with aspiration pneumonia. he completed a course of cefpodoxime and flagyl. around 8 pm, the patient was noted to be lethargic and did not open eyes with name calling, moaning. he desat'ed to 88% on ra and improved to 92% on 2 l nc he was also noted to be febrile. md was called and referred patient via ambulance to . vs at : 140/69 hr 121 rr 28 t 100.6. ambulance diverted to . of note, patient was to complete hospice referral on . . in the ed, initial vs: t 101.6 hr 122 bp 127/70 rr 33 o2 96% on 10 l nrb. labs, blood cultures x 2, and urine culture were sent. portable cxr was completed. ekg completed, noted with some lateral changes so cards consulted. the patient was intubated with etomidate and succinylcholine, then sedated with fentanyl and midazolam. abg performed. placed og tube and noted thick green coating on dry tongue. ng lavage with some thick black looking material, ? coffee grounds, but cleared quickly. rectal with guiaic + brown stools, so gi consulted. he was given levofloxacin 750 mg iv x 1 and zosyn x 1. acetaminophen 1300 mg pr x 1, iv protonix 40 mg iv x 1 then gtt at 8/hour, and vitamin k 10 mg iv x 1 were given. he was also given 3.5 l ivfs. discussed cvl but deferred given supratherapeutic inr. . currently, the patient is sedated and intubated. . ros: unable to obtain due to sedation and intubation past medical history: per records type 2 dm htn hyperlipidemia s/p r nephrectomy due to renal cancer pvd (s/p rle bypass, s/p aaa repair) l carotid artery occlusion h/o alcohol withdrawal sz in positive ppd with negative cxr incisional hernia severe pharyngeal dysphagia embolic cva at in (left superior frontal, posterior parietal and temporal-occipital) stage 4 ckd with r arm fistula (not used) cad with positive dobutamine stress in atrial fibrillation on coumadin history of aspiration pneumonia (on nectar thickened liquids) social history: lives at family history: dm in 2 brothers. aneurysms - mom in brain, fatal; brother in heart. brother with melanoma. physical exam: vitals - t: 98.7 bp: 110/57 hr: 85 rr: 14 02 sat: 100% on ac 500 x 16, peep 5, fio2 100% general: sedated, intubated, appears older than stated age heent: eyes not reactive to light, but equal, no cervical lad cardiac: iii/vi sem best heard at llsb, no r/g lung: on anterior exam, breath sounds bilaterally, no w/r/r abdomen: ndnt, soft, nabs ext: no c/c/e, r knee with ecchymoses neuro: sedated derm: sacral decub stage ii pertinent results: : inr 5.01 on : wbc 10.7, hgb 8.8, hct 28.5, plt 307, neut 75.3, l 15, monos 6, eos 3.1, baso 0.4 . microbiology: blood culture x 2 - pending urine culture - pending . studies: ekg: tachy at 100 bpm, lad; ii-iii-avf with qwaves, depression in v4-v6. no prior to compare to. . portable cxr : ett tube 2 cm above carina. ngt over luq in stomach. dense opacity at lll with diffuse nodular consolidation in mid and upper lungs. air bronchograms in retrocardiac space. r lung clear. worrisome for pneumonia. impression: extensive pna in left lung. brief hospital course: 67 y.o. m from with recent history of pneumonia, presented with fever, tachycardia, and increased lethargy, found to have pneumonia, admitted to icu s/p intubation for respiratory failure. 1. respiratory failure: secondary to dense pneumonia that was seen on portable cxr. intubated in ed for tachypnea and work of breathing. pt was admitted to the icu. treated with broad spectrum antibiotics, vancomycin / cefepime / ciprofloxacin, for hospital acquired pneumonia given recent hospitalization and living in . pt was rapidly weaned from ventilator and extubated on . sputum culture without pseudomonas, so ciprofloxacin was stopped. course of antibiotics for 8 days. 2. sepsis: secondary to pneumonia on cxr. treated with antibiotics as above. pan-cultured. lactate was not elevated. no pressors needed. 3. altered mental status: on admission to icu, pt's eyes noted to be non-reactive to light. ? cataract surgery, but unable to get history. ct head negative for acute bleed. per family, pt's baseline is "yes" and "no". likely altered mental status due to infections, r arm pain (rsd). 4. ? gi bleeding: + guiaic positive in ed with supratherapeutic inr. gi was consulted. followed patient's hct which was stable. active t&s maintained, guiaiced all stools. 2 large bore pivs. iv ppi gtt initiated in the ed, then changed to iv ppi . 5. elevated troponins: elevated troponin may be secondary to renal failure, ruled out mi with serial enzymes and ekgs. cards evaluated ekg in ed and believed it was demand ischemia. by report, ekg with old inferior qs. . 6. coagulopathy: pt, ptt, inr all elevated. likely interaction between recent flagyl use and coumadin. but also may be secondary to dic, although platelets within normal limits. also likely nutritional deficiency. dic labs negative. held coumadin. given 10 iv k in ed with decrease in inr. restarted low dose coumadin but stopped given goals of care. 7. ckd, stage 4: recently discharged with cr 2 from . likely pre-renal as pt appeared intravasculary dry on admission. fluid resuscitated with d5w given hypernatermia. cr trended down. 8. hypernatremia: na 155 on admission. d5w @ 120 cc / hour for 20 hours for correction. na serially monitored and normalized during icu stay. 9. type 2 dm: fingersticks and labs were discontinued as per family wishes for patient to receive comfort measures only. 10. hyperlipidemia: zetia and lipitor were discontinued as per family wishes for patient to receive comfort measures only. 11. htn: beta blocker and amlodipine were initially held in setting of questionable gi bleed, but discontinued as per family wishes for patient to receive comfort measures only. 12. stage 2 sacral decub: patient received wound care. cleaned with normal saline, duoderm gel, and gauze dressing daily. 14. r arm pain: x ray negative. from osh records, may be rsd. continued low dose neurontin and lidocaine patch. 15. goals of care: on , family meeting was held and patient was made dnr/dni/comfort measures only by hcp. was transferred to the floor on . antibiotics were continued as he was clinically improving, but they were discontinued on discharge. morphine for pain. palliative care was consulted. patient is discharged with hospice care. contact: medications on admission: vitals - t: 98.7 bp: 110/57 hr: 85 rr: 14 02 sat: 100% on ac 500 x 16, peep 5, fio2 100% general: sedated, intubated, appears older than stated age heent: eyes not reactive to light, but equal, no cervical lad cardiac: iii/vi sem best heard at llsb, no r/g lung: on anterior exam, breath sounds bilaterally, no w/r/r abdomen: ndnt, soft, nabs ext: no c/c/e, r knee with ecchymoses neuro: sedated derm: sacral decub stage ii discharge medications: 1. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 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. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 2-4 puffs inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 5. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 6. gabapentin 100 mg capsule sig: one (1) capsule po tid (3 times a day). 7. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): please apply to right arm. 12 hours on, 12 hours off. 8. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 9. morphine 10 mg/5 ml solution sig: 5-10 mg po q2h (every 2 hours) as needed for pain, turning. 10. wound care sacral decubitus ulcer - please clean with duoderm gel and cover with 4 x 4 mepilex border dressing daily discharge disposition: extended care facility: sachem skilled nursing & rehabilitation - discharge diagnosis: primary diagnosis: pneumonia discharge condition: afebrile, minimal pain, saturating well on room air. discharge instructions: you were admitted to for pneumonia. you required intubated and an icu stay during this admission because of respiratory failure. the pneumonia was treated with antibiotics during your admission. you do not need any further antibiotics after discharge. the decision was made by your health care proxy to only pursue comfort measures. you are being discharged with hospice care. your medications have changed, please take only the medication listed on your discharge medication list. followup instructions: follow up with your primary care physician, . , as needed. md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified septicemia Hyposmolality and/or hyponatremia Severe sepsis Chronic kidney disease, Stage IV (severe) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Pulmonary collapse Occlusion and stenosis of carotid artery without mention of cerebral infarction Other and unspecified hyperlipidemia Acute respiratory failure Blood in stool Long-term (current) use of anticoagulants Pressure ulcer, lower back Pressure ulcer, heel Accidents occurring in residential institution Acquired absence of kidney Fall from other slipping, tripping, or stumbling Contusion of face, scalp, and neck except eye(s) Pressure ulcer, stage II Other acute and subacute forms of ischemic heart disease, other Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus Pain in limb Late effects of cerebrovascular disease, dysphasia Dysphagia, pharyngeal phase

allergies: no known allergies / adverse drug reactions attending: chief complaint: status epilepticus major surgical or invasive procedure: intubation (at outside hospital) extubation history of present illness: the pt is a 42 year-old man, with a past medical history significant for tbi and seizure disorder, reported etoh use, who presents after being found down at or around his house, and then taken to an osh where he was intubated and sedated out of concern for status. there is not a great deal of information known about this patient. all information is obtained throughout the chart and ems report. he had an address without a phone number listed, there was no contact information otherwise and could not find a number for the given address. what is known is that ems was called to his house where he was found lying on the floor breathing, presumed post ictal from a seizure. at first he was given narcan because there was a concern that there was an overdose, but here was no effect. fter learning the patient has a seizure d/o he was given ~4mg of ativan in the field and taken to . there he was noted on exam to have brainstem reflexes, but minimal withdrawal to pain. a head ct was obtained but did not show any acute pathology. he had levels of the two aeds he is reportedly on (pht and vpa), pht was 12 and vpa 44, but it is not clear if these are pre or post load. he may have gotten 2 more mg of ativan at this point. he was seen by neurology at the outside hospital who felt that he was still not very responsive and that this may be due to "subtle" status, and recommended intubating the patient, he was bolused 500mg pht and started on a versed gtt and transferred to bimdc for further neurological management. past medical history: traumatic brain injury epilepsy previous alcohol dependence social history: he lives with his mother who is rn at hospital. he smokes (unclear amount), and has not drunk any alcohol for many years. family history: non-contributory physical exam: physical exam: vitals: t: 99 p: 100 r: 16 bp: 136/92 sao2: 100 general: intubated/sedatated heent: nc/at, no scleral icterus noted, mmm, neck: supple, no carotid bruits appreciated. no nuchal rigidity pulmonary: lungs cta bilaterally cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bowel sounds extremities: no c/c/e bilaterally, neurologic: -mental status: intaubted and sedated, grimaces and slightly opens eyes to deep sternal rub. pulls away from painful stimulus. no tracking. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk. iii, iv, vi: vor intact v, vii: corneal intact ix, x: gag -motor: normal bulk, tone throughout. withdraws to pain at all 4 ext -sensory: feels pain at all 4 -dtrs: tri pat ach l 2 2 2 2 1 r 2 2 2 2 1 plantar response was flexor bilaterally. no clonus -coordination and gait: not tested pertinent results: 08:15pm glucose-98 urea n-10 creat-0.6 sodium-145 potassium-4.7 chloride-111* total co2-23 anion gap-16 08:15pm ctropnt-<0.01 08:15pm calcium-8.2* phosphate-4.4 magnesium-2.0 08:15pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 08:15pm urine bnzodzpn-pos barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 08:15pm wbc-9.5 rbc-4.03* hgb-14.0 hct-38.6* mcv-96 mch-34.8* mchc-36.4* rdw-13.4 08:15pm neuts-77.5* lymphs-15.9* monos-5.5 eos-0.7 basos-0.4 08:15pm plt count-196 08:15pm pt-12.7 ptt-25.0 inr(pt)-1.1 08:15pm urine color-straw appear-clear sp -1.006 08:15pm urine blood-sm nitrite-neg protein-25 glucose-tr ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg eeg showed no epileptiform features brief hospital course: initial impression / hospital course: the pt is a 42 year-old man, with a past medical history significant for tbi and seizure disorder, reported etoh use, who presents after being found down at or around his house, and then taken to an osh where he was intubated and sedated out of concern for status. the patient was found down after a presumed seizure, and he received 4-6mg of ativan on route to the local hospital (it is not clear why so much was given). at the osh he was noted to have brainstem reflexes but not much response to pain. he had two aeds level drawn which indicated he was slightly subtherapuetic . a neurologist saw the patient at and was concerned that the patient had not returned to baseline and was possibly in status, so was given more ativan, intubated and placed on a versed gtt. at , on exam he is more rousable then before. he moves and grimaces to pain, withdraws at all fours to pain. this patient is currently intubated and will need admission to the icu and an eeg to help determine if he is in sub-clinical status. given the patient history of etoh/drug, his sub-therapeutic aeds level were likely provoking factors. mr. was admitted to the icu. his tox screen was negative except for benzos. he was weaned off of versed and then extubated and transferred to the icu. his aeds were adjusted. he received 1 gram fosphenytoin for low dilantin level, and then was maintained on dilantin 500mg qhs. due to the difficulty in maintaining therapeutic dilantin levels with valproate, his valproate was decreased to 500mg . valproate was not completely removed due to need for mood stabilization. he was started on zonegran, which is titrating up. currently the dose is at 200mg qhs, but will continue to increase as an outpatient to 300mg qhs. infectious work-up was negative. medications on admission: he was on depakote and dilantin but the drug doses were not the same as what his neurologist prescribed, as his doses were checked with his pharmacy. the patient was non-compliant with his meds so the actual drug dose was unclear. was supposed to be on dilantin 400 mg qhs and depakote 1 g as per his neurologist dr. . discharge medications: 1. divalproex 500 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po bid (2 times a day). disp:*60 tablet sustained release 24 hr(s)* refills:*2* 2. phenytoin sodium extended 100 mg capsule sig: five (5) capsule po qhs (once a day (at bedtime)). disp:*150 capsule(s)* refills:*2* 3. zonisamide 100 mg capsule sig: two (2) capsule po hs (at bedtime). disp:*60 capsule(s)* refills:*2* 4. lorazepam 1 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for agitation. discharge disposition: home discharge diagnosis: primary generalized seizure secondary traumatic brain injury discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were found unresponsive, likely after having a generalized seizure. you were taken to an outside hospital, intubated, before transfer to for further management. your stayed in the icu briefly. on the floor service, we adjusted your anti-epileptic medications (dilantin and depakote). we also started a new anti-epileptic medication called zonisamide. followup instructions: please follow-up with your outpatient neurologist dr. (tel:() in one week, he requested that you call to schedule an appointment. your dilantin level at the time of discharge was 10.3. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Enteral infusion of concentrated nutritional substances Diagnoses: Tobacco use disorder Long-term (current) use of other medications Grand mal status Personal history of noncompliance with medical treatment, presenting hazards to health Late effects of motor vehicle accident Encounter for therapeutic drug monitoring Unspecified nonpsychotic mental disorder following organic brain damage Late effect of intracranial injury without mention of skull fracture

allergies: no known allergies / adverse drug reactions attending: addendum: of note, patient's serum potassium level was within normal limits throughout his hospital course until the day of discharge on rose to 5.3. he was without any associated cardiac symptoms. it was rechecked prior to discharge that day and was the upper limits of normal at 5.1. on discharge, instructions were given to the rehab facility to recheck his potassium level on to ensure that it remained within normal limits. discharge disposition: extended care facility: hospital - md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Interruption of the vena cava Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Excisional debridement of wound, infection, or burn Other incision of pleura Debridement of open fracture site, femur Debridement of open fracture site, femur Closure of skin and subcutaneous tissue of other sites Closure of skin and subcutaneous tissue of other sites Open reduction of fracture with internal fixation, radius and ulna Suture of tendon sheath of hand Application of external fixator device, tarsals and metatarsals Closed reduction of fracture with internal fixation, femur Internal fixation of bone without fracture reduction, humerus Closed reduction of fracture without internal fixation, femur Application of external fixator device, femur Debridement of open fracture site, tarsals and metatarsals Removal of implanted devices from bone, femur Suture of laceration of scrotum and tunica vaginalis Suture of laceration of diaphragm Open reduction of fracture without internal fixation, tarsals and metatarsals Application of external fixator device, monoplanar system Application of external fixator device, ring system Open reduction of dislocation of foot and toe Other operations on spleen Suture of laceration of testis Diagnoses: Acute posthemorrhagic anemia Hyposmolality and/or hyponatremia Cocaine abuse, unspecified Open wound of hand except finger(s) alone, with tendon involvement Closed fracture of one rib Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Closed fracture of lumbar vertebra without mention of spinal cord injury Traumatic hemothorax without mention of open wound into thorax Open fracture of shaft of femur Street and highway accidents Closed fracture of nasal bones Subarachnoid hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration Closed fracture of shaft of humerus Open wound of knee, leg [except thigh], and ankle, complicated Fracture of medial malleolus, closed Closed fracture of olecranon process of ulna Open fracture of astragalus Open fracture of lower end of femur, unspecified part Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma Injury to diaphragm, without mention of open wound into cavity Retained glass fragments Injury to cervical sympathetic nerve, excluding shoulder and pelvic girdles Open dislocation of tarsometatarsal (joint) Open wound of scrotum and testes, complicated

allergies: no known allergies / adverse drug reactions attending: chief complaint: s/p motor vehicle crash major surgical or invasive procedure: : general surgery: 1. exploratory laparotomy, repair of l diaphragmatic rupture 2. ivc filter placement vascular surgery: 1. le angiograms orthopedic surgery: 1.closed treatment left femoral shaft fracture with manipulation. 2. application uniplanar external fixator left femur. 3. washout and debridement open fracture down to and inclusive of bone left femur. 4. repair dehiscence extensive/complicated left knee. 5. repair intermediate trunk extremities left anterior tibia approximately 3 cm in length. 6. washout and debridement open fracture right talus. 7. operative treatment of right tarsal dislocation with external fixator. 8. operative treatment tarsometatarsal dislocation right foot with external fixator. 9. application negative pressure wound therapy 10. open debridement irrigation down to and inclusive of bone of left femur fracture via 14 x 8 cm incision. 11. removal of external fixator left femur. 12. retrograde nailing of left femur with 12 x 360 mm retrograde synthes nail. 13. open reduction internal fixation comminuted left olecranon fracture with dorsal and medial plate. 14. operative treatment, right humeral shaft fracture, with intramedullary nail. 15. adjustment/revision, external fixator, right ankle. plastic surgery: 1.irrigation debridement of skin, subcutaneous tissue of left dorsal hand wound. 2.repair of eip, and edc to index, middle, and ring fingers. urology: 1. scrotal exploration, repair of testicular capsular disruption and primary closure, washout of scrotal hematoma. history of present illness: 27m was brought to ed by s/p motor vehicle crash. patient underwent 15 min extrication and was intubated at the scene for a gcs of 8. +loc. past medical history: none social history: history of alcohol and cocaine abuse. family history: noncontributory physical exam: upon presentation to : hr: 149 bp: 190/89 resp: 25 o(2)sat: 100 normal constitutional: intubated heent: pupils 2 bilaterally, minimally reactive, frontal midline hematoma, small abrasion to midline chin and c-collar, tympanic membranes clear chest: equal breath sounds bilaterally, sternum stable, no crepitance cardiovascular: tachycardia abdominal: soft, nondistended pelvic: pelvis stable rectal: minimal rectal tone, no gross blood extr/back: rue: swollen, abrasion, deformity to anterior shoulder. lue: laceration to elbow and proximal forearm, open fracture to wrist with exposed bone and likely a foreign body. lle: open femur fracture, tibia laceration with foreign body, patella laceration with glass, ecchymosis and swelling over the dorsal aspect of the foot, decreased pedal pulse. rle: laceration over the patella, open ankle fracture dislocation. 2+ pulse in the dorsal pedal artery on the right. back: no spinal step-offs, no gross deformities skin: as above neuro: intubated and paralyzed at discharge: vitals: 97.8 110 152/60 18 97% ra gen: a&ox3, nad, calm and cooperative card: normal s1,s2, no mrg pulm: cta bilaterally gi: abd soft, nontender, nondistended. +flatus. abd incision with steristrips intact, no errythema extr: all for extremities with +pp/csm. rle with exfix in place. pertinent results: lactate trend: on admission: 2.8 peak: 4.7 (pod#1) resolution: 1.7 (pod#2) troponin trend: 0.38 () -> 0.19 () cpk trend: 3737 --> 2847 hct trend: on admission: 33.5 pod#2: 22 (received 2u) --> asa-neg ethanol-298* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg cxr (): - findings concerning for left diaphragmatic rupture. - right basilar patchy opacity may reflect atelectasis or contusion. cspine: no evidence of acute fracture or malalignment. ct head: - small foci of subarachnoid hemorrhage involving right frontal and parietal regions. - 2-mm hyperattenuating foci and subcutaneous tissues overlying left frontal sinus may represent foreign bodies, correlate clinically. - soft tissue edema of the frontal region, without underlying fracture. - minimally displaced fracture of the right lateral nasal wall. ct chest/abd/pelvis: 1. left diaphragmatic rupture with associated herniation of nearly the entire stomach and small segment of the colon within the left hemithorax. there is minimal right-sided shift of midline structures. left lower lobe opacification likely represents atelectasis. 2. small amount of hemorrhagic fluid is noted posterior to the spleen, near the site of diaphragmatic rupture. the spleen itself appears intact without a distinct laceration. 3. small area of right lower lobe opacification is non-specific and may represent aspiration. an additional ill-defined ground-glass opacity in the right lower lobe may represent a small contusion. 3. fractures involving left transverse processes of l1 and l2 vertebral bodies. right ninth rib fracture. r arm xray: a comminuted displaced fracture involving the mid to proximal diaphysis of the right humerus bilateral ankle xray: severe talocalcaneal joint dislocation and medial displacement of the talus along with the tibia and fibula. extensive overlying soft tissue edema and subcutaneous gas, likely post-traumatic. left femur xray: an open comminuted displaced fracture of the mid-to-distal diaphysis of the left femur, as described above. bilateral eblow xrays: left: comminuted fracture of the left elbow with avulsion of the olecranon and potential avulsion fracture of the coronoid process are noted. substantial soft tissue swelling is seen. right: no definitive evidence of fracture is seen on the right, although note is made that the patient was imaged with the casting material on. bilateral wrist xrays: right: fracture of the radial styloid process is noted, otherwise no abnormality seen on the right. left: fracture of the hamate is present. on the lateral view, there is an 8-mm radiopaque object projecting at the dorsal aspect of the palm at the level of hamate and might represent either bone chip or foreign body, exploration of this area is required. scrotal us: 1. findings are concerning for rupture of the left testicular lower pole with adjacent hematoma. 2. hypoechoic lesion with septations in the upper pole of the left testicle laterally. a followup ultrasound of this finding in six months is recommended should the testicle be spared. ct head : 1. interval resolution of previously seen subarachnoid hemorrhage. no evidence of new hemorrhage. brief hospital course: mr. was evaluated in the trauma bay for severe polytrauma with the following injuries identified based on primary & secondary surveys and radiographic imaging: - left diaphragmatic rupture - right frontal/parietal subarachnoid hemorrhage - minimally displaced nasal bone fracture - l1/l2 transverse process fractures - right 9th rib fracture - right comminuted displaced humerus fracture - right fracture of the radial styloid process - left elbow fracture - left wrist open fracture of the hamate, tendon injury - left open comminuted displaced femur fx - right subtalar dislocation racture - left testicle rupture - splenic laceration operarations: diagnostic laparoscopy,exploratory laparotomy;reduction of thoracic contents;left chest tube placement;repair of diaphragmatic rupture.splenorraphy,left femur i & d and external fixator, right foot open reduction and external fixator and i&d ,left femur thigh wound vac placement,left lower extremity angiogram. placement of femoral ivc filter 1. orif left femur with synthes femoral nail. 2. orif left olecranon. 3. washout left femur and left olecranon.4. examination under anaesthesis left lower leg. 5 removal ext fix 1. orif right humerus with synthes humeral nail. 2. adjustment of right lower lef ex-fixator. 3. scrotal exploration, partial orchiectomy, repair of testicular fracture he was admitted to the acute care surgery team and taken to the or emergently for repair of his diaphragmatic injury and multiple orthopedic procedures as previously listed. intraoperatively he was noted to have a cool left foot with diminished pulses. despite orthopedic reduction of injuries, the left foot remained cool and a vascular surgery consultation was obtained emergently. angiogram was performed with no evidence of vascular compromise. patient was transferred to the trauma icu intubated. his hospital course is described by system: neuro: small sah was noted on initial imaging but found to resolve on repeat ct of the head. neurosurgical consultation was obtained with recommendations for no seizure prophylaxis and no log-roll precautions for lumbar transverse process fractures. patient was following commands and neurologically intact throughout. pain was well controlled with iv and then po narcotics and tylenol. he currently still remains alert and oriented x3, moving all extremties only limited by pain and his non weight bearing status in 3 of his 4 extremities. cv: patient was hemodynamically stable throughout. a troponin of 0.38 was noted at the time of injury which trended down thereafter. no ekg abnormalities were present. lactate also trended down. on hd# 11 because of high fevers, tachycardia and elevated white cell count he underwwent ct torso shwoing a pericardail effusion; a surface echo was performed the following day which showed minimal effusion and no other gross abnormalities. he is still experiencing intermittent tachycardia which is not uncommon in young trauma patients bu no other associated symptoms. his na+ was also noted to be low in the high 120's range, he was fluid restricted and his na+ level has normalized to 134 on . resp: patient was extubated on pod#4. intraoperatively a chest tube was placed had minimal output and was put to water seal on pod#2. chest tube was left in for 12 days due to high output initially but as the output decreased and he remained stable on water seal for several days the chest tube was removed on . post pull chest xray showed only a tiny left apical pneumothorax persisting. he currently has no oxygen requirements and has stable saturations. gi/fen: he was initially kept npo with ngt decompression. once extubated, he was tolerating a regular diet. there are no active issues with his gi system. gu: patient's creatinine remained normal throughout. a scrotal hematoma was noted to be stable, though us showed evidence of left testicular rupture. urologic consultation was obtained and he was taken to the operating room by urology for repair of his injury. he is voiding without any issues and has had no further issues from a gu standpoint. heme: ivc filter was placed at time of laparotomy in anticipation of limited mobility and high risk for bleeding with anticoagulation. hct trended down from 33 to 22 over first two postoperative days and he was given 2u prbcs. postoperatively, patient's pulses were intact in bilateral le. hct remained stable thereafter. his hematocrit at time of discharge was 27. id: treated with ancef and cipro for complex open wounds and fractures. antibiotics were stopped on . his wbc intermittently has trended along with fevers upward for which he was cultured and to date there has been no growth on his fluids with exception of some yeast from bal that was done while he was in the icu. his fevers have defervesced and white count coming down each day. msk: multiple orthopedic injuries were managed by the orthopedic and plastic surgical teams. after multiple trips to the or (as detailed above), patient's injuries were gradually repaired. he is non weight bearing in all extremities with exception of his right arm. he has been actively participating with pt and ot and is being recommended for acute rehab after his hospital stay. medications on admission: none discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 4. oxycodone 5 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. 5. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 6. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain; temp > 101.0 . 7. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 8. trazodone 100 mg tablet sig: one (1) tablet po hs (at bedtime). 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. discharge disposition: extended care facility: hospital - discharge diagnosis: s/p motor vehicle crash injuries: - left diaphragmatic rupture - right frontal/parietal subarachnoid hemorrhage - minimally displaced nasal bone fracture - l1/l2 transverse process fractures - right 9th rib fracture - right comminuted displaced humerus fracture - right fracture of the radial styloid process - left elbow fracture - left wrist open fracture of the hamate, tendon injury - left open comminuted displaced femur fx - right subtalar dislocation racture - left testicle rupture - splenic laceration - hyponatremia - acute blood loss anemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted to the hospital following a motor vehicle crash where you sustained mulitple injuries requiring many operations to repair some of these injuries. due to the extent of your trauma it is being recommended that you go to a rehabilitation facility after your hospital discharge to strengthen you. followup instructions: department: surgical specialties when: thursday at 3:00 pm with: , md building: campus: east best parking: garage department: surgical specialties when: monday at 1:15 pm with: , md building: sc clinical ctr campus: east best parking: garage department: general surgery/ when: thursday at 3:15 pm with: acute care clinic building: lm bldg () campus: west best parking: garage we are working on a follow up appointment in the orthopedics department. the rehab will be called with the appointment. if you have not heard in the next two business days, please call option 6 for the status md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Interruption of the vena cava Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Excisional debridement of wound, infection, or burn Other incision of pleura Debridement of open fracture site, femur Debridement of open fracture site, femur Closure of skin and subcutaneous tissue of other sites Closure of skin and subcutaneous tissue of other sites Open reduction of fracture with internal fixation, radius and ulna Suture of tendon sheath of hand Application of external fixator device, tarsals and metatarsals Closed reduction of fracture with internal fixation, femur Internal fixation of bone without fracture reduction, humerus Closed reduction of fracture without internal fixation, femur Application of external fixator device, femur Debridement of open fracture site, tarsals and metatarsals Removal of implanted devices from bone, femur Suture of laceration of scrotum and tunica vaginalis Suture of laceration of diaphragm Open reduction of fracture without internal fixation, tarsals and metatarsals Application of external fixator device, monoplanar system Application of external fixator device, ring system Open reduction of dislocation of foot and toe Other operations on spleen Suture of laceration of testis Diagnoses: Acute posthemorrhagic anemia Hyposmolality and/or hyponatremia Cocaine abuse, unspecified Open wound of hand except finger(s) alone, with tendon involvement Closed fracture of one rib Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Closed fracture of lumbar vertebra without mention of spinal cord injury Traumatic hemothorax without mention of open wound into thorax Open fracture of shaft of femur Street and highway accidents Closed fracture of nasal bones Subarachnoid hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration Closed fracture of shaft of humerus Open wound of knee, leg [except thigh], and ankle, complicated Fracture of medial malleolus, closed Closed fracture of olecranon process of ulna Open fracture of astragalus Open fracture of lower end of femur, unspecified part Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma Injury to diaphragm, without mention of open wound into cavity Retained glass fragments Injury to cervical sympathetic nerve, excluding shoulder and pelvic girdles Open dislocation of tarsometatarsal (joint) Open wound of scrotum and testes, complicated

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea major surgical or invasive procedure: avr(23mm tissue) history of present illness: history of present illness: f with known severe as( <0.77cm2) presents to with sub-acute onset sob associated with l neck pain but without chest pain, palpitations, nausea or dizziness. sob not ameliorated by sl ntg x2, but did improve with supplemental o2 once emt arrived. she has had increasing dyspnea over the past year and has some limitations due to this. at she was diuresed, placed on ntg and heparin gtts, loaded with 600 plavix and admitted to the icu. cardiac cath on was clean and she was transferred to for evaluation of aortic valve. past medical history: dyslipidemia, hypertension, b12 def, chronic renal insufficiency(gfr 55), appendectomy, hysterectomy, subtotal thyroidectomy(cyst) social history: -tobacco history: denies -etoh: denies -illicit drugs: denies lives with her husband who is deaf and is his primary caretaker. stress from this. has 4 children. family history: father died from chf in his 80s. no other family history of early coronary disease or sudden cardiac death. physical exam: 77 hr 111/62 bp 16 rr 100%/ra height: 67 in weight: 133 lbs bsa 1.70 general: skin: dry intact heent: perrla eomi neck: supple full rom neck stiffness with limited rom chest: lungs clear bilaterally , slight diminished at bases b heart: rrr irregular iii/vi sem @base (non-radiating) abdomen: soft, non-distended, non-tender extremities: warm, well-perfused , edema , varicosities neuro: grossly intact pulses: femoral right: nd left: nd dp right: 1+ left: 1+ pt : 2+ left: 2+ radial right: 1+ left: 2+ carotid bruit: right: (-) left: (-) pertinent results: admission: 09:36am hgb-10.3* calchct-31 10:54am urine blood-mod nitrite-neg protein-25 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 11:24am hgb-6.6* calchct-20 12:31pm pt-15.2* ptt-33.8 inr(pt)-1.3* 12:31pm fibrinoge-180 12:31pm plt count-144* 12:31pm wbc-11.8* rbc-2.85* hgb-8.7* hct-25.5* mcv-90 mch-30.6 mchc-34.1 rdw-13.6 12:31pm glucose-133* lactate-2.3* na+-138 k+-4.2 cl--109 01:55pm urea n-16 creat-0.7 sodium-141 potassium-4.2 chloride-111* total co2-26 anion gap-8 discharge: 04:40am blood wbc-11.0 rbc-3.08* hgb-9.4* hct-27.8* mcv-90 mch-30.5 mchc-33.8 rdw-14.1 plt ct-121* 04:40am blood plt ct-121* 11:50pm blood pt-13.4 ptt-28.1 inr(pt)-1.1 04:40am blood glucose-71 urean-24* creat-0.7 na-138 k-3.5 cl-99 hco3-32 angap-11 radiology report chest (pa & lat) study date of 3:15 pm medical condition: year old woman with tissue avr reason for this examination: eval for effusion or infiltrate final report there is probable background copd. the patient is status post sternotomy, with apparent radiolucent prosthetic valve. the ascending aorta is prominent. the hila are prominent, suggesting pulmonary hypertension. there is upper zone redistribution, without overt chf. there are small right greater than left pleural effusions, with underlying collapse and/or consolidation. there is mild wedging of a mid-to-lower thoracic vertebral body with degenerative changes of the thoracic spine. dr. echocardiography report interpret md: , md echocardiographic measurements results measurements normal range left atrium - long axis dimension: *5.5 cm <= 4.0 cm left ventricle - septal wall thickness: *1.2 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: *6.3 cm <= 5.6 cm left ventricle - systolic dimension: 4.6 cm left ventricle - fractional shortening: *0.27 >= 0.29 left ventricle - ejection fraction: 55% >= 55% left ventricle - stroke volume: 79 ml/beat aorta - annulus: 2.3 cm <= 3.0 cm aorta - sinus level: 3.3 cm <= 3.6 cm aorta - sinotubular ridge: 2.8 cm <= 3.0 cm aorta - ascending: *3.8 cm <= 3.4 cm aorta - descending thoracic: *3.0 cm <= 2.5 cm aortic valve - peak velocity: *3.3 m/sec <= 2.0 m/sec aortic valve - peak gradient: *45 mm hg < 20 mm hg aortic valve - mean gradient: 29 mm hg aortic valve - lvot vti: 25 aortic valve - lvot diam: 2.0 cm aortic valve - valve area: *0.8 cm2 >= 3.0 cm2 aortic valve - pressure half time: 810 ms findings left atrium: moderate la enlargement. dilated la. no spontaneous echo contrast or thrombus in the la/laa or the ra/raa. good (>20 cm/s) laa ejection velocity. right atrium/interatrial septum: no asd by 2d or color doppler. left ventricle: mild symmetric lvh. moderately dilated lv cavity. overall normal lvef (>55%). right ventricle: normal rv chamber size and free wall motion. aorta: normal ascending aorta diameter. mildly dilated descending aorta. simple atheroma in descending aorta. aortic valve: three aortic valve leaflets. moderately thickened aortic valve leaflets. severe as (area 0.8-1.0cm2). mild (1+) ar. mitral valve: no mvp. moderate to severe (3+) mr. tricuspid valve: physiologic tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. pulmonic valve not well seen. pericardium: very small pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope. no tee related complications. the patient appears to be in sinus rhythm. patient. see conclusions for post-bypass data conclusions pre cpb: no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the descending thoracic aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is severe aortic valve stenosis (valve area 0.8-1.0cm2). mild (1+) aortic regurgitation is seen. moderate to severe (3+) mitral regurgitation is seen. there is restriction of the posterior leaflet that results in 2+ to 3+ mr depending on loading conditions. the mr at one point worsening to 4+ mr with high pa pressures briefly and then got back to baseline findings with normal pa pressures and 3+ mr at worst. dr. was notified in person of the results. post cpb: the cardiac output is 3.1l/min on phenylephrine gtt with atrial pacing. there is moderate (2+) mitral regurgitation with bp 100/50. there is a well seated bioprosthetic valve in the aortic position, with a mean gradient of 7mmhg. the biventricular systolic function is preserved. the visible contours of the thoracic aorta are intact. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 00:35 brief hospital course: ms. was a same day admission for aortic valve replacement. on she was admitted directly to the operating room for her surgery. please see the operative report for details. iin summary she had an aortic valve replacement with #23mm ultra porcine valve. her bypass time was 64 minutes with a crossclamp time of 45 minutes. she tolerated the operation well and post-operatively was transferred to the cardiac surgery icu for monitoring. she was hemodynamically stable in the immediate post-op period, awoke neurologically intact and was extubated. on pod1 she was slightly confused, most likely from narcotics and therefore was kept in the icu for monitoring. she was clear on pod2 and was transferred to the stepdown floor for continued recovery. all tubes lines and drains were removed per cardiac surgery protocol. she was preparing for discharge on pod6 when she developed rapid atrial fibrillation with a heart rate to 130 and a stable blood pressure. iv metoprolol and amiodarone were given without conversion or good rate control. an amiodarome infusion was begun and she had an 8 sec conversion pause as she converted to sinus rhythm. oral amiodarone was then administered, iv was stopped and her beta blocker dose was decreased. coumadin was begun concomittently. her activity level was somewhat slow to improve and it was felt that she would benefit from a short rehabilitation stay. on pod 8 she was cleared for transfer to rehabilitation at haven. medications on admission: metoprolol , lisinopril , furosemide , asa , sl ntg prn meds on transfer: plavix 75, asa 81, lasix 20'/40' discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain/fever. 5. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 6. furosemide 40 mg tablet sig: one (1) tablet po once a day for 1 weeks. 7. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day for 1 weeks. tab sust.rel. particle/crystal(s) 8. lisinopril 2.5 mg tablet sig: one (1) tablet po once a day. 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po three times a day. 10. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 400mg x 2 weeks, then 400mg daily x 2 weeks, then 200mg daily until further instructed. 11. warfarin 1 mg tablet sig: one (1) tablet po once a day: dose daily for goal inr 2-2.5, dx: a-fib. discharge disposition: extended care facility: haven discharge diagnosis: s/p aortic valve replacement (23mm tissue) dyslipidemia hypertension b12 deficiency chronic renal insufficiency s/p appendectomy s/p hysterectomy s/p subtotal thyroidectomy(cyst) discharge condition: alert and oriented x3, nonfocal ambulating with steady gait incisional pain managed with incisions: sternal - healing well, no erythema or drainage edema- trace, bilateral lower extremities discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr date/time: 1:00 cardiologist: dr on at 11:45am please call to schedule appointments with your primary care dr , g. in 4-5 weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Congestive heart failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, unspecified Other B-complex deficiencies Other and unspecified hyperlipidemia Mitral valve insufficiency and aortic valve stenosis Drug-induced delirium Chronic diastolic heart failure Other specified analgesics and antipyretics causing adverse effects in therapeutic use

allergies: penicillins / keflex / niacin / paper tape / fish product derivatives / iodine / adhesive tape attending: addendum: if right arm pain/dismobility continues ms. can make an appointment with dr. or dr. at ( from orthopedics at . discharge disposition: home with service facility: regional vna md Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Diagnoses: Obstructive sleep apnea (adult)(pediatric) Asthma, unspecified type, unspecified Aortic valve disorders Dysthymic disorder Obesity, unspecified Chronic fatigue syndrome Congenital insufficiency of aortic valve Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Pain in joint, shoulder region Dysmenorrhea Plantar fascial fibromatosis

allergies: penicillins / keflex / niacin / paper tape / fish product derivatives / iodine / adhesive tape attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: avr (19mm st. mechanical)/aortic root enlargement with pericardial patch history of present illness: is a 32-year-old female with a longstanding history of aortic stenosis with a bicuspid aortic valve, which has been followed over the past several years by serial electrocardiograms. over the past several months, she has noted progressive worsening of her symptoms, which include dyspnea on exertion, chest pain, fatigue, and peripheral edema. multiple echocardiograms and cardiac cath have confirmed severe sortiv stenosis. past medical history: aortic stenosis/bicuspid aortic valve migraines plantar fasciitis asthma depression/anxiety chronic fatigue obesity dysmenorrhea rhinitis ? obstructive sleep apnea recent poison /sumac/ tick bite social history: occupation is ot assistant. her last dental exam was in . she denies any tobacco use and drinks alcohol socially. she currently lives with her husband. family history: her family history is notable for her mother who had valvular surgery x 2. physical exam: gen: well-developed and well-nourished female in no acute distress. skin: warm, dry, and intact. heent exam showed her to be normocephalic and atraumatic. pupils were equally round and reactive to light. extraocular muscles were intact. sclerae anicteric. oropharynx was benign. teeth were in good repair. neck: supple with full range of motion. no jvd. chest: lungs were clear to auscultation bilaterally. cv: rrr, normal s1 and s2 with a iv/vi systolic ejection murmurs. abdomen: soft, nontender, and nondistended with normoactive bowel sounds. ext: warm and well perfused with 1+ lower extremity edema. there were no varicosities noted on standing and her pulses were 2+ throughout. neuro: grossly intact without carotid bruits. pertinent results: 10:56am pt-14.8* ptt-32.2 inr(pt)-1.3* 10:56am plt count-182 10:56am wbc-22.6*# rbc-2.56*# hgb-8.2*# hct-24.3*# mcv-95 mch-32.1* mchc-33.8 rdw-13.4 07:33am glucose-99 lactate-1.3 na+-138 k+-4.1 cl--102 12:15pm urea n-12 creat-0.8 chloride-113* total co2-25 05:28am blood wbc-13.6* rbc-2.98* hgb-9.4* hct-28.1* mcv-94 mch-31.5 mchc-33.4 rdw-13.6 plt ct-116* 05:53am blood pt-25.9* ptt-73.0* inr(pt)-2.5* 05:28am blood glucose-107* urean-8 creat-0.9 na-132* k-4.4 cl-100 hco3-28 angap-8 05:28am blood mg-1.7 echo: pre bypass: the left atrium is moderately dilated. the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve is bicuspid. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis (valve area 0.8-1.0cm2). trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. post bypass: preserved biventricular function. lvef>55%. there is a mechanical aortic prosthesis insitu (#19 by report) with good leaflet motion and no perivalvular leaks. peak gradient 40's, mean 20's post bypass. aortic contours intact. tr is now mild. remaining exam is unchanged. all findings discussed with surgeons at the time of the exam. , f 32 radiology report chest (pa & lat) study date of 3:01 pm medical condition: 32 year old woman with avr/ao root enlargement final report history: 32-year-old female status post avr. assess interval change. pa and lateral chest radiographs are compared to . a right ij central venous catheter tip projects over the mid svc, as before. median sternotomy wires are intact. the cardiac silhouette is unchanged. there is improved aeration in the retrocardiac region compared to one day prior. there is improved aeration at the bases compared to one day prior. small pleural effusions are probably unchanged allowing for positional differences. the upper lungs are clear. the study and the report were reviewed by the staff radiologist. dr. dr. approved: 4:52 pm brief hospital course: was a same day admit after undergoing pre-operative work-up prior to surgery. on she was brought to the operating room where she underwent an aortic valve replacement and aortic root enlargement. please see operative report for surgical details. in summary she had an aortic valve replacement with #19 mechanical valve, she also had an aortic root enlargment with a pericardial patch. her bypass time was 84 minutes with a crossclamp of 66 minutes. she tolerated the operation well and following surgery she was transferred to the cvicu for invasive monitoring in stable condition. within 24 hours she was weaned from extubation, awoke neurologically intact and extubated. on post-op day one patient was transferred to the telemetry floor for further care. chest tubes and epicardial pacing wires were removed per protocol. coumadin was started on pod#1 and iv heparin on pod#2. inr was therapeutic on pod#4 and heparin was discontinued. ms. complained of right shoulder pain radiating down humerus with limited abduction; sensation and strentgh is intact. symptoms likely d/t positioning on or table. evaluated by pt/ot/and orthopedic service sling given for support when out of bed. neurontin added to pain med regimen. will have home pt/ot. on pod 4 ms was ready for discharge home with visiting nurses aas well as home pt/ot. she is to follow-up w/dr in 1 month medications on admission: acyclovir 400mg prn for cold sores, albuterol mdi 2 puffs prn, celexa 20mg qd, epipen prn, fexofenadine 180mg qd, lasix 20mg qd, daypro 1200mg qd prn, mvi discharge medications: 1. citalopram 20 mg tablet sig: one (1) tablet po every other day (every other day). 2. fexofenadine 60 mg tablet sig: three (3) tablet po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for temp. 6. furosemide 20 mg tablet sig: one (1) tablet po once a day. 7. potassium chloride 10 meq tablet sustained release sig: two (2) tablet sustained release po once a day. disp:*30 tablet sustained release(s)* refills:*0* 8. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 9. warfarin 2 mg tablet sig: as directed to target inr 2-2.5 tablets po once a day: dose as directed by coumadin clinic. target inr 2-2.5. disp:*90 tablet(s)* refills:*2* 10. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 11. gabapentin 100 mg capsule sig: two (2) capsule po bid (2 times a day). disp:*120 capsule(s)* refills:*2* 12. ibuprofen 600 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain. 13. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*90 tablet(s)* refills:*2* discharge disposition: home with service facility: regional vna discharge diagnosis: aortic stenosis/bicuspid aortic valve s/p aortic valve replacement/aortic root enlargement migraines plantar fasciitis asthma depression/anxiety chronic fatigue obesity dysmenorrhea rhinitis ? obstructive sleep apnea recent poison /sumac/ tick bite discharge condition: good discharge instructions: no lotions, creams, powders or ointments to incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness, drainage, or weight gain of 2 pounds in 2 days or 5 pounds in one week shower daily at pat incison dry; no baths or swimming call with any questions or concerns followup instructions: , np (pcp)in weeks (. first inr to be drawn on with results sent to the coumadin clinic at the office of fax (. plan confirmed with on . dr. (cardiologist) in weeks dr. (cardiac surgeon) in 4 weeks please call to make all appointments. Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Diagnoses: Obstructive sleep apnea (adult)(pediatric) Asthma, unspecified type, unspecified Aortic valve disorders Dysthymic disorder Obesity, unspecified Chronic fatigue syndrome Congenital insufficiency of aortic valve Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Pain in joint, shoulder region Dysmenorrhea Plantar fascial fibromatosis

allergies: no known allergies / adverse drug reactions attending: chief complaint: ich major surgical or invasive procedure: right hemicraniectomy with evacuation of clot l evd placement peg placement history of present illness: the pt is a 40 y/o man who presents as an osh transfer after being found to have a large right sided iph.he showed up at hospital around 10pm with complaints of headaceh and left sided weakness. he was found to have left hemiplegia and a ct was done which showed a large iph on the right side. he was also noted to be hypertensive to at least 225 over 133. he was elactively intubated with fentanyl, succs. for his hypertension he recieved labetolol. he also received lasix and 50grams of mannitol. on transfer he was on a nipride gtt and versed gtt intubated.no family at bedise at that time to get more information. past medical history: htn, psoriasis, cva? social history: unknown family history: unknown physical exam: physical exam: vitals: t: p: 70 r: 18 bp: 165/118 sao2:100% general: intubated. not on sedation. pulm: some light crackles bilaterally cvl: rrr, with systolic flow murmum ext: no edema. neurologic: intubated. eyes closed not opening to voice or pain. pupils pinpoitn at 2mm with very very minimal reaction. dolls present. positive corneals bilaterally. no gag noted, no cough noted. lue flacid. lle triple flexion. rue postures. rle spontaneous flexion at the knee. upgoing toes bilaterally. physical exam upon discharge: eyes open to voice/minimal stimulation alert to self perrl following simple commands with r ue and le. moves both spontaneously. l ue hemiparesis, extends to noxious stimuli l le withdraws incision- well healing. no sign of infection pertinent results: laboratory data: 135 97 15 168 agap=16 2.5 25 0.8 7.45 pco245 po2368 hco332 11.9 14.8 228 pt: 14.3 ptt: 22.3 inr: 1.2 fibrinogen: 414 ua negative serum tox negative radiologic data: nchct : intraparenchymal hemorrhage centered in the r basal ganglia measuring approx 7.3 x 4.1 cm, similar in size to the osh study. interval increase in the intra-ventricular extension of the bleed. sub-falcine herniation, with stable to minimal increase in the leftward shift of midline structures. mass-effect on the third ventricle with mild dilation of the lateral ventricles. ct brain - 1. stable large hematoma centered in the right basal ganglia, with stable intraventricular extension. stable mass effect. stable size of the ventricles. 2. s/p right parietal craniectomy with a small right extraaxial hematoma, as before. 3. hypodensities in the left subinsular white matter could represent chronic small vessel infarcts, unusual for age. please correlate with risk factors. if clinically indicated, they may be further assessed by contrast-enhanced mri to exlude other etiologies, when the patient is stabilized. ct brain - 1. large right basal ganglionic hematoma with intraventricular extension and surrounding vasogenic edema, unchanged in size and appearance from most recent study, with stable size of ventricles. 2. leftward shift of normally-midline structures appears slightly worse when compared to the most recent study, some of which may be due to differences in plane of scanning. 3. status post right parietal craniectomy, with small right extra-axial hematoma is unchanged. renal u/s - bilateral renal calcifications. overall, the pattern is suggestive of medullary nephrocalcinosis. in the right lower pole, a partially calcified cyst or stones within a caliceal diverticulum are also seen. no solid mass is identified. normal renal doppler, with resistive indices ranging from 0.64-0.69 in the right and 0.69-0.77 on the left. ct brain - 1. right basal ganglia intraparenchymal hematoma, surrounding edema and mass with shift of midline structures similar to the prior study. 2. left frontal approach evd in stable position terminating in the left caudothalamic groove. 3. mild interval decrease in the intraventricular hemorrhage.ventricular size not significantly changed. ct of the abdomen without and with intravenous contrast: included lung bases are clear and there is no pleural or pericardial effusion. no focal masses are noted within the adrenal glands which display symmetrical, slightly increased thickening bilaterally, which may reflect a component of hyperplasia with no additional masses noted along the sympathetic chain including in the expected location of the organ of zuckerkandl. limited evaluation of the liver, gallbladder, spleen, pancreas, stomach, and bowel appear unremarkable. a post-pyloric feeding tube is in place with its tip terminating at the third portion of the duodenum. dense medullary calcification is present within the kidneys. in addition to some cysts within the medulla, the largest within the left lower pole measuring 14 x 14 mm. normal excretion of contrast is noted within the collecting systems. no free air, free fluid, or pathologically enlarged lymph nodes are present. no significant atherosclerotic plaque is noted near the origins of the renal arteries to suggest any underlying stenosis. bone windows: no aggressive osseous lesions are noted. impression: 1. no focal adrenal masses or findings of adrenal/extra-adrenal paraganglioma. mild symmetrical thickening to the adrenal glands may suggest a component of underlying hyperplasia. 2. bilateral medullary nephrocalcinosis with imaging appearance most suggestive of medullary sponge kidney, with differential including renal tubular acidosis or hyperparathyroidism. bue dopplers: impression: no dvt in either upper extremity cta head:impression: 1. stable appearance of a right basal ganglia parenchymal hemorrhage with ventricular extension. slight increase in anterior parenchymal edema is seen, with suggestion of increased transcranial herniation at the anterior aspect of the craniectomy site. 2. no vascular stenosis, aneurysm, dissection, or malformations seen. there is no active contrast extravasation (so-called "cta spot sign"). ct head: impression: no interval change of a right basal ganglia hematoma, with neighboring edema or evolving infarction, local mass effect, intraventricular extension, and mild transgaleal herniation through the craniectomy site. ct head: impression: status post removal of the ventricular drain without change in ventricular size or brain compared with the prior ct from . lenis: impression: no evidence of deep vein thrombosis in either leg. 06:45a 138 103 57 104 agap=14 4.3 25 1.0 ca: 9.3 mg: 2.7 p: 6.2 brief hospital course: pt was brought immediately to the or for hemicraniectomy and evacuation of clot. post-operatively his exam showed localizing on the right and left plegic. he had evd placed at bedside with high icp upon insertion. records were obtained from a previous admission to hospital that indicated a previous hospitalization for hypertensive emergency resulting in a right ganglia hemorrhage. exam is somewhat improved on this mornings exam with intermitant commands. evd was raised to 15 after review of ct that shows the left lateral ventricl to be collapsed. a fever work up has been initiated for fevers and elevated wbc. oral antihypertensive meds were increased to wean off the iv nicardipine. patient was febrile and was pancultured. overnight, he remained febrile and on csf cultures were sent and were essentially negative for growth. sputum culture was positive for multiple organisms and as a result pt was started on vanc/cef. on he was extubated without incident and respiratory status has remained unchanged during his icu course. he continued to remain stable during is icu course and received tpa through evd daily. he became febrile on and csf was sent which showed some pmns. additionally, his evd was increased to 20 cm h20 and his icps continued to remain stable. overnight he remained afebrile. his serum na was 150 and he was given free water with good effect. later in the day, it was noted that the distal portion of the evd tubing had air and his system was changed out. on , his evd was raised again to 25cm. his serum na was stable. he was afebrile overnight. coreg was increased and he was given a dose of lasix 20mg. he underwent his peg placement on . his feeds were started on and tolerating. on , he remained stable with his evd clamped. a head ct was done whcih showed no evidence of ventricular enlargement after clamping of his evd. he remained stable without icp spikes and on 5.6 his evd was removed and a stitch placed. he was transferred to the sdu for further montioring ojn the evening of . he remained stable voernight and on he had a temperature of 101 and urine was sent for testing. on he was evalauted by renal medicine regarding his sponge kidney and recommendations for 24 urine metanephrines and increasing free water through his peg were recieved. on screening leni's were negative and free water was again increased per renal. on repeat 24hr urine revealed increased na so his free water was increased. on he was neurologically stable. free water was decreased and increased per renal recs and serum na's. on the patient's hypernatremia continued to resolve. his ivf was discontinued and he was continued on 400ml of free water. overnight his tube feed residuals were high so tube feeds were held. he was started on reglan to stimulate gastric motility. feeds were restarted at 6 am on . he remained neurologically stable overnight and was cleared for discharge in the am. medications on admission: unknown discharge medications: 1. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 2. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 3. acetaminophen 650 mg/20.3 ml solution sig: one (1) solution po q6h (every 6 hours) as needed for pain or fever >100.4. 4. insulin regular human 100 unit/ml solution sig: per ss injection asdir (as directed). 5. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 6. levetiracetam 100 mg/ml solution sig: ten (10) ml po bid (2 times a day). 7. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 8. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical (2 times a day) as needed for puritis. 9. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 10. labetalol 100 mg tablet sig: one (1) tablet po tid (3 times a day). 11. senna 8.6 mg tablet sig: one (1) tablet po daily (daily). 12. reglan 5 mg tablet sig: one (1) tablet po every eight (8) hours. discharge disposition: extended care facility: hospital - discharge diagnosis: left intraparenchymal hemorrhage obstructive hydrocephalus intraventricular hemorrhage intracranial hypertension hypertension fever left hemipalegia dysphagia acute respiratory failure hypernatremia spongy renal disease discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: bedbound. discharge instructions: general instructions ?????? have a friend/family member check your incision daily for signs of infection. ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? you may wash your hair only after sutures and/or staples have been removed. if your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? you may shower before this time using a shower cap to cover your head. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? if you were on a medication such as coumadin (warfarin), or plavix (clopidogrel), or aspirin, prior to your injury,do not resume these until cleared by your surgeon. ??????you have been discharged on keppra (levetiracetam), you will not require blood work monitoring. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. followup instructions: *** please follow up with dr in 3 weeks with a non-contrast head ct. this can be scheduled by calling . *** please call the clinic to make a follow up for your Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Injection or infusion of thrombolytic agent Percutaneous [endoscopic] gastrostomy [PEG] Other incision of brain Other cranial puncture Ventricular shunt to extracranial site NEC Diagnoses: Obstructive hydrocephalus Unspecified essential hypertension Unspecified protein-calorie malnutrition Intracerebral hemorrhage Compression of brain Acute respiratory failure Disorders of phosphorus metabolism Personal history of noncompliance with medical treatment, presenting hazards to health Hyperosmolality and/or hypernatremia Other disorders of calcium metabolism Hemiplegia, unspecified, affecting nondominant side Dysphagia, unspecified Medullary sponge kidney

allergies: ace inhibitors attending: chief complaint: abdominal pain, fever major surgical or invasive procedure: laparoscopic cholecystectomy history of present illness: ms. is a 78 yo f cantonese speaking w/ significant pmh for dm, hl and osteoporosis who presented to with epigastric and ruq abdominal pain. per outside hospital records on the pt developed epigastric and ruq pain after eating a meal. the pain continued to wax and wane throughout the day but kept continually getting worse. she did have a fever to 101.9 during this episode of pain as well. she went to her pcp ordered a ct abdom/pelvis which showed distended gall bladder w/ stones present as well as a intrahepatic and extrahepatic biliary duct dilations. her cbd measured was 18mm in diameter. at a ruq u/s was obtained which again showed the findings present in ct of a/p. she remained febrile with a tmax of 103 with a wbc of 25,000 on admission. also while febrile she developed a.fib with rvr. she does not have a hx of a.fib and is not on rate control as an outpt. with this rvr she developed depressions in v4-5 and had a minor troponin leak with flat mb. she was started on iv dilt and given po metoprolol. her rate responded and the st depressions resolved. she was made npo and started on flagyl and zosyn and has been afebrile since. she was started on heparin gtt as atrial fibrillation has persisted. she was transferred to for ercp. . on arrival to the icu, she was jaundice and in nad. she was hemodynamically stable and not complaining of abdominal pain. . past medical history: dm-diet controlled hl htn osteoporosis social history: lives with her son - : denies ever smoking - alcohol: denies - illicits: denies family history: her son has htn as well physical exam: on admission: vitals: t:98.3 bp:120/60 p:80 r:18 o2: 98% ra general: alert, oriented, no acute distress, jaundice heent: icteric sclera, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, able to press firmly on abdomen w/o iliciting response from pt gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema physical examination upon discharge: vital signs: 98.4, hr=65 regular, resp rate 18, bp=130/58 general: nad cv: ns1, s2, -s3, -s4 lungs: clear, diminshed in bases bil. abdomen: soft, non-tender, port dressings clean and dry ext: + dp bil., no pedal edema bil., no calf tenderness mentation: follows simple commands in english pertinent results: osh labs: wbc , hct 31, plt 303, amylase 980, lipase 1455, troponin t 0.07, ast 74, alt 112, alk phos to 297, tbili 3.7, direct bili 3.3, 12:00am blood wbc-8.0 rbc-3.79* hgb-11.6* hct-36.3 mcv-96 mch-30.7 mchc-32.0 rdw-14.0 plt ct-448* 07:00am blood wbc-7.7 rbc-3.98* hgb-11.9* hct-38.3 mcv-96 mch-29.8 mchc-31.0 rdw-14.0 plt ct-465* 07:05am blood wbc-9.7 rbc-3.38* hgb-10.2* hct-32.4* mcv-96 mch-30.1 mchc-31.4 rdw-14.0 plt ct-382 01:46pm blood wbc-20.3* rbc-3.27* hgb-9.9* hct-31.9* mcv-97 mch-30.3 mchc-31.1 rdw-14.0 plt ct-321 03:58am blood neuts-88.5* lymphs-7.5* monos-2.9 eos-1.1 baso-0.2 12:00am blood plt ct-448* 12:00am blood pt-11.1 ptt-72.8* inr(pt)-1.0 03:20pm blood ptt-96.8* 07:00am blood plt ct-465* 12:00am blood glucose-139* urean-8 creat-1.2* na-144 k-3.2* cl-99 hco3-31 angap-17 07:00am blood glucose-159* urean-9 creat-1.1 na-143 k-3.3 cl-101 hco3-29 angap-16 07:05am blood glucose-128* urean-12 creat-1.0 na-139 k-3.4 cl-102 hco3-27 angap-13 12:00am blood alt-72* ast-44* alkphos-226* amylase-95 totbili-0.9 07:00am blood alt-70* ast-41* alkphos-241* totbili-0.9 01:46pm blood alt-104* ast-70* ld(ldh)-213 ck(cpk)-332* alkphos-245* totbili-1.8* 12:00am blood lipase-193* 03:58am blood lipase-472* 01:46pm blood lipase-840* 03:58am blood ck-mb-3 ctropnt-0.08* 01:46pm blood ck-mb-6 ctropnt-0.09* 12:00am blood calcium-9.9 phos-4.4# mg-1.5* 07:05am blood calcium-8.8 phos-2.8 mg-1.7 03:58am blood triglyc-92 hdl-30 chol/hd-3.7 ldlcalc-62 01:46pm blood tsh-0.69 02:08pm blood lactate-1.4 : ekg: atrial fibrillation with moderate ventricular response. minor diffuse non-specific st-t wave abnormalities. no previous tracing available for comparison. tracing #1 : echo: the left atrium is normal in size. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. left ventricular systolic function is hyperdynamic (ef 75%). right ventricular chamber size and free wall motion are normal. the number of aortic valve leaflets cannot be determined. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. impression: hyperdynamic left ventricle : ekg: atrial fibrillation with moderate ventricular response. borderline criteria for left ventricular hypertrophy with repolarization changes. compared to the previous tracing of criteria for left ventricular hypertrophy are now seen. there are no other significant changes. : mrcp: 1. mild central intrahepatic biliary dilatation with the common bile duct measuring up to 9 mm in maximum diameter and tapering normally towards the head of the pancreas, without evidence for choledocholithiasis. mild enhancement noted of the common bile duct which is non-specific but may represent resolving cholangitis. 2. numerous gallstones are identified within the gallbladder, but without over acute or chronic cholecystitis. 3. diffusely low signal intensity of the pancreas on t1-weighted imaging which can be seen in the setting of pancreatitis. there is no peri-pancreatic stranding or free fluid to suggest acute pancreatitis at this time. relative atrophy of the pancreas in keeping with patient's age with preservation of the parenchyma in the tail. this is somewhat unusual in distribution, however no clear mass lesion is seen in the tail of the pancreas. follow-up mri may be considered in 6 months to assure stability of above. 4. two sub-5-mm cystic lesions noted in the neck and tail of the pancreas as described, with differential diagnosis including either side branch ipmn versus other cystic lesion of the pancreas. these can be monitored for stability at time of mrcp to evaluate the pancreatic parenchyma. brief hospital course: transferred to for ercp after presenting to an hospital with acute cholecystitis and gallstone pancreatitis. the patient met criteria for sirs w/ leukocytosis to 25,000 and febrile to 101 with a presumed biliary source initial labs were pertinent for elevated transaminases, alk phos, total and direct bili as well as an elevated amylase and lipase suggestive of gallstone pancreatitis. imaging showed distended gallbladder with stones present and a significant amount of intrahepatic and extrahepatic biliary dilatation. this clinical picture was consistent with gall stone pancreatitis and cholangitis. on transfer to the intensive care unit, the patient was jaundiced but comfortably lying in bed, afebrile and without pain, with improvement in lfts indicating likely passage of obstructing stone. ercp was initially planned but deferred in the setting of downtrending bilirubin and new onset atrial fibrillation. surgery was consulted to evaluate for cholecystectomy. she was treated with zosyn for gram neg / anaerobe coverage and improved after antibiotics were started and became afebrile. she reportedly converted into atrial fibrillation with rapid ventricular response prior to her admission with no known past history. her blood work showed mild troponin leak and v4-v5 st depressions, thought to be related to demand ischemia. her ekg on admission showed resolution of st changes with a flat cmbk. troponins were trended and were downtrending and the ckmb remained flat. pt was without chest pain or evidence of acute coronary syndrome. she was started on a diltiazem drip at the outside hospital which was subsequently discontinued with rate controlled. cardiology was consulted and recommended an echo which a hyperdynamic left ventricle and an ejection fraction of 75%. she was subsequently started on a heparin drip. on hd #5 she was taken to the operating room for a laparoscopic cholecsytectomy. her operative course was stable. she was extubated after the procedure and monitored in the recovery room. her post-operative course has been stable. her vital signs have been stable and she has been afebrile. she has been tolerating a regular diet. her white blood cell count has normalized. she has resumed her home medications and was started on coumadin with a lovenox bridge. her current inr is 1.0. she is preparing for discharge home with vna services and monitoring of of pt/inr by her primary care provider. son will administering her lovenox after instruction. of note: mri of pancreas recommended in 6 months ( as per radiologist rec) medications on admission: medications home: actos 15mg daily fosamax 70mg qweek antivert 12.5mg q8hrs prn asa 81mg daily benicar (olmesartan/hydrochlorothiazide) 40/25mg daily imdur 30mg daily hydralazine 25mg tid atorvastatin 20mg daily claritin 10mg daily vitamin d 400iu daily multivitamin daily . medications on transfer: asa 81mg dilaudid iv 0.5mg q4 prn flagyl 500mg iv q8 heparin gtt imdur 30mg daily lopressor 50mg q12 diltiazem 100mg iv q20? vitamin c protonix 40mg iv q 24 vitamin d 400iu daily zocor 10mg qhs zofran 4mg q6 prn zosyn 4.5g q6hrs discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 3. isosorbide mononitrate 30 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 4. losartan 50 mg tablet sig: two (2) tablet po daily (daily). 5. hydrochlorothiazide 12.5 mg capsule sig: two (2) capsule po daily (daily). 6. atorvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 7. enoxaparin 60 mg/0.6 ml syringe sig: sixty (60) mg subcutaneous q12h (every 12 hours). disp:*60 syringes* refills:*0* 8. oxycodone 5 mg tablet sig: 0.5-1 tablet po q4h (every 4 hours) as needed for pain: may cause increased drownsiness. disp:*15 tablet(s)* refills:*0* 9. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 10. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 11. diltiazem hcl 240 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 12. hydralazine 25 mg tablet sig: one (1) tablet po three times a day: hold for systolic blood pressure <100. 13. coumadin 1 mg tablet sig: one (1) tablet po once : daily dosing by primary care provider, . according to pt/inr. disp:*10 tablet(s)* refills:*0* 14. colace 100 mg capsule sig: one (1) capsule po twice a day: hold for loose stool. discharge disposition: home with service facility: vna discharge diagnosis: atrial fibrillation gallstone pancreatitis cholangitis discharge condition: mental status: clear and coherent ( cantonese speaking) level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with right upper quadrant pain and a fever. you underwent a cat scan of the abdomen which showed gallstones. during this time, you developed a rapid heart rate and required medication to control her heart rate. you were admitted to the intensive care unit for monitoring. you underwent an mri of the abdomen which showed gallstones. you were taken to the operating room room where you had your gallbladder removed. you have done well since the surgery and you are preparing for discharge home with the following instructions: please follow up with dr. on 11:30 am so you can have your inr monitored. you will be discharged on coumadin with lovenox bridge. please follow these instructions upon discharge: please call your doctor or return to the emergency room if you have any of the following: * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomiting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomiting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. activity: no heavy lifting of items pounds for 6 weeks. you may resume moderate exercise at your discretion, no abdominal exercises. wound care: you may shower, no tub baths or swimming. if there is clear drainage from your incisions, cover with clean, dry gauze. your steri-strips will fall off on their own. please remove any remaining strips 7-10 days after surgery. please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. followup instructions: department: primary care name: dr. when: it is requested that you see your primary care provider days after your hospital discharge. please call the number listed below to make this appointment. address: , , phone: you have an appointment with dr. on at 11:30am, please keep this appointment. your inr should be repeated and follow-up appointments made department: general surgery/ when: tuesday at 4:15 pm with: dr. in the acute care clinic phone: building: lm bldg () campus: west best parking: garage repeat mri of pancreas recommended as per radiology in 6 months (report to dr. Procedure: Laparoscopic cholecystectomy Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Severe sepsis Atrial fibrillation Other and unspecified hyperlipidemia Other late effects of cerebrovascular disease Cholangitis Acute pancreatitis Other acute and subacute forms of ischemic heart disease, other Calculus of gallbladder and bile duct with acute and chronic cholecystitis, with obstruction

allergies: no known allergies / adverse drug reactions attending: chief complaint: encephalopathy major surgical or invasive procedure: liver transplant history of present illness: 51f with primary biliary cirrhosis, currently on the transplant list, with meld 24 at today's admission (recent meld scores have been between 23-28). she is brought in now by her boyfriend who reports that she has been increasingly somnolent over the past 2-3 days. she initially was just "very sleepy," but has slowly become more confused and difficult to arouse. she has also complained of abdominal pain and bloating. he believes that she is taking all of her medications, but is unsure of how her bowel habits have been. he called ems who took her to her local ed; after ivf hydration she was transferred to for further monitoring. history was obtained mostly from the chart and patient's boyfriend as she was minimally responsive at time of consult. ros: unable to obtain past medical history: pmh: - primary biliary cirrhosis since years old - cirrhosis complicated by portal hypertension, portal gastropathy, ascites and hepatic encephalopathy - history of anemia requiring blood transfusions - history of thrombocytopenia - hemorrhoids - anal fissure - rectal swab vre -klebsiella uti -r ij non-occlusive thrombus psh: - cholecystectomy - caesarean section - orthotopic deceased donor liver transplant, portal vein to portal vein anastomosis, common bile duct to common bile duct without a t-tube, celiac axis of the donor to common hepatic artery of the recipient, piggyback. social history: - she is currently unemployed. she was laid off from her job as an administrative assistant about a year ago. -tobacco: 30-pack-year smoking history, she quit smoking about two years ago. -etoh: none -illicit drugs: none family history: mother with pancreatic cancer at age 79 physical exam: 99 80 95/54 20 97% gen: somnolent, will open eyes to pain. a&ox1-2, follows commands intermittently but falls asleep quickly. jaundiced heent: sclera icteric cv: rrr pulm: ctab abd: soft, distended w/shifting dullness. mildly ttp throughout ext: wwp, 2+ pedal edema bilat pertinent results: 9:19 pm urine **final report ** urine culture (final ): klebsiella pneumoniae. 10,000-100,000 organisms/ml.. cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 64 i tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s rectal swab vre 06:50pm blood wbc-4.4 rbc-2.50* hgb-9.3* hct-26.9* mcv-108* mch-37.3* mchc-34.7 rdw-17.3* plt ct-60* 05:58am blood wbc-4.8 rbc-2.87* hgb-9.1* hct-27.7* mcv-97 mch-31.9 mchc-33.0 rdw-17.5* plt ct-147* 06:05am blood pt-10.8 ptt-28.0 inr(pt)-1.0 06:50pm blood pt-16.2* ptt-45.5* inr(pt)-1.5* 06:50pm blood glucose-88 urean-37* creat-1.2* na-129* k-4.2 cl-105 hco3-16* angap-12 04:58am blood glucose-164* urean-111* creat-4.9* na-137 k-4.1 cl-99 hco3-18* angap-24* 06:05am blood glucose-114* urean-45* creat-1.1 na-142 k-4.2 cl-111* hco3-27 angap-8 05:58am blood glucose-85 urean-49* creat-1.4* na-139 k-5.2* cl-106 hco3-25 angap-13 05:58am blood tacrofk-8.3 06:50pm blood alt-168* ast-346* alkphos-179* totbili-20.3* 12:48am blood alt-152* ast-295* alkphos-156* totbili-28.1* 05:58am blood alt-53* ast-20 alkphos-74 totbili-2.1* brief hospital course: 51 yo f with h/o primary biliary cirrhosis (listed for liver transplant)c/b ascities, portal htn, hepatic encephalopathy presented with worsening encephalopathy and hypotension. she was admitted to the sicu and intensive work-up for the etiology of her poor mentation was begun. initial labs confirmed she was not intoxicated. it was noted that she had not taken her lactulose for a week. liver enzymes were elevated. creatinine had increased to 1.5 from baseline of 1.0. she was treated with iv fluid, colloids and lactulose as well as rifaximin. mental status improved and she was transferred out of the sicu. urine isolated klebsiella sensitive to ceftriaxone. ceftriaxone was also used to cover empirically for sbp given abdominal pain. us did not demonstrate enough ascites to do paracentesis. on , a liver donor was available and accepted. she underwent orthotopic deceased donor liver transplant, portal vein to portal vein anastomosis, common bile duct to common bile duct without a t-tube, celiac axis of the donor to common hepatic artery of the recipient, piggyback. two jp drains were placed. please refer to operative note for details. surgeon was dr. assisted by dr. . postop, she was sent to the sicu for management. she received blood products per transplant protocol goals. she was extubated on and had decreasing lfts. hepatic duplex on demonstrated patent veins w/lack of diastolic flow in main ha. repeat duplex on showed patent veins with improved diastolic flow in ha. lfts continued to decrease. jp drains were non-bilious. urine output gradually decreased. iv fluid boluses were initially given. lasix was then given with minimal response. nephrology was consulted noting oliguria/ and recommended lasix. crrt was not indicated. on , a dobhoff advanced under fluoroscopy. she was oliguric with increased creatinine, but no indications for crrt. tube feeds were started. diet was also started and tolerated. r arm was noted to be edematous and was larger than the left arm. a non-occlusive thrombus was noted in the right ij on dopplar. central line in that location was removed. no anticoagulation was initiated. the lateral jp was d/c'd on . she transferred out of the sicu on . tube feeds continued as well as lasix for generalized edema. lasix was given daily. urine output gradually increased as well as urine output. creatinine decreased to a low of 1.1. she was drinking up to 5 nutritional supplements a day as well as eating small amounts of food. she was had slow return of gi function and required dulcolax rectal suppositories a few times, but eventually was able to move her bowels. she disliked the feeding tube and demonstrated that she could take sufficient kcals to meet her nutritional needs. the feeding tube was subsequently removed on . medial jp was d/c'd and site sutured. pt worked with her and felt that she was safe for discharge to home without home pt. she was ambulating independently at time of discharge. she continued to have a fair amount of ruq incision area pain for which she took oxycodone 5mg (only a couple times per day). abdominal incision was intact with staples without redness or drainage. glucoses were elevated and were treated with glargine and humalog. was consulted and adjusted insulin daily. insulin 70/30 (pen )was recommended for home regimen. she received instruction from the rn educator. immunosuppression consisted of tapering steroid protocol, cellcept which was adjusted to qid for some gi complaints and prograf. she did very well with medication teaching. vna services were arranged. she was discharged home on lasix 40mg daily for bilateral leg edema. medications on admission: preadmission medications listed are correct and complete. information was obtained from patient. 1. anucort-hc *nf* (hydrocortisone acetate) 25 mg rectal qhs hold on 2. lactulose 30 ml po tid titrate to bms per day 3. omeprazole 20 mg po daily 4. rifaximin 550 mg po bid 5. ursodiol 300 mg po qid 6. lidocaine jelly 2% (urojet) 1 appl tp prn anal pain 7. ferrous sulfate 325 mg po daily discharge medications: 1. omeprazole 20 mg po daily 2. freestyle freedom lite *nf* (blood-glucose meter) 1 meter miscellaneous x1 rx *blood-glucose meter 1 meter for qid blood sugar checks disp #*1 kit refills:*0 3. freestyle lite strips *nf* (blood sugar diagnostic) 1 bottle miscellaneous x1 check blood sugars prior to meals and bedtime rx *blood sugar diagnostic 1 four times a day disp #*1 bottle refills:*3 4. docusate sodium (liquid) 100 mg po bid 5. fluconazole 400 mg po q24h 6. furosemide 40 mg po daily rx *furosemide 40 mg 1 tablet(s) by mouth once a day disp #*14 tablet refills:*0 7. mycophenolate mofetil 500 mg po qid 8. oxycodone (immediate release) 5-10 mg po q4h:prn pain rx *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours disp #*40 tablet refills:*0 rx *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours disp #*40 tablet refills:*0 9. prednisone 20 mg po daily decrease per taper. due to decrease to 17.5mg on 10. sulfameth/trimethoprim ss 1 tab po daily 11. tacrolimus 2.5 mg po q12h 12. valganciclovir 900 mg po daily 13. 70/30 15 units breakfast 70/30 5 units dinner rx *insulin nph & regular human 100 unit/ml (70-30) take 15 units before bkft; 5 units before dinr; disp #*1 not specified refills:*3 14. insulin pen needles bd nano ultrafine needles for 70/30 insulin pen for injections and prn supply: 1 box refill: 6 discharge disposition: home with service facility: area vna discharge diagnosis: hepatic encephalopathy, primary biliary cirrhosis non occlusive thrombus r ij vre + rectal swab klebsiella uti discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: please call the transplant clinic at if you develop any of the following: temperature of 101 or greater, chills, dizziness/lightheadedness, thirst, nausea, vomiting, jaundice, inability to take any of your medications, increased abdominal pain or bloating/distension, incision redness/bleeding/drainage, constipation, or edema worsens or legs are thin (no swelling), weight loss of 3 pounds _you will need to have blood drawn twice weekly for labs monitoring at lab, office medical building (every monday and thursday) followup instructions: provider: , md phone: date/time: 1:00 provider: , phone: date/time: 3:30 provider: , md phone: date/time: 10:00 md, Procedure: Enteral infusion of concentrated nutritional substances Other transplant of liver Other operations on lacrimal gland Transplant from cadaver Diagnoses: Anemia, unspecified Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Portal hypertension Personal history of tobacco use Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other complications due to other vascular device, implant, and graft Other ascites Hepatic encephalopathy Hypercalcemia Family history of malignant neoplasm of gastrointestinal tract Biliary cirrhosis Edema Acute venous embolism and thrombosis of internal jugular veins Anomalies of other specified sites of peripheral vascular system Other pancytopenia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hydrothorax major surgical or invasive procedure: tips placement (failed x2) history of present illness: is a 64 year old male with alcoholic cirrhosis c/b portal hypertension, ascites, and varices who presented as a transfer from for tips evaluation. of note, he has guillain- syndrome and is currently wheelchair bound due to lower extremity weakness. . he was diagnosed with cirrhosis in and was unaware of his liver disease prior to then. per patient report, he has had paracentesis about twice monthly since then with volumes of l. he reports failing diuretic therapy due to symptomatic hypotension. he also reports that he has had endoscopy showing mild varices and denies ever having upper or lower gi bleeding. . per the patient, he has needed recurrent paracentesis over the past few months despite being on furosemide and spironolactone. his hepatologist suggested a tips procedure to relieve the recurrent ascites and hepatic hydrothorax which he has had over the past year. the patient states that he initially went to to have the tips procedure done, but later requested a transfer since he wanted one of the ir physicians to do the procedure. . per the transfer summary he was admitted to on for increasing ascites and hypotension. the transfer summary is confusing but it appears as if there was a concern for sbp. he was given an albumin infusion which was later discontinued due to pleural effusion. he was then seen by pulmonary who noted his cirrhosis, ascites, and a large pleural effusion. they decided to observe him, and offered thoracentesis for to help with dyspnea. the patient declined thoracentesis. according to the patient, he received large volume paracentesis taps ranging from 8-9 l a tap. he states that during his hospitalization his diuretic therapy was stopped because he was hypotensive and required albumin infusions. . ros was otherwise essentially negative. the patient denied recent fevers, night sweats, chills, hematemesis, coffee-ground emesis, nausea, vomiting, melena, hematochezia. he does have significant lower extremity weakness due to his ongoing guillain- syndrome. . past medical history: guillain- syndrome alcoholic cirrhosis portal hypertension postural hypotension anemia anxiety gait disorder social history: he previously worked as a dentist. he is married and his wife is supportive. # smoking: quit over 15 years ago # alcohol: stopped drinking over 10 years ago # drugs: no recreational drug use family history: noncontributory physical exam: vs: t 97.4(96.9-97.4), bp 106/65(100-115/58-71), hr 81(77-88) ....rr 22(20-22), spo2 96(96-100) on ra gen: nad. alert and oriented x3. mood and affect appropriate. pleasant and cooperative. resting in bed. heent: ncat. perrl, eomi, anicteric sclera. mmm, op benign. neck: supple. jvp not elevated. no cervical lymphadenopathy. cv: rrr. normal s1, s2. no m/r/g appreciated. chest: respiration unlabored. decreased breath sounds on right. no wheezes, rhonchi, or rales. abd: bs present. soft, nt, nd. ascites present but not tense. ext: wwp, no cyanosis or clubbing. no le edema. digital cap refill <2 sec. distal pulses radial 2+, dp 2+, pt 2+. neuro: cn ii-xii grossly intact. le strength hip flexion , knee flexion and extension , dorsiflexion and plantarflexion . ue strength intact. pertinent results: labs on admission: 12:50am blood wbc-2.4* rbc-3.10* hgb-10.3* hct-30.4* mcv-98 mch-33.2* mchc-33.8 rdw-14.6 plt ct-136* 12:50am blood pt-16.2* ptt-28.7 inr(pt)-1.4* 12:50am blood glucose-107* urean-22* creat-0.9 na-136 k-5.2* cl-103 hco3-29 angap-9 12:50am blood alt-15 ast-22 alkphos-82 totbili-1.2 12:50am blood albumin-3.1* calcium-8.5 phos-3.4 mg-2.3 . thoracentesis: 11:48am pleural wbc-23* rbc-428* polys-11* lymphs-51* monos-10* meso-4* macro-24* 11:48am pleural totprot-2.3 ld(ldh)-68 albumin-1.6 . other relevant labs: 05:25am blood vitb12-761 folate-18.9 05:35pm blood caltibc-114* ferritn-558* trf-88* 05:35pm blood iron-35* . 05:05am blood triglyc-63 hdl-25 chol/hd-3.0 ldlcalc-37 06:10am blood tsh-7.8* 06:10am blood cortsol-8.3 . 05:05am blood hav ab-positive 05:35pm blood hbsag-negative hbsab-borderline hbcab-negative 05:35pm blood hcv ab-negative 05:35pm blood ama-negative smooth-negative 05:35pm blood -negative 05:05am blood cea-4.2* psa-0.4 afp-1.5 05:35pm blood igg-898 iga-422* igm-33* . . 17:35 test result reference range/units alpha-1-antitrypsin qn 177 83-199 mg/dl . . 17:35 test result reference range/units ceruloplasmin 18 18-36 mg/dl . . 11:48 am pleural fluid gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. anaerobic culture (final ): no growth. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): no mycobacteria isolated. . . 5:05 am blood (toxo) toxoplasma igg antibody (final ): negative for toxoplasma igg antibody by eia. 0.0 iu/ml. . 5:05 am serology/blood varicella-zoster igg serology (final ): positive by eia. a positive igg result generally indicates past exposure and/or immunity. . 5:05 am serology/blood rubella igg/igm antibody (final ): negative by latex agglutination. a negative result generally indicates lack of immunity. . 5:35 pm blood (ebv) - virus vca-igg ab (final ): positive by eia. - virus ebna igg ab (final ): positive by eia. - virus vca-igm ab (final ): negative <1:10 by ifa. interpretation: results indicative of past ebv infection. . 5:35 pm blood (cmv ab) cmv igg antibody (final ): negative for cmv igg antibody by eia. < 4 au/ml. . 5:35 pm serology/blood consent received. rapid plasma reagin test (final ): nonreactive. . . tte (complete) done at 3:50:26 pm the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef 70%). there is no left ventricular outflow obstruction at rest or with valsalva. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. . . abdomen u.s. (complete study) study date of 10:22 am findings: the liver is nodular and shrunken in appearance but no solid liver lesion is identified. a simple cyst is seen at the dome of the right lobe measuring 1.0 cm and a simple cyst is seen at the dome of the left lobe also measuring 1.0 cm. no biliary dilatation is seen and the common duct measures 0.4 cm. several shadowing gallstones are seen within the lumen of the gallbladder. the pancreas and midline structures are obscured from view by overlying bowel. the spleen is enlarged measuring 19.7 cm. no hydronephrosis is seen. the right kidney measures 9.4 cm and the left kidney measures 10.8 cm. a moderate amount of ascites is seen within the abdomen. a large right pleural effusion is identified. doppler examination: color doppler and pulse-wave doppler images were obtained. the main, right and left portal veins are patent with hepatopetal flow. appropriate flow is seen in the ivc, the hepatic veins, and the hepatic arteries. impression: 1. nodular shrunken liver with two small simple cysts but no solid liver lesion identified. 2. large right pleural effusion and ascites. 3. splenomegaly. 4. cholelithiasis. . . chest (pa & lat) study date of 2:52 pm findings: a large right pleural effusion causes collapse of the right lung. the left lung and cardiac size are normal. impression: extensive right pleural effusion with associated right pulmonary collapse. . . chest (portable ap) study date of 11:58 am findings: in comparison with the study of , there has been removal of a substantial amount of fluid from the right hemithorax. however, a large amount of pleural fluid remains. the left lung is clear and there is no evidence of pneumothorax. . . cytology report pleural fluid procedure date of report approved date: specimen received: pleural fluid specimen description: received 2000ml cloudy yellow fluid. prepared 1 thinprep slide. diagnosis: pleural fluid: negative for malignant cells. macrophages, mesothelial cells, and inflammatory cells. . . radiology report tips study date of 8:26 am procedure: 1. abdominal paracentesis. 2. right pleural thoracocentesis. 3. hepatic venography via right internal jugular vein approach. 4. unsuccessful transhepatic cannulation of the portal vein. history: 64-year-old man with cirrhosis and intractable ascites, requires tips for control of ascites and recurrent right-sided hydrothorax. anesthesia: general anesthesia was provided by the anesthesiology service. in addition, 1% lidocaine was administered to the skin around the internal jugular vein puncture, thoracocentesis and paracentesis site. radiologist: dr. , dr. , dr. and dr. performed the procedure. dr. , the attending radiologist, was present throughout the procedure. procedure: informed consent was obtained outlining the risks and benefits of the procedure involved. following this, the patient was brought to the angiography suite where general anesthesia was induced. the right neck and right-sided chest and upper abdomen were prepped and draped in the usual sterile fashion. a preprocedure huddle and timeout were performed as per protocol. ultrasound of the right side demonstrates a large right-sided pleural effusion and a large volume of ascites. under ultrasound guidance, centesis needle was positioned within the peritoneal space and wire advanced under fluoroscopic guidance. a 5 french omniflush catheter was then advanced over the wire and attached to a suction drainage device. again under ultrasound guidance and following administration of 1% lidocaine, a 7 french all purpose drainage catheter was advanced into the right pleural space and again attached to a underwater seal on suction drainage. both drainage catheters were secured. attention was then turned to access the right internal jugular vein. 1% lidocaine was administered to the skin overlying the internal jugular vein and under direct ultrasound guidance, a micropuncture needle advanced into the right internal jugular vein. a 4.5 french micropuncture sheath was advanced over an 018 nitinol wire. the 018 wire and inner dilator were removed and an 035 wire advanced into the ivc. the micropuncture sheath was removed and the venotomy site dilated with an 8 french dilator. the sheath was then advanced to the level of the origin of the hepatic veins and a 035 glidewire advanced into the right hepatic vein. the sheath was advanced over the wire to lie in the mid portion of the right hepatic vein. pressure gradients were obtained at this time. following this, a 5 french 035 occlusive balloon was advanced into the distal right hepatic vein branch and co2 portography was performed to evaluate the position of the right and left main portal vein. ap and lateral projections were obtained. following this, the roshida needle was used to attempt to access the portal vein from the right hepatic vein approach. despite multiple needle passes in multiple orientations, it was not possible to enter the portal vein and advance a wire. in addition, an attempt was made to by the portal vein via a right flank percutaneous transhepatic approach. again despite multiple wire passes, we were unable to sufficiently opacify the portal vein. following a total procedure time of 6 hours and a fluoroscopic time of 80 minutes, a decision was made to abort the procedure. the internal jugular vein access sheath was removed and manual pressure was applied for 10 minutes, ensuring good hemostasis. the peritoneal drainage catheter was removed over a wire and a sterile dressing applied. a 7 french right pleural drain was left in situ to continue pleural drainage and lung expansion. the catheter was attached to an underwater seal. the referring clinician, dr. , was contact at the time of procedure. there were no early complications and the patient was extubated in the angiography suite and transferred to the anesthesia care unit. findings: ultrasound demonstrated large volume right-sided pleural effusion and ascites. there was uncomplicated placement of right pleural and right peritoneal drainage catheter. portal venography demonstrated a markedly narrowed right hepatic vein. in addition, co2 portography demonstrated a small right portal vein branch. given the overall anatomy and severe background ascites added to the difficulty in accessing the portal vein transhepatically. conclusion: successful right-sided thoracocentesis and abdominal paracentesis. hepatic venography and pressure measurements. the right atrial pressure was measured at 8 mmhg. the hepatic wedge pressure was measured at 20 mmhg. the staff radiologist, dr. , has reviewed the report. . . ct pelvis w/o contrast study date of 1:03 pm history: alcoholic cirrhosis with known portal hypertension, status post attempted tips procedure x2, most recent complicated by hepatic venous arterial fistula and subsequent embolization. evaluate for subcapsular or retroperitoneal bleed. comparison: outside ct , as well as angiogram images from . ct abdomen without contrast limited evaluation of the included lung bases displays normal-appearing left lung. the right lung displays significant interval decrease in size to a now slightly high-attenuation small-to-moderate pleural effusion with persistent adjacent compressive atelectasis involving portions of the right lower lobe as well as the small locule of air noted posterior to the sternum and a small anterior pneumothorax present. unenhanced images of the abdomen display no large retroperitoneal or subcapsular hematoma. there has been interval decrease in the amount of ascites when compared to the prior outside imaging; however, the fluid is now more mixed density with hounsfield values measuring 20-30, suggestive of a mixture of underlying ascites hemorrhage likely related to some oozing after capsular puncture on tips attempt. contrast is noted within the gallbladder and there is streak artifact from the indwelling coils and amplatz occluder devices in the right hepatic artery. distal to these devices, the hepatic parenchyma displays abnormal low attenuation, which may suggest underlying infarction given the poor flow noted on the post-embolization angiogram images to this region. some residual air is noted within the liver parenchyma likely related to a recent procedure. multiple small hypoattenuating lesions in the liver are again seen, likely hepatic cysts and there is unchanged configuration to known underlying cirrhosis with sequelae of portal hypertension including splenomegaly, massive esophageal/paraesophageal varices, and intra-abdominal collateral vessels. limited unenhanced evaluation of the remaining solid organs within the abdomen including the pancreas and adrenal glands are normal. kidneys displays persistent corticomedullary differentiation involving the kidneys suggestive of underlying renal dysfunction from prior contrast administration one day prior. there are some prominent air-filled loops of small and large bowel with the small bowel measuring up to 3.4 cm, which may suggest some mild underlying ileus with no findings of obstruction. scattered mesenteric and retroperitoneal lymph nodes are better appreciated on prior contrast-enhanced ct. ct of the pelvis without intravenous or oral contrast: significant interval decrease in amount of free fluid within the pelvis is identified, although the fluid is noted to be slightly higher in attenuation as compared to the prior outside exam with hounsfield value of approximately 20. a large fecal ball is noted within the rectal vault, with the intrapelvic bowel appearing otherwise unremarkable. contrast is noted within the bladder from prior procedure. bone windows: no malignant-appearing osseous lesions are identified. impression: 1. no significant retroperitoneal or subcapsular hematoma identified. while the amount of intra-abdominal/pelvic ascites has significantly decreased from prior exam the fluid is of slightly higher density suggesting that it is a mixture of underlying ascites and blood likely related to oozing from capsular puncture during tips attempt. 2. abnormal appearance to the inferior right hepatic lobe parenchyma distal to site of known embolization. this may reflect underlying parenchyma infarction. 3. persistent corticomedullary differentiation of the kidneys with contrast within the collecting systems. this suggests underlying contrast-induced nephropathy/atn and should be correlated with serial creatinine values. 4. interval decrease in size to now moderate right pleural effusion which is also of slightly higher density than before and may have a component of blood within it. a very small anterior right pneumothorax is also noted, not unexpected given the recent pleural catheter removal. . . brief hospital course: the patient is a 64 year old male with alcoholic cirrhosis c/b portal hypertension, ascites, and varices who presented as a transfer from osh for tips evaluation. he has had two failed tips placement attempts with hepatic artery puncture on the second attempt. . # tips placement attempts: he was sent from osh for tips evaluation and placement. cxr, echocardiogram, and duplex us of liver were completed and no contraindication to the procedure was identified on this imaging. viral and autoimmune hepatitis assays were negative. imaging from the osh was uploaded and reviewed by ir. tips placement was attempted on , but the shunt could not be passed through his liver tissue. he had a second attempt on , which was also not successful. the hepatic artery was punctured during the procedure and repaired without blood loss or significant hemodynamic instability. he had a brief stay in the micu and returned to the floor. his transaminases were significantly elevated after the second procedure, but were trending down rapidly at the time of discharge. per ir, further tips placement attempts would be technically possible, but will be deferred until a later time. . # creatinine elevation: his cr increased to 1.3 after his second tips attempt. ct scan on showed findings concerning for contrast-induced nephropathy/atn. his cr remained stable at 1.3 for the last three days. a prerenal etiology may also have been contributing given his limited po intake and recent fluid losses. he will likely need aggressive hydration and acetylcysteine with any future contrast loads. . # pain control: he has significant pain from immobility due to - syndrome, which was made worse by chest tube placement during his first tips attempt. he was much more comfortable after the chest tube was removed. he was started on oxycodone 5 mg po with close monitoring. he did not show any signs of hepatic encephalopathy or sedation. he was switched to q6h prn dosing on , which worked well for the patient. . # hydrothorax: he has a history of recurrent hepatic hydrothorax. his cxr on admission showed a large pleural effusion / hydrothorax with complete whiteout of the right hemithorax. he was asymptomatic and maintaining good oxygen saturation. he had thoracentesis with removal of 2 l of fluid. he tolerated the procedure well, with only some mild coughing. the fluid was transudative based on light's criteria, with no evidence of infection. during his tips procedure on , he had 3.5 l of fluid drained and a chest tube was placed. the chest tube drained large amounts of fluid over the days following its placement. the chest tube was removed at the time of his repeat tips attempt on . patient has oxygen saturation 98% on room air at time of discharge. . # ascites: his outpatient hepatologist was contact for more information regarding his prior diuresis, recurrent ascites, and hydrothorax. he was previously taking furosemide and spironolactone, but developed hypotension with use of the diuretics and continued to have significant hydrothorax and recurrent ascites requiring large volume paracentesis. during his stay at , he was kept on a low sodium diet and fluid restriction of 1500 ml. strict i/os and daily weights were monitored. he did not require additional paracentesis after 4 l of fluid were removed during his first tips attempt. . # alcholic cirrhosis: the indications for tips include recurrent ascites, hepatic hydrothorax, or variceal bleeding. his meld score on admission was 11, so tips was not contraindicated. he denied any prior episodes of hepatic encephalopathy or gi bleeding. he was continued on a regimen of lactulose and rifaximin. his rifaximin dosing was changed to 400 mg tid so that he could take smaller pills. meld labs were checked daily and his score remained stable around 11, but acutely increased to 15 after his second tips attempt. . # nutrition: on admission he appeared cachectic and chronically ill, reporting a significant weight loss over the last few months. his po intake was poor during his admission. nutrition consult felt that he would clearly benefit from additional nutrition through tube feeds. a dobhoff tube was placed on and tube feeds were initiated. nutrition recommended nutren 2.0 at 70 ml/hr. continued po intake was encouraged and he was provided ensure and beneprotein supplements with each meal. . # hypotension: he has a history of symptomatic hypotension. his tsh was mildly elevated at 7.8 and his morning cortisol was 8.3, which is wnl but on the low side. he will need followup of his tsh as an outpatient. further workup of his cortisol level is probably not necessary at this time. he remained hemodynamically stable with sbp in the 90s to 100s after admission mild diuretic treatments, paracentesis, and thoracentesis. diuretic treatment was discontinued pending tips. he was given albumin (5%) 25 g on several occasions for volume repletion. . # - syndrome: he had an episode of gbs in which resolved and a second episode which started several months ago. he is currently wheelchair bound due to le weakness. he was seen by pt and was able to stand with a walker but not ambulate. he will require additional pt after discharge. . # anemia: he has a slightly macrocytic anemia with a hematocrit stable around 30. his wbc count and platelets are also low, suggesting a component of marrow suppression. iron studies show an moderately elevated ferritin, low tibc, and low serum iron consistent with chronic inflammation. his b12 and folate levels were normal. his hematocrit was monitored closely, and he showed no signs of gi bleeding. . # dvt prophylaxis: provided with heparin 5000 units sc tid. . # micu course : patient was admitted to the micu after puncture of hepatic artery during tips procedure for hemodynamic monitoring. patient remained stable and serial hematocrits were stable. a ct scan was completed showing: no significant hematoma, with decreased ascites, with some blood mixed in (likely oozing from the tips procedure attempts). it also demonstrated possible kidney damage secondary to contrast nephropathy so patient's creatinine needs to be monitored clinically. patient was transferred back to the floor after 24 hour monitoring. . # followup: -- appointment scheduled in 2 weeks with dr to begin transplant evaluation process -- pending results: ca -9 and vitamin d assays medications on admission: home medications: heparin 5,000 units daily lactinex 1 packet lactulose 30 ml tid lorazepam 1 mg qhs lorazepam prn colace 100 mg senna lactobacillus mvi daily . discharge medications: morphine sulfate 2 mg q6h prn heparin sc 5,000 units lactulose 30 ml tid rifaxamin 400 mg nasal spray 1 spray each nostril tid lorazepam 2 mg q6h prn lorazepam 1 mg qhs colace 100 mg senna 2 tabs qhs lactobacillus 1 mg po bid mvi daily . discharge medications: 1. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day): titrate to bowel movements per day. 2. rifaximin 200 mg tablet sig: two (2) tablet po tid (3 times a day). 3. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): 12 hours on, 12 hours off. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 6. multivitamin tablet sig: one (1) tablet po daily (daily). 7. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain: hold for sedation, rr<12, or signs of encephalopathy. 8. tube feeds nutren 2.0 full strength; starting rate:10 ml/hr; advance rate by 10 ml q4h; goal rate:70 ml/hr; flush with 50 ml water q6h 9. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection three times a day. discharge disposition: extended care facility: northeast - discharge diagnosis: primary: alcoholic cirrhosis complicated by ascites right hepatohydrothorax ascites secondary: guillain- syndrome discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted to on to have an evaluation for a tips procedure. two attempts were made and unsuccessful. you also had a chest tube placed temporarily for fluid in your right lungs; this was removed several days prior to your discharge. during this hospitalization we discussed undergoing evaluation for a liver transplant; many tests were done in the hospital, and the workup will continue on an outpatient basis. you are scheduled to see dr. , a liver specialist, for this and further management of your liver disease. a feeding tube was also placed to aid with your nutrition. during the hospitalization you also worked with physical therapy; improvement in your strength was noted. your medication regimen has changed. please review the medication list closely. followup instructions: please be sure to keep the following appointment with the liver center. department: transplant when: friday at 8:40 am with: , md building: lm campus: west best parking: garage department: transplant social work when: friday at 10:00 am building: lm campus: west best parking: garage please also schedule an appointment to see your primary care doctor within 1-2 weeks of discharge from the rehabilitation facility. during this hospital course you were noted to have a slightly elevated tsh, which is a marker of thyroid function. this should be rechecked as an outpatient, particularly after you start feeling better. please discuss this with your primary care doctor. Procedure: Insertion of intercostal catheter for drainage Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Thoracentesis Thoracentesis Percutaneous abdominal drainage Phlebography of the portal venous system using contrast material Phlebography of the portal venous system using contrast material Central venous catheter placement with guidance Diagnoses: Anemia, unspecified Acute kidney failure with lesion of tubular necrosis Alcoholic cirrhosis of liver Unspecified protein-calorie malnutrition Portal hypertension Personal history of tobacco use Abnormality of gait Accidental puncture or laceration during a procedure, not elsewhere classified Anxiety state, unspecified Hypotension, unspecified Cachexia Other ascites Esophageal varices in diseases classified elsewhere, without mention of bleeding Personal history of alcoholism Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute infective polyneuritis Chronic inflammatory demyelinating polyneuritis Body Mass Index less than 19, adult Accidental cut, puncture, perforation or hemorrhage during aspiration of fluid or tissue, puncture, and catheterization Wheelchair dependence Other specified forms of effusion, except tuberculous

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath major surgical or invasive procedure: pericardiocentesis, with placement of pericardial drain history of present illness: this is a 62 year old female with history of resected pancreatic cancer stage iib on current gemcitabine rx who presents to ccu s/p pericardial drain. . she intially presented to with shortness of breath and dyspnea on exertion over the last week. she complained of sharp cp in the side of the chest wall bilaterally. moderate severity, not alleviated by sitting forward, not radiating. she also complained of puffy eyes and le edema. her sister had a uri recently. she has a history of pulmonary tb (with pleural effusion) in her 40s. she has been on several diuretics for the edema. the patient also notes cough productive of clear sputum which began in the past few months after the initiation of lisinopril. she denies purulent sputum, fevers/chills. . at , cxr showed cardiomegaly and a subsequent us showed a pericardial effusion. she was transferred to for further evauation. . in the ed her initial vital signs were: 97.3 83 181/87 20 96%ra. cxr showed cardiomegaly and ecg showed nsr. cardiology was called and they confirmed the effusion on bedside echo. a pulsus was intially 12, as evaluated by the fellow. on report her pulsus decreased to after several hrs but there were no interventions in the ed. her vital signs prior to transfer were 98 165/65 83 20 96ra. . the patient underwent pericardial drain placement with drainage of 450 cc of blood-tinged serous fluid. right heart cath showed ra 20/18/13, rv , pa 54/23/40, pcw 32/34/50. . the patient was transferred to the ccu, where her initial vital signs were hr 85, bp 162/74, rr 16, sat 93%/4l nc. on arrival, the patient was complaining of bilateral chest/shoulder pain with inspiration. she denied dyspnea or lightheadedness. . ros: she denied any fever, chills, headache, dizziness, lightheadedness, abdominal pain, vomiting, diarrhea, weakness, tingling, numbness, difficulty speaking/swallowing, or bowel/bladder incontinence. past medical history: past medical history: pancreatic cancer s/p whipple in 09 htn history of tb treated 40 years ago with inh and pyrazinamide r eyelid basal cell skin cancer (r) carpal tunnel syndrome s/p hysterectomy for symptomatic fibroids (menorrhagia and anemia) in carpal tunnel release basal cell skin cancer excision from (r) eyelid . oncologic history: in , the patient was noted to have biliary obstruction secondary to pancreatic cancer. she underwent whipple procedure and open cholecystectomy. one of eight lymph nodes were involved, margins were positive, and lymphovascular invasion was indeterminate with positive perineural invasion seen. she was diagnosed with t3n1a stage iib pancreatic cancer with positive margins. she is status post cyberknife boost on followed by radiation with concurrent capecitabine. currently, she is undergoing gemcitabine rx, that has been complicated by neutropenia, requiring dose reduction. she completed her course (c6d8) on 02/. social history: former rn, lives at home with husband, has two children (son and daughter) - both are healthy; denies tobacco currently, quit >40yrs ago, previously smoked approx. 6 cigarettes per day for 3yrs, ocassional etoh with dinner, no ivdu. family history: mom - ovarian ca, cml; older brother - prostate ca, grandmother on father's side - colon ca, grandfather on mom's side - hogkin's lymphoma; denies any breast or pancreatic cancer in family. physical exam: exam on admission to ccu: vs: hr 85, bp 162/74, rr 16, sat 93%/4l nc, pulsus 10 (sbp 190->180) gen: complaining of chest pain. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. no xanthalesma. neck: supple. cannot assess jvd with patient lying flat post-cath. cv: rrr. loud s1, s2. no m/g/r. chest: normal respiratory effort. cta anteriorly. abd: soft, ntnd. ext: no femoral bruits. clean dressing in place over right cath site. bilateral pitting le edema. skin: no stasis dermatitis, ulcers, or xanthomas. neuro: a+ox3. moving all extremities. . pulses: right: radial 2+ dp 2+ pt 2+ left: radial 2+ dp 2+ pt 2+ pertinent results: 11:35pm wbc-5.5 rbc-2.45* hgb-7.7* hct-21.5* mcv-88 mch-31.5 mchc-35.9* rdw-18.8* 11:35pm neuts-74.8* lymphs-12.4* monos-10.6 eos-1.9 basos-0.3 11:35pm plt count-138* 11:35pm glucose-92 urea n-47* creat-2.2* sodium-137 potassium-4.3 chloride-108 total co2-19* anion gap-14 02:46am pt-13.0 ptt-25.1 inr(pt)-1.1 06:19am blood qg6pd-10.7 09:10am blood esr-89* 04:35pm blood cd55-done cd59-done 06:19am blood -negative ret aut-6.8* 09:10am blood ret aut-6.7* 09:10am blood caltibc-208* hapto-<5* ferritn-> trf-160* 06:19am blood hapto-33 02:45am blood hapto-<5* 06:40pm blood hapto-<5* 06:15am blood hapto-<5* 06:10am blood hapto-13* 06:00am blood hapto-44 06:30am blood hapto-48 09:10am blood tsh-2.6 09:10am blood free t4-1.4 06:19am blood anca-negative b 06:19am blood dsdna-negative 09:10am blood -negative 06:19am blood c3-142 c4-30 pericardial fluid: 03:00pm other body fluid wbc-500* rbc-* polys-1* lymphs-3* monos-0 mesothe-11* macro-52* other-33* 03:00pm other body fluid wbc-500* rbc-* polys-1* lymphs-3* monos-0 mesothe-11* macro-52* other-33* 03:00pm other body fluid totprot-3.5 glucose-107 ld(ldh)-120 albumin-2.4 05:33pm other body fluid tb-pcr-pnd 05:33pm other body fluid tb-pcr-pnd 01:27pm other body fluid adenosine deaminase, fluid-test cytology negative for malignant cells tte impression: moderate circumferential pericardial effusion with echocardiographic evidence of increased pericardial pressure/early tamponade physiology. if clinically indicated, follow-up studies are suggested. ct torso impression: 1. slight decrease in pericardial effusion post-placement of a pericardial catheter. 2. increase in right greater than left pleural effusions with compressive atelectasis. 3. peri-bronchovascular ground-glass opacity may represent pulmonary edema. 4. at least one subcentimeter nodular opacity which was not previously identified; recommend continued ct followup to exclude recurrence, and if possible iv contrast. tte the left atrium is mildly dilated. the right atrium is moderately dilated. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the aortic arch is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. there is mild pulmonary artery systolic hypertension. there is a very small pericardial effusion anterior to the right atrium. pathology from renal biopsy pending at the time of discharge brief hospital course: #. pericardial effusion: pt admitted to micu and pericardial drain placed. pericardial fluid with wbc 500 (diff polys 1, lymphs 3, mesothel 11, macro 52, other 33), rbc . total protein 3.5, glucose 107, ldh 120, albumin 2.4. gram stain negative. cultures ngtd. viral titers were not c/w acute infection. , c3, c4wnl, tsh normal and wnl. pt had repeat tte after pericardial effusion removed (see above). etiology of pericardial effusion was ultimately idiopathic. . #. renal insufficiency: thought to most likely represent gemcitabine induced hus. anca, , dsdna, c3, c4, antihistone ab, spep, upep all within normal limits. pt had renal biopsy which showed tma (by prelim path) which would be c/w hus. -final pathology pending at the time of discharge . #. hemolysis: treated supportively. pt required 3 transfuions over the course of her admission. g6pd and flow cytometry for pnh both wnl. prep negative. dat neg x2. haptoglobin trended up throughout admission. . # b/l le edema: lower extremity u/s negative for dvt. pt treated c teds, elevation of le and lasix 40 mg daily. she will follow up closely with nephrology in 1 week. , #. htn: thought secondary to new renal failure. pt was continued on amlodipine and hctz-lisinopril switched to labetolol given . . #. pancreatic cancer: stage iib s/p whipple, radiation, capecitabine and recent gemcitabine course. pt to f/u c outpt providers after discharge. . # pulmonary nodule: new, recommend re-imaging with iv contrast once renal function improves. pt will require repeat ct chest . #. communication: hcp is husband ( (cell) medications on admission: amlodipine - 10 mg tablet - 1 tablet(s) by mouth daily lipase-protease-amylase - 120,000 unit-,000 unit-,000 unit capsule, delayed release (e.c.) - 1 capsule(s) by mouth four times a day lisinopril-hydrochlorothiazide - 10 mg-12.5 mg tablet - 1 tablet(s) by mouth daily pantoprazole - 40 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth two times a day paroxetine hcl - 10 mg tablet - 1 tablet(s) by mouth daily calcium citrate-vitamin d3 - 315mg-200 unit tablet - 2 tablet(s) by mouth daily cholecalciferol (vitamin d3) - 400 unit tablet - 1 tablet(s) by mouth daily multivitamin,tx-minerals - capsule - 1 capsule(s) by mouth daily omega-3 fatty acids - 1,200 mg-144 mg capsule - 1 capsule(s) by mouth daily discharge medications: 1. amlodipine 10 mg tablet sig: one (1) tablet po once a day. 2. creon 24,000-76,000 -120,000 unit capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po four times a day. 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 4. paxil 10 mg tablet sig: one (1) tablet po once a day. 5. calcitrate-vitamin d 315-200 mg-unit tablet sig: two (2) tablet po once a day. 6. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 7. multivitamin,tx-minerals capsule sig: one (1) capsule po once a day. 8. omega-3 fatty acids capsule sig: one (1) capsule po daily (daily). 9. labetalol 200 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 10. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. outpatient lab work cbc, bun/cr, pt/ptt/inr, haptoglobin, total bilirubin, ldh, d-dimer, fibrinogen to be done at pcp . results to be faxed to attn: fax 12. furosemide 20 mg tablet sig: two (2) tablet po once a day. disp:*60 tablet(s)* refills:*0* 13. zofran odt 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. discharge disposition: home discharge diagnosis: primary: gemcitabine induced hemolytic uremic syndrome, pericardial effusion secondary: pancreatic cancer discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - independent discharge instructions: you were transferred to because of fluid around your heart. we also noticed that you were having hemolysis (red blood cells were bursting) and an injury to your kidneys that was new. we did lots of blood tests and biopsied your kidney and took out the fluid from around your heart. with all of the information that we have we think you probably had a rare side effect of gemcitabine called gemcitabine-induced hemolytic uremic syndrome which causes hemolysis and kidney injury. this does not usually cause the fluid around your heart but there have been other rare reports of getting fluid around the heart with syndrome in the medical literature. it is also possible that the fluid around your heart was unrelated and was caused by a virus or by tb (the tb test is still pending). the good news is that there were not any cancer cells in the fluid around your heart. when you go home, please continue all of your regular medicines with the following changes: 1. stop hydrochlorothiazide-lisinopril 2. start labetolol 3. lasix 40 mg daily 4. folic acid 1 mg daily you can discuss with dr and dr whether you need additional chemotherapy when you see them next week. you will not be able to get gemcitabine in the future. followup instructions: appointment #1 md: dr. specialty: internal medicine-primary care date/ time: 9:45am location: , ma phone number: special instructions for patient: please have cbc, hemolysis labs, and bun/cr drawn at this office visit and have results faxed to attn: fax . this is the hematology/oncology fellow. appointment #2 md: dr. specialty: hematology date/ time: 3:00pm location: building , ma phone number: appointment #3: provider: , md phone: date/time: 11:30 provider: , md phone: date/time: 1:00 appointment #4: nephrology (kidney doctor) physician: . date: wednesday time: 10:00 am address: .; , phone: patient instructions: clinic will call you if they have a cancellation and can see you earlier. *** if you do not hear from their office by wednesday, , please arrange to be seen at the next week to ensure your kidneys are doing ok. it is very important you are seen by a nephrologist next week. if you need to be seen at , the # to call is ( and you should be seen by dr (attending) and dr (fellow). if they don't have an appointment, you can be seen by dr. in the same office. if you cannot get an appointment, please ask them to get in touch with (who saw you while you were here) and who will help arrange for you to be seen. after you are seen by the kidney doctors , sooner, (they are recommended by your pcp) you should continue to follow up at that office. **you previously had a cat scan scheduled for . please talk to dr or dr at before going to this appointment as they may not want to do it anymore given your kidney function. Procedure: Combined right and left heart cardiac catheterization Pericardiocentesis Closed [percutaneous] [needle] biopsy of kidney Transfusion of packed cells Diagnoses: Unspecified essential hypertension Acute kidney failure, unspecified Unspecified disease of pericardium Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Other specified peripheral vascular diseases Anemia in neoplastic disease Cardiac tamponade Malignant neoplasm of pancreas, part unspecified Acute pericarditis in diseases classified elsewhere Hemolytic-uremic syndrome

history of present illness: the patient is a 77 year old woman with a history of melanoma diagnosed twenty-three years ago. in , she noted a nodule in her left submandibular area and excisional biopsy was done in of last year, which was consistent with malignant melanoma. she was in a protocol and, in of last year, she was noted to have some palpable lymph nodes in the area of her surgery. she had a ct of the neck at the end of of last year, which showed incidental lesion in the brain. a magnetic resonance imaging scan was then performed which was done with and without contrast. it shows two small lesions, one in the right frontal and the other in the left posterior sylvian fissure. two lumbar punctures were performed for suspicion of left meningeal disease. both were negative for malignant cells. she is admitted for excision of the right frontal lesion. hospital course: she was admitted on , and had a right frontal craniotomy for excision of this lesion without intraoperative complication. postoperatively in the post anesthesia care unit, she was awake, alert and oriented times three. the pupils were equal, round and reactive to light. extraocular movements were full. no drift. motor strength was five out of five in all muscle groups. her sensation was intact to light touch. her dressing was clean, dry and intact. she spent the night in the recovery room and was transferred to the regular floor on postoperative day number one. she was seen by neuro-oncology, who will continue to follow-up with her after discharge. her vital signs remained stable. she was seen by physical therapy and occupational therapy and found to be safe for discharge home. medications on discharge: 1. levothyroxine 137 mcg p.o. daily. 2. decadron to wean down to two twice a day over five to seven days. 3. percocet one to two tablets p.o. q4hours p.r.n. 4. pantoprazole 40 mg p.o. daily. 5. colace 100 mg p.o. twice a day. condition on discharge: her condition was stable at the time of discharge. follow up: she will follow-up for a magnetic resonance imaging fusion scan on , and follow-up in the brain clinic on . , Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Computer assisted surgery with MR/MRA Diagnoses: Secondary malignant neoplasm of brain and spinal cord Personal history of malignant melanoma of skin

allergies: aspirin / nsaids / technetium-m / gadolinium-containing agents attending: chief complaint: nausea, hypotension, dizziness major surgical or invasive procedure: ivc filter placement history of present illness: patient is an 81 year old female with metastatic melanoma, known metastases to brain and adrenals, who was receiving chemotherapy on day of admission (cycle 2 of dacarbazine), and sent to ed for hypotension after chemo and dizziness on . per admission note from that time, she is poor historian, and details from omr documentation. she presented to chemotherapy with nausea and anxiety. she received dexamethasone and zofran, and eventually ativan, which helped her relax. during treatment noted to be sleepy, and vitals signs reveal sbp 70, hr 80, 96% ra. she received a bolus of ivf (2l ns in total) with improvement of sbp to 106, but remained orthostatic (bp dropped to 88/60 with sitting). she had been vomiting up to 3x daily at home after chemotherapy, with poor po intake. of note, also c/o indigestion, vague right sided abdominal vs chest discomfort ("dull, achy"). she is known to have hiatal hernia; she reported a recent abdominal u/s at osh was normal. she received iv pepcid at infusion center and took own home omeprazole. in ed, initial vs: t 99.2, bp 116/66, hr 86, rr 16, 99%2l. pt had unremarkable labs including lfts, except for ldh of 848 and mild anemia with hct 32. two sets cardiac enzymes negative. ecg unchanged from prior. cxr unremarkable. vital signs prior to transfer from ed to : t 96, bp 153/65, hr 88, rr 20, 100%ra. past medical history: pmh: - metastatic melanoma, with known brain metastases (see details below) - hypertension - osteoporosis - tuberculosis in and - gerd - thyroid adenoma diagnosed in - hiatal hernia - cholecystectomy in - hysterectomy in - diverticulitis with lower gi bleeds - neurogenic bladder from disk disease - benign paroxysmal positional vertigo > 10 years . oncologic history: metastatic melanoma prior treatment: 1. resection of a left nasal primary melanoma in . 2. recurrence on the left mandible (biopsy-documented) in . 3. left radical lymph node dissection and partial thyroidectomy in 08/. 4. thirteen cycles of gm-csf per ecog 4697. 5. in revealed right frontal and left central sulcus metastases with hemorrhage with question of leptomeningeal disease. , underwent resection of the frontal lesion; path c/w met melanoma. she subsequently underwent stereotactic radiosurgery to the left central sulcus metastasis and the right frontal surgical cavity. recurrance of brain tumor in . 6. had two new subcutaneous nodules in the right lateral abdominal wall and the anterior lower chest wall, progression of bilateral adrenal metastases, new lesion in the anterolateral left kidney, and slight retroperitoneal lymphadenopathy. 7. initiation of treatment with off-study dacarbazine because of fulminant disease progression at multiple sites. second cycle given . social history: she is widowed, lives in senior citizen housing, denies smoking. she rarely drinks alcohol. her son, daughter-in-law, and children live in the area. her daughter--law is np. son, identified as hcp although she has not signed the hcp forms yet. family history: non contributory physical exam: vs: t 95.1 (ax), bp 158/85, hr 78, rr 18, 100% ra gen: comfortable appearing heent: dry mucous membranes lungs: cta b/l heart: rrr, nl s1s2, no m/r/g abd: +bs, soft, non-distended. mild ttp llq ext: + pitting edema ankles b/l neuro: aaox3 skin: seborrheic keratosis scattered over entire skin pertinent results: admission labs: cbc: 01:23pm plt count-240 01:23pm neuts-67.5 lymphs-24.1 monos-6.8 eos-1.3 basos-0.2 01:23pm wbc-8.6 rbc-3.18* hgb-10.8* hct-32.2* mcv-101* mch-33.9* mchc-33.5 rdw-16.9* cardiac enzymes: 01:23pm ck-mb-2 ctropnt-<0.01 liver function tests: 01:23pm alt(sgpt)-15 ast(sgot)-21 ld(ldh)-848* ck(cpk)-9* alk chemistries: 01:23pm glucose-111* urea n-11 creat-0.7 sodium-136 potassium-3.9 chloride-100 total co2-25 anion gap-15 01:23pm albumin-3.4 calcium-8.4 urine analysis: 07:33pm urine mucous-few 07:33pm urine granular-0-2 hyaline-0-2 07:33pm urine rbc-0 wbc- bacteria-few yeast-none epi-0 07:33pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-tr bilirubin-sm urobilngn-neg ph-6.5 leuk-tr 07:33pm urine color-amber appear-clear sp -1.024 07:33pm urine gr hold-hold 07:33pm urine hours-random =============== discharge labs: cbc: 12:00am blood wbc-9.5 rbc-2.80* hgb-9.3* hct-26.6* mcv-95# mch-33.3* mchc-35.0 rdw-18.2* plt ct-94* chemistries: 12:00am blood glucose-101 urean-23* creat-0.8 na-137 k-3.7 cl-108 hco3-22 angap-11 ================ microbiology: 9:25 pm blood culture **final report ** blood culture, routine (final ): escherichia coli. identification and sensitivities performed on culture # from . aerobic bottle gram stain (final ): gram negative rod(s). anaerobic bottle gram stain (final ): gram negative rod(s). ------ 12:00 am urine source: catheter. **final report ** urine culture (final ): escherichia coli. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s ------ time taken not noted log-in date/time: 9:43 am blood culture set # 1. **final report ** blood culture, routine (final ): escherichia coli. final sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s aerobic bottle gram stain (final ): reported by phone to @ 430pm . gram negative rod(s). anaerobic bottle gram stain (final ): gram negative rod(s). ----- 2:17 pm blood culture source: line-picc. blood culture, routine (pending): ============== ecg : sinus tachycardia. occasional premature atrial contractions. ---- imaging studies: cta chest : impression: 1.findings suggest acute subsegmental pulmonary emboli in the left lower lobe. 2.increase in the burden of metastatic disease, including adrenal, pulmonary, nodal, and soft tissue metastasis. ---- transthoracic echocardiogram : impression: suboptimal image quality. ventricular function difficult to assess due to marked tachycardia. mild left ventricular hypertrophy with preserved overall left ventricular function. normal right ventricular cavity size and systolic function. mild pulmonary hypertension. ---- lower extremity venous ultrasounds : 1. no evidence of deep vein thrombosis in either lower extremity. 2. an non-specific 1.6 cm lymph node in the left groin region. brief hospital course: mrs. is an 81 year old female with metastatic melanoma (known brain mets, adrenal mets), who presented with nausea and hypotension. # urosepsis/hypotension: patient developed hypotension while on the floor requiring transfer to the icu. on transfer to the icu the pt had leukocytosis, elevated lactate, and fever, which were concerning for evolving sepsis, with urinary and gi sites as the most likely sources of infection. atrial fibrillation with rapid rate was also likely contributing to poor forward flow. in the icu a central line was placed in order to follow central venous pressure and resuscitation with fluids was initiated. the pt was initially on broad-spectrum antibiotics (ceftriaxone, vancomycin and ciprofloxacin) and these were narrowed to ciprofloxacin once the pt's blood and urine cultures grew e. coli sensitive to ciprofloxacin. the patient was on intermittent norepinephrine for blood pressure support for less than 24 hours, and was then able to be weaned off pressors entirely. as pt had positive blood cultures it was decided that pt should stay on iv abx and continued for a 14 day course of iv ciprofloxacin (day 1 =, day 14 ). patient had a picc line placed on . pt's had surveillance cultures from are still pending at time of discharge. patient was afebrile and hemodynamically stable at time of discharge. # tachycardia/atrial fibrillation: on transfer to the icu the pt was alternating between sinus tachycardia (rate 90-120) to what appeared to be atrial fibrillation. initially the pt's tachycardia was responsive to ivf but ultimately the pt was loaded amiodarone for better rate control. the pt did well on amiodarone and on the amiodarone loading was completed and the pt continued with a heart rate in the 80's. pt reverted back into afib and pt was started on metoprolol, eventually 25mg tid. pt was stable on this regimen at time of transfer. it is possible that this dose of metoprolol may continue to require uptitration for continued rate control. # pulmonary emboli: on admission the pt did have small subsegmental pe's, however no significant hypoxia or tachynpea. given the small size of pes anticoagulation was initially held. however in consultation with the patient's primary oncologist a heparin drip was initiated. the patient was then transitioned from heparin drip to lovenox. however, given the patient's high risk for bleeding on anti-coagulation, especially her high risk for bleeding in the brain given her metastatic disease our team felt that ultimately this risk of bleeding outweighed her risk for developing additional thrombi. the decision was made to place an ivc filter and stop lovenox therapy. patient's evista was stopped given thrombogenic side effects. # acute renal failure: the pt's cr peaked at 1.7 from 1. the patient's arf was likely due to atn in the setting of hypotension while septic. # metastatic melanoma: given progression of patient's disease in spite of chemotherapy treatment her primary oncologist dr. does not plan to offer additional chemotherapy treatment. patient is scheduled to follow up with dr. as an outpatient. discussed with patient's poor prognosis with her family and also initiated the discussion of eventual need for hospice. # anemia: most likely represents anemia of chronic inflammation. patient's hematocrit is has ranged around 24-28. she was transfused two units on for a hematocrit of 23. should continue to monitor. # thrombocytopenia: the pt's platelets were markedly lower during this admission and did decrease by greater than 50% from admission. after discussions with the patient's primary oncologist it was decided that there were multiple possible causes of thrombocytopenia (vancomycin exposure, recent chemotherapy with dacarbazine) in addition to heparin, and hit ab was not sent per oncology recommendations. # hypothyroidism: partial thyroidectomy. levoxyl was continued. # gerd/hiatal hernia: continued omeprazole, anti-emetics prn # code: the pt was dnr/dni per discussion the pt's family. the health care proxy is the patient's son and daughter-in-law . medications on admission: emend 125 mg (1)-80 mg (1)-80 mg (1) capsule, dose pack daily riopan (apparently low sodium maalox) prn dexamethasone 8mg po bid prn nausea zofran 8mg po q8h prn nausea compazine 10mg po q6h prn nausea ativan 0.5mg, 1-2 tabs q8h prn nausea levoxyl 125mcg po daily omeprazole 20mg po daily raloxifene (evista) 60mg po daily acetaminophen 325mg po q4h prn ascorbic acid 1000mg po daily calclium carbonate multivitamin, 1 tab po daily vitamin e 400 units po daily vit c-vit e-lutein-minerals - 1 capsule(s) by mouth daily discharge medications: 1. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). 2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 3. acetaminophen 500 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 4. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for indigestion, acid reflux. 5. multivitamin tablet sig: one (1) tablet po daily (daily). 6. ascorbic acid 500 mg tablet sig: two (2) tablet po daily (daily). 7. vitamin e 400 unit capsule sig: one (1) capsule po daily (daily). 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 10. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath, wheezing. 11. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath, wheezing. 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 13. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. 14. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 15. ciprofloxacin in d5w 400 mg/200 ml piggyback sig: one (1) intravenous q12h (every 12 hours): last day for total of 14 day course. 16. zofran 8 mg tablet sig: one (1) tablet po every eight (8) hours as needed for nausea. 17. compazine 10 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea. discharge disposition: extended care facility: healthcare - discharge diagnosis: primary: pulmonary embolism, urosepsis, atrial fibrillation secondary: metastatic melanoma, hypothyroidism, gastroesophageal reflux disease discharge condition: stable discharge instructions: you were admitted to the hospital due to your low blood pressure and nausea. we found that had an infection in your urine and in your blood in urine. you required a brief stay in the icu where you were given antibiotics, fluids and medications to stabilize your blood pressure.you will need to continue an intravenous antbiotic for these infections until . we also determined that you have a blood clot in your lungs. we have placed a filter in your inferior vena cava to try and protect you from additional clots in your lungs. at time of discharge you are breathing comfortably on room air. please take all medications as directed and follow up as listed below. if you experience fevers, chills, night sweats, chest pain or shortness of breath please contact your primary care physician or primary oncologist or come to the emergency department for evaluation. followup instructions: the following appointments were previoulsy scheduled: provider: , md phone: date/time: 1:00 provider: , rn phone: date/time: 2:00 provider: phone: date/time: 10:00 Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Interruption of the vena cava Diagnoses: Esophageal reflux Urinary tract infection, site not specified Unspecified essential hypertension Acute kidney failure, unspecified Severe sepsis Atrial fibrillation Secondary malignant neoplasm of brain and spinal cord Osteoporosis, unspecified Secondary malignant neoplasm of lung Septicemia due to escherichia coli [E. coli] Personal history of malignant melanoma of skin Other pulmonary embolism and infarction Anemia in neoplastic disease Postsurgical hypothyroidism Secondary malignant neoplasm of adrenal gland

allergies: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath major surgical or invasive procedure: 1. mitral valve repair with a p2 triangular resection and ring annuloplasty using a physio ii ring. 2. coronary artery bypass grafting x 1 with a left internal mammary artery to left anterior descending coronary artery. 3. pericardial reconstruction with core matrix. 4. resection left atrial appendage. history of present illness: 57 year old male with suspected multiple sclerosis and recently diagnosed severe mitral regurgitiation in who preseted with complaints of dyspnea. he recently moved to , when he developed acute onset of dyspnea, chest pain, and body aches. on he went to an outside hospital, and he was found to have a pneumonia and a new holosystolic murmur. he was admitted for further work up. he was treated w/ antibiotics (azithromax, ceftriaxone). per review of osh records tte showed severe prolapse of the mv posterior leaflet with severe mr, which was confirmed by tee that showed ruptured chordae and flailing of the posterior leaflet. he also had a bal that showed usual respiratory flora, was negative for malignancy and negative for acid fast organisms. cardiothoracic surgery, cardiology, and pulmonary were consulted. he declined further intervention and wanted to have further work up in . he left and returned to . throughout this time he continued to have shortness of breath. he he is now being referred to cardiac surgery for surgical evaluation of mitral valve. past medical history: -mitral regurgitation -right third digit finger fracture two years ago -asthma (allergy induced) -eustachian tube abscess four years prior -progressive myelopathy of unknown cause with single episode of abrupt worsening responding to steroids; probably progressive relapsing multiple sclerosis. -head trauma after falling 20 feet from a deck. suffered a r orbital blow out fracture and mandibular fracture. operated with insertion of sigma plates. residual symptoms of r esotropia/double vision from entrapment of the extraocular eye muscles. s/p tonsillectomy social history: lives with:wife in and alone in occupation:lawyer :quit 1 month ago, smoked 4 cigarettes/day x37 years etoh:denies illicit drugs: denies family history: no family hx of heart disease. physical exam: pulse:93 resp:18 o2 sat: 97/2l b/p 118/77 height:70" weight:82.6 kgs general: no acute distress sitting up in bed skin: dry intact heent: pupils equal right gaze to lateral, both reactive to light. impaired ocular movement, diminished peripheral vision neck: supple chest: lungs clear bilaterally heart: rrr irregular murmur 4/6 systolic abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema + 2 pitting pedal edema neuro: alert and oriented x3 gait - spastic ataxic with bilateral hyperextension pulses: femoral right:+2 left:+2 dp right:+2 left:+2 pt :+2 left:+2 radial right:+2 left:+2 carotid bruit transmitted murmur pertinent results: preop 09:28am hgb-10.2* calchct-31 09:28am glucose-108* lactate-1.0 na+-136 k+-4.1 cl--105 10:05am hgb-6.9* calchct-21 11:00am wbc-6.7 rbc-2.22*# hgb-7.0*# hct-20.1*# mcv-91 mch-31.6 mchc-34.7 rdw-15.1 01:16pm urea n-25* creat-1.0 sodium-137 potassium-4.1 chloride-109* total co2-24 anion gap-8 discharge 04:55am blood wbc-5.7 rbc-3.34* hgb-10.1* hct-28.9* mcv-86 mch-30.2 mchc-35.0 rdw-15.3 plt ct-278 04:55am blood pt-13.3 ptt-29.2 inr(pt)-1.1 04:55am blood glucose-103* urean-22* creat-1.0 na-140 k-4.1 cl-105 hco3-26 angap-13 04:55am blood mg-2.2 , intra-op tee pre-cpb: no spontaneous echo contrast is seen in the left atrial appendage. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. torn mitral chordae are present. moderate to severe (3+) mitral regurgitation is seen. 3d views show a flail p2, with an anteriorly directed jet. there is no pericardial effusion. post-cpb: the patient is in sr, on no inotropes. preserved biventricular systolic fxn. there is a mitral ring with no leak and no mr. = 4 mmhg. no ai. aorta intact. cxr: the patient is status post sternotomy, with sternal wires and clips and a prosthetic valve. there is mild cardiomegaly. the aorta is slightly unfolded. there is upper zone redistribution, without overt chf. there is a small left effusion and minimal blunting of the right costophrenic angle with mild-to-moderate bibasilar collapse and/or consolidation. brief hospital course: mr. was admitted on with severe mitral regurgitation and critical stenosis in the left anterior descending coronary artery. he was taken to the operating room on where he underwent mitral valve repair and coronary artery bypass grafting x 1. please see operative note for details. immediately post-operatively he was transferred to the cvicu intubated and sedated on propofol and phenylephrine. later this day he awoke neurologically intact and was weaned and extubated. neo was weaned off and he was started on beta blockers, statin and lasix. on post-op day one he was transferred to the step down unit for ongoing post-operative care. chest tubes and pacing wires were removed per protocol. he experienced post-op atrial fibrillation and was treated with increased beta blockers and amiodarone and converted to sinus rhythm. he was transfused 2 units prbc for post-operative anemia (hct 22.8, at discharge 28.9). he was evaluated by physical therapy for strength and conditioning and a brief rehab stay was recommended prior to his return home. he redeveloped atrial fibrillation and was started on coumadin. at time of discharge he was in rate controlled atrial fibrillation and will need titration of his coumadin for a goal inr 2-2.5 (currently 1.1). on post-op day 7 he was discharged to rehab ( at rye, ny) with the appropriate medications and follow-up appointments. medications on admission: dalfampridine - 10 mg tablet extended release 12 hr - 1 (one) tablet(s) by mouth twice a day diphenhydramine hcl - (otc) - dosage uncertain discharge medications: 1. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain, fever. 6. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*65 tablet(s)* refills:*0* 7. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 8. amiodarone 200 mg tablet sig: two (2) tablet po once a day: for 7 days then decrease to 200mg daily ongoing. 9. temazepam 15 mg capsule sig: one (1) capsule po hs (at bedtime) as needed for insomnia. disp:*30 capsule(s)* refills:*0* 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day) as needed for constipation. 11. warfarin 3 mg tablet sig: one (1) tablet po once a day: indication: post-op atrial fibrillation. please titrate for a goal inr 2-2.5. 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). discharge disposition: extended care facility: hospital network discharge diagnosis: -mitral regurgitation s/p mitral valve repair -coronary artery disease s/p coronary artery bypass graft x 1 -post-op atrial fibrillation past medical history: -right third digit finger fracture two years ago -asthma (allergy induced) -eustachian tube abscess four years prior -progressive myelopathy of unknown cause with single episode of abrupt worsening responding to steroids; probably progressive relapsing multiple sclerosis. -head trauma after falling 20 feet from a deck. suffered a r orbital blow out fracture and mandibular fracture. operated with insertion of sigma plates. residual symptoms of r esotropia/double vision from entrapment of the extraocular eye muscles. past surgical history: s/p tonsillectomy discharge condition: alert and oriented x3 nonfocal ambulating, gait steady but deconditioned sternal pain managed with percocet sternal incision - healing well, no erythema or drainage edema 1+ discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: provider: : , md 2:45 provider: surgery: , md 10:00 please call to schedule the following: primary care dr. in weeks labs: pt/inr for coumadin ?????? indication: post-op atrial fibrillation goal inr: 2-2.5 first draw, day after discharge, Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Open heart valvuloplasty of mitral valve without replacement Operations on other structures adjacent to valves of heart Excision, destruction, or exclusion of left atrial appendage (LAA) Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Atrial fibrillation Personal history of tobacco use Multiple sclerosis Accidents occurring in unspecified place Diplopia Rupture of chordae tendineae Late effect of fracture of skull and face bones Esotropia, unspecified Late effects of accidental fall

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: decreasing activity tolerance major surgical or invasive procedure: coronary artery bypass graft x 2 (left internal mammary artery to left anterior, saphenous vein graft to obtuse marginal), mitral valve replacement (33mm st. epic porcine) history of present illness: 83 year old male with recent episodes of heart failure, echo revealed ef 40% with severe mr. further evaluation by cardiac catheterization revealed coronary artery disease. past medical history: mitral regurgitation atrial fibrillation depression pacemaker - chronic systolic heart failure epistaxis hypertension appendectomy ~ 5 years ago right knee surgery bilateral cataracts with iols social history: occupation: retired car dealer last dental exam: clearance obtained lives alone race: caucasian tobacco: quit 18 months ago; approx. 15-20 pyhx etoh: quit 18 months ago no recr. drugs family history: non-contributory physical exam: pulse: 69 afib resp: 18 o2 sat: 98 ra b/p 135/84 general: no acute distress skin: dry intact healed incision left lower quadrant, scabbed area right ankle no erythema heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + extremities: cool edema: trace neuro: alert and oriented x3, 5/5 strength bilateral gait unsteady pulses: femoral right: +2 left: +2 dp right: +1 left: +1 pt : doppler left: doppler radial right: +1 left: +1 carotid bruit right: no bruit left: no bruit pertinent results: carotid u/s: right ica with stenosis <40%. left ica with stenosis <40% . echo: pre-bypass: the left atrium is markedly dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. the right atrium is dilated. no atrial septal defect is seen by 2d or color doppler. there is moderate to severe regional left ventricular systolic dysfunction with severe hypokinesis in the anteroseptal distribution on top of global hypokinesis.. overall left ventricular systolic function is severely depressed (lvef= 30 %). there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. there is a minimally increased gradient consistent with minimal aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the eccentric mitral regurgitation vena contracta is >=0.7cm. severe (4+) mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results on , a at 10am before surgical incision. the thoracic aorta is tortuous and pacing wires are seen in the right atrium and ventricle. post-bypass: patient is on milrinone 0.2 mcg/kg/min. mild rv global hypokinesis. mild tr. the bioprosthesis in the mitral position is well placed, and functioning well with no residual mr and mean gradient of 2mm of hg. thoracic aorta is intact. anteroseptal hypokinesis persists on top of global hypokinesis. 05:13am blood wbc-8.2 rbc-3.14* hgb-9.6* hct-28.4* mcv-91 mch-30.7 mchc-33.9 rdw-16.3* plt ct-131* 03:45pm blood wbc-6.5 rbc-4.65 hgb-14.2 hct-41.9 mcv-90 mch-30.6 mchc-34.0 rdw-14.4 plt ct-180 05:14am blood pt-20.0* ptt-30.1 inr(pt)-1.8* 03:45pm blood pt-13.5* ptt-25.4 inr(pt)-1.2* 05:13am blood glucose-94 urean-23* creat-0.8 na-139 k-3.5 cl-100 hco3-31 angap-12 03:45pm blood glucose-112* urean-21* creat-1.0 na-139 k-4.0 cl-104 hco3-26 angap-13 03:45pm blood alt-17 ast-26 ld(ldh)-124 ck(cpk)-147 alkphos-71 amylase-54 totbili-1.6* brief hospital course: mr. was admitted one day prior to surgery for pre-operative work-up and heparin bridge do to history of atrial fibrillation with coumadin. on he was brought to the operating room where he underwent coronary artery bypass graft x 2 (left internal mammary artery to left anterior, saphenous vein graft to obtuse marginal), mitral valve replacement (33mm st. epic porcine). cardiopulmonary bypass time= 128 minutes. cross clamp time= 104 minutes. please see dr operative report for surgical details. he was intubated, sedated, and on pressors and inotropes to optimize hemodynamics. he was transferred to the cvicu in critical but stable condition. pod#1 he awoke neurologically intact and was weaned to extubation. all drips were weaned off. electrophysiology interrogated the permanent pacemaker. all lines and drains were discontinued in a timely fashion. beta-blocker, statin, aspirin, and diuresis was initiated. he continued to progress and on pod# 4 was transferred to the step down unit for further monitoring. physical therapy was consulted for evaluation and assessment. anticoagulation with coumadin was resumed. the remainder of mr. course was essentially uneventful. he was cleared by dr. for discharge to rehab on pod# 5. all follow up appointments were advised. medications on admission: medications at home: coumadin daily last dose wed digoxin 0.125 mg daily lisinopril 2.5 mg daily bisoprolol 5 mg daily lasix 20 mg prn discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po q12h (every 12 hours) for 10 days. 3. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 4. warfarin 1 mg tablet sig: md to dose tablet po daily (daily). 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 6. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 7. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 8. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 10. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 11. multivitamin,tx-minerals tablet sig: one (1) tablet po daily (daily). 12. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 13. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 14. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 15. lasix 20 mg tablet sig: one (1) tablet po twice a day for 10 days. 16. warfarin 5 mg tablet sig: one (1) tablet po once (once) for 1 days. 17. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. discharge disposition: extended care facility: country manor - discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 2 mitral regurgitation s/p mitral valve replacement past medical history: atrial fibrillation depression pacemaker - chronic systolic heart failure epistaxis hypertension appendectomy ~ 5 years ago right knee surgery bilateral cataracts with iols discharge condition: good discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month until follow up with surgeon no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: please call to schedule appointments surgeon dr. in 4 weeks primary care dr. in weeks cardiologist dr. in weeks wound check appointment - 6 () - your nurse will schedule Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of one coronary artery Open and other replacement of mitral valve with tissue graft Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Personal history of tobacco use Depressive disorder, not elsewhere classified Long-term (current) use of anticoagulants Cardiac pacemaker in situ Acute on chronic systolic heart failure

allergies: codeine / dilaudid / penicillins / levaquin / buspar attending: chief complaint: lung cancer major surgical or invasive procedure: flexible bronchoscopy history of present illness: 65yo f who had 3 months of lower respiratory tract infection symptoms that acutely worsened over the last month resulting in multiple admissions. previous bronchoscopy on showed extrinic compression affecting the right lower lobe. bronchial brushing and cytologies were consistent with squamous cell carcinoma. she was transferred to for further evaluation and management. past medical history: 1. nsclc likely squamous cell of rll, malignant r effusion, liver mets (likely), t11 lytic bone lesion; 2. r calf dvt on lovenox; 3. left foot arterial emboli on lovenox, asa; 4. htn; 5. asthma; 6. depression/anxiety; 7. cad "non critical"; 8. acute on cri stage 3; 9. dm; 10.osa social history: she is separated from her husband. five children. tobacco: 75 pack-year quit smoking 20 years ago. etoh: social family history: non-contributory physical exam: intubated cmv fio2 0.4 peep 10 rr 15 vt 500 ml ppeak 32 sedated profol general: sedated cardiac rrr normal s1,s2 resp: right lobe coarse, left decreased gi: obese, bowel sounds positive neuro. moves extremities with stimulation pertinent results: wbc-14.6* rbc-3.31* hgb-9.7* hct-30.5* mcv-92 mch-29.3 mchc-31.8 rdw-14.3 plt ct-582* neuts-90.7* lymphs-5.2* monos-2.9 eos-0.9 baso-0.3 pt-12.4 ptt-23.7 inr(pt)-1.0 k-4.9 glucose-169* urean-49* creat-0.7 na-142 k-5.7* cl-104 hco3-26 alt-82* ast-22 ld(ldh)-330* alkphos-241* amylase-19 totbili-0.3 albumin-2.8* calcium-8.9 phos-5.3* mg-2.5 cholest-pnd brief hospital course: mrs. was transferred from center, intubated. she has a newly diagnosis of right lower lobe lung cancer with extrinsic compression. she was kept intubated. a bedside flexible bronchoscopy was done at the bedside which showed right middle bronchus, bronchus intermediate and right lower lobe patent. the subsegmental bronchi and right middle lobe completely occluded with extrinsic compression. impression: stage iv nsclc that is ventilator dependent. unfortunately no effective endoscopic options to optimize and increase chance of weaning to extubation. a long conversation with her son and daughter took place. given the poor prognosis considering metastatic malignancy with no reversible causes of respiratory failure. option of terminal wean was discussed with the family. there wishes were to have the patient transferred back to . medications on admission: insulin ss, albuterol nebs, amlodipine 10, asa, clinda 600mg q8, moxiflox 400mg qd, enoxaparin 100mg sq q12, protonix, simvastatin 80mg. discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 2. enoxaparin 100 mg/ml syringe sig: one (1) injection subcutaneous q12h (every 12 hours). 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: three (3) ml inhalation q6h (every 6 hours) as needed for sob. 4. ipratropium bromide 0.02 % solution sig: three (3) ml inhalation q6h (every 6 hours) as needed for sob. 5. famotidine(pf) in (iso-os) 20 mg/50 ml piggyback sig: one (1) dose intravenous q12h (every 12 hours). 6. morphine sulfate 2-4 mg iv q4h:prn pain 7. morphine in d5w injection 8. propofol 10 mg/ml emulsion sig: 5-20 mcg/kg/min intravenous titrate to (titrate to desired clinical effect (please specify)). 9. ciprofloxacin in d5w 400 mg/200 ml piggyback sig: four hundred (400) mg/200 ml intravenous q12h (every 12 hours) for 2 days: day 1. 10. clindamycin phosphate 150 mg/ml solution sig: six hundred (600) mg injection q8h (every 8 hours) for 2 days: day 1. discharge disposition: extended care discharge diagnosis: 1. nsclc likely squamous cell of rll, malignant r effusion, liver mets (likely), t11 lytic bone lesion; 2. r calf dvt on lovenox; 3. left foot arterial emboli on lovenox, asa; 4. htn; 5. asthma; 6. depression/anxiety; 7. cad "non critical"; 8. acute on cri stage 3; 9. dm; 10.osa discharge condition: guarded discharge instructions: follow-up with your pcp . followup instructions: follow-up as previous Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Fiber-optic bronchoscopy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Malignant neoplasm of liver, secondary Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Asthma, unspecified type, unspecified Secondary malignant neoplasm of pleura Chronic kidney disease, Stage III (moderate) Acute respiratory failure Personal history of venous thrombosis and embolism Malignant neoplasm of lower lobe, bronchus or lung Secondary malignant neoplasm of bone and bone marrow Dependence on respirator, status

allergies: sulfa (sulfonamides) / iodine; iodine containing / cephalexin / celecoxib / rofecoxib / lisinopril / methylene blue attending: chief complaint: infected necrotic ulcers of the right lower extremity. major surgical or invasive procedure: 11/23/9 debridement of infected necrotic right extremity ulcers. 11/30/9 right above-knee amputation history of present illness: 81-year-old woman with history of severe peripheral arterial disease, who had previously presented with acute limb ischemia and she has subsequently underwent endovascular revascularization of the right lower extremity with stent of the right superficial femoral artery, balloon angioplasty of right superficial femoral artery in-stent stenosis and angiojet thrombectomy of the right superficial femoral artery, popliteal artery, and tibioperoneal trunk. despite revascularization she was not able to heal the right lower extremity and therefore developed significant gangrene of the right leg with necrotic ulcers on the posterior calf. she was admitted for iv antibiotics, wound care and possible debridement in the or. past medical history: pmh: dm 2, afib, cdiff colitis, cad, gout, depression, dialstolic chf, chronic angina (afib), : group b strep bacteremia, ra (prednisone), osteopenia, carpal tunnel. psh: : angioplasty and stent right sfa : ballon angioplasty and full-lenght stent right sfa : balloon angioplasty of right sfa in-stent stenosis and angiojet thrombectomy of the right superficial femoral artery, popliteal artery, and tibioperoneal trunk. : cabg x 4 hernia repair social history: non drinker non smoker family history: unknown physical exam: physical exam neuro/psych: oriented x3, affect normal, nad. neck: no masses, trachea midline, thyroid normal size, non-tender, no masses or nodules, no right carotid bruit, no left carotid bruit. nodes: no clavicular/cervical adenopathy, no inguinal adenopathy. skin: no atypical lesions. heart: regular rate and rhythm. lungs: clear, normal respiratory effort. gastrointestinal: non distended, no masses, guarding or rebound, no hepatosplenomegally, no hernia, no aaa. rectal: not examined. extremities: no popiteal aneurysm, no femoral bruit/thrill, no varicosities, abnormal: b/l le edema. pulse exam (p=palpation, d=dopplerable, n=none) rue radial: p. ulnar: p. brachial: p. lue radial: p. ulnar: p. brachial: p. rle femoral: p. dp: d. pt: d. lle femoral: p. dp: d. pt: d. pertinent results: 12:05pm wbc-10.8 rbc-3.66* hgb-10.7* hct-34.7* mcv-95 mch-29.3 mchc-30.9* rdw-17.0* 12:05pm plt count-530* 12:05pm glucose-81 urea n-14 creat-0.5 sodium-143 potassium-3.9 chloride-99 total co2-34* anion gap-14 12:05pm calcium-7.7* phosphate-3.3 magnesium-1.6 12:05pm pt-31.5* inr(pt)-3.2* brief hospital course: patient was admitted on with multiple necrotic infected ulcers after undergoing revascularization of her right leg chronic ischemia. she was started on iv antibiotics, wound care and underwent debridement of these necrotic infected ulcers on /9. she has failed a course of antibiotics and nonoperative treatment, therefore patient was consented for a right above-knee amputation. as a result of her multiple high-risk comorbidities, postoperatively she developed acute renal failure, a.fib with rvr and sepsis. cardiology was consulted and measures to keep her chronic atrial fibrillation with adequate hr were made. nephrology was also involved and hd was suggested as a possible therapy for her uremia. on /9 patient significant abdominal distention with ?colonic pseudo-obstruction, ct scan consistent with disease and hemodynamic compromise on /9. no free air or fluid, no bowel wall edema, mesenteric or portal venous air were seen. ngt and rectal tubes were placed. gi and general surgery were consulted. she was then transferred from the vicu to the intensive care unit. after extensive conversations with the family and son - health care proxy), patient was made dnr/dni. after seing progressive impairment on her clinical status, family was contact again and she was made , and died soon thereafter. report of death at 16:30 11/05/9. patient's family, the admitting office and medical examiner were notified. the me did not accept the case, and therefore the death certificate was signed. medications on admission: : novolin n 10uam 13upm, novolin r sliding scale, digoxin 0.125mcg , 81mg', bisacodyl sup ', gabapentin 600mg 9am, 1pm, 900mg 9pm, folic acid 1mg', plavix75mg', miralax17g', vit v12 50mcg', oxycontin 30mg", lasix 80mg", metoprolol 100mg tid, simvastatin 80mg', methotrexate 12.5mg qfri, remeron 15mg qhs, tylenol prn, oxycodone 5-15mg q4hprn pain, coumadin - varying dose based on inr, prednisone 7.5' discharge medications: none discharge disposition: expired discharge diagnosis: cardiopulmonary arrest septic shock acute renal failure syndrome status post above-the-knee amputation status post rle debridement pvd, dm2, cad s/p cabg , chf, a. fib, htn, ra discharge condition: expired Procedure: Venous catheterization, not elsewhere classified Arterial catheterization Insertion of other (naso-)gastric tube Excisional debridement of wound, infection, or burn Amputation above knee Transfusion of packed cells Excision of lesion of muscle Diagnoses: Subendocardial infarction, initial episode of care Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Other specified intestinal obstruction Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Peripheral vascular disease, unspecified Septic shock Long-term (current) use of anticoagulants Pressure ulcer, buttock Rheumatoid arthritis Pressure ulcer, heel Atherosclerosis of native arteries of the extremities with gangrene Diastolic heart failure, unspecified Pressure ulcer, unspecified stage Ulcer of thigh Ulcer of calf Pressure ulcer, unstageable

allergies: sulfa (sulfonamide antibiotics) / levaquin / zithromax / cephalosporins / cephalexin / ciprofloxacin / reglan / metronidazole / gentamicin / terbinafine / motrin / augmentin / amoxicillin attending: chief complaint: uti major surgical or invasive procedure: none history of present illness: ms is a 73yof with h/o uti x3 months with klebsiella sensitive to ceftriaxone presenting to ed with cc of frequency dysuria. she has an long history of recurrent utis and multiple drug reactins to various antibiotics (see below) she has no recent fevers of cva tenderness. is endorsing mild nausea. no vommiting. no suprapubic tenderness. . with regards to her cystitis. this particular episode began at the end of where she was started on 9 days of monurol however had no effect. she also reports having been placed on "tertacycline" however there are no records. she has multiple urine cultures since showing klebsiella resistant to ampicillin, nitrofurantoin, tetracycline, bactrim. also one urine culture showing citrobacter farmeri resistant to cefazolin, cefuroxime, nitrofuantoin. all cultures have been sensitive to ceftriaxone. . she has been seen by urology who completed a cystoscopy which did not show evidence of fistula disease(per osh records with patient). she has been managed on estrogen cream and methenimine. past medical history: - gerd - asthma - intertrigo - dvt - obesity - iron deficiency anemia - polymyalgia rheumatica allergies: sulfa, duricef, azithromycin, levofloxacin, doxycycline, ceftin, flagyl, advil, vicodin, ultram, ciprofloxacin social history: widowed. retired. lives in , ma. never smoked, minimal etoh, no drugs. no animals at home. family history: several family members with asthma, hay fever, and shrimp allergy physical exam: admission general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, no suprapubic tenderness. gu: no foley. no cva tenderness ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema discharge general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, no suprapubic tenderness. gu: no foley. no cva tenderness ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: 12:15pm blood wbc-9.6 rbc-4.73 hgb-12.6 hct-38.1 mcv-81* mch-26.7* mchc-33.2 rdw-14.3 plt ct-241 12:15pm blood neuts-88.1* lymphs-8.4* monos-2.2 eos-1.0 baso-0.2 12:15pm blood glucose-131* urean-18 creat-1.2* na-143 k-3.7 cl-103 hco3-29 angap-15 cxr picc line is seen in appropriate position, entering the subclavian and terminating within the distal superior vena cava. there are lung low volumes and elevated right hemidiaphragm. the heart is normal in size. the aorta is mildly tortuous with calcifications. the mediastinal silhouette is otherwise unremarkable. the pleural surfaces are within normal limits. impression: successful placement of right picc line. brief hospital course: 73 with history of recuttent utis presenting with persistent culture positive cystitis since , with multiple drug allergies admitted to medicine for antibiotic desensitization. . # uti: positive ua + culture with ceftriaxone sensitive klebsiella. per allergy note ceftriaxone has minimal cross reactivity to duracef. she was successfully desensitized to ceftriaxone. a picc line was successfully placed. she will complete a 7 day course of ceftriaxone, to finish on . she will get her dosing at the clinic, which was set up with the assistance of her pcp (at ) dr . . # polymyalgia rheumatica- continued prednisone . # gerd- continued omeprazole . # asthma- continued albuterol mdi ======================== transitional issues # uti's: she has h/o multiple uti's, and can be expected to have more in the future. with her multiple drug allergies, she unfortunately may need to come to the micu for desensitization each time. pcp has tried longterm suppressive therapy, which she has not been tolerant too. have set her up with appointments with allergy and uro/gyn, in hopes that a better long term plan to manage her uti's can be found. medications on admission: - lisinopril 40mg po daily - lasix 40mg po daily - omeprazole 20mg po daily - atarax 10-25mg po daily - prn - pulmicort turbuhaler prn - albuterol inhaler prn - epipen: never used - prednisone 5mg po daily - topical estrogen cream discharge medications: 1. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 2. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 4. atarax 10-25mg po daily 5. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 6. epipen 0.3 mg/0.3 ml pen injector sig: one (1) injection intramuscular prn as needed for anaphylaxis. 7. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q6h (every 6 hours) as needed for sob/wheezing. 8. ceftriaxone in dextrose,iso-os 1 gram/50 ml piggyback sig: one (1) intravenous q24h (every 24 hours) for 5 days. 9. pulmicort 0.25 mg/2 ml suspension for nebulization sig: prn . inhalation . discharge disposition: home discharge diagnosis: urinary tract infection, multiple drug allergies discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dr , it was a pleasure taking care of you at . you were admitted for desensitization to antibiotics that you need to treat your urinary tract infection. this desensitization went well. you will go home on 5 more days of antibiotics. to get them, you will need to go to the infusion clinic. this has been set up by dr . the following changes were made to your medications: ** start ceftriaxone (antibiotic). take this medication once daily iv through . you will get it at infusion clinic. followup instructions: department: west clinic when: monday at 2:30 pm with: , md building: de building ( complex) campus: west best parking: garage department: medical specialties when: wednesday at 11:45 am with: , md building: sc clinical ctr campus: east best parking: garage department: uro/gynecology cc8 (sb) when: friday at 9:15 am with: lefevre, md building: sc clinical ctr campus: east best parking: garage name: , r. location: conconrd /- address: , , phone: appointment: tuesday 10:15am department: medical specialties when: wednesday at 11:45 am with: , md building: sc clinical ctr campus: east best parking: garage department: uro/gynecology cc8 (sb) when: friday at 9:15 am with: lefevre, md building: sc clinical ctr campus: east best parking: garage Procedure: Central venous catheter placement with guidance Diagnoses: Polymyalgia rheumatica Esophageal reflux Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Asthma, unspecified type, unspecified Personal history of allergy to other antibiotic agent Iron deficiency anemia, unspecified Personal history of venous thrombosis and embolism Obesity, unspecified Other chronic cystitis Personal history of allergy to penicillin Personal history of allergy to sulfonamides

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: etoh withdrawal abdominal pain major surgical or invasive procedure: diagnostic paracentesis history of present illness: 41yf with alcoholic cirrhosis who presented from osh with 3d of ruq pain nausea/vomiting. her abdominal pain was made worse with eating or laying flat. she denies fevers/chills. ruq us at osh demonstrates gb wall thickening 7mm without pericholecystic fluid. her wt ct was 16.7 at osh with tbili 5. she was transferred to for management of putative acute cholecystitis. . at , pt started on unasyn, but u/s and ct showed no evidence of acute chole, but rather gb wall edema c/w cirrhosis. was admitted to sicu with plan for diagnostic para and hida scan, but plan for hida was dropped. meanwhile, patient was feeling more agitated c/w previous <24 hour periods w/o etoh. patient reported last etoh intake on , with a decades-long history of 1bottle of wine or vodka daily hx of etoh use. . in the sicu, patient was thought to be showing some increased signs of agitation, and so was transferred to the micu for possible etoh w/d. past medical history: - cirrhosis (dx day of admission) - etoh abuse - bilateral carpal tunnel release 2y ago - breast augmentation 14 years ago - c-section x 2 social history: former dialysis rn. etoh abuse x 20 years 6 cocktails/day. 1 bottle of wine/day. prefers merlot and vodka. no ivdu or other illicit drug use. tobacco 1.5ppd x 30 years. family history: father with stomach ca. mother with htn physical exam: physical exam on discharge: vitals: t:97 bp:98/60 p:92 r: 18 o2:96% ra general: alert, anxious, nad heent: mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, mild abdominal tenderness, full belly, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: 1. labs on admission: 09:30pm blood wbc-13.6* rbc-2.26* hgb-8.7* hct-26.4* mcv-117* mch-38.6* mchc-33.0 rdw-15.6* plt ct-212 10:57pm blood pt-16.4* ptt-30.6 inr(pt)-1.5* 09:30pm blood glucose-115* urean-3* creat-0.5 na-139 k-2.6* cl-100 hco3-26 angap-16 09:30pm blood alt-40 ast-177* alkphos-268* totbili-4.7* dirbili-3.4* indbili-1.3 09:30pm blood lipase-21 09:30pm blood albumin-3.0* calcium-8.2* phos-2.6* mg-1.2* 09:59pm blood k-2.4* . 2. labs on discharge; 05:35am blood wbc-10.3 rbc-2.01* hgb-7.7* hct-24.4* mcv-121* mch-38.1* mchc-31.5 rdw-15.7* plt ct-261 05:35am blood pt-16.0* ptt-32.9 inr(pt)-1.4* 05:35am blood glucose-108* urean-5* creat-0.4 na-140 k-4.1 cl-112* hco3-20* angap-12 05:35am blood alt-38 ast-196* alkphos-221* totbili-2.7* 05:35am blood calcium-7.7* phos-2.2* mg-1.9 11:30am blood caltibc-107* vitb12-741 folate-11.8 ferritn-782* trf-82* 10:27am blood hbsag-negative hbsab-positive hbcab-negative hav ab-positive 11:30am blood igg-952 iga-253 igm-134 10:27am blood hcv ab-negative 10:56am blood freeca-0.96* . 3. imaging/diagnostics: - cxr: normal chest. - abdominal u/s: 1. heterogeneous nodular echotexture of the liver with increased echogenicity that is compatible with provided history of cirrhosis. 2. moderate amount of simple intra-abdominal ascites. 3. main portal vein is patent. 4. gallbladder sludge. no evidence of cholecystitis. 5. mild splenomegaly measuring up to 14.3 cm. - ct abdomen/pelvis: 1. no evidence of acute cholecystitis. diffuse fatty liver infiltration/heterogeneity and a moderate amount of abdominal and pelvic ascites and varices c/w cirrhosis. 2. the patient has diverticulosis with colonic wall hypertrophy; however, there are no surrounding changes to suggest acute diverticulitis. . ================================================== pending labs on discharge (to be followed up: 09:30pm blood ama-pnd smooth-pnd 09:30pm blood -pnd 09:30pm blood ceruloplasmin-pnd 09:30pm blood alpha-1-antitrypsin-pnd =================================================== brief hospital course: 41 yo f with history of alcohol abuse, initially admitted for concern of acute cholecystitis and alcohol withdrawal, found to have cirrhosis. . # etoh withdrawal: no prior history of dts or active withdrawal however concern given high daily etoh intake. no hallucinations. ciwa < 10 throughout hospitalization. thiamine, folate, multivitamins given and a social work consult was ordered. patient declined social work consult. patient instructed to attend aa meeting or join support group to help alcohol cessation. patient declined. . # abdominal pain/nasea/vomiting: exam negative for acute abdomen. mild diffuse abdominal tenderness but non-localizable. ct scan without evidence of acute process and ruq us at osh with gb wall thickening 7mm but without pericholecystic fluid. transaminitis remained stable, likely chronic. transitioned to oral diet. weaned off pain medication. . # cirrhosis: new diagnosis on on transfer from osh (). transaminitis and cholestatic picture noted on labs, unclear past history but pt reports heavy drinking and ast/alt ratio > 4, which remained stable. viral hepatitis panel negative for acute infection. autoimmune panel and wilson's disease labs pending at the time of discharge. diagnostic paracentesis negative for spontaneous bacterial peritonitis. serum-ascites albumin gradient 2.6, consistent with ascites due to portal hypertension. . ================================================== pending labs on discharge (to be followed up: 09:30pm blood ama-pnd smooth-pnd 09:30pm blood -pnd 09:30pm blood ceruloplasmin-pnd 09:30pm blood alpha-1-antitrypsin-pnd =================================================== medications on admission: none discharge medications: 1. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: cirrhosis transaminitis alcohol abuse discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ms. , you were admitted to () because you had abdominal pain. we found that you have fibrosis of the liver called cirrhosis, most likely from your alcohol use. your liver enzymes were elevated but remained stable. you had withdrawal from alcohol and we treated you for that. we tapped the fluid in your abdomen which did not show an infection. . it is very important that you call the liver clinic at to make a follow-up appointment on monday . the phone number is listed below. you should join a support group and stop alcohol consumption to prevent progression of your liver disease. . we made the following changes to your medications: started: - folic acid 1 mg by mouth daily - thiamine 100 mg by mouth daily - multivitamins 1 tab by mouth daily followup instructions: please call the liver center at at ( on to schedule a follow-up appointment within the next 2 weeks. Procedure: Percutaneous abdominal drainage Diagnoses: Anemia, unspecified Alcoholic cirrhosis of liver Portal hypertension Hypopotassemia Other ascites Chronic pancreatitis Other abnormal blood chemistry Other abnormal glucose Acute alcoholic hepatitis Alcohol withdrawal

allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization with drug eluting stent placement history of present illness: mr. is a 73 year old man with a history of aaa repair in , hyperlipidemia, svt who presents with chest pain this afternoon and found to have a stemi. mr. was running on the treadmill at the gym and after the work out he noticed he started to feel uncomfortable. he then noticed left sided chest pressure that was not getting better. he then noted the pressure was turning into pain and he turned to look for a trainer. he noted associated dizziness, diaphoresis. when he found a trainer, the trainer called 911 and ems brought him to the er. in the er, the patient was found to have an inferior stemi. he was plavix loaded with 600mg po once, aspirin 324mg po once, heparin bolus, eptifibatide bolus, and was given sublingual nitroglycerin. he was rushed to the cath lab. in the cath lab, he was found to have a completely occluded mid rca clot, that was removed and a des was placed with good flow. he was also noted to have a 60-70% proximal lad lesion and an 80% distal lad lesion, clean lmca, and lcx with mild dz. repeat ekg showed resolution of his st elevations and his pain completely resolved. 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. past medical history: 1. cardiac risk factors: -diabetes, +dyslipidemia, -hypertension 2. cardiac history: - aaa repair in , found via a routine kub looking for kidney stones - svt on metoprolol 3. other past medical history: - asthma: mild intermittent, uses albuterol prn - nephrolithiasis - hernia repair - gerd social history: he lives in with his wife, he is a psychologist. - tobacco history: 30 packyears, quit 15 years ago - etoh: rare use - illicit drugs: none family history: - no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: physical examination on admission: vs: t=98.2 bp=104/hr= 92 rr=14 o2 sat= 98%ra general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 3cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. neuro: aaox3, cnii-xii intact, 5/5 strength biceps, triceps, wrist, knee/hip flexors/extensors, 2+ reflexes biceps, brachioradialis, patellar, ankle. pulses: right: 2+ dp 2+ left: 2+ dp 2+ physical examination on discharge: vs: t=98.3 bp=102/58 hr= 76 rr=16 o2 sat= 98%ra general: nad. oriented x3. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 3cm. cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: resp were unlabored, no accessory muscle use. ctab abdomen: soft, ntnd. no hsm or tenderness. extremities: no c/c/e. pertinent results: labs on admit: 01:20pm blood wbc-14.4* rbc-4.72 hgb-14.0 hct-40.1 mcv-85 mch-29.7 mchc-35.0 rdw-12.9 plt ct-125* 01:20pm blood pt-12.2 ptt-130.0* inr(pt)-1.1 01:20pm blood glucose-132* urean-24* creat-1.5* na-144 k-4.2 cl-107 hco3-22 angap-19 01:20pm blood ck-mb-76* mb indx-9.0* ctropnt-1.37* 03:53am blood ck-mb-86* mb indx-5.4 ctropnt-5.94* 01:20pm blood calcium-9.4 phos-1.8* mg-2.1 cholest-138 01:20pm blood %hba1c-5.7 eag-117 01:20pm blood triglyc-59 hdl-54 chol/hd-2.6 ldlcalc-72 cath: comments: 1. selective coronary angiography of this right dominant system revealed two-vessel coronary artery disease. the lmca was free of angiographically significant disease. the lad had serial stenoses with a 60-70% stenosis in the proximal segment and an 80% stenosis in the distal segment. the lcx had only mild diffuse disease. overall the left system was relatively small compared with the right. the mid-rca was thrombotically occluded. there were no distal collaterals. 2. limited resting hemodynamics revealed normal resting central aortic pressure (105/62mmhg). final diagnosis: 1. two vessel coronary artery disease with mid-rca occlusion as culprit for stemi. 2. normal resting central aortic pressures. 3. rca stented with bms echo : the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with hypokinesis of the basal and mid inferior and inferolateral segments. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. no mitral regurgitation is seen. there is no pericardial effusion. impression: mild focal lv systolic dysfunction consistent with cad. no significant valvular abnormality seen. brief hospital course: 73 year old man with a history of aaa repair in , hyperlipidemia, svt who presents with chest pain this afternoon and found to have a stemi who is doing well after pci. . # stemi: patient presents with an rca mi consistent with inferior territory, who improved significantly after pci. no signs of rv failure or shock. his lad lesions are likely not symptomatic given his excellent baseline functional capacity, however, this will need to be reassessed in 1 month. his asa was continued at 325 for 1 month, then 81 for life. plavix 75mg po daily was started for at least 1 year. atorva 80mg po daily was started. pt was given eptifibatide for 18 hours post pic. an echo was performed which showed. lisinopril and metoprolol xl were started. # chf: no signs of chf on exam. # rhythm: sinus rhythm at present, no evidence of vt or svt. pt had some pvcs but no runs of svt. # ldl pipid panel showed well controlled lipids. atorva 80 was started # asthma: stable. home albuterol prn was continued. # gerd: pt was dc/ed on home omeprazole. - dvt ppx with hsc - pain management with tylenol - bowel regimen with docusate code: full code medications on admission: - metoprolol 25mg po daily - simvastatin 20mg po daily - aspirin 81mg po daily - omeprazole 1 tab po daily - multivitamin 1 tab po daily - calcium and vitamin d - albuterol neb prn - tylenol prn discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 6. albuterol sulfate inhalation 7. tylenol oral 8. metoprolol succinate 25 mg tablet extended release 24 hr sig: three (3) tablet extended release 24 hr po daily (daily). disp:*90 tablet extended release 24 hr(s)* refills:*2* 9. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. nitroglycerin sublingual discharge disposition: home discharge diagnosis: st-elevation myocardial infarction discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr , it was a pleasure taking care of you here at the . you were admitted with concern that you were having a heart attack. you underwent cardiac catheterization which revealed a blockage in your arteries which was relieved with a stent. you were discharged home with several medication changes. new medications: 1. plavix (blood thinner to prevent a blood clot) for at least one year 2. atorvastatin (cholesterol lowering medication) 3. lisinopril(blood pressure lowering and heart-protective medication) changed medications: 1. aspirin (increased from 81 to 325) - please keep taking larger dose for at least one month 2. metoprolol (increased from 25 once daily to 75 once daily) 2. aspirin 325 (blood thinner to prevent a blood clot) for at least one month. medications stopped: 1. simvastatin 2. aspirin 81mg followup instructions: please follow up with your pcp and your cardiologist, dr , for your continued care. . name: , specialty: internal medicine location: - address: , , phone: appointment: wednesday at 10:10am . name: , b. md location: address: , , phone: appointment: friday at 11:50am **you will be seeing dr nurse practioner at this visit.** Procedure: Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Left heart cardiac catheterization Insertion of drug-eluting coronary artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Acute kidney failure, unspecified Asthma, unspecified type, unspecified Personal history of tobacco use Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Acute myocardial infarction of other inferior wall, initial episode of care Chronic total occlusion of coronary artery

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: neck pain major surgical or invasive procedure: acdf c5-7 posterior laminectomy and fusion c5-t1 history of present illness: mr. is a 68 year-old man with hx of alcohol abuse, pancreatic insufficiency, dm, and htn who was admitted on to ortho-spine after falling from a 12-foot ladder while intoxicated. mri spine at hospital revealed unstable right c7 facet fracture and c6/7 disc herniation. he was transferred to for further management. past medical history: dm htn prostate cancer s/p prostatectomy alcohol abuse pancreatic insufficiency social history: lives with wife. history of tobacco or drug abuse. according to wife, pt began drinking heavily at age 60 when diagnosed with prostate cancer. he has been intermittently sober since then. he has recently been drinking 0.5-1 pint vodka. he often goes through withdrawal at home which manifests as tremors and anxiety. he once had hallucinations, but there is no history of seizures. family history: n/c physical exam: vitals: t 98.3 bp 140/80 hr 67 rr 18 o2 sat 96%ra general: alert and oriented to person but not place or time, agitated and delirious cv: rrr, no murmurs/rubs/gallops resp: ctab, no wheezes/crackles/rhonchi gi: abd soft nt/nd, bowel sounds present extremities: bue- 4/5 strength at deltoid and biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact c5-t1 dermatomes; - , reflexes symmetric at biceps, triceps and brachioradialis ble- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, /fhl; sensation intact l1-s1 dermatomes; - clonus, reflexes symmetric at quads and achilles pertinent results: on admission: 06:58pm blood wbc-5.8 rbc-3.47* hgb-10.5* hct-32.0* mcv-92 mch-30.4 mchc-33.0 rdw-16.7* plt ct-128* 06:58pm blood neuts-89.9* lymphs-6.1* monos-3.2 eos-0.7 baso-0.1 06:58pm blood plt ct-128* 07:41pm blood pt-11.7 ptt-23.0 inr(pt)-1.0 01:45pm blood fibrino-505* 06:58pm blood glucose-129* urean-22* creat-1.2 na-139 k-5.2* cl-103 hco3-20* angap-21* 06:50am blood calcium-7.6* phos-3.2 mg-1.2* 06:39pm blood type-art temp-37.1 rates-/40 tidal v-600 fio2-40 po2-155* pco2-41 ph-7.34* caltco2-23 base xs--3 intubat-intubated vent-controlled 02:04pm blood glucose-166* lactate-0.9 na-132* k-3.9 cl-97* 06:39pm blood hgb-9.8* calchct-29 11:34pm blood freeca-1.04* . on discharge: 04:09pm urine bnzodzp-pos barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg 12:55pm blood asa-neg ethanol-neg acetmnp-19 bnzodzp-neg . and blood culture-pending ucx neg & ucx neg 06:10am blood wbc-5.7 rbc-3.01* hgb-8.7* hct-26.7* mcv-89 mch-28.8 mchc-32.5 rdw-16.1* plt ct-484* 06:10am blood plt ct-484* 06:10am blood glucose-261* urean-8 creat-0.9 na-140 k-3.9 cl-105 hco3-25 angap-14 06:10am blood calcium-8.3* phos-3.4 mg-1.8 12:55pm blood asa-neg ethanol-neg acetmnp-19 bnzodzp-neg barbitr-neg tricycl-neg 07:35am blood wbc-5.4 rbc-2.94* hgb-8.2* hct-25.7* mcv-88 mch-28.0 mchc-32.0 rdw-16.3* plt ct-522* 07:35am blood glucose-206* urean-14 creat-0.8 na-137 k-4.1 cl-101 hco3-27 angap-13 07:35am blood calcium-8.4 phos-2.8 mg-1.8 . ct c-spine w/o contrast : impression: fracture of right superior articulating facet of c7 with anterior subluxation of c6 inferior facet. c6-c7 disc space widening, concerning for ligamentous injury; posterior osteophyte disc complex at c5-c6 that narrows the canal; recommend mri to further assess. . mr w/o contrast : impression: 1. disruption of the anterior and posterior longitudinal ligaments and the ligamentum flavum at the level of c6/7, with adjacent soft tissue abnormalities, compatible with highly unstable extension-type fracture injury. 2. right c7 facet fracture with impaction of the c6 inferior facet into the fracture site. this has not significantly changed since the ct examination from the prior day. 3. acute c6/7 posterior disc herniation resulting in moderate stenosis of the spinal canal at this level. signal abnormalities within the cord are suggestive of contusion. no hematoma is seen. . c-spine (portable); spinal fluoro : impression: there is an anterior plate at the c5 through c7 levels with normal alignment at this time. . portable cxr : impression: ap chest reviewed in the absence of prior chest radiographs: tip of the endotracheal tube is substantially above the upper margin of the clavicles, at least 9 cm above the carina, 6 cm above optimal placement. subsequent chest radiograph, 6:05 a.m. on available at the time of this review showed no change in this malposition. lungs are low in volume but aside from mild left basal atelectasis, clear. heart size normal. no pleural abnormality. . ecg : sinus rhythm. consider left atrial abnormality. left anterior fascicular block. delayed r wave progression is non-specific but clinical correlation is suggested. no previous tracing available for comparison. . ct head w/o contrast : impression: 1. no acute hemorrhage or fracture is detected. 2. fluid in the paranasal sinuses, may be secondary to recent intubation/surgery. . right elbow xray : impression: 1. slight irregularity at the radial head suspicious for an occult fracture. small joint effusion. 2. enthesopathy at medial and lateral epicondyles of distal humerus and triceps insertion on the olecranon. . portable cxr : findings: endotracheal tube is in a proximal location, 9.5 cm above the carina. new nasogastric tube terminates within the stomach with side port near the ge junction. dr. has been paged with these results. exam is otherwise remarkable for worsening atelectasis at the left lung base, with no other relevant short interval changes. . portable cxr : findings: the feeding tube has been removed. the lungs are grossly clear without focal consolidation. hardware within the lower cervical spine is seen. . oropharyngeal videofluoroscopic swallowing evaluation : evaluation: an oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with radiology. nectar-thick liquid (tspn, cup) and pureed consistency barium (1 tspn only) were administered. results follow: . oral phase: oral phase was most remarkable for moderately reduced bolus control resulting in premature spillover of nectar thick liquid to the valleculae and airway before the swallow. mild-moderate tongue weakness (specifically base of tongue) contributed to pharyngeal residue. oral transit time for individual swallows was wnl. . pharyngeal phase: swallow was initiated in a timely manner, however pt presented with severely reduced hyolaryngeal excursion, moderately reduced laryngeal valve closure, and near absent epiglottic deflection. pt had at least moderately reduced bolus propulsion and apparent edema near the level of the ues (in line with new cervical spinal hardware). deficits in combination with oral phase deficits resulted in moderate to severe vallecular and pyriform sinus residue after swallows per bolus. . aspiration/penetration: pt demonstrated penetration before and during the swallow which resulted in aspiration after the swallow with both nectar thick liquids and purees. pt had spontaneous throat clear which temporarily would improve the amount of aspiration or penetration, however it did not fully clear and thus the material would be re-aspirated. cued cough was also ineffective at fully eliminating aspirated material. . treatment techniques: pt benefits partially but not fully from spontaneous repeat swallows (5-6 per bite/sip) and cued swallow-cough-swallow maneuver. there is no strategy, however, which eliminates aspiration or pharyngeal residue. . summary: pt, currently pod # from anterior and posterior cervical spinal surgeries with hardware, demonstrates severe oropharyngeal dysphagia as described above most notable for reduced movement of the pharyngeal swallow mechanism and swelling at the level of the cervical hardware. deficits result in significant pharyngeal residue and aspiration across all consistencies assessed. based on the results of today's evaluation, he does not appear safe for po intake and should remain fully npo at this time including no dobbhoff today. given the length of time pt will require to recover from his current deficits and his propensity to self-d/c ngts despite our efforts otherwise, md team may wish to consider longer term means of nutritional support such as peg. if we can be of further assistance with discussion regarding plan of care, please contact us. otherwise, we will f/u in approximately 1 week's time for reassessment, if he remains at this facility. alternatively, pt could have swallow f/u in a rehab setting. . recommendations: 1. npo, no ice chips, no oral meds 2. q4 oral care while npo. 3. support non-oral means of nutrition, hydration, and medication 4. consider longer term means of non-oral nutrition. 5. repeat swallowing evaluation in 1 week's time. page/reconsult if we can be of further assistance prior to that f/u. 6. pt will benefit from intensive swallow therapy and cognitive-linguistic dx/tx in a rehab setting upon d/c. . ng tube placement : impression: successful placement of a nasointestinal tube into the post-pyloric position. the tube is ready to use. . ct head non contrast: there is no acute hemorrhage, edema, mass effect or acute major vascular territorial infarction. global, predominantly central parenchymal atrophy is likely age-related. periventricular white matter hypodensities are most likely the sequelae of chronic small vessel ischemic disease. there is minimal fluid in ethmoid air cells and frontal sinuses, bilaterally. the remainder of the paranasal sinuses and mastoid air cells appear clear. surgical clips and post-surgical changes are noted in the scalp overlying the left occipital bone. impression: no acute intracranial abnormality. . cxr : findings: small retrocardiac opacity, could be atelectasis. there is no pneumonia. there is no pleural effusion, or pneumothorax. hilar, mediastinal, and cardiac silhouette are within normal limits. there is mild rightward scoliosis in the thoracic spine. anterior posterior cervical fusion at the lower c-spine. impression: 1. no pneumonia. 2. small retrocardiac opacity, could be atelectasis. brief hospital course: mr. was admitted to the spine surgery service on and taken to the operating room for a cervical fusion through an anterior approach c5-7. please refer to the dictated operative note for further details. the surgery was without complication and the patient was transferred to the pacu in stable condition. teds/pnemoboots were used for postoperative dvt prophylaxis. intravenous antibiotics were given per standard protocol. initial postop pain was controlled with a pca. post-operatively he was noticed to be confused and withdrawing from alcohol. he was transfered to the t/sicu for further management. on hd#3 he returned to the operating room for a scheduled posterior cervical fusion as part of a staged 2-part procedure. please refer to the dictated operative note for further details. the second surgery was also without complication and the patient returned to the t/sicu intubated. . he was subsequently extubated without difficulty but failed a speech and swallow likely secondary to soft tissue swelling from his surgeries. a dobhoff was placed and he was given tubefeeds. his further withdrawal symptoms were managed with ativan and valium. he pulled out his dobhoff tube on . he was transfered to the medical service for further management. . on the medical service, he failed a second speech and swallow evaluation on and another dobhoff tube was placed on . we started him on thiamine and a multivitamin and continued his folate. it was felt that his altered mental status was largely due to delirium and not alcohol or benzodiazepine withdrawal, and we thus sought to minimize use of narcotics and benzodiazepines. . on , mr. an unfortunate fall to the floor as he was getting out of his chair. he had a ct scan of his head and complete spine, which showed no acute intracranial process and no fractures. an x-ray of his right elbow showed a tiny non-displaced fracture of his radial head. his right arm was put in a sling, and on discahrge was recommended for full of motion, non weight bearing, and sling for comfort. subsequently, he was kept with a 1:1 sitter until his transfer to an outside hospital. . the patient had several aspiration events associated with a brief desaturation and occasional fever. the differential for these fevers included aspiration pneumonitis vs. neuroleptic malignant syndrome. his cxrs did not demonstrate a consolidation and making pneumonia less likely although he certainally is at risk for developing a true aspiration pna. all psych meds were stopped due to concern of nms and he remained afebrile without leukocytosis throughout rest of hospital stay. while at hospital these psych meds should be restarted soon after arrival. he was re-evaluated by speech and swallow on and again failed a bedside speech and swallow exam. on he underwent a video swallow study that showed mild-moderate tongue weakness, near absent epiglottic deflection, and edema near the level of the ues in line with new cervical spinal hardware. these defects resulted in aspiration with both nectar thick liquids and purees. based on these results, it was recommended that patient be kept npo without oral meds. a dobhoff was placed for nutrition but he pulled it out the same day before it could be utilized for tube feeds. the next day, another dobhoff was attempted and patient was kept on restraints so as not to pull it out. tube feeds were started on . . given that he does not tolerate -gastric tube well, a more long-term means of non-oral nutrition should be pursued, possibly with a peg tube. we discussed the issue of the peg tube with the patient and his wife on . however, his wife expressed her desire for the patient to be transferred to center to be under the care of his primary care physician. patient should continue this discussion on a means for long-term nutrition at his outside hospital. if he is discharged to a rehab facility without a peg tube in place, he should continue to be kept npo until re-evaluation one week later with a repeat swallow study. he should receive intensive swallow therapy and cognitive-linguistic treatment in a rehab setting. he should also receive q4h oral care while npo. he also had episodes of oxygen desaturations to the high 80s that improved to the high 90s with both oxygen via nasal cannula and with suctioning of oral secretions. by discharge, his oxygen saturation was stable in the mid to high 90s on room air. please note: blood cultures were still pending on discharge. . of note, patient continued to show signs of sun-downing until the 2 days before transfer. delirium persisted despite the fact that he was ostensibly taken off all possible sedatives, including benzos and his psychiatric medications. patient periodically agitated, often requiring restraints. he was combative off restraints and received one dose of 5mg zyprexa im which did not alleviate symptoms. psych consult was obtained to evaluate and recommended starting 1mg haldol standing and 1mg qhs prn on . qtc was mildly prolonged to 455 and thus he was changed to liquid haldol. his psych meds were so far in the hospitalization but citalopram was started at low dose and should be titrated up. patient's mental status improved after the haldol; he was alert and oriented x 3 the next morning . cxr, ua, and blood cx were unremarkable. tsh, b12, folate, and rpr were checked as part of delirium work up and were pending on discharge. . however, throughout the day, he became more somnolent and lethargic, out of proportion to the amount of haloperidol he was receiving. a urine toxicology returned on positive for benzos in the urine which had been discontinued since . it is unclear why he had benzos in the urine at that time. blood toxicology was negative. of note mrs. was updated daily by several members of the medical team including dr. (attending), dr. (pgy3), and dr. (pgy1). she repeatedly expressed concern that we were not caring for her husband well. was transferred to hospital on per the wishes of his wife. medications on admission: lantus 12 units metformin 500 mg lisinopril 30 mg qam nifedipine 30 mg qam simvastatin 10 mg pm pancrease 10 mg tid clonazepam 0.5 mg qid citalopram 40 mg qam albuterol neb prilosec 20 mg pm chromium 500 mcg fenugreek 600 mg /meals discharge medications: 1. lipase-protease-amylase 12,000-38,000 -60,000 unit capsule, delayed release(e.c.) sig: one (1) cap po tid w/meals (3 times a day with meals). 2. metformin 500 mg tablet sig: one (1) tablet po bid (2 times a day). 3. lisinopril 20 mg tablet sig: 1.5 tablets po qam (once a day (in the morning)). 4. simvastatin 10 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 5. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 6. multivitamin tablet sig: one (1) tablet po daily (daily). 7. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po qhs (once a day (at bedtime)). 9. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 10. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection three times a day. 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 12. insulin per attached sliding sclae 13. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 14. acetaminophen 650 mg tablet sig: one (1) tablet po q6h (every 6 hours). 15. haloperidol lactate 2 mg/ml concentrate sig: o.5 po bid (2 times a day). 16. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 17. ondansetron 4 mg iv q6h:prn nausea discharge disposition: extended care discharge diagnosis: primary diagnosis: c7 superior facet fracture and c6 perched right inferior facet with c6-7 disc injury, delirium, ?nms, failed speech and swallow secondary diagnoses: diabetes mellitus type 2, hypertension, alcohol abuse, pancreatic insufficiency, history of prostate cancer s/p prostatectomy discharge condition: discharge instructions: you were admitted after falling off a ladder and fracturing a cervical vertebra (a part of your spine). our surgeons performed anterior and posterior fusion of your cervical spine. you a fall while you were in the hospital. ct scans of your head and spine showed no acute bleeding in your head and no disruption of your spine. an elbow x-ray showed a tiny nondisplaced fracture of your right radius (one of the bones in your forearm), and you were given a sling. it was not possible to tell the age of that fracture. . you were very confused at the hospital and psychiatry was consulted. you are now on haldol. your confusion is getting better. . you also showed symptoms of alcohol withdrawal which was treated with medications. you should abstain from alcohol in the future. you also had some confusion due to sedating medications which slowly improved. you had some fevers that were thought to be due to neuroleptic malignant syndrome (in which patients develop high temperatures due to psychiatric medications) or aspiration pneumonia. however, your chest x ray was clear, making pneumonia less likely. your fevers resolved when your psychiatric medications were stopped, your psych medications will be restarted after transfer to your new hospital but they may be restarted slowly. we started your citalopram at a low dose on . . you had persistent difficulty with swallowing, as shown by several swallowing tests in the hospital. as a result of your swallowing difficulties, you like aspirated while in the hospital. we tried to give you nutrition through a tube that goes through your nose into your stomach but you pulled it out several times. you will likely need a more long-term source of nutrition such as a peg tube, which is a tube that goes into your stomach and attaches to the outside. you will be transferred to an outside hospital as you and your family requested. there, this issue of the feeding tube should be addressed further. for now you have a tube through your nose. . post op instructions from our surgeons: -activity: you should not lift anything greater than 10 lbs for 2 weeks. you will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -rehabilitation/ physical therapy: 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. you can walk as much as you can tolerate. limit any kind of lifting. -brace: you have been given a collar. this is to be worn for when you are walking. you may take it off when sitting in a chair or while lying in bed. -wound care: remove the dressing in 2 days. if the incision is draining cover it with a new sterile dressing. if it is dry then you can leave the incision open to the air. once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. do not soak the incision in a bath or pool. if the incision starts draining at anytime after surgery, do not get the incision wet. cover it with a sterile dressing. call the office. -you should resume taking your normal home medications once you are taking things by mouth. no nsaids (ibuprofen, aleve). -please call the office if you have a fever>101.5 degrees fahrenheit and/or drainage from your wound. . we will send the doctors at your hospital a list of your medications on transfer. followup instructions: please schedule a follow-up appointment with dr. in 10 days at (. Procedure: Enteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Other cervical fusion of the anterior column, anterior technique Excision of intervertebral disc Alcohol detoxification Repair of vertebral fracture Other cervical fusion of the posterior column, posterior technique Removal of skull tongs or halo traction device Insertion or replacement of skull tongs or halo traction device Plastic operation on pharynx Fusion or refusion of 2-3 vertebrae Fusion or refusion of 2-3 vertebrae Excision of bone for graft, unspecified site Diagnoses: Anemia, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Personal history of malignant neoplasm of prostate Asthma, unspecified type, unspecified Depressive disorder, not elsewhere classified Long-term (current) use of insulin Unspecified accident Injury to bladder and urethra, without mention of open wound into cavity Accidents occurring in residential institution Closed fracture of seventh cervical vertebra Alcohol abuse, continuous Accidental fall from ladder Diabetes with other specified manifestations, type II or unspecified type, uncontrolled Other specified diseases of pancreas Closed fracture of head of radius Alcohol withdrawal delirium Accidental fall from chair Foreign body in respiratory tree, unspecified Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation Degeneration of cervical intervertebral disc Malnutrition of moderate degree Other dysphagia Sedative, hypnotic or anxiolytic abuse, continuous Closed dislocation, sixth cervical vertebra

allergies: levaquin attending: chief complaint: hypoxemic respiratory failure major surgical or invasive procedure: intubation x2 central line insertion picc line insertion history of present illness: 89m afib (on coumadin), chronic diastolic chf (on lasix and home o2), htn, cri (cr 1.4), that presented wuth worsening dyspnea over the past 2 days. . in , pt underwent surgical debridement of perforated appendicitis complicated by sepsis. post-operatively, the pt developed afib and was also found to have a pe. his icu stay was also complicated by encephalitis. . since that time, the pt has had worsening chf and respiratory failure. the family also reports that pt has had delirium and agitation. two weeks prior to this admission, he was readmitted to to be treated for respiratory distress and chf. yesterday, he presented to his pcp with increased respiratory distress, rr=30 and o2 sat=76% with walking to the exam room and o2 sat=85% after 5 min of rest. moreover, his weight had increased 9lbs from dry weight of 184lbs(84kg) over the past 10 days. his furosemide and lasix dosing was increased, but his family reports that today his breathing was "the worst it has ever been." the pt was brought by ems to and on route was given lasix 100mg po at nsh, 40mg iv en route and " of nitro paste. . upon arrival to (4pm) initial vitals: bp=124/77 p=88 rr=30 t=99.1 o2=97% on 5l nc. he was noted to have increased work of breathing and labs notable for wbc 6.1, hct 31.1, inr 1.3, hco3 38, bun 33, cr 1.4, ca 8.4, negative troponin, bnp 410. his ua showed few squams epi, trace leukocyte esterase, 0-2 wbc, 1+ bacteria. a foley was placed and drained 1.75l. while in the ed the pts respiratory status continued to decline and he was subsequently intubated. he was given vancomycin 1gm. he was then transfered to . . en route to the pt received fentanyl 100mcg. . upon arrival to initial vitals: t 98.9, p 87, bp 150/128, rr 18, 100% on vent. while in the pt noted to tm 101.4; exam notable for intubated, sedated, guaiac negative. sbp initially in 140s then dropped to 80s with hr in 80s. cvl placed, levophed initiated and he was given a dose of cefepime 2gm following bcx. labs notable for wbc 6.9, hct 26.9, trop 0.03, inr 1.4, bnp 4735, lactate 1.6, hco3 of 33. ecg shows a fib rate of 75, nl axis, narrow qrs, biphasic t in v2, no other st changes. an cardiac echo in the ed revealed showed no obvious wall motion abnormalities. the patient underwent a ct head which showed no hemorrhage or edema. he received a total of 1l of fluid. vitals prior to transfer to the floor p 72, bp 124/65, rr 22, o2 98%. . review of systems: (+) per hpi . family also reports that the pt was having some erythema of his right lower extremity, thought to be due to cellulitis but not formally diagnosed. (-) per family, no recent fever, cough, cp. past medical history: - htn - chronic diastolic heart failure (per pcp ) - cad, distant mi - laparotomy for ruptured appy - af on coumadin, diagnosed - pe postoperatively - gout x 40 years - cri, cr 1.3-1.4 at baseline - depression, on celexa since , switched to remeron and trazodone a few months prior, and restarted on celexa yesterday - discectomy complicated by footdrop - bph s/p prostatectomy in - lymphadenopathy, with blocked salivary duct - veritigo - rectal prolapse with chronic constipation social history: lives at a facility called orchard . has 5 sons and girlfriend. grandaughter gave birth during his icu stay. oldest son is healthcare proxy. - tobacco: quit smoking 50 years prior. 20 pack years - alcohol: occasional. no drinks in last 3 months. - illicits: family denies. family history: non contribtory physical exam: vs 96.6ax 110/60 p95 rr18 95% ra general: alert, meets gaze, speech fluent but illogical. unable to answer questions, mumbled frequently. heent: perrla. mucous membs dry. fair dentition with no ttp and no obvious carries. jvp non elevated. cards: s1 s2 normal in quality/intensity rrr no mrg pulm: equal air entry bl, poor inspiratory result, crackles at the bases bl, no wheezes no ronchi abd: soft, nt, nd +bs. extremities: warm, well perfused no peripheral edema. dps, pts 2+ neuro/psych: unable to assess cranial nerves, unable to follow commands, pt. is moving all 4 extremities. localizes pain, unable to assess gait. pertinent results: 11:49pm glucose-126* urea n-36* creat-1.5* sodium-146* potassium-4.2 chloride-106 total co2-31 anion gap-13 11:49pm wbc-7.1 rbc-2.79* hgb-8.6* hct-27.2* mcv-98 mch-30.7 mchc-31.5 rdw-16.1* 09:28pm type-art po2-160* pco2-69* ph-7.35 total co2-40* base xs-9 intubated-intubated 07:15pm lactate-1.6 07:10pm probnp-4735* 07:10pm blood neuts-87.8* lymphs-7.4* monos-3.7 eos-0.9 baso-0.3 07:10pm blood pt-15.5* ptt-26.3 inr(pt)-1.4* . cbc 11:49pm blood wbc-7.1 rbc-2.79* hgb-8.6* hct-27.2* mcv-98 mch-30.7 mchc-31.5 rdw-16.1* plt ct-234 03:30am blood wbc-6.7 rbc-2.85* hgb-9.0* hct-27.2* mcv-95 mch-31.7 mchc-33.2 rdw-16.2* plt ct-172 01:59am blood wbc-6.3 rbc-2.91* hgb-9.1* hct-27.9* mcv-96 mch-31.3 mchc-32.5 rdw-16.3* plt ct-150 04:24am blood wbc-7.6 rbc-2.73* hgb-8.5* hct-27.2* mcv-100* mch-31.1 mchc-31.1 rdw-16.2* plt ct-184 04:00am blood wbc-7.7 rbc-2.76* hgb-8.6* hct-27.6* mcv-100* mch-31.2 mchc-31.1 rdw-16.2* plt ct-145* 04:00am blood wbc-7.0 rbc-2.53* hgb-7.9* hct-25.2* mcv-99* mch-31.1 mchc-31.3 rdw-16.3* plt ct-128* 03:35am blood wbc-4.7 rbc-2.41* hgb-7.5* hct-23.3* mcv-97 mch-30.9 mchc-32.0 rdw-16.0* plt ct-122* 11:49pm blood wbc-7.1 rbc-2.79* hgb-8.6* hct-27.2* mcv-98 mch-30.7 mchc-31.5 rdw-16.1* plt ct-234 03:30am blood wbc-6.7 rbc-2.85* hgb-9.0* hct-27.2* mcv-95 mch-31.7 mchc-33.2 rdw-16.2* plt ct-172 01:59am blood wbc-6.3 rbc-2.91* hgb-9.1* hct-27.9* mcv-96 mch-31.3 mchc-32.5 rdw-16.3* plt ct-150 04:00am blood wbc-7.7 rbc-2.76* hgb-8.6* hct-27.6* mcv-100* mch-31.2 mchc-31.1 rdw-16.2* plt ct-145* 04:00am blood wbc-7.0 rbc-2.53* hgb-7.9* hct-25.2* mcv-99* mch-31.1 mchc-31.3 rdw-16.3* plt ct-128* 03:35am blood wbc-4.7 rbc-2.41* hgb-7.5* hct-23.3* mcv-97 mch-30.9 mchc-32.0 rdw-16.0* plt ct-122* 03:40am blood wbc-4.1 rbc-2.32* hgb-7.3* hct-22.6* mcv-98 mch-31.6 mchc-32.4 rdw-15.8* plt ct-122* 05:22am blood wbc-4.1 rbc-2.35* hgb-7.4* hct-22.9* mcv-97 mch-31.6 mchc-32.5 rdw-15.6* plt ct-133* 06:11am blood wbc-8.5# rbc-3.04* hgb-9.1* hct-29.2* mcv-96 mch-29.9 mchc-31.2 rdw-16.1* plt ct-194 05:10am blood wbc-8.1 rbc-2.72* hgb-8.5* hct-25.4* mcv-93 mch-31.2 mchc-33.5 rdw-16.4* plt ct-181 05:53am blood wbc-9.0 rbc-2.95* hgb-9.1* hct-27.6* mcv-94 mch-30.8 mchc-33.0 rdw-16.1* plt ct-221 03:08am blood wbc-8.6 rbc-2.83* hgb-8.7* hct-26.4* mcv-93 mch-30.9 mchc-33.2 rdw-15.9* plt ct-246 03:02am blood wbc-7.7 rbc-2.83* hgb-8.8* hct-27.3* mcv-96 mch-31.0 mchc-32.2 rdw-15.7* plt ct-312 03:25am blood wbc-11.0 rbc-3.15* hgb-9.7* hct-29.0* mcv-92 mch-30.9 mchc-33.6 rdw-15.8* plt ct-336 10:51pm blood wbc-9.1 rbc-2.93* hgb-9.0* hct-27.4* mcv-94 mch-30.7 mchc-32.7 rdw-15.7* plt ct-308 09:11am blood wbc-9.2 rbc-2.75* hgb-8.4* hct-26.3* mcv-96 mch-30.5 mchc-32.0 rdw-15.7* plt ct-363 02:04pm blood wbc-7.9 rbc-2.67* hgb-8.2* hct-26.3* mcv-99* mch-30.7 mchc-31.1 rdw-15.6* plt ct-278 06:29am blood wbc-8.6 rbc-2.69* hgb-8.4* hct-25.6* mcv-95 mch-31.3 mchc-32.9 rdw-15.7* plt ct-290 05:06am blood wbc-8.6 rbc-2.81* hgb-8.7* hct-26.1* mcv-93 mch-31.1 mchc-33.5 rdw-15.3 plt ct-271 08:02am blood wbc-14.0* rbc-2.89* hgb-8.7* hct-27.8* mcv-96 mch-30.1 mchc-31.2 rdw-15.6* plt ct-262 05:31am blood wbc-10.0 rbc-2.64* hgb-8.1* hct-24.7* mcv-94 mch-30.7 mchc-32.8 rdw-15.4 plt ct-238 07:02am blood wbc-6.9 rbc-2.44* hgb-7.6* hct-23.1* mcv-95 mch-31.1 mchc-32.9 rdw-15.5 plt ct-214 07:02am blood wbc-6.9 rbc-2.44* hgb-7.6* hct-23.1* mcv-95 mch-31.1 mchc-32.9 rdw-15.5 plt ct-214 .......................... imaging ct head indication: 89-year-old intubated male with agitation. question intracranial hemorrhage. . comparison: . . technique: contiguous non-contrast axial images were acquired through the brain. . ct head: there is no evidence of infarction, hemorrhage, mass effect, edema, or shift of normally midline structures. the -white matter differentiation is preserved. mild subcortical (for example, left subinsula) areas of hypoattenuation are re-demonstrated, suggestive of underlying small vessel ischemic disease. ventricles and sulci are mildly prominent, compatible with age-related involution. patient remains intubated with nasogastric feeding tube in place. paranasal sinuses and mastoid air cells appear within normal limits. vascular calcifications are noted in the cavernous carotid arteries and left vertebral artery. lens extraction may be present in the right eye. . impression: 1. no acute intracranial process, no evidence of hemorrhage. 2. age-related involution and mild small vessel ischemic disease. ......................... ct head history: 89-year-old male with altered mental status. evaluate for intracranial hemorrhage. . comparison: none available in the pacs. . technique: imaging was performed from the foramen magnum to the cranial vertex without iv contrast. . head ct without iv contrast: there is no hemorrhage, edema, mass effect, shift of normally midline structures, or evidence of major vascular territorial infarction. prominence of the ventricles and sulci is indicative of age-related parenchymal involutional change. there is mild periventricular hypodensity, which suggests chronic small vessel ischemic change. bilateral punctate basal ganglia calcifications are incidentally noted. the patient is intubated and has an ng tube in place; allowing for this, the visualized paranasal sinuses and soft tissues appear unremarkable. . impression: no hemorrhage or edema. . the study and the report were reviewed by the staff radiologist. brief hospital course: 89m afib (on coumadin), chronic diastolic chf (on lasix and home o2), htn, cri, that presented with worsening dyspnea and fevers. his clinical improvement was slow and was extubated on . throughout his stay, his delirium was difficult to control with several different strategies, however, his mental status improved as he improved clinically. . # hypoxemic hypercarbic respiratory distress - patient arrived to intubated and sedated from osh. his blood pressures dropped into the 80s and he was febrile to 101.4. a central line was placed and patient was started on levophed, vanco and cefepime, then transferred to the micu for further management. an tte was obtained which showed preserved systolic function and no evidence of right heart strain. it was thought his respiratory distress was likely due to a diastolic chf exacerbation with a possible underlying pneumonia. cxr showed pleural effusions and basilar alveolar infiltrate. he also had abundant secretions from ett suctioning. the patient was diuresed with lasix and continued on abx. his respiratory status failed to improve with an 8 day course of antibiotics, and the pt was diuresed in order to help improve respiratory function. after diuresing overall 6 liters negative from admission, the patients respiratory status improved and he was extubated on . he did well on nc. his dry weight is 84 kg . #fever - throughout his course, the pt intermittently spiked fevers while on vancomycin and cefepime. his central line was pulled on . urine swab from grew mrsa and enterobacter, he was again started on vancomycin as well as meropenem. his antibiotic coverage was stopped on after completing a course of vanco and meropenem. . #parotitis: on the patient developed bilateral swelling at the angle of the jaw, with pain, leukocytosis, and fever. he was started on a course of augmentin and transitioned to unasyn for a total of 7 days of therapy. after two days of antibiotics, his wbc trended down, the swelling improved and pain resolved. he is being transferred to orchard with two days of augmentin to finish on a 7 day total course of antibiotics . #delirium - the pt had baseline problems with delirium and agitation since , when he was hospitalized for perforated appendicitis c/b sepsis. his benzodiazepine sedation was stopped, and his mental status improved with dexmedetomidine. he was transitioned to clonidine and prn olanzepine. his qtc was closely monitored and measured around 440ms. on we restarted his home medications and geriatric medicine was consulted to help with management of his delirium. after transfer to the general medical floor, his mental status remained poor. he had a waxing and waining level of consciousness and was often responsive only to pain. as the parotitis resolved, an improvement in his mental status was noted. he began to speak in full sentences with more clearly understandable speech. . # dysphagia - patient was seen and evaluated by speech and swallow who determined that he posed a significant aspiration risk. a nasogastric feeding tube was placed and used briefly until patient pulled the tube. a picc line was placed and tpn was initiated for three days during which time the patient's hcp asserted his unwillingness to place a feeding peg tube or resume nasogastric feeding. in this time, the patient's mental status improved and he became more willing and able to tolerate po intake. the family requested that the patient be feed po regardless of aspiration risk. at the time of discharge, he had been fed two days po without significant aspiration. . #atrial fibrillation - the patient was continued on heparin drip throughout his stay and transitioned back to coumadin prior to his transfer from the hospital to orchard . his heparin sliding scale was fine tuned owing to wide variation in his ptt with a typical sliding scale. his inr was persistently subtherapudic owing to his dysphagia and inability to tolerate po medications. as his mental status improved, he resumed po coumadin, receiving a total of three doses before discharge. his inr remained subtherapudic at transfer to orchard . he will need to continue to have his inr checked daily and coumadin dose adjusted until he reaches the goal of inr=. his rate was controlled with iv metoprolol while npo and po metoprolol when he resumed po meds. medications on admission: per recent pcp notes coumadin 1mg as directed daily metoprolol 25mg daily simvastatin 10mg daily furosemide 20mg daily (but increased to 60mg on ) flomax 0.4mg daily combivent 103-18 mcg/act 2 puffs q4hr allopurinol 50mg daily colace 100mg senna 8.6 mg daily remeron 30mg daily celexa 20mg daily trazodone 25mg qhs prn calcium and d twice daily mvi daily discharge medications: 1. outpatient lab work please check inr daily and adjust warfarin dosage as needed for inr goal of . 2. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. 3. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 4. simvastatin 10 mg tablet sig: one (1) tablet po once a day. 5. furosemide 20 mg tablet sig: one (1) tablet po once 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. combivent 18-103 mcg/actuation aerosol sig: 1-2 puffs inhalation every four (4) hours as needed for cough/wheezing. 8. allopurinol 100 mg tablet sig: 0.5 tablet po once a day. 9. senna 8.6 mg tablet sig: one (1) tablet po once a day as needed for . . 10. docusate sodium 50 mg/5 ml liquid sig: two (2) ml po bid (2 times a day). 11. mirtazapine 30 mg tablet sig: one (1) tablet po once a day. tablet(s) 12. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 13. trazodone 50 mg tablet sig: 0.5 tablet po at bedtime as needed for insomnia. 14. calcium carbonate-vitamin d3 oral 15. multiple vitamin oral 16. insulin lispro 100 unit/ml solution sig: one (1) subcutaneous asdir (as directed): blood glucose 0-150 = 0 units, 151-200 = 2units, 201-250 =4units, 251-300 =6units, 301-350 =8units, 351-400 =10units, >401 =12 units and md. 17. outpatient lab work check fs qachs 18. outpatient physical therapy evaluate and treat 19. heparin, porcine (pf) 10 unit/ml syringe sig: two (2) ml intravenous prn (as needed) as needed for line flush: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. . 20. heparin iv sliding scale diagnosis: pulmonary embolism patient weight: 95 kg initial bolus: 0 units ivp initial infusion rate: 1400 units/hr target ptt: 60 - 100 seconds ptt <40: 1000 units bolus then increase infusion rate by 200 units/hr ptt 40 - 59: 500 units bolus then increase infusion rate by 100 units/hr ptt 60 - 100*: ptt 101 - 120: reduce infusion rate by 100 units/hr ptt >120: hold 60 mins then reduce infusion rate by 200 units/hr 21. amoxicillin-pot clavulanate 500-125 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 2 days. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary diagnosis: respiratory failure secondary to congestive heart failure ventilator-associated pneumonia delirium ... secondary diagnosis: hypertension coronary artery disease atrial fibrilltion chronic renal insufficiency depression benign prostatic hypertrophy discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , you were admitted to the hospital after you were found to be in acute respiratory distress and were intubated at the outside hospital. upon transfer to the medical intensive care unit at , you were treated with diuretics to help with your breathing. you had about 30lbs of water weight taken off during your hospitalization and your respiratory status improved. while you were intubated, you developed a ventilator-associated pneumonia. you were started on antibiotics and completed a full course before you were transferred to the general medical floors. your stay in the medical intensive care unit was complicated by delirium and we suspect that your delirium was related to medication that was started in the intensive care unit. . after transfer to the general medical floor, you were found to have an infection in the parotid glands (salivary glands) you were treated with intervenous antibiotics and are being discharged on oral antibiotics which you will need to take for an additional 2 days. . you should resume all of your home medications on discharge from the hospital. . you should continue your oral antibiotics for 2 more days. . you will need to have your warfarin levels monitored because you are not fully therapeutic yet. in the meantime, you will be kept on a heparin drip. . please follow-up with your primary care physician, . , in 1 to 2 weeks after discharge. followup instructions: please follow-up with your primary care physician, . , in 1 to 2 weeks after discharge. please call his phone number at to schedule an appointment. Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Pneumonia, organism unspecified Acidosis Congestive heart failure, unspecified Unspecified septicemia Severe sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Acute on chronic diastolic heart failure Depressive disorder, not elsewhere classified Candidiasis of mouth Chronic kidney disease, unspecified Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Acute respiratory failure Septic shock Retention of urine, unspecified Unspecified accident Other encephalopathy Injury to bladder and urethra, without mention of open wound into cavity Hyperosmolality and/or hypernatremia Ventilator associated pneumonia Foreign body in respiratory tree, unspecified Sialoadenitis Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use

allergies: penicillins / cipro / macrolide antibiotics attending: chief complaint: fatigue major surgical or invasive procedure: central line insertion in ed history of present illness: 62yo m h/o chronic gastric outlet obstruction pancreatic ca p/w 6-8 weeks luq abd pain and worsening nausea, decreased po intake and vomiting. today the pt presented to cyberknife center for 1 of 3 planned fractions to pancreas. a ct abdomen revealed a gastric outlet obstruction. the pt was tachyc and an o2 sat was 77% on ra, placed on 4lo2nc with improvement to 96% and hr returned to low 90's. pt reports decreased po intake over the last couple of days and increased nausea. he reports pain to his left mid-abdomen which radiates through to his back and up to his left shoulder and across to his right shoulder. the pt was subsequently sent to the e.d. . in the ed, his vitals were 98.4 75 133/69 rr 16 98%, the pt received 2l ns, zofran 4mg, morphine 2mg, combivent nebs, solumedrol 125mg, cefepime 2gm, protonix 40mg. a central line was placed following a hypotensive episode to the 70s and the pt was started on levophed 0.06mcg. cvp was ~7. cxr revealed a large gastric bubble and an ngt was placed revealing coffee ground emesis. labs revealed a 4 point hct drop. ekg showed new biphasic tws v1-2 although ces 1st set neg. a ct torso was performed to r/o pe, dissection, infection. the pt received unasyn. . the pt was seen by both ercp and surgery that suggested the pt be kept npo overnight, with transfer to the micu for likely duodenal stenting in the am for gastric outlet obstruction. . ros: the patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, pnd, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. past medical history: # pancreatic ca (dx at me med) # cad s/p cabg ' # s/p laser ablation of plaque ' # s/p ex lap, ccy (unable to do whipple - me med) # s/p chemotx # ?copd (pt denies) # s/p umbo hernia repair # multiple back & shoulder surgeries . social history: lives in brewer me with wife. several children both in and . no etoh, + tob abuse ppdx40yrs. family history: non-contributory physical exam: vitals:t. 98.3, bp 91/56, hr 74, rr 10 sat 94% on 6l gen: lying in bed, nad, pale, thing heent:perrla, eomi, icteric, slightly dry mm, neck: supple, no jvd, no lad chest: b/l ae +crackles to mid lung field heart: s1s2 rrr 3/6 systolic flow murmur abd: +bs, +ruq ccy scar, soft, ttp llq, +hepatomegaly, no guarding or rebound ext: no c/c/e 2+pulses neuro: aaox3, cn 2-12 intact, non-focal. pertinent results: admission labs: 03:45pm blood wbc-12.8*# rbc-3.35* hgb-12.1* hct-34.4* mcv-103* mch-36.1* mchc-35.1* rdw-13.2 plt ct-183 05:10pm blood neuts-84.1* lymphs-9.3* monos-5.6 eos-0.3 baso-0.7 03:45pm blood pt-15.2* ptt-31.1 inr(pt)-1.3* 03:45pm blood plt ct-183 03:45pm blood glucose-280* urean-29* creat-0.7 na-134 k-4.2 cl-92* hco3-26 angap-20 05:10pm blood alt-12 ast-11 ck(cpk)-56 alkphos-123* totbili-0.6 05:10pm blood ctropnt-<0.01 09:30pm blood ck-mb-notdone probnp-6151* 03:45pm blood albumin-3.5 calcium-8.4 phos-2.9 mg-1.9 07:02pm blood lactate-1.3 ct torso: impression: 1. scattered ground-glass opacities within the lungs (new since ) for which the differential is broad. differential diagnosis includes drug toxicity from chemotherapeutic , infectious process (consider pcp in the neutropenic patient), atypical edema, and pulmonary hemorrhage. aspiration and lymphangitic tumor spread are not favored diagnoses. clinical correlation is advised to narrow this differential. 2. new mediastinal and hilar lymphadenopathy since . 3. gastric outlet obstruction likely secondary to known tumor encasement at the level of the second portion of the duodenum. 4. debris within the metallic common bile duct stent which was previously air-filled without evidence of intrahepatic biliary ductal dilatation. 5. new hypoattenuating lesion at the dome of the liver (series 3: image 72), which is not fully characterized on this arterial phase study. 6. renal calculi within the left kidney as described above. possible mild obstruction. recommend correlation with ultrasound if there are corresponding symptoms. 7. coronary artery calcifications, status post coronary artery bypass grafting. 8. increased size and new pulmonary nodules within the right middle lobe for which monitoring on followup exams is recommended. tte: the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is mild global left ventricular hypokinesis and focal akinesis of the distal half of the inferior wall and mid inferolateral wall (lvef = 40 %). right ventricular chamber size is normal with mild global free wall hypokinesis. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: normal left ventricular cavity size with mild global and mild regional systolic dysfunction. portable abd u/s: findings: the bowel gas pattern is essentially within normal limits with no evidence of obstruction. no free intraperitoneal gas, though this could be difficult to detect on the left decubitus view presented. if there is strong clinical suspicion for either obstruction or free intraperitoneal gas, ct would be the next imaging study. brief hospital course: mr. is a 62yo m w/ h/o chronic gastric outlet obstruction pancreatic ca now presenting with acute respiratory distress and hypotension. . # acute respiratory distress: the pt arrived in the icu now on 6l nc from a baseline of no o2 in the setting of new ground glass opacities. ddx included infection (aspiration pna, atypical), inflamatory rxn (potentially secondary to chemotherapy- gemzar), edema, hemorrhage. he was initially put on vanco, cefepime and doxycycline for coverage of aspiration and atypical pna given his h/o allergy to cipro and macrolides. he was given nebs prn. he was diuresed on without significant improvement in respiratory status. he respiratory status continued to deteriorate during his icu course despite these treatments and his o2 sat gradually trended down to the high 80's on 6lnc. given his metastatic disease, he and his family did not feel intubation was appropriate. unfortunately, he was also not stable enough for transport home to where he and his family had thought he might like to be hospice. he was made cmo in the am on . he was surrounded my his family during that day while on dilaudid gtt with ativan prn and oxygen mask. he died early in the morning of . his family was staying nearby and was notified as was his oncologist in . . # hypotension: pt was briefly placed on levophed in the ed for hypotension which quickly resolved on arrival to the icu and was discontinued. blood pressure was supported with ivf boluses prn. . # gastric outlet obstruction: the pt had originally come to on to be evaluated for cyberknife treatment but was transferred to the ed with low o2 sat. cyberknife team was contact during his icu stay but did not feel he was stable enough for treatment and was not available for consultation over the weekend of and . obstruction was likely the origin of luq abd pain and worsening nausea and secondary to extrinsic compression from pancreatic mass. ng placed and lavaged but discontinued soon an arrival to the icu. ercp was negative . pain was controlled with vicodin then morphine with fentanyl patch then finally dilaudid gtt. . # cad: pt presented with ekg changes in the setting of a hx of cad and hct < 30. ces negative x2. pt had no further ekg changes during hospitalization. medications on admission: amitriptyline - 10mg po daily clonazepam - 0.5 mg tablet - po bid fentanyl - 12mcg patch hydrocodone-acetaminophen - 5mg-500mg tablet - 2 tabs tid metformin - 1,000 mg po bid metoprolol succinate (sr)- 50 mg po bid pregabalin 75 mg po daily compazine - 10 mg po q8h prn take 30 minutes prior to cyberknife ranitidine hcl- 150 mg po bid discharge medications: pt expired. discharge disposition: expired discharge diagnosis: pt expired. discharge condition: expired. discharge instructions: . followup instructions: . Procedure: Other endoscopy of small intestine Diagnoses: Pneumonia, organism unspecified Sciatica Anemia, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Obstructive chronic bronchitis with (acute) exacerbation Aortocoronary bypass status Acute respiratory failure Pneumocystosis Malignant neoplasm of head of pancreas Hypoxemia Secondary malignant neoplasm of lung Hemorrhage of gastrointestinal tract, unspecified Esophagitis, unspecified Volume depletion, unspecified Gastroparesis Neoplasm related pain (acute) (chronic) Secondary malignant neoplasm of retroperitoneum and peritoneum

allergies: penicillins / bactrim attending: chief complaint: fever major surgical or invasive procedure: pericardial window and chest tube placement- history of present illness: 46 year old man with advanced aids with cd4 count of 1 and viral load of 30,000 on harrt (darunavir/etravirine/truvada and raltegravir) through a clinical trial who presented to osh with shortness of breath, chest pain, and fever. patient reports that 2 days pta, he began having chest pain that he describes as a very heavy person sitting on his chest, it did not radiate, was worse when he leaned forward or took a deep breath, better when laying back and was accompanied by mild sob. he took asa and celebrex (that a friend gave him) and the pain got better. his pain worsened w/ fevers to the low 101 one day pta. he initially went to hospital. he was found to have a mild elevation of troponins, negative d-dimer. his ekg showed pr depression in the inferior leads. an echo which revealed pericardial effusion. he has no history of coronary artery disease and was diagnosed with "pericarditits". he continued to have symptoms and his tte showed rapidly increasing pericardial effusion with tamponade physiology. he was taken to or emergently by c- on for pericardial window placement. patient states that his breathing improved markedly post procedure. however overnight he was found to be hypoxic with new oxygen requirement (c/t post window status) to 4lnc. he continued to spike temp to 102 and his hr also increased from 110s to 140s, sinus tachycardia. his uop decreased overnight and recieved 40 iv lasix at midnight and has put out >2.5 l to that. he recieved another 40 iv lasix early this morning. his pleuritic chest pain worsened however still markedly better than his admission pain. patient was transfered to ccu for further management of his care. . he denies any palpitations, worsening shortness of breath, nausea, vomitting, diaphoresis, abdominal pain, diarrhea, constipation, headache, neck stiffness, lower extremity swelling. review of systems is otherwise negative. past medical history: hiv infection/aids- dx . pt states he has been on "every med in the book". per omr records, multiple different drug regimens. followed by dr. in id since cmv retinitis thrush/candidal esophagitis gerd erectile dysfunction. seasonal allergies. social history: recently married to his same-sex partner, x 5 years and reports that they use protection. quit tobacco approximately 4 months ago. occasional etoh. denies recreational drug use family history: sister with cancer denies any significant disease, parents still alive and healthy. two siblings both healthy physical exam: general: pleasant, in nad, sitting up in bed, well developed, well nourished, following commands heent:perrl, eoemi, sclerae anicteric, mmm neck: jvp 8 cm cardiovascular: rrr, normal s1, s2 with rubs chest wall: no sternal chest pain, drain in place respiratory: decreased bs in right base. no wheeze. gastrointestinal: +bs, soft, non-tender, non-distended musculoskeletal: moving all extremities ext: warm and well perfused, no edema. 2+ dp pulses palpable bilaterally pertinent results: tte the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the right ventricular free wall is hypertrophied. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. there is a small pericardial effusion. the effusion appears circumferential. there are no echocardiographic signs of tamponade. impression: mild symmetric left ventricular hypertrophy with normal systolic function. small pericardial effusion with no evidence of tamponade tte overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is mildly dilated with normal free wall contractility. there is a moderate sized circumferential pericardial effusion. there is brief right ventricular diastolic invagination consistent with elevated intrapericardial pressure, low right-sided filling pressures, or both. impression: moderate sized pericardial effusion with evidence of elevated intrapericardial pressures. compared with the prior study (images reviewed) of , pericardial effusion may be slightly larger. the other findings are similar. tte the left atrium is normal in size. a patent foramen ovale is present. the estimated right atrial pressure is 0-5 mmhg. overall left ventricular systolic function is mildly depressed (lvef= 30-35 %). the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. there are three aortic valve leaflets. the mitral valve appears structurally normal with trivial mitral regurgitation. there is a large pericardial effusion. the effusion appears circumferential. the pericardium appears thickened. there is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. pericardial fluid drained surgically with resolution of tmaponade physiology. small size left sided pleural effusion tte there is a small pericardial effusion appears somewhat echo dense, consistent with blood, inflammation or other cellular elements. there are no echocardiographic signs of tamponade. no right atrial or right ventricular diastolic collapse is seen. compared with the prior study (images reviewed) of , the pericardial effusion size has decreased. tte due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size is normal. there is abnormal septal motion suggestive of pericardial constriction. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. the mitral valve leaflets are mildly thickened. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. there is a small pericardial effusion with echodense elements in the pericardial space consistent with organization and probable adhesion/pericardial constriction. the pericardium appears thickened. compared with the prior study (images reviewed) of , findings are similar. ct head impression: no acute intracranial process. note added in attending review: there is moderate mucosal thickening involving the anterior ethmoidal air cells, bilaterally, and limited included left maxillary sinus, which appears new (though bone algorithm reconstructions were not performed, previously). the remaining included paranasal sinuses, as well as the mastoid air cells and middle ear cavities are clear, as above. such findings are seen commonly in hiv(+) patients, and should be correlated clinically. abdominal ultrasound: 1. right interpolar hypoechoic focus, while likely represents a prominent renal pyramid, cannot exclude a small focus of pyelonephritis. 2. gallbladder wall edema, with pericholecystic fluid, but no gallbladder wall distention. unlikely to represent acute cholecystitis. likely secondary to iv hydration or low oncotic pressure. 3. three left and one right lobe hepatic hemangioma as described above. essentially unchanged in size and appearance compared to the prior ct study, allowing the difference of technique. 4. small amount of ascites. ct chest with and without contrast 1. no pulmonary embolism to segmental level, although determination of the distal pulmonary arteries is not possible due to inadequate contrast opacification and respiratory motion artifact.v/q scan may be useful if clinically indicated 2. no dissection or aortic aneurysm. 3. large pericardial effusion 4. small-to-moderate bibasilar pleural effusions with probable loculated effusion in the right lung base. small pulmonary nodules with the soft tissue in a periaortic and peribronchovascular distribution raises the possibility of kaposi's sarcoma, correlation with presence of cutaneous lesions is recommended. 5. bibasilar and retrocardiac atelectasis in the left lower lobe. 6. splenomegaly with ascites surrounding the liver edge. , p m 46 radiology report renal u.s. study date of 11:21 am , m. med cc7a 11:21 am renal u.s. clip # reason: arf please eval for acute renal process medical condition: 46 year old man with hiv, pericardits now w/ new cva tenderness. please eval for acute renal process reason for this examination: please eval for acute renal process final report indication: a 46-year-old man with acute renal process. comparison: abdomen ultrasound . findings: the right kidney measures 13.9 cm. the left kidney measures 12.8 cm. there is no hydronephrosis. a right renal pyramid with the questionable appearance on the prior ultrasound is less prominent on today's exam and does appear consistent with the pyramid. the kidneys are slightly echogenic bilaterally. there is no cyst or stone or solid mass identified. the pre-void bladder is only partially distended, but is otherwise unremarkable. impression: no hydronephrosis and no perinephric collection identified. the study and the report were reviewed by the staff radiologist. , rdms dr. sun approved: fri 2:14 pm imaging lab pericardial tissue and fluid grew mrsa, blood (+) for cryptococcal antigen titre 1:4, known prior to admission; all other cultures negative to date 05:20pm blood wbc-4.2# rbc-3.24*# hgb-10.2*# hct-30.4*# mcv-94 mch-31.5 mchc-33.6 rdw-14.0 plt ct-139* 10:45am blood wbc-5.8 rbc-3.05* hgb-9.6* hct-29.0* mcv-95 mch-31.5 mchc-33.1 rdw-14.8 plt ct-137* 05:40am blood wbc-6.2 rbc-2.86* hgb-9.1* hct-27.2* mcv-95 mch-31.8 mchc-33.5 rdw-14.5 plt ct-142* 03:36pm blood wbc-7.1 rbc-2.52* hgb-7.9* hct-23.9* mcv-95 mch-31.2 mchc-33.0 rdw-15.0 plt ct-153 03:24am blood wbc-5.9 rbc-2.67* hgb-8.3* hct-25.1* mcv-94 mch-31.3 mchc-33.2 rdw-14.9 plt ct-159 06:12am blood wbc-5.2 rbc-2.15* hgb-6.7* hct-20.9* mcv-97 mch-30.9 mchc-31.9 rdw-14.3 plt ct-393 09:38am blood hct-27.1*# 06:00am blood wbc-4.2 rbc-2.64* hgb-8.0* hct-25.5* mcv-97 mch-30.5 mchc-31.5 rdw-14.4 plt ct-385 05:31pm blood wbc-3.9* rbc-2.84* hgb-8.4* hct-27.2* mcv-96 mch-29.6 mchc-30.8* rdw-14.5 plt ct-405 05:49am blood wbc-4.3 rbc-2.94* hgb-8.9* hct-27.8* mcv-95 mch-30.5 mchc-32.1 rdw-14.1 plt ct-454* 10:45am blood neuts-86.8* bands-0 lymphs-6.2* monos-6.3 eos-0.7 baso-0.1 05:30am blood neuts-72.3* lymphs-16.2* monos-9.5 eos-1.7 baso-0.2 05:20pm blood pt-12.6 ptt-25.2 inr(pt)-1.1 10:45am blood pt-13.1 ptt-28.0 inr(pt)-1.1 03:36pm blood pt-13.5* ptt-28.8 inr(pt)-1.2* 04:08pm blood pt-13.5* ptt-27.0 inr(pt)-1.2* 05:18am blood pt-13.5* ptt-26.4 inr(pt)-1.2* 11:15am blood parst s-negative 06:00am blood cd45-d kappa-d cd2-d cd7-d cd19-d lambda-d 06:00am blood cd3%-d cd4%-d cd8%-d 05:36am blood ret aut-0.9* 06:00am blood ipt-d 05:20pm blood glucose-100 urean-18 creat-1.0 na-140 k-4.3 cl-106 hco3-25 angap-13 10:45am blood glucose-122* urean-25* creat-1.2 na-141 k-4.0 cl-109* hco3-24 angap-12 05:40am blood glucose-109* urean-17 creat-0.9 na-142 k-4.2 cl-111* hco3-21* angap-14 03:36pm blood urean-17 creat-1.0 cl-110* hco3-21* 03:24am blood glucose-91 urean-18 creat-1.3* na-137 k-4.8 cl-108 hco3-19* angap-15 06:10am blood glucose-98 urean-27* creat-2.3* na-136 k-4.2 cl-103 hco3-19* angap-18 04:08pm blood urean-27* creat-2.7* na-136 k-3.7 cl-102 hco3-20* angap-18 05:18am blood glucose-87 urean-29* creat-2.8* na-140 k-3.8 cl-105 hco3-21* angap-18 05:36am blood glucose-103 urean-28* creat-2.7* na-143 k-3.9 cl-110* hco3-23 angap-14 05:30am blood glucose-97 urean-26* creat-2.5* na-146* k-4.2 cl-110* hco3-25 angap-15 05:41am blood glucose-100 urean-28* creat-2.1* na-143 k-4.5 hco3-25 06:00am blood glucose-95 urean-29* creat-2.1* na-142 k-4.8 cl-107 hco3-25 angap-15 05:31pm blood glucose-114* urean-30* creat-2.0* na-140 k-4.7 cl-105 hco3-26 angap-14 05:49am blood glucose-85 urean-29* creat-2.1* na-144 k-4.9 cl-108 hco3-23 angap-18 10:45am blood alt-46* ast-37 ld(ldh)-180 ck(cpk)-146 alkphos-98 amylase-35 totbili-1.1 05:40am blood alt-70* ast-84* ld(ldh)-216 alkphos-112 totbili-0.8 03:36pm blood alt-49* ast-54* ld(ldh)-182 alkphos-100 amylase-27 totbili-1.1 06:10am blood alt-50* ast-58* alkphos-154* totbili-3.0* 05:18am blood alt-44* ast-65* alkphos-212* totbili-2.1* 05:36am blood alt-45* ast-57* alkphos-206* totbili-1.2 05:59am blood alt-34 ast-33 ld(ldh)-311* alkphos-167* totbili-0.9 03:24am blood lipase-14 03:36pm blood lipase-13 10:45am blood lipase-16 10:45am blood ck-mb-3 ctropnt-0.07* 05:20pm blood ck-mb-4 ctropnt-0.16* 05:20pm blood calcium-8.0* phos-2.8 mg-2.1 10:45am blood albumin-3.4 calcium-7.3* phos-2.0* mg-2.1 iron-11* 05:40am blood calcium-7.4* phos-1.1* mg-2.2 06:00am blood calcium-8.5 phos-3.1 mg-2.1 05:49am blood calcium-8.6 phos-3.6 mg-2.0 10:45am blood caltibc-179* hapto-338* ferritn-522* trf-138* 05:59am blood hapto-564* 02:03pm blood freeca-1.06* 03:41pm blood freeca-1.05* 06:38pm blood freeca-1.09* 01:26am blood freeca-1.10* 01:50am blood herpes simplex virus 1 and 2 antibody igm-test name 01:50am blood herpes simplex (hsv) 1, igg-test 01:50am blood herpes simplex (hsv) 2, igg-test name 11:15am blood anaplasma phagocytophilum (human granulocytic ehrlichia ) igg/igm-test 11:15am blood mountain spotted fever ab igg, igm-test 11:15am blood vitamin d 25 hydroxy-test 05:36am blood b-glucan-test 05:36am blood aspergillus galactomannan antigen-test 02:21pm blood ebv pcr, quantitative, whole blood- 09:29am urine color-straw appear-clear sp -1.005 02:25am urine color-yellow appear-clear sp -1.009 09:29am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg 02:25am urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-neg 02:25am urine rbc-0-2 wbc-0-2 bacteri-none yeast-none epi-0 02:31pm urine rbc-1 wbc-3 bacteri-few yeast-none epi-0 08:36pm urine rbc-* wbc-0-2 bacteri-many yeast-none epi-0-2 02:31pm urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 02:31pm urine color-yellow appear-clear sp -1.005 12:37pm urine casthy-0-2 02:25am urine eos-negative 08:36pm urine eos-negative 02:25am urine hours-random urean-447 creat-74 na-48 10:50am urine hours-random creat-38 na-33 phos-11.3 08:36pm urine hours-random urean-371 creat-74 na-58 12:37pm urine histoplasma antigen-test 03:25pm other body fluid wbc-4350* rbc-7850* polys-75* lymphs-9* monos-11* eos-5* time taken not noted log-in date/time: 4:12 pm fluid,other pericardial fluid. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): reported by phone to dr , 110pm. staph aureus coag +. rare growth. sensitivities performed on culture # 280-8328h . staphylococcus, coagulase negative. rare growth. anaerobic culture (final ): no anaerobes isolated. fungal culture (final ): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): time taken not noted log-in date/time: 4:35 pm tissue pericardium. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. tissue (final ): reported by phone to dr , 110pm. staph aureus coag +. sparse growth of two colonial morphologies. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations rifampin should not be used alone for therapy. dr requested sensitivities to daptomycin and linezolid . trimethoprim/sulfa sensitivity testing confirmed by . daptomycin = 0.19mcg/ml sensitivity testing performed by etest. linezolid sensitivity testing performed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- =>8 r daptomycin------------ s erythromycin---------- =>8 r gentamicin------------ 8 i levofloxacin---------- =>8 r linezolid------------- s oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- =>16 r trimethoprim/sulfa---- r vancomycin------------ <=1 s anaerobic culture (final ): no anaerobes isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): fungal culture (final ): no fungus isolated. viral culture (preliminary): no virus isolated so far. brief hospital course: # pericarditis: patient presented from osh w/ presumed pericarditis. on admission he had chest pain and ekg changes consistent w/ pericarditis. he as initially treated w/ nsaids for pain control. tte was done which showed a small pericardial effusion. on hd 3 he developed cardiac tamponade and was taken to the or for an emergent pericardial window. he tolerated the procedure well and was transfered to the floor on post-op day 1. pericardial fluid culture and tissue pathology revealed mrsa. he was continued on vancomycin and discharged w/ instructions to finish a 4 week course of vancomycin. he had no more issues w/ chest pain after the pericardial window. he was discharged w/ follow up appointment with cardiology. . # low grade fevers: after his pericardial window was placed (and while on vancomycin), he continued to have low-grade fevers, the etiology of which was not determined. a thorough workup, with the notable exception of a ct abd/pelvis with contrast (given acute renal failure), was performed. he was discharged with follow up with his outpatient pcp/hiv physician and possible bone marrow biopsy. . # sinus tachycardia and hypoxia: on post-op day 2 patient developed sinus tachycardia to 140s and hypoxia sats to high 80s. this was thought to be due to a combination of fluid overhydration causing pleural effusion and infectious process. he was treated w/ iv lasix and after diuresing his respiratory status imporoved. he was transfered to the ccu for closer monitoring. pcp sputum negative. negative influenza panel. no evidence of end organ ischemia currently. not thought to be haveing significant reaccumilation of pericardial fluid as pt had tte that showed small pericardial effusion. vancomycin was continued. he was ruled out for tb w/ 3 (-)afb sputum and cultures. his respiratory status was stable throughout ccu course, upon transfer to the floor and throughout the rest of his hospitalization. . # aids treatment - patient w/ history of aids, cd4 count at 1, viral load 30k, currently enrolled in a experimental rescue study. he was continued on his current haart therapy including his study meds. ppx medications were continued except for dapsone which was stopped when patient developed arf. dapsone was re-strated on discharge. . # arf: patient had normal renal function on admission. he developed arf on hd 4, w/ cr peaking at 2.8 and stabilizing at 2.0-2.1. this was thought to be due to the contrast that the patient received for the cta with a component of hypoperfusion while he was in tamponade. he continued to make urine throughout admission and did not require hemodialysis. medications were subsequently renally dosed. he was discharged w/ follow up appointment with nephrology. . # pulmonary nodule: patient was found to have a small pulmonary nodules with the soft tissue in a periaortic and peribronchovascular distribution raised the possibility of kaposi's sarcoma. pt also had well-circumscribed mass in right posterior lung base at periphery. patient was discharged w/ an appointment with hematology/oncology to follow up this finding. . # anemia: patient's hematocrit was 40.8 3 month. on admission it was 30.4 and it continued to decrease until it stabilized in 24-27 range. he had no overt source of bleed and remained asymtomatic throughout admission. patient was discharged w/ an appointment with hematology/oncology to follow up this new anemia. medications on admission: medications on transfer to ccu: emtricitabine-tenofovir (truvada) 1 tab po q48h darunavir 600mg tablet study med 600 mg po bid etravirine 100mg tablet study med 200 mg po bid raltegravir 400mg tablet study med 400 mg po bid ritonavir (oral solution) 100 mg po bid vancomycin 1000 mg iv q12h furosemide 40 mg iv once @ 0915 ipratropium bromide neb 1 neb ih q4h:prn dyspnea diphenhydramine 50 mg po q6h:prn itching zolpidem tartrate 5 mg po hs:prn insomnia pantoprazole 40 mg po q24h hydromorphone (dilaudid) 2-4 mg po q3h:prn pain atorvastatin 40 mg po daily dapsone 100 mg po daily mupirocin cream 2% 1 appl tp tid gabapentin 300 mg po bid fluconazole 400 mg po q24h azithromycin 1200 mg po qsunday doxycycline hyclate 100 mg iv q12h milk of magnesia 30 ml po daily:prn constipation aspirin ec 81 mg po daily acetaminophen 650 mg po/pr q4h:prn discharge medications: 1. vancomycin 500 mg recon soln sig: one (1) recon soln intravenous q 12h (every 12 hours) for 18 days. disp:*36 recon soln(s)* refills:*0* 2. sash protocol flush with ns 10ml pre & post dose; heparin 50 units after each dose 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. azithromycin 600 mg tablet sig: two (2) tablet po qsunday (). 5. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 6. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours). 7. ritonavir 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. raltegravir 400 mg tablet sig: one (1) tablet po bid (2 times a day). 9. darunavir 600 mg tablet sig: one (1) tablet po bid (2 times a day). 10. etravirine 100 mg tablet sig: two (2) tablet po bid (2 times a day). 11. emtricitabine-tenofovir 200-300 mg tablet sig: one (1) tablet po q48h (every 48 hours). 12. dapsone 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 13. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for temperature >100.4. 14. esomeprazole magnesium 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (). 15. lipitor 20 mg tablet sig: 1.5 tablets po at bedtime. 16. ambien 5 mg tablet sig: one (1) tablet po at bedtime. discharge disposition: home with service facility: vna discharge diagnosis: primary diagnosis: mrsa pericarditis acute renal failure persistent fevers secondary diagnosis hiv/aids discharge condition: stable discharge instructions: you came to the hospital with chest pain, difficulty breathing, and spiking fevers on . you were diagnosed with mrsa pericarditis that resulted in a large percardial effusion requiring surgical drainage. a window was made between your pericardium and your pleural space and a chest tube was placed to drain the pericardial fluid from the pleural space. the chest tube was subseuqently removed and your chest pain and shortness of breath have improved significantly over the course of your stay. . you also developed acute renal failure during the hospital stay that we believe to be related to poor perfusion in the setting of cardiac tamponade (constriction of the heart in the setting of a large pericardial effusion). hydration and renal dosing of your medication have improved your renal function and urine output; however, you may have a new baseline in terms of your renal function. we have changed your truvada dosing to 1 tablet every other day and your fluconazole to 200mg/day. . in addition, you have had spiking fevers at night throughout the hospital stay. we performed an extensive infectious workup including blood and urine cultures, imaging, and pcr/antibody tests which did not reveal any infectious sources, other than the mrsa that was found in the pericardial tissue/fluid. we are continuing to treat the mrsa with a 4 week course of vancomycin. in addition, we would like you to take flucanzole, azithromycin, and dapsone for fungal, mac, and pcp respectively. . we would like you to continue to monitor your vital signs (heart rate, temperature, blood pressure) at least 3x/day at home for the next 7 days and then follow up with dr. and dr. . while you were here, we have made the following changes to your medications: 1. we would like you to continue taking your aids medications, as well as vancomycin for mrsa and flucanzole, azithromycin, and dapsone for prophalaxis. 2. we decreased your truvada dose (1 tablet every other day) 3. we decreased your fluconazole to 200 mg daily 4. we started you on dapsone 100 mg po daily 5. we started you on aspirin 81 mg daily we also need you to follow up with nerphrology for evaluation of your kidney function, cardiology for a repeat echo in months, and hematology for evaluation of potential bone marrow biopsy. we will call you with appointment times in the next day when we schedule them. . if you develop chest pain, palpitations, shortness of breath, reduced urine output, high fevers, shaking chills or any other concerning symptoms, please go to your nearest emergency room. followup instructions: please ensure that loculated pleural effusion seen on ct scan is followed up upon discharge provider: , md phone: date/time: 10:00 provider: , m.d. (nephrology) phone: date/time: 1:30 we will contact you regarding you upcoming appointment with hematology/oncology for a bone marrow bx. it is very important that you come to this appointment. provider: , md (cardiology) phone: date/time: 2:20 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Arterial catheterization Other incision of pleura Pericardiotomy Diagnoses: Anemia, unspecified Esophageal reflux Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Congestive heart failure, unspecified Personal history of tobacco use Human immunodeficiency virus [HIV] disease Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Other diseases of lung, not elsewhere classified Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site Acute diastolic heart failure Hyperosmolality and/or hypernatremia Cytomegaloviral disease Other antimycobacterial drugs causing adverse effects in therapeutic use Other drugs and medicinal substances causing adverse effects in therapeutic use Candidal esophagitis Cardiac tamponade Impotence of organic origin Other acute pericarditis Chorioretinitis, unspecified Kaposi's sarcoma, lung

allergies: no known allergies / adverse drug reactions attending: chief complaint: s/p mechanical fall, displaced nail from l hip repair major surgical or invasive procedure: conversion of left failed hip fixation to hip hemiarthroplasty with bone grafting and removal of an existing tfn implant history of present illness: yof with htn, hld, glaucoma s/p l intertrochanteric hip fracture repair with intramedullary nail placement presenting from rehab for left hip pain and drainage from the site of the procedure. . in brief, the patient was found to have displacement of the nail into the acetabulum and underwent left hemiarthroplasty repair . she received 2 units prbc intra-op for a 900cc blood loss, and received 2 additional units prbc, 1 unit ffp, 250cc albumin, and 500cc bolus ns for sbp 80's and hct 30.2 in the pacu. she also received lasix 10mg iv. sbp increased to 100's-110's subsequently with a total i/o in the pacu of 3.3l/1.1 for net postive 2.2l. in this context, she was noted to have decreased uop, increased lethargy, and hypoxia of 88% 3l on transfer to the floor and subsequently required a nrb for po2 mid-90's. she was given lasix 20mg iv with mild improvement to po2 92% on 5l nc, and unclear urine output. she was also noted to be in acute renal failure 1.4 -> 1.8 with an unclear baseline. she was noted to be disoriented and lethargic, and medicine was consulted. the patient was transferred to the micu team for further management. . in the micu, the patient received lasix 20mg iv for diuresis and was negative 1l overnight. her po2 improved to 97-98% on 4l nc and was to be called out yesterday, but had an episode of desaturation to low 90s on 4l nc and the patient was monitored for another night in the micu without any further episodes of hypoxia. the etiology of the episode of hypoxia was unclear. she has been stable and breathing comfortably without hypoxia since. . currently, the patient denies shortness of breath, chest pain, nausea, abdominal pain, or pain at her surgical site. . ros: unable to obtain. past medical history: hypertension hyperlipidemia depression glaucoma, legally blind heard of hearing social history: was in rehab on newbridge on the , generally lives independently. no tobacco, alcohol or drug use family history: non-contributory physical exam: vs: afebrile hr 77 po2 97% on 4l nc bp 97/38 . gen: alert, interactive, appropriate, comfortable, nad heent: pupils equal and round, dry mm neck: jvp to earlobe sitting at 45 degrees cv: rrr, harsh gii systolic murmur at rusb, gii holosystolic murmer at lsb, gii low pitched holosystolic murmer at apex resp: diffused crackles at bases b/l with rales to mid-lung fields on the left. breathing comfortably without accessory muscle use. gi: soft ntnd ext: no c/c, stockings and pneumoboots in place . . exam at discharge: 979.8 142/60 hr 77 rr 20 93% ra weight 71.2 kg gen: alert, interactive, appropriate, comfortable, nad heent: pupils equal and round, mmm neck: no jvd cv: rrr, no m,r,g resp: rare crackles at bases, that clear with deep inspiration. breathing comfortably without accessory muscle use. gi: soft ntnd ext: no c/c, stockings and pneumoboots in place left hip with staples in place, wound clean and dry without ecchymosis, non-tender to palpation pertinent results: 04:10pm sed rate-100* 04:10pm pt-12.7 ptt-27.9 inr(pt)-1.1 04:10pm plt count-240 04:10pm neuts-71.6* lymphs-19.3 monos-6.4 eos-2.3 basos-0.3 04:10pm wbc-7.1 rbc-3.81* hgb-11.6* hct-36.1 mcv-95# mch-30.4 mchc-32.1 rdw-16.8* 04:10pm crp-27.4* 04:10pm calcium-9.4 phosphate-3.2 magnesium-2.8* 04:10pm estgfr-using this 04:10pm glucose-127* urea n-61* creat-2.0* sodium-138 potassium-4.3 chloride-106 total co2-25 anion gap-11 imaging: the patient is status post orif of a left proximal femur fracture transfixed by gamma nail and short intramedullary rod. on the current images, the proximal gamma nail tip extends through the femoral head articular cortex, across the joint space, into the acetabulum. there is increased lucency about the proximal tip of the gamma nail within the acetabulum, suggesting bone loss in the acetabulum. no displacement of the intramedullary portion of the hardware is identified. aside from the areas immediately about the hardware, the articular cortex remains intact, without resorption. the femoral neck fracture line remains visible. ununited greater trochanteric and lesser trochanteric fragments are present. there is some surrounding callus/heterotopic bone. some of this density may also represent bone debris secondary to the hardware. of note, a 1 cm metallic density projects adjacent to the proximal femur, new compared with the preoperative film, ?surgical clip or displaced metal component. some increased density in the surrounding soft tissues is noted, question of superimposition of shadows vs. localized hemorrhage . . exam at discharge: wbc rbc hgb hct mcv mch mchc rdw plt ct 7.6 2.74* 8.5* 25.3* 93 31.2 33.7 16.4* 281 glucose urean creat na k cl hco3 angap 121 43 1.4 143 3.7 107 28 12 calcium phos mg 8.0* 2.6* 1.7 tsh 5.9 free t4 0.93 crp 27.4* esr 100 brief hospital course: f w/ htn, hld s/p orif l-hip now s/p left hemiarthroplasty repair with persistent hypoxia, intermittent altered mental status, both resolved. 1. hypoxic respiratory distress- secondary to volume overload given fluid repletion in or and 4u prbc and 1u ffp. pt w/ evidence of volume overload on cxr and +2200cc from pacu. pt has no prior documentation of cardiac dysfunction in our system and ef is unknown. patient tolerated gentle diuresis w/ 20mg iv lasix. she was not hypercarbic so did not need bipap initiation. weaned oxygen slowly over two days and patient had o2 sat of 93% on room air on day of discharge. . 2. ams- patient at baseline is alert and oriented. evaluated for infectious etiology, cultures negative to date. once patient's respiratory status improved, her mental status returned to baseline. . 3 elevated troponin- troponin elevated at 0.06, mb not done, this could be elevated creatinine or demand ischemia from hypoxia. ekg c/w rbbb w/ lafb, new lateral st changes w/ upward sloping of st segment in v4-v6. ces and mbs remained flat, ecg changes resolved. no evidence of infarct, likely due to demand ischemia. . 4 leukocytosis- likely secondary to inflammation following surgery. evaluated for infectious etiology, cultures negative to date. resolved. . 5 acute kidney injury- could be atn from hypotension as pt was reported to be hypotensive to 80s on the floor. this seems to respond to fluid boluses and currently has improved to 119. creatinine returned to baseline of 1.4 after diuretics were held. acei started prior to discharge, creatinine stable. . 6 chronic diastolic heart failure- small lv on tte. has history of htn. bp improved, hematocrit stable. metoprolol tartrate uptitrated to 50 tid. started lisinopril prior to discharge without change in renal function. patient euvolemic at discharge, no need for diuretics. will need periodic monitoring, and if weight increases above 72 kg, patient will need furosemide 40 mg po daily until weight returns below 72 kg. . . glaucoma- continued home eye drops . 6. s/p hemiarthroplasty repair- patient is weight bearing as tolerated. will need three more weeks of lovenox. follow up appointment with orthopedic surgeon next week. will need continued pt. . 7. htn- has hx htn but has been hypotensive in house. home antihypertensives held. . full code medications on admission: metoprolol 150, norvasc 10', triamterine-hctz37.5-25', zocor 10', paxil 10', melphagan 1 dropbid per eye 15ml, cozoft 10 ml eye drop qday. discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po q8h (every 8 hours). 4. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 5. paroxetine hcl 10 mg tablet sig: one (1) tablet po daily (daily). 6. acetaminophen 325 mg tablet sig: one (1) tablet po tid (3 times a day). 7. enoxaparin 30 mg/0.3 ml syringe sig: one (1) subcutaneous q24h (every 24 hours) for 3 weeks: to finish on . 8. dorzolamide-timolol 2-0.5 % drops sig: one (1) drop ophthalmic (2 times a day). 9. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 10. multivitamin tablet sig: one (1) tablet po daily (daily). 11. brimonidine 0.15 % drops sig: one (1) drop ophthalmic (2 times a day). 12. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day): hold for sbp < 100, hr < 55. 13. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 14. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily): hold for sbp < 100. discharge disposition: extended care facility: senior healthcare of discharge diagnosis: primary diagnosis: left failed hip fixation s/p hip hemiathroplasty diastolic heart failure secondary diagnosis: htn glaucoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted to the hospital after falling, and needed a surgical repair your left hip. in the operating room, you needed blood transfusions, and you oxygen level dropped from the blood and iv fluids. you were monitored in the icu and received medications to help you remove the fluids. you were then transferred out to the floor, and your oxygen levels became normal. your medications were adjusted, see below for details. you were then discharged from the hospital to a rehab facility to continue physical therapy. . please see below for your follow up appointments. . followup instructions: please keep these follow up appointments: department: orthopedics when: thursday at 11:20 am with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage department: orthopedics when: thursday at 11:40 am with: , md building: campus: east best parking: garage Procedure: Partial hip replacement Removal of implanted devices from bone, femur Diagnoses: Anemia, unspecified Pure hypercholesterolemia Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Acute on chronic diastolic heart failure Unspecified glaucoma Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Osteoporosis, unspecified Hypoxemia Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Altered mental status Other mechanical complication of other internal orthopedic device, implant, and graft

allergies: no known allergies / adverse drug reactions attending: chief complaint: s/p cardiac arrest in ed major surgical or invasive procedure: endotracheal intubation history of present illness: 74 h/o mr, schizophrenia, htn, lives at group home, last seen normal 8pm. went to sleep at group home. 11 pm noted to be unresponsive. fs 170. pinpoint pupis. afib in 90s. no h/o afib. came to ed. in ed, went for head ct. when came back, jaw clenched and had tonic clonic activity. noted to be cyanotic and pulseless. cpr intiated at 0404. was difficult to assess rhythm. not given shock. given 1 mg epi, 1 mg atropine. 0409 resumed spontaneous circulation and was in afib. then transistioned to sinus rhythm. intubated. fem line placed. started levophed. given vanc/ceftriaxone/acyclo, was initially in afib and then converted to sinus. cards wasnt worried about acute ischemia. recommended jsut pr aspirin. was mildly hypothermic when came in, rectal temp 34. past medical history: urinary incont obesity hypertension paranoid schizophrenia: in psych f/u: geropsych hx glaucoma: open angle: last eye eval:_8/: next due:: retinal ophth: sees ne eye (due ) hx dementia hx ppd (+) hx anxiety hx dry eyes head trauma (bike) 10yo hx wandering hx cataract hx left vith nerve palsy elev creat: 1.8, anemia: nml fe, nml hgb electrophoresis: c/w anem chron dis/cri cri: ref'd renal social history: the patient lives currently in a group home and attends the day program. he apparently does have some issues when he becomes increasingly anxious. no known substance abuse or sexual activity. family history: unable to elicit given patient's cognitive status. physical exam: vitals: t 34c bp 141/73 hr 67 o2 sat 100% (intubated) general appearance: no acute distress eyes / conjunctiva: perrl head, ears, nose, throat: endotracheal tube cardiovascular: (s1: normal), (s2: normal), no(t) s3, no(t) s4, no(t) rub, (murmur: no(t) systolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: clear : ) abdominal: soft, non-tender, bowel sounds present extremities: right lower extremity edema: absent, left lower extremity edema: absent, no(t) cyanosis, no(t) clubbing skin: not assessed, no(t) rash: , no(t) jaundice neurologic: no(t) attentive, responds to: noxious stimuli, movement: not assessed, tone: not assessed . discharge exam: vs: 96.6 bp: 130-180/60-90, hr 60-70 18 97% ra gen: no apparent distress. says yes sir to most questions. eyes: anicteric heent: op clear, mmm cv: normal s1 and s2, no s3 or s4. res: cta-posteriorly abd: soft, nt, nd, +bs ext: warm, no c/c/e. pertinent results: 12:25am blood wbc-4.4 rbc-3.42* hgb-11.0* hct-33.0* mcv-97 mch-32.1* mchc-33.2 rdw-14.6 plt ct-118* 12:25am blood neuts-62.5 lymphs-25.7 monos-5.1 eos-6.3* baso-0.4 04:25am blood pt-13.1 ptt-150* inr(pt)-1.1 04:26am blood ret aut-1.9 01:30am blood glucose-169* urean-32* creat-1.6* na-138 k-3.9 cl-101 hco3-30 angap-11 01:30am blood alt-47* ast-36 ld(ldh)-160 alkphos-126 totbili-0.2 04:25am blood ck(cpk)-546* 01:30am blood lipase-17 01:30am blood ctropnt-0.10* 04:25am blood ck-mb-17* mb indx-3.1 04:25am blood ctropnt-0.25* 04:25am blood calcium-8.7 phos-4.7* mg-2.2 12:14pm blood caltibc-189* vitb12-525 folate-7.1 hapto-77 ferritn-216 trf-145* 04:25am blood osmolal-310 04:25am blood tsh-6.0* 04:25am blood cortsol-18.5 04:25am blood ethanol-neg 01:30am blood asa-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 02:03am urine color-straw appear-clear sp -1.012 02:03am urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 02:03am urine rbc-3* wbc-2 bacteri-few yeast-none epi-0 rapid plasma reagin test (final ): nonreactive. reference range: non-reactive. ct head : impression: no acute intracranial process, and no change. echo : the left atrium is elongated. the right atrium is moderately dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the right ventricular cavity is mildly dilated with borderline normal free wall function. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: normal global and regional left ventricular systolic function. mildly dilated right ventricle with borderline normal function. mild mitral regurgitation. cta chest : 1. no acute cardiothoracic process including no evidence of pulmonary embolism. 2. no acute process of the abdomen and pelvis. 3. slightly limited assessment of the upper abdomen due to lack of oral contrast. mr acute abnormalities. small vessel ischemic changes as described. . discharge labs: 06:50am blood wbc-4.8 rbc-2.73* hgb-8.6* hct-25.4* mcv-93 mch-31.4 mchc-33.7 rdw-15.5 plt ct-218 06:25am blood neuts-48* bands-0 lymphs-36 monos-9 eos-7* baso-0 atyps-0 metas-0 myelos-0 06:50am blood plt ct-218 06:50am blood plt ct-218 06:50am blood glucose-71 urean-21* creat-1.7* na-141 k-4.1 cl-105 hco3-30 angap-10 06:50am blood alt-66* ast-42* alkphos-95 totbili-0.3 04:04pm blood ck-mb-28* mb indx-3.2 ctropnt-0.19* 06:50am blood albumin-3.2* calcium-8.9 phos-3.6 mg-2.1 12:14pm blood caltibc-189* vitb12-525 folate-7.1 hapto-77 ferritn-216 trf-145* . ecg : sinus rhythm with a-v conduction delay. low limb lead qrs voltage. delayed r wave progression. modest inferolateral lead t wave changes. findings are non-specific. clinical correlation is suggested. since the previous tracing of sinus tachycardia and right bundle-branch block are both now absent. . ecg : sinus bradycardia. delayed r wave progression with late precordial qrs transition. modest diffuse t wave changes. prominent u waves. findings are non-specific but cannot exclude drug/electrolyte/metabolic effect. since the previous tracing of probably no significant change. . cxr there are persistent low lung volumes. cardiac size is top normal, accentuated by the low lung volumes. pulmonary edema is unchanged. small bilateral pleural effusions associated with atelectasis left greater than right are unchanged. there are no new lung abnormalities. . microbiology: no growth for bc and uc to date. brief hospital course: 74 yo admitted for found unresponsive at group home. during his initial evaluaiton he had a cardiac arrest in the ed. he was admitted to the micu for post-arrest cooling protocol and transferred to the floor. his post-icu course was complicated by hypertension and hyperglycemia. 1. status post cardiac arrest - circumstances regarding arrest are somewhat unclear. after being found unresponsive at his group home during standard bed checks, mr. was brought to the ed for eval. in the ed, he was awake, but altered. a nurse from his group home stated that she witnessed possible seizure like activity. shortly after, mr. was found to be pulseless and acls was initiated. initial rhythm is unknown as no rhythm strips were available from the ed. he underwent 3 minutes of resuscitation with epinephrine, atropine and cpr with return to pulsatile rhythm afterwards. initial perfusing rhythm was atrial fibrillation with rvr. he was intubated during the code and admitted to the icu for further managment. cta was negative for pe. in the icu, he was started on post-arrest cooling protocol, which was uneventful during the cooling and re-warming phases. he spontaneously awoke and moved during the re-warming phase. he was followed by neuro. they felt that the seizure-like activity was likey as a result of and not the cause of his arrest. they did not feel that seizure ppx was neccessary. he was also seen by cardiology who did not identify an etiology for his arrest. after waking up, he was at his baseline mental status. he was called out to the general medicine floor, where he continued to improve. 2. altered mental status - mr. has known developmental delay and schizophrenia. he had change in mental status over past months. no report of fever, cough or shortness of breath. initial working differential included seizure, meningitis, medication reaction; urine and serum tox screens were negative. lp was attempted by both icu and neurology teams with no csf fluid obtained. he was empirically covered with vanc/ceftriaxone/ampicillin/acyclovir for meningitis. he had an ir guided lp after warmed. this showed no e/o infection. antibiotics were stopped. mri was unrevealing. on the medical floor, however, he was noted to have a few episodes of agitation, usually in the setting of being cleaned by nursining staff. he never required medication for this. 3. stage iii ckd: creatinine varied from 1.2 to 1.9 throughout the hospital course. hypertension controlled as below and he will follow-up with renal as an outpatient. 4. pancytopenia: present on admission, unclear etiology. reticulocyte index was inappropriately low. iron studies consistent with anemia of chronic disease. potentially some component was related to the cooling/rewarming process; however, this will need to be followed as an outpatient and he was set up to follow with hemaotlogy. 5. afib: currently in sinus and no recurrence of afib. will continue on asa 325 mg daily at discharge. due to his instability with pt he will not be anti-coagulated with warfarin at this time. 6. hypertension: on transfer from the icu to the medical floor, the patient was noted to be hypertensive. he was restarted on his home regimen of amlodipine and lisinopril; however, his blood pressures remained elevated. given persistent hypertension, he was also started on hydralazine and lasix. a beta blocker was not started out of concern for pauses and bradycardia on telemetry. blood pressures will need to be rechecked as an outpatient, and blood pressure medications will need to be titrated as needed. he was discharged on norvasc, lisinopril, hydralazine and lasix for blood pressure control. of note, given episodes of agitation while in house, it was felt that this could possibly be contributing somewhat to the patient's elevated blood pressures. - he will need an elecytrolyte check next week since he was started on daily lasix. 7. dm: he is currently on 6 units of nph in the hospital, but his sugars have been noted to be in the 200's to 300's after eating. he was also started on 3 units of humalog with meal with a sc for coverage for higher sugars. he was written for a pen perscription to help with administration at his group home. - his pcp will need to follow up his hgba1c and insulin regiment medications on admission: humulin n 6 unit once a day in am cosopt 1 drop lumigan 0.3% qhs aspirin 81mg ditropan 5 mg tid norvasc 10 mg qhs senna-gen 8.6 zestril 40 mg qam zocor 20 mg qd risperdal 1 mg qhs risperdal 0.5mg qam colace 300 mg qhs vit d 5000 iu once a week caps prn lasix 40 mg prn, bisacodyl prn, tylenol prn discharge medications: 1. docusate sodium 100 mg capsule sig: three (3) capsule po hs (at bedtime). 2. risperidone 1 mg tablet sig: one (1) tablet po hs (at bedtime). 3. risperidone 0.25 mg tablet sig: two (2) tablet po qam (once a day (in the morning)). 4. amlodipine 5 mg tablet sig: two (2) tablet po at bedtime. 5. humulin n 100 unit/ml suspension sig: six (6) units subcutaneous once a day: in am. 6. zocor 20 mg tablet sig: one (1) tablet po once a day. 7. zestril 40 mg tablet sig: one (1) tablet po once a day: in am. 8. senna lax 8.6 mg tablet sig: one (1) tablet po twice a day. 9. lumigan 0.03 % drops sig: one (1) ophthalmic at bedtime. 10. cosopt 2-0.5 % drops sig: one (1) ophthalmic twice a day. 11. tylenol 325 mg tablet sig: two (2) tablet po four times a day as needed for temp > 100.5 or general discomfort. 12. bisacodyl 5 mg tablet sig: one (1) tablet po once a day as needed for constipation. 13. lasix 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 14. vitamin d-3 5,000 unit tablet sig: one (1) tablet po once a week. 15. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 16. hydralazine 25 mg tablet sig: one (1) tablet po q8h (every 8 hours): please increase hyralazine to 50 mg q8 if patient blood pressure is > 130/80. disp:*90 tablet(s)* refills:*0* 17. insulin lispro 100 unit/ml insulin pen sig: one (1) variable subcutaneous four times a day: please see attached sliding scale for daily meal time insulin requirements. disp:*120 variable* refills:*0* 18. outpatient lab work please get chem 8 on 19. oxybutynin chloride 5 mg tablet sig: one (1) tablet po three times a day. discharge disposition: extended care discharge diagnosis: cardiac arrest discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. you were admitted to for unresponsiveness, and concern for a cardiac arrest. you were in the intensive care unit and your body was cooled after you were found unresponsive. you were subsequently brought to he medical floor where your blood sugars were high, and you had high blood pressure. you will need to see several specialists listed below to help manage your care. the following medication changes were made: added: lasix scheduled added: hydralazine added: humalog stopped: lasix prn f/u with pcp re blood pressure. your pcp was holding your iron. you should follow-up with him regarding restarting this medication. followup instructions: provider: , md phone: date/time: 9:30 please have the patient see his pcp: : Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Anemia in chronic kidney disease Tobacco use disorder Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Atrial flutter Other persistent mental disorders due to conditions classified elsewhere Pulmonary collapse Chronic kidney disease, Stage III (moderate) Cardiac arrest Altered mental status Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Unspecified intellectual disabilities Paranoid type schizophrenia, unspecified Facial nerve disorder, unspecified

allergies: nut sup, glucose intolerant #1 / spironolactone / bactrim ds / fluarix - (pf) attending: chief complaint: residual pituitary adenoma major surgical or invasive procedure: right craniotomy for resection of pituitary ademona history of present illness: 69yo woman with pituitary lesion who underwent a subtotal transphenoidal resection in 2/. pathology was c/w acth secreting pituitary adenoma. mri showed residual adenoma centered in the supracellar cistern with radiologic compression on the optic apparatus. on her last visit it was recommended that she have an open resection to decompress the optic apparatus. the patient wanted to wait and have an reconsultation with radiation oncology. patient denies visual problems, heat intolerance, breast leakage, wt loss or gain. past medical history: diabetes, hypertension , gerd, glaucoma, cataract, hypokalemia, (+)ppd s/p inh, av reentrant and nodal tachycardia, left knee oa, ectopic pregnancy surgery, tubal ligation, appendectomy, parathyroidectomy, knee surgery social history: no tob/etoh. lives independently with husband. ft in environmental services here at . family history: mother died in childbirth, father 98 and only hard of hearing; 4 children, daughter with ms. physical exam: on admission: gen: af vss; wd/wn, comfortable, nad. heent: pupils: perrl eoms intact without nystagmus neck: supple. lungs: no adventicious sounds cardiac: rrr to auscultation abd: soft, nt warm peripherals neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. language: speech fluent with good comprehension and repetition. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3mm to 2mm bilaterally. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to finger rub bilaterally. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: . strength full power throughout. no pronator drift sensation: intact to light touch; no paresthesias symmetric brisk reflexes toes downgoing bilaterally coordination: normal on finger-nose-finger bilaterally no extrapyramidal signs on discharge: pertinent results: mri brain : surgical planning study with surface markers demonstrates a sellar and suprasellar mass suggestive of residual pituitary neoplasm. no other abnormalities are seen. no hydrocephalus or enhancing brain lesions are identified. ct head post-op 1. expected post-surgical changes with bilateral prefrontal pneumocephalus and a small amount of blood products layering along the right frontal dural surface. 2. no evidence of intraparenchymal hemorrhage. mri brain post-op : 1. no evidence of residual enhancement within the resection bed. recommend continued followup after the immediate postoperative changes have resolved. 2. normal postoperative appearance after right craniotomy without evidence of large postoperative hemorrhage brief hospital course: was admitted to the neurosurgery service after right craniotomy for resection of residual pituitary adenoma. postoperatively she was admited to the neuro-icu for frequent neuro checks and blood pressure control less than 140. endocrinology service was consulted. postoperative head ct showed expected post-operative changes. she was monitered with frequent labs and uas and her urine output was monitered closely for signs of di. she had increasign sodiums overnight on into , endocrinology did not feel that she required ddavp or vasopressin. she was started on iv fluids and her urine output and lab valuyes continued to be closely monitoried. on she underwent an mri scan of teh brain to assess for post-operative change which showed no evidence of residual enhancement within the resection bed. endocrine recommended hydrocortisone 40mg in am and 20mg in pm, then on she should recieve 20mg in am and 10mg in pm. she may drink to thirst. d5w was discontinued and q6h labs were continued. she was albe to be oob and dangle her feet at the edge of the bed. on , a-line was removed and foley d/c'ed. hydorcortisone was decreased to 20mg in am and no dose in pm. on , cortisol level was drawn and was 12.9. she remains in stable condition, ambulating independently and reports no drainage. she was transferred to the floor and pt/ot consulted. she recieved on dose of 20mg hydrocortisone in the am. her cortisol level was normal, so hydrocotisone was discontinued. she was cleared by pt and nursing was working with her and stairs. patient felt unsteady on her feet and requested that she have more time in the hospital. on , patient was doing well. she was ambulating independently and felt more comfortable being discharged home today. she was discharged home and should follow up with endocrine in one week and neurosurgery in 4 weeks. medications on admission: preadmission medications listed are correct and complete. information was obtained from patientwebomr. 1. amlodipine 10 mg po daily 2. aprepitant 40 mg po once duration: 1 doses 3 hours prior to preop 3. dorzolamide 2%/timolol 0.5% ophth. 1 drop both eyes 4. latanoprost 0.005% ophth. soln. 1 drop both eyes hs 5. metoprolol succinate xl 200 mg po daily 6. potassium chloride 30 meq po daily duration: 24 hours hold for k >4.0 7. valsartan 320 mg po daily 8. bisacodyl 10 mg po daily:prn constipation 9. calcium carbonate 600 mg po daily 10. vitamin d 1000 unit po daily 11. fish oil (omega 3) dose is unknown po daily discharge medications: 1. outpatient lab work seurm and urine na, serum osm and urine osm 2. docusate sodium 100 mg po bid rx *colace 100 mg 1 capsule(s) by mouth twice a day disp #*90 capsule refills:*0 3. oxycodone (immediate release) 5-10 mg po q4h:prn pain rx *oxycodone 5 mg capsule(s) by mouth every four (4) hours disp #*60 capsule refills:*0 4. metoprolol succinate xl 200 mg po daily 5. valsartan 320 mg po daily 6. latanoprost 0.005% ophth. soln. 1 drop both eyes hs 7. vitamin d 1000 unit po daily 8. fish oil (omega 3) 1000 mg po daily 9. dorzolamide 2%/timolol 0.5% ophth. 1 drop both eyes 10. calcium carbonate 600 mg po daily 11. bisacodyl 10 mg po daily:prn constipation 12. amlodipine 10 mg po daily discharge disposition: home discharge diagnosis: pituitary adenoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: general instructions ?????? have a friend/family member check your incision daily for signs of infection. ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? you may wash your hair only after sutures and/or staples have been removed. if your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? you may shower before this time using a shower cap to cover your head. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? if you have been prescribed dilantin (phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. this can be drawn at your pcp??????s office, but please have the results faxed to . if you have been discharged on keppra (levetiracetam), you will not require blood work monitoring. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? fever greater than or equal to 101?????? f. followup instructions: follow-up appointment instructions ??????please return to the office in days(from your date of surgery) a wound check. this appointment can be made with the nurse practitioner. please make this appointment by calling . if you live quite a distance from our office, please make arrangements for the same, with your pcp. ??????please call ( to schedule an appointment with dr. , to be seen in 4 weeks. ??????you will need an mri of the brain with or without gadolinium contrast. ?????? please follow up with endocrine in 1 week. you can schedule this appointment by calling . Procedure: Other repair of cerebral meninges Frontal sinusectomy Partial excision of pituitary gland, transfrontal approach Diagnoses: Esophageal reflux Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hypopotassemia Osteoarthrosis, localized, not specified whether primary or secondary, lower leg Benign neoplasm of pituitary gland and craniopharyngeal duct Multiple endocrine neoplasia [MEN] type I Disorders of optic chiasm associated with pituitary neoplasms and disorders

allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: left heart catheterization with percutaneous coronary intervention history of present illness: the patient is a 61 year old female with a past medical history of diabetes, hypertension, hyperlipidemia who presents with substernal chest pain for three days. she was in her normal state of health until saturday when she developed sudden onset substernal chest pressure - "like someone was sitting on my chest." she initially attributed this to her upper respiratory tract illness. the pain did not radiate, was not pleurtic, and was associated with diaphoresis and some shortness of breath. she went to bed for the rest of the day and all of sunday. she woke up monday morning and the pain was still present. she went to an oncology appointment (s/p resection of lung nodule several months ago) where she relayed the above history, so she was sent to urgent care for evaluation. ekg there reportedly showed 1.5mm ste iii, 1mm ste avf. she was given one aspirin and was transferred to . . of note, pt notes intermittent chest pain with activity for past six months. she an had abnormal stress test in with small to moderate intensity perfusion defect in the basal and mid inferolateral and lateral wall with complete reversibility. this was managed medically. . in the ed, her initial vitals were 104/54 hr:77, rr: 15, 100%o2 on 2lnc . labs notable for a wbc count of 17, creatinine of 1.0, and troponin of 0.9. ekg notable for 1mm st elevation in lead iii. she was started on heparin and was taken to the cardiac catheterization lab. access was right radial, she was found to have mid rca 100% occlusion that underwent poba as well as lcx with focal 70% om1 stenosis. . on review of systems, s/he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. s/he denies recent fevers, chills or rigors. s/he denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . past medical history: 1. cardiac risk factors: +diabetes, +dyslipidemia, +hypertension 2. other past medical history: -lung carcinoid s/p right upper lobe wedge resection in at , complicated by wound dehiscence -left adrenal adenoma -adjustment disorder with depression -thyroidectomy in not on thyroid replacement -obstructive sleep apnea not on cpap -cataract surgery in -obesity hypoventilation with pfts showing some restrictive physiology -suburethral sling in social history: - works for school department in special ed - married, three children - tobacco history: former 80 pack year smoker, quit 14wks ago - etoh: denies - illicit drugs: denies family history: - mother: mi - father: mi physical exam: admission exam vs: afebrile, 125/61 66 98%2l nc general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: jvp difficult to assess due to body habitus cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: right wrist in band, no edema skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ . discharge exam: vitals - tm/tc:9.9/98.6 hr: 82-86 bp:103-113/61-65 rr: 16-18 02 sat: 95% ra in/out: last 24h: last 8h: . tele: sr, no vea general: 61 yo f in no acute distress heent: perrla, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, jvp non elevated chest: ctabl no wheezes, no rales, no rhonchi cv: s1 s2 normal in quality and intensity rrr no murmurs rubs or gallops abd: soft, non-tender, non-distended, bs normoactive. ext: wwp, no edema. dps, pts 2+. right wrist with no ecchymosis or hematoma. neuro: cns ii-xii intact. 5/5 strength in u/l extremities. gait wnl. skin: no rash psych: a/o, somewhat sad this am. pertinent results: admission labs 12:15pm blood wbc-17.0* rbc-4.10* hgb-12.4 hct-37.6 mcv-92 mch-30.3 mchc-33.0 rdw-13.2 plt ct-228 12:15pm blood neuts-82.0* lymphs-14.9* monos-2.6 eos-0.3 baso-0.2 12:15pm blood pt-11.3 ptt-32.8 inr(pt)-1.0 12:15pm blood glucose-140* urean-23* creat-1.0 na-137 k-4.2 cl-98 hco3-26 angap-17 05:03am blood alt-24 ast-83* ld(ldh)-500* ck(cpk)-626* alkphos-65 totbili-1.2 05:03am blood calcium-9.1 phos-3.0 mg-1.9 pertinent labs and studies 12:15pm blood %hba1c-6.3* eag-134* 12:15pm blood ck-mb-75* mb indx-9.8* 12:15pm blood ctropnt-0.90* 09:53pm blood ck-mb-58* mb indx-6.8* 05:03am blood ck-mb-34* mb indx-5.4 ctropnt-2.00* 07:23pm blood ck-mb-10 mb indx-3.5 ctropnt-2.06* 01:36am blood ck-mb-7 ctropnt-2.59* 12:15pm blood ck(cpk)-762* 09:53pm blood ck(cpk)-857* 07:23pm blood ck(cpk)-283* 01:36am blood ck(cpk)-229* 06:50am blood triglyc-212* hdl-37 chol/hd-3.9 ldlcalc-64 left heart cath (prelim) 1. selective coronary angiography of this right dominant system demonstrated two vessel disease. the lmca was patent. the lad had less than 30% lumen irregularities. the lcx had a focal 70% om1 stenosis, and a difuse 80% stenosis om2. the rca had 100% occlusion of mid rca with contrast staining. 2. limited resting hemodynamics revealed normal systemic arterial pressures at the central aortic level 102/52 mmhg. 3. successful aspiration thrombectomy and balloon angioplasty of the rca (see ptca comments). final diagnosis: 1. two vessel coronary artery disease. 2. successful pci of the rca. cxr heart size is enlarged. mediastinum is unremarkable. bilateral perihilar interstitial opacities are most likely consistent with pulmonary edema. underlying infectious process might be obscured, in particular in the right lower lung. evaluation of the patient after diuresis is recommended. no evidence of pneumothorax is seen. small amount of pleural effusion cannot be excluded. echocardiogram the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with mild basal inferior hypokinesis. the remaining segments contract normally (lvef = 50-55%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: mild regional left ventricular systolic dysfunction, c/w cad. no echocardiographic evidence of right ventricular involvement with the recent infarction. mild mitral regurgitation. discharge labs 06:50am blood wbc-11.7* rbc-3.71* hgb-11.4* hct-33.5* mcv-90 mch-30.8 mchc-34.1 rdw-13.1 plt ct-205 06:50am blood glucose-152* urean-17 creat-0.9 na-140 k-3.8 cl-103 hco3-29 angap-12 brief hospital course: the patient is a 61 year old female with risk factors of diabetes, hypertension, hyperlipidemia, tobacco use presenting with several day of chest pain found to have late presentation st elevation inferior myocardial infarction with 100% mid rca occlusion now s/p balloon angioplasty . #inferior stemi: late presentation of inferolateral stemi (elevations in iii>ii), found to have two vessel cad on catheterization with culprit thought to be mid rca lesion, with successful recanalization using balloon ptca. she has remained chest pain free since the cath. she was started on medical management with aspirin, prasugrel, heparin x24hours, atorvastatin, metoprolol, lisinopril. . #diabetes: a1c is 6.3%, suggesting good control prior to admission. on 50-56 units of lantus qam at home as well as metformin. am fs was 142 today, treated with iss during hospitalization. . #hypertension: systolic bp remains in the 90-100s since admission, is currently on metoprolol and lisinopril. also on amlodipine and hctz as an outpatient, but this was held at time of d/c as the patient's bp was consistently 90-100 systolic. . #hyperlipidemia: ldl 91, hdl 46, tg 377 in in atrius records. on simvastatin 80mg daily at home, this was changed to atorvastatin 80mg. she may benefit from better dietary control or fibrate for tg control as an outpatient. . # full code # contact: , husband # issues to address at follow up: -consider fibrate for improved tg control -lcx with untreated disease: focal 70% om1 stenosis, and a diffuse 80% stenosis om2. # pending studies at time of discharge: final cardiac cath report. medications on admission: -metoprolol tartrate 25 mg -hydrochlorothiazide 12.5 mg daily -nystatin (nystop) topical powder apply under breast -simvastatin 80mg qhs -lisinopril 40 mg daily -amlodipine 5 mg daily -oxybutynin chloride 10 mg daily -metformin 1,000 mg oral -insulin glargine (lantus solostar) 58-65 units daily -betamethasone dipropionate non-augmented 0.05 % ointment discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po twice a day. 2. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. prasugrel 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. insulin glargine 100 unit/ml solution sig: 52-65 units subcutaneous once a day: resume home dosing. 6. oxybutynin chloride 10 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po at bedtime. 7. atorvastatin 80 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 8. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. discharge disposition: home discharge diagnosis: st elevation myocardial infarction . secondary diagnosis: hypertension hyperlipidemia diabetes mellitus type 2 lung carcinoid discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you had chest pain and was found to be having a heart attack. you were transferred to and a cardiac catheterization was performed that showed blockages in 2 arteries. the right coronary artery was opened with a balloon procedure because it was felt that this blockage was causing the heart attack. the second blockage was not treated at this time. you will be started on medicines to help keep the blockages open and help your heart recover from the heart attack. it is very important that you take these medicines every day and see your new cardiologist, dr. . an echocardiogram was done that showed your heart function is nearly normal and your heart vavles are working well. . we made the following changes to your medicines: 1. start taking prasugrel to keep the blockage that was treated open and prevent more clots in your heart arteries. do not stop taking this medicine until dr. tells you it is ok. 2. increase your aspirin to 325 mg daily for now to work with the prasugrel 3. stop taking simvastatin, take atrovastatin (lipitor) instead to lower your cholesterol. 4. decrease your lisinopril to 10 mg daily for now as your blood pressures have been a bit lower during your hospital stay. 5. stop hydrochlorothiazide and amlodipine for now as your blood pressure have been somewhat low followup instructions: cardiology: dr. , , 8:40 am phone: . name: , location: address: 291 independence dr, , phone: appointment: wednesday 3:45pm Procedure: Coronary arteriography using two catheters Left heart cardiac catheterization Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Transluminal coronary atherectomy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Personal history of tobacco use Acute myocardial infarction of inferolateral wall, initial episode of care Adjustment disorder with depressed mood Obesity hypoventilation syndrome Personal history of malignant neuroendocrine tumor

allergies: penicillins attending: chief complaint: left leg swelling major surgical or invasive procedure: endotracheal intubation bronchoscopy history of present illness: ms. is an obese, otherwise healthy 52-year-old woman with a history of psoriasis and "seasonal lower leg swelling" referred from for further evaluation of filling defect withing the thoracic aorta at the arch and extending into the descending aorta. she originally presented to ed in early with nausea, vomiting, and watery diarrhea and mild left lower extremity pain and swelling in early . she was treated with antinausea and antidiarrheal medications and instructed to use hot compresses for the lower leg pain. the diarrhea, nausea, and vomiting resolved after approximately 2 weeks, but the lower extremity pain worsened. approximately 1 week prior to admission, she reports that her left lower extremity began "swelling up like a helium balloon" and the pain in her calf and thigh worsened to the point where she had difficulty walking. she returned to the ed on (1 day prior to admission) with worsening left lower extremity pain and swelling. per surgery and heme/onc notes in omr, at she had elevated d-dimer but initial ultrasound did not show a dvt. ct angiogram performed to evaluate for pulmonary embolism showed a filling defect in the aortic arch extending in to the descending aorta. no evidence of pulmonary embolism. per the patient, she was then referred to health for outpatient follow-up. health referred her to for further evaluation and management by the cardiac surgery service. she was admitted to on . in ed, ultrasound was negative for dvt, but chest ct (presumably from , not record in omr) showed evidence of aspiration pneumonia and antibiotics were given (no record). she was tranferred to surgery. cardiac and vascular surgery were consulted. she underwent a lower extremity duplex ultrasound on , which showed an acute dvt with occlusive thrombus in the left femoral and popliteal veins and a nonocclusive thrombus seen in the left common femoral vein. no dvt seen in the right leg. chest mri showed a filling defect in transverse and proximal descending aorta in the same distribution as seen on the ct scan. no visualized focal dissection. echo showed mild symmetric left ventricular hypertrophy with preserved global systolic function. ecg was read as normal sinus rhythm. rheumatology was consulted given concern for aortitis, vasculitis. per omr, rheumatology stated no clear evidence for systemic vasculitis or connective tissue disorder based on the negative review of systems and exam. recommended esr, crp, anticardiolipin igm and igg, bet2 glycoprotein. recommended against lupus anticoagulant due to heparin gtt. recommended heme/onc consult. heme/onc was consulted for hypercoaguable workup given the finding of aortic arch thrombosis and given her recent history of dvt. for the venous clot, did not recommend testing for inherited thrombophilias as it would not change the management of this patient. recommended anticoagulatoin for dvt for 3 months. for the arterial clot, recommended testing for antiphospholipid antibodies, testing for lupus anticoagulant once of heparin. also recommended all age- appropriate cancer screening if not done before (mammograms, colonoscopy). of note, ms. reports previous seasonal experience with lower extremity swelling (l>r), but denies any prior history of dvt or pe. history is significant for remote miscarriage, no further pregnancies. no recent surgeries, trauma. she was relatively bed-bound for of ~2-3 weeks with nausea/vomiting/diarrheain early . past medical history: - lle dvt (on coumadin) - descending aortic arch thrombosis - hyperlipidemia - appendectomy social history: smoking - 1 ppd x 36 years, occassional etoh 2 drinks/month, no recreation/illicts, widowed without children family history: mother with dm physical exam: physical examination: general: patient is alert, pleasant, obese, no acute distress, appears uncomfortable with movement heent: pupils equal, round, reactive to light. extraocular muscles intact. sclerae anicteric. conjunctivae pink. oropharynx clear. neck: supple, nontender. no thyromegaly. lymph nodes: no palpable cervical, supraclavicular, or axillary lymphadenopathy. chest: left clear to auscultation. expiratory wheezes in right mid posterior lung field. abdomen: obese, soft, nondistended, diffusely tender to deep palpation. no hepatosplenomegaly appreciated (exam limited by abdominal obesity). extremities: bilateral lower extremity non-pitting edema. left worse than right. left warmer than right. left proximal lower extremity warmer than distal lower extremity. skin: multiple erythematous lesions on all four extremities, back consistent with psoriatic plaques. neurologic: patient is alert and oriented to person, place, time, purpose. cranial nerves ii-xii intact. pertinent results: labs at admission: 10:10pm plt count-381 10:10pm neuts-76.0* lymphs-17.8* monos-3.7 eos-1.8 basos-0.8 10:10pm wbc-11.4* rbc-4.44 hgb-14.3 hct-44.3 mcv-100* mch-32.3* mchc-32.3 rdw-14.3 10:10pm probnp-58 10:10pm ctropnt-0.01 10:10pm estgfr-using this 10:10pm glucose-113* urea n-9 creat-0.5 sodium-141 potassium-3.7 chloride-104 total co2-32 anion gap-9 10:37pm pt-13.6* ptt-25.3 inr(pt)-1.2* 12:06am lactate-0.9 03:44am pt-12.2 ptt-21.1* inr(pt)-1.0 ++++++++++++++++++++++++++++++++++++++++++++++ imaging: ----ct-chest w/ contrast findings impression: 1. pulmonary embolism of the right main pulmonary artery - this finding was discussed with at 16:13 on . 2. persisting nonocclusive descending aortic thrombus. 3. prominent mediastinal lymph nodes, likely reactive in nature. 4. rapid onset of diffuse ground-glass opacities with increased consolidation of the right lower posterior lung and apical segment of the left lower lobe; the differential diagnosis is broad but includes edema/ards,infectious/inflammatory causes, hemorrhage, or aspiration. ------duplex venous doppler study of the left upper extremity clinical indication: patient with known left lower extremity dvt and pain in left upper extremity. the left internal jugular, axillary and brachial veins are fully compressible as are the superficial basilic and cephalic veins. color flow and pulse doppler assessment of all of the veins in the left upper extremity is normal with no evidence of occlusive or non-occlusive clot. procedures: bronchial lavage: --negative for malignant cells. +++++++++++++++++++++++++++++++++++++++++++++++++++++++ labs at discharge: 06:40am blood wbc-9.2 rbc-4.31 hgb-13.8 hct-42.2 mcv-98 mch-31.9 mchc-32.7 rdw-14.1 plt ct-654* 06:40am blood plt ct-654* 06:40am blood pt-31.6* ptt-28.5 inr(pt)-3.2* 06:40am blood glucose-111* urean-11 creat-0.4 na-137 k-4.3 cl-101 hco3-28 angap-12 06:40am blood calcium-9.1 phos-3.4 mg-1.8 brief hospital course: she was admitted to on . in ed, ultrasound was negative for dvt, but chest ct (presumably from , not record in omr) showed evidence of aspiration pneumonia and antibiotics were given (no record). she was tranferred to surgery. cardiac and vascular surgery were consulted. she underwent a lower extremity duplex ultrasound on , which showed an acute dvt with occlusive thrombus in the left femoral and popliteal veins and a nonocclusive thrombus seen in the left common femoral vein. no dvt seen in the right leg. chest mri showed a filling defect in transverse and proximal descending aorta in the same distribution as seen on the ct scan. no visualized focal dissection. echo showed mild symmetric left ventricular hypertrophy with preserved global systolic function. ecg was read as normal sinus rhythm. rheumatology was consulted given concern for aortitis, vasculitis. per omr, rheumatology stated no clear evidence for systemic vasculitis or connective tissue disorder based on the negative review of systems and exam. recommended esr, crp, anticardiolipin igm and igg, bet2 glycoprotein. recommended against lupus anticoagulant due to heparin gtt. recommended heme/onc consult. heme/onc was consulted for hypercoaguable workup given the finding of aortic arch thrombosis and given her recent history of dvt. for the venous clot, did not recommend testing for inherited thrombophilias as it would not change the management of this patient. recommended anticoagulatoin for dvt for 3 months. for the arterial clot, recommended testing for antiphospholipid antibodies, testing for lupus anticoagulant once of heparin. also recommended all age- appropriate cancer screening if not done before (mammograms, colonoscopy). of note, ms. reports previous seasonal experience with lower extremity swelling (l>r), but denies any prior history of dvt or pe. history is significant for remote miscarriage, no further pregnancies. no recent surgeries, trauma. she was relatively bed-bound for of ~2-3 weeks with nausea/vomiting/diarrheain early . pt on ct surgery team for several days until the decision was made not to remove the aortic clot surgically. rheumatology was consulted 2 days after admission for concern for aortitis as the cause of the aortic clot. cxr showed diffuse opacities and ct a/p showed ggo's at lung bases. she was also started on levofloxacin for possible cap. they did not feel as though her presentation was consistent with a systemic vasculitis as inflammatory markers not significantly elevated as they would be if systemic vasculities. recommended neoplastic workup, and anticardiolipin ab, complement, . heme recommended apa workup, anticaog for 3 months and lupus anticoag. work up for inherited thrombophilias was negative (factor v leiden an b-2 glycoprotein). . she was transferred to the medical service. she was noted to have large b/p difference in ue - 60/d on l and 110/s on r. vascular was aware and did not recommend any intervention. one day after transfer to medicine, she developed a new o2 requirement. cxr showed diffuse pulmonary infiltrates and pulm was consulted for concern for diffuse alveolar hemorrhage. she also had transient hypoxia to 80's while ambulating got bathroom that resolved with rest. she was transferred to the micu for bronchoscopy micu course : patient was admitted from the floor for elective bronchoscopy for increasing o2 requirement and sob in setting of aortic thrombus, multiple dvt's, ggo's on ct scan and diffuse infiltrates on cxr. differential was broad - dah, apa, lupus. decision was made to intubate given patient's inability to lay flat. she was bronched which showed no evidence of bleeding. she has been started on coumadin prior to transfer and remianed therapeutic while in the icu. cta chest showed pe - thought to be embolic from known dvt and not representative of coumadin failure. ivc was considered but not done as she was tolerating her pe without difficulty and therapeutuc on anticoagulation. she was extubated with out difficulty and called out to the floor. on the floor the patient did well. we discussed with vascular the need to continue antiplatelet and anticoagulation given she has vte and an arterial issue. this was done and the patient was advised of potential risk of clot. follow up was arranged and she was discharged home. medications on admission: patient denies taking prescribed or otc medications at home. denies use of supplements, home remedies, herbs discharge medications: 1. outpatient lab work serial pt/inr dx: dvt, aortic thrombus goal inr results to dr. 2. simvastatin 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. clobetasol 0.05 % cream sig: one (1) appl topical (2 times a day). 5. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm: take as directed by dr. . disp:*30 tablet(s)* refills:*2* 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: 1. aortic arch arterial thrombosis 2. deep venous thrombosis in the left lower extremity 3. pulmonary embolism 4. hypoxemia 5. vitamin b12 deficiency . secondary: 1. psoriasis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you came to the hospital due to swelling in your left leg. you were found to have blood clots in the veins of your left leg, in your lungs, and in your aorta. you were started on blood thinning-medications (aspirin and coumadin) for this. we did some tests to evaluate why you are forming blood clots in several different parts of your body. so far, this testing has not revealed the cause of your blood clots, but further testing will need to be done after you leave the hospital. there was some concern about the blood flow to your left arm due to the blood clot in your aorta. you were followed by the vascular surgery team for this. you should return to the hospital right away if you develop persistent pain in your left arm or hand, or if your left arm becomes cold or blue. there was also concern about your lungs due to a low oxygen level and abnormalities on chest imaging. you were transferred to the icu due to this and underwent a study called bronchoscopy. this did not reveal the cause of your abnormalities but may need to be repeated in the future. you were briefly intubated for the bronchoscopy, but the breathing tube was removed after the study was done. you should return to hospital emergency immediately if you feel sudden pain/numbness especially in your hands, feet, arms or legs. return to the emergency room if any extremity turns blue or cold. talk to your doctor about further evaluation for vitamin b12 defiency. you received a vitamin b12 shot here, and should received further shots from your primary doctor. you have also been started on a vitamin called folic acid. there have been some changes to your medications: start coumadin (warfarin) to prevent the formation of blood clots. take this as directed by dr. . you will need frequent blood tests while on coumadin to prevent serious complications due as bleeding (if your level is too high) and further blood clots (if your level is too low). your follow-up blood tests will be managed by dr. . your next blood test will be on , when you see dr. . start aspirin start simvastatin start folic acid . follow up as indicated below. followup instructions: please follow up with the following appointments: . pcp : thursday, @ 8:45am name: ,md location: chc address: , , phone: . department: rheumatology when: tuesday at 12:00 pm with: , md building: lm campus: west best parking: . garage . department: hematology/oncology when: friday at 9:30 am with: , md building: sc clinical ctr campus: east best parking: garage . please call the pulmonology clinic at ( to make an appointment to see dr. . you should see dr. within the next month. . please call the vascular surgery clinic at ( to make an appointment with dr. . you should be seen by dr. within the next 3 months. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Closed [endoscopic] biopsy of bronchus Diagnoses: Hypocalcemia Hyposmolality and/or hyponatremia Other and unspecified hyperlipidemia Acute respiratory failure Morbid obesity Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Other psoriasis Other pulmonary embolism and infarction Embolism and thrombosis of thoracic aorta

allergies: penicillins attending: chief complaint: abdominal pain, nausea, vomiting, diarrhea major surgical or invasive procedure: sma embolectomy exploratory laparotomy with ileocolectomy ileocolic anastomosis history of present illness: 52f with h/o aortic thrombus and recent dvt, anticoagulated on coumadin, presents to ed with 3 day h/o nausea/vomiting, inability to tolerate po intake, and diarrhea. pt denies blood in the vomit or diarrhea. has not been able to tolerate anything po at all. she was recently discharged from after being admitted with le swelling and found to have dvt and a proximal aortic thrombus, for which she was being anticoagulated and monitored expectantly. on her discharge from the hospital she was tolerating pos without any problem. she notes that her inr was 2.0 on the last check and she has been taking her coumadin daily. ros negative for fevers, chills, chest pain, shortness of breath, swelling in the extremeties. past medical history: - lle dvt (on coumadin) - descending aortic arch thrombosis - hyperlipidemia - appendectomy social history: smoking - 1 ppd x 36 years, occassional etoh 2 drinks/month, no recreation/illicts, widowed without children family history: mother with dm physical exam: vss, afebrile neuro: intact, a&o x3 cards: rrr lungs cta pulses: dp/pt palp lateral abdomimal wound- sutures/steri strips below umbillicus- suture/opening 1cmx1cm pertinent results: cta 1. status post sma embolectomy, with patent proximal mesenteric vessels. pre-sma mesenteric induration with trace intermediate density fluid and tiny foci of free gas, likely expected post-surgical change. no focal collection. ct interval development of extensive ischemic bowel with pneumatosis of ascending colon and distal small bowel involving ileocolic and right colic territory. some nonocclusive thrombus is likely still identified within these distal branches. extensive portal venous and mesenteric venous gas. ct 1. patent mesenteric vasculature including the proximal and mid branches of the sma, , and celiac axis. the distal branches are not well evaluated. 2. no specific findings to suggest recurrent bowel ischemia. 3. intact anastomosis in the right upper quadrant, however, there is a small focus of fluid and air bubbles adjacent to the anastomotic site, likely postoperative, however attention on follow-up exams is recommended. 4. small fluid collections within the mesentery and lower midline subcutaneous fat, both of which appear more discrete than on prior exams, including enlargement of the central mesenteric fluid collection following surgery. there is no substantial rim enhancement or fat stranding about the collection. brief hospital course: ms was admitted on with possible acute mesenteric ischemia. she was taken urgently to the operating room for an exploratory laparotomy and an embolectomy of the sma was performed. she returned to the icu. on her wound remained oozy and she received ffp. on she had low urine output of cc/hr which did not respond to lasix, but did respond to il of crystalloid and albumin. on she developed severe abdominal pain and diarrhea, for which the acute care surgery team was consulted. she had a ct performed that showed portal venous gas and pneumatosis of the large and small bowel. she went to the or emergently for an exploratory laparotomy, where they found a mid-gut infarction secondary to distal superior mesenteric artery occlusion. the acs team performed a resection of necrotic mid gut from mid ileum to transverse colon and loosely closed the skin. she returned to the icu where she remained intubated and sedated. she was taken again to the or on for a second look exploration, at which time an ileocolic anastomosis was performed and her abdomen was closed. she returned to the icu post-operatively, intubated and sedated, with an ng tube for bowel decompression. tpn was started for nutritional support. she required aggressive diuresis with lasix for fluid overload of >10l. she developed abdominal pain and a temperature of 100.9 on , for which she had blood cultures drawn and chest and abdominal x-rays done, none of which showed evidence of infection. she was weaned from the ventilator and extubated . she was transferred out of the icu . she began having bowel movements again , which became liquid and melanotic. her heparin drip was stopped and her melena improved. she received 2 units prbc's on , after which her hematocrit stabilized at 29. her melena resolved and she was able to restart her heparin on . she was tolerating a regular diet by and coumadin was restarted. her heparin drip was stopped when her inr was therapeutic. she had a minimal amount of serosanguinous drainage from the inferior aspect of her laparotomy incision on , which likely represented drainage of a seroma. she had difficulties throughout her stay with ambulation, for which pt was seeing her regularily. her mass health application was denied and she remained in hospital getting daily physical therapy and being taught her wound care. on , she was cleared by phiscal therapy for discharge and a chair car has been scheduled for transportation home. her inr was 4.7 so her coumadin is being held for 2 days. she will restart 1mg daily on with an inr check on . she will follow up with her pcp . she will manage her coumadin. follow up with dr. has been scheduled. medications on admission: simvastatin 20', asa 325', clobetasol cream, coumadin 5', folate 1' . discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily): refills from pcp . phone: fax: . disp:*30 tablet(s)* refills:*0* 2. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily): refills from pcp . phone: fax: . disp:*30 tablet(s)* refills:*0* 3. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): refills from pcp . phone: fax: . disp:*30 tablet(s)* refills:*0* 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 6. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 7. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days. disp:*14 tablet(s)* refills:*0* 8. outpatient work pt/inr check on monday and then as directed by dr. . dr. will be following your values and adjust your coumadin dose. phone: fax: 9. warfarin 1 mg tablet sig: one (1) tablet po once a day: refills from pcp . phone: fax: . disp:*30 tablet(s)* refills:*0* 10. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*40 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: aortic arch thrombus superior mesenteric artery thrombus s/p sma embolectomy ileocolonic ischemia s/p ileocolectomy discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: incision care: keep clean and dry. -you may shower, and wash surgical incisions. -avoid swimming and baths until your follow-up appointment. -please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. please call your doctor or return to the er for any of the following: * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomiting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomiting, diarrhea or other reasons. * signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * your skin, or the whites of your eyes become yellow. * your pain is not improving within 8-12 hours or not gone within 24 hours. call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. * do not drive or operate heavy machinery while taking any narcotic pain medication. you may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * continue to ambulate several times per day. followup instructions: restart coumadin 1mg on . continue normal saline w-d pack wound care to abdomen three times per day provider: , md phone: date/time: 9:30 provider: , md phone: date/time: 1:45 pt/inr check (dr. will follow) - go to downtown monday at 1030am dr. 10am - to see the doctor Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Other partial resection of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Open and other right hemicolectomy Other small-to-large intestinal anastomosis Incision of vessel, abdominal arteries Diagnoses: Unspecified essential hypertension Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Blood in stool Morbid obesity Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Seroma complicating a procedure Acute vascular insufficiency of intestine Embolism and thrombosis of thoracic aorta

allergies: penicillins attending: chief complaint: left flank pain major surgical or invasive procedure: central line placement history of present illness: 54 yo woman with a pmh significant for dvt/pe, aortic atheroma c/b sma embolization requiring bowel resection who presented to with a 1 day h/o acute, sharp left flank pain. the patient had recently been taken off warfarin for a rectus sheath hematoma. she was in her usoh until the morning prior to presentation when she woke from sleep with 10/10 sharp, l sided flank pain. the pain started on her left side, with some radiation to her back. the pain was somewhat colicky, but mostly constant and sharp. the pain was somewhat relieved by sitting upright, but had few alleviating or exacerbating factors. the patient presented to where she was given dilaudid and zofran. a ct abdomen was done that showed a left renal artery infarct. the patient was transfered to our ed for more acute care. in the ed, the patient's vs: 98.5 84 139/85 20 98% 2l. a cta was repeated that once again showed non-enhancement of the left upper pole of the left kidney c/w renal infarct. the patient was given levaquin and vanco for leukocytosis and fever. the patient was seen by vascular surgery and ir and started on a heparin gtt before being transfered to the floor for further management. on the floor, the patient's vs 99.7, 124/88, 86, 18, 97% ra. the patient was still with 10/10 left sided pain with radiation to her back and abdomen. the patient is still making urine, no gross blood. otherwise, the patient's condition is unchanged. past medical history: left lower leg dvt pulmonary embolism (on coumadin, dx ) descending aortic arch thrombosis (dx ) mesenteric ischemia s/p embolectomy, hyperlipidemia psoriasis peripheral vascular disease (treated medically at by dr. past surgical history: appendectomy (remote) distal sma embolectomy (, ) ex-lap, ileocolectomy (resection from mid-ileum to mid-transverse colon) (, ) second-look exlap, packing removal and washout (, ) social history: smoking - 1 ppd x 36 years, occassional etoh (no longer drinking), no illicts, widowed without children family history: mother with dm physical exam: admission exam vs - temp 99.7 f, 124/88 bp , 86 hr , 18 r , 97 o2-sat % ra general - obese women in intermittent pain, sitting upright in bed heent - perrla, eomi, sclerae anicteric, dry mm neck - supple, no thyromegaly, no jvd, no carotid bruits lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - distant heart sounds, rrr, no mrg, nl s1-s2 abdomen - obvious bruising of rectus, more so on left side, exquisitely tender of left abdomen/flank, voluntary guarding, hypoactive bowel sounds extremities - wwp, 1+ pitting edema bilaterally neuro - awake, a&ox3, cns ii-xii grossly intact discharge exam vs: 98.2 112/62 75 18 98% ra general: obese woman sitting up comfortably in chair heent: perrla, eomi, sclerae anicteric, mmm lungs: ctab, good air movement without crackles/wheezes heart: distant heart sounds, rrr, no m/r/g, nl s1/s2 abdomen: large scattered ecchymoses on abdomen, very mild tenderness to palpation on exam extremities: wwp, 2+ pitting edema bilaterally neuro: awake, speech fluent, moving all extremities spontaneously pertinent results: admission labs 12:20am blood wbc-11.5*# rbc-3.85* hgb-12.1 hct-37.7# mcv-98 mch-31.5 mchc-32.2 rdw-14.0 plt ct-513* 12:20am blood neuts-85.9* lymphs-9.7* monos-3.2 eos-0.9 baso-0.3 12:20am blood pt-12.8 ptt-19.2* inr(pt)-1.1 12:20am blood glucose-135* urean-11 creat-0.7 na-139 k-3.6 cl-103 hco3-25 angap-15 12:28am blood alt-12 ast-16 alkphos-57 totbili-0.8 09:16pm blood calcium-8.4 phos-2.6* mg-1.6 09:16pm blood cortsol-11.4 pertinent studies cta abd/pelvis impression: 1. non-enhancement of portions of the renal parenchyma involving the left upper pole, large portions of the lateral and anterior mid kidney consistent with renal infarct. no obvious filling defect within the left renal artery to suggest thrombus. 2. stable-sized rectal sheath hematoma and intra-abdominal extraperitoneal hematoma. 3. stable-appearing paraumbilical hernia containing colon. echo the left atrium is mildly dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the number of aortic valve leaflets cannot be determined. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. study inadequate to exclude a patent foramen ovale. l upper extremity ultrasound : left upper extremity ultrasound: the left internal jugular vein could not be visualized on axial images for compression maneuvers. on sagittal images, the vein appears diminutive but patent. catheter is identified in the left subclavian vein, without surrounding thrombus. there is normal compressibility, flow, and augmentation in the bilateral subclavian and left axillary, brachial, basilic and cephalic veins. there is diffuse subcutaneous edema. impression: 1. no left upper extremity dvt. 2. diffuse subcutaneous edema. l lower extremity ultrasound : -scale and doppler images of the right and left common femoral, left superficial femoral, popliteal and proximal calf veins were obtained. there was wall-to-wall flow with normal response to compression and augmentation in all visible veins. the popliteal artery is superficial to the popliteal vein. impression: no dvt or fluid collections in left lower extremity. microbiology: blood culture : negative brief hospital course: 54 year-old woman with a history of dvt and pe on warfarin who was also on aspirin and cilostazol for pvd recently had been taken off warfarin for a rectus sheath hematoma presents with left renal infarction confirmed by cta of abdomen and pelvis. whether the renal infarct was caused by embolism or thrombosis is unknown. hematology and vascular surgery consults were obtained. she was started on heparin gtt. subsequently, she had a drop in hematocrit 36.6-->31.9 and was hypotensive, so was transferred to the micu for concern of active bleeding. she received 2 units of prbcs. repeat ct abdomen did not show any enlargement of rectus sheath hematoma. hematocrit stabilized and patient was transferred back to the floor. she was continued on heparin gtt until her inr was therapeutic. the decision was made to not restart aspirin or cilostazol for pvd for now given her recent spontaneous rectus sheath hematoma. hematocrit was stable for 3 days at a level of about 36. problem list: # renal infarct: patient presented from with diagnosis of left renal infarct, which was confirmed on cta of abdomen and pelvis. it remains unclear whether the infarct of the left renal artery is from an embolic source or is thrombotic. both hematology and vascular surgeries were consulted. of note, prior coagulation workup has been negative for lupus anticoagulant, anticardiolipin, anti-beta2-glycoprotein-1 antibodies and factor v leiden were negative. pt has an atheroma at the descedning aorta right beneath the aortic arch, which was considered as possible embolic source. she was continued on simvastatin. heparin gtt was continued until inr therapeutic. dilaudid po was used for pain. # anticoagulation: given her extensive history of arterial and venous clots, she will likely require lifelong anticoagulation. patient was started on heparin gtt and bridged over to coumadin. on the day of discharge, patient's inr was 2.1. patient will follow up with her pcp for inr checks. given her recent bleeding, her aspirin and cilostazol were held on discharge. # rectus sheath hematoma: patient was recently taken off her coumadin after developing hematoma. there was concern for enlarging hematoma as described above, but the hematoma remained stable in appearance both in exam and on ct scans. # fever: patient had fever on admission and it was thought to be secondary to renal infarct or her hematoma, without any evident infectious source. patient denies cough, dysuria, diarrhea, or change in mental status. her only complaint is abdominal pain, which is associated with her known renal infarct. given multiple recent hospitalizations and instrumentation along with fevers and embolic event, diagnosis of endocarditis was considered, but her echo was negative. she was empirically covered with vancomycin and meropenem in the micu, but it was discontinued on the floor. the fevers resolved on their own and her blood culture are negative at the time of discharge. # anemia: patient developed 7 pt hct drop after being started on heparin drip on the floor, which was concerning for hemorrhage. patient did not have any melena/hematochezia/hemetemesis. she was transferred to micu for monitoring and her heparin gtt was initially discontinued while work up was done for source of bleed. pt received 2 units prbcs. her hct remained stable afterwards and she was restarted on heparin gtt and coumadin bridge. # hypotension: pt developed hypotension on the floor with anemia as above, most likely related to bleeding. a-line and central venous line were placed in the micu and pt received 2 u prbc. no pressor was given during her micu stay. her hypotension resolved on the floor. # copd: pt was continued on spiriva # pvd: aspirin was held on admission. she was initially continued on cilostazol, but upon discussion with the vascular surgery team and the patient, decision was made to stop cilostazol as it added to the bleeding risk that she has and patient did not feel that she derived much symptomatic benefit from the medication. # constipation: patient developed constipation while in the hospital. she was given senna, docusate and home miralax without effect. it was thought to be due to the increase in narcotics that she was receiving for l renal infarct. lactulose was added to her bowel regimen with good effect. she was given prescription for lactulose on discharge. medications on admission: aspirin 325mg po pletal 100mg po bid clobetasol 0.05% cream pepcid 20mg po bid folic acid 1mg po qday miralax 17g po qday zocor 40mg qday spiriva qday lasix 40mg qday prn for fluid retention nitro q5min for chest pain atarax 10mg po 1-2 tabs tid prn anxiety oxycodone 5/325 1-2 tabs q6hrs prn pain coumadin recently held discharge medications: 1. clobetasol 0.05 % cream sig: one (1) appl topical (2 times a day). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 4. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 5. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 6. furosemide 40 mg tablet sig: one (1) tablet po once a day as needed for fluid retention/leg swelling. 7. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet sublingual every 5 mins as needed for chest pain: take one tablet, if chest pain does not get better, call 911. 8. atarax sig: one (1) tablet three times a day as needed for anxiety. 9. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*0* 10. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. 11. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*20 tablet(s)* refills:*0* 12. lactulose 10 gram/15 ml syrup sig: fifteen (15) ml po twice a day as needed for constipation. disp:*300 ml(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnoses: - left renal infarct - abdominal rectus sheath hematoma - acute blood loss anemia secondary diagnoses: - deep venous thrombosis - pulmonary embolism - peripheral vascular disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , you were transferred to the for decreased blood supply to your left kidney, which caused a lot of pain. our vascular doctors saw and recommended that you start anticoagulation to prevent further kidney damage. on anticoagulation, your blood pressure dropped as did your red blood cell count, which was concerning for bleeding. as you had a known abdominal hematoma, the thought was that you had some bleeding into your abdomen. you were transfered to the icu for stabilization and received some blood. once your blood counts stabilized, you were started back on warfarin and your inr was monitored. given swelling in your leg, ultrasound of your legs were done and did not show any hematoma or clot. on the day of your discharge, your inr was 2.1. please get your inr checked on thursday when you follow up with dr. . because of your repeated clots, you will likely need to be on lifelong coumadin. please speak with your pcp about getting referral to a local hematologist who can follow you. stop taking these medications: - pletal 100 mg by mouth twice daily - aspirin 325 mg daily - percocet 5/325 for pain as needed these new medications were started for you: - coumadin 5 mg by mouth every evening. please follow up with your pcp to follow your inr level and follow his directions on how to take coumadin. - dilaudid 2 mg tablet: take tablet every 4 hours by mouth as needed for pain - lactulose 10 mg (15 ml = 1 tablespoonful) as needed for constipation complete medication list: - clobetasol 0.05 % cream: apply to affected area 2 times a day - folic acid 1 mg tablet: one tablet by mouth daily - simvastatin (zocor) 40 mg tablet: one tablet by mouth every evening - tiotropium bromide (spiriva) 18 mcg capsule: one capsule by inhalation every day - famotidine (pepcid) 20 mg tablet: one tablet by mouth twice daily - furosemide (lasix) 40 mg tablet: one tablet by mouth once a day as needed for fluid retention/leg swelling. - nitroglycerin 0.4 mg tablet, sublingual: one tablet under the tongue every 5 mins as needed for chest pain; take one tablet, if chest pain does not get better, call 911. - atarax 10 mg tablet: one tablet three times a day as needed for anxiety. - polyethylene glycol (miralax) 17 gram/dose powder: dissolve 1 tablespoonful powder in water and drink daily as needed for constipation. - warfarin (coumadin) 5 mg tablet: one tablet by mouth daily at 4 pm. - hydromorphone (dilaudid) 2 mg tablet: take 1-2 tablets by mouth every 4 hours as needed for pain. - lactulose 10 gram/15 ml syrup: take fifteen (15) ml by mouth twice a day as needed for constipation. followup instructions: name: , e. location: chc address: , , phone: appointment: thursday at 9am Procedure: Venous catheterization, not elsewhere classified Diagnoses: Acute posthemorrhagic anemia Peripheral vascular disease, unspecified Other and unspecified hyperlipidemia Personal history of venous thrombosis and embolism Primary hypercoagulable state Nontraumatic hematoma of soft tissue Chronic obstructive asthma, unspecified Other psoriasis Vascular disorders of kidney Embolism and thrombosis of thoracic aorta

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: stemi major surgical or invasive procedure: cardiac catheterization history of present illness: the patient is 68 y/o m w/hx of cad s/p mi in , htn, hyperlipidemia who is transferred from for stemi. pt was first admitted on and underwent l3-l5 laminectomy, fusion, foraminotmy, and durotomy with bone autograft. posteroperatively, the patient developed chest pain, which was treated with iv ntgl, morphine, and metoprolol. the patient was treated with these conservative measures, and given resolution of chest pain and contraindication of anticoagulation, cardiac catheterization was deffered. cardiac markers were cycled, and ck peaked on at 5021, trop 70, and has trended down since. he has remained chest pain free since. on , the patient went into atrial fibrillation with a rapid ventricular response of 144, and the patient was transfered to the nebh ccu. iv lopressor was administered, without effect. the patient was started on a diltiazem gtt, with improvement of hr control to 90s-120s. the patient remained asymptomatic and hemodynamically stable throughout. he was managed with a dilt gtt, po lopressor and amioderone. at that time, heparin gtt was also started. the patient converted to sinus rhythm, and the dilt gtt was stopped. on the morning of transfer, the patient went back into afib again with hrs in the 140 and dilt gtt was restarted. lopressor increased to 200mg po bid and amio to 400mg po bid. pt was reportedly noted to have long pauses and ? of new lbbb, and had transvenous pacer wire placed on . on the night prior to transfer, the patient spiked temp to 101.6, despite rtc tylenol. cxr was obtained and ua and culture was taken. despite a normal wbc on admission, the patient has had a leukocytosis since of 26.5. he has not received antibiotics and no blood cultures were drawn. on review of systems, s/he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. s/he denies recent fevers, chills or rigors. s/he denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors:: dyslipidemia, hypertension 2. cardiac history: -percutaneous coronary interventions: : mid lcx with bms : pci to rca and lad, likely des following + ett -pacing/icd: transvenous pacer placed at nebh 3. other past medical history: . s/p spine surgery w/ laminectomy, fusion, and instrumentation social history: -tobacco history: quit smoking: -etoh: 2 glasses of wine daily. -illicit drugs: no history of illicit drugs . the patient is married with four children he is a retired construction worker. family history: no family history of early mi, otherwise non-contributory. physical exam: vs: t=98.7 bp= 95/51 hr= 78 rr= 25 o2 sat= 93% on 50% o2 general: wdwn male, tachypnic and diaphoretic. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp at mandible. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: could not assess as did not want to alter patient's position pain. per nursing, crackles at bases b/l. abdomen: soft, mildy tense, and distended. decreased bowel sounds. = extremities: no c/c/e. no femoral bruits. back: dressin in place, c/d/i, jp drain in place. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: laboratory studies: 08:51pm blood wbc-21.6* rbc-3.29* hgb-10.8* hct-30.7* mcv-93 mch-33.0* mchc-35.3* rdw-12.4 plt ct-251 05:23am blood wbc-20.4* rbc-3.10* hgb-10.1* hct-28.8* mcv-93 mch-32.4* mchc-34.9 rdw-13.1 plt ct-232 04:16am blood wbc-18.7* rbc-2.94* hgb-9.5* hct-27.2* mcv-92 mch-32.3* mchc-34.9 rdw-13.4 plt ct-439 . 08:51pm blood neuts-87.7* lymphs-7.1* monos-4.8 eos-0.3 baso-0.1 . 08:51pm blood pt-14.6* ptt-42.2* inr(pt)-1.3* 04:16am blood pt-18.8* ptt-107.2* inr(pt)-1.7* . 08:51pm blood glucose-142* urean-26* creat-1.4* na-132* k-4.5 cl-99 hco3-26 angap-12 05:23am blood glucose-143* urean-31* creat-1.6* na-134 k-4.0 cl-99 hco3-27 angap-12 04:12pm blood glucose-141* urean-29* creat-1.4* na-138 k-3.7 cl-98 hco3-33* angap-11 04:28am blood glucose-178* urean-32* creat-2.2* na-133 k-3.5 cl-95* hco3-28 angap-14 04:16am blood glucose-140* urean-40* creat-2.8* na-134 k-3.9 cl-98 hco3-27 angap-13 . 08:51pm blood ck-mb-7 ctropnt-2.21* probnp-* 08:51pm blood calcium-9.2 phos-1.6* mg-2.3 04:53am blood calcium-9.6 phos-2.5* mg-1.9 04:16am blood calcium-9.1 phos-3.8 mg-2.4 . 06:16am blood type-art temp-37.0 po2-115* pco2-37 ph-7.47* caltco2-28 base xs-4 . 10:56pm blood type-art po2-84* pco2-37 ph-7.50* caltco2-30 base xs-4 06:16am blood lactate-1.1 06:16am blood freeca-1.27 . urine studies: . 03:27pm urine color-straw appear-clear sp -1.009 03:27pm urine blood-tr nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 03:27pm urine rbc-6* wbc-1 bacteri-few yeast-none epi-0 03:27pm urine casthy-25* 06:49am urine color-yellow appear-hazy sp -1.014 06:49am urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-tr 06:49am urine rbc-21-50* wbc-0-2 bacteri-few yeast-none epi-0 . 03:27pm urine hours-random urean-422 creat-98 na-30 06:49am urine hours-random urean-248 creat-88 na-42 09:30am urine hours-random urean-270 creat-95 na-35 . microbiology: . bcx, ucx, mrsa screen- were all negative from . bcx , urinary leginella , ifnluenza nasal washing stool c. diff were all negative. catheter tip cx was negative. sputum smear and cx were persistently contaminated w/ epithelial cells. . imaging/stdies: . echo - the left atrium is mildly dilated. no left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). there is mild symmetric left ventricular hypertrophy with normal cavity size. there is moderate regional systolic dysfunction with severe hypokinesis of the distal half of the anterior septum and anterior walls. the apex is akinetic and mildly aneurysmal. the remaining segments contract well (lvef= 35-40 %). no thrombus is seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. there is no aortic regurgitation. the mitral valve leaflets are mildly thickened. mild mitral regurgitation is seen. there is pulmonary artery systolic pressure is high normal. there is an anterior space which most likely represents a fat pad. impression: mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w cad (mid-lad distribution). mild mitral regurgitation. . ecg - atrial fibrillation with moderate ventricular response and one ventricularly paced beat. there is anterolateral st segment elevation suggestive of acute myocardial infarction. no previous tracing available for comparison. clinical correlation is suggested. tracing #1 read by: , intervals axes rate pr qrs qt/qtc p qrs t 63 0 98 412/417 0 -29 4 . cxr . temporary pacer lead traverses the pulmonary outflow tract, but loops in the main pulmonary artery and probably ends in the upper right ventricle. heart is moderately to severely enlarged. pulmonary vasculature and mediastinal veins are mildly engorged, but there is no edema or appreciable pleural effusion. no pneumothorax or mediastinal widening. . kub : supine and left decubitus views of the abdomen show no pneumoperitoneum. there is gas in the colon, but gas distending the entire small bowel is disproportionately larger, sometimes present with adynamic ileus, which is the most likely diagnosis. stabilization device spans the lower lumbar and lumbosacral levels of the spine. . cxr - small left pleural effusion is new. there might be a region of developing consolidation in the infrahilar left lower lobe, but this area subsequently clears on chest radiographs performed at 8:15 a.m. available at the time of this dictation and reported separately. no pneumothorax. moderate cardiomegaly and mediastinal vascular engorgement unchanged. pulmonary vasculature unremarkable, right lung clear. as before, the transjugular temporary pacer lead loops in the main pulmonary artery and returns to the upper right ventricle. . ecg - atrial fibrillation with controlled ventricular response. right bundle-branch block. compared to the previous tracing of the rate is slower. read by: , intervals axes rate pr qrs qt/qtc p qrs t 77 0 140 438/467 0 -34 95 . cxr : findings: in comparison with the study of , the right central catheter has been removed. nasogastric tube remains in place. there is continued enlargement of the cardiac silhouette persists with only minimal fullness of pulmonary vessels. bibasilar atelectasis persists. there is blunting of the left costophrenic angle that could represent pleural fluid or superimposition of soft tissues. . leni . impression: negative for dvt bilaterally. . cxr - the ng tube was removed in the meantime interval. the cardiomediastinal silhouette is unchanged including moderate-to-severe cardiomegaly. there is overall interval improvement of the pulmonary edema which is almost completely resolved. no substantial pleural effusion is demonstrated. minimal bibasilar atelectasis is seen. . cardiac catheterization : 1. selective coronary angiography of this right dominant system revealed single vessel coronary artery disease. the lmca had minimal disease. the lad had a mid vessel high grade 90% lesion with thrombus. the lcx and rca had patent prior stents without angiographically apparent obstructive lesions. 2. resting hemodynamics revealed elevated right and left sided filling pressures with rvedp of 20 mm hg and lvedp of 30 mm hg. there was moderate pulmonary arterial hypertension of 57/25 mm hg. there was a normal systemic arterial blood pressure of 110/59 mm hg. there was no gradient upon pullback of the catheter from lv to the aorta. the cardiac index was mildly low at 2.0 l/min/m2. 3. left ventriculography was deferred due to renal dysfunction. 4. stenting of lad stent thrombosis lesion with a xience 3x18mm stent final diagnosis: 1. single vessel coronary artery disease. 2. moderate biventricular diastolic dysfunction. 3. moderate pulmonary arterial hypertension. 4. stenting of lad with drug eluting stent. . cxr - mild pulmonary edema. . brief hospital course: patient is a 68 y/o male w/ a hx of cad and mi who is transfered from nebh after a stemi following spinal surgery complicated by atrial fibrillation and resolving acute renal failure. # hypoxia. patient was admitted w/ 95% oxygen saturation on non-rebreather mask. he was afebrile and tachypneic. this was felt to be primarily pulmonary vascular congestion anterior mi and poor ef, confirmed by exam, cxr showing vascular engorgement and bnp of on admission. ddx included pna, pe, atelectasis and hypoventilation given abdominal distension (see below) among others. pt. was diuresed with lasix gtt w/ volume balance of nearly -5l w/o significant improvement in oxygenation. on hd#2, patient became febrile to 102f rectal and given the continued oxygen requirement w/ leukocytosis (20.4k) and fever, patient was started on broad spectrum antibiotic therapy w/ iv vancomycin/zosyn. on hd#3 levofloxacin was added for atypical coverage given no improvement in oxygenation. ct chest on showed mild pulmonary edema w/calcified plaques. lenis b/l were negative. bcx, urinary legionella and influenza nasal washings were negative. as patient's prolonged ileus resolved, he became more mobile and he continued to diurese, his o2 requirement improved to 2l nc w/ saturations in 92-95% range by and was weaned off lasix gtt. his vancomycin and zosyn were discontinued. on , patient underwent caridiac catheterization, received 3l of ivf and returned to afib w/ rvr (see below) w/ resultant flash pulmonary edema. pt. was diuresed further w/ iv lasix with additional 1l negative and resolution of oxygen requirement. on day of discharge, patient had clear lungs except for a few crackles at the bases and only trace peripheral edema and oxygen saturation of 94-96% on ra. he was afebrile w/ persistent leukocytosis of 16.2k (reported baseine of wbc of up yo 14k). his smear was negative for atypical cells and differential was slightly neutrophil predominant. patient completed 10 days of levofloxacin renally dosed for suspected hcap. # coronaries: the patient has a history of cad, with prior mi, and multiple pcis, with 2 stents placed in . the patient with chest pain following surgery, with prominant aterior st elevations c/w mid lad. the patinet was treated conservatively, and was not anticoagulated due to risk of bleeding in the post-operative period. the patient's troponin's peaked at 72at osh and ck maximum 551 at . he remained chest pain free after his intial event. the patient was begun on heparin gtt after developing new af peri-mi. he was continued on asa 81 mg daily, metoprolol 100mg tid (discontinued hypotension on ) and simvastatin. patient denied cp throughout hospitalization but reported sob at rest until hd#3. pt. was restarted on metoprolol on , but stopped given issues with bradycardia detailed below. he underwent cardiac catheterization on showing single vessel disease in lad, 90% w/ thrombosis and received des. ventriculography was deferred elevated cr (see below). he was discharged on asa 325, plavix 75mg, acebutolol 400 mg , simvastatin 80mg, and 2.5 mg lisinopril qd. he was free of cp and sob at time of discharge. # rhythm: patient developed af in post-mi setting, with hr of 140s, managed on amioderone, dilt gtt, and metoprolol at nebh. pt. had a transvenous pacer in place for a reported pause at osh, this was removed on hd2 and no evidence of pauses was noted on telemetry. on arrival pt was in af w/ rvr, and started on heparin gtt, loaded w/ iv amiodarone followed by amiodarone gtt and diltiazem gtt for rate control. metoprolol resulted in singificant hypotension, sbps 80s mmhg. a 200 j cardioversion was attempted on hd#2 w/ patient converting to sinus for 30seconds and eventual reversion to atrial fibrillation. amiodarone was discontinued, cardizem gtt was continued. patient had failed two transitions to po diltiazem of 60mg qid with recurrence of rvr. pt. was also intremittently in atrial flutter. he was started on metoprolol titrated to 25mg tid by . he was eventually weaned off diltiazem gtt after catheterization at a dose of 90mg qid on . he was continued on heparing gtt since hd#1 and transitioned to warfarin. pt. converted to sinus rhythm on , but reverted by . heparin was discontinued once inr reached > 2 over 24 hours and patient continued on warfarin of 4 mg qd. on patient was noted to have an asymptomatic pause of 5 seconds on telemetry w/o conversion from atrial fibrillation. he was seen by electrophysiology who recommended stopping his diltiazem and metoprolol and starting acebutolol 400 mg . he will follow up with dr. and have a holter in 1 month as an outpatient. he is being discharged with vna whow will fax his inr results to his pcp. # pump: echo at nebh showed ef of 40% with apical and septal hk, echo at showed mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w cad (mid-lad distribution)and mild mr w/ ef of 35-40%. initially was in failure on exam (crackles on exam posteriorly to apices) and jvp to mandible. he was aggressively diuresed w/ lasix gtt, intermitent use of thiazide for total of x l negative over los. given stable bps, metoprolol was restarted on (however this was changed to acebutolol prior to discharge as above. on patient was transitioned to iv lasix and then 120 mg po daily. on exam had no pulmonary edema and trace edema at legs b/l. # leukocytosis: marked leukocytosis following surgery, was felt to be likely stress response and possible bowel distension prolonged post-opeartive ileus. pt. defevesced by . please see hypoxia for infectious w/up. patient did have fever up to 102f rectally. ucx, c.diff and bcx were negative at time of discharge. wbc peaked at 20.4k. no source of infection could be identified and he was afebrile w/ persistent leukocytosis of 16.2 k (reported baseine of wbc of up yo 14k). his smear was negative for atypical cells and differential was slightly neutrophil predominant. # anemia: pronounced hct drop in days following surgery to hct of 30. this has remained stable throughtout admission and was suspect may be to ivf prior to surgery. no sources of bleeding were noted, including benign back exam, w/o neurological deficits. pt. did not recall history of colonoscopy or endoscopy. at time of discharge hct was 27.4. # prolonged post operateive ileus. pt. w/ distended abdomen and no bm x2 days on admission. pt. was started on senna, colace, bisacodyl. presentation was consistent w/ post operative ileus, kub consistent w/ this and no stool in vault. pt. was kept npo and received ngt w/ > 1l output at time of placement. by hd2, patient had small bms and ngt declined, abdominal distension decreased. patient was advanced to clears, then regular cardiac healthy diet with good tolerance and bms q3d. # spinal surgery. pt underwent a lumbar spine surgery () for spinal stenosis/l3-l5 right laminectomy, posteior fusion, foraminotomy and repair of dural tear (by at nebh). he was noted w/ stabilization device spaning the lower lumbar and lumbosacral levels of the spine on kub. given leukocytosis there was some concern regarding infection, but no signs of infection were noted on exam. ortho-spine service was consulted who agreed w/ assessment and advised activity. pain was treated with tylenol rtc and iv morphine prn, which was changed to oxycodone 5mg q4h prn at time of discharge. pain at time of discharge was and patient was able to ambulate w/ walker. fen: cardiac/low sodium diet prophylaxis: -dvt ppx with systemic heparin -pain managment with iv morphine -bowel regimen as listed above code: full, discussed with family and patient. patient was discharged home in a hemodynamically stable condition, w/o chest pain or dyspnea. medications on admission: home medications- simvastatin 40mg dialy folic acid 1mg daily metoprolol 100mg qam and 50mg qpm niaspan 500mg daily aspirin 81mg daily medications at time of transfer: zocor 40mg daily heparin gtt amioderone 400mg cardizem gtt lopressor 5-10mg q6h asa 81 altace 2.5mg daily morphine 2-4mg iv q2h tylenol 650mg q6h morphine pca lopressor 100mg reglan folic acid thiamine discharge medications: 1. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*11* 3. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for back pain. disp:*20 tablet(s)* refills:*0* 4. acetaminophen 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. 5. furosemide 40 mg tablet sig: three (3) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 6. outpatient lab work check cbc, inr, pt, and panel 7(electrolytes, cr, bun). please fax the results to dr. at 617-. 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 8. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm. disp:*60 tablet(s)* refills:*2* 9. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. acebutolol 200 mg capsule sig: two (2) capsule po bid (2 times a day). disp:*120 capsule(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: primary diagnoses: 1. st-elevation myocardial infarcion 2. atrial fibrillation 3. acute systolic heart failure 4. bowel ileus 5. acute renal failure 6. spinal stenosis s/p surgery secondary diagnoses: 7. coronary artery disease 8. hypertension 9. hypercholesterolemia discharge condition: afebrile, hemodynamically stable discharge instructions: you were admitted to the hospital with a heart attack after your back surgery. you had symptoms of congestive heart failure and were given lasix (furosemide) to remove fluid from your lungs to help you breathe better. your heart was in an abnormal rhythm called atrial fibrillation. you were started on medictions to control your heart rate and to thin your blood. you had a cardiac catheterization which showed a partial blockage in one of the arteries that supplies the heart. a stent was put in to relieve this blockage. you improved and you were discharged home. the following changes were made to your medications: start taking aspirin 81mg by mouth once a day. start taking plavix 75mg by mouth once a day. start taking acebutolol 500mg twice a day start taking coumadin 4mg by mouth once a day. you should never stop taking your plavix or aspirin unless instructed by your cardiologist. you should continue to take coumadin as instructed to thin your blood. if you develop any bleeding or notice blood in your bowel movements, you should come to the emergency room immediately. you will need a holter monitor in one month to evaluate if you are still in atrial fibrillation. weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: 1500ml you should follow-up with your pcp weeks. you should see your cardiologist within 1-2 weeks. you should call your doctor or come to the emergency room for any fevers > 100.4, chills, night sweats, chest pain, shortness of breath, heart palpitations, abdominal pain, blood in your bowel movements, leg swelling or any other symptoms that concern you. followup instructions: please see your pcp weeks. an appointment has been made for you to follow up with your cardiologist, dr. , you have an appointment scheduled for at 11:45 at the office on , . the office number is . dr. requests that you follow up at least once for evaluation after discharge. you should have your blood drawn to check your inr in 2 days and fax this result to your primary doctor, dr. , at . Procedure: Injection or infusion of platelet inhibitor Atrial cardioversion Insertion of drug-eluting coronary artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Acute myocardial infarction of anterolateral wall, initial episode of care Long-term (current) use of anticoagulants Paralytic ileus Hypoxemia Acute systolic heart failure Leukocytosis, unspecified Long-term (current) use of aspirin

allergies: no known allergies / adverse drug reactions attending: addendum: in this patient, his presentation of colangitis with bacteremia was consistent with sepsis/sirs. discharge disposition: home md Procedure: Endoscopic insertion of stent (tube) into bile duct Diagnoses: Thrombocytopenia, unspecified Other chronic pain Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Severe sepsis Personal history of malignant neoplasm of bronchus and lung Candidiasis of mouth Hypopotassemia Cardiac pacemaker in situ Septicemia due to escherichia coli [E. coli] Cholangitis Backache, unspecified Other and unspecified coagulation defects Calculus of bile duct without mention of cholecystitis, with obstruction Swelling of limb

allergies: no known allergies / adverse drug reactions attending: chief complaint: cholangitis major surgical or invasive procedure: ercp history of present illness: mr. is a 74 m with a medical history notable for cholecystectomy and post-cholecystectomy cholangitis requiring ercp in at . he reports intermittent biliary colic for the past year. however, on he noted a ruq pain that did not improve. he became weak and delirious and his wife called 911. initially presented to his local hospital and shortly after arrival he spiked a fever and his sbp dropped to the 80s. his initial evaluation was notable for the following: alt 722, ast 365, alk phos 241, lipase 470, bili 3.1, and a ct scan that revealed common bile duct dilation and possible gallstones. he received iv fluids, vancomycin, and zosyn. his blood pressure was fluid-responsive and did not require vasoactive medications. he was transferred to the ed. on arrival to the ed he recieved additional iv fluids and unasyn. he then went for ercp on . the ercp revealed a single 15 mm round stone that was partially-obstructing and pus in the biliary tree. a double pigtail biliary stent was placed and he was transferred to the icu for closer monitoring. while in the icu he required no vasoactive medications to support his blood pressure and was not intubated. one of his admission blood cultures grew gram negative rods and his antibiotics were changed from unasyn to cefepime and gentamycin. other active issues in the icu included a rising white blood cell count without additional fevers, acute renal failure that improved with iv fluids, and left upper extremity swelling of unclear etiology. on arrival to the floor he noted no abdominal pain. he had no nausea and was hungry. review of systems: pain assessment on arrival to the floor: 0/10 (no pain). no recent illnesses other than above. no sob, cough, or chest pain. no urinary symptoms. no arthralgias or joint swelling. other systems reviewed in detail and all otherwise negative. past medical history: previous cholecystectomy ercp for cholangitis as above in at gastric ulcers status post billroth-i gastric resection lung cancer status post rul resection in bradycardia s/p pacemaker hypertension type ii diabetes previous knee and shoulder surgeries chronic back pain primary care physician: . social history: he lives with his wife. does not currently smoke; he quit 30 yrs ago and had a previous 30-45 pack-year history. he drinks 1 glass of wine three times a week. family history: father had a stroke, brother died of an unclear type of cancer. physical exam: exam on arrival to the floor: - vital signs: t 97.7, p 74, bp 136/77, 97% on ra. - gen: well-appearing in nad. - heent: sclera anicteric. somewhat hard of hearing. oropharynx clear w/out lesions. - neck: supple. - chest: normal respirations and breathing comfortably on room air. lungs clear to auscultation bilaterally. - cv: pmi normal size and not displaced. regular rhythm. normal s1, s2. no murmurs or gallops. jvp 7 cm. - abdomen: normal bowel sounds. soft, nontender; somewhat distended. - extremities: tace ankle edema. - skin: 2 small blisters on left hand. left upper arm slightly swollen. - neuro: alert, oriented x3. good fund of knowledge. able to discuss current events and memory is intact. cn 2-12 intact. speech and language are normal. - psych: appearance, behavior, and affect all normal. discharge: - ent: dry/chapped lips with mild swelling; white plaque on tongue - abdomen: soft and non-tender - lue with mild edema and two vesicule on left hand pertinent results: admission labs wbc-16.8* rbc-4.39* hgb-13.0* hct-36.9* mcv-84 mch-29.7 mchc-35.4* rdw-14.1 plt ct-105* neuts-84* bands-4 lymphs-8* monos-2 eos-0 baso-0 atyps-0 metas-2* myelos-0 pt-14.5* ptt-28.6 inr(pt)-1.3* glucose-92 urean-28* creat-1.8* na-145 k-3.0* cl-109* hco3-26 angap-13 alt-348* ast-481* alkphos-167* amylase-205* totbili-2.8* dirbili-2.2* indbili-0.6 discharge labs wbc-11.6* rbc-4.11* hgb-12.2* hct-35.2* mcv-86 mch-29.6 mchc-34.6 rdw-13.4 plt ct-96* glucose-89 urean-15 creat-1.1 na-140 k-3.4 cl-102 hco3-29 angap-12 alt-87* ast-29 ld(ldh)-285* alkphos-131* totbili-0.9 ercp (): previous sphincterotomy noted. cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. contrast medium was injected resulting in complete opacification. a single 15 mm round stone that was causing partial obstruction was seen at the biliary tree with pus suggesting cholangitis a 5cm by 10fr double pigtail biliary stent was placed successfully u/s lue (): no evidence of dvt in the left upper extremity. non-visualization of the left basilic vein. brief hospital course: 1. cholangitis: underwent succesful ercp on but will need repeat ercp to confirm duct clearance in weeks. in addition to erpc, treated with supportive care and antibiotics (cipro sensitive e.coli grew in blood). 2. bacteremia: initially treated emperically with cefepime and gentamicin, but this was narrowed to ciprofloxacin given sensitivies. 10 days planned. 3. acute renal failure: improved with supportive care with creatinine at baseline 1.1 4. right upper extremity swelling: unclear cause; leni was negative. treated with elevation with improvement noted. 5. thrush: noted on hospital day . improved with nystatin oral. 6. type ii diabetes without complications: metformin and januvia were held on admission but restarted on discharged. insulin used as inpatient. 7. hypertension: continued on carvedilol; ace inhibitor and lasix were intially held but both were resumed at discharge. 8. chronic lumbar back pain: home standing oxycontin was decreased to dosing from tid given renal failure and illness but also written for prn oxycodone. resumed tid on discharge. 9. coagulopathy: likely secondary to critical illness. medications on admission: -list confirmed with patient on admission- carvedilol 6.25mg daily furosemide 20mg daily lisinopril 40mg daily oxycontin 80mg q8h percocet q4h prn metoclopromide 5mg qid levemir 24u qhs januvia 100mg daily metformin 500mg simvastatin 40mg qhs discharge medications: 1. carvedilol 6.25 mg tablet sig: one (1) tablet po daily (daily). 2. oxycodone 80 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po every eight (8) hours. 3. percocet 5-325 mg tablet sig: one (1) tablet po every four (4) hours as needed for pain. 4. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 5. metoclopramide 5 mg tablet sig: one (1) tablet po four times a day. 6. levemir 100 unit/ml solution sig: twenty four (24) units units subcutaneous at bedtime. 7. januvia 100 mg tablet sig: one (1) tablet po once a day. 8. metformin 500 mg tablet sig: one (1) tablet po twice a day. 9. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 6 days. disp:*12 tablet(s)* refills:*0* 10. nystatin-tcn-hc-diphenhydramin 1.2-1.5-0.06 gram/237 ml suspension for reconstitution sig: one (1) dose mucous membrane once a day as needed for mouth pain for 5 days. disp:*qs ml* refills:*0* 11. furosemide 20 mg tablet sig: one (1) tablet po once a day. 12. simvastatin 40 mg tablet sig: one (1) tablet po once a day. discharge disposition: home discharge diagnosis: 1. cholangitis 2. bacteremia, e.coli 3. acute renal failure 4. coagulopathy 5. thrombocytopenia 6. lue swelling 7. diabetes, type ii 8. hypertension 9. back pain, chronic discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted with cholangitis and treated with ercp and also with antibiotics. please be sure to complete a full 10 day course of antibiotics, as directed (6 days more). you will need a repeat ercp, which has been scheduled by the ercp service for . followup instructions: name: , address: , , phone: appointment: friday at 9:45am department: endo suites when: friday at 12:30 pm department: digestive disease center when: friday at 12:30 pm with: , md building: building (/ complex) campus: east best parking: main garage Procedure: Endoscopic insertion of stent (tube) into bile duct Diagnoses: Thrombocytopenia, unspecified Other chronic pain Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Severe sepsis Personal history of malignant neoplasm of bronchus and lung Candidiasis of mouth Hypopotassemia Cardiac pacemaker in situ Septicemia due to escherichia coli [E. coli] Cholangitis Backache, unspecified Other and unspecified coagulation defects Calculus of bile duct without mention of cholecystitis, with obstruction Swelling of limb

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chset pain, myocardial infarction major surgical or invasive procedure: off pump coronary artery bypass graft x1 (lima-lad) history of present illness: 61 year old gentleman with chest pain and anterior st-elevation myocardial infarction. he underwent cardiac catheterization which revealed severe left anterior descending artery stenosis which was unable to be intervened on at . an intra-aortic balloon pump was placed. he is now transferred via for urgent surgical revascularization. at the time of admission he was pain free on heparin infusion with iabp 1:1 past medical history: hypertension and gerd social history: race:caucasian last dental exam: lives with: occupation:works in machine shop tobacco:none etoh:none family history: non history of coronary artery disease physical exam: physical exam pulse: resp: o2 sat: b/p right: 117/70 left: height: weight: general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur: none abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema: none varicosities: none neuro: grossly intact, nonfocal exam pulses: femoral right: 2+/iabp left: 2+ dp right: 2+ left: 2+ pt : 2+ left: 2+ radial right: 2+ left: 2+ carotid bruit right: none left: none pertinent results: inr 1.2 inr 1.2 intra-op echo findings left atrium: normal la and ra cavity sizes. no spontaneous echo contrast or thrombus in the body of the laa. right atrium/interatrial septum: normal interatrial septum. no asd by 2d or color doppler. left ventricle: normal lv wall thickness. normal lv cavity size. moderate regional lv systolic dysfunction. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. normal aortic arch diameter. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: mildly thickened aortic valve leaflets (3). no as. no ar. mitral valve: normal mitral valve leaflets. mild to moderate (+) mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. physiologic (normal) pr. pericardium: trivial/physiologic pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope. no tee related complications. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions pre-bypass: the left atrium and right atrium are normal in cavity size. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is moderate regional left ventricular systolic dysfunction with anterior and septal akinesis. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild to moderate (+) mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. post-bypass: the patient is not receiving inotropic support with a cardiac output of 4.9 l/min. biventricular function is similar to pre-bypass function. all other findings consistent with pre-bypass findings. all findings communicated to the surgeon. preliminary report developed by a cardiology fellow. not reviewed/approved by the attending echo physician. certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 20:00 brief hospital course: mr was medflighted from mwmc with chest pain and anterior st-elevation myocardial infarction from 95% left anterior descending artery stenosis and emergently taken to the operating room for revascularization. see operative note for details. opst-operatively he was admitted to the icu intubated and sedated on propfol and phenylephrine drips and iabp inplace. he awoke neurologically intact and was extubated on pod#1. the phenylephrine was weaned off and the iabp was weaned and removed without complication. his chest tubes and wires were removed per protocol. he was transferred to the stepdown unit for ongoing care and rehab. he was started on betablockers and lasix. he developed rapid afib which was trated with amiodarone and diltiazem. given the afib was paraoxysmal, couamdin therapy was started. his inr was 1.2 and he received 2.5mg of coumadin on ; 5mg on and . he was evaluated by physical therapy and cleared for discharge to home. his statin therpay was held per his primary doctor lft's. his lft's have normalized but his statin therapy was not resumed at time of discharge. he will follow up with his pcp regarding statin therapy. he remained in sinus rhythm and was cleared for discharge to home by dr. on pod#5. medications on admission: prilosec, hydrochlorothyazide, atenolol discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. furosemide 20 mg tablet sig: one (1) tablet po once a day for 5 days. disp:*5 tablet(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 5. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day for 5 days. disp:*5 tab sust.rel. particle/crystal(s)* refills:*0* 6. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 7. diltiazem hcl 30 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 8. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily) for 1 months. disp:*30 tablet(s)* refills:*0* 9. coumadin 2.5 mg tablet sig: as directed for afib tablet po once a day: goal inr 2-2.5 for afib dr. will dose . disp:*60 tablet(s)* refills:*2* 10. outpatient lab work inr draw on and call results to dr. at coumadin clinic for coumadin dosing. 11. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* discharge disposition: home with service facility: tba discharge diagnosis: hypertension, gerd, coronary artery disease discharge condition: alert and oriented ambulating independently sternal incision without redness or drainage. healing well. no leg incision- trace edema discharge instructions: weigh yourself every morning, md if weight goes up more than 3 lbs.please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month until follow up with surgeon no lifting more than 10 pounds for 10 weeks please call with any questions or concerns your inr and coumadin will be managed at the coumadin clinic by dr. **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: , md phone: date/time: 1:00 please call to schedule appointments with your primary care dr. in weeks cardiologist dr. in weeks your inr and coumadin dosing will be managed by clinic . your first inr will be drawn on **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Single internal mammary-coronary artery bypass Diagnostic ultrasound of heart Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Acute myocardial infarction of other anterior wall, initial episode of care Atrial fibrillation Other and unspecified hyperlipidemia

allergies: patient recorded as having no known allergies to drugs attending: addendum: the vascular surgery service wished to keep the patient another day to repeat the creatinine which has fluctuated. it has been 1 to 1.4. the repeat this am was 1.2 (down from 1.4). the spironalactone and hctz were changed to a combination (dyazide) to reduce his potassium wasting and simplify his regimen a bit. he was discharged on with a reiteration of the need for close followup and regulation of his bp with his primary care physician. chief complaint: type a dissection major surgical or invasive procedure: emergent repair of aortic dissection(replacement of ascending aorta and hemiarch with resuspension of aortic valve) history of present illness: see original summary past medical history: hypertension dyslipidemia s/p mesenteric biopsies hyperaldoseteronism, adrenal adenoma depression, history of suicidal ideation hemorrhoids s/p appendectomy social history: denies tobacco and etoh. married, lives with wife. unemployed, previously worked as a landscaper. family history: mother with hypertension. no premature coronary artery disease. physical exam: see original summary brief hospital course: see original summary and addendum. discharge medications: 1. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 5. amlodipine 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 6. terazosin 10 mg capsule sig: one (1) capsule po at bedtime. disp:*30 capsule(s)* refills:*2* 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. tablet(s) 8. labetalol 300 mg tablet sig: four (4) tablet po twice a day. disp:*360 tablet(s)* refills:*2* 9. hydralazine 50 mg tablet sig: 1 and tablet po q6h (every 6 hours). disp:*180 tablet(s)* refills:*2* 10. lisinopril 40 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 11. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours). disp:*50 tablet(s)* refills:*0* 12. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsun (every sunday). disp:*4 patch weekly(s)* refills:*2* 13. potassium chloride 20 meq tab sust.rel. particle/crystal sig: two (2) tab sust.rel. particle/crystal po once a day. disp:*60 tab sust.rel. particle/crystal(s)* refills:*2* 14. triamterene-hydrochlorothiazid 37.5-25 mg capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: type a aortic dissection - s/p repair hypertension hypercholesterolemia prior abdominal surgery - s/p mesenteric biopsies adrenal adenoma depression, history of suicidal ideation discharge condition: good discharge instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swiming report any temperature gretaer than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week report any redness of, or drainage from incisions no lotions, creams or powders to incisions take all medications as directed followup instructions: dr. in weeks () dr. in 1 week () dr. () on @ 1:45 pm ct scan appt () on @ 1pm clinic in 2 weeks md Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Resection of vessel with replacement, thoracic vessels Open heart valvuloplasty of aortic valve without replacement Diagnoses: Unspecified pleural effusion Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Aortic valve disorders Depressive disorder, not elsewhere classified Hypopotassemia Pulmonary collapse Hypoxemia Dissection of aorta, thoracoabdominal Benign neoplasm of adrenal gland Hyperaldosteronism, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: emergent repair of aortic dissection(replacement of ascending aorta and hemiarch with resuspension of aortic valve) history of present illness: mr. is a 41 year old male with known history of poorly controlled hypertension, hyperaldosteronism and right adrenal adenoma who presented to with chest pain. ct scan revealed type a aortic dissection and he was emergently transferred to the for surgical repair. past medical history: hypertension dyslipidemia s/p mesenteric biopsies hyperaldoseteronism, adrenal adenoma depression, history of suicidal ideation hemorrhoids s/p appendectomy social history: denies tobacco and etoh. married, lives with wife. unemployed, previously worked as a landscaper. family history: mother with hypertension. no premature coronary artery disease. physical exam: discharge exam: vss, afebrile bp 144/74 lungs- clear heart:rsr. at72 abdomen:benign ext:w/o edema neuro:intact wounds:clean and dry. sternum stable. pertinent results: intraop tee: prebypass 1. the left atrium is normal in size. no atrial septal defect or pfo is seen by 2d or color doppler. 2. there is severe symmetric left ventricular hypertrophy. overall left ventricular systolic function is normal (lvef>55%). 3. right ventricular chamber size and free wall motion are normal. 4. a mobile density is seen in the ascending, arch and descending aorta consistent with an intimal flap/aortic dissection. the intimal flap terminates at the sinotubular junction. the arch and head vessels are difficult to visualize. flow is seen in the left subclavian artery. there are no echocardiographic signs of tamponade. there are simple atheroma in the aortic arch and descending thoracic aorta. 5. there are three aortic valve leaflets. mild (1+) aortic regurgitation is seen. 6. the mitral valve appears structurally normal with trivial mitral regurgitation. postbypass 1. preserved biventricular systolic function. 2. trace aortic insufficiency, trace mitral regurgitation. renal ultrasound: limited examination. however, there is evidence of vascular flow in both renal hila. chest/abd ct scan: 1. similar appearance of aortic dissection, with all major branches arising from the true lumen, including each main renal artery. 2. small nodule in the right adrenal gland of fat density, consistent with a myelolipoma. 04:26am blood wbc-11.6* rbc-3.43* hgb-9.7* hct-28.7* mcv-84 mch-28.2 mchc-33.7 rdw-14.4 plt ct-598* 04:26am blood glucose-84 urean-19 creat-1.2 na-139 k-3.6 cl-95* hco3-33* angap-15 04:26am blood mg-2.3 01:47am blood wbc-12.0* rbc-3.39* hgb-9.5* hct-28.4* mcv-84 mch-28.0 mchc-33.5 rdw-14.6 plt ct-621* 04:00am blood wbc-12.6* rbc-3.23* hgb-9.2* hct-27.1* mcv-84 mch-28.6 mchc-34.1 rdw-14.9 plt ct-503* 01:47am blood plt ct-621* 01:47am blood glucose-85 urean-16 creat-1.1 na-138 k-3.5 cl-96 hco3-30 angap-16 04:00am blood glucose-104 urean-16 creat-0.9 na-137 k-3.7 cl-97 hco3-31 angap-13 01:47am blood alt-51* ast-31 alkphos-126* totbili-0.7 09:30am blood wbc-13.9* rbc-3.52* hgb-10.0* hct-29.0* mcv-82 mch-28.3 mchc-34.4 rdw-14.4 plt ct-646* 09:30am blood glucose-111* urean-21* creat-1.4* na-138 k-3.2* cl-93* hco3-33* angap-15 brief hospital course: mr. was admitted and underwent emergent repair of his type a aortic dissection. for surgical details, please see operative note. following the operation, he was brought to the cvicu for invasive monitoring. on postoperative day one, he awoke neurologically intact and was extubated without incident. he initially appeared somewhat confused and at times disoriented to time and place. he remained hypertensive and was initially maintained on nitroglycerin and labetalol with hydralazine prn. antihypertensives were titrated for goal sbp < 120mmhg. given resistent hypertension, the cardiology service was consulted. he was placed on multiple antihypertensives, and underwent workup for secondary hypertension. he concomitantly experienced persistent hypoxia and desaturations. he required face tent and high flow nebulizers. with gentle diuresis, ambulation, incentive spirometry, and aggressive pulmonary toilet there was gradual improvement of oxygen saturations. postoperative ct scan was notable for a stable type b aortic dissection with all major branches arising from the true lumen, including each main renal artery. the ct scan was also notable for bibasilar atelectasis and small to moderate pleural effusions. the vascular service was consulted for possible aortic fenestration. aortic fenestration was not performed on this admission as there was no indication for same. the bp was controlled on multiple medications, with systolics in 140 range. he was stable and ready for discharge. a repeat ct scan will be done to assess stability of his dissection. medications, restrictions and follow up were discussed with the patient prior to his discharge. medications on admission: pravachol 20 qd, aspirin 81 qd, procardia 90 qd, kcl 40 meq qd, neurontin 300 tid, trazadone 200 qhs, wellbutrin , flouxetine 20 qd, atenolol 100 qd, aldactone 100 qd, risperdal 2 qhs, ? methadone discharge medications: 1. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 5. amlodipine 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 6. terazosin 10 mg capsule sig: one (1) capsule po at bedtime. disp:*30 capsule(s)* refills:*2* 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. tablet(s) 8. labetalol 300 mg tablet sig: four (4) tablet po twice a day. disp:*360 tablet(s)* refills:*2* 9. hydralazine 50 mg tablet sig: 1 and tablet po q6h (every 6 hours). disp:*180 tablet(s)* refills:*2* 10. lisinopril 40 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 11. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours). disp:*50 tablet(s)* refills:*0* 12. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsun (every sunday). disp:*4 patch weekly(s)* refills:*2* 13. hydrochlorothiazide 50 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 14. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 15. potassium chloride 20 meq tab sust.rel. particle/crystal sig: two (2) tab sust.rel. particle/crystal po once a day. disp:*60 tab sust.rel. particle/crystal(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: type a aortic dissection - s/p repair hypertension hypercholesterolemia prior abdominal surgery - s/p mesenteric biopsies adrenal adenoma depression, history of suicidal ideation discharge condition: good discharge instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swiming report any temperature gretaer than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week report any redness of, or drainage from incisions no lotions, creams or powders to incisions take all medications as directed followup instructions: dr. in weeks () dr. in 2 weeks () dr. () on @ 1:45 pm ct scan appt () on @ 1pm clinic in 2 weeks md Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Resection of vessel with replacement, thoracic vessels Open heart valvuloplasty of aortic valve without replacement Diagnoses: Unspecified pleural effusion Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Aortic valve disorders Depressive disorder, not elsewhere classified Hypopotassemia Pulmonary collapse Hypoxemia Dissection of aorta, thoracoabdominal Benign neoplasm of adrenal gland Hyperaldosteronism, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypertensive emergency. major surgical or invasive procedure: none. history of present illness: 42 yo man with history of depression and suicidal ideation, anxiety, history of hyperaldosteronism, poorly-controlled hypertension, type a dissection s/p emergent repair (), type b dissection extending to iliac arteries, now transferred from vascular surgery service for further management of malignant hypertension. this history is obtained from patient and medical records. in summary, he was scheduled for an elective fenestration of his type b dissection and possible left renal artery stenting on . when he was seen in the clinic he was noted to have an elevated bp in the 220s, symptomatic and was taken to the ed. in the ed, it appears he alluded to some si and was thus admitted for si in addition to management of malignant hypertension. he was admitted to the cardiovascular icu. he reports having htn (sbp >180s) over the past 10 years and has been on numerous meds. he has been seen intermittently at with lab data showing a history of hypokalemia (2.6) in . in , he was noted to have a pac/pra ratio of 776 (aldosterone 46, renin <0.06); a transtubular k gradient was 8.36 at that time. he was on acei, bb at that time, but not on an aldosterone antagonist. he also has undergone imaging which showed a 13mm myolipoma in the right adrenal in and , but no adenoma. he was recently hospitalized in at for an emergent type a dissection repair. during that admission, he was noted again to be hypokalemic and hypertensive requiring a labetalol drip. at that time it appears he underwent a secondary hypertension work-up with a pac/pra of 80 (16/0.2), vna 1.7, serum metanephrine and normetanephrine of 282 and 608 respectively. he was discharged on a regimen of amlodipine, labetalol, hydralazine, lisinopril, hctz, clonidine patch, and spironolactone. he was subsequently followed by ct surgery with serial ct scans. his initial post-op showed a 17 mm myolipoma in the right adrenal gland and a type b dissection extending from scl to internal/external iliacs. subsequent scans on , , , have shown no change in the appearance of the right adrenal mass but have shown new left renal and left renal wedge infarcts. it also appears that the left renal artery communicates with both true and false lumens with a flap noted. his most recent scan shows a stable lipoma (-70 houndsfield units). currently, he reports feeling better. he states that prior to this admission, his wife had been helping him with his bp meds and that he has been compliant. usually, when bp very high in 220's, he feels some headache. he denies any vision changes, chest pain, palpitations, abdominal pain, n/v, diarrhea. last bm 4 days ago. no weakness, numbness/tingling. past medical history: type a aortic dissection s/p emergent repair () type b aortic dissection (scl->ext/int iliacs; all major vessels originate from true lumen, left ra originates from both) hypertension hyperlipidemia prior abdominal surgery s/p mesenteric biopsies adrenal myolipoma depression history of suicidal ideation social history: he currently lives at home with his wife. denies any tobacco history, he does admit to etoh use 3-4 beers on the weekend, he denies any recreational drug use. family history: extensive history of familial early onset htn. grandfather - htn, diagnosed in his 30s; chest palpitations passed away 73 mother - htn, diagnosed in her late 30s father - htn, diagnosed early in life sister - htn, diagnosed in her teens aunt - thyroid physical exam: on admission to micu: general: middle aged, slightly depressed affect, nad heent: perrl, eomi, no scleral icterus noted. neck: no thyromegaly noted, no buffalo hump chest: lungs cta bilaterally, no wheezes, ronchi or rales. no gynecomastia cardiac: rr, s1 s2, 2/6 systolic @ lusb abdomen: non-tender, non-distended, normoactive bowel sounds, no striae. extremities: no edema, 2+ dp pulses b/l, warm to touch skin: numerous well healed surgical scars neurologic: alert, oriented to hospital, , person. cn ii-xii intact strength: upper and lower bilaterally sensation: decreased sensation to light touch in r lateral thigh and foot, but pinprick intact bilaterally pertinent results: imaging: ct head w/o contrast (): findings: there is no intracranial hemorrhage, mass effect or vascular territorial infarction. ventricles are normal in size and in configuration. grey-white matter differentiation is slightly indistinct globally. in addition, minimal sulcal effacement is noted diffusely. this latter finding is most prominent near the vertex. the basilar cisterns are unremarkable. slight caudal position of the cerebellar tonsils thus most likely represents incidental tonsillar ectopia. extracranial soft tissue structures are unremarkable. visualized osseous structures, paranasal sinuses and mastoid air cells are clear. impression: 1. subtle loss of grey-white matter differentiation with minimal sulcal effacement, particularly at the vertex, raising the possibility of early cerebral edema, in this context. there is no specific evidence of pres. 2. low-lying cerebellar tonsils, unlikely to be related to #1, above; this may represent coincidental tonsillar ectopia. cxr portable (): impression: stable cardiomegaly and prominence of the aortic arch, unchanged compared to prior study of . although there is no change in the mediastinal contours, complications related to prior aortic dissection and repair cannot be excluded and a ct of the chest should be obtained if there is clinical concern for such complications. ct abd: ct of the abdomen with and without iv contrast: there is a right adrenal lesion measuring 1.8 cm x 1.7 cm, which is predominantly fatty in attenuation, with internal hounsfield units of approximately -70 . these findings are most compatible with a myelolipoma, and has not significantly changed from the prior study. immediately superior to this myelolipoma, there is a slight fullness of the right adrenal gland which is within the range of normal, without evidence of a discrete nodule. a nonspecific punctate focus of calcification is seen. the right adrenal gland is otherwise unremarkable. similarly, the left adrenal gland is slightly prominent in appearance. however, there is no evidence to support adrenal hyperplasia or a discrete nodule, and is within normal limits. within the visualized lung bases, there is minimal dependent atelectases. again seen is a dissection of the aorta, with the dissection flap extending into the left renal artery. these findings were better assessed on dedicated cta . the visualized liver, gallbladder, spleen, and pancreas are unremarkable. within the left kidney, there are peripheral, wedge-shaped areas of low attenuation, which may reflect areas of renal infarct. previously noted suspicious area for infarct within the right kidney is not imaged on this study. no free fluid or pathologic adenopathy is identified. there is a "" appearance of the mesentery, which is unchanged. visualized osseous structures reveal no suspicious sclerotic or lytic lesion. impression: 1. stable right adrenal myelolipoma. otherwise, the remainder of the adrenal glands are within normal limits, without evidence for an additional nodule or hyperplasia. 2. aortic dissection, with dissection flap extending into the left renal artery, and probable areas of left renal infarct. these findings were better assessed on dedicated cta . 3. stable "" mesenteric appearance. brief hospital course: a 42 yo man with history of malignant hypertension, type a aortic dissection s/p emergent repair in , type b dissection, and depression admitted for hypertensive emergency requiring icu stay. # malignant hypertension: he presented with a systolic blood pressure in excess of 200 with accompanying lethargy. he was taken to the cardiovascular icu on admission, where he was started on nitro and labetalol drip. this was switched to oral labetalol, hctz-triamterene, clonidine patch, lisinopril, and hydralazine; meds were than adjusted to target a systolic blood pressure of 130-150, which has been recommended by the vascular surgery service. endocrinology was consulted regarding the history of hyperaldosteronism. per their recs, he was started on aldosterone antagonist therapy first with spironolactone then eplerenone to avoid gynecomastia. at time of discharge, his antihypertensive regimen consists of clonidine patch, labetalol, eplerenone, and amlodipine at the doses listed later in the report. he has achieved target blood pressure on this regimen, with stable electrolytes for the last two days. if bp meds are to be readjusted, consideration could be given to decreasing the frequency of the labetalol from tid to dosing to simplify his regimen. # depression: psychiatry was consulted in the emergency room when patient appeared depressed and endorsed suicidal ideation. he was started on a clonazepam, risperidone, and citalopram per their recommendations. his symptoms improved with this treatment. he has follow-up scheduled with his previous therapist and psychiatrist for the upcoming month. # question of primary hyperaldosteronism: his refractory hypertension and hypokalemia prompted endocrine consult and imaging. on ct, there was a right adrenal lesion measuring 1.8 cm x 1.7 cm compatible with myelolipoma, with slight fullness of the right adrenal gland within the range of normal. there was no evidence of adenoma. aldosterone and renin levels were sent, although the utility of these tests is questionable given that he was on spironolactone at the time the labs were drawn. it is believed that he has primary hyperaldosteronism. there may be a secretory adrenal adenoma not picked up on imaging or it is possible, given his family history of premature hypertension, that he has glucocorticoid remedial hyperaldosteronism. he will continue on eplerenone for the time being, and will follow-up in endocrine clinic at in early . # left renal infarct: likely in the setting of aortic dissection. he denied flank pain during this admission and there was no hematuria. vascular surgery did not feel endovascular intervention was necessary and recommended blood pressure control as above. # type b aortic dissection: on ct scan, there was evidence of aortic dissection, with dissection flap extending into the left renal artery, and probable areas of left renal infarct. vascular service deferred surgical intervention, and felt that blood pressure control with target sbp 130-150 was the preferred treatment. he should follow-up in vascular clinic later this month. # code status: full medications on admission: medications on admission: (confirmed with pharmacy) catopress 0.3mg qsunday (rx due ) lisinopril 40mg (last picked up ) pravastatin 20mg daily labetalol 1200mg terazosin 10mg at bedtime (last picked up ) amlodipine (rx due ) triamterene-hctz 37.5mg/25mg daily (rx due ) amlodipine 75mg q6hrs (last picked up ) feso4 325mg daily colace 100mg asa 81mg daily ranitidine 150mg (last picked up ) zolpidem 10mg at bedtime (rx due ) discharge medications: 1. amlodipine 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 2. eplerenone 50 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 3. labetalol 300 mg tablet sig: two (2) tablet po three times a day. disp:*180 tablet(s)* refills:*2* 4. clonidine 0.3 mg/24 hr patch weekly sig: one (1) transdermal qwed. disp:*4 qs* refills:*2* 5. blood pressure kit kit sig: one (1) miscellaneous twice a day. disp:*1 qs* refills:*0* 6. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. clonazepam 0.5 mg tablet sig: one (1) tablet po twice a day: do not drive after taking this medicine. this medicine will cause you to be sleepy. disp:*60 tablet(s)* refills:*1* 8. risperidone 1 mg tablet sig: one (1) tablet po at bedtime: this medicine should be taken at night. it may make you drowsy. disp:*30 tablet(s)* refills:*1* 9. pravastatin 20 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 10. outpatient lab work please have labs drawn qweekly for chem 7 and faxed to dr. at . discharge disposition: home with service facility: health systems discharge diagnosis: primary diagnoses: hypertensive emergency type b aortic dissection depression . secondary diagnoses: hyperlipidemia history of suicidal ideation discharge condition: vital signs stable. blood pressure controlled with systolic blood pressure 130-140s. discharge instructions: you were admitted to the hospital for very high blood pressure (hypertensive emergency) and damage to a blood vessel in the chest (aortic dissection). you required icu-level care. your blood pressure medicines were changed. your goal blood pressure after discharge, for the time being, should be 130-150/70-80. . you were also evaluated by psychiatry for depression and anxiety. they have recommended that you take citalopram, clonazepam and risperidone. . we have provided you with a new medication list. we have also given you prescriptions for all of these medicines: -amlodipine 10 mg once daily for blood pressure -eplerenone 50 mg once daily for blood pressure -labetalol 600 mg three times daily for blood pressure -clonidine patch 0.3 mg to be changed every week for blood pressure -citalopram 20 mg once daily for depression and anxiety -clonazepam 0.5 mg twice daily for anxiety -risperidone 1 mg once daily at night for anxiety -pravastatin 20 mg once daily at night for high cholesterol -terazosin 10 mg once daily at night -blood pressure kit to measure blood pressure two times daily . please call your doctor or return to the emergency room if you experience any back or chest pain, changes in vision, headache, or any other new concerning symptoms. . it is imperative that you follow a low-salt diet (no more mcdonald's), that you take your medications on time, and that you follow-up with your providers as recommended below. followup instructions: appointments outside of : -we scheduled an appointment with dr. for friday at 11:15. it is very important that you go to this appointment for blood pressure check and blood tests. her office phone is . -you have an appointment with your therapist ms. on at 10am. -you have an appointment in psychopharmacology clinic with dr. on at 10am. . appointments at : - , m.d. phone: date/time: 1:00 - , md phone: date/time: 2:15 Procedure: Arterial catheterization Diagnoses: Acute kidney failure, unspecified Hypopotassemia Dysthymic disorder Other and unspecified hyperlipidemia Atherosclerosis of renal artery Malignant essential hypertension Vascular disorders of kidney Benign neoplasm of adrenal gland Dissection of aorta, unspecified site Suicidal ideation Hyperaldosteronism, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: stemi major surgical or invasive procedure: cardiac catheterization history of present illness: mr. is a 68 y/o gentleman with little past medical history who presented with chest pain around 1pm today with radiation down his l arm and diaphoresis. . on arrival to the ed, initial vitals were pain , temperature 97.8, heart rate 75, blood pressure 99/75, 16 respirations, 100%. labs with leukocytosis to 13.2 with neutrophil predominance, hct and plts normal. chem significant for cr 1.3 without known baseline. trop 0.03 with no ck/mb measured. ekg with minimal ekg changes (st depression in iii, avf with twi; slight ste in avl, v2). pt was started on asa 324, plavix 75 . . stemi called in , pt went to cath lab where he was found to have ostial lad occlusion and received bms. lmca with minimal disease, lcx with 30% proximal, rca with minor disease. hemodynamics showing elevated l and r pressures with ra 15, mean pa 30, wedge pressure 30. prominenet v waves on pcwp tracing, possible mr. sbp low at 85 mmhg. . pt transferred to ccu for further monitoring. past medical history: no known (no medical care for 35 years). social history: tobacco use: no current tobacco use. quit 25 yrs ago no drug use no etoh family history: brother with stents and dm2. physical exam: 96.3 90/63 68 15 middle aged man in no distress, daughter at bedside, pleasant conversant oriented to time and place. no jvd noted, no hepatojugular reflux, no carotid bruits. ctab anteriorly, no w/c/r/r, good air movement, no labored breathing rrr but faint s1 s2, no murmurs appreciated. radial and dp pulses palpable bilaterally abd slightly obese, nt nd, no aaa palpable. swan ganz catheter in place no ble edema noted. extremities warm, well perfused. no groin bruits, normal distal pulses. pertinent results: cardiac cath performed on demonstrated: comments: 1. coronary angiography in this right dominant system revealed one vessel coronary artery disease. the lmca had minimal disease. the lad was totally occluded at the origin. the lcx had a proximal 30% stenosis. the rca had minor disease. 2. resting hemodynamics revealed significantly elevated left- and right-sided filling pressures, with mean pcw pressure of 30 mmhg and mean ra pressure of 15 mmhg. there was moderate pulmonary hypertension, with mean pa pressure of 30 mmhg. there were prominant v waves on the pcw tracing, consistent with possible mitral regurgitation. there was systemic hypotension, with sbp of 85 mmhg. final diagnosis: 1. one vessel coronary artery disease. 2. severe left- and right-sided filling pressures. 3. moderate pulmonary artery hypertension. 4. systemic hypotension. tte (complete) done at 7:40:13 pm the left atrium and right atrium are normal in cavity size. left ventricular wall thicknesses and cavity size are normal. there is severe regional left ventricular systolic dysfunction with hypokinesis of basal segments and near akinesis of the distal 2/3rds of the anterior septum and anterior walls and apex. the remaining segments contract normally (lvef = 30 %). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. there is an anterior space which most likely represents a prominent fat pad. impression: normal left ventricular cavity size with regional systolic dysfunction c/w cad (proximal lad distribution). no ventricular septal defect or pathologic flow identified. . cbc 03:37am blood wbc-11.1* rbc-4.26* hgb-13.2* hct-38.8* mcv-91 mch-30.9 mchc-34.0 rdw-13.7 plt ct-163 04:25pm blood wbc-13.9* rbc-4.77 hgb-15.1 hct-43.9 mcv-92 mch-31.7 mchc-34.5 rdw-14.1 plt ct-198 . chemistry 03:37am blood glucose-118* urean-13 creat-1.0 na-139 k-4.0 cl-105 hco3-27 angap-11 04:25pm blood glucose-138* urean-16 creat-1.3* na-140 k-4.2 cl- 102 hco3-27 angap-15 03:37am blood calcium-8.3* phos-3.2 mg-2.1 cholest-pnd 04:25pm blood calcium-9.3 phos-3.3 mg-2.2 . cardiac enzymes 03:37am blood ck(cpk)-1662* 04:25pm blood ck(cpk)-177 03:37am blood ck-mb-195* mb indx-11.7* 04:25pm blood ctropnt-0.03* . hba1c 03:37am blood %hba1c-5.7 eag-117 brief hospital course: 68yom without any major cardiac history or other known medical comorbidities presents with chest pain and found to have lad occlusion, s/p bms with good results; also with elevated l and r sided filling pressures and asymptomatic hypotension. . 1. stemi: pt presented with minimal ekg changes (st elevation in v2-minimal in v3 that looked more like repolarization changes and not true ste, however he had some elevation in avl) however with high clinical suspicion, was taken to cath lab where he was found to have ostial occlusion of his lad and he received bms x1 to lad. minimal disease in rest of coronaries. he tolerated the procedure well and did well post procedure. he was transferred to ccu for further monitoring and was started on asa, plavix 75 x1 week then daily thereafter, statin, acei, and long acting beta blocker. a1c was 5.7% and lipid panel with total cholesterol 200, ldl 138, hdl 43, trigly 95. appointments were made for the pt to f/u. he was started on coumadin for apical akinesis, will have his coumadin level followed by the at discharge. . 2. elevated filling pressures: the pt was noted to have elevated r and l sided filling pressure during catheterization and prominent v waves concerning for mr. received a formal echo on which showed he has systolic failure and akinesis of the anterior wall from base to apex (which corresponds to his lad occlusion) however does not appear volume overloaded on exam and did not start a diuretic regimen. he will need a repeat echo in weeks to further evaluate any recovery of his systolic function. his medication regimen for heart failure is as above. . 3. hypotension: with evidence of elevated filling pressures and depressed ef in setting of stemi, likely due to heart failure. his blood pressures were stable in the 90's through admission and he was totally asymptomatic. acei and beta blockade for the stemi and heart failure were added cautiously. . medications on admission: none discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 weeks: last day on . . disp:*14 tablet(s)* refills:*0* 3. warfarin 2 mg tablet sig: 2.5 tablets po once a day. disp:*75 tablet(s)* refills:*2* 4. lisinopril 5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 5. metoprolol succinate 25 mg tablet sustained release 24 hr sig: 0.5 tablet sustained release 24 hr po once a day. disp:*30 tablet sustained release 24 hr(s)* refills:*2* 6. outpatient lab work please check chem-7 and pt/inr on tuesday and call results to at . please get your blood drawn at the clinical center. 7. clopidogrel 75 mg tablet sig: one (1) tablet po once a day: start on . disp:*30 tablet(s)* refills:*2* 8. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet sublingual every 5 minutes for a total of 3 : call 911 if you still have chest pressure after 3 . disp:*25 tablets* refills:*0* 9. simvastatin 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: st elevation myocardial infarction acute systolic dysfunction discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you had a heart attack and needed one bare metal stent placed in your left anterior coronary artery. one wall of your heart is not moving well and we have started you on some medicines to help your heart function better and prevent complications. you need to take these medicines every day without fail. you also need to change your diet to a low sodium and heart healthy diet. there is a nutrition class you can take here that will help you with your diet. there are 2 medicines that can lower your blood pressure: lisinopril and metoprolol. please check your blood pressure before taking these medicines and do not take them if your top blood pressure number is less than 90. recheck your blood pressure again in a few hours. call dr. if you cannot take your medicine all day because your blood pressure is less than 90. new medicines: 1. aspirin and clopidogrel (plavix) to prevent the stent from clotting off and causing another heart attack. do not stop taking this medicine or miss unless dr. tells you to. you will take 2 clopidogrel tablets a day until , then decrease to 1 clopidogrel tablet daily. 2. simvastatin (zocor) to lower your cholesterol and help your heart recover from the heart attack. 3. metoprolol succinate to lower your heart rate and help your heart recover from the heart attack 4. lisinopril to help your heart pump better 5. warfarin to prevent blood clots. you will need to have your blood level checked frequently to make sure it isn't too high or too low. we want the level of coumadin to be between 2.0 and 3.0. you will be in contact with the who will tell you what dose of coumadin to take starting on tuesday. 6. nitroglycerin: to take if the chest pressure returns. sit down and take up to 3 tablets 5 minutes apart. please call 911 if you have chest pain after 3 tablets. call dr. if you have chest pressure at all. . your weak heart function means you are at risk for fluid retention. weigh yourself every morning, call dr. if your weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. followup instructions: primary care: dr. on at 2:45pm, on the of building, . phone: . cardiology: dr phone: date/time: at 2:20pm. clinical center, . Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Primary pulmonary hypertension Acute systolic heart failure Acute myocardial infarction of unspecified site, initial episode of care Renal failure, unspecified

allergies: patient recorded as having no known allergies to drugs attending: addendum: prior to discharge, the nurse was concerned that the pt may have a urinary tract infection and a urinalysis was sent. general urine information type color appear sp 12:23pm yellow hazy 1.006 source: cvs dipstick urinalysis blood nitrite protein glucose ketone bilirub urobiln ph leuks 12:23pm lg pos 30 neg neg neg neg 7.0 mod source: cvs microscopic urine examination rbc wbc bacteri yeast epi transe renalep 12:23pm * 21-50* mod none 0-2 source: cvs 12:23pm source: cvs we have started her on cipro 500mg x 5 days. discharge disposition: extended care facility: life care center of md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Resection of vessel with replacement, aorta, abdominal Diagnoses: Tobacco use disorder Urinary tract infection, site not specified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Occlusion and stenosis of carotid artery without mention of cerebral infarction Abdominal aneurysm without mention of rupture Other acute postoperative pain

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: aaa major surgical or invasive procedure: resection and repair of abdominal aortic aneurysm with 18-mm dacron tube graft. history of present illness: this 83-year-old lady has an enlarging abdominal aortic aneurysm. it is tender to the touch. maximum diameter is about 7 cm. it extends up to the renal arteries and is not suitable for endovascular repair past medical history: pmh: copd, aaa, htn, carotid stenosis, bladder incontinence psh: cysto, bladder suspension, right ear drum repair social history: she has a long cigarette smoking history of two packs a day for most of her adult life family history: n/c physical exam: on physical examination, she is a thin spry-appearing elderly lady in no acute distress. blood pressure is 172/100. pulse is 61. respirations are 15. she has no cervical bruits. chest is clear. heart is in regular rhythm. abdomen is soft, with pos bs. it starts at the level of the left upper quadrant and extends below the umbilicus. femoral and popliteal pulses are strongly palpable without evident peripheral aneurysm. her foot pulses are nonpalpable. pertinent results: 06:20am blood wbc-6.8 rbc-3.80* hgb-11.8* hct-34.7* mcv-91 mch-31.1 mchc-34.0 rdw-14.0 plt ct-240# 06:20am blood glucose-88 urean-9 creat-0.5 na-137 k-3.6 cl-103 hco3-28 angap-10 06:20am blood calcium-8.4 phos-2.2* mg-1.9 12:09pm blood hgb-13.7 calchct-41 cxr: impression: clear lungs. normal tube and line placement. brief hospital course: mrs. , was admitted on with aaa. she agreed to have an elective surgery. pre-operatively, she was consented. a cxr, ekg, ua, cbc, electrolytes, t/s - were obtained, all other preparations were made. it was decided that she would undergo a resection and repair of abdominal aortic aneurysm with 18-mm dacron tube graft. she was prepped, and brought down to the operating room for surgery. intra-operatively, she was closely monitored and remained hemodynamically stable. she tolerated the procedure well without any difficulty or complication. post-operatively, she was extubated and transferred to the for further stabilization and monitoring. while in the , pt had respiratory distress. she had to be re intubated. she was then transferred to the cvicu intubated. she was eventually weaned from her vent, she was then transferred to the vicu in stable condition. while in the vicu she received monitored care. when stable she was delined. her diet was advanced. a pt consult was obtained. when she was stabilized from the acute setting of post operative care, she was transferred to floor status on the floor, she remained hemodynamically stable with his pain controlled. she progressed with physical therapy to improve her strength and mobility. she continues to make steady progress without any incidents. she was discharged to a rehabilitation facility in stable condition. medications on admission: advair, albuterol, norvasc 5, asa 81, atenolol 50, calcium, lisinopril 10 discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q6h (every 6 hours) as needed for wheeze. 2. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily): (new med). 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 6. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 7. oxycodone-acetaminophen 5-325 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for pain. 8. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 9. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). discharge disposition: extended care facility: life care center of discharge diagnosis: abdominal aortic aneurysm discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - independent discharge instructions: division of vascular and endovascular surgery endovascular abdominal aortic aneurysm (aaa) discharge instructions medications: ?????? take aspirin 325mg (enteric coated) once daily ?????? do not stop aspirin unless your vascular surgeon instructs you to do so. ?????? continue all other medications you were taking before surgery, unless otherwise directed ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort what to expect when you go home: it is normal to have slight swelling of the legs: ?????? elevate your leg above the level of your heart (use pillows or a recliner) every 2-3 hours throughout the day and at night ?????? avoid prolonged periods of standing or sitting without your legs elevated it is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? drink plenty of fluids and eat small frequent meals ?????? it is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? to avoid constipation: eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do: ?????? when you go home, you may walk and go up and down stairs ?????? you may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? no heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? after 1 week, you may resume sexual activity ?????? after 1 week, gradually increase your activities and distance walked as you can tolerate ?????? no driving until you are no longer taking pain medications ?????? call and schedule an appointment to be seen in weeks for post procedure check and cta what to report to office: ?????? numbness, coldness or pain in lower extremities ?????? temperature greater than 101.5f for 24 hours ?????? new or increased drainage from incision or white, yellow or green drainage from incisions ?????? bleeding from groin puncture site sudden, severe bleeding or swelling (groin puncture site or incision) ?????? lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. if bleeding stops, call vascular office. if bleeding does not stop, call 911 for transfer to closest emergency room. followup instructions: provider: , md phone: date/time: 12:50 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Resection of vessel with replacement, aorta, abdominal Diagnoses: Tobacco use disorder Urinary tract infection, site not specified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Occlusion and stenosis of carotid artery without mention of cerebral infarction Abdominal aneurysm without mention of rupture Other acute postoperative pain

allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: : emergency repair of type a dissection with ascending aorta and hemi arch replacement axillary artery cannulation on the right side. history of present illness: 66 year old male who developed chest pain yesterday with radiation down left arm. ct at outside hospital revealed type a aortic dissection. transferred for surgical management. past medical history: hypertension basal cell carcinoma depression hearing loss s/p appendectomy s/p vasectomy s/p kidney cyst removal social history: lives: alone, divorced occupation: hearing aid specialist tobacco: current, 1/ppd etoh: 2 drinks/week family history: non-contributory physical exam: pulse: 70 resp: 18 o2 sat: 98% 4l nc b/p 131/75 general: well-developed male lying supine skin: warm dry intact heent: ncat perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur - abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema - varicosities: none neuro: grossly intact pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 2+ left: 2+ radial right: 2+ left: 2+ carotid bruit right: - left: - pertinent results: echo prebypass the interatrial septum is aneurysmal. no atrial septal defect is seen by 2d or color doppler. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. a mobile density is seen in the aortic arch consistent with an intimal flap/aortic dissection. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results by dr who performed the prebypass study on at 1730am. post bypass very poor image quality. biventricular systolic function unchanged. graft material seen in the aortic arch. small portion of the dissection flap still seen in the distal arch. surgeon aware. mild aortic insufficiency present. cta 1. type a acute aortic syndrome. there is intramural hematoma eccentrically affecting the lateral aspect of the ascending aorta with a focal defect demonstrating contrast abutting pre-existing hematoma. this suggests a pre-existing intramural hematoma progressing to dissection, which likely precipitated the acute presentation. there is no extension of dissection into the coronary arteries or the origins of the great vessels. however the intramural hematoma does involve the great vessel origins, most notably that of the left subclavian artery. 2. left complex renal mass which requires further workup following treatment for the aortic dissection. renal cell carcinoma cannot be excluded. dr. was informed of this finding and recommendation via email by dr. at 1:07 am on in light of urgent clinical presentation detailed in #1 above. 05:40am blood wbc-13.0* rbc-3.62* hgb-11.5* hct-33.1* mcv-91 mch-31.8 mchc-34.8 rdw-14.0 plt ct-347 02:10pm blood wbc-13.8* rbc-3.59* hgb-11.3* hct-32.4* mcv-90 mch-31.4 mchc-34.8 rdw-13.0 plt ct-240# 04:00pm blood wbc-12.0* rbc-4.78 hgb-15.3 hct-42.9 mcv-90 mch-32.0 mchc-35.6* rdw-12.9 plt ct-224 04:00pm blood neuts-82.5* lymphs-10.7* monos-4.9 eos-1.2 baso-0.6 05:40am blood plt ct-347 05:40am blood pt-24.3* inr(pt)-2.3* 04:39am blood pt-19.9* inr(pt)-1.8* 05:59am blood pt-16.4* ptt-27.5 inr(pt)-1.5* 04:00pm blood pt-12.3 ptt-23.4 inr(pt)-1.0 09:12pm blood fibrino-249 05:40am blood glucose-87 urean-27* creat-0.9 na-137 k-4.0 cl-105 hco3-24 angap-12 04:00pm blood glucose-110* urean-21* creat-1.0 na-137 k-3.7 cl-103 hco3-23 angap-15 05:59am blood alt-38 ast-45* ld(ldh)-196 alkphos-34* amylase-34 totbili-0.9 05:59am blood lipase-55 04:00pm blood ctropnt-<0.01 05:40am blood calcium-8.5 phos-3.1 mg-2.1 brief hospital course: was admitted for emergent repair of type a aortic dissection. he was taken directly to the operating room where he underwent replacement of his ascending aorta and hemiarch. please see operative note for details. postoperatively he was taken to the instensive care unit for monitoring. over the next 24 hours, he awoke neurologically intact and was extubated. he developed atrial fibrillation which was treated with amiodarone and beta blockers. his blood pressure was aggressively controlled with hydralazine and beta blockade. on postoperative day three he was transferred to the step down unit for further recovery. he was gently diuresed towards his preoperative weight. the physical therapy service was consulted for assistance with his postoperative strength and mobility. a psychiatry consult was obtained due to mr. depression and irritability. wellbutrin was continued and follow-up with his primary care physician was recommended. his oral antihypertensive agents were titrated for adequate blood pressure control. his goal systolic blood pressure is less then 120mmhg. mr. continued to make steady progress and was discharged to rehab on postoperative day 6. medications on admission: aspirin chantix hctz labetalol lisinopril xalatan nitro discharge medications: 1. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po once a day. 5. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed for dry nares . 6. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 7. bupropion hcl 150 mg tablet sustained release sig: one (1) tablet sustained release po qam (once a day (in the morning)). 8. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 400 mg twice a day until then decrease to 400 mg once a day until , then decrease to 200 mg daily and continue with that dose until follow up with cardiologist . 9. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 10. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day): 75mg three times a day . 11. warfarin 2 mg tablet sig: one (1) tablet po once (once) for 1 days: please give 2 mg on then check inr for further dosing . 12. amlodipine 5 mg tablet sig: one (1) tablet po bid (2 times a day). 13. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 14. lisinopril 20 mg tablet sig: one (1) tablet po bid (2 times a day). 15. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for rt wrist phlebitis for 7 days. 16. acetaminophen 500 mg tablet sig: two (2) tablet po every six (6) hours: please give around the clokck for 5 days then change to q6h prn pain . discharge disposition: extended care facility: of discharge diagnosis: aortic dissection s/p repair post operative atrial fibrillation hypertension new finding of a left renal mass history of pneumothorax basal cell carcinoma left ear discharge condition: alert and oriented x3 nonfocal ambulating with 1 assist incisional pain managed with ultram incisions: sternal - healing well, no erythema or drainage 1+ edema bilateral lower extremities right wrist phlebitis - being treated with keflex discharge instructions: 1) please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage. 2) please no lotions, cream, powder, or ointments to incisions. 3) each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) no driving for approximately one month and while taking narcotics. driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) no lifting more than 10 pounds for 10 weeks 6) please call with any questions or concerns 7) warm packs qid to right wrist for phlebitis - please call if worsens or does not improve with warm packs and keflex **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: surgeon: dr phone: date/time: 1:15 please call to schedule appointments with your primary care dr. in weeks cardiologist: dr ( - cardiologist recommended by pcp urology dr for f/u on renal mass **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** labs: pt/inr for coumadin ?????? indication atrial fibrillation goal inr 2.0-2.5 first draw rehab physician to follow inr and dose coumadin - please set up prior to leaving rehab for continued coumadin monitoring please check inr sunday and tuesday and thrusday for at least 2 weeks md Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Arterial catheterization Resection of vessel with replacement, thoracic vessels Diagnoses: Tobacco use disorder Unspecified essential hypertension Acute posthemorrhagic anemia Other pulmonary insufficiency, not elsewhere classified Cardiac complications, not elsewhere classified Atrial fibrillation Dysthymic disorder Personal history of other malignant neoplasm of skin Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Unspecified hearing loss Unspecified disorder of kidney and ureter Other vascular complications of medical care, not elsewhere classified Dissection of aorta, thoracic Phlebitis and thrombophlebitis of upper extremities, unspecified Embolism and thrombosis of thoracic aorta Vasectomy status

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: large left hepatic mass major surgical or invasive procedure: left hepatic lobectomy, ccy history of present illness: ms. is a 70-year-old woman who presents with a large hepatoma involving the medial segment of the liver extending across into the right lobe. afp was 70.3. the tumor abuts the confluence of the portal vein and the hepatic hilum. she presented for left hepatic lobectomy. past medical history: pcom aneurysm found hyperlipidemia, discontinued lipitor due to myopathy htn for 20yrs hypothyroidism cluster headaches myopathy, probable atorvastatin induced (neurology) cervical and thoracic djd gerd osteopenia psh: d&c, orthopedic repair of fractured ritght lower extremity social history: 25pk-yr smoker retired airline attendant etoh, several drinks every other day family history: mother had physical exam: wt 54.55kg, height 165cm, 98 71 139/49 16 97%ra nad, a&o cor rrr lungs clear ext no cce pertinent results: 12:18pm blood wbc-10.8 rbc-2.87*# hgb-9.0*# hct-26.2*# mcv-91 mch-31.4 mchc-34.5 rdw-14.6 plt ct-209 06:20am blood wbc-13.9* rbc-3.50* hgb-10.9* hct-31.9* mcv-91 mch-31.1 mchc-34.2 rdw-14.3 plt ct-400 03:08am blood pt-14.5* ptt-41.2* inr(pt)-1.3* 12:18pm blood glucose-145* urean-11 creat-0.6 na-141 k-3.9 cl-114* hco3-23 angap-8 06:20am blood glucose-99 urean-10 creat-1.0 na-139 k-3.1* cl-101 hco3-27 angap-14 02:57am blood alt-205* ast-240* ld(ldh)-238 alkphos-63 amylase-45 totbili-1.3 06:20am blood alt-67* ast-43* alkphos-87 totbili-0.3 06:20am blood calcium-8.5 phos-3.6# mg-1.6 brief hospital course: on , she had left hepatic lobectomy, cholecystectomy, intraoperative cholangiogram for left hepatic mass. surgeon was dr. . please refer to operative report for details. postop, she experienced a lot of pain. pca dilaudid was adjusted. she became confused, tachycardic and was treated for a combination of mild post encephalopathy and etoh withdrawal (drinks several martinis per day)in the sicu. she was maintained on a ciwa scale. she had been pan cultured and was subsequently found to have positive blood cultures on with enterococcus faecalis and staph coag negative. iv vancomycin was started on . mental status improved. an abdominal ct was done noting heterogeneous material along the cut surface of the liver containing small foci of gas, diverticulosis, small bilateral pleural effusions, bilateral renal cysts as well as other hypodensities too small to characterize, likely also cysts and small focal aneurysmal dilation of the infrarenal aorta, 2.4 cm in diameter. the jp drain was left in place and averaged 100cc of serosanguinous drainage per day. lfts increased a little postop then trended down. diet was slowly advanced. the incision remained intact without redness/drainage. on , an ultrasound was done to reassess the fluid collection. preliminary read demonstrated a collection that was not larger. the jp drain was removed (). pt evaluated her and recommended rehab. she was accepted at . iv vancomycin was stopped on and oral ampicillin was started on for bacteremia on . blood cultures on were negative to date. wbc remained in the 14-13 range. pathology report from or was as follows: . gallbladder (a-c): 1. chronic cholecystitis. 2. cholelithiasis. 3. one lymph node with no carcinoma seen (0/1). 2. portal lymph node (d-f): one lymph node with no carcinoma seen (0/1). 3. liver, left lobe (g-q): 1. poorly differentiated adenocarcinoma, most consistent with primary intrahepatic cholangiocarcinoma (6.5 cm), present within 1 mm of the cauterized resection margin; see synoptic report. 2. focal large vessel (venous) invasion and multifocal small vessel invasion identified. 3. non-neoplastic liver parenchyma with mild portal and lobular mixed inflammation, most likely secondary to surgical procedure. 4. no increase in fibrosis on trichrome stain. 5. iron stain shows no iron deposition. she will follow up with dr. . medications on admission: amlodipine 2.5', hctz 50 alt with 25 qod , synthroid 100, lisinopril 40, omeprazole 20, bisphosphonate 70qwk, mvi, xanaz .25 prn discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection q8h (every 8 hours). 2. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 3. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 4. amlodipine 5 mg tablet sig: 0.5 tablet po daily (daily). 5. hydrochlorothiazide 12.5 mg capsule sig: fifty (50) mg po every other day (every other day): started . 6. hydrochlorothiazide 12.5 mg capsule sig: two (2) capsule po every other day (every other day): started . 7. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing. 8. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 10. hydrocodone-acetaminophen 5-500 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for incision pain. 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 12. alendronate 70 mg tablet sig: one (1) tablet po qfri (every friday). 13. ampicillin 500 mg capsule sig: one (1) capsule po q8h (every 8 hours) for 2 weeks. 14. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. discharge disposition: extended care facility: - discharge diagnosis: hepatic mass cholangiocarcinoma discharge condition: alert, oriented. forgetful ambulating with assist tolerating small amounts of regular food discharge instructions: you will be discharged to based on physical therapy assessment please call dr. office if warning signs followup instructions: provider: , md phone: date/time: 9:00 call and speak with , rn coordinator Procedure: Cholecystectomy Intraoperative cholangiogram Lobectomy of liver Diagnoses: Esophageal reflux Tobacco use disorder Other postoperative infection Unspecified essential hypertension Hypopotassemia Anxiety state, unspecified Alkalosis Bacteremia Calculus of gallbladder with other cholecystitis, without mention of obstruction Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other encephalopathy Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Disorders of magnesium metabolism Diverticulosis of colon (without mention of hemorrhage) Disorder of bone and cartilage, unspecified Other and unspecified alcohol dependence, continuous Alcohol withdrawal Cervical spondylosis without myelopathy Cyst of kidney, acquired Other specified disorders of liver Malignant neoplasm of intrahepatic bile ducts Other acute postoperative pain Thoracic spondylosis without myelopathy Cluster headache syndrome, unspecified

allergies: no known allergies / adverse drug reactions attending: chief complaint: palpitations/pre-syncope major surgical or invasive procedure: ep study dual chamber pacemaker history of present illness: this is a 49 yo female who has a history of hypothyroidism, morbid obesity, polycystic ovarian disease, but no know heart disease presenting here with twinges in her chest and lightheadedness. in early she reported to her pcp that she was having episodic lightheadedness and palpitations. in particular she reported an episode of palpitation with her heart racing and a fluttering in her neck. she presented to her pcp where on ecg she was noted to have a wide complex tachycardia with rbbb morphology and left superior axis. she was then referred to the nwh er where she was treated with adensine up to 12mg, metoprolol 5mg, lidocaine 25 and 50mg boluses, and diltiazem 20 and 25mg. she was eventually transferred to er where she was started on an esmolol gtt after which she converted to sinus and remain in sinus throughout her hospitalization at . she was discharged on metoprolol with follow up with ep for possible ep study. . it was unclear if this wide complex tachycardia was svt with aberrency or vt. she was seen by dr. (see his note on ). he continued metoprolol at 100mg daily. an adenosine mibi didn't show any ischemia and her echo was normal. she was started on a holter monitor. . today she presents to the ed after more intermittent episodes of twinges in her chest and lightheadedness. she described 2 episodes where she was sitting on her couch watching her 4 year old daughter and 'blacked out'. she recorded the episode on her holter. the cardiologist from the holter company called her at home and told her to go immediately to the ed for evaluation for long pauses. . in the ed, the patient experience another episode where she passed out, which corresponded with a 15 second pause. the patient also experience two more epiosodes of 12 second pauses with syncope. her hemodynamics were stable with these pauses and did not drop her blood pressure of her o2 sats's. she was urgently taken to the cardiology suite where a temporary pacer was placed with a minimal rate to 60. she was transfer to the ccu for further observation. . on arrival to the ccu, she was chest pain free and denies lightheadness or sob. she complainted of appropriate pain at the site of the pacer insertion site on her neck. . on review of systems, s/he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. s/he denies recent fevers, chills or rigors. s/he denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . past medical history: herpes simplex polycystic ovaries hypothyroidism iritis - acute / subacute, unspec infertility - female, unspec etiol obesity - morbid hypomenorrhea/oligomenorrhea cholelithiasis social history: - tobacco history: never - etoh: rare - illicit drugs: no family history: cad-grandfather lung ca in father physical exam: physical examination on admission: general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of *** cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. neuro: aaox3, cnii-xii intact, 5/5 strength biceps, triceps, wrist, knee/hip flexors/extensors, 2+ reflexes biceps, brachioradialis, patellar, ankle. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: labs on admission: 05:43am blood wbc-6.6 rbc-3.31* hgb-10.3* hct-29.4* mcv-89 mch-31.3 mchc-35.1* rdw-13.1 plt ct-170 09:29pm blood pt-11.3 ptt-29.8 inr(pt)-1.0 09:29pm blood glucose-101* urean-11 creat-0.7 na-140 k-3.8 cl-107 hco3-21* angap-16 09:29pm blood ctropnt-<0.01 09:29pm blood calcium-9.3 phos-2.9 mg-1.9 09:29pm blood d-dimer-636* 09:29pm blood tsh-1.2 labs on dc: 02:34am blood wbc-7.2 rbc-3.60* hgb-11.1* hct-31.7* mcv-88 mch-30.7 mchc-35.0 rdw-13.1 plt ct-192 02:34am blood pt-12.0 ptt-28.7 inr(pt)-1.1 02:34am blood glucose-103* urean-7 creat-0.6 na-136 k-4.0 cl-107 hco3-21* angap-12 02:34am blood albumin-3.6 calcium-8.1* phos-2.9 mg-1.9 02:34am blood -positive * titer-1:80 cxr : findings: chest pa and lateral radiograph demonstrates unremarkable mediastinal, hilar and cardiac contours. lungs are clear. no pleural effusion or pneumothorax evident. interval placement of a left-sided pacemaker with lead tips positioned in the right atrium and right ventricle. brief hospital course: hospital course: 49f with a recent history of svt vs. vt treated with metoprolol, presenting with symptomatic bradyarrythmias with 12-15 second pauses, who got a temporary pacer for paroxysmal atrioventricular block # paroxysmal atrioventricular block: the patient presented with 3 second pauses resulting in syncope due to non-conducted p-waves. a temporary pm was placed with a back-up rate of 60. lyme serology was -ve. a permanent pacemaker placement was subsequently palced after an ep study. pt was discharged on keflex. ep recs: sinus node: not formally assessed, no abnormalities atria: normal, no inducible arrhythmias av node: dual pathway physiology present. no sustained arrhythmias induced. very poor va conduction with poorly tolerated rv pacing. no paroxysmal av block induced. hps: abnormal hiv with infra-hisian conduction disease evident ventricles: no inducible arrhythmias. no evidence of accessory pathway conduction antegrade or retrograde # h/o svt with aberrancy vs. vt- the patient was on metoprolol 100mg daily for rate control. she was being followed by dr. # hypothryoidism: we continued home medication of levothyroxine 150mcg transitional issues: followup with dr was arranged. pt had an elevated that may require further workup. only med change was addition of keflex. medications on admission: metoprolol succinate oral 100 mg po in the evening levothyroxine (levoxyl) 150 mcg oral tablet 1 tablet po qd fluticasone 50 mcg/actuation nasal spray, suspension 1 spray in each nostril once daily urea (carmol 40) 40 % topical cream apply to feet as directed multivitamin vitamin d 1000 units discharge medications: 1. levothyroxine 150 mcg tablet sig: one (1) tablet po once a day. 2. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 3. cephalexin 500 mg capsule sig: one (1) capsule po q8h (every 8 hours) for 2 days. disp:*6 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: high grade av block s/p dual chamber pacemaker discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms , it was a pleasure taking care of you at the . you presented with problems with your heart rhythm causing you to blackout. you were admitted and got a permanent pacemaker which should prevent such episodes from happening. you were discharged home with followup with your cardiologist, dr , and some medicine changes. the following changes were made to your medications: start keflex 500 mg q8h for 2 days followup instructions: please call to set up an appointment with dr. . please follow up with dr. next week Procedure: Catheter based invasive electrophysiologic testing Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Diagnoses: Unspecified acquired hypothyroidism Morbid obesity First degree atrioventricular block Polycystic ovaries

allergies: no drug allergy information on file attending: chief complaint: right sided weakness major surgical or invasive procedure: none history of present illness: 71 yo lhm, who speaks spanish only, with a pmhx, of htn, s/p left cea on due to "blockage by a large plaque", after he had a tia on with symptoms including a transient right sided weakness (with apparent mri changes), represented to the hospital today. he was feeling well, earlier in the day at around 4 pm he asked his daughter to help him shave, which was out of character, but around 7 pm, according to his daughter , he had slurred speech, initially he appeared to understand what she was saying, but then started to respond only with a "no", and then had a blank expression. he did not follow any commands that his daughter requested of him. he was then taken to the by the ems who arrived in about 10 minutes. at the , he had a ct head which showed a left basal ganglia hemorrhage (6.3x5.8 cm), with a 5 mm midline shift, and he was transferred to er by mediflight. on arrival to the er at about 22:50 h, he was found have a lot of secretions, and he was not protecting his airway well. ros: his daughter mentioned that he had complained of feeling weak, dizzy, having insomnia, and pain in the area of the surgery, otherwise the rest of the ros is unknown. past medical history: htn hyperlipidemia copd b12 deficiency oral thrush bilateral cataracts arrhythmia (unknown morphology) gastritis social history: retired factory worker, made brillo pads. close to his family. gave up smoking 5 months a day, smoked 2 packs/day for many years. alcohol dependence, gave up some years ago (family unclear of timeline). no illicit drug history. pcp: . ( medical) is the daughter who helps him with his medications and medical care family history: his mother died at childbirth, and his father died when he was very young (cause unclear) physical exam: exam: t-98.6 bp-163/105 (at the scene his sbp was 188/105) hr-97 rr-17 o2sat-99%, tele sr gen: lying in bed, thrashing around, l cea scar in tact heent: nc/at, moist oral mucosa neck: no tenderness to palpation, normal rom, supple, no carotid or vertebral bruit back: no point tenderness or erythema cv: difficult to hear due to transmitted upper airway sounds lung: coarse crackles at the bases, and a pronounced expiratory wheeze throughout abd: +bs soft, nontender ext: no edema neurologic examination: mental status: even when spoken to in spanish, did not appear to understand anything. cranial nerves: pupils equally round and reactive to light, 3 to 2 mm bilaterally. bilateral cataracts. blinks to threat bilaterally. corneals intact bilaterally. pronounced right facial droop, so the tongue looks deviated. gag in tact. motor: normal bulk bilaterally. tone increased in the right leg more than the right arm. no observed myoclonus or tremor no pronator drift moves the left side forcefully, and antigravity sensation: no movement of the right leg to noxious stimulus, right arm moves away from noxious stimulus reflexes: +2 on the right and 2 on the left. left toe downgoing, right toe mute pertinent results: ct cns: as compared to osh ct scan: in the interval, there has been increased subfalcine rightward shift from 5 to 15 mm. there is increase in size in the left frontal intraparenchymal hemorrhage from 2.0 x 5 cm to approximately 3.5 x 5.4 cm. peri-lesional edema has also increased with descending transtentorial herniation. the intraparenchymal hemorrhage extends to the frontotemporal area. there is complete effacement of the left lateral ventricle, worsened from before. mastoid air cells are clear. visualized paranasal sinuses demonstrate ethmoidal sinus thickening. impression: increased size of left frontotemporal intraparenchymal hemorrhage with increased rightward shift. brief hospital course: the patient wa sdeveloping a transtentorial herniation. hi sfamily decided to make dnr and dni and then cmo. he was hence extubated and made comfortable. he passed the way without any evidence suggestive of pain or anxiety. his family was in the hospital when these decisions were made after discussing the options with dr. (neurology). medications on admission: lotrel stopped on by md 81 mg simvastatin 40 mg folic acid vitamin b12 advair albuterol prn hydrocodone 5-500 started post-op prn nystatin po for thrush discharge medications: deceased discharge disposition: expired discharge diagnosis: letf frontal intraparenchimal hemorrhage with mass effect and subsequent herniation. discharge condition: deceased discharge instructions: deceased followup instructions: deceased md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Personal history of tobacco use Candidiasis of mouth Intracerebral hemorrhage Other B-complex deficiencies Compression of brain Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Unspecified cataract

allergies: diovan / fosamax / prinivil / 4-aminoquinolines / pecans and fish attending: chief complaint: elective admission for evacuation of the subdural hematoma major surgical or invasive procedure: : left sided burr holes for evacuation of sdh history of present illness: elective admission for evacuation of the left subdural hematoma past medical history: htn cad hypothyroidism dementia high cholesterol cardiac stent > 10 yrs ago social history: previously lived alone in an apartment with a daughter who lives upstairs, but sent to rehab from her last admission. family history: non-contributory physical exam: on admission: awake, alert, oriented to self, place, and month. , . upon discharge: neurologically intact left sided cranial wound c/d/i with nylon suture closure pertinent results: head ct w/o contrast: s/p evacuation of septated left subdural hematoma. decreased posterior compartment of the hematoma with decreased mass effect on the left parietal and temporal structures. in the anterior compartment of the hematoma, fluid has been replaced by air, and mass effect on the left frontal structures is unchanged. brief hospital course: 87f elective admission for surgical evacuation of the subdural hematoma. please see operative report for full details. post-op she was admitted to the icu for monitoring. she remained stable overnight. a post-op ct head was performed on which showed decreased posterior compartment of the hematoma with decreased mass effect on the left parietal and temporal structures. she was transferred to the floor on where she was assessed by pt/ot for transfer back to rehab. her neurological status remained stable. she is discharged to extended care facility in stable condition. medications on admission: levothyroxine, plavix, one daily multivitamin, calcium, aspirin, isordil titradose, amlodipine, simvastatin, donepezil, metoprolol tartrate discharge medications: 1. pneumococcal 23-valps vaccine 25 mcg/0.5 ml injectable sig: one (1) ml injection now x1 (now times one dose). 2. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain fever. 3. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). 4. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 5. multivitamin tablet sig: one (1) tablet po daily (daily). 6. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 7. amlodipine 5 mg tablet sig: two (2) tablet po hs (at bedtime). 8. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 9. donepezil 10 mg tablet sig: one (1) tablet po hs (at bedtime). 10. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 11. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 12. isosorbide dinitrate 20 mg tablet sig: one (1) tablet po tid (3 times a day). discharge disposition: extended care facility: nursing & rehabilitation center - discharge diagnosis: left subacute subdural hematoma with midline shift discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: general instructions ?????? have a friend/family member check your incision daily for signs of infection. ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? you may wash your hair in three days. ?????? you may shower before this time using a shower cap to cover your head. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? you have been prescribed keppra (levetiracetam), you will not require blood work monitoring for this med, but continue to take until directed to discontinue by your neurosurgeon. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. followup instructions: please follow-up with dr in 4 weeks with a head ct w/o contrast. please call to make the appointment. please follow up with your pcp regarding this admission. Procedure: Incision of cerebral meninges Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Unspecified acquired hypothyroidism Other persistent mental disorders due to conditions classified elsewhere Subdural hemorrhage

allergies: paxil / fosamax / erythromycin estolate / adhesive bandage attending: chief complaint: ventral hernia major surgical or invasive procedure: exploratory laparotomy lysis of adhesions re-siting of ileostomy component separation closure of hernia history of present illness: 47f s/p lap-assisted total proctocolectomy w/end ileostomy , complicated by wound infection and pelvic abscess, now with incisional hernia and pain. her initial hospital course was uncomplicated, but ms. was re-admitted with purulent vaginal drainage and wound drainage. she was discharged to rehab with a vac dressing to her surgical wound and a pigtail drain in her abscess. she had one post-discharge follow-up visit on , at which time her midline wound was healing well with the vac and her pigtail drain was removed. she failed to make/keep her follow-up appointments after that visit, and has not been seen in clinic since that time. since her last visit, she has developed a large hernia in her surgical incision. her sister, who is her healthcare proxy, called the office one day pta, stating that is in terrible pain from her hernia and that it needs to be repaired. ms. presented to clinic for admission. she states that the pain has been developing over the past 2 months, and has worsened over the past 2 weeks. she also states that the pain is impairing her breathing, and that she only feels ok when she is lying down. she also complains of passing gas from her vagina over the past few months. she saw her doctor and had a ct scan performed, and was told that she may have a fistula. she has also had several uti's in the past few months. she has been afebrile. she denies nausea, vomiting, change in ostomy output, chest pain, cough, sob, hematemesis, melena, muscle weakness. past medical history: past medical history: crohn's disease malrotation of the colon gastroesophageal reflux asthma irritable bowel syndrome gastroparesis osteoporosis anxiety and/or depression endometriosis past surgical history: hysterectomy, appendectomy, total proctocolectomy w/end ileostomy social history: she works fulltime at hospital food services. does not smoke cigarettes or drink alcohol. sister is her health care proxy. family history: question of a sister with colitis, otherwise nc. physical exam: vitals: t 98.4, hr 73, bp 97/62, rr 16, o2 99% ra gen: alert and oriented x3, nad cv: rrr, no murmur lungs: cta bilaterally, good respiratory effort abd: large hernia at midline incision, edges of defect not well-defined, protrudes from abdomen when sitting, approx 15x15cm; ileostomy in rlq w/pink, healthy stoma; otherwise soft, obese, nt, nd, +bs extr: warm, well-perfused, 2+ pulses pertinent results: admission labs: wbc-7.8 rbc-4.50 hgb-12.5 hct-36.0 plt ct-247 glucose-85 urean-15 creat-0.5 na-142 k-3.6 cl-108 hco3-24 angap-14 albumin-4.0 calcium-9.3 phos-4.2 iron-68 urine culture : escherichia coli ampicillin------------ =>32 r ampicillin/sulbactam-- =>32 r cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 128 r tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r ct abd/pelvis : 1. diastasis of the anterior abdominal wall containing non-obstructed, non-dilated loops of bowel. there is a small amount of free fluid within the dependent portion. 2. non-obstructed appearance to an end ileostomy. 3. status post proctocolectomy with trace fluid at the surgical site. at the site of prior drain in the low pelvis there is no residual fluid collection. cystogram : no evidence of leak or fistula with adequate distention of the urinary bladder. blood culture : source: line-picc. staphylococcus, coagulase negative. isolated from one set only. sensitivities performed on request.. viridans streptococci. isolated from one set only. urine culture : negative blood culture : negative brief hospital course: ms. was admitted to the colorectal surgery service on for evaluation and management of her large incisional hernia. she was seen by plastic surgery for assistance with closure of her large abdominal wall defect. she was taken to the or on , where she had an exploratory laparotomy, lysis of adhesions, re-siting of her end ileostomy, and closure of her hernia with the assistance of dr. of the plastic surgery service. she tolerated the procedure well and returned to the floor post-operatively. neuro: the patient received a dilaudid pca with good effect and adequate pain control. when tolerating oral intake, the patient was transitioned to oral pain medications. cv: on , ms. developed atrial fibrillation. troponins were negative. she was initially rate controlled with diltiazem. however, the atrial fibrillation continued and cardiology was consulted for recommendation of management. on she was started on metoprolol and titrated up to 37.5 tid, aspirin 325 qd, and had a trans thoracic echocardiogram which revealed: "normal global and regional biventricular systolic function. no clinically-significant valvular disease seen. left atrial enlargement." she remained tachycardic and was started on diltiazem 30mg every 6 hours. this did not sufficiently control her rate and she was transferred to the icu on for diltiazem drip. she converted to nsr on and was transferred back to the floor on . cardiology recommended a po regimen of 180mg diltiazem extended release qd and 325mg aspirin qd. she remained asymptomatic, but she had sinus tachycardia to 140s on , likely realted to post-op deconditioning as her pain was controlled, she was well-hydrated, and she had no signs of infection or pulmonary embolism. her diltiazem was increased to 360 qd. pulmonary: ms. was treated with incentive spirometry and encouraged to have good pulmonary toilet during this admission. her asthma was managed with fluticasone-salmeterol diskus (250/50) 1 inh ih and albuterol inhaler prn. gi/gu/fen: ms. was made npo for scans, procedures, and operations. after the surgical ventral hernia repair on , she was initially npo, then experienced nausea and vomiting and an ng tube was placed and remained until . on she tolerated clears, then full liquids on . she was advanced to a regular diet on . she tolerated this diet and was supplemented with ensure. her electrolytes were monitored and repleted as needed. id: a urine culture on admission revealed e.coli sensitive to cephalosporins. she was treated with ceftazadine for 14 days. ms. a fever to 102.3 on pod 3, for which blood and urine cultures and chest/abdominal x-rays were obtained. the radiology studies were normal. her urine culture was negative, blood cultures revealed strep viridans and coagulase negative staphylococcus. she was treated with iv vancomycin and her picc line was replaced. endocrine: the patient's blood sugar was monitored throughout this stay; insulin dosing was adjusted accordingly. hematology: the patient's complete blood count was examined routinely; she was transfused 1 unit packed rbcs for a heamtocrit of 24.6 on . prophylaxis: the patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. at the time of discharge, the patient was doing well, afebrile with stable vital signs. the patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. medications on admission: albuterol inh prn, advair diskus , vitamin c 500 , vistaril 25 prn, prilosec 20', kcl 30', vitamin d qmonth, clonazepam 1", ferrous sulfate 350', calcium 600''' discharge disposition: extended care facility: rehabilitation and nursing center - discharge diagnosis: ventral hernia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital for surgical managment of your ventral hernia. you had a hernia repair with mesh and re-siting of your ostomy, which you tolerated well. you have tolerated a regular diet, passed gas, your pain is well controlled with pain medications by mouth and you are now ready to be discharged to rehab. it is important that you monitor your bowel function closely. it is not required that you have a bowel movement prior to returning home, however it is important that you have a bowel movement in the next 2-3 days. please call the office if you do not have a bowel movement. please monitor yourself for the following abdominal symptoms: nausea, vomiting, increased abdominal distension, increased abdominal pain, frequent loose stools, or inability to tolerate food or liquids. if you develop any of these symtpoms, please call the office or go to the emergency room if severe. it is expected that your first bowel movmement after surgery will be loose and it may have a small amount of blood. feel free to call the office if there is an alarming amount of blood. eat small frequent meals and keep yourself well hydrated. the pain medication we have given you causes constipation. continue taking colace and senna while you are on the narcotics (oxycodone). you may add miralax or milk of magnesia if you are still constipated. if you have diarrhea or loose stools, you may remove the medications one at a time until your stools are soft and formed. you have an incision on your abdomen that is closed with dermabond (skin glue). the drains will stay until you follow-up with dr. . please keep the abdominal binder on at all times. this will fall off on its own. you may shower, please do not rub the incision dry, pat dry with a towel. please watch for signs and symptoms of infection near the incision such as: increased redness, increased pain, white/green/yellow/thick/malodorous drainage, or increased swelling at the incision thin or if you develop a fever. you may cover the area with a dry gauze dressing if it becomes irritated from your clothing. you will be given a small amount of oxycodone for pain. please take this medication directly as prescribed and do not drink alcohol or drive a car while taking this medication. you may also take tylenol as written, do not drink alcohol while taking this medication and do not take more than 4000mg of tylenol daily. please walk frequently at home. no heavy lifting greater than 6 pounds or heavy excersise for at least 3-4 weeks after surgery. you have 2 drains in your abdomen. please empty the bulbs daily and as needed, and record the amount and character of the fluid. please bring your log to your follow-up appointments. please look at the drain sites once a day and monitor for redness or drainage. please keep you abdominal binder on at all times. if the drains drain over 100cc in a day or begin to drain frank blood please call the office for advice or go to the emergency room if the bleeding is severe. good luck with your recovery! followup instructions: a follow up appointment has been made for you with dr. , plastic surgeon, at 2:45 pm on at his office. please call for any questions pertaining to this appointment or if you will be unable to keep it. you also have a follow-up appointment with dr. , cardiologist ; on monday @ 15:30. address: 15 brothers , ; , ; ; (f) you have an appointment with dr. and the wound/ostomy nurse date/time: 12:30 phone: Procedure: Venous catheterization, not elsewhere classified Percutaneous abdominal drainage Other lysis of peritoneal adhesions Revision of stoma of small intestine Other cystogram Incisional hernia repair Size reduction plastic operation Removal of other device from thorax Removal of other device from thorax Central venous catheter placement with guidance Diagnoses: Esophageal reflux Mitral valve disorders Urinary tract infection, site not specified Atrial fibrillation Asthma, unspecified type, unspecified Pulmonary collapse Dysthymic disorder Bacteremia Incisional hernia without mention of obstruction or gangrene Iron deficiency anemia, unspecified Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Obesity, unspecified Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus Calculus of kidney Tachycardia, unspecified First degree atrioventricular block Gastroparesis Irritable bowel syndrome Regional enteritis of small intestine with large intestine Other colostomy and enterostomy complication Anomalies of intestinal fixation Localized adiposity Body Mass Index 36.0-36.9, adult

allergies: keflex / aciphex / protonix / bacitracin / talwin / adhesive / metoprolol / plaquenil / femara / levaquin / cytotec / aspirin / ibuprofen / bactrim / statins-hmg-coa reductase inhibitors / sorbitol attending: addendum: medication addendum: as per id- vanco dosing was decreased to 500 mg iv q 12h based on elevated trough level this am. -cont to check vanco trough levels at rehab discharge disposition: extended care facility: of md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Arterial catheterization Incision of chest wall Internal fixation of bone without fracture reduction, scapula, clavicle, and thorax [ribs and sternum] Diagnoses: Systemic lupus erythematosus Thrombocytopenia, unspecified Other postoperative infection Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Cardiac complications, not elsewhere classified Atrial fibrillation Disruption of internal operation (surgical) wound Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Personal history of malignant neoplasm of breast Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other late effects of cerebrovascular disease Epilepsy, unspecified, without mention of intractable epilepsy Other diseases of lung, not elsewhere classified Chronic obstructive asthma, unspecified Esophagitis, unspecified Myalgia and myositis, unspecified Secondary malignant neoplasm of bone and bone marrow Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Pseudomonas infection in conditions classified elsewhere and of unspecified site Irritable bowel syndrome Restless legs syndrome (RLS) Cellulitis and abscess of other specified sites Myopathy, unspecified Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Suicidal ideation Muscle weakness (generalized) Ankylosing spondylitis Refusal of treatment for reasons of religion or conscience

allergies: keflex / aciphex / protonix / bacitracin / talwin / adhesive / metoprolol / plaquenil / femara / levaquin / cytotec / aspirin / ibuprofen / bactrim / statins-hmg-coa reductase inhibitors / sorbitol attending: chief complaint: sternal wound infection major surgical or invasive procedure: sternal debridement/rem. wires/vac placement sternal plating and closure history of present illness: pt is a 62 yo f s/p cabgx2 (lima to diag, vein to om) which was complicated by a pseudomonal sternal wound infection. she initially returned on with ongoing low grade fevers and "pustular bloody drainage" from the lower border of her sternal wound. at this time, she was started on vancomycin. however her wound continued to have copious purulent drainage which was swabbed on and returned with a pan sensitive pseudomonas. her wound was opened and debrided and noted to extend fairly deep. id was consulted and recommended iv cipro in addition to the vancomycin. as her wound cultures were performed while pt was on vanco, it was uncertain if any component of her sternal wound infection was due to a gram positive organism. her chest ct w/o contrast showed up to a 6mm dehiscence of the upper sternum with a small, gas-containing retrosternal collection. a wound vac placed but no further debridement was performed at that time. she was discharged on with a plan for 6 weeks of iv antibiotics. she was seen in id f/u on at which time she continued to have a wound vac in place and due to persistently elevated inflammatory markers, it was decided to continue her abx until seen by cardiothoracic surgery on at which time her wound vac was discontinued. it was finally determined by id that her iv vancomycin and po cipro would be completed on . she was seen today in the clinic on routine follow-up where she was noted to have "black/green drainage" requiring dressing changes twice daily. she notes the discharge began to increase 1-2 weeks ago and appeared "like meat juice". she has also noted the top of her sternal wound developing increasing erythema over the last few days with some erythema extending into her r. breast. she has also noted an increase in right pleuritic chest pain over the past week and now has an element of constant pain through the respiratory cycle. she denies any ongoing fevers, shakes or chills. she notes her sternal wound has been healing well despite the ongoing drainage. however, she does state that she is aware of some degree of instability, especially in the upper portion of the incision. she notes a clicking sound when making certain twisting movements or with use of her arms. at a scheduled visit to the clinic today a new area of drainage at the midpoint of the sternal wound was noted, raising concern for a recurrence of infection. she was referred to the ed by the id physicians for chest ct and evaluation by ct surgery. past medical history: s/p cabg x2 cholelithiasis fibromyalgia hypothyroid coronary artery disease s/p stent cerebral vascular accident - residual weakness chronic lung disease - asthma breast cancer - metastatic to bone hypertension diabetes mellitus type 2 dyslipidemia lupus myopathy svt arthralgias esophagitis seizure disorder - last one a few years ago gall stones thrombocytopenia depression with verbaized history of suicidal ideation muscle weakness ankylosing spondylitis irritable bowel syndrome lumpectomy social history: race: caucasian last dental exam: dentures upper and lower lives alone occupation: disabled tobacco: denies etoh:denies family history: family history: mother deceased mi , father cad deceased at 52 from aneurysm, brother cabg diabetes deceased 50, sister with lupus deceased at 50 physical exam: 99.2 82 133/57 17 98%ra physical exam: general: no acute distress, well nourished, obese skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally sternum with some instability to palpation, worse superiorly. erythema extending 1cm out radially from the sternal wound with an area of spontaneous drainage at the mid incision. this probes to the sternum but not deep to the sternum. a pocket is defined inclusive of the upper of the incision. there is streaking erythema extending over onto the r breast without associated masses heart: rrr irregular murmur - none abdomen: soft non-distended non-tender bowel sounds + no palpable masses extremities: warm , well-perfused edema none varicosities: none neuro: gait steady, alert and oriented x3 right = left strength pulses: femoral right: +1 left: +1 dp right: +1 left: +1 pt : +1 left: +1 radial right: +1 left: +1 carotid bruit right: no bruit left: no bruit pertinent results: impression: 1. progression of bone resorption at the site of median sternotomy. the sternal wires remain intact. findings are concerning for continued dehiscence. infection may be present. 2. retrosternal fluid collection. be postoperative seroma, though infection cannot be excluded based on imaging. 3. right pleural-based nodular opacity may represent a focus of inflammation. previously described pulmonary nodules appear stable. 4. right breast nodule, stable. correlation with mammography is recommended. the study and the report were reviewed by the staff radiologist. dr. dr. approved: wed 3:09 pm imaging lab 05:41am blood hct-24.6* 04:23am blood wbc-7.0 rbc-2.86* hgb-7.4* hct-23.2* mcv-81* mch-25.7* mchc-31.7 rdw-13.9 plt ct-238 04:17am blood neuts-76.2* lymphs-14.0* monos-6.0 eos-3.4 baso-0.4 04:23am blood plt ct-238 04:17am blood pt-14.8* inr(pt)-1.3* 05:41am blood urean-23* creat-1.2* na-139 k-3.7 cl-101 05:41am blood mg-1.9 06:00pm blood crp-48.7* 04:23am blood vanco-25.8* brief hospital course: admitted from er on for further mgmt. evaluated by dr. and dr. (plastics). iv abx started with id recs. taken to or for sternal debridemewnt/wire.rem./vac placement on , and the subsequently on for sternal plating/ closure. transferred to the cvicu in stable condition. extubated .went into a fib and trated with diltiazem and amiodarone. transferred to the floor on pod # to begin increasing her activity level. picc is in place for iv abx therapy for 6 weeks with vanco/cefepime. she has f/u scheduled with plastic , cardiac , and dr. (id). 12-lead ekg should be done daily to monitor qtc while on amiodarone. labs per discharge sheet to be drawn this friday . vanco trough level should be done after every 4th dose. jp drain to stay in place until seen by plastic . heparin sq stopped today as she is a jehovah's witness and is currently on plavix. she should be ambulated frequently at rehab to help decrease risk of dvt. additional meds have been added for tighter glucose management with new fixed dose and ssi attached. cleared for discharge to at rehab on pod #. medications on admission: clopidogrel - (prescribed by other provider) - 75 mg tablet - 1 tablet(s) by mouth once a day ezetimibe - (prescribed by other provider) - 10 mg tablet - 1 tablet(s) by mouth once a day levothyroxine - (prescribed by other provider) - 88 mcg tablet - 1 tablet(s) by mouth once a day metformin - (prescribed by other provider) - 500 mg tablet - 1 tablet(s) by mouth four times a day montelukast - (prescribed by other provider) - 10 mg tablet - 1 tablet(s) by mouth once a day ropinirole - (prescribed by other provider) - 0.25 mg tablet - 1 tablet(s) by mouth twice a day medications - otc amino acids-protein hydrolys - (prescribed by other provider) - 15 gram-101 kcal/30 ml liquid - 30mls by mouth once a day aspirin - (prescribed by other provider) - 81 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth once a day bisacodyl - (prescribed by other provider) - 5 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth twice a day docusate sodium - (prescribed by other provider) - 100 mg capsule - 1 capsule(s) by mouth twice a day ferrous sulfate - (prescribed by other provider) - 325 mg (65 mg iron) tablet - 1 tablet(s) by mouth three times a day multivitamin - (prescribed by other provider) - tablet - 1 tablet(s) by mouth once a day niacin - (prescribed by other provider) - 500 mg capsule, sustained release - 1 capsule(s) by mouth twice a day --------------- --------------- --------------- --------------- discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 weeks. 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 5. ropinirole 1 mg tablet sig: one-half tablet po bid (2 times a day). 6. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 7. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 8. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 9. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 10. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 11. glyburide 5 mg tablet sig: one (1) tablet po bid (2 times a day). 12. bisoprolol fumarate 5 mg tablet sig: two (2) tablet po bid (). 13. glimepiride 1 mg tablet sig: one (1) tablet po bid (). 14. metformin 500 mg tablet sig: one (1) tablet po three times a day. 15. cefepime 2 gram recon soln sig: two (2) grams injection q12h (every 12 hours) for 6 weeks. 16. vancomycin 500 mg recon soln sig: seven y (750) mg intravenous q12h (every 12 hours) for 6 weeks: please check trough level after 4th dose. 17. outpatient lab work cbc/bun/creat friday with results to dr. (id) 18. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day) for 5 days: 400 mg through ; then 200 mg , then 200 mg daily ongoing. 19. 12-lead ekg 12-lead ekg daily while pt is on amiodarone;please check qtc 20. diltiazem hcl 90 mg tablet sig: one (1) tablet po qid (4 times a day). 21. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 22. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po q12h (every 12 hours): hold for k+ > 4.5. 23. sliding scale insulin and fixed dose lantus per attached discharge disposition: extended care facility: of discharge diagnosis: sternal wound infection/ s/p debridement/vac place./rem. sternal wires sternal plating/closure a fib s/p cabg cholelithiasis fibromyalgia hypothyroid coronary artery disease s/p stent cerebral vascular accident - residual weakness chronic lung disease - asthma breast cancer - metastatic to bone hypertension diabetes mellitus type 2 dyslipidemia lupus myopathy svt arthralgias esophagitis seizure disorder - last one a few years ago gall stones thrombocytopenia depression with verbaized history of suicidal ideation muscle weakness ankylosing spondylitis irritable bowel syndrome lumpectomy discharge condition: alert and oriented x3 nonfocal ambulating with assist - please have her increase ambulation; sc heparin stopped today incisional pain managed with tramadol incisions: sternal - healing well, jp drains to remain in place until plastics f/u visit discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month until follow up with surgeon no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: surgeon: dr. ( for dr. at thursday @ 9:00 am dr. plastic ( for dr. wednesday @ 9:15 am dr. ( clinic) thursday @ 10:00 am basement suite g please call to schedule appointments with your primary care dr. in 4 weeks cardiologist dr. in weeks ****please check vanco trough levels after 4th dose **** cbc/bun/creatinine labs for friday ; results to dr. iv vanco/cefepime to continue for 6 weeks with id f/u appt as above; jp drains to remain in place; please record outputs for dr. **** 12 lead ekg daily to check qtc while on amiodarone **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Arterial catheterization Incision of chest wall Internal fixation of bone without fracture reduction, scapula, clavicle, and thorax [ribs and sternum] Diagnoses: Systemic lupus erythematosus Thrombocytopenia, unspecified Other postoperative infection Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Cardiac complications, not elsewhere classified Atrial fibrillation Disruption of internal operation (surgical) wound Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Personal history of malignant neoplasm of breast Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other late effects of cerebrovascular disease Epilepsy, unspecified, without mention of intractable epilepsy Other diseases of lung, not elsewhere classified Chronic obstructive asthma, unspecified Esophagitis, unspecified Myalgia and myositis, unspecified Secondary malignant neoplasm of bone and bone marrow Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Pseudomonas infection in conditions classified elsewhere and of unspecified site Irritable bowel syndrome Restless legs syndrome (RLS) Cellulitis and abscess of other specified sites Myopathy, unspecified Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Suicidal ideation Muscle weakness (generalized) Ankylosing spondylitis Refusal of treatment for reasons of religion or conscience

allergies: keflex / aciphex / protonix / bacitracin / talwin / adhesive / metoprolol / plaquenil / femara / levaquin / cytotec / aspirin / ibuprofen / bactrim attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: off pump coronary artery bypass grafting x 2; left internal mammary artery to very proximal diagonal artery close to the left anterior descending artery and saphenous vein graft obtuse marginal artery. history of present illness: 62 year old female with recurrent extertional dyspnea, chest aches, and neck aches. she underwent mibi which showed anterior lateral and inferior apical reversal defects with lvef 57%. she was referred for cardiac catheterization that revealed coronary artery disease.dr. consulted for coronary revascularization. past medical history: cholelithiasis fibromyalgia hypothyroid coronary artery disease s/p stent cerebral vascular accident - residual weakness chronic lung disease - asthma breast cancer - metastatic to bone hypertension diabetes mellitus type 2 dyslipidemia lupus myopathy svt arthralgias esophagitis seizure disorder - last one a few years ago gall stones thrombocytopenia depression with verbaized history of suicidal ideation muscle weakness ankylosing spondylitis irritable bowel syndrome lumpectomy social history: race: caucasian last dental exam: dentures upper and lower lives alone occupation: disabled tobacco: denies etoh:denies family history: family history: mother deceased mi , father cad deceased at 52 from aneurysm, brother cabg diabetes deceased 50, sister with lupus deceased at 50 physical exam: pulse: resp: o2 sat: b/p right: left: height: 62" weight: 102.1 kg (pre-op) general: no acute distress, well nourished, obese skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur - none abdomen: soft non-distended non-tender bowel sounds + no palpable masses extremities: warm , well-perfused edema none varicosities: none neuro: gait steady, alert and oriented x3 right = left strength pulses: femoral right: +1 left: +1 dp right: +1 left: +1 pt : +1 left: +1 radial right: +1 left: +1 carotid bruit right: no bruit left: no bruit pertinent results: 04:45am blood wbc-6.3 rbc-2.91* hgb-7.7* hct-25.0* mcv-86 mch-26.6* mchc-30.9* rdw-14.8 plt ct-291 05:10pm blood wbc-5.1 rbc-4.03* hgb-10.9* hct-35.0* mcv-87 mch-27.1 mchc-31.3 rdw-14.3 plt ct-187 05:36pm blood pt-13.8* ptt-30.1 inr(pt)-1.2* 05:10pm blood pt-13.7* ptt-28.1 inr(pt)-1.2* 04:45am blood urean-26* creat-1.3* k-4.6 05:10pm blood glucose-124* urean-14 creat-1.1 na-141 k-4.8 cl-105 hco3-25 angap-16 09:05pm blood alt-16 ast-41* ld(ldh)-270* alkphos-33* amylase-53 totbili-1.5 echocardiography report , (complete) done at 1:36:21 pm final referring physician information , division of cardiothoracic , status: inpatient dob: age (years): 62 f hgt (in): 62 bp (mm hg): 117/62 wgt (lb): 226 hr (bpm): 63 bsa (m2): 2.02 m2 indication: coronary artery disease. left ventricular function. icd-9 codes: 786.05, 786.51 test information date/time: at 13:36 interpret md: , md test type: tee (complete) son: , md doppler: full doppler and color doppler test location: anesthesia west or cardiac contrast: none tech quality: adequate tape #: 2010aw001-0:00 machine: ie33 echocardiographic measurements results measurements normal range left ventricle - inferolateral thickness: 0.9 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.9 cm <= 5.6 cm left ventricle - ejection fraction: 45% >= 55% aorta - ascending: 2.8 cm <= 3.4 cm findings right atrium/interatrial septum: a catheter or pacing wire is seen in the ra and extending into the rv. no asd by 2d or color doppler. left ventricle: normal lv wall thickness. mild regional lv systolic dysfunction. mildly depressed lvef. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. normal descending aorta diameter. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: mild (1+) mr. tricuspid valve: mild tr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. no tee related complications. the patient appears to be in sinus rhythm. results were personally reviewed with the md caring for the patient. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. there is mild regional left ventricular systolic dysfunction with xxx. overall left ventricular systolic function is mildly depressed (lvef= 45%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results on at 1400. post revascularization lv function globally depressed- lvef= 35%. rv function mildly depressed. 2+ mitral regurgitation present. lvef improved with time. lvef= 45% at the time of chest closure. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 14:13 ?????? caregroup is. all rights reserved. brief hospital course: the patient was admitted to the hospital and brought to the operating room on where the patient underwent an off-pump coronary artery bypass graft x2; left internal mammary artery to very proximal diagonal artery close to the left anterior descending artery and saphenous vein graft obtuse marginal artery and endoscopic harvesting of the long saphenous vein. see operative note for full details. she was treated with macrodantin for a uti preoperatively. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. vancomycin was used for surgical antibiotic prophylaxis. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. she did develop copius serosanginous sternal drainage at lower sternal pole which grew out pseudomonas on wound culture. a picc line was inserted and she was started on vancomycin.also started on oral cipro. vac placed . by the time of discharge on pod # 17, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to in rehab in good condition with appropriate follow up instructions. pt will return to 6 for wound check next thursday . medications on admission: -ntg sl prn -singular 10 mg daily -imdur 30 mg daily - stopped taking 1 year ago -glimeperide 1 mg four times a day -metformin 500 mg four times a day -levothyroxine 88 micrograms daily -plavix 75 mg daily -aspirin 325 mg daily -ropinirole 0.5 mg -hctz 12.5 mg daily - stopped taking > 2 weeks ago because caused dry mouth -zebeta 10 mg -prevacid 30 mg daily -aromasin 25mg daily -benicar 40 mg daily - ran out so stopped taking prn medications - listed as stronger meds if needed -lomotil - diarrhea - substitutes with diphenoxylate/atropine tab 2-4 times a day as needed -naproxen 500 mg takes as needed for pain last time 6 months ago l-lysine 500 mg and olive leaf for colds and sinus 2+4, 3x a day citrucel/psyllium seed for diarrhea colloidal silver - kill germs, prevent infections, cold sores lidoderm 5% patch pain percocet pain at night uvi ursi water retention take 3 up to 3x a day flexeril 10 mg as needed sever muscle spasm or leg cramps bronchial soothe leaf syrup enzymatic therapy "for immune system and blood sugar acidophilus 3x week b-100 complex caps 1 daily digestive enzymes - sometimes separate b vitamins - takes at night b - 1 100 mg 1 daily b-2 100 mg 1 daily b-12 1000mcg 1 daily b-6 100 mg 1 daily biotin 1000 mcg choline and inositol caps 500 mg 1 daily folic acid 400 mg 1 daily pantethine 300 mg 1 daily niacin 500 mg twice a day blood sugar control acetyl l carnitine 1000 mg split alpha lipoic acid 600 mg glutithione 500 mg gymnema slyvestre 400 mg 4 times a day l glutamine 1000 mg split taurine 1000 mg split magnesium 400 mg vitamin c 500 mg chromium picolinate 500 mcg four times a day vanadyl sulfate 20 mg + 20 mg four times a day vitamin d - 3 5000 mg 1 daily vanadyl sulfate 20 mg four times a day other things co q 10 100 mg split fish oil 500 mg 8 times a day ginger root 1.1 melatonin 3 mg at night valerian root four at bed time selenium 250 mcg 1 a day l theanine 200 mg twice a day garlic 1000 mg 1 daily grape seed 50 mg once a day calms forte three at night milk thistle 80% silymarin 350 mg two times a day l thyptophan 500mg twice a day discharge disposition: extended care facility: of discharge diagnosis: coronary artery disease status post off pump coronary artery bypass grafting x 2 postop sternal wound infection cholelithiasis fibromyalgia hypothyroid coronary artery disease s/p stent cerebral vascular accident - residual weakness chronic lung disease - asthma breast cancer - metastatic to bone hypertension diabetes mellitus type 2 dyslipidemia lupus myopathy svt arthralgias esophagitis seizure disorder - last one a few years ago gall stones thrombocytopenia depression with verbaized history of suicidal ideation muscle weakness ankylosing spondylitis irritable bowel syndrome discharge condition: good discharge instructions: weigh yourself every morning, md if weight goes up more than 3 lbs. shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage. no lotions, cream, powder, or ointments to incisions. each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart . no driving for approximately one month, until follow up with surgeon. no lifting more than 10 pounds for 10 weeks. please call with any questions or concerns (). females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge of sternal wound. **please call cardiac surgery office with any questions or concerns (). answering service will contact on call person during off hours.** followup instructions: surgeon: dr. (for dr. appointment at at 9:00 am. please call for appointments with your cardiologist/pcp weeks after discharge cardiologist:dr. # pcp:, # md Procedure: Venous catheterization, not elsewhere classified Single internal mammary-coronary artery bypass (Aorto)coronary bypass of one coronary artery Pericardiotomy Nonexcisional debridement of wound, infection or burn Other immobilization, pressure, and attention to wound Diagnoses: Other primary cardiomyopathies Systemic lupus erythematosus Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Other postoperative infection Urinary tract infection, site not specified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Cardiac complications, not elsewhere classified Atrial fibrillation Asthma, unspecified type, unspecified Personal history of malignant neoplasm of breast Depressive disorder, not elsewhere classified Percutaneous transluminal coronary angioplasty status Candidiasis of mouth Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Myalgia and myositis, unspecified Secondary malignant neoplasm of bone and bone marrow Pseudomonas infection in conditions classified elsewhere and of unspecified site Disruption of external operation (surgical) wound Other esophagitis Irritable bowel syndrome Adhesive pericarditis Ankylosing spondylitis

allergies: no known allergies / adverse drug reactions attending: chief complaint: s/p 15 ft fall major surgical or invasive procedure: placement of ivc filter history of present illness: 43 year old male who is s/p 15ft fall. 43-year-old man status post slip and fall off a truck fell onto a railing on his left side. he did not hit his head or lose consciousness. at the at that hospital he was found to have a large splenic laceration with active extravasation and a renal he hematoma. he was given one unit of blood and transferred here. he denies any chest pain shortness of breath weakness or numbness in his arms or legs. he was transported to for further care. past medical history: psh: l4/5 disk ?laminectomy social history: social history: history of cocaine abuse, 2 times/year for 20 years (may be under-reporting his use), buys methadone off the street, takes 30mg po qod. works as a sanitation engineer. current smoker. no hx of alcohol abuse. family history: noncontributory physical exam: upon presentation to : hr:84 bp:158/111 resp:17 constitutional: comfortable heent: normocephalic, atraumatic, extraocular muscles intact, pupils equal, round and reactive to light supple chest: clear to auscultation cardiovascular: regular rate and rhythm, normal first and second heart sounds abdominal: firm tender left side abdomen no rebound or guarding abrasion left eye pelvic: frank hematuria the foley placed prior to arrival gu/flank: no costovertebral angle tenderness extr/back: no cyanosis, clubbing or edema skin: no rash, warm and dry neuro: speech fluent strength 5 out of 5 in upper and lower extremities pertinent results: 06:15am blood wbc-11.3* rbc-3.21* hgb-9.8* hct-28.4* mcv-88 mch-30.6 mchc-34.6 rdw-13.3 plt ct-279 03:00pm blood hct-26.9* 02:56am blood wbc-9.4 rbc-2.94* hgb-9.3* hct-26.0* mcv-88 mch-31.8 mchc-36.0* rdw-13.4 plt ct-219# 02:00am blood wbc-12.0* rbc-2.96* hgb-9.3* hct-25.4* mcv-86 mch-31.5 mchc-36.8* rdw-13.6 plt ct-141* 10:49pm blood hct-31.4* 07:25pm blood wbc-24.1* rbc-3.90* hgb-12.2* hct-34.4* mcv-88 mch-31.3 mchc-35.5* rdw-13.1 plt ct-262 02:46am blood neuts-89.7* lymphs-5.4* monos-4.4 eos-0.2 baso-0.3 06:15am blood plt ct-279 02:56am blood plt ct-219# 02:56am blood pt-12.9 ptt-22.9 inr(pt)-1.1 06:15am blood glucose-110* urean-13 creat-0.7 na-135 k-4.3 cl-96 hco3-32 angap-11 02:56am blood glucose-115* urean-15 creat-0.7 na-137 k-4.0 cl-100 hco3-28 angap-13 02:00am blood glucose-113* urean-14 creat-0.8 na-136 k-3.8 cl-100 hco3-28 angap-12 06:15am blood calcium-8.7 phos-3.2 mg-1.9 02:56am blood calcium-8.6 phos-2.6* mg-1.9 07:25pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg ct head: impression: 1. no acute intracranial process. 2. no fracture. 3. sinus disease. ct c- spine: impression: no acute fracture or traumatic malalignment of the cervical spine. : cta abdomen and pelvis: impression: 1. grade 5 splenic and left renal parenchymal injury, with interval increase in subcapsular and extracapsular hemorrhage. no clear evidence of arterial extravasation, with slow splenic bleeding likely due to tamponade from subcapsular hematoma. focal left interpolar caliceal injury, without definite evidence of urinary extravasation. multiple vascular irregularities consistent with superimposed vascular injury. 2. several mildly displaced left rib fractures, with associated trace hemothorax bilat le ultrasound: findings: -scale, color, and spectral doppler son was performed on the lower extremities. the bilateral common femoral, superficial femoral and popliteal veins are normal in compressibility, augmentation, and doppler waveforms. the calf veins are patent and compressible. there is no deep vein thrombosis in either lower extremity. impression: no dvt in either lower extremity. brief hospital course: after being evaluated in the trauma bay with repeat imaging, mr. was admitted to the trauma sicu for hemodynamic monitoring and frequent serial hematocrits. he continued to have gross hematuria but his catheter continued to drain and so continuous bladder irrigation was not initiated. serial hematocrits were followed and the patient continued a slow gradual decline indicative of the ongoing hematuria. his abdominal exam remained tender but did not acutely worsen and thus it was elected to continue observing him carefully. on hd 2, he was evaluated by aps and started on ms contin, continued on his pca and started on tizanidine. on hd 3 methadone was added to his pain regimen in order to help achieve good pain control. additionally, he underwent a ct of the abdomen and pelvis which showed some increased fluid at the r colic gutter. there was also a possible renal pseudoaneurysm on the left however gu felt his urine was starting to clear and thus advised no further interventions at that time. his hematocrits continued to trend down but only slightly. as his hematocrit decreased down to 22.8, he was given 2 units of rbcs on , and hematocrits since then have remained stable and have actually begun to increase. due to his inability to be anticoagulated, he had bilateral lower extremity ultrasound which showed no dvt and as he was going to have limited mobility, an ivc filter was placed on . once hemodynamically stable he was transferred to the floor where his diet was advanced to regular. his pain control had primarily been managed by the pain service; he initially required pca with iv narcotics for breakthrough pain. methadone was recommended to be added to his regimen and he will be discharged on this in tapering doses. he was eventually changed to oral narcotics, tizanidine and ultram were added as adjunct therapy. as his urine had turned clear and yellow without clots, his foley was removed and he voided without issue. he was evaluated by physical therapy and was cleared for discharge to home. medications on admission: denies discharge medications: 1. tizanidine 2 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*1* 2. dilaudid 4 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain. disp:*90 tablet(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. senna 8.6 mg tablet sig: one (1) tablet po twice a day as needed for constipation. 5. tramadol 50 mg tablet sig: one (1) tablet po every six (6) hours. disp:*120 tablet(s)* refills:*1* 6. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 7. methadone 5 mg tablet sig: three (3) tablet po once a day: taper doses: begin on 2.5 tablets for 3 days; then on take 2 tablets for 3 days; then on take 1.5 tablets for 3 days; then on take 1 tablet for 3 days and then discontinue taking after last dose. disp:*37 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: s/p 15 ft fall injuries: splenic laceration (grade 5) renal laceration (grade 5) mildly displaced left rib fracture left t8-12 transverse process fracture discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital after you fell off a rail landing on your left side. you sustained mutliple left sided rib fractures, and bleeding injuries to your spleen and kidney. because of your multiple injuries there wasconcern that you would be at risk for blood clots to your lung and a special device called an ivc filter was placed into the large vein near your lungs to catch any blood clots that may develop. it is important that you walk 3-4 times daily around the house or outside on even surfaces. avoid any contact sports of any kind for the next 6 weeks that may cause injury to your abdominal and back areas as these can aggravate the bleeding injuries from your spleen and kidney. do not take any ibuprofen or aspirin products for at least the next 10 days. * your fall caused multiple rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * you should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. if the pain medication is too sedating take half the dose and notify your physician. * pneumonia is a complication of rib fractures. in order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. this will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * you will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * symptomatic relief with ice packs or heating pads for short periods may ease the pain. * narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * do not smoke * if your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, ibuprofen, motrin, advil, aleve, naprosyn) but they have their own set of side effects so make sure your doctor approves. * return to the emergency room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). followup instructions: please follow up with the acute care clinic in weeks. you will need to have a standing end expiratory chest xray for this appointment; call to schedule. follow up with your primary care doctor in the next couple of weeks for a general physical. Procedure: Interruption of the vena cava Diagnoses: Cocaine abuse, unspecified Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Gross hematuria Closed fracture of lumbar vertebra without mention of spinal cord injury Closed fracture of eight or more ribs Closed fracture of clavicle, unspecified part Injury to kidney without mention of open wound into cavity, laceration Injury to spleen without mention of open wound into cavity, massive parenchymal disruption Injury to kidney with open wound into cavity, complete disruption of kidney parenchyma Injury to renal vein Noncollision motor vehicle traffic accident while boarding or alighting injuring other specified person

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: 2units prbcs transfused history of present illness: this is an 81 yo female with history of cad, htn, ?gib in the past was transferred from for management of melena, doe and chest tightness. the episode begain this morning. she was walking to the bathroom and began to experience sob, along with 8/10 'chest tightness', +nausea, +diaphoresis. she denies vomiting, palpitations or radiating pain. this episode lasted for 5 minutes and resolved on its own. she was taken to her pcps office by her daughter and was then referred to the ecg changes and concern for acs. she reports similar episodes for the past two days, 4-5 episodes each day, but today's episode was worse, which was the reason she sought medical attention. she was sent to er where she had witnessed melena, documented as guaiac positive. at , she was hemodynamically stable. her trop i was found to be 7.37. hct 26.6. ecg showed st depressions ii, iii, avf, v3-v5, st elevation avr. patient was given lopressor, 1uprbc, tylenol, lasix 40mg x 1. cxr showed small right pleural effusion with minimal basilar atelectasis. she was transferred to ccu for further management. on arrival here, the patient was asymptomatic. she denied any chest pain, sob, n/v, diarrhea, abd pain. last bm was this morning. no fevers, chills. +dry cough for the past few days. past medical history: cad s/p mi and cabg in at hypertension hypothyroidism anxiety cardiac risk factors: htn, former smoker 30 pack year, quit 15 years ago cardiac history: -cabg: -percutaneous coronary interventions: social history: lives alone, has daughter, 50 year pack history tobacco, quit 15 years ago, no etoh, no drugs. from poland. family history: unknown, parents died when she was young. physical exam: vs: general: nad, lying comfortably in bed heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink. op clear, mmm neck: supple with jvp of 10 cm. cardiac: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, non-tender, non-distended extremities: no c/c/e rectal: normal tone, minimal black specks of stool, guaiac positive pertinent results: osh lab data: : wbc 5.8, hct 26.6, plt 153 na 135, k 4.6, cl 103, co2 25, bun 31, cr 1.0 pt 12.6, ptt 32.4, inr 1.14 troponin i 7.37, bnp 1340 . labs on admission: 08:45pm glucose-103 urea n-30* creat-1.0 sodium-139 potassium-3.9 chloride-102 total co2-26 anion gap-15 08:45pm ck(cpk)-140 08:45pm ck-mb-16* mb indx-11.4* ctropnt-1.12* 08:45pm calcium-8.7 phosphate-5.1* magnesium-2.2 08:45pm wbc-4.9 rbc-3.22* hgb-9.7* hct-27.9* mcv-87 mch-30.1 mchc-34.8 rdw-16.4* 08:45pm neuts-61.9 lymphs-28.0 monos-7.5 eos-2.1 basos-0.5 08:45pm plt count-153 08:45pm pt-12.8 ptt-24.1 inr(pt)-1.1 ecg: nsr, 1mm st depressions i, ii, v2-v5, <1mm std v6, 1mm st elevation avr . cxr: . ct chest: . brief hospital course: # nstemi: ms. had diffuse ecg changes and troponin leak in the setting of melena and ugib. global ecg changes and troponin leak were consistent with demand ischemia in the setting of her ugib. enzymes trended down and she remained chest pain free during her hospitalization. initially we held her asa, plavix, metoprolol, lasix in setting of bleed. she was started on a statin given her history of severe cad and no reported adverse events in her prior history with statins. as her stent was placed >1 month ago and was bare metal the plavix was stopped, not to be restarted. she was continued on 81mg aspirin for stent restenosis. metoprolol was restarted prior to discharge once her blood pressure was found to be stable and she had no evidence of further bleeding. she was taking lasix as an outpatient for unclear reasons, thus this was not restarted. the patient was instructed to follow up with her primary cardiologist, dr. , in for evaluation of possible diagnostic cardiac catheterization given her ischemic event in the setting of a gi bleed. at this follow up visit, she should discuss the future need for lasix. # ugib: the patient has a history of gave syndrome per her records from dr. office, her primary gastroenterologist. she presented to with melena. at that time she has a hct of 26 which was down from 31 on her last admission in 12/. on transfer to , 2 large bore ivs were placed and she was started on her first unit of prbcs. at , serial hcts were monitored and remained stable after transfusion of 4 units of prbcs total. she was initially on ppi iv bid and then switched to oral once daily (40mg). in the meantime gi was consulted and said in the setting of no acute bleeding, there was no need for emergent egd. she should follow up with her primary gastroenterologist for outpatient egd in the next 2-4 weeks. prior to discharge she was restarted on her iron and sucralfate. # htn: initially held metoprolol, lasix in setting of bleed. metoprolol was restarted prior to discharge, however lasix was held given not clear reason for lasix use. blood pressures were well controlled on metoprolol only. # hypothyroidism: continued levoxyl # anxiety: held lorazepam at first but then restarted when patient was started back on pos. # decreased breath sounds on rll: cxr was initially ordered to evaluate this finding on physical exam. a ct scan was recommended for follow up. ct scan showed pleural thickening on the right, either indicative of fat or fluid however not evidence of infection. the patient never reported symptoms of dyspnea or cough during her hospitalization. a small 2mm pulmonary nodule was noted on her ct scan. as she has a long history of tobacco abuse, it would be indicated to follow this nodule as an outpatient. # access: 2 large bore pivs # prophylaxis: ppi as above, hold home colace # code: full code, confirmed with patient # comm: with patient, hct is daughter medications on admission: aspirin 81 mg daily (took this morning) lorazepam 0.5 mg q8h prn colace 100 mg po bid levothyroxine 175 mcg daily omeprazole 20 mg clopidogrel 75 mg daily (took this morning) metoprolol tartrate 25 mg nitroglycerin 0.3 mg prn chest pain lasix 40mg daily kcl 20 meq p0 daily hydromorphone 2mg (one) tab tid sucralfate qid ferrous sulfate daily discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 2. lorazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for foot cramps. 3. levothyroxine 175 mcg tablet sig: one (1) tablet po daily (daily). 4. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 5. iron (ferrous sulfate) 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 6. sucralfate 1 gram tablet sig: one (1) tablet po four times a day. 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 8. atorvastatin 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: primary diagnoses: gave upper gib anemia nstemi in the setting of ugib secondary diagnoses: cad discharge condition: the patient was afebrile and hemodynamically stable without chest pain prior to discharge. discharge instructions: you were admitted to the hospital with chest pain. you had low blood counts because you were bleeding from your stomach. this caused you to have strain on your heart which caused your chest pain. you were given a blood transfusion and the pain went away. the gi doctors here not feel that you need to have another procedure to look at your stomach because you have had several that have all showed the same thing. medication changes: these medications were discontinued, do not restart these medications on discharge: - plavix - lasix . these medications were started, please take them as prescribed on discharge: - atorvastatin 80mg daily . these medications were continued, please take them as prescribed: - aspirin 81mg daily - iron - sucralfate - levothyroxine - lorazepam - omeprazole to 20mg two times daily . please come back to the hospital or call your primary care physician if you have fainting or near-fainting, dizziness, light-headedness, shortness of breath, chest pain, jaw pain, arm pain, abdominal pain, nausea, blood in your stools, black tarry stools, leg swelling, or any other concerning symptoms. followup instructions: please follow up with dr. in the next 2-4 weeks. please follow up with dr. in weeks to schedule outpatient upper endoscopy. please follow up with dr. in about 4 weeks. he will check your liver tests to make sure you can take the high doses of the statin we gave you. Procedure: Transfusion of packed cells Diagnoses: Anemia, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Percutaneous transluminal coronary angioplasty status Anxiety state, unspecified Old myocardial infarction Other chest pain Angiodysplasia of stomach and duodenum with hemorrhage Long-term (current) use of aspirin

allergies: penicillins / sulfa (sulfonamides) / risperidone / oxycodone / dilaudid / codeine / vicodin attending: chief complaint: r sided weakness and trouble speaking major surgical or invasive procedure: intubation history of present illness: 82 yo rh woman with h/o afib (not on coumadin multiple falls), htn, pd, cad, recent ivh fall who presents after being found down. she was speaking to her son-in-law this am ~9am who found her initially to be speaking normally (although conversation was brief but able to ask about her daughter who is out of the country) - incidentally she called him. however, soon after the call, he was answering a question and then noted no response on the other end of the telephone. he called her name, but heard no response. a friend had been planning to pick her up at 10 am, so he figured the phone was having technical difficulties and that he would be contact/seen by the people she was supposed to meet. he didn't hear anything and presumed that things were ok. ~12:30, her daughter in law came by her apt to see how she was doing. when she knocked, she heard someone (the pt) trying to say something but not really saying anything clearly. she called 911 and the fire dept responded, broke open the door and found the patient dressed (ready to go out per children), unable to communicate - not making word salad, but only word that was understandable was "no" with r sided weakness. as a result, she was brought to ed where she was sbps in 150. she could follow simple commands, but was not moving her rue. she also appeared to have trouble getting words out per ed staff. she was then intubated for airway protection. cth was attained which revealed hypodensity involving lmca territory with small amount of hemorrhage concerning for hemorrhagic conversion of infarction and neurology service was contact. incidentally, the patient's children describe her as having gradual worsening of her language with worsening word finding difficulties over the past year. after a recent admission for ivh, she has also had a tendency to sit with her eyes close (although awake) per their report. per family, patient with h/o tia with dysarthria and l hand "shaking" lasting minutes. they don't recall results of workup from . ros: gen: pt unable to relate. but per family, no recent illness, no complaints of ha, no other previous weakness, vision changes, sensory symptoms. past medical history: atrial fibrillation-diagnosed (on coumadin) arthritis cad (inferolateral reversible defect per mibi in ) zoster asthma arthroscopic surgery to knees (bilat) wrist tah ccy hypothyroidism tia in (self limited with no residual defecits) osteoporosis parkinson's disease hypertension hiatal hernia social history: lives alone in an apartment. her daughters are involved. she denies alcohol, tobacco and illicit drugs. family history: no significant physical exam: vs: t 97.3 hr 62 bp 154/94 rr 18 sat 100% ra pe: heent at/nc, mmm no lesions neck supple, no bruits chest cta b cvs irregularly irregular abd soft, ntnd, + bs skin neurological ms: intubated, sedated on propofol. when taken off, bps into 200s eyes closed, not following commands, no spont eye opening or eye movements. spont movements of all extremities except rue. cn: surgical pupils bilaterally, + corneal reflexes bilaterally, no ocrs, no gag, no grimace noted. pt with ett taped onto r nlf motor: tone: increased tone throughout. moving extremities except for rue spontaneously. with noxious to rue, localizes with left, but no movement noted on r. lle moving greater than rle, but rle is easily antigravity. : all extremities save for rue withdraw to mild stim reflex: 2+ bilaterally, except for ankles 0. toe on l is up. toe on r is mute. pertinent results: 03:11pm glucose-116* lactate-2.2* na+-143 k+-3.5 cl--95* tco2-31* 02:55pm glucose-122* urea n-21* creat-0.8 sodium-140 potassium-3.5 chloride-98 total co2-28 anion gap-18 02:55pm ck(cpk)-106 02:55pm ck-mb-7 02:55pm ctropnt-0.01 02:55pm calcium-9.4 phosphate-3.2 magnesium-1.8 02:55pm calcium-9.4 phosphate-3.2 magnesium-1.8 02:55pm wbc-8.3 rbc-3.89* hgb-12.5 hct-37.7 mcv-97 mch-32.2* mchc-33.3 rdw-14.4 02:55pm neuts-83.1* lymphs-11.1* monos-4.5 eos-0.7 basos-0.6 02:55pm plt count-235 02:55pm pt-13.7* ptt-27.1 inr(pt)-1.2* 04:05pm urine blood-sm nitrite-neg protein-100 glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-8.0 leuk-neg 04:05pm urine rbc-0-2 wbc-0-2 bacteria-rare yeast-none epi-0 11:21pm type-art po2-494* pco2-36 ph-7.56* total co2-33* base xs-10 ct head: large hypodense area concerning for acute ischemia in distribution of left mca, with foci of blood products. mri is recommended for further evaluation, and neurology consult. findings were discussed with dr. at 4:10 p.m. on and posted on the ed dashboard. 2. scattered area of low attenuation in the subcortical white matter on the right, likely consistent with chronic small vessel ischemic changes. 3. no evidence of fracture. ct head after change in exam: 1. massive hemorrhagic conversion of a left mca territory infarct with local mass effect, including effacement of the left lateral ventricle including near complete effacement of the left lateral ventricle, as well as significant subfalcine and left uncal herniation. some mild interval dilatation of the right lateral ventricle atrium should be monitored on followup examinations. brief hospital course: mrs was admitted to the icu with large lmca infarction. no intervention was indicated as she was outside the window. overnight she had a change in her pupilary exam and stat repeat head ct was ordered. she was found to have massive hemorrhagic conversion of her stroke. she was not on any anti-platlet or anticoagulants at the time. full medical management was maintainted until when her daughter was able to arrive home from . on after a family meeting with bother daughters, son-in-law, , and other family members care was withdrawn and she was made comfort measures only. she passed away shortly after extubation. medications on admission: 1. carbidopa-levodopa 25-100 mg tablet sig: two (2) tablet po qid (4 times a day). 2. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day): in one week (starting , dose should be incresed to 750 mg foe one week, then (on ), dose should be increased to 1000 mg , as long as pt.s mental status remains clear. if there are questions about this, contact pt.s primary care md, dr. at . tablet(s) 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 6. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 7. colace 100 mg capsule sig: two (2) capsule po at bedtime. 8. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 9. lisinopril 10 mg tablet sig: three (3) tablet po daily (daily). 10. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 11. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 12. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). 13. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours). discharge medications: none, pt passed away discharge disposition: expired discharge diagnosis: massive hemorrhagic conversion of a left mca territory infarct with local mass effect, including effacement of the left lateral ventricle including near complete effacement of the left lateral ventricle, as well as significant subfalcine and left uncal herniation atrial fibrillation discharge condition: expired discharge instructions: the patient was admitted with a large left mca infarct with large hemorrhagic conversion and subfalcine and left uncal herniation. the patient was made cmo, and expired with her family at the bedside. followup instructions: none md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Asthma, unspecified type, unspecified Intracerebral hemorrhage Diaphragmatic hernia without mention of obstruction or gangrene Compression of brain Paralysis agitans Osteoporosis, unspecified

allergies: no drug allergy information on file attending: chief complaint: left sided weakness and unresponsiveness major surgical or invasive procedure: none history of present illness: hpi: patient's real name is (dob ). he is a 88 yo right handed man with hx of dementia, htn and stroke who was living in a nursing home ( healthcare and nursing) and found to be lethargic with l sided weakness around 9:30 per staff. per nursing home staff, patient ambulated with superversion and able to feed himself. although he has dementia, he is also aware of his surrounding as well. he awoke this morning and walked to the dining room under supervision as usual but was found to be slow hence the nurse was called who found him less responsive with l sided weakness hence the ems was called. patient was initially taken to where head ct revealed large r frontal iph measuring 8x5cm seen through 14 slices with 8mm midline shift to the l. his initial bp was elevated up to 230/120 hence he received labetalol (10x3) and nipride as well. although he is dnr/dni, patient vomited while at hence he was sedated. paralyzed and admitted prior to the transfer. past medical history: 1. htn 2. stroke 3. alzheimer's dementia 4. hypercholesterolemia 5. falls 6. renal failure social history: lives in home ( or 156). code status is dnr/dni and hcp is daughter, who resides in . family history: nc physical exam: t 96.6 (rectal) bp 179/92 hr 53 rr 12 o2sat 100% on cmv gen: sedated and intubated. cv: brady but regular, no murmurs/gallops/rubs lung: clear anteriorly. abd: +bs soft, nontender ext: no edema neurologic examination: mental status: sedated and intubated. occasional myoclonic jerks especially to stimulation but keeps eyes closed and no other spontaneously movements. cranial nerves: r pupil larger than left (6 and 3mm respectively) and minimally reactive bilaterally. no blinking to visual threat and no corneal's bilaterally. no doll's eyes but positive gag and cough. face appears symmetric. motor: normal tone - occasional myoclonic jerks (more on r than l) especially to stimulation. extensor posturing to noxious stim on both ues and triple flexion in both les. sensation: appears intact to noxious stim. reflexes: +2 and symmetric throughout except for r patellar. 3~5 beat ankle clonus bilaterally, more coarse on r than l. both toes upgoing. pertinent results: admission labs: 141 | 105 | 29 ----------------< 129 3.8 | 27 | 1.1 11.2 9.2 >------<161 33.2 imaging: nchct ( - 6pm) large right frontotemporal intraparenchymal hemorrhage with marked subfalcine herniation and near-complete obliteration of the basilar cisterns consistent with central herniation. mass effect causing near complete effacement of the bilateral frontal horns and third ventricle and enlargement of the left occipital and temporal . brief hospital course: mr. is an 88 year old right handed man with hx of dementia, htn and stroke (unclear residual deficits) who was living in a nursing home but almost independently ambulatory found to be lethargic with l sided weakness per staff this morning around 9:30am. he was initially taken to where head ct revealed large r frontal iph measuring 8x5cm seen in 14 slices with 8mm shift to the l. although dnr/dni, he was intubated for transport and currently he has minimal exam. he has markedly asymmetric pupils with r>l and both minimally reactive. although he had +gag/cough, no other brains stem reflexes but likely reflective of recent paralytic and sedation as well. he has occasional myoclonic jerks, more often with stimulation. no clear lateralization with tone or movement. both toes are going up and he has 3~5 beat ankle clonus bilaterally but more coarse on r than l. he was admitted to the icu and remained intubated pending the arrival of his family to discuss further goc. he was placed on dilantin for seizure prophylaxis, and home blood pressure medications were resumed, with prn hydralazine and labetalol for goal sbp<160. ~3 hours after admission, his pupillary asymmetry was noted to worsen, and a repeat head ct was obtained which showed worsening subfalcine as well as central herniation. upon return from head ct he was noted to have bilateral blown pupils. as family was still en route, he was hyperventilated and given mannitol as a temporizing measure. his imaging was discussed with neurosurgery, who agreed that surgical intervention would be futile at this point. upon arrival of the family, discussion was had regarding the grim prognosis, and the patient was made cmo. he was extubated, and expired shortly thereafter. medications on admission: 1. benazepril 40mg daily 2. hctz/reserpine/hydralazine (25/0.1/15) daily 3. lipitor 10mg daily 4. atenolol 25mg daily 5. asa 81mg daily 6. bactrim ds 7. seroquel 50mg daily 8. prostate soluble daily discharge medications: none discharge disposition: expired discharge diagnosis: intraparenchymal hemorrhage discharge condition: deceased discharge instructions: none followup instructions: none md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Pure hypercholesterolemia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Intracerebral hemorrhage Chronic kidney disease, unspecified Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance History of fall

allergies: no known allergies / adverse drug reactions attending: chief complaint: concern of compartment syndrome left leg major surgical or invasive procedure: - 4-compartment fasciotomy and fascial biopsies. - 1. irrigation and debridement of left lower extremity wounds, skin, soft tissue and muscle (168 cm^2). 2. application of negative-pressure dressing (greater than 50 sq cm). - 1. washout and debridement left leg on lateral side down to bone approximately 192 cm2. 2. medial side debridement of skin to muscle 160 cm2. 3. application of a large vac sponge. - 1. irrigation and debridement down to all muscle compartments with aggressive debridement of all musculature from all lower extremity compartments. 2. staged delayed closure medial fasciotomy. 3. placement of vacuum sponge over lateral fasciotomy. - staged debridement and irrigation, staged closure left lateral fasciotomy and placement of vacuum sponge. history of present illness: 28 yo female awoke thursday morning with severe leg pain which became worse throughout the day and overnight became excruciating. she denies any trauma to the leg. she works as a home health aide and on wed the day before her pain started she said she had a normal day at work. she does admit to purchasing a hair removal device which she has been using that has produced a number of ingrown hairs with regrowth as an explanation for the many scabs on her arms and legs. she denies iv drug use or recent infections. past medical history: low back pain migraines social history: lives in with 8 year old son. divorced from her son's father. not currently in relationship. was recently in relationship, sexually active, always used condoms. immigrated from at age 12. 2 cigarettes to ppd, denies current or past illicit drug use. last tattoo about 6-8 months ago. currently working as a nurse's aide. family history: mother and grandmother have type ii dm. no fh of liver disease physical exam: initial exam (per vascular surgery note) vital signs: temp: 99.8 rr: 20 pulse: 133 bp: 130/71 neuro/psych: oriented x3, affect normal, nad. neck: no masses, trachea midline. nodes: no clavicular/cervical adenopathy. skin: abnormal: multiple punctate lesions throughout entire body. heart: regular rate and rhythm. lungs: clear. gastrointestinal: non distended, no masses, guarding or rebound. rectal: not examined. extremities: no rle edema, abnormal: severe lle edema, tenderness throughout. decreased sensation throughout distal lle . pulse exam (p=palpation, d=dopplerable, n=none) rue radial: p. lue radial: p. rle femoral: p. popiteal: p. dp: p. pt: p. lle femoral: p. popiteal: d. dp: n. pt: n. discharge exam: vs: 98.1 118/66 92 18 98 ra i/o: 2l/3l gen: nad, alert and awake heent: mmm, op clear cv: regular rate and rhythm, no murmurs resp: ctab anteriorly, no wheezes or crackles abd: soft nd; no hsm, +bs ext: no c/c/e, lle wrapped in bandage. rle with palpable dp. psych: stable, complaining of pain pertinent results: admission labs: 08:30pm blood wbc-16.7*# rbc-4.99 hgb-13.4 hct-43.0 mcv-86 mch-26.8* mchc-31.1 rdw-16.6* plt ct-222 08:30pm blood neuts-86.8* lymphs-8.3* monos-4.5 eos-0.3 baso-0.1 08:30pm blood pt-12.5 ptt-28.5 inr(pt)-1.2* 08:30pm blood glucose-111* urean-9 creat-0.7 na-136 k-4.1 cl-96 hco3-28 angap-16 08:30pm blood ck(cpk)-* 11:10pm blood calcium-7.6* phos-4.1 mg-2.2 08:44pm blood lactate-2.8* discharge labs: 09:05am blood wbc-8.4 rbc-2.81* hgb-8.3* hct-25.9* mcv-92 mch-29.6 mchc-32.2 rdw-13.9 plt ct-433 09:05am blood glucose-115* urean-8 creat-1.7* na-140 k-5.1 cl-101 hco3-35* angap-9 05:51am blood ck(cpk)-157 micro: bcx: negative x2 wound swab: negative mrsa screen: negative wound swab: negative tissue cx: all negative except for acid fast bacilli culture cdiff: negative tissue cx: negative wound swab: negative x2 ucx: negative studies: tissue path: benign fibroadipose tissue. tissue path: necrosis of skeletal muscle and fibrinopurulent exudate. imaging: l leni: limited exam due to patient discomfort demonstrates patent common femoral and superficial femoral veins, without dvt. cxr: ap single view of the chest has been obtained with patient in semi-upright position. the findings are normal. there is no cardiac enlargement, no pulmonary vascular congestion, or no evidence of acute parenchymal infiltrates. lateral pleural sinuses remain free, and no pneumothorax is present in the apical area. brief hospital course: transitional issues: pain: patient discharged on significant amount of narcotics due to difficult to control pain during this hospitalization. she will need close follow up with pain clinic for weaning off narcotics as an outpatient. : will need repeat labs in the future to monitor creatinine/kidney function pt: patient discharged with home pt, may need further outpatient pt to gain full mobility. f/u ortho: patient has an appointment for suture removal and wound check on , and will need further follow up appointments with orthopedic surgery. ===================== ms. is a 28 year old woman with h/o recent liver injury, chronic migraines who p/w compartment syndrome of her lle. the patient was initially admitted to the orthopaedic trauma service for left leg compartment syndrome. the patient was taken to the or and underwent a 4 compartment fasciotomy with serial irrigation and debridements until her leg was finally closed on . psychiatry, social work, infectious disease, medicine and the pain service were all consulted and involved in her care while on the orthopedic surgery service. on she was transferred to the medicine service for management of acute renal failure, anemia, transaminitis and tachycardia. patient's pain control was an issue during this hospitalization, and pain service was consulted for management. she was weaned off ketamine gtt and dilaudid pca and transitioned to oral pain medications. she was evaluated by physical therapy and discharged home with services. # compartment syndrome: unclear etiology, patient reports waking up with pain in lle. denied trauma or iv drug use. patient was taken to or on admission and had 4 compartment fasciotomy. she was taken back to or multiple times for irrigation and debridement of necrotic tissues. initially there was a concern for necrotizing fasciitis and she was treated with antibiotics, but they were eventually stopped when all cultures returned negative. patient had staged closure of the wound, and her last surgery was on . # acute kidney injury: patient with acute increase in creatinine, peaked at 2.7 and downtrended afterwards. it is possibly due to rhabdomyolysis (ck on admission was >110k), however, does not fit with timing. most likely due to atn from hypotension in or. patient's medications were renally dosed during this episode of . she will need further monitoring of creatinine to make sure it returns to baseline. # electrolyte abnormalities: mild hyperkalemia/hyperphosphatemia, and elevated bicarb as well. hyperkalemia and hyperphosphatemia was thought to be due to po intake in setting of . she was started on phos binder for a short term while her creatinine continued to improve and it began decreasing. bicarb elevation was thought to be due to contraction alkalosis with patient's post atn autodiuresis. # pain: lle pain from her compartment syndrome/multiple procedures, being followed by pain service. she was initially managed with dilaudid pca and ketamine gtt. after her last surgery on , she was weaned off ketamine gtt and dilaudid pca and transitioned to po medications. her oxycontin was increased to 60 mg q8hrs and oxycodone was maintained at 10-20 mg q4hrs prn pain. her gabapentin was uptitrated as her kidney function improved. cymbalta and tizanidine were started as adjuvant medications for pain control. multiple discussions were had with the patient regarding risk of long term high dose narcotics use and importance of attempting to wean down narcotics as tolerated after discharge. she was instructed not to drive, drink alcohol or combine narcotics with other sedating medications. she was also instructed to take the medications only as prescribed given the risk of respiratory depression and risk of death. # anemia: patient had acute drop in hct, most likely related to frequent procedures, and responded well to prbcs. no other obvious sources of bleeding were found during this hospitalization. after her surgeries were completed, her hct remained stable. # tachycardia: patient had persistent sinus tachycardia, concerning for hypovolemia, pain/anxiety, pe vs. medication effect from ketamine. she was getting continuous ivf for rhabdomyolysis/ so hypovolemia less likely. tachycardia improved after stopping ketamine gtt. her acute pain was managed as above, and she was continued on dvt prophylaxis during this hospitalization. # chronic migraine: pt on gabapentin as outpatient. unfortunately, due to her , gabapentin dose had to be decreased. patient complained of worsening headache intermittently during this hospitalization, concerning for rebound headache given that pt has been on large amount of pain medications. however, given the extensive surgeries she has had, tapering off her pain medication did not seem to be a reasonable option at this time. # transaminitis: patient with initial transaminitis, ?subacute injury to acetaminophen toxicity. now resolved. medications on admission: gabapentin wellbutrin - prescribed, but not taking discharge medications: 1. bisacodyl 10 mg po/pr daily:prn constipation rx *bisacodyl 5 mg daily disp #*60 tablet refills:*0 2. docusate sodium 100 mg po bid rx *colace 100 mg twice a day disp #*60 tablet refills:*0 3. senna 1 tab po bid rx *natural senna laxative 8.6 mg twice a day disp #*60 tablet refills:*0 4. duloxetine 60 mg po daily rx *cymbalta 60 mg daily disp #*30 capsule refills:*0 5. gabapentin 600 mg po tid pain hold if sedated rx *gabapentin 600 mg every 8 hours disp #*90 tablet refills:*0 6. multivitamins 1 cap po daily rx *daily multi-vitamin daily disp #*30 tablet refills:*0 7. tizanidine 4 mg po q8h rx *tizanidine 4 mg every 8 hours disp #*90 capsule refills:*0 8. lorazepam 1 mg po hs:prn insomnia hold if sedated or rr<12 rx *ativan 1 mg at bedtime disp #*10 tablet refills:*0 9. oxycodone sr (oxycontin) 60 mg po q8h pain hold if sedated or rr<12 rx *oxycontin 20 mg every 8 hours disp #*40 tablet refills:*0 10. oxycodone (immediate release) 10-20 mg po q4h:prn pain hold if sedated or rr<12 rx *oxycodone 5 mg every 4 hours disp #*100 tablet refills:*0 discharge disposition: home with service facility: homecare discharge diagnosis: primary diagnosis: compartment syndrome of left lower leg s/p fasciotomy and debridement, acute kidney injury secondary diagnosis: chronic migraine discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital because of your left leg pain, and were found to have compartment syndrome (high pressures in the leg). you had multiple surgeries to your left leg. you were seen by pain service for pain control, and is being discharged on very high doses of narcotics which will need to be weaned off as outpatient. please do not drive automobile, do anything that requires you to be alert, drink alcohol or take other sedating medications (that's not prescribed for you) while you are taking oxycodone/oxycontin or ativan as they make you drowsy, decrease your breathing rate and can cause death. please take these medications only as prescribed. please keep your appointments as listed below. it is very important that you keep these appointments for further management of your leg and pain. please try to decrease the amount of short acting pain medication (oxycodone) as tolerated at home. you can try take 3 tablets first, and then decrease to 2 and 1 as tolerated. if you are not requiring as much of the short acting pain medications, you can decrease your long acting (oxycontin) by 20 mg every days as well. followup instructions: department: orthopedics when: thursday at 1:20 pm with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage department: orthopedics when: thursday at 1:40 pm with: , np building: campus: east best parking: garage department: when: thursday at 3:00 pm with: , md building: sc clinical ctr campus: east best parking: garage dr. is your new physician at . he works closely with dr , both will be involved in your care. please call your insurance and name dr. as your pcp. must be done before your appointment. the pain service is recommending that you decrease your oxycontin by 20 mg every 3-4 days as your acute pain decreases. you can start by taking less oxycontin in the morning, then in the afternoon, and then in the evening. you can start taking less oxycontin at home as your pain improves. the following pain clinic appointment has been made for you, but you have also been placed on cancellation list, so the clinic may call you with an earlier appointment. department: pain management center (sb) when: wed at 12:50 pm with: dr. building: one place (, ma), campus: off campus Procedure: Fasciotomy Other suture of muscle or fascia Other suture of muscle or fascia Other myectomy Other myectomy Other myectomy Other irrigation of wound Diagnoses: Tobacco use disorder Acute kidney failure with lesion of tubular necrosis Acute posthemorrhagic anemia Depressive disorder, not elsewhere classified Hypopotassemia Other specified cardiac dysrhythmias Hypotension, unspecified Alkalosis Disorders of phosphorus metabolism Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Scoliosis [and kyphoscoliosis], idiopathic Lumbago Urinary complications, not elsewhere classified Other specified antibiotics causing adverse effects in therapeutic use Rhabdomyolysis Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Nontraumatic compartment syndrome of lower extremity Aromatic analgesics, not elsewhere classified, causing adverse effects in therapeutic use Chronic migraine without aura, without mention of intractable migraine without mention of status migrainosus

allergies: no known allergies / adverse drug reactions attending: chief complaint: hypotension major surgical or invasive procedure: central venous catheter placement history of present illness: 81 year old male initially presented to with chief complaint of ruq pain, fever, and hypotension. patient was at passover started c/o ruq pain starting at noon, very minor per the patient. it did not radiate and was constant. by report cxr at showed ?free air vs bowel. follow-up ct was initially thought to be free air, however turned out to be bowel. on ct scan pericardial effusion was noted. given the innability to get a ruq u/s at the patient was was given zosyn and flagyl at and transfered to for ruq u/s. . he denies doe, cp, sob, objective chills or rigors, or sick contacts. . in the ed, initial vs were 100.2 60 89/50 20 97% 2l nc. a bedside ultrasound showed no rv collapse, patient couldn't participate in a pulsus. most recent vitals 57 104/47 on levofed, 15 98% ra rij. cardiology was called but not consulted. . on the floor, he states he is comfortable. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: hearing impaired chronic 1st degree hb hocm recurrent afib/aflutter, s/p dccv , dccv bradycardia elevated psa htn hyperlipidemia m.r. social history: employee, non-smoker, non-drinker family history: there is no family history of premature coronary artery disease or sudden death. physical exam: admission physical: general: non-verbal, a+o x3 through interpreter heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp unassessable cvl lungs: bibasilar crackles cv: distant faint sem abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: large errythematous rash over left knee, multiple sites of skin breakdown. . discharge physical: vs: t98.4 bp100/54 (100-121/54-70) hr78 (76-102) rr 18 o2sat98% on ra general: well appearing elderly man in nad, non verbal heent: sclera anicteric, mmm, oropharynx clear neck: supple, no cervical, submandibular or supraclavicular lad lungs: lll with crackles cv: irregularly irregular, sem, no rubs or gallops; abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: 2+ le edema b/l; stockings on; wwp skin: erythematous purpuric rash over left knee pertinent results: admission labs: 01:30am wbc-12.4* rbc-3.35*# hgb-10.8*# hct-30.8* mcv-92 mch-32.3* mchc-35.1* rdw-14.2 01:30am neuts-90.0* lymphs-6.2* monos-2.6 eos-1.1 basos-0.3 01:30am plt count-179 01:30am pt-25.9* ptt-37.9* inr(pt)-2.5* 01:35am glucose-103 lactate-1.7 na+-136 k+-3.5 cl--105 tco2-22 01:35am freeca-1.05* 01:30am urea n-22* creat-0.9 01:30am alt(sgpt)-26 ast(sgot)-35 alk phos-87 tot bili-0.9 01:30am lipase-23 01:30am ctropnt-<0.01 05:28am wbc-17.5* rbc-3.65* hgb-11.5* hct-33.7* mcv-92 mch-31.4 mchc-34.0 rdw-14.3 05:28am plt count-231 05:28am blood tsh-3.2 05:28am blood psa-15.2* 02:45am urine color-amber appear-clear sp ->1.050* 02:45am urine blood-mod nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-4* ph-6.0 leuk-neg 02:45am urine rbc-34* wbc-1 bacteria-none yeast-none epi-0 02:45am urine hyaline-4* . discharge labs: 06:55am blood wbc-8.1 rbc-3.85* hgb-12.1* hct-35.4* mcv-92 mch-31.5 mchc-34.2 rdw-14.3 plt ct-225 06:55am blood glucose-80 urean-13 creat-0.7 na-141 k-3.3 cl-107 hco3-25 angap-12 06:55am blood calcium-8.1* phos-3.3 mg-1.9 02:59am blood caltibc-164* vitb12-690 folate-9.7 ferritn-700* trf-126* . micro: bcx : pending ucx : no growth . studies: ct abd/pelvis ( ): 1. large pericardial effusion. an echocardiogram is recommended to evaluate for tamponade physiology. 2. tiny layering stones/sludge within a nondistended gallbladder. 3. liver hypodensities which represent cysts or hemangiomas however which are not further characterized. mri can be considered for further characterization. 4. left lower lobe opacity representing aspiration/infection versus atelectasis. 5. enlarged pelvic and prominent retroperitoneal lymph nodes. further evaluation is warranted as these have enlarged compared with the prior examination and could signify an underlying malignancy. recommend correlation with psa and consideration to additional imaging including pet ct scan. 6. right inguinal hernia partially containing the anterior bladder wall. 7. markedly enlarged prostate gland. 8. bladder calculus. 9. splenomegaly. . tte : conclusions the left atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is mildly dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). trace aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is severe mitral annular calcification. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. the pericardial effusion appears circumferential and is largely small (with a moderate sized lateral portion). there are no echocardiographic signs of tamponade. echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. . cxr : impression: 1. right internal jugular line in mid-to-distal svc. 2. markedly enlarged cardiac silhouette, secondary to underlying pericardial effusion. . ruq u/s : impression: cholelithiasis, without acute cholecystitis. . ct chest : impression: 1. severe cardiomegaly and moderately large pericardial effusion suggest tamponade physiology. 2. severe bronchial wall thickening and mucoid impaction bilaterally indicates small airways disease. 2. generalized ground-glass opacity, small bilateral pleural effusions, and interstitial thickening consistent with mild pulmonary edema. brief hospital course: hospital course: pt is an 81m with pmh of hocm, atrial fibrillation on coumadin, who was transfered here from for ruq u/s in the setting of ruq pain, fever, and hypotension. pt was admitted to the micu for closer monitoring given hypotension and concern for tamponade. he was placed on broad spectrum antibiotics and required brief pressors. pressors were quickly weaned off. pt's abdominal pain resolved after bowel movement. pt defervesced and broad spectrum antibiotics were discontinued in favor of levofloxacin for cap given mucoid impaction on ct chest. he was transferred to the medicine floors where his condition continued to improve with a bowel regimen. antibiotics were discontinued as pneumonia was felt clinically unlikely. . # fever/hypotension: ddx included sepsis vs. tamponade. pt was thought to have a large pericardial effusion on ct scan. however, given pulsus of 4, this was thought to be unlikely- subsequent echo confirmed a small effusion. given fevers there was concern for sepsis with possible sources including cholecystitis given ruq pain, pna, or uti. on presentation, pt had no ruq and abdominal discomfort overall improved after a bowel movement. ruq demonstrated cholelithiasis but not cholecystitis. ua was clean. cap possible though initial cxr did not show consolidation. he was placed initially on broad spectrum antibiotics. a ct chest showed mucoid impaction, and pt was switched on hod#2 to levofloxacin for planned 7 day course for cap. this was discontinued after two doses as the patient clinically did not have signs of pneumonia and was doing well. given low and then normal blood pressures, verapamil was held during this hospitalization and pt was discharged off of it. . # pericardial effusion: most likely chronic given asymptomatic and pulsus of only 4. differential for etiology is broad. there was concern for malignancy given lad on imaging. tte was done which showed no evidence of tamponade physiology. per cardiology, recommended follow-up in weeks. tsh was checked and was normal. pulsus were checked in the icu and remained <10. pt should have further workup for evaluation of lad. # ruq pain: suspect gas/constipation vs. less likely intermittent gallstone obstructions. ruq pain resolved after large bowel movement. as above, no evidence of cholecystitis on u/s. no other obvious pathology on ct abdomen. pt was treated with bowel regimen and symptoms improved. . # pelvic/rp lad: unclear etiology, concern for malignancy. patient also with report of recent 20 lb weight loss. no clear source on ct chest or abd/pelvis. last colon - evidence of internal hemorrhoids but otherwise normal. psa is at baseline since per omr; prostate biopsies in were negative for malignancy. given splenomegaly, concern for lymphoma. ldh was within normal limits. outpatient pet scan was arranged for patient. he will need further follow up with his pcp. . # anemia- normocytic and new since . no obvious signs of bleeding. normal in . ddx fe deficiency vs. chronic disease (?malignancy) vs. b12/folate (less likely). b12 and folate wnl. iron studies suggestive of anemia of chronic disease. hematocrit trended and remained stable during this hospitalization. . # rash: erythematous macular, non-blanching rash over left knee of month duration. unclear etiology. dermatology was consulted, and thought most likely purpuric rash to trauma. rash improved over course of hospitalization. derm also recommended amlactin cream for venous stasis rash b/l. patient was discharged on this medication. . inactive issues: . # bph: continued finasteride. given pericardial effusion, and concern for possible malignancy, psa was checked and was 15.1, similar to prior values since . pt should follow-up with pcp for further management. . # hocm: home atenolol and verapamil were held initially given concern for sepsis. he was continued on home dose of statin. once bp normalized, pt was started on metoprolol for titration of bp meds and rate control for afib as below. he was discharged back on his home atenolol. . # afib: rate controlled on admission. he was continued on coumadin with daily pt/inr checked given antibiotics. as above, ccb and atenolol initially held given concern for sepsis. metoprolol was started in the icu after bp's normalized for improved titration. he was discharged back on his home atenolol. . transitional care: 1. code: full 2. hcp: 3. follow-up required: ct abd/pelvis at : a) liver hypodensities which represent cysts or hemangiomas however which are not further characterized. mri can be considered for further characterization. b). enlarged pelvic and prominent retroperitoneal lymph nodes. further evaluation is warranted as these have enlarged compared with the prior examination and could signify an underlying malignancy. recommend correlation with psa and consideration to additional imaging including pet ct scan. 4. pending on discharge: blood cultures x2- pending (ngtd) medications on admission: atenolol - (prescribed by other provider: . ) - 25 mg tablet - one tablet(s) by mouth once daily finasteride - (prescribed by other provider) - 5 mg tablet - one tablet(s) by mouth once daily simvastatin - (prescribed by other provider) - 20 mg tablet - one tablet(s) by mouth once daily verapamil - (prescribed by other provider) - 240 mg cap,24 hr sust release pellets - 1 cap(s) by mouth once a day warfarin - (prescribed by other provider) - 1 mg tablet - one tablet(s) by mouth once daily . medications - otc ergocalciferol (vitamin d2) - (prescribed by other provider) - 1,000 unit capsule - one capsule(s) by mouth once daily vitamin e - (prescribed by other provider) - 400 unit capsule - one capsule(s) by mouth once daily discharge medications: 1. psyllium packet sig: one (1) packet po daily (daily). disp:*30 packet(s)* refills:*2* 2. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. 3. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 4. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 5. atenolol 25 mg tablet sig: one (1) tablet po once a day. 6. sennosides 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*30 tablet(s)* refills:*0* 7. ammonium lactate 12 % lotion sig: one (1) appl topical (2 times a day): please apply to the rash on your legs. disp:*1 bottle* refills:*1* 8. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. disp:*60 capsule(s)* refills:*1* discharge disposition: home discharge diagnosis: abdominal pain discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , you were admitted to the hospital with abdominal pain. because of your low blood pressure you were admitted to the intensive care unit and then transferred to the general medical when you were doing better. we believe this pain may have been related to constipation. your ct scan of your abdomen showed enlarged lymph nodes- this will need to be evaluated further with a pet scan, which we have scheduled for you (see below). we have made the following changes to your medications: - stop taking verapamil for your blood pressure- your blood pressure was low and then normal during your hospitalization - start taking psyillium for your bowel movements - start taking colace and senna as needed for constipation - start using amlactin lotion for the rash on your calves it was a pleasure taking care of you. we wish you a speedy recovery. followup instructions: you have a pet scan scheduled for , at 8:45 in the morning. this is located on the of the building. you will need to drink a bottle of the clear scan prep the night before the pet scan. the pet scan people will be sending you more information regarding the special diet that you will have to follow for dinner the night before your pet scan, and when to drink the clear scan prep. . primary care doctor appointment: name: , d. address: , , , phone: when: thursday, , 1pm Procedure: Central venous catheter placement with guidance Diagnoses: Abdominal pain, unspecified site Mitral valve disorders Unspecified essential hypertension Atrial fibrillation Atrial flutter Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other and unspecified hyperlipidemia Hypotension, unspecified Long-term (current) use of anticoagulants Other constipation Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Rash and other nonspecific skin eruption First degree atrioventricular block Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent)

allergies: no known allergies / adverse drug reactions attending: addendum: he experienced postoeprative repsiratory distress likely due to acute pulmonary edema; intravenous lasix was administered with immediate effect. upon arrival to the icu, he was placed on bipap, which was weaned to nasal cannula on pod 1. he remained stable from a pulmonary standpoint for the remainder of his hospitalization and was weaned off supplemental oxygen entirely. discharge disposition: extended care facility: for the aged - md, Procedure: Non-invasive mechanical ventilation Other and open repair of indirect inguinal hernia with graft or prosthesis Diagnoses: Other primary cardiomyopathies Mitral valve disorders Unspecified essential hypertension Atrial fibrillation Aortic valve disorders Atrial flutter Other and unspecified hyperlipidemia Personal history of other malignant neoplasm of skin Cellulitis and abscess of leg, except foot Long-term (current) use of insulin Hypoxemia Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Other alteration of consciousness First degree atrioventricular block Acute edema of lung, unspecified Family history of other cardiovascular diseases Elevated prostate specific antigen [PSA] Deaf, nonspeaking, not elsewhere classifiable Inguinal hernia, with obstruction, without mention of gangrene, unilateral or unspecified,recurrent

allergies: no known allergies / adverse drug reactions attending: chief complaint: incarcerated right inguinal hernia left lower extremity cellulitis major surgical or invasive procedure: : right inguinal herniorraphy with mesh history of present illness: 81m with right inguinal hernia with non-reducible bulge since noon today. pain in right groin since then. noted some discomfort as early as this morning. has had some nausea throughout day as well. no vomiting or other abdominal pain. has not noted a hernia before. additionally left leg has been red for a couple of weeks; has been using cream and has not seen a physician for it. did not notice that it was swolen. past medical history: past medical history: hearing impaired (fluent with sign language), chronic 1st degree heart block, recurrent atrial fibrillation/ atrial flutter, s/p dccv , s/p dccv , bradycardia, elevated psa, htn, hyperlipidemia, m.r., basal cell ca s/p excision past surgical history: none social history: lives alone. works for , independent in adls. no tobacco, rare etoh. family history: mother breast cancer, leg cancer, stomach cancer. father cva. brother w/ cabg at 64yrs. physical exam: on admission: vitals:97.2 95 182/91 16 100% gen: a&o, nad heent: no scleral icterus, mucus membranes moist cv: rrr, no m/g/r pulm: clear to auscultation b/l, no w/r/r abd: soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds. right groin with palpable non-reducible large hernia, hernia contents extending into scrotum as well, ttp. dre: normal tone, no gross or occult blood ext: no le edema, le warm and well perfused pertinent results: labs: 05:30am blood wbc-10.0 rbc-3.50* hgb-10.9* hct-33.3* mcv-95 mch-31.3 mchc-32.8 rdw-14.9 plt ct-197 glucose-93 urean-22* creat-0.6 na-140 k-3.7 cl-105 hco3-27 angap-12 05:30am blood calcium-8.5 phos-2.4* mg-2.0 : chest (portable ap): severe bilateral opacities appear to be unchanged with no change in the element of pulmonary edema. cardiomegaly is severe. known pericardial effusion is most likely present. consolidations in the left lower lobe are slightly asymmetric and might represent superimposed abnormality such as infectious process, please correlate clinically. : echo: impression: mildly depressed left ventricular systolic function. moderately dilated right ventricle. focal asymetric hypertrophy of the basal antero-septum. heavily calcified aortic valve. moderate amount of pericardial effusion with no evidence of tamponade physiology. ecg: atrial fibrillation with rapid ventricular response and probable ventricular premature beats. slight intraventricular conduction delay may be incomplete left bundle-branch block. delayed r wave progression may be due to intraventricular conduction delay, left ventricular hypertrophy or possible prior septal myocardial infarction, although is non-diagnostic. st-t wave abnormalities are non-specific but cannot exclude myocardial ischemia. clinical correlation is suggested. since the previous tracing of the rate is faster and lateral lead st-t wave changes appear more prominent. chest (portable ap): findings: as compared to the previous radiograph, there is unchanged massive cardiomegaly. in addition, there is evidence of mild to moderate pulmonary edema. presence of co-existing pneumonia cannot be excluded. no pneumothorax. bilat lower ext veins port: impression: no dvt in the right or left lower extremity. labs: 04:10am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-30* 11:02am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-31* 06:33pm blood ck-mb-4 ctropnt-<0.01 ck(cpk)-33* : ecg: atrial fibrillation. slight intraventricular conduction delay may be incomplete left bundle-branch block. delayed r wave progression with late precordial qrs transition may be due to intraventricular conduction delay, left ventricular hypertrophy or possible prior anterior wall myocardial infarction, although is non-diagnostic. st-t wave abnormalities are non-specific. since the previous tracing of the ventricular rate is faster and the qtc interval is shorter. labs: 05:50pm blood wbc-11.5* rbc-4.17* hgb-13.2* hct-39.1* mcv-94 mch-31.6 mchc-33.7 rdw-15.1 plt ct-172 pt-13.9* ptt-27.1 inr(pt)-1.2* glucose-114* urean-19 creat-0.7 na-135 k-3.4 cl-98 hco3-27 angap-13 glucose-111* lactate-1.8 k-3.6 05:50pm blood ctropnt-<0.01 brief hospital course: the patient presented to the emergency department on due to a non-reducible right groin bulge with associated pain and nausea. additionally, the patient reported left leg erythema which had been present for a few weeks without fevers. given physical findings consistent with incarcerated hernia, the patient was taken to the operating room where he underwent a laparoscopic right inguinal hernia repair with mesh. there were no adverse events in the operating room; please see the operative note for details. pt was extubated, taken to the pacu until stable, then transferred to the for observation. shortly following transfer to the general surgical , the patient was triggered for lethargy, hypoxia and atrial fibrillation with rapid ventricular response. intravenous metoprolol and lasix were administered and the patient was maintained on a non-rebreather with improved oxygenation. he was subsequently transferred to the trauma intensive care unit for further management. neuro: the patient was somnolent post-operatively, which was deemed post-operative baseline by the als interpreter, who reportedely knew patient well. the somnolence resolved by pod1 and he remained alert and oriented throughout the remainder of his hospitalization. the patient is deaf at baseline and was able to communicate via an als interpreter. pain was well controlled with oral tylenol and intermittent intravenous hydromorphone. cv: the patient has baseline rate controlled atrial fibrillation on warfarin. however, as described above, he developed a fib with rvr on pod 0, which responsed to intravenous metoprolol without recurrence. additionally, an ekg obtained upon transfer to the icu revealed st changes; cycled cardiac enzymes were negative. an echocardiogram was obtained and revealed mildly depressed left ventricular systolic function, a moderately dilated right ventricle, focal asymetric hypertrophy of the basal antero-septum, heavily calcified aortic valve and a moderate amount of pericardial effusion with no evidence of tamponade physiology. his home medication regimen was resumed and the patient remained stable from a cardiovascular standpoint for the remainder of his hospitalization; vital signs were routinely monitored. pulmonary: as described above, the patient experienced an episode of hypoxia on pod 0, likely due to pulmonary edema. intravenous lasix was administered with immediate effect. upon arrival to the icu, the patient was placed on bipap, which was weaned to nasal cannula on pod 1. the patient remained stable from a pulmonary standpoint for the remainder of his hospitalization and was weaned off supplemental oxygen entirely on pod 3. good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. gi/gu/fen: the diet was advanced to regular on pod 1, which was well tolerated. patient's intake and output were closely monitored; electrolytes were repleted routinely. id: the patient's fever curves were closely watched for signs of infection, of which there were none. the left lower extremity cellulitis improved on intravenous cefazolin and treatment was transitioned to oral antibiotics on pod 4, which will continue for an additional seven days. skin: a deep tissue injury to the sacrum was identified while in the icu. aggressive skin care was provided via nursing without evidence of further skin breakdown. heme: the patient's blood counts were closely watched for signs of bleeding, of which there were none. prophylaxis: the patient received subcutaneous heparin and dyne boots were used during this stay; he was encouraged to ambulate early and often. additionally, given the events of pod0, a lower extremity ultrasound was obtained and was negative for a dvt. rehab: the patient received physical therapy while hospitalized due to deconditioning, but was deemed unsuitable for discharge to home. short term rehabilitation was recommended to maximize independence and regain conditioning and independence. at the time of discharge, the patient was doing well, afebrile with stable vital signs. the patient was tolerating a regular diet, ambulating with a walker and physical therapy, voiding without assistance, and pain was well controlled. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. he will be discharged to a rehab facility for additional physical therapy. medications on admission: atenolol 25mg daily finasteride 5mg daily simvastatin 20mg daily verapamil er 240mg daily coumadin 1mg daily vitamin d2 1,000 units daily vitamin e 400 units daily discharge medications: 1. verapamil 240 mg tablet extended release sig: one (1) tablet extended release po q24h (every 24 hours). 2. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours). 3. warfarin 2 mg tablet sig: 0.5 tablet po once daily at 4 pm. 4. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five (5) ml po q6h (every 6 hours) as needed for cough. 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold for loose stool. 6. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 8. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 9. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. 10. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). 11. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for gas pain. 12. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every 6 hours) for 7 days. discharge disposition: extended care facility: for the aged - discharge diagnosis: incarcerated right inguinal hernia left lower extremity cellulitis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital for an incarcerated right inguinal hernia and subsequently underwent surgical repair with mesh. additionally, you were noted to have cellulitis on the lower aspect of your left leg, which was treated with antibiotics. during your stay, you also received treatment from a physical therapist, who recommended discharge to a rehabiliation facility to furhter improve your conditioning and independence. you are now preparing for disharge to a rehabiliation facility with the following instructions: please call your doctor or nurse practitioner or return to the emergency department for any of the following: *you experience new chest pain, pressure, squeezing or tightness. *new or worsening cough, shortness of breath, or wheeze. *if you are vomiting and cannot keep down fluids or your medications. *you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *you see blood or dark/black material when you vomit or have a bowel movement. *you experience burning when you urinate, have blood in your urine, or experience a discharge. *your pain in not improving within 8-12 hours or is not gone within 24 hours. call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. *any change in your symptoms, or any new symptoms that concern you. please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon. avoid driving or operating heavy machinery while taking pain medications. incision care: *please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *avoid swimming and baths until your follow-up appointment. *you may shower, and wash surgical incisions with a mild soap and warm water. gently pat the area dry. *if you have staples, they will be removed at your follow-up appointment. *if you have steri-strips, they will fall off on their own. please remove any remaining strips 7-10 days after surgery. followup instructions: please contact the acute care service at to make a follow-up appointment within 2 weeks. please contact your primary care provider to make follow-up appointment within 1 week from discharge from the rehabilitation facility. provider: , dpm phone: date/time: 3:50 provider: , rn,ms,: date/time: 10:00 md, Procedure: Non-invasive mechanical ventilation Other and open repair of indirect inguinal hernia with graft or prosthesis Diagnoses: Other primary cardiomyopathies Mitral valve disorders Unspecified essential hypertension Atrial fibrillation Aortic valve disorders Atrial flutter Other and unspecified hyperlipidemia Personal history of other malignant neoplasm of skin Cellulitis and abscess of leg, except foot Long-term (current) use of insulin Hypoxemia Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Other alteration of consciousness First degree atrioventricular block Acute edema of lung, unspecified Family history of other cardiovascular diseases Elevated prostate specific antigen [PSA] Deaf, nonspeaking, not elsewhere classifiable Inguinal hernia, with obstruction, without mention of gangrene, unilateral or unspecified,recurrent

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abscess major surgical or invasive procedure: ir drainage of peri-j-pouch abscess history of present illness: 34 yo man with h/o uc s/p lap total colectomy with end ileostomy with ileoanal j pouch and diverting colostomy presents with 1 week nausea/vomiting and 3 days with minimal uop. pt was recovering well post-op until 1 week ago when he began to feel nauseated and complained of rectal pain. presented to clinic on , rectum assessed w/o evidence of abscess. pt went home but still felt nauseated and had decreased po intake. over the next 3 days, he only urinated once and noted decrease in his ileostomy output by about 25%. nausea continued through day of presentation when the patient vomited brownish fluid and felt "he could no longer go on like this." he presented initially to , where labs where drawn and a kub was done. labs suggested acute renal failure per patient, and kub showed "air in stomach." pt then transferred to for further workup. pt denies fevers, but has had temperature drops (94.7 f at osh). reports periods of shaking chills of minute duration since his surgery that may coincide with narcotic troughs. denies loose output from ileostomy. past medical history: crohn's disease migraine headaches. disc operation. social history: he does not smoke cigarettes. he drinks alcohol socially. he is married and works as a lawyer for the department of labor. family history: noncontributory physical exam: at discharge: gen: a and o x 3, nad v.s: 98.6, 80, 118/62, 18, 96% ra cv: rrr, no m/r/g resp: lscta, nard abd: soft, nt, nd, +bs, ostomy beefy red ext: c/c/e pertinent results: 04:10am blood wbc-14.1* rbc-3.57* hgb-10.9* hct-33.1* mcv-93 mch-30.6 mchc-33.0 rdw-13.8 plt ct-633* 03:00am blood neuts-82* bands-2 lymphs-8* monos-4 eos-1 baso-0 atyps-1* metas-1* myelos-1* 04:10am blood plt ct-633* 04:10am blood glucose-81 urean-9 creat-1.6* na-139 k-4.4 cl-101 hco3-29 angap-13 04:10am blood alt-52* ast-36 ld(ldh)-121 alkphos-399* totbili-1.0 04:10am blood calcium-9.5 phos-3.4 mg-2.1 10:33am blood caltibc-217* vitb12-1669* folate-11.5 hapto-473* ferritn-420* trf-167* . micro: blood: no growth final abscess: multiple micro on gram stain. mssa pan sensitive and beta streptococci, not group a moderate growth. : jp drain 4+ poly, 2+ gpc pairs/clusters . ct abd: 4x6cm abscess near j pouch brief hospital course: the patient was admitted to the icu for close assessment. a ct scan of his abd/pelvis were ordered and indicated 4x6cm abscess near j pouch, new gallstone without any secondary findings of acute cholecystitis and no findings of bowel obstruction. the patient was made npo with iv hydration and iv medications/abx. a foley and ngt were placed. labs indicated acute renal failure and leukocytosis. . #.severe sepsis: caused by abscess at site of j pouch detected by ct. patient with significant leukocytosis, thrombocytosis. received zosyn in the ed, unsure if he received vancomycin. has been hemodynamically stable. lactate 0.7. abx were continued and surgery requested ir guided drainage of the abcess. . #.acute renal failure. baseline cr. 1.0. presented with cr 9.9. ua without nitrites but with wbc and bacteria. likely prerenal from poor renal perfusion in setting of sepsis. k is 5.1. has put out 4000cc of urine in ed, 1225 out of ostomy. responsive to fluid. abg was obtained and renal was notifed. naprosyn was held and labs were trended (k, po4, cr) . #leukocytosis: likely from abscess at j pouch. . #.anemia: baseline hematocrit ranges between 34-39.0. mcv 94 possibly from gi bleeding in setting of colitis and surgeries, may also be anemia of chronic disease. iron studies, b12, folate, hemolysis labs-guaiac ostomy. . #.thrombocytosis: likely reactive from infection and inflammatory disease, anemia. monitor. . #.transaminitis: with elevated alk phos, consistent with cholestasis, may be due to sepsis. unsure of common bile dcut dilation. will fractionate bilirubin. wait for acute process to resolve before pursuing other etiologies. ct showing stones but no acute cholecystitis. . ppx: -dvt ppx with pneumoboots, sub q heparin -bowel regimen colace, senna -pain management with dilaudid . : -had ir drainage of j-pouch abscess -cr steadily improved over course of the day and leukocytosis and thrombocytosis improving on pm labs -got hydromorphone for pain with good effect -picc postponed as febrile -apap negative, iron studies c/w iron of chronic inflammation, b12 elevated and folate normal -kept uop > 100/hr. . the pt was admited to 5. a picc line was placed and he was started on a regular diet which he tolerated well. his foley was d/c'd and voided without any issues. iv fluids were d/c'd and the pt was continued on iv abx. cultures were obtained from the jp fluid and zosyn was started. . the patient will go home with 6 more days of iv zosyn, with home therapies. he will have a ct and drain study on at 12:30 and follow up with dr. on at 3:00. discharge paperwork was reviewed with patient and all questions were answered. medications on admission: clonazepam 1mg tid, naproxen 500mg q12h, percocet 7.5/325 tab q4-6hrs prn, oxycontin 20mg , atenolol 75mg daily discharge medications: 1. atenolol 25 mg tablet sig: three (3) tablet po daily (daily). 2. clonazepam 1 mg tablet sig: one (1) tablet po 1800 (). 3. clonazepam 1 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. oxycodone 20 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po q12h (every 12 hours). 6. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every four (4) hours as needed for 2 weeks: please do not exceed more than 4000 mg of acetaminophen in 24 hrs. disp:*45 tablet(s)* refills:*0* 7. loperamide 2 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 8. zosyn 4.5 gram recon soln sig: one (1) intravenous every eight (8) hours for 6 days. disp:*6 * refills:*0* 9. picc care picc line care per neht protocol discharge disposition: home with service facility: vna discharge diagnosis: primary: abscess . secondary: pmh: "abnormal heart rhythm", acne, migraine, indeterminate colitis psh: lap total colectomy, open proctectomy with ileo-anal pull through, diverting ileostomy discharge condition: stable. tolerating regular diet. pain well controlled oral medications. discharge instructions: please call your doctor or return to the er for any of the following: * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomiting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomiting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * your pain is not improving within 8-12 hours or not gone within 24 hours. call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *avoid driving or operating heavy machinery while taking pain medications. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. * continue to ambulate several times per day. . drain: -please continue to empty drain twice a day or as needed. -please continue to record daily output from drain. -please continue to assess drain site for signs and sypmtoms of infection. -the visiting nurse you will this. . picc line- -please continue to administer antibiotics as ordered for the next six days every 8 hrs. -please continue with picc care as by rn and vna/infusion company. -please continue to assess for signs and symptoms of infection. followup instructions: scheduled appointments : 1. provider: scan phone: date/time: 1:30 2. provider: , md phone: date/time: 3:00 neither dictated nor ready by me Procedure: Venous catheterization, not elsewhere classified Percutaneous abdominal drainage Diagnoses: Other postoperative infection Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Regional enteritis of unspecified site Peritoneal abscess Ileostomy status Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Leukocytosis, unspecified Essential thrombocythemia

allergies: no known allergies / adverse drug reactions attending: addendum: patient was discharged home with outpatient pt. discharge disposition: home md Procedure: Arteriography of cerebral arteries Endovascular (total) embolization or occlusion of head and neck vessels Endovascular embolization or occlusion of vessel(s) of head or neck using bioactive coils Diagnoses: Esophageal reflux Intracerebral hemorrhage Pulmonary collapse Nausea alone Lack of coordination Anomalies of cerebrovascular system Nystagmus, unspecified

allergies: no known allergies / adverse drug reactions attending: chief complaint: ha, dizziness, progressive lethargy and ataxia major surgical or invasive procedure: diagnostic cerebral angiogram cerebral angiogram with coil embolization of the left middle meningeal artery. cerebral angiogram with oynx embolization to the r occipital dural fistulas history of present illness: dr. is a 32 year old male who initially presented c/o several days of progressive lethargy, nausea, and difficulty ambulating. he also reports slurring of his words while dictating medical notes. he reports of intermittent headaches over several days which he says is bitemporal and squeezing, and not associated with photophobia, numbness, weakness or paresthesia. at the osh a head ct was done which showed diffuse multifocal predominantly cortical abnormalities w/ numerous (too many to count) hyperdensities. a few hyperdense lesions noted in the posterior fossa as well. midline shift of the falx 11.4 mm. there was no transcortical infarction. mri done here on demonstrated vascular malformation that seems to be centered in the right occipital/temporal lobe and cerebellum. are of susceptibility with surr flair signal in right lower pons (7;60 with mild mass effect may represent small hemorrhage. no evidence of ischemia or infection. the neurology team here at is requesting a consult for cerebral angiography from the neurosurgical team. past medical history: gerd social history: works as a hospitalist at . he graduated from medical school and did a med/peds residency at , tx. he is married and his wife is a resident in med/peds at brown. he does not smoke and drinks alcohol rarely. he lives the time in and the other half in . family history: mother - had a throat cancer (possibly squamous) treated surgically and w/ radiation father - had a tachy-arrhythmia sister - healthy / 2 brothers - twins - both healthy physical exam: on admission: vitals: 99.1 90 125/77 18 95% general: awake, cooperative, nad. slightly overweight heent: nc/at, non-icteric, mo oral lesions, no thrush neck: supple, no carotid bruits appreciated. no nuchal rigidity. no thyromegaly, no palpable lymph nodes pulmonary: ctabl cardiac: rrr, no murmurs abdomen: soft, nontender, nondistended extremities: no edema, pulses palpated, no splinter hemorrhages skin: no rashes or lesions noted. neurologic: -mental status: alert, oriented x 3. able to relate history without difficulty. attentive, able to spell world backward without difficulty. language is fluent with intact repetition and comprehension. normal prosody. there were no paraphasic errors. pt. was able to name both high and low frequency objects from stroke card. able to read without difficulty. speech was not dysarthric. able to follow both midline and appendicular commands. pt. was able to register "red, , honesty" objects and recall all 3 at 5 minutes. the pt. had good knowledge of current events. there was no evidence of apraxia or neglect. -cranial nerves: i: olfaction not tested. ii: perrl 5 to 2mm and brisk. vff to confrontation. funduscopic exam revealed no papilledema, exudates, or hemorrhages. iii, iv, vi: eomi without nystagmus. saccades to the right were not smooth. with head thrust test to the left he had peristent nystagmus. v: facial sensation intact to light touch. vii: left nasolabial fold flattening, facial musculature symmetric. viii: hearing intact to high-pitched tuning fork b/l ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: normal bulk, tone throughout. no pronator drift bilaterally. no adventitious movements, such as tremor, noted. no asterixis noted. delt bic tri wre ffl fe io ip quad ham ta edb l 5 5 5 5 5 5 5 5 5 5 5 5 5 5 r 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -sensory: no deficits to light touch, pinprick, cold sensation, vibratory sense. missed a few subtle movements of the left toe on proprioceptive testing. ankle was normal -dtrs: tri pat ach l 2 2 2 2 1 r 2 2 2 2 1 plantar response was flexor bilaterally. -coordination: no intention tremor, no dysdiadochokinesia noted. no dysmetria on fnf or hks bilaterally. no difficulty w/ or mirroring -gait: romberg had a slight sway. wide based stance with short-stepping gait. low confidence and required assistance in order to walk. on discharge: awake, alert, oriented x3, mae with full motor, no nystagmus noted. pertinent results: mri brain 1. extensive arteriovenous malformation/fistula predominantly involving the right cerebral and the right cerebellar hemisphere and the right side of the brainstem structures along with a few prominent venous tributaries in the left temporal and occipital lobes and the left cerebellar hemisphere. assessment of the vascular structures and venous sinuses is limited on the present study. correlate with angiogram- cta/conventional angiogram, to be performed subsequently. 2. small-moderate focus of hemorrhage and surrounding in the right side of the pons, medulla/cerebellar hemisphere with mild mass effect on the fourth ventricle and in the inferior midbrain. minimal displacement of the cerebellar tonsils inferiorly. attention on close followup. mild leftward shift of midline structures is noted. 3. mild paranasal sinus disease as described above cxr the cardiac, mediastinal and hilar contours appear unremarkable. low lung volumes are noted bilaterally with crowding of bronchovascular markings. opacification at the right lung base may represent atelectasis versus aspiration; infectious process cannot be completely excluded in the correct clinical setting but is less likely. opacification in the left lung base likely represents atelectasis. echo the left atrium is elongated. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef 65%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. cxr: findings: supine portable ap view of the chest. there is mild bibasilar linear opacities consistent with atelectasis. the upper lungs are clear. the cardiac, mediastinal, and hilar contours are unremarkable. possible sclerosis of the t9 left rib posteriorly and lateral portion of the left scapula. no pleural effusions. no pneumothorax. impression: 1. mild bibasilar atelectasis. 2. possible sclerosis of the left posterior t9 rib and left scapula, which may be artifactual. can further assess with conventional pa and lateral chest radiographs, and bone detail views, if clinically indicated. ct head w/o contrast 1. no new intracranial hemorrhage identified. assessment for acute parenchymal ischemic changes is limited on the present study. 2. stable minimal mass effect on the fourth ventricle and in the inferior mid brain/pons, with stable minimal displacement of the cerebellar tonsils inferiorly. stable mild leftward shift of midline structures lenis findings: there is normal compressibility, flow, and augmentation of bilateral common femoral, superficial femoral, left popliteal and the calf veins on both sides. compression of the right popliteal vein was limited since the caliber of the vein is small. however, there is normal augmentation and flow. impression: no dvt. brief hospital course: 32 year-old right handed man who presnted to from lgh after a 3 day history of increasing lethargy, intermittent vertigo, nausea and difficulty ambulating who presented to lgh and was transferred after abnormal ct findings. he underwent mri imaging which confirmed an extensive vascular anomoly confimring avm / fistual. he was monitored in the icu and brought down for cerebral angiogram on the 25th. he returned to angiography for coiling/embolization of the avm. this embolization was complex and was treated partially. he was returned to the icu. his headaches were fairly easy to manage. his dizziness and nausea were not so easily controlled. we consulted with the pharmacist to assist in this. patient had desaturations and required nc, question if this is a result of narcotics. a cxr was done which showed atelectasis and he was encouraged to use the is. ct imaging was obtained due to his emesis and dizziness to rule out continued hemorrhage. this was negative. on , nausea and dizziness improved. headaches continued, but were managed with pain medication. he continued to be intact on exam except for upward and lateral gaze nystagmus. on , patient continued to do well, he was transferred to the sdu but remained in icu until a bed was available. he was encouraged to be oob. on , pt was consulted and patient made npo after midnight for preparation of angiogram in am. he returned to angiography on friday the 2nd for attempt at completion of coiling of the avm. he underwent this procedure without event. over the weekend, patient was doing well, he was transferred to the stepdown unit and lenis were ordered to rule out dvts. he was encouraged to ambulated and be oob as much as possible. on , patient remained intact, some mild headache and nausea, but overall better. he has been ambulating with pt and advancing his diet showly. his lenis were negative for dvts and rad oncology was consulted for radiosurgery of the avm. on , it was reported that while working with pt patient was developing desats, and pa and lateral chest x-ray were ordered to better evaluate the reported bibasilar atelectasis and left lower lobe effusion. medicine was consulted and felt this was most likely deconditioning and encourage is. he did better the next day and was discharged home with services on . medications on admission: omeprazole 20mg daily discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. senna 8.6 mg tablet sig: 1-2 tablets po daily (daily). disp:*30 tablet(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*100 tablet(s)* refills:*0* 6. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 7. dimenhydrinate 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea/ dizziness. disp:*30 tablet(s)* refills:*0* 8. promethazine 25 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea. disp:*90 tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: multiple dural av fistulas pons hemorrhage nausea headache dizziness hypoxia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: angiogram with embolization and/or stent placement medications: ?????? continue all other medications you were taking before surgery, unless otherwise directed ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort. what activities you can and cannot do: ?????? when you go home, you may walk and go up and down stairs. ?????? you may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? no heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? no driving until you are no longer taking pain medications ?????? please refrain from heavy lifting > 10 lbs or heavy activity until cleared by the neurosurgeon. what to report to office: ?????? changes in vision (loss of vision, blurring, double vision, half vision) ?????? slurring of speech or difficulty finding correct words to use ?????? severe headache or worsening headache not controlled by pain medication ?????? a sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? trouble swallowing, breathing, or talking ?????? numbness, coldness or pain in lower extremities ?????? temperature greater than 101.5f for 24 hours ?????? new or increased drainage from incision or white, yellow or green drainage from incisions ?????? bleeding from groin puncture site *sudden, severe bleeding or swelling (groin puncture site) lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. if bleeding stops, call our office. if bleeding does not stop, call 911 for transfer to closest emergency roo followup instructions: please follow-up with dr in 4 weeks for a follow-up angiogram. please call to make this appointment. after this angiogram, radiosurgery can be planned. you have been referred to dr at and dr at . their offices will contact you to make these appointments. Procedure: Arteriography of cerebral arteries Endovascular (total) embolization or occlusion of head and neck vessels Endovascular embolization or occlusion of vessel(s) of head or neck using bioactive coils Diagnoses: Esophageal reflux Intracerebral hemorrhage Pulmonary collapse Nausea alone Lack of coordination Anomalies of cerebrovascular system Nystagmus, unspecified

allergies: hydralazine attending: chief complaint: unresponsive according to family major surgical or invasive procedure: bilateral evds l vps placement history of present illness: mr. is a 74-year-old man with a history of hypertension, bph, aortic regurg., recent syncope, presenting to from osh, unresponsive with intraventricular bleed and obstructive hydrocephalus. patient was in with family. found slumped down unresponsive this a.m. son noted normal respiratory pattern and called ems. taken to hospital where ct performed - patient was noted to have intraventricular blood and transferred to . he was actually noted to be breathing well and was not intubated at that time. on arrival, gcs noted to be 6. neurology saw the patient and observed, along with neuroradiology, that the patient had obstructive hydrocephalus with third ventricular bleed. cta was performed and did not reveal aneurysm as a source, thus, dr. suggests possible ruptured colloid cyst, or other periventricular source for blood, without evidence of parenchymal bleed. patient had gastroenteritis recently and had been treated for a uti. patient was on holiday in . head bleed about one year ago after fall. patient had syncopal episode on friday. sister had mentioned that he'd had cool extremities for the last few days. patient's family report no recent change in mental status, difficulty with sensation, no weakness, no speech or language difficulty. past medical history: past fall with intracranial hemorrhage (type unknown), one year ago - hypertension, controlled - recent gastroenteritis and uti - prostatic hypertrophy - aortic regurgitation - appendectomy at 10 years social history: remote smoking 1 ppd 10-12 years, 50 year ago. - alcohol 1 oz month. - no recreation drug use. - construction worker, family business. family history: noncontributory physical exam: 10:31: t 98.3, hr 68, bp 134/64, rr 14, o2s 99% ra (values prior to intubation. bp increased to 160s during exam, including painful stimuli). gen: tanned and slightly overweight man looks stated age. snoring sounds, patient stuporous and only moving to vigorous stimuli. heent: pupils: 3 -> 2 mm bilaterally. neck: supple. lungs: cta bilaterally. cardiac: rrr. sem. no r/g. abd: soft, nt, bs+ extrem: warm and well-perfused. neurologic: mental status: stuporous. gcs 6 (localizing to pain) cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2 mm bilaterally. iii, iv, vi: extraocular movements intact to doll's eye manoeuver. v, vii: some grimace to pain, snout reflex intact. corneal reflexes brisk and normal. viii: not tested. ix, x: not tested. : not tested. xii: not tested. motor: moved both upper limbs to noxious stimlui of nailbed - withdrew. sensation: not tested. reflexes: intact and symmetric biceps, brachioradialus, patella. toes upgoing bilaterally. on discharge: a&ox2 perrl eoms: intact face symmetrical tongue midline motor: throughout incision c/d/i stutures in place pertinent results: cta head w&w/o c & recons 1. intraventricular hemorrhage centered within the third ventricle with interval increase in blood layering within the occipital horns of the lateral ventricles and within the interpeduncular cistern. the blood clot within the third ventricle is somewhat heterogeneous in appearance, although less so when compared to the prior study. an underlying intraventricular mass cannot entirely be excluded, and an mri of the brain may be obtained for further characterization. 2. stable enlargement of the lateral and third ventricles secondary to intraventricular hemorrhage. 3. no evidence of aneurysm formation ct head w/o contrast interval placement of external ventricular drains with tips in lateral ventricles, persistent enlargement of ventricles and stable interventricular hemorrhage. mr head w & w/o contrast 1. redemonstration of the extensive intraventricular hemorrhage as described above, with obstructive hydrocephalus, with mild increase in the ballooning of the septum pellucidum to the left side compared to the prior ct study and mild increase in the size of the ventricles. to correlate with the catheter function and closely followup. 2. while there is no obvious focus of abnormal enhancement, evaluation for lesions within the ventricles is limited due to the pre-existing blood products. ct head w/o contrast decreased blood in lateral and third ventricles, dilated but stable ventricles. cxr:findings: there is some subsegmental atelectasis in the left mid and lower lung but there is no focal infiltrate or effusion. ng tube has been removed. head ct: impression: 1. no significant change in mildly dilated ventricles status post intraventricular hemorrhage with interval decrease in the amount of blood layering within the occipital horns. 2. stable right frontal intraparenchymal hemorrhage. head ct: 1. stable right frontal intraparenchymal hemorrhage. 2. slightly increased ventriculomegaly compared to prior study evident in bilateral lateral and third ventricles : impression: suboptimal image quality. mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function.no valvular pathology or pathologic flow identified ct head: impression: stable right frontal intraparenchymal hemorrhage. slightly decreased ventriculomegaly compared to prior study. : renal us impression: 1. no hydronephrosis or stones. 2. left lower pole renal cyst. 3. normal-appearing bladder brief hospital course: mr was admitted to neurosurgery service, prior to admission he had bilateral evds placed to drain 10-15cc/hr. he was started on ancef to cover the drain. he was intubated in the er. a cta showed no evidence of aneurysm. his sbp was kept 120-140. an mri was ordered which showed no focus of abnormal enhancement. on his first admission day he received 24 hours of tpa to keep the drain open and help decrease the size of the clot. his right sided drain was noted not to be functioning. it was removed on his second hospital day and he was extubated. he was following commands moving the right slightly more than the left but purposeful in all extremities. on , patient's exam declined, no eye opening or commands. patient was also febrile. a repeat head ct was done which was stable, cultures were also sent. patient improved over the day, and cultures were negative. icp was also increase due to febrile event. on , patient remained unchanged. head ct was stable. patient's exam was improved on , but had episodes of tachycardia and htn. po lopressor started. on , patient's evd was lowered to 5 and ngt placed to provide adequate nutrition. repeat head ct shows decrease in 3rd ventricle hemorrhage. patient's exam much improved on . eo spontaneously and he follows commands. he was alert and oriented to self and hospital and purposeful. pt underwent clamping trial of evd on and icp's climbed into the low 30's. drain was reopened and leveled at 10cm above the tragus. pt foley catheter was removed on as purulent drainage was noted from the penis. u/a with c&s sent and ua was negative. blood cx on showed gpc and id team was consulted. id agreed with current treatment of vancomycin and also recommended a tte to evaluate for vegetation. the patient's evd was clamped and trialed for toleration. a repeat ct was obtained after icp's remained <20 x 24 hours but revealed increasing ventricles. pt was noted to be somnolent as well, therefore the evd was unclamped and leveled at 15cm above the tragus. pt was preop'd for vp shunt placement. : npo after midnight for vps placement on . evd clamped at 6 a.m on . : the patient was taken to the or and his left-sided evd was removed. it was replaced with a vps (valve set at 15cm h2o) through the same burr hole. no complications, and a post-op nchct showed vents more decompressed than on and vps well-placed; also stable r-frontal blood from previous/removed evd on the right. arf began (cr 2.0-2.1 7/27 up from 0.9-1.0 at baseline; started once vanc level/trough mid-30s). id c/s said no more vancomycin, as levels of this antibiotic will stay therapeutic for now without additional dosing due to decreased clearance. renal u/s and urine studies (for fena/feurea/eos) were ordered. ivf run at 125ml/h; patient euvolemic on exam. also noted was a rash, which looks like contact dermatitis -- erythematous papules @low back, chest, under bp cuff on left and right upper arms (after bp cuff moved l-->r). afebrile. given benedryl and 0.5mg iv dilaudid for htn/sinus tach. :pt transfered from step down unit to the floor. creatinine remained at 2.1 and his foley remained in place. pt remained on ivf throughout this day. plan was to continue holding vancomycin and running ivf. renal was consulted to aid in further management of his persistently elevated creatinine. renal's recommendations were to discontinue vancomycin which is nephrotoxic and control blood pressure using norvasc. over the weekend, patient's bun and creat were trending down. prednisone was also started. patient pulled foley out and was found to have urinary retention in which another foley was placed. renal's final recommendations were to continue the prednisone at 30mg qd for 3 weeks and then follow up with dr. in weeks. he will be discharged to rehab on to follow up with dr. in 4 weeks with a noncontrast head ct. medications on admission: - lisinopril 10 mg - amlodipine 5 mg - tamsulosin sr 0.4 mg - bactrim ds - florastor (macrobiotic given with abx) discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 3. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 6. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 7. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po daily (daily). 8. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 9. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for itching. 10. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for itchiness. 11. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed) as needed for dry eyes. 12. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 13. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 14. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 15. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). 16. prednisone 20 mg tablet sig: 1.5 tablets po daily (daily) for 3 weeks. 17. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 18. dextrose 50% in water (d50w) syringe sig: one (1) intravenous prn (as needed) as needed for hypoglycemia protocol. discharge disposition: extended care facility: rehab unit at - discharge diagnosis: ivh r iph hydrocephalus acute interstitial nephritis discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, or ibuprofen etc. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion, lethargy or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? new onset of the loss of function, or decrease of function on one whole side of your body. followup instructions: follow-up appointment instructions ?????? your sutures will have to be removed (approximately on )after the time of your procedure. this can be done at the rehab facility. ??????please call ( to schedule an appointment with dr. , to be seen in 4 weeks. ??????you will need a ct scan of the brain without contrast prior to your appointment. this can be scheduled when you call to make your office visit appointment. ?????? you will be contact by nephrology to schedule an appointment in weeks with dr. . if you have any further questions please call (. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Ventricular shunt to abdominal cavity and organs Arterial catheterization Removal of ventricular shunt Closed biopsy of skin and subcutaneous tissue Ventricular shunt to extracranial site NEC Diagnoses: Obstructive hydrocephalus Urinary tract infection, site not specified Unspecified essential hypertension Aortic valve disorders Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Intracerebral hemorrhage Bacteremia Cerebral edema Retention of urine, unspecified Acute glomerulonephritis with other specified pathological lesion in kidney Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Mechanical complication of nervous system device, implant, and graft Contact dermatitis and other eczema, unspecified cause

allergies: plavix attending: chief complaint: gi bleeding due to esophageal ulcers major surgical or invasive procedure: endoscopic gastroduodenography (egd) external beam radiation therapy history of present illness: 89 year-old female with a history of bladder cancer metastatic to liver who presents with melena, hematemesis. the patient was initially evaluated in the emergency room and found to be tachycardic and given iv fluids. the patient was transferred to 11 where the patient triggered for tachycardia to the 130s. an ng lavage was done that showed coffee ground emesis that cleared with 700 cc lavage. shortly after the lavage was finished a clot with bright red blood was suctioned from the ng tube. at that point gi consultation was called who recommended icu transfer, pantoprazole iv drip and serial hematocrit. in the ed the initial bp was 133/60 with hr 120s rr 16 with 02 sat 99% ra. she was given pantoprazole 40 mg iv, zofran 4 mg iv, kayexelate 30 gm, cipro iv and 0.25 ativan. on arrival to the medical floor the patient was afebrile with bp 118-123/60-78, hr 120-130s 100% ra. on evaluation on the floor and on icu transfer the patient had only mild dizziness and lightheadeness. she denies chest pain, abdominal pain. she was also noted with increasing acute renal failure on her stage iii ckd. ros: in reviewing the recent weeks with the son, the patient has had worsening mental status over the last few weeks, increased weakness in the last month. she has intermittent presyncopal episodes that have also been increasing in frequency. she has had persistent lq abdominal pain that is treated with meds listed. the pain has been intermittently controlled. this is her first episode of epigastric chest pain, hematemesis and melena in the last few years. she has had poor po intake in the recent weeks. past medical history: bladder cancer with known lung metastases, currently on radiation therapy for pain control hypothyroidism anemia celiac sprue copd (previous exacerbations requiring steroids) history of ventricular septal defect history of hysterectomy/bso nephroureterectomy in . cva -- d/c with aggrenox ? hx dvt social history: she lives in with her son who moved in with her. she ambulates around her apartment with a walker. she was a housewife and raised 6 children. she smoked for 70-pack-years and quit last year when she developed copd. she does not drink alcohol. family history: non-contributory physical exam: gen: thin cachetic appearing woman in no acute distress. heent: eomi, perrl, sclera anicteric, no epistaxis or rhinorrhea, pale, dry mm, op clear, swelling of right cheek neck: no jvd, no bruits, no cervical lymphadenopathy, trachea midline cor: rrr, no mrg, normal s1 s2, radial pulses +2 pulm: lungs ctab, no w/r/r abd: soft, nt, nd, +bs, no hsm, no masses ext: 2+ edema of le, pitting to knees, no palpable cords neuro: alert, oriented to person, place, and time. cn ii ?????? xii grossly intact. moves all 4 extremities. strength 5/5 in upper and lower extremities. patellar dtr +1. plantar reflex downgoing. no gait disturbance. no cerebellar dysfunction. alert and oriented x (in hospital , , knows dob) skin: no jaundice, cyanosis, or gross dermatitis. no ecchymoses. pertinent results: cardiology report ecg study date of 12:13:56 pm baseline artifact. sinus tachycardia. leftward axis. late r wave progression. mild j point and st segment elevation in the early precordial leads with q waves through to lead v3 may be related to axis but consider anteroseptal myocardial infarction, age undetermined. clinical correlation is suggested. no previous tracing available for comparison. chest (portable ap) study date of 7:15 am impression: 1. diffuse intrathoracic metastatic disease. 2. likely mild volume overload. abdomen u.s. (complete study) study date of 8:14 am impression: 1. extensive infiltrative process in the liver consistent with the history of metastatic bladder cancer. 2. mild central biliary dilatation. 3. lack of visualization of the left kidney. 4. small aortic aneurysm of 23 mm in diameter. ct could be performed, if clinically indicated, for a more thorough staging assessment, and if available, comparison to prior studies could be helpful. bilat lower ext veins study date of 8:14 am impression: 1. residual evidence of old nonocclusive bilateral lower extremity deep venous thrombosis. it is unlikely that any of the findings are acute or even recent. 2. cyst in the right popliteal fossa. 06:40am blood wbc-10.8 rbc-3.07* hgb-10.6* hct-31.4* mcv-102* mch-34.6* mchc-33.9 rdw-17.7* 01:18pm blood wbc-7.3 rbc-3.28* hgb-10.9* hct-33.7* mcv-103* mch-33.3* mchc-32.4 rdw-17.4* 12:05pm blood wbc-11.5* rbc-3.24* hgb-10.9* hct-33.7* mcv-104* mch-33.6* mchc-32.3 rdw-16.7* 05:11am blood neuts-89* bands-1 lymphs-5* monos-5 eos-0 baso-0 atyps-0 metas-0 myelos-0 nrbc-1* 04:24pm blood pt-15.0* ptt-37.2* inr(pt)-1.3* 05:11am blood pt-15.3* ptt-145.1* inr(pt)-1.4* 12:05pm blood pt-15.1* ptt-29.5 inr(pt)-1.3* 06:40am blood glucose-88 urean-56* creat-2.7* na-140 k-4.9 cl-112* hco3-19* angap-14 05:10am blood glucose-95 urean-48* creat-2.4* na-139 k-4.8 cl-109* hco3-19* angap-16 07:10am blood glucose-151* urean-47* creat-2.3* na-143 k-4.9 cl-115* hco3-19* angap-14 05:20am blood glucose-99 urean-49* creat-2.4* na-142 k-4.8 cl-111* hco3-19* angap-17 01:18pm blood glucose-152* urean-42* creat-2.3* na-141 k-4.7 cl-111* hco3-19* angap-16 04:32pm blood glucose-193* urean-40* creat-2.0* na-142 k-4.0 cl-111* hco3-19* angap-16 04:47pm blood glucose-135* urean-38* creat-2.1* na-139 k-4.0 cl-109* hco3-21* angap-13 05:11am blood glucose-124* urean-38* creat-2.0* na-141 k-3.6 cl-111* hco3-22 angap-12 05:11pm blood glucose-221* urean-42* creat-2.2* na-139 k-4.3 cl-107 hco3-20* angap-16 06:33am blood glucose-108* urean-45* creat-2.2* na-140 k-4.8 cl-113* hco3-14.3* angap-18 11:05pm blood glucose-99 urean-49* creat-2.3* na-142 k-5.6* cl-115* hco3-13* angap-20 12:05pm blood glucose-140* urean-51* creat-2.6* na-138 k-5.8* cl-106 hco3-16* angap-22* 11:05pm blood ck(cpk)-310* 12:05pm blood alt-69* ast-110* ld(ldh)-678* ck(cpk)-376* alkphos-492* totbili-0.9 06:33am blood ggt-536* 11:05pm blood ck-mb-19* mb indx-6.1* ctropnt-0.16* 12:05pm blood ctropnt-0.28* 12:05pm blood ck-mb-23* mb indx-6.1* 06:40am blood calcium-7.5* phos-3.4 mg-2.1 06:40am blood calcium-7.5* phos-3.4 mg-2.1 04:47pm blood calcium-7.6* phos-3.7 mg-2.3 12:05pm blood albumin-3.1* calcium-8.6 phos-4.2 mg-1.9 06:33am blood tsh-1.0 06:48am blood type-art temp-37.1 rates-/13 o2 flow-2.5 po2-84* pco2-38 ph-7.38 caltco2-23 base xs--1 intubat-not intuba comment-nasal 04:05am blood glucose-73 na-138 k-5.0 cl-114* calhco3-15* 04:05am blood hgb-11.8* calchct-35 04:05am blood freeca-1.16 01:49pm urine color-yellow appear-cloudy sp -1.015 01:49pm urine blood-lg nitrite-pos protein-30 glucose-neg ketone-tr bilirub-sm urobiln-4* ph-5.0 leuks-mod 01:49pm urine rbc-21-50* wbc->50 bacteri-many yeast-none epi-0-2 renalep-0-2 09:51am urine hours-random urean-580 creat-67 na-50 k-24 cl-26 09:51am urine osmolal-404 1:49 pm urine site: catheter **final report ** urine culture (final ): gram positive rods. >100,000 organisms/ml.. due to loss of viability, unable to identify further chest (portable ap) study date of 4:49 am findings: metastatic lung nodules are again visualized with nodules and diffuse lymphangitic infiltration. there is no new infiltrate. there is likely small left effusion that is increased. chest (portable ap) study date of 5:05 am impression: ap chest compared to and 19: over the past two days, there has been a slight increase in background radiodensity of the lungs. this may be due in part to lower lung volumes, but a small component of mild pulmonary edema is probably present even though heart size is normal and there has been no engorgement of mediastinal or hilar pulmonary vasculature. severe metastatic involvement of both lungs consists of scores of nodules up to 2 cm in size and diffuse lymphangitic infiltration. small bilateral pleural effusion is probably present. there is no pneumothorax. brief hospital course: 1. gastrointestinal bleeding due to esophageal ulcers: she underwent endoscopy, which showed a superficial linear ulceration in the distal 3rd of esophagus. no evidence of bleeding during the egd. at the ge junction, there was more extensive ulceration with a single 1 cm shelf-like lesion. there was a 5 mm red spot without a vissible vessel and no active bleeding. in the esophagus. there was a large greyish material in fundus. the esophageal ulcerations could be secondary to the prednisone use. otherwise normal egd to second part of the duodenum. she was started on protonix, and had no further bleeding. her hematocrit remained stable throughout. she was started on a slow prednisone taper, as the reason for steroids is unclear. would be wary of hypotension, and would suspect adrenal insufficiency if it develops and would give stress dose steroids. 2. history of deep vein thrombosis, possible pulmonary embolism: she was persistently tachycardic, and had lower extremity ultrasounds that showed evidence of an old dvt. in the icu, she was started on heparin and transitioned to low dose lovenox. due to risk of bleeding, with recent gi bleed and severe thrombocytopenia, lovenox was discontinued except for prophylaxis dose subcutaneous heparin. 3. non st elevation myocardial infarction: she had evidence of elevated troponin and ck, in the setting of her upper gi bleed. she did complain of chest pain which resolved with pain control. further treatment was deferred given her overall clinical situation. 4. bladder cancer metastatic to liver, lung: she was recently diagnosed with a new bladder tumor, after having longstanding bladder cancer. per discussions with her oncologist, and work up here, this was found to be metastatic to liver and lung. she continued xrt while here in the hospital for palliation of her bladder tumor, and will continue this as long as she is able to tolerate it. she was followed by palliative care, and was started on standing oxycodone for pain control, with good effect. after she completes xrt, she will likely transition to home hospice. 5. acute renal failure on chronic kidney disease stage iii, hyperkalemia: she has baseline stage iii chronic kidney disease, with worsening here in the setting of the bleed. her abdominal ultrasound showed no kidney on the left, consistent with her prior nephrectomy, and no hydronephrosis on the right. she was hydrated, and continued to have a creatinine of over 2 which is her baseline. 6. copd: patient without signs of current exacerbation. normal 02 sat. will continue outpatient meds with albuterol prn 7. history of stroke: aspirin is currently on hold, and may be restarted post discharge for cva prophylaxis. 8. urinary tract infection: her initial ua showed many white cells, but culture showed gram positive rods. she was treated with ciprofloxacin for 5 days, although the culture was never speciated due to technical reasons. # fen: ivf, check lytes , npo for now, but need to address nutritional status after able to eat. # disposition: to nursing facility, with likely transition to home hospice. patient is dnr/dni medications on admission: aspirin 81 mg daily wellbutrin 150 once a day megestrol 3 tabs once a day tums a thousand mg a day iron flex prednisone 15mg a day (copd?) diovan 160 mg qdaily spiriva 1 puff a day jinseng l-thyroxine 130 mcg a day ? discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: one (1) puff inhalation q4h (every 4 hours) as needed for dyspnea. 2. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 3. menthol-cetylpyridinium 3 mg lozenge sig: one (1) lozenge mucous membrane prn (as needed). 4. bupropion 150 mg tablet sustained release sig: one (1) tablet sustained release po qam (once a day (in the morning)). 5. oxycodone 5 mg tablet sig: 0.5 to 1 tablet po q4h (every 4 hours) as needed. 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day for 30 days. 7. prednisone 10 mg tablet sig: one (1) tablet po daily (daily) for 7 days: then transition to 5mg daily x 7 days, then off. 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. senna 8.6 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 11. oxycodone 5 mg tablet sig: 0.5 tablet po tid (3 times a day). 12. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 13. acetaminophen 325 mg tablet sig: two (2) tablet po tid (3 times a day) as needed for fever or pain. 14. glycolax 100 % powder sig: one (1) packet po once a day as needed for constipation. 15. nystatin 100,000 unit/ml suspension sig: ten (10) ml po qid (4 times a day): for thrush. discharge disposition: extended care facility: of discharge diagnosis: gastrointestinal bleed esophageal ulcers metastatic bladder cancer with mets to liver acute renal failure chronic kidney disease stage iii urinary tract infection thrombocytopenia discharge condition: stable discharge instructions: you were admitted with vomiting blood from an esophageal ulcer. you were admitted to the icu and stabilized, and then transferred to the floor. you did not require any blood transfusions. you were also found to have old blood clots in your legs, and worsening kidney failure. return to the emergency room if you develop shortness of breath, chest pain, severe abdominal pain, inability to urinate, black tarry stools, vomitting blood, vomitting coffee ground material. make sure to drink plenty of fluids followup instructions: follow up with drs. and , c. as needed. Procedure: Other endoscopy of small intestine Other radiotherapeutic procedure Diagnoses: Anemia, unspecified Malignant neoplasm of liver, secondary Urinary tract infection, site not specified Long-term (current) use of steroids Adrenal cortical steroids causing adverse effects in therapeutic use Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Personal history of tobacco use Chronic kidney disease, Stage III (moderate) Pressure ulcer, lower back Celiac disease Personal history of venous thrombosis and embolism Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Secondary malignant neoplasm of lung Abdominal aneurysm without mention of rupture Tachycardia, unspecified Other pulmonary embolism and infarction Personal history of irradiation, presenting hazards to health Acquired absence of both cervix and uterus Neoplasm related pain (acute) (chronic) Pressure ulcer, stage II Ulcer of esophagus with bleeding Malignant neoplasm of other specified sites of bladder Lipoma of intra-abdominal organs

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: palpitations major surgical or invasive procedure: ivc filter history of present illness: mr. is a 57 year old male with a past medical history significant for cholangiocarcinoma (unresectable and s/p chemo w/ gemcitabine and cisplatin), hypertension, and recent gib (ischemic v. infectious colitis) who presents with svt to 180s from clinic. . the patient was in his usual state of health, with chronic abdominal pain, and was seen today in clinic by dr. for a third round of chemotherapy. while sitting in the chair in the waiting room, he felt his heart beat "fast." there he was found to have svt to 180s and was sent to the ed. his bp at the time was 102/60. he denies any chest pain, cough, shortness of breath, lightheadedness, nausea, or vomiting. at baseline, he ambulates independently and without dyspnea on exertion. of note, he also denies noticing any lower extremity edema, fevers, chills, diarrhea, constipation, melena or brbpr. he endorses ~30lb weight loss over the course of 3 months. . in the ed, initial vs were: hr in 170s. vagal maneuver was attempted and failed. he was given adenosine 6mg and converted to sinus tachycardia. he remained persistantly tachycardic to 120s and so a cta was done that showed bilateral subsegmental pes. his labs were notable for negative ce, leukocytosis of 12.4, hgb/hct 9.9/29.9. on exam he was guaiac neg. heme/onc was consulted and recommended heparin gtt without bolus. vs on transfer were: 109, 124/96, 25, 100% on 2l. . notably, he was recently hospitalized () for brbpr s/p colonoscopy significant for segmental colitis with biopsies suggestive of ischemic vs infectious colitis. on that admission, he developed a fever 2 days and ct scan showed likely colitis; he was treated with cipro, flagyl, and asacol (which was discontinued recently by dr. . he did not receive any blood products at that time, and his hct on discharge was 27. . review of sytems: (+) per hpi (-) denies fever, chills, night sweats. denies headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest pain or tightness. denied nausea, vomiting, diarrhea, constipation. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: #. cholangiocarcinoma: - presented with abdominal pain and jaundice. percutaneous transhepatic cholangiography was performed on w/ malignant cells on brushing. - he was taken to operating , found to have extensive common hepatic involvement and extension into the liver duodenum as well as head of the pancreas and was unresectable. - he is s/p bilateral metallic biliary stent placement on (removed on ). - started palliative chemotherapy with gemcitobine and cisplatin (cycle 1 , cycle ends ) #. hypertension #. gi bleed: s/p sigmoidoscopy w/ ulcerated friable colon biopsy c/w ischemic type colitis. social history: he works in a restaurant. he moved to the usa 20 years ago. he is married with 5 kids, the oldest 33 years old. he speaks minimal english. wife speaks no english. children speak english well. he smoked 1 pack for many years but quit 20 years ago. he denies alcohol or illicit drug use. family history: no history of gi cancer. physical exam: vitals: bp 133/88 hr 104 rr 20 o2 100 2l o2 general: alert, oriented, laying in bed, conversant and following commands, in no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate, normal s1 + s2, no murmurs, rubs, gallops abdomen: surgical scar appreciated along ruq, abdomen mildly tense and tender to palpation at mid-epigastric area, no guarding/rebound tenderness and normal bowel sounds ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, neg pain on dorsiflexion skin: no jaundice neuro: a&ox3, tongue midline, perrl, eomi, scm/trap, neg babinski, gait deferred pertinent results: cta 1. bilateral segmental and subsegmental pulmonary embolism without evidence of right heart strain. 2. nodular mural atheroma in the descending thoracic aorta with configuration worrisome for future embolization. 3. hypoenhancing infiltrative hepatic mass extending into the porta hepatis and left hepatic lobe compatible with known cholangiocarcinoma. associated biliary obstruction again noted. 4. increasing ascites with persistent multiple nodular peritoneal implants. 5. persistent pancreatic ductal dilation. echo the left atrium is normal in size. there is a 2x2 cm echodensity posterior to the left atrium (cine loop 52), probably in the posterior mediastinum. it is outside the heart and anatomically could be associated with the esophagus or the surrounding structures. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is borderline pulmonary artery systolic hypertension. very small pericardial effusion. there is an anterior space which most likely represents a fat pad. there are no echocardiographic signs of tamponade. no right atrial or right ventricular diastolic collapse is seen. impression: very small pericardial effusion without signs of tamponade. normal global and regional biventricular systolic function. no pulmonary hypertension or clinically-significant valvular disease seen. probable extracardiac posterior mediastinal mass. compared with the prior study (images reviewed) of , cardiac findings are similar. the extracardiac mass was not appreciated on the prior study. findings discussed with dr. at 1650 hours on the day of the study. ultrasound le: occlusive dvt in one of the two right posterior tibial veins. r v patent. no other thrombus noted. admission labs: 02:25pm blood wbc-12.4*# rbc-3.25* hgb-9.9* hct-29.9* mcv-92 mch-30.5 mchc-33.1 rdw-16.5* plt ct-510* 02:25pm blood neuts-79.1* lymphs-14.9* monos-5.0 eos-0.4 baso-0.6 02:25pm blood pt-12.5 ptt-21.7* inr(pt)-1.1 02:25pm blood glucose-115* urean-10 creat-0.7 na-135 k-3.5 cl-101 hco3-28 angap-10 02:25pm blood ck(cpk)-50 05:56am blood alt-19 ast-32 ld(ldh)-219 alkphos-117 totbili-0.6 02:25pm blood calcium-8.9 phos-3.0 mg-2.3 discharge labs: 07:15am blood wbc-9.3 rbc-2.88* hgb-9.3* hct-27.1* mcv-94 mch-32.2* mchc-34.2 rdw-16.6* plt ct-282 06:45am blood neuts-69.8 lymphs-22.8 monos-5.6 eos-1.3 baso-0.4 06:10am blood pt-12.0 ptt-21.4* inr(pt)-1.0 07:15am blood glucose-92 urean-7 creat-0.5 na-136 k-3.7 cl-106 hco3-22 angap-12 06:10am blood alt-17 ast-23 alkphos-111 totbili-0.8 07:15am blood albumin-3.7 calcium-8.5 phos-3.5 mg-2.2 brief hospital course: 57m with cholangiocarcinoma (unresectable and s/p chemo w/ gemcitabine and cisplatin), hypertension, and recent gib (ischemic v. infectious colitis) who presents with svt to 180s from clinic and was found to have bilateral subsegmental pes and right le dvt. initially admitted to the icu for monitoring and then transferred to the oncology service. . # pulmonary embolism / dvt: patient was started on heparin gtt for bilateral subsegmental pe noted on cta and dvt on leni then switched to lovenox sq. she had ivc filter placed today due to hx of gi bleed and the risk of bleeding with anticoagulation. she tolerated the procedure well and had no signs of bleeding. all stools were guaiac negative. her hct was stable at 27 on the day of discharge. . #. history of brbpr / ischemic colitis: sigmoidoscopy sig for biopsies consistent with ischemic colitis though patient was also treated for possible infectious colitis. he was recently seen by his outpatient gi doctor, dr. , who stopped his asacol and has sent off stool cx for e. coli and c diff which were negative. as noted above she was guaiac negative and hct stayed stable. . . #. svt: likely avnrt/avrt with termination by adenosine. in the had a brief episodes of svt, but is currently in sinus. has had episodes of avnrt/avrt in the past controlled by metoprolol/amiodarone though these have been held since last admission, given concern for bleed. metoprolol was restarted on at higher dose at 25mg tid and was started on diltiazen 30mg qid (will change to long acting prior to discharge) for rate control. pt had short runs, only a few seconds of sinus tachycardia, asymptomatic. she also had aggressive electrolytes control. pe management as outlined above. . #. metastatic cholangiocarcinoma: preliminary read is concerning for progression of metastatic disease, increase size of hepatic mass, and worsening ascites. prior ct scan notable for sclerotic lesion in sacrum. prior head ct w/ multiple subcentimeter low density regions (likely small vessel disease) and no evidence of obvious mets. followed by dr. as outpatient and is currently undergoing palliative chemotherapy. pt also has increase in abdominal girth and fluid shift on exam consistant with ascitis. she had therapeutic tap with 1 l removed. she was continued on home meds including megace, pain management with dilaudid prn, antiemetics with compazine/zofran and ativan prn. . # fen: regular diet tolerating well, replete electrolytes prn. . # ppx: pain control with dilaudid prn, bowel regimen, dvt ppx lovenox . # comm: with patient # code: full # dispo: pending above medications on admission: docusate sodium 100 hydromorphone 2 mg q4hr prn msir 15 mg q12 prochlorperazine maleate 10 mg every 4-6 hours prn lorazepam 1 mg every 6-8 hours prn zofran odt 8 mg tablet, rapid dissolve every 6-8 hours as needed for nausea. megestrol 400 mg/10 ml (40 mg/ml) suspension sig: once a day. sennosides 8.6 mg discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. 3. lorazepam 1 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea, anxiety. 4. ondansetron 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed for nausea. 5. megestrol 40 mg tablet sig: one (1) tablet po bid (2 times a day). 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 7. metoprolol succinate 50 mg tablet sustained release 24 hr sig: 1.5 tablet sustained release 24 hrs po once a day. disp:*45 tablet sustained release 24 hr(s)* refills:*0* 8. diltiazem hcl 120 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). disp:*30 capsule, sustained release(s)* refills:*0* 9. morphine 15 mg tablet sustained release sig: one (1) tablet sustained release po twice a day. 10. dilaudid 2 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. 11. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*30 capsule, delayed release(e.c.)(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: cholangiocarcinoma bilateral subsegmental pe dvt avnrt/avrt discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: you were admitted to for a fast heart rate and you were found to have a pulmonary embolism and blood clot in your right leg. you were initially treated with anticoagulation (blood thining medication) and medication to decrease your heart rate. you had a filter placed in your vein to hopefully prevent clots from moving to your lungs. you did well after your procedure. you were also very uncomfortable due to fluid in your abdomen. you had fluid removed from your abdomen and you are feeling better. you also had episodes of increase heart rate and you were started on medication to lower your heart rate. we added the following medications to your regimen: -started you on metoprolol xl 75mg once daily -diltiazem 120mg orally once daily -omeprazole 20mg daily we have not made any changes to your other medications. you will need to follow-up tomorrow with oncology as listed belw and with cardiology for your fast heart rate. followup instructions: cardiology: you have an appointment with dr. on at 11:00 am on building , cardiology phone # oncology: you have an appointment with dr. tomorrow at 1:00pm on ( Procedure: Interruption of the vena cava Diagnoses: Other specified cardiac dysrhythmias Other pulmonary embolism and infarction Malignant neoplasm of intrahepatic bile ducts Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity

allergies: aspirin attending: addendum: the patient will not be started on aspirin on (he is allergic to it), but plavix 75 qd. discharge disposition: extended care facility: nursing & rehabilitation center - md Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Laryngoscopy and other tracheoscopy Diagnoses: Thrombocytopenia, unspecified Abnormal coagulation profile Anemia, unspecified Unspecified essential hypertension Atrial fibrillation Aortocoronary bypass status Depressive disorder, not elsewhere classified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Intracerebral hemorrhage Hypopotassemia Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Disorders of phosphorus metabolism Right bundle branch block Long-term (current) use of anticoagulants Epilepsy, unspecified, without mention of intractable epilepsy Heart valve replaced by transplant Hemiplegia, unspecified, affecting unspecified side Cardiomegaly Edema of larynx Dysphagia, unspecified Other facial nerve disorders

allergies: aspirin attending: addendum: this addendum pertains the hospital course section. brief hospital course: we will not restart your aspirin (81 mg in the morning) because you are allergic to it. you will start taking plavix 75 qd on . discharge disposition: extended care facility: nursing & rehabilitation center - md Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Laryngoscopy and other tracheoscopy Diagnoses: Thrombocytopenia, unspecified Abnormal coagulation profile Anemia, unspecified Unspecified essential hypertension Atrial fibrillation Aortocoronary bypass status Depressive disorder, not elsewhere classified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Intracerebral hemorrhage Hypopotassemia Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Disorders of phosphorus metabolism Right bundle branch block Long-term (current) use of anticoagulants Epilepsy, unspecified, without mention of intractable epilepsy Heart valve replaced by transplant Hemiplegia, unspecified, affecting unspecified side Cardiomegaly Edema of larynx Dysphagia, unspecified Other facial nerve disorders

allergies: aspirin attending: addendum: this addendum pertains the results section. pertinent results: ct cns w/o contrast: there is an approximately 2.6 x 2.5 cm parenchymal hematoma extending from the left putamen to the left thalamus, with surrounding edema, unchanged since the previous study. blood from the frontal of the left lateral ventricle and the foramen of has migrated into the posterior third ventricle. blood in the occipital horns of both lateral ventricles is unchanged. there is unchanged mild effacement of the frontal of the left lateral ventricle. the inferior septum pellucidum and the upper third ventricle are minimally shifted to the right. periventricular white matter hypodensities are present likely the sequela of chronic microvascular change. there is prominence of ventricles and sulci consistent with moderate cerebral atrophy, as well as ex vacuo dilatation of the right occipital related to right occipital encephalomalacia. there is near complete opacification of the ethmoid air cells. there is mild mucosal thickening in the maxillary sinuses and sphenoid sinuses. calcifications are noted in the vertebral and carotid arteries. impression: 1. unchanged parenchymal hematoma involving the left putamen and thalamus. 2. redistribution of intraventricular blood. the left foramen of is no longer occluded. discharge disposition: extended care facility: nursing & rehabilitation center - md Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Laryngoscopy and other tracheoscopy Diagnoses: Thrombocytopenia, unspecified Abnormal coagulation profile Anemia, unspecified Unspecified essential hypertension Atrial fibrillation Aortocoronary bypass status Depressive disorder, not elsewhere classified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Intracerebral hemorrhage Hypopotassemia Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Disorders of phosphorus metabolism Right bundle branch block Long-term (current) use of anticoagulants Epilepsy, unspecified, without mention of intractable epilepsy Heart valve replaced by transplant Hemiplegia, unspecified, affecting unspecified side Cardiomegaly Edema of larynx Dysphagia, unspecified Other facial nerve disorders

allergies: aspirin attending: addendum: we will not restart your aspirin (81 mg in the morning) because you are allergic to it. you will start taking plavix 75 qd on . discharge disposition: extended care facility: nursing & rehabilitation center - md Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Laryngoscopy and other tracheoscopy Diagnoses: Thrombocytopenia, unspecified Abnormal coagulation profile Anemia, unspecified Unspecified essential hypertension Atrial fibrillation Aortocoronary bypass status Depressive disorder, not elsewhere classified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Intracerebral hemorrhage Hypopotassemia Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Disorders of phosphorus metabolism Right bundle branch block Long-term (current) use of anticoagulants Epilepsy, unspecified, without mention of intractable epilepsy Heart valve replaced by transplant Hemiplegia, unspecified, affecting unspecified side Cardiomegaly Edema of larynx Dysphagia, unspecified Other facial nerve disorders

allergies: aspirin attending: chief complaint: intracranial hemorrhage transferred for osh major surgical or invasive procedure: peg tube. history of present illness: 81 year-old man with a history of atrial fibrillation and aortic valve replacement on warfarin, stroke in , seizure disorder (two generalized tonic-clonic seizures in life, last in ), who presents as a transfer from hospital for evaluation of a left basal ganglionic hemorrhage. the patient was in his usual state of health until this morning, when his wife noted that he fell forward and to the right while bending over at the edge of the bed to put his socks on. she did not witness any head trauma, but cannot exclude the possibility either. she states that he was weakly walking thereafter, and she felt that she had to accompany him as he walked downstairs. in the kitchen, he urinated on the floor, though he did not seem to realize that this had occurred. concerned, his wife drove him to hospital for further evaluation and management. at , his laboratory evaluation was notable for a platelet count of 147 and an inr of 1.96. urinalysis was negative and ekg revealed sinus bradycardia, rbbb, and left ventricular hypertrophy, all of which were apparently noted on prior ekg. cxr showed no acute abnormalities. however, non-contrast ct of the head revealed a left basal ganglionic hemorrhage with 4 mm of shift and intraventricular spread. the patient was given 10 mg vitamin k (5 mg iv and 5 mg im), 2 units of ffp, 5 mg norvasc, 5 mg of lopressor x 2, and a 1 gram load of dilantin. he was transferred to for further evaluation; his wife noted that he has become more somnolent and dysarthric since arrival. review of systems: he denies headache, fevers, nausea, vomiting, chest pain, dyspnea, focal weakness, numbness, and tingling. his wife notes that he has been declining since the year began, and that there is occasional evidence of mild confusion (she cannot cite specific evidence, and only states that he is "not with the program" at times. past medical history: -aortic valve replacement and reported atrial fibrillation on warfarin -stroke in , presented with left arm numbness, no residual deficits according to wife -seizure disorder: had two seizures in life. the first occurred while he was an infant and the second was a generalized convulsive seizure in in the setting of paxil use and alcohol consumption. he remained seizure free for 2 years and dilantin was discontinued without further recurrence in . -coronary artery disease s/p cabg in -multiple abdominal aortic aneurysms s/p repair in -hospitalized with urinary tract infection in -orthostatic hypotension -bradycardia (baseline heart rate ~50 bpm according to his wife) -depression -remote spinal surgery nearly 45 years ago -dyslipidemia -bph social history: he is retired () from a clerical job with the state. he had a long history of tobacco use, but quit in . no reported alcohol or drug use. family history: a granddaughter and cousin have seizures, otherwise no known neurologic history physical exam: vitals: t 97.7 f bp 142/55 p 47-52 rr 16 sao2 97 4lnc general: elderly man, appears restless in bed heent: nc/at, sclerae anicteric, mmm, no exudates in oropharynx neck: spondylotic, no nuchal rigidity, no bruits lungs: poor effort with decreased breath sounds cv: bradycardic, regular rhythm, systolic murmur noted abdomen: softly distended, non-tender, bowel sounds present ext: warm, no edema, pedal pulses appreciated skin: no rashes neurologic examination: mental status: somnolent, but arousable and opens eye to calling his name (""), tends to keep eyes closed. he is oriented to person only and inattentive. his speech is hypophonic and dysarthric, difficult to understand. many of his answers are not appropriate to the question posed. he appears to pay less attention to the right side of space, though it is difficult to ascertain whether this represents neglect given somnolence. cranial nerves: fundoscopy was technically limited; blinks to threat bilaterally. pupils equally round and reactive to light, 3 to 2 mm bilaterally. extraocular movements intact, to left and right on horizontal gaze, but limited on vertical gaze. no nystagmus. he reports facial sensation intact to light touch bilaterally. right upper motor neuron pattern facial weakness is noted. hearing: turns to examiner on calling his name. palate elevates midline. tongue protrudes midline, no fasciculations. would not comply to test cn trapezius or scm strength. sensorimotor: normal bulk throughout with evidence of paratonia bilaterally. right pronator drift. no tremor. d t b we fif ip q h ta edb right 4 4 5 4 4 5 4 5 4 5 5 5 5 left 5 5 5 5 5 5 5 5 5 5 5 5 5 he withdraws to noxious less briskly in the right arm and leg than on the left side. reflexes: did not relax appropriately for adequate assessment, though right toe upgoing and left toe downgoing. coordination: unable to follow commands to perform fnf or hks. gait: deferred, given that the patient was taken for urgent head imaging. pertinent results: 06:50pm wbc-8.6 rbc-4.29* hgb-13.4* hct-38.1* mcv-89 mch-31.1 mchc-35.0 rdw-14.6 06:50pm neuts-73.8* lymphs-17.7* monos-5.0 eos-2.8 basos-0.7 06:50pm pt-18.2* ptt-30.0 inr(pt)-1.7* 06:50pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 06:50pm osmolal-288 06:50pm albumin-4.4 calcium-8.4 phosphate-2.2* magnesium-2.0 06:50pm alt(sgpt)-14 ast(sgot)-20 ld(ldh)-235 ck(cpk)-64 alk phos-78 tot bili-0.6 06:50pm ck-mb-notdone ctropnt-<0.01 06:50pm glucose-93 urea n-14 creat-0.9 sodium-138 potassium-3.4 chloride-102 total co2-25 anion gap-14 09:55pm pt-15.1* ptt-28.4 inr(pt)-1.3* 12:07am blood ck-mb-4 ctropnt-<0.01 06:50pm blood ck-mb-notdone ctropnt-<0.01 brief hospital course: 81 year-old man with a history of atrial fibrillation and aortic valve replacement on warfarin, stroke in , seizure disorder (two generalized tonic-clonic seizures in life, last in ), who presents with left basal ganglionic hemorrhage. he was admitted to the icu overnight for observation. his exam and vital signs remained stable. repeat head ct the following am showed movement of blood from the foramen to the 3rd ventricle with no increased blood. plan is for mri with and without contrast to evaluate for possibility of an underlying mass and mra head and neck to exclude vascular malformation. this can be done when he's better able to cooperate and hold still. neurosurgery consulted in the ed and will follow. routine laboratory evaluations, including cardiac enzymes, lfts, toxicologies, and urine studies were wnl. all anti-coagulant and anti-platelet therapy were held. subq heparin was started 48hr after his intracerebral hemorrhage. goal systolic blood pressure 120-160 was maintained without intervention after nicardipine drip for 2 hours overnight. code is dnr/dni. he received a peg on 06 17 09 without complications. his anticoagulation will be held given his bleed in the brain. will resume antiplatelets (aspirin 81 qd) on . please, give jevity 1.2 tonight and change to fiber-source hn 15 ml/hr; advance rate by 10 ml q4h goal rate: 65 ml/hr tomorrow. medications on admission: -warfarin: 5 mg on mwthf, 2.5 mg on sutuessa. inr on was 1.6, on was 2.2, and on was also 2.2. he forgot to take his warfarin dose yesterday. -zocor 40 mg qhs -metoprolol 50 mg -finsateride 5 mg daily -celexa 60 mg daily (increased from 40 mg on ) -alendronate 70 mg q monday -multivitamin -vitamin d discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po hs (at bedtime) as needed for constipation. 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 3. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for antifungal. 4. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 6. aspirin 81 mg tablet sig: one (1) tablet po once a day: start on . 7. celexa 40 mg tablet sig: one (1) tablet po once a day. 8. alendronate 70 mg tablet sig: one (1) tablet po once a week: on mondays. 9. vitamin d 1,000 unit capsule sig: one (1) capsule po once a day. discharge disposition: extended care facility: nursing & rehabilitation center - discharge diagnosis: left basal ganglia bleed. discharge condition: mr. examination is relevant for his dysarthria and aphasia. he has a right hemiparesis and facial droop. there is no field cuts or any other abnormalitites at discharge. discharge instructions: you have had a bleed in the brain. we needed to stop you coumadin for this reason. given the fact that you have paroximal atrial fibrillation, you are at a high risk to have a stroke. however, we do not recommend to restart your coumadin because your risk of rebleeding would be high. we will restart your aspirin (81 mg in the morning) in 1 week from now () followup instructions: provider: , .d. phone: date/time: 3:00 Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Laryngoscopy and other tracheoscopy Diagnoses: Thrombocytopenia, unspecified Abnormal coagulation profile Anemia, unspecified Unspecified essential hypertension Atrial fibrillation Aortocoronary bypass status Depressive disorder, not elsewhere classified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Intracerebral hemorrhage Hypopotassemia Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Disorders of phosphorus metabolism Right bundle branch block Long-term (current) use of anticoagulants Epilepsy, unspecified, without mention of intractable epilepsy Heart valve replaced by transplant Hemiplegia, unspecified, affecting unspecified side Cardiomegaly Edema of larynx Dysphagia, unspecified Other facial nerve disorders

allergies: penicillins / iv contrast / fantap attending: chief complaint: ulcerative colitis major surgical or invasive procedure: open total abdominal colectomy with end ileostomy. history of present illness: patient is a 41 yo f with h/o ulcerative colitis, le fracture, dvt/pe on warfarin, anxiety/bipolar disorder, with ongoing uc flare. patient was seen yesterday by her pcp. complains of continued diarrhea- having up to 17 liquid brown stools with occasional blood/mucus. she has been having urgency and nighttime symptoms. her nighttime stools are often associated with bloody bms. she had a recent colonoscopy on which showed colitis and she was given prednisone 60 mg po daily. despite treatment, still with 17-20 bm's per day while on pred 60 mg/day. however, she states she is only taking the mesalamine rectal suppository 'as tolerated' and is not taking it every day. she reports chills but no fevers. she denies black stools . . review of systems: positive: chills, nausea, sob yesterday while at pcp's office, cough productive of green sputum negative: vomiting, change urinary habits, cp, orthopnea. past medical history: -bipolar disorder -anxiety -ptsd -sleep onset insomnia -history of alcohol abuse -history of tobacco addiction. -vitamin d deficiency -ulcerative colitis -- diagnosed in , shortly after patient stopped a long history of smoking -l ankle orif w/ dr. - chronic bronchitis followed by dr. - cellulitis: in - pe/dvt on warfarin social history: she currently lives by herself with her 2 cats. she has vna who come twice a week. she quit smoking 11 months ago. she has a 50 pack-year history of smoking, having smoked 2-3 packs per day from the age of 22 to 39, and 1 pack per day starting at the age of 15. sober from alcohol and illicit drugs. family history: per omr: mother is alive and well, 78 years old, has diabetes. father has had prostate cancer, copd and has bowel issues. she has a brother who is alive and well, but has had some type of acute immune disorder, recently diagnosed, details unknown. physical exam: admission: vs: t 97.9, p 90, bp 138/88, rr: 20, o2 97% on ra gen: morbidly obese female seen in bed, labile affect, cries intermittently in the interview otherwise nad, aaox3 heent: mmm, no lesions neck: supple. unable to appreciate jvp. cv: distant heart sounds, rrr. normal s1, s2. no murmur, rubs, or gallops noted. chest: respiration unlabored, no accessory muscle use. ctab. no wheezes or rhonchi. abd: hypoactive bowel sounds. obese, soft, mild diffuse ttp, nd, no rebound/ guarding rectal: tender, mild erythema, guaic positive ext: lle- 2+ edema to knee, evidence of lymphadema, rle- no edema, 2+ dp/pt/ radial pulses bilaterally neuro/psych: cns ii-xii grossly intact. moving all extremities. gait wnl. discharge: general: patient appears well, ambulating with walker, ileostomy output stable at 1870, immodium being tapered, pain controled on oral regimen. mother by this author prior to discharge. vs: 98.1, 102bom, 148/78, 20, 98% ra, bs: 113-126 neuro: alert & orientedx3, flat affect (baseline) cv: rrr lungs: slightly deminished at bases b/l, otherwise clear. abd: obese, soft, appropriate post-operative tenderness, ileostomy pink and intact, midline surgical wound closed with evenly spaced staples, wicks removed in icu prior to transfer to floor, healthy granulation tissue between staples, sero-sang exudate between staples, exoriation at panus fold. ext: edematous, ace wrap on left lower extremity, please see nursing note. pertinent results: admission labs: 09:28pm blood wbc-8.2 rbc-4.02* hgb-10.4* hct-32.8* mcv-81* mch-25.9* mchc-31.8 rdw-16.5* plt ct-364 09:28pm blood pt-56.9* inr(pt)-6.2* 09:28pm blood glucose-153* urean-7 creat-0.8 na-143 k-2.8* cl-107 hco3-24 angap-15 06:45am blood glucose-82 urean-8 creat-0.7 na-140 k-3.6 cl-107 hco3-23 angap-14 09:28pm blood alt-23 ast-17 ld(ldh)-187 alkphos-56 totbili-0.2 06:45am blood albumin-3.4* calcium-8.8 phos-2.8 mg-2.0 hepatitis serologies: 06:45am blood hbsag-negative hbsab-negative hbcab-negative 06:45am blood hcv ab-negative inflammatory markers: 09:28pm blood crp-23.6* 09:28pm blood esr-17 micro: 10:38 pm stool consistency: soft source: stool. **final report ** fecal culture (final ): no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. fecal culture - r/o vibrio (final ): no vibrio found. fecal culture - r/o yersinia (final ): no yersinia found. fecal culture - r/o e.coli 0157:h7 (final ): no e.coli 0157:h7 found. clostridium difficile toxin a & b test (final ): reported to and read back by @ 0554 on . clostridium difficile. feces positive for c. difficile toxin by eia. (reference range-negative). a positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). 04:30am blood wbc-10.0 rbc-3.16* hgb-9.3* hct-27.8* mcv-88 mch-29.5 mchc-33.6 rdw-14.8 plt ct-332 04:38am blood wbc-14.0* rbc-3.07* hgb-9.0* hct-27.4* mcv-89 mch-29.4 mchc-32.9 rdw-14.9 plt ct-292 03:25am blood wbc-16.5* rbc-3.48* hgb-10.3* hct-30.8* mcv-89 mch-29.6 mchc-33.4 rdw-15.0 plt ct-249 06:05pm blood hct-31.0* 04:21am blood wbc-13.8*# rbc-3.55* hgb-10.4* hct-31.5* mcv-89 mch-29.2 mchc-32.9 rdw-15.2 plt ct-282 11:50am blood hct-30.1* 02:05am blood wbc-7.6 rbc-3.47* hgb-10.4* hct-30.5* mcv-88 mch-30.1 mchc-34.2 rdw-15.1 plt ct-252 06:35pm blood hct-26.5* 12:21pm blood hct-26.0* 01:54am blood wbc-5.5 rbc-3.02* hgb-8.9* hct-26.4* mcv-87 mch-29.4 mchc-33.7 rdw-16.2* plt ct-271 10:15pm blood hct-28.5* 03:38pm blood hct-28.0* 06:02am blood wbc-6.2 rbc-3.37* hgb-9.9* hct-29.4* mcv-87 mch-29.3 mchc-33.6 rdw-16.2* plt ct-251 09:40pm blood wbc-8.0 rbc-3.25* hgb-9.5* hct-28.3* mcv-87 mch-29.1 mchc-33.5 rdw-16.5* plt ct-258 08:37pm blood wbc-7.5 hct-25.0* plt ct-263 02:54pm blood wbc-8.6 rbc-3.48* hgb-9.9* hct-29.0* mcv-83 mch-28.4 mchc-34.0 rdw-17.0* plt ct-251 05:27am blood wbc-6.8 rbc-3.34* hgb-9.6* hct-27.8* mcv-83 mch-28.9 mchc-34.7 rdw-16.9* plt ct-226 10:17am blood hct-28.6* 05:20am blood wbc-7.1 rbc-3.11* hgb-9.2* hct-25.7* mcv-83 mch-29.5 mchc-35.6* rdw-16.7* plt ct-238 04:25am blood pt-12.5 ptt-21.9* inr(pt)-1.1 04:30am blood plt ct-332 04:38am blood plt ct-292 04:38am blood pt-13.1 ptt-23.9 inr(pt)-1.1 03:25am blood plt smr-normal plt ct-249 04:21am blood plt ct-282 04:21am blood pt-13.0 ptt-19.9* inr(pt)-1.1 02:05am blood pt-13.0 ptt-21.4* inr(pt)-1.1 01:54am blood pt-12.3 ptt-21.0* inr(pt)-1.0 06:02am blood plt ct-251 06:02am blood pt-11.8 ptt-20.7* inr(pt)-1.0 05:27am blood pt-12.0 ptt-21.4* inr(pt)-1.0 05:16pm blood pt-11.8 ptt-23.9 inr(pt)-1.0 05:20am blood pt-12.2 ptt-24.0 inr(pt)-1.0 03:50am blood pt-14.4* ptt-28.1 inr(pt)-1.2* 11:04pm blood pt-16.1* ptt-150* inr(pt)-1.4* 03:19am blood pt-16.4* ptt-26.0 inr(pt)-1.4* 06:50am blood pt-46.4* ptt-31.1 inr(pt)-4.9* 06:45am blood pt-38.1* ptt-29.3 inr(pt)-3.9* 10:55am blood pt-32.5* ptt-27.7 inr(pt)-3.2* 06:35am blood pt-25.4* inr(pt)-2.4* 06:20am blood pt-30.3* inr(pt)-3.0* 06:20am blood pt-35.5* inr(pt)-3.6* 05:37am blood pt-41.0* ptt-32.6 inr(pt)-4.2* 12:05pm blood pt-42.6* ptt-30.8 inr(pt)-4.4* 06:30am blood pt-32.5* ptt-83.9* inr(pt)-3.2* 08:36am blood pt-21.7* ptt-95.2* inr(pt)-2.0* 06:00am blood pt-15.3* ptt-58.7* inr(pt)-1.3* 10:30am blood pt-14.7* ptt-51.2* inr(pt)-1.3* 06:50am blood pt-20.4* ptt-23.7 inr(pt)-1.9* 04:25am blood glucose-117* urean-6 creat-0.4 na-136 k-4.5 cl-106 hco3-22 angap-13 11:15am blood glucose-111* urean-13 creat-0.4 na-135 k-3.9 cl-103 hco3-23 angap-13 04:30am blood glucose-143* urean-14 creat-0.4 na-135 k-4.6 cl-102 hco3-25 angap-13 04:38am blood glucose-160* urean-11 creat-0.3* na-134 k-4.8 cl-100 hco3-27 angap-12 03:25am blood glucose-163* urean-10 creat-0.3* na-135 k-4.5 cl-101 hco3-27 angap-12 04:21am blood glucose-147* urean-14 creat-0.3* na-135 k-4.6 cl-105 hco3-22 angap-13 02:05am blood glucose-150* urean-15 creat-0.3* na-138 k-4.3 cl-106 hco3-24 angap-12 01:54am blood glucose-163* urean-15 creat-0.3* na-137 k-4.2 cl-105 hco3-26 angap-10 04:25am blood calcium-7.9* phos-4.2 mg-2.0 11:15am blood calcium-8.2* phos-4.0 mg-1.7 05:20am blood phos-4.4 mg-1.8 03:25am blood calcium-7.9* phos-2.8 mg-1.6 04:21am blood calcium-7.5* phos-3.1 mg-1.6 09:25pm blood mg-1.5* 02:05am blood mg-1.7 01:54am blood calcium-7.8* phos-3.0 mg-2.0 06:02am blood calcium-7.8* phos-2.2* mg-2.2 05:27am blood crp-64.6* 06:50am blood crp-46.1* 08:15pm blood crp-140.4* 06:30am blood crp-106.0* 09:28pm blood crp-23.6* 1:27 am urine source: catheter. **final report ** urine culture (final ): pseudomonas aeruginosa. >100,000 organisms/ml.. piperacillin/tazobactam sensitivity testing confirmed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- <=1 s ceftazidime----------- 2 s ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem------------- 1 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s chest (pa & lat) study date of 9:39 am findings: low lung volumes result in bronchovascular crowding. the right picc tip ends in the mid svc. pulmonary edema and atelectasis have significantly improved since with mild residual bibasilar atelectasis and perihilar pulmonary vascular engorgement. no pneumothorax. small left pleural effusion. cardiac and mediastinal silhouettes are normal. interup ivc study date of 8:58 am impression: 1. uncomplicated placement of a retrievable option ivc filter in the infrarenal ivc location. 2. venogram performed through the left iliac vein demonstrating attenuated left iliac vein likely secondary to chronic thrombosis or hypoplasia. bilat lower ext veins study date of 9:55 am findings: grayscale and doppler son of bilateral common femoral, superficial femoral and deep femoral were performed. right lower extremity veins: there is normal compressibility, flow and augmentation throughout. no dvt in the right lower extremity. left lower extremity: there is a non-occlusive thrombus involving the left common femoral and proximal superficial femoral vein and an occlusive thrombus involving the left popliteal vein. recanalization of the mid and distal portion of the left superficial femoral vein compared to the prior study. flow is demonstrated within the proximal left calf veins. ct abd & pelvis w/o contrast study date of 7:15 pm impression: 1. no retroperitoneal hemorrhage or findings to explain hematocrit drop. 2. little interval change to the appearance of large bowel which is predominantly ahaustral and consistent with the provided history of chronic ulcerative colitis. no definite findings of superimposed acute inflammation. 3. unchanged cholelithiasis and hepatic steatosis. 4. stable sub-4 mm pulmonary nodules. in a patient of this age without any risk factors for intrathoracic malignancy no further followup for these nodules is necessary society guidelines. brief hospital course: patient is a 41 yo f with h/o ulcerative colitis, le fracture, dvt/pe on warfarin, anxiety/bipolar disorder, admitted with profuse diarrhea and ongoing uc flare despite 2 weeks of prednisone 60 mg po daily who improved with iv steroids, hydrocortisone and mesalamine enemas. #micu course: she was transfered to the micu for managment of hypotension on hospital day 15. vancomycin and cefepime were started empirically. she was volume resucsitated and was noted to have acute blood loss anemia with a hematocrit drop of 25 to 20 acutely. she was resuscitated with six units of packed red cells, resulting in a post transfusion hematocrit of 31.5. her blood pressure stabilized. gi was for consideration of an ivc filter versus heparin gtt in the setting of a gi bleed/ulcerative colitis flare. an ivc filter was placed and anticoagulation was discontinued in anticipation of a surgical procedure. gi recommened a 48 hour trial of cyclosporin prior to consideration for colectomy. this did not improve her symptoms, so she was transferred to colorectal surgery with plans of total abdominal colectomy with ileostomy with dr. . icu post-operative course: patient was transferred to the surgical service on and she underwent tac and end ileostomy. she stayed in the icu post-operatively. she had a rectal tube in place from the or for decompression of her rectal stump. initially she was on a dilaudid pca for pain control. she was continued on methylprednisolone 20 q8 and this was tapered by half every other day. on pod #2 the wicks between the staples in her midline incision were removed. she was out of bed to a chair. she was kept npo until ostomy function was noted. she was started on cipro and bactrim on respectively for a + uti and her foley was exchanged. the urine cultured demonstrated pseudomonas and she was started on cefepime (the bactrim and cipro were d/c'ed). on when there was ostomy function and she was given sips of liquids and advanced to clears. on her rectal tube was dc'ed. cxr performed on demonstrated largely improved pulm edema and atelectasis with sm l pleural effusion. she was transferred to the surgical floor on . surgical floor post-operative course: on transfer to the inpatient unit, the patient was stable. she was diagnosed with a pseudomonis urinary tract infection and she was started on a 14 day course of intravenous cefepime. on the foley catheter was removed. she had adequate bowel function and was started on a regular diet. the tpn was discontinuned, she was later supplemented with ensure with each meal. she tolerated a regular diet well and the dilaudid pca was transitioned to po pain medications. her pain was well controlled. the patient had increased ileostomy output and required intravenous boluses of fluids to control her heart rate which was elevated to 140 with ambulation. this resolved with supplemental intravenous fluids. the patient was started on imodium 2mg on , however this was increased to 2mg qid on with goog affect. on the day of discharge imodium therapy was titrated to 2mg tid and her stool output was stable as well as her vital signs. the patient' coumadin therapy was restarted on as described below. she worked closely with physical therapy as well as the wound ostomy team and she was stable for discharge on . # ulcerative colitis: patient was admitted for ungoing ulcerative colitis flare despite treatment with prednisone 60 mg po daily and mesalamine po and suppositories. a colonoscopy performed on on showed severe colitis and ulcerative colitis flare is the most likely cause of her ongoing symptoms. infectious work-up was initially negative for cmv colitis, c. diff x 3, stool ova and parasites. she was treated with mesalamine 1600 mg po tid, mesalamine enema, hydrocorticone enema as well as methylprednisolone 20 mg iv q8h. she was maintained on a low residue diet. her symptoms then progressed and her inflammatory markers (esr, crp) increased. repeat c. diff testing was done and came back positive. she was started on iv metronidazole and vancomycin 500 mg po q6h. she continued to have bright red blood per rectum associated with her bowel movements. her hematocrit dropped and she became hypotensive and was transferred to the micu as detialed above. post-operatively, as the colon has been removed, it is the surgical teams intension that prednisone therapy may be tapered. she will recieve on additional dose of 10mg of prednisone on and this may be discontinued. she should be monitored for signs of steroid withdrawal. # pe/dvt: diagnosed in . her was initially inr elevated at 6.8 on admission. when her inr <3.0, she was restarted on warfarin therapy 10 mg po daily. her inr then became supratherapeutic once again, likely in the setting of concomittant metronidazole administration. an ivc filter was placed in anticipation of the patient needing a total abdominal colectomy. the ivc filter will remain in place. because of recent bleeding and ivc filter, the patient remained on subcutaneous heparin post-operatively until when she was restarted on coumadin therapy at 5mg daily. her inr was 1.1 on . she will be discharged on 5mg of coumadin daily with intention that the rehabilitation facility will work with the patient in achieving the goal inr of . # anxiety/bipolar disorder: patient was maintained on her home regimen of clonazepam, lorazepam, paliperidone. social work and pyschiatry were consulted for support and assistance with management. social work evaluated the patient post-operatively and beleived the patient was at her baseline. she should continue to be followed by her outpatient psychiatric provider. # chronic pain: patient's chronic pain was well controlled on home regimen of oxycodone, oxycontin and tylenol. post-operatively her managed with oxycodone and tylenol. the patient stated her pain was well controlled. # chronic bronchitis: stable. continued on home spiriva and albuterol. medications on admission: albuterol sulfate 90 mcg inhaler 2 puffs q4h prn wheezinf, sob clonazepam 2 mg po tid prn anxiety; 6 mg po qhs and 4 mg po qhs prn insomnia clotrimazole-betamethasone lotion fluticasone - 50 mcg 1 spray each nostril daily lorazepam mesalamine - 1,000 mg suppository at bedtime (only taking 'when tolerated') mesalamine 1.2 gm po tid oxycodone 20 mg tablet po qhs oxycodone - 15 mg tablet tid prn pain paliperidone 6 mg po daily tiotropium bromide - 18 mcg 1 inhalation daily warfarin 10 mg daily - on hold given inr 6.8 acetaminophen 650 mg tablet po q6h prn pain calcium carbonate 650 mg po tid camphor-menthol cholecalciferol (vitamin d3) 1,000 unit capsule po once a day miconazole nitrate multivitamin po daily potassium - dosage uncertain discharge medications: 1. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 2. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 3. paliperidone 3 mg tablet extended rel 24 hr sig: two (2) tablet extended rel 24 hr po daily (daily). 4. fluticasone 50 mcg/actuation spray, suspension sig: one (1) spray nasal daily (daily). 5. clotrimazole 1 % cream sig: one (1) appl topical (2 times a day): to left lower extremity. 6. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q4h (every 4 hours) as needed for wheezes. 7. clonazepam 1 mg tablet sig: two (2) tablet po tid (3 times a day) as needed for anxiety. 8. clonazepam 1 mg tablet sig: three (3) tablet po qhs (once a day (at bedtime)). 9. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day): skin folds, breast and groin, reddness . 10. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) for 7 days. 11. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain for 5 days: use caution when taking with other sedating medications. . 12. prednisone 10 mg tablet sig: one (1) tablet po daily (daily): patient on a taper, last dose of prednisone should be 10 mg daily on . 13. loperamide 2 mg capsule sig: one (1) capsule po tid (3 times a day): please titrate stool to 500cc-1200cc in 24 hours, call the colorectal surgery office if ileostomy output is not within these goals. . 14. cefepime 1 gram recon soln sig: one (1) intravenous every twelve (12) hours for 14 days: total of 14 days for uti, start date . 15. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 16. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day): continue dvt prevention per rehab facility protocol. . 17. warfarin 5 mg tablet sig: one (1) tablet po once a day: please give at 1600 on , inr on = 1.1, goal inr is . discharge disposition: extended care facility: rehabilitation & care center - discharge diagnosis: 1. medically refractory ulcerative colitis. 2. morbid obesity. 3. recent clostridium difficile colitis. 4. deep venous thrombosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital after an open total abdominal colectomy for surgical management of your refractory ulcerative colitis. you have recovered from this procedure well and you are now ready to return home. samples from your colon were taken and this tissue has been sent to the pathology department for analysis. you will receive these pathology results at your follow-up appointment. if there is an urgent need for the surgeon to contact you these results they will contact you before this time. you have tolerated a regular diet, passing gas and liquid stool through your ileostomy and your pain is controlled with pain medications by mouth. you are ready to be discharged to rehab today to continue your recover. please monitor your bowel function closely. if you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, or constipation. please see ileostomy instructions below. you have a new ileostomy. the most common complication from a new ileostomy placement is dehydration. the output from the stoma is stool from the small intestine and the water content is very high. the stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. you must measure your ileostomy output for the next few weeks. the output from the stoma should not be more than 1200cc or less than 500cc. if you find that your output has become too much or too little, please call the office for advice. the office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. keep yourself well hydrated, if you notice your ileostomy output increasing, take in more electrolyte drink such as gatoraide. please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. if you notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. you may eat an ileostomy appropraite regular diet with your new ileostomy, please follow the advice of the ostomy nurses. avoid spicy foods. please monitor the appearance of the ileostomy and stoma and care for it as instructed by the wound/ostomy nurses. the stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. the skin around the ostomy site should be kept clean and intact. monitor the skin around the stoma for buldging or signs of infection listed above. please care for the ostomy as you have been instructed by the wound/ostomy nurses. you will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery, you will be discharged to a rehab facility where nurses will assist you to monitor your ileostomy until you are comfortable caring for it on your own. you have a long vertical incision on your abdomen that is closed with staples. the staples in this incision are far apart as you had a difficult abdomen to close, there were wicks in these spaces which ahve since been removed. the incision should be monitored closely and covered with adaptic and a dry sterile gauze dressing. the staples will stay in place until your first post-operative visit when they are evaluated by the wound ostomy nurse and dr. . please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. you may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. no heavy lifting for at least 6 weeks after surgery unless instructed otherwise by dr. . you may gradually increase your activity as tolerated but clear heavy excersise with dr. . you will be prescribed a small amount of the pain medication oxycodone, please take this medication exactly as prescribed. you may take tylenol as recommended for pain. please do not take more than 4000mg of tylenol daily. do not drink alcohol while taking narcotic pain medication or tylenol. please do not drive a car while taking narcotic pain medication. use caution when taking oxycodone while taking medications use as clonipin. or other antianxiety/sedating medications. you were diagosed with a deep venous thrombosis while you were in the hospital, you will need treatment with the medications coumadin for at least 6 months. you have a ivc filter placed to protect you from blood clots in the lungs. you will start with taking 5mg of coumadin, with a goal inr of . on discharge you recieved your first dose of coumadin on of 5mg and your inr today is 1.1, you will be discharged on the dose of 5mg of coumadin daily with a goal inr of . the hospital where they will monitor the inr and coumadin therapy. thank you for allowing us to participate in your care! our hope is that you will have a quick return to your life and usual activities. good luck! followup instructions: you will need to make an appointment with the wound ostomy nurses on , call the wound ostomy clinic at to confirm this appointment. dr. may look at your midline wound during this appointment. call the colorectal surgery office at this appointment or with any questions or conserns related to the ostomy. Procedure: Parenteral infusion of concentrated nutritional substances Interruption of the vena cava Flexible sigmoidoscopy Other permanent ileostomy Application or administration of an adhesion barrier substance Open total intra-abdominal colectomy Central venous catheter placement with guidance Diagnoses: Other chronic pain Urinary tract infection, site not specified Congestive heart failure, unspecified Acute posthemorrhagic anemia Hyposmolality and/or hyponatremia Personal history of tobacco use Hypopotassemia Anxiety state, unspecified Intestinal infection due to Clostridium difficile Morbid obesity Personal history of venous thrombosis and embolism Bipolar disorder, unspecified Chronic diastolic heart failure Insomnia, unspecified Pseudomonas infection in conditions classified elsewhere and of unspecified site Obstructive chronic bronchitis without exacerbation Unspecified vitamin D deficiency Orthostatic hypotension Posttraumatic stress disorder Body Mass Index 40.0-44.9, adult Unspecified chronic bronchitis Universal ulcerative (chronic) colitis

allergies: nsaids / flagyl / diltiazem / triazolam / ciprofloxacin / lisinopril / aspirin attending: chief complaint: tongue swelling major surgical or invasive procedure: intubation history of present illness: ms. is a 77yof with multiple medical problems including htn who was started on lisinopril approximately 6m ago who presented to osh with right facial swelling that started at 5am. at the osh, she was given benadryl, solumedrol, and pepcid. this helped somewhat initially, but then left and tongue swelling developed. he was transfered to the ed. initial ed vitals: t 98.8, hr 58, bp 138/84, rr 18, 95% ra. in the ed, initially she got epinephrine, but was ultimately intubated to protect airway after trying some epi. she had some hypotension on propofol, and so sedation was switched to vent/versed. of note, she ate scallops and clams for dinner last night. her son does not recall any issues with shelfish in the past, although she does not eat it terribly frequently because these foods are often too for her. she has a number of medicaion allergies, although no recent exposure to any of these meds. she has never had a reaction that has caused throat swelling before that her son is aware of. she may have had hives before, but her medication allergies all happened a number of years ago. . . vitals prior to transfer: t 97, hr 88, bp 146/88, rr 15, 100% on cmv with fio2 100% . on the floor, she is intubated and sedated. she responds to voice and is able to follow simple commands. past medical history: g6pd deficiency ercp htn diverticulitis (multiple hospitalizations per son) gerd asthma (well-controlled as of late per son) hernia cataract colon polyps arthrits social history: - tobacco: former - alcohol: none - illicits: none lives alone, retired. son is hcp. family history: g6pd deficiency physical exam: admission physical exam: general: intubated, sedated, responds to voice and follows sipme commands heent: sclera anicteric, perrl, tongue and neck swelling neck: edematous lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: hypoactive, bs, soft, non-tender, non-distended ext: warm, well perfused, no clubbing, cyanosis or edema . . physical exam at discharge: vitals: t: 98.0f bp: 140/77 p: 74 r: 18 o2: 97%/ra general: alert and interactive with family conversations, nad heent: sclera anicteric, perrl, mmm , tongue with no edema neck: no longer edematous, no lad, no jvd, supple lungs: ctab, no wheezes, rales, ronchi cv: rrr, normal s1 + s2, no murmurs, rubs, gallops abdomen: hypoactive, bs, soft, non-tender, non-distended ext: warm, well perfused, no clubbing, cyanosis or edema pertinent results: admission labs: 04:50pm blood wbc-8.7 rbc-4.30 hgb-14.1 hct-39.5 mcv-92 mch-32.8* mchc-35.7* rdw-14.0 plt ct-141* 12:55pm blood pt-11.7 ptt-24.9 inr(pt)-1.0 12:55pm blood urean-13 creat-0.9 01:31am blood calcium-8.4 phos-3.7 mg-1.5* 01:48pm blood type-art rates-14/ tidal v-450 peep-5 fio2-100 po2-515* pco2-33* ph-7.45 caltco2-24 base xs-0 aado2-182 req o2-39 intubat-intubated 01:06pm blood glucose-107* lactate-2.5* na-142 k-3.5 cl-95* calhco3-25 01:06pm blood hgb-15.8 calchct-47 o2 sat-90 cohgb-4 methgb-0 chest (portable ap) study date of 1:25 pm the lungs are low in volume. there is minimal atelectasis in the left lung base. remainder of the lungs are clear. the cardiac silhouette is normal. the mediastinal silhouette shows a tortuous aortic knob. the hilar contours are normal. there may be a small left pleural effusion. no pneumothorax is present. an et tube terminates with its tip 3 cm above the carina. multiple clips are noted in the right upper quadrant of the abdomen. impression: possible small left effusion and left basilar mild atelectasis. et tube is appropriate. . . brief hospital course: 77 yo f with asthma, htn, and recurrent episodes of diverticulitis who presented to osh with tongue swelling and despite steroids, histaime blockade, and epi, requried intubation for airway protections gien worsening angioedema. # angioedema: ddx - allergic reaction to shellfish vs acei. acei-associated angioedema can happen any time while on the medication. however, timing is suspicious for allergic etiology. pt does appear to have atopic tendencies given asthma and multiple medication allergies. lisinopril was added to her allergy list, and she was told to avoid shellfish. she was intubated in the ed secondary to severe angioedema. he was started on 80mg q8 x 24h. she received benadryl 25mg q6h, for the first 24 hours, then had it stopped. morning after her admission, her tongue swelling resolved and she was extubated successfully, started on po prednisone taper. patient satting well on ra and eating a regular diet. she will need follow-up with allergy to flesh out her reaction, but likely to ace inhibitors given that shellfish didn't give her trouble in past and that rxn happened the next morning after a dinner meal. also, if her angioedema was secondary to a mast-cell mediated anaphylactic reaction, we would have expected her to respond to epinephrine, which she did not. # asthma: pt did not require intubation for any intrinsic pulmonary process. prior to transfer to the floor she was satting well on room air. continue her inhalers with budesonide. # htn: pt was hypotensive in the setting of propofol. h/h in ed looked hemoconcentrated, improved after 1l ns in ed. pressures 120s-130s in the unit, but she had low uop overnight and was given 2l ns. her hctz was held initially. # gerd: pantoprazole iv while intubated. changed to po after extubation. # s/p ercp: held cholestyramine while npo. # cataracts: her son brought her eye drops in and she used her own medications while in house. . . pending tests: none. . . transitional issues: patient will have follow up appt with allergist/pcp. stop ace inhibitors indefintiely. medications on admission: protonix 40mg daily hctz 25mg daily budesonide 1 puff kcl 20 meq daily w-3 fatty acids 1200mg daily mvi cholystyramine 4g daily albuterol q4 prn flonase 1 spray fluocinonide 0.05% 4 drops ou daily prn oloatadine 0.1% 1 drop ou vitamin d discharge medications: 1. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). disp:*1 inhaler* refills:*2* 2. prednisone 10 mg tablet sig: two (2) tablet po once (once) for 1 doses: please take 2 pills for a total of 20 mg tomorrow, . disp:*2 tablet(s)* refills:*0* 3. prednisone 5 mg tablet sig: one (1) tablet po once (once) for 1 doses: please take 1 pill for a total of 5mg on . then stop all prednisone. disp:*1 tablet(s)* refills:*0* 4. prednisone 10 mg tablet sig: one (1) tablet po once for 1 doses: please take one pill on for a total of 10mg. disp:*1 tablet(s)* refills:*0* 5. cholestyramine-sucrose 4 gram packet sig: one (1) packet po daily (daily). 6. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 7. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. 8. olopatadine 0.1 % drops sig: one (1) drop ophthalmic (2 times a day): to both eyes. 9. fluocinolone-shower cap 0.01 % oil sig: one (1) drops topical four times a day: to both eyes. 10. vitamin d oral 11. kcl sig: twenty (20) meq once a day. 12. w-3 fatty acids 1200mg daily sig: one (1) pill once a day. 13. m-vit oral 14. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: one (1) puff inhalation every 4-6 hours as needed for shortness of breath or wheezing. 15. flonase 50 mcg/actuation spray, suspension sig: one (1) spray nasal twice a day. 16. epinephrine 1 mg/ml (1:1,000) (1ml) solution sig: one (1) injection injection prn as needed for anaphylaxis: use epi pen if feeling throat, tongue swelling, shortness of breath. please call 911 after administering this drug. disp:*1 pen* refills:*0* discharge disposition: home discharge diagnosis: angioedema, likely to ace inhibitor discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you at the . you presented to the hospital with an allergic reaction, tongue and throat swelling, and was admitted to the hospital. while you were here, we provided you with supportive care, which included intubating you to help you breathe. once you were stable, the breathing tube was removed and you have been stable since. at this time, we believe the reaction is to your lisinopril, an ace inhibitor. please throw the rest of these medications away and don't take them again until further notice. the following changes have been made to your medications: --stop lisinopril --stop budesonide 1 puff --start fluticasone inhaler 2 puffs to replace your budesonide inhaler. --start prednisone by mouth (a steroid that we started you on here, treats severe allergic reactions). we are tapering you off of them. tomorrow, on , you will need to take 20mg by mouth. on , take 10mg, and on , take 5mg. then stop. please continue to take all of your other medications as previously prescribed. followup instructions: you have the following appointments: name: pa location: physicians address: 100 way, , phone: appointment: friday 11:00am *this is a follow up appointment of your hospitalization. you will be reconnected with your primary care physician after this visit. department: div of allergy and inflam when: thursday at 9:00 am with: . , md building: one place (, ma) campus: off campus best parking: parking on site **you have also been placed on a waitlist for this appointment. the office will call you at home if a sooner appointment becomes available. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Other iatrogenic hypotension Esophageal reflux Unspecified essential hypertension Asthma, unspecified type, unspecified Acute respiratory failure Accidents occurring in other specified places Angioneurotic edema, not elsewhere classified Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use

allergies: oxycodone attending: chief complaint: asymptomatic saccular aneurysm of the aortic arch and focal dissection within the proximal left subclavian artery major surgical or invasive procedure: : 1. ultrasound-guided puncture of bilateral common femoral arteries. 2. catheter placement in the thoracic aorta. 3. descending thoracic aortogram. 4. endograft exclusion of descending thoracic aortic pseudoaneurysm using a cook zenith 32 x 120 graft. 5. perclose closure of bilateral common femoral arteriotomies. history of present illness: 75 old female who was found to have a saccular aneurysm of the aortic arch and focal dissection within the proximal left subclavian artery in while being worked up for a lung nodule. repeat ct scan in showed the aneurysm and dissection to be stable and unchanged. she has been referred to dr. for further recommendations. she underwent a repeat ct scan today. past medical history: hypertension pituitary adenoma childhood asthma psoriasis polycystic ovary syndrome anemia lung cancer of left upper lobe - large cell stage 1a - s/p vat left upper lobectomy and mediastinal lymph node sampling social history: married to husband with three children. supportive family. sister able to help in perioperative period and pt verbally states can take care of health decisions. husband with early dementia for which pt is feeling stressed/depressed slightly over. retired nursing education in human genetics, growth and developement. 60 pack yr hx of smoking quit 5 years ago. exposed to jet fuel when she worked making such as a teenager. family history: mother- died of breast ca in 50's father- died of mi in 60's siblings brother with pit adenoma. sister healthy physical exam: pulse: 82 resp: 20 o2 sat: 99% ra b/p right: 164/80 left: 156/89 general: no acute distress skin: dry intact small scope sites and mini thoracotomy left side healed - no erythema or drainage heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur none abdomen: soft non-distended non-tender bowel sounds + no palpable masses extremities: warm well-perfused edema none neuro: alert and oriented x3 nonfocal steady gait pulses: femoral right: +1 left: +1 dp right: +1 left: +1 pt : +1 left: +1 radial right: +2 left: +2 carotid bruit right: no bruit left: no bruit pertinent results: echo: no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the descending thoracic aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. at distal arch, saccular aortic aneurysm is identified. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. mild (1+) mitral regurgitation is seen. ct: 1. interval thoracic aorta stenting without evidence of an endoleak. the aortic arch pseudoaneurysm appears successfully excluded. 2. persistent left pleural effusion. 3. multiple foci of abnormal arterial enhancement in the liver with the largest 1.8 cm, but more geographic than mass-like. in the absence of risk factors for hepatocellular carcinoma or hypervascular metastases, these could be followed up as part of patient's routine follow-up protocol. alternatively, follow-up imaging could be performed in three months with mri using eovist to ensure stability. 4. small hiatus hernia. 5. diverticulosis without evidence of diverticulitis. 04:28am blood wbc-16.2* rbc-2.68* hgb-7.0* hct-21.8* mcv-82 mch-26.1* mchc-32.0 rdw-18.5* plt ct-341 10:27am blood pt-14.6* ptt-37.1* inr(pt)-1.3* 04:28am blood glucose-131* urean-15 creat-1.0 na-140 k-3.2* cl-103 hco3-27 angap-13 brief hospital course: mrs. was a same day admit and brought directly to the operating room where she underwent stent graft repair of descending thoracic aortic pseudoaneurysm. please see operative report for surgical details. following surgery she was transferred to the cvicu for invasive monitoring. later that day she was weaned from sedation, awoke neurologically intact and extubated. on post-op day one she was transferred to the telemetry floor for further care. during her immediate post-op period she complained of hoarseness (worse than before surgery) and some tongue swelling. denied aspirating or dysphagia with solids or fluids. she received humidified oxygen with slight improvement. she received aggressive management for hypertension throughout hospital course with goal sbp<140. on post-op day two she received blood transfusion for hct of 22. hct the following day was 32. on post-op day 3 she was discharged home with the appropriate medications and follow-up appointments. medications on admission: hydrochlorothiazide 25 mg daily atenolol 50 mg prn fast heart rate albuterol sulfate inhaler prn sob pepcid 10mg prn heartburn aspirin 325mg prn pain (1-2 times a week) ferumoxytol - unsure of dose discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 3. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. atenolol 50 mg tablet sig: 1.5 tablets po daily (daily). disp:*45 tablet(s)* refills:*0* 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 6. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: aortic pseudoaneurysm s/p thoracic endograft hypertension pituitary adenoma childhood asthma psoriasis polycystic ovary syndrome anemia lung cancer of left upper lobe - large cell stage 1a - s/p vat left upper lobectomy and mediastinal lymph node sampling discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with incisions: bilateral groin - healing well, no erythema or drainage. edema - none discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart please call with any questions or concerns monitor blood pressure - systolic (or top number) should be below 140 but greater than 100. if you develop symptoms of dizziness or lightheaded, please contact your pcp. **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments ent: dr. on @ 1045am (location: . please obtain referral from pcp prior to appt) cardiac surgeon: dr. on @ 1pm hematologist dr. on @ 2pm at thoracic surgeon: dr. on @ 230pm (if you develop worsening shortness of breath prior to appointment with dr. , please contact dr. office for earlier appointment. () please call to schedule appointments with your primary care dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Arteriography of other intrathoracic vessels Endovascular implantation of graft in thoracic aorta Diagnoses: Unspecified essential hypertension Thoracic aneurysm without mention of rupture Personal history of malignant neoplasm of bronchus and lung Anxiety state, unspecified Other specified cardiac dysrhythmias Iron deficiency anemia, unspecified Swelling, mass, or lump in head and neck Chronic obstructive asthma, unspecified Other psoriasis Unspecified drug or medicinal substance causing adverse effects in therapeutic use Polycystic ovaries Other drug allergy

allergies: codeine attending: chief complaint: s/p assault major surgical or invasive procedure: open reduction, internal fixation of right angle mandible fracture, extraction of teeth (two mandible incisors). history of present illness: ms. is a 37yo woman s/p assault, found walking around confused/incoherent. she initially presented to where a noncontrast head ct demonstrated a right subarachnoid hemorrhage. she also had significant face and mouth lacerations and swelling. she was intubated for airway protection. she was given one unit of packed red blood cells at the outside hospital, reportedly for low blood pressure. on arrival to , she was intubated and sedated. toxicology screen was positive for cocaine, barbituates, opiates, and alcohol. past medical history: depression, bipolar disorder social history: lives with son, has multiple family members nearby. reports not taking any psychiatric medications xseveral months lack of insurance. daily heroine use, frequent cocaine, etoh. family history: noncontributory physical exam: on admission: hr: 108 bp: 100/p resp: 16 o(2)sat: 100 normal constitutional: intubated, sedated heent: ecchymosis, crepitance, edema to face, dried blood, laceration to r cheek. , pupils equal, round and reactive to light, no proptosis or evidence of obvious globe rupture ett in place, ccollar on chest: clear to auscultation cardiovascular: regular rate and rhythm, normal first and second heart sounds abdominal: soft, nondistended pelvic: no evidence trauma on external exam gu/flank: ecchymosis to r thigh extr/back: no cyanosis, clubbing or edema skin: no rash, warm and dry neuro: intubated/sedated, purposeful movements of all exts psych: intubated, sedated heme//: no petechiae vitals at time of discharge: t 98.2, hr 73, sbp 118/60, rr 16, sat 99% pertinent results: 05:48am blood wbc-17.6* rbc-4.25 hgb-10.5* hct-32.7* mcv-77* mch-24.7* mchc-32.2 rdw-16.1* plt ct-415 10:15pm blood neuts-88.5* lymphs-8.4* monos-1.8* eos-1.2 baso-0.2 10:15pm blood glucose-95 urean-8 creat-0.8 na-135 k-3.4 cl-103 hco3-25 angap-10 10:15pm blood alt-21 ast-43* ld(ldh)-168 alkphos-75 totbili-0.9 05:48am blood lipase-13 10:15pm blood albumin-3.5 calcium-8.2* phos-3.4 mg-2.3 10:15pm blood hbsab-negative hbcab-negative igm hbc-negative 05:41am blood hiv ab-negative 05:48am blood asa-neg ethanol-108* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 10:15pm blood hcv ab-positive* imaging: ct c-spine wet read: no acute traumatic c-spine injury. ct head preliminary report 1. trace subarachnoid hemorrhage along the right sylvian fissure, without evidence of interval increase. no intraventricular hemorrhagic extension. no evidence of mass effect. 2. extensive right facial soft tissue contusion with a sizable right temporal subgaleal hematoma. 3. minimally displaced fracture of the right lamina papyracea, with mild/small pockets of intraconal air. no rectus muscle entrapment. 4. minimally displaced right nasal bone fracture. no ct mandible available. however, ct scout head view demonstrates right open angle fracture through distal of tooth #31. mandible series status post orif of right mandibular fracture, in overall anatomic alignment. brief hospital course: ms. was transferred to the trauma icu for close monitoring and management. n: she was initially intubated and sedated. when sedation was weaned, she was appropriately responsive, moving all extremities, following commands. neurosurgery was consulted, she was initially kept on dilantin for seizure prophylaxis per recommendations, and will follow up with an outpatient ct scan in four weeks. plastic surgery was consulted for her facial lacerations and facial fractures. ophtho was consulted for her orbital fracture. omfs was consulted for her mandibular fracture. she was given peridex mouthwashes. her intra-oral laceration and facial lacerations were sutured by plastic surgery. she was given narcotic medication for pain control. she was taken to the or on by omfs for her mandibular fracture and underwent --- cv: she remained hemodynamically stable. she was placed on methadone for her tachycardia, which improved. pulm: she was initially intubated for airway protection. she was weaned off the vent and successfully extubated. she was febrile on hd1 and sputum cultures were sent, which grew strep pneumo. she was started on ceftriaxone and switched to azithromycin. gi: once extubated, she was placed on a soft mechanical diet. she was on a bowel regimen. heme: her hematocrit remained stable id: her sputum grew strep pneumo and 1 of 2 blood culture bottles grew strep pneumo as well. she was placed on azithromycin , with a planned 7 day course. she remained afebrile for the rest of her icu course. a sexual assault screen was done and she was given a dose of metronidazole, azithromycin, and ceftriaxone on . she was hcv positive as well and given hiv post-exposure prophylaxis. on , mrs. was taken to the operating room with omfs for orif of her mandibular fracture and removal of her two mandibular incisors. she was recovered in the pacu and transferred to mrs. was transferred to the surgical floor. she was continued on azithromycin for a total course of four days. pain was controlled with narcotic and non-narcotic analgesics. methadone was also started due to patient's history of opioid dependence. the patient's diet was ordered as full liquids and she will continue to follow that diet until she follows up with omfs as an outpatient. she was started on subcutaneous heparin for dvt prophylaxis. during her inpatient stay, plastics, opthalmology, neurosurgery, and omfs were consulted for various issues. folllow up appointments have been made with all those services as an outpatient basis within the next month of discharge. because mrs. continues on anti-retroviral therapy, a follow-up appointment was also made with infectious disease within the upcoming week. social work has made plans for the patient to attend a methadone clinic. as part of that arrangement, prescriptions for narcotics were only administered to cover the patient until her first visit to the clinic, which is , . social work also made arrangements for the patient to . at the time of discharge, mrs. was hemodynamically stable and afebrile. she has finished her course of antibiotics. all necessary prescriptions have been provided and discharge instructions have been provided by myself and the bedside nurse. the patient was being discharged with the assistance/care of her sister. medications on admission: none. discharge medications: 1. acetaminophen (liquid) 650 mg po q6h:prn pain 2. chlorhexidine gluconate 0.12% oral rinse 15 ml oral rx *chlorhexidine gluconate 0.12 % swish and spit with 15ml twice a day disp #*240 milliliter refills:*1 3. darunavir 600 mg po bid rx *prezista 600 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*0 4. docusate sodium (liquid) 100 mg po bid hold for loose stools 5. emtricitabine-tenofovir (truvada) 1 tab po daily rx *truvada 200 mg-300 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 6. methadone 10 mg po bid rx *methadone 10 mg 1 tablet by mouth twice a day disp #*7 tablet refills:*0 7. oxycodone (immediate release) 10-15 mg po q3h:prn pain rx *oxycodone 10 mg 1 - 1.5 tablet(s) by mouth every three (3) hours disp #*40 tablet refills:*0 8. ritonavir (oral solution) 100 mg po bid rx *norvir 100 mg 1 tablet by mouth twice a day disp #*60 tablet refills:*0 9. senna 1 tab po bid:prn constipation hold for loose stools discharge disposition: home discharge diagnosis: right subarachnoid hemorrhage right mandible fracture right nasal bone fracture discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to hospital on after being assaulted. your injuries include: right mandible (jaw) fracture, right nasal bone fracture, right subarachnoid hemorrhage (bleeding in the brain). you were initially sent to the icu because you were intubated (on a ventilator/breathing machine). once you were stabilized and taken off the ventilator, you were sent to the surgical floor for further management and observation. you were taken to the operating room on for repair of your right jaw fracture and the removal of two of your mandible (lower jaw) incisors. the following are your discharge instructions: wound care: do not disturb or probe the surgical area with any objects. the sutures placed in your mouth are usually the type that self dissolve. if you have any sutures on the skin of your face or neck, your surgeon will remove them on the day of your first follow up appointment. smoking is detrimental to healing and will cause complications. do not smoke. bleeding: intermittent bleeding or oozing overnight is normal. placing fresh gauze over the area and biting on the gauze for 30-45 minutes at a time may control the bleeding. if you had nasal surgery, you may have occasional slow oozing from your nostril for the first 2-3 days. bleeding should never be severe. if bleeding persists or is severe or uncontrollable, please call our office immediately. if it is after normal business hours, please come to the emergency room and request that the oral surgery resident on call be paged. healing: normal healing after oral surgery should be as follows: the first 2-3 days after surgery, are generally the most uncomfortable and there is usually significant swelling. after the first week, you should be more comfortable. the remainder of your postoperative course should be gradual, steady improvement. if you do not see continued improvement, please call our office. physical activity: it is recommended that you not perform any strenuous physical activity for a few weeks after surgery. do not lift any heavy loads and avoid physical sports unless you obtain permission from your surgeon. swelling & ice applications: swelling is often associated with surgery. swelling can be minimized by using a cold pack, ice bag or a bag of frozen peas wrapped in a towel, with firm application to face and neck areas. this should be applied 20 minutes on and 20 minutes off during the first 2-3 days after surgery. if you have been given medicine to control the swelling, be sure to take it as directed. hot applications: starting on the 3rd or 4th day after surgery, you may apply warm compresses to the skin over the areas of swelling (hot water bottle wrapped in a towel, etc), for 20 minutes on and 20 min off to help soothe tender areas and help to decrease swelling and stiffness. please use caution when applying ice or heat to your face as certain areas may feel numb after surgery and extremes of temperature may cause serious damage. tooth brushing: begin your normal oral hygiene the day after surgery. soreness and swelling may nor permit vigorous brushing, but please make every effort to clean your teeth with the bounds of comfort. any toothpaste is acceptable. please remember that your gums may be numb after surgery. to avoid injury to the gums during brushing, use a child size toothbrush and brush in front of a mirror staying only on teeth. mouth rinses: you have been given a prescription for peridex. rinse with a tablespoon of the solution twice a day. your surgery will tell you how long you should continue to do this when you go to your follow up appointment. showering: you may shower 1-2 days after surgery, but please ask your surgeon about this. if you have any incisions on the skin of your face or body, you should cover them with a water resistant dressing while showering. do not soak surgical sites. this will avoid getting the area excessively wet. as you may physically feel weak after surgery, initially avoid extreme hot or cold showers, as these may cause some patients to pass out. also it is a good idea to make sure someone is available to assist you in case if you may need help. sleeping: please keep your head elevated while sleeping. this will minimize swelling and discomfort and reduce pain while allowing you to breathe more easily. one or two pillows may be placed beneath your mattress at the head of the bed to prop the bed into a more vertical position. pain: most facial and jaw reconstructive surgery is accompanied by some degree of discomfort. you will usually have a prescription for pain medication. some patients find that stronger pain medications cause nausea, but if you precede each pain pill with a small amount of food, chances of nausea will be reduced. the effects of pain medications vary widely among individuals. if you do not achieve adequate pain relief at first you may supplement each pain pill with an analgesic such as tylenol or motrin. if you find that you are taking large amounts of pain medications at frequent intervals, please call our office. if your jaws are wired shut with elastics, you may have been prescribed liquid pain medications. please remember to rinse your mouth after taking liquid pain medications as they can stick to the braces and can cause gum disease and damage teeth. diet: unless otherwise instructed, only a cool, clear liquid diet is allowed for the first 24 hours after surgery. after 48 hours, you can increase to a full liquid diet, but please check with your doctor before doing this. avoid extreme hot and cold. if your jaws are not wired shut, then after one week, you may be able to gradually progress to a soft diet, but only if your surgeon instructs you to do so. it is important not to skip any meals. if you take nourishment regularly you will feel better, gain strength, have less discomfort and heal faster. over the counter meal supplements are helpful to support nutritional needs in the first few days after surgery. a nutrition guidebook will be given to you before you are discharged from the hospital. remember to rinse your mouth after any food intake, failure to do this may cause infections and gum disease and possible loss of teeth. nausea/vomiting: nausea is not uncommon after surgery. sometimes pain medications are the cause. precede each pill with a small amount of soft food. taking pain pills with a large glass of water can also reduce nausea. try taking clear fluids and minimizing taking pain medications, but call us if you do not feel better. if your jaws are wired shut with elastics and you experience nausea/vomiting, try tilting your head and neck to one side. this will allow the vomitus to drain out of your mouth. if you feel that you cannot safely expel the vomitus in this manner, you can cut elastics/wires and open your mouth. inform our office immediately if you elect to do this. if it is after normal business hours, please come to the emergency room at once, and have the oral surgery on call resident paged. graft instructions: if you have had a bone graft or soft tissue graft procedure, the site where the graft was taken from (rib, head, mouth, skin, clavicle, hip etc) may require additional precautions. depending on the site of the graft harvest, your surgeon will you regarding specific instructions for the care of that area. if you had a bone graft taken from your hip, we encourage you to ambulate on the day of surgery with assistance. it is important to start slowly and hold onto stable structures while walking. as you progressively increase your ambulation, the discomfort will gradually diminish. if you have any problems with urination or with bowel movements, call our office immediately. elastics: depending on the type of surgery, you may have elastics and/or wires placed on your braces. before discharge from the hospital, the doctor you regarding these wires/elastics. if for any reason, the elastics or wires break, or if you feel your bite is shifting, please call our office. medications: you will be given prescriptions, some of which may include antibiotics, oral rinses, decongestants, nasal sprays and pain medications. use them as directed. a daily multivitamin pill for 2-3 weeks after surgery is recommended but not essential. followup instructions: infectious disease clinic when: , building: lm bldg (), basement level campus: west best parking: garage phone: omfs (oro-maxillo-facial surgeon), dr. when: at 2pm , building . department: center when: thursday at 4:00 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage name: , md specialty: primary care location: community health center address: , , phone: we have left dr. office a message that you will need an appt to be seen within the next 3 weeks. if you have not heard within 2 business days or have questions, please call the number listed above. department: div. of plastic surgery when: friday at 10:00 am with: , md and dr. ,md phone: building: lm bldg () campus: west best parking: garage department: radiology when: tuesday at 8:15 am with: cat scan building: cc campus: west best parking: garage department: neurosurgery when: tuesday at 9:00 am with: , md building: lm campus: west best parking: garage md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Closure of skin and subcutaneous tissue of other sites Open reduction of mandibular fracture Other surgical extraction of tooth Suture of laceration of gum Diagnoses: Unspecified viral hepatitis C without hepatic coma Asthma, unspecified type, unspecified Alcohol abuse, unspecified Cocaine abuse, unspecified Opioid type dependence, continuous Open wound of forehead, without mention of complication Anxiety state, unspecified Bacteremia Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia] Attention deficit disorder with hyperactivity Drug withdrawal Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Closed fracture of other facial bones Assault by unspecified means Sedative, hypnotic or anxiolytic abuse, unspecified Restless legs syndrome (RLS) Closed fracture of nasal bones Open wound of cheek, without mention of complication Bipolar I disorder, most recent episode (or current) depressed, unspecified Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Cellulitis and abscess of face Other specified disorders of the teeth and supporting structures History of physical abuse Adult sexual abuse Other orbital disorders Open fracture of mandible, angle of jaw Rape Perpetrator of child and adult abuse, by unspecified person Other specified dentofacial anomalies

allergies: no known allergies / adverse drug reactions attending: chief complaint: abdominal pain, hematemesis major surgical or invasive procedure: - exploratory laparotomy, ileocecectomy with primary anastamosis history of present illness: 36m with n/v x3 days. began as bilious, turned to hematemesis yesterday. developed abdominal pain and distention. felt weak, continued emesis so brought himself to ed. denies nsaid use, no history of ulcers, no significant abdominal history. no strange foods, excessive alcohol risk. in ed, received 3u crystalloid and 2u prbc which brought his sbp from 60's up to 110's. remained tachycardic to 140's. past medical history: pmh: iddm, htn psh: right knee surgery social history: social history: no tobacco, no etoh family history: non-con family history: no hx diabetes physical exam: on admission: vitals: t 98.2 p 155 bp 104/62 rr 42 o2 94 ra gen: a&o, nad heent: no scleral icterus, mucus membranes moist cv: rrr, no m/g/r pulm: clear to auscultation b/l, no w/r/r abd: distended, diffusely tender, + rebound dre: normal tone, no gross or occult blood ext: no le edema, le warm and well perfused pertinent results: admission data: cbc - 4.9 > 42.3 < 418 glucose 494 ca: 9.2 mg: 1.6 p: 4.4 alt: 36 ap: 76 tbili: 0.7 alb: 3.4 ast: 45 ldh: dbili: tprot: : lip: 52 imaging: cxr on admission - free air under r hemidiaphragm fast on admission - grossly positive in morissons pouch echo: normal left ventricular cavity size with global hypokinesis c/w diffuse process (e.g., toxin, metabolic, etc.). right ventricular cavity dilation with free wall hypokinesis. no valvular pathology or pathologic flow identified. ruq ultrasound: normal right upper quadrant ultrasound ct abd & pelvis with contrast: status post ileocecectomy with ileocolic anastomosis. post-surgical enhancing fluid collections, most notable right lower quadrant and left pelvis. ct abd & pelvis with contrast: 1. extravasated oral contrast and free intraperitoneal air consistent with anastomotic leak, most likely at the ileocecal anastomosis. 2. rectosigmoid colitis. 3. small bilateral pleural effusions and associated atelectasis. abdomen (supine & erect): 1. paucity of bowel gas without definite evidence of obstruction. if there is a concern for mechanical bowel obstruction, ct can be considered. 2. left lower lobe pneumonia. chest x-ray: retrocardiac opacity may represent atelectasis or pneumonia. bilateral pleural effusions. brief hospital course: mr was taken directly to the operating room on from the emergency department. he underwent exploratory laparotomy and ileo cecectomy for perforated appendicitis. there was frank purulence throughout the peritoneum. please see dr operative report for further details. he was take to the trauma icu still intubated for further resuscitation. he remained stable on and transferred to the surgical floor. he was taken emergently back to the operating room due to an anastomotic leak for washout and creation of a diverting ileostomy on . postoperatively he was taken back to the icu due to sirs response and remaining on pressors. on he remained hemodynamically stable off pressors and was transferred back to the floor. his overall hospital course is summarized below by organ system. neurologic: while intubated he was sedated with fentanyl & propofol. once extubated his pain was well controlled on a dilaudid pca which was subsequently changed to intermittent dilaudid. cardiovascular: he presented in hypotensive shock from sepsis and hypovolemia. following his inital operation, he had dual pressor requirement (vaso/levo) despite significant resuscitation with crystalloid and colloid (prbc/albumin). an echocardiogram on hd3 showed decreased ejection fraction and wall motion, consistent with his florid sepsis. he received a total of 5u prbc and 2u ffp peri-operatively. by , his pressors were able to be weaned off. he was transferred to the floor on with stable hemodynamics. postoperatively after return to the or on for anastamotic leak, he again required pressors for hypotension related to sepsis, but only for a transient period of less than 24 hours. on pressors were able to be weaned of and on he was transferred back to the surgical floor where he remained hemodynamically stable. his home lisinopril was restarted at a lowere dose 20 mg vs 40 mg daily and his hctz was not restarted as his blood pressures ranged in low to mid 110's during his hospital stay. pulmonary: he initially had respiratory failure, being unable to wean from the vent. as his sepsis improved, ventilation was weaned and he was extubated the morning of hd 4. pulmonary toilet was encouraged and he remained without respiratory compromise until he was again intubated for reoperation on , but was able to be weaned and extubated by when his sepsis improved. on he had a kub which showed ? infiltrate in the left lower lobe. a chest x-ray was then obtained to further evaluate which showed atelectasis vs. pneumonia. however, he remained afebrile without a cough or respiratory symptoms so incentive spirometry was encouraged as well as ambulation. gastrointestinal/abdomen: on admission he went emergently to the operating room for ileocectomy as described above. postoperatively, he developed an ileus and an ng tube was placed on for nauesa/emesis. due to persistent ileus and low grade fever, a ct scan was peformed on , which was only significant for an unorganized fluid collection in the pelvis. in discussion with radiology, this fluid appeared to be thin with low suspicion for abscess. however, patient had persistent nausea and fevers and ct was repeated on with placement of a percutaneous drain in pelvic collection. serous fluid drained with no growth on cultures. patient remained on his postop cipro and flagyl. on he began passing flatus and having multiple loose bowel movements and his ng tube was subsequently removed. however, on the night of , the patient had multiple episodes of emesis and ngt was replaced. despite normal wbc count and lack of fever, his persistent ileus was suggestive of an unidentified abdominal pathology and ct was repeated on . ct revealed an anastomotic leak and patient was taken to the or on for abdominal washout and end ileostomy. intraoperatively, patient had a sirs response and was brought to the icu postop on neosinephrine. his pressors were weaned over pod#1 and he was significantly improved by pod#2. ngt was clamped on and the patient was transferred to the floor. on tube feeds were initiated via ng tube. however, he demonstrated inablity to tolerate tube feeds with nausea and vomiting and therefore the ng tube was returned to suction. a picc line was placed and tpn was started given the patient's poor nutritional status. on a dobhoff tube was placed under radiology postpyloric and tube feeds were started. the patient tolerated the tube feeds via dobhoff with the ng tube continued to suction with bilious output. on his ng tube was removed as he continued to tolerate the tube feeds without nausea or abdominal distention. over the next 48 hours his diet was slowly advanced and his tube feeds were weaned and eventually stopped. renal: he presented with acute renal failure (cr 6.0, elevated k). a nephrology consult was obtained, who determined this to be a combination of pre-renal azotemia and atn. continued resuscitation was recommended, please see their consult note for further details. his electrolytes and creatinine normalized over post-op days . a foley was placed on admission and removed on at which time he voided adequate amounts of urine without difficulty. msk: there were no issues - he was able to able to ambulate independently during throughout his stay. hematology: he displayed an elevated inr as high as 3.6 post-operatively. this was not well explained, though believed to be due to rbc transfusions or coagulopathy from sepsis. coags were monitored and his inr trended downward toward normal at 1.7 on and 1.3 on . he was maintained on heparin subcutaneously for prophylaxis during his hospital stay. endocrine: he presented with blood glucose of 500 and elevated hba1c but no ketones in his urine. he reported being a type-ii diabetic but notes suggest he is type-i. he was initially controlled on an insulin drip which rapidly normalized his blood sugar. this was transitioned to sliding scale on pod 1. when started on tpn he again demonstrated uncontrolled blood glucose levels and in the 200's-300's. his insulin scale and standing dose were adjusted by , and his tpn formula was also adjusted as needed. he is being discharged on lantus and sliding scale insulin and will follow up with his new pcp and with . infectious disease: he was initially treated with iv vanco, cipro and flagyl for purulent peritonitis and septic physiology. his operating room cultures showed strep milleri and ecoli so he was narrowed to ceftriaxone and flagyl on based on sensitivity data. postoperatively on he was started on zosyn for empiric coverage given the anastamotic leak and stool spillage seen intraoperatively. at time of discharge he is afebrile and his white blood cell count was 7.0. his antibitoics were all eventually stopped. dispo: he was discharged to home with instructions for follow up in acute care surgery clinic and with his new pcp at . visiting nursing services were set up for his discharge. medications on admission: lisinopril 40', hctz 25', lantus 34u daily discharge medications: 1. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 2. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 3. loperamide 2 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 4. psyllium 1.7 g wafer sig: one (1) wafer po tid (3 times a day). disp:*90 wafer(s)* refills:*2* 5. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). disp:*120 tablet(s)* refills:*2* 6. ondansetron hcl 4 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for nausea. disp:*60 tablet(s)* refills:*0* 7. glargine sig: ten (10) units at bedtime. disp:*2 vials* refills:*2* 8. lisinopril 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 9. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. disp:*30 tablet(s)* refills:*0* 10. ostomy supplies 1 " convatec appliance. moldable wafer dist # # disp: 3 boxes refills: 6 11. ostomy supplies pouch dist # # disp: 3 boxes refills: 6 12. regular insulin sig: one (1) dose four times a day as needed for per sliding scale: see attached sliding scale. disp:*2 vials* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: perforated appendicitis hyperosmolar nonketotic acidosis acute kidney injury sepsis acute respiratory failure anastamotic leak postoperative wound infection right lower abdominal fluid collection discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with abdominal pain and you were found to have a perforation in your bowels on ct scan. you were taken emergently to the operating room and underwent a procedure to repair the perforation. you experienced complication following your operation that required another procedure to repair an area that was found to be leaking and as a result you now have an ileosotmy bag that produces stool. this type of an ostomy is know to produce large amounts of stool and it is very important that you drink at least 64 to 80 ounces of non alcoholic fluids each day. you ahve also been prescribed medications to slow down the amount of stool - continue to take these as prescribed. you have a special device called a vac dressing on your abdominal incison that became infected. this device is used to aid in faster wound healing. a visiting nurse is being arranged for you to help care for your wound and the vac dresing. you also had extremely elevated blood sugars and required an insulin drip and admission to the icu and was followed closley by the diabetes doctors. you will need to continue to be followed by these specialists after you are discharged from the hospital. you are being discharged on medications to treat the pain from your operation. these medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. you must refrain from such activities while taking these medications. please call your doctor or return to the emergency room if you have any of the following: * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomiting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomiting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. activity: no heavy lifting of items pounds for 6 weeks. you may resume moderate exercise at your discretion, no abdominal exercises. wound care: you may shower, no tub baths or swimming. followup instructions: department: when: tuesday at 3:00 pm with: , md building: sc clinical ctr campus: east best parking: garage dr is your new physician at . he works closely with dr , both will be involved in your care. please call your insurance and name dr. as your pcp. must be done before your appointment. please also discuss follow up for your diabetes management. department: general surgery/ when: thursday at 3:15 pm with: acute care clinic with dr phone: building: lm bldg () campus: west best parking: garage Procedure: Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Percutaneous abdominal drainage Open and other right hemicolectomy Other appendectomy Ileostomy, not otherwise specified Open and other cecectomy Diagnoses: Hyperpotassemia Abnormal coagulation profile Acute kidney failure with lesion of tubular necrosis Other postoperative infection Unspecified essential hypertension Acute and subacute necrosis of liver Unspecified septicemia Severe sepsis Alkalosis Long-term (current) use of insulin Septic shock Paralytic ileus Hematemesis Hypovolemia Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus Diabetes with ketoacidosis, type I [juvenile type], uncontrolled Other and unspecified Escherichia coli [E. coli] Acute appendicitis with generalized peritonitis Other digestive system complications

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p motor vehicle crash major surgical or invasive procedure: s/p orif left radius/ulnar fractures; left acetabular fracture s/p peg placement history of present illness: 36 yo female driver s/p rollover motor vehicle crash, ejected, unresponsive at scene, intubated in field w/ gcs 3t. she was trnapsorted to for further care. past medical history: unknown family history: noncontributory physical exam: upon admission: o: t: 96.2 bp: 111/74 hr: 84 r: 16 o2sats: 95% ventilated gen: intubated, sedated heent: pupils: 3-2mm b/l, sluggish; no eoms, frontal scalp hematoma neck: c-collar. lungs: cta bilaterally anteriorly. cardiac: rrr. s1/s2. abd: soft, nt, decreased bs extrem: cool, well-perfused, lue in cast/sling, positive withdrawal to pain in rue & bilater les. neuro: mental status: intubated, sedated orientation: intubated, sedated. recall: unable to assess language: intubated, sedated. cranial nerves: i: not tested ii: pupils equally round and sluggishly reactive to light, 3 to 2mm bilaterally. iii, iv, vi: no extraocular movements bilaterally v, vii: unable to assess. viii: unable to assess. ix, x: unable to assess. : unable to assess. xii: unable to assess. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. unable to assess strength throughout/pronator drift. sensation: unable to assess reflexes: b t br pa ac right 2 2 2 1 1 left in cast 1 1 toes downgoing bilaterally coordination: unable to assess pertinent results: 10:02pm glucose-103 urea n-16 creat-1.1 sodium-143 potassium-4.1 chloride-113* total co2-21* anion gap-13 10:02pm calcium-8.6 phosphate-4.2 magnesium-2.1 03:12pm ck(cpk)-1654* 03:12pm wbc-25.5* rbc-3.20* hgb-9.9* hct-29.0* mcv-91 mch-31.0 mchc-34.1 rdw-13.7 03:12pm plt count-310 03:12pm pt-15.8* ptt-25.6 inr(pt)-1.4* ct head impression: 1. diffuse brain edema resulting in sulcal effacement, particularly posteriorly. 2. no intracranial hemorrhage or herniation. likely compression of the right lateral ventricle. 3. aerosolized secretions in the left maxillary sinus and adjacent nasal cavity, raising suspicion for medial orbital wall fracture. no calvarial fracture. 4. scalp hematoma overlying the right occipital bone inferiorly, and the right vertex. ct cervical spine impression: 1. no fracture or malalignment of the cervical spine. 2. pulmonary contusion of the right lung apex. 3. suggestion of dense material within the spinal canal of the upper thoracic spine, although this may be artifactual related to adjacent bone. mri is more sensitive for evaluation of the thecal sac and its contents. attending note: agree with above findings. the increased demsity projected over upper thoracic spine is more likely to be artifactual. however, if there is clinical concern for spinal cord injury then mri can help. incidentally noted is widened right vertebral foramen at c4 which can be a normal variation from tortuous vertebral artery. lcency in c3 has benigh characteristis and can be due to hemangioma. mri head impression: 1. small hemorrhagic contusions in the superior anterior frontal lobes. 2. small subdural hygromas. 3. small amount of subarachnoid hemorrhage. 4. several foci of presumed diffuse axonal injury, as described above. small embolic infarctions are less likely, given the clinical history. renal ultrasound findings: the right kidney measures 12.2 cm and the left kidney measures 12.7 cm. there is no hydronephrosis, and no stones or cysts or solid masses are identified in either kidney. the urinary bladder was not imaged as there is a foley catheter in place. impression: no hydronephrosis. brief hospital course: she was admitted to the trauma service. neurosurgery and orthopedics were consulted given her injuries. she was transferred to the trauma sicu for close monitoring given her multiple injuries. she was taken to the operating room on for repair of her radius/ulna and acetabular fractures. she was given 3 units packed cells on pod #1. her hematocrits have remained stable (28.3 on ). a dobbhoff was placed and she was started on feedings early on. she was noted with hematuria on and underwent renal ultrasound which did not reveal any hydronephrosis, stones, cysts or solid masses in either kidney. this did eventually resolve. during her icu stay she was started on labetalol drip for bp control. her blood pressures have been remained relatively stable for the remainder of her course, still on higher side. her neurosurgical issues did not warrant operative intervention. ct imaging of her head revealed diffuse brain edema and she was started on mannitol;repeat ct head with increasing edema/increase in frontal sah and the mannitol was increased. her na became elevated which required that the mannitol be withheld until return to baseline (last na 138 on ). mr scan of brain did reveal a diffuse axonal injury. she remained sedated on propofol and minimally responsive for several days in the trauma icu, vented. when her sedation was decreased there was still little change in her mental status. the first trial extubation was unsuccessful requiring re-intubation; she was also bronched at that time. she was started on vancomycin for bal growing gram positive cocci. she was eventually extubated on and transferred to the regular nursing unit the following day. once on the nursing unit she was noted to become somewhat more responsive for short periods. she will answer to her name and respond to very simple commands, but is dysarthric when she tries to elaborate. for the most part she is very somnolent. the dobbhoff that was placed previously was self removed and replaced several times for which she consistently removed. discussions with family for peg placement were initiated; she underwent this procedure on . tube feedings were resumed and she is tolerating these without any difficulties. her left arm staples were removed on . she was evaluated by physical and occupational therapy and is being recommended for rehab after her acute hospital stay. medications on admission: unknown discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 2. metoprolol tartrate 50 mg tablet sig: 1 tablet po tid (3 times a day). 3. lisinopril 10 mg tablet sig: three (3) tablet po daily (daily). 4. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml's po bid (2 times a day). 5. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 6. acetaminophen 325 mg tablet sig: 1-2 tablets po every hours as needed for fever or pain. 7. milk of magnesia 800 mg/5 ml suspension sig: thirty (30) ml's po twice a day as needed for constipation. 8. dulcolax 10 mg suppository sig: one (1) rectal once a day as needed for constipation. 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 10. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. 11. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). discharge disposition: extended care facility: - discharge diagnosis: s/p motor vehicle crash traumatic brain injury t4-t10 spinous process fractures l1-l4 transverse process fractures left 11th posterior rib fractures left open radius/ulna fractures left midshaft humerus fracture left si joint widening/posterior acetabular fracture secondary diagnosis: hypertension discharge condition: hemodynamically stable followup instructions: follow up in 2 weeks with dr. , orthopedics. call for an appointment. follow up in 4 weeks with dr. , trauma surgery. call for an appointment. follow up in 4 weeks with dr. , neurosurgery. call for an appointment. inform the office that a repeat head ct scan will need to be done for this appointment. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Closed [endoscopic] biopsy of bronchus Open reduction of fracture with internal fixation, radius and ulna Debridement of open fracture site, radius and ulna Repair of vertebral fracture Open reduction of fracture with internal fixation, humerus Diagnoses: Unspecified essential hypertension Pulmonary collapse Other and unspecified hyperlipidemia Acute respiratory failure Alkalosis Cerebral edema Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Traumatic pneumothorax without mention of open wound into thorax Closed fracture of two ribs Closed fracture of lumbar vertebra without mention of spinal cord injury Contusion of lung without mention of open wound into thorax Closed fracture of acetabulum Closed fracture of shaft of humerus Motor vehicle traffic accident of unspecified nature injuring passenger in motor vehicle other than motorcycle Open fracture of shaft of radius with ulna Injury to other intra-abdominal organs without mention of open wound into cavity, adrenal gland Subarachnoid hemorrhage following injury without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness

allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: chief complaint: fever reason for micu transfer: hypotension major surgical or invasive procedure: none history of present illness: a 71 year old male with pmh cholelithiasis and biliary colic s/p unsuccessful open cholecystectomy is called out of the micu after a one day hospitalization for hypotension following ercp. . according to the patient, he had an episode of abdominal pain in and presented to where he underwent an attempted laparoscopic cholecystectomy which was converted to an open proceedure due to fibrosis. he reports that the surgeon was able to remove some stones and closed leaving a bile drain in place. he was then sent to for ercp on with biliary stent placement which was successful. following the procedure, the patient noted decreased output from the external biliary drain and had resolution of abdominal pain. on the day of admission () the patient presented for an repeat ercp to place a larger biliary stent which was performed successfully. he returned home where he noted chills and an oral temperature of 100.7. he called his pcp who recommended referral to the ed. in the ed, initial vs were: 98.3 78 91/52 18 94%, labs were remarkable for wbc 5.0 73%pmn 3% bands, he was given amp/sulbactam and 2l ivns and admitted to the micu. . while in the micu, antibiotics were changed to vancomycin and zosyn. biliary drain fluid was cultured with initial gram stain showing gram neg rods and gram positive cocci and culture showing polymicrobial growth. ercp fellow was who noted that the fluid in a cholecystomy bag is rarely cultured and is likely to be colonized with non-pathogenic bacteria. the patient was given a total of 5 liters of fluid in the ed and micu. bp has now been stable without requring fluid for over 24 hrs and therefore patient was able to leave the micu. . on arrival to the floor, patient denies any current complaints and states that he feels as well as he normally does at home. . 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 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. past medical history: htn hyperlipidemia type ii dm status post carotid endarterectomy thrombocytopenia fibrotic lung disease: likely due to asbestosis bladder ca status post turbt social history: lives in with his wife and son. significant 30+ pack year history, quit 3 months ago. no alcohol use. emigrated to the u.s. in the , worked in shipyards for 30 years. family history: denies family history of coronary artery disease, congestive heart failure. physical exam: admission physical exam vitals: 98.9 hr 75 bp 105/51 rr 16 97% 2 liters n/c general: alert, oriented, no acute distress, slightly agitated heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: bibasilar crackles that clear somewhat with ventilation, rare wheeze lul abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly. biliary drain in place gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation pertinent results: admission labs ============== 10:00am blood wbc-5.0 rbc-3.20* hgb-9.8* hct-30.9* mcv-96 mch-30.7 mchc-31.8 rdw-16.8* plt ct-76* 11:25pm blood neuts-73* bands-3 lymphs-10* monos-8 eos-5* baso-0 atyps-1* metas-0 myelos-0 10:00am blood pt-13.9* ptt-28.2 inr(pt)-1.2* 10:00am blood glucose-121* urean-21* creat-1.1 na-136 k-4.4 cl-100 hco3-27 angap-13 10:00am blood alt-28 ast-39 alkphos-207* amylase-31 totbili-0.6 dirbili-0.3 indbili-0.3 10:00am blood lipase-11 06:15am blood albumin-2.5* calcium-7.5* phos-3.4 mg-1.5* 11:25pm blood iron-26* 11:25pm blood caltibc-251* vitb12-450 folate-11.8 ferritn-135 trf-193* 11:25pm blood tsh-1.5 06:15am blood cortsol-27.3* 11:30pm blood lactate-1.1 k-4.2 . discharge labs: =============== 06:27am blood wbc-2.8* rbc-3.02* hgb-9.0* hct-28.3* mcv-94 mch-30.0 mchc-31.9 rdw-16.7* plt ct-85* 06:27am blood glucose-111* urean-21* creat-1.3* na-139 k-3.9 cl-100 hco3-31 angap-12 05:56am blood alt-21 ast-40 alkphos-235* totbili-0.6 06:27am blood mg-1.8 . other studies: ============== cxr : 1. diffuse interstitial opacities likely pulmonary fibrosis (evidence of asbestos exposure) with or without interstial pulmonary edema or atypical infection. 2. dilated azygous vein indicates elevated central venous pressure or volume. . cxr : as compared to the previous radiograph, there is no relevant change. borderline diameter of the azygos vein indicating minimal systemic fluid overload. however, there is no other indicator for pulmonary fluid overload, in particular no widening of the mediastinum, no presence of pleural effusions and no interval enlargement of the cardiac silhouette. unchanged extensive bilateral interstitial opacities, in the context of known pulmonary fibrosis. no interval appearance of new focal parenchymal opacities. . tte : the left atrium is mildly dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. mild diastolic lv dysfunction. no clinically-significant valvular disease seen. . microbiology: ============= 12:10 am bile gram stain (final ): no polymorphonuclear leukocytes seen. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. 3+ (5-10 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): gram positive rod(s). smear reviewed; results confirmed. fluid culture (preliminary): due to mixed bacterial types (>=3) an abbreviated workup is performed; p.aeruginosa, s.aureus and beta strep. are reported if present. susceptibility will be performed on p.aeruginosa and s.aureus if sparse growth or greater.. anaerobic culture (preliminary): no anaerobes isolated. . blood cultures and : ngtd brief hospital course: 71 year old male with history of htn, hyperlipidemia, who presented with fever and relative hypotension after elective ercp. . active issues: ============== # fever, hypotension- this may have been related to transient bacteremia from manipulation of tube during ercp, however could not exclude acending cholangitis therefore patient was started on empiric antibiotics. workup unremarkable for other localizing source of infection. - he will po cipro and metronidazole based on discussion with ercp. will complete a 7 day course of antibiotics as outpatient. . # pancytopenia: appears to be chronic based upon review of records. no evidence of portal hypertension on exam. given diverse differential on cbc, concern for a marrow process. patient is not deficient in b12, folate, or iron. these findings do not appear to be directly related to current admission but warrant further workup possibly including bone marrow biopsy. however patient eager to go home and have any further testing as outpatient with pcp. risk is low based on current values. - pcp informed and will evaluate and refer appropriately at f/u appointment - further workup as outpatient . # hypoxemia- during his stay the patient was noted to have low o2 sats on room air. ambulatory o2 sats dipped as low as 79% transiently. the patient denied any feeling of shortness of breath. he reported that his breathing was at baseline. it was unclear if he is chronically hypoxemic. the patient's pcp did not have any pft records available. osh records indicated a history of fibrotic lung disease and evidence of asbestosis likely due to his career working in a ship-yard. chest x-rays performed here are concordant with this history. the patient's pcp was and he could not recall any history of de-saturations to this degree. it is unclear what component of his hypoxemia is from his chronic lung disease and what is acute. it was initally thought that he had a component of pulmonary edema because patient 5 liters positive in micu and cxr suggestive. therefore he was diuresed with iv lasix and he was clinically euvolemic but there was minimal improvement in oxygenation. tte showed preserved ef with mild diastolic dysfunction. there was nothing obvious on history or physical to suggest another etiology for patient's acute insult to his chronic lung disease. he was low risk for pulmonary embolism therefore cta was not indicated. he has a long smoking history however patient denied any known diagnosis of copd and patient was not on any copd medications. the patient was strongly opposed to any further workup while inpatient and threatened to leave ama on multiple occassions. therefore he will follow-up with his pcp tomorrow and will have further workup including referral to pulmonology with ct and pfts as outpatient. he was unable to maintain ambulatory o2 sats above 88% therefore he will go home with o2. patient, patient's wife, and daughter all state they are committed to maintaining no smoking in the home. they understand the risks including fire and serious injury. patient counseled on smoking cessation. . chronic issues: ================ # htn- continue home lisinopril . # hl- cont home simvastatin . # type ii dm- continue home metformin . transitional issues: ==================== - contact: daughter () - patient's pcp will coordinate further workup of hypoxemia including chest ct and referal to pulmonology - patient's pcp will coordinate further workup of pancytopenia medications on admission: lisinopril 5 mg daily simvastatin 40 mg daily metformin 850 daily discharge medications: 1. simvastatin 40 mg tablet sig: one (1) tablet po at bedtime. 2. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 3. metformin 850 mg tablet sig: one (1) tablet po once a day. 4. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours): last dose in evening on . disp:*5 tablet(s)* refills:*0* 5. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day): last dose in evening on . disp:*7 tablet(s)* refills:*0* 6. home oxygen therapy 2 liters/minute for portability: pulse dose system discharge disposition: home with service facility: homecare discharge diagnosis: primary - sepsis - post ercp fever - hypoxemia - pulmonary fibrosis secondary - pancytopenia - type 2 dm - hypertension - hyperlipidemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , you were admitted to the hospital because you had fever and low blood pressure after your ercp procedure. there was concern that you could have a serious infection. therefore you were admitted to the intensive care unit and given antibiotics and fluid to help maintain your blood pressure. you did well and were able to leave the icu. you will take 2 more days of antibiotics when you get home as described below. an additional reason that you needed to stay in the hospital was that your oxygen levels were low. although you may not always have symptoms, it is very dangerous to have low oxygen levels for a long period. part of the explanation for your low oxygen levels may have been extra fluid in your lungs, therefore that was removed with medication. however you still had low oxygen levels afterwards. most likely this is from lung disease that you have had for some time. as we discussed, it is very important that you and everyone else in your household quit smoking. oxygen is very flammable and can cause a fire. you will need the following additions were made to your medications: start: ciprofloxacin 500 mg tablet twice daily. last dose in evening on . start: metronidazole 500 mg tablet three times daily. last dose in evening on you should continue taking all of your other medications as you were previously. you will need to see your primary care doctor soon for further evaluation of your lung disease. you also will need further evaluation for your low blood counts. followup instructions: name: vlagopoulos,triphon p. address: , , phone: appointment: wednesday 2:00pm your primary care doctor should refer you to see a pulmonologist (lung specialist) for further evaluation. md, Procedure: Endoscopic retrograde cholangiopancreatography [ERCP] Replacement of stent (tube) in biliary or pancreatic duct Diagnoses: Thrombocytopenia, unspecified Tobacco use disorder Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other and unspecified hyperlipidemia Postinflammatory pulmonary fibrosis Personal history of malignant neoplasm of bladder Cholangitis Personal history of contact with and (suspected) exposure to asbestos Postprocedural fever Other pancytopenia Other specified counseling

allergies: no known allergies / adverse drug reactions attending: chief complaint: open thoracotomy major surgical or invasive procedure: extended vram to the back history of present illness: 64yom w/ a hx of small cell ca. has had a left upper lobectomy & superior segmentectomy following induction radiotherapy and chemotherapy, then resection as well as postoperative empyema with bronchopleural fistula. has also had a modified eloesser flap, and currently has an open thoracotomy cavity that he continues to dress with every other day dressing changes and presents for further potential reconstructive options. past medical history: -hypercholesterolemia -osteoarthritis of hip -squamous cell ca (lul), s/p rt, s/p left upper lobectomy, mediastinal lymph node dissection, intercostal muscle flap buttress and partial pulmonary decortication on . the pathology revealed an 8.8cm moderately differentiated squamous cell carcinoma, with negative lns and negative margins (t3n0) -s/p vats decortication . dvt: non-occlusive thrombosis of bilateral popliteal, the right peroneal and the left posterior tibialis veins social history: lives alone, has always lived in ma, works as a post office letter carrier (prior employment- government contractor), smoked 1 ppd x 40 yrs (quit on ), drinks a few beers 2-3 times/weekly family history: prostate cancer (father, deceased) hypertension (mother, alive) physical exam: preoperative physical exam: on exam, he is alert, oriented, in no apparent distress, fully ambulatory, fully conversant. he has a weight of 185 pounds. he has a height of 5 feet 10 inches. examination of the abdominal region reveals a small umbilical hernia. he has adequate tissue for abdominally based reconstruction. posteriorly on the left side, he has a thoracotomy cavity that is quite deep and extends medially from the prior resection. the cavity is at this point clean and does not reveal areas of granulation tissue and does not reveal any areas of purulence, and it is the cavity that extends significantly anterior and medial. cranial nerve examination is otherwise intact pertinent results: 09:32pm pt-13.5* ptt-32.6 inr(pt)-1.3* 09:33pm wbc-8.1 rbc-3.51* hgb-10.1* hct-31.5* mcv-90# mch-28.7# mchc-32.1 rdw-15.5 brief hospital course: the patient was admitted to the plastic surgery service on sp small cell resection with an open thoracotomy cavity. patient was taken to the operating room and underwent free extended vram to back. patient tolerated the procedure without difficulty and was transferred to the pacu, then the floor in stable condition. please see operative report for full details. neuro: the patient received oxycodone with good effect and adequate pain control. cv: the patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. pulmonary: the patient was stable from a pulmonary standpoint; vital signs were routinely monitored. gi/gu: a po diet was tolerated well. patient was also started on a bowel regimen to encourage bowel movement. intake and output were closely monitored. id: the patient's temperature was closely watched for signs of infection. prophylaxis: the patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. at the time of discharge on , the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. all questions were answered, and patient has appropriate follow-up care. discharge medications: 1. acetaminophen 650 mg po q6h:prn pain, fever 2. aspirin 121.5 mg po daily please take for one month rx *aspirin 81 mg 1.5 tablet(s) by mouth every day disp #*45 tablet refills:*0 3. docusate sodium 100 mg po bid 4. oxycodone (immediate release) 5-10 mg po q4h:prn pain rx *oxycodone 5 mg tablet(s) by mouth every 4-6 hours disp #*60 tablet refills:*0 5. senna 1 tab po bid:prn constipation 6. levofloxacin 750 mg po q24h antibiotic rx *levofloxacin 750 mg 1 tablet(s) by mouth once a day disp #*7 tablet refills:*0 discharge disposition: extended care facility: hospital - discharge diagnosis: sp extended vram to the back discharge condition: stable discharge instructions: followup instructions: -you should continue taking the antibiotics as prescribed. -please do not put pressure on your incision -please keep your incision dry -if your incision begins to worsen after discharge home with an acute increase in swelling or pain, please call the clinic at the number given and ask to speak with a doctor. . medications: * resume your regular medications unless instructed otherwise. * you may take your prescribed pain medication for moderate to severe pain. you may switch to tylenol or extra strength tylenol for mild pain as directed on the packaging. please note that percocet and vicodin have tylenol as an active ingredient so make sure that your tylenol intake does not exceed 4 grams/day. * take prescription pain medications for pain not relieved by tylenol. * take colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication to prevent constipation. you may use a different over-the-counter stool softener if you wish. * do not drive or operate heavy machinery while taking any narcotic pain medication. you may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . return to the er if: * if you are vomiting and cannot keep in fluids or your medications. * if you have shaking chills, fever greater than 101.5 (f) degrees or 38 (c) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. followup instructions: please fu with dr. in one week. please schedule an appointment with the plastic surgery clinic. Procedure: Arterial catheterization Attachment of pedicle or flap graft to other sites Dermal regenerative graft Diagnoses: Other iatrogenic hypotension Chronic airway obstruction, not elsewhere classified Atrial fibrillation Personal history of malignant neoplasm of bronchus and lung Personal history of tobacco use Iatrogenic pneumothorax Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Pulmonary congestion and hypostasis Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and thigh Non-healing surgical wound Other fluid overload

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: lung cancer major surgical or invasive procedure: thoracotomy, left upper lobectomy, mediastinal lymph node dissection, intercostal muscle flap buttress and partial pulmonary decortication history of present illness: 62m w/biopsy proven poorly differentiated squamous cell. he was recently treated with rt for a left upper lobe bronchus lesion with post obstruction pneumonia as well as with associated upper extremity dvt. he was treated with therapeutic lovenox for the dvt. he presents this admission for left upper lobectomy. past medical history: hypercholesterolemia osteoarthritis of hip social history: lives alone, has always lived in ma, works as a post office letter carrier (prior employment- government contractor), smoked 1 ppd x 40 yrs (quit on ), drinks a few beers times/weekly family history: prostate cancer (father, deceased) hypertension (mother, alive) physical exam: awake alert oriented lungs with good breath sounds on the right; some crackles at the left base; some rub; neck: smooth, nontender right supraclavicular lymph node; just over 1cm. otherwise, no supraclavicular or cervical lymphadenopathy. heart: regular; no murmur abd soft; extremities: no edema; pertinent results: : in comparison with the study of , there is progressive opacification replacing the air in the upper portion of the left lung. bilateral chest tubes remain in place. continued opacification at the left base reflecting some combination of hemorrhage, effusion, and atelectasis with elevation of the hemidiaphragm. shift of the midline structures to the left are again seen. the right lung is essentially clear. - inr 1.2 brief hospital course: mr. was admitted to the thoracic surgery service on for left thoracotomy, left upper lobectomy, decortication, and mediastinal lymph node dissection. he tolerated the procedure well and went to the icu post-operatively for blood pressure monitoring. he was transferred to the floor on pod 2, where he did well. the basilar chest tube was removed on pod 4, and the apical chest tube on pod 5. he was discharged home on pod 6. neuro: pain was initially well-controlled with an epidural, which was removed on pod 4. he began oral pain medications on pod 4 with good effect. cv: his blood pressure was low post-operatively, with map's in the 50's, requiring low-dose vasopressors on pod 0-1. he received 2 units prbc's and his pressure improved. before transfer to the floor, his map's were consistently in the high 60's without pressors. his blood pressure remained stable through the remainder of his admission. pulm: he underwent a left upper lobectomy with decortication and mediastinal lymph node dissection, with 2 chest tubes placed in the or. immediately post-operatively, he had a large, 4-chamber air leak in both chest tubes. his air leak decreased daily, until it was a 1-chamber leak only in the apical tube. his basilar chest tube was removed on pod 4, and the apical chest tube on pod 5. his chest x-rays consistently showed moderate expansion of the remaining left lower lobe and left midline shift. he was encouraged to use is and ambulate often. gi: he was given a regular diet immediately post-operatively, which he tolerated well. he did not have any issues with diarrhea or constipation. gu: a foley catheter was placed in the or, and was kept in place while he had the epidural. his urine output was monitored. it was removed at midnight on pod 5, after the epidural was removed. heme/id: he required 2 units of prbc's for low blood pressure and decreased urine output, to which he responded well. he did not require any transfusions after pod 1. he was given cipro empirically for possible abscess in the resected specimen. cipro was stopped when the cultures from the or returned negative. he was begun on coumadin at discharge with instructions to follow-up immediately with dr . prophylaxis: he was given subcutaneous heparin tid and scd's. he was encouraged to ambulate early. at the time of discharge on pod 6, he was ambulating independently, voiding, and had good pain control with oral pain medications. he will follow-up with dr. in 2 weeks and dr tomorrow. medications on admission: combivent 18-103 mcg/actuation aerosol ''q4-6hrs,acetaminophen 325 qid,lovenox 70 , lorazepam 0.5q4h, ranitidine hcl 150 od, morphine 15 q4h discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 2. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). disp:*600 ml* refills:*2* 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*60 tablet(s)* refills:*0* 4. oxycodone 10 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po q12h (every 12 hours). disp:*30 tablet sustained release 12 hr(s)* refills:*0* 5. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for breakthrough pain. disp:*20 tablet(s)* refills:*0* 6. warfarin 5 mg tablet sig: one (1) tablet po once a day. disp:*10 tablet(s)* refills:*0* 7. warfarin 5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: lung cancer discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: call dr. office at if you have fevers greater than 101.5, chills, shakes, shortness of breath, cough or excessive drainage from left chest tube site. call if your left incisions open, drain, or become swollen or red. the incisions have dermabond covering them that will come of in a few weeks. you may shower tomorrow but no submerging in water until incisions fully healed. you may take off your left chest tube dressings on monday morning. then keep the area covered with bandaids changing daily until incisions are healed. continue to walk several times a day and use incentive spirometer to deep breath. while on narcotics for pain, do not drive, and take stool softeners to prevent constipation. followup instructions: follow up with dr at on monday the 29th of . call his office monday morning to be seen the same day for inr check and coumadin adjustment. follow up with dr. : please call the office on monday to schedule your appointment for 1-2 weeks from now. get a chest xray the same day before your appointment on radiology. Procedure: Decortication of lung Division or crushing of other cranial and peripheral nerves Regional lymph node excision Other lobectomy of lung Diagnoses: Other iatrogenic hypotension Pure hypercholesterolemia Unspecified pleural effusion Personal history of tobacco use Iatrogenic pneumothorax Malignant neoplasm of upper lobe, bronchus or lung Loss of weight Personal history of venous thrombosis and embolism Personal history of irradiation, presenting hazards to health Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and thigh Pleurisy without mention of effusion or current tuberculosis Other acute postoperative pain

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fever, cough, weakness major surgical or invasive procedure: rigid bronchoscopy and endobronchial debulking of squamous cell lung mass endotracheal intubation history of present illness: mr. is a 62 y/o man w/ recently-diagnosed lul poorly-differentiated squamous cell lung cancer admitted for hypotension and fever secondary to a post-obstructive pneumonia. patient had back pain, weight loss, and productive cough with mild hemoptysis at the beginning of ; at that time revealed a lul opacity. f/u ct thorax on revealed lul mass 5 x 6.7 cm concerning for malignancy. on , patient underwent a flexible bronchoscopy with endobronchial biopsies, and a linear endobronchial ultrasound with lymph node biopsies (both procedures performed by dr. . endobronchial biopsies revealed poorly-differentiated squamous cell carcinoma. patient presented to pcp's (dr. angels) office with worsening cough, fever and weakness on . vitals at pcp's office were: 101.7, sbp 82/52, tachycardic to 115, and breathing 98% on ra; had diminished l upper lung breath sounds, per pcp. on revealed new infiltrate peripheral to the mass lesions; likely consistent with pna. he was referred to the ed by pcp at that time. in the ed, vitals were: 99.0, 88/65, 93, and 96% on 2l. done in ed also showed likely post-obstructive pna. patient was given 3l ns, 1 gram iv vancomycin, and 750 mg po levofloxacin, and sent to the micu. started on ampicillin/sulbactam (unasyn) and continued on levofloxacin in the micu. hypotension was stablized- proven to be fluid responsive. breathing comfortably on 4 l oxygen. lul mass thought to be obstructing airway- or endobronchial debulking performed this afternoon, , prior to transfer from micu to the floor; suggested by ip consult. patient's procedure was c/b hypoventilation and paco2 noted at one point to be > than 100. mechanical ventilation/intubation in pacu lowered paco2 to ~ mid-50's and patient was extubated, then transferred to the floor (o2 saturation > 90%). past medical history: hypercholesterolemia osteoarthritis of hip social history: lives alone, has always lived in ma, works as a post office letter carrier (prior employment- government contractor), smoked 1 ppd x 40 yrs (quit on ), drinks a few beers times/weekly family history: prostate cancer (father, deceased) hypertension (mother, alive) physical exam: on admission: vs: t 98.7 bp 108/60 p 87 r 18 sat 97%ra gen: nad, aaox3, looks comfortable heent: mm slightly dry, no lesions or exudate noted neck: no cervical or supraclavicular lad cv: rrr, s1/s2, no m/r/g audible lungs: focal area of wheezing, rales in left upper lobe, scattered wheezes in left lung as a whole, right lung ctab with no w/r/r; dullness to percussion at left upper of lung, no noted egophony abd: +bs, normoactive; soft ntnd; no hepatosplenomegaly noted ext: wwp, 2+ pitting edema present in legs bilaterally to halfway up shin, non-tender to palpation neuro: aaox3, cns ii-xii intact, sensation intact to lt . on discharge: vs: tc:97.8, hr:89, bp:140/80, rr:18, so2:100%ra general: comfortable appearing, nad heent: op clear cv: rrr, normal s1, s1, no m/r/g resp: unlabored breathing, minimal diffuse end-expiratory wheezing throughout, worse in lul with decreased bs in left lung abdominal: s/nt/nd extremities: 2+ pulses pertinent results: admission labs: . 05:45pm blood wbc-22.8* rbc-4.27* hgb-12.0* hct-36.3* mcv-85 mch-28.1 mchc-33.0 rdw-13.6 plt ct-309 05:45pm blood neuts-91* bands-2 lymphs-2* monos-5 eos-0 baso-0 atyps-0 metas-0 myelos-0 05:45pm blood pt-15.8* ptt-31.4 inr(pt)-1.4* 05:45pm blood glucose-114* urean-20 creat-1.2 na-138 k-4.2 cl-99 hco3-26 angap-17 05:45pm blood alt-21 ast-19 alkphos-118 totbili-3.1* 09:28pm blood calcium-7.7* phos-3.8 mg-1.8 . ct chest with contrast (): 1. enlarging left upper lobe mass with left upper bronchial stenosis, at the level of stenosis the pulmonary artery is less than 11mm posterior to the bronchus. encasement of the left upper lobe pulmonary artery and post-obstructive pneumonia. 2. new bilateral small pleural effusions. 3. new left basal pneumonia, probably aspiration of left upper lobe contents. . interval results: . mri head with and without contrast (): no evidence of intracranial metastatic disease. . ct chest without contrast (): 1. progression of left upper lobe atelectasis and consolidation as above. 2. status post recent debridement with gas in the area of the previously seen lesion and re-opening of the left upper lobe bronchus, as above. there is stenosis of the left upper lobe bronchus, however there is mild increase in aeration of the apicoposterior segment with peripheral dilated bronchioles. 3. progression of ground-glass and consolidation in left lower lobe, possibly related to aspiration and in part to compressive atelectasis due to enlarging left pleural effusion. 4. small right pleural effusion with adjacent atelectasis. 5. unchanged lymphadenopathy. . pleural fluid analysis (): 4+ pmns, no organisms, fluid culture without growth, anaerobic culture without growth. . fdg tumor imaging (): 1. fdg avid left upper lobe consolidation, with more focally increased fdg avidity surrounding a narrowed left upper lobe bronchus, compatible with the known squamous cell carcinoma with post-obstructive collapse and consolidation of the left upper lobe. 2. fdg avid consolidation of the left lower lobe and lingula, likely pneumonia or aspiration. 3. moderate left and small right pleural effusions. 4. fdg avid mediastinal lymphadenopathy. 5. trace free fluid in the pelvis. . chest ct with contrast (): 1. interval improvement in left upper lobe post-obstructive pneumonia with improved aeration of the anterior aspect of the left upper lobe. foci of gas within this consolidated parenchyma are similar in appearance, and potential communication between a left upper lobe segmental bronchus and these collections of air is possible. known mass lesion is not well evaluated due to surrounding consolidation. 2. slight interval increase in left pleural effusion. resolution of right pleural effusion. 3. extensive lymphadenopathy, unchanged. it is unclear what component is reactive versus involved with malignancy. . ultrasound with doppler of lower extremities (): non-occlusive thrombosis of bilateral popliteal, the right peroneal and the left posterior tibialis veins. . blood cultures were repeated 9 times during admission and were always without growth. . chest x-rays were repeated 11 times throughout admission and demonstrated left upper lobe post-obstructive pneumonia with little to no improvement. images later in stay further revealed almost complete white out of the left lung with collapse of the left lower lobe detected late in the hospital course. . mediastinal lymph node biopsy (): 1. lymph node, 4r, biopsy (a-d): no malignancy identified. 2. lymph node, 4l, biopsy (e-f): no malignancy identified. 3. lymph node, level 7, biopsy (g-h): no malignancy identified. 4. lymph node, 2r, biopsy (i): no malignancy identified. 5. lymph node, 2l, biopsy (j): no malignancy identified. . discharge results: . 07:20am blood wbc-9.1 rbc-3.66* hgb-9.9* hct-31.1* mcv-85 mch-27.0 mchc-31.7 rdw-15.7* plt ct-470* 07:20am blood glucose-86 urean-5* creat-0.7 na-140 k-3.8 cl-101 hco3-32 angap-11 07:20am blood albumin-2.4* calcium-8.0* phos-3.6 mg-2.3 brief hospital course: 62 y/o man with left upper lobe poorly-differentiated squamous cell carcinoma, who presented with fevers, leukocytosis and hypotension in the setting of lul post-obstructive pna. . # hypotension: patient presented with systolic blood pressures in the 80s. patient was sent to the micu and pressure came up to the 100s following 4l ns. mental status was never compromised. lactate was 1.7. the patient was subsequently transferred to the general medicine floors. the patient continued to have intermittent hypotensive episodes during his stay that were associated with severe night sweats and fevers. after infectious work up was negative on multiple occassions, the fevers were attributed to his tumor and he was started on scheduled acetaminophen and continuous ivf. the patient did not have subsequent episodes of hypotension. . # post-obstructive pneumonia: in the setting of known left upper lobe squamous cell carcinoma and radiographic evidence there was high concern for a post-obstructive pneumonia. the patient was started on vancomycin and levofloxacin in the ed but was switched to ampicillin/sulbactam in the micu. interventional pulmonology performed a rigid bronchoscopy with bulk resection on . antibiotics were again switched to levofloxacin and metronidazole per id's recommendations. the patient subsequently began radiation therapy in an effort to shrink the tumor with hopes that this would be definitive therapy for the pneumonia. repeat chest x-rays throughout admission demonstrated little to no improvement in the post-obstructive pnemonia with subsequent collapse of the left lower lobe and progression of the ateletctasis of the left upper lobe. the patient was again transitioned from levofloxacin and flagyl to ampiclliin/sulbactam. antibiotics were discontinued at discharge as the patient had completed over 20 days of antibiotics and there was little concern for infectious etiology of his fevers per above. . # left upper lobe poorly differentiated squamous cell carcinoma: patient was diagnosed several weeks prior to admission at which time the lymph nodes were clear. brain mri showed early in the hospitalization revealed no evidence of brain metastases. pet scan on revealed mediastinal lymph nodes suspicious for metastases. the patient subsequently began xrt treatments to shrink the tumor enough to treat the post-obstructive pneumonia. thoracic surgery was consulted and performed a mediastinoscopy for which the sampled lymph nodes were negative for malignant cells. the patient was discharged with instructions to follow up with his oncologist as well as with the chest disease center. . # pleural effusion: pleural fluid was negative for malignant cells on thoracentesis with cultures showing no empyema. an exudative parapneumonic effusion was suspected, with no evidence of empyema. the patient was treated for pneumonia as per above. . # partial occlusive thromboses: patient had mild right-sided lower extremity edema midway through admission. an ultrasound study with dopplers revealed non-occlusive thromboses of the bilateral popliteal, the right peroneal and the left posterior tibialis veins. the patient was initially treated with a heparin drip due to concerns over renal function. the patient was eventually treated with enoxaparin 80 mg subcutaneous injection twice daily and was discharged home with instructions to continue the injections. . # thrombocytosis: likely acute phase reactant in the setting of ongoing infection and inflammation. patient's platelet counts remained elevated throughout admission. . # anemia: hematocrit stable throughout admission. iron studies consistent with anemia of chronic inflammation. medications on admission: none discharge medications: 1. combivent 18-103 mcg/actuation aerosol sig: inhalation every 4-6 hours as needed for shortness of breath or wheezing. disp:*1 * refills:*0* 2. codeine-guaifenesin 10-100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough for 2 weeks. disp:*1 300 ml bottle* refills:*1* 3. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 8 days. disp:*8 tablet(s)* refills:*0* 4. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). disp:*120 tablet(s)* refills:*0* 5. lovenox 80 mg/0.8 ml syringe sig: seventy (70) mg subcutaneous twice a day. disp:*10 syringes* refills:*0* 6. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for anxiety. disp:*20 tablet(s)* refills:*0* 7. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. morphine 15 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*20 tablet(s)* refills:*0* discharge disposition: home with service facility: all care vna of greater discharge diagnosis: primary diagnoses: post-obstructive pneumonia seconday diagnoses: squamous cell lung cancer discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure taking care of you at the . you were admitted to the hospital for pneumonia, fever and low blood pressure, also known as hypotension. your known lung cancer was obstructing your airways, leading to what is known as a post-obstructive pneumonia. you had a procedure to debulk the lung cancer and attempt to open your airways in order to allow the pneumonia to resolve. you received antibiotics, which you will need to continue as an outpatient. while you were in the hospital, we began the work-up for staging your lung cancer. you had a brain mri which did not show any metastases. you are scheduled for a pet-ct scan as an outpatient, you will need to follow the directions for oral contrast as provided prior to discharge. you should follow up with dr. from medical oncology at , dr. from thoracic surgery, and dr. from radiation oncology. the following changes were made to your medications: 1. start using combivent inhaler, inhalations every hours as needed for shortness of breath 2. start using codeine-guaifenesin cough syrup, ml by mouth every six hours as needed for cough 3. start using fluconazole 200 mg by mouth once a day. this medication is for your sore throat. you will need to take it for 8 more days. 4. start taking acetaminophen 325 mg. take two tablets by mouth every six hours as needed for fever. do not exceed 8 tablets per day. 5. start using lovenox 70 mg subcutaneous injection twice a day. this medication is for the blood clots found in your legs. 6. start using lorazepam 0.5 mg by mouth every four hours as needed for anxiety. 7. start taking ranitidine 150 mg by mouth once a day. this medication helps with reflux. 8. start taking morphine sulfate ir 15 mg by mouth every four hours as needed for pain. followup instructions: department: chest disease center name: , when: please call the thoracic oncology program to schedule your upcoming appointment with dr. 4-8 days after your hospital discharge. please call the office number listed below to make this appointment. location: address: , 9, , phone: department: pulmonary function lab when: monday at 10:30 am with: pulmonary function lab building: gz building (felbeerg/ complex) campus: east best parking: main garage department: radiology when: wednesday at 5:40 pm with: xmr building: cc campus: west best parking: garage with: pet-ct scan department: radiology when: thursday at 1:45 pm location: center, campus: east department: primary care name: dr. when: monday at 4:30 pm location: address: , 3rd fl, , phone: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Thoracentesis Other bronchoscopy Biopsy of lymphatic structure Mediastinoscopy Endoscopic excision or destruction of lesion or tissue of lung Other radiotherapeutic procedure Diagnoses: Pneumonia, organism unspecified Anemia of other chronic disease Obstructive sleep apnea (adult)(pediatric) Pure hypercholesterolemia Unspecified pleural effusion Unspecified protein-calorie malnutrition Personal history of tobacco use Candidiasis of mouth Malignant neoplasm of upper lobe, bronchus or lung Hypoxemia Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Hypovolemia Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Leukocytosis, unspecified Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and thigh Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Fever presenting with conditions classified elsewhere Dysphagia, unspecified

allergies: bupropion analogues attending: chief complaint: fall major surgical or invasive procedure: left sided craniotomy for sdh evacuation open gastrostomy tube history of present illness: this is an 85 year old man with history of dementia who lives at home with his daughter. today he was in his driveway when he fell and struck his head. he went back into his house and called 911 for help. upon ems arrival he was in his usual state answering questions and oriented to himself and his family. pt taken to osh where he began to have mental status changes and became less responsive. he was intubated and ct of the head showed left sided sdh with midline shift and diffuse sah with bifrontal contusions. he was transfered to for further evaluation. he was taking asa and plavix for a previous cardiac stenting. he did not receive any blood products prior to transfer. past medical history: s/p removal of duodenal adenoma dysplasia and pancreatic endocrine tumor depression ankle fracture 3 wks ago hypercholesterolemia mild dementia gerd chronic constipation known urinary frequency social history: retired pathologist, no smkg, etoh, drugs, married, lives at home with wife family history: father: mi in his 70s uncle: died in 60s of mi physical exam: on admission: physical exam: bp: 151/86 hr: 74 r 18 o2sats gen: intubated and sedated heent: pupils: 2-1.5mm eoms unable to evaluate occipital laceration noted, not currently bleeding neck: c collar in place extrem: warm and well-perfused. neuro: mental status: intubated and sedated. not following commands. mae to noxious stimuli. sensation: intact to noxious stimuli on discharge: ******************** pertinent results: head cta: impression: 1. extensive acute subdural hematoma along the left cerebral convexity with subdural hemorrhage along the falx and subarachnoid hemorrhage as described above. there is midline shift of approximately 6 mm. 2. limited opacification of the distal/small branches of the intracranial internal carotid and vertebrobasilar system. the cervical and intracranial vertebral and basilar arteries appear unremarkable. the proximal branches of the intracranial internal carotid and vertebrobasilar system appear unremarkable. cspine ct: impression: 1. no evidence of fracture. 2. grade 1 anterolisthesis of c3 on 4, of indeterminant chronicity. if there is high clinical concern for a ligamentous injury, an mri is suggested. 3. right thyroid nodules, partially calcified. head ct:impression: overall similar appearance of extensive subdural hematoma and subarachnoid hemorrhage, with mild redistribution of blood products, making the right lateral ventricle intraventricular portion more prominent. head ct: impression: no significant change in extent of the predominantly left holohemispheric subdural hematoma and subarachnoid and intraventricular hemorrhage. stable 3-mm left to right midline shift. no new hemorrhage is identified. : ct head 1. interval increase in the size of subdural collection with focal increased density suggestive of rebleeding. 2. continued evolution of the previously described bilateral subarachnoid hemorrhage and bifrontal hematomas. : video swallow abnormal oropharyngeal swallowing videofluoroscopy with aspiration of thin liquids and nectar-thickened liquids. there was penetration of honey-thickened liquids. patient was able to swallow puree and soft solids without aspiration or penetration. ct head interval increase in the thickness of the left subdural fluid collection, which appears to be appropriately evolving with regard to its density. appropriate evolution of the subarachnoid hemorrhage and bifrontal hematomas without evidence of new bleeding or infarction. ct head post-op status post left subdural hematoma evacuation with improvement of midline shift and expected pneumocephalus and subcutaneous emphysema; persisting but largely unchanged subarachnoid blood. shoulder x-ray 3 views calcific tendinopathy. mild acromioclavicular and glenohumeral osteoarthritis. brief hospital course: dr. was admitted to the sicu for close neurological observation. there were discussions with his family and it was decided that he would not want extreme measures if a meaningful outcome was not expected. at that time he was made dnr/dni. over the first couple of hours the patients exam improved significantly therefore there were further discussions with the family. his code status was then changed to dnr only. on he was extubated and noted to be expressively aphasic but mae's with 4/5 strengths. on pt and ot consults were requested for discharge planning. speech and swallow was also consulted to assess his risk for aspiration. he did not pass and was kept npo at this time. he was cleared for transfer to the floor. on & he continued to improve neurologically. per the patient's daughter, he had a low testosterone level at an osh. endocrine was consulted and did not recommend repletion at this time. on the patient was awake, alert but continued to be aphasic. he is ambulating with nursing and complaining about being hungry and thirsty. speech and swallow consultation for re-evaluation was requested. on video swallow study was done which the patient failed and thus remained npo, the patient had a head ct which showed that there was new blood and as such plavix was not restarted and his aspirin was discontinued. an attempt was made to place a dobhoff tube which was unsuccessful. he also pulled out his iv and the iv nurse was unable to place a new peripheral so a picc line was requested. on his exam remained stable and his oob to chair. a picc line was placed and his potassium was repleted for a level of 3.0. he also spiked a fever to 101.0 for which he was pancultured. pt was planned for a peg tube on as he was deemed unsafe for po diet by the speech and swallow team multiple times. he was scheduled for placement on . he did have lower extremity dopplers for screening purposes given his prolonged hospital stay and bedrest. these were negative for dvt. he did have left upper extremity swelling on exam and upper extremity dopplers showed dvt within axilary vein and plan was for anticoagulation and removal of his picc line. a routine head ct obtained prior to anticoagulation showed an increase in his left sided subdural hematoma with increase in midline shift. his exam was slightly worse on this day and was only oriented to himself. surgery was offered to the family and they agreed to move forward with his care and he was brought to the operating room on for burr hole drainage of his now chronic sdh. post operatively he did well and was transported from the pacu to the floor on . his cipro was changed from po to iv, and his peg was placed on hold as his daughter was to consent for the procedure. also on he pulled out his picc line. post-operatively his exam was stable as well. he remained stable on the floor over the weekend and on consent was obtained by ir for him to receive a peg tube. he was taken by ir for placement of the peg but they were unable to place it secondary to agitation and bowel positioning. on , general surgery was consulted for peg placement under general anesthesia. on pt taken to the or with general surgery and underwent open peg placement without complication. after the procedure his g tube was opened to gravity and on medications were administered through his tube. the plan was to continue medications on this day and start tubefeeds via g tube on the morning of . on he was noted to have some abdominal pain and swelling and general surgery was contact to evaluate him. after valuation they felt he was at his baseline. also on he was noted to have some right shoulder pain so an orthopedics consult was called and a single view of the shoulder was ordered. the scan showed moderate ac joint arthropathy. on he remained stable and nutrition was consulted to give recommendations for tube feeds which were obtained and implemented. his exam continued to be consistent and on he will be discharged to rehab medications on admission: asa, plavix discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain/fever. 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. ondansetron hcl (pf) 4 mg/2 ml solution sig: one (1) injection q8h (every 8 hours) as needed for nausea. 5. multivitamin tablet sig: one (1) tablet po daily (daily). 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 7. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 8. calcium carbonate 200 mg (500 mg) tablet, chewable sig: two (2) tablet, chewable po tid (3 times a day). 9. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 11. levetiracetam 100 mg/ml solution sig: ten (10) ml po bid (2 times a day). 12. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 13. effexor xr 75 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po once a day. 14. aricept 10 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: - discharge diagnosis: left sdh subarachnoid hemorrhage respiratory failure dysphagia discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: general instructions ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, or ibuprofen etc. you are being discahrged on keppra (levetiracetam), you will not require blood work monitoring. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion, lethargy or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? new onset of the loss of function, or decrease of function on one whole side of your body. followup instructions: follow-up appointment instructions ??????please call ( to schedule an appointment with dr. , to be seen in 4 weeks. ??????you will need a ct scan of the brain without contrast prior to your appointment. this can be scheduled when you call to make your office visit appointment. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Incision of cerebral meninges Enteral infusion of concentrated nutritional substances Other lysis of peritoneal adhesions Closure of skin and subcutaneous tissue of other sites Other gastrostomy Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Percutaneous transluminal coronary angioplasty status Open wound of scalp, without mention of complication Constipation, unspecified Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Peritoneal adhesions (postoperative) (postinfection) Other complications due to other vascular device, implant, and graft Long-term (current) use of anticoagulants Retention of urine, unspecified Fall from other slipping, tripping, or stumbling Other late effects of cerebrovascular disease, dysphagia Acute venous embolism and thrombosis of deep veins of upper extremity Dysphagia, unspecified Calcifying tendinitis of shoulder Cortex (cerebral) contusion without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness

allergies: no known allergies / adverse drug reactions attending: chief complaint: mononucleosis, odynophagia major surgical or invasive procedure: : bilateral tonsillectomy history of present illness: the patient s a 22 yo male previously healthy who presented to ed on with fevers, sore throat, difficulty swallowing and handling secretions. he was recently diagnosed with mono by his pcp. initially went to an osh yesterday and was discharged home after receiving a dose of decadron and clindamycin and was feeling better, but over the course of the day, the symptoms recurred. now with severe b/l throat pain l slightly more than r, difficulty swallowing, b/l tender neck swelling. he denies difficulty breathing or noisy breathing. a ct neck in the ed showed a possible left pta, and the orl service was asked to evaluate. past medical history: shoulder and knee surgery social history: senior at . has been with same girlfriend per report x2 years. no tobacco, social alcohol, no illicit drugs. his brother does ride horses and family has a dog who gets recurrent ear infections at home. he is a baseball player and has traveled with his team but no recent foreign travel. family history: noncontributory physical exam: on admission: nad, breathing comfortably, no stertor or stridor, voice slightly muffled head nontraumatic, cn ii-xii intact b/l b/l anterior nc wnl except for mild inferior turbinate watery edema oc/op: no trismus, significant op erythema and exudate, b/l tonsillar erythema and hypertrophy 3+, uvula midline, peritonsillar region soft b/l but a small area of fullness just lateral to left tonsil. after local topical spray anesthesia, a 19g needle was used to attempt to aspirate the peritonsillar space lateral to left tonsil in area of fullness that coincides with ct finding of possible collection. after two passes, no purulent fluid was identified. coincidentally, the patient reported feeling slightly better after the attempted needle aspiration. neck: b/l tender lymphadenopathy, full rom foe: b/l nc with mild inferior turbinate watery edema, otherwise wnl. op b/l edema but no airway occlusion. b/l tvf fully mobile. no glottic/supraglottic/hp masses, lesions or edema. crisp epiglottic borders. pertinent results: 05:05am wbc-14.2* rbc-4.56* hgb-13.3* hct-39.2* mcv-86 mch-29.3 mchc-34.0 rdw-13.8 05:05am neuts-57 bands-5 lymphs-7* monos-5 eos-0 basos-0 atyps-0 metas-0 myelos-0 other-26* brief hospital course: the patient is a 22 y/o young man, previously healthy, who was transferred from osh to ed on with known diagnosis of ebv mononucleosis and significant pharyngotonsillitis. he had complaint of sore throat, inability to tolerate po at home with fevers to 102.1. a neck ct at was concerning for left peritonsillar abscesse and right phlegmon. bedside needle aspiration of the left peritonsillar area was negative. throat culture from outside hospital grew mssa and group c strep. blood culture from also at outside hospital grew group c strep. given persistent leukocytosis, fever and bacteremia with group c strep, id consulted for recommendations on antibiotics. vancomycin was added to clindamycin and based on culture results and concern for polymicrobial abscess, clindamycin was changed to ampicillin/sulbactam, per id recommendations. because of persistent symptoms are fever, the patient had a repeat ct neck on which showed increase in the left peritonsillar abscess and possible right peritonsillar abscess. he was taken to the or on for bilateral tonsillectomies and drainage of bilateral peritonsillar abscesses. intubation was difficult given the size of his tonsils, with concern for aspiration. he remained intubated until in the icu. he was extubated without issue and transferred to the floor later that day. the remainder of his hospital course was uneventful. he remained afebrile and continued to steadily improve. his pain was initially controlled with iv medications, and he was transitioned to po pain medications with good control. his diet was advanced to softs and he was maintaining adequate po intake and hydration. he was continued on iv unasyn per id recommendations. because of need for iv antibiotics at home, a picc line was placed on . repeat blood cultures here were negative and abscess culture from or grew strep milleri with polymicrobial flora on gram stain. per id recommendations, he was transitioned to iv ceftriaxone and po clindamycin on with plan for 2 weeks of iv ceftriaxone starting given history of bacteremia. a total antibiotic plan for at least 4 weeks with possible transition to po antibiotics was recommended. the patient received sqh and pneumoboots were in place until the patient was fully ambulatory. by , both the patient, family and team agree that the patient was ready for discharge to home. he is being discharged afebrile, tolerating a soft diet without nausea or vomitting, pain controlled on po pain medication. his exam was notable for soft, healing tonsillar fossa with exudate and eschar and no evidence of bleeding. he is being discharged to home with vna services,on iv ctx and po clindamycin, picc line in place. he is to follow up with dr. , id and his pcp as an outpatient. medications on admission: none discharge medications: 1. acetaminophen 650 mg/20.3 ml solution sig: six y (650) mg po q6h (every 6 hours). 2. oxycodone 5 mg/5 ml solution sig: ml po q4h (every 4 hours) as needed for pain. disp:*500 ml* refills:*0* 3. docusate sodium 50 mg/5 ml liquid sig: five (5) ml po bid (2 times a day). 4. erythromycin 5 mg/gram (0.5 %) ointment sig: one (1) application ophthalmic qhs (once a day (at bedtime)) for 7 days. disp:*1 tube* refills:*0* 5. white petrolatum-mineral oil 56.8-42.5 % ointment sig: one (1) appl ophthalmic tid (3 times a day). disp:*1 tube* refills:*2* 6. ceftriaxone 2 gram recon soln sig: two (2) grams intravenous once a day for 14 days. disp:*14 day supply* refills:*0* 7. clindamycin hcl 300 mg capsule sig: one (1) capsule po every eight (8) hours for 14 days: for a total of 450 mg per dose q8h. disp:*42 capsule(s)* refills:*0* 8. clindamycin hcl 150 mg capsule sig: one (1) capsule po every six (6) hours for 14 days: for a total of 450 mg per dose q8h. disp:*42 capsule(s)* refills:*0* 9. outpatient lab work cbc with diff, bmp, lfts, crp, esr weekly x 4 weeks. please fax results to clinic fax # discharge disposition: home with service facility: critical care systems discharge diagnosis: ebv mononucleosis tonsillitis peritonsillar abscesses bacteremia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you will need to get weekly labs that should be sent to id office for monitoring. these should be faxed to the clinic at . you will need to keep on iv ceftriaxone until you follow-up with id. they will decide at that time whether you need further iv antibiotics. what should i expect? it is normal to feel tired or washed out for several weeks after surgery. rest is important, but walking is also important to prevent problems and to regain your strength and energy. pace yourself according to how you feel. rest when you feel tired. it is normal for you to have pain in your ears after a tonsillectomy. your doctor will give you a prescription for pain medicine. after surgery you will notice white patches on the sidewalls of your throat. this is normal and not cause for alarm. how do i manage my pain? pain is normal after a tonsillectomy. for mild pain take acetaminophen (tylenol). do not take aspirin, ibuprofen, motrin, aleve, advil, or naprosyn for 2 weeks after surgery. these medicines may cause bleeding. for moderate to severe pain you may be given a prescription for a narcotic pain medicine. take pain medicine only as directed by your doctor. please do not drive. narcotics may cause drowsiness and lightheadedness. acetaminophen (tylenol) is contained in many medications. do not take tylenol at the same time as another product that contains tylenol, such as percocet, vicodin, or tylenol #3 unless recommended by your doctor. do not take a total of more than 4,000mg of tylenol in 24 hours. narcotic pain medicine can cause constipation. to make it easier to have a bowel movement: drink extra fluids. eat foods high in fiber. take a stool softener like docusate (colace). how do i care for myself at home? putting an ice pack on your throat and eating ice chips may help you feel better. use a humidifier or vaporizer for comfort. drink plenty of fluids. what activities am i allowed to do at home? showering/bathing you may shower or bathe 24-to-48 hours after your surgery. activity walking is recommended. climbing stairs is allowed. restart your normal daily activities when you are recovered from the anesthesia. slowly start to do more each day. for two weeks avoid any activity that increases the pressure in your head. do not do any strenuous activity like aerobics, running, weight lifting, or swimming. after two weeks you can slowly begin any activity. driving do not drive for 24 hours after surgery. do not drive while you are taking narcotic medicine for pain. safety do not drink alcoholic beverages for 24 hours or while taking narcotic pain medicine. do not make any important decisions for 24 hours or while taking narcotics. call your doctor if you have any questions. what may i eat? drink fluids. getting enough fluids is an important part of your recovery. if you feel nauseous, do not eat until your nausea goes away. eat light foods and soft solids in the beginning like ice cream, yogurt, and mashed potatoes. avoid sharp, dry, or rough foods such as crackers, pretzels, potato chips, or pizza crust for two weeks. seek immediate medical attention for fever >101.5, chills, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. ok to shower. no strenuous exercise or heavy lifting until follow up appointment, at least. do not drive or drink alcohol while taking narcotic pain medications. narcotic pain medications may cause constipation, if this occurs take an over the counter stool softener. resume all home medications. call dr. office at to make follow up appointment to be seen within 1-2 weeks. follow-up with your pcp weeks. followup instructions: - call dr. office at to make follow up appointment to be seen within 1-2 weeks. his office is located at , , , . - follow-up with infectious disease at as instructed by id team. you have an appointment on at 3:10 pm with dr. and on at 9:30 am with dr. . the clinic is located in th in , basement floor. please call to confirm your appointment. - follow-up with your pcp weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Incision and drainage of tonsil and peritonsillar structures Incision and drainage of tonsil and peritonsillar structures Tonsillectomy without adenoidectomy Diagnoses: Pneumonitis due to inhalation of food or vomitus Bacteremia Streptococcal sore throat Infectious mononucleosis Peritonsillar abscess Disseminated retinitis and retinochoroiditis, pigment epitheliopathy

allergies: ibuprofen / lipitor / deer tick attending: chief complaint: chest pain major surgical or invasive procedure: coronary artery bypass grafting x four (left internal mammary artery > left anterior descending, saphenous vein graft > diagonal, saphenous vein graft > obtuse marginal, saphenous vein graft > posterior descending artery) history of present illness: mr. is a 66 year old male has a history of dyslipidemia and prior tobacco abuse. he reports that over the past six to eight weeks he has noticed "heartburn" or chest pressure type symptoms when exerting himself after a meal or walking up and down inclines. these symptoms always resolve quickly with rest. he has also noticed occasional dyspnea on exertion. for this reason, he underwent non imaging stress testing where he was noted to have 3mm st depression in the inferoapical/anterior leads along with a fall in blood pressure. he was referred for left heart catheterization. he was found to have three vessel coronary artery disease and was referred to cardiac surgery for revascularization. past medical history: dyslipidemia lower back pain with spinal stenosis gib in the setting of high dose ibuprofen use (approximately 5-6 years ago) occasional hematuria on low dose aspirin (no prior workup) bph mild arthritis bilateral arthroscopic knee surgery hernia repair bilaterally teeth extraction in social history: he lives with his wife. mr. works four days a week in maintenance at . he quit smoking in and has a history of cigars per week for 40 years. he rarely drinks alcohol. family history: mr. father had angina in his 80's. his mother had a pacemaker. physical exam: pulse:59 resp:18 o2 sat:95/ra b/p right:111/66 left:100/72 height:5'.5" weight:187 lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + b groin hernia incisions extremities: warm , well-perfused edema varicosities: none neuro: grossly intact pulses: femoral right: cath site left: +2 dp right: +2 left: +2 pt : +2 left: +2 radial right: +2 left: +2 carotid bruit right: 0 left: 0 discharge: vs: t: 98.2 hr: 70 sr bp: 122/80 18 sats: 100% ra general: 66 year-old male in no apparent distress heent; normocephalic, mucus membranes moist neck: supple no lymphadenopathy card: rrr normal s1.s2 no murmur resp: clear breath sounds throught out gi: benign extr: warm no edema incision: sternal & lle clean, dry intact neuro: awake, alert, oriented walking in halls pertinent results: left atrium: normal la size. right atrium/interatrial septum: normal ra size. pfo is present. left ventricle: normal lv wall thickness and cavity size. normal lv wall thickness, cavity size, and global systolic function (lvef>55%). normal lv wall thickness, cavity size and regional/global systolic function (lvef >55%). right ventricle: normal rv chamber size and free wall motion. aorta: normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. normal diameter of aorta at the sinus, ascending and arch levels. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: normal mitral valve leaflets with trivial mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. pericardium: no pericardial effusion. prebypass: essentially normal exam. he has a small pfo with left to right flow. normal function, normal valves. the left atrium is normal in size. a patent foramen ovale is present. left ventricular wall thicknesses and cavity size are normal. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque . the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. postbypass: unchanged. no segmental wall motion abnormalities. lvef 50-55%, no dissection seen after removal of aortic cannula. 06:25am blood wbc-8.9 rbc-3.52* hgb-10.4* hct-31.4* mcv-89 mch-29.7 mchc-33.3 rdw-13.1 plt ct-334 05:50am blood glucose-126* urean-76* creat-6.7* na-136 k-4.2 cl-103 hco3-22 angap-15 08:51am blood urean-64* creat-5.4* 10:00pm blood urean-70* creat-5.9*# na-138 k-3.7 cl-106 05:55am blood glucose-114* urean-77* creat-7.0* na-137 k-4.4 cl-104 hco3-23 angap-14 brief hospital course: on he was brought to the operating room for coronary artery bypass graft surgery. please see the operative note for details. he received cefazolin for perioperative antibiotics and was transferred to the intensive care unit for post operative management. that evening he was weaned from sedation, awoke neurologically intact and was extubated without complications. on post operative day one he was started on lasix and beta blockers, additionally chest tubes were removed and was noted for bilateral apical pneumothorax. he had serial chest xrays that revealed continued improvement over the next few days without further intervention. his chest xray at the time of discharge showed stable pneumothoraces. on post operative day two his epicardial wires were removed and transferred to the floor. respiratory: aggressive incentive spirometer, ambulation and good pain control he titrated off oxygen with room saturations of 98% cardiac: hemodynamically stable sinus rhythm 80's without ectopy. beta-blockers were titrated. blood pressure 110-130's stable. statins and aspirin continued. gi: proton pump inhibitor & bowel regimen. tolerated a regular diet renal: pod 3 developed atn with peak cre of 7.0 (baseline 0.9). furosemide and toradol was discontinued. he continued to make adequate urine. electrolytes were replete as needed. he was seen by renal who recommended chem 10 labs daily keeping sbp>100 and dose meds for egfr<15. he was given 1 liter of lr on pod 9 and 10 and his cratinine and bun had decreased after stopping all diuretics and ivf was given. his creatinine had decreased to 4.1 at the time of discharge. endocrine: insulin sliding scale with blood sugars < 150. pain: toradol discontinued with rising creatinine, oxycodone and acetaminophen were continued with good pain control. disposition: he was seen by physical therapy for strength and mobility. he continued to make steady progress and was discharged to home on . he will need his electrolytes, bun and creatinine checked on . all follow-up appointments were advised. medications on admission: bisoprolol fumarate 5 qhs ascorbic acid 1000 asa 81 daily ergocalciferol 1,000u daily flaxseed 1,000 vitamin e 400u daily discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold for loose stools. 4. oxycodone 5 mg tablet sig: one (1) tablet po every 4-6 hours as needed for fever or pain. disp:*40 tablet(s)* refills:*0* 5. acetaminophen 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for fever or pain. 6. rosuvastatin 5 mg tablet sig: one (1) tablet po daily (daily). 7. outpatient lab work bun/cre monday and call results to discharge disposition: home with service facility: all care vna of greater discharge diagnosis: coronary artery disease s/p cabg pneumothorax dyslipidemia lower back pain with spinal stenosis gastrointestinal bleeding hematuria benign prostatic hypertrophy mild arthritis discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: date/time: bun/creatinine check call results to surgeon: dr date/time: 1:30 building cardiologist: / 1:00 pm please call to schedule appointments with your primary care dr in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Acute kidney failure with lesion of tubular necrosis Other and unspecified hyperlipidemia Iatrogenic pneumothorax Urinary complications, not elsewhere classified Spinal stenosis, unspecified region

allergies: iv dye, iodine containing contrast media attending: addendum: hydralazine was discontinued prior to discharge. discharge medications: 1. dorzolamide 2 % drops sig: one (1) drop ophthalmic daily (daily). 2. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 6. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 7. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 8. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed for dyspnea. 9. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 10. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 11. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). 12. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 13. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 14. furosemide 40 mg tablet sig: one (1) tablet po twice a day for 7 days: resume hctz when lasix course complete. 15. metformin 500 mg tablet sig: one (1) tablet po twice a day. 16. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po q12h (every 12 hours) for 7 days. 17. insulin lispro 100 unit/ml solution sig: one (1) subcutaneous four times a day: see attached sliding scale. discharge disposition: home with service facility: bay skill nursing & rehab ctr- md Procedure: Venous catheterization, not elsewhere classified Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Personal history of malignant neoplasm of prostate Aortic valve disorders Other chronic pulmonary heart diseases Personal history of tobacco use Unspecified glaucoma Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Long-term (current) use of insulin Macular degeneration (senile), unspecified Chronic systolic heart failure Examination of participant in clinical trial Legal blindness, as defined in U.S.A. Chronic total occlusion of coronary artery Acute myocardial infarction of other anterior wall, subsequent episode of care Postoperative air leak

allergies: iv dye, iodine containing contrast media attending: chief complaint: chest pain major surgical or invasive procedure: 1. urgent coronary artery bypass graft x2 left internal mammary artery to left anterior descending artery and saphenous vein graft to posterior descending artery. 2. aortic valve replacement with a size 25-mm - magna tissue valve. history of present illness: 75 year old male with recent onset of heart failure without angina in the setting of long-standing diabetes. he developed shortness of breath and was referred for a stress test. a persantine stress test showed dilated lv at stress and rest, global hypokinesis, ef of 23%, anterior infarct with a large area of peri-infarct ischemia, large inferior infarct without ischemia. a recent echo showed ef 30%, moderate aortic stenosis peak gradient 24, mean 13, 1.3 cm2 and mild to moderate aortic insufficiency. he reported to dr that aspirin causes worsening bleeding from his macular degeneration and ophthalmologist does not want him on aspirin. he was referred for right and left heart catheterization. he was found to have coronary artery disease upon cardiac catheterization and was referred to cardiac surgery for revascularization. past medical history: primary diagnosis: coronary artery disease aortic stenosis secondary diagnosis: ischemic cardiomyopathy diagnosed hypertension diabetes mellitus type 2 lumbar radiculopathy glaucoma prostate cancer treated with radiation anemia legally blind macular degeneration social history: lives with:lives alone and is legally blind contact: (daughter) phone # occupation:retired cigarettes: smoked no yes hx:history of 40 pack year, quit 4 years ago other tobacco use:denies etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use:denies family history: premature coronary artery disease-father with mi at age 74, brother with multiple stents physical exam: pulse:66 resp:18 o2 sat:100/ra b/p right:135/57 left:144/55 height:5'.5" weight:225 lbs general: nad skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + , obese extremities: warm , well-perfused edema __none___ varicosities: none neuro: grossly intact pulses: femoral right: 2 left:2 dp right: 1 left:1 pt : 1 left:1 radial right: 2 left:2 carotid bruit right: x left:x pertinent results: 05:50am blood wbc-7.1 rbc-2.71* hgb-8.3* hct-25.3* mcv-94 mch-30.7 mchc-32.9 rdw-15.4 plt ct-228 03:14am blood wbc-6.5 rbc-2.68* hgb-8.0* hct-25.2* mcv-94 mch-29.8 mchc-31.7 rdw-15.4 plt ct-217 05:03am blood wbc-8.9 rbc-2.91* hgb-9.0* hct-27.0* mcv-93 mch-31.0 mchc-33.5 rdw-15.7* plt ct-150 05:50am blood glucose-55* urean-27* creat-0.9 na-135 k-3.7 cl-98 03:14am blood glucose-73 urean-32* creat-0.9 na-134 k-3.6 cl-100 05:03am blood glucose-81 urean-24* creat-0.8 na-133 k-3.9 cl-100 hco3-24 angap-13 brief hospital course: the patient was admitted to the hospital and brought to the operating room on where the patient underwent urgent coronary artery bypass graft x2 left internal mammary artery to left anterior descending artery and saphenous vein graft to posterior descending artery, aortic valve replacement with a size 25-mm - magna tissue valve. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. he was weaned off antihypertensive drips and oral agents were added. the patient was transferred to the telemetry floor for further recovery. pacing wires were discontinued without complication. chest tubes remained in for extra days due to an air leak. this was followed via cxr and advanced slowly. eventually, cts were discontinued without complication. a small left pneumothorax persisted on cxr following removal of cts. lantus was decreased, and ultimately discontinued for hypoglycemia. metformin will be re-introduced slowly. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 5 the patient was ambulating, yet deconditioned, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to rehab in in good condition with appropriate follow up instructions. medications on admission: atenolol 100 mg daily bimatoprost 0.03 % drops - one drop each eye daily dorzolamide 2 % drops - one drop each eye daily hydrochlorothiazide 12.5 mg daily lantus 60 units in am and 20 units at supper time. levmefolate-b6 phos-methyl-b12 2 mg-3 mg-35 mg tablet lisinopril 40 mg daily metformin 1,000 mg pravastatin 20 mg daily aspirin 325 mg daily discharge medications: 1. dorzolamide 2 % drops sig: one (1) drop ophthalmic daily (daily). 2. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 6. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 7. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 8. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours) as needed for dyspnea. 9. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 10. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 11. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). 12. hydralazine 25 mg tablet sig: one (1) tablet po q6h (every 6 hours). 13. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 14. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 15. furosemide 40 mg tablet sig: one (1) tablet po twice a day for 7 days: resume hctz when lasix course complete. 16. metformin 500 mg tablet sig: one (1) tablet po twice a day. 17. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po q12h (every 12 hours) for 7 days. 18. insulin lispro 100 unit/ml solution sig: one (1) subcutaneous four times a day: see attached sliding scale. discharge disposition: home with service facility: tba discharge diagnosis: primary diagnosis: coronary artery disease aortic stenosis secondary diagnosis: ischemic cardiomyopathy diagnosed hypertension diabetes mellitus type 2 lumbar radiculopathy glaucoma prostate cancer treated with radiation anemia legally blind macular degeneration discharge condition: alert and oriented x3 nonfocal ambulating, deconditioned incisional pain managed with oral analgesia incisions: sternal - healing well, no erythema or drainage leg, left - healing well, no erythema or drainage. edema 2+ discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments provider , md phone: date/time: 1:30 cardiologist/pcp: . at 11:15a **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** md Procedure: Venous catheterization, not elsewhere classified Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Personal history of malignant neoplasm of prostate Aortic valve disorders Other chronic pulmonary heart diseases Personal history of tobacco use Unspecified glaucoma Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Long-term (current) use of insulin Macular degeneration (senile), unspecified Chronic systolic heart failure Examination of participant in clinical trial Legal blindness, as defined in U.S.A. Chronic total occlusion of coronary artery Acute myocardial infarction of other anterior wall, subsequent episode of care Postoperative air leak

allergies: shrimp attending: chief complaint: polytrauma major surgical or invasive procedure: i&d r femur, r tibia; retrograde im nail r femur, im nail r tibia, closed reduction r hip and skeletal traction orif l radius, front r acetabulum orif r posterior acetabulum ivc filter i&d, partial closure tibial wound. start wtd history of present illness: the patient is a 47 y/o m s/p mvc, moped vs car. he was transferred from osh to the ed. imaging revealed multiple pelvic fractures, closed left diaphyseal radius fracture, and right midshaft tib/fib fracture. he was taken to the or, where he became acidotic and had elevated lactate. he recieved 8l crystalloids, 2u albumin and 2u prbc intraoperatively. total ebl was 600ml and urine output was about 3l intraop.he was brought to the icu for further management past medical history: htn/hld psh: oral surgery social history: lives in an apartment in with girlfriend, . in risk and pricing at jp & . he drinks 7-10 beers a week socially. he denies smoking or illicit drug use. he notes in the past 5 years he has travelled to the midwest, west coast (specifically ), (, , hiroshima, ), , , and . family history: non-contributory physical exam: admission physical exam temp: 97.5 hr: 103 bp: 98/53 resp: 22 o(2)sat: 100 normal constitutional: pain with movement heent: normocephalic, atraumatic, pupils equal, round and reactive to light, extraocular muscles intact, pupils 2mm bilaterally, midface stable, no ttp or stepoffs of mandible, mmm, oropharynx within normal limits, no blood in nares chest: clear to auscultation, airways intact, equal breath sounds bilaterally, tm's clear cardiovascular: regular rate and rhythm, normal first and second heart sounds, palpable radial pulse bilaterally abdominal: soft, nontender, nondistended gu/flank: no costovertebral angle tenderness extr/back: no tenderness or stepoffs of the spine, no cyanosis, clubbing or edema skin: abrasion over left thumb, good capillary refill bilaterally, abrasions over left thigh, deep lacerations on right knee and thigh with foreign body(glass), laceration of left shin with bleeding, no rash, warm and dry neuro: awake, alert and oriented, cms intact, speech fluent psych: normal mentation discharge physical exam v: 98.4f 96 141/81 18 100% ra gen: nad, aaox3 lue: splint in place; silt r/m/u +thumbs up +ok sign lle: brace in place; silt dp/sp/s/s; +/fhl/gs/ta; 2+ dp/pt, : wet-to-dry dsg in wounds; silt dp/sp/s/s; +/fhl/gs/ta; 2+ dp/pt, pertinent results: labs on admission 06:56pm blood wbc-27.6* rbc-4.25* hgb-13.2* hct-38.9* mcv-91 mch-31.0 mchc-33.9 rdw-13.1 plt ct-270 01:29am blood wbc-8.9# rbc-3.77* hgb-11.5* hct-33.6* mcv-89 mch-30.4 mchc-34.1 rdw-14.4 plt ct-184 01:29am blood glucose-214* urean-12 creat-0.9 na-142 k-5.1 cl-109* hco3-21* angap-17 05:52am blood glucose-182* urean-13 creat-0.9 na-143 k-4.8 cl-109* hco3-24 angap-15 01:29am blood ck(cpk)-* 08:16am blood ck(cpk)-* labs on discharge: 05:10am blood wbc-7.6 rbc-3.18* hgb-9.3* hct-28.4* mcv-89 mch-29.4 mchc-32.9 rdw-14.1 plt ct-581* 05:10am blood glucose-128* urean-6 creat-0.5 na-137 k-3.6 cl-101 hco3-29 angap-11 imaging: please see imaging on separate disk brief hospital course: mr. initially arrived to the ed from an osh; imaging revealed multiple pelvic fractures, closed left diaphyseal radius fracture, and right midshaft tib/fib fracture. he was taken to the operating room with orthopedics for im nail r tibia + femur and closed reduction of the right hip; for full details please see the dictated operative note. post-operatively he was taken to the trauma icu for continued monitoring. on , he was extubated in the icu and his c-spine was cleared clinically and radiographically. he was off all pressors. he took small amounts of po and pain was well controlled. a tertiary survey was performed and revealed no new injuries. he was transferred to the ortho trauma team on for continued management of his numerous fractures. on he was taken to the or for orif of his l radius, and anterior r acetabulum fractures. on his wounds were i&d'd in the or and he underwent orif for his r post acetabular fracture. on he had an ivc filter placed, and underwent further i&ds for his on and . the patient tolerated these procedure without complications and was transferred to the pacu in stable condition each time. please see the individual operative reports for details. post operatively pain was controlled with a pca with a transition to po pain meds once tolerating pos. the patient tolerated diet advancement without difficulty and made steady progress with pt. the patient was transfused 1 unit of blood on for acute blood loss anemia. weight bearing status: - nwb lue in splint - tdwb - wbat lle with brace in locked position. the patient received peri-operative antibiotics as well as lovenox for dvt prophylaxis. the incision was clean, dry, and intact without evidence of erythema or drainage; and the extremity was nvi distally throughout. the patient was discharged in stable condition with written instructions concerning precautionary instructions and the appropriate follow-up care. the patient will be continued on chemical dvt prophylaxis for 2 weeks post-operatively. all questions were answered prior to discharge and the patient expressed readiness for discharge. medications on admission: anti-hypertensives, specifics unknown remained of medication history undocumented discharge medications: 1. enoxaparin sodium 40 mg sc q24h duration: 2 weeks 2. acetaminophen 650 mg po q6h:prn temp, pain 3. tramadol (ultram) 50 mg po q6h:prn pain rx *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours disp #*90 tablet refills:*0 4. docusate sodium (liquid) 100 mg po bid 5. senna 1 tab po bid constipation 6. lorazepam 0.5 mg po q4h:prn anxiety rx *lorazepam 0.5 mg 1 tablet by mouth every four (4) hours disp #*60 tablet refills:*0 7. moxifloxacin *nf* 400 mg oral q24h discharge disposition: extended care facility: discharge diagnosis: polytrauma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: ******wound care****** - do not remove splint before the follow-up appointment, and do not get it wet. - keep left leg brace locked in extension when standing/weight-bearing. it may be unlocked when laying down. - right leg: continue wet-to-dry dressings twice a day. - you can get wounds wet/take a shower starting from 3 days post-op. no baths or swimming for at least 4 weeks. ******weight-bearing****** - weight-bearing as tolerated right upper extremity - non-weight-bearing left upper extremity - touch-down weight-bearing right lower extremity - weight-bearing as tolerated left lower extremity with brace in locked position ******medications****** - resume your pre-hospital medications. - you have been given medication for your pain control. please do not operate heavy machinery or drink alcohol when taking this medication. as your pain improves please decrease the amount of pain medication. this medication can cause constipation, so you should drink eight 8-oz glasses of water daily and take a stool softener (colace) to prevent this side effect. - medication refills cannot be written after 12 noon on fridays. ******anticoagulation****** - take lovenox for dvt prophylaxis for 2 weeks post-operatively. physical therapy: ******weight-bearing****** - weight-bearing as tolerated right upper extremity - non-weight-bearing left upper extremity - touch-down weight-bearing right lower extremity - weight-bearing as tolerated left lower extremity with brace in locked position pt treatment daily treatments frequency: continue wet-to-dry dressings right lower extremity twice daily followup instructions: please follow up with an orthopedic surgeon in your area in 2 weeks. for questions about your orthopedic operations, please call dr. at . please follow up with your pcp regarding this admission and any new medications/refills. md, Procedure: Interruption of the vena cava Debridement of open fracture site, tibia and fibula Debridement of open fracture site, tibia and fibula Debridement of open fracture site, tibia and fibula Debridement of open fracture site, tibia and fibula Open reduction of fracture with internal fixation, tibia and fibula Open reduction of fracture with internal fixation, femur Debridement of open fracture site, femur Open reduction of fracture with internal fixation, radius and ulna Open reduction of fracture with internal fixation, other specified bone Open reduction of fracture with internal fixation, other specified bone Other radiotherapeutic procedure Closed reduction of fracture with internal fixation, other specified bone Angiocardiography of venae cavae Central venous catheter placement with guidance Diagnoses: Acidosis Other postoperative infection Unspecified essential hypertension Acute posthemorrhagic anemia Other and unspecified hyperlipidemia Paralytic ileus Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Obesity, unspecified Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction Open fracture of shaft of femur Closed fracture of pubis Open fracture of shaft of fibula with tibia Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Closed fracture of acetabulum Closed fracture of shaft of radius (alone) Other digestive system complications Body Mass Index 33.0-33.9, adult

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypoxia major surgical or invasive procedure: none history of present illness: 70 yo m with a history of recently diagnosed, widely metastatic non-small cell lung cancer with mets to the brain, liver, adrenals and bone admitted with progressive hypoxia. the patient was recently diagnosed with diffusely metastatic non-small cell lung cancer. he had not yet started chemotherapy or xrt. on the day of admission, the patient presented for a scheduled neuro-oncology visit with dr. for consideration of therapy for brain mets. the patient was found to be hypoxic to 60%. by report of the family, the patient was lethargic and seemed 'not himself' this weekend however he was ambulating and eating and able to largely take care of himself. in the ed 97.8 132 137/71 30 91% 4l . he received albuterol and ipratropium nebs, dexamethasone 10mg iv, vanc and zosyn. upon arrival to the floor, the patient was found to be on a nrb with agonal breathing and minimally responsive. past medical history: - non-small-cell lung cancer. originally presented to hospital with increasing sob and upper right-sided abdominal pain. x-ray revealed a lung mass. ct scan revealed multiple lung nodules. biopsy at hospital on revealed poorly differentiated non-small-cell lung cancer, pulmonary primary. positive for pancytokeratin and negative for other markers. deemed not a surigcal candidate due to diffuse disease on pet scan per dr. . seen by drs. and at on . the patient was scheduled to be seen by neuro-onc for consideration of possible xrt or other therapy for intracranial disease though this appointment has not yet occurred. the patient has not started chemotherapy. - copd - hypertension - platelets disorder, not specified - tia's vs. 'mini' cva's social history: illiterate. supported by his daughters for decision-making. lives with his wife and daughter. smoked for 40+ years, 2ppd, quit 14 years ago. denies etoh. family history: 2 brother with lung cancer, 1 brother with liver cancer, 1 brother with pancreatic cancer and a sister with breast cancer. mother deceased of copd, father deceased of a cva. physical exam: gen: agonal breathing, minimally responsive cv: tachycardic. normal s1 and s2. no m/r/g pulm: rhoncorous breath sounds on the left abd: distended. soft, nontender. pertinent results: na 136, k 4.6, cl 93, bicarb 31, bun/cr 53/2.1, glucose 140, wbc 21.8 (80% n, 4% b, 7% l), hct 31.5, platelets 406 alt 59, ast 50, ap 113, lip 18, t bili 0.3, inr 4.2 trop 0.01 lactate 1.5 ekg: sinus tachycardia at 131. normal axis and intervals. no acute st or t wave changes. 12:12pm blood wbc-16.5* rbc-2.95* hgb-9.1* hct-27.5* mcv-93 mch-31.0 mchc-33.3 rdw-15.4 plt ct-330 11:50am blood wbc-21.8* rbc-3.44* hgb-10.5* hct-31.5* mcv-92 mch-30.5 mchc-33.2 rdw-16.1* plt ct-406 12:12pm blood neuts-95* bands-0 lymphs-3* monos-1* eos-0 baso-0 atyps-0 metas-1* myelos-0 12:12pm blood hypochr-1+ anisocy-1+ poiklo-1+ macrocy-1+ microcy-normal polychr-1+ ovalocy-1+ stipple-1+ tear dr1+ 12:12pm blood pt-15.2* ptt-24.1 inr(pt)-1.3* 11:50am blood pt-38.7* ptt-51.4* inr(pt)-4.2* 12:12pm blood glucose-173* urean-52* creat-1.5* na-137 k-4.2 cl-97 hco3-28 angap-16 11:50am blood glucose-140* urean-53* creat-2.1* na-136 k-4.6 cl-93* hco3-31 angap-17 12:12pm blood alt-64* ast-74* ld(ldh)-600* alkphos-111 totbili-0.3 11:50am blood alt-59* ast-50* alkphos-113 totbili-0.3 11:50am blood lipase-18 11:50am blood ctropnt-0.01 12:12pm blood calcium-8.6 phos-3.6# mg-2.5 11:50am blood albumin-3.3* calcium-9.2 phos-5.8*# mg-2.3 03:02pm blood type-art po2-76* pco2-96* ph-7.11* caltco2-33* base xs--2 03:02pm blood lactate-2.3* 01:25pm blood lactate-1.5 03:02pm blood o2 sat-88 brief hospital course: patient was admitted for diffusely metastatic non small cell lung cancer with lymphangitic spread, recently diagnosed within the last two weeks which significantly worsened both clinically and radiographically. he presented in extreme respiratory distress, tiring with co2 retention and mental status changes. given the rapidity of his progression his oncologist and the icu team decided with the family to focus treatment on comfort. treated for copd flare with steroids and levofloxacin. patient died at 14:48 on of respiratory failure associated with his rapidly progressive non small cell lung cancer. medications on admission: tylenol with codeine 300/30 1-2 tabs by mouth every 4-6 hours prn dexamethasone 20mg daily at 12 and 5 hours prior to chemo diltiazem 180mg sustained release daily warfarin fluticasone-salmeterol 250/50mcg 2 inh daily megestrol 400mg/10ml suspension 20ml daily omeprazole 10mg daily compazine 10mg every 6-8 hours as needed rosuvastatin 10mg daily triamterene-hydrochlorothiazide 37.2/25mg daily pediatric multivitamin with iron and minerals polysaccharide iron complex 60mg daily home oxygen discharge medications: expired discharge disposition: expired discharge diagnosis: expired discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Non-invasive mechanical ventilation Diagnoses: Pneumonia, organism unspecified Malignant neoplasm of liver, secondary Unspecified essential hypertension Obstructive chronic bronchitis with (acute) exacerbation Acute respiratory failure Secondary malignant neoplasm of brain and spinal cord Malignant neoplasm of upper lobe, bronchus or lung Encounter for palliative care Secondary malignant neoplasm of bone and bone marrow Secondary malignant neoplasm of adrenal gland Other specified diseases of blood and blood-forming organs Qualitative platelet defects

allergies: codeine attending: chief complaint: seizure major surgical or invasive procedure: none history of present illness: 59m with a pmh of t2dm on insulin, esrd not on dialysis s/p open peritoneal dialysis catheter placement due to have first dialysis , htn, hld, cad s/p 4 stents in , cml recently stopped dasatinib on recent admission, depression who presents as an osh transfer following altered mental status and seizures and is now being transferred to the icu for concern for hypertensive emergency. . recently admitted from 8/8-15/ for volume overload and fatigue with culture negative diarrhoea in addition to worsening of his chronic renal failure up to cr 5.6 () which improved with holding his diuretics and hydration and returned patient's baseline of cr~. given persistence of ckd without improvement he was due to start peritoneal dialysis today. . per patient's wife he was feeling perfectly fine through this morning when she heard him fall. she ran to the room where she found him on the ground. no shaking or seizure activity at that time. when brought to osh had witnessed seizure with shaking and tongue biting. no prior history of seizures. started on phenytoin and transferred to for further evaluation and management given his new onset seizures. . neurology felt this was most likely toxic/metabolic and started him on keppra (instead of phenytoin at osh). he had no further seizures however he was felt to have continuing altered mental status. his blood pressures were labile with sbps ranging from 120-210. his renal attending saw him and was concerned that his ams could be due to htn encephalopathy and is requesting that he be transferred to the micu for aggressive bp control with a labetalol drip. . on arrival to the micu he appeared slightly agitated but otherwise in no acute distress. has a headache. past medical history: -type 2 diabetes, -leukemia/cml -hypertension -coronary artery disease status post stenting in -obesity -depression, -hyperlipidemia. -right inguinal hernia repair with mesh. -ckd baseline cr 3.0 social history: former smoker. he is on disability, but was previously an electronics assembler. live with wife in . has two grown daughters. no etoh. family history: no known history of kidney problems in family physical exam: exam on admission: general: alert, oriented, no acute distress heent: sclera anicteric, dry mm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+ edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred exam on discharge: vs - temp 98.7 f (afeb), bp 138/68 (126-156/60-80), hr 79 (60s-80s), r 20, sao2 95%ra general - well-appearing man in nad, comfortable, appropriate, currently being dialyzed on pd heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, no jvd, no carotid bruits lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, soft, slightly distended, slightly tender near pd catheter site. no masses/hsm, no rebound/guarding extremities - wwp, 1+ edema bilaterally, no c/c, 2+ peripheral pulses (radials, dps) neuro - a+o x3, cns ii-xii intact, moving all extremities, gait pertinent results: admission labs: 11:03pm glucose-268* urea n-78* creat-2.7* sodium-140 potassium-3.3 chloride-97 total co2-33* anion gap-13 11:24pm freeca-1.18 11:24pm type- ph-7.47* 11:03pm calcium-10.1 phosphate-3.5 magnesium-1.5* 11:03pm pth-14* 11:03pm tsh-4.5* 11:03pm blood free t4-1.5 08:15am blood phenyto-7.6* 11:03pm wbc-6.1 rbc-3.69* hgb-10.6* hct-32.0* mcv-87 mch-28.8 mchc-33.3 rdw-16.9* 11:03pm free t4-1.5 05:30pm other body fluid wbc-450* rbc-8900* polys-0 lymphs-87* monos-0 mesotheli-5* macrophag-6* other-2* 08:15am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 08:30am urine color-straw appear-clear sp -1.007 08:30am urine blood-sm nitrite-neg protein-100 glucose-300 ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg 08:30am urine rbc-1 wbc-1 bacteri-few yeast-none epi-0 relevant labs: 12:50pm blood ck(cpk)-65 07:30am blood ck(cpk)-44* 12:50pm blood ck-mb-2 ctropnt-0.22* 07:30am blood ck-mb-2 ctropnt-0.18* discharge labs: 07:30am blood wbc-4.3 rbc-3.29* hgb-9.8* hct-28.6* mcv-87 mch-29.9 mchc-34.3 rdw-16.7* plt ct-200 07:30am blood glucose-147* urean-52* creat-2.8* na-136 k-3.4 cl-95* hco3-36* angap-8 07:30am blood calcium-8.5 phos-2.8 mg-1.8 microbiology: urine culture: <10,000 organisms/ml. dialysate fluid: gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. mrsa screen: no mrsa isolated. imaging: eeg: findings: abnormality #1: there were frequent bursts of mixed frequency slow with a generalized distribution. there were also less frequent bursts of slowing in the right or left temporal region, independently. background: included some 9 hz alpha frequency posteriorly in wakefulness. hyperventilation: could not be performed. intermittent photic stimulation: could not be performed. sleep: the patient progressed from wakefulness to drowsiness but did not appear tender stage ii of sleep during this recording. cardiac monitor: showed a generally regular rhythm. impression: abnormal eeg due to the bursts of slowing, most of them generalized but with some of these findings suggest multifocal subcortical dysfunction. vascular disease is the most common cause at this age. the generalized slowing implies a dysfunction and midline structures, but this is not specific with regard to etiology. there was no particularly prominent posterior slowing. there were no epileptiform features. non-contrast head ct: there is no evidence of hemorrhage, edema, mass effect, or large acute territorial infarction. the ventricles and sulci are slightly prominent for age, likely related to minimal atrophy. the basal cisterns appear patent and there is preservation of -white matter differentiation. no fracture is identified. the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. the visualized portions of the globes are unremarkable. impression: no intracranial hemorrhage or mass effect. cxr (ap portable): ap single view of the chest has been obtained with patient in sitting semi-upright position. comparison is made with the next preceding chest examination of . there is moderate cardiac enlargement. no typical configurational abnormality is present. the thoracic aorta is of ordinary dimensions. the pulmonary vasculature demonstrates bilateral perivascular haze, consistent with venous congestion. this probably explains the bilateral pleural effusions blunting the lateral pleural sinuses, more on the right than the left. similar findings consistent with chronic chf and bilateral pleural effusion was already present on the previous chest examination of . increasing basal density on the right side suggest that the pleural effusion has increased. no acute pulmonary processes can be identified. mri head: there is no acute intracranial hemorrhage or acute transcortical infarction. there are a few subcortical foci of height and signal predominantly in the parietal and occipital lobes, which may be seen in the setting of pres. no associated mass effect or edema. no chronic blood products. flow voids maintained. there is minimal mucosal thickening in the right aspect of the sphenoid sinus. impression: mild subcortical changes predominantly in the parietooccipital white matter which may be seen in the setting of pres. no evidence for acute ischemia. kub: no previous images. dialysis catheter appears to be coiled within the pelvis. bowel gas pattern is within normal limits. brief hospital course: 59m with a pmh of t2dm on insulin, esrd just started on pd , htn, hld, cad s/p 4 stents in , cml, transferred from osh with altered mental status, seizures and hypertensive emergency. active issues: # hypertensive emergency: unclear cause of hypertension prior to admission, as outpatient dr. reports that patient has excellent complicance. have been cause of patient's ams prior to admission, as he has evidence of pres on mri. initially continued on home regimen with iv labetalol drip to bring pressures under control in the icu. labetalol dripwas stopped. his carvedilol increased to 25mg but then decreased to 9.75mg due to asymptomatic bradycardia. diltiazem changed to amlodipine in setting of asymptomatic bradycardia. he was started on lisinopril which had previously been held in the setting of hyperkalemia. he was briefly started on hydralazine which was tapered and stopped prior to discharge. at the time of discharge his blood pressures were well-controled on carvedilol, lisinopril, amlodipine and furosemide. # seizures and ams: single seizure at osh without prior history of seizures. most likely etiology is hypertensive encephalopathy or pres. mri concerning for pres, but head ct negative. loaded with phenytoin at osh, and then treated with keppra. eg without epileptiform features. neuro believes toxic-metabolic encephalopathy is also on the differential. other possible etiologies include hypercalcemia and uremia. patient's mental status cleared with control of blood pressures. patient will have follow up mri in 3 weeks to evaluate resolution of pres, prior to discontinuing keppra. # hypercalcemia: with hyperparathyroidism, secondary to ckd. have contributed to ams as above. corrected calcium was 10.9 on admission which decreased to 10.0 by the next morning and then remained within normal limits. a pth was elevated but significantly lower than a prior. his calcitonin and calcium carbonate supplements were stopped. a low calcium bath was used for his pd. after calcium normalized, renal team advised that it was safe to restart calcium supplements. # esrd: started on pd on day of admission (), which continued throughout his admission. a low calcium bath was used. he was continued on nephrocaps. some bruising surrounding pd catheter (placed on 10th) but without evidence of infection or active bleeding. chronic issues: # t2dm: treated with iss while in house, and discharged on home regimen. # osa: patient has known osa however has not been using his cpap in the past few weeks. this was continued in house with auto-set cpap. he was instructed to resume cpap at home. transitional issues: # full code. # patient will have repeat mri in 3 weeks to evaluate for resolution of pres. after this has been done, he will be seen in clinic, and given instructions on whether to continue or stop keppra. # patient noted to have asymptomatic st-elevations on ekgs, which by review of cardiology fellow, were deemed consistent with j-point elevations. ces were trended, with flat ck-mbs. clinical picture was not consistent with acute ischemia. medications on admission: preadmissions medications listed are incomplete and require futher investigation. information was obtained from webomr. 1. aspirin 81 mg po daily 2. calcitriol 0.5 mcg po daily 3. doxazosin 4 mg po daily per pharmacy (should be daily dosing rather than ; half-life ~22hrs) 4. detemir 10 units bedtime 5. multivitamins 1 tab po daily 6. ranitidine 150 mg po daily:prn reflux 7. bicitra 30 ml po bid low bicarbonate 8. calcium carbonate 500 mg po tid low calcium 9. prednisone 20 mg po daily duration: 2 days stop after last dose on 10. multivitamins w/minerals 1 tab po daily 11. glimepiride *nf* 2 mg oral qam 12. epoetin alfa 10,000 units sc as directed 13. carvedilol 6.25 mg po bid 14. diltiazem extended-release 300 mg po daily 15. furosemide 160 mg po bid discharge medications: 1. aspirin 81 mg po daily 2. calcitriol 0.25 mcg po daily 3. calcium carbonate 500 mg po bid 4. carvedilol 9.375 mg po bid hold for sbp < 100 or hr < 60 5. doxazosin 4 mg po hs hold for sbp <100 6. furosemide 160 mg po bid 7. detemir 10 units bedtime 8. ranitidine 150 mg po daily 9. amlodipine 10 mg po daily hold for sbp <100 rx *amlodipine 10 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 10. levetiracetam 500 mg po q24h rx *levetiracetam 500 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 11. lisinopril 20 mg po daily hold for sbp < 110 rx *lisinopril 20 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 12. nephrocaps 1 cap po daily rx *b complex-vitamin c-folic acid 1 mg 1 capsule(s) by mouth daily disp #*30 capsule refills:*0 13. polyethylene glycol 17 g po daily rx *polyethylene glycol 3350 17 gram 1 packet by mouth daily disp #*30 packet refills:*0 14. senna 1 tab po bid rx *sennosides 8.6 mg 1 tablet by mouth twice a day disp #*60 tablet refills:*0 15. epoetin alfa 10,000 units sc as directed 16. glimepiride *nf* 2 mg oral qam discharge disposition: home with service facility: steward home care discharge diagnosis: primary diagnoses: seizure hypertensive emergency esrd on peritoneal dialysis secondary diagnoses: insulin-dependent diabetes hypertension hyperlipidemia cad s/p 4 stents cml depression discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure to participate in your care here at ! you were admitted with a seizure and altered mental status, and were found to have very elevated blood pressures. a ct scan of your head showed that you had no bleeding in your brain. an mri of your brain showed that your seizures may have been related to the high blood pressures. your seizures were treated with a new medication called levetiracetam (keppra). your high blood pressure was initially treated with an intravenous blood pressure medication drip, then changed over to an oral regimen that you can continue at home. your mental status improved. there have been several changes to your home medications. please see the attached list. please follow up with your primary care physician, and neurologist at the appointments listed below. additionally, you should have a follow-up mri of your brain in three weeks. this has been ordered for you. please see below for scheduling. wishing you all the best! followup instructions: **please call (#1) to schedule a follow-up mri of your brain in 3 weeks.** name: brown, location: family medicine associates address: , , phone: appt: at 3:45pm name: , e. md location: diabetes center address: one place, , phone: appt: at 2:30 (this appt was booked before your admission. if you are unable to make this appt, please call the office to cancel.) appt: at 2:30 department: neurology when: tuesday at 11:15 am with: & sainju campus: east best parking: garage ***you have also been placed on a wait list and will be called with a sooner appt if one becomes available. Procedure: Peritoneal dialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease End stage renal disease Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Renal dialysis status Coronary atherosclerosis of native coronary artery Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Personal history of tobacco use Depressive disorder, not elsewhere classified Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Long-term (current) use of insulin Hypertensive encephalopathy Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Generalized convulsive epilepsy, without mention of intractable epilepsy Chronic myeloid leukemia, in remission

allergies: amitriptyline attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: aortic valve replacement (21 mm ce pericardial magne ease) resection of left atrial appendage history of present illness: 57 year old male with bicuspid aortic valve. aortic stenosis has been followed by echocardiogram. he has recently experienced progressive doe and now admitted post cardiac catheterization for aortic valve surgery. past medical history: childs a cirrhosis- followed by hepatology h/o esophageal varices atrial fibrillation osa (does not use cpap) copd/emphysema cri (baseline cr 1.4) non-hodgkins lymphoma 5yrs. ago s/p rituximab and chop hepatitis c cirrhosis gerd chronic abdominal pain syndrome appendectomy social history: lives with: mother and dog, has daughter in hcp is occupation: medical leave x 6 yrs. was a plumber tobacco: quit 4 yrs. ago etoh: none for 10 years family history: non contributory physical exam: pulse: 60 resp: 20 o2 sat: 100%ra b/p right: left: 125/93 height: weight: general: nad skin: dry intact heent: perrla eomi pupils fixed 4mm neck: supple full rom chest: lungs clear bilaterally audible wheezing heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + , distended extremities: warm , well-perfused edema 1+ varicosities: none neuro: grossly intact x pulses: femoral right: left: dp right: 1+ left: 1+ pt : left: np edema radial right: 1+ left: 1+ carotid bruit right: left: no bruits appreciated pertinent results: cardiac catheterization 1. selective coronary angiography in this right dominant system revealed no angiographically significant coronary artery disease. 2. resting hemodynamics revealed significant respiratory variation in all intracardiac and pulmonary pressure recordings. the mean ra pressure was elevated at 16mmhg. there was moderate pulmonary artery hypertension (52/31 mmhg with a mean of 38mmhg). the pcw was elevated at a mean of 21mmhg. final diagnosis: 1. coronary arteries are normal. 2. elevated left and right heart filling pressures. 3. moderate pulmonary artery hypertension echo right atrium/interatrial septum: no asd by 2d or color doppler. left ventricle: moderate symmetric lvh. normal lv cavity size. normal regional lv systolic function. overall normal lvef (>55%). right ventricle: mildly dilated rv cavity. normal rv systolic function. aorta: simple atheroma in descending aorta. aortic valve: severely thickened/deformed aortic valve leaflets. critical as (area <0.8cm2). trace ar. mitral valve: moderately thickened mitral valve leaflets. moderate mitral annular calcification. moderate thickening of mitral valve chordae. mild valvular ms (mva 1.5-2.0cm2). mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets. mild tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. physiologic (normal) pr. prebypass no atrial septal defect is seen by 2d or color doppler. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is mildly dilated with normal free wall contractility. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area 0.6 cm2). trace aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is moderate thickening of the mitral valve chordae. there is mild valvular mitral stenosis (area 1.9cm2). mild (1+) mitral regurgitation is seen. biventricular systolic function is preserved. there is a well seated, well functioning bioprosthesis in the aortic position. no ai is visualized. the remaining study is unchanged from prebypass. 08:50am blood wbc-8.2 rbc-3.37* hgb-10.4* hct-31.1* mcv-92 mch-31.0 mchc-33.6 rdw-17.0* plt ct-177 08:50am blood pt-21.9* ptt-41.5* inr(pt)-2.0* 08:50am blood glucose-120* urean-41* creat-1.4* na-138 k-4.3 cl-100 hco3-26 angap-16 08:50am blood alt-17 ast-38 alkphos-151* amylase-85 totbili-1.5 08:50am blood lipase-82* brief hospital course: presented for cardiac catheterization that revealed normal coronary arteries and was admitted for preoperative workup. on was brought to the operating room for aortic valve replacement and resection of left atrial appendage. see operative report for further details. he received vancomycin and cefazolin for perioperative antibiotics, and transferred to the intensive care unit for post operative management. that evening he was weaned from sedation, awoke neurologically intact and was extubated without complications. post operative day one he was weaned from pressors. he was transferred to the surgical step down floor. he was restarted on coumadin for chronic atrial fibrillation and his inr quickly became supertherapeutic requiring vitamin k so he was restarted on a reduced dose of coumadin. diltiazem and lopressor was increased for better rate control. chest tubes and pacing wires were removed per cardiac surgery protocol. his pain was controlled with dilaudid and ativan. once on the step down unit he was ambulating with assistance, tolerating a full oral diet and his incisions were healing well. slight erythema was noted at the mediastinal incision so he was started on keflex. while his liver function tests were elevated post-operatively, they were downtrending and near normal by discharge. he was discharged to center. medications on admission: toprol xl 100mg daily colace 100mg zolpidem tartrate 5mg hs insomnia mvi quetiapine fumarate 25 mg po/ng qam and 50 mg po/ng at 4 p.m. and qhs lorazepam 1 mg po/ng :prn anxiety hydromorphone (dilaudid) 6 mg q4hrs prn lactulose 30 ml po/ng albuterol 0.083% neb soln 1 neb ih q2h:prn sob, wheeze, albuterol 0.083% neb soln 1 neb ih q4h, ipratropium bromide neb 1 neb ih q4hrs digoxin 0.125 mg po/ng every other day cyanocobalamin 1000 mcg po/ng daily aspirin 81 mg po daily fluoxetine 40 mg po/ng daily mirtazapine 30 mg po/ng hs omeprazole 20 mg po daily coumadin 2.5mg discharge medications: 1. lorazepam 0.5 mg tablet sig: one (1) tablet po twice a day as needed for anxiety. 2. hydromorphone 2 mg tablet sig: three (3) tablet po q4h (every 4 hours) as needed for pain. 3. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po twice a day. 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation every four (4) hours as needed for wheezes. 5. ipratropium bromide 0.02 % solution sig: one (1) inhalation every four (4) hours. 6. digoxin 125 mcg tablet sig: one (1) tablet po qod (). 7. cyanocobalamin (vitamin b-12) 100 mcg tablet sig: one (1) tablet po daily (daily). 8. aspirin, buffered 81 mg tablet sig: one (1) tablet po once a day. 9. fluoxetine 20 mg capsule sig: two (2) capsule po daily (daily). 10. mirtazapine 15 mg tablet sig: two (2) tablet po hs (at bedtime). 11. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 14. diltiazem hcl 60 mg tablet sig: one (1) tablet po qid (4 times a day). 15. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 10 days: sternal erythema. 16. quetiapine 25 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 17. quetiapine 25 mg tablet sig: two (2) tablet po daily at 1600 (). 18. quetiapine 25 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). 19. rifaximin 550 mg tablet sig: one (1) tablet po bid (2 times a day). 20. lasix 20 mg tablet sig: two (2) tablet po once a day for 10 days. 21. potassium chloride 20 meq tablet, er particles/crystals sig: two (2) tablet, er particles/crystals po once a day for 10 days. 22. warfarin 1 mg tablet sig: 0.5 tablet po once (once) for 1 doses: titrate for inr goal of for afib. check inr . 23. multivitamin tablet sig: one (1) tablet po daily (daily). 24. zolpidem 5 mg tablet sig: one (1) tablet po once a day as needed for insomnia. discharge disposition: extended care facility: rehabilitation and nursing center - discharge diagnosis: aortic stenosis s/p avr atrial fibrillation s/p resection of laa childs a cirrhosis obstructive sleep apnea emphysema chronic renal insufficiency non-hodgkins lymphoma hepatitis c cirrhosis gerd chronic abdominal pain syndrome discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with incisions: sternal - healing well, no erythema or drainage edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr on at 1:00pm cardiologist: dr. at 1:00 pm wound check: , md 1:45 please call to schedule appointments with your primary care dr in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** labs: pt/inr for coumadin ?????? indication a fib goal inr 2.0-3.0 first draw: rehab to arrange coumadin follow up upon discharge Procedure: Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Excision or destruction of other lesion or tissue of heart, open approach Open and other replacement of aortic valve with tissue graft Diagnoses: Other chronic pain Abdominal pain, unspecified site Anemia, unspecified Esophageal reflux Mitral valve disorders Cirrhosis of liver without mention of alcohol Chronic hepatitis C without mention of hepatic coma Atrial fibrillation Aortic valve disorders Other chronic pulmonary heart diseases Chronic kidney disease, unspecified Personal history of other lymphatic and hematopoietic neoplasms Other emphysema Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus Congenital insufficiency of aortic valve Other ill-defined heart diseases

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: left main coronary artery disease major surgical or invasive procedure: coronary artery bypass graft x 4 (left internal mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to ramus, saphenous vein graft to obtuse marginal) history of present illness: this 45 year old hispanic male with history coronary artery disease and multiple interventions to the circumflex and a nstemi in who had recurrent chest pain with minimal exertion and a positive exercise mibi. he underwent cardiac catheterization in which revealed left main disease and he was referred for surgery. he was discharged after catheterization to allow plavix washout and to stop smoking. past medical history: coronary artery disease s/p myocardial infarction (nstemi ) and multiple pcis to lcx - hypercholesterolemia gastroesophageal reflux disease anxiety depression kidney stones s/p laser surgery social history: race: hispanic last dental exam: 2 months ago lives with: partner occupation: flight attendant tobacco: + 0.5 ppd x 20 years etoh: glasses of wine/week rec drug: denies family history: father died of mi age 67, brother with age 40 physical exam: admission: pulse:76 resp:14 o2 sat:96%ra b/p right:133/76 left:133/83 height:5'9" weight:225 lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema varicosities: none neuro: grossly intact pulses: femoral right: +2 left: +2 dp right: +2 left: +2 pt : +2 left: +2 radial right: +2 left: +2 carotid bruit right: none left: none pertinent results: 04:03am blood wbc-16.3* rbc-3.83* hgb-11.0* hct-33.8* mcv-88 mch-28.6 mchc-32.5 rdw-13.7 plt ct-235 04:03am blood glucose-125* urean-16 creat-0.8 na-139 k-4.5 cl-106 hco3-26 angap-12 09:55am hgb-13.8* calchct-41 09:55am glucose-104 lactate-1.9 na+-136 k+-4.5 cl--98* 02:12pm glucose-118* lactate-2.8* na+-134* k+-3.8 cl--106 03:24pm pt-14.1* ptt-33.1 inr(pt)-1.2* 03:24pm plt count-235 03:24pm wbc-16.4* rbc-3.91* hgb-11.6* hct-34.1* mcv-87 mch-29.6 mchc-33.9 rdw-13.7 03:24pm urea n-17 creat-0.7 chloride-108 total co2-27 echo: pre bypass: the left atrium is moderately dilated. no mass/thrombus is seen in the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is mildly dilated there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. mild to moderate central (+) mitral regurgitation is seen, worse at pressures of 140's systolic. vena contracta for mitral jet ranged from 0.2-0.4 cm. there is mild partial anterior prolapse and borderline annular dilation of the mitral valve. there is no pericardial effusion. cxr: there again is noted bilateral areas of consolidation throughout both lung fields, which are stable. findings are worse within the lung bases. cardiac silhouette is upper limits of normal, but stable. brief hospital course: mr. was a same day admit for coronary bypass grafting. he had previously undergone pre-operative work-up and cardiac catheterization on which revealed severe left main coronary artery disease. on he was brought to the operating room where he underwent coronary artery bypass graft x 4. please see operative report for surgical details. in summary he had: coronary artery bypass grafting x4; with left internal mammary artery grafted to the left anterior descending, reverse saphenous vein graft to the first marginal branch, ramus intermedius and first diagonal branch. his bypass time was 89 minutes with a crossclamp of 70 minutes. he tolerated the surgery well. following surgery he was transferred to the cvicu for invasive monitoring in stable condition. he was hemodynamically stable in the immediate post operative period and later that day he weaned from sedation, awoke neurologically intact and was extubated. on pod1 he was transfered to the floor for further recovery. beta blockers were resumed and diuresis was initiated with a goal of matching his pre operative weight. all tubes lines and drains were removed according to cardiac surgery protocol. on pod3 he was noted to be febrile. a white blood cell couont was checked and found to be elevated, a chest xray at that time revealed bilateral opacities, sputum cultures were sent. the eventually grew gram positive rod(s) and he was begun on appropriate antibiotics. his fever and elevated white count resolved. physical therapy worked with him for strengthening and mobilization. his antidepressents and anxiolytics were resumed post-operatively. the remainder of his post operative course was uneventful and he was discharged home with visiting nurses on post-operative day six. all medications, restrictions and follow up care was discussed with him prior to going home. medications on admission: plavix 75mg po daily amlodipine 5mg po daily lipitor 80mg po daily wellbutrin sr 150mg celexa 40mg daily folic acid zestril 10mg po daily trazodone 100mg po daily asa 325mg po daily omeprazole 40 mg daily discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). disp:*60 capsule, delayed release(e.c.)(s)* refills:*2* 4. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). disp:*270 tablet(s)* refills:*2* 6. bupropion hcl 150 mg tablet sustained release sig: one (1) tablet sustained release po bid (2 times a day). disp:*60 tablet sustained release(s)* refills:*2* 7. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 8. hydromorphone 2 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*40 tablet(s)* refills:*0* 9. furosemide 40 mg tablet sig: one (1) tablet po daily (daily) for 7 days. disp:*7 tablet(s)* refills:*0* 10. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po daily (daily) for 7 days. disp:*7 tab sust.rel. particle/crystal(s)* refills:*0* 11. levofloxacin 250 mg tablet sig: two (2) tablet po q24h (every 24 hours) for 7 days. disp:*14 tablet(s)* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 4 hypercholesterolemia s/p multiple percutaneous interventions to circumflex - gastroesophageal reflux disease anxiety depression kidney stones- s/p laser surgery discharge condition: good discharge instructions: monitor wounds for signs of infection. these include redness, drainage or increased pain. report any fever greater then 100.5. report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. shower daily. wash incision with soap and water. no lotions, creams or powders to incision for 6 weeks. no driving for 1 month and taking narcotics. no lifting greater then 10 pounds for 10 weeks. please call with any questions or concerns. take all medications as directed followup instructions: dr. in 4 weeks() dr. in weeks dr. in weeks () 6 wound clinic in 2 weeks please call for appointments Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Tobacco use disorder Depressive disorder, not elsewhere classified Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Anxiety state, unspecified Other and unspecified angina pectoris Old myocardial infarction Family history of ischemic heart disease Personal history of urinary calculi Chronic total occlusion of coronary artery

history of present illness: this is a 36 year old male with a history of nephrolithiasis admitted to ccu from catheterization laboratory after complaining of chest pain described as "burning", substernal radiating to the left and right upper extremities and back. the patient was in class at the time of the onset at 7:00 a.m. on the day of admission. the patient went to unit health where he reports received three nitroglycerin sublingual and chewed on an aspirin. the patient was brought in by ambulance to . at , his heart rate was 58, blood pressure 152/64 with a respiratory rate of 24. his electrocardiogram was consistent with an inferior myocardial infarction with 5. elevations in leads ii, iii, avf, v6. the patient was treated with aspirin, nitroglycerin, oxygen, heparin, intravenous nitroglycerin drip 80 mcg. the patient was taken to the catheterization laboratory where he was found to have a patent right coronary artery, patent left anterior descending, and the left circumflex with a subtotal occlusion. wire across the lesion, percutaneous transluminal coronary angioplasty was performed. the stent was placed where upon the patient complained of some chest pain and treated with fentanyl. after the procedure, the patient's chest pain abated. right heart catheterization was performed with right atrial mean pressure of 13, right ventricular pressure of 36/14 with a wedge pressure of 18. the patient received 180 cc of contrast during the procedure. review of systems: no shortness of breath, no nausea, no vomiting, no diaphoresis, no light-headedness, no abdominal pain. some difficulty with urination, status post fentanyl. past medical history: no past medical history other than nephrolithiasis. the patient reports a past surgical history for kidney stone. allergies: no known drug allergies. medications: no medications at admission. social history: the patient moved to from rio de janiero, two years ago. he has a nine pack year history of tobacco use. he quit two years ago and then recently restarted. family history: significant for coronary artery disease. father passed away from myocardial infarction at age 67. physical examination: vital signs on admission revealed temperature 98, heart rate 60, systolic blood pressure 134, diastolic blood pressure 75 on 40 mcg nitroglycerin. mean atrial pressure 95. the patient is on 800%. examination revealed the patient pleasant, no apparent distress, alert and oriented to person, place and date. no pallor, no jaundice, no anasarca. extraocular movements are intact. sclera anicteric. no jugular venous distention. no carotid bruit. normal s1 and s2, bradycardic in the 50s, no murmurs, rubs or gallops. the lungs are clear to auscultation anteriorly. the abdomen is soft, nontender, nondistended, bowel sounds auscultated. the patient with angio to right femoral artery with no evidence of hematoma or bruit. the right femoral vein sheath is in place. no lower extremity edema. laboratory data: white blood count 11.0 with a differential of 74% neutrophils, 19% lymphocytes, 0 bands, 4.7% monocytes, platelets 305,000. red blood cell morphology within normal limits. prothrombin time 12.8, inr 1.1, partial thromboplastin time 29.9. biochemical profile as follows: sodium 135, potassium 3.9, chloride 100, bicarbonate 25, blood urea nitrogen 8, creatinine 0.8, glucose 108, ck from 9:45 a.m. 107 with a troponin less than 0.3. assessment: this is a 36 year old male with a family history of coronary artery disease and positive tobacco use, status post percutaneous transluminal coronary angioplasty and stent of left circumflex artery with decrease in chest pain following catheterization. the patient with negative ck at 9:45 a.m., the pain beginning at 7:00 a.m., the patient hemodynamically stable on reopro drip and nitroglycerin drip on admission. hospital course: 1. coronary artery disease - the patient's cks were cycled during hospital course. the patient had a peak ck mb of 157 with an index of 10 at 10:00 p.m. on . the patient's troponin was measured to be greater than 50. the patient was treated with aspirin, plavix, lopressor, captopril, bedrest, reopro drip for twelve hours and then discontinued. nitroglycerin drip was titrated and discontinued. the patient was maintained on telemetry. the patient had episodes of nonsustained supraventricular tachycardia on telemetry as well as bradycardia after lopressor treatment began. ldl was checked which was 120. the patient was started on lipitor 10 milligrams p.o. q.d. during the hospital course, the patient was adequately beta blocked to a heart rate of 80 with a systolic blood pressure of 100 to 120 on 50 milligrams b.i.d. lopressor. the patient was also treated with captopril 12.5 milligrams p.o. t.i.d. his blood pressure tolerated this treatment. the patient was provided nutritional counseling for cardiac diet. the patient's urine output was within normal limits during hospital course. after contrast during cardiac catheterization, blood urea nitrogen and creatinine were within normal limits. after reopro drip and heparin treatment, the patient's platelets were within normal limits. during hospital course, the patient complained of chest pain within the hour after arrival to the ccu. serial electrocardiograms were obtained showing no electrocardiographic changes and no evidence of in stent restenosis. stat transthoracic echocardiogram was obtained which showed normal left atrium, mild symmetric left ventricular hypertrophy, mild regional left ventricular systolic dysfunction with hypokinesis of the posterior wall and basal inferior wall. aortic leaflets appeared within normal limits. mitral leaflets were structurally normal. no mitral valve prolapse and 1+ mitral regurgitation was noted. no pericardial effusion. for further workup of the patient's predisposition for myocardial infarction, lipid protein a and homocystine laboratories were sent which are pending at the time of discharge. the patient complained of gastric upset. he was treated with prilosec 20 milligrams p.o. q.d. as well as maalox p.r.n. the patient was noted to have an elevated white count which decreased consistent with myocardial infarction. the patient was noted to have a low grade temperature to 101 which abated which was consistent with recent myocardial infarction. amylase and lipase were sent when the patient complained of epigastric pain with back pain. amylase and lipase were both noted to be within normal limits. the patient was discharged on , with the following medications: 1. atenolol 50 milligrams p.o. q.d. 2. zestril 2.5 milligrams p.o. q.d. 3. nitroglycerin 0.4 milligrams sublingual q5minutes p.r.n. chest pain. 4. prilosec 20 milligrams p.o. q.d. 5. lipitor 10 milligrams p.o. q.d. 6. aspirin 325 milligrams p.o. q.d. 7. plavix 75 milligrams p.o. q.d. times twenty-eight days. follow-up: the patient will follow-up with and on , at 1:30 p.m. and with , on , at 3:00 p.m. discharge diagnosis: acute myocardial infarction, left circumflex artery thrombosis with percutaneous transluminal coronary angioplasty and stent. condition on discharge: stable. , m.d. dictated by: medquist36 d: 15:22 t: 21:16 job#: Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Mitral valve disorders Acute myocardial infarction of inferolateral wall, initial episode of care Diseases of tricuspid valve

allergies: ciprofloxacin / zolpidem attending: chief complaint: right pleural effusion and sob major surgical or invasive procedure: r thoracentesis with chest tube placement left lung thoracentesis right lung chest tube placement and drainage right lung thoracentesis history of present illness: ms. is an 80 year old female with history of chf, cad s/p pci, and recently diagnosed multiple myeloma, transfered here from hospital with recurrent right sided pleural effusion and dyspnea. patient was diagnosed with multiple myeloma in of this year and has been tapped 4 times for r pleural effusions since diagnosis. previous drainage procedures have yielded "murky" fluid suspicious for chyle which her pulmonologist states was positive for triglycerides in the past. patient was tapped one week ago with relief of dyspnea but symptoms recurred one day prior to transfer. patient denies chest pain, weakness, fatigue, nausea, and abdominal pain. past medical history: coronary stents x3 in ; hx of chf; hx of dvt on coumadin and hx of paroxismal a fib. s/p right mastectomy; s/p thyroidectomy, hysterectomy; multiple myeloma diagnosed in - due to investigation for anemia; with myelodisplastic syndrome; s/p blood transfusion. social history: no cigarette or alcohol use. no illicit drug use. lives alone but has support from neice and son who live in area. family history: family history of cad physical exam: tc: 97.5 p:64 bp:103/45 rr:22 o2sat: 96%2lnc gen: female in no acute distres heent: supple neck without lymphadenopathy. no jvd. chest: decreased breath sounds at the bases bilaterally extending to the lower mid lung zones, higher on the right side. bandage at r midaxillary at site of pig tail. heart: regular rate and rhythm, mild 2/6 systolic murmur in the 2nd intercostal space. abdomen: soft, nontender and nondistended external:no pitting edema of lower extremities. appropriate temperature neuro: cn 2-12 intact. alert and oriented x 3. moving all extremities. pertinent results: pleural fluids 10:16am pleural totprot-2.6 glucose-198 ld(ldh)-127 cholest-30 triglyc-86 10:16am pleural wbc-500* rbc-* polys-0 lymphs-87* monos-13* 05:36pm pleural totprot-2.6 glucose-146 ld(ldh)-128 cholest-27 triglyc-40 05:36pm pleural wbc-350* rbc-* polys-2* lymphs-68* monos-0 plasma-1* meso-2* macro-16* other-11* . pertinent labs 02:42pm blood wbc-2.9* rbc-3.41* hgb-9.8* hct-31.2* mcv-92 mch-28.6 mchc-31.3 rdw-17.1* plt ct-174 08:15am blood glucose-144* urean-33* creat-1.6* na-138 k-4.4 cl-100 hco3-28 angap-14 07:20am blood glucose-155* urean-31* creat-1.7* na-138 k-4.5 cl-102 hco3-31 angap-10 07:25am blood glucose-173* urean-29* creat-1.8* na-136 k-4.4 cl-100 hco3-29 angap-11 07:00am blood ck-mb-5 ctropnt-0.04* probnp-2376* 02:30pm blood ck-mb-12* mb indx-5.7 ctropnt-0.39* 06:56pm blood ck-mb-10 mb indx-4.8 ctropnt-0.33* 02:51am blood ck-mb-8 ctropnt-0.23* 07:30am blood ck-mb-3 ctropnt-0.07* 07:03am blood type-art po2-84* pco2-50* ph-7.42 caltco2-34* base xs-6 05:29am urine rbc-10* wbc-519* bacteri-mod yeast-none epi-5 05:29am urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-0.2 ph-5.5 leuks-mod . discharge labs . pertinent reports pleural fluid cytology: negative for malignant cells. . ct chest (): impression: 1. complete interval resolution of right pleural effusion since drainage today. 2. moderately large left pleural effusion with associated atelectasis and probable lymphatic obstruction. 3. right upper lobe cicatricial atelectasis, likely secondary to radiotherapy. 4. extensive severe vascular calcification, more commonly described in hyperparathyroidism than multiple myeloma. diffuse mixed sclerotic and lytic lesions with soft tissue calcification. correlation with parathyroid hormone levels is suggested. . tte (): mild symmetric left ventricular hypertrophy with normal systolic function. moderate diastolic dysfunction with elevated estimated left ventricular filling pressures. . rhc (): 1. elevated right- and left-sided filling pressures. 2. moderate pulmonary hypertension. 3. no constrictive physiology. 4. no significant mitral or aortic stenosis. 06:25am blood wbc-4.2 rbc-2.95* hgb-8.6* hct-26.1* mcv-89 mch-29.3 mchc-33.1 rdw-16.8* plt ct-152 06:45am blood wbc-4.4 rbc-3.07* hgb-9.0* hct-27.1* mcv-88 mch-29.3 mchc-33.1 rdw-16.8* plt ct-156 06:35am blood wbc-3.5* rbc-3.40* hgb-9.5* hct-30.9* mcv-91 mch-27.9 mchc-30.7* rdw-17.1* plt ct-198 06:00am blood wbc-3.9* rbc-3.05* hgb-8.9* hct-26.9* mcv-88 mch-29.3 mchc-33.2 rdw-17.1* plt ct-164 07:35am blood wbc-3.7* rbc-2.73* hgb-8.1* hct-24.5* mcv-90 mch-29.7 mchc-33.2 rdw-16.9* plt ct-138* 02:42pm blood neuts-50.9 lymphs-39.9 monos-7.8 eos-0.5 baso-0.9 08:00am blood neuts-39* bands-1 lymphs-46* monos-9 eos-3 baso-0 atyps-2* metas-0 myelos-0 08:00am blood hypochr-1+ anisocy-occasional poiklo-occasional macrocy-normal microcy-occasional polychr-normal ovalocy-1+ stipple-occasional 06:25am blood plt ct-152 06:25am blood pt-14.3* ptt-27.7 inr(pt)-1.2* 06:45am blood plt ct-156 06:45am blood pt-17.8* ptt-29.0 inr(pt)-1.6* 06:35am blood plt ct-198 06:35am blood pt-26.0* ptt-32.6 inr(pt)-2.5* 06:25am blood glucose-216* urean-47* creat-1.9* na-137 k-3.5 cl-96 hco3-33* angap-12 06:45am blood glucose-160* urean-48* creat-2.1* na-135 k-3.9 cl-94* hco3-32 angap-13 08:00pm blood glucose-181* urean-44* creat-2.3* na-135 k-4.2 cl-93* hco3-30 angap-16 06:35am blood glucose-154* urean-40* creat-2.2* na-137 k-3.7 cl-93* hco3-32 angap-16 04:25pm blood ck(cpk)-114 02:51am blood ck(cpk)-184 06:40am blood probnp-1354* 07:30am blood ck-mb-3 ctropnt-0.07* 04:25pm blood ck-mb-3 ctropnt-0.20* 02:51am blood ck-mb-8 ctropnt-0.23* 06:25am blood calcium-8.6 phos-4.6* mg-2.3 06:45am blood calcium-8.8 phos-5.6* mg-2.3 08:00pm blood calcium-8.9 phos-5.7* mg-2.1 06:35am blood calcium-9.1 phos-5.9* mg-2.1 08:15am blood triglyc-156* hdl-50 chol/hd-2.6 ldlcalc-50 05:00pm blood digoxin-1.8 07:25am blood pth-65 04:10pm blood ph-7.45 comment-pleural fl 04:52pm blood type- ph-7.46* 07:03am blood type-art po2-84* pco2-50* ph-7.42 caltco2-34* base xs-6 04:52pm blood freeca-1.04* 04:01pm pleural wbc-450* rbc-3800* polys-3* lymphs-86* monos-11* 05:36pm pleural wbc-350* rbc-* polys-2* lymphs-68* monos-0 plasma-1* meso-2* macro-16* other-11* 10:16am pleural wbc-500* rbc-* polys-0 lymphs-87* monos-13* 04:01pm pleural totprot-3.5 glucose-191 ld(ldh)-127 albumin-2.3 cholest-38 triglyc-65 05:36pm pleural totprot-2.6 glucose-146 ld(ldh)-128 cholest-27 triglyc-40 10:16am pleural totprot-2.6 glucose-198 ld(ldh)-127 cholest-30 triglyc-86 . 8:36 am pleural fluid add-on from #65422y. fluid culture and gram stain requested by fax from on at 08:36am. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (preliminary): no growth. anaerobic culture (preliminary): gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. fungal culture (preliminary): no fungus isolated. \ . 8/30cxr findings: there are relatively low lung volumes. there is a small right pleural effusion with possible adjacent pleural thickening. prominence of the hila is seen, which may relate to fluid overload, although underlying consolidation is not excluded. recommend repeat when patient clinically able to take deeper inspiration. underlying pulmonary lesion not excluded. the aorta is calcified and tortuous. the cardiac silhouette is not enlarged. marked thoracolumbar scoliosis is noted. there is diffuse osteopenia. . pleural fluid right pleural fluid: negative for malignant cells. mesothelial cells, macrophages and lymphocytes . ekg irregular rhythm may be "fine" atrial fibrillation but baseline artifact makes assessment difficult. left bundle-branch block. no previous tracing available for comparison. . echo the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). doppler parameters are most consistent with grade ii (moderate) left ventricular diastolic dysfunction. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild symmetric left ventricular hypertrophy with normal systolic function. moderate diastolic dysfunction with elevated estimated left ventricular filling pressures. . cxr impression: stable moderately large pleural effusions, worse on the right side. . 1. resting hemodynamics revealed elevated right- and left-sided pressures with mean ra pressure of 18 mmhg and mean pcw pressure of 30 mmhg. there was moderate pulmonary hypertension, with mean pa pressure of 55 mmhg. there was moderate to severe systemic hypertension, with sbp of 193 mmhg. there was no significant mitral stenosis, and no significant aortic stenosis detected by lv pullback technique. there was no evidence of constrictive physiology. final diagnosis: 1. elevated right- and left-sided filling pressures. 2. moderate pulmonary hypertension. 3. no constrictive physiology. 4. no significant mitral or aortic stenosis. . renal ultrasound . no son evidence for renal artery stenosis. 2. cortical thinning with minimally elevated resistive indices. 3. right pleural effusion. . cxr findings: ap single view of the chest has been obtained with patient in upright position. comparison is made with the next previous similar study of . the previously identified moderate amount of right-sided pleural effusion has decreased markedly following the successfully performed thoracocentesis. only a mild degree of fluid blunting of the right lateral pleural sinus remains. no new parenchymal infiltrates are seen and no pulmonary vascular congestion is identified. right apical area is examined with magnification device and there is no evidence of any apical pneumothorax or chest wall emphysema. previously described marked s-shaped scoliosis as before. impression: no evidence of pneumothorax following successful right-sided thoracocentesis. brief hospital course: patient was admitted to thoracic surgery on for evaluation and treatment of right pleural effusion. on admission, patient was short of breath but with sats 90-95% on 2lnc. cxr showed large right pleural effusion and interventional pulmonology was consulted for thoracentesis. patient's inr on admission was 3.2 (on coumadin for afib) which was reversed overnight with 4u ffp and lasix. on am of , patient's dyspnea worsened and she desaturated to high 88-90 on 6lnc with bp of 200/130. patient was given sublingual nitro with bp returning to 140/90. ekg was performed revealing no st-t changes and a left bundle branch block, present on previous ekg from . stat cxr was done with stable effusion and no evidence of pulmonary edema. ckmb was normal at 5 with trop of 0.04. bnp was 2357. lung exam demonstrated bilateral wheezes but no crackles. cardiology was consulted and team was present during this workup. patient's increased oxygen requirements and concern for acute on chronic heart failure prompted a transfer to first icu bed available, in trauma icu. in ticu, patient was started on bipap and briefly on nitro drip for sbp in 180s. her dyspnea and hypertension responded well to bipap with o2 sats >95% on 4lnc. ip performed right pigtail placement with 1600cc of serosanginous fluid drained and samples sent for analysis. preliminary results showed fluid c/w transudate, although chylothorax cannot be ruled out since patient had been npo. patient reported significant improvement in dyspnea and sats remained 95% on 2lnc. trops peaked at 0.39 with ckmb of 12 and began to trend downward, c/w demand ischemia from fluid overload and hypertensive urgency. patient was kept on her home medications, including her aspirin, although coumadin was held. at this point, patient was transferred to medical service for continued management of multiple medical problems. had her left pleural effusion also tapped by ip with transudative findings on analysis. her bps were noted to be in the 60s-70s, although the patient was completely asymptomatic and was able to walk from her bed to bedside chair without difficulty. o2 was able to be weaned slightly. . medicine service course # shortness of breath: due to acute on chronic diastolic heart failure. she was started on lasix 20 mg po qdaily but was held due to low systolic blood pressure. she continued to desaturate in 70s and 80s upon ambulation. her pleural effusion on cxr were slightly large but stable. cardiology was consulted for further management of her diastolic heart failure. betablocker could not be started due to her sinus bradycardia. pulmonology was also consulted with history of radiation for breat cancer in the past. pulmonology did not think there was a pulmonary pathology based on their evaluation and ct chest. rhc was done to evaluate furthere whether her heart failure is restrictive or constrictive. rhc showed elevated right and left heart filling pressure with moderate pulmonary hypertension and severe systemic hypertension. lasix was increased to 20 mg po bid. she was transferred to cardiology service for further management of her diastolic heart failure. . #. abnormal ua: start bactrim ds once a day for 7 days (day #7 will be ). . # ckd: likely due to multiple myeloma. creatine @ baseline at 1.8. . # paroxysmal atrial fibrillation: currently in sinus bradycardia with rates in 50s. continue anticoagulation with aspirin. coumadin started on . inr was therapeutic on . no av nodal blocker as she is in sinus bradycardia with rates in 50s. . # cad s/p 3 stents to rca in : continue aspirin 81 mg po qdaily and atorvastatin 40 mg po qdaily. no bb secondary to sinus bradycardia. . # pancytopenia: likely due multiple myeloma and mds. no need for transfusion during this hospital stay. recent therapy with revlimide and prednisone. . # dm2: sliding scale insulin. . # hyperthyroidism: levothyroxine was continued . #. gerd: omeprazole 20 mg po qdaily was continued. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ service course 80f with multiple myeloma s/p revlimide/prednisone one month ago, htn, dm, cad s/p 2 rca stents, diastolic heart failure presents with recurrent bilateral pleural effusions and shortness of breath . # shortness of breath: likely due to acute on chronic diastolic heart failure. rhc showed elevated right and left heart filling pressure with moderate pulmonary hypertension.pleural effusions , with right greater than left both of which have been tapped on this admission and drained fluid was transudative without high triglycerides. strict in/outs. the patient responded well to a iv lasix drip and was net negative approx. 3.5l in 2 days.her weight on discharge was 62.1 kg decreased from 66.5kg on . discontinued iv lasix drip ( measured systolic was around 100 on arms and 140-180 on thigh readings, drip was on from 9/11pm to 9/13am).transitioned to oral lasix 60mg with net fluid goal of even to net negative 500cc a day with 1500cc/day fluid restriction. ip drained on pm her right pleural effusion and removed around 1000cc and sent for extensive lab workup of the removed pleural fluid.f/u on the post drain chest x ray and pleural labs. ambulatory oxygen saturation-84-94% on ra, did not feel sob .ordered cxr -the previously identified moderate amount of right-sided pleural effusion has decreased markedly following the successfully performed thoracocentesis. only a mild degree of fluid blunting of the right lateral pleural sinus remains. no new parenchymal infiltrates are seen and no pulmonary vascular congestion is identified. right apical area is examined with magnification device and there is no evidence of any apical pneumothorax or chest wall emphysema. . #. hypertension: noted to have low sbp by electronic and manually on left arm (right breast mastectomy in the past). rhc showed severe systemic hypertension. popliteal blood pressures with dopplers measured while lying were greater than 120s-150s. renal ultrasound to assess for renal artery stenosis given diffuse calcified arteries on ct chest study-results included: no son evidence for renal artery stenosis, cortical thinning with minimally elevated resistive indices, right pleural effusion. obtained bp readings from all four limbs. . #. abnormal ua: indicative of uti with moderate positive leuk.esterase continued bactrim ds once a day for 7 days and completed course as an inpatient.had no dysuria on discharge. . # ckd: likely due to multiple myeloma. creatine @ baseline at 1.7-1.9.renal ultrasound given diffuse calcified arteries on ct chest-results included: no son evidence for renal artery stenosis, cortical thinning with minimally elevated resistive indices, right pleural effusion. . # paroxysmal atrial fibrillation: was in sinus rhythm with rates in 60s-70s and episode of atrial fibrilliation for 15 minutes up to 120's, which was asymptomatic on . she transitioned spontaneously back into 60-90 normal sinus rhythm.no contraindication to beta blockers given systolic blood pressures ranging from 130-170's.start metoprolol tartrate 12.5mgbid for rate control (), given some bradycardic episodes on the patient will be d/c'd on 12.5mg/daily of metoprolol succinate.restarted coumadin on with one time dose of 5mg/daily and standing on 3mg coumadin on to reach therapeutic range of . . # cad s/p 2 stents to rca in : continued aspirin 81 mg po qdaily and atorvastatin 40 mg po qdaily.started metoprolol tartrate 12.5mg during the admission for rate control of atrial fibrilliation and cad,dchf.given some bradycardic episodes on the patient will be d/c'd on 12.5mg/daily of metoprolol succinate. . # pancytopenia: multiple myeloma and mds. s/p treatment with revlimide and prednisone one month ago.stopped because the patient thought she was becoming short of breath because of the chemo's side effects. no need for transfusions.trended platelets, hct, wbc daily -stable . # dm2: will follow finger sticks.continued insulin sliding scale. discharged on home dose glipizide and metformin . # hyperthyroidism: continued levothyroxine . #. gerd: continued omeprazole 20 mg po qdaily . outpatient follow up the patient was started on metoprolol for rate control of paf some pleural labs were pending at the time of discharge. patient was in nsr at the time of discharge medications on admission: digoxin - 0.125 mg thyroxine - 88 mcg lasix - 40 mg qd glipizide - 5 mg coumadin - 2.5 mg daily lipitor - 40 mg qd asa - 81 mg iron - 65 mg prilosec - 20 mg dexamethasone and revlimid-> was tried for mm but she could not tolerated it. discharge medications: 1. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. iron (ferrous sulfate) 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 5. metoprolol succinate 25 mg tablet sustained release 24 hr sig: 0.5 tablet sustained release 24 hr po once a day: please take 12.5mg daily . disp:*30 tablet sustained release 24 hr(s)* refills:*2* 6. furosemide 20 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* 7. coumadin 2.5 mg tablet sig: one (1) tablet po once a day: please take 5mg on , and then take 2.5mg per day as prescribed thereafter. . 8. outpatient lab work please have inr checked friday and send to: name: , r. address: 4 dr, , phone: fax: 9. outpatient lab work please check electrolytes (bmp) on at your primary care doctor's appointment. 10. lovastatin 40 mg tablet sig: one (1) tablet po once a day. 11. glipizide 5 mg tablet sig: one (1) tablet po twice a day. 12. metformin 500 mg tablet sig: one (1) tablet po twice a day. discharge disposition: home with service facility: vna discharge diagnosis: primary diagnosis 1. acute on chronic diastolic heart failure 2. atrial fibrillation . secondary diagnosis 1. coronary artery disease 2. hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to an outside hospital because you had shortness of breath. you were found to have fluid in your lungs,and were transferred to to help drain that fluid. fluid was tapped from your lung by interventional pulmonology team which helped improve your shortness of breath. . please measure your weight every day. if your weight increases over 3 lbs, contact your md. . following medication changes were made to your regimen: start metoprolol 12.5mg per day, it is a medication for your heart stop digoxin . your lasix was increased to 60mg twice a day. . please take the rest of your medications as you were before coming to the hospital. . please take 5mg on , and then take 2.5mg per day as prescribed thereafter. . please have your inr checked on friday and have the results faxed to your primary care doctor. . please follow up with the outpatient appointments below: followup instructions: . name: , r. date: 11:15am address: 4 dr, , phone: please have your electrolytes checked at this appointment. . name: , location: the cardiovascular specialists address: 90 ter huen dr, , phone: appt: at 2pm . department: west clinic when: wednesday at 9:30 am with: , md building: de building ( complex) campus: west best parking: garage . department: chest disease center when: wednesday at 9:00 am building: building ( complex) campus: west best parking: garage . department: west clinic when: wednesday at 9:00 am building: de building ( complex) campus: west best parking: garage Procedure: Insertion of intercostal catheter for drainage Combined right and left heart cardiac catheterization Thoracentesis Thoracentesis Thoracentesis Diagnoses: Unspecified pleural effusion Urinary tract infection, site not specified Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Acute on chronic diastolic heart failure Other chronic pulmonary heart diseases Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Other specified forms of chronic ischemic heart disease Multiple myeloma, without mention of having achieved remission Personal history of venous thrombosis and embolism Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site Scoliosis [and kyphoscoliosis], idiopathic Other and unspecified coagulation defects Personal history of irradiation, presenting hazards to health

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fever altered mental status major surgical or invasive procedure: arterial line placement red blood cell transfusion history of present illness: the patient is a 62 yo m with no significant past medical history per his wife. was admitted to science benevolent association facility approx 6 weeks ago for urinary retention. staff at this facility assisted him with eating and toileting. he has not had any medical care for this issue. per family, he went to this facility because of problems with hematuria and urinary retention. he has also had trouble ambulating for multiple weeks and was complaining of lower back pain. per his family, over course of last week, mental status slowly declined, pt would "drift off," became sleepy but arousable, still communicating. this worsened in the leading up to admission and on day of admission patient was unable to take anything by mouth and was sent to the emergency department. in the emergency department, patient was febrile, tachycardic, and demonstrated altered mental status and combative behavior. a foley catheter was placed and was clamped after 1 liter of urine was released. initial vitals: t 101.4, hr 136, bp 138/110, rr 18, sat 94. of note, lactate 4.4, na 167, wbc 28.1, hct 33 (no baselines for comparison). he was empirically treated with vancomycin, levaquin, flagyl, tylenol, haldol, and morphine (to facilitate ct). he received a total of 4 l normal saline, followed by initiation of normal saline at 250cc/hr per renal service recommendations. total urine output in ed was 3.8 liters. past medical history: none social history: married with two daughters. and his wife are scientists and live in upperstate ny. he does not consume tobacco/etoh/drugs family history: non-contributory physical exam: vs (on arrival to micu): t 97 hr 111 bp 113/69 rr 20 sat 94% 2 l nc gen: pale, cachectic; minimally responsive to verbal stimuli, withdraws to pain heent: perrl; mm extremely dry; neck: stiff lungs: ctab heart: tachycardic, s1s2 present abd: +bs, soft, non-tender, non-distended ext: radial & dorsalis pedis pulses 2+, + muscle wasting, moves lower extremities skin: no petechiae/purpura gu: foley in place, draining brown urine neuro: minimally responsive; difficult to obtain deep tendon reflexes pertinent results: admission labs: 05:05pm glucose-115* urea n-110* creat-2.3* sodium-162* potassium-3.5 chloride-125* total co2-30 anion gap-11 05:15pm freeca-2.03* 05:05pm tot prot-5.3* 02:21pm albumin-3.0* calcium-14.8* phosphate-4.2 magnesium-3.0* iron-47 02:21pm caltibc-228* ferritin-133 trf-175* 02:21pm pth-22 02:21pm psa-9.5* 02:21pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 02:21pm wbc-20.8* rbc-3.04* hgb-8.4* hct-26.8* mcv-88 mch-27.8 mchc-31.5 rdw-17.6* 02:21pm neuts-90.5* lymphs-6.6* monos-2.7 eos-0.2 basos-0 02:21pm pt-18.0* ptt-23.2 inr(pt)-1.6* 09:30am urine hours-random creat-39 tot prot-81 prot/crea-2.1* 09:30am urine u-pep-multiple p ife-negative f osmolal-262 09:14am alt(sgpt)-35 ast(sgot)-15 ck(cpk)-49 alk phos-106 tot bili-0.8 09:14am lipase-28 09:14am ctropnt-0.01 07:35am urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-mod 07:35am urine rbc-* wbc-21-50* bacteria-many yeast-none epi-0-2 07:31am glucose-108* lactate-4.4* na+-167* k+-5.1 cl--116* tco2-35* discharge labs: wbc rbc hgb hct mcv plt ct 19.6* 2.93* 8.4* 25.4* 87 369 glucose urean creat na k cl hco3 angap 106* 19 1.1 146* 3.5 106 31 13 microbiology: blood cx : no growth 7:35 am urine site: catheter leg added @ 14:33. **final report ** urine culture (final ): culture workup discontinued. further incubation showed contamination with mixed skin/genital flora. clinical significance of isolate(s) uncertain. interpret with caution. escherichia coli. >100,000 organisms/ml.. work-up per dr. , pager . gram positive bacteria. 10,000-100,000 organisms/ml.. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. gram positive bacteria. 10,000-100,000 organisms/ml.. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. 2nd morphology. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ 8 i meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ 4 s trimethoprim/sulfa---- <=1 s legionella antigen : negative cytology: urine atypical keratinizing squamous cells. atypical urothelial cells. note: the squamous cells display hyperchromatic angulated nuclei. the differential diagnosis includes urothelial carcinoma with squamous differentiation, squamous cell carcinoma, squamous dysplasia and metaplasia. imaging studies: ct head : findings: there is no evidence of hemorrhage, edema, masses, mass effect, or infarction. the ventricles and sulci are normal in caliber and configuration. there are no fractures identified. the sinuses are clear. two destructive bony lesions are seen in the occipital bones which are concerning for metastatic disease. these are seen on series 2, images 15 and 24. impression: 1. no evidence for hemorrhage or masses. 2. destructive bony lesions in the occipital bones, concerning for metastatic disease. ct abdomen/pelvis ct of abdomen without contrast: the visualized lungs are clear without nodule or masses. there are no pleural effusions. the heart is normal in appearance without pericardial effusion. there is a 3.9 x 3.5 cm soft tissue mass in the right posterior chest wall causing a convex bulge along the right posterior pleura. this lesion which is arising from the right 12th rib is compatible with metastasis (2:11). an enlarged lymph node is seen in the posterior mediastinal space on s2, i2, measuring 1.7 cm. additional prominent retrocrural nodes are noted measuring up to 13mm. the noncontrast appearance of the liver, spleen, adrenals, pancreas, and gallbladder is unremarkable. within the right kidney, two hypodense rounded lesions are seen, the larger of which measured 3.2 x 2.9 cm. these may represent simple cysts but are incompletely characterized on this noncontrast evaluation. there are punctate calcifications within the lower pole of the left kidney which could represent nonobstructing stones. there is no hydronephrosis seen within either kidney. the abdominal loops of small and large bowel are grossly unremarkable on this noncontrast study. there is no free air. there is no free fluid. there is extensive bulky retroperitoneal lymphadenopathy, most prominent along the left aortic chain extending into the left hemipelvis. the largest of these (2:26) measures 3.4 x 3.2 cm. ct of the pelvis without contrast: there is a large irreguylar mass arising from the anterior bladder wall measuring approximately 8.2 (tr) x 4.6 (ap) x 9.6 (cc) cm. there is peripheral calcification noted along the luminal (posterior) border of this mass. there is irregularity along the bladder wall with apparent infiltration of the prevesical fat, compatible with tumor extension. there is likely a second area of disease along the posterior wall of the urinary bladder where calcification (4.9 x 1.8 cm) is also noted though evaluation is quite limited without contrast. there is a foley catheter present within the bladder. there is no free air, there is no free fluid. there is significant bulky pelvic lymphadenopathy, measuring up to 6.3 x 2.7 cm (s301b, i50). the rectum, sigmoid colon and pelvic small and large bowel are grossly unremarkable. there are scattered diverticula within the sigmoid colon without evidence for diverticulitis. bone windows: there are multiple destructive bony lesions which are compatible with metastasis. these are seen throughout the vertebral column, pelvis and proximal femurs. in particular there is a large lesion eroding the right proximal femoral shaft measuring 4.7 x 4.1 cm. there is soft tissue density in the marrow cavity of the left proximal femur (2:88). there is a 2.4 x 2.5 cm soft tissue density causing lytic destruction of the anterior right- sided pubic ramus. there is a 3.3 x 2.9 cm soft tissue density with lytic destruction of the posterior inferior left sacral ala (2:60). there is a 3.8 x 2.6 cm left sided iliac crest lytic soft tissue density and a 3.2 x 2.3 cm soft tissue mass causing lytic destruction of the posterior left-sided ischium and a 2.4 x 2.1 cm soft tissue mass causing lytic destruction of the posterior right-sided ischium. within the left sided posterior aspect of the l5 vertebral body (2:44), there is a 1.4 x 1.3-cm lytic soft tissue mass with cortical disruption. this soft tissue density mass protrudes into the spinal canal and indents the thecal sac. there are no fractures identified; however, given the burden of lytic lesions, there is a high risk of possible future pathological fractures. impression: 1. large calcified bladder mass with bulky retroperitoneal and pelvic lymphadenopathy and extensive osseous metastasis. recommend biopsy for definitive diagnosis. 2. l5 vertebral body metastatic lesion indents the thecal sac. recommend mri for further evaluation as clinically warranted. 3. no evidence of pathologic fracture but the lesions in the femur, especially on the right, place this patient at high risk for future complications. mr lumbar spine findings: there are multiple metastatic masses throughout the imaged bones. a mass in the left posterior elements of l1 extends into the left l1/2 neural foramen, where it may contact the left l1 nerve root. a mass in the left posterior superior aspect of the l5 vertebral body extends into the left anterior epidural space, displacing the left l5 nerve root posteriorly. there is an at least 3.5 cm mass in the inferior sacrum, partially imaged on the sagittal images only, which extends into the presacral soft tissues, as seen on the concurrent abdominal/pelvic ct scan. its effect on the sacral plexus is not evaluated. there is no evidence of cauda equina compression in the lumbar spine. the conus terminates at l1, and it appears unremarkable. there is a partially visualized mass in the right lower ribs, which is better seen on the concurrent ct scan. at l4/5, there is a disc bulge and a central disc protrusion, which does not contact any nerve roots. facet joint arthropathy is also present at this level. at l5/s1, there is a disc bulge and facet joint arthropathy, resulting in mild narrowing of the neural foramina without evidence of nerve root impingement. there is a partially imaged mass in the bladder. retroperitoneal lymphadenopathy is present. cystic lesions are noted in the kidneys. these findings are better evaluated on the concurrent abdominal/pelvic ct scan. impression: 1. metastases throughout the imaged bones. 2. a mass in the left posterior elements of l1 extends into the left l1/2 neural foramen, where it may contact to the left l1 nerve root. 3. a mass in the posterior left vertebral body of l5 extend into the left anterior epidural space, displacing the left l5 nerve root posteriorly. 4. partially imaged mass in the inferior sacrum, which extends into the presacral soft tissues. given the patient's symptoms, sacral plexus protocol mri of the pelvis would be helpful for evaluation of the sacral plexus. 5. partially visualized bladder mass, retroperitoneal lymphadenopathy, cystic renal lesions, and right lower rib mass, which are better evaluated on the concurrent abdominal/pelvic ct scan. mr cervical and thoracic spine : cervical spine: multifocal cervical spine metastases are identified including involvement of the dens and left aspect of the c2 vertebral body with involvement of the right pedicle and facet of c2 also observed. there is also evidence of involvement of the spinous process and right facet at c4 as well as involvement of the left pedicle and facet at c6. vertebral body height and alignment is maintained and there is no evidence for spinal canal narrowing or cord compression. cervical spinal cord signal intensity is normal. thoracic spine: there is vertebral height loss secondary to diffuse metastasis at t2 with mild retropulsion of t2 into the spinal canal, which appears to contact the anterior aspect of the thoracic cord. there is also evidence for metastasis to t3, though tvertebral height appears maintained at this level. signal intensity changes and enhancement involving the inferior aspect of t12 is noted without significant height loss and metastasis here cannot be excluded. the same is noted along the superior aspect of the t7 vertebral body. the remainder of the vertebral body heights appears preserved. at t7/t8 a moderate-to-severe posterior disc protrusion appears to cause narrowing of the spinal canal and cord compression. smaller disc protrusions from t8/9 through t11/12 cause only mild spinal canal narrowing without compression. multiple rib metastases are identified including the right 7th and 12th and left 8th ribs. multiple prominent posterior mediastinal lymph nodes are partially imaged, though evaluation of the chest is incomplete on this study. impression: 1. multilevel cervicothoracic metastatic disease, with the most significant height loss and posterior retropulsion noted at t2 which produces moderate canal narrowing and contacts the anterior thoracic cord. rib metastases as described. 2. multilevel thoracic degenerative disc changes, most severe at t7/8 where disc protrusion compresses the anterior thoracic spinal cord. 3. prominent posterior mediastinal nodes incompletely evaluated. recommend chest ct for more complete evaluation. lung scan : interpretation: ventilation images obtained with tc-m aerosol in 8 views demonstrate central clumping of the tracer, consistent with diffuse airway disease. perfusion images in the same 8 views show heterogeneity in a sub-segmental distibution, also most likely due to airways disease. chest x-ray shows hyperinflation without evidence of pneumonia. there is no ventilation- perfusion mismatch to suggest a pulmonary embolus. impression: low probability of pulmonary embolus. diffuse airway disease. cxr : portable chest radiograph: compared to prior study, is increasing opacity in the medial aspect of right lower lung. pulmonary vascularity is unchanged. there are no focal consolidations in the left lung. there are no large pleural effusions. impression: increasing opacity in the right lower lung, concerning for possible infection. discussed with dr. on , . bilat femur (ap and lat) : findings: right femur: there is a lytic expansile lesion in the proximal right femur located immediately inferior to the greater trochanter. in addition, note is made of a lytic lesion in the right pubic symphysis. there is no evidence of fracture at this time, however, these lesions are consistent with metastates and the right proximal femur lesion in particular is concerning for an impending pathologic fracture. left femur: there are multiple lytic lesions in the proximal left femur, some of which are causing endosteal scalloping. there is no evidence of acute fracture at this time, but these lesions which are consistent with metastases place the patient at risk for pathologic fracture. there is a tiny lytic lesion along the distal left femoral cortex which may also represent metastasis. mr head : comparison is made with ct head from . there are multiple calvarial metastases including lesions in the left temporal bones, left occipital bone and the right parietal bone. the lesion in the left occipital bone just to the left of midline has a dural component to it. there is no extension into the venous sinuses at this timw. no evidence for parenchymal metastases is seen. there is no mass, mass effect or midline shift. impression: multiple calvarial metastases, no evidence for intraparenchymal metastasis in the brain. cxr : pa and lateral upright chest radiograph was compared to , . the heart size is normal. mediastinal position, contour and width are unremarkable. bilateral lower lung opacities projecting at the level of inferior hila, and might represent worsening foci of infection. there is an area of rib destruction surrounding by soft tissue component, seventh and fifth on the right that most likely represent metastasis, unchanged. there is small amount of bilateral pleural effusion most likely unchanged since the prior study. multiple nodular opacities are seen in the lungs that might represent pulmonary nodules. impression: bibasilar focal opacities, progressing over the period of last couple of days, dating back to and may represent worsening pneumonia. rib metastasis. multiple pulmonary nodules that might represent metastatic spread as well. brief hospital course: this is a sixty two year old male presenting with confusion, urinary retention, hypernatremia and hypercalcemia found to have a large calcified bladder mass and likely metastatic squamous cell carcinoma of the bladder. 1)metastatic cancer: patient has evidence of significant metastatic disease. ct and mri demonstrate diffuse lytic lesions of the calvarium, all levels of the spine, bilateral femurs and ribs. there is also evidence of pulmonary nodules, significant mediastinal lymphadenopathy and bulky pelvic lymphadenopathy (details in reports section). ct of the pelvis demonstrates a 8.2 x 4.6x 9.6 cm bladder mass, as well as, bulky pelvic lymphadenopathy highly suggestive for a bladder cancer. this is further supported by urine cytology demonstrating atypical keratinizing squamous cells. patient was seen by the hematology/oncology consult team who felt that patient likely has terminal metastatic bladder cancer. they felt that tissue diagnosis should be obtained in order to proceed with palliative radiation therapy and possibly chemotherapy. the urology consult team felt that bladder biopsy should be obtained by interventional radiology rather than via cystoscopy due to the risk of bleeding with cystoscopy. patient was also seen by both the orthopedic spine team regarding metastic spinal lesions. the spine team was concerned about the patient's t2 compression fx with epidural extension and t7/8 disc protrusion w/ effacement of anterior cord. the team suggested vertebroplasty for the t2 fracture rather than surgery given the widespread nature of disease. radiation oncology was also consulted and felt it was reasonable to treat both the patient's spine and femur lesions palliatively with xrt. however, if the patient and his family wanted more aggressive treatment they recommended surgical resection of the t2 lesion with adjuvant xrt. the orthopedic trauma team saw the patient in regards to his femur lesions and recommended im rod for the right femur given the large size of the bony metastasis and the risk of fracture. none of these interventions were pursued given the family's request to have the patient transferred to st. hospital in ny for further medical management. 2)mental status changes: patient has been oriented to person, year, month, day. he has been consistently confused about his location. we feel that this confusion is due to a combination of his hypercalcemuia, hypernatremia, multiple infections and his metastatic cancer. patient continues to be treated for pneumonia and urinary tract infection. hypernatremia has resolved with intravenous fluids. hypercalcemia has been treated with pamidronate and calcitonin and intravenous fluids, though free calcium continues to be high. at time of transfer free calcium is 1.35 and total calcium is 11.1. the patient's continued disorientation is likely secondary to his calcium which has been difficult to control. 3)pneumonia:a cxr on showed possible right sided infiltrate concerning for pneumonia. in addition, the patient had an elevated white count that was trending up at the time these symptoms developed. that patient was initially treated for community acquired pneumonia with levaquin,however, white count continued to increase and patient's oxygen requirment became greater so his antibiotic coverage was switched to vancomycin and zosyn on . at time of discharge patient is afebrile and oxygen saturation is stable on room air -mid 90's. his wbc count remains elevated though it is unclear whether this represents persistent infection or presence of his malignancy. patient has a picc line in place. he should continue vancomycin and zosyn for 7 more days to complete a 14 day course (now on day 7). 4)urinary tract infection: urine positive for pansensitive e.coli. patient was initially treated with levaquin which was switched to zosyn for empiric treatment of hospital acquired pneumonia as noted above. as noted above, he should continue vancomycin and zosyn for another 7 days to complete a 14 day course of antibiotics. 5)hypercalcemia: ionized calcium was 2.03 on admission. patient was treated with pamidronate 30 mg iv x 1 on and calcitonin 100 units x 6 days. calcium has trended down following this treatment though free calcium remains elevated at 1.35 and total calcium of 11.1. we have continued the patient on intravenous fluids. 6)hypernatremia: sodium was 164 on admission. patient felt to be profoundly dehydrated and with large free water deficit. patient seen by the renal consult team who recommended fluid resucitation with d5w. as patient's mental status cleared his po intake also improved and he was more conscious of his thirst. serum sodium resolved and remains stable at time of transfer. 7)acute renal failure: cr was 2.4 upon admission. this was likely secondary to both urinary obstruction and hypovolemia. cr normalized with fluid resuscitation. 8)anemia: this is likely an anemia of chronic disease secondary to the patient's malignancy. iron studies demonstrated normal iron level and ferritin with low tibc and transferrin. hct has remained stable. he was transfused 1 unit prbc on 10/0 for hct of 21.7. hct remained stable >21 for rest of admission. would suggest continuing to monitor hct. 9)malnourishment:patient appears chronically ill and malnourished. albumin 2.4 and inr elevated (1.4-1.6)at time of transfer. patient seen by nutrition who felt that peg placement for tube feeds would be necessary given poor caloric intake. peg was not pursued given plans for transfer and family wishing for all procedures to occur at st. . patient was a full code during this admission. medications on admission: none discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day) as needed for ppx. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 4. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 5. ibuprofen 600 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain, headache. 6. potassium chloride 20 meq packet sig: two (2) packet po daily (daily). 7. sodium chloride 0.9% flush 3 ml iv prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 8. piperacillin-tazobactam na 4.5 g iv q8h 9. vancomycin 1000 mg iv q 12h 10. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. discharge disposition: extended care discharge diagnosis: primary: metastatic malignancy, pneumonia, urinary tract infection secondary:hypercalcemia, acute renal failure discharge condition: stable discharge instructions: you were admitted becuase you had a significant change in your mental status and were not urinating. on admission you were found to have many abnormalities in your electrolytes. further testing and imaging revealed that you have a metastatic cancer, which we believe to be bladder cancer. you have a large mass in your bladder and evidence of metastatic disease throughout your spine, leg bones, and possibly your lungs. you were seen by our oncology team who agreed that you likely have a terminal bladder cancer. they felt that it was important for you to have a biopsy of the mass in your bladder so as it appropriately guide palliative treatment. you were also seen by our orthopedic surgeons who suggested that you have surgery to your spine and right leg to stabilize these bones. the radiation oncology team also saw you and felt that radiation treatment could be an appropriate therapy for your spine and leg bones, as well. we presented you and your family with the perspectives and suggestions of the aforementioned specialists. you and your family decided that you would prefer to have your treatment at st. hospital since this facility is closer to your home in , . we have also been treating you for pneumonia and a urinary tract infection. you have been recieving intravenous antibiotics. we suggest that you continue taking these antibiotics for another 7 days. you have also recieived treatment for elevated calcium. your calcium remains high and will require further treatment. we feel that this is likely contributing to your confusion and disorientation. you are being transferred to st. hospital to continue your medical care, including your work-up and management of your cancer. followup instructions: you are being transferred to st. hospital in , per the request of you and your family. the accepting physician is . . Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Urinary tract infection, site not specified Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Retention of urine, unspecified Dehydration Hyperosmolality and/or hypernatremia Secondary malignant neoplasm of bone and bone marrow Malignant neoplasm of other specified sites of bladder

allergies: no known allergies / adverse drug reactions attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: aortic valve replacement (21mm tissue valve) history of present illness: 85 year old female with known history of heart murmur. she was recently referred to dr. for cardiac evaluation. an echocardiogram in revealed left ventricular hypertrophy and severe aortic stenosis. she is symptomatic with dyspnea on exertion and 3 pillow orthopnea however her symptoms vary in the sense that she often has days where she is very active without limitation or symptoms. given the severity of her disease, she has been referred for surgical management. cardiac cath was performed prior to admission. coronary arteries are without significant disease. past medical history: aortic stenosis hyperlipidemia hypertension right renal cyst asthma past surgical history: s/p laparoscopic cholecystectomy yrs ago social history: lives with: lives with son. contact: phone # occupation: retired cigarettes: smoked no yes last cigarette - 60 yrs ago other tobacco use: denies etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use: denies family history: one sister with cva in her 70s physical exam: pulse: 84 resp: 16 o2 sat: 98% b/p right: 120/70 left: height: 5'3.5" weight: 169 lbs general: well-developed elderly female appears less than stated age skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade 3/6 systolic abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema _trace__ varicosities: large varicosities on both legs neuro: grossly intact pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 2+ left: 2+ radial right: cath site left: 2+ carotid bruit - right/left: transmitted murmur pertinent results: intra-op tee: conclusions pre-bypass: the left atrium is mildly dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no spontaneous echo contrast is seen in the body of the right atrium. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is low normal (lvef 50-55%). the right ventricular cavity is mildly dilated with normal free wall contractility. there are simple atheroma in the ascending aorta. there are complex (>4mm) atheroma in the descending thoracic aorta. there is severe aortic valve stenosis (valve area 0.8-1.0cm2). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is moderate thickening of the mitral valve chordae. there is no pericardial effusion. post cpb: 1.preserved -ventricular systolic function 2. a bioprosthetic valve is identified in aortic position. well seated and good leaflet excursion. np ai. peak transvslvular gradient of 45 mm hg, with carfiac output = 6.5 liters/min. 3. mr is now mild. 4. no other change 04:53am blood wbc-8.4 rbc-3.06* hgb-9.8* hct-29.3* mcv-96 mch-32.1* mchc-33.5 rdw-13.5 plt ct-219 01:00pm blood wbc-6.5 rbc-4.13* hgb-13.5 hct-39.2 mcv-95 mch-32.7* mchc-34.5 rdw-12.8 plt ct-192 12:30pm blood pt-12.9* ptt-29.6 inr(pt)-1.2* 01:00pm blood pt-11.9 inr(pt)-1.1 04:53am blood glucose-96 urean-19 creat-0.6 na-141 k-4.4 cl-99 hco3-33* angap-13 01:00pm blood glucose-102* urean-14 creat-0.6 na-140 k-3.4 cl-102 hco3-25 angap-16 brief hospital course: the patient was brought to the operating room on where she underwent an aortic valve replacement (#21 mm biocor apical tissue valve)with dr. . overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. beta blocker, statin, aspirin, and diuresis was initiated and the patient was gently diuresed toward her preoperative weight. pod#3 mrs. was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod #6 she was ambulating freely, the wound was healing and pain was controlled with oral analgesia. the patient was discharged to house rehab & nursing center in in good condition. all follow up appointments were advised. medications on admission: amlodipine 10mg daily, advair diskus 100/50 one puff , simvastatin 20mg daily, asa 81mg daily discharge medications: 1. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*45 tablet(s)* refills:*0* 2. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing. 4. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 5. fluticasone 50 mcg/actuation spray, suspension sig: one (1) spray nasal daily (daily). 6. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 7. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 8. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 9. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 10. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever, pain. 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 12. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po q12h (every 12 hours). 13. guaifenesin 600 mg tablet extended release sig: one (1) tablet extended release po bid prn () as needed for secretions. 14. lasix 20 mg tablet sig: one (1) tablet po twice a day: & reevaluate weight & edema. discharge disposition: extended care facility: house rehab & nursing center - discharge diagnosis: aortic stenosis hyperlipidemia hypertension right renal cyst asthma past surgical history: s/p laparoscopic cholecystectomy yrs ago discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge followup instructions: you are scheduled for the following appointments: surgeon dr. 07/11/12/12 at 1:30pm cardiologist: 2:45p please call to schedule the following: primary care dr. , e. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Open and other replacement of aortic valve with tissue graft Diagnoses: Thrombocytopenia, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Asthma, unspecified type, unspecified Aortic valve disorders Personal history of tobacco use Other and unspecified hyperlipidemia Other acquired absence of organ Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery

allergies: no known allergies / adverse drug reactions attending: chief complaint: tachycardia and hypotension major surgical or invasive procedure: r picc line removal l picc line placement history of present illness: mrs. is a 76 year-old woman with htn, hl, hypothyroidism, h/o strokes with dementia who was found to have acute renal failure at rehab and was sent to our ed for evaluation, but developped tachycardia an hypotension. she was in her prior state of health until aproximately 8-9 weeks ago when she started to be progressively tired, weak and not able to take care of herself. she was driving and managing all her adls. she made one of her long-time friends her hcp given she has no family. one day she was unable to walk from one room to another and she was taken to our ed on . she was diagnosed with chronic aspiration and a zenker's diverticula and was placed on tpn. she was discharged to rehab () on where she had been able to walk, interactive, chatting and doing well. plans were to bring her back to fix the diverticulum. there were discussions about fixxing it with endoscopic techniques. she also developped a pna that was treated with 10-day course of vancomycin/ctx (last day ). the course was finished at rehab. . during the last week she has been progressively confused. she keeps talking about her husband her (who died 5 years ago). yesterday when at rehab they noted that she started to be very "anxious" and confused. normally, she can follow commands and is oriented x2 (person and place). she started to pull her oxygen off her face and be less verbally responsive. labs were drawn and they noted acute renal failure (creatinine of 1.7) at rehab and decided to send her to our hospital for evaluation. she was febrile to yesterday at rehab per nursing report. she was being treated for pneumonia with levofloxacin. on her way to our ed she developped afib with rvr and became hypotensive. in our ed her initial vs were fs=113, 97.4 138 105/72 24 95% nrb. she was oriented in self and mildly agitated. she had a clonidine patch on that was removed. she was screaming "help". her lungs were clear. her cxr showed a multi-focal pna in the right lung. she was "broadened" to vancomycin 1g iv/levofloxacin 750 mg (got at rehab today the later). her hcp was and made aware that patient was here. the dnr was confirmed, but cvls would be ok (per ed resident's conversation). her initial labs were significant for: wbc 18.3 with n:90 band:0 l:4 m:6 e:0 bas:0, h&h of 7.9/25, plts 307, ca: 7.9 mg: 2.6 p: 4.1, na 156, 3.7, cl 123, co2 23, bbun 97, cr 1.9, glucose 95, lactate:1.9. blood and urine cultures wre sent. her ecg showed afib with rvr up to 150s. she also received ativan for unclear reasons, calcium gluconate for her low calcium and diltiazem 10 mg iv for rate control. her initial bp dropped up to 70 sbp, but responded to fluids. it has been ranging from 70-130. she has had only 40 cc of dark urine. she has a picc line and an iv in the left forearm. foley catheter was placed. she got a total of 3 l ns and 1 l ns with 40 meq of kcl. her urine output was ~400 cc. past medical history: htn hypothyroidism hypercholesterolemia h/o tonsillar cancer s/p rt >20 yrs ago and discharged from the cancer institute after surveillance and follow-up cva or r mcv (critical r ica stenosis ct) vertebral fracture fracture of the right olecranon. ischemic colectomy is listed as part of her past medical history which the patient denies jak2 postive tah-bso social history: she used to smoke, but quit 20 years ago. has history of 30 pack-years. has a drink per day when at home. denies any current or past use of illegal substances. she was exposed to radiation in her tonsils, but denies any other exposures. she is widowed and used to live alone. family history: father: deceased from heart condition @ 57 other: neg for lung or esophageal disease physical exam: physical exam on admission to signs - temp 95.7 f, bp 101/63 mmhg, hr 118 bpm, rr 28 x', o2-sat 97% ra general - ill-appearing woman in nad, yelling "help", not appropriate, not jaundiced (skin, mouth, conjuntiva), only responding to her name, good speech, moving all 4 extremities, lying in bed, breathing comfortably on room air, cachectic heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear, slyghtly dry mucous membranes neck - supple, no thyromegaly, no jvd, no carotid bruits lungs - expiratory wheezes, mostly in both bases (r>l), good air movement, resp unlabored, no accessory muscle use heart - pmi in l ant axillary line 6th intercostal space, irregular, no mrg, nl s1-s2, tachycardic, abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding. extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps) skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox1 (person), cns ii-xii grossly intact, muscle strength 5/5 throughout, sensation not evaluated, dtrs 2+ and symmetric, cerebellar exam defered, gait defered pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: admission labs: 02:30pm blood wbc-18.3*# rbc-2.58* hgb-7.9* hct-25.0* mcv-97# mch-30.4# mchc-31.4 rdw-18.5* plt ct-307 02:30pm blood neuts-90* bands-0 lymphs-4* monos-6 eos-0 baso-0 06:29am blood pt-17.4* ptt-35.3* inr(pt)-1.5* 02:30pm blood ret aut-0.3* 02:30pm blood glucose-95 urean-97* creat-1.9*# na-156* k-3.7 cl-123* hco3-23 angap-14 02:30pm blood alt-41* ast-20 ld(ldh)-258* alkphos-92 totbili-0.3 02:30pm blood ctropnt-0.06* 02:30pm blood albumin-2.5* calcium-7.9* phos-4.1 mg-2.6 iron-41 02:30pm blood caltibc-142* ferritn-1169* trf-109* 02:30pm blood tsh-2.5 02:33pm blood lactate-1.9 k-3.3* 04:15pm urine color-yellow appear-hazy sp -1.013 04:15pm urine rbc-10* wbc-4 bacteri-few yeast-many epi-0 04:15pm urine casthy-3* 04:15pm urine mucous-occ 04:15pm urine eos-negative 05:40pm urine hours-random urean-644 creat-72 na-16 k-94 cl-19 05:40pm urine osmolal-440 06:15pm blood vanco-18.6 04:07am blood alt-25 ast-8 alkphos-79 totbili-0.4 04:52am blood wbc-10.5 rbc-2.41* hgb-6.9* hct-22.7* mcv-94 mch-28.5 mchc-30.3* rdw-19.1* plt ct-381 04:52am blood glucose-149* urean-104* creat-3.4* na-143 k-3.9 cl-113* hco3-17* angap-17 discharge labs: na 143, k 3.9, cl 113, bicarb 17, bun 104, cr 3.4 glucose 149 ca 7.8 mg 2.4, phos 5.1 wbc 10.5, hct 22.7, plt 381 microbiology - blood culture, routine (final ): albicans. consultations with id are recommended for all blood cultures positive for staphylococcus aureus and species. fluconazole = s. sensitivity testing performed by . this test has not been fda approved but has been verified following clinical and laboratory standards institute guidelines by clinical microbiology laboratory.. staphylococcus, coagulase negative. isolated from only one set in the previous five days. sensitivities performed on request.. aerobic bottle gram stain (final ): budding yeast cells. reported to and read back by () @ 11:00 am. anaerobic bottle gram stain (final ): gram positive cocci in clusters. reported to and read back by () @1630. - blood culture, routine (final ): albicans. consultations with id are recommended for all blood cultures positive for staphylococcus aureus and species. identification and sensitivities performed on culture # 323-2775b . aerobic bottle gram stain (final ): budding yeast with pseudohyphae. - urine culture (final ): yeast. >100,000 organisms/ml.. - urine legionella antigen: negative - picc catheter tip: no significant growth - blood culture: ngtd - blood culture: ngtd imaging: ecg: atrial fibrillation with mean ventricular rate of 152. non-diagnostic repolarization abnormalities. no previous tracing available for comparison. cxr: multifocal pneumonia. a repeat chest radiograph with a lateral view is recommended after adequate treatment to assess resolution. echo: the left atrium is normal in size. the right atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular ejection fraction is moderately depressed (lvef= 35 %) (tachycardia and adverse interventricular interaction are likely playing a significant role in the reduction of left ventricular ejection fraction). the right ventricular free wall is hypertrophied. the right ventricular cavity is dilated with depressed free wall contractility. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen. significant elevation of pulmonary artery systolic pressure is likely present cxr: in comparison with the study of , there is continued enlargement of the cardiac silhouette with large bilateral pleural effusions and compressive atelectasis as well as mild elevation of pulmonary venous pressure. the central catheter has been pulled back to the mid portion of the svc. right upper extremity ultrasound: nonocclusive thrombi in the right subclavian, axillary, basilic, and one of the brachial veins. brief hospital course: mrs. is a 76 year-old woman with htn, hl, hypothyroidism, h/o strokes with dementia who was found to have acute renal failure at rehab and was sent to our ed for evaluation, but developped tachycardia an hypotension. septic shock/candidemia: the patient did not respond to initial iv fluid boluses and so a central line was placed, she was started on dopamine. she remained on this until the decision was made to transition to cmo. the source of the candidemia was likely a picc line infection, increased risk given the tpn. her picc was removed and then replaced. from her severe sepsis she developed severe acute renal failure and associated uremia, also she was noted to have acute systolic heart failure with an ef of 35% and severe 3+ mitral regurgitation. she also had new atrial fibrillation with a rapid ventricular rate. she was noted also to have multifocal pneumonia on chest x ray and a right upper extremity dvt which was picc line associated. she was treated with micafungin initially for candidemia, then fluconazole, on therapy was discontinued as the patient was transitioned to cmo. she was transferred to an inpatient hospice facility (riverbend in ) and was on morphine for comfort. she was sleeping, opening eyes briefly to voice but non verbal on discharge. she appeared comfortable in terms of pain and shortness of breath. access ?????? picc - hcp: (friend) mobile and home. medications on admission: ativan 0.25-0.5 mg po q6 hrs prn dulcolax 10 mg pr prn heparin 5,000 unit/ml injection synthroid 37.5 mcg po daily clonidine 0.1 mg patch qmondays albuterol sulfate 2.5 mg/3 ml (0.083 %) neb q6 hrs prn ipratropium bromide 0.02 % soln q6hrs prn lidoderm 5 % tp levaquin 500 mg po daily tpn electrolytes discharge medications: 1. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for sob / wheezing. 2. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for sob / wheezing. 3. white petrolatum-mineral oil 56.8-42.5 % ointment sig: one (1) appl ophthalmic (2 times a day). 4. morphine concentrate 100 mg/5 ml (20 mg/ml) solution sig: 5-15 mg po q1h (every hour) as needed for sob, pain. 5. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q6h prn () as needed for aggitation. discharge disposition: extended care facility: riverbend of discharge diagnosis: primary diagnosis: candidemia, sepsis acute systolic heart failure acute renal failure discharge condition: level of consciousness: lethargic but arousable. (opens eyes to voice) mental status: confused - always. activity status: bedbound. discharge instructions: was admitted to the hospital with a severe infection caused by (a fungus) in the blood stream, this caused a low blood pressure and damage to her kidneys and heart. a decision was made between the health care proxy and the icu team to move treatments towards comfort measures and avoid any invasive procedures, with a goal of improving quality of life. followup instructions: follow up with inpatient hospice physician Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Pneumonia, organism unspecified Acidosis Hypocalcemia Anemia, unspecified Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Severe sepsis Unspecified acquired hypothyroidism Atrial fibrillation Personal history of tobacco use Other and unspecified hyperlipidemia Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Septic shock Other complications due to other vascular device, implant, and graft Disseminated candidiasis Infection and inflammatory reaction due to other vascular device, implant, and graft Encounter for palliative care Acute systolic heart failure Do not resuscitate status Hyperosmolality and/or hypernatremia Vascular dementia, uncomplicated Cerebral atherosclerosis Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx Acute venous embolism and thrombosis of deep veins of upper extremity

allergies: niacin / colestid / accupril attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: coronary artery bypass graft x 4 (left internal mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) bronchosccopy-reintubated history of present illness: is a 71-year-old gentleman who experienced an episode of congestive heart failure while in . work up was notable for abnormal stress test and he underwent cardiac catheterization, which was significant for severe three-vessel coronary artery disease. at the time of catheterization, there was also notable for severe mitral regurgitation and an ejection fraction of approximately 40%. given these findings, he was referred to me for cardiac surgical evaluation. currently, his symptoms include a cough and dyspnea on exertion. past medical history: coronary artery disease mitral regurgitation hypertension hypercholesterolemia congestive heart failure tobacco abuse carotid disease subclinical hypothyroidism fatty liver kidney stones social history: retired. quit smoking in after ppd x 40 years. denies alcohol use. family history: brother died from myocardial infarction at age 52. another brother had bypass surgery at age 62 physical exam: vital signs: pulse of 80, respirations of 16, and blood pressure of 112/72. in general, he was a well-developed and well-nourished male in no acute distress. his skin was unremarkable. his oropharynx was benign. he was noted to have poor dentition. neck was supple with full range of motion. there was no jvd. lungs were clear to auscultation bilaterally. heart had a regular rate and rhythm, normal s1 and s2, with a iii/vi holosystolic murmur best heard at the left lower sternal border and apex. abdomen was benign. extremities were warm and well perfused without edema. he had no varicosities of the greater saphenous vein. neurologically, he was alert and oriented x3. cranial nerves ii through xii were grossly intact. he had 5/5 strength and no focal deficits were appreciated. his distal pulses were 2+ and carotid bruits could not been appreciated secondary to his cardiac murmur. pertinent results: 02:17pm glucose-87 na+-138 k+-4.2 01:42pm urea n-23* creat-1.2 chloride-116* total co2-23 01:42pm wbc-22.2* rbc-3.05*# hgb-9.6*# hct-28.3*# mcv-93 mch-31.4 mchc-33.8 rdw-14.9 12:32pm wbc-16.2* rbc-2.29*# hgb-7.1*# hct-21.8*# mcv-95 mch-30.8 mchc-32.3 rdw-15.0 12:32pm plt count-151 06:10am blood hct-34.6* 05:29am blood wbc-14.3* rbc-3.89* hgb-11.5* hct-34.1* mcv-88 mch-29.4 mchc-33.6 rdw-16.4* plt ct-250 05:29am blood plt ct-250 05:23am blood pt-16.7* ptt-26.5 inr(pt)-1.5* 06:10am blood glucose-83 urean-38* creat-1.3* na-141 k-4.4 cl-104 hco3-27 angap-14 04:13am blood alt-34 ast-30 ld(ldh)-346* alkphos-96 amylase-226* totbili-0.7 echo: prebypass: 1. the left atrium is moderately dilated. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. 2. left ventricular wall thicknesses and cavity size are normal. lv ef is 60%. 3. right ventricular chamber size and free wall motion are normal. 4. there are complex (>4mm) atheroma in the aortic arch and descending thoracic aorta. epiaortic imaging at the site of cross clamping and aortic cannulation revealed simple atheroma. 5. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and trace aortic regurgitation. 6. the mitral valve leaflets are mildly thickened. there is partial mitral leaflet flail. moderate to severe (3+) mitral regurgitation is seen. due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (coanda effect). 7. there is no pericardial effusion. 8. dr. was notified in person of the results during the surgery on at 821. postbypass: 1. patient is on epinepherine and phenylepherine infusions. av and later a paced. 2. there is a mitral annuloplasty ring insitu with a shortened posterior leaflet consistent with a mitral valve repair. there is trace mitral regurgitation. peak and mean gradients are less than 6 mm hg. 3. there is preserved biventricular function on low dose epinepherine infusion. initial septal diskinesis resolves when converted from av to a pacing. 4. aortic contours are intact. 5. remaining exam is unchanged. 6. all findings are discussed with surgeons at the time of the exam. , m 71 radiology report chest (pa & lat) study date of 10:45 am , r. csurg fa6a 10:45 am chest (pa & lat) clip # f/u ptx final report study: pa and lateral chest radiograph. indication: patient is status post cabg, mvr, for evaluation. technique: frontal and lateral chest radiographs were obtained. comparison: radiograph is compared to . report: the patient is status post sternotomy and mitral valve repair as well as lima grafting. there has been interval removal of a right-sided central line. the patient's right-sided pneumothorax probably effectively has resolved. there are persistent changes along the left pleura superiorly likely representing a loculated pleural process. interestingly, the left lower lobe effusion has somewhat improved and there is continued improved aeration in the left lower lobe. a small amount of blunting in the right costophrenic sulcus is unchanged. a right upper lobe opacity persists and continued attention to this is recommended. conclusion: effective resolution of pneumothorax. improved postoperative changes in the right and left lung bases, but with worsening left apical opacity which is lobulated and broad-based to the left pleura, suggesting pleural origin. small right-sided opacity for which continued followup is recommended. dr. brief hospital course: mr. was a same day admit after undergoing all pre-operative work-up as an outpatient. on day of admission he was brought to the operating room where he underwent a coronary artery bypass graft x 3 and mitral valve repair. please see operative report for surgical details. following surgery he was transferred to the cvicu for invasive monitoring in stable condition. within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. he was weaned off nitro and milrinone by post-op day two and was transferred to the telemetry floor for further care. chest tubes and epicardial pacing wires were removed per protocol. he was gently diuresed towards his preoperative weight. the physical therapy service was consulted for assistance with his postoperative strength and mobility. he developed atrial fibrillation for which amiodarone and coumadin were started. a chest x-ray revealed a right pneumothorax which had increased in size. the interventional pulmonology service was consulted who elected to place an anterior chest tube (dart). the procedure was hemoptysis requiring intubation. he was transferred back to the intensive care unit and a chest tube was placed. a bronchoscopy revealed fresh clot but patent airways. he developed hemodynamic instability which was thought to be related to a blood transfusion as his hemodynamics improved with steroids. a transesophageal echocardiogram was without significant abnormalities. as he fully stabilized, he was extubated the next day. he was transferred back to the step down unit for further recovery. he continued to make steady progress and was discharged home on pod 10. he will follow-up with dr. , his cardiologist and his primary care physician as an outpatient. medications on admission: carvedilol 6025 mb , lisinopril 10mg daily, crestor 40mg daily, aspirin 81mg daily, lasix 20mg daily, plavix 75mg daily (stopped ), nitro 0.3mg sl prn discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for temperature/pain. 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 5. rosuvastatin 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 6. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day): x10 days then qd. disp:*40 tablet(s)* refills:*0* 7. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 400mg x7 days, then 400mg qd x7 days, then 200mg qd. disp:*60 tablet(s)* refills:*1* 8. carvedilol 3.125 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* 9. lisinopril 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: all care vna of greater discharge diagnosis: coronary artery disease mitral regurgitation hypertension hypercholesterolemia congestive heart failure tobacco abuse carotid disease subclinical hypothyroidism fatty liver kidney stones discharge condition: good discharge instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed followup instructions: dr. in 4 weeks dr. in weeks dr. in weeks Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Insertion of endotracheal tube Closed [endoscopic] biopsy of bronchus Other incision of pleura Other incision of pleura Open heart valvuloplasty of mitral valve without replacement Operations on chordae tendineae Diagnoses: Acidosis Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified acquired hypothyroidism Atrial fibrillation Other chronic pulmonary heart diseases Accidental puncture or laceration during a procedure, not elsewhere classified Other and unspecified angina pectoris Iatrogenic pneumothorax Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Chronic systolic heart failure Rupture of chordae tendineae

allergies: no known allergies / adverse drug reactions attending: chief complaint: dyspnea major surgical or invasive procedure: 1. left atrial appendage resection. 2. coronary artery bypass grafting x3: left internal mammary artery to left anterior descending artery, and reverse saphenous vein graft to the posterior descending artery and obtuse marginal artery. 3. aortic valve replacement with a 25-mm st. epic tissue valve, model #eft100-25- 00. history of present illness: 66 year old male who presented with worsening shortness of breath and hypotension. he presented to his pcp's office for follow up and was noted to be short of breath and hypotensive with sbp's in the 80's. his symptoms started approximately 2-3 weeks prior to presentation. he mainly had difficulty with shortness of breath. this shortness of breath would prevent him from sleeping comfortably. he describes symptoms consistent with orthopnea and pnd. he notes that he saw dr. a couple of weeks ago and was started on lasix and aldactone. he was also noted to be in atrial fibrillation at that time as well. he is now being referred to cardiac surgery for evaluation of revascularization and possible aortic valve replacement. past medical history: atrial fibrillation coronary artery disease aortic stenosis pmh: diastolic and systolic chf (ef 30-35%) type 2 diabetes hypertension hypercholesterolemia chronic back pain degenerative neurological disease ? ms bilateral drop foot social history: lives with his wife. retired for 30 years, used to own a bagel shop and was a landlord. able to ambulate around the home with assistance and/or walker. uses a wheelchair outside of the home. -tobacco: smoked 1 ppd for 40 yrs, quit about 6 months ago -etoh: drinks 3-4 glasses of scotch or wine daily -drugs: marijuana ~once weekly family history: father died of an mi at age 73. mother died at 78 of unknown causes. physical exam: pulse:94 resp:18 o2 sat:98/ra b/p right:117/84 left:116/78 height:73" weight:97.2 kgs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema +1 edema ankles/feet,mild purplish discolouration to balateral feet_____ varicosities: none neuro: grossly intact upper extremity hand grasps week bilaterally, lower ext bilateral weakness, can raise both legs off bed but poor resistence, bilaterl foot drop, thought process slow pulses: femoral right:cath site left:+1 dp right:trace left:trace pt : trace left:trace radial right: +2 left:+2 carotid bruit right: +1 left:+1 pertinent results: admission labs: 06:30pm blood wbc-15.1* rbc-4.56* hgb-14.7 hct-41.4 mcv-91 mch-32.2* mchc-35.5* rdw-12.8 plt ct-176 06:30pm blood pt-13.8* ptt-26.5 inr(pt)-1.2* 06:30pm blood glucose-126* urean-31* creat-2.1* na-130* k-5.7* cl-95* hco3-23 angap-18 06:25am blood alt-21 ast-24 ld(ldh)-277* ck(cpk)-73 alkphos-129 totbili-0.5 06:30pm blood probnp-7438* 06:30pm blood ctropnt-0.07* 06:25am blood ck-mb-3 ctropnt-0.07* 06:15pm blood ck-mb-3 ctropnt-0.05* cxr : semi-upright portable ap view of the chest obtained. moderate-to-severe cardiomegaly with diffuse ground-glass haziness throughout the lungs compatible with pulmonary edema. the right hemidiaphragm remains somewhat elevated and overall low lung volumes are noted which somewhat limit the evaluation. there are no large pleural effusions and no sign of pneumothorax. hilar engorgement is compatible with congestive heart failure. bony structures appear intact. impression: cardiomegaly, pulmonary edema. lhc : 1) selective coronary angiography of this right-dominant system demonstrated severe three vessel cad. the lmca was normal without any angiographically-apparent flow-limiting lesions. the stent in the proximal lad had diffuse 60% in-stent restenosis. there was 80% stenosis throuhgout the proximal lcx, with a 60-70% stenosis at the origin of the omb. the rca had a 100% proximal stenosis with prominent left-to-right collaterals. 2) resting hemodynamics showed elevated right and left-sided filling pressures with an rvedp of 17 mmhg and an lvedp of 27 mmhg. the peak gradient over the aortic valve was 14 mmhg. using the gorlin equation, the was calculated to be 1.1 cm2, indicating moderate aortic stenosis. 3) left ventriculography was deferred. final diagnosis: 1. three vessel coronary artery disease. 2. moderate aortic stenosis. 3. atrial fibrillation with rapid ventricular response. 4. needs diuresis prior to cardioversion. 5. consideration for avr-cabg. leni : negative for dvt carotid u/s : panorex : brief hospital course: the patient underwent the usual preoperative work-up. dental examined the patient and recommended extraction of one tooth. the patient refused. the patient was brought to the operating room on where the patient underwent avr (tissue), cabg x 3, resection of left atrial appendage with dr. . overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. he does have a history of heart failure with an ef of 30% and initially required multiple inotropes and vasopressors. he remained intubated due to pulmonary congestion, which improved with diuresis. rapid a-fib developed and amiodarone drip was initiated. this was discontinued when rate was controlled. he failed a trial of precedex. he self-extubated and was re-intubated without incident. he developed a leukocytosis and was started on cipro for a positive urinalysis. there was no growth on culture, and cipro was discontinued. tube feeds were started on pod 3. he was extubated on pod 4. by this time, all vasoactive drips had been weaned. coumadin was resumed for chronic a-fib. chest tubes and pacing wires were discontinued without complication. beta-blocker was initiated and the patient was gently diuresed toward the pre-operative weight. ace inhibitor was not initiated due to a rise in creatinine, which would start to trend down prior to discharge. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod #10 the patient was ambulating freely, and pain was controlled with oral analgesics. due to upper and lower pole serosanguinous sternal drainage, mr. was placed on prophylactic antibiotics x 1 week per dr.. the patient was discharged to rehab in good condition with appropriate follow up instructions. medications on admission: diltiazem hcl - 240 mg capsule, ext release 24 hr - 1 capsule(s) by mouth every day furosemide - 20 mg tablet - 2 tablet(s) by mouth once a day home oxygen - - use as directed by nasal cannula once a day ( 1-2 liters by nasal cannula) lisinopril - 5 mg tablet - 1 tablet(s) by mouth once a day metformin - 850 mg tablet - 1 (one) tablet(s) by mouth twice a day metoprolol succinate - 100 mg tablet extended release 24 hr - 1 (one) tablet(s) by mouth once a day mupirocin - 2 % ointment - apply to affected area (s) twice a day nitroglycerin - 0.4 mg tablet, sublingual - one tablet(s) sublingually prn for cp overnight oximetry on room air - - as directed dx: cad, dyspnea physical conditioning and strengthening - - for diabetic neuropathy, gait instability and general weakness; 1-3 visits weekly; evaluation and treatment pregabalin - 50 mg capsule - 2 capsule(s) by mouth three times a day for painful diabetic neuropathy sildenafil - 100 mg tablet - 1 tablet(s) by mouth no more than every day as directed simvastatin - 10 mg tablet - 1 tablet(s) by mouth every day spironolactone - 25 mg tablet - 1 tablet(s) by mouth once a day propecia discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain or temp>38.4. 4. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 6. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 7. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). 8. carvedilol 12.5 mg tablet sig: two (2) tablet po bid (2 times a day). 9. pregabalin 25 mg capsule sig: two (2) capsule po tid (3 times a day). 10. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 11. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 12. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 13. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 14. cephalexin 500 mg capsule sig: one (1) capsule po qid (4 times a day) for 7 days. 15. warfarin 2 mg tablet sig: one (1) tablet po once (once) for 1 doses. 16. warfarin 1 mg tablet sig: md to dose daily tablet po once a day: indication:atrial fibrillation/ inr goal=2-2.5. 17. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical (2 times a day) as needed for dry skin. 18. furosemide 10 mg/ml solution sig: eight (8) injection (2 times a day): total=80 mg . 19. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po bid (2 times a day). discharge disposition: extended care facility: for the aged - macu discharge diagnosis: atrial fibrillation coronary artery disease aortic stenosis pmh: diastolic and systolic chf (ef 30-35%) type 2 diabetes hypertension hypercholesterolemia chronic back pain degenerative neurological disease ? ms bilateral drop foot discharge condition: alert and oriented x3 nonfocal max assist sternal pain managed with oral analgesics sternal incision - scant serosanguinous drainage from upper and lower pole. sternum stable. mild erythema-evaluated by dr. prior to dc. edema 1+ discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge followup instructions: you are scheduled for the following appointments: surgeon dr. on at 1:30pm () cardiologist dr. at 3:15pm please call to schedule the following: primary care dr. , j. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** labs: pt/inr coumadin for a-fib goal inr 2-2.5 **please arrange for coumadin follow-up on discharge from rehab** Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization (Aorto)coronary bypass of two coronary arteries Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Open and other replacement of aortic valve with tissue graft Combined right and left heart angiocardiography Excision, destruction, or exclusion of left atrial appendage (LAA) Diagnoses: Hyperpotassemia Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Atrial fibrillation Aortic valve disorders Lumbago Other acquired deformities of ankle and foot Acute on chronic combined systolic and diastolic heart failure Other specified disorders of nervous system Primary cerebellar degeneration

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: headache, nausea, vomiting, and amnestic events major surgical or invasive procedure: lp lp intubated in the micu and extubated within 24h 13 out of 15 scheduled total brain radiation treatments history of present illness: 40 m with hiv, lung ca, with mets to brain s/p radiation therapy yesterday with nausea, vomiting,confusion/syncopal episode last night. patient recieved radiation yesterday (day 2) after which he went home. he has been having a constant, bilaterally frontal throbbing headache for about 1 week which has been worsening for the last three days. his headache is worsened by movement and walking and ameliorated by staying still and laying down. ibuprofen and hydromorphone also improve his headache but do not completely make it dissapear. he describes his pain as on the pain scale. when the patient arrived home from xrt he started to get confused and does not remember a couple of hours while he was in his bedroom. he says his memory started to come back when as he was walking to the bathroom he fainted and lost consciousness. the patient denies any trauma from his fall. his roomate wittnessed this event and was unavailable for questioning, however the patient told me that his freind said he simply looked like he was sleeping and did not describe anything like shaking, or eyes rolling to the back of his head. the patient woke up in his bed and denies any tongue biting, numbness or paralysis of limbs, or funny smells. he also felt nauseated during the whole day yesterday, without vomiting, which has improved overnight without any meds and currently the patient has an appetite. the patient has received radiation in the past for lung cancer and day 1 currently of his radiation regimen, however he never experienced such severe headache, syncope or amnesia before. he has completed two of 15 planned fractions of radiation therapy to the whole brain for metastatic cancer. he was told by his np to proceed to the e.r. past medical history: past oncologic history: current therapy: -he has completed two of 15 planned fractions of radiation therapy currently to the whole brain for metastatic brain cancer. . previous chemotherapy: -completed courses of cisplatin and etoposide concurrently with radiation therapy on and ending ; of note, just prior to starting therapy, he was found to have a large left pleural effusion with cytology positive for metastatic adenocarcinoma, indicating the presence of stage iv disease. -alimta for three cycles finishing on ; with disease progression noted on sunitinib on , this was stopped on . -his disease has remained radiographically stable since that time, with his most recent ct scan obtained on . -at the time of his last visit in the medical oncology clinic on , he admitted to recurrent headaches. an mri revealed innumerable enhancing lesions within the supra- and infra tentorium of the brain as well as at least one lesion within the left frontal calvarium and an additional lesion within the upper spinal cord. many punctate lesions appeared to be present within the cortical sulci. in addition, he had enhancement along the sulci, brainstem internal auditory canals, and trigeminal nerve - consistent with leptomeningeal metastases. . previous radiation: -competed on 21 fractions of treatment to the left upper lung; hilum and mediastinum at dose of 6120 cgy . other past medical history: 1. hiv infection - family unaware of diagnosis - diagnosed several years ago, most recent cd4 count 143,000. the patient started antiretroviral medications in 08/. 2. history of syphilis, treated. he has had no other opportunistic infections. 3. hemorrhoids, status post surgical resection in . 4. history of peptic ulcer disease. social history: patient lives in , lives with roomate. works as a waiter. has smoked marijuana daily for the last 3-4 years. smoked cigarettes/week; has 15 pack year history but stopped 4-5 years ago. reports 1 beer per week. tried cocaine and crystal meth in the past. has sex only with men and reportedly uses protection for all sexual practices. family history: denies any history of cad, cancer, dm, htn, hyperlipidemia physical exam: vs: 119/79 105 25 98% ra gen: aox3, nad heent: perrla. mmm. no lad. no jvd. neck supple. cards: mild systolic murmer heard in the aortic area in 2nd intercostal space.does not radiate,no rubs or gallops. pulm: left diffuse rhonci present with decreased breath sounds on the left. right lung is clear. abd: soft, nt, +bs. no rebound/guarding. neg hsm. neg sign. extremities: wwp, no edema. dps, pts 2+. skin: no rashes or bruising neuro/psych: cns ii-xii intact. 5/5 strength in u/l extremities. dtrs 2+ bl. sensation intact to lt, cerebellar fxn intact (ftn, hts). gait wnl. pertinent results: admission labs . 01:30pm plt count-204 01:30pm neuts-71.4* lymphs-22.5 monos-5.3 eos-0.6 basos-0.3 01:30pm wbc-4.1 rbc-3.97* hgb-14.6 hct-42.5 mcv-107* mch-36.7* mchc-34.3 rdw-15.0 01:30pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 01:30pm estgfr-using this 01:30pm glucose-132* urea n-14 creat-0.9 sodium-140 potassium-3.8 chloride-102 total co2-27 anion gap-15 01:39pm glucose-127* lactate-1.8 09:19pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 09:19pm urine color-straw appear-clear sp -1.011 09:19pm urine bnzodzpn-neg barbitrt-neg opiates-pos cocaine-neg amphetmn-neg mthdone-neg 09:19pm urine hours-random . discharge labs . 08:05am blood wbc-6.3 rbc-3.24* hgb-12.0* hct-34.7* mcv-107* mch-36.9* mchc-34.5 rdw-13.4 plt ct-168 09:00am blood neuts-89.3* lymphs-6.1* monos-4.2 eos-0.2 baso-0.1 08:05am blood plt ct-168 08:30am blood pt-11.7 ptt-24.9 inr(pt)-1.0 09:45am blood wbc-7.0 lymph-7* abs -490 cd3%-83 abs cd3-409* cd4%-9 abs cd4-46* cd8%-74 abs cd8-361 cd4/cd8-0.1* 08:15am blood wbc-4.6 lymph-10* abs -460 cd3%-83 abs cd3-383* cd4%-14 abs cd4-65* cd8%-69 abs cd8-316 cd4/cd8-0.2* 07:30am blood glucose-114* urean-17 creat-0.5 na-140 k-4.0 cl-103 hco3-29 angap-12 06:38am blood glucose-132* urean-8 creat-0.6 na-130* k-3.3 cl-95* hco3-27 angap-11 04:29am blood glucose-112* urean-10 creat-0.5 na-124* k-4.0 cl-92* hco3-22 angap-14 02:44pm blood alt-20 ast-17 ck(cpk)-99 alkphos-161* totbili-0.3 09:00am blood calcium-8.8 phos-3.0 mg-2.2 . imaging: cxr: impression: 1) significant interval increase in opacification of the left hemithorax likely representing combination of right pleural effusion, underlying partial collapse of the left lung. left upper lobe/suprahilar spiculated opacity likely represents patient's known mass, lymphadenopathy and fluid, better evaluated on ct. . ct-head with contrast: impression: no ct evidence of acute intracranial abnormality. please note that mri is more sensitive in assessing brain lesions. . mri-head with contrast: impression: 1. stable appearance of innumerable enhancing lesions within the supra and infratentorial brain as well as at least one lesion within the left frontal calvarium consistent with metastatic disease. 2. stable enhancement along the sulci, brainstem, internal auditory canals, and trigeminal nerves, consistent with leptomeningeal spread of disease. 3. no acute infarction or hemorrhage. . eeg: mpression: this is an abnormal routine eeg in the waking and sleeping states due to two regions of focal slowing seen in the right posterior quadrant and left posterior temporal regions independently. these abnormalities are suggestive of subcortical lesions in these areas. there were no epileptiform abnormalities noted. . cytology: cerebrospinal fluid: positive for malignant cells consistent with metastatic adenocarcinoma. . ct-head without contrast: impression: no acute intracranial pathology. . ct-stroke: conclusion: 1. stable right frontal hypodensity, most suggestive of metastasis with vasogenic edema. no acute intracranial hemorrhage. 2. widely patent head and neck arteries. 3. incompletely evaluated pleural and parenchymal disease in the left upper lobe most likely representing sequelae of the known lung cancer. . eeg: mpression: abnormal eeg due to the persistent left frontal focal delta slowing. this suggests a focal structural abnormality in the left anterior quadrant. anatomic correlation would be of interest if clinically indicated. the background rhythm was otherwise well maintained posteriorly, and there were no epileptiform features. . ct-head: impression: 1. no acute intracranial pathology. 2. stable right frontal hypodensity, compatible with edema from known metastatic disease at this site. . ct-head: impression: no acute intracranial process, and no change from . stable right frontal hypodensity, reflecting vasogenic edema from known metastatic lesion at this site. . cxr: there is interval increase in left pleural effusion which is currently large and is most likely combined with a known advanced lung cancer within the left lung. only minimal apical portion of the left lung continues to be aerated. the right lung is essentially clear with no evidence of right pleural effusion. . ct-head: impression: no acute intracranial process. right frontal hypodensity, possible metastatic, stable since . mri is more sensitive for evaluating for metastatic disease. . cxr: findings: in comparison with the study of , the endotracheal and nasogastric tubes have been removed. extensive opacification involving the left hemithorax is essentially unchanged, consistent with the known advanced lung cancer and associated effusion and atelectasis. there is only a small amount of the apical portion of the left lung continues to be aerated. the right lung remains essentially clear. . cxr: increased rightward mass effect on mediastinal structures compared to two days prior suggests interval increase in left pleural effusion. . ekg: : sinus tachycardia. compared to the previous tracing of the rate is slower. : sinus tachycardia. compared to the previous tracing of there is no significant diagnostic change. : sinus tachycardia. compared to the previous tracing of the rate has increased. otherwise, no diagnostic interim change. brief hospital course: summary & formulation on presentation, : 40 yom with hiv, metastatic lung ca with brain metastases, s/p first whole brain radiation treatment, now with nausea, vomiting, headache, confusion, amnesia, and a syncopal episode prior to admission. . hospital course by problem on discharge : . # headache/nausea/vomiting/confusion/amnesia/syncope - after an extensive work-up including multiple ct-scans of the head with and without contrast, mri of the head with contrast, eeg x 3, and lp x 2 - both of which revealed elevated icp and were palliative for the patient's headache, and the first of which grew out negative cultures and demonstrated malignant cells - neurology diagnosed the patient's constellation of symptoms to be caused by progressive metastatic leptomeningeal lung metastases in the setting of whole-brain xrt-associated cerebral edema; seizure and stroke were ruled out. during the hospitalization, the patient was started and continued on anti-seizure medication, titrating keppra up to 1250mg twice daily. dexamethasone was also started and continued to treat cerebral edema in the setting of ongoing whole brain radiation. the patient is being discharged on these medications to a rehab facility with hospice. . # progressive decline in cognitive function - over the course of the hospitalization, the patient suffered a stroke-like episode thought to be caused by leptomeningeal disease. this episode precipitated a number of tests described above, which ultimately pointed to the diagnosis of progressive leptomeningeal metastatic lung cancer. following this episode, after which the patient recovered some function, the patient's cognitive function precipitously and progressively declined, presumably due to the natural history of leptomeningeal metastatic lung cancer and due to superimposed cerebral edema caused by what was at the time ongoing daily whole brain radiation as well as superimposed hyponatremia secondary to siadh, itself caused potentially by pain or some other unclear etiology. the patient's mental status waxed and waned after the initial stroke-like episode, but overall, his mental status has steadily declined - he is now inconsistently oriented to person, place, and time, unable to concentrate, and intermittently visually hallucinating; he has also developed intermittent, sporadic ballistic movements and change in voice. of note, he still recognizes his loved ones, including his mother, who obtained an emergency visa from through the assistance of the social work department in conjunction with senator office in order to visit her son in his now imminently declining state. . # leptomeningeal metastatic lung cancer: the patient received 13 out of 15 daily scheduled whole brain radiation treatments in conjunction with daily dexamethasone for cerebral edema. he tolerated the treatments reasonably well. . # transient unresponsiveness - on the patient was found unresponsive on the floor and was intubated for airway protection and transferred to the . his respiratory status improved, and he was extubated on . in the icu, the patient received neuro checks q2hrs and his anti-sz medications, including keppra and steroids, were given by iv. he developed hyponatremia while in the icu, which was likely secondary to his malignancy. he was administered hypertonic saline and po salt tabs. his sodium gradually improved from 124 to 130. the patient was maintained on his haart regimen in the icu, and both the oncology and neurology services continued to follow the patient. for dvt prophylaxis the patient was maintained on pneumoboots and famotidine for gi ppx. . # non-traumatic falls - on several occasions during the hospitalization, the patient was found on the floor by his bed; none of these episodes resulted in any trauma. safety and a sitter were implemented to reduce the risk of falls. restraints were also used, but eventually removed due to a slight improvement in mental status. . # hyponatremia - analysis of serum and urine osmolality in the setting of euovolemia pointed to a diagnosis of siadh. the patient's hyponatremia was managed conservatively in collaboration with the consulting nephrology team with fluid restriction titrated to 2l daily and salt tabs titrated to 2 gm po every 6h. . # pleural effusion - presumed to be a malignant pleural effusion, since it has been a recurring chronic problem. diagnostic tap was not pursued. the patient required no supplemental oxygen. . # hiv/aids- we continued home hiv meds and pcp ; cd4 count on admission was 84 and 46 on discharge. patient had thrush detected on and was treated by nystatin swish and swallow. of note, the family and potentially his partner are unaware of his hiv status. . # bacteremia - the patient had gram positive cocci in pairs and clusters growing in his blood early in the hospitalization; it most likely was a contaminant because of only one positive culture and no signs of clinical infection, vancomycin was started and discontinued on . . # c.dif - the patient developed loose stool over the course of the hospitalization, was placed on contact precautions and started empirically on oral flagyl, which was subsequently discontinued after cultures were negative for c.dif. . # mrsa - found to be mrsa negative. medications on admission: omeprazole 20mg daily p.o hydromorphone 2mg q6h prn p.o ondansetron 8mg q8h prn p.o lorazepam 0.5mg --->prior to lp dexamethasone -4mg p.o bactrim - daily atripla- emtricitabine 200mg , tenofovir disoproxil fumarate-300 mg , efavirenz- 600mg cyclobenzaprine 10 mg tablet discharge medications: 1. levetiracetam 100 mg/ml solution : 1250 (1250) mg po bid (2 times a day): seizure prevention. disp:* mg* refills:*2* 2. lorazepam 2 mg/ml syringe : 0.5 mg injection q4h (every 4 hours) as needed for seizure: if suspected seizure, give 0.5mg, reassess, then give 0.5mg again if needed to break seizure. disp:*4 mg* refills:*2* 3. dexamethasone sodium phosphate 4 mg/ml solution : four (4) mg injection q6h (every 6 hours): cerebral edema. disp:*480 mg* refills:*2* 4. truvada 200-300 mg tablet : one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 5. efavirenz 600 mg tablet : one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. sulfamethoxazole-trimethoprim 800-160 mg tablet : one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. sodium chloride 1 gram tablet : two (2) tablet po q6h (every 6 hours) as needed for hyponatremia: for hyponatremia caused by siadh. disp:*60 tablet(s)* refills:*2* 8. dextran 70-hypromellose drops : one (1) drop ophthalmic qid (4 times a day): one drop in each eye for dry eyes. disp:*1 bottle* refills:*2* 9. acetaminophen 500 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed for pain. disp:*60 tablet(s)* refills:*2* 10. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 11. lactulose 10 gram/15 ml syrup : thirty (30) ml po q8h (every 8 hours) as needed for constipation. disp:*750 ml(s)* refills:*2* 12. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 13. senna 8.6 mg tablet : 1-2 tablets po bid (2 times a day) as needed for constipation . disp:*56 tablet(s)* refills:*4* 14. ondansetron hcl (pf) 4 mg/2 ml solution : eight (8) mg injection q8h (every 8 hours) as needed for nausea. disp:*168 mg* refills:*4* 15. prochlorperazine edisylate 5 mg/ml solution : ten (10) mg injection q6h (every 6 hours) as needed for nausea. disp:*280 mg* refills:*4* 16. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). disp:*30 tablet,rapid dissolve, dr(s)* refills:*2* 17. nystatin 100,000 unit/ml suspension : five (5) ml po qid (4 times a day) as needed for thrush . disp:*560 ml(s)* refills:*2* 18. sodium chloride 0.9 % 0.9 % syringe : three (3) ml injection q8h (every 8 hours) as needed for line flush. disp:*252 ml(s)* refills:*4* discharge disposition: extended care facility: hospice house discharge diagnosis: # progressive metastatic lung cancer # progressive cognitive decline due to brain metastases discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: bedbound. discharge instructions: it was a pleasure to care for you as your doctor. . you were brought to the hospital because of a chronic severe headache, nausea, vomiting, and memory loss after you had started whole brain radiation treatment for known metastatic lung cancer in your brain. we carried out imaging tests to assess your brain tumors and you were seen by the neurology physicians, who believed that your chronic symptoms as well as your acute episode of right sided weakness early in your hospitalization course may have been caused by seizures or stroke. you were started on medications to prevent seizure and reduce the brain swelling normally caused by whole brain radiation. your symptoms improved on these medications as well as analgesics and they improved further after the neurology physicians drained fluid from around your brain on two occasions. after evaluating you extensively, reviewing the brain image, and observing your brain's electrical activity, the neurology physicians determined that your symptoms were not caused by seizures or stroke and that they were most likely caused by the progressing metastatic lung tumors in your brain. we continued the radiation to your brain at the hospital to treat the tumors and you tolerated these procedures well; we also continued your anti-seizure and anti-swelling medications and started you on a salt tablet and fluid restrictions to maintain normal electrolyte levels, which are important to brain function. unfortunately, due to the progressive nature of your disease, despite these interventions, your mental status precipitously and permanently declined from your baseline prior to being admitted to the hospital. as we have already discussed with your family, we are unable to provide further treatments that may reverse the progression of your brain metastases and we anticipate that your mental functioning will continue to decline. . we are discharging you from the hospital on the following medications: . # levetiracetam oral solution 1250 mg twice daily for seizure # lorazepam 0.5 mg iv every 4h as needed for seizure # dexamethasone 4 mg iv every 6h # emtricitabine-tenofovir (truvada) 1 tab daily # efavirenz 600 mg daily # sulfameth/trimethoprim ds 1 tab daily # sodium chloride 2 gm po every 6h for hyponatremia # hydroxypropyl methylcellulose one drop in each eye daily for dry eyes # acetaminophen mg every 6h as needed for pain # bisacodyl 10 mg by mouth or per rectum daily as needed for constipation # lactulose 30 ml every 8h as needed for constipation # docusate sodium 100 mg twice daily for constipation # senna 1 tab twice daily for constipation # ondansetron 8 mg iv every 8h as needed for nausea # prochlorperazine 10 mg iv every 6h as needed for nausea # lansoprazole oral disintegrating tab 30 mg daily # nystatin oral suspension 5 ml swish and swallow daily as needed for thrush # sodium chloride 0.9% flush 3 ml iv q8h:prn line flush . followup instructions: none Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Spinal tap Incision of lung Insertion of endotracheal tube Other radiotherapeutic procedure Diagnoses: Obstructive hydrocephalus Secondary malignant neoplasm of pleura Candidiasis of mouth Human immunodeficiency virus [HIV] disease Acute respiratory failure Secondary malignant neoplasm of brain and spinal cord Cerebral edema Malignant neoplasm of other parts of bronchus or lung Dehydration Other disorders of neurohypophysis Secondary malignant neoplasm of other parts of nervous system

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath major surgical or invasive procedure: none history of present illness: ms. is a 78 year old female with a remote history of lung cancer s/p lobectomy, copd on 2l at baseline, type ii diabetes and hypertension who presents from rehab with shortness of breath. per notes over the past weekend she developed upper respiratory tract symptoms with nasal congestion, and cough productive of thick sputum. she was not experiencing any fevers. she was given increased nebulizer treatments with some relief. she was not experiencing chest pain or pleuritic type pain. she was not experiencing nausea, vomiting, abdominal pain, constipation, dysuria, hematuria, leg pain or swelling. she does endorse some mild diarrhea. she says that her breathing has been getting progressively worse over the past three days despite increasing nebulizer and oxygen therapy (titrated to 4l). she appeared progressively worse and ems was called for transport to . when ems arrived she was complaining of shortness of breath. initial oxygen saturations were in the low 80s and these improved to 94% on a non-rebreather. she was noted to have scant wheezes in her upper lung fields. ekg showed sinus tachycardia, right bundle branch block, q waves in iii, avf, twf v1-v3. she was taken to the emergency room. . in the ed, initial vs were: t: 98.8 p: 113 bp: 130/84 r: 25 o2 sat: 85% on ra. initial cxr showed possible infiltrate in the l upper lobe. ekg showed sinus tachycardia, left axis, right bundle branch block, twi v1-v3, q waves iii, avf, no change compared to prior earlier in the day. she received vancomycin 1 gram iv x 1, zosyn 4.5 grams x 1, combivent nebulizers x 3, solumedrol 125 mg iv x 1. she was placed on bipap with mild improvement. she also received nitroglycerine for potential volume overload as well as lasix 20 mg iv x 1. her bnp was elevated at 1122. her wbc was 15.1 with 91% neutrophils. she had one set of negative cardiac enzymes. she was admitted to the intensive care unit for further management. . on arrival to the icu she reported that her shortness of breath has improved somewhat from this morning. she denied fevers, chills, chest pain, nausea, vomiting, abdominal pain, constipation, dysuria, hematuria, leg pain or swelling. comes from rehab. has had recent rhinorrhea and productive cough without fevers. mild diarrhea at rehab. all other review of systems negative in detail. past medical history: lung cancer s/p chemotherapy and lobectomy (date unknown) type ii diabetes on insulin macular degeneration (legally blind) hypertension copd breast cancer s/p lumpectomy hypercholesterolemia diverticulosis obesity depression/anxiety anemia b12 deficiency colon polyps s/p polypectomy social history: positive smoking history, quit at the time of her diagnosis of lung cancer. no current smoking, alcohol or illicit drug use. she has been living at rehab for one year. family history: no history of lung disease physical exam: vitals: t: 99.6 bp: 151/76 p: 111 r: 27 o2: 99% on nrb general: aggitated, oriented, mild respiratory distress using abdominal musculature heent: sclera anicteric, mm dry, oropharynx clear neck: supple, jvp 12 cm, no lad lungs: decreased breath sounds throughout, scarce expiratory wheezes, no crackles or ronchi appreciated, right sided thoracotomy scar well healed cv: tachycardic, normal s1 + s2, no murmurs, rubs or gallops appreciated abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley draining clear yellow urine ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neurologic: grossly intact pertinent results: labs on admission 06:35pm blood wbc-15.1* rbc-4.00* hgb-10.5* hct-31.8* mcv-80* mch-26.2* mchc-32.9 rdw-15.2 plt ct-269 06:35pm blood neuts-91.0* lymphs-5.2* monos-3.1 eos-0.5 baso-0.2 06:35pm blood pt-12.1 ptt-24.8 inr(pt)-1.0 06:35pm blood glucose-201* urean-25* creat-1.2* na-139 k-4.3 cl-97 hco3-31 angap-15 06:35pm blood calcium-11.1* phos-3.0 mg-1.9 06:44pm blood lactate-1.2 06:35pm blood probnp-1122* 06:35pm blood ck(cpk)-126 ck-mb-5 probnp-1122* 02:54am blood ck(cpk)-204* ck-mb-7 ctropnt-0.02* 10:17pm blood type-art po2-51* pco2-47* ph-7.44 caltco2-33* base xs-6 . influenza dfa: negative urine legionella ag: negative blood cultures x 2: no growth urine culture: no growth . cxr: opacities at the left lung base, left upper lung, and right mid lung as above, these are nonspecific. multifocal pneumonia is primarily considered. in addition, note is made of cardiomegaly and sequelae of thoracic surgery. labs on discharge: 08:50am blood wbc-16.0* rbc-4.01* hgb-10.2* hct-32.4* mcv-81* mch-25.5* mchc-31.5 rdw-15.6* plt ct-422 08:50am blood plt ct-422 08:50am blood glucose-177* urean-55* creat-1.6* na-146* k-3.6 cl-104 hco3-29 angap-17 08:50am blood calcium-10.0 phos-3.4 mg-2.3 09:58am urine color-straw appear-clear sp -1.013 08:50am blood wbc-16.0* rbc-4.01* hgb-10.2* hct-32.4* mcv-81* mch-25.5* mchc-31.5 rdw-15.6* plt ct-422 08:50am blood glucose-177* urean-55* creat-1.6* na-146* k-3.6 cl-104 hco3-29 angap-17 vbg 12:15pm blood type- po2-41* pco2-42 ph-7.49* caltco2-33* base xs-7 comment-green top brief hospital course: this is a 78 year old female with a history of lung cancer s/p lobectomy, copd on two liters at baseline, insulin dependent diabetes, hypertension who presents with rhinorrhea, cough and shortness of breath likely due to copd exacerbation and multifocal pneumonia. cough/shortness of breath: questionable small infiltrate in left upper lung field in setting of low grade fevers, leukocytosis, and upper respiratory tract symptoms. likely represents exacerbation of patients known copd in the setting of possible viral versus bacterial lung infection. there may be a component of volume overload although no clear cardiac history. started on vancomycin, zosyn and levofloxacin for hcap as coming from rehab facility and titrated from bipap to 4 liters nasal cannula in icu. urine legionella negative. influenza dfa was negative. solumedrol weaned to prednisone for possible copd exacerbation with plan for quick taper, which was completed while patient was in house. ruled out for mi. patient was started on vancomycin, zosyn and levofloxacin x 7 day course (d1 = for vancomycin and zosyn and d1 = for levofloxacin.) blood cultures were negative for growth at discharge. on the floor, patient had an episode of persistent hypoxia to 85% on oxygen likely in the setting of delerium that was relieved with ativan and anti-psychotics. she was satting >90% on discharge, but still had evidence of multifocal pneumonia on cxr and expiratory wheezes on exam. copd: on 2l nasal cannula at baseline. started on solumedrol and standing ipratropium and albuterol nebs for likely exacerbation. finished a quick prednisone taper given emotional lability. o2 sats were titrated sats 88-92% . acute renal failure: baseline of 0.9-1.0 as of 10/. creatinine up to 1.9 this morning from 1.2 on presentation. likely prerenal in the setting of infection and decreased po intake. differential diagnosis includes atn v. ain with zosyn. urine eosinophils negative. patient was hydrated with normal saline. creatinine improved from 1.9 to 1.6. hydration was changed to 1/2 normal saline in the setting of mild hypernatremia. her lisinopril and hydrochlorothiazide were held. all medications were renally dosed. . delirium: patient was noted to be delirious on the floor. this is likely caused by a combination of being in a hospital setting with underlying infectious process and uremia. it should resolve with the patient returning to the familiar setting and treating the underlying infectious process and prerenal causes of arf. hypertension: blood pressures were stable throughout hospitalization. home amlodipine continued but lisinopril and hctz held in setting of arf. . positive ua: urine culture negative during this hospitalization. . hypercalcemia: calcium levels elevated at 11.1. calcium supplement was held with improvement in ca from 11.1 to 9.9 with iv fluids. . anion gap: the patient has an anion gap, likely secondary to dehydration in setting of decreased po intake. lactate was normal. gap closed with administration of iv fluids and resumtion of diet on repeat labs. . depression/anxiety: the patient was very tearful, anxious throughout hospitalization and reported ongoing difficulties with depression. continued home venlafaxine, trazodone prn and ativan with holding parameters. the patient was given ativan iv q12h:prn for anxiety. pt. stated that she has suicidal ideations if she stays in the hospital. should resolve with return to her home environment. . anemia: hematocrit remained stable at baseline 26-28. we continued iron supplements type and screen was active. . type ii diabetes: the patient was continued on lantus and humalog sliding scale. home lantus dose initially halved given npo status but increased when diet was restarted. the patient had elevated fsg, likely secondary to steroid treatment, humalog insulin sliding scale tightened and pt restarted on home dose lantus. . hypercholesterolemia: continued statin. . lung cancer: details are unclear but patient is s/p chemotherapy and lobectomy at unknown date. this is not currently considered an active issue. . fen: low sodium / heart healthy / diabetic diet. prophylaxis: patient was on ppi for gi prophylaxis and subutaneous heparin for dvt prophylaxis. . access: peripheral iv . code: dnr/dni (discussed with patient) . communication: (friend) dispo: pt. with improved oxygenation. discharge to rehab macu. medications on admission: bactrim ds (started ) lorazepam 1 mg qhs trazodone 25 mg qhs albuterol nebulizers q4h (started ) ipratropium nebulizers q4h (started ) fluticasone inhaler 1 puff iron 1250 mg lorazepam 0.5 mg daily:rpn tylenol 650 mg q4h:prn and qhs amlodipine 10 mg daily cholecalciferol 1000 u daily hydrochlorothiazide 25 mg daily lisinopril 40 mg daily insulin glargine 54 u qam, 30 u qpm calcium carbonate 650 mg venlafaxine xr 75 mg daily simvastatin 40 mg daily albuterol discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) 1 injection injection tid (3 times a day). 2. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 3. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 4. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 5. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 6. venlafaxine 75 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po daily (daily). 7. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 8. levofloxacin 750 mg tablet sig: one (1) tablet po q48h (every 48 hours) for 2 doses: needs 1 dose on and a final dose on . 9. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 10. ipratropium bromide 0.02 % solution sig: one (1) inhalation inhalation q6h (every 6 hours). 11. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation inhalation q6h (every 6 hours). 12. fluticasone 100 mcg/actuation disk with device sig: one (1) puff inhalation twice a day. 13. lorazepam 0.5 mg tablet sig: one (1) tablet po q12h (every 12 hours) as needed for anxiety. 14. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 15. piperacillin-tazobactam 2.25 gram recon soln sig: one (1) recon soln intravenous q6h (every 6 hours) for 4 days: start date: end date: pt. received antibiotics at from to . total course of antibiotics should be 7 days. 16. vancomycin in dextrose 1 gram/200 ml piggyback sig: one (1) gram intravenous q48h (every 48 hours) for 4 days: start date: end date: pt. received antibiotics at from to . total course of antibiotics should be 7 days. 17. insulin glargine 100 unit/ml cartridge sig: fifty four (54) units subcutaneous qam. 18. insulin glargine 100 unit/ml cartridge sig: thirty (30) units subcutaneous qpm. 19. insulin lispro 100 unit/ml cartridge sig: as directed units subcutaneous four times a day: per attached sliding scale. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary: copd exacerbation, pneumonia and delirium secondary: dm2, htn, lung ca (s/p lung resection), depression discharge condition: vitals stable, o2 saturation >90% on 2 liters nasal canula. discharge instructions: you were admitted to with shortness of breath, which likely resulted from a combination of exacerbation of your copd and a respiratory infection, likely pneumonia. you were treated for pneumonia with antibiotics (vancomycin, zosyn, levaquin). you were given nebulizer treatments and steriods (solumedrol, followed by prednisone) for copd exacerbation. you initially were put on noninvasive positive pressure respiration (bipap) to help with you breathing and later were switched to oxygen. your kidney function has worsened over the past several days likely secondary to dehydration. you should continue to receive iv fluids and drink plenty of fluids over the next several days to help your kidneys. your breathing and oxygenation have improved over several days. you should continue taking iv antibiotics (zosyn, vancomycin and levaquin) for a period of 7 days total (you received 4 days in the hospital). we treated you with a fast steroid taper which has completed while in the hospital. you should also continue with nebulizer treatments (albuterol, atrovent) for now. we have made the following medication changes. we have held your lisinopril and hydrochlorothiazide because of your acute renal failure. we have also stopped your advair discus and switched you to fluticasone inhaler, because you were tachycardic and because your are already getting albuterol and atrovent nebs. we have made the changes to your sliding scale to control your blood sugars while you were on steroids. we do not recommend that you receive any further antipsychotics or lasix. you should return to the hospital should your breathing worsen or you develop new chest pain, fever, severe cough. you should follow up with your pcp at rehab upon discharge from the hospital. followup instructions: you should follow up with your pcp at rehab upon discharge. you should follow up with your psychiatrist upon discharge. Procedure: Non-invasive mechanical ventilation Diagnoses: Pneumonia, organism unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Personal history of malignant neoplasm of bronchus and lung Obstructive chronic bronchitis with (acute) exacerbation Personal history of malignant neoplasm of breast Depressive disorder, not elsewhere classified Other B-complex deficiencies Hypoxemia Dehydration Diverticulosis of colon (without mention of hemorrhage)